Gynaecology and obstetrics

Endometriosis

What is Endometriosis?

Endometriosis is a medical condition where there is a growth of abnormal cells called endometrial cells that generally form as a lining or inside of the uterus but in a location outside the uterus.

The endometrial cells are shed every month during the menstrual cycle. Endometriosis implants occur due to the cells of endometriosis growing outside the uterus. Such implants are generally observed in the ovaries, Fallopian tubes, exterior surfaces of the intestines or uterus and on the surface lining of the pelvic cavity. Growth of such implants is rarely observed in areas like the pelvis, liver, lung or brain. It is important to understand that endometriosis implants are benign which means that they are not cancerous.

  • Statistics
  • Causes of Endometriosis
  • Symptoms of Endometriosis
  • Diagnosis of Endometriosis
  • Treatment of Endometriosis
  • Conclusion

 

endo

Statistics

Endometriosis emerge in women during their reproductive years. The approximate incidence rate of endometriosis is yet to be found. This is mainly due to the fact that many women have the medical condition and do not show any symptoms that will indicate this condition. However, over 1 million women are estimated to be affected in America accounting to about 3% to 18% of women. Endometriosis is the leading cause of pelvic pain and one of the main reason for laparoscopic surgery and hysterectomy. Furthermore, statistics show that around 20% to 50% of women who are said to be infertile have this medical condition.

Although, endometriosis has been diagnosed in women aged from 25 to 35 years; endometriosis has also been diagnosed in young girls who are 11 years of age. Additionally, the medical condition is rarely reported in women who are postmenopausal. White women are mostly diagnosed with endometriosis in comparison to African American or Asian women. Clinical findings show that this medical condition is more frequently reported in tall, thin women who have a low BMI (body mass index). Other women at risk of developing this condition include those who delay pregnancy to an older age. Genetic factors may also play a role in the development of endometriosis. Having a close relative with endometriosis will increase the chance of you developing this condition later on in your life.

Causes of Endometriosis

The exact causes that lead to endometriosis is yet to be found. Retrograde menstruation is thought to be one of the causes. Retrograde menstruation is where the endometrial cells are sent to other locations due to the backward movement of menstrual fluids in the Fallopian tubes and other cavities like the pelvic cavity and the abdominal cavity. However, the exact cause of retrograde menstruation is still unknown. One clearly understood concept is that this reason alone does not contribute to endometriosis. Retrograde menstruation is seen in many women at varying severity but not all of these women develop endometriosis.

Another suggested cause for endometriosis is that surfaces of pelvic organs contain primitive cells that possess the ability to grow into other types of tissue like endometrial cells. Another possibility of developing endometriosis is during surgery when these cells may be directly transferred and are seen in surgery scars. Endometriosis is very rarely observed in the brain and other organs that are at a distance to the pelvis. Endometriosis in such organs can be explained by the transfer of cells through the blood and the lymphatics. Another cause for endometriosis is due to altered or severed immune response in women with this medical condition. This will directly affect one from being able recognise and eliminate such abnormal growth of endometrial cells.

Symptoms of Endometriosis

An important point to note down is that many women who are diagnosed with endometriosis, do not show any symptoms of having it! The most common symptoms that are presented is infertility as well as pain in the pelvic region. Women complain of this pain prior to menstruation or during menstruation which lessens considerably after their monthly cycle. Some women also have reported pain and cramping during sexual intercourse. Additionally, pain during excretion (bowels movements and urination) can also be felt. Pain may also be felt during a pelvic examination by your medical doctor. The intensity of the pain may change from one month to the other which will have the tendency to vary considerably among women diagnosed with this medical condition.

In addition, pelvic pain in these women depend moderately on the location of the endometrial implants.

  • Deep endometriosis implants and implants that are located in areas that contain many pain sensing nerves will result in pain.
  • Endometriosis implants also possess the ability to produce and release substances that can enter the blood stream to be carried away which will produce pain.
  • Finally, endometriosis implants can bring about pain when they form scars.

One of the reasons for infertility in healthy women is endometriosis. When the medical doctor utilise laparoscopic techniques to evaluate infertility, he or she may find endometrial implants. Many of these women may not have painful symptoms that will indicate endometriosis. Thereby, this medical condition goes unnoticed in many. Infertility as a result of endometriosis is not a fully understood concept but it is thought to be a result of anatomical factors as well as hormonal factors. Endometrial implants may be present as a mass of accumulated tissue or scarring within the pelvis. This accumulation will bring about changes in the normal anatomy of related structures like the Fallopian tubes which plays a main role in transporting the eggs from the ovaries. On the other hand, infertility which arise due to this medical condition affecting many women may be a result of hormone production and production of other chemical substances. These substances will affect ovulation, fertilisation of the released egg and/or implantation of the embryo onto the wall of the uterus.

