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Infecção Vaginal: Determinantes, Microbiota, Inflamação E Sintomas

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Infecção Vaginal: Determinantes, Microbiota, Inflamação E Sintomas 1 UNIVERSIDADE FEDERAL DO ESPÍRITO SANTO CENTRO DE CIÊNCIAS DA SAÚDE PROGRAMA DE PÓS-GRADUAÇÃO MESTRADO EM DOENÇAS INFECCIOSAS CHIARA MUSSO RIBEIRO DE OLIVEIRA SOUZA INFECÇÃO VAGINAL: DETERMINANTES, MICROBIOTA, INFLAMAÇÃO E SINTOMAS. ESTUDO DESCRITIVO COM AUTOCOLETA DIÁRIA AO LONGO DO CICLO MENSTRUAL. VITÓRIA – ES 2009 2 CHIARA MUSSO RIBEIRO DE OLIVEIRA SOUZA INFECÇÃO VAGINAL: DETERMINANTES, MICROBIOTA, INFLAMAÇÃO E SINTOMAS. ESTUDO DESCRITIVO COM AUTOCOLETA DIÁRIA AO LONGO DO CICLO MENSTRUAL. Dissertação apresentada ao Programa de Pós-Graduação Mestrado em Doenças Infecciosas do Núcleo de Doenças Infecciosas, Centro de Ciências da Saúde, Universidade Federal do Espírito Santo, como requisito parcial para a obtenção do Grau de Mestre em Doenças Infecciosas. Orientador: Prof. Dr. Paulo Roberto Merçon de Vargas VITÓRIA 2009 3 Dados Internacionais de Catalogação-na-publicação (CIP) (Biblioteca Central da Universidade Federal do Espírito Santo, ES, Brasil) Souza, Chiara Musso Ribeiro de Oliveira, 1975- S729a Infecção vaginal : determinantes, microbiota, inflamação e sintomas : estudo descritivo com autocoleta diária ao longo do ciclo menstrual / Chiara Musso Ribeiro de Oliveira Souza. – 2009. 264 f. : il. Orientador: Paulo Roberto Merçon de Vargas. Dissertação (mestrado) – Universidade Federal do Espírito Santo, Centro de Ciências da Saúde. 1. Mulheres - Saúde e higiene. 2. Mulheres - Estudos longitudinais. 3. Esfregaço vaginal. 4. Papanicolaou. 5. Comportamento sexual. 6. Leucorréia. 7. Produtos de higiene feminina. 8. Microbiota. I. Vargas, Paulo Roberto Merçon de. II. Universidade Federal do Espírito Santo. Centro de Ciências da Saúde. III. Título. CDU: 61 4 5 Ao meu esposo, Aron. Aos meus pais, Norival ( in memorian ) e Leda. Aos meus afilhados, Matheus e Letícia. Ao meu orientador, Prof. Dr. Paulo Roberto Merçon de Vargas. Aos acadêmicos de Medicina (e meus mais novos melhores amigos) Rafaela Batisti Nery e Rafael Callil Salim. Ao Dr. Raymundo Schmitz M. Ferreira ( in memorian ). Ao Prof. Dr. José Antonio Simões ( in memorian ). 6 Agradeço: a meu marido, Aron e a minha mãe, Leda o apoio irrestrito, mesmo que, para isso, tenham carecido de minha atenção, que lhes é tão necessária; a Aron as doces palavras de conforto que renovaram minha determinação e esperança nos diversos momentos em que parecia tê-las perdido, assim como o apoio técnico que prestou em várias etapas deste estudo; a minha mãe agradeço o estímulo desde muito cedo ao hábito da leitura, sua presença e ajuda desde as primeiras pesquisas escolares, ensinando a produção dos primeiros textos, insistindo para “ir fundo nas coisas” e o estímulo e apoio ao meu crescimento cultural e intelectual; a Dr. Paulo Roberto Merçon de Vargas, que não se limitou a ser o orientador da tese, tendo sido orientador em sentido muito mais amplo, orientando para a vida, despertando o espírito crítico, estimulando o crescimento intelectual, profissional e científico, sempre contagiando os que estão ao seu redor com sua aguçada “sensibilidade para se espantar diante de fatos corriqueiros, aliada à observação apurada e perspicaz, que são as maiores armas do pesquisador na construção do conhecimento médico.” GOULART 1998 a Dra. Renata Scarpat Caretta a inestimável ajuda prestada na definição do desenho e dos protocolos deste estudo, bem como o apoio operacional durante a realização do mesmo; a Dra. Patrícia Ribeiro Pinto a ajuda prestada no preparo dos protocolos deste estudo; a Dra. Carla Regina Santos De Carli a ajuda prestada na catalogação das referências bibliográficas; a Rafael Callil Salim, acadêmico de Medicina, as orientações técnicas sobre fotografia, o esmero com que realizou a maior parte da documentação fotográfica, a 7 edição de todas as fotografias incluídas no estudo, a imensurável ajuda prestada durante a leitura das lâminas, digitação dos dados da microscopia e confecção dos gráficos e dos quadros pictóricos; a Rafaela Batisti Nery, acadêmica de Medicina, a aferição e digitação das áreas dos esfregaços das lâminas do estudo e a imensurável ajuda prestada na confecção dos gráficos e dos quadros pictóricos; a Karina da Silva Araújo, acadêmica de Medicina, a ajuda prestada na digitação dos resultados das citologias; a Antonio Alfim Malanchini Ribeiro, acadêmico de Medicina, o auxílio técnico prestado na operacionalização das planilhas do Excel; a Antonio Alfim Malanchini Ribeiro, Felipe Schwenck Galvão, Karina da Silva Araújo, Lissa Severo Sakugawa, Rafael Calil Salim, Viviane Almeida Marchesi, acadêmicos de Medicina, a ajuda prestada na aferição da área de intertrigo e das medidas vulvares; aos amigos Dra. Danieli Castro Oliveira Andrade e Dr. Victor Piana Andrade agradeço