Vulvovaginitis: A Guide

Huge shout out to my friend and occasional friend-with-benefits Alex Paige for putting this all together, I've just edited it and added in some factoids using publicly available sources; I also added the bits about men. She said it was excellent for me to throw up in a blog post! She has gathered this information by being in a highly relevant field and using her university research resources.

Vulvovaginits refers to an itching and inflamed vulva/vagina. It can be caused by Candida albicans (a fungus – often called thrush), Gardnerella Vaginitis (a bacteria – often called bacterial vaginosis/BV), or Trichomonas vaginalis (a parasite).
All of these can be clinically indistinguishable, although often if you’ve had repeated episodes you probably know which is which. Even if you think you definitely know which is which in yourself, if you keep getting any of these it may be worth going to the doctor to get a swab to show exactly what organism is causing your vulvovaginitis. The following conditions all come under vulvovaginitis ("vulvo" = of the vulva; "vagin" = of the vagina; "itis" = inflammation).

This is also called a yeast infection! Candida albicans is a fungus that grows in your vagina, mouth, gastrointestinal tract and skin. About 20% of people have it growing in their vagina and they do not have symptoms of vulvovaginits. It is usually identified by a chunky, white discharge combined with an itchy or burning vulva; you are more likely to get thrush if you are on antibiotics, have a weakened immune system or have diabetes. Uncomplicated thrush is defined as thrush in an otherwise healthy, non-pregnant person who has not had more than 3 episodes in a year; you can go to your local pharmacy for treatment. Recurrent thrush is defined as more than 3 episodes in a year; at this point you should go to a doctor. The reason for recurrence is usually that the same Candida that caused a previous episode wasn’t cleared by the initial treatment, but you should go get a swab to make sure you do actually have thrush (and not BV or trichomoniasis), that the thrush is caused by Candida albicans not a different species of Candida that is resistant to the above medications, and that there isn’t another reason that you continuously get thrush (smoking, uncontrolled high blood sugar, or high dose oestrogen contraceptives).

Men can get yeast infections too! It is usually incorrectly called "jock itch" and I've seen so many clients who have it. As it isn't contagious, I tend to just let them know to get treatment. The signs and symptoms can include irritation, burning, and redness around the head of the penis and under the foreskin, white discharge, an unpleasant smell, and difficulty pulling back the foreskin. You might also see what looks like an excess of smegma that is actually discharge caught under the foreskin.

Thrush Treatments:
1. Oral Fluconazole (single dose, 150mg – available over the counter). If severe, 2 doses 3 days apart.
2. Topical Clotrimazole (1% cream intravaginal for 7 consecutive days up to 14 days if persistent). You can also apply externally to your vulva to decrease the itching/pain. This medication can weaken or damage latex condoms.

If you do have recurrent thrush with C. albicans, the doctor will give you a longer course of oral fluconazole (150mg every 72hrs for 3 doses, then every 1 week for 6 months. This should be under the supervision of a doctor and cannot be done with other oral antifungals. If you’ve had many infections it’s possible that you do have C. albicans but it is resistant to even Fluconazole, your doctor can prescribe a different antifungal drug in this case.

Thrush Myths:

Boric acid has no evidence for the treatment of thrush. Thrush is not the result of a pH imbalance and doesn’t change the pH of the vagina.
There is also no evidence that people with recurrent candida vulvovaginits have a deficiency in vaginal lactobacilli (normal vaginal bacteria) and no evidence that oral pro or pre-biotics affect thrush recurrence rates at all. Additionally, all the studies on the use of vaginal yoghurt or lactobacilli supplements have shown that this does nothing to treat or prevent thrush.

Thrush is not sexually transmitted, so there is no need to screen partners for such.

