Bactericidal vaginosis treatment. Bacterial vaginosis. Causes, modern diagnostics, effective treatment and prevention of the disease. What candles are effective in the treatment of vaginosis

Vaginosis: causes, symptoms, diagnosis, treatment, prevention

Bacterial vaginosis is a pathological condition in which the normal composition of the microflora of the female vagina is disturbed, both in terms of its quantity and quality. According to statistics, vaginosis is diagnosed in more than 15% of all women aged 17 to 45 years. Moreover, the problem does not always have a vivid clinical picture, and sometimes it is simply impossible to notice violations without the help of a doctor.

Vaginosis in women

When a woman notices the first signs of vaginosis, often the disease is already fully progressing, and the normal microflora of the vagina has already undergone numerous pathological changes. It is important to know that in the case of vaginosis, a timely visit to the gynecologist does not always help to get rid of the disease quickly. Therapy and its duration depend on many factors, including the stage of the disease, the age of the patient and the presence of chronic concomitant diseases.

The normal microflora of the vagina is a unique environment in which various types of fungi and fungi continuously grow, develop and die. The vital activity of these microorganisms is controlled by several systems of the woman's body, including hormonal and immune systems. If this control is violated, the composition of the microflora, therefore, changes.

In women, vaginosis can occur in different ways. Often the clinical picture is blurred, there may be no symptoms of vaginosis at all, or vice versa, abundant fetid discharge, burning and discomfort during intercourse may disturb.

A pathological condition in which the normal composition of the vaginal microflora is disturbed is diagnosed in approximately every 4-5 women who bear a fetus. This fact is due to a significant decrease in the functioning of the immune system.

Vaginosis during pregnancy is treated comprehensively. Most often, medications with metronidazole are prescribed and in most cases they are recommended in the form of suppositories or a special gel, which is administered using a convenient syringe. The course of therapy is on average 6-8 days. Also, for the treatment of bacterial vaginosis during late pregnancy, doctors advise using Metrogyl, Ornidazole and Trichopolum. Up to 22 weeks of pregnancy, drugs with metronidazole in the composition are prescribed extremely rarely.

In addition to the antimicrobial treatment of vaginosis, agents with lactobacilli are recommended, which have a restorative effect on the vaginal microflora. Therapy during the period of gestation should be prescribed only to attending gynecologists.

Vaginosis in men: is it possible?

In relation to men, the diagnosis in the form of bacterial vaginosis is incorrect, because this, in fact, is a violation of the balance of the vaginal microflora. Vaginosis in men as a statement is sometimes used in practice, especially if the representative of the stronger sex received an infection that appeared in a partner against the background of an imbalance in the vaginal microflora.

Treatment of the partners of a woman diagnosed with bacterial vaginosis is not mandatory.

Risk factors

Among the existing risk factors for the development of bacterial vaginosis, it is worth highlighting:

• the use of intrauterine devices for a long period of time, oral contraceptives;
• gynecological diseases of an inflammatory nature in history;
• uncontrolled intake of antibacterial drugs;
• background pathological processes on the mucous membrane of the cervix;
• operations in the pelvic area;
• several abortions in history;
• menstrual disorders of various nature.

The level of significance of the transmission of bacterial vaginosis through sexual intercourse has not been determined today, but one thing can be said for sure - bacterial vaginosis is not a sexually transmitted disease.

Of course, during intimacy, the pathogenic microflora that lives in the vagina can be transmitted to a partner. But, for example, the same Gardnerella vaginalis cannot cause vaginosis in a healthy woman, because this microbe is often an integral part of the normal vaginal microflora.

But, despite all the above data, protected sex plays an important role in the emergence and development of vaginosis. And the point here is not infection, but the fact that the constant change of partner contributes to the imbalance of the vaginal microflora.

Causes of vaginosis

Among the main and most significant causes of vaginosis, one should single out hormonal failure, deterioration of the immune system, and taking certain medications. The cause of vaginosis is not the presence of pathogens, but a change in the ratio of pathogens that provoke the appearance of vaginosis, and lactobacilli. Bacterial vaginosis is often referred to as vaginal dysbiosis.

It is worth considering each of the causes of vaginosis in more detail.

• When diagnosing most of the gynecological diseases and those diseases that are associated with the endocrine system, there is a violation of the hormonal background. Hormonal imbalance leads to disorders associated with the renewal of the epithelium in the vagina. But in order to eliminate the cause of vaginosis, in this case, a comprehensive and thorough diagnosis is needed under the strict guidance of a competent specialist.
• If the immune system fails, an imbalance occurs in the microflora of the vagina. The activity of the process of producing secretory antibodies and immune cells decreases.
• If the bacterial composition of the gastrointestinal tract (GIT) changes, then this fact also affects changes in the vaginal microflora. Therefore, intestinal dysbacteriosis can cause vaginosis.
• The development of vaginosis can be affected by taking antibacterial drugs, because the effect of these drugs on certain types of bacteria in particular is not selective. So, for example, in the treatment of pneumonia, bacteria in the gastrointestinal tract, as well as in the vagina, can also be destroyed.

The risks of vaginosis increase in cases where a woman does not adhere to the basic rules of personal hygiene, often douches, is constantly washed away with antiseptic solutions, is promiscuous, has some malformations of the reproductive system, and often uses tampons during menstruation. Also, the risks are high after surgical interventions on the organs of the genitourinary system.

Bacterial vaginosis: symptoms

The whole clinical picture is ambiguous, and if one patient has both discharge and burning, then the other does not have any symptoms at all. Signs of vaginosis depend on numerous factors, so it is wrong to make a diagnosis based on symptoms on your own.

If we consider bacterial vaginosis, then the symptoms are primarily associated with discharge. They may have an unpleasant smell, a whitish-grayish tint. Sometimes they go abundantly, and in some cases they appear extremely rarely and almost imperceptibly.

According to statistics, discharge with vaginosis appears on average in an amount of up to 20 ml in 24 hours. When the condition becomes chronic and can be traced in a woman for 2-4 years, the mucus secreted from the genital tract may become more specific - become thick, frothy, with a greenish tint.

The amount of discharge in a woman with vaginosis can be different, and this depends on numerous nuances, including age, the presence of concomitant diseases and the level of activity in the sexual sphere. Also, the discharge may be different in its consistency and volume, depending on the day of the menstrual cycle.

Sometimes a woman with vaginosis may complain to the doctor about pain during intercourse or urination. Often, the discharge is accompanied by itching.

If a woman seeks help from a competent specialist in the medical field, then with vaginosis, the inflammatory process on the vaginal mucosa is most often not traced. Even with colposcopy, tissue swelling and redness are not observed, although more than 30% of all patients are diagnosed with pathological changes in the cervix, and more precisely in its vaginal part. It can be erosion, and scars.

Also, adhesion of the labia minora can be added to the description of the clinical picture, which is caused by copious discharge from the vagina. All signs of vaginosis are: discharge, itching, burning, discomfort during intercourse and/or emptying of the bladder.

Diagnosis of vaginosis

The microbiocenosis of the vagina undergoes changes in bacterial vaginosis. The number of lactobacilli decreases, in the microflora of the vagina, bacteroids, mycoplasmas, and gardnerella begin to predominate.

Determine violations in the vaginal microflora due to the results of laboratory tests, gynecological examination on the chair and taking into account the patient's complaints. Identifying bacterial vaginosis is not difficult for a competent doctor. On a gynecological examination, discharge of a mucopurulent nature is traced, and there is no inflammation of the mucosa.

If the attending physician detects additional diseases, then, most likely, consultations of different specialists will be needed. It can be a venereologist, and a mycologist, and an endocrinologist. Perhaps ultrasound diagnostics of the small pelvis, a biochemical blood test, hormone tests, etc. will be prescribed.

It is also important to know that during the diagnosis of the patient, the doctor must differentiate vaginosis from trichomoniasis, nonspecific vaginitis and gonorrhea. It is necessary to accurately diagnose, therefore, at the slightest doubt, the specialist will prescribe a set of additional diagnostic manipulations.

If vaginosis is suspected, the doctor will make a smear for microscopic examination without fail. The effectiveness of this diagnosis is extremely high. Confirming vaginosis, if present, is not difficult.

A bacteriological laboratory test is ideal if a doctor suspects an infectious lesion associated with bacterial vaginosis. An amino test and determination of the acidity level of the vaginal secretion may also be recommended. Analyzes for vaginosis are extremely important, because without their results it is impossible to accurately determine the problem and prescribe an adequate effective solution to it.

If a woman suspects vaginosis, then you should immediately go to the gynecologist. Unfortunately, the symptoms of such an imbalance in the vaginal microflora are nonspecific, so the signs can be confused with other diseases, including those of an infectious nature.

Vaginosis: treatment

Therapy for bacterial vaginosis is carried out in stages. Therefore, all causes of the development of imbalances in the balance of the vaginal microflora are initially eliminated. Perhaps they will stimulate the immune system, correct the hormonal background, etc. Next, the stage of using antibacterial agents and restoring the balance of the vaginal microflora is carried out. But the patient does not always need treatment for bacterial vaginosis. Sometimes the doctor can make a bias towards expectant management, especially if the woman does not experience any discomfort and does not speak of pronounced symptoms of vaginosis.

Preventive therapy for vaginosis is necessary before abdominal surgery or invasive gynecological procedures.

Combination therapy for vaginosis may be:

• Tablets with metronidazole for 5-7 days.
• Metronidazole in the form of a gel for intravaginal use.