Other symptoms that are generally linked to endometriosis include the following:-

  • Pain felt in the lower abdomen
  • Constipation or diarrhoea
  • Low back pain
  • Fatigue (chronic)
  • Heavy or irregular menstrual cycle
  • Blood seen in urine

In addition to these, other rare symptoms that can indicate endometriosis include chest pain or coughing up blood. This can be a consequence of endometriosis that is present in the lungs. Headaches and seizures may occur when endometriosis is present in the brain of the patient. 

Diagnosis of Endometriosis

Endometriosis can be evaluated and diagnosed by your medical doctor based on certain symptoms like pain in the pelvic region during a physical examination. A doctor may feel the presence of the endometrial implants during a rectovaginal examination where he or she would insert a finger into the vagina and another finger into the rectum. The doctor will feel the presence of nodules which will indicate endometrial implants. These nodules may be present in the uterus and along the ligaments of the pelvic surface. However, during some examinations no nodules will be felt. Having mentioned that, the examination itself may cause abnormal pain and discomfort indicating endometriosis.

Regrettably, the symptoms of endometriosis and the physical examination results cannot be solely relied upon to diagnose this medical condition. Other imaging studies are generally employed. An ultrasound scan will help eliminate other diseases related to the pelvis and in addition it may indicate endometriosis in the vagina and bladder areas. But this technique too cannot accurately diagnose the condition. For a more definite diagnosis, a direct visual inspection of the abdomen and pelvis and a tissue biopsy will be required.

Due to these complications of diagnosis, one may only accurately diagnose this medical condition during surgery. This will include a large incision of the abdomen (laparotomy) or small incision of the abdomen (laparoscopy).

Video of endometriosis


The most commonly employed surgical protocol for endometriosis is Laparoscopy. It is a minor surgical procedure where the patient will be under general anaesthesia. Some patients are given local anaesthesia too. This procedure is generally an out-patient procedure which means that the patient will not be asked to stay over at the hospital overnight and may leave the same day. Laparoscopy is undertaken by first inflating the patient’s abdomen with carbon dioxide via a small incision at the navel after which a long thing needle called the laparoscope will be inserted into the abdomen to examine the pelvis as well as the abdomen. Endometrial implants, if present, may be observed now.

This technique can be employed to take biopsy sample for diagnosis. Here, small tissue samples will be removed to be viewed under the microscope through which endometrial cells can be viewed. Moreover, biopsies obtained during this minor surgical procedure show endometrial cells when no such implants would have seen by the surgeon during this procedure. Laparoscopy and pelvic ultrasound are important procedures that can be utilised in order to rule out the presence of certain malignancies, like ovarian cancer, that produce symptoms quite similar to endometriosis.

Treatment of Endometriosis 

There are two main ways to treat the condition: medications and/or surgery. The main aim of such treatments is to relieve pain and enhance fertility.

Medications 

Medications are available that will relieve you from pelvic pain as well as menstrual cramping. Doctors may prescribe certain medications which will not only relieve your pain but also reduce the size of the endometriosis implants. These drugs interrupt oestrogen production by interfering with the regulatory hormones that are secreted via the pituitary gland. Due to this phenomena, the menstrual cycle comes to a stop, a state quite similar to menopause. Another popular drug that is used to treat the condition relieves you from the pain that you may experience and shrinks the implants. Although, 80% of women have reported these benefits around 75% of women have developed side effects. A new type of drug that was developed interrupts the production of oestrogen in the implants, ovary, brain and in other places like adipose tissue.

Surgery

Surgical procedures may be undertaken for endometriosis under two main conditions: when the symptoms of endometriosis is very severe and when the medical treatment that was taken to treat the condition failed to trigger the desired response. Surgery is mostly preferred when the anatomy of certain parts of the body is distorted. These parts include some of the organs in the pelvic region. Surgery can also be considered when there is an obstruction in the urinary or bowel tract. Surgical procedures involved in the treatment of endometriosis can be categorised into two:

  • Conservative- where the uterus and the tissue of the ovaries are preserved or protected. 
  • Definitive- this involves the removal of the uterus known as hysterectomy with or without the removal of the ovaries.

The above mentioned conservative surgery is performed by a laparoscopy procedure. The implants cane be removed or obliterated through laser. If the disease is in its more severe stages where the anatomy of organs are distorted, laparotomy may be necessary which involves opening the wall of the abdomen through a larger incision.

