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Vaginal Dysplasia and Pain: FAQs
Frederick R. Jelovsek MD
   
Possible recurrent bacterial vaginosis
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
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.
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
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
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
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.
Either.
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).
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.
Yes. Sometimes they can cause the Skene's urethral glands to just over
produce mucous.
If the brownish discharge is from the urethra, it implies a small
amount of old blood.
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.
No.
Yes. We have just added that home UTI test to our store.
Chronic vaginal/vulvar itching
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?
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.
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?
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?
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.
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
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.
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