Reproductive and Sexual Health Handbook

The vagina is a muscular canal between the uterus and the vulva. The vaginal mucosa is similar to that in the mouth, and similar diseases can infect the vagina as in the oral cavity. The anatomical relationships of the vagina are shown in Figure 4.1:

bladder and urethra cervix rectum and anus uterovesical and rectovaginal peritoneal pouches scarum and coccyx

Figure 4.1 The Vagina

The normal vagina is colonised by lactobacilli and other aerobic and anaerobic bacteria from puberty onwards. Commensal lactobacilli metabolise glycogen in the vaginal epithelium to produce lactic acid which results in the maintenance of an acidic vaginal environment (pH<4.5). Other commensal bacteria include anaerobic streptococci, diphtheroids, coagulase-negative staphylococci and beta-haemolytic streptococci. In the normal vaginal ecosystem the ratio of anaerobic to aerobic bacteria is 2-5:1. Some commensal organisms can constitute infection if they ‘overgrow’ including candida albicans, staphylococcus aureus and beta-haemolytic streptococci and the organisms associated with bacterial vaginosis.

Normal vaginal discharge is a mixture of the transudate fluid across the vaginal mucosa and the mucus secretions from the endocervical glands. Clinicians are frequently asked about vaginal discharge by concerned patients, however it may often by physiological and not represent pathology. A variation in oestrogen and progesterone levels during the menstrual cycle alters the quantity and type of cervical mucus (and resultant vaginal discharge) in the following ways:

The increase in oestrogen prior to ovulation changes cervical mucus from thick and sticky (non-fertile) to clearer, wetter, stretchy and slippery (fertile). Fertile mucus facilitates the passage of sperm through the cervix to the uterus. After ovulation, with the production of progesterone, the mucus becomes thick and sticky again and hostile to sperm, so sperm are unable to swim through the mucus.

Consider the possibility of abnormal vaginal discharge if there is complaint of an increase in the amount of vaginal discharge, a change in the consistency or colour, and/or the presence of an offensive odour. There may or may not be associated symptoms such as itching, soreness, dysuria and dyspareunia.

Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in women of childbearing age worldwide.⁽¹⁾ It typically occurs in sexually active women, and is associated with douching, early age at first sexual intercourse, inconsistent condom use, higher number of sexual partners, or recent partner change. For women who have sex with women (WSW) bacterial vaginosis is associated with increased numbers of recent and past female partners and with confirmed bacterial vaginosis in a female partner.⁽²⁾ BV is less common when male partners are circumcised.⁽²⁾

Bacterial vaginosis is a polymicrobial condition, characterised by an overgrowth of anaerobic organisms that replace normal lactobacilli, leading to an increase in vaginal pH (≥4.5). This may lead to an increase in vaginal discharge and a change in odour, often described as a fishy or ammonia-like smell. However, up to 50 per cent of women with BV are asymptomatic.⁽³⁾

Gardnerella vaginalis is the most commonly found bacteria in BV. Other organisms associated with BV include Atopobium vaginae, Prevotella species, Mycoplasma hominis and Mobiluncus species. Despite growing understanding of its physiology and sequelae, the precise pathogenesis of BV is controversial and its aetiology, pathology, microbiology and transmission are still poorly understood.⁽⁴⁾ BV

Vulvovaginal candidiasis is a syndrome and diagnosis relies on a combination of laboratory and clinical criteria. Isolation of candida is common in asymptomatic women and the disease spectrum ranges from ‘innocent bystander’ (where symptoms are wrongly attributed to its coincidental isolation) to complicated disease (where vulvovaginal candidiasis is severe, persistent or recurrent). Candidiasis is not considered to be an STI.

Group B streptococcus is frequently isolated on high vaginal swabs. It is a commensal organism of the gastrointestinal and genital tract in up to 30 per cent of healthy women.⁽¹⁶⁾ It is not generally considered a pathological cause of discharge except in pregnancy when it can cause early onset neonatal infection. Group B streptococcus is screened for antenatally and treated with IV intrapartum antibiotics.