Conclusion

Endometriosis is a medical condition where there is a growth of abnormal cells called endometrial cells that generally form as a lining or inside of the uterus but in a location outside the uterus. Endometriosis emerge in women during their reproductive years. Although, endometriosis has been diagnosed in women aged from 25 to 35 years; endometriosis has also been diagnosed in young girls who are 11 years of age.The exact causes that lead to endometriosis is yet to be found. Retrograde menstruation is thought to be one of the causes. The most common symptoms that are presented is infertility as well as pain in the pelvic region.

Other symptoms that are generally linked to endometriosis include the following:-

  • Pain felt in the lower abdomen
  • Constipation or diarrhoea
  • Low back pain
  • Fatigue (chronic)
  • Heavy or irregular menstrual cycle
  • Blood seen in urine

Endometriosis can be evaluated and diagnosed by your medical doctor baed on certain symptoms like pain in the pelvic region during a physical examination. There are two main ways to treat the condition: medications and/or surgery. The main aim of such treatments is to relieve pain and enhance fertility.

 

We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

 

 

Click here for PDF

 

 

We welcome your comments at the end of the article.

 

 

The Team Manager Web Diseases

 

 

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Polycystic Ovarian Disease (PCOD)

Polycystic Ovarian Disease (PCOD) was originally described in 1935 by Stein and Leventhal as a syndrome manifested by obesity, amenorrhoea and hirsutism associated with enlarged polycystic ovaries. This is one of the most common endocrine disorders in female. PCOD is more common in young women. It is the leading cause of infertility in females.Its incidence is increased as 1 in 15 women are affected with it. PCOD causes irregularities in menstruation  leading difficulties in conceiving.Untreated cases can leads to complications like diabetes ,heart disease etc. Proper treatment on time helps to relieve symptom and long term complications.

PCOD

  • Definition of  polycystic ovarian disease.

  •  Incidence of polycystic ovarian disease.

  • Hormonal changes in polycystic  ovarian disease.

  • Etiology of polycystic ovarian disease.

  • Pathology of polycystic ovarian disease

  • Signs and symptoms of polycystic ovarian disease.

  •  Diagnosis of  polycystic ovarian disease.

  • Differential diagnosis of polycystic ovarian disease.

  • Pathophysiology of polycystic ovarian disease.

  • Management of polycystic ovarian disease.

  • Complications of polycystic ovarian disease.

  • Life style modification of polycystic ovarian disease

  • Conclusion.

                                

Definition of  polycystic ovarian disease.

Polycystic ovarian disease is a complex disorder characterised by excessive production of androgen by the ovaries and adrenal which interferes with ovarian follicular growth. So PCOD is a state of androgen excess and chronic unovulation.

 Incidence of polycystic ovarian disease.

The incidence varies between 0.5-4 percent. Polycystic ovarian disease is more common amongst infertile women. It is more prevalent in young women of reproductive age group.

Hormonal changes in polycystic  ovarian disease.

Hormones plays an important role in maintaining the vital functions of the body. In PCOD sex hormones are affected. In normal state ovaries produces only tiny amount of androgen but in case of  PCOD the ovaries produce more androgen which inhibit ovulation and enhances the acne,hair growth of the body and face.

The bodies capacity to use insulin is  affected  called insulin resistance which in turns leads to high glucose level and diabetes.

 Aetiology of polycystic ovarian disease.

Exact etiology of  PCOD is unknown. But it is believed to be a genetic diseases   as many cases occurs within the family, greater concordance in monozygotic compared with dizygotic twins  and heritability of endocrine and metabolic features of PCOD. The genetic component is inherited in autosomal dominant fashion with high genetic penetrance but varying with individuals. This means the child has 50 % chance of inheriting the predisposing genetic variants from the parent. If the daughter is receiving the variants then she is having more chances of getting disease than the son who may be asymptomatic carriers or may have symptoms such as early baldness or excessive hair. The genetic variant(s) can be inherited from either the father or the mother. The exact gene that causes the disease is not yet identified. The clinical severity of PCOD symptoms appears to be largely determined by factors such as obesity.

Increased amount of insulin can leads to PCOD. In PCOD the ability to utilise the insulin is affected so the pancreas produces more insulin to make glucose available to the cells. Excess insulin again increases the androgen production.It alters the ovulation.

 Pathology of polycystic ovarian disease.

