Dear Dr. Eva,

I have not had anything in my vagina bigger than a finger since I was 20, and I’m 50 now. Obviously, I don’t want to go through a pelvic exam as they are extremely painful for me.

I am having problems with vaginal discharge. I assumed it was yeast since I only have sex with women, and very rarely at that, so I wouldn’t have a sexually transmitted disease. Is there a way to find out what it is and get it taken care of without having a speculum exam?

AJ

 

Dear AJ,

First, keep in mind that not all vaginal discharge is abnormal. Many women have a clear or whitish discharge which can change color and consistency at different times of the menstrual cycle. Normal vaginal discharge, also called physiologic discharge, is not itchy or irritating and does not have an unusual or strong odor.

If your discharge has changed from what is usual for you, is itchy, is irritating, or has an odor that’s not normal for you, there are three common causes. The first, as you mentioned, is yeast, also called candida, which is a common fungal infection. The second is bacterial vaginosis, and the third is trichomonas.       

It is sometimes possible to diagnose the cause of vaginal discharge without doing a speculum exam. This is done in a medical office using a self-administered vaginal swab. The woman collects a sample of discharge from the outer part of her vagina using a long Q-tip, then puts the Q-tip in a test tube. A medical professional immediately checks the discharge under a microscope for signs of yeast, trichomonas, and bacterial vaginosis (BV). If none of these are found on microscopic exam, a speculum exam is usually the next step. (The speculum exam doesn’t have to be done that same day.) Not all doctors’ offices do the self-administered vaginal swab test; not all doctors’ offices have a microscope. Any office that does women’s healthcare or sexually transmitted disease care should be able to do this.

If it does turn out that you need a speculum exam, tell your healthcare provider that you have vaginal stenosis, which means narrowing of the vagina, and ask them to use a small speculum. Speculums (the duckbill-like instrument used to examine the vagina) come in a whole range of sizes, including very small ones used for small girls. Vaginal exams are rarely necessary for girls who have not yet started menstruating, but they are done in cases of suspected abuse.

If trying several times to get a good discharge sample using self-administered swabs hasn’t led to a diagnosis, and you are unable to have a vaginal exam even with a small speculum, there is still the option of trying treatment for each of the three most common problems and seeing if one of these treatments helps.

If the discharge is itchy or irritating, try treatment for yeast first. There are some non-prescription products for treating yeast that are as good as prescription products, and other products that are useless. The best choices are either miconazole or clotrimazole creams or vaginal suppositories.  These are available in one-day, three-day, and seven-day treatments. The one-day form of miconazole (Miconazole 1, Monistat 1) is the most-recommended treatment. Surprisingly, the one day treatment is just as effective as three, five, or seven day treatments. Any form of miconazole or clotrimazole, if you use it according to the directions on the package, , is 95% effective for treating vaginal yeast.  Creams come with applicators to use for inserting the cream into the vagina.

Treatments for the two other common causes of vaginal discharge are only available by prescription. For bacterial vaginosis, which is overgrowth of normal vaginal bacteria and is not a sexually transmitted disease, the treatment is an oral antibiotic, usually metronidazole, taken by mouth twice a day for seven days. Discharge that has a strong odor is often caused by BV.

Trichomonas is the third common cause of abnormal vaginal discharge. Trichomonas (“trich”) is a sexually transmitted disease which can be transmitted from one woman to another woman. Trichomonas vaginitis often causes larger amounts of discharge than yeast or BV vaginitis does. Herpes and trichomonas are by far the most common sexually transmitted diseases transmitted between women.

Trichomonas is usually treated with metronidazole, the same antibiotic used for bacterial vaginosis, but the treatment is much shorter, as little as one day.

Many medical providers may not be willing to prescribe treatment for possible trichomonas or bacterial vaginosis without making a definite diagnosis first. Providers who are knowledgeable about women’s health issues and aware that some women cannot tolerate a speculum exam, may be willing to prescribe. A trial of any these treatments would be harmless.

Dr. Eva

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Dr. Eva Hersh, MD
Dr. Eva Hersh, MD
Eva Hersh is a family physician. Send your comments and questions to her by email at dreva@baltimoreoutloud.com

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