Although group B streptococcus has been associated with symptomatic vulvovaginitis, other causes of vulvovaginitis are more common; other than in pregnancy, it is generally an incidental finding.⁽¹⁶⁾

Group A beta haemolytic streptococcus can cause low grade persistent vulval and perianal rash or acute vulvovaginitis in pre-pubertal children. It is virtually never seen in the adult vagina.

Streptococcal vulvovaginitis presents with sudden onset of a red, swollen painful vulva and vagina and may have an associated discharge. There may be a history of preceding throat infection as the organism is believed to reach the vagina by haematogenous spread from the throat.

Diagnosis is made by taking a skin swab of the vulva. It is not necessary to insert the swab into the vagina.

Treatment is with oral penicillins or cephalosporins based on antibiotic sensitivity testing. A 10 day course is recommended.

Trichomoniasis, chlamydia, gonorrhoea, mycoplasma genitalium and herpes simplex virus infections can all cause a vaginal discharge due to either a vaginitis or cervicitis. A sexual history is thus important in all women with a vaginal discharge to ensure possible STIs are not overlooked. See Chapter 12: Sexually Transmissible Infections for more on this.

The two Bartholin’s glands are located on either side of the lower vaginal entrance. They secrete fluid which helps to lubricate the introitus. The glands are about the size of a pea and are not normally palpable. The mucus secretion passes to the skin surface along a narrow duct which is about 2 cm long; this can become blocked by exfoliated skin cells, trauma or infection of the gland. This leads to swelling of the glands causing a Bartholin’s cyst which can be palpable and painless (see Figure 4.2). If the secretions within the blocked gland become infected the cyst will become painful and can increase greatly in size and distort or obscure the entrance to the vagina. The common bacteria that can cause infection are Escherichia coli and Staphylococcus spp. and sexually transmitted pathogens such as chlamydia and gonorrhoea.

Figure 4.2 Bartholin’s Cyst

Used with permission of Mayo Foundation for Medical Education and Research, all rights reserved

Bartholin’s cysts and abscesses develop in three per cent of women and are more common in those aged 20-30 years.⁽¹⁷⁾ Rarely in women over 40 years the cyst can be malignant.⁽¹⁸⁾

Occasionally, the cyst will spontaneously discharge the accumulated secretions but if large,

Toxic shock syndrome (TSS) is a very rare but potentially serious illness that can affect both males and females. It is caused by bacteria that are normally commensals on the skin such as Staphylococcus aureus and Streptococcus pyogenes although in more than 30 per cent of cases no bacterial pathogen is isolated.⁽¹⁹⁾

TSS can occur after surgery and in childbirth, although in women most cases of TSS are diagnosed during menstruation in association with the use of tampons. Menstrual cups and use of the contraceptive diaphragm during menstruation have also been implicated. It is postulated that the blood on the tampon provides a culture medium for bacterial overgrowth and the exotoxin produced is absorbed into the blood stream.

Cases of TSS are extremely rare with today’s tampons, however hygienic handling and frequent change of tampons every 4 to 8 hours is advised.⁽²⁰⁾ In cases reported in men there have been concurrent staphylococcal skin infections.

Symptoms of TSS include:

sudden onset of high fever vomiting diarrhoea sunburn like skin rash joint and muscle pain headaches confusion hypotension peeling of palms and soles of feet 2-3 weeks after skin rash appears

When TSS is suspected with tampon use the tampon should be removed immediately and the person referred for emergency care. Bacterial cultures should

The vulva is the external part of the female genitalia. Problems with this area of the body are primarily related to skin conditions. It is also related to the genital, urinary and gastroenterological tracts and encompasses the exit routes for all of these body systems. Therefore, it is also prone to the stresses imposed upon it by these functions. Specific problems can also arise for transgender women who have a neovagina (see Gender-affirming care in Australia in Chapter 15: Reproductive and Sexual Health for Trans and Gender Diverse People).

