ELIZABETH GUNTHER STEWART, M.D.
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Board Certified Gynecologist
FACOG (Fellow, American College of Gynecologists)
Director of the Stewart-Forbes Vulvovaginal Specialty Service
Author and Advisory Board Member, Vagisil Women's Health CenterSM
A renowned vulvovaginal expert and author of The V Book: A Doctor's Guide to Complete Vulvovaginal Health (Bantam Books, 2002), Dr. Stewart is working with the Vagisil Women’s Health CenterSM (VWHC) as a member of the medical advisory board. Below are informative excerpts from Chapter 7 of The V Book, dealing with many of the most common vulvovaginal problems. For information on how to obtain the full book, visit www.randomhouse.com.
The Most Bothersome Symptoms
Possible Causes and Cures
An aggravating,can't-take-your-mind-off-it irritation begins. Or you notice that your vaginal discharge has a funny scent and is more profuse than normal. Or you feel uncomfortably, even painfully, dry, so that intercourse or even inserting a tampon hurts. One or more of these symptoms may represent a V problem, either on the vulva, in the vestibule, or up in the vagina. A variety of harmless scenarios also may be to blame. To help you evaluate the situation, here's a detailed tour of some of the most common–and annoying–vulvovaginal symptoms women experience: odor, itching, unusual discharge, and dryness.
Odor
Almost every woman worries at one time or another that she has an unpleasant odor associated with vaginal secretions. Yet this is one symptom that my patients are especially reluctant to admit to because they believe that odor implies poor personal hygiene. Inadequate washing is almost never the cause of a V scent. Remember that some scent is to be expected from all activity in the Vs. As I mapped out in Chapter 2, the vulva has many sweat glands, and sweat produces odor. Normal secretions from the vagina may not be noticeable at all or may smell faintly like sour milk. Then there are the secretions, discharge, and menstrual flow that stay on a pad or underwear and are exposed to bacteria normally present, producing an odor. Not least, you should realize that every woman has her own unique scent. Most women are especially sensitive to this personal scent, which may not be detectable to others. If the same odor that you've had for as long as you can remember is suddenly bothering you or your partner, first consider whether anything simple discussed in this chapter–sweat, a new vitamin pill–might be responsible. If not, it should be checked out by your clinician…
Vaginitis is the number-one reason behind an unpleasant odor. More specifically, the leading culprits include the following types of vaginitis:
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Of all the causes of odor, BV is the likeliest suspect. The leading cause of vaginal complaints in the United States, BV is not an infection but an imbalance in the bacteria normally found in the vagina. Instead of being the most predominant bacteria, the lactobacilli disappear. In their place large numbers of other bacteria overgrow. They can wax and wane during the menstrual cycle, and are often worse after intercourse. These huge numbers of bacteria cause a heavy discharge and change the acid-base balance of the vagina to alkaline. With the elevated pH come increased concentrations in the vaginal fluid of proteins that tell you how bad they smell: putrescine and cadaverine. In mild form the odor is like ammonia; a bad case smells like dead fish.
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Yeast can also cause bad-smelling discharge, which women often variously describe as "sour-smelling," "yeasty," or even "putrid." Generally, yeast is a much less common cause of odor than BV. Sometimes, however, yeast occurs with BV, causing a mixed bacterial and yeast infection with odor.
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Like BV, trich will also cause a fishy odor accompanied by discharge and itching. What if a thorough workup rules out vaginitis as the cause of an odor problem? Then there are other possibilities.
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We all worry about our underarms producing odor from sweat, but the vulva is just as relevant. Ordinary sweating is a common cause of vulvovaginal odor. Remember that the genital region contains numerous apocrine glands, which produce sweat, as well as oil glands and glands associated with each hair follicle. Odor from sweat happens for one reason: Sweat includes the waste product urea, filtered from the blood (it’s actually dilute urine), and the resident bacteria in the region interact with sweat-gland secretions, giving the external genitalia its odor. Treatment of a problem with odor from sweat involves (1) washing daily with antibacterial soap, then drying well…
…There are also prescription medicines, available either by mouth or to apply topically, to help control sweating. They will help cut down sweating everywhere in the body; it's not possible to take a pill that works only on V sweat glands. Dermatologists who are interested in the problem can prescribe these antiperspirants when a chronic condition known as hyperhidrosis, or excessive sweating, is thought to be the cause of odor.