Typically, there is an enlargement in the size of ovaries up to 2 to 5 times from normal; as a result of these stroma is increased. The capsule become pearly white in color and thickened. On bisection, multiple follicular cysts measuring about 8-10 mm in diameter are crowded around the cortex.

Histologically, there is thickening of tunica albuginea. The cysts are follicles at varying stages of maturation and atresia. There is theca cell hypertrophy. The patient may present the feature of diabetes mellitus.

 Signs and symptoms of polycystic ovarian disease.

  • The menstrual abnormalities in the form of oligomenorrhoea, amenorrhoea or dysfunctional uterine bleeding.

  • Acne.
  • Thin brittle hairs.
  • Infertility.
  • Obesity.
  • Hirsutism( abnormal hair growth).It occur more in the face ,chest,belly and back.
  • Infertility -Many women with PCOD have difficulty in getting pregnant.
  • Depression.
  • Virilism is rare.
  • Acanthosis nigricans is characterised by specific skin changes due to insulin resistance. The skin is thickened and pigmented. Commonly affected sites are nape of the neck, inner thighs and axilla.
  • HAIR-AN Syndrome in patient with PCOD is characterised by hyperandrogenism, insulin resistance and acanthosis nigricans.
  • Internal examination reveals bilateral enlargement cystic ovaries which however, may not be revealed due to obesity.

 

Diagnosis of   polycystic ovarian disease.

  • Detailed medical history reveals any history of illness,familial predisposition,signs and symptoms etc.
  • Thorough physical examination helps to identify signs of the client.
  • Pelvic examination helps to identify the pelvic masses.
  • Sonography – Transvaginal sonography is especially useful in obese patient. Ovaries are enlarged in volume. Increased numbers of peripherally arranged cysts are seen.
  • Serum value
  1.  LH(Luteinizing hormone) level is elevated and the ratio LH:FSH is greater than 3:1
  2.  The  oestrone level is markedly elevated:-Reversible oestradiol: oestrone ratio
  3. SHBG level is reduced.
  4.  Androstenedione is elevated.
  5.  Marginally   elevated Serum testosterone and DHEA-S.
  6.  Raised serum insulin level or the ratio fasting glucose:fasting insulin is less than 4.5.
  • Laproscopy – Bilateral polycytitis ovaries are characteristics of PCOD.

 

 Differential diagnosis of polycystic ovarian disease.

Other condition that causes of irregular or absent menstruation and excessive hair growth (hirsutism) are congenital  adrenal hyperplasia (21-hydroxylase deficiency), hypothyroidism , hyperprolactinemia, androgen secreting neoplasm’s, Cushing’s syndrome and other pituitary or adrenal disorders, should be investigated. Occurrence of PCOD in other insulin-resistant situations such as acromegaly has also been reported.

 Pathophysiology of polycystic ovarian disease.

Exact pathology of PCOD is not clearly understood. It can be discussed under the following headings.

a)      Hypothalamic –pituitary compartment abnormality.

b)      Androgen excess.

c)      Anovulation.

d)      Obesity and insulin resistance.

e)      Long term consequences.

a)      Hypothalamic –pituitary compartment abnormality.

  • Increased pulse frequency of GnRH leads to increased pulse frequency of LH. Leptin, a peptide, secreted by fat cells and by the ovarian follicle, in presence of hyperinsulinaemia may be responsible for this.
  • Elevated  level of LH due to increased pulse frequency and amplitude of LH.
  • FSH level is not increased. This is mainly due to the negative feedback effect of chronically elevated oestrogen and follicular inhibin.
  • Increased free oestradiol due to reduced sex hormone binding globulin (SHBG) bears positive feedback relationship to LH.
  • The LH : FSH ratio is increased.

b)      Androgen excess.

Abnormal regulation of the androgen forming enzyme is thought to be the main cause for excess production of androgens from the ovaries and adrenals. The principal sources of androgens are

(A) Ovary

(B)Adrenal

(C) Systemic metabolic alteration.

 

 (A). Ovary produces excess androgens due to

  • High  LH causes stimulation of theca cells.
  • P450 C17 enzyme hyperfunction.
  • Defective aromatisation of androgens to oestrogen.
  • Stimulation of theca cells by IGF-1( Insulin growth factor-1)

 (B). Adrenals are stimulated to produce excess androgens by

  • Stress.
  • P450 C17 enzyme hyper function.
  • Associated high prolactin level (20%).

(C). Systemic metabolic alteration.

  I.    Hyperinsulinaemia causes

  1.  Stimulation of theca cells to produce more androgens.
  2. Insulin results in more free IGF-1 by autocrine action, IGF-1 stimulates theca cells to produce more androgens.
  3. Insulin inhibits hepatic synthesis of SHBG, resulting in more free level of androgens.

