• Types of Vaginal Irritation — What is Up "Down There"?

    by Renee Cotter, MD
    on Oct 15th, 2015

As women, we know that it’s common to get that occasional little irritation “down there”. In fact, about 1 in 3 women will experience this sometime in their life. Sometimes it’s an itch, sometimes it’s a burn, sometimes it just feels wrong overall. Then along with that there might be a funny smell, discharge of a different color or texture, or painful intercourse. Unfortunately, there may be many different causes of the vaginal irritation you are experiencing. Vaginal irritation, or inflammation of the vagina, is referred to medically as “Vaginitis”. There are several types of vaginitis and oftentimes, the symptoms you are experiencing are similar or even identical to another type of vaginitis. 

 

For example, you may have had yeast infections in the past, and though the symptoms you experience now are similar to your past yeast infections, you may actually have a Trichomonas infection. Types of vaginitis are yeast infections, bacterial vaginosis (BV), trichomoniasis (Trich), vaginitis due to STI, atrophic vaginitis, and vaginitis due to material sensitivity. Up to 72 percent of women with vaginitis remain undiagnosed, concerning information considering that treatment and medication are all different depending on the type of vaginitis that is diagnosed. For these reasons, it is recommended to visit a doctor for a proper diagnosis. Women and girls of any age may experience vaginitis, however, it most commonly affects women during their reproductive years.


A Little Bit of Science Behind Things

As mentioned above, there are many causes of vaginitis. It may be as simple as an irritation to your soap or as complicated as an infection with a specific microorganism. The vagina is a tissue on the body that is a natural little environment for many other living creatures. It’s funny to imagine your body as a place for other little organisms to live, but it’s absolutely true. Lactobacillus is a type of bacteria that lives in the vagina and it is considered a “good” microorganism and an important player in “normal vaginal flora”. Flora is another word that refers to the many organisms that live in the vagina. So, “normal vaginal flora” is means “the normal type and amount of microorganisms that live in and around the vagina”. When you have an infection that causes vaginitis, it is highly likely that you will have “abnormal vaginal flora”. This may be due to an invasion of yeast, bacteria, or a protozoan parasite. This invasion and tipping of the normal flora balance can be caused by many factors:

Estrogen and pH

Estrogen plays a large role in vaginal health and vaginitis. In prepubescent girls and postmenopausal women, low levels of Estrogen cause the vaginal tissues to be thinner and the pH of the vagina to be higher. pH plays an important role in vaginal health because pH helps determine whether or not a certain microorganism can potentially live in the vagina. A high pH allows more types of organisms to live and thrive in the vagina while a low pH causes are more harmful environment for many types of organisms and therefore less types of organisms are able to live. Thus, it is good for your vaginal to have a slightly lower pH. Although douching is not generally recommended when women do, a vinegar and water douche can be occasionally used to keep the acidic pH. A pH that is too low, however, may be from too much lactobacillus. Thus it is important that your pH be in the proper balance. Always consult your doctor before douching and never use it as a first line of treatment.

During reproductive years (about age 13 to age 51), women have a higher levels of estrogen. The presence of estrogen in the vagina causes more sugars to be present in the area. Because microorganisms love sugar, this allows Lactobacillus - the good bacteria mentioned above - to come and live in the vagina. Lactobacillus will then produce a small amount of acid, lowering the pH and creating a protective environment for your vagina where fewer organisms should (hopefully) be able to live. Basically, lactobacillus protects your vagina in exchange for the sugar your body provides it. It’s a cool little “room and board” exchange system your body naturally does. Changes in your body’s pH are caused by hormonal changes during your cycle, menopause, pregnancy, and breastfeeding. ​


Risk Factors for Vaginitis

Though pH and hormones play an important role in your normal vaginal flora, there are also many other factors that may cause vaginitis. 

These include:

Antibiotic Use: Antibiotics have the potential to kill off your normal flora, including lactobacillus, the bacteria responsible for maintaining a low pH of your vaginal tissues. When the normal flora is killed, this allows other microbes, particularly yeast, to move in. Thus, antibiotic use is a leading cause of yeast infections.

Douching: Douching is discouraged for many reasons, however, in this case it is harmful in a similar way to antibiotic use. Douching harms the normal vaginal flora, but increases the possibility BV rather than a yeast infection. As an aside, douching also increases the risk of many other infections including HIV and other STDs. These are only a few of the risks associated with douching and it is a practice that should be avoided.

