Gynecological Infections refer to infections of the lower genital tract (vulva and vagina), or the upper organs cervix, uterus, tubes, and ovaries. The lower and upper genital organs in women are located in the pelvis which is the ring of bones between the hips on either side, below the abdomen. Infections can be bacterial, viral, fungal, or parasitic, and in some cases mixed.
TYPES OF INFECTIONS AND CAUSATIVE ORGANISMS
Infections may be endogenous (due to bacterial or yeast overgrowth) or sexually transmitted infections (STI).
Normal vaginal flora
The vagina is normally protected by a group of ‘good’ bacteria that keep the ‘bad’ infection-causing bacteria and other pathogens (germs) like yeast in check and prevent their overgrowth. These good bacteria belong mainly (99%) to a group called Lactobacilli as these bacteria produce lactic acid that makes the vaginal pH acidic and protects against the entry of pathogens.
The other smaller group (<1%) of good bacteria is Bifidobacteria which help to enhance the lining barrier and prevent the adhesion of pathogens.
Both Lactobacilli and Bifidobacteria produce ‘bacteriocins’ that are antibacterial substances that reduce the growth of bad bacteria.
The risk factors listed below reduce or disrupt the normal vaginal flora, and predispose to gynecological infections. More the risk factors, more the chances of recurrent and persistent gynecological infections.
- processed and unhealthy diet
- alcohol abuse
- physical and mental stress in daily life
- high or abnormal sexual activity
- douching (repeated washing of the vagina)
- high levels of estrogen seen with pregnancy and birth control pills
- repeated use of antibiotics
- genetic predisposition
Types of Infection
Endogenous vaginal infections are most commonly:
- Bacterial vaginosis (BV) – Caused by bacteria Gardnerella vaginalis, Prevotella, Peptostreptococcus and Bacteroides)
- Vaginal candidiasis (fungal yeast infection)
Sexually transmitted infections (STIs) are caused by the parasite Trichomonas vaginalis, and the bacteria Chlamydia trachomatis or Neisseria gonorrhoeae (infection is called Gonorrhoea). Viral vaginitis is caused by Herpes Simplex virus (HSV) that can also be sexually transmitted.
Vaginitis and Cervicitis
Gynecological infections of the lower genital area like vaginitis or vulvovaginitis present with abnormal vaginal discharge (a fluid with dead cells, bacteria/other pathogens, and mucus) that can be yellowish/yellowish brown, greenish-yellow or grey, and also have a strong odor or fowl/fishy smell. The discharge due to yeast infection is often thick and curdy. There is usually accompanying irritation, itching, and sometimes pain in the vulva and vagina.
Vaginal discharge due to infection (abnormal vaginal discharge) should be differentiated from the natural normal vaginal discharge that constitutes the lubricating fluid of the vagina which is milky white or off-white in color, may have a slight (but not unpleasant) odor, and does not cause irritation/itching.
Sometimes there may be visible swelling and redness as seen in yeast infections or vulvovaginal sores as seen in HSV infections.
There may also be accompanying pain while urinating (dysuria) or during intercourse (dyspareunia), along with discharge and itching. There may also be some bleeding in between periods or after intercourse. Such symptoms are more common when the cervix also gets infected (cervicitis).
Pelvic inflammatory disease (PID).
Infection of the upper organs that is the uterus (endometritis), fallopian tubes (salpingitis), and ovary (oophoritis) constitute what is called pelvic inflammatory disease (PID).
Symptoms may include lower abdominal or pelvic pain sometimes with swelling, fever, chills, body ache, weakness, pain during intercourse, painful and frequent urination, bleeding in between periods or after intercourse, and nausea-vomiting or constipation, along with abnormal vaginal discharge. Occasionally pus-filled pockets (abscesses) may develop.
PID usually occurs due to infection traveling up from the vagina and cervix when one develops vaginitis especially when the vaginitis is recurrent and persistent. Occasionally PID can occur due to direct infection of these upper organs during childbirth, miscarriage, pelvic surgery, or intrauterine devices (IUD).