Figure 4.3 The vulva

Dermatitis is the most common cause of chronic vulval symptoms and accounts for about a third of all vulval irritation presentations. Vulval dermatitis is itchy or painful. Where visible skin changes are present on examination, the diagnosis is likely to be one of the vulval dermatoses (atopic or contact), lichen sclerosus or lichen planus.

Superficial dyspareunia is a common symptom of vulval dermatoses and other vulval conditions. Regardless of the cause of the vulval symptoms there is often a psychosexual impact for the woman. The patient may experience embarrassment, fear or guilt as a result of the condition. There may be concerns regarding STI or possible genital cancer. Dyspareunia may make sexual intercourse difficult or impossible, and if longstanding may impact on relationships or mental illness.

Lichen sclerosus accounts for about 10 per cent of patients with vulval symptoms.⁽²¹⁾ It affects skin anywhere on the body, but most commonly affects the genital area. The aetiology is unclear, but it is thought to be an autoimmune disorder. Lichen sclerosus can occur at any age; ten per cent of cases start in childhood and may be mistakenly diagnosed as sexual abuse.⁽²¹⁾ It is more common in postmenopausal women.

Lichen sclerosus can be asymptomatic and the diagnosis is only made at the time of a vulval examination for an STI or cervical screening test.

It is important to recognise and treat lichen sclerosis for two reasons:

It is associated with squamous cell carcinoma of the vulva – lifetime risk of 2-6 per cent.⁽²¹⁾

If not treated, it can result in significant atrophy and distortion of the genital skin.

Lichen planus causes typical smooth, shiny flat-topped purple papules on the skin and non-specific erosions on mucous membranes. Erosions may be limited to (or alternate between) the vaginal or oral cavity. Lichen planus is probably the major cause of chronic erosive vulvitis.

Psoriasis does not always have the typical salmon pink/ silvery appearance on the vulva that it has on skin elsewhere. It rarely occurs on the vulva alone and it is important to check for other sites on physical examination, particularly less obvious areas such as the scalp, nails (pitting) and the cleft between the buttocks.

Vitiligo is a common autoimmune disease which results in patchy, well-defined areas of complete loss of pigmentation on the skin which leads to a striking white discolouration. The skin retains its normal texture which is a distinguishing feature from lichen sclerosis. Vitiligo is asymptomatic but loss of pigmentation can be progressive over time and the cosmetic effect can lead to significant distress for the patient.

Vitiligo is a harmless condition but it can be associated with autoimmune thyroiditis. It affects both men and women and is not uncommonly seen on the genital skin, although face, hands, arms and legs are more common sites. It can be localised to one area of skin or be seen at multiple sites.

Diagnosis does not require skin biopsy and a simple method is to look at the skin in a darkened room under ultraviolet light as the affected skin fluoresces brightly. If there is any concern for the presence of lichen sclerosus a skin biopsy can be taken.

Treatment of vitiligo is difficult and may need to be used over many months before melanocytes return to the affected areas. Typical treatments are potent corticosteroid creams, tacrolimus, calcipotriol and topical psoralens on skin which can be exposed to sunlight.

Vulval pain may be secondary to a dermatosis as above or may have no obvious cause, in which case it is usually known as vulvodynia. Vulvodynia is a term that simply means vulval pain or discomfort. This is a diagnosis of exclusion.⁽²²⁾

Female genital mutilation/cutting (FGM/C), also known as female circumcision or genital cutting, refers to all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons.⁽²⁴⁾

FGM/C has no known health benefits and Section 45 of the NSW Crimes Act 1900 states that it is against the law to:

excise, infibulate or mutilate the whole or any part of the labia minora or labia majora or clitoris of another person aid, abet, counsel or procure a person to perform any of these acts on another person

Female Genital Cosmetic Surgery (FGCS) refers to non-medically indicated cosmetic surgical procedures which change the structure and appearance of the healthy external or internal genitalia of women.

