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Vaginal Discharge

by David H. Barad, MD, MS

A discharge from the vagina may occur normally or may result frominflammation of the vagina (vaginitis), which may be due to an infection. The genital area (vulva)—the area around the opening of the vagina—may also be inflamed. Depending on the cause of the discharge, other symptoms are often also present. They include itching, burning, irritation, redness, and sometimes pain during urination and sexual intercourse.

Normal discharge

A vaginal discharge can result from normal changes in estrogen levels. When levels are high, estrogen stimulates the cervix to produce secretions (mucus), and a small amount of mucus may be discharged from the vagina. Estrogen levels are high

  • During menstrual cycles a few days before the egg is released

  • In newborns for a week or two after birth because they absorb estrogen from their mother before birth

  • A few months before girls have their first menstrual period

  • During pregnancy

Typically, a normal discharge has no odor. It is usually milky white or thin and clear. During the childbearing years, the amount and appearance may vary during the menstrual cycle. For example, in the middle of the cycle when the egg is released (at ovulation), the cervix produces more mucus, and the mucus is thinner. Pregnancy, use of birth control pills (oral contraceptives), and sexual arousal also affect the amount and appearance of the discharge. After menopause, estrogen levels decrease, often reducing the amount of normal discharge.

Abnormal discharge

A vaginal discharge is considered abnormal if it is

  • Heavier than usual

  • Thicker than usual

  • Puslike

  • White and clumpy (like cottage cheese)

  • Grayish, greenish, yellowish, or blood-tinged

  • Foul- or fishy-smelling

  • Accompanied by itching, burning, a rash, or soreness

Causes

An abnormal vaginal discharge is usually caused by vaginitis, which most often results from irritation by a chemical or from an infection (see Vaginal Infections and Pelvic Inflammatory Disease).

Common causes

Likely causes of a vaginal discharge depend on age.

During childhood, common causes include

  • An infection due to bacteria from the digestive tract

  • Chemicals in bubble baths or soaps

  • A foreign object (body), such as a piece of toilet paper or sometimes a toy

An infection may occur when hygiene is poor. For example, young girls, especially those 2 to 6 years old, may transfer bacteria from the digestive tract to the genital area when they wipe from back to front or do not wash their hands after bowel movements.

If a foreign object is the cause, the discharge may contain small amounts of blood.

During the childbearing years, a discharge is usually caused by a vaginal infection. The most common are

  • Bacterial vaginosis

  • Candidiasis

  • Trichomonas vaginitis (trichomoniasis of the vagina), which is usually sexually transmitted

Sometimes a discharge is caused by another infection, including sexually transmitted diseases (such as gonorrhea or a chlamydial infection).

Vaginal infections are usually prevented by the protective bacteria (lactobacilli) that normally live in the vagina. These bacteria keep the acidity of the vagina in the normal range. When acidity in the vagina decreases, the number of protective bacteria decreases, and the number of harmful bacteria increases.

The following make the growth of harmful bacteria more likely (and thus increase the risk of vaginal infections):

  • Use of antibiotics (because they may reduce the number of protective bacteria)

  • Menstrual blood or semen in the vagina (because they reduce the acidity of the vagina)

  • Poor hygiene

  • Frequent douching (because it can reduce the acidity of the vagina)

  • Pregnancy

  • Diabetes mellitus

After menopause, many women have an abnormal discharge. It occurs because the decrease in estrogen levels causes the vagina to thin and become drier. Moderate to severe thinning and drying is called atrophic vaginitis. A thin, dry vagina is more likely to become irritated and inflamed, resulting in a discharge.

Less common causes

During childhood, sexual abuse may be the cause. Such abuse can result in injury or a sexually transmitted disease.

During the childbearing years, the cause is sometimes a foreign object (such as a forgotten tampon). But in this age group, a discharge seldom results from inflammation alone (without infection).

In older women, urine or stool may irritate the area around the genitals and anus, resulting in a vaginal discharge. Such irritation may occur when women are incontinent (involuntarily pass stool or urine) or bedbound.