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Substances in the urine are another potential source of odor. When evaluating an odor problem, specify for your clinician whether the odor comes out of the toilet bowl after you have used the toilet or whether the odor is present at times unrelated to the bathroom. Urinary odors are produced by foods such as asparagus, certain vitamins (especially B complex) and herbs, and medications, especially antibiotics such as ampicillin and nitrofurazone. Urinary tract infections can cause foul-smelling urine…
…Loss of urine (incontinence) can be another source of odor, as bacteria act on even small amounts of urine in the underwear. Sometimes a woman may be losing urine in small quantities without even being aware of it. To check, a clinician can give a substance that colors the urine orange (Pyridium); then the woman can see if there are orange stains on a pad that she wears after taking the medication. Some women are afraid to ask their clinicians about incontinence, thinking that surgery is the only cure for urinary loss. Fortunately, we have nonsurgical ways to help with this problem, such as exercises and the use of vaginal weights. But even if you need a surgical remedy, these procedures are becoming faster, better, and smarter each year. For example, a sling of tape or mesh can be put into place to support and stabilize the bladder neck and urethra; this can now be done as day surgery or in the office.
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A tampon forgotten in the vagina long enough after a menstrual period will create a very bad odor. Check by feeling inside the vagina to make sure no tampon has been left behind.
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Not only does each woman have an individual scent, but it's also possible for that odor to change, possibly leading you to suspect a problem when none exists. Odor in body fluids is very complex, since hundreds of ingredients present in the fluids contribute to the odor…
…Not a lot of work has been done on vaginal odor. There seem to be two distinct types of women, those who produce large amounts of a certain kind of acid (short-chain aliphatic acids) and those who produce little or no acid other than the weak acetic acid of vinegar. Acid producers seem to have a stronger and more distinct odor. The top notes of this odor result from the acids with a cheesy smell. In both the high acid producers and the low acid producers, the most common acid was lactic acid, one of the components of milk. It's assumed to be the principal cause of vaginal acidity. The odor of lactic acid is almost identical to that of sour milk or yogurt and is often the top note in secretions from women who are non-acid-producers. If you are a high acid producer, you may have secretions that have a slight cheesy kind of smell, and if you are a low acid producer the faint odor of sour milk may predominate…
…Sweat, urine, and vaginal secretions are part of the great design. In the absence of another physical problem, they're not something that needs fixing.
So if you are concerned about odor, rule out vaginal infection. Deal with sweating and urinary causes as suggested. In addition, you can use a plastic squeeze bottle filled with warm water to rinse vaginal secretions from the vulva after using the bathroom, and you can change underwear (carry extra sets) two or three times a day.
Itching
…In the vulvovaginal area, everything itches! That's how most problems first show up. Correctly pinpointing the source of this annoying symptom is important, because misdiagnosis can prolong or even complicate it…
…What causes itching? The possibilities can range from the truly benign (and easily remedied) to more serious conditions that require a clinician's care.
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The simplest reason for itching comes from moisture trapped under tight layers of clothing. I've mentioned this before, but it bears repeating here because my patients are surprised to discover that some irritation problems can be eased simply by changing the way they dress. Just think about how many layers could cover your vulva in a given day. Many women wear a panty liner, with a moisture-trapping adhesive backing, every day. On top of this go underpants, which may be synthetic or fit snugly. On top of these may go panty hose (perhaps a tightly woven control-top kind) and a skirt or jeans or pants… These may be replaced during the day with tights or other exercise clothes of spandex for vigorous activity.
Remember, the V area is one of the key places on the body where we perspire. If locked under many layers, this moisture has nowhere to go. Moisture alone, or the combination of moisture plus friction plus chemicals left in the fabric after laundering, may irritate the skin and leave you feeling the need to scratch…
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Another common cause of itching is the way you bathe. How could keeping clean have unpleasant consequences? Being overly enthusiastic or obsessive about bathing can lead to drying and irritation of the vulva. When some women wash, they use the hottest water they can stand, scrub vigorously with pure soap, and even turn a hair dryer on the vulva. Others wash the vulva with soap and water after every urination… Recognize that while moisture is not desirable in the groin folds, the area between the thin inner lips (the vestibule) is part mucous membrane, like the mouth. It does not need to be dried out.
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…Irritants are limited to the skin only; true allergies start with itchy skin and then may proceed to systemwide reactions, from watery eyes to trouble breathing to, in severe cases, drop of blood pressure and shock. Allergic reactions to personal products are rarer than irritations.
A substance that causes a skin reaction is called a contactant. Contact (irritant) vaginal dermatitis can come from anything that touches your skin: cleansers, abrasive clothing with chemical residues in it, beauty products, topical medications, products that have been dyed or colored. You probably have several of the most common contactants around your house right now…
…Women often fail to nab their beauty or hygiene habits as the source of an itching problem if they haven't used any new products lately. Yet sensitivity develops through exposure over time to chemicals. This is very important – it's the product used repeatedly that finally gets to you.
Irritant reactions can be soothed by stopping the use of the irritant and bathing in comfortable (neither hot nor cold) water. Problems with irritants can be further assisted by working with a dermatologist who is expert in these areas.