  II.   Hyperprolactinaemia

In about 20 per cent cases, there may be mild elevation of prolactin level due to increased pulsitivity of GnRH or due to dopamine deficiency or to both. The prolactin further stimulates adrenal androgen production.

  III.   Anovulation : follicular growth is arrested at different phases of maturation (5-10mm diameter) due to  low FSH level. The net effect is diminished oestadiol and increased inhibin production. Due to elevated LH, there is hypertrophy of theca cells and more androgens are produced either from theca cells or stroma. There is defective FSH induced aromatisation of androgens to oestrogens. Follicular microenvironment is therefore more androgenic rather than oestrogenic. Unless there is oestrogenic follicular microenvironment, follicular growth, maturation and ovulation cannot occur. There is huge number of atretic follicles that contribute to increased ovarian stroma. LH level is tonically elevated without any surge. LH surge is essential for ovulation to occur.

c) Obesity and insulin resistance.

One of the most important contributory factors for the development of PCOD is obesity. Obesity is also associated with reduced SHBG apart from excess production of androgens. It also induces insulin resistance and hyperinsulinaemia which in turn increases the gonadal androgen production.

d) Long term consequences in a patient suffering from PCOD includes.

The excess androgens (mainly androstenedione) either from the ovaries or adrenals are peripherally aromatised to oestrone (E1 ).There is concomitant diminished SHBG. Cumulative excess unbound E2 and oestrone results in a tonic hyper oestrogenic state. There is endometrial hyplasia.

  • Risk of developing (DM) diabetes mellitus due to insulin resistance.
  • Risk of developing endometrial carcinoma due to persistently elevated level of oestrogens. Oestrogen effects are not opposed by progesterone because of chronic anovulatory state.
  • Abnormal lipid profile increases the risk of cardiovascular disease and hypertension.

 Management of polycystic ovarian disease.

Management of PCOD needs individualisation of the patient. It depends on her presenting symptoms, like menstrual disorder, infertility, obesity, hirsutism or combined symptoms. Patient counselling is important. Treatment is primarly targeted to correct the biochemical abnormality.

Weight reduction in obese patients is the first line of treatment. Problems associated with menstrual irregularities, infertility and hirsutism improves in the client with Body mass index (BMI) <25.

Do regular activity to reduce the weight.Walking daily for 30 minutes is a common and good exercise that every one can practice.

Diet should include lot of green leafy vegetables, whole grains, nuts,beans and fruits. The client with PCOD should avoid food containing high saturated fatty acid like meat,dried fruit and cheese.

Fertility not concerned

  • Androgen excess- combined oral contraceptive pills are effective. progestin suppresses LH and oestrogen improves SHBG, reducing free testerone level. Norgestrel  containing pill is avoided because of its high androgenicity. Newer progestins (desogestrel) are best suited.
  • GnRH agonists- Leuprolide acetate 3.75 mg IM or goserelin3.6 mg SC every four weeks can be used to suppress ovarian steroid production.
  • Cyproterone acetate, Ketoconazole , spironolactone Flutamide, Finasteride are the other androgens that can be used for the management of hirsutism.
  • Addition of dexamethasone 0.25 mg-0.5mg at bed time is effective to minimise excess adrenal androgen. However it should not be used in obese patient.

Patient wanting pregnancy

  • Ovulation induction is achieved by ovulation induction drug called clomiphine citrate with or without dexamethone or bromocriptine. In unresponse cases, pure FSH or HMG along with hcg may be administered backed up with monitoring facilities.
  • Anovulatory women with PCOD and obesity, ovulate satisfactorly when clomiphine is combined with metformin. Metformin 500 mg thrice daily is found to correct the biochemical abnormalities observed in PCOD.

Surgery

Surgery is the alternative procedure for PCOD who are resistant to medical therapy. Endoscopic cauterisation or CO2 laser vaporization of multiple cysts is the better substitute of conventional wedge resection of the ovaries.

  Complications of polycystic ovarian disease.

  •  Diabetes due to insulin resistance that is type 2 diabetes.
  •  Elevated blood pressure.
  • Abnormal Cholesterol and lipid level , that is  elevated triglycerides or low high-density lipoprotein (HDL) cholesterol which is considered to be good for the body.
  • High levels of C-reactive protein, a protein released by heart .
  • Cardiovascular diseases.
  • Nonalcoholic steatohepatitis- It is a severe liver inflammation mainly due to the  accumulation of fat  in the liver.
  • Difficulty in breathing while sleeping(Sleep apnea).
  • Abnormal uterine bleeding.
  • Due the continous elevated level of eostrogen leads to endometrial cancer(Cancer of the uterine lining).
  • In pregnancy it can causes Gestational diabetes or pregnancy-induced high blood pressure.

