Vaginal Dysplasia and Pain: FAQs

Frederick R. Jelovsek MD

 

• Possible recurrent bacterial vaginosis
• Vaginal lump swelling, ? Bartholin gland
• Thick, odorless heavy vaginal discharge
• Vaginal dysplasia and pain
• Urethral versus vaginal discharge
• Chronic vaginal/vulvar itching
• Itching, feminine powder - can vaginal creams affect getting pregnant?
• What is a wet-prep test?
• I want to be tested for all STDs

 

Possible recurrent bacterial vaginosis

Last August, I noticed an "odor"... I tried all kinds of things and finally went to the GYN in October. She diagnosed "BV", bacterial vaginitis, and prescribed metronidazole. I've used 8 prescriptions, but... guess what?! It doesn't go away! Here it is July and it's still coming back... every month it seems...in fact, now I have a yellowish discharge that I didn't have before... why? And why did it start in the first place? My husband and I have been married 15 years and are monogamous. Any suggestions? This is actually depressing...

You are now in a category of having chronic vaginitis rather than just acute vaginitis. It is very important to continue to reconfirm the exact diagnosis. This means when you have symptoms, you need an exam that includes wet prep, cervical culture for gonorrhea and chlamydia (even though you are both monogamous), a vaginal pH measurement, and possibly a yeast culture. While bacterial vaginosis can be recurrent, most of the time there is something else going on.

I just saw a patient recently who had a similar story and the wet prep showed predominantly white cells and no bacterial laden clue cells (to diagnose BV). The pH was 4.0 which is physiologic (should be higher than 4.5 for BV). This patient probably has either cervicitis, allergic vaginitis (due to reaction to lubricant in condoms) or desquamative vaginitis. Our studies and plan will help figure it out but it isn't BV even though she has been treated 4 times for it. I won't deny that it could have started as BV but I hope you see my point about getting it fully diagnosed.

 

Vaginal lump swelling, ? Bartholin gland

I have been experiencing a lump in the right side of my vagina. It started a few days ago and has become sore to the touch & feverish. Please give me your suggestions.

It's difficult to say without an exam, but what you describe would be consistent with a Bartholin duct abscess. They can get big and extremely painful before they either drain spontaneously or you have to see the doctor to do an incision and drainage.

Thank you for your advice. You were right-on! I went to my GYN today and she lanced it. It drained for several hours, but is MUCH smaller now and not as painful. Thanks again for the help. Also, what would cause such a situation to occur and can I prevent it. My GYN had no comments on that.

The Bartholin gland duct opens at about 4 o'clock and 8 o'clock around the vaginal opening near the hymeneal ring. If that duct get blocked, usually by infection, then the infection travels down to the gland and an abscess forms. The infection is usually introduced by sexual intercourse altho it's not usually a sexually transmitted bacteria. Some women just seem to be susceptible to infection there. You can get infection on both sides at different times. If the abscesses recur, you may have to have the gland sewn open (marsupialized) or removed surgically so you don't keep getting an infection.

 

Thick, odorless heavy vaginal discharge

I am 39 years old and have been having a problem for the last 7 months. I have a thick odorless clear discharge that is very heavy. I can feel it come out of me. Needless to say this is not my normal vaginal discharge. I have had itching and burning due to the constant wetness in this area. My OBGYN has done several yeast cultures with negative results. He has done an endometrial biospy with normal results.

My pH balance, vaginal flora and hormone levels are all testing normal. The discharge seems to be the heaviest after my menstrual period. I have searched through so much info on vulvovaginitis and do not see anything about a clear odorless heavy discharge. I am seeing a specialist soon. I hope there is an answer out there for me. I am currently using an estrogen creme that takes the itching and burning right away.

My doctor also tried me on birth control pills to change my cervical mucus but I broke out in a rash and had to stop taking them. Any info would be greatly appreciated.

Clear, odorless discharge that is of normal pH and with normal vaginal flora and negative cultures is a physiologic rather than an infectious discharge. For some reason the cervical glands are putting out excessive amounts of secretions. The two most common causes are increased estrogens and allergic reactions.

Estrogen cream inside the vagina seems to me will only increase the amount of discharge. Just use a small amount on the outside of the vagina, on the vulva where it itches, or have your physician give you a mild steroid cream, not estrogen containing. If you can go without cream on the outside, that would be better. A vaseline based ointment lightly applied should help the irritation from a non-infected discharge. It only irritates the vulva because the secretions are slightly acid.

As far as allergic reaction goes, you have to be your own detective. We have seen reactions to foams, gels, condom lubricants, etc. If you avoid anything intravaginal for 3-4 weeks and see a decrease in amount, then its cause is likely due to an intravaginal irritant.

Make sure you don't have extra estrogens in your diet (extra soy products, alfalfa tablets, herbal products etc.)