Inflammation and scarring due to PID can cause obstructions of the tube, leading to infertility and difficulty in conceiving. Sometimes symptoms may be non-specific, vague, or even absent, and the first sign may be the inability to conceive. Blockage of the tubes also increases the chances of ectopic pregnancy (fertilized egg being implanted outside the uterus) which can be a life-threatening condition. Many women go on to develop chronic pelvic pain due to PID.
A history of symptoms and a general physical examination is performed. This is followed by a pelvic examination where the doctor inserts one or two lubricated, gloved fingers into your vagina with one hand, and presses gently on the lower belly from outside with the other hand. This exam helps to evaluate the uterus and ovaries for size, shape, abnormal growth, swelling, and tenderness (pain on touching).
Examination of vaginal discharge is done by collecting the sample during the pelvic exam. Its smears are studied under the microscope, as well as the causative organism is cultured. This gives a definitive diagnosis of the type of infecting organism.
Blood tests to look for white blood cell counts, sugar, HIV if suspected, etc. are also done.
Urine routine examination should also be done. Because the vagina and urethra in women are so close together, bacteria that cause vaginitis can spread to the urethra and vice versa, therefore a urinary tract infection should be looked for with a urine examination.
A pelvic ultrasound may also be performed, and in some cases, a laparoscopy may be required (insertion of a thin, lighted instrument through a small incision in the abdomen to view pelvic organs). An endometrial biopsy may also be done (removal of a small piece of uterus lining tissue).
Gynecological infections especially when recurrent can cause a lot of distress and compromise in quality of life, as well as have long-term consequences on fertility. Therefore, appropriate and thorough treatment is very important.
These are started depending on the organism involved. Antibiotics are available as vaginal creams and also as oral tablets. The doctor will take the appropriate call on what type of antibiotic to start. The choice of antibiotic is based on the sensitivity seen in the culture report of the discharge sample.
- Bacterial vaginosis is commonly treated with antibiotics like clindamycin and metronidazole.
- Treponema (parasitic) STI is treated with tinidazole or secnidazole
- Chlamydia (bacterial STI) is treated with doxycycline
- Gonorrhea, an STI caused by the bacteria Neisseria gonorrhoeae is treated by 3rd generation cephalosporin antibiotics.
- Yeast infections are treated with antifungals like fluconazole.
- HSV is treated with acyclovir, famciclovir, and valacyclovir.
It is important to treat both the woman and her sexual partner. The antibiotics should be taken for the entire course duration prescribed in the right dose and frequency. Treatment should not be discontinued prematurely, as that can lead to the persistence or recurrence of infection.
These are now emerging as important supportive care. These consist of multiple strains of friendly or good bacteria mainly Lactobacilli and Bifidobacterium.
Often these are available as ‘pre-probiotics’ (prebiotics are indigestible foods that enhance the growth or activity of beneficial bacteria like fructooligosaccharide (FOS), lactoferrin, or alpha-lactalbumin). Pre-probiotics help to restore vaginal flora, prevent further disruption of vaginal flora by antibiotics, and prevent the persistence and long-term recurrence of vaginal infections.
The following points are important:
- Repeated intra-vaginal washing (douching) should be avoided.
- pH-balanced acidic vaginal washes should be used.
- Dry the vulvovaginal area properly after showering and using the toilet.
- Always wipe from front to back.
- Avoid using sprays, fragrances, or powders in the genital area.
- During periods, use pads and not tampons while the infection is being treated.
- Let more air reach the genital area by wearing loose-fitting clothes, and cotton non-synthetic underwear (avoid underwear at night while sleeping).
Surgical treatment may be needed to drain a ruptured abscess and to repair the tubes or remove tube adhesions and blockages to restore fertility.
If the woman is not planning future pregnancies, and the scarring and damage due to PID are severe, then the damaged ovaries and tubes may be removed (salpingo-oophorectomy) sometimes with the uterus (hysterectomy).