Sexual Intercourse: Sexual intercourse increases the risk of BV, Trich, and other STIs that cause vaginal irritation. These infections are passed from one partner to another. Thankfully, BV, Trich, and other STIs that cause vaginitis are able to be treated with medication.

Spermicide: Spermicide may increase the possibility of vaginitis for multiple reasons. Though spermicide is a good addition to condoms during sexual intercourse due to its ability to prevent pregnancy and decrease the risk for certain STIs, it is a common irritant. Some people are sensitive or allergic to a compound found in spermicide and it may be a cause of vaginitis itself. Furthermore, increased spermicide use has also been associated with increased bacterial vaginosis. This may be due to the potential of spermicide to harm your vaginal flora.

Infection: Some infections, can weaken your immune system and increase susceptibility to infections such as yeast infection, BV, Trich, and other STIs that cause vaginitis. Infections, if bacterial, are also treated with antibiotics. Use of antibiotics increases the risk of yeast infections because of the potential for lactobacillus to be killed.

Menopause: During menopause, your risk of vaginitis increases for several reasons, all due to the drop in estrogen your body experiences. As mentioned above, when estrogen falls, the pH of your vagina rises. This allows more other microorganisms and less lactobacillus to live in your vagina. Another reason menopause increases your risk of vaginitis is that the low levels of estrogen cause your vaginal tissues to become thin, dry, and irritated. This is called “atrophic vaginitis”.

Hygiene: Improper vaginal hygiene may also increase the possibility of BV due to E. coli, a bacteria that lives in your own rectum. Incomplete sanitization, wiping from front to back, or fecal incontinence all increase the possibility of E. coli in the vaginal area. Even one E. coli bacterium has the potential to divide and multiply into many bacteria that cause an infection. Thus complete hygiene should always be done in the shower, on the toilet, and in the prevention of fecal incontinence.

Material Irritants: Women with sensitive skin may be allergic to various materials they are exposed to throughout the day. The irritant may come from clothing, soap, detergent, fragrances, lack of airflow to the area, and more. If you have sensitive skin and experience frequent vaginal irritation, this is a possible cause.

Diabetes: Diabetics have a larger amount of sugar in their blood and this sugar is more easily distributed to other parts to other parts of their bodies. As mentioned earlier, bacteria and other microorganisms love sugar -- it is their primary food source. Thus, diabetics are at an increased risk of vaginitis due to a microorganism infection, especially yeast. Often I am able to tell if the yeast and glucose are poorly controlled in a diabetic by smell alone.

Poorly Ventilated Clothing: Constant use of tight, poorly ventilated clothing can increase a woman’s likelihood of vaginitis due to a microorganism. A poorly ventilated area creates damp conditions, perfect for tiny organisms to live and thrive. Material type matters as well so those that do not breathe well, such as spandex, leather, or other materials, may be more likely to create this damp environment even if the clothing isn’t abnormally tight.


Types of Vaginitis

Yeast Infection

A yeast infection occurs when there is an overgrowth of yeast in the vagina and it is the second most common type of vaginitis. A small amount of yeast always lives in the vagina, however, when changes to the vaginal pH or hormones occur, yeast can grow to abnormally high numbers and cause an infection. The type of yeast that causes yeast infections is called Candida. Candida albicans, or C albicans, is the species that most commonly causes a yeast infection, however other species of Candida can also cause them. These other, non-albicans, yeasts are less responsive to medications that treat yeast infections.

Symptoms:

Diagnosis:

Because symptoms of yeast infection are nearly identical to those of BV, Trich, and other STI infections, it is important to see a doctor for diagnosis and to rule out any other infection. Medications for yeast infection will not cure BV, Trich, or other STIs, which cause similar symptoms. To positively diagnose a woman with a yeast infection, your doctor must either visualize yeast under the microscope or have a positive vaginal culture that shows yeast in addition to symptoms. Sometimes women with frequent or recurring yeast infections may choose to self-medicate with over the counter yeast infection treatments such as Monostat. These are relatively low dose and are safe to use, however they can less effective than any prescribed medication.

