Thrush and Other Vaginal Infections

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Most vaginal infections are caused by an imbalance in the naturally occurring bacteria or fungi in the vagina, or by a parasite. The three most common vaginal infections in women are bacterial vaginosis, candidiasis (also known as thrush) and trichomoniasis. While candidiasis is often considered by women to be responsible for most vaginal infections, bacterial vaginosis is actually more common. Bacterial vaginosis accounts for approximately 40-50% of vaginal infections, with candidiasis being the cause for 20-25% and trichomoniasis for 10-15% of cases (1).

The most common symptom of a vaginal infection is an abnormal vaginal discharge, although some infections may not cause any symptoms. Vaginal discharge is normal and differs in consistency and amount during different phases of the menstrual cycle and life stages. Normal vaginal discharge can range from clear and slippery, like raw egg white (around the time of ovulation) to sticky and white or cloudy (just before and after a period). The discharge can have an odour but it is generally not unpleasant. Women who take the oral contraceptive pill may experience an increase in vaginal discharge while menopausal women commonly report a reduction. All these changes make it sometimes difficult for women to know whether an infection is present or not.

Bacterial vaginosis

Bacterial vaginosis (BV) was previously referred to as Gardnerella or non-specific vaginitis. It is caused by an overgrowth in bacteria which occur naturally in the vagina in small numbers. Normally, these types of bacteria are kept in check by the presence of 'good' bacteria, lactobacilli, which keep the vagina acidic, an environment not favoured by other bacteria. A decrease in the normally dominant lactobacilli allows for other bacteria to grow. BV is associated with pelvic inflammatory disease (PID) and increases the risk of miscarriage and preterm delivery (2).

While it is unclear if BV is actually sexually transmitted, it is associated with sexual activity. Sexual intercourse and changing sexual partners are both associated with the decrease in acidity of the vagina which contributes to the growth of other bacteria. Smoking also appears to increase a woman's risk of bacterial vaginosis as does douching (rinsing the vagina out with water or a solution).

Symptoms
Approximately 50% of women with BV will be asymptomatic (experience no symptoms) (3). If present, symptoms can include:

• Fishy smelling vaginal discharge (often worse at menstruation or after unprotected vaginal intercourse).
  
• Grey or white vaginal discharge, thin or watery in consistency.
  
• Vaginal itching.
  

Diagnosis and treatment
Women who suspect they may have a vaginal infection should visit their doctor. If possible, women should abstain from penetrative sex for at least 24 hours prior to the visit as the presence of semen, lubricants or spermicides can make the diagnosis of a vaginal infection more difficult. Women should also avoid douching, using a tampon or vaginal medications (ie. thrush medication) for at least 24 hours prior to the visit. A doctor will examine the genital area to look for signs of other conditions and take a swab of vaginal discharge for laboratory testing. Taking a swab is an important step in obtaining a diagnosis. A doctor cannot accurately diagnose a vaginal infection by asking the woman about symptoms and/or by conducting an examination.

BV is treated with either oral antibiotics or antibacterial vaginal creams. During pregnancy only selected drugs are considered safe to use. Similarly, some of the drugs used to treat BV react with alcohol and, therefore, it must be avoided while taking these drugs and for a few days after the course. Recurrence of BV can be as high as 30-40% (4). Recurrent infections are also treated with antibiotics or antibacterial creams.

Prevention
To reduce the risk of recurrence, women should avoid practices that upset the natural bacterial balance in the vagina. It is best to avoid using perfumed talcs and deodorants in the perineal area, as well as douching and using bubble-bath, soap, bath salts and shampoo when taking a bath (sitting in water which contains these products can disturb the natural environment in the vagina). Quitting smoking may also be helpful.

Candidiasis (Thrush)

Candidiasis is caused by the overgrowth of yeast-like fungi called Candida. Candida inhabit the vagina, mouth and digestive tract in small numbers and are normally harmless. When the balance of naturally occurring organisms in the vagina is disrupted an overgrowth of Candida can occur. Thrush can develop as a result of the use of antibiotics, oral contraceptives or steroids and is more prevalent in women who have conditions like diabetes or multiple sclerosis or who are pregnant. Prolonged exposure to moist conditions, poor hygiene and a weakened immune system can also lead to thrush (5). Thrush does not appear to be a sexually transmitted infection (STI).

Symptoms
Approximately 10-20% of women with thrush are asymptomatic (6). Symptoms are often worse in the week before menstruation. Symptoms can include:

• A thick white or creamy vaginal discharge (may be cottage-cheese like in appearance).
  
• Itchiness and redness in and around the vagina.
  
• Discomfort and/or pain during sexual intercourse.
  