At any age, various products that come in contact with the genital area can irritate it, sometimes causing a discharge. Such products include hygiene sprays, perfumes, menstrual pads, laundry soaps, bleaches, fabric softeners, and sometimes spermicides, vaginal creams or lubricants, vaginal contraceptive rings, diaphragms, and, for women who are allergic to latex, latex condoms. Rarely, women have abnormal openings (fistulas) between the intestine and genital tract, resulting in a discharge from the vagina. This discharge sometimes contains stool. Fistulas may result from damage to the vagina during delivery (mainly in developing countries), Crohn disease, radiation therapy directed at the pelvis (the lowest part of the torso), injury during pelvic surgery, or tumors in the pelvis. Radiation therapy, pelvic surgery, and tumors can cause a vaginal discharge whether they cause fistulas or not.

Evaluation

Often, doctors can identify the cause of an abnormal discharge based on characteristics of the discharge (such as appearance and odor), the woman's age, other symptoms, and simple tests that provide quick results.

Warning signs

In women with an abnormal discharge, certain characteristics are cause for concern:

  • In girls, a fever or a yellow or green discharge with a fishy odor (because they may have a sexually transmitted disease resulting from sexual abuse)

  • Severe abdominal or pelvic pain or pain that lasts more than 2 hours

  • Drainage of pus, a fever, or other signs of infection in the reproductive organs

  • Stool in the vaginal discharge

  • A bloody discharge after menopause

When to see a doctor

Women or girls with warning signs should see a doctor within a day. However, if the only warning sign is stool or blood in the discharge, a delay of several days is not likely to be harmful.

Women without warning signs should see a doctor within a few days.

If women recognize the symptoms of a yeast infection (see Vaginal Yeast Infection (Candidiasis)), are confident that what they have is a yeast infection, and have no other symptoms, they probably do not need to see a doctor every time they have a discharge. A discharge caused by a yeast infection is usually distinctive. It is thick, white, and often clumpy, resembling cottage cheese. However, sometimes yeast infections cause mainly itching and burning with only a small amount of discharge.

What the doctor does

Doctors first ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the pain and the tests that may need to be done (see Table: Some Causes and Features of a Vaginal Discharge).

Doctors ask about the discharge:

  • What it looks and smells like

  • When it occurs in relation to menstrual periods and sexual intercourse

  • Whether other symptoms (such as itching or pain) are present

Doctors also ask about other symptoms, such as abdominal or pelvic pain, pain during urination or sexual intercourse, itching, fever, and chills.

Other questions include whether women use hygiene sprays or other products that may irritate the genital area and whether women have any conditions that can increase the risk of having a vaginal discharge.

The physical examination focuses on the pelvic examination (see Gynecologic Examination).

Some Causes and Features of a Vaginal Discharge

Cause

Common Features*

Tests

During childhood

A foreign object (often toilet paper) in the vagina

A discharge, usually with a foul odor and often containing small amounts of blood

A doctor's examination, sometimes done after the girl is sedated or given a general anesthetic

Infections such as

  • Yeast (candidiasis)

  • Pinworm

  • Streptococcal

  • Staphylococcal

Itching, redness, and swelling

Often pain during urination

With pinworm infection, itching that worsens at night

With streptococcal or staphylococcal infection, redness and swelling in the genital area

Examination under a microscope and analysis of a sample of the discharge to check for microorganisms that can cause vaginal infections

Examination of the genital area and anus to check for pinworms

Sexual abuse

Soreness in the genital area

Sometimes discharge that has a foul odor or contains blood

Often vague symptoms (such as fatigue or abdominal pain) or changes in behavior (such as starting to have temper tantrums or to withdraw)

Examination under a microscope and analysis of a sample of the discharge

Tests to detect sexually transmitted diseases using a sample of secretions taken from the cervix