Causes:

Yeast infections may be caused by several factors including:

Prevention:

Because yeast infections may be caused by factors out of your control -- i.e. hormonal imbalances or pH changes -- it can be difficult to prevent yeast infections. Factors that you can control, however, should be practiced if you experience frequent yeast infections.

Begin by:

Treatment:

Most yeast infections can be treated with a vaginal suppository (dissolvable pill that is inserted into the vagina), vaginal cream, or an oral tablet. The vaginal suppository and vaginal cream treatments can be associated with burning, irritation, or increased itching. This could be for several reasons. Oral tablets are typically more effective but have the potential to cause upset stomach and headache. Additionally, due the overuse of prescribed oral yeast infection treatment -- i.e. Diflucan -- there has been a rise of Diflucan resistant yeast.

Non-albicans species of yeasts are more resistant to these treatment and can require a more rigorous cure. Boric acid is used vaginally for 14 days to cure these uncommon species of yeast. In the case that boric acid is ineffective, a specialist should be seen.

Bacterial Vaginosis (BV)

BV is the most common type of vaginitis and is caused by a decrease in healthy Lactobacillus and an overgrowth of unhealthy bacterial organisms. Lactobacillus creates a protective, low pH environment for your vagina. So when their numbers are depleted, the vagina pH increases and it allows for other bacteria to move in. These bacteria the cause BV include Gardnerella, E. coli, and Mycoplasma and may be transmitted from one partner to another. Along with causing vaginal irritation, BV increases your risk for other dangerous complications including increased HIV risk, miscarriage, infertility, preterm birth, and more. Again, because of the similarity of its symptoms to other microorganism infections, diagnosis by a doctor is essential and there is no true over the counter cure for BV.

Symptoms

Diagnosis

Diagnosis is made during a doctor's visit when you have symptoms of BV, cells called “clue cells” seen under a microscope, high vaginal pH, and/or a vaginal culture that returns positive for BV. BV cannot be diagnosed at home, but a woman may suspect or know she has BV if she has a history of the infection and has become aware of her typical symptoms.

Causes

The exact cause of BV is unknown, however it is positive that a decrease in Lactobacillus is associated with the infection. It is possible to be transmitted from one sexual partner to the other as well.

Factors that increase your risk for BV:
Prevention

In order to prevent BV, it is important that you limit the risk factors above.Probiotics are a more recent area of study for the prevention of BV. Probiotics can be used in supplemental form, applied locally to the vagina, or through consumption of probiotic foods including yogurt, kefir, kombucha, etc. These supplements and foods are thought to add lactobacillus to your body and help prevent the disappearance of this good bacteria. Though probiotics do not work very well to treat BV, it is possible that they may help in its prevention. Over the counter probiotics are available in all forms. If lactobacillus through the mouth has not been effective, it may be worthwhile to try vaginal lactobacillus either through a vaginal suppository or a dissolvable tablet.

Treatment

Treatment of BV is usually done through an antimicrobial treatment and must be prescribed by your doctor. There is no current over the counter treatment for BV aside from probiotics, which, as mentioned above are not truly meant for the treatment of BV. Because bacteria thrive in a higher pH vaginal environment, it is also good to make sure that your vaginal environment is not conducive to bacterial growth.

Trichomoniasis (Trich)

Trichomoniasis is a common cause of vaginitis and one of the most common sexually transmitted infections (STIs), affecting 7.4 million people in the U.S. annually. Trichomonas is a protozoan parasite, rather than a bacteria, yeast, or virus and is completely treatable with medication. Medication for Trich is completely different from medications that treat BV or yeast. Its symptoms are also nearly identical to other types of vaginitis, adding more reasons to why you should visit a doctor for a proper diagnosis of vaginitis symptoms. Without treatment, Trich can last from a few months to multiple years. A Trich infection can also, unfortunately, increase the chances of becoming infected with other STIs including the virus, HIV.

Symptoms

Diagnosis

The microorganism that causes Trich has a little tail like structure at its end that allows it to swim and move about. For this reason, your doctor may be able to diagnose Trich simply by looking under the microscope. If no Trich is seen and your doctor suspects that this is the culprit of your symptoms, he or she can send a culture to a lab which has a much higher possibility of diagnosing Trich.

Causes

Trichomonas is transmitted sexually from one partner to the other, but symptoms are much more common in women. In fact, only 30% of people overall will ever show symptoms of Trich. The protozoa can still be passed from one person to another, whether they show symptoms or not. It can even infect other body parts including the mouth, anus, or hands.