The effectiveness of therapy is determined by several factors, including the results of repeated laboratory tests. Dynamic changes in the signs of vaginosis are taken into account.

After the start of treatment for bacterial vaginosis, after about 2 weeks, the patient must undergo a control laboratory examination.

Treatment of vaginosis during pregnancy

During the period of gestation, vaginosis is quite insidious, and even if the results of smears indicate an increased number of pathogenic microorganisms, a woman may not complain of any symptoms. The attending physician in this case, most likely, will not prescribe medication, but will only monitor the dynamics of the development of the condition.

If vaginosis during pregnancy is clinically pronounced, then therapy is selected on an individual basis and may include antibacterial drugs and eubiotics. Accurately and unambiguously at the first appointment, more than one specialist will not be able to say how to treat bacterial vaginosis. In any case, a comprehensive diagnosis is needed.

Vaginosis is treated with complex therapy aimed at eliminating the causes of disturbances in the vaginal microflora, as well as antimicrobials and eubiotics.

Particular attention requires the final stage of treatment of bacterial vaginosis - this is the restoration of the balance of the vaginal microflora. In addition, this is one of the most difficult therapeutic stages, and it is not so easy to achieve positive results even for a competent doctor.

You need to know that the use of only eubiotic vaginal suppositories is rarely considered by the attending physician. The advantage is given to complex treatment with the use of both inside and locally. Thus, a specialist may recommend Linex, Hilak forte or, for example, Baktisubtil.

Antibiotics for vaginosis

In the treatment of vaginosis, antibacterial drugs are prescribed.

• It can be Metronidazole - an antiprotozoal and antimicrobial agent. Moreover, in the treatment of bacterial vaginosis, as a rule, this drug is prescribed 0.5 g several times a day for 1 week.
• Suppositories Povidone-iodine is a good antibiotic that is prescribed for vaginitis. Apply suppositories several times a day for 1 week.
• Ornidazole is one of the most common drugs for vaginosis. Take an antibiotic several times a day for 5 days.
• Another effective antibacterial drug is clindamycin. Use the drug for vaginosis for 1 week several times a day.

Candles for bacterial vaginosis

Suppositories are one of the common dosage forms successfully used in the treatment of bacterial vaginosis. The doctor may prescribe different suppositories, depending on the clinical picture and the age of the patient.

• Neo-penotran is an excellent drug with antibacterial and antifungal effects. This medication can be prescribed even during the period of gestation, mainly after 20 weeks. The course of treatment of vaginosis with Neo-penotran is 10 days.
• Hexicon - candles from bacterial vaginosis with an excellent antibacterial effect, and this medication does not affect the vital activity of lactic acid bacteria.
• Metronidazole is a well-established drug in the treatment of vaginosis. In addition, this remedy is also effective for vaginosis, the development of which is due to the reproduction of Trichomonas in the vaginal environment. The average course of treatment is 6 days.
• Clindamycin is an antibacterial drug. These are good suppositories for bacterial vaginosis, used at different stages of the development of the condition.
• Bifidumbacterin is a good drug that helps restore the vaginal microflora. Assign these suppositories 1 per day for 7-10 days.
• Ecofemin - this remedy restores the microflora of the vagina. The therapeutic course is about 7-10 days.

All presented suppositories from bacterial vaginosis should not be used without consulting a doctor. Only a competent specialist will determine the causes of violations of the vaginal microflora and select medications on an individual basis.

For the treatment of vaginosis, folk remedies are used quite often, since they can be used to supplement effective drug therapy. It is important not to change the treatment regimen prescribed by the doctor and continue therapy until the problem is completely eliminated, which must be confirmed by appropriate tests.

Additionally, bacterial vaginosis can be treated with tinctures of medicinal plants that should be taken orally. Among them, the most effective are the following: leuzea root, sweet clover, cudweed, lavender color, elecampane root, birch leaves, licorice, thyme, geranium leaves, meadowsweet, etc.

Tinctures from all these mixtures are prepared and used according to the same principle. You need to mix certain ingredients in equal parts. Then 2 tbsp. spoons of the resulting mixture are steamed with boiling water (1 liter). After 5-7 hours, the tincture can be drunk 1/2 cup 3 times a day, always before meals. The course lasts 2-3 months, which the attending physician will definitely tell.

In addition to internal use for vaginosis, folk remedies (decoctions of medicinal plants) are used for baths. In addition, the doctor may prescribe douching. To do this, you may need such mixtures:

• blueberry (berry), birch leaves, tansy color, Greek;
• oak bark, geranium leaves, mugwort, chamomile blossom, violet blossom, etc.

These mixtures are prepared and used as follows. The necessary ingredients are taken in equal proportions. The resulting mixture (2 tablespoons) is steamed with boiling water (1000 ml) and infused for approximately 7-8 hours. Then the tincture is filtered and used for douching. For one douching, you need 1 glass of decoction.

But before taking into account information about douching, it is important to take into account the fact that such therapy is acceptable for use only on the strict recommendations of a specialist. The fact is that incorrect or frequent douching changes the level of acidity and further disrupts the balance of the vaginal microflora.

Washing with infusions of herbs is also practiced for vaginosis. It can be a prepared solution of walnut and sage leaves, chamomile flowers, oak bark. Also a common recipe is a mixture of coltsfoot leaves and juniper (fruits).

In the treatment of vaginosis, folk remedies are sometimes recommended for baths. To do this, pour 2 cups of a pre-prepared decoction of specific medicinal herbs into water at a comfortable temperature (10 liters) and mix. The procedure lasts from 15 to 25 minutes. It should be noted that such baths bring a very good result in cases where bacterial vaginosis is accompanied by severe itching.

Before treating bacterial vaginosis with tinctures for internal use, you should think about individual intolerance to one or another ingredient. If this is not available, it will not be difficult to cure vaginosis with folk remedies and medicines with their correct and regular use, but only under the guidance of a doctor.

Traditional medicine requires a serious attitude. Self-medication or correction of the treatment regimen prescribed by the doctor is unacceptable. It is important to know that improperly selected or applied infusions and decoctions of herbs can aggravate the situation with vaginosis, provoke the development of side effects, allergies.

An imbalance in the microflora of the vagina increases the risk of developing various diseases of the genitourinary system, including inflammatory processes associated with the uterus and appendages. Bacterial vaginosis can cause premature birth, provoke the appearance of complications during the period of gestation.

Vaginosis and vaginitis: the difference

As mentioned in the above information, vaginosis is not accompanied by an inflammatory process on the vaginal mucosa, which cannot be said about vaginitis.

With vaginitis, a vivid clinical picture is traced: liquid discharge, itching and burning, as well as pain during intercourse. Anti-inflammatory drugs are prescribed. It can be a medicated antiseptic or / and some traditional medicine recipes with sage and chamomile. Antibacterial agents are recommended for recurrent disease. In addition, vaginitis can be different - gonorrheal, trichomonas, mycoplasma, chlamydia, candidiasis.

It can be said with certainty that the prevention of a disease such as vaginosis is aimed at achieving one goal: to eliminate as much as possible all the factors that can provoke a problem. Based on this, preventive measures for bacterial vaginosis are as follows:

• It is necessary to maintain immunity at a high level, and, therefore, to eat correctly, fully and balancedly and adhere to a healthy lifestyle.
• It is necessary to provide a comprehensive and complete treatment of all concomitant diseases (among other things, they reduce immunity, as a result of which bacterial vaginosis may develop).
• It is necessary to maintain the intestinal microflora at the proper level in order to prevent intestinal dysbacteriosis (especially while taking antibiotics, which destroy not only harmful, but also beneficial microorganisms and can thus provoke their deficiency in vaginosis).
• To normalize the hormonal background, it is necessary to comprehensively treat gynecological and endocrine diseases, if any.
• Be sure to observe personal hygiene. It's not just about keeping your body clean and changing your underwear every day. People should not use towels, washcloths and other bath and toilet accessories at the same time. Each person should have their own personal body care products! In no case should you wear someone else's underwear, and in public baths or toilets, never sit on the surface without protection. Experts strongly do not recommend the use of cosmetic soap: it should be replaced with special care products with an appropriate pH value. Also, do not douche without first consulting with your doctor.
• Alcoholic drinks should not be abused (the best thing is to minimize their use or refuse them altogether). Any bad habits - smoking, taking drugs - are unacceptable. They can lead not only to vaginosis, but also to many other, sometimes very serious problems.
• Women who are actively sexually active need to be extremely careful when choosing a sexual partner. It is necessary to avoid indiscriminate relationships and contacts with several men. The best solution is an intimate relationship with only one partner.
• When changing partners, do not forget about condoms. This method of contraception will not only protect against infection, but also prevent unwanted pregnancy. Meanwhile, it is worth knowing that in some cases the use of condoms and other means of vaginal contraception is not allowed (you should consult your doctor about this).
• If there is a problem, you can not self-medicate by taking antibiotics and any antimicrobial medications. Before treating bacterial vaginosis and using any drugs, you should consult with your doctor.
• If a doctor has prescribed hormonal medications against the background of diabetes mellitus, it is necessary to undergo a gynecological examination at least twice a year and take appropriate tests.

By following all preventive measures, you can avoid the disease and never know how to treat bacterial vaginosis. Health is the most important thing, and you should always follow it.

• Bacterial vaginosis or bacvaginosis, vaginal dysbacteriosis, vaginal dysbiosis is a polymicrobial infectious non-inflammatory syndrome of the lower genitalia, which occurs against the background of a violation of the healthy balance of the vaginal microflora and a decrease in the acidity of the vaginal environment.

