Chronicle Editor
Dr Tatenda Simango
I HOPE I find you well and in good health. This past week has seen an increase in the number of Covid-19 deaths at a time when the country is preparing to reopen schools. The reminder is coming stronger than ever now; let us not be complacent, let us maintain physical distancing and keep our masks on. When we are unwell and exhibiting the signs of cough, sneezing, shortness of breath, tiredness, vomiting and diarrhoea please call the toll-free number 2019 for a Covid-19 test.
This week we shall be exploring a condition that haunts several women in their reproductive age group. The issue of vaginal discharge, which is an ordeal for most women.
The normal flora (bacteria environment) of the vagina changes under the influence of oestrogen. The presence of oestrogen leads to a glycogen-rich environment, which favours acid-tolerant organisms and lactobacilli.
The vagina has a delicate environment and anything that can upset the balance may lead to the lactobacilli being lost, for example douching, the use of strongly perfumed soaps, etecetera. Other flora can then increase which may lead to bacterial vaginosis.
All women of reproductive age will have normal physiological discharge and this will vary throughout their cycle. The quality and quantity of the discharge may alter in cycles, over time, and with hormonal influences, for example menarche (first period a girl has), the combined oral contraceptive pill, pregnancy and menopause.
Non-physiological (abnormal) causes of vaginal discharge include infective:
• Candida albicans,
• Bacterial vaginosis sexually transmitted infections (STIs),
• Trichomonas vaginalis,
• Chlamydia trachomatis,
• Neisseria gonorrhoeae,
• Cervical herpes (primary infection),
• Cervical warts,
• Syphilitic chancre.
Non-infective causes of vaginal discharge include:
• Retained tampon or foreign body in vagina
• Cervical polyps (growth),
• Neoplasm (cancer),
• Retained products of conception (incomplete miscarriage),
• Oestrogen deficiency,
• Trauma,
• Allergy,
• Fistula.
Important points about the discharge that help in identifying the cause include:
• Colour,
• Consistency,
• Amount,
• Odour (enquire if it changes after sex),
• Onset,
• Duration,
• Similar symptoms before,
• Change with menstrual cycle,
• Exacerbating factors,
• Any recent change in contraception, e.g. loop,
• Current medications, e.g antibiotics, immunosuppressives
• Diabetes
The following factors increase the risk of getting an infective vaginal discharge:
• Multiple partners in the last six months (usual length of contact tracing),
• Recent partner change,
• Unprotected sexual intercourse with a new partner or number of partners,
• Recurrent symptoms,
• Symptoms in the partner,
• Other symptoms such as abdominal pain, menstrual problems, post-coital bleeding (PCB), rash, dyspareunia, arthralgia (bone pain).
Your doctor may take a sample from the cervix to confirm the diagnosis which will guide in getting the correct diagnosis and ultimate treatment. We shall go into more depth on bacterial vaginosis and thrush as these are more common among women.
Bacterial Vaginosis (BV) is the commonest cause of abnormal discharge in women of childbearing age. It is common in sexually active women, black women, smokers, and those with an Intra Uterine Contraceptive Device (loop).
It presents with an offensive fishy smelling grey discharge, often worse after intercourse. It is not usually associated with vulval itching or irritation. BV is not an STI but is caused by an overgrowth of predominantly bacteria in the anaerobic organisms, e.g. Gardnerella vaginalis. These replace the lactobacilli (good flora) and make the vagina less acidic. It can resolve spontaneously.
Advise against douching and using feminine hygiene products, strong soaps or shower gels. Reassure partners regarding the normal flora in the vagina and how delicate the area is. There is no evidence to support treating partners.
Complications include having BV causing bacteria moving upwards to infect other organs in the pelvis like the uterus and fallopian tubes and ovaries causing pelvic inflammatory disease. Recurrence is common.
BV is associated with, but not causative of, late miscarriage, pre-term birth and pre-term premature rupture of membranes in pregnant women.
Thrush is another common cause of vaginal discharge in women. Over 75 percent of women will suffer with vulvovaginal candidiasis (thrush in the groin and vagina) at some point, some recurrently. It can be exacerbated by antibiotic treatment and synthetic underwear, and is common in diabetic patients.
Candida is a yeast that can be found as a commensal organism (living in harmony within the vagina). It may or may not be sexually transmitted. It may overgrow or it may colonise the vagina by spreading from the perineum and perianal area, causing an infection. This happens especially if the normal flora of the vagina is affected by antibiotics. Vulvovaginal candidiasis is caused by Candida albicans in 80 to 92 percent of cases.
It usually presents with
• Vulval itching,
• Soreness,
• Vaginal discharge, which may be curdy and thick,
• Superficial dyspareunia,
• External dysuria (from local irritation to skin),
• Erythema,
• Fissuring,
• Satellite lesions, small white plaques,
• Oedema (swelling) of vulva.
Avoid local irritants, e.g. perfumed products as this increases the risk of thrush. Cotton underwear is advised.
Thrush can recur, defined as four or more symptomatic episodes yearly. It is associated with diabetes, immunodeficiency, corticosteroid use, and antibiotic therapy.
In pregnancy one can have thrush and show no symptoms, but can persist throughout pregnancy and may need creams to control it.
Many natural remedies have been proposed on the internet for thrush, however, it is important to discuss with your doctor for guidance. As a general rule, do not be in the habit of inserting and applying non-medical portions to the vagina as this could predispose you to irritation and even cancers.
Eating yoghurt, particularly plain Greek yoghurt, helps increase the gut microbiome (good bacteria) and can reduce yeast in the body. Make sure that the yoghurt doesn’t contain added sugar, which fuels growth of the Candida fungus. If you don’t like yoghurt, then take probiotics (good bacteria tablets). Probiotics are best taken with food.
If you’d like to try garlic to treat a yeast infection, add more garlic to your diet. Vitamin C (also called ascorbic acid) has antimicrobial components, so some women add it to their diet to treat Candida overgrowths.
It is also important that I remind you on the importance of regular cervical cancer screening. Till next week, stay safe.
Dr Tatenda Simango can be contacted on [email protected] or follow him on Facebook@ 9th Avenue Surgery.
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