During the childbearing years

Bacterial vaginosis

A thin, white or gray cloudy discharge with a fishy odor

Itching and irritation

Examination under a microscope and analysis of a sample of the discharge

Yeast infections

Irritation, itching, redness, and swelling in the genital area

A thick, white, clumpy discharge that resembles cottage cheese

Sometimes worsening of symptoms after intercourse and before menstrual periods

Sometimes recent use of antibiotics or a history of diabetes

Examination under a microscope and analysis of a sample of the discharge

Trichomoniasis (a protozoan infection)

A usually profuse, yellow-green, frothy discharge with a fishy odor

Itching, redness, swelling, and soreness in the genital area

Sometimes pain during sexual intercourse and urination

Examination under a microscope and analysis of a sample of the discharge

Pelvic inflammatory disease

Aching pelvic pain that becomes increasingly severe and may be felt on one or both sides

A discharge that sometimes has a foul odor and, as infection worsens, can become puslike and yellow-green

Abnormal bleeding from the vagina

Sometimes pain during sexual intercourse or urination, fever or chills, nausea, or vomiting

Tests to detect sexually transmitted diseases using a sample of secretions taken from the cervix

Sometimes ultrasonography of the pelvis

A foreign object (often a forgotten tampon) in the vagina

An often profuse discharge with an extremely foul odor

Often redness in the genital area, pain during urination, and sometimes pain during sexual intercourse

A doctor's examination

After menopause

Thinning of the lining of the vagina (atrophic vaginitis)

A scant discharge

Pain during sexual intercourse

A doctor's examination

Examination under a microscope and analysis of a sample of the discharge

Irritation caused by urine or stool

General redness in the area around the genitals and anus

Conditions that increase the risk of such irritation, such as being incontinent or bedbound

A doctor's examination

Cancer of the vagina, cervix, or lining of the uterus (endometrium)

A watery or bloody discharge

Often no other symptoms until the cancer is advanced

Pain that develops gradually and sometimes becomes chronic

Sometimes weight loss

A Papanicolaou (Pap) test

A biopsy

Imaging tests such as ultrasonography and sometimes MRI or CT

At any age

Chemical irritation (such as that due to soaps, bubble baths, hygiene sprays, or vaginal creams and ointments)

Redness, itching, swelling, and soreness in the genital area

A doctor's examination

An abnormal opening (fistula) between the intestine and genital tract, which may result from

  • An injury during childbirth

  • Surgery

  • Inflammatory bowel disease

  • Cancer of the digestive tract or reproductive organs

A discharge with a foul odor

Presence of stool in the vagina or in the vaginal discharge

A doctor's examination

Inflammation due to

  • Radiation therapy

  • Pelvic surgery

  • Certain chemotherapy drugs

Recent treatment of a disorder affecting the pelvis

A discharge that contains pus

Pain during urination and sexual intercourse

Sometimes irritation, itching, redness, burning pain, and mild bleeding

A doctor's examination

Usually examination under a microscope and analysis of a sample of the discharge

*Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

CT = computed tomography; MRI = magnetic resonance imaging.

Testing

Simple tests, which can be done in or near the examination room, can provide quick results that often enable doctors to identify the cause. Additional tests are done to confirm or, if needed, to identify the cause.

Unless the cause is obvious (such as a foreign object or an allergic reaction), doctors use a cotton swab to take a sample of the discharge from the vagina or cervix (see Screening Tests : Screening for Sexually Transmitted Diseases). They examine the sample under a microscope to check for yeast infections, bacterial vaginosis, and Trichomonas vaginitis (see Overview of Vaginal Infections). They usually also send a sample to the laboratory to test for gonorrhea and chlamydial infections (which are sexually transmitted).

Treatment

The underlying condition is corrected or treated if possible. For example, bacterial vaginosis is treated with antibiotics.

Some general measures can help relieve symptoms, although they do not eliminate an infection.

General measures

The genital area should be kept as clean as possible. Washing every day without soap or, if soap is necessary, with a mild, nonallergenic soap (such as glycerin soap) and rinsing and drying thoroughly are recommended. Changing underwear and bathing or showering once a day may help relieve symptoms.