Prevention
Because Trich is transmitted sexually alone, the best ways to prevent the infection are:

Though condoms are effective at preventing the spread of Trich, it is still possible to become infected, even when using a condom.Treatment
Trich is completely treatable once diagnosed. It is treated with a single oral antibiotic medication prescribed by your doctor (either metronidazole or tinidazole). Treatment of Trich should be done for both you and your partner in order to prevent reinfection. This medication is also safe to use while pregnant. Unfortunately, recurrence of Trich is possible and about 1 in 5 people will become reinfected within 3 months of treatment.  Those who do not also treat their partner are much more likely to become reinfected.

Resistant Trich is rare and only accounts for about 5% of cases. Though rare, it is possible that if Trich is not responding to initial medication, it may be treated with a longer, lower dose course of medication. Before assuming your Trich is resistant, it is important to make sure that your partner has also been treated for Trich and that you have been strict with sticking to the medication instructions.

Other STIs

It is possible for other STIs to cause symptoms similar to vaginitis. STIs that cause vaginitis type symptoms include Gonorrhea and Chlamydia. These are typically screened for on a pap smear for young women. Older women will have to request a Gonorrhea and Chlamydia screen. This should be done if you ever have a new partner or suspect fidelity issues with your current partner.

Symptoms and Cause

Symptoms of these are vague and do not affect most people. Symptoms are:

STIs are transmitted from one partner to another via sexual contact alone.

Diagnosis

Gonorrhea and Chlamydia are diagnosed by a culture taken at by your doctor. STI screening clinics also may diagnose these two infections.

Prevention and Treatment

The best way to prevent Gonorrhea and Chlamydia is through the use of condoms, limiting sexual partners, abstaining from intercourse, and having a full knowledge of your partner’s sexual history before engaging in intercourse.

Gonorrhea and Chlamydia are completely treatable infections but require a diagnosis before treatment. It is important that both you and your partner are treated for these infections if diagnosed.

Cytolytic Vaginosis (CV)

Cytolytic vaginosis is a less common type of vaginitis, accounting for 5-7% of vaginitis cases. It occurs when there is too much lactobacillus which causes the pH of the vagina to be too low. This low pH causes the cells in the lining of the vagina to breakdown. CV is frequently confused with other types of vaginitis, most commonly yeast infections and sometimes BV. After unsuccessful treatment for recurrent yeast infections, CV can be suspected. If your doctor has also ruled out yeast infection, BV, trich, and other STIs as a cause of your vaginitis symptoms, CV could be the culprit. ​

Symptoms

Diagnosis

Because symptoms of CV are identical to those of a yeast infection, a yeast infection must first be ruled out. Your doctor may also test the pH of your vagina. Under a microscope, he or she may also check for excess lactobacillus and breakdown of vaginal cells. ​

Causes

The causes of CV are not completely understood, however certain factors are known to increase the chances of CV. Some women simply seem to be more prone to having excess lactobacilli.

Other factors:

Prevention

Since the causes are still not well known, there are few recommendations on the avoidance of CV. The best recommendation at this moment is to control diabetes and limit consumption of added sugars. ​

Treatment

Treatment of CV is done by raising the pH of the vagina back to a normal level. Though douching is not normally recommended, under this uncommon circumstance, it is. To treat for CV, baking soda is mixed with water and then douched with twice a week for two weeks. Alternatively, a baking soda capsule can be inserted into the vagina. It is important to consult your doctor for a diagnosis with CV before self-treating.

Desquamative Inflammatory Vaginitis

This is another rare form of vaginitis that is not well known and is more common in women of menopausal age and older. Because it is rare, it will only briefly be discussed here. Its symptoms include burning, painful intercourse, and yellow-green discharge. It is frequently associated with a type of bacteria called “group B strep” but it is not caused by this bacteria. Typically, vaginal pH is high and no proteins called “amines’ are present. Desquamative Inflammatory Vaginitis is easily mistaken for Trich due to its symptoms, however no protozoans are found. Little is still known about this type of vaginitis, but studies have shown that a type of vaginal cream will treat the problem.

Sensitivity and Allergy

Vaginitis can also occur due to an allergy or sensitivity to something you are exposed to. This could have various causes and it's important to rule out any other cause of vaginitis before assuming this one. If you are sensitive to something you've been exposed to, you vaginal tissues will naturally become red, swollen, and irritated.

