Vaginosis
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Bacterial vaginosis (BV) is the most common cause of vaginal infection (vaginitis). For grammatical reasons, some people prefer to call it vaginal bacteriosis. It is not generally considered to be a sexually transmitted infection¹ (see causes below). BV is caused by an imbalance of naturally occurring bacterial flora, and should not be confused with yeast infection (candidiasis), or infection with Trichomonas vaginalis (trichomoniasis) which are not caused by bacteria.

Symptoms and signs

The most common symptom of BV is an abnormal vaginal discharge (especially after sex) with an unpleasant fishy smell. While some women do not experience symptoms, many women experience intense itching, swelling and irritation (which is why it is often misdiagnosed by patients and even health care practitioners as a yeast infection), as well as stomach pains, which feel like severe cramps. By contrast, a 'normal' discharge will be odorless and will vary in consistency and amount with the menstrual cycle - a normal discharge is at its clearest about 2 weeks before the period starts. hoihoihoihoihoihoihoihoihoihoi

Diagnosis

A healthcare professional seeing a woman presenting with questions about vaginal discharge and irritation in the vagina and vulva will have several diagnoses in mind to account for it. These may include:

• The discharge is normal for the woman
• Candidiasis (thrush, or a yeast infection)
• Trichomoniasis, an infection caused by Trichomonas vaginalis
• Bacterial vaginosis

Simple tests can be done to make the proper diagnosis. The healthcare provider will carry out a speculum examination and take some swabs from high in the vagina. These swabs will be tested for:

• A characteristic "fishy" odor on wet mount. This test, called the "whiff test", is performed by adding a small amount of potassium hydroxide to a microscopic slide containing the vaginal discharge. A characteristic "fishy" odor is considered a positive whiff test and is suggestive of bacterial vaginosis.
• Loss of acidity. To control bacterial growth, the vagina is normally slightly acidic with a pH of 3.8–4.2. A swab of the discharge is put onto litmus paper to check its acidity. A pH greater than 4.5 is considered alkaline and is suggestive of bacterial vaginosis.
• The presence of clue cells on wet mount. Similar to the whiff test, the test for clue cells is performed by placing a drop of sodium chloride solution on a slide containing vaginal discharge. If present, clue cells can be visualized under a microscope. They are so-named because they give a clue to the reason behind the discharge. These are epithelial cells (like skin) that are coated with bacteria.

Two positive results in addition to the discharge itself are enough to diagnose BV. If there is no discharge, then all three criteria are needed.² A 1990 study demonstrated that the single best test for BV was the test for clue cells on wet mount examination. The best combination of two tests for BV was the test for clue cells and the whiff test.³

In clinical practice

In clinical practice BV is diagnosed using the Amsel criteria:²

1. Thin, white, yellow, homogeneous discharge
2. Clue cells on microscopy
3. pH of vaginal fluid >4.5
4. Release of a fishy odor on adding alkali—10% potassium hydroxide (KOH) solution.

At least three of the four criteria should be present for a confirmed diagnosis.¹

An alternative is to use a Gram stained vaginal smear, with the Hay/Ison⁴ criteria or the Nugent⁵ criteria. The Hay/Ison criteria are defined as follows: ¹

• Grade 1 (Normal): Lactobacillus morphotypes predominate.
• Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present.
• Grade 3 (Bacterial Vaginosis): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli. (Hay et al., 1994)

What this technique loses in interobserver reliability, it makes up in ease and speed of use.

The standard for research are the Nugent⁵ Criteria. In this scale a score of 0-10 is generated from combining three other scores. It is time consuming and requires trained staff but is has high interobserver reliability:

• 0–3 is considered negative for BV
• 4–6 is considered intermediate
• 7+ is considered indicative of BV.

At least 10–20 high power (1000× oil immersion) fields are counted and an average determined.

A recent study ⁶ compared the gram stain using the Nugent criteria and the DNA hybridization test Affirm VPIII in diagnosing BV. The Affirm VPIII test detected Gardnerella in 107 (93.0%) of 115 vaginal specimens positive for BV diagnosed by gram stain. The Affirm VPIII test has a sensitivity of 87.7% and specificity of 96% and may be used for the rapid diagnosis of BV in symptomatic women.

