Introduction
Vaginal infections are among the most common reasons that women seek gynecological care. Organisms that are frequently associated with vaginal infection include Trichomonas vaginalis, Candida albicans, and Gardnerella vaginalis (formerly Haemophilas vaginalis), in association with other organisms, primarily anaerobes. G. vaginalis, with other organisms, causes a bacterial vaginosis (also referred to as nonspecific vaginitis). Chlamydia trachomatis, and Mycoplasma hominis may also be associated with vaginitis. (1)
Certain vulvovaginal infections have serious sequelae, and thus vulvovaginal symptoms or signs warrant careful evaluation and appropriate therapy that is specific for the anatomic site and type of infection. Vaginal trichomoniasis and bacterial vaginosis early in pregnancy are independent predictors of premature onset of labor. (2) Bacterial vaginosis may also be a risk factor in developing upper genital tract infection by anaerobic bacteria. Vaginitis also may be an early sign of toxic shock syndrome. Vaginal discharge may be the presenting symptom of genital herpes, or may occasionally reflect mucopurulent cervicitis or pelvic inflammatory disease (PID) caused by chlamydial or gonococcal infections. A careful pelvic examination should usually precede more invasive or expensive tests in the evaluation of women with vulvovaginal, pelvic, or abdominal symptoms. (3)
It must be remembered that there are several non-pathologic reasons for an increase in vaginal discharge. Physiologic vaginal discharges are generally nonodorous, white, highly viscous or floccular, and acidic. Physiologic discharges may become more profuse at mid-cycle secondary to increased cervical mucous or increased vaginal epithelial cells. (4) , (5) Other conditions resulting in excessive vaginal discharges include retention of foreign bodies (e.g., tampons), allergic reactions to vaginal spermicidal agents or products used for douching, or the presence of cervicitis. (6)
Bacterial vaginosis is the most common cause of vulvovaginal symptoms in most clinical settings; it is closely followed in frequency by vulvovaginal candidiasis. (7) Trichomoniasis is a sexually transmitted disease (STD) that is much less common in most settings in developed countries.
Factors that may lead to the development of bacterial vaginosis are not established, but may be linked to sexual activity. (8) The syndrome is associated with STD factors, such as multiple sex partners or recent intercourse with a new partner; however, no single sexually transmitted pathogen has been identified as the cause. The prevalence and concentrations of G. vaginalis, Mycoplasma hominis, and several other anaerobic bacteria are markedly greater than women without bacterial vaginosis. The presence of G. vaginalis, however, can be detected in up to 50 percent of healthy women. One difference routinely found is that hydrogen peroxide-producing Lactobacillus sp., which constitutes most of the bacterial flora of healthy women, is usually absent in women with bacterial vaginosis. This situation may be at least partly responsible for the overgrowth of anaerobic bacteria. Vaginal douching, use of intravaginal nonoxynol-9 spermicide, and new sexual partners are associated with loss of vaginal colonization by hydrogen peroxide-producing lactobacilli.
Women of all ages are susceptible to vaginal candidiasis but predisposing factors may include pregnancy and diabetes mellitus, thought to be due in part to elevated glucose levels in urine, and the use of broad-spectrum antibiotics, cytotoxic drugs, or corticosteroids, thought to alter the normal bacterial flora, allowing yeast overgrowth. Finally, dietary intake (e.g., high calorie or high carbohydrate diets) may influence the incidence of candidiasis. (9)
Atrophic vaginitis is most commonly associated with postmenopausal women and is due, at least in part, to atrophy of tissues formerly dependent upon high estrogen concentrations. Large numbers of estrogen receptors are located in the vagina, vulva, urethra, and trigone of the bladder. (10) The vulva undergoes atrophy, and there is shrinkage of the labia minora. A decrease in the subcutaneous fat and elasticity of the tissue causes the labia majora to flatten. Atrophic changes of the vulva (Kraurosis vulvae) lead to pruritis and pain. (11) , (12) Additionally, the vaginal epithelium becomes thin and pale, leading to reduced secretion and diminished distensibility; the tissue becomes easily traumatized and may bleed. The normal premenopausal pH of 4.5 to 5 rises to an alkaline 6 to 8, creating a favorable environment for growth of pathogens.
Statistic
World Health Organization, 2001.
- Worldwide prevalence of trichomoniasis to be 174 million and to account for 10% to 25% of vaginal infections.
National Institute of Allergy and Infectious Diseases (NIAID), 2000.
Doctors estimate that approximately 75 percent of all women will experience at least one symptomatic yeast infection during their lifetimes.
Signs and Symptoms
The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.
Specific signs and symptoms help determine the underlying cause of vaginitis. Vulvular itching with a non-odorous, white or curd like discharge is usually indicative of candidiasis. Microscopy generally verifies candidiasis. Trichomonal vaginitis usually has symptoms that include itching, a profuse, yellowish discharge that may have an odor, an elevated pH, and microscopy that reveals trichomonads in 80-90% of cases. The discharge from bacterial vaginitis also has an odor, however, it is only slightly increased in quantity, is of low viscosity and is white or gray in color. Microscopy generally shows profuse mixed flora, including G. vaginalis and anaerobic species on Gram’s stain. An atrophic vaginitis generally involves itching, bleeding and dyspareunia.
