Bacterial vaginosis (BV) is known by many terms, including nonspecific vaginitis, Gardnerealla vaginalis, bacterial vaginitis, Haemophilus vaginalis, Corynebacterium vaginalis, and anaerobic vaginosis. This condition is caused by an overgrowth of several species of vaginal organisms, which may be transmitted by sexual activity. Bacterial vaginosis is considered a sexually associated condition but not necessarily a sexually transmitted infection. Although Bacterial vaginosis does not usually cause complication on its own, it is considered to be a co-factor in the acquisition of other sexually transmitted disease, including HIV. Bacterial vaginosis is more prevalent among women with more than one sexual partner, intrauterine device (IUD) users, and women who have cervicitis.
The most common cause of abnormal vaginal discharge, bacterial vaginosis is very common, usually detected in 10% to 40% of women worldwide. Symptoms include a gray or white frothy discharge that may be thick or watery and that may have an objectionable odor. Painful urination, vaginal pain or burning during intercourse, redness, and itching may also be present.
White many women complain of vaginal odor, discharge, or irritation, as many as 50% of women with bacterial vaginosis may be asymptomatic, thus, routine screening is recommended whenever STI testing is indicated. Identifying bacterial vaginosis is relatively straightforward. Diagnosis may be made with microscopic examination of a discharge sample or a wet mount of vaginal cells. Recent studies have shown that pregnant women with bacterial vaginosis have an increased risk of delivering preterm, low birth-weight infants. Bacterial vaginosis may coexist with other STIs and has been indentified as a possible factor in HIV transmission. Because bacterial vaginosis also may be associated with PID, definitive, diagnosis is important to ensure adequate treatment.
Recommended treatment regimens consist of antibiotics, usually either oral or vaginal metronidazole or vaginal clindamycin. The vaginal treatment regimen is associated with fewer gastrointestinal side effects that the oral regimen. Treatment of sexual partners is not standard procedure, although it may be indicated if re-infection occurs after treatment or if sexual transmission is suspected as the mode of acquisitions.
Regular douching can increase a woman’s risk of bacterial vaginosis. Douching may harm the vaginal flora and can increase the risk for bacterial vaginosis as well as other infection.
Incidence of Bacterial vaginosis
According to the CD bacterial vaginosis is the most vaginal infection in women of childbearing age and is common in pregnant women. It is not considered exclusively an STD.
- The main etiologic agent in bacterial vaginosis is an increase in anaerobers in the vagina. The reason this occurs is unknown. The normal lactobacilli of the vagina decrease and vaginal pH is increased in bacterial vaginosis. The organisms present in BV cause the level of vaginal amines to be high. These amines are volatilized when the pH is increased, causing the characteristic “fishy” odor.
- Bacterial vagnitis is primarily polymicrobial, and the pathogens seen include Bacterial species, Peptostreptococcus species, Eubacterium species, Mobiluncus species, Gardnerella, and Mycoplasma hominis. The incubation period is unknown.
Predisposing Factors of bacterial vaginosis
- History of sexually transmitted diseases
- Multiple sexual partners
- Intrauterine device use
- Factors that change the normal vaginal flora:
- Hormonal changes (means, pregnancy)
- Medication: Oral contraceptive use and antibiotic therapy
- Foreign bodies in the vagina (tampons, IUDs), semen, and douching
- Vaginal discharge (thin, white, gray, or milky)
- Fishy vaginal odor
- Postcoital odor
Other signs and symptoms of bacterial vaginosis
- Increase in odor after menses
- Itching and burning, occasional
- Elicit onset, duration, and course of presenting symptoms.
- Review any changes in the characteristics and color of vaginal discharge. Does the patient’s partner (s) have any symptoms?
- Review any symptoms of pruritis, perineal excoriartion, burning; signs of urinary tract infection.
- Review medications and medical history.
- Determine if the patient is pregnant; note date of last menstrual period (LMP).
- Question the patient for a history of STIs or other vaginal infections.
- Review previous infection, treatment, compliance with treatment, and results.
- Note last intercourse date.
- Elicit information about possible foreign body.
- Review use of vaginal deodorants or sprays, scented toilet paper, tampons, pads, and douching habits.
- Review a change in laundry detergent, soaps, and fabric softeners.
- Review the use of tight restrictive clothing, tight, jeans, and nylon panties.
