Understanding vaginal health

A. What all these terms mean?

Vaginal health: A balanced ecosystem, has a resident Vaginal Flora and it is a delicate & dynamic equilibrium that is dependent on 4 factors:

the presence or absence of estrogen
the presence or absence of glycogen,
the presence of flora, & whether it’s healthy or unhealthy flora,
pH- should be acidic

Protective defences in the vagina:

Vaginal mucosa is a physical barrier designed for friction like epithelial cells on skin.
Continuous mucus stream coming from vaginal walls & cervix carries antimicrobial factors and washes microorganisms from vagina.
Squamous cells produce defensins and cytokines in response to pathogens and pro inflammatory changes (can cause dz as well as pathogen) > immune response.
pH <4.5 is inhospitable to many bacteria. Acidity created as bi-product of lactobacilli metabolism of glycogen.
Other non-specific antimicrobial factors.
Immunocompetent cycle is result of hormone stimulation.

Normal vaginal discharge:

Clear or White
Discharge does not cause itching or burning,
On average, 1.6 gm of discharge within 8hours. For some women having more or less is normal.

Diagnostic Findings with a Normal Flora:

Patient Complaints: None,
Vaginal pH: 3.8-4.2,
Discharge: White, clear, flocculent,
Aminc Odor (KOH whiff test): Absent,
Microscopic: Lactobacilli

Factors affecting normal vaginal flora:

Douching – Hygiene (should not be any soap in the vagina),
Vaginal ph,
Vaginal Infections,
Different phases of Menstrual Cycle (different hormones- growth of yeast just before menses),
Pregnancy,
Sexual Risk,
History,
Contraceptive Use,
Medical History,
Diet

Microbial Shift: Term used for the abundance of flora present in Bacterial Vaginosis. Clue cells are visible under a microscope.

Lactobacilli: Lactobacillus is a genus of Gram-positive, facultative anaerobic or microaerophilic, rod-shaped, non-spore-forming bacteria. They are a major part of the lactic acid bacteria group. In humans, they constitute a significant component of the microbiota at a number of body sites, such as the digestive system, urinary system, and genital system. In the vagina:

Lactobacilli form as a response to estrogen.
Increase in glycogen content of vaginal epithelial cells,
Produce hydrogen peroxide H2O2 as part of natural life cycle, which inhibits Bacterial Vaginosis (BV) , NG, CT, Trichomonas, and HIV.
Lactobacilli compete for binding sites on epithelial cell sites.
Lactobacilli also stimulate the immune system on local cellular level.

When do lactobacilli increase or decrease? It’s the predominant vaginal flora from puberty (not there prior as there is no estrogen) Numbers decrease immediately postpartum and during menopause because of the decrease in estrogen.

Vaginal pH: Vagina is normally acidic: 3.8-4.2, this facilitates metabolism of glycogen to lactic acid by lactobacilli and other bacteria.

Measuring vaginal pH: There are several types of pH paper that is used.

Normal vaginal pH is between 3.8 and 4.2.
If higher that 4.5: at risk for BV or trich,
If between 4.2 and 4.5: Maybe at risk for yeast. Need re-evaluation. Possibly cervical fluids have been mixed with the vaginal fluids. Note that Cervical ecosystem is different from Vaginal ecosystem.

Factors falsely affecting pH:

Saline falsely elevates pH,
Endocervical secretions have a higher pH than vaginal secretions,
Cervical & menstrual secretions tend to be alkaline,
Lubricant on the speculum can falsely change pH

What raises pH > 4.5:

NON-INFECTIOUS: Menses, Ovulation, Semen/Saliva (basic), Hypoestrogenism (atrophic), Hormones (Pregnancy, Oral Contraceptive Pills),
INFECTIOUS: Trichomonas,
INFLAMMATION: retained foreign object (tampon, condom), overgrowth of normal flora, Yeast, Bacterial Vaginosis, Group A Strep.

Vaginitis: Inflammation of the Vagina. Inflammation is a process by which the body’s white blood cells and substances they produce protect us from infection with foreign organisms, such as bacteria and viruses.

Clinical presentation of Vaginitis:

90% of patients report Itching, because of the fungal metabolism of sugars into alcohol,
Erythema (red skin) is often a sign,
Edema of labia minora (inner lips),
Excoriations from scratching,
20% vaginal redness,
Thrush patches in 20% of non-pregnant patients, and 70% of pregnant patients
Musty odor,
Dry mucous membranes,
Satellite lesions,
Fissures (paper cuts),
Could also be Herpes (HSV)

Vulvitis: Inflammation of Vulva (external female sex organs)

Vulvovaginitis: Inflammation of the Vulva and the Vagina.

