BACTERIAL VAGINOSIS, A Trouble Maker!

Nature has maintained a precise balance in our bodies, which assures a normal healthy body. There are various lines of defense against diseases which are supplemented with various chemical factors, pH or level of acidity is one of it; a little disturbance in it can create problems.

You will be surprised to know that to protect against sexually transmitted diseases, there is balance between various organisms. Most important of which is H₂O₂ (Hydrogen per Oxide) producing Lactobacilli which give protection to body by maintaining acidic vaginal pH. Competitively arresting growth of other disease-causing organisms by making them susceptible to destruction and also killing them.

This blog will guide you about a very common but ignored problem of infective vaginal discharge, it’s causes, treatment and problems associated with it.

What is bacterial vaginosis (BV)?
It is vaginal discharge caused by infection of mixed bacteria.

What is the cause?
There is change of normal maintained acidic vaginal pH due to decrease or imbalance of normal H₂O₂ (Hydrogen per Oxide) producing vaginal flora (Lactobacilli), resulting in increase in alkanity due to which other bacteria or fungi start to grow.

What is normal vaginal pH?
Normal vaginal pH is acidic around 4 to 4.5 

How common is this problem?
It affects nearly half of female population out of which only one third of patients consult a doctor for its treatment.

What do patient’s complaint?
Some of the most common complaints are:

• Vaginal sourness and pain
• Pain and irritation while passing urine 
• Painful intercourse

What are signs of BV?
There is mild to moderate thin greyish white watery vaginal discharge with (amine) fishy smell, which increases after periods or intercourse.

Which age group is affected?
Females of 15 to 49 years of age have this issue.

What are associated risk factors?
There is certainly a genetic predisposition and family history of susceptibility for BV, may be due to alkaline vaginal pH.

What are predisposing factors?
There are certain intrinsic and extrinsic disruptors of vaginal pH like:

• Increase in pH 
• Obesity 
• High carbohydrate diet 
• Decreased immunity 
• Hormone imbalance (reduced estrogen)
• Poor perineal hygiene 
• antibiotic use 
• Intrauterine device 
• Abnormal irregular bleeding 
• Douching 
• Sexual activity
• Smoking 
• Decrease in acidity 
• Decrease in growth of bacteria (Lactobacilli) normal vaginal flora 
• Overgrowth of other disease-causing organisms

This alkanity results in overgrowth of bacteria (anaerobes like bacteroid, gardnerella fusobacterium, fungi (candida), trichomoniasis.

How is diagnosis made?

• Clinical examination showing thin gray white discharge 
• Vaginal pH more than 4.5 
• Saline microscopy showing > 40 % clue cells
• Special tests include, positive KOH, whiff test, gram staining and molecular studies

Why to treat all patients with BV?
All patients should be treated to relieve symptoms to reduce risk of acquisition and transmission of STIs (sexually transmitted infections). Treatment before pregnancy can reduce pre-clinical pregnancy losses and infective complications during pregnancy and after delivery.

How BV is treated?
The main aim of treatment is to restore balance of normal vaginal flora and maintaining an acidic pH by promoting acidic bacteria (Lactobacilli) and suppressing growth of other infective organisms. This includes:

• Dietary modification
• Perineal hygiene
• Stop smoking 
• Clinicians use Oral and vaginal antibiotics (metronidazole, secnidazole, tinidazole, clindamycin) for treatment. They are also safely used during pregnancy and during breast feeding. In some cases, boric acid vaginal capsules are also given to maintain a pH balance.

What are the risks associated with untreated BV?
There are is a significant increase in acquiring sexually transmitted infections (STI) and coexisting infections like pelvic infections by other organisms (trichomonas, gonorrhea, chlamydia, HPV human papilloma virus infection, AIDS). It can result in preterm labor due to:

• Inflammation of placenta and membranes (chorioamnionitis),
• Infection of lining of uterus (endometritis) 
• Post-operative infections specially after uterus removal (hysterectomy)

In some cases, it results in infertility and preclinical pregnancy losses.

Does it increase the chance of having cancers?
Yes, if its left untreated then chronic pelvic infections can lead to precancerous conditions of cervix (CIN) cerival intraepithelial neoplasia or (SIL) squamous intraepithelial lesions. It also increases the infection rate with (HPV) human papilloma virus infection which is corelated with aggressive cancers of cervix and vulva.

Remember… BV is associated with poor reproductive health outcome, all women with BV should be treated to avoid risk of sequelae.

Dr. Ayesha Azam Khan