ITCH AN AFFLICTION
Infections of the female genitalia are not only bothersome, but may also lead to serious complications
By Dr. Sheila R. Alcantara
The vagina's inherently dynamic "ecosystem" guards and protects itself from both internal and external insults. Nature has bathed it in secretions produced by sweat, oil, and numerous other glands, as well as exfoliated cells, cervical mucus, and fluids from the upper genital tract, to ensure that harmful organisms are kept at bay.
Nature keeps the vagina's pH low, around 3.8 to 4.2, making the environment unfavorable to the overgrowth of pathogens. This milieu is under hormonal control, and is sustained by lactobacilli, a type of helpful bacteria present in normal and healthy women and produce lactic acid from glycogen. Other aerobic and anaerobic bacteria also thrive in the vagina, though at low, nonpathogenic concentrations.
All these factors produce a normal vaginal discharge characteristically clear or white in color, odorless, and nonirritating. The amount will depend on the stage of the menstrual cycle, since ovulation causes an increase in cervical mucus, and hence, amount of secretions.
However, if it becomes foul-smelling, and causes an itchy or burning sensation, then something wrong must be going on. Such an abnormal discharge may just herald the presence of an infection.
Common Problem
Vaginitis is an inflammation of the vagina characterized by the presence of an abnormal vaginal discharge. It may be due to a number of causes, foremost of which is infection. Bacterial vaginosis, trichomoniasis, and fungal vaginitis represent the top three vaginal infections, and are among the most common conditions found in women in health- care settings.
In the United States alone, an estimated five million cases of trichomoniasis are diagnosed each year, and as many as 16 percent of pregnant women have bacterial vaginosis. These rates further vary by race and ethnicity, from six percent in Asians and nine percent in whites to 23 percent in African Americans.
In 1997, more than three million women were diagnosed with vaginitis in private doctors' offices, and because these numbers do not include women who are diagnosed in public health facilities or who are not diagnosed at all, these merely represent the minimum number of infections.
How They Occur
Just like any other part of the body, the vagina is a potential breeding ground for disease-causing organisms. Its normal environment may be altered by both external and host factors alike, and numerous studies have explored the potential contributions of a number of risk factors to these infections. First, of course, is hygiene, especially because the vagina is close to the anal and urethral orifices. Maintaining strict hygiene is primarily important during menstruation, as vaginal discharge admixed with blood becomes more basic.
On the other hand, sexual promiscuity is a risk factor only for trichomoniasis, although indirectly, semen, which is alkaline, can alter the pH of the vagina, and can lead to bacterial vaginosis.
Meanwhile, conditions that set the stage for eradication of good bacteria and overgrowth of fungal organisms, like prolonged use of broad-spectrum antibiotics and steroids, can increase susceptibility to fungal vaginitis. Overuse of intimate feminine products, especially for douching, as well as tight and poorly ventilated underwear and clothing, can also upset the normal flora. There have also been reports of vaginal yeast infections following binges of high sugar intake, as yeast thrives on sugar and acid. What's more, stress may also be related to bacterial vaginosis, as it can shift the pH of the vagina towards the more basic or alkaline side.
When conditions become favorable, pathogenic bacteria normally present in small numbers can grow in excess or may be introduced externally via sexual intercourse. The vagina's protective defenses may then be overwhelmed, giving rise to an infectious process.
Bacterial Vaginosis
Considered the most common cause of vaginal complaints, bacterial vaginosis (BV) represents an alteration of the vagina's normal flora with subsequent overgrowth of harmful bacteria. Hydrogen peroxide-producing lactobacilli are eradicated, and what's left are mostly anaerobic bacteria, such as Gardnerella vaginalis and Mycoplasma hominis, at concentrations 100 to 1,000 times higher than in normal women.
Although what triggers this disturbance of the vaginal ecosystem is not precisely known, studies suggest that repeated alkalinization of the vagina, which occurs with frequent sexual intercourse or use of douching, may play a role. Once lactobacilli disappear, it is difficult to reestablish the normal flora; hence, recurrence bouts of BV are common.
The hallmark of BV is the presence of an odorous, fishy vaginal discharge noticeable especially after intercourse. But about half of patients do not report any symptoms. Diagnosis may be confirmed by doing tests of vaginal fluid. Treatment consists mainly of oral antibiotics like metronidazole and clindamycin. Generally, male sexual partners are not treated as it has not been shown to decrease the rate of recurrence.
