Vaginosis a Growing Scourge Among

Vaginosis

A GROWING SCOURGE AMONG CHILDBEARING WOMEN

Chief Complaint -- Julita, 22 years old, complained of abnormal vaginal discharge (Brown, 2007). She described the discharge as offensive and fishy-smelling.

I last saw the patient two weeks ago on July 2, 2009.

History of Present Illness -- She said she had no vulval itching, soreness or pain during intercourse, pelvic or abdominal pain.

Menstrual History -- She had no bleeding between menstrual periods or dysuria. Her last menstrual period was three weeks before the day of consultation and was normal.

Gynecological History -- She had no history of post-coital bleeding

Reproductive History -- She is not married and has no children.

Past History -- She had no concurrent medical conditions. Her only medication was the combined oral contraceptive pill.

Family History -- there is no history of sexually transmitted disease in the patient's family

Social and Psychological History -- Julita is an average woman with no remarkable or significant social or psychological abnormality.

X Physical Assessment -- Examination showed thin, white or grey homogenous

Discharge coating the vaginal walls. There was offensive or fishy odor but no vulvitis, or vaginitis, cervical discharge, cervicitis or contact bleeding. However, she had a raised vaginal pH of 6 (Brown).

The patient was examined and tested for sexually transmitted infections, inflammation and any abnormality, such as cuts fissure, ulcers and blisters (Brown, 2007). She was also subjected to speculum examination for consistency of vaginal discharge, amount, color, odor, vaginitis, cervicitis, cervical discharge and contract as well as for the collection of specimen for further tests. Vaginal pH of higher than 5 indicates bacterial vaginosis or trichomoniasis. Endocervical swabs were taken to test for Chlamydia and gonorrhoea. The likeliest diagnosis is bacterial vaginosis, as it is the most common cause of abnormal vaginal discharge among childbearing women. Bacterial vaginosis is characterized by an overgrowth of mostly anaerobic organisms, which replace protective lactobacilli and raise vaginal pH level (Brown).

XI. Differential Diagnoses -- the first is likelier to be trichomoniasis than bacterial vaginosis. Trichomoniasis produces a thin, frothy, green or yellow and foul-smelling vaginal discharge with a raised pH. The patient has no dyspareunia or soreness, no cervicitis and no erythema of the external genitals or vagina. The second is candidiasis, although unlikely because the vaginal discharge produced by the infective agent, candida, has a pH lessen than 4.5. The discharge is thick, white and looks like cottage cheese and has no odor. Associated symptoms of candidiasis include vulval itch, edema and fissures. The third and fourth diagnoses are Chlamydia and gonorrhea, which produce muco-purulent discharge from the cervix (Brown).

XII. Final Diagnosis -- tests and examinations revealed bacterial vaginosis.

XIII. Management -- this includes 2 grams of metronidazole as a single dose or 400

mg metronidazole twice a day for seven days (Brown, 2007). If the patient cannot tolerate oral metronidazole, she may use topical treatments, such as intravaginal metronidazole or clindamycin cream, although they are costlier options. She is advised from performing vaginal douching, washing the genitals with shower gels or soaps and using bath antiseptics. These will affect the vaginal flora and allow the recurrence of bacterial vaginosis (Brown).

Vaginal discharge may be caused by non-sexually transmitted infections or sexually transmitted infections or STIs (Brown, 2007). Non-STIs are bacterial vaginosis and candidiasis. STIs are richomonas vaginalis, Chlamydia trachomatis, and neisseria gonorrhea. Non-infective causes are retained tampon or condom, allergic reactions, ectropian, cervical polyp, fistulae, atrophic changes and genital tract malignancy. The duration of the discharge, the amount, color, consistency, blood staining, odor, pattern of cycle, previous episodes and associated symptoms should be determined. These associated symptoms include dysuria, itching, soreness, bleeding between menstrual periods or after intercourse, superficial or deep dyspareunia or lower abdominal and pelvic pain. An assessment of the patient's risk and clinical history helps in diagnosing and managing her condition. Women at risk of STI are those below age 25, those who changed sexual partners within the previous year and those with more than one sexual partner in the previous year (Brown).

Bacterial Vaginosis

Bacterial vaginosis or BV is among the most prevalent lower genital tract infections among 25-36% of childbearing women (Mashburn, 2007). It is characterized by profuse vaginal discharge, bacterial adherence to desquamated epithelial cells, bacterial overgrowth, a specific odor revealed by the addition of potassium hydroxide, and the absence of inflammation (Monif, 2001). Many infected women do not have symptoms. The 10-66% who do, report foul odor as the most common symptom. Vaginal inflammation is caused by an excess of leukocytes in the vaginal wall, the condition in vaginitis rather than vaginosis. BV may bring on complications, such as second-trimester miscarriage, pelvic inflammatory disease, preterm birth, preterm premature rupture of the membranes, chorioamnionitis, postpartum endometritis, post-operative infection and increased susceptibility to HIV (Mashburn).

