DEAR DOCTOR K: I have a strong "fishy" vaginal odor and a little discharge. My doctor recommended Monistat, but that hasn't helped. What can I do?

DEAR READER: Miconazole (Monistat) is an antifungal medication. It treats vaginal yeast infections, which are caused by a fungus. If Monistat didn't work, you most likely don't have a yeast infection. Instead, you probably have bacterial vaginosis (BV). This condition causes symptoms that are similar to those of a yeast infection, but it results from a change in the type of bacteria found in the vagina.

Normally, bacteria belonging mostly to the Lactobacillus family live harmlessly in the vagina. There, they produce chemicals that keep the vagina mildly acidic. In BV, these bacteria are replaced by other types of bacteria. These "newcomers" are not normally present in the vagina in such large numbers.

Many women with BV do not have symptoms. In those who do, it can cause the "fishy" vaginal odor that you describe. It can also cause a yellow or white vaginal discharge. The discharge seen in BV tends to be thinner than the "cheesy," thick discharge seen in vaginal yeast infections.

Your doctor can diagnose BV based on the results of a gynecological exam and lab tests of your vaginal fluid. There is no perfect test. But if you have three of the following criteria, you likely have bacterial vaginosis:

-- white, thin coating on your vaginal walls during the pelvic exam;

-- a pH test of vaginal discharge that shows low acidity;

-- fishy odor of vaginal discharge;

-- vaginal skin cells that are coated with bacteria when the doctor looks at your discharge under a microscope.

Doctors commonly treat BV with antibiotics that eliminate specific bacteria. These drugs can be taken as pills by mouth or applied as a vaginal cream or gel; both treatments are equally effective. But if you are pregnant, some experts recommend the pills instead of the vaginal gel, because they get deeper into potentially infected tissues and may be more effective in eradicating the infection.

All women with symptoms of BV should be treated. Left untreated, the condition may cause pelvic inflammatory disease, an infection involving the uterus, ovaries, or the tubes from the ovaries to the uterus (the oviducts). The infection can spread to other nearby organs, such as the liver.

Pelvic inflammatory disease can produce pain, fevers and sometimes discharge from the vagina. If it is not promptly diagnosed and treated, it can cause scarring of the oviducts. This, in turn, can lead to infertility. That's because the eggs cannot get past the scar tissue.

In women who are pregnant, BV increases the risk of premature labor and delivery.

Very few of my patients have heard of bacterial vaginosis (BV), but it is a relatively common condition that can change from a minor annoyance to a serious medical problem. So ask your doctor if this might be what is causing the bothersome odor.

(Dr. Komaroff is a physician and professor at Harvard Medical School. To send questions, go to AskDoctorK.com, or write: Ask Doctor K, 10 Shattuck St., Second Floor, Boston, MA 02115.)

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