Vulvovaginal candidiasis
- Vulvular itching and/or irritation
- Scant discharge, white in color, clumped or curd-like
- No odor
- Microscopy shows leukocytes, epithelial cells, mycelia or pseudomycelia in up to 80% of C. albicans positive persons
Trichomonal vaginitis
- Vulvular itching
- Discharge is profuse, yellow and homogenous
- Erythema of vaginal and vulvar epithelium
- Odor may be present
- Elevated pH (usually >5)
- Microscopy shows leukocytes and motile trichomonads in 80-90% of symptomatic patients
Bacterial vaginosis
- Slightly increased discharge, white or gray in color, low viscosity
- Amine odor with 10% KOH
- pH >4.5
- Microscopy shows clue cells: few leukocytes, lactobacilli outnumbered by profuse mixed flora, nearly always including G. vaginalis plus anaerobic species on Gram’s stain
Treatment Options
Conventional
Vulvovaginal candidiasis: Standard therapy is miconazole or clotrimazole intravaginally, 100mg nightly for three to seven nights, or fluconazole 150mg orally as a single dose. Prolonged or periodic therapy with oral fluconazole or ketoconazole may be indicated for especially severe or frequently recurrent cases, or for those not responding to intravaginal or single dose oral therapy.
Trichomonal vaginitis: The standard treatment includes metronidazole 2 grams as a single oral dose, or metronidazole, 500mg orally, twice daily for seven days (partner should be treated as well).
Bacterial vaginosis: The standard regimen for treatment is metronidazole 500mg orally twice daily for seven days. Clindamycin 300mg orally twice daily for seven days has been used and is effective, but not preferred. Intravaginal treatment with 2% clindamycin cream (one applicator full is 5 grams, containing 100mg clindamycin phosphate) nightly for seven nights, or 0.75% metronidazole gel, (one applicator full is 5 grams containing 37.5mg of metronidazole) twice daily for five days is also effective and does not elicit systemic side effects. A single 2-gram dose of metronidazole may be given orally; however, short-term recurrence rates are somewhat higher.
Atrophic vaginitis is treated by the use of intravaginal estrogen or systemic estrogen replacement therapy.
Nutritional Supplementation
Lactobacillus acidophilus
Vaginitis can be caused by bacterial, fungal/yeast, or protozoal infections. Several studies report that ingestion of products containing therapeutic amounts of acidophilus bacteria is successful at reducing the incidence of candida vaginitis. (13) , (14) , (15)
One study evaluated a group of women who were experiencing candida vaginitis during their first trimester of pregnancy. Vaginal applications of yogurt-containing lactobacillus proved to be more effective than treatment with acetic acid preparations. Although both protocols lower pH levels, the fact that treatment with acidophilus was much more effective than acetic acid suggests that more is involved than simply creating a more acidic environment. In fact, it is known that acidophilus organisms generate both lactic acid and hydrogen peroxide, which help to inhibit the growth of many pathological organisms. (16) , (17) While numerous studies have reported the success of intravaginal administration of lactobacillus organisms, other studies indicate that oral ingestion of acidophilus products is also therapeutically effective. (18)
In addition to candida, women with inadequate levels of hydrogen peroxide-producing lactobacillus bacteria in the vagina were also much more likely to harbor other vaginal pathogens such chlamydia trachomatis, porphyromonas, peptostreptococcus, mobiluncus, and gardnerella vaginalis. (19) , (20)
Herbal Supplementation
Cat’s Claw
Cat’s claw is one of the most promising herbs to come out of the rain forest to date. It has been used as a traditional medicine, possibly dating back as far as the Incan civilization. Cat’s claw reportedly affects the immune system and acts as a potent free radical scavenger. (21) Cat’s claw has glycosides which reportedly reduce inflammation and edema. (22) The anti-inflammatory effects of cat’s claw are considered to be due to the sum total of the plant’s constituents, but the sterols have demonstrated anti-inflammatory activity in animal studies. The glycosides are also reported to enhance and stimulate phagocytosis, which if true would be a key part of cat’s claw’s immune function activity. (23) Isopteridine, an alkaloid which has been isolated, is claimed to have immuno-stimulatory properties. Triterpenoid alkaloids and quinovic acid glycosides have been isolated and studied for antiviral activity, possibly inhibiting replications of some DNA viruses. (24) , (25)
Colon toxicity has been somewhat ignored in Western medicine. It is now becoming apparent that bowel hygiene and proper flora are essential to good health. If the colon flora is out of balance (dysbiosis) or if food is not being properly digested and assimilated, toxic metabolites and mutagens may be produced. Cat’s claw is reported to have the ability to soothe irritated and inflamed tissues and help eliminate pathogens from the GI tract. (26)
Many clinicians agree that the use of pentacyclic alkaloids (POA’s) from cat’s claw root bark are the health promoting constituents. Tetracyclic alkaloids (TOA’s) do occur in the root bark, but should be kept to a minimum in the final product as to maximize the health benefits of cat’s claw as a dietary supplement.
