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Mar 11, 2008



MRS Chong (not her real name) came to see me the other day. She has been plagued by a vaginal discharge that never seems to go away.

“It is not like pus, has a sort of a grayish-white colour, not very itchy, does not distress me very much, but it smells horrible, at least to me. I really feel unclean and it is really getting me down, doc,” she lamented.

“How long have you had it?” I asked.

“For more than a year,” was her reply.

“But have you sought treatment?” I interjected.

“I have consulted almost every other doctor in town,” she exaggerated.

“All they do is either give me a course of antibiotics or a course of vaginal tablets. I do get some relief but within a week or two it is back.”

“How long does a course of antibiotics last?” I asked with curiosity.

“About three to four days” was her reply.

“That’s too short,” I murmured to myself.

“Did they do any tests for the discharge?” I asked. No was her prompt reply.

“I have even tried to douche myself with antiseptic solutions but it only made it worse,” she said. I knew what was coming next.

“Just out of curiosity, doc. Has my husband been up to no good?” she asked. I avoided the question and reserved my reply till I had more facts.

About ‘itis’ and ‘osis’

Mrs Chong’s problem, like so many other women’s, is becoming an increasingly common one. She was probably having bacterial vaginosis. In medical parlance, an “itis” means an inflammation and an “osis” generally means that “something has gone wrong”.

The fact that it is called a bacterial vaginosis rather than a vaginitis implies that it is not an infection per se by bacteria. Rather, something has simply gone wrong with the vaginal bacterial ecosystem.

If you recollect, the previous article emphasised that the vagina has an ecosystem of its own – the silent guardian of which is the Lactobacillus species. It maintains the pH of the vaginal milieu acidic.

The problem occurs when for some reason, hitherto still unclear, certain bacteria called anaerobes (because they thrive in less oxygen) overgrow and replace the lactobacillus species. Their scientific names include the Gardnerella and Mycoplasma species.

Besides causing a discharge and sloughing of the vaginal lining, the pH of the vagina becomes less acidic and this further propagates the problem.

A common problem

Bacterial vaginosis is now recognised as the most common cause of vaginal discharge in middle aged women, being present in about 10% to 40% of women attending gynaecological clinics.

It was initially thought to be a sexually transmitted disease because of its presence in sexually active women. However, the bacteria has been isolated in virgins, and treatment of the male partner makes no difference to the recurrence rate. (In any case, Mrs Chong was reassured.)

Notwithstanding, there are pre-disposing conditions and these include douching with antiseptics, previously sexually transmitted disease, a change in sexual partner and the use of intra-uterine contraceptive device.

The diagnosis

Making a diagnosis is not easy. The type of discharge and its characteristic smell are some clues but not accurate ways to a diagnosis because such appearances are also present in other kinds of discharge.

Placing a bit of the discharge in a solution of potassium hydroxide will emit a characteristic “fishy” odour.

The gold standard however, is to do a smear of the vaginal discharge and after suitable preparation, the cells are examined under the microscope to look for the characteristic “clue cell”.

Unfortunately most of these techniques are seldom carried out by the doctor because they take time and involve cost, and he usually makes a diagnosis on a “hunch”.

The treatment

Once a diagnosis is made, treatment should be started. The usual drugs are either metronidazole or clindamycin.

Metronidazole is taken as tablets but clindamycin can either be taken either as tablets or given vaginally.

Be that as it may, the important thing is to give an adequate course and the treatment must be completed – at least seven days. It has been found that one of the common causes for a recurrence is inadequate treatment at the first go.

Treatment may be effective, but that is not the end of the story. There is about a 60% that the infection will return within a year.

The complications

It was fortunate that Mrs Chong was no more going to be in the family way because there are long-term gynaecological and obstetric complications too.

Pelvic inflammatory disease (PID) may occur through an ascending infection into the pelvis via the cervix, uterus and fallopian tubes. Once PID sets in, it is difficult to eradicate and the ability to conceive is compromised.

The cervix may become infected, resulting in a possible, but not proven, risk of developing pre-cancerous lesions there. But it is the risks during pregnancy that we must pay heed to.

Inflammation to the lining of the water bags or chorioamnionitis by the bacteria is the forerunner to a bigger problem – that of premature labour and pre-mature rupture of the water bags.

The consequences of having a premature baby are only too well known. Furthermore, during the postpartum period, there is always the risk of infecting the womb, a condition called endometritis.

These complications cannot be taken lightly because the prevalence of bacterial vaginosis in pregnancy is not small – up to 20% of pregnant women harbour the infection.

A healthy vaginal ecosystem

How then do we deal with this perplexing and enigmatic problem?

Since the root cause of the problem is a “take over” of the vaginal ecosystem, the most sensible strategy therefore would be some form of pro-biotic therapy with Lactobacilli.

To the best of the author’s knowledge, such a strategy, though well established for intestinal disorders, has not proven to be the case with the vagina.

The next best alternative would be to create an environment that promotes the growth of Lactobacillus species. One such strategy would be to maintain the vaginal pH in an acidic state with an appropriate solution and hopefully, with time, the vaginal ecosystem will return to its original state.

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