The consequences of untreated BV are severe. Researchers have found an association between BV and pelvic inflammatory disease (PID), which can lead to infertility and ectopic pregnancy. It has also been related to such adverse pregnancy outcomes as premature delivery, "low birth weight" infants, and disseminated infections in the mother and the newborn. It may also increase the risk of gonorrhea and HIV infection.
Trichomoniasis
Sometimes referred to as "trich" (pronounced trick), this sexually transmitted disease is caused by a protozoan parasite called Trichomonas vaginalis.
Trichomoniasis can only develop through sexual contact an infected partner. Transmission rate between couples is high-70 percent of males contract the disease after a single contact with an infected female.
Women with trichomoniasis present with a profuse, yellowish-green, foul-smelling discharge that may be accompanied by vaginal itching or burning, and pain during intercourse or urination. The diagnosis is clinched by microscopic evidence of motile organisms on vaginal secretions. Metronidazole given as a single dose or in multiple doses is highly effective in eradicating these organisms. It is important, however, for people taking this drug not to drink alcohol, as interactions between the two may cause severe nausea and vomiting. Treatment of the partner is necessary due to the sexual mode of transmission.
Research has shown that trichomoniasis is associated with increased risk of HIV transmission. Pregnant patients may give birth to "low birth weight" or preterm babies.
Vaginal Yeast Infection
Fungal infections are a common cause of vaginal irritation. It is estimated that 75 percent of women will experience at least one episode of yeast infection during their lifetime; some 45 percent, two or more times.
Fungi, most notably Candida albicans, are present in small amounts in the vagina. Overgrowth of these organisms occurs when changes in the environment alter the vaginal "ecosystem." This may arise in women with lowered immune resistance associated with pregnancy, diabetes, and use of oral contraceptives and steroids. Meanwhile, prolonged antibiotic intake kills off good bacteria that prevent excessive fungal growth.
Vaginal yeast infections typically present with intense itching, burning, and irritation of the vagina. Whitish vaginal discharge that resembles "cottage cheese" is characteristic. It is also common to experience painful urination and intercourse. On microscopic examination of secretions, fungal elements may be demonstrated. Once diagnosed, various topical antifungals (creams or suppositories) may be used to treat infection, with note of relief from symptoms in two to three days. Meanwhile, oral regimens may be given in cases of recurrent or chronic infections, which may actually signal a more serious medical condition such as HIV or diabetes. Treatment of the sexual partner is not necessary.
No complications are usually noted.
Other Causes of Vaginitis
Although most cases of vaginitis are caused by BV, trichomonas, or fungi, there are other causes as well. Other STDs would have to be ruled out. Moreover, it is important to remember that not all abnormal discharge is infectious in origin. Allergic and irritative symptoms may be secondary to the use of spermicides, feminine hygiene products, perfumed soaps, detergents, fabric softeners, even toilet paper. Appropriate diagnostic tests can help distinguish them from true infections.
What the Specialist Recommends
Vaginal infections, just like most bug-related diseases, are clearly a preventable cause of not just benign annoyance but also more serious sequalae like PID and pregnancy complications. It does not even take powerful drugs or sophisticated technology to keep the vagina free of harmful microorganisms.
According to noted obstetrician-gynecologist and specialist in women's infectious diseases Ricardo Manalastas, the best way to prevent vaginal infections is through feminine hygiene. He explains: "I tell my patients to use a mild soap solution for external washing, and it doesn't matter what soap solution, as long as they're not allergic to it. The important thing is you wash after you urinate or move your bowels, or maybe during your menstruation after each change of napkin." He further emphasizes that for healthy women, feminine washes should not be utilized for internal cleansing. Very strong washes are also not recommended, as these may kill the vagina's normal flora, leaving behind highly pathogenic organisms.
The University of the Philippines consultant also advises against douching, unless it is indicated, such as in patients with vaginal wounds. However, it can only be used for a limited period of time, as studies have shown an increased risk for PID with prolonged douching.
On the other hand, other risk factors should be avoided, especially those that involve lifestyle changes only. For example, the use of the barrier method can prevent sexually transmitted diseases such as trichomoniasis, while wearing loose, well-ventilated underwear and clothing can reduce the incidence of vaginal fungal infections. Women should also steer clear of indiscriminately using broad-spectrum antibiotics.
Your Vagina and You
It only takes some effort to keep the vagina, and its other contiguous structures, out of harm's way. Women should always be aware of what's happening to their bodies and find the means to keep themselves healthy, whether down there or elsewhere. While more research is underway to help people understand these diseases better-especially in knowing exactly how these diseases come about and how they can be prevented from giving rise to graver consequences-it is imperative that every woman take the first step. If you can't clean up, bugs will certainly keep up.
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