Women’s Views and Experiences of the Triggers for Onset of Bacterial Vaginosis and Exacerbating Factors Associated with Recurrence

Background

Bacterial vaginosis (BV) is the most common vaginal infection affecting women of childbearing age. While the aetiology and transmissibility of BV remain unclear, there is strong evidence to suggest an association between BV and sexual activity. This study explored women’s views and experiences of the triggers for BV onset and factors associated with recurrence.

Methods

A descriptive, social constructionist approach was chosen as the framework for the study. Thirty five women of varying sexual orientation who had experienced recurrent BV in the past five years took part in semi-structured interviews.

Results

The majority of women predominantly reported sexual contact triggered the onset of BV and sexual and non-sexual factors precipitated recurrence. Recurrence was most commonly referred to in terms of a ‘flare-up’ of symptoms. The majority of women did not think BV was a sexually transmitted infection however many reported being informed this by their clinician. Single women who attributed BV onset to sex with casual partners were most likely to display self-blame tendencies and to consider changing their future sexual behaviour. Women who have sex with women (WSW) were more inclined to believe their partner was responsible for the transmission of or reinfection with BV and seek partner treatment or change their sexual practices.

Conclusion

Findings from this study strongly suggest women believe that BV onset is associated with sexual activity, concurring with epidemiological data which increasingly suggest BV may be sexually transmitted. Exacerbating factors associated with recurrence were largely heterogeneous and may reflect the fact it is difficult to determine whether recurrence is due to persistent BV or a new infection in women. There was however evidence to suggest possible transmission and reinfection among WSW, reinforcing the need for new approaches to treatment and management strategies including male and female partner treatment trials.

Below:  Triggers for BV onset

Full article at:  http://goo.gl/FqXVLz

By:  

Jade Bilardi, Sandra Walker, Clare Bellhouse, Christopher Fairley, Marcus Chen, Catriona Bradshaw
Central Clinical School, Monash University, Melbourne, Victoria, Australia

Jade Bilardi, Meredith Temple-Smith, Ruth McNair

Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia

Jade Bilardi, Sandra Walker, Clare Bellhouse, Christopher Fairley, Marcus Chen, Catriona Bradshaw

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia

Julie Mooney-Somers

Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, New South Wales, Australia

Catriona Bradshaw

Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia

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Recent Biomarker-Confirmed Unprotected Vaginal Sex, But Not Self-Reported Unprotected Sex, Is Associated with Recurrent Bacterial Vaginosis

BACKGROUND:

Self-reported unprotected vaginal sex seems to increase risk of bacterial vaginosis (BV). However, the validity of self-reports is questionable, given their inconsistency with more objective measures of recent semen exposure such as detection of prostate-specific antigen (PSA). We examined whether recent unprotected sex, as measured both by PSA detection on vaginal swabs and by self-report, was associated with increased BV recurrence.

METHODS:

We analyzed randomized trial data from nonpregnant, BV-positive adult women recruited from a sexually transmitted disease clinic. Participants received BV therapy at enrollment and were scheduled to return after 4, 12, and 24 weeks. Bacterial vaginosis (by Nugent score) and PSA were measured at each visit. We used Cox proportional hazards models to examine the association between PSA positivity and recurrent BV. We also evaluated associations between self-reported unprotected sex (ever/never since the last visit and in the last 48 hours, analyzed separately) and recurrent BV.

RESULTS:

Prostate-specific antigen and BV results were available for 96 women who contributed 226 follow-up visits. Prostate-specific antigen positivity was associated with increased BV recurrence (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.28-4.21). In contrast, we observed no significant increase in BV recurrence among women self-reporting unprotected sex since the last visit (aHR, 1.63; 95% CI, 0.77-3.43) or in the last 48 hours (aHR, 1.28; 95% CI, 0.70-2.36).

CONCLUSIONS:

Estimates from earlier studies linking self-reported unprotected sex and BV may be biased by misclassification. Biomarkers can improve measurement of unprotected sex, a critical exposure variable in sexual health research.

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By:  Turner AN1, Carr Reese P, Snead MC, Fields K, Ervin M, Kourtis AP, Klebanoff MA, Gallo MF.

• 1From the *Division of Infectious Diseases, College of Medicine, Ohio State University, Columbus, OH; †School of Medicine and Health Sciences, George Washington University, Washington, DC; ‡Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA; §Sexual Health Clinic, Columbus Public Health, Columbus, OH; ¶The Research Institute at Nationwide Children's Hospital, Columbus, OH; and ∥Department of Pediatrics, Ohio State University, Columbus, OH; and **Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH. 
• Sex Transm Dis. 2016 Mar;43(3):172-6. doi: 10.1097/OLQ.0000000000000414.

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Factors Associated with Bacterial Vaginosis among Women Who Have Sex with Women: A Systematic Review

Background

Women who have sex with women (WSW) have a higher burden of bacterial vaginosis (BV) than heterosexual women; studies of risk factors specific to this population are limited. We summarised current knowledge regarding risk factors for BV among WSW by systematic review.

Methods

This systematic review was conducted according to the PRISMA statement. PUBMED, EMBASE, Web of Science and The Cochrane Library were searched to 31^st December, 2014. Inclusion criteria: 1) WSW included in the study population; 2) accepted BV diagnostic method; 3) investigated or could extrapolate factors(s) associated with BV acquisition, persistence or transmission in WSW specifically by comparing BV positive to BV negative women. Search was limited to English-language publications.

