Vaginitis is the inflammation of the femal vagina, of which there are various types. Some are caused by an increase in abnormal organisms (e.g., trichomonads) and others by an increase in normal flora (e.g., Candida, Gardnerella vaginalis, anaerobes). Candidiasis in the vaginal tract is called vulvovaginitis and is the most common cause of vaginal discharge in women. The Candida yeast-like fungus causes approximately 40% of all vaginitis, and about 75% of women get Candida vaginitis at some time.

Candida vaginitis is primarily caused by Candida albicans but may be caused by C. tropicalis or C. glabrata. Yeast is a part of the normal flora of the vaginal tract in nearly one-third of women; infection occurs when there are changes in host resistance or bacterial flora. A small amount of vaginal discharge is normal at midcycle and should not be confused with vaginitis.

• Antibiotic therapy—especially with broad spectrum types
• Pregnancy—from increased heat and moisture and hormonal shifts
• Diabetes
• Corticosteroid use
• Immunosuppressive drugs and conditions
• Human immunodeficiency virus (HIV) infection—frequent candidiasis can be an early sign of HIV in women
• Anemia
• Hypothyroidism
• Oral contraception—controversial, predominately for recurrence
• Being overweight
• High sugar intake
• Use of panty hose, constrictive clothing, or underwear that is not cotton

• Vaginal and vulvar pruritus (proportional to the number of organisms)
• Thin, creamy, or curd-like vaginal discharge; more copious during pregnancy; nonodorous
• Red, swollen, painful vaginal mucous membranes and external genitalia
• Satellite lesions (tender, red, discrete pustules that spread to thighs and anus)

• Trichomoniasis
• Gardnerella vaginalis
• Anaerobes
• Vaginal foreign bodies (retained tampons)
• Allergic reaction to douching or vaginal contraception
• Gonorrhea (especially in prepubertal girls)
• Contact dermatitis/vaginitis, including latex in condoms

• Vagina may appear hyperemic, bright red, with dry, white, and curd-like plaques or may have no erythema
• Vulva may have fissures, edema, and erythema
• Discharge appears creamy or curd-like

• Microscopic wet mount scraping of vaginal plaque, discharge, or vulva scraping mixed with 10% potassium hydroxide (KOH) shows yeast, spores, and/or pseudohyphae; 50% to 70% accuracy rate.
• Gram's stain is more sensitive; identifies both mycelial and blastospore forms.
• pH
• Wet prep for trichomonas.

For recurrent infections (vaginal pH <4.5):

• Culture's findings on Nickerson's or Sabouraud's media
• Glucose tolerance test rules out diabetes
• HIV testing
• Possibly obtain endocervical swabs for chlamydia and gonorrhea detection assays

• Pustule lesion dissects horizontally under the stratum corneum and peels it away; may appear like hyperplastic indurated plaques, atrophic inflamed plaques, or a leukoplakic area
• Accumulation of scale and inflammatory cells
• The pH of discharge is normal

Topical treatment is initiated before systemic, but patient preference may influence choice. Length of treatment and dose are both typically increased for chronic infection. Patients should avoid excessive exertion and sweating, keep vaginal area as dry as possible during infection, avoid sexual relations until symptoms clear, take showers instead of baths, and use unscented soap. Use proper hygiene when cleansing after bowel movement by wiping from front to back. Wear cotton underwear and avoid pantyhose and tight-fitting pants.

Topical and oral therapies are considered to be almost equally effective.

• Topical therapies—may initially cause burning from inflammation: polyenes (nystatin)—one tablet bid for two weeks placed high in the vagina with applicator; 70% to 80% effective; no systemic side effects. Azole derivatives such as imidazole (e.g., miconazole, butoconazole) and triazole (e.g., fluconazole, terconazole)—intravaginal cream one to five days, also may be used externally for satellite lesions; 85% to 90% effective; no systemic side effects.
• Oral therapies: fluconazole—75% to 92% effective; 150 mg once; often considered the treatment of choice; contraindicated during pregnancy; appears to help HIV infected women. Ketoconazole—83% effective, but higher rate of recurrence with cessation of short- and long-term therapy; 400 mg/day for five days, or for two weeks with recurrent infection. Oral nystatin helps reduce intestinal colonization.

