Vaginitis Symptoms with Negative Tests!
Help! I have vaginitis symptoms and my doctor says my testing is normal, but I still have symptoms!
It is not uncommon for me to see a patient in the office that has recurrent vaginitis with common symptoms such as discharge, vulvar pain, itching, and burning. Sometimes, they have been seen by multiple practitioners and have had negative testing. What does this mean?
Well, when a patient comes in with this concern, most of us perform laboratory swabs that help us determine if patients have some of the common causes of vaginitis- bacterial vaginosis or yeast infections. The problem is that some of these tests are not that accurate. One of the DNA tests is only right 56% of the time when it says you have BV. This means there is a large number of patients being treated for BV that don’t have BV. And you know what? You don’t get better if you don’t treat the right thing!
And sometimes all the send-off swabs, even the good ones, come back negative. Then what? When you see a vulvovaginal expert, we generally do wet mounts. This is when we take the vaginal discharge and put it on a glass slide with some saline and look at it under the microscope. This is where I channel my inner microbiology nerd self. This is the absolute coolest thing! It tells me SO much. I can see the cells of your vaginal walls (squamous cells), bacteria like lactobacilli, white blood cells that can indicate inflammation, and anything else that might be there.
Certain vaginal conditions can ONLY be diagnosed through a wet mount and could very easily be missed when only send off laboratory swabs are used. What are those things?
Desquamative Inflammatory Vaginitis (DIV). This is a noninfectious inflammatory condition of the vagina that causes copious vaginal discharge, pain, and burning. It is usually a yellowish discharge and it is enough that most of these patients notice it all the time. A send-off swab for this will be negative. A wet mount will show many squamous cells that are from the parabasal layer of vaginal mucosa meaning that the vagina is sloughing off that layer in larger amounts than expected. There will also be a lot of white blood cells due to inflammation. This condition can be hard to treat, but is generally treated with clindamycin, estrogen, steroids, or a mix of all of them.
Cytolytic Vaginosis (CV). This is not a common vaginal condition. I tend to see it mostly when women are using probiotics, but it's from an overgrowth of normal lactobacilli. This causes too much acid production making the discharge painful when it touches the vulva. These patients often tell me they need to wear a tampon to keep the discharge off the vulva. The discharge can be white and thin, thick and paste-like or even have the texture of cottage cheese, like a yeast infection. Under the microscope, you find tons of lactobacilli and a very low pH. Treatment is baking soda baths or clindamycin.
Genitourinary syndrome of menopause/lactation/contraceptive pills. This is a condition of hormonal changes. It’s most commonly seen in menopause but sometimes we see it during other times where estrogen levels are low. It can cause thinning of the vaginal mucosa, dryness, irritation, fissures, and pain with sexual activity. It can feel like an infection, but actually be a result of hormonal changes. It is diagnosed with an exam and can be treated with topical estrogen.
Vulvar dermatologic condition. Many vulvar conditions can mimic vaginitis, especially if you are not getting a thorough exam of the vulva when you come in with your symptoms.
Lichen sclerosus is a common condition that causes whitening of the skin on the vulva, changes in anatomy of the vulva, and often is associated with itching or burning, but not always. A good exam can rule this out or sometimes a biopsy.
Lichen planus is not as common, but can be associated with some skin changes but also erosions, ulcers, or even tissue getting stuck together.
Plasma cell vulvitis is rare, but can cause itching or burning at the opening of the vagina and, generally, we see rust colored stains at the opening of the vagina. This can be diagnosed by biopsy as well. These conditions are best treated by a vulvar specialist.
If you are suffering from ongoing vaginal or vulvar symptoms and aren’t getting answers from your doctor, consider making an appointment to see me, Ashley Fuller, MD LLC. I love helping women with these conditions and want you to feel good again!
