White Discharge (Leucorrhea)

Usually, leucorrhoea that is uninfected is a thin, transparent watery discharge. In infections, the amount, thickness and colour of the release are varied. It may also be accompanied by other symptoms such as:

• Thick, white, yellow or greenish discharge.
• Strong foul smelling fishy odour.
• Redness and itching in the genital region.
• Burning or painful urination.
• Bleeding after sexual intercourse.
• Bleeding or spotting between menses. (Read more - Vaginal bleeding causes and treatment)

Causes

Leucorrhoea occurs as a result of hormonal changes during puberty, menstrual cycle, pregnancy and menopause. It may also be caused by:

• Use of feminine hygiene products like intimate washes, tampons, pads, and panty liners.
• Spermicidal jellies and ointments used for contraception. (Read more - How to have safe sex)
• Injury to the cervix and vagina during sex.
• Conditions like diabetes and anaemia.

Bacterial and fungal infections that cause leucorrhoea include:

• Bacterial vaginosis
  Bacterial vaginosis (BV) occurs when the growth of bacteria in the vagina is increased. It is the most prevalent vaginal infection in women between the ages of 15 and 44 years, especially in sexually active women. The balance of good versus bad bacteria residing in the vagina gets altered. Factors like multiple sexual partners, new sexual partner, douching, and contraceptive devices have been linked to an imbalance of vaginal flora. Although BV is not a sexually transmitted infection, the condition is often triggered by sex. There is no research to conclude how sexual partners may contribute to an increased risk of BV, but this infection is rarely seen in women who have never been sexually active. BV is not caused by using toilet seats, beds or swimming pools. Suspicion of BV can occur when the woman complains of white or grey vaginal discharge with a fish-like odour, especially after sex, along with itching in the vaginal area. Untreated BV can increase the risk of developing HIV and other sexually transmitted diseases.
• Thrush
  Thrush, also known as candidiasis, is a fungal infection caused by a type of yeast. Candida is a part of the normal body flora and is found in the mouth, throat, gut as well as the vagina without causing any symptoms. It is estimated that almost 20% of the women have had candidal infections without showing any signs. When the environment inside the vagina gets disturbed, the candida begins to multiply and grow. Women who use hormonal pills, pregnant women, those suffering from diabetes, and women with poor immunity have a higher chance of getting a fungal infection. Even the use of antibiotics can cause this disease. Pain and discomfort during urination or sexual intercourse along with a thick white discharge usually are the symptoms of candidiasis. A course of antifungal medicines clears up the infection in most cases, but for recurrent candidal infections, other medications may also be required.
• Trichomoniasis
  Trichomoniasis is a sexually transmitted disease caused by the parasite Trichomonas vaginalis. It is a curable disease which is more common in women than men. Trichomonas infections are more likely to occur in older women. The condition spreads via sexual contact from an infected person during intercourse. The most common sites of infection are cervix, vulva, vagina or the urethra. In men, the part of urethra inside the penis is commonly affected. A person's overall health and age are likely the factors as to why some people get infected while others do not. Usually, people are asymptomatic, but complaints can range from mild irritation to severe inflammation within a month of being infected. Women affected with trichomonas often complain of burning, itching and redness of the genital region. They also complain of greenish to yellowish vaginal discharge with a foul fishy smell. An untreated infection can last for years and also increase the risk of HIV and other sexually transmitted diseases.