The prevalence of bacvaginosis is very high. The disease was noted in 55.8% of women of childbearing age who applied to a gynecologist; in 60-70% of patients with inflammatory diseases of the genitals and 35% of pregnant women. The combination of intestinal dysbacteriosis with bacterial vaginosis is observed in 71% of cases.

Bacterial vaginosis. ICD-10 code:

N89 Other non-inflammatory diseases of the vagina
Clarification:
There is no diagnosis of bacterial vaginosis in the ICD-10. Over the years, this syndrome was repeatedly renamed: until 1955, the disease was called nonspecific vaginitis; since 1980 - gardnerellosis.

Later it was found that the conditionally pathogenic bacterium gardnerella (Gardnerella vaginalis), which was considered the causative agent of bacvaginosis, is found in the vaginal discharge in 47-75% of healthy women without any clinical symptoms and is not the only "culprit" of the disease. Therefore, in 1981, gardnerellosis was renamed anaerobic vaginosis, and in 1984 the modern name appeared: bacterial vaginosis.

To identify the prevailing infectious agent, an additional ICD-10 code is used:
B96 Other bacterial agents listed as the cause of diseases classified elsewhere.

Healthy vaginal flora

The determining factor in the normal microflora of the vagina is the Doderlein flora. At 90-98% it is represented by lactobacilli (Doderlein sticks), bifidobacteria and, to a small extent, strict anaerobes (in particular, peptostreptococci).

The share of other (more than 40 species) microorganisms that inhabit the vaginal space of a woman normally accounts for only 3-5%.

/the most clinically significant microbial communities are indicated/

• A sharp decrease or disappearance of peroxide- and acid-forming lactobacilli (lactobacilli). As a result, an increase in the pH of the vaginal environment.
• Massive reproduction of strict (obligate) anaerobes: Peptostreptococcus spp., Mobiluncus spp., Bacteroides spp., Prevotella spp., etc.

These microorganisms belong to the normal vaginal microflora. But their excessive growth, against the background of a deficiency of lactobacilli, leads to a decrease in the content of acids in the vaginal contents and creates a favorable environment for the rapid development of opportunistic and pathogenic infections.

• Colonization of the vagina with gardnerella.
• An increase in the total concentration of bacteria in the vaginal discharge to 10 9 - 10 11 microorganisms in 1 ml (CFU / ml).

Representatives of the Doderlein flora

In the vaginal contents of various women, more than 10 types of unequal lactobacilli are isolated. They produce lactic acid (as a result of the destruction of glycogen accumulated by the vaginal epithelium), hydrogen peroxide, lysozyme, and stimulate local immunity.

By blocking the receptors of the cells of the surface epithelium, lactobacilli prevent the adhesion of pathogenic agents. Colonizing the mucous membrane, they participate in the formation of a protective ecological film and provide colonization resistance of the vaginal biotope.

The pronounced acidic environment created by lactobacilli suppresses the reproduction of acidophobic opportunistic and transient pathogenic microorganisms.

The second representatives of the useful flora of Doderlein also belong to acid-forming microorganisms. They play an important role in maintaining low pH values ​​of the vaginal environment, produce alcohols, lysozyme, bacteriocins, amino acids, vitamins, and stimulate the immune system.

propionic acid bacteria- useful representatives of anaerobes. Actively processing glycogen, they secrete acetic and propionic acids, inhibit the growth of opportunistic microflora.

Causes of bacterial vaginosis

The mechanisms of development of vaginal dysbiosis are still not entirely clear.

An important role in the pathogenesis of the disease is played by:

• Change in hormonal status.
• Changes in general and / or local immunity, a decrease in the body's resistance.
• Decompensated diabetes.
• Taking antibiotics, cytostatics, radiation therapy, ionizing radiation.

Risk factors for bacterial vaginosis:

- Puberty, menopause, pathology of pregnancy, postpartum, post-abortion period, menstrual disorders (amenorrhea, oligomenorrhea).
- Hypotrophy and atrophy of the vaginal mucosa.
- Violation of the sensitivity of the vaginal mucosa to sex hormones.
- Sexually transmitted infections.
- Inflammatory processes of the urogenital tract.
- Taking glucocorticosteroids, antibacterial, antiviral, chemotherapeutic drugs.
- Long-term, uncontrolled use of oral and intrauterine contraceptives.
- Foreign bodies in the vagina and uterus (tampons, IUDs, etc.)
- Cysts, polyps of the genital tract.
— Surgical gynecological operations.
- Violation of the hygiene of the genital organs.
- Inadequate use of douches, vaginal douches, deep washing.
- The use of condoms, uterine caps, diaphragms treated with spermicide (nonoxynol -9).
- Frequent change of sexual partners.
- Chronic stress.

Development of bacterial vaginosis

Under the influence of external and / or internal factors that disrupt the healthy balance of the vaginal microecosystem, the number of H 2 O 2 -producing pool of lactobacilli decreases, the production of lactic acid decreases, the pH of the vaginal contents increases.

The growth of the pool of strict anaerobes is increasing. The waste products of these bacteria decompose to volatile amines, with a characteristic smell of "rotten fish".

Hormonal imbalance "progesterone / estrogens" accelerates the proliferation (reproduction) of the vaginal epithelium. Activation of the receptors of these cells to bacteria stimulates the adhesion (adhesion) of strict anaerobes to the vaginal mucosa and the formation of "key" cells.

• "Key" cells are desquamated cells of the vaginal epithelium, covered with gram-negative bacilli (rod-shaped bacteria, not lactobacilli).

Abundant exfoliation of the "key" epithelium is accompanied by increased production of vaginal discharge up to 20 ml per day (at a rate of 2 ml).

Symptoms of bacterial vaginosis

1. Whitish-gray, creamy vaginal discharge, usually with a "fishy" smell of varying intensity. The unpleasant odor either disappears or intensifies after intercourse, menstruation, douching, washing.

It is the characteristic discharge that is the main complaint of patients with bacterial vaginosis. Liquid secretions can subsequently acquire a yellowish-greenish color, become sticky, thick, foamy.

2. Often patients feel discomfort in the external genital area, painful sexual contact (dyspareunia).

3. Very rarely there is itching and burning of the genital organs or painful urination (dysuria).

Objective clinical symptoms of bacterial vaginosis
Amsel criteria
1. Abundant, homogeneous whitish-gray discharge from the vagina.
2. "Key" cells in vaginal smears.
3. Acidity of vaginal content: pH>4.5.
4. Positive amino test.

The presence of 3 out of 4 possible signs confirms the diagnosis of bacterial vaginosis.

Diagnosis of bacterial vaginosis

1. Inspection of the walls of the vagina with a mirror.
In favor of bacvaginosis testify:
- The presence of abundant secretions (whites), evenly covering the vaginal mucosa.
- The usual pink color of the walls of the vagina no signs of inflammation.

2. Calposcopy.
Confirms the absence of inflammation of the vaginal mucosa.

3. Microscopy: bacterioscopic examination vaginal smears are the main, most accessible and reliable method for diagnosing bacterial vaginosis.

Microscopy of smears of patients with bacvaginosis reveals:
- Reduction or disappearance of lactobacilli (gram-positive rods of various sizes).
- Increased mixed non-lactobacillary microflora.
- "Key" cells. The edges of the "key" epithelial cells are uneven, indistinct due to the adherence of gram-variable rods and cocci, including Gardnerella vaginalis, Mobiluncus, etc., to them; it is often difficult to distinguish microorganisms from each other.
- In most cases: a small number of leukocytes.

Not characteristic of isolated bacterial vaginosis.

4. Determination of acidity (pH) of the vaginal secretion using indicators.

5. Aminotest.
When mixed on a glass slide of vaginal discharge from a patient with bacvaginosis with an equal amount of potassium hydroxide solution (solution KOH 10%), an unpleasant smell of rotten fish appears.

Additional methods for diagnosing bacterial vaginosis

They are used according to indications, in cases of frequent recurrence of the disease.

1. Cultural study.
It consists in determining the species and quantitative composition of the vaginal microflora: isolation and identification of Gardnerella v., other facultative and obligate anaerobes, lactobacilli (with a sharp decrease in their number

2. Molecular biological methods: PCR, etc.
Test systems detect specific fragments of DNA and/or RNA of microorganisms (A. vaginae, G. vaginalis, M. hominis and Ureaplasma spp., etc.), including difficult-to-cultivate bacteria.

Differential Diagnosis

The diagnosis of bacvaginosis requires the exclusion of urogenital microbial-viral sexually transmitted infections (gonococcal, trichomonas, chlamydial, and other STIs). It is also important to differentiate infections caused by opportunistic agents and fungi (genital mycoplasmas, facultative anaerobic and aerobic microorganisms, candida).

Degrees of bacterial vaginosis

/Microscopic characteristics of smears according to Mavzyutov A.R./

1 degree

It is characterized by a meager amount of any microbial, including lacto-flora in a vaginal smear.

Such a smear is not considered a pathology. Often it is due to excessive preparation of the patient for a visit to the gynecologist (deep washing with disinfectants), previous antibacterial treatment (taking broad-spectrum antibiotics) or intensive chemotherapy.

2 degree

Subcompensated bacterial vaginosis:- decrease in the number of lactobacilli;
— a commensurate increase in other microbial flora;
- the appearance in the smear of single (1-5) "key" cells.

