Bacterial vaginosis is an infectious non–inflammatory lesion of the vagina, in which the normal flora is replaced by polymicrobial associations of conditionally pathogenic bacteria. Bacterial vaginosis occurs against the background of immune disorders, inflammatory diseases of the reproductive system, menstrual cycle disorders, prolonged use of the intrauterine device, haphazard administration of antibiotics and hormonal drugs. Accompanied by copious discharge with an unpleasant odor. Sometimes it is asymptomatic. The diagnosis is established on the basis of complaints, anamnesis and data from special tests. Treatment – local and general pharmacotherapy.
Bacterial vaginosis is a non–inflammatory infectious process in which the normal lactoflora of the vagina is replaced by associations of anaerobes. It is a widespread pathology, diagnosed in 21-33% of patients who turn to gynecologists. It may occur covertly or with obvious clinical symptoms. With the improvement of the general condition of the body, the symptoms of bacterial vaginosis disappear or smooth out, when exposed to various endogenous and exogenous factors reappear, which causes a long-term recurrent course of the disease. Pathology does not belong to venereal diseases. Due to hormonal changes, it often occurs during gestation and menopause. Bacterial vaginosis is treated by specialists in the field of gynecology.
Normally, more than 95% of the vaginal microflora in women of childbearing age are aerobic and anaerobic lactobacilli. The remaining 5% includes more than 40 types of various microorganisms. The ratio of anaerobes and aerobes in a healthy vaginal microflora is 10:1. Lactobacilli are the basis of the natural barrier between the external environment and the uterine cavity. Due to acid formation and the release of hydrogen peroxide, they create an acidic environment that prevents the reproduction of pathogenic and conditionally pathogenic microbes.
Under unfavorable conditions arising under the influence of one or more endogenous and exogenous factors, the quantitative and qualitative composition of the microflora changes. The number of lactobacilli decreases, other microorganisms begin to multiply actively, primarily obligate anaerobes. The total number of bacteria is increasing. Bacterial vaginosis develops. A distinctive feature of this pathology is the absence of a specific pathogen. The cause of the infectious process is not one type of microorganisms, but polymicrobial associations.
Bacterial vaginosis can occur with immune disorders as a result of general weakening of the body, acute and chronic infectious diseases. Another factor contributing to the development of bacterial vaginosis are changes in the hormonal background during the phase change of the menstrual cycle, amenorrhea, oligomenorrhea, single-phase cycles, during gestation, during adolescence and menopause. Of great importance is the intake of hormonal drugs (corticosteroids, oral contraceptives), antibacterial, antiviral and antifungal drugs.
The likelihood of bacterial vaginosis increases with non-compliance with hygiene rules, frequent douching, increased radiation exposure (radiation therapy, radiation exposure during professional contact with radioactive substances), malformations of the reproductive system, conditions after surgical interventions, vaginal polyps and cysts, the use of an intrauterine device, diaphragms, tampons and spermicides. Risk factors for bacterial vaginosis also include conditions after abortion and childbirth, atrophic changes in the vaginal mucosa and intestinal dysbiosis.
The most characteristic and often the only symptom of bacterial vaginosis is discharge from the genital tract, often with an unpleasant odor similar to the smell of stale fish. Usually the whites are liquid, white or slightly grayish. They can be abundant, permanent, persisting for several years, or scarce, short-term, appearing from time to time. The average amount of whites in bacterial vaginosis is about 20 ml per day, which is 10 times higher than the volume of normal secretions. With a long course of the disease (for several years) the color and consistency of secretions often change. The whites become thicker, foamy, sticky, yellowish or greenish.
The nature and number of whites in bacterial vaginosis vary depending on age, general health, mental and emotional state of a woman (mental trauma and intense stress), sexual activity, menstrual cycle phases, endocrine disorders, diseases of the reproductive system and somatic diseases. In some cases, patients with bacterial vaginosis complain of burning, itching, urination disorders, pain or discomfort during intimacy.
Acute or torpid, asymptomatic, monosymptomatic (only with secretions) or polysymptomatic course of the disease is possible. In some patients, manifestations of bacterial vaginosis persist for a long time, in others they periodically occur under the influence of adverse factors. When collecting anamnesis, it turns out that more than 90% of patients with suspected bacterial vaginosis had previously contacted a gynecologist and other specialists with complaints of discharge and other symptoms. Three quarters of the patients were repeatedly treated for nonspecific vaginitis using antibacterial candles and taking various oral antibacterial agents.