• Burning on urination.

Diagnosis and treatment
Women who suspect they may have a vaginal infection should visit their doctor (see bacterial vaginosis section). Treatment for thrush involves the use of anti-fungal creams, vaginal pessaries and/or oral medication. Many of these treatments are now available over the counter (no prescription required). Women who choose to self-treat with over the counter preparations should see their doctor if symptoms persist or recur as they may have a different vaginal infection or condition (eg. bacterial vaginosis, dermatitis) or a resistant strain of thrush.

Prevention
There are a number of practices that are said to reduce a woman's chances of getting thrush. While in some cases there is limited scientific evidence about their effectiveness, many women believe they are helpful. Practices include:

• Avoid wearing tight fitting clothing like jeans and pantyhose and underwear made from synthetic fibres. This creates a moist, warm environment which encourages the growth of Candida.
  
• Remove wet or damp bathing suits immediately after swimming.
  
• Avoid douching, perfumed soaps, bubble baths and bath salts, perfumed toilet paper and panty liners.
  
• Change underwear daily.
  
• Wash underwear in hot water (to destroy fungi) and double rinse (to remove any irritating detergent).
  
• Maintain a strong immune system by getting adequate nutrition and sleep, not smoking and managing stress levels through regular exercise, massage, yoga, relaxation, meditation or Tai chi.
  
• If prescribed antibiotics for a health complaint, ask the doctor about also taking anti-fungal preparations in combination as a preventative measure.

There is currently insufficient evidence to support dietary changes (eliminating high sugar foods and/or foods containing yeast) in the prevention of thrush. Eating a healthy, well-balanced diet is the best preventative strategy. Consuming yoghurt or other products containing the 'good' bacteria, lactobacilli, or using plain yoghurt in the vagina appear to be of little benefit in treating or preventing thrush (7).

Trichomoniasis

Trichomoniasis is caused by a small parasite, Trichomonas vaginalis, and is almost always sexually transmitted. Rarely, it is transmitted by the use of wet towels or washcloths (8). Trichomoniasis is associated with preterm delivery and also increases the risk of acquiring HIV (9).

Symptoms
Nearly half of the women with trichomoniasis are asymptomatic (10). When present, symptoms may include:

• Yellow, green or grey coloured vaginal discharge.
  
• Vaginal discharge which is frothy or has an unpleasant odour.
  
• Irritation or itching around the outside of the vagina.
  
• Burning sensation when urinating.
  
• Lower abdominal pain.
  
• Discomfort and/or pain during sexual intercourse.

Diagnosis and treatment
Women who suspect they may have a vaginal infection should visit their doctor (see bacterial vaginosis section). Women who are found to have trichomoniasis should also consider being tested for other sexually transmitted infections. Trichomoniasis is treated with either oral antibiotics or vaginal creams. It is important that current sexual partners are treated at the same time to prevent a woman becoming reinfected. Alcohol should be avoided during treatment as combining it with some of the antibiotics used can cause severe nausea and vomiting.

Prevention
TThe best strategy to avoid being infected with trichomoniasis is to always practise safe sex. Barrier protection (condoms, dams) should always be used when having sex with a partner whose previous sexual habits or partners are unknown.

References

1.  Benrubi, G. Bacterial vaginosis: Diagnosing and treating the most common vaginal infection The Female Patient 1999 Supplement p4-8
   
2. Stewart E & Spencer P. The V Book: Vital Facts About the Vulva , Vestibule, Vagina and More London: Piatkus, 2002 p222
   
3. National Institute of Allergy and Infectious Diseases. Vaginitis Due to Vaginal Infections (factsheet) National Institute of Allergy and Infectious Diseases [website] http://www.niaid.nih.gov/factsheets/stdvag.htm , date accessed 31st March 2005
   
4. Schwebke, JR. Vaginal infections. In Goldman, MB & Hatch MC. Women and Health San Diego: Academic Press 2000 p356
   
5.  Syrop, J. Vaginal infections: What you should know The Female Patient Supplement 23 p25-27
   
6. Dayan L & Wines N. Management of common vaginal discharges Medicine Today 2001 Vol 2 No 4 p79-86
   
7. Stewart E & Spencer P. Ibid p200-202
   
8. Syrop, J. Ibid p27
   
9. Schwebke, JR. Ibid p354
   
10. Schwebke, JR. Ibid p354

Further help and information from Women's Health Queensland Wide

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Further reading

See our

• Chlamydia factsheet
• Gynaecological health library booklist
  

This factsheet was originally published in October 2001. It was revised by Kirsten Braun and the Editorial Committee in March 2005.

Last Modified: March 1, 2005