3 degree

Clinical bacterial vaginosis:- almost complete absence of lactobacilli;
- the field of view is filled with "key" cells;
- the bacterial flora is represented by various (except for lactobacilli) cultures in various species combinations.

How to treat bacterial vaginosis

The first stage of treatment of the disease is carried out with antibacterial agents of the 5-nitroimidazole or clindamycin group, to which anaerobic bacteria and gardnerella are most highly sensitive.

• Metronidazole
  Trade names: Trichopolum, Metrogil, Flagyl, Klion
• Tinidazole
  Trade names: Fazizhin, Tiniba (500 mg)
• Ornidazole
  Trade names: Tiberal, Dazolik, Gyro, Ornisid, etc.
• Clindamycin
  Trade names: Dalacin, Clindamin

Vaginal tablets and suppositories for bacterial vaginosis:

In recent years, local combined vaginal agents with antibacterial, antifungal, anti-inflammatory effects have been considered a promising method for treating bacvaginosis:

• Polygynax
• Terzhinan
• Vagisept
• Vagiferon
• Elzhina

Apply: one suppository (tablet) in the vagina for 10 days.

The second stage of treatment is carried out after the complete eradication of anaerobic and conditionally pathogenic microflora. Restoration of the normocenosis of the vagina is carried out by local administration of biological preparations:

• Lactoginal
• Acylact
• Floragin Gel
• Laktonorm
• Lactobacterin
• Bifidumbacterin
• and etc.

The effectiveness of bottom biopreparations, unfortunately, is limited by the low survival rate of "foreign" strains of lactobacilli in the vagina.

To restore normal vaginal microflora, intravaginal agents are also recommended:

• Lactogel (lactic acid + glycogen)
• Multi-Gyn Actigel
• Vaginorm

They are used both for the treatment and prevention of bacterial vaginosis.

In cases of atrophic changes in the vaginal mucosa, local estrogens (estriol preparations) are used:

• Trioginal
• Orniona vaginal cream 1%

According to indications, antiallergic drugs and vitamins A, E, C are prescribed.

Recommended Antibacterial Treatments for Bacterial Vaginosis

Metronidazole 500mg tablets. 1 tablet 2 times a day, orally (by mouth).
Course of treatment: 7-10 days.

Tinidazole 2.0 g (4 tablets of 500 mg) at a time, by mouth orally, once a day.
Course of treatment: 3 days.

Given the local nature of the infection, many specialists prefer topical treatment for bacterial vaginosis. The best therapeutic effect was shown by intravaginal suppositories and gels with Metronidazole or Clindamycin.

3.1 Vaginal suppositories with Metronidazole 500 mg (Flagyl, vaginal suppositories)
Apply once a day, intravaginally, at night.
Course: 7-10 days.

3.2 Metrogyl (Metronidazole), gel 1%
Apply intravaginally at 5.0 g (one full applicator) 1 time per day, at night.
Course: 5 days.

3.3 Metronidazole gel 0.75%. Apply 5.0 g intravaginally (one full applicator) 1 time per day, at night.
Course: from 5 days to 2 weeks.

Dalacin (Clindamycin, Clindamycin), cream 2%
1 full applicator (5.0 g cream = 100 mg clindamycin) deeply intravaginally 1 time per day, at night.
Course: 7 days

Alternative Treatments for Bacterial Vaginosis

Metronidazole 2.0 g (8 tablets of 250 mg or 4 tablets of 500 mg) at a time, once, inside, orally.
Treatment result:
closest is good
remote - not good enough

Scheme 2A Tiberal (Ornidazole) 500 mg, 1 tablet orally 2 times a day.
Course: 5 days.

The effectiveness of the drugs Metronidazole and Clindamycin is approximately the same. But taking Clindamycin is less likely to cause unwanted side effects.

During treatment and within 24 hours after the end of taking Metronidazole it is forbidden to take alcohol.

Bacterial vaginosis during pregnancy - treatment features

Treatment of bacvaginosis in pregnant women requires an individual approach in the choice of dosages and therapeutic regimens. Taking oral antibiotics is possible only from the 2nd trimester of pregnancy under the strict control of laboratory diagnostics in a specialized medical facility.

1. Metronidazole, tablets 500 mg.
Take 1 tablet 2 times a day orally. Course of treatment: 7 days.

2. Metronidazole, tablets 250 mg.
Take 1 tablet 3 times a day orally. Course: 7 days.

3. Clindamycin 300 mg capsules.
Take 1 capsule orally 2 times a day. Course: 7 days.

Prognosis for bacterial vaginosis

The disease does not pose a direct threat to the life of the patient. Treatment takes place at home (there are no indications for hospitalization).

The control of the therapeutic effect is carried out 14 days after the end of treatment: examination by a gynecologist + repeated smear.

If the result is insufficient, the doctor chooses alternative drugs or methods.

Despite the "harmlessness" of the disease, it is important to carry out its timely treatment and prevention.

Possible complications of bacterial vaginosis:

- Spontaneous abortion (miscarriage).
- Pathology of pregnancy: intra-amniotic infection.
- Pathology of childbirth and the postpartum period: premature rupture of amniotic fluid, premature birth, endometritis and / or sepsis after caesarean section.
- The risk of having children with low body weight.
- The risk of developing infectious complications after gynecological operations or abortions.
- The risk of developing inflammatory diseases of the pelvic organs: peritonitis, abscesses of the pelvic organs after the introduction of intrauterine contraceptives, after invasive manipulations.
- The risk of developing dysplasia (neoplasia) of the cervix. Read in detail:.
- Increased susceptibility to sexually transmitted infections, including HIV, genital herpes.

Risks of recurrence of bacterial vaginosis

Frequent recurrence of bacvaginosis is observed in women with impaired immune and/or endocrine status. Such patients need advice:
– gynecologist-endocrinologist,
— endocrinologist,
- gastroenterologist.

Practice shows that prophylactic treatment of the sexual partner has little effect on the recurrence of episodes of bacvaginosis in the patient. Examination and treatment of a sexual partner is mandatory in the presence of clinical symptoms of balanoposthitis, urethritis or other urogenital diseases.

Alternative methods of treatment of bacterial vaginosis

Among the non-traditional methods of treating gynecological diseases, douching with solutions of medicinal herbs remains the "favorite" means of traditional healers.

In the case of bacterial vaginosis, such procedures are undesirable and even dangerous. They provoke the washing out of useful vaginal lactoflora, the introduction of pathogenic and opportunistic microorganisms into the cervical canal, allergic reactions and inflammation of the mucous membranes.

Permitted procedures:

Dissolve 1 teaspoon of Boric acid pharmaceutical powder (sold in bags) in 1 cup of boiling water. Cool down. With a sterile syringe, inject 100 ml of a freshly prepared tepid solution into the vagina. The procedure is carried out 1 time per day for a week.

Prepare a weakly concentrated (barely noticeable pinkish color) solution of potassium permanganate. Wash and douche once a day for a week.

Dilute 1 tablespoon of hydrogen peroxide solution for external use 3% (hydrogen peroxide 3%, sold in a pharmacy) in 500 ml of freshly boiled tepid water. Wash and douche once a day for a week.

Prevention of bacterial vaginosis

• Controlled intake of antibacterial and other drugs.
• Adequate diagnosis and therapy of gynecological (including age-related dyshormonal) diseases.

Thanks to the correct treatment of gynecological and endocrine pathology, the content of glycogen (the main nutritional component of lactobacilli) in the vaginal epithelium normalizes, normal vaginal microflora develops.

• Hygiene of the genitals.
• Hygiene of sexual life, fidelity to one partner.
• Giving up bad habits (smoking, etc.)
• Normalization of immune and neuroendocrine status.
• Physical activity: the fight against congestion in the pelvic area.

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Bacterial vaginosis

general information

Bacterial vaginosis - an infectious non-inflammatory disease characterized by a change in the normal ecosystem and pH of the vagina in women. In particular, there is an imbalance of microorganisms that, under physiological conditions, colonize and protect the vaginal environment (the so-called saprophytic microflora).

The result is a polymicrobial infection that affects the vagina, in which various types of bacteria are involved, able to synergistically create suitable conditions for the development of others. Thus, there is a change in the microflora of the vagina with a decrease in the number lactobacilli(usually protective and responsible for maintaining the slightly acidic environment of the vagina) and the reproduction of pathogenic microorganisms.

Indication of bacterial vaginosis itching, intimate burning and increase (homogeneous grayish-white discharge, characterized by a bad smell), but in about half of the cases it is asymptomatic.

If ignored, the disease can cause gynecological complications, as well as promote sexual transmission of sexually transmitted diseases.

What is meant by bacterial vaginosis?

Bacterial vaginosis is one of the most common vaginal infections among women.

The most important aspect is that the disease is characterized by severe change in the vaginal ecosystem, i.e. various populations of microorganisms that usually inhabit this region of the body and acquire a state of mutual equilibrium ( flora or vaginal microbiota).

The most important bacteria in the vaginal ecosystem are lactobacilli(Dederlein rods), and like the organism itself, these protective microorganisms benefit from this symbiosis. The lactobacillus flora feeds on essentially the glycogen present in vaginal secretions and synthesizes lactic acid, helping to keep the vaginal environment slightly acidic, while pH around 3.8-4.5. This acidity is especially important for the body, as it inhibits the growth of other harmful pathogens that can cause infections.