Vaginitis causes: Vaginal complaints are responsible for more than 10 million office visits per year. Three most common causes in order of prevalence is: Bacterial Vaginosis (BV), Candidiasis (VVC) and Trichomoniasis (Trich).

Vaginosis

Infection of the Vagina by anaerobic bacteria.

Cytologic Vaginosis: Results from Lactobacillus overgrowth and is characterized by a transformation in the length of lactobacilli, frequently confused with candidiasis. It’s easily diagnosed and treated.

Symptoms of Cytologic Vaginosis: Complaints include:

thick or thin white cheesy vaginal discharge,
pruritus, dyspareunia,
vulvar dysuria, and a
cyclic increase in symptoms that are more pronounced in the luteal phase (latter phase of the menstrual cycle)

Pathogens associated with Vaginosis: Polymicrobial condition of mixed flora including: Gardnerella vaginalis, anaerobes (Bacteroides ureolyticus, Prevotella, Porphyromonas, Peptostreptococcus, Mobiluncus), and Mycoplasma hominis.

Cervicitis: Inflammation of the Cervix, because of Herpes Simplex Virus (HSV), Human Papillomavirus (HPV), Chlamydia and other General Conditions.

Yeast infections: Also knows as: Candida, Vulvovaginal Candidiasis, Monilia. Cause a sunburn-like red rash.

Trichomoniasis: Trichomoniasis is an infectious disease caused by the parasite Trichomonas vaginalis. About 70% of women and men do not have symptoms when infected.

What is “Wet Prep”: Normal vaginal secretions seen on wet smear. Wet smear is a gynecological test wherein a sample of vaginal discharge is observed by wet mount microscopy by placing the specimen on a glass slide and mixing with a salt solution. It is used to find the cause of vaginitis and vulvitis.

OB / GYN medical tools used to exam someone with vaginitis:

Speculum,
pH paper,
long Q-tip,
wooden spatula,
grease pencil (if multiple slides),
gloves, medicine
dropper bottles of normal 0.9% NaCl & 10-20% KOH,
glass slides,
cover slips,
microscope w/ both low & high power objective settings

Probiotics: Live micro-organisms which are used to displace the harmful ones, and can be found in Lactobacillus preparations and yogurts containing live cultures.

They can potentially:

Displace/ kill pathogens,
Modulate immune response,
Interfere with cytokine levels,
Promote embryo development,
Lactobacilli can regenerate the vaginal flora of women with recurrent episodes of bacterial vaginosis

Chronic vaginal symptoms and complaints: Women with chronic vaginal symptoms often use Over-The-Counter (OTC) treatments and alternative medicines that add to health care costs and are unlikely to be of benefit Based on a study by Nyirjesy, 42% of women used alternative methods for the treatment of vaginal symptoms. Alternative medicines may change the data physicians collect for diagnosis and treatment. It’s wise to inform your doctor.

B. Bacterial Vaginosis

Bacterial Vaginosis (BV): Overgrowth of Gram-negative and Gram-variable rods and cocci (i.e., G. vaginalis, Prevotella, Porphyromonas, and peptostrept-ococci).

Curved Gram-negative rods (Mobiluncus) characteristic of BV is considered the gold standard laboratory method for diagnosing BV.

Culture of G. vaginalis is not recommended as a diagnostic tool because it is not specific, as it would get tons of bacteria.

Is Bacterial Vaginosis (BV) an STI? It’s not a sexually transmitted infection. 50% of women have no symptoms, but many women are carriers. Gray discharge with a pungent fishy odor is common when infected.

BV basic symptoms: Main reported and identifieds symptoms are:

gray discharge,
odor,
Vaginal pH > 4.5,
positive amines,
clue cells

Clinical Presentation of BV:

Increased vaginal discharge.
Itching, and fishy odor, particularly after intercourse. Fishy odor results primarily from metabolic by-products of anaerobic bacteria. Itching and burning of the vagina and lips similar to yeast.
Odor is usually noticeable after menses and intercourse due to the alkalinity of blood and semen.
Thin, gray-white, homogeneous discharge tends to adhere to vaginal wall.
Vulvar pruritis/irritation is not common but may occur.

BV affect on pH: BV causes an increase in vaginal pH. May be worse after intercourse, as semen is causing the release of amines; semen creates an alkalotic pH, more than the optimum below 4.5 for vagival balance.