With the exception of pelvic inflammatory disease, gonoccocal, and chlamydia infections, alternative therapies for acute and chronic vaginitis can be effective for treating both symptoms and causes. Begin with a douche and an acidophilus supplement. For chronic or recurrent vaginitis, also incorporate vitamins, minerals, and herbs into the treatment plan.

Topical Applications: Use only one of the following douches at one time. Do not douche during menstrual flow. For first time or acute infection try the vinegar douche or boric acid capsules. For chronic vaginitis, use the herbal combination douche. For recurrent vaginitis, use the Betadine douche. Discontinue douching immediately if there is pain or exacerbation of symptoms.

• White vinegar: 1 to 2 tbsp. white vinegar to 1 pint of water. Douche daily for 10 to 14 days.
• Boric acid: One capsule (600 mg) inserted daily for 10 to 14 days. May cause irritation or problems from systemic absorption.
• Herbal combination: Mix equal parts of oregano leaf (Oreganum vulgare), goldenseal root (Hydrastis canadensis), and coneflower (Echinacea purpurea). Steep 1 heaping tbsp. of herbal mixture in one pint of water. Cool and douche daily for 10 to 14 days.
• Povidone iodine (Betadine): Douche with one part iodine to 100 parts water twice daily for 10 to 14 days. Prolonged use can suppress thyroid function.

• Avoid simple and refined sugars (breads, pasta, baked goods, sweets), dairy products, alcoholic beverages, peanuts, fresh or dried fruit, fruit juice, and all known food allergens. Eat whole foods with plenty of protein, fresh vegetables, and grains.
• Lactobacillus acidophilus reestablishes normal flora in the body and prevents the overgrowth of Candida. Take one capsule orally bid to tid, and insert one capsule into the vagina nightly (not to exceed 14 nights).
• Vitamin A (10,000 IU/day) or beta-carotene (50,000 IU/day) enhances the integrity of the vaginal mucosa. Required for proper immune functioning. Avoid high doses of vitamin A in pregnant patients or those who plan to get pregnant within three months.
• Zinc (30 mg/day) and vitamin E (400 to 800 IU/day) are essential for immune function.
• Vitamin C (1,000 mg tid to qid) optimizes immunity and helps to restore the integrity of vaginal mucosa.

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Pau d'arco tea has antifungal effects. Drink 2 to 4 cups/day.
• Garlic (Allium sativum) has antimicrobial, antifungal, and immune stimulating properties. Prepare a tea with two cloves of garlic. Drink 2 to 4 cups/day. May add lemon and honey for flavor.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Calcarea carbonica for intense itching with thick white or yellowish discharge that is worse before menses.
• Borax for burning pains with egg-white colored discharge that occurs midcycle.
• Sepia for burning pains with milky white discharge and pressure in vaginal area. Depression and irritability are usually present.
• Graphites for backache with thin white discharge that is worse in the morning and when walking.
• Arsenicum album for burning, offensive discharge in a patient who is easily chilled.
• Homeopathic combinations are also available as creams to apply intravaginally.

Acupuncture may relieve pelvic congestion and improve immune function.

Patients should be educated about the various risks for infection. Strict diabetic control is essential for diabetic patients. There is no specific follow-up unless infection persists. Repeat pelvic examination and a culture is then warranted. Treating the partner will minimize the possibility of reinfection.

• Avoid risks (see above).
• Avoid sweating, overheating, and sexual relations until symptoms clear.
• Use unscented soap, take showers instead of baths, and follow proper hygiene.

• Chronic candida vaginitis—no definitive cure
• Often a result of persistent yeast in vagina, not recurrent infection
• Use oral and topical therapies together in higher doses for two to three weeks; maintenance therapy with azoles.
• Additional risk factors include oral contraception, vaginal douching, increased frequency of sexual intercourse.
• Fifteen percent of men have symptomatic balanitis and should be treated to prevent recurrent female infection.
• Antifungal therapy or acidophilus supplementation is started prophylactically with known antibiotic-associated candida vaginitis.
• HIV infection and diabetes predispose patients to chronic infections.
• Secondary bacterial infections

Some cases of candida vaginitis resolve spontaneously while others progress or become chronic. Recurrence is common. Chronic cases should be evaluated for systemic infections.

Treatment should only be conducted under the supervision of a physician.

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