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Abnormal Vaginal Discharge

 

Vaginal discharge is secreted by glands on the cervix and is a normal physiological process that cleans and moistens the vagina. The amount and consistency of discharge is dependent on the age of the woman and stage of menstrual cycle (see flow chart.) Prescribed contraception methods can also affect vaginal discharge. Normal discharge is white or clear and non-offensive smelling.

 

Vaginal Discharge and Ageing

Factors that can cause a change in vaginal discharge

 

Many factors can cause a change in the amount and consistency of discharge, these factors can be categorised as infective or non-infective. Infective causes are further categorised into sexually transmitted and non-sexually transmitted.

 

Non-Infective Causes

     

    • Foreign bodies (e.g retained tampon) - causes a foul smelling, dark coloured discharge.
    • Cervical ectopy – presents with a mucous discharge.
    • Gynaecological malignancy (cancer of cervix, uterus, ovary) can present with concurrent weight loss.
    • Irritation from vaginal sprays or strong soaps – presents with abnormal discharge with odour and itching/soreness (vaginitis symptoms.)
    • Vulval dermatitis/eczema - presents with abnormal discharge, itching and soreness.

     

    Infective Causes

     

    Sexually transmitted

    • Chlamydia trachomatis – may be asymptomatic or cause a purulent discharge. Patients may have dyspareunia and post-coital spotting.
    • Neisseria gonorrhoeae – may be asymptomatic or cause purulent discharge. It can also cause dyspareunia.
    • Trichomonas vaginalis – frothy yellow vaginal discharge with itchiness and soreness.

     

    Non-sexually transmitted

     

    • Candida infection – causes a white, thick and curdy discharge.
    • Bacterial vaginosis – fishy smelling discharge without itchiness or soreness.

     

        Assessment

         

        When a woman presents complaining of abnormal vaginal discharge it is important to ask about the nature of the discharge (see spider diagram below).

         

        A sexual history, past-medical history and a list of the patient’s current medications aid in diagnosis.

         

        Presentation

        Investigations

         

        Patients who present with symptoms of Candida infection (white, thick and curdy discharge) or bacterial vaginosis (fishy smelling discharge) can be treated without sampling.

         

        Candidiasis – Candida albicans → Clotrimazol 500mg pessary once at night and clotrimazol cream 12-hourly

        Bacterial vaginosis - Gardenella Vaginalis → Metronidazole 400mg twice a day for 5-7 days or Metronidazole 2g once only dose

           

          For patients with other symptoms triple swabs should be taken.

           

          Triple swabs

          • High vaginal swab to identify bacterial vaginosis, Candida infections, and Trichomonas vaginalis
          • Endocervical swab in transport medium (charcoal or non-charcoal) to diagnose gonorrhoea
          • Endocervical swab for a chlamydial DNA amplification test to diagnose chlamydia trachomatis
          Image shows where the swabs should be taken from.

          Management

           

          Treatment depends on the cause. A thorough history should be taken and if the cause of the discharge is thought to be due to a gynaecological problem (cervical ectopy, malignancy) the patient should be referred to a gynaecology clinic. Some women’s symptoms may disappear on stopping using vaginal sprays and highly perfumed soaps. If the history suggests that the patient has a sexually transmitted infection, the patient should be referred to the genitourinary (GUM) clinic, where they should be investigated for all STI’s and receive education and counselling about STD’s and sexual contact tracing.

           

          Treatment of STI’s

           

          Trichomonas vaginalis → Metronidazole 400mg BD for 5 to 7 days or Metronidazole 2g once only dose

            Gonorrhoea → Cefixime 400mg single dose

            Chlamydia trachomatis → Doxycycline 100mg BD for 7 days

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