BV diagnostic criteria: Clinical criteria require three of the following symptoms:

1) Homogenous, white noninflammatory discharge coats the vaginal wall,

2) Clue cells (Clue cells have irregular borders full of bacteria, with a granular appearance),

3) A pH of vaginal fluid >4.5

4) A fishy odour of vaginal discharge before or after the addition of 10% KOH (whiff test)

Not recommended for BV diagnosis:

1) Cervical Pap tests are not used for d of BV because of low sensitivity.

2) A card test for the detection of elevated pH and trimethylamine (QuickVue Advance Quidel) as it has low sensitivity and specificity and not recommended.

BV & Douching: If women douche will have BV more often. Women who douched for the purpose of hygiene were 2 times more prone to have a BV hazard than of all other women. Those who douched because of symptoms at least 1time/mo was associated with increased frequency of BV by 1.4-fold. Alterations in the vaginal pH from douching can disrupt the vaginal environment and be less protective against pathogenic organisms. Douching can also increase the risk of Pelvic inflammatory Disease (PID).

BV & HIV: BV increases the risk of getting HIV and increases the risk of giving HIV, because the normally low pH of the vagina inhibits CD4+ lymphocyte activation and decreases the number of HIV target cells, such as lymphocytes and macrophages, in the vagina.

Most treatments recipients failed to regain normal lactobacilli in the vagina after treatment, suggesting incomplete resolution of disturbances that may contribute to the increased detection of HIV.

BV and other flora: Lactobacillus species that produce H2O2 are present in the healthy vagina, and can be virucidal to HIV. With BV, H2O2-producing lactobacilli disappear and high levels of Mycoplasma hominis are found. These positive effects may be lost with the rise in pH associated with BV.

BV prevalence: 15-50% of vaginitis cases are caused by Bacterial Vaginosis.

Recurrent BV: It is found that for reasons that are not yet clear enough and agreed upon, BV becomes recurring in some people but does not recur among others. 58% of women had BV recurrence and 69% had a return of abnormal flora at a 12-month follow-up OB/GYN visit.

CDC (Centers for Disease Control and Prevention) categorizing of BV: An emerging infectious disease: increasingly recognized as a cause of adverse pregnancy outcomes, associated with an increased risk of HIV in women, not routinely recognized by either women or healthcare providers, treatments aren’t always successful (1/5 women will recur in 1 month following treatment).

CDC recommendations for pregnant women with BV: Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (i.e., those with a previous preterm birth) has yielded mixed results. Evidence is insufficient to assess the impact of screening for BV in pregnant women at high risk for preterm delivery.

Complications of Pregnancy associated with BV: Staphylococcal bacteremia (SAB), Premature rupture of membranes (PROM) and Pre-term labor.

Treating did not always get rid of risk of complications. Probably it has to do with inflammatory response. Even if you get rid of the pathogen, women still have inflammatory response.

Holistic treatment for Recurrent BV: The concept is to to re-colonize vagina with healthy lactobacilli: One school of thinking is that BV has reservoir in gut & will not get the vagina healthy until gut becomes healthy. Take Probiotics orally, as probiotics suppress the growth of pathogens within the vaginal vault associated with BV.

C. Yeast Infections and Candida

Candida prevalence: They are responsible for 33% of all vaginitis cases. Most common in premenopausal women. 10-55% of women are asymptomatic. It’s a Fungus called Candida species: 80% Candida Albicans, 20% by other Candida.

Cause of Candidiasis: Predisposing factors are Pregnancy, Diabetes, Antibiotics, Immunosuppression.

Causes of Yeast Infections: Main causes are:

1) Antibiotics: probably the leading cause of vaginal yeast infections- destroys lactobacilli,
2) Clothing: non-cotton, tight, or dirty clothes that trap heat and moisture,
3) Chemicals: inks, dyes, and perfumes, douches, nonoxynol-9,
4) Hormones,
5) Intercourse: oral or penile, change in the vaginal environment, injury, sexual transmission, or HIV,
6) Common environmental disruptions

Diagnostics for Yeast Infections: In order to diagnose for possible Yeast Infections we use:

1) pH testing: 4.0 – 4.7
2) Wet mount: See if positive or negative for Lactobacilli
3) KOH: Hyphae or Spores identified. They may also be seen on wet mount.