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Coital allergy, which is sensitivity to your partner or his semen, is another possible cause of itching. It's one of several different kinds of allergies that show symptoms in the V area. These are discussed in detail in Chapter 14, "Could You Be Allergic?"
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Skin disorders are a cause of often intense itching. Eczema, psoriasis, lichen sclerosus, lichen planus, and lichen simplex chronicus are examples of such conditions. Properly diagnosed, they can be controlled with cortisone ointment, but they usually do not go away entirely. (These conditions are discussed in Chapter 15, "When Skin Gets Sick.") Problems such as warts and herpes may also begin with itching. (See Chapter 20, "The Lifetime Virus.")
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As levels of estrogen drop in a woman approaching menopause, she may experience a dry and itchy sensation. Untreated estrogen deficiency progresses to burning for many women. Small amounts of estrogen cream solve the problem.
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Skin cancer is a rare vulvar problem, but it may show up as an itchy bump that does not go away. Skin cancer is completely curable when diagnosed early. Precancerous skin changes will also cause itching with bumps.
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The microscopic pinworm can lead to itching around the vagina, although it's mainly a cause of anal itching. In order to diagnose, a clinician would have to suspect it was present: Maybe another family member has the problem. Pinworms are diagnosed by finding them under the microscope on a piece of Scotch tape that has been plastered against the perineum or anus; the pinworms' eggs are easily visible. The problem is treated with drugs active against worms.
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Finally, of course, vaginal infections–bacterial vaginosis, yeast, and trichomonas–all cause itching.
Unusual Discharge
Remember that all women have discharge. It's useful to be familiar with what's normal for you so that you can use a change from that baseline to help figure out what's wrong if you develop a problem. The appearance, texture, scent, and amount of discharge differ for different women; what's normal for you can also vary depending on where you are in the menstrual cycle and your stage of life… …Individual women tolerate widely different amounts of secretions–another reason to cue into what is normal for you…
Here's what normal discharge is not: It does not itch, irritate, or burn. It does not smell like fish. It does not smell like ammonia.
Abnormal discharge usually occurs when there is an infection. There's no single variation to look for. Abnormal can mean many things: The discharge may vary from scant, to more than usual, to quite profuse. Its color may be gray-white, yellow-white, or yellow-green. It might be bloodstained if the inflammation is severe. If you notice any of these things, or if there is suddenly a marked change in the amount of discharge and it bothers you, you’ll want to have it checked out.
Among the possible causes of unusual discharge:
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The most common reason for a change in discharge is some kind of vaginitis. Remember, that's just a catchall word to characterize vaginal itching and burning. The root problem may be a yeast infection, bacterial vaginosis, trichomonas, or another kind of vaginitis. (Follow-up tests can help determine this and direct you toward the proper treatment.)…
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Persistent vaginal discharge always signals for your clinician to check for some very common sexually transmitted diseases (STDs). The most prevalent is chlamydia, but gonorrhea shares similar symptoms. They cause a yellowish-white discharge, perhaps a little itching, and, sometimes, constant pelvic pain. These infections affect the cervix but give vaginal symptoms. (See "The Silent STDs Worth a Routine Test" in Chapter 9.) Herpes, before the blisters appear, may cause vulvar stinging and burning along with discharge, as well as muscle aches and general discomfort with fever.
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Excess discharge may be associated with this pain problem. See Chapter 17.
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Sometimes you might experience normal discharge in greater-than-usual amounts because of a condition in the cervix. The cells that line the cervical canal (endocervical cells) can grow out onto the surface of the cervix, creating a condition known as an ectropion. The ectropion has a characteristic reddish, slightly raised appearance, and the cells are glandular, so they may make mucus. This leads to an increased amount of ordinary cervical mucus. A cervical ectropion develops because there is enough estrogen present to cause this outgrowth of cells. Until twenty years ago, clinicians thought the ectropion was abnormal and recommended freezing or destruction by cauterization. We now know that it’s a perfectly normal occurrence. Common among women taking oral contraceptives, it's also seen in normal women not on the pill. This is not a condition that needs treatment, and freezing or cauterization may alter the cervical production of mucus considered necessary for fertility.
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Less often, but particularly in postmenopausal women, discharge that doesn't fit any other category may be coming through the vagina from a place above the vagina. This is true especially if red blood cells are seen in the discharge under the microscope. If the discharge has your clinician stumped, ask if there's any possibility your discharge might be coming from higher up. Sometimes other tests, such as a check of the uterine lining (an endometrial biopsy), are done.
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A fistula is an opening between two places that isn't supposed to be there–like a chink in a wall. In gynecology, the best known of these chinks are tiny holes between the vagina and the rectum (called rectovaginal fistulas) or between the vagina and the bladder (vesicovaginal fistulas). A rectovaginal fistula often happens after an injury related to a complicated labor. As a result, gas and stool in tiny amounts can come out of the vagina. As you might imagine, this fistula is quickly recognized and repaired.
