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Vaginal Infections

By Dr. Wong Heng Fok
Consultant Obstetrician & Gynaecologist, Urogynaecologist
MBBS (Singapore), MRCOG (London, UK)

Many women unknowingly suffer in silence. In this article, Dr H.F Wong shares with us his insight into Vulvovaginitis, or commonly known as vaginal infection in women.

1. Thrush/Fungus

When doctors say "yeast," we usually mean a fungus named Candida albicans. It's common on the skin and can be found in the gastrointestinal tract anywhere from the mouth to the anus.

Candida lives harmlessly in the vagina in as many as one in five healthy women of childbearing age without causing any symptoms. Most of the time, a healthy vaginal environment and the normal immune system probably keep the harmless yeast from overgrowing and causing vaginitis. A yeast infection results when there's too much yeast. It overwhelms the vaginal defense system.

Yeast infections produce a spectrum of symptoms. In general, the more intense the itching and redness, the greater the number of yeast organisms present. For some women, secretions predominate, with profuse discharge that sticks to the vaginal wall in thick white patches or white plaques. This is sometimes called vaginal thrush. Odor is not a usual complaint, though candida causes a yeasty smell for some women.

This problem can usually be diagnosed simply with a pelvic examination where the vaginal discharge is swabbed and sent for culture.

Treatment is usually a combination of vaginal pessaries on the market from one to seven days. We usually give a anti-fungal/steroid cream to reduce local itchiness as well. If you have recurrent or persistent fungal infections, these can be a challenge to treat and you would need to see your GP or gynaecologist to confirm the diagnosis and ensure it is not a different condition such as bacterial vaginosis, which is as common as fungal infections.

2. Bacterial vaginosis (BV)

This problem is as common as yeast/thrush or fungal infection and presents as vaginal discharge (may be yellow green in contrast to white discharge in yeast infection) as well. The difference between fungal infections and BV is that the discharge in BV tends to be foul smelling with a fishy odour and they are the number one cause of funny odours. You can also get some soreness and some irritation around the vulva from it.

Most of the time, we can confirm the diagnosis by obtaining a vaginal swab and sending it off to the laboratory. In the meantime, we usually order some vaginal pessaries or even oral medication for 7 - 10 days to treat the condition. The usual  organisms are Gardneralla and Trichomonas infections.

BV is not considered a sexually transmitted infection but rather an imbalance in the bacteria normally found in the vaginal in the same way like a yeast infection. You should see a gynaecologist or GP for treatment.

3. Sexually transmitted disease(STD)

There is a whole lot of STD to be described but we shall briefly describe the common ones below.

i) Herpes infection

Herpes simplex virus (HSV) infections are very common worldwide. HSV-1 is the main cause of herpes infections that occur on the mouth and lips, including cold sores and fever blisters. It is transmitted through kissing. HSV-1 can also cause genital herpes, however, HSV-2 is the main cause of genital herpes. HSV-2 is contracted through sexual contact. You may be infected with HSV-1 or HSV-2 but not show any symptoms. Often symptoms are triggered by exposure to the sun, fever, menstruation, emotional stress, a weakened immune system, or an illness.

There is no cure for herpes, and once you have it, it is likely to recur; however, some people may have one outbreak and then never have another one.

Genital herpes present with multiple painful blisters and ulcers around the vulva and perineum (area immediately next to the vagina) and in serious cases, may having trouble even passing urine because of pain

In many instances, your doctor is able to make the diagnosis of herpes from examining you without additional tests. If your doctor is not 100% certain, however, then he or she may take a sample from the blisters to test for the virus.

Treatment for genital herpes: Antiviral medicines may help shorten the duration of a herpes outbreak and suppress recurring outbreaks. We give oral tablets and topical antiviral cream for 1 week. Some patients require admission due to the level of pain from the ulcers.


ii) Chlamydiae

Chlamydiae is a common sexually transmitted disease (STD) caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man.

Chlamydia is the most frequently reported bacterial sexually transmitted disease, especially in young girls, in the United States.

Any sexually active person can be infected with chlamydia. The greater the number of sex partners, the greater the risk of infection. Because the cervix (opening to the uterus) of teenage girls and young women is not fully matured and is probably more susceptible to infection, they are at particularly high risk for infection if sexually active.

Chlamydia is known as a "silent" disease because the majority of infected people have no symptoms. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra (urine canal). Women who have symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from the cervix to the fallopian tubes (tubes that carry fertilized eggs from the ovaries to the uterus), some women still have no signs or symptoms; others have lower abdominal pain and fever.

In women, untreated infection can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease. This happens in about 10 to 15 percent of women with untreated chlamydiae and may lead to problems later on with fertility.

Chlamydia can be easily treated and cured with antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments.

When we discover any STD, contact tracing of the male partner is also needed and all sex partners should be evaluated, tested, and treated.


iii) Gonorrhoea

Gonorrhoea is a sexually transmitted disease (STD). Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract.

Any sexually active person can be infected with gonorrhea.

In women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. Even when a woman has symptoms, they can be so non-specific as to be mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods.

Gonorrhoea can lead to pelvic inflammtory disease (PID.)  PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy.

Again, easily diagnosed by taking a vaginal swab. Easily treated with antibiotics. See your gynaecologist for treatment.


iv) Genital warts

Genital warts are usually asymptomatic, but depending on the size and anatomic location, they can be painful or itchy or just embarrassing cauliflower like growths. They usually occur outside the vaginal and anus. Sometimes, they can appear in the vagina and around the cervix.

Diagnosis of genital warts is usually clinical, made by visual inspection.

External warts (outside of the vagina) can be treated with a topical cream applied for 3 times/per week for 6-12 weeks. Internal vaginal warts or warts that fail to respond to topical cream may require laser vaporisation, a day surgery procedure done under general anaesthesia.


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