 Life style modification of polycystic ovarian disease.

Life style modification of polycystic ovarian disease include weight reduction ,regular exercise and dietary modification.

Weight reduction helps to reduce the insulin level as well as androgen level.It can be done after consulting with dietitian.For weight reduction the client has to take diet containing low calorie.

Dietary modification is recommended for polycystic ovarian disease.Always prefer the diet containing low fat,low carbohydrates and high fiber diet.High fiber diet will be slowly digested so the glucose will be slowly raised with creating much complications.The diet containing high fiber are whole grains ,fruits,vegetable,cereals, barley,brown rice and beans.

Exercise or regular activity helps to keep your body active. It always help in lower the insulin level and to reduce the weight of the client.

Conclusion

PCOD is a common endocrine disorder found in the woman of reproductive age group but most of them are unaware about it. This is one of the leading causes of infertility in woman. But the proper management on time will help to correct the condition.

We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

Click here for PDF

We welcome your comments at the end of the article.

The Team Manager Web Diseases

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Gardnerella Vaginalis

What is Gardnerella Vaginalis?

It is a gram-variable rod, facultative anaerobic bacteria as it can appear as gram positive or gram positive. It was previously known as Haemophilus vaginalis, Coryebacterium vaginalis and finally renamed to Gardnerella vaginalis.

Gardnerella vaginalis is responsible for a disorder named Bacterial Vaginosis where the normal flora of women’s vagina is displaced by a group of other floras. Inother term, there will be an imbalance of bacterial in the vagina. Other bacteria that could cause this are Mobiluncus, Peptostreptococcus, Ureaplasma, Bacteriodes, Prevotella, Veillonella, Eubacterium and Mycoplasma hominis.The mechanism of vaginal flora imbalance is not clear and understood yet.

Bacterial vaginosis is the commonest cause for vaginitis and presents with acute symptoms for 50% of women. It is not considered a sexually transmitted disease because this can occur spontaneously; without sexually activity. Gardnerella vaginalis can be found as a normal flora of vagina in some women.

This is easily diagnosed and easily treated with antibiotics.

 

Gardnerella Vaginalis

 

  • Symptoms of Gardnerella Vaginalis
  • Pathogenesis of Gardnerella Vaginalis
  • Diagnosis and Investigation of Gardnerella Vaginalis
  • Treatment of Gardnerella Vaginalis
  • Prevention of Gardnerella Vaginalis
  • Complication of Gardnerella Vaginalis
  • Conclusion

 

 

Symptoms of Gardnerella Vaginalis

Infection of Gardnerella is usually at the vaginal, called bacterial vaginosis. Most women present with thin, greyish white discharge with fishy odour. The discharges are more prominent and copious after sexual intercourse and during menses. There can be symptoms of vaginal irritation such as itchiness, redness and edematous. Although it is rare, some women experience dyspareunia, which is pain at vagina during sexual intercourse. Not all, but it is common to have burning sensation during urination.

In some women, around 30% are asymptomatic.

For men with Gardnerella Vaginosis, they will too be asymptomatic.

 

 

Pathogenesis of Gardnerella Vaginalis

How Gardnerella vaginalis causes bacterial vaginosis is not clear as it is still in a debate. More studies and evidence suggest that the key component in this disorder is actually the biofilm produced by Gardnerella vaginalis. Some theorize that the adherence of Gardnerella vaginalis to the vaginal wall epithelium forms a net for other species of bacteria to take place and grow there.

A normal vagina flora has good amount of lactobacilli to produce hydrogen peroxide. When the amount of lactobacilli in the vagina decreases, overgrowth of vaginal anaerobs happens, this is usually the Gardnerella vaginalis. The pH of vagina increases to facilitate further growth of the organisms there. With this large amount of anaerobic bacterias, large amount of proteolytic carboxylase enzyme promotes squamous epithelial cell exfoliation and adherence of Gardnerella vaginalis. This will go into the cycle that promotes even more growth of Gardnerella vaginalis and other bacterias.

 

 

Diagnosis and Investigation of Gardnerella Vaginalis

It is important to seek medical care as many of vaginal discharge or irritations are symptoms of sexually transmitted disease. So it is advisable to seek treatment in a healthcare early, to not wait until complications develop.

