Infectious Diseases in Obstetrics and Gynecology 8:184-190 (2000) (C) 2000 Wiley-Liss, Inc. Gynecologic Conditions and Bacterial Vaginosis: Implications for the Non-Pregnant Patient Richard L. Sweet Department of OB/GYN/RS, Magee- Womens Hospital, Pittsburgh, PA ABSTRACT Bacterial vaginosis is characterized by a shift from the predominant lactobacillus vaginal flora to an overgrowth of anaerobic bacteria. Bacterial vaginosis is associated with an increased risk of gyne- cologic complications, including pelvic inflammatory disease, postoperative infection, cervicitis, hu- man immunodeficiency virus (HIV), and possibly cervical intraepithelial neoplasia (CIN). The obstetrical risks associated with bacterial vaginosis include premature rupture of membranes, pre- term labor and delivery, chorioamnionitis and postpartum endometritis. Despite the health risks associated with bacterial vaginosis and its high prevalence in women of childbearing age, bacterial vaginosis continues to be largely ignored by clinicians, particularly in asymptomatic women. Infect. Dis. Obstet. Gynecol. 8:184-190, 2000. (C) 2000Wiley-Liss, Inc. KEY WORDS vaginal flora; Gardnerella vaginalis; pelvic inflammatory disease; endometritis; cervical intraepithelial neoplasia acterial vaginosis (BV) is the most .common yet BV has been noted in virginal women as }vaginal infection among women of childbearing well.11, z age. 1-4 BV occurs in 33% to 36% of women attend- The most common outward symptoms of BV ing sexually transmitted disease clinics, 16% to include a thin, homogeneous, milky white or dull 20% of pregnant women, and in up to 25% of gray vaginal discharge, a foul or fishy odor that may women attending gynecologic clinics, s-9 Thus, rou- intensify following sexual intercourse, and some- tine screening and prompt treatment of BV in these times vaginal burning or itching. However, as many populations may be critical in certain clinical sce- as 50% of all women with BV are asymptomatic. 13 narios. Therefore, it is critical that patients are educated BV is characterized by a disruption in the vagi- about BV and routinely screened for this infection. nal flora whereby anaerobic bacteria, Mycoplasma Clinically, bacterial vaginosis is diagnosed by the hominis and Gardnerella vaginalis overgrow at the presence of three of the following four criteria: a expense of protective lactobacilli. Although the vaginal pH of greater than 4.5, the presence of clue exact cause of bacterial vaginosis is unknown, cells in the vaginal fluid, a thin, white or gray ho- predisposing factors include douching, previous mogeneous vaginal discharge, or a positive KOH sexually transmitted disease, a change in sexual whiff testmthe release of an amine (fishy) odor partner, and use of intrauterine devices. 9-11 High upon the addition of 10% potassium hydroxide to prevalence rates have been reported in patients the vaginal fluid. 3 Use of Gram stain is an alter- attending sexually transmitted disease clinics, native using the Nugent criteria for the diagnosis of Grant sponsor: 3M Pharmaceuticals *Correspondence to: Richard L. Sweet, M.D., Magee-Womens Hospital, Department of OB/GYN/RS, 300 Halket Street, Pittsburgh, PA 15213-3180. E-mail: [email protected] Received 23 November 1999 Review Article Accepted 6 April 2000 BACTERIAL VAGINOSIS SWEET BV. 14 It has been shown to correlate well with clini- third to one-half of all infectious vaginal condi- cal criteria and is an effective way to screen for tions, s Moreover, because non-pregnant women asymptomatic BV. However, because Gram stain represent the majority of BV cases, many of whom can be logistically more difficult due to the need may be asymptomatic, routine screening and for laboratory evaluation, the majority of practitio- prompt treatment in this population is critical. This ners use wet mount to detect the presence of clue article will discuss the pathogenesis of BV and re- cells, pH tests, and "whiff" tests. view the literature documenting the link between While BV was once thought to be merely a nui- BV and several of the most common gynecologic sance condition, more recent investigations have conditions. demonstrated that it is associated with an increased risk of gynecologic and obstetric complications. ETIOLOGY OF BV: A NATURAL LINK TO Gynecologic conditions associated with BV include GENITAL TRACT COMPLICATIONS pelvic inflammatory disease, ls,6 postoperative in- Though the etiology of bacterial vaginosis is not fection such as postabortion endometritis 7,8 and completely understood, research has confirmed pelvic cuff cellulitis following hysterectomy, 9,z that BV is a synergistic, polymicrobial infection cervicitis, el human immunodeficiency virus characterized by a shift in the bacterial flora of the (HIV), zz-z4 