Other possible risk factors for yeast infection:

Oral Contraceptive Pill (OCP) use is debated because: Cyclic administration of Est/Prog creates “normal” Leukorrhea, creates a vaginal environment similar to pregnancy and causes the thinning of the vaginal wall by progestational agent, that may increase susceptibility to infection.
Being Premenarcheal or Post menopausal.
Heat of Summer or Dead of Winter.
Diabetes (increased alkalinity).
Non-diabetic glycosuria (excretion of glucose into the urine, caused by elevated blood glucose levels)
Being Immunocompromised (HIV, steroids),
Lovers of sweets,
Debilitated patients

Recurrent yeast infections: A lot of women have recurrent yeast infections, which is defined as ≥ 4 symptomatic episodes per year.

Recurrent yeast infections via gut: More than 2 episodes per year is common and not “recurrent”. There is an intestinal reservoir for candida. The question of whether its pathogenic. Large volume of candida in the gut can be a source of re-infection. 75% of the population have recoverable candida in stool and oral secretions.

Recurrent yeast infections via sexual transmission: Sometimes, Candida stored in prepuce of penis can re-infect. Also it’s found in ejaculate of 15% of men. 36% of couples have oral candidiasis, and 33% rectum.

Recurrent yeast infections via vaginal allergic response:If there is an allergic response in the vagina, candida can be influenced by this.

Candida albicans: Candida albicans is an opportunistic pathogenic yeast that is a common member of the human gut flora. It can also survive outside the human body. It is detected in the gastrointestinal tract and mouth in 40–60% of healthy adults. High frequency of genetic switching which has to do with what it has been exposed to Over-The-Counter (OTC) meds, expression of differing antigen and virulence factors.

Other Candida Species: CandidaTropicalis , C. Glabrata , C.Krusi (>risk of chronicity), C. Pseudotropicalis, C. Stellatoida, C. Quillurmondi.

Candida infection: Symptoms when infected by candida (most common is Candida albicans: Itching, White discharge, Dyspareunia (painful intercourse), Vulvar erythema (red-skin, rush), pH 4-4.5, Negative amines, Pseudo- hyphae, White Blood Cells (WBC).

Diagnostic Findings with Vulvovaginal Candidiasis (VVC):

Patient Complaints: Itching, burning, discharge
Vaginal pH: 4.0 – 4.5 usually,
Discharge: White, curdy, cottage cheese-like, sometimes increased,
Aminc Odor (KOH whiff test): Absent; KOH may mislead,
Microscopic: Mycclia, budding yeast, pseudohyphae with KOH prep

CDC definition of Complicated VVC:

Recurrent VVC OR
Severe VVC from Non-Allbicans candidiasis OR
Women with uncontrolled diabetes, debilitation, or immunosuppression, or those who are pregnant

Complicated VVC: Affects a small percentage of women (<5%). Pathogenesis of RVVC is poorly understood. Majority of women have no apparent predisposing/underlying conditions,

Common environmental disruptions causing yeast infections:

increased pH,
increased heat and moisture,
allergic reactions,
elevated sugar levels (the more glycogen the more the yeast is fed like with diabetes),
hormonal fluxes,
reductions in the populations of bacteria that are normally present.

D. Trichomoniasis

What causes Trichomoniasis: Caused by protozoan T.vaginalis. Trichomonads are small flagellated organisms and are grayish-blue in color, with a nucleus and flagella (hair-like structure used for motion). They are smaller than epithelial cells and may be confused with white blood cells.

Protozoa are organisms that have no cellular make-up and possess only one nucleus. Easily transmitted (warm and wet- by washcloth)

Symptoms:

Strawberry cervix (A “strawberry cervix” is a finding upon examination where the cervix has a punctate and papilliform appearance) and or diffuse of
Malodorous discharge,
Yellow-green, purulent discharge
Vulvar irritation
pH 4-6
Dyspareunia (Dyspareunia is painful sexual intercourse)
Presence of white blood cells
Trich-flagella (seen under microscope)

Trich prevalence:

It’s responsible for 15-20% of vaginitis but probably underdiagnosed.

It’s most prevalent in 20-45 year olds,
25-50% of cases are asymptomatic,
Infected women have increased risk for HIV when also have Bacterial Vaginosis (BV).
Also they have increased risk for being infected from the gynaecological examination because of E. coli can attach to trich-flagella.

Diagnosis of Trichomoniasis: There are mainly three methods used:

1) Microscopic: wet prep with 60-70% sensitivity. It means that there is a 30-40% chance the doctor could miss it.
2) Pap-smear: has limited sensitivity and low specificity. Use of a liquid-based testing has enhanced sensitivity, although false-positive tests can occur.
3) Culture: Is sensitive and highly specific. Mainly, the prefered method.

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