Finally, remember that if it is just an exaggerated physiologic discharge, it is not harmful to you. It's inconvenience can be controlled by tampons. Eventually it gets better. I have seen this problem persist for months but never for years. Something changes.

 

Vaginal dysplasia and pain

My biopsy came in negative today. I am a 34 year old 5'8" 135 lbs and in good health. I am a heavy smoker and drinker. (7-10 packs a week). My doctor has diagnosed vaginal dysplasia (which I have found no description of in my search). I have an approximate 3- 5mm in diameter sensitive spot near my vaginal opening in the lower area. This spot causes me great discomfort when it is touched and, therefore, I have not had intercourse in about six months which is when it first appeared.

From my research, I understand that this may fall into the mild dysplasia category. However, the doctor has prescribed in-patient surgery to remove this tissue. I recently read an article that states that Retin-A® therapy may be sufficient and that if I were to stop smoking and drinking, this could also cause the cells to return to normal. I also read an article recently in HEALTH magazine dated May/June 1998. The article describes symptoms similar to the pain described above and is called vulvar vestibulitis. I am wondering if this is what I could be suffering from due to my highly stressful job and life style. I asked the doctor about it but he skirted the subject. I was wondering if you could give me your opinion on these matters?

It sounds as if there are at least two problems going on. Vaginal dysplasia is a change in the skin cells that, if left alone, could possibly turn into cancer cells in 10-15 years. Usually it is recommended that the tissue is destroyed so the body's normal healing mechanism can replace those cells with unaffected (unirritated) cells. Dysplasia in the vagina or on the cervix or even on the vulva is NOT painful. It is difficult to excise a large area of this in the office. Usually an outpatient surgical procedure is performed.

You are correct that smoking is associated with dysplasia. Stopping smoking will help your body's immune system heal over the dysplasia cells.

There are several things associated with pain in the entrance area of the vagina. Vulvar vestibulitis is one of them. It has a characteristic area of pain distribution and should be easy to diagnose but it is extremely difficult to treat. Retin-A has been used but I'm not aware that it is very sucessful. Sometimes it is treated with surgical excision.

 

Urethral versus vaginal discharge

How would one be tested to see whether or not a discharge was vaginal or from the urethra?

On vaginal exam a speculum is used to look into the vagina to see a cervical discharge or a vaginal discharge. After the speculum exam, a finger is used to press on the anterior vaginal wall under the urethra and "milk out" a discharge or secretions.

Can an gynecologist test for it or does a urologist have to test for it.

Either.

What color is a urethral discharge? Is it clear, white or yellow?

Normally there is no discharge present from the urethra. If there is discharge expressed from the urethra, it can be clear, white, bloody or brown (indicates small amount of blood).

What causes a urethral discharge?

Infection of the Skene's glands of the urethra, a urethritis or bladder infection, gonorrhea or chlamydia infection, polyps, just over active Skene's glands, a urethral diverticulum, urethral prolapse, and cancer of the urethra come immediately to mind.

I do not have burning or itching. The fluid is sometimes clear and sometimes rarely yellow. I have been tested for STD's the last 3 years and they always come up negative. Because I have no burning or itching pain I usually don't seek medical care. Can birth control pills cause a urethral discharge?

Yes. Sometimes they can cause the Skene's urethral glands to just over produce mucous.

There is no blood with the discharge. Sometimes rarely, I get a brownish discharge.

If the brownish discharge is from the urethra, it implies a small amount of old blood.

Would you know the cost of a test for urethral discharge? There is no foul odor with this discharge. Please advise on what doctor I should seek a test from.

It sounds as if you have already had a exam in which the discharge can be expressed from the urethra. Once that is done and cultures of the discharge are taken, the next step is to rule out any mechanical causes such as polyps or diverticula in the urethra. This needs to be looked at by urethrocystoscopy, an office procedure in which a scope is placed in the urethra and bladder. It is usually performed by a urologist or urogynecologist. Cost is in the $200-300 range plus office visit for initial assessment. Usually covered by insurance.

Have they yet made a home test to test for yeast/urethral discharge?

No.

I know there is a strip test out on the market which you can get over the counter for urinary tract infection.

Yes. We have just added that home UTI test to our store.

 

Chronic vaginal/vulvar itching

I have been dealing with vaginal itching for approximately 3 years. No unusual discharge or odors. My doctor prescribes creams that help but I want a cure. I'm 37, have had a partial hyterectomy and the itching is located in the vulva area.

Any suggestions?

Vaginal itching has numerous causes. If you describe no odors or discharge, then the likelihood of infection with bacteria or yeast is low. Itching can be caused by infection, atrophic vaginitis (low estrogen), contact vulvitis (like allergy to topical substances) or dysplasia (precancerous). Some helpful information would be to know what medications have you tried so far for this or any other problems. Also, where exactly is the itching?

I will have to check for the correct names of the creams. The cream I have used most is dexamethasone 0.025%, most recently the doc prescribed Temovate (clobetasol propionate 0.05%) and a pill- Phenergan® 25mg.