Causes

A healthy vagina normally contains many microorganisms; some of the common ones are Lactobacillus crispatus and Lactobacillus jensenii. Lactobacillus, particularly hydrogen peroxide-producing species, appears to help prevent other vaginal microorganisms from multiplying to a level where they cause symptoms. (Note: Lactobacillus acidophilus is not one of the species of Lactobacillus identified as playing a protective role in vaginal flora.) The microorganisms involved in BV are very diverse, but include Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma. A change in normal bacterial flora including the reduction of lactobacillus, which may be due to the use of antibiotics or pH imbalance, allows more resistant bacteria to gain a foothold and multiply. In turn these produce toxins which affect the body's natural defenses and make re-colonization of healthy bacteria more difficult.

There are a variety of causes for bacterial vaginosis. Thongs are notorious for causing bacterial vaginosis due to the cloth rubbing against the anus and vagina. Cases of bacterial vaginosis are more likely to occur in sexually active women between the ages of 15 and 44, especially after contact with a new partner. Condoms may provide some protection and there is no evidence that spermicide increases BV risk. Although BV can be associated with sexual activity, there is no clear evidence of sexual transmission.⁷ It is possible for virgins to get infected with bacterial vaginosis. Rather, BV is a disordering of the chemical and biological balance of the normal flora. Recent research is exploring the link between sexual partner treatment and eradication of recurrent cases of BV. Pregnant women and women with sexually transmitted infections are especially at risk for getting this infection. Bacterial vaginosis may sometimes affect women after menopause. A 2005 study by researchers at Ghent University in Belgium showed that subclinical iron deficiency (anemia) was a strong predictor of bacterial vaginosis in pregnant women. A longitudinal study published in February 2006 in the American Journal of Obstetrics and Gynecology showed a link between psychosocial stress and bacterial vaginosis independent of other risk factors.

A higher incidence in women who have sex with women have led some to hypothesize that sexual exchange of vaginal secretions is a possible mechanism for acquisition.⁸⁹

In pre-pubescent girls, bacterial vaginosis may be caused by strep, or by bacteria introduced from the anus due to improper hygiene (wiping) after bowel movements.

Complications

Although previously considered a mere nuisance infection, untreated bacterial vaginosis may cause serious complications, such as increased succeptibility to sexually transmitted infections including HIV, and may present other complications for pregnant women.¹⁰ It has also been associated with an increase in the development of Pelvic inflammatory disease (PID) following surgical procedures such as a hysterectomy or an abortion.

Treatment

Bacterial vaginosis can be treated with antibiotics such as metronidazole and clindamycin. However, there is a high rate of recurrence.⁷ Moreover metronidazole is suspected cancerogenic.¹¹ It is banned in EU for veterinary use as it is proved cancerogenic in animals. ¹²

BV is twice as common as thrush and it is estimated that 1 in 3 women will develop the condition at some point in their lives.¹³¹⁴ In addition to the physical discomfort and symptoms, BV can also have a significant impact on a woman’s quality of life.

Currently, there are very few over the counter products that address bacterial vaginosis. They work after different principles: 1. Eliminating the unwanted bacteria. Example Tea-tree oil products, FemiGel. Same principle as the antibiotics. 2. Adding buffer / acid to lower the pH. RepHresh is an example. 3. Adding lactic bacteria. Fem-dophilus (Jarrow Formulas) is a lactobacillus product which specifically claims to help maintain healthy vaginal flora.¹⁵. 4. Adding nutrient (lactose) to supply the indigenous bacteria with substrate, to grow and produce acid. The effect is due to the protection obtained by a strong bacterial flora. This principle is used in LadyBalance.¹⁶ Most of the over-the-counter products are not documented by clinical trials. But as many women cannot eliminate bacterial vaginosis by prescription drugs, they select from the abovementioned products.¹⁷

References