• Chlamydia
  Chlamydia is a sexually transmitted disease affecting both men and women. The risk of chlamydia is increased with vaginal, anal and even oral sex. Young individuals who are sexually active are at a higher risk. As a safety measure, every sexually active woman above the age of 25 years should be screened for chlamydia infections. If left untreated, it may lead to severe complications in the reproductive tract thereby affecting chances of future conception or pregnancy. It may also cause a condition known as ectopic pregnancy where the foetus grows at places other than the womb. A pregnant woman infected with chlamydia can pass on the infection to the baby at the time of delivery. This could lead to eye or lung infections like pneumonia in the newborn. A pregnant woman should be screened for chlamydia infections in the first antenatal visit itself. 
• Gonorrhoea
  Gonorrhoea is a common sexually transmitted disease affecting young women, commonly between the ages of 15-24 years. Infection can spread via unprotected vaginal, anal or oral sex and can be passed from an infected pregnant woman to her newborn during birth. A gonorrhoea infection should be suspected when the woman complains of vaginal bleeding between periods, painful urination and increased vaginal discharge. Even men complain of swollen testicles along with a white, yellow or green discharge from the penis. People with multiple sexual partners, partners with a current or previous sexually transmitted infection, gays or bisexual males should be regularly tested for gonorrhoea infections every year.
• Genital herpes
  There are two viruses, namely herpes simplex virus I (HSV-I) and herpes simplex virus II (HSV-II) that cause genital herpes. HSV - I causes oral herpes leading to cold sores (blisters on or around the lips) during, before or after an episode of common cold or fever. Oral HSV-I infection can spread to the genitals during oral sex. There is no risk of disease being spread by using toilets, towels, utensils or swimming pools. Foul smelling vaginal discharge along with sores or blisters is frequently seen in women with genital herpes. There may also be additional symptoms like fever, body ache and enlarged lymph nodes. There is a chance of miscarriage in pregnant women affected with herpes, and the infection can pass during birth to the baby, leading to a potentially fatal condition called neonatal herpes. Hence, it is essential to avoid herpes infections during pregnancy or opt for a C- section (surgical delivery), if advised by the doctor.
• Pelvic inflammatory disease
  If sexually transmitted diseases are left untreated, they can lead to a condition known as the pelvic inflammatory disease (PID). Women affected with PID may have difficulty getting pregnant. The disease affects the organs of the female reproductive tract. Along with infections like chlamydia, gonorrhoea which are sexually transmitted, other non-sexually transmitted infections can also lead to PID. Usually, symptoms are mild and unnoticeable but they include pain in the lower abdomen with abnormal and foul discharge from the vagina. There may be bleeding between periods along with burning urination and bleeding after sexual intercourse. Multiple sex partners, history of a PID, use of contraceptive devices also increase the risk of PID. If PID is untreated, there may be a form of scarring in the fallopian tubes which can lead to a blockage. There are also increased chances of infertility, ectopic pregnancy and chronic abdominal pain.
• Other causes:
  • Cervical cancer.
  • Cervicitis (inflammation of the cervix).
  • Vaginal atrophy (breakdown of the tissue of the vagina after menopause due to ageing and an imbalance of hormones).
  • Rectovaginal fistula (an abnormal opening formed between the vagina and rectum through which stools can enter the vagina).
  • Vaginal cancer.
  • Vaginitis (inflammation of the vagina).
  • Retained tampons during menses.
  • Use of douches, scented sprays.