Vesicovaginal fistulas result chiefly from obstetrical injury, complications of hysterectomy, radiation treatment for cervical cancer, or after surgery for incontinence. With a vesicovaginal fistula, urine may leak out of the vagina, but it may be small in amount and, mixed with other vaginal secretions, may seem like discharge. So this kind of fistula can be harder to recognize…
While a rare cause of vaginal discharge, it's something for your clinician to explore if you have significant discharge that does not fit into the usual categories. Have you had any pelvic surgery or bladder work? Did you have a complicated delivery with forceps, or a bad infection after a cesarean delivery? Have you had gyn cancer surgery and radiation treatment? Once recognized, the fistula can be surgically closed off…
Dryness
V lubrication is one of those things you don't think about until it's gone. Normal secretions from the vulva, vestibule, and vagina keep you comfortable. Their amounts vary from woman to woman, with a wide range of normal. During sexual arousal, a clear and relatively odorless fluid adds to the normal secretions as the perfect natural lubricant. When normal day-to-day V lubrication is present, you may not notice, but when it's absent, you may start to feel dry and uncomfortable. Sexual intercourse can be painful.
V dryness is a problem that plagues women of all ages from time to time. Fortunately, it can usually be remedied fairly simply.
What causes vulvovaginal dryness? A number of things can, many of them the same causes of V itching…
… Key causes of dryness include:
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All you really need to clean your V area is warm water. If it's too hot, your vulva will dry just like the rest of your skin. Soap isn't necessary on the vulva, but if you use it while bathing or showering, choose a superfatted hypoallergenic soap with no dyes or fragrances–one that is nonalkaline and pH balanced…
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If your skin is reacting to a substance that is irritating or to which you are allergic, you may have to do some work to find the problem. The treatment for allergy can also cause drying. Older antihistamines (called first-generation H1 blockers), prescription or over-the-counter, if taken on a regular basis can dry out all tissues, including the Vs… Other medications can also have drying effects. Read the package inserts; they are not going to talk about V dryness, but look for the word anticholinergic. This means the drug dries up respiratory secretions, causes constipation–and may contribute to V dryness.
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The fluid that lubricates the vagina comes through the vaginal wall from the bloodstream. Diseases that affect blood vessels make them less flexible and less able to act as a conduit, possibly contributing to a dry vagina. Such diseases include high blood pressure (hypertension), hardening of the arteries (arteriosclerosis), diabetes, and some connective-tissue diseases. Vaginal dryness combined with pain at intercourse may be the first signs of a connective-tissue disease called Sjögren's syndrome. A wide range of skin conditions can cause vaginal dryness too…
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Vulvodynia, pain believed to develop when nerve fibers are not working as they should, can also lessen lubrication in some women; for others, secretions may actually increase without the proper nerve controls. (See Chapter 17 for a full discussion of this problem.)
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If you are breast-feeding, vaginal dryness and even painful intercourse can be troublesome. Estrogen levels are low during lactation, so the vagina becomes thin, inelastic, and dry. Your clinician can give you some estrogen cream to use vaginally every night for a week or two and then once or twice a week. This will improve your symptoms without affecting your milk supply. Breast-feeding women vary in how quickly the dryness resolves. For some it is with the return of menstrual periods; for others dryness lasts a longer period of time.
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Some kinds of combination estrogen-progestin birth control pills change the secretions of the cervix, making them scanty and thicker. For some women, this reduced contribution of the cervix to V moisture can be a noticeable change. The influence of the pill on cervical secretions depends on the type of progestin, and the balance between the progestin and estrogen. If you are on the pill and dryness is a problem, talk with your clinician. A different pill in which estrogen is a little more dominant than progestin may help. If you are going to go off the pill because of a dryness problem, be careful to plan another method of birth control.
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Low estrogen can also develop if body weight drops to a low level, usually less than 100 pounds (depending on height and frame). Controls in the hypothalamus (a part of the brain) shut down the hormones to the ovaries, and menstrual periods stop (amenorrhea). Hypothalamic amenorrhea can be seen in athletes, especially runners whose high levels of exercise drop weight below the level that the brain thinks is safe for reproduction. This type of amenorrhea is also seen in women who have anorexia. Restoring the weight will usually restore menstrual function. Vaginal estrogen helps with the dryness.
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With the decline in estrogen that occurs during late perimenopause and menopause, significant V changes occur, including dryness. I am a big proponent of supplemental estrogen, not least to relieve the annoying vaginal dryness these natural changes inevitably bring. In Chapter 4, "At Different Ages," I describe the most popular current remedies for vaginal dryness caused by menopause. Explore the options with your clinician….
