Causes and Effects of Bacterial vaginosis

Bacterial vaginosis (BV) or less commonly vaginal bacteriosis is a disease of the vagina caused by bacteria. According to the U.S. Centers for Disease Control and Prevention (CDC), risk factors for BV include douching and having new or multiple sex partners, although it is unclear what role sexual activity plays in the development of BV.

BV is caused by an imbalance of naturally occurring bacterial flora and is often confused with yeast infection (candidiasis) or infection with Trichomonas vaginalis (trichomoniasis), which are not caused by bacteria.

Symptoms and signs

The most common symptom of BV is an abnormal homogeneous off-white vaginal discharge (especially after vaginal intercourse) that may be accompanied by an unpleasant (usually fishy) smell.

This malodorous discharge coats the walls of the vagina, and is usually without significant irritation, pain, or erythema (redness), although mild itching can sometimes occur.

By contrast, the normal vaginal discharge will vary in consistency and amount throughout the menstrual cycle and is at its clearest at ovulation - about 2 weeks before the period starts. Some practitioners claim that BV can be asymptomatic in almost half of affected women, though others argue that this is often a misdiagnosis.

Causes

A healthy vagina normally contains many microorganisms; some of the common ones are Lactobacillus crispatus and Lactobacillus jensenii. Lactobacilli, particularly hydrogen peroxide-producing species, appear to help prevent other vaginal microorganisms from multiplying to a level where they cause symptoms.

The microorganisms involved in BV are very diverse, but include Gardnerella vaginalis, Mobiluncus, Bacteroides, and Mycoplasma.

A change in normal bacterial flora including the reduction of Lactobacilli, which may be due to the use of antibiotics or pH imbalance, allows more resistant bacteria to gain a foothold and multiply.
One of the most direct causes of BV is douching, which alters the vaginal flora and predisposes women to developing BV.

Douching is strongly discouraged by the U.S. Department of Health and Human Service and various medical authorities, for this and other reasons.


Although BV can be associated with sexual activity, there is no clear evidence of sexual transmission. It is possible for sexually inactive persons to get infected with bacterial vaginosis.

Rather, BV is a disordering of the chemical and biological balance of the normal flora. Recent research is exploring the link between sexual partner treatment and eradication of recurrent cases of BV. Pregnant women and women with sexually transmitted infections are especially at risk for getting this infection.

Bacterial vaginosis may sometimes affect women after menopause. A 2005 study by researchers at Ghent University in Belgium showed that subclinical iron deficiency (anemia) was a strong predictor of bacterial vaginosis in pregnant women.

A longitudinal study published in February 2006 in the American Journal of Obstetrics and Gynecology showed a link between psychosocial stress and bacterial vaginosis independent of other risk factors.

Diagnosis

To make a diagnosis of bacterial vaginosis, a swab from inside the vagina should be obtained. These swabs should be tested for:

• A characteristic "fishy" odor on wet mount. This test, called the whiff test, is performed by adding a small amount of potassium hydroxide to a microscopic slide containing the vaginal discharge. A characteristic fishy odor is considered a positive whiff test and is suggestive of bacterial vaginosis.

• Loss of acidity. To control bacterial growth, the vagina is normally slightly acidic with a pH of 3.8–4.2. A swab of the discharge is put onto litmus paper to check its acidity. A pH greater than 4.5 is considered alkaline and is suggestive of bacterial vaginosis.
• The presence of clue cells on wet mount. 

• Similar to the whiff test, the test for clue cells is performed by placing a drop of sodium chloride solution on a slide containing vaginal discharge. If present, clue cells can be visualized under a microscope. 

• They are so-named because they give a clue to the reason behind the discharge. These are epithelial cells that are coated with bacteria.

Two positive results in addition to the discharge itself are enough to diagnose BV. If there is no discharge, then all three criteria are needed. Differential diagnosis for bacterial vaginosis includes the following:

• Normal discharge.
• Candidiasis (thrush, or a yeast infection).
• Trichomoniasis, an infection caused by Trichomonas vaginalis.