Risk factors

The risk of leucorrhoea without any pathology depends on many factors like the age of the woman, educational status, family background, number of pregnancies, use of contraceptives and the method of childbirth. The risk of abnormal vaginal discharges is increased in:

• Sexually active individuals.
• Multiple sexual partners.
• Past untreated infections.
• Unprotected sexual contact.
• Sexually active women under 25 years.
• Previous history of sexually transmitted diseases.
• HIV infection.
• Weak immunity.
• Not using condoms often.
• Use of contraceptive devices.

The best way to prevent leucorrhoea is to maintain thorough personal and menstrual hygiene. Some tips to prevent leucorrhoea are:

• Women should use sanitary napkins instead of cloth.
• Avoid excess use of products for feminine hygiene like vaginal washes, sprays, tampons.
• Abstain from sexual contact until treatment is complete. Use condoms, diaphragms and other barrier methods, and dental dams during intercourse.
• Ensure that all babies are delivered in a hospital or a primary health care centre with qualified medical and nursing staff and adequate facilities. Proper family planning practices should also be adopted. 

The diagnosis of non-pathological leucorrhoea can be made from medical history. However, abnormal vaginal discharge needs to be investigated before a complete diagnosis is made.

Medical history

A complete medical history of the woman is obtained. Details about sexual history, number of sexual partners, and history of previous sexual and non-sexual infections are noted. Use of contraceptive devices and family planning practices will also be noted. Physical examination to check for sores or blisters, redness around the affected area will be performed. If the woman is pregnant, a thorough antenatal checkup will be done.

Laboratory tests

Sexually transmitted infections will be diagnosed with the help of specific laboratory tests. A urine sample or vaginal secretions will be sent for culture and sensitivity tests to look for infections. In some instances, a CD4, CD8 count, ELISA test can be advised to rule out other causes.

Medications

Leucorrhoea can be treated with a short course of antimicrobial medicines. For abnormal vaginal discharges, the procedure will depend on the type of infection diagnosed. For candida infections, a course of antifungal medications is usually prescribed. Symptoms of BV subside without any treatment. There is no cure available for herpes. Antiviral drugs can shorten outbreaks. Antiviral medicines are also given to minimize the transfer of infection. At present, there is no vaccine available for herpes, although several clinical trials are being conducted.

Herbal remedies like including fenugreek, dried coriander, ripe bananas in your diet can control mild leucorrhoea. Ayurvedic preparations made from “Peepal” tree, Ficus racemosa, and Thespia have also known to help in reducing the discharge.

Lifestyle management

Along with medicinal and herbal remedies, the best way is to practice proper hygiene

• Avoid wearing synthetic innerwear. Wear cotton or linen panties. Wash with an irritant-free soap. Do not over wash the genital area as it may disrupt the pH balance and cause an overgrowth of the bacteria.
• Wash in a forward to backward direction after taking a dump to prevent infection of the vagina.
• Clean the vaginal area after every visit to the washroom.
• Eat a balanced diet.
• Drink 10 to 12 glasses of water daily to flush out toxins.
• Perform light exercises like walking, jogging, yoga, meditation as high impact exercises can cause increased leucorrhoea.
• Always maintain a monogamous (having only one sexual partner at a time) sexual relationship.
• Use latex condoms during each sexual activity.

Prognosis

Leucorrhoea is a natural vaginal discharge. However, in moderate to severe cases, the symptoms are relieved promptly with medications, which offer an excellent outcome. If the release is abnormal, the prognosis depends on the cause of the infection. Conditions like bacterial vaginosis have a better prognosis than PID in which there are complications related to fertility and conception.

Complications

Leucorrhoea is a physiological process, however, if it is associated with other symptoms like pelvic pain, fever, foul smell from the discharge, itching and redness in the pelvic area, yellow or greenish discharge, it may indicate an underlying medical condition or sexually transmitted disease. If these diseases are left untreated, they may cause worsening, advancement, or development of certain conditions, such as:

• Chronic abdominal pain.
• Sexually transmitted diseases such as gonorrhoea, HIV, herpes among others.
• Recurrent infections.
• Pelvic inflammatory disease.

One-fifth of the global population consists of women in the reproductive age group. In India,  women in this age group constitute 19% of the population according to the 2001 census. Vaginal discharge is a neglected problem in Indian women, especially in those living in rural areas. Infections of the female reproductive tract are a public health concern in several developing countries including India and Bangladesh where the incidence of reproductive tract infections ranges between 52-92%. Even though leucorrhoea is a natural vaginal discharge, it is still considered a disease. Even though leucorrhoea is a symptom in adult women, vaginal discharge can still be seen in young pre-pubertal girls between the ages of 3 to 10 years.

Leucorrhoea means a whitish discharge from the vagina without any underlying medical concern. In clinical practice, all types of excessive discharge, white or yellowish, but not containing blood are termed as leucorrhoea. Normal vaginal fluid varies in colour, amount and consistency depending upon the stage of a woman's menstrual cycle. Leucorrhoea is colourless and odourless, but if the secretion is green or yellow along with redness, itching and emitting a foul smell, it is a sign of a reproductive tract infection (RTI).