Placing ice packs on the genital area or sitting in a warm sitz bath (with or without baking soda) may reduce soreness and itching. A sitz bath is taken in the sitting position with water covering only the genital and rectal area. Sitz baths can be taken in the bathtub filled with a little water or in a large basin. Flushing the genital area with lukewarm water squeezed from a water bottle may also provide relief.

Improved hygiene is particularly useful if the cause is being incontinent or bedbound. Young girls should be taught good hygiene—to wipe from front to back, to wash their hands after bowel movements and urinating, and to avoid fingering the genital area.

If a product (such as a cream, powder, soap, or brand of condom) consistently causes irritation, it should not be used. Women are advised not to use feminine hygiene sprays and not to douche. These products do not eliminate the discharge and may make it worse. Douching may increase the risk of pelvic inflammatory disease (see Pelvic Inflammatory Disease (PID)).

Drugs

If symptoms are moderate or severe or do not respond to general measures, drugs may be needed. For example, a corticosteroid cream (such as hydrocortisone) or sometimes antihistamines taken by mouth can relieve itching. Most antihistamines also cause drowsiness and may be useful if symptoms interfere with sleep.

Essentials for Older Women

After menopause, estrogen levels decrease markedly. As a result, the amount of normal discharge usually decreases. However, because the lining of the vagina thins and becomes drier (called atrophic vaginitis), the vagina is more likely to become irritated, often resulting in an abnormal discharge from the vagina. This discharge may be watery and thin or thick and yellowish.

Thinning also makes certain vaginal infections more likely to develop. The thin, dry vaginal tissues are more easily damaged, allowing usually harmless bacteria from the skin to enter tissues under the skin and cause infection there. Such infections are usually not serious but can cause discomfort.

Older women are more likely to have treatments that can reduce estrogen levels and thus make the vagina more likely to become irritated. Such treatments include removal of both ovaries, radiation therapy directed at the pelvis, and certain chemotherapy drugs.

Problems that make good hygiene difficult, such as being incontinent or bedbound, are more common among older women. Poor hygiene can result in chronic inflammation of the genital area due to irritation by urine or stool.

Vaginal infections, such as bacterial vaginosis, yeast infections, and Trichomonas vaginitis are uncommon after menopause but may occur in women with risk factors for these infections. Risk factors for yeast infections include diabetes and incontinence. Risk factors for bacterial vaginosis and Trichomonas vaginitis include new or several sex partners.

If older women are sexually active, condoms should be used to reduce the risk of sexually transmitted diseases. However, because condoms can irritate the vaginal tissues, particularly in older women, using lubricants is essential. Only water-based lubricants should be used with latex condoms. Oil-based lubricants (such as petroleum jelly) can weaken latex and cause the condom to break.

Older women should see a doctor promptly if they have a discharge, particularly if the discharge contains blood or is brown or pink (possibly indicating a small amount of blood). A discharge that occurs after menopause can be a warning sign of a precancerous disorder (such as thickening of the lining of the uterus) or cancer and should not be ignored.

Antihistamines can relieve itching. Most (including diphenhydramine, hydroxyzine, and cyproheptadine) cause drowsiness, which increases the risk of falls in older people. Thus, if older women need to take an antihistamine during the day, they should take one that is less likely to cause drowsiness, such as loratadine, cetirizine, or fexofenadine.

Key Points

  • A vaginal discharge may be accompanied by itching, redness, burning, and soreness.

  • Likely causes depend on age.

  • Usually, doctors examine a sample of the discharge to check for microorganisms that can cause infections.

  • Treatment depends on the cause, but applying cold packs or sitting in a warm sitz bath can help relieve symptoms.

  • Any discharge that occurs after menopause requires prompt evaluation by a doctor.

Resources In This Article

Drugs Mentioned In This Article

  • Generic Name
    Select Brand Names
  • CORTEF, SOLU-CORTEF
  • No US brand name
  • ALLEGRA
  • VISTARIL
  • ZYRTEC
  • ALAVERT, CLARITIN