BV is (most likely) caused by an increase in the bacteria Gardnerella vaginalis, which colonises the vaginal wall and starts making hydrogen peroxide, which allows many other bacteria that are normally present in small numbers in the vagina to overgrow and overtake the number of good vaginal bacteria – Lactobacillus. This is the reason you should NOT douche with diluted hydrogen peroxide when you have thrush, you’ll end up getting BV. 50-75% of BV is asymptomatic, so if you’re thinking ‘I’ve douched with it before and it was fine’, that might not be true. Even if asymptomatic it can cause long term complications.
Symptoms of BV include a ‘fishy’ smell with thin white discharge. It shouldn’t be itchy! If it’s itchy you either don’t have BV or have BV and another infection.

BV treatment:
1. Oral metronidazole 500mg twice a day for 7 days. You should not drink alcohol when taking metronidazole -- not just you probably shouldn't because you'll feel sick; you are actually at risk for kidney failure.
2. Vaginal metronidazole 0.75% cream in 5g doses for 5 days. It is much less risky to drink alcohol with the topical metronidazole as it isn’t absorbed systemically.

BV Myths:
1. Vaginal boric acid pessaries are ineffective at prevention and cure when used alone, but many anecdotes state that people have had success with them alone. They have no role in acute BV, but may be effective at reducing recurrence of people with chronic BV; only if you take the metronidazole orally as prescribed as well. Boric acid pessaries should never be used intravaginally for more than 30 days.
2. Boric acid can kill you if taken orally – make sure if you have these pessaries as capsules that you keep them separate from any other pills you take and keep them away from anywhere children can reach.
3. All other vaginal acidifying agents have no effect on the treatment or cure of BV (including vinegar).
4. Probiotics are not better than placebo for BV
5. Douching with anything can cause BV. Just don’t douche.

6. BV is not sexually transmitted, but can be caused by dirty fingers or dirty penises or toys. Ensure your partner and your toys are cleaned before use, do not go from the anus to the vagina when having sex.

This one is sexually transmitted (unlike the other two), it is caused by trichomonas vaginalis, a protozoan parasite. It is the most common non-viral STI and most people are asymptomatic and don't know they have been infected. The symptoms and smell are quite similar to BV but you will also have burning and itching. The discharge will be thin and white or yellowish, and you may have bleeding after sex; if you have a chronic infection these symptoms can be much milder. This parasite can make it easier to be infected with other STIs, there is also evidence that it causes pre-term birth and low birth weight in pregnant people.

Men can get trichomoniasis too! This is how it is sexually transmitted. Signs and symptoms include: itchiness and irritation inside the penis, burning after urination or ejaculation, a discharge from the penis. If you see these signs or a client communicates these symptoms to you, please encourage them to see a doctor and get them started on treatment. You likely will not catch this if you use condoms, so you can give these men a normal service.

Trichomoniasis Treatment:

1. Metronidazole 2g as a single oral dose.
This has a 95%+ cure rate and recurrence is unlikely. If that does happen, you will need to take a week of metronidazole as with BV. Since this one is an STI you should tell partners that you had it.

Thrush = fungus. White, chunky discharge, and you're very itchy. Oral fluconazole, topical clotrimazole (be aware this can damage condoms). More than three episodes per year: see your doctor.

BV = bacteria. Thin, clear, light coloured discharge with a fishy smell, NO itch. Go to the doctor for a metronidazole prescription. Do not drink alcohol if given oral tablets.

Trichomoniasis = parasite. Thin, light coloured discharge with a fishy smell AND an itch. Go to the doctor for more antibiotics, and tell any fluid bonded partners that you have to get tested, as this one is sexually transmitted.

DO NOT put foreign substances in your vagina without a prescription or direction from a doctor. This includes boric acid, vinegar, yoghurt, hydrogen peroxide solution, probiotics, any sort of feminine hygiene soap.

DO NOT DOUCHE. Please for the love of everything that is holy, don't douche for infections. It's okay to do with a clean douche as a stopgap measure for having (protected) sex with a partner before your appointment, but please please please don't do it otherwise, it will make your infections worse.

Men can get two of these conditions, so keep an eye out for symptoms in clients.

The Royal Women's Hospital Victoria - Thrush information page, BV information page.

The CDC - Trichomoniasis fact sheet.

The NHS - Thrush fact sheet.

Alex Paige and her university education on women's health!