Causes and risk factors

Usually, in women of reproductive age, lactobacilli (or Dederlein sticks) are the predominant components of the vaginal microflora. Colonization with these bacteria is usually protective as it maintains the vaginal pH at normal values ​​(between 3.8 and 4.2) and prevents overgrowth of pathogens. However, in the presence of situations that change the vaginal ecosystem, the sexual organ becomes vulnerable.

What are the causes of bacterial vaginosis?

The causes of bacterial vaginosis are still being studied and researched medically. The etiological picture is actually quite complex: the occurrence of the disease seems to depend on simultaneous interaction of various factors rather than from a single microorganism or factor.

In any case, certain circumstances create an imbalance in the vaginal flora, where microorganisms predominate, which, as a rule, should not be present or should be present only in limited quantities. All this affects the microflora of the vagina.

Thus, some microbes can find favorable conditions and multiply abnormally, becoming dangerous and causing bacterial vaginosis.

Microorganisms that play a leading role in pathogenesis include: Gardnerella vaginalis, Mobiluncus spp. and Prevotella spp..

Predisposing and/or aggravating factors

Any woman can get bacterial vaginosis, but certain activities and behaviors can greatly increase this risk.

- Unprotected intercourse and a large number of sexual partners.

Bacterial vaginosis is more common in sexually active women.

Failure to use condoms during intercourse is a possible cause of vaginosis. In particular, vaginal dysmicrobiosis may be associated with a period of greater frequency of unprotected intercourse. In fact, sperm cells raise the pH of the vagina to create a more favorable environment for sperm to live; however, this condition may encourage the growth of certain bacteria.

Frequent change of sexual partner is also considered an important risk factor for the disease.

- Other risk factors.

Other conditions that disrupt the normal balance of the bacterial flora of the vagina and predispose to the development of bacterial vaginosis:

• topical or systemic antibiotic therapy;
• use of intrauterine mechanical contraceptives, for example, spirals;
• intimate hygiene with too aggressive detergents or insufficient pH.

Factors such as psychophysical stress can also affect the immune system, thus predisposing to bacterial vaginosis.

In determining vaginal dysmicrobiosis, which sets the ideal conditions for an increase in pathogenic bacteria and genital infections, the patient's medical history and age also contribute, in particular, it has been noted that bacterial vaginosis is rarer in prepubertal women than in postmenopausal women. probably due to the lower number of relationships and sexual partners in these two age groups and the characteristic hormonal pattern that distinguishes them from the period of fertility.

Bacterial vaginosis in pregnancy

During pregnancy vitamin D deficiency, seems to play a role in the occurrence of vaginosis, and also correlates with , preeclampsia and the need to resort to caesarean section. Vitamin D is involved in the modulation of the immune system and the regulation of cell proliferation, so an adequate supply of the vitamin is essential for the health of the pregnant woman and the fetus. If the supply of a vitamin is insufficient, it is necessary to supplement it (after consulting a doctor) to reduce the risk of these gestational complications.

Symptoms and signs

Bacterial vaginosis is not always symptomatic (it can be asymptomatic in 50% of cases), but it is usually indicated by plentiful greyish-white, rather thin and foul-smelling vaginal discharge.

Some women with vaginosis compare bad smell secretions from smell fish and report it, especially after intercourse, soap use, or menstruation. This foul-smelling leucorrhea due to the production by some microbes of certain substances obtained as a result of the decomposition of amino acids, called aromatic amines (putrescine, cadaverine, tyramine).

In some cases, the presence of the disease may signal:

• itching in an intimate place;
• burning sensation when urinating;
• pain during intercourse.

Possible Complications

In most cases, bacterial vaginosis does not cause serious complications, but the characteristic increase in vaginal pH increases the risk of infection with various sexually transmitted diseases, such as and .

Bacterial vaginosis can also contribute to pelvic inflammatory disease (PID)) :

• endometritis;
• parametritis.

If not treated promptly and correctly, the condition can damage the tubes, increasing the risk of ectopic pregnancy and even infertility.

In addition, in the case of vaginosis during pregnancy and if not properly treated, there is a chance of preterm labor because the infection can spread to the amniotic membrane, causing early rupture. During pregnancy, there is a risk of developing fetal-placental infections and postpartum endometritis.

Diagnostics

Bacterial vaginosis is diagnosed when gynecological examination. The doctor examines the vagina and measures the pH level. In the case of bacterial vaginosis, the pH level is usually above 4.5.

During a gynecological examination, the vulva and vagina have a normal appearance, but there is a homogeneous milky-grayish leucorrhea adhering to the walls of the vaginal canal.

During the examination, a sample of vaginal secretions is also taken for microscopic examination to look for bacteria associated with bacterial vaginosis. When in contact with an alkaline substance such as potassium hydroxide (KOH), the sample releases a fishy odor suggestive of vaginosis.

Microscopic examination of a vaginal secretion sample reveals the classic " clue cells”, i.e. epithelial cells of the vagina, covered with numerous bacteria, which give the cells a granular appearance. Presence white blood cells(leukocytes) on microscopic glass indicates co-infection such as gonorrhea or chlamydia and requires test cultures. However, cultural studies on ( Gardnerella vaginalis) are weakly specific (this bacterium can be isolated from 50% of healthy women).

Diagnosis can also be confirmed:

• the Gram stain method (a relatively fast test used to detect the presence of bacteria);
• analysis of the ratio of lactobacilli and other bacteria (Nugent criteria).

But the Pap smear is unlikely to be useful, because it is not very sensitive to the diagnosis of bacterial vaginosis.

- Clinical criteria (Amsel criteria) for the diagnostic definition of bacterial vaginosis.

The diagnosis of the disease is established when 3 of the 4 following clinical criteria are met:

• copious discharge from the vagina of a grayish-white, homogeneous consistency (leukorrhea), evenly covering the walls of the vagina;
• vaginal pH >4.5;
• positive fishy odor test (10% KOH);
• presence on re-examination of cue cells (vaginal epithelial cells [at least 20% of epithelial cells]).

Treatment of bacterial vaginosis

Sometimes vaginosis spontaneously regresses, but if symptoms or complications are present, a specific therapeutic protocol established by a general practitioner or reference gynecologist is always indicated.

The first drug of choice for the treatment of bacterial vaginosis is metronidazole(tablets of 500 mg 2 times a day for a week).

Intravaginal therapy using 2% clindamycin cream(applied every night for a week) or 0.75% metronidazole gel(applied 2 times a day for 5 days) is also effective.

Treatment with a single dose of 2 g of metronidazole usually gives good clinical results, but is characterized by an increased rate of recurrence of infection.

Topical treatments based on creams or gels are preferred for pregnant women because they are less likely to develop systemic side effects.

These drugs have the advantage of providing a quick response, but they should be combined with foods that can stimulate the proliferation of lactobacilli: in the presence of vaginosis, it is important to restore the normal ecosystem by taking probiotics. A diet high in fiber and low in simple sugars may also be beneficial. various sweets, candies and drinks with sugar.

Finally, it should be remembered that during treatment it is always important to avoid contact or sexual intercourse in order to reduce the risk of reinfection.

Attention! The topical drug clindamycin, used to treat bacterial vaginosis, reduces the effectiveness of latex condoms and diaphragms. Therefore, women using them cannot rely on these methods of contraception during therapy.

Forecast

The prognosis is favorable. Bacterial vaginosis usually clears up after a few days but often recurs. If it recurs often, you may need to take antibiotics for a long time.

Prevention

To prevent vaginosis and an imbalance in the vaginal bacterial flora, it is important to follow a few simple tips. First of all, it is important to take care of intimate hygiene.

An intimate cleanser should be selected so as not to damage the acid-base balance (pH level) of the vagina. Also, excessive vaginal washing, vaginal cleansing, intimate hygiene sprays, and overly harsh or perfumed soaps should be avoided.

Additionally, when washing intimate places, it is recommended to perform a movement starting from the vulva to the anus, and not vice versa; thus, the spread of fecal bacteria from the anal area to the vagina is prevented. After completing intimate hygiene procedures, dry the area well and gently. Finally, another important tip - avoid wearing synthetic and too tight underwear.

Specialty: Cardiologist, Therapist, Doctor of Functional Diagnostics.

Today we will talk about:

Vaginosis- This is a pathological condition of the vaginal mucosa of non-inflammatory origin, caused by the replacement of normal microflora with anaerobic microorganisms. There is no specific causative agent for vaginosis. Among the causes that provoke it, there are many different microorganisms, but their presence does not provoke local inflammatory changes in the vagina. It is on this feature of the course of the disease that the differential diagnosis of vaginosis is based.

The causes of vaginosis are not well understood, and the question of whether it belongs to diseases continues to be discussed. The only condition for the development of vaginosis is a change in the parameters of normal vaginal microbiocenosis and, as a result, a violation of the mechanism for protecting mucous membranes from unwanted microorganisms.

To understand the essence of the pathological processes in vaginosis, it is necessary to have a clear idea of ​​​​how the vaginal epithelium functions, and by what mechanisms it protects the reproductive system from potential infection.

The vagina connects the uterus (and indirectly, the appendages) with the external environment and therefore is in a state of constant resistance to its negative influence in order to protect the internal genitalia from inflammation.

The vaginal wall is formed by three layers: connective tissue, muscle and epithelial. The vaginal epithelium is formed by layers of squamous cells, its uppermost layer (the one that lines the inside of the uterine cavity) is in a state of constant renewal. Every month, according to cyclical changes in other genital organs, the surface layer of the vaginal epithelium is shed (sloughed off) and replaced by new cells. Thus, the mucosa is "cleared" of the potential cause of inflammation and protects the upstream organs from infection.

