VAGINAL DISCHARGE18 August 2020
Vaginal discharge is a normal physiologic occurrence in all females. Its variation in colour, volume and consistency depends on the reproductive age of the female and the stage of the menstrual cycle. What you see as vaginal discharge is composed of cells, fluid and normal bacteria flora. It is produced by a couple of cells and glands in the female reproductive system which include; glands of the endometrial cavity in the uterus, the epithelia cells of the cervix, transudation from the vaginal epithelium, from the Skene’s and Bartholin’s glands. Please note that the term ‘’toilet infection’’ colloquially used to describe abnormal vaginal discharge does not exist in the medical literature. That does not mean you cannot get infected from a dirty toilet. There are both normal and abnormal situations where the vaginal discharge might change in colour, volume or consistency. If you pay attention to your normal vaginal discharge then, it will be easy to know when there is a shift from the normal.
NORMAL VAGINAL DISCHARGE
The normal vaginal discharge varies from clear to a paper white fluid in colour, a thin stretchy to a thick fluid in consistency with a scanty or increased volume. Note that the normal vaginal discharge also has a scent which varies with the menstrual cycle, diet and PH of the vagina which is acidic. The acidic PH of the vagina is maintained by the normal bacteria flora called the lactobacillus species which is in turn maintained by oestrogen. This bacteria flora maintains vaginal health and prevents infection. Any alteration that interferes with the normal vaginal environment might eliminate these healthy bacteria flora, thereby, exposing the vagina to organisms that are alien to take over. It might be difficult to tell exactly how a normal vaginal discharge should smell however, it is important to note that the smell should not be unpleasant. The types of vaginal discharge described below are normal.
VAGINAL DISCHARGE DURING PREGNANCY AND AFTER DELIVERY
Due to hormonal changes in pregnancy, there is an increase in volume of vaginal discharge. It is slightly thick, white in colour and has no unpleasant smell. Vaginal discharge after delivery is called lochia which is initially bloody for a few days, later becomes pale or pink, at about the 10th day it becomes white or yellowish-white. Anytime you notice a variation in colour from these during pregnancy and after delivery, you should seek healthcare as well as when the discharge becomes offensive, associated with fever, itching or painful urination.
The vaginal discharge varies with the stage of the menstrual cycle from a thin stretchy non foul-smelly clear fluid (like your egg white when you crack open a raw egg) during ovulation, to a thick sticky non foul-smelly paper white fluid before the start of your period. This thin stretchy clear discharge is used to track ovulation time to either avoid sexual intercourse or have it because the chances of conception is high at this time. This secretion comes from the cervix. It is alkaline and under the influence of the female hormone called oestrogen.
SEXUAL AROUSAL AND ORGASM
Vaginal discharge is also produced when a woman feels like having sex and she is aroused. The secretion is from the Bartholin’s glands which is similar to the Cowper’s glands in the male, located on the right and left side of the vaginal opening posteriorly and releases a clear or whitish non foul-smelly mucus. This helps to lubricate the vagina and makes penetrative sex not painful. There is another gland called the Skene’s glands similar to the male prostate, located on either sides of the urethral opening which also secretes a clear fluid during sex or orgasm and the volume might be quite much that might be confused with urine. It is normal and there is nothing to feel ashamed about. Also, after vaginal sexual intercourse and ejaculation, the semen deposited can trickle down the vagina so, there is no need to be alarmed.
This normally marks the end of a woman’s reproductive career. The common symptom here is the cessation of menses. The vaginal discharge here becomes scanty due to the fall in the level of the hormone oestrogen.
ABNORMAL VAGINAL DISCHARGE
Abnormal vaginal discharge also varies in colour, volume, consistency and smell which is often offensive. This can be caused by different micro-organisms, foreign body in the vagina or cancer. Practices like douching (which means, washing or cleaning out the inside of the vagina with water or other mixtures including soap) can eliminate normal bacteria flora and wearing clothes that do not allow proper aeration of the vagina can predispose to vaginal infection. Note that the vagina is self-cleansing. Wash the vulva with soap and water but not inside the vagina. The vulva is the area of skin around the vagina opening. The following situations or disease conditions can result in abnormal vaginal discharge;
Foreign bodies such as a tampon (especially when forgotten), gauze and vaginal pessaries are the commonly identified causes of vaginal discharge due to foreign objects. You should seek healthcare when vaginal pessaries for contraception or pessaries used for conservative management of utero-vaginal prolapse causes allergic or inflammatory reaction in the vagina. This can increase the vaginal discharge and might be associated with bleeding, pain on urination or defecation.
This is caused by a fungus called Candida species which is a commensal found in the vagina, mouth, and rectum. The vaginal discharge here is described as thick white curdy or cottage cheese-like. It is associated with itching, painful sex or urination, redness of the vulva and excoriation. It is common in warm climate, immunosuppressed individuals, diabetes, pregnancy, obesity, recent use of broad spectrum antibiotics. Although sexual transmission is possible, it is NOT regarded as a sexually transmitted infection (STI). Antifungal medication is used here for treatment.
This is caused by an over growth of anaerobic bacteria and reduction in the lactobacilli population. Common species involved here include; Gardnerella vaginalis, mycoplasma hominis, bacteroides and Mobilincus species. The vaginal discharge here is a malodorous creamy or greyish-white discharge with a fishy smell, this is treated with antibiotics.
Caused by the bacteria Neisseria gonorrhoeae and it is a sexually transmitted infection. The discharge here is copious yellowish-white and can be from the vagina, urethra or anus associated with burning sensation on urination, lower abdominal pain with or without fever. Sexual partners should also be treated with antibiotics.
This is caused by a protozoan called Trichomonas vaginalis. It is a sexually transmitted infection, associated with a yellow or green thin foul-smelly vaginal discharge. It is also associated with pain on urination, painful sex, swelling, itching of the vulvar with excoriation and spotting of blood. Some women with this infection do not have symptoms but can transmit it. This is treated with antibiotics.
A sexually transmitted infection caused by the bacteria Chlamydia trachomatis. The vaginal discharge here is mucopurulent associated with painful urination and infertility later in life if not treated or when poorly treated. Some women do not manifest symptoms but can transmit the infection. This is treated with antibiotics.
PELVIC INFLAMMATORY DISEASE
This is an ascending polymicrobial infection of the female upper genital tract which can be caused by Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis. Pelvic inflammatory disease is associated with a mucopurulent vaginal discharge, fever, lower abdominal pain, nausea, vomiting, painful sex and abnormal menses. It is sexually transmitted and treatment is with antibiotics. Poor treatment or when not treated can result in infertility later in life.
Cervical cancer is a preventable female cancer caused by exposure to human papilloma virus type 16 and 18. It is associated with a foul- smelly watery discharge mixed with blood and pus. It is commonly associated with bleeding after sex and lower abdominal pain. Other symptoms depend on the stage of the cancer.
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