- Review history for seizures and anticoagulant therapy.
Diagnosis of bacterial vaginosis
- Clinical picture. The discharge is white (rarely gray), creamy, bubbly (rarely foamy).
- pH value. With bacterial vaginosis, the pH is between 4.8 and 5.5 (pH strips from Merck, product No. 9542), whereas a normal lactobacillus flora is associated with a pH between 3.8 and 4.5, depending on lactobacilli numbers.
- Amine test. The fishy odor associated with bacterial vaginosis is caused by amines produced by anaerobic bacteria. The odor is only noticeable when these bacteria are present in high numbers. Addition of one to two drops of 10% potassium hydroxide solution to the discharge on a cotton or microscopic slide intensifies the fishy odor.
- Microscopy. Clue cells are visible in wet mounts and less clearly in gram-stained pre-parations. These are cells from the vaginal epithelium that are covered with a dense layer of small bacteria, most often Gardnerella vaginalis. The epithelial cells also be covered with other bacteria, for example, mobiluncus, fusobacteria, and cocci. They are especially easy to recognize in the wet mount after staining with 0.1% methylene blue solution. In addition to clue cells, a high count of small, morphologically distinguishable bacteria is also characteristic for bacterial vaginosis: for example, curved gram-negative bacteria like mobiluncus are easily identified in a wet mount by their spinning movements.
Very long, thin, and straight bacteria with pointed ends are also seen occasionally: these are fusobacteria. The methylene blue stain allows only a distinction according to shape and size, whereas it is possible to differentiate between gram-positive and gram-negative bacteria in pre-parations stained with the Gram method.
Treatment of bacterial vaginosis
A single 2-g oral dose of metronidazole (Flagyl) is the recommended treatment of choice. An alternative regimen is metronidazole, 500 mg orally twice daily for 7 days. The cure rate is 95% in females. If symptoms persist and wet smears from the vagina still show trichomonads, the course of treatment is repeated. Only in unusually persistent cases is a third course necessary.
Strains resistant to metronidazole are rare findings. The patient should be warned of possible gastrointestinal side effects (nausea, diarrhea). Alcohol can aggravate the side effects of metronidazole therapy and cause a disulfiram (antabuse) like reaction. Thus, the patient should be instructed not to consume alcoholic beverages during treatment. She should be told that trichomoniasis is a sexually transmitted disease and that her sexual partner should be treated. Reacquisition of infection should be prevented via sexual abstinence or use of condoms.
Metronidazole is not a recommended drug during the fist trimester of pregnancy because of reports of spontaneous abortion, developmental anomalies, and prenatal death. A risk of preterm labor has been reported from the use of imtronidazole prescribed for Trichomonas infection during the first trimester of pregnancy. Clotrimazole vaginal suppositories, one a day for 7 days, have been found to cure two thirds of patients. Gentle vaginal douching with vinegar and water may relieve symptoms somewhat but should not be encouraged during pregnancy. Metronidazole gel has been studied for the treatment of trichomoniasis and, therefore, should not be used.
Homeopathic treatment of bacterial vaginosis
Homeopathy is one of the most popular holistic systems of medicine. The selection of remedy is based upon the theory of individualization and symptoms similarity by using holistic approach. This is the only way through which a state of complete health can be regained by removing all the sign and symptoms from which the patient is suffering. The aim of homeopathy is not only to treat bacterial vaginosis but to address its underlying cause and individual susceptibility. As far as therapeutic medication is concerned, several medicines are available for the treatment of bacterial vaginosis that can be selected on the basis of cause, sensation and modalities of the complaints. For individualized remedy selection and treatment, the patient should consult a qualified homeopathic doctor in person. Some important remedies are given below for bacterial vaginosis treatment:
Belladonna, Hydrastis, Caladium, Cannabis Sativa, Cantharis, Helonias, Kreosote, Medorrhinum, Thuja, Staphisagria, Platina and many other medicines.
- Linda Lewis Alexander, Judith Larosa, William James Alexander- New Dimensions in Women’s Health; 2009; 184-185.
- Jill C. Cash, Cheryl A. Glass- Family Practice Guidelines; 2010; 321.
- Eiko E Petersen- Infections in obstetrics and gynecology: textbook and atlas; 2006; 125
- Ralph D. Feigin- Textbook of pediatric infectious diseases, Volume 1; 2004; 581