According to figures from Medicare, the number of women undergoing FCGS in Australia has increased dramatically in recent years.⁽²⁵⁾ It appears that in response to changing cultural norms this surgery is increasingly being sought by women who want to feel ‘normal’ or look ‘desirable’. As a result, general practitioners are increasingly managing patients who present seeking surgery due to concerns about the appearance of their genitalia.

The resource ‘Female genital cosmetic surgery – A resource for general practitioners and other health professionals RACGP 2015’ provides information on what FGCS is, the factors driving demand and a set of practical recommendations on how to manage women requesting referral for FGCS or expressing concerns regarding their genitalia.⁽²⁶⁾ Recommendations from this resource are included below.

Family Planning NSW resources:

Common Vaginal and Vulval conditions factsheet Fisher G, Bradford J. The Vulva: a Practical handbook for Clinicians. Second Edition Cambridge University Press 2016

Melbourne Sexual Health Centre factsheets:

Bacterial Vaginosis Vulvovaginal candida Vuvlval pain Vulvodynia

Jean Hailes Foundation resources:

The Vulva: Irritation, Diagnosis & Treatment booklet Discussion of Vulva and Vaginal Irritants Managing sexual pain: a multidisciplinary approach webinar (2016)

Royal Australian College of General Practitioners resource:

Female genital cosmetic surgery: a resource for general practitioners and other health professionals  

Women’s Health Victoria

The Labia Library

NSW Education Program on Female Genital Mutilation

Family Planning Queensland: Female Genital Mutilation (FGM) in clinical practice. Fortitude Valley, QLD: FPQ, 2008.

Australian STI Management Guidelines for use in primary care

Madhivanan P, Krupp K, Chandrasekaran V, Karat C, Arun A, Cohen CR, et al. Prevalence and correlates of Bacterial Vaginosis among young women of reproductive age in Mysore, India. Indian J Med Microbiol. 2008;26(2):132-7. Forcey D, Vodstrcil LA, Hocking JS, Fairley CK, Law M, McNair RP, et al. Factors associated with Bacterial Vaginosis among women who have sex with women: a systematic review. PLoS ONE. 2015;10(12):e141905. British Association for Sexual Health and HIV (BASHH). UK National Guidelines for the Management of Bacterial Vaginosis. [internet]. United Kingdom: BASHH; 1999 [updated 2012]. Available from: https://www.guidelinecentral.com/summaries/uk-national-guideline-for-the-management-of-bacterial-vaginosis-2012/#section-society. Pirotta M, Fethers KA, Bradshaw CS. Bacterial Vaginosis: more questions than answers. Aust Fam Physician. 2009;38(6):394-7. Gottschick C, Zhi-Luo D, Vital M, Clarissa M, Abels C, Pieper DH, et al. Treatment of biofilms in Bacterial Vaginosis by an amphoteric tenside pessary-clinical study and microbiota analysis. Microbiome. 2017;5(119). Sexual Health Fact Sheets [internet]. Alfred Hospital, VIC: Melbourne Sexual Health Centre (MSHC); 2019. Bacterial Vaginosis (BV); [updated 2020 Feb]. Available from: https://www.mshc.org.au/SexualHealthInformation/SexualHealthFactSheets/BACTERIALVAGINOSIS/tabid/135/Default.aspx#.Xx-zv54zZaR. 2015 Sexually Transmitted Disease Treatment Guidelines [Internet]. Centers for Disease Control and Prevention; 2015. Disease Characterized by Vaginal Discharge; [updated 2015 June 4; cited 2015 July 14]. Available from: https://www.cdc.gov/std/tg2015/vaginal-discharge.htm. Australian STI management guidelines for