There are many kits that can be found at the pharmacy or hospitals for a quick test of Gardnerella vaginalis. These tests are made in simple easy reading cards for the detection of Gardnerella vaginalis. Some are DNA probe based test for the concentration of Gardnerella vaginalis, testing for elevation of sialidase activity or test cards for proline-aminopeptidase.

A sample of discharge will be taken from the vagina for a few tests. The sample should be taken from swabs of sides of vaginal wall.

 

pH Test

It is a test where a pH indicator paper is used. A pH of 4.0-4.5 is normal and a pH of more than 4.5 is suggestive of Gardnerella vaginalis and Trichomoniasis.

There are also test cards that can be bought in pharmacy for quick testing. Although it is very sensitive for Bacterial vaginosis, one must remember that it is just a pH testing card. This result has to be correlated to the clinical symptoms and findings.

 

Microscopy

The obtained vaginal discharge sample will be prepared with normal saline and seen under a microsope. If more than 20% of clue cells are seen, then it is very suggestive of Bacterial vaginosis. Clue cells have granular appearance where bacteria, in coccobacilli form adhere to the squamous epithelial cells of vagina. They usually adhere at the edge of the epithelial cells giving a studded appearance.

If clue cells are seen with more white blood cells than epithelial cells, called leukorrhea, it is often associated with Chlamydia infection. Although not confirmative, it is advisable to get a STD screening done.

 

Whiff Test

The Whiff test is where a small portion of vaginal discharge is added with 10% potassium hydroxide. If a very strong fishy odour is present, it is very likely to be Bacterial vaginosis. This test is highly sensitive.

 

Culture

The culture of vaginal discharge is not indicated in the diagnosis of Gardnerella vaginalis or bacterial vaginosis. As Gardnerella vaginalis can be a normal flora in a healthy woman, so a culture will be positive in most women. Thus, culture plays no role in diagnosis of Gardnerella vaginalis.

 

Diagnosis Standard

The diagnostic standard in research uses Hay/Ison criteria for the evaluation of gram stain smear of vaginal discharges. But this uses more expertise, resources and very time consuming.

For that, most healthcare centres prefer to use the Amselcriteria, that is simpler and easier. This is because the test for the criteria is widely available in most hospitals and not expensive or time consuming.

 

Amsel criteria

Amsel criteria are often used for the diagnosis of Bacterial vaginosis. If 3 out of 4 criteria are present, then it is highly suggestive of Bacterial vaginosis.

  1. An appearance of thin vaginal discharge
  2. A vaginal pH of more than 4.5
  3. More than 20% of clue cells seen
  4. Positive Whiff test

 

Fast Tests

Affirm VP III

The Affirm VP III test is a DNA probe assay for detecting Gardnerella vaginalis at high concentration. It is a recommended test as it complements a physical examination of vaginal discharges’ appearance and pH testing. The best feature is that it takes less than 1 hour for the test result.

 

 OSOM BVBlue system

The OSOM BVBlue system is a test to detect the presence of high sialidase enzyme activity which is produced by Gardnerella vaginalis in vaginal discharge. This enzyme activity can also be produced by Mobiluncus, Bacteriodes and Prevotells. The result can be obtained between 10-20 minutes and is highly sensitive

 

FemExam Pip Activity Test

The FemExam Pip Activity Test card detects prolineamino peptidase activity of anaerobes, usually the Gardnerella vaginalis. It is also a very sensitive test. And the fastest test that yields result in less than 10 minutes.

There is also the FemExam pH and amines test card that detects the vaginal fluid pH where an elevation of pH is suggestive of Gardnerella vaginalis. This test is also one of the favourites as the result is ready in approximately 2-5 minutes.

 

 Other screenings

Although Gardnerella vaginalis or Bacterial vaginosis is not a sexually transmitted disease, it is important to remember that the commonest cause for vaginal discharge is sexually transmitted disease. It is good to have STD screening done if there is vaginal discharge and irritation.

 

 

Treatment of Gardnerella Vaginalis

Medical Treatment

Non pregnant patients

The recommended regime for Bacterial vaginosis is 7 day course of oral Metronidazole and vaginal Metronidazole gel and vaginal Clindamycin cream. The dosage for oral Metronidazole should be 500mg, to be taken twice a day. Metronidazole gel is recommended to be at 0.7% and Clindamycin cream to be 2%.

A single oral dose of high concentrated Metronidazole is not advisable.

Alternatively, if one is allergic to Metronidazole, oral Clindamycin can be taken. The dosage is recommended for 300mg twice a day for 7 days.