The patient is among those who develop foul vaginal odor as a symptom. Other than this, she is asymptomatic.

The normal vagina of a childbearing woman is full of lactobacilli, which produce baceriocins, hydrogen peroxide and lactic acid (Mashburn, 2007). Low pH is hostile to bacteria other than lactobacilli. A decrease in the number of lactobacilli and a lowering of pH level enhances the overgrowth of hostile bacteria and the development of BV. Gardnerella vaginalis, Mycroplasma hominus,, Ureaplasma urealyticum, Prevotella, Mobiluncus, Bateroides and Peptostreptococcus cause or are associated with BV (Mashburn).

The patient has an above-normal vaginal pH of 6.

Types I and II BV

Studies in the 80s categorized Gardnerella vaginitis into Types I and II according to the presence or absence of large numbers of white blood cells (Monif, 2001). Type II was characterized by prevalent endocervicitis, similar to sexually transmitted diseases or STDs. Findings in the 90s supported the assumption that Type II BV develops from particular lifestyles with some negative consequences similar to those of STDs. These findings revealed that women with BV had their first sexual intercourse at a younger age than women without BV. The number of lifetime partners was also higher in those with BV than those without. The sexual behavior of women with BV was found to be similar to those at risk for STDs. Those with BV also smoked more and contracted chlamydial infection than those without BV (Monif).

Type II BV could be considered an STD in that its mechanisms of spread are similar to those of STDs (Monif, 2001). The probability of co-infection with partners is high in both diseases. Attributing adverse consequences to BV -- uh as pelvic inflammatory disease, HIV, cervical intraepithelial neoplasm, ectopic pregnancy and secondary infertility -- is, however, without scientific basis at this time. Nonetheless, BV is deemed to be an STD from evidence. The concomitant infection induced by the major STD should be identified and treated along with the major disease (Monif).

Risk Factors

These are douching and race (Mashburn, 2007). Studies showed that BV occurs more often among those who douch once or more a week than those who do not. It occurs 44.8% among black adolescents who regularly douch and after their menstrual period. It is assumed that douching reduces the number of lactobacilli and encourages bacterial growth, although findings have been inconsistent. Vaginal flora is also unstable after the menstrual flora and may enhance infection (Mashburn).

Studies also found BV to be more common among young African-American women at twice the rate than other races (Mashburn, 2007). Smokers and those in poor general health are more susceptible to BV (Mashburn).

Symptoms

Many women with BV present no symptoms (Mashburn, 2007). Fishy odor and vaginal discharge are not reliable symptoms. These were the main findings of a recent study on women, aged 15 to 44, at 12 health departments. They were subjected to a pelvic examination, which included gram stain, gonorrhea and chlamydia tests, and interviews about their symptoms. The results between those later found positive for BV showed that 82% had no vaginal odor while 75% did. Despite the negligible difference, vaginal odor is not considered a reliable symptom of BV (Mashburn).

The patient reports fishy-smelling vaginal discharge.

Diagnosis and Diagnostic Tests

Signs and symptoms merely assist in diagnosing common infections, especially in women who show no signs or symptoms (Mashburn, 2007). Amsel's four diagnostic tests have been trusted in testing for BV. These criteria consist of vaginal fluid pH greater than 4.5; 20% fewer epithelial cells, milky homogenous vaginal discharge; and a positive amine test or "fishy" odor after 10% potassium hydroxide is added. Three out of the four criteria are recommended for an accurate diagnosis. In the absence of a microscope or a skilled practitioner, the Affirm VPIII microbial identification system may be substituted. This DNA probe system can detect significant levels of Gardonella, trichomonads and candida from vaginal fluid. Test results are ready within an hour. The Affirm VPIII Ambient Temperature Transport System keeps a specimen stable up to 72 hours after collection if it needs to be transported. One more test is the QuickVue Advance pH and Amines Test card. The card rapidly tests the pH level of a drop of vaginal fluid at a 94% precision. A newer and easy test is the OSOM BVBlue, which mixes a swabbed specimen from the vagina with a reagent. The test yields sialidase activity or presence in the vaginal fluid in 10 minutes. Sialidase is produced by BV pathogens (Mashburn).

pH Level

The most reliable criterion for detecting BV is a pH>4.5 (Mashburn, 2007). A normal pH should, therefore, rule out BV. A pH >4.5 can also indicate trichomoniasis or muco-purulent cervicitis. Vaginal inflammation more strongly suggests trichomonas or muco-purulent cervicitis, in turn associated with gonorrhea or chlamydial trachomatis (Mashburn).

