Evaluation of Women With Vulvovaginal Complaints

Jeanne M. Marrazzo, MD, MPH


April 19, 2012

In This Article

Vaginitis: It's Common

Vaginal symptoms occur frequently and prompt many women to seek healthcare. However, our ability to accurately diagnose and effectively treat vaginitis syndromes has evolved relatively little over the past decade. Almost no new antimicrobial options have emerged, and diagnostic testing options remain limited. This unfortunate scenario has fostered a situation in which affected women are generally managed on a syndromic basis. One can only hope that we are on the threshold of a new era in enhanced diagnosis and management of these all-too-common conditions.

This commentary will review key features of the 3 most common infectious causes of vulvovaginal complaints, with an eye toward emerging developments. Diagnosis is presented as a comprehensive approach to women with these complaints, but none of the infectious etiologies will explain the symptoms of many, if not most, women. A thorough history will often reveal the use of over-the-counter products including douches, external cleansing agents, cosmetics, and exposure to latex condoms or lubricants that can cause irritant or even allergic reactions.

What Makes a Healthy Vagina Healthy?

The vagina is a dynamic ecosystem that evolves over the course of a woman's lifespan, and is heavily influenced by hormones, sexual activity, and reproductive context. The vaginal pH in premenarchal women is near neutral (pH 7.0) until puberty. At puberty, under the influence of estrogen, the vaginal squamous epithelium increases in thickness, with a concomitant increase in the glycogen levels in the epithelium and vagina. The increase in glycogen supports a shift in the predominant flora to lactobacilli, and vaginal pH falls to less than 4.5. In healthy women, this low pH is maintained until menopause, when the vaginal epithelium thins, and the vaginal pH rises above 6.0.

The presence of hydrogen peroxide (H2O2)-producing Lactobacillus species characterizes the normal, healthy vaginal ecosystem, typically defined by a lack of symptoms and a normal pH. When present, these species -- typically L crispatus and L jensenii -- occur at very high concentrations (10 million organisms per gram of vaginal fluid). Whereas other commensal bacteria, including anaerobic gram-negative rods, streptococci, staphylococci, and diphtheroids, are relatively common in normal women, they are present at considerably lower concentrations.

Women with high vaginal concentrations of H2O2-producing lactobacilli are less likely to be colonized by Gardnerella, genital mycoplasmas, and anaerobes, to have bacterial vaginosis (BV), and to acquire HIV and other sexually transmitted infections (STIs). Such women are more likely to have healthy pregnancy outcomes. In HIV-infected women, higher levels of vaginal lactobacilli have been associated with reduction in the quantity of HIV shed in genital secretions.[1]


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