 

Pregnant patients

For pregnant patients, a lower dose of oral Metronidazole 250mg, three times a day is prescribed with vaginal Metronidazole gel and vaginal Clindamycin cream. It is important to have regular check up with a certified Obstetrician as there is a risk of preterm labour. This is to prevent preterm labour and other adverse outcomes of the pregnancy.

There is no role in screening all pregnancy with Gardnerella vaginalis. There is only indication for treatment when it is symptomatically diagnosed and investigated.

 

Asymptomatic patients

There is no indication for the treatment of asymptomatic patients unless she has an upcoming gynaecology procedure. Asymptomatic patients are well and has no risk of other infections.

 

Metronidazole

Metronidazole is a commonly used antibiotic for anaerobic bacteria. When on a course of Metronidazole, it is important to not consume alcohol during the antibiotic course and 24 hours later to avoid disulfiram like reactions. The reactions include flushing of the skin, headache, nausea and vomiting.

Other side effects of Metronidazole are metallic taste in the mouth, transient neutropenia, prolonged INR and possibility of peripheral neuropathy. There is a chance of having an allergic reaction to Metronidazole although it is very rare. If such reactions present, please visit the nearest healthcare centre immediately.

 

Clindamycin

Oral Clindamycin is usually take if one is allergic or cannot tolerate oral Metronidazole. However, oral Clindamycin has lower efficacy than oral Metronidazole. But, the vaginal Clindamycin cream is preferred more than Metronidazole gel. It is important to watchout for pseudomembranous colitis when Clindamycin is prescribed.

 

Recurrence

About 30% of women with Bacterial vaginosis will have recurrence after 3 months. While there is no solid cause for the recurrence, reinfection is possible but it is actually more likely to be due to failed eradication of the offending organism by the prescribed antibiotics.

For this group, a 2 week course of oral antibiotics is recommended with vaginal Metronidazole or Clindamycin cream.

 

 Lifestyle

Another important step is to stop douching or any other vaginal cleansing product as this will further displace the normal flora of the vaginal and cause more imbalance of the flora.

 

Sexual partners

There are no role and benefits in treating the male sexual partners as there is no association of women’s therapy response being influence by the treatment of her male sexual partner.

However, because of the high incidence of association of Bacterial vaginosis with sexually transmitted diseases, it is important to screen her male counterpart for sexually transmitted diseases.

 

 

Prevention of Gardnerella Vaginalis

Gardnerella Vaginalis infection or Bacterial vaginosis can be prevented by practicing a good vaginal hygiene. If one regularly uses a tampon during menstruation, it is advisable for a frequent change. A tampon usage of more than 6 hours predisposes to infection.

Any intrauterine device or diaphragm that is used during sexual intercourse should be cleaned before usage. The best will be using a sterile disposable device to minimise the risk of infection.

Douching is a common practice for some women. But excessive douching could displace the good and important flora in the vagina. This will cause an imbalance of flora that is predisposed to bacterial vaginosis.

A condom provides a barrier at the genitalia between men and women during sexual intercourse. Although not 100%, condom prevents the transmission of Gardnerella vaginalis from men to women or vice versa. As most men with Gardnerella vaginalisis asymptomatic, they would not know if they have them.

Finally, a monogamy sexual practice can prevent Bacterial vaginosis as it is more commonly associated with multiple sexual partners. This can also prevent sexually transmitted diseases.

 

 

Complications of Gardnerella Vaginalis

Gardnerella vaginalis infection is not a life threatening or chronic illness but it should be treated. If Bacterial vaginosis is not treated, this could lead to ascending infection. Pelvic Inflammatory Disease is not the complication, but it is closely association with sexually transmitted diseases. With that, STD could be undetected and leads to more adverse outcomes.

In pregnancy, there is a higher risk for premature labour with premature birth of a preterm baby. There could also be chorioamnionitis; the infection of amniotic fluid that could cause premature birth and predisposing the baby to sepsis. There could also be a postpartum fever experienced by mothers with Gardnerella vaginalis.

 

 

Conclusion

Although it is a mild condition and treatable, it is important to check for associated infections such as Gonorrhea and Chlamydia. About 60% of women with sexually transmitted disease have Bacterial vaginosis also.

 

 

 

We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

Click here for PDF

We welcome your comments at the end of the article.
The Team Manager Web Diseases

 

 

 

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Be the first to comment - What do you think?  Posted by Natalie C - April 22, 2013 at 20:18

Categories: Gynaecology and obstetrics, Infectious diseases   Tags: , , , , ,