One prevalent issue for women of reproductive age is vaginal discharge. One subjective and vague sign is abnormal vaginal discharge. An STI-concerned woman might think a physiological discharge is unusual.
The healthy vaginal environment
A dynamic ecosystem, the vagina first becomes sterile before commensal bacteria—mostly Gram-positive—quickly populate it.
Premenarchal females have a vaginal pH of about neutral (7.0).
Puberty marks the change of the vaginal epithelium from cuboidal to stratified squamous. The primary flora of the vaginal epithelium, lactobacilli , break down glycogen to produce lactic acid. The pH of the vaginal milieu drops to less than 4.5.
The vagina also harbors small quantities of other commensals like Candida albicans, Staphylococcus aureus, and Streptococcus agalactiae (Group B streptococcus). ‘Overgrowing’ them can result in aberrant vaginal discharge.
Vaginal discharge
Normally, physiological discharge from women of reproductive age comprises bacteria, mucus from the cervical glands, desquamated epithelial cells from the vagina and cervix, and transudate from the vaginal wall. The amount and kind of this white, innocuous fluid change with the menstrual cycle.
There are infectious as well as non-infectious causes of abnormal vaginal discharge.
Infective causes
Though it usually remains untreated, bacterial vaginosis (BV) is the main reason why women of reproductive age have abnormal vaginal discharge.
Women often get the diagnosis of candida, although it is often over diagnosed. While less common than BV or candida, TV usually results in abnormal vaginal discharge.
While both gonorrhea and chlamydia can result in irregular vaginal discharge, 70% of women with chlamydia do not have any symptoms. In women who have vaginal discharge, a chlamydia infection may be an accidental finding rather than the cause of the symptoms. Though many of them are symptom-free, over 50% of women with gonorrhea have abnormal vaginal discharge.
A HSV infection can cause vaginal discharge and cervicitis. Infection with HSV can result in vaginal discharge, vulval exudate, and local discomfort.
Like BV and chlamydia, several conditions can coexist.
History
Get a complete clinical history—including a sexual history—to determine the risk of STIs.
Ask about the kind of vaginal discharge to help with a diagnosis. Irritation, for instance, can be a sign of VVC but not of BV.
Find out about signs of an upper respiratory tract infection.
Examination
Patients with low risk of STIs and without signs of an upper reproductive tract infection (PID) may not need an evaluation in non-specialist settings. Should the test be negative, the clinical history alone may be used to provide syndromic therapy.
Evaluations should be conducted on women who have had genital tract instrumentation lately, are pregnant, postpartum, post-abortion, or have recurrent symptoms.
Vaginal pH
The two most common reasons of irregular vaginal discharge—candida and BV—can be distinguished by this reasonably priced test. Take care while measuring vaginal pH because ‘contaminants’ may change it .Patients can be empirically treated before more tests are done by using clinical history and vaginal pH.
Investigations
Every sexually active woman should have access to STI testing.
TV, candida, BV and gonorrhea can be found with immediate wet mount and Gram stain microscopy. Should facilities on location not be accessible, specimens can be transported to a laboratory for microscopy. This approach, meanwhile, is less sensitive than direct microscopy.
Both an endocervical sample and a self-taken vulvo-vaginal swab can be used for NAAT testing for gonorrhoea and chlamydia.
Take an endocervical swab for culture and sensitivity tests to check for gonorrhoea. The sample can be transported to the lab for delayed plating, or it can be plated straight on growth media (see the GC chapter for transport requirements).
Commonly used in non-specialist settings to identify candida, TV, and BV are high vaginal swabs (HVS). But because commensals are involved, they could lead to overtreatment. Should other requirements be lacking, BV could be misdiagnosed as HVS. Only in cases of failed treatment, recurring symptoms, pregnancy, postpartum or post abortion, or recent genital tract instrumentation may an HVS be performed.
Management
In the diagnosis of a retained foreign body, such a condom or tampon, the clinical history and examination should be conclusive.
Contraception and vaginal discharge
BV is more likely to strike Cu-IUD users. Condom or COC users run less of a chance of developing BV. Recurrent BV sufferers who utilize the CU-IUD might choose to try an alternative method.
Although the risk of VVC is not definitively shown to rise with hormonal contraception, women who utilize CHC methods might wish to consider switching to another approach.
Recurrent VVC and BV risk may be reduced with injectables that exclusively include progestogen.
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