The patient's pH level is 6, indicating BV.

Wet Smears

These are an inexpensive and relatively easy screening procedure for the most common sexually transmitted diseases, such as BV (Iglesias, Alderman & Fox, 2000). The practitioner should be appropriately trained and experienced in using this procedure. Hence, the proper protocol and quality control are needed to insure accurate diagnosis. The wet smear is quite useful and reliable in diagnosing BV because of the presence of clue cells. These are epithelial cells, which have irregular borders, full of bacteria and appear granular. A diagnosis of BV, using wet smear, is made when three of four findings are present. These four are a vaginal pH greater than 4.5; an abnormal and homogeneous vaginal discharge, fishy odor and presence of clue cells (Iglesias, Alderman & Fox).

A study undertaken by Schmidt and Hansen showed that the wet smear criteria are suitable for general practice (Iglesias, Alderman & Fox, 2000). Accuracy, however, depends on the practitioner's level of education, training and experience in conducting the test properly. Another study compared the wet smear with Pap-stained vaginal smear and the Gram-stain smear. It used 107 women, 34 of whom were diagnosed with BV. The study showed that the Gram-stain test correlated well with the diagnosis and the presence of clue cells on wet smears. Vural and co-authors examined wet smears, cervical smears and biopsies of 131 patients for criteria on lower genital inflammation. They found a close correlation between clue cells on wet smear, on examination and with the grade of inflammation on examination (Iglesias, Alderman & Fox).

Data gathered by Judson and Ehret provided evidence that wet smears had a 54-80% sensitive and 96% specific in detecting C. albicans, 50-70% sensitive and 99-100% specific for T. vaginalis, and 72-80% sensitive and 71-95% specific for BV (Iglesias, Alderman & Fox, 2000). Chacko and Rosenfeld's review of the use of wet smears in the diagnosis of cervical infections showed that cultures were more sensitive to the cause of vaginal discharge. Culture techniques are, however, expensive and labor-intensive. The turnaround time can be long and not in routine use in diagnosing the conditions in many health facilities. Faster techniques need to complement wet smears (Iglesias, Alderman & Fox).

The patient was subjected to tests for sexually transmitted infections, inflammation and to speculum examination for vaginal discharge.

Gram Stain Criteria

Federal regulatory agencies now acknowledge that these criteria have partly replaced the wet-mount criteria as the most reliable diagnostic test for BV (Monif, 2001). This shift brought about two significant conceptual changes. It broadened the conditions of inducible odor, the presence of "clue cells,: and Gram Stain confirmation. It also gave less value to the presence of inflammatory cells. The Gram Stain test is considered excellent in documenting bacterial overgrowth. Poly-microbial flora found in women with BV is also called BV flora. BV flora is associated with abnormalities in pregnancy and after delivery, urinary tract infections, secondary fertility, ectopic pregnancies, upper female genital infections, pre-malignant cervical dysplasia and HIV infection. Demographic studies strongly suggest that BV is "one of the most important diseases of the 20th century (Monif)."

Management/Treatment

The oral regimen for BV consists of 500 mg of metronidazole daily for 7 days (Mashburn, 2007).The recommended intra-vaginal treatment is .75% metronidazole gel daily for 5 days or clindamycin cream 2% once a day for 7 days. Other treatments are 2 grams oral metronidazole as a single dose or ofloxacin 200 orally twice a day. Those who are allergic to metronidazole should be treated with clindamycin. Those with gastrointestinal complications should use intra-vaginal metronidazole, instead. This cream, however, can weaken latex condoms and diaphragms. Another form of contraception should be used as substitute while applying clindamycin vaginal preparations. HIV-positive women are treated the same way as those who are HIV-negative for BV. Oral metronidazole medicines cost much less than the two other recommended regimens (Mashburn).

The patient's oral treatment consists of 2 grams of metronidazole as a single dose or 400 mg metronidazole twice daily for seven days. She may substitute intra-veginal metronidazole or clindamycin cream in case of intolerance for oral metronidazole. She is advised against vaginal douching and the use of genital shower gels or soaps and bath antiseptics.

Recurrence of BV

As high as 70% of women treated for BV experience a recurrence within 9 months after initial diagnosis (Mashburn, 2007). Realizing the problem, the 2006 Center for Disease Control guidelines recommend consultation with a specialist. Another recommendation is diagnosis by Gram stain as the gold standard technique, followed by a 10-to-14-day regimen of oral metronidazole 500 mg twice a day. One more regimen is vaginal metronidazole .075% cream once daily for 10 days and then twice a week for 4 to 6 months. Studies showed that the twice-a-week application for 6 months sustained a clinical cure (Mashburn).