Symptoms

Diagnosis

If your doctor has ruled out other types of vaginitis, he or she may suspect a material irritant if you are exposed to several. There is no solid diagnosis for this type of vaginitis and women experiencing and unknown vaginitis are frequently recommended to simply avoid common irritants, especially if they notice irritation, itching, or burning after use.

Causes

There are many different possible causes of vaginitis due to a material sensitivity. Often, it is dependent on your unique body.

Common irritants:

Prevention and Treatment

The best way to both prevent and treat this type of vaginitis is to avoid any of the common irritants above. If you are more aware of what specific irritant is causing your symptoms, you may simply cut out that irritant alone.

Atrophic Vaginitis

This type of vaginitis is caused by menopause. In menopause, estrogen drops, and so does the amount of moisture in the vagina. The tissues also become much thinner and less elastic. This constant dryness and thinness causes the vagina to become irritated, inflamed, and red. This is referred to medically as “Atrophic Vaginitis”.

Symptoms

Diagnosis

You doctor can typically make a swift diagnosis through visual examination and history. If you are in menopause and have the typical pale color of vaginal atrophy, you will usually be diagnosed the same day.

Causes

The cause of vaginal atrophy is a loss of estrogen associated with menopause and age. Rarely, younger women may have vaginal atrophy. Reasons for this are unclear, but typically are associated with a high vaginal pH.

Prevention and Treatment

Though there is no way of preventing menopause, vaginal atrophy may prevented with hormone replacement therapy (HRT) at the onset of menopause. If this is not enough to prevent atrophy or if vaginal atrophy is already present, it may be treated with a topical estrogen. Topical estrogens include estrogen creams applied to the vagina, vaginal estrogen rings, or a dissolvable pill placed inside the vagina. There are alternatives to estrogen that may improve atrophic vaginitis but many are less effective than their hormonal counterparts. Virgin coconut oil can be applied to the area. This may help improve dryness and health of the tissue.


Conclusion

There are many different types of vaginitis, all with different causes and treatments. Types of vaginitis are yeast infection, BV, Trich, other STIs, material sensitivity, atrophic vaginitis, and CV. To properly treat a type of vaginitis, it is important to see a doctor for diagnosis, especially since symptoms of vaginitis are almost identical between types. Common symptoms of all vaginitis include itchiness, irritation, abnormal discharge, abnormal odor, burning or pain during urination, and painful intercourse. Depending on your risk factors, history, and more, women may be able to self diagnose their vaginitis. Currently, yeast infections and material sensitivities are the only type of vaginitis that you are able to self treat at home. It is possible, however to limit your risk of vaginitis by avoiding factors that increase your risk for vaginitis (discussed above). In the end, vaginitis is incredibly common and will affect many women at least once in their life. Control your comfort.



References

Cottrell, B.H. An updated review of of evidence to discourage douching.MCN Am J Matern Child Nurs. 2010 Mar-Apr;35(2):102-7
NIAID. Vaginal yeast infection. NIH. 2015.
Larsson, P., Stray-Pedersen, B., Ryttig, K.R., Larsen, S. Human lactobacilli as supplementation of clindamycin to patients with bacterial
     vaginosis reduce the recurrence rate; a 6-month, double-blind, randomized, placebo-controlled study. BMC Womens Health. 2008; 8: 3.
Medline Plus. Bacterial vaginosis - aftercare. US national Library of Medicine. 2013.
Kumar, N. et al. Bacterial vaginosis: Etiology and modalities of treatment - a brief note. J Pharm Bioallied Sci. 2011 Oct-Dec; 3(4): 496–
​     503.
Trichomoniasis - CDC fact sheet. CDC. 2015.
Suresh, A., Rajesh, A., Bhat, R.M., & Rai, Y. Cytolytic vaginosis: A review. Indian J Sex transm Dis. 2009; 30(1):48-50.
ACOG. Vaginitis. ACOG Practice Bulletin. 2015;72.
Author Renee Cotter, MD

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7320 Woodlake Ave, Suit 160
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West Hills, CA 91307
Phone: 818-208-4280
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Renee Cotter, MD
7320 Woodlake Ave
Suit 160
West Hills, CA 91307