Female Genital Infections

Common female genital infections compared

Symptoms

• a change in vaginal discharge: color, consistency, amount or smell
• itching or irritation of the vagina or vulva
• burning, especially with urination
• pain or bleeding during or after sex
• redness, swelling or soreness of the vulva
• blisters, sores or warts
• pelvic or lower abdominal pain
• spotting between periods

Many STIs, especially chlamydia, gonorrhea and trichomoniasis, cause no symptoms, which is why screening is important.

Causes and risk factors

• Bacterial vaginosis: an imbalance of vaginal bacteria, with fewer protective lactobacilli. Linked to new or multiple partners, douching and smoking.
• Yeast infection: overgrowth of Candida. More likely after antibiotics, in pregnancy, with uncontrolled diabetes, high-estrogen contraception or weakened immunity.
• STIs: spread through vaginal, oral or anal sex. Risk rises with new or multiple partners and inconsistent condom use.
• Other: retained tampons or foreign bodies, irritants such as scented soaps and sprays, and low estrogen after menopause.

Pelvic inflammatory disease

When chlamydia, gonorrhea or other bacteria travel up from the cervix to the uterus and fallopian tubes, they cause pelvic inflammatory disease (PID). Symptoms include lower abdominal pain, fever, abnormal discharge and pain during sex. PID can scar the fallopian tubes, leading to infertility, ectopic pregnancy and chronic pelvic pain, so prompt treatment is important.

Diagnosis

A clinician will ask about symptoms, sexual history, contraception and recent antibiotics, then may examine the vulva, vagina and cervix.

Tests include:

• vaginal pH: above 4.5 suggests BV or trichomoniasis; yeast usually has normal pH
• microscopy of discharge (clue cells in BV, yeast forms, motile trichomonads)
• whiff test for fishy odor with potassium hydroxide
• NAAT tests on vaginal swabs or urine for chlamydia, gonorrhea and trichomoniasis
• swab of sores for herpes PCR
• blood tests for HIV and syphilis when STIs are suspected

Self-diagnosis is often wrong: many people who treat themselves for yeast actually have BV or another condition.

Treatment

• Yeast infection: antifungal vaginal creams or suppositories (miconazole, clotrimazole) available over the counter, or a single oral fluconazole tablet by prescription.
• Bacterial vaginosis: metronidazole tablets or gel, or clindamycin cream. Avoid alcohol with metronidazole as advised.
• Trichomoniasis: metronidazole; partners must be treated too.
• Chlamydia: doxycycline for 7 days (azithromycin in pregnancy).
• Gonorrhea: an injection of ceftriaxone.
• Herpes: antiviral tablets (acyclovir, valacyclovir) to shorten outbreaks, and daily suppressive therapy for frequent recurrences.
• PID: a combination of antibiotics, sometimes in hospital.

For STIs, avoid sex until you and your partners have completed treatment, and retest for chlamydia, gonorrhea and trichomoniasis about 3 months later.

Prevention

• Use condoms and get regular STI screening. CDC recommends yearly chlamydia and gonorrhea screening for sexually active women under 25, and for older women with risk factors.
• Avoid douching, scented washes, sprays and harsh soaps; wash the vulva with water or a mild unscented cleanser.
• Wear breathable cotton underwear and change out of wet swimwear promptly.
• Get the HPV vaccine.
• Control blood sugar if you have diabetes.

Frequently asked questions

How can I tell if I have a yeast infection or bacterial vaginosis?

Yeast infections usually cause intense itching and a thick, white, odorless discharge. Bacterial vaginosis causes a thin gray-white discharge with a fishy smell, often worse after sex, and less itching. A simple pH test and microscopy at a clinic can confirm which one you have.

Are vaginal infections sexually transmitted?

Some are. Trichomoniasis, chlamydia, gonorrhea and herpes are sexually transmitted. Yeast infections are not, and bacterial vaginosis is not classified as an STI, although it is linked to sexual activity.

Can female genital infections go away on their own?

Mild BV sometimes clears on its own, but it often returns, and STIs do not go away without treatment. Untreated chlamydia and gonorrhea can cause pelvic inflammatory disease and infertility, so testing and treatment are important.

Should my partner be treated?

For STIs such as trichomoniasis, chlamydia and gonorrhea, yes: partners need treatment to avoid reinfection. Male partners of women with yeast infections or BV usually do not need treatment.