Olive Leaf
Olive trees, widely cultivated throughout Mediterranean countries as a source of olives and olive oil, have been traditionally used not only in foods, but in health conditions including malaria, infections, cardiovascular diseases and general well-being. (27) The natural antioxidants including oleuropein from the olive tree may play a role in prevention of cardiovascular diseases through a decreased formation of atherosclerotic plaques by inhibiting of LDL oxidation. (28)
Olive leaf extract has been reported to be an effective antimicrobial agent against a wide variety of pathogens, including Salmonella typhi, Vibrio parahaemolyticus and Staphylococcus aureus (including penicillin-resistant strains), Klebsiella pneumonia and Eschericha coli, causal agents of intestinal or respiratory tract infections in man. (29) The component usually associated with olive leaf’s antimicrobial properties is oleuropein. (30) , (31) Oleuropein also has been reported to directly stimulates macrophage activation in laboratory studies. (32)
Olive leaf extract has reported antiviral activity, reportedly caused by the constituent calcium elenolate, a derivative of elenolic acid. (33) , (34) As an antifungal and antiviral agent, olive leaf extract is currently used as a supportive agent in maintaining bowel flora, beneficial in problems such as ulcerative colitis. Recent laboratory studies in laboratory animals reported hypoglycemic and hypolipidemic activity. (35) , (36) The constituent with the activity was reported to be oleuropein, with a proposed mechanism of action being: (1) potentiation of glucose-induced insulin release, and (2) an increase in peripheral blood glucose uptake.
Grapefruit Seed
Grapefruit seed extract has been reported to be a broad-spectrum antimicrobial both in vitro and in vivo. Studies indicate that the antimicrobial activity of grapefruit seed extract exists in the cytoplasmic membrane of the invading bacteria, where the uptake of amino acids is prevented, there is disorganization of the cytoplasmic membrane and leakage of low molecular weight cellular contents ultimately resulting in inhibition of cellular respiration and death. (37)
Grapefruit seed extract also inhibits the growth of H. pylori and C. jejuni, both causative agents in gastrointestinal ulcers. (38) By inhibiting causative agents of bowel dysbiosis (the imbalance of normal bacterial flora in the GIT) including Candida sp. In vivo, grapefruit seed extract is a useful agent in maintaining bowel integrity. (39) In this human study, an improvement in constipation, flatulence, abdominal distress and night rest were noticed after 4 weeks of therapy. Many clinicians now agree on the importance of maintaining homeostatis of the microflora in health and disease. (40)
Garlic
Garlic is well known for its positive benefits in cardiovascular health. (41) , (42) Other uses however include antibacterial, antifungal, antiviral and antiparasitic activities. There are several important actions that are attributed to the sulfur-containing compounds in garlic. These compounds (allicin and alliin) are reported to have anti-infective effects against bacteria and fungi. (43) , (44) , (45)
The impact of processing is an important fact to keep in mind when recommending garlic supplements. Changes can occur in the active constituents when exposed cooking or other processing which can render the garlic product virtually ineffective. Cooking is known to denature proteins and therefore may inactivate the enzyme (allinase) that is necessary in converting alliin into allicin, the major bio-active constituent in garlic.
Also, research has reported that allinase may be irreversibly inhibited by stomach acid and may fail to form adequate amounts of allicin or other thiosulfinates below pH 3.6. (46) , (47) Recommending a quality garlic supplement is essential, and enteric coating may be advantageous. Of further note, as reported in a few laboratory studies, is the potential for large amounts of allicin to damage liver tissue if absorbed due to its oxidation potential. (48) , (49) However, there are positive studies while using high quality garlic preparations standardized to allicin potential without adverse effects.
Acupuncture & Acupressure
Su Sao Jia treated 13 cases of senile vaginitis with acupuncture. The primary acupoints used were Zhong Ji (Ren 3), Guan Yuan (Ren 4), Qu Quan (Liv8), Tai Chong (Liv3), Yin Ling Quan (Sp9), San Yin Jiao (Sp6), and Shen Shu (B23). Treatment occurred once a day for the first 3 days and then every other day thereafter. After 6 to 15 courses of treatment, significant therapeutic effects occurred in all 13 cases. Symptoms like pruritus and pain subsided markedly and soreness and leukorrhea improved. (50)
Traditional Chinese Medicine
Vaginitis
Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.
Clinical Lab Assessment
Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.
Venereal Disease Screening
- Cervical/Vaginal Cytology
- Chlamydia Culture
- Candida Albicans Genital Culture
- Neisseria Gonnorrhoeae Culture
- Neisseria Gonnorrhoeae Smear
- Herpes Cytology
- Trichomonas Preparation
- Rapid Plasma Reagin (RPR): A widely used test for secondary stage syphilis.
- Venereal Disease Research Laboratory (VRDL) Test: This test is done to rule out syphilis.
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