The key to successful mucosal barrier function is the constancy of the vaginal microenvironment. In a healthy vagina, it is represented by a dominant amount (98%) of lactobacilli and a small population of opportunistic microorganisms. The quantitative superiority of lactoflora provides reliable protection of mucous membranes from infection. If there are fewer lactobacilli, opportunistic microbes take their place.

In order to provide themselves with a numerical advantage, lactobacteria create conditions unsuitable for the vegetation of "harmful" microorganisms. They attach to the membranes of desquamated cells of the surface epithelium and “extract” glycogen from them, and then synthesize lactic acid from the latter. As a result, a constant level of acidity is maintained in the vagina (3.8 - 3.5). In an acidic environment, opportunistic flora is not able to compete with lactobacteria, therefore it remains small and safe.

Vaginosis is formed in the event that, against the background of a quantitative decrease in lactobacilli and a change in acidity (pH), populations of opportunistic microorganisms begin to multiply in the vagina, i.e. in fact, it is a local dysbiotic disorder.

Thus, vaginosis is formed due to "its own" microflora, which is constantly present in the vagina of any healthy woman. It is impossible for them to "get infected" or betray a partner during intimacy.

Acute vaginosis is rarely diagnosed. Since vaginosis does not provoke pronounced inflammation, the disease often does not have active subjective complaints. The pathological process in the mucous membranes of the vagina is able to proceed erased, then aggravating, then fading again.

Chronic vaginosis depletes local immunity and can cause inflammation when, against the background of a significant decrease (or complete disappearance) of lactoflora, unwanted microorganism begin to multiply excessively in the vagina.

Perhaps the only symptom of vaginosis is abnormal discharge. Their color and consistency depend on which microflora displaces lactobacilli, how long vaginosis exists, and what background processes occur in the surrounding tissues.

Diagnosis of vaginosis is based on a visual examination of the mucous membranes and a laboratory study of the vaginal discharge. By studying the microbial composition of vaginal leucorrhoea, the severity of the disease is determined: the less lactobacilli in the material, the more severe the vaginosis.

Therapy of vaginosis does not have a clearly defined plan. Each regimen for the treatment of vaginosis is the result of an individual study of the clinical situation. As a rule, treatment is aimed at eliminating unwanted microbial flora and restoring the lactobacillus population. Inside pills for vaginosis are prescribed according to indications. Preference is given to a local preparation (ointments, creams, suppositories).

Vaginosis often recurs. Prevention of vaginosis and its recurrence consists in the exclusion of provoking factors and a reasonable attitude towards sexual life.

The reason for the formation of vaginosis is its own opportunistic microflora present in the vagina of a healthy woman. Perhaps this is the uniqueness of vaginosis: the body independently provokes the disease without the involvement of external resources.

The microbial composition of the vaginal environment for each individual woman is individual, so it is impossible to name the only culprit in the development of vaginosis. It is provoked by polymicrobial complexes, which consist mainly of anaerobic microorganisms (mainly coccal nature). More often, with vaginosis, corynebacteria, mycoplasmas, epidermal staphylococcus aureus, lactic acid streptococci and other microbes prevail in the vaginal contents. It should be noted that the previously existing idea of ​​the dominant role of gardnerella in the pathogenesis of vaginosis has now been refuted by numerous studies. It turned out that gardnerella colonize the vagina in more than 50% of healthy women, without causing pathological dysbiotic changes in the habitat. Obviously, this microorganism acts as a pathological agent only if it is associated with another microflora.

Factors provoking dysbiotic disorders in the vagina are:

Incorrect hygiene measures. Some patients use douching too often, during which the “useful” microflora is simply mechanically washed off the surface of the mucous membranes. Also, aggressive cosmetics (soaps, gels) that are not suitable for intimate care have a negative effect on the vaginal epithelium.

The lack of proper intimate hygiene can also provoke vaginosis, as many unwanted microbes and their waste products accumulate on the mucous membranes.

Irrational antibiotic therapy. Free access to the purchase of antibiotics (including very "strong" ones) has very negative consequences: without the participation of a qualified medical examination, the sick are treated on their own, not always choosing and taking medicines correctly.

Antibiotic therapy prescribed by specialists always involves measures to prevent dysbiotic disorders and rarely leads to the formation of vaginosis.

Hormonal dysfunction. All ongoing processes in the vaginal mucosa are closely related to cyclic hormonal fluctuations. The state of the vaginal microflora is affected by the level of estrogens, they support the processes of renewal of the surface mucous layer, providing lactobacilli with a sufficient amount of glycogen. Under conditions of hypoestrogenism (especially long-term), the mucous layer becomes thinner, the population of lactobacilli decreases, and conditionally pathogenic microorganisms begin to vegetate intensively.

Changes in the normal hormonal background are more likely to explain vaginosis in pregnant women, women in menopause, or in women who have had a recent abortion.

Taking hormone-containing medications or contraceptives can also contribute to the appearance of vaginosis.

• Unprotected intimate relationships with different partners. In addition to an increased likelihood of getting a venereal infection, promiscuity leads to serious changes in the composition of the vaginal microflora and depletes local immunity. Moreover, the number of sexual partners increases the risk of vaginosis much more than the number of unprotected sex.
• Intestinal dysbacteriosis. Symmetric dysbiosis of the intestinal and vaginal mucosa is often diagnosed, especially against the background of endocrine diseases or antibiotic therapy. Every second patient with vaginosis has a diagnosed intestinal dysbacteriosis.
• Violations of immunological reactivity. The cause of vaginosis can be systemic allergic diseases or short-term local allergic reactions, for example, to hygiene products (vaginal tampons, soap, etc.), intimate lubricant, latex or talc contained in condoms.
• Intrauterine contraception (spiral). It provokes the appearance of vaginosis quite often (52%). Obviously, the spiral is perceived by the mucous membranes as a foreign body, and they respond to its presence with a local allergic reaction. In addition, any (even the most “good”) intrauterine contraception serves as a source of local non-infectious inflammation. In order for the intrauterine contraceptive to fulfill its intended purpose without concomitant negative manifestations, it is necessary to follow simple medical recommendations and not leave it in the uterine cavity for longer than the prescribed period.

Whatever the causes of vaginosis, a short-term change in the normal composition of the vaginal microflora in most healthy patients is eliminated through self-regulatory mechanisms. The disease develops only if the body is unable to eliminate local dysbiosis on its own.

Symptoms and signs of vaginosis

The leading, and sometimes the only, symptom of vaginosis is pathological discharge (leucorrhoea). Their number and appearance depend on several factors, one of which is the duration of the disease.

Acute vaginosis is accompanied by abundant white liquid leucorrhoea, sometimes the vaginal discharge has a grayish tint and an unpleasant odor. More often, an acute process occurs after hypothermia, severe emotional shock, allergic reactions, due to antibiotic therapy.

Chronic vaginosis can exist for years. If dysbiotic disorders in the vagina last more than two years, the discharge becomes thick and sticky, and its color changes to yellow-green. The change in the nature of leucorrhea in chronic vaginosis is associated with the degree of local dysbiosis: the longer vaginosis lasts, the less lactobacilli remain in the vagina, and the more pronounced the influence of opportunistic microflora. Long-term vaginosis significantly depletes the mechanism of local protection of the mucous membranes and can often cause the attachment of secondary pathological microflora and the development of infectious inflammation.

Allocations with vaginosis have one specific difference - an unpleasant odor, reminiscent of the smell of stale fish. It is “provided” by anaerobic bacteria competing with lactoflora. They synthesize substances (amines), which decompose with the release of an unpleasant, "rotten" odor. Often the patient is brought to the doctor not by the presence of whites, but by their unusual smell.

The clinic of vaginosis also depends on the state of hormonal function, in particular, on the level of estrogen. Lower (in comparison with progesterone) concentrations of estrogens lead to a decrease in glycogen content in the vaginal epithelium. Since less lactobacilli are required to process a small amount of glycogen, their number decreases, and anaerobic microflora occupies the vacated place on a competitive basis. Prolonged lack of proper estrogenic influence provokes thinning of the mucous layer of the vagina (orthia). The vagina becomes "dry", easily vulnerable, so the amount of whiteness against the background of vaginosis decreases, and the patient has subjective complaints of discomfort, dryness, burning and / or itching. Similar ones are typical for women with physiological (older age) or artificial (removal of the ovaries) menopause.

Diagnosis of vaginosis does not require a large number of examinations, however, the analysis of the data obtained is associated with some difficulties. Vaginosis should be distinguished from vaginitis, which, unlike the latter, is the result of an infectious inflammation of the vaginal mucosa. Often, patients treat non-existent vaginitis for years, using antibiotics, which only aggravate vaginal dysbiosis and lead to the development of chronic vaginosis.

The diagnosis of vaginosis is confirmed by several reliable criteria:

• Absence of inflammatory changes in the vaginal mucosa. On visual examination, the mucosa has the usual "healthy" appearance and pink color. In the vagina there is an increased amount of light discharge without external signs of the presence of pus, often (87%) during examination, their unpleasant odor is felt.
• Change in the acidity of the vaginal environment. To measure pH quantitatively, special indicator test strips are used. The division scale applied to them with vaginosis indicates a characteristic shift in acidity to the alkaline side (more than 4.5).

