Focus attention on bacterial vaginosis

Your next patient says she has a vaginal discharge. A closer examination reveals a white, noninflammatory discharge that smoothly coats the vaginal walls. What is your next step?

If you suspect bacterial vaginosis (BV), you have just identified the most common cause of vaginal discharge in the United States.1 In a just-published study of nearly 2,000 young, healthy women entering military recruit training, findings show that the condition is more common than previous estimates indicated, including among women who are virgins.2

BV is an infection caused by an overgrowth of certain bacteria that occur naturally in the vagina. Although the main symptom is an increased thin, white vaginal discharge with a strong fishy odor, approximately 50% of women have no symptoms.

Accurate diagnosis and treatment of BV is essential, states Jeffrey Peipert, MD, MPH, professor in the School of Medicine’s obstetrics and gynecology department at Providence, RI-based Brown University.

"BV is important to providers since it is associated with a number of potential adverse outcomes: sexually transmitted diseases [STDs], pelvic inflammatory disease [PID], postoperative infections such as post-hysterectomy infections and postpartum endometritis, and HIV acquisition," says Peipert, whose own research linked presence of bacterial vaginosis to a threefold increased risk of upper genital tract infection.3

Researchers with the new study looked at a cross-section of diverse young women from all 50 states and Puerto Rico who were enrolling in the military. What led to their current investigation?

"For the military, these women were going to have a Pap smear regardless of sexual experience status, and we were invited to do an STD and pregnancy intervention," explains Sophia Yen, MD, an adolescent medicine specialist in the department of pediatrics in the School of Medicine at the University of California-San Francisco and lead author of the research paper. "We seized the opportunity and tested them for STDs, [as well as] BV."

Researchers found the overall prevalence of BV was higher than expected and it differed by race and ethnicity. Asian/Pacific Islander women had the lowest prevalence (11%), while Native Ameri-can women (34%) and black women (32%) had the highest rates.

In the finding of low prevalence among Asian/Pacific Islanders, Yen theorizes there may be a biological difference, as evidenced in previous research.4 The finding also could be due to differences in women’s hygiene practices, such as tampon use (introduction of a foreign body), douching, or anything that might affect the vaginal ecosystem,5 she notes.

Researchers also noted that women who took the birth control pill had a lower rate of BV (24.9%) compared to women who did not (30.6%). What could have influenced this finding?

"It may be that the birth control pills maintain the vaginal flora at a more stable, even, balanced state than the regular hormonal swings of a woman off birth control," Yen observes.

Investigators in the new study used the Nugent criteria, the current gold standard for diagnosing BV, she says. Participants’ self-collected vaginal swabs were applied to a glass slide for Gram stain evaluation, according to the Nugent criteria.

Providers must be vigilant when it comes to treatment of BV, due to the high recurrence rate after treatment, observes Peipert. Be sure to counsel women to use all of the medicine prescribed for treatment of the infection, even if the signs and symptoms go away.

References

1. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47:70-74.

2. Yen S, Shafer M-A, Moncada J, et al. Bacterial vaginosis in sexually experienced and nonsexually experienced young women entering the military. Obstet Gynecol 2003; 102:927-933.

3. Peipert JF, Montagno AB, Cooper AS, et al. Bacterial vaginosis as a risk factor for upper genital tract infection. Am J Obstet Gynecol 1997; 177:1,184-1,187.

4. Evans B, Kell P, Bond R, et al. Racial origin, sexual lifestyle, and genital infection among women attending a genitourinary medicine clinic in London (1992). Sex Transm Infect 1998; 74:45-49.

5. Holzman C, Leventhal JM, et al. Factors linked to bacterial vaginosis in nonpregnant women. Am J Public Health 2001; 91:1,664-1,670.


Correction

An error appeared in the executive summary that accompanied the December 2003 article, "Contraception forecast: You’ll have new options," p. 136. The executive summary incorrectly states the time period that the contraceptive implant Implanon, now under review by the Food and Drug Administration, provides contraception. The correct time period is three years.