a preocupação, as dicas e as palavras tranquilizadoras; a Josiane Braga Lima, técnica de enfermagem, o esmero e carinho com que me auxiliou nas consultas ginecológicas das participantes, tendo sido peça fundamental para o sucesso dessa fase do estudo; a Dra. Sonia Rabelo Doxsey, que, nos idos de 1987, num gesto espontâneo, interveio para que me fosse concedida uma bolsa integral para estudo da Língua Inglesa, a qual se tornou imprescindível em minha vida, sobretudo para o ingresso na pós-graduação e realização da revisão bibliográfica desta dissertação e por esse gesto sou-lhe eternamente grata; 8 a Vera Lúcia Vieira, coordenadora do Centro de Referência Ambulatorial de Carapina, Serra, ES, o apoio e compreensão, sem os quais não teria sido possível cumprir a maioria dos créditos da pós-graduação; aos colegas e professores da pós-graduação a contribuição de cada um à construção do meu conhecimento; às voluntárias do projeto piloto desenvolvido em 2006 que, através de sua participação, possibilitaram que percebêssemos a viabilidade deste estudo; às voluntárias que participaram deste estudo a contribuição que deram a mim e à ciência; aos laboratórios Solvay Pharma e Bayer Schering Pharma Brasil e respectivos representantes comerciais o fornecimento das sacolas utilizadas pelas participantes para transportar o material do estudo; à Produtos Roche Químicos e Farmacêuticos S.A. o suprimento de grande parte dos artigos científicos utilizados para nortear a escrita deste texto. 9 “Our knowledge of leukorrhea is unsatisfactory and incomplete. The majority of physicians neither appreciate the gross aspects of the condition nor discover the locality from which discharges arise, practically none of us possesses an adequate knowledge of the bacteria involved, and most clinicians admit that their curative efforts yield poor results.” Arthur H. Curtis 1913 10 “I never travel without my diary. One should always have something sensational to read on the train .” Oscar Wilde 1895 11 RESUMO A saúde vaginal depende de complexas interações entre a microbiota vaginal, a histofisiologia da mucosa escamosa, o estado hormonal e os mecanismos de defesa do hospedeiro. Muitos fatores podem alterar essas relações, induzindo citólise, infecção e inflamação, genericamente denominados infecção vaginal (IV). A IV manifesta-se por graus e combinações variáveis de ardor, prurido, dispareunia, disúria, mau odor e aumento e modificações do conteúdo vaginal. A abordagem clínica tem sido orientada apenas empiricamente e há pouca percepção do risco potencial das IV. Isso se deve a vários fatores, incluindo uma complexa rede de causas, inespecificidade das manifestações, discordâncias conceituais, dificuldade diagnóstica, natureza íntima da prática sexual e limitados recursos diagnósticos e terapêuticos. Objetivos : Avaliar em nosso meio o uso dos intrumentos autocoleta do conteúdo vaginal, diário de hábitos, sintomas e práticas sexuais e descrever as variações diárias da microbiota, da citólise, do exsudato inflamatório e dos sintomas. Casuística : 18 mulheres no menacme, não grávidas, recrutadas em clínicas ginecológicas na região metropolitana de Vitória, ES. Métodos : Estudo descritivo com exame ginecológico inicial, registro diário de hábitos de vestuário, higiene, práticas sexuais e sintomas e autocoleta vaginal por um mínimo de trinta dias. Os esfregaços vaginais foram examinados (Gram e Papanicolaou), sumarizando-se os achados como grau lactobacilar, candidíase, citólise e inflamação. Os achados históricos, do exame ginecológico e do estudo seqüencial foram registrados em um quadro pictórico individual e sumarizados por freqüência simples. Resultados: A mediana dos dias com respostas às perguntas do diário foi maior que 87% em todas as participantes. A autocoleta do conteúdo vaginal garantiu espécimes adequados em mais de 85% dos dias em todas as participantes. Microbiota bacteriana anormal, candidíase, citólise e inflamação foram observadas em 27,8%, 50,0%, 83,3% e 94,4% das participantes em algum momento durante o estudo. Os hábitos de vestuário, higiene, e práticas sexuais e os sintomas, microbiota, citólise e inflamação variaram marcadamente tanto entre as mulheres como ao longo dos dias em uma mesma mulher. Conclusão: O registro diário e a autocoleta foram bem aceitos e garantiram dados e espécimes adequados que, sumarizados em um quadro pictórico, mostram que há marcadas variações diárias entre os elementos das redes de causas e efeitos de IV, indicando que somente com estudos seqüenciais é possível identificar todo o espectro das IV. Palavras-chave: 1. Mulheres - Saúde e higiene. 2. Mulheres - Estudos longitudinais. 3. Esfregaço vaginal. 4. Papanicolaou. 5. Comportamento sexual. 6. Leucorréia. 7. Produtos de higiene feminina. 8. Microbiota. 12 ABSTRACT Vaginal health depends on complex interactions between the vaginal microbiota,
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