Persistent vaginal itching unresponsive to topical therapy requires a skin biopsy of the affected area to rule out the possibility of cancer. If on visual exam, there is any white or red appearing tissue it needs to be biopsied. The doctor may also want to put an acetic acid solution (vinegar) on the vulva area and if any white tissue appears, it needs to be biopsied. All this should be done before using Temovate (which is often a good medicine for this). A biopsy of the vulvar area that itches has to be done to rule out any premalignant or malignant changes which can often present as chronic vulvar itching.

I'm fine during the day but at night I begin itching. I have several Rx creams that help, but I really want a cure. Do you have any suggestions?

Are you putting any soap, deodorants or anything on the vulvar area prior to going to bed? If so, you may hve a contact vulvitis. You will have to be your own detective and eliminate causes.

The only other thing that comes to mind when you describe the itching only at night is the possiblilty of pinworms. If the itching is more around the anus and lower vulva rather than primarily on the sides of the vaginal opening, you may need to be checked for pinworms which reside in the rectum and can come to the skin surface outside the rectum especially at night. This is a much more common infection than most people realize and is not just confined to children. The test is to take a perirectal smear and look for eggs under the microscope. If, however you see a bunch of tiny white spots (like rice) in your stool, this may be the problem.

 

Itching, feminine powder - can vaginal creams affect getting pregnant?

Since the weather has gotten warmer, I have been using a feminine powder to prevent odor and wetness during and after my period. Well, last night I started experiencing burning and itching. After I went to the bathroom, I noticed a white clumpy ball with traces of blood on the bathroom tissue (I just finished my period on Saturday). This substance continued to come out. Before I went to bed I used a prescription that my gynecologist gave me a few months ago (metronidazole vaginal gel) for a bacterial infection. I should start ovulating in the next 5 or 6 days and my husband and I are trying to have a baby. If this is a yeast infection, will it have any bearing on my ovulation this month? And how can I get rid of, and prevent another infection?

This sounds like possibly a yeast (fungus, not bacteria) infection. These usually present with itching, burning, white "cottage cheese like" discharge and redness. If these are your symptoms, then an over-the-counter intravaginal cream like Gyne-lotrimin (clotrimazole) or Monistat (miconazole) will help. Metronidazole is used to treat bacterial infections and would not work if this is a yeast infection.

Another possibility is a contact vulvitis to the feminine powder. It can take awhile to get sensitized and then all of a sudden you react to it. The discharge you have right now could just be physiologic with a lot of cells after your menses and not a yeast discharge.

A bacterial or yeast infection should not affect ovulation at all. I don't think we really know if the vaginal creams decrease your chance of getting pregnant though. It is possible because they may act as a barrier to decrease sperm even if they are not spermicidal and don't alter ovulation.

In your current circumstances, I would suggest a trial of over-the-counter, anti-yeast medication for three days then discontinue before ovulation time. Also stop the feminine powder. If the symptoms come back later in this cycle or the next, you need to see your physician to get a proper diagnosis.

 

What is a wet-prep test?

Have you ever heard of a wet-prep test before? I was told by a girlfriend about this wet-prep but she didn't expand on it?

A wet-prep is a simple test we use frequently in the office to diagnose three of the most common vaginal infections: bacterial vaginosis, trichomoniasis and yeast (candidiasis). Trichomonas is an STD (sexually transmitted and requires simultaneous treatment of partner). Bacterial vaginosis (BV) may be transmitted sexually but not usually so, and yeast is not an STD.

Does a Gyn normally do wet-prep tests as a routine? Or would I have to request a wet prep test? Sorry to bother you with this but I want to make sure that when I go see my Gyn that I am asking the right questions. Please advise if doing a wet prep test is normal procedure?

A wet-prep is not a normal component of a regular exam. It is a normal office procedure for someone complaining of a vaginal discharge or, if on speculum exam the Gyn sees a discharge that might be trichomonas or BV. If you wanted the test just to be absolutely sure you did not have a sexually transmitted trichomonas infection, you would have to ask separately for it.

 

I want to get tested for all the STDs

I've been tested for herpes and AIDs both negative and negative for chlaymadia and gonorheaa. I would like to ensure that I am getting tested for every possible STD. How does one go about doing this? Is it costly?

If you have a negative wet-prep test for trichomonas, GC (gonorrhea) and chlamydia tests, herpes and AIDs, you have covered by far the most common STD's. Any further testing should be guided by your signs and symptoms and your physician's clinical exam especially for the rare STD's like chancroid, lymphogranuloma venereum, and granuloma inguinale.

Blood tests can be used to pick up the not-so-rare sexually transmitted infections such as hepatitis B and C and syphyllis (you've already had the AIDs blood test for HIV 1 and 2, I assume). These tests have variable costs but should be under US $100. Many public health departments will do them for free and insurance often covers their cost.