Vaginal symptoms are among the most common reasons for gynecologic consultation in primary care (1). In current practice, the evaluation of vaginal complaints among premenopausal women is based primarily on the diagnosis of one of the three conditions: bacterial vaginosis (BV), trichomoniasis, and vaginal candidiasis (2-4). Despite the general acceptance of this approach, studies in a variety of settings have demonstrated that neither BV nor any pathogenic microbe can be found in approximately one-third of symptomatic women (5,6). Furthermore, asymptomatic women can be infected with Candida (7) and Trichomonas (8), whereas Gardnerella vaginalis is considered part of the normal vaginal flora (9). Thus, the presence or absence of a microbe corresponds poorly with the presence or absence of symptoms.
Clinicians often encounter patients with symptoms for which there is no obvious cause. One possible explanation may be that the patient is interpreting normal physiologic processes as evidence of disease. This explanation, in turn, raises the question of how patients and physicians decide what is normal and what is disease.
There is little agreement among patients with vaginitis about the characteristics of normal vaginal discharge (10). Although most women think that some vaginal discharge is normal, an important minority believe that a healthy vagina should be dry. Even among women who accept vaginal wetness as normal, there can be little agreement about the characteristics of this discharge, such as its timing or color. Physicians also disagree and tend to base their opinions about normal versus abnormal discharge more on clinical experience than on textbooks.
Textbooks also disagree about what constitutes normal vaginal discharge and offer a variety of conflicting terms to describe the color of normal discharge (white, gray, yellow, clear) and its consistency (clumpy, floccular, semisolid, cream, high viscosity, nonhomogeneous, thin) (11 -14). Although most textbook authors state that vaginal fluids were either odorless, minimally odorless, or did not have an unpleasant odor (12,13,15-17), one source mentioned the possibility that the normal vaginal odor might be unpleasant (18). Textbooks, however, generally agreed that irritative symptoms—itching, irritation, redness, and swelling—normally should not be present (12,15,17).
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