Changes in the microbial composition of the vaginal discharge according to the results of laboratory diagnostics. In smears, there is no increased number of leukocytes inherent in inflammatory diseases, but there is a quantitative shift in the microbial composition: against the background of a decrease (or complete absence) of lactoflora, an excessive increase in populations of opportunistic microorganisms is observed.

Among other anaerobic bacteria, a large number of Gardnerella are often found. In acceptable quantities, their population is completely harmless to the mucous membranes, but under conditions of pronounced dysbiosis, gardnerella enter into microbial associations and “help” maintain the pathological process. The simple detection of Gardnerell in a smear does not have independent significance.

The presence in the smear of the so-called "key cells". Microscopy of the vaginal discharge with vaginosis often visualizes a large number of desquamated epithelial cells with microbes adhering to their membranes. They are called "key".

Thus, the diagnosis of vaginosis is confirmed by:

• specific vaginal discharge (often with a "fishy" smell);
• increased above 4.5 vaginal pH;
• positive "amine test";
• key cells in the smear.

In 40% of patients with signs of vaginosis, when viewed on the cervix, background diseases (cervicitis, ectropion, scars) are found, more often pseudo-erosion. They often change the clinic of vaginosis and require additional colposcopic examination.

Despite the meager symptoms, the presence of vaginosis can be suspected at the stage of studying the clinical symptoms. Often in a conversation, patients point to a long, unsuccessful treatment of the so-called "inflammation" of the vagina. They may also note that the next course of anti-inflammatory therapy does not eliminate, but exacerbates negative symptoms.

In recent years, patients often face the conclusion of "cytological vaginosis". Unlike the usual, cytological vaginosis is the result of excessive reproduction of lactobacilli. This condition is often provoked by intimate hygiene products with an acidic pH, especially if they contain lactobacilli. Sometimes this type of vaginosis can appear against the background of hyperestrogenism. Excess estrogen stimulates excessive production of glycogen, which requires more lactobacilli to utilize.

Clinically, cytological vaginosis resembles candidal vaginitis, when, against the background of vaginal discomfort, burning or itching, abundant white "curdled" discharge appears. Both conditions are clinically so similar that diagnostic errors often occur.

It is possible to differentiate cytological vaginosis from according to the following criteria:

• vaginal pH less than 3.5;
• microscopically: many cells of the destroyed epithelium in the form of fragments against the background of a large number of lactobacilli;
• false key cells: instead of opportunistic microbes, lactobacilli are attached to the surface of epithelial cells, imitating true key cells;
• cultures and smears for the presence of candidal fungi are negative;
• no signs of inflammation (white blood cells are normal) in smears.

Vaginosis during pregnancy

In half of the cases, the disease does not cause pathological subjective sensations, and an increased amount of vaginal discharge is accepted by the pregnant woman as the norm.

The only reliable symptom of vaginosis in pregnant women is abundant liquid leucorrhoea with an unpleasant odor. If the discharge continues for a long time, the patient may notice a change in their consistency from liquid to thick, and in color from white to yellowish. Often in a conversation it turns out that episodes of the appearance of such whites were observed even before pregnancy.

Diagnosis of vaginosis in pregnant women is similar to that in non-pregnant women and includes examination of complaints (if any), visual examination of the vaginal mucosa, and laboratory examination of vaginal contents. An amine test and a vaginal pH measurement are also performed.

Pregnant women are examined for the presence of vaginosis three times: at the first visit, before maternity leave (27-30 weeks) and on the eve of childbirth. In the case of a positive result after the course of therapy, an additional examination is carried out to monitor the cure.

Vaginosis during pregnancy can provoke an infectious inflammation. Against the background of reduced immunity, an infection from the vagina can rise into the cervical cavity and uterus. And although the likelihood of such a scenario is small, it is impossible to leave vaginosis in pregnant women unattended.

The treatment regimen for vaginosis in pregnant women is characterized by the predominant use of local therapy. Systemic drugs are used infrequently and only in the second half of pregnancy.

Treatment of vaginosis

To cure vaginosis, it is necessary to consistently eliminate its causes: remove the unfavorable background that provokes dysbiosis in the vagina; destroy the excessively multiplied opportunistic microflora and restore the normal amount of lactobacilli.

To choose the right treatment tactics, it is necessary to take into account the severity of vaginosis. It is measured by the amount of lactoflora remaining in the vagina and the microbial composition of the vaginal environment.

Conventionally, there are three significant degrees of severity of vaginosis:

• The first degree of severity (compensated vaginosis) is characterized by the complete absence of microflora in the test material, the presence of unchanged, normal, vaginal epithelium. The cause of such vaginosis may be excessive intimate hygiene or antibiotic therapy. Compensated vaginosis does not always require detailed therapy, sometimes the body independently copes with a temporary violation of the microbial balance after the disappearance of the cause of its appearance.
• The second degree (subcompensated) severity of vaginosis is characterized by a decrease in the number of lactobacilli, a quantitative increase in the population of anaerobic bacteria and the manifestation of key cells in a small amount (up to five in the field of view).
• Decompensated (third) degree of severity is manifested by a pronounced clinic of vaginosis, the complete absence of lactobacilli against the background of a large number of microbial populations and a significant number of key cells (covering the entire field of view).

After the unwanted infection is eliminated, a niche is released in the vaginal environment, which must be occupied by lactobacilli. At the second stage of treatment, favorable conditions are created for restoring normal microbial balance with the help of eu- and probiotics, which contain lacto- and bifidobacteria.

Two-stage treatment of vaginosis is successful in 90% of cases, but it does not guarantee the absence of recurrence of the disease. Relapses of vaginosis are treated similarly to the acute process. To avoid the return of vaginosis, simple preventive measures should be followed. Prevention of vaginosis involves:

• adequate intimate hygiene;
• rational antibiotic and hormone therapy;
• prevention (or treatment) of intestinal dysbiosis;
• culture of sexual life: restriction of sexual partners and use of barrier contraception;
• regular examinations in the conditions of the antenatal clinic.
• Candles and preparations for vaginosis

The choice of medicine depends on which microorganisms are found in the material during laboratory testing.

The local method of administering the drug is preferable, therefore, the following are more often prescribed: Chlorhexidine in solution or Hexicon vaginal suppositories; suppositories or cream Clindamycin (Metronidazole), Flagyl suppositories.

An alternative to local treatment is taking Metronidazole, Tinidazole, Ornidazole tablets according to the scheme chosen by the doctor.

Today, one of the most common problems among women of reproductive age is bacterial vaginosis (abbreviated as bacterial vaginosis). Currently, this pathology is considered as a dysbiotic condition of the vaginal environment, which has characteristic clinical manifestations.

This material is devoted to the main causes of bacvaginosis, its clinical manifestations, laboratory diagnostics and drug therapy.

Introduction

The term "bacterial vaginosis" arose and began to be perceived as a separate pathology with its own pathogenesis only in the 80s of the twentieth century.

In the past, this condition was on the same level as infectious and inflammatory diseases of the external genital organs (in particular,).

This pathology also had various "names", such as hemophilic, gardnerella vaginitis, anaerobic vaginosis and many others.

The term acquired its modern name only in 1984 at the International Conference in Stockholm on the recommendation of a scientific group.

Indeed, it is difficult to attribute to inflammatory, since there are no symptoms characteristic of inflammation (hyperemia, edema, hyperthermia, leukocytosis).

Vaginosis is much closer to intestinal dysbiosis, and, as a rule, accompanies it. (according to L. G. Tumilovich, V. P. Smetnik 1997)

2. Epidemiology

The question of the prevalence of bacvaginosis is currently quite acute. This is because:

1. 1 First, in about 50% of women, this condition is asymptomatic and can be discovered incidentally during routine examination and smear taking;
2. 2 Secondly, a large number of women have obvious symptoms of vaginosis, but do not go to their doctor and stay in this condition for years.

All this complicates not only timely diagnosis, but also further treatment.

One way or another, there is evidence that in the outpatient work of an obstetrician-gynecologist, the incidence of bacvaginosis is approximately 15-19% of all cases, among pregnant women - 10-30%, among women with inflammatory diseases of the genitourinary system - about 35% of cases.

As you can see, the numbers are by no means small, so the urgency of the problem is quite high.

3. What is bacterial vaginosis?

Bacterial vaginosis is a non-inflammatory syndrome that is characterized by a significant decrease in the number or complete absence of normal lactobacilli flora, followed by its replacement with polymicrobial associations of facultative flora. Or, in a nutshell, it is "vaginal dysbacteriosis."

4. Composition of the vaginal microflora

To fully understand the pathology, you need to know. It is represented not only by lactobacilli, in addition to them, a minor, facultative flora is found, which is necessary to maintain local immunity.

This associated flora is called conditionally pathogenic.

Normally, the biocenosis of the vagina is represented by the following types of microorganisms:

In addition to species diversity, the number of microorganisms in the vaginal biotope is of great importance.

Their total number is permissible within the range of up to 10 8 - 10 12 CFU / ml, among them 10 3 - 10 ⁵ CFU / ml fall on facultative anaerobic microorganisms, 10⁵ -10⁹ CFU / ml on aerobes.

As can be seen from the table, the main place in the vaginal biocenosis belongs to lactobacilli. This is due to their ability to maintain not only the pH of the environment, but also local defenses due to:

1. 1 Ability to reproduce quickly in the vaginal environment;
2. 2 Tight attachment to the surface of epitheliocytes;
3. 3 Breakdown of glycogen to organic acids;
4. 4 Synthesis of natural bactericidal substances (lysozyme, bacteriocins, hydrogen peroxide).