In clinical practice

In clinical practice BV is diagnosed using the Amsel criteria:

1. Thin, white, yellow, homogeneous discharge
2. Clue cells on microscopy
3. pH of vaginal fluid >4.5
4. Release of a fishy odor on adding alkali—10% potassium hydroxide (KOH) solution.

At least three of the four criteria should be present for a confirmed diagnosis.

Gram stain

An alternative is to use a Gram-stained vaginal smear, with the Hay/Ison criteria or the Nugent criteria. The Hay/Ison criteria are defined as follows:

• Grade 1 (Normal): Lactobacillus morphotypes predominate.
• Grade 2 (Intermediate): Mixed flora with some Lactobacilli present, but Gardnerella or Mobiluncus morphotypes also present.
• Grade 3 (Bacterial Vaginosis): Predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli. (Hay et al., 1994)

What this technique loses in interobserver reliability, it makes up in ease and speed of use.
The standards for research are the Nugent Criteria. In this scale, a score of 0-10 is generated from combining three other scores. This method is time consuming and requires trained staff, but it has high interobserver reliability. The scores are as follows:

• 0–3 is considered negative for BV
• 4–6 is considered intermediate
• 7+ is considered indicative of BV.

At least 10–20 high power (1000× oil immersion) fields are counted and an average determined.

Lactobacillus morphotypes — average per high powered (1000× oil immersion) field. View multiple fields.	Gardnerella / Bacteroides morphotypes — average per high powered (1000× oil immersion) field. View multiple fields.	Curved Gram variable rods — average per high powered (1000× oil immersion) field. View multiple fields (note that this factor is less important — scores of only 0–2 are possible)
Score 0 for >30 Score 1 for 15–30 Score 2 for 14 Score 3 for <1 (this is an average, so results can be >0, yet <1) Score 4 for 0	Score 0 for 0 Score 1 for <1 (this is an average, so results can be >0, yet <1) Score 2 for 1–4 Score 3 for 5–30 Score 4 for >30	Score 0 for 0 Score 1 for <5 Score 2 for 5+

A recent study compared the Gram stain using the Nugent criteria and the DNA hybridization test Affirm VPIII in diagnosing BV. The Affirm VPIII test detected Gardnerella in 107 (93.0%) of 115 vaginal specimens positive for BV diagnosed by Gram stain. The Affirm VPIII test has a sensitivity of 87.7% and specificity of 96% and may be used for the rapid diagnosis of BV in symptomatic women.

Treatment

Antibiotics

Metronidazole or clindamycin either orally or vaginally are effective treatment. However, there is a high rate of recurrence.

The usual medical regimen for treatment is the antibiotic Metronidazole (500 mg twice a day, once every 12 hours) for 7 days.

A one-time 2g dose is no longer recommended by the CDC because of low efficacy. Extended release metronidazole is an alternative recommendation.
Alternatively, antibiotics may be applied topically (vaginally).


In contrast to some other infectious diseases affecting the female genitals, according to some sources, treatment of the sexual partners is not necessarily recommended.

Probiotics

In 2009 one Cochrane review did not find probiotics useful in the treatment of BV while another concluded they were effective when combined with antibiotics. Other studies have found probiotics to be highly effective (88–90% cure rate at 1 month) either alone or in combination with antibiotics, either taken orally or applied topically (vaginally), and significantly superior to antibiotics alone.



Some studies have also found probiotics useful in maintenance therapy, preventing recurrence. One Italian study found that once-weekly application of probiotics for 6 months almost completely prevented recurrence at 6 months (96%), and was still effective at 12 months.

Complications

Although previously considered a mere nuisance infection, untreated bacterial vaginosis may cause complications, such as increased susceptibility to sexually transmitted infections including HIV, adverse pregnancy outcomes, notably preterm birth, and presents other complications for pregnant women.

Epidemiology

It is estimated that 1 in 3 women will develop the condition at some point in their lives.