Tinidazole

Relapse does occur after termination of even extended therapy, however (Mashburn, 2007). Furthermore, long-term use of vaginal metronidazole enhances vulvovaginal candidiasis infection. The use of nystatin and metronidazole combined is recommended following evidence of significantly lower recurrence in the combination treatment even up to 104 days after treatment. Tinidazole has also been recommended. It is a derivative of nitroimidazole with a higher peak of concentration and longer half-life than metronidazole. A case report found that treatment with tinidazole 500 mg twice daily for two weeks on a woman with refractory BV made her asymptomatic for 10 months. A 2-gram single-dose tinidazole was likewise effective on non-recurrent BV. Tinidazole also produced fewer gastrointestinal side effects than metronidazole. Recolonization of the vagina with lactobacilli is still under study for recurrent BV and has not been recommended (Mashburn).

Sexual Transmission

Australian researchers found that BV recurs because of sexual transmission (Kerr, 2006). High rates of recurrence were found among first-line therapy users of oral metronidazole, according to Carolina S. Bradshaw of the University of Melbourne and the Melbourne Sexual Health Center at The Alfred Hospital. This was the conclusion reached by the study undertaken by Dr. Bradshaw and her team on 121 respondents with BV symptoms. The respondents took 400 mg of metronidazole twice a day for seven days for the test. The team reported in the June 1st issue of The Joural of Infectious Diseases that 58% of the respondents had a recurrence and 69% at the 12th month of follow-up. The research team determined that the risk factors were a past history of BV, a regular sexual partner and a female sex partner. Dr. Bradshaw suspected an unknown and unresponsive virus or bacterium that disturbs vaginal immunity and kills protective lactobacilli. Current treatment did not treat the cause of the infection either in the woman or the sexual partner. In addition, there is substantial evidence that BV is transmitted between women. The team's position was that the definite cause of BV has not been established and practitioners only assume that it will respond to antibiotics. Dr. Bradshaw also said that new therapies were being developed. One of these is probiotics, which contain lactobacillus species (Kerr).

Efficacy of Human Lactobacilli

A recent study was conducted to determine if supplementary lactobacilli could improve cure rate after a vaginal clindamycin treatment and increase time of relapse (Larsson, Stray-Pedersen & Larsen, 2008). The study used the Amsel criteria on 100 respondents with BV who were asked to use the treatment and vaginal gelatine capsules or placebo. The gelatine capsules contained 109 freeze-dried lactobacilli. These were applied for 10 days during their menstrual cycles. The respondents were regularly menstruating women 18 years old and older. They had normal gynecological conditions, neither pregnant nor breast feeding at the time of the study and had no signs of other genital tract problems. Results showed that supplementation did not improve the effectiveness of BV therapy in the first month of treatment. But it increased the time of relapse up to 6 months during which the women were free of BV (Larsson, et al.).

There is loss or reduction of lactobacilli in BV, which increases overgrowth of harmful bacteria (Larsson, et al., 2008). BV can also adversely affect pregnancy, so that treatment in early pregnancy is needed to reduce the chances of preterm deliveries. In a follow-up study on the efficacy of oral and vaginal metronidazole showed that only 48% of the respondents were BV-free in the 12 months after therapy. The presence of sufficient lactic-acid-producing bacilli maintains the normal bacterial environment of the vagina and maintains a low pH at below 4/5. It also protects against harmful bacteria. The most dominant strain is lactobacillus acidophilus. But tests run on women who had BV and received ovules with the bacterial strain were only initially cured. A relapse following their next menstruation reduced the cure rate to only 18% after 4 weeks. Reid and his team, however, restored asymptomatic BV to the lactobacilli-filled environment of the normal vagina of 37% of respondents after an oral regimen of L. fermentum and L. casei. Another team who administered an oral regimen of metronidazole obtain a high 88% cure among select respondents of women in Nigeria (Larsson, et al.).

The results showed that it took long for BV to recur in some of the respondents (Larsson, et al., 2008). The increase in the number of recurring Gardnerella morphotype was 0 in the first month, 50 in the second, 100 in the third, 500 in the fourth, 2000 in the fifth and 4000 in the sixth. This suggested that the infection was not new but only suppressed and escaped detection by clinical methods. Clindamycin vaginal cream is the recommended treatment. It destroys almost all bacteria in the vagina and significantly reduces the number of lactobacilli morphotype bacteria (Larsson, et al.).