There is another, often forgotten, ability of microorganisms to form so-called biofilms by creating a special matrix when isolated communities come into contact with each other and uniting into a common structure.

Microorganisms in biofilms are practically inaccessible to antimicrobial agents and other unfavorable factors, including cells of the immune system.

This ability can both protect and harm the body. It all depends on which microorganisms were involved in the formation of biofilms.

5. Risk factors

The formation of bacterial vaginosis has a significant difference from the classical course of an infectious disease.

Here, the leading role belongs to the suppression of the body's defenses, a decrease in the number or complete disappearance of Dederlein's sticks (lactic acid bacteria, lactobacilli) and their replacement with facultative flora.

The reason for this may be the following conditions:

1. 1 Endocrine diseases, hormonal imbalance;
2. 2 Immunosuppression;
3. 3 Somatic diseases contributing to the development of the above conditions;
4. 4 Diseases of the genitals, accompanied by the ingestion of a large number of foreign microorganisms into the vagina;
5. 5 Violation of mechanical factors of protection (damage to the perineum, genital tract, intrauterine contraceptives);
6. 6 Massive, frequent and inadequate antibiotic therapy.

Another difference between bacvaginosis and an infectious disease is the absence of any one pathogen (, staphylococci, etc.).

When comfortable conditions arise, the amount of a more aggressive opportunistic environment increases, the number of lactobacilli decreases, the acidity of the vaginal environment shifts to the alkaline side.

All this leads to the intensive growth of facultative flora, the formation of pathological biofilms, the appearance of secretions with a specific unpleasant odor.

During the vital activity of opportunistic microorganisms, amines are released (putrescine, cadaverine, trimethylamine, and others). One of the tests aimed at detecting vaginal dysbiosis, the amine test, is based on this feature.

6. Clinical manifestations

As mentioned earlier, signs of inflammation in bacterial vaginosis are usually not detected.

The leading clinical symptoms of bacterial vaginosis are:

1. 1 Homogeneous, with a grayish tinge, frothy, viscous, moderate or plentiful (on average, no more than 20 ml per day). Such secretions can accompany a woman for many years, eventually changing their color to yellowish-green, becoming curdled, thicker.
2. 2 One of the leading symptoms of bacvaginosis is characteristic,. This is what most often confuses women who turn to the doctor. This "flavor" arises due to the release of volatile amines in the process of vital activity of opportunistic microbes.
3. 3 Symptoms such as burning, irritation are noted by almost 23% of patients. At the same time, there is no exact evidence that such symptoms are caused by dysbiosis, and not by any other process. The opinions of different authors on this issue are radically different.
4. 4 In rare cases, it is possible to change the nature and duration of menstruation, irregular pains of a pulling nature, mainly in the lower abdomen. Such manifestations are more often observed with long-term dysbiosis and indicate possible complications.

7. Diagnostic methods

1. 1 Complaints with which the woman first turned to the doctor. Most often - discharge from the genital tract, more abundant than normal, with a characteristic "fishy" smell.
2. 2 When viewed in the mirrors, the color of the mucosa is not changed, the usual pink color. The only alarming symptom is abundant discharge, evenly covering all the vaults of the vagina, with possible involvement of the cervix. With colposcopy, dystrophic changes in the cervical mucosa can rarely be detected.

7.1. Amine test

An elementary test that reliably proves the presence of pathological growth of facultative flora in the vagina. The principle of the test is based on the detection of amine waste products of microbes formed during the life of opportunistic microbes.

The essence of the test is to add an alkaline solution (10% potassium hydroxide solution) in a ratio of 1:1. With a positive result, the characteristic “fishy” smell is enhanced. This method is affordable, economical and reliable.

7.2. Laboratory diagnostics

The material for assessing the state of the vaginal flora is a smear from the posterior fornix and cervix. The most common, economical and affordable is the bacterioscopic method.

In recent years, there has been an active search for more specific markers of dysbiosis. For example, in 1992 it was first found in the vaginal contents, and in 1996 a representative of the facultative flora Atopobium vaginae was described.

In 2006, Australian scientists proved that this microorganism is a highly sensitive marker of bacterial vaginosis.

7.2.1. Bacterioscopy

Characteristic for bacvaginosis. One of the leading signs.

These are desquamated epithelial cells of the mucosa, along the edge of which gram-variable bacteria, rods and cocci are adhered. These bacteria give the cells a vague outline and a granular appearance, which is clearly visible under microscopy.

Figure 1 - Key cells in a vaginal smear for bacterial vaginosis

With a smear microscopy, the number of leukocytes can be assessed. With dysbiosis, their number will be within the normal range, and an increase in their level indicates an inflammatory process.

With bacterioscopy, the acidity of the vaginal environment can be assessed. In the absence of pathological growth of facultative flora, the pH of the vagina varies within 3.8-4.5. Alkalinization of the medium with a pH value of more than 4.5 confirms the dysbiotic state.

7.2.2. Bacteriological research

This is the sowing of the discharge from the vagina, obtained with, on a nutrient medium. More complex, time-consuming and lengthy research. At the same time, the probability of detecting opportunistic bacteria is high, and it is also possible to immediately assess the sensitivity of microorganisms to antibacterial agents.

If during bacterioscopy there is a possibility of a subjective assessment of the quantitative and qualitative composition of the flora, then with bacteriology this is not possible.

When performing bakposev, it must be remembered that the material is taken under aseptic conditions (that is, with a sterile instrument in a sterile test tube with a nutrient medium). If this condition is violated, the study is considered invalid, and the result is incorrect.

Due to its laboriousness, high requirements for the conditions of the study, the culture of vaginal discharge is rarely performed.

7.2.3. PCR diagnostics

The most popular type of PCR diagnostics is. With its help, it is possible to analyze not only the species, but the quantitative composition of the vaginal flora. This, in turn, allows you to prescribe adequate etiotropic therapy.

It is possible to identify criteria confirming the diagnosis of bacterial vaginosis a:

1. 1 The presence of homogeneous grayish discharge from the genital tract with a characteristic "fishy" smell;
2. 2 Increasing the pH level of the vaginal environment (above 4.5);
3. 3 Positive amine test with 10% KOH solution;
4. 4 Presence of key cells in smear microscopy for flora.

8. Possible complications

The disease may worsen:

1. 1 Inflammatory diseases of the organs of the reproductive system (vulvovaginitis, endometritis, salpingo-oophoritis);
2. 2 Cystitis, urethritis both in a woman and in a sexual partner;
3. 3 Decreased resistance to sexual infections, including, etc.

9. Treatment regimens

Despite the fact that bacterial vaginosis is not considered an inflammatory disease, its treatment is carried out. Treatment of bacterial vaginosis is two-stage.

The first step is antibiotic therapy, it can be local (more often) or systemic (less often).

The purpose of prescribing antibiotics is to suppress the growth of sensitive opportunistic flora.

The second step in the treatment of bacterial vaginosis is the restoration of the normal composition of the vaginal biocenosis and its colonization with lactoflora.

Tables 2-4 below list the most commonly used drugs for topical and systemic treatment of bacterial vaginosis.

Table 2 shows the main treatment regimens recommended by Russian and foreign (CDC) guidelines.

Table 2 - Main and alternative schemes of antibiotic therapy for bacterial vaginosis

Other drugs for the treatment of bacterial vaginosis are also being studied, in particular, chlorhexidine-based suppositories, combined preparations (antibiotic of the nitroimidazole group + antifungal) have a good effect.

There is a certain logic in this, as we remember, bacvaginosis is a violation of the ratio between different representatives of the vaginal microflora.

The drugs listed in Table 3 have not yet taken confident positions in clinical guidelines. Experience with their use is accumulating.

Table 3 - Other drugs for the treatment of bacterial vaginosis. Click on the table to view

The second stage - the restoration of the pH of the vaginal environment and the use of lactobacilli - is widely used only in the Russian Federation. Table 4 shows the main schemes for the use of drugs based on lactobacilli. Whether there is a future behind this stage of correction of vaginal dysbiosis, time and adequate research will show.

Table 4 - Correction of vaginal dysbiosis with drugs based on lactobacilli and lactic acid

So, we examined how and with what it is necessary to treat bacterial vaginosis in women, then we will move on to the prevention of pathology.

10. Prevention

10.1. Vaccination

Currently, non-specific vaccination is possible, aimed at activating specific and non-specific immunity with the help of the SolkoTrichovac vaccine.

Vaccination involves three injections of the vaccine intramuscularly with an interval of 14 days. The first injection is performed the next day after the end of the course of antibiotic therapy. The method is experimental, but, according to the authors, quite effective.

10.2. General preventive measures

1. 1 Maintenance of normal immune status.
2. 2 Limitation of harmful effects on the body of the environment, minimization of stress.
3. 3 Control and maintenance by a woman of her gynecological health: regular visits to a gynecologist, timely treatment of diseases, maintaining a healthy sex life with a regular partner, maintaining personal hygiene, wearing natural linen made from natural materials that does not restrict movement.
4. 4 Often, the multiplication of an opportunistic infection is caused by the patient's uncontrolled intake of systemic antibiotics to treat comorbidities. Therefore, the appointment and administration of antibacterial drugs should be carried out under the strict supervision of the attending physician.
5. 5 Restoration of hormonal balance.
6. 6 Prevention of recurrence of the disease: it is necessary to monitor the effectiveness of therapy after 1 week and 4-6 weeks after the end of the course.