During a gynecological examination of a patient with bacterial vaginosis, signs of inflammation are not detected. The vaginal walls are usually pink, and small reddish spots are sometimes detected in menopausal patients. Discharge from bacterial vaginosis is evenly distributed along the walls of the vagina, well removed with a cotton swab. When measured using an indicator strip, a pH of more than 4.5 is determined. When mixing whites with a 10% solution of potassium hydroxide, the appearance or strengthening of the smell of rotten fish is noted. With colposcopy, there is no edema, hyperemia, infiltration and hemorrhages. In 39% of patients with bacterial vaginosis, pathological changes in the vaginal part of the cervix are diagnosed: scars, erosions, ectropion or cervicitis.
The diagnosis of bacterial vaginosis is established on the basis of complaints, anamnesis, gynecological examination data and the results of special tests. During the survey, the doctor clarifies whether a woman suffers from diseases of the reproductive system, endocrine and somatic diseases, whether she takes hormonal drugs and antibacterial agents, whether she uses contraceptives, whether there has been a history of childbirth, abortions and surgical interventions on the genitals, what is the intensity of sexual activity, etc.
The main laboratory study for bacterial vaginosis is microscopy of smears taken from the posterior arch and stained by Gram. During microscopy, the number of leukocytes is estimated, the forms and types of microorganisms that make up the vaginal microflora are studied. The presence of a large number of anaerobes with a decrease in the number of lactobacilli indicates the presence of bacterial vaginosis. A characteristic feature of the disease are key cells – mature epithelial cells, on the membrane of which various microorganisms are detected (gardnerella, cocci, mobiluncus). Normally, such cells, as a rule, are not detected. In some cases, a false diagnosis of bacterial vaginosis is possible due to the presence of epithelial cells with adhered lactobacilli in the smear.
In some works devoted to the research of bacterial vaginosis, serological, enzyme immunoassay and cultural methods of diagnosing this pathology are mentioned, however, such methods are still of purely scientific interest and are not used in wide clinical practice. Diagnostic criteria for bacterial vaginosis are the presence of specific whites, the identification of key cells by smear microscopy, a pH greater than 4.5 and the appearance of the smell of stale fish during the reaction of whites with potassium hydroxide. To make a diagnosis of bacterial vaginosis, at least three out of four criteria are required.
If concomitant pathology is detected, additional examinations and consultations of various specialists may be required. Patients with bacterial vaginosis can be referred for consultation to a therapist, endocrinologist, urologist, venereologist, mycologist or gastroenterologist. If necessary, ultrasound of the pelvic organs, general blood and urine tests, biochemical blood analysis, fecal analysis for dysbiosis, blood test for hormones and other studies are prescribed.
Bacterial vaginosis is differentiated with gonorrhea, trichomoniasis, vaginal candidiasis and nonspecific vaginitis. Distinctive signs of gonorrhea are liquid discharge with a yellowish or greenish tinge in combination with painful urination. The presence of trichomoniasis is indicated by abundant sticky or foamy gray-yellow-green discharge, possibly with a stale odor. Sometimes white spots are combined with itching and soreness when urinating. Candidiasis can be suspected when flaky curd-like white secretions appear in combination with burning and itching of the vagina. To exclude these diseases, special laboratory tests are required.
The treatment regimen is determined individually, taking into account the severity of symptoms, duration and form of bacterial vaginosis, the presence of concomitant inflammatory processes, changes in the reproductive system, somatic and endocrine diseases. Treatment includes two stages: taking antibacterial agents and restoring normal microflora. For the entire period of therapy, a patient with bacterial vaginosis is recommended to exclude alcoholic beverages, limit the intake of spicy and spicy food.
At the first stage, metronidazole or clindamycin is prescribed orally or intravaginally, in the form of vaginal tablets, candles or creams. The duration of taking these drugs for bacterial vaginosis is 7-10 days. If necessary, immunocorrectors and antihistamines are used simultaneously. For the prevention of candidiasis (especially important – in the presence of a fungal lesion in the anamnesis), antifungal drugs are used. To correct the pH, local remedies with a high lactic acid content are administered.
1-2 weeks after the completion of the first stage of treatment, a second examination and laboratory tests are carried out to assess the effectiveness of therapy for bacterial vaginosis. After another 2-3 days, the second stage begins, the main task of which is to restore normal lactoflora. Probiotics and eubiotics are used. In 90% of cases, the result of treatment is the normalization of the vaginal microflora. The tests are repeated after 10 days and 1-1.5 months after the completion of the second stage of therapy. With a persistent course of bacterial vaginosis, additional examinations are prescribed to identify pathogenic factors contributing to the development of relapses of the disease.
The measures to prevent and timely detection of bacterial vaginosis include compliance with the rules of intimate hygiene, thoughtful use of hygiene products, the exclusion of frequent douching and rational selection of methods of prevention, taking into account the intensity of sexual activity, health status and hormonal background of the patient. Uncontrolled intake of antibacterial and antifungal drugs should be avoided, timely consult a doctor when symptoms of inflammatory diseases appear, regularly visit a gynecologist for preventive examinations, and treat intestinal dysbiosis.