and possibly cervical intraepithelial vagina. Normal vaginal flora consists predomi- neoplasia (CIN). zs The obstetrical risks associated nantly of lactobacilli, though both aerobic and an- with BV include premature rupture of membranes, aerobic bacteria also can be found in small num- preterm labor and delivery, 7 chorioamnionitis, z6 bers. Lactobacilli serve as a natural host defense by and postpartum endometritis, z6 producing both lactic acid, which maintains the Despite its prevalence and associated health vaginal pH below 4.5, and hydrogen peroxide, risks, bacterial vaginosis remains underdiagnosed which inhibits the growth of non-catalase- by clinicians and poorly understood by patients. producing microorganisms, z6 This combination Research by Wiesenfeld and Macioz7 found that creates a potent defense against the overgrowth of three of the four standard diagnostic procedures for other vaginal bacteria, particularly anaerobes, z6 bacterial vaginosis were not routinely performed to In women with BV, the concentration of lacto- evaluate women with vulvovaginal symptoms. Of bacilli is significantly reduced (fewer than 10,000 150 office visits with 50 different physicians, 58% colonies/ml of vaginal fluid) allowing for the over- routinely performed microscopy, while pH and growth of anaerobes, Gardnerdla vaginalis and My- whiff tests were performed by only 2% and 8% of coplasma hominis, which prevail in numbers 100 to physicians, respectively. 1000 times higher than in women with normal Low patient awareness of BV is suggested by flora, z6 In particular, G. vaginalis, Peptostreptococcus two recent surveys. In a 1993 Gallup survey of spp., Prevotdla spp., and Mobiluncus spp. are pres- 1,011 women aged 18 years or older, 64% of re- ent in increased numbers in women with BV. spondents reported that they had never heard of Due to the proximity and permeability of the bacterial vaginosis, z8 Similarly, a 1998 survey of 301 lower and upper genital tract mucosa, a dominance women aged 18-50 who reported having at least of pathogens in the vagina places women with BV one vaginal infection in the previous three years, at higher risk for upper genital tract infection, z6 In determined that 80% of the respondents could not addition, enzymes and metabolic byproducts of ab- identify the symptoms of bacterial vaginosis, z9 normal vaginal flora impede normal white blood Given the health risks associated with bacterial cell response to infection. e Specifically, BV has vaginosis, low patient awareness combined with been implicated in the gynecologic conditions dis- poor diagnostic practice may have significant im- cussed below. plications for the female patient. While much of the recent literature has focused on obstetrical POSTOPERATIVE INFECTION complications, greater emphasis should be placed Postoperative infection continues to be a common on the non-pregnant patient for whom gynecologic complication of gynecologic surgery. Specifically, health risks pose the greatest threat. Indeed, bac- pelvic inflammatory disease (PID) following first- terial vaginosis is believed to be the cause of one- trimester abortion and pelvic cellulitis following INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 185 BACTERIAL VAGINOSIS SWEET abdominal hysterectomy are particularly prevalent. treatment with metronidazole in women with bac- The incidence of PID following first-trimester terial vaginosis undergoing first-trimester abortion abortion is 4% to 12% and postoperative pelvic cel- resulted in a threefold reduction in the rate of post- lulitis occurs in up to 70% of patients undergoing operative pelvic inflammatory disease. hysterectomy without prophylaxis. 1s,3 Research Postabortion pelvic inflammatory disease was has identified bacterial vaginosis as a risk factor for defined as two or more of the following six criteria development of both of these conditions. fulfilled within 28 days of the surgery: (1) abnormal or purulent vaginal discharge after week, (2) ab- Postabortion Endometritis/PID normal bleeding after the third day, (3) tempera- The presence of Mobiluncus and clue cells in vagi- ture > 38.0C (100.4F) for > 24 hours, (4) palpable nal smears has been clinically correlated with bac- adnexal masses, (5) tenderness over the uterus or terial vaginosis. In a study by Larsson et al., 17 adnexa on pelvic examination, or (6) erythrocyte women in whom Mobiluncus and clue cells were sedimentation rate > 30 mm. detected were found to have a higher risk of posta- bortion pelvic inflammatory disease than women Posthysterectomy Infection/Pelvic Cuff without presence of these organisms. Women in Cellulitis/Postcesarean Endometritis this study also were examined for C. trachomatis, A study by Soper et al. 19 found that women with which