Results

A limited number of studies have investigated BV in WSW. Of 71 unique references, 18 full-text articles were assessed and 14 studies fulfilled inclusion criteria. BV was positively associated with higher numbers of female partners, both lifetime and in the three months prior to diagnosis, and confirmed BV in a female partner, but inconsistently associated with partners’ BV history or symptoms. BV was not associated with ethnicity, vaginal douching or hormonal contraception. The impact of specific sexual activities, male sexual contact, smoking and the menstrual cycle varied considerably between study populations.

Conclusion

BV in WSW is associated with increased numbers of recent and past female partners and confirmed BV in a female partner. There are limited studies of BV in WSW populations, and research is needed to further elucidate risk factors for BV among WSW. However these data provide epidemiological evidence that BV risk in women is directly related to exposure to other female partners and a partner with BV, providing support for the concept that BV is likely to be transmitted between women.

Below:  Summary of associations with prevalent or incident/recurrent/persistent BV

Full article at:   http://goo.gl/dc21MY

By:   

Dana S. Forcey, Lenka A. Vodstrcil, Christopher K. Fairley, Catriona S. Bradshaw

Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, 3053, Victoria, Australia

Dana S. Forcey, Lenka A. Vodstrcil, Jane S. Hocking, Catriona S. Bradshaw

Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Level 5, 207 Bouverie Street, The University of Melbourne, Parkville, 3010, Victoria, Australia

Christopher K. Fairley, Catriona S. Bradshaw

Central Clinical School, Monash University, The Alfred Centre, 55 Commercial Road, Melbourne, 3004, Victoria, Australia

Matthew Law

The Kirby Institute, The University of New South Wales, 101 West Street, Darlinghurst, 2010, New South Wales, Australia

Ruth P. McNair

Department of General Practice, The University of Melbourne, Parkville, 3010, Victoria, Australia

 

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Home Screening for Bacterial Vaginosis (BV) to Prevent Sexually Transmitted Diseases

BACKGROUND:

Longitudinal studies have consistently found a significant association between bacterial vaginosis (BV) and acquisition of sexually transmitted diseases (STDs). However, there is limited prospective data to confirm these findings.

METHODS:

We conducted a prospective, randomized, open-label trial of home screening and treatment of young women with asymptomatic BV who were also at high risk for STD. These women were screened every 2 months for 12 months and randomized to treatment with oral metronidazole 500 mg twice daily for 7 days versus observation alone. The primary outcome was the incidence of gonorrhea and/or chlamydia.

RESULTS:

1365 subjects were enrolled in the study across 10 sites. Adherence with mailing specimens obtained at home was excellent in both groups (84-88%). The incidence of gonorrhea and/or chlamydia was 19.1 per 100 person years (95% CI: 15.1-22.1) for the treatment group and 18.5 per 100 person-years (95% CI: 15.1-22.8) for the observation arm, a difference that was not statistically significant.

CONCLUSIONS:

Young women were very amenable to home screening for BV, gonorrhea, and chlamydia. Treatment of asymptomatic BV with one week of oral metronidazole did not result in a decreased incidence of gonorrhea and/or or chlamydia.

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By:  Schwebke JR1, Lee JY2, Lensing S2, Philip SS3, Wiesenfeld HC4, Seña AC5, Trainor N3, Acevado N6, Saylor L6, Rompalo AM7, Cook RL8.

• 1Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.
• 2Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR.
• 3San Francisco Department of Public Health, San Francisco, CA.
• 4Department of Obstetrics and Gynecology, Magee-Women's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA.
• 5Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
• 6Family Health International, Durham, NC.
• 7Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
• 8Departments of Epidemiology and Medicine, University of Florida, Gainesville, FL. 

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Impact of Bacterial Vaginosis on Perineal Tears during Delivery: A Prospective Cohort Study

Long term effects of perineal tears pose a major worldwide health issue for women during delivery. Since bacterial vaginosis is related to major obstacles in obstetrics the aim of this study was to determine the relationship between bacterial vaginosis and the occurrence of perineal tears during vaginal delivery.

Between June 2013 and December 2013 pregnant women delivering after 37 weeks were recruited at one University hospital / tertiary care referral center in the course of this single-center, prospective cohort study. Bacterial vaginosis was assessed according to Nugent score method. Logistic-regression model was used to estimate odds ratios, adjusted for other risk factors to test the relationship between bacterial vaginosis and the occurrence of 1st to 4th degree perineal tears in women undergoing vaginal delivery.

A total of 728 woman were included, 662 analyzed with a complete Nugent Score of the vaginal swab. The prevalence of 1st to 4th degree perineal tears was 35.8% (95% Confidence Interval (95%CI) = [32.2; 39.6]). The presence of BV was not significantly associated to the incidence of perineal tears neither in the univariate analysis (crude Odds Ratio = 1.43; 95%CI = [0.79; 2.60]; p = 0.235) nor in the multivariate analysis (adjusted Odds Ratio = 1.65; 95%CI = [0.81; 3.36]; p = 0.167). Instrumental delivery was the most important risk factor for perineal lacerations.

There is no evidence that vaginosis is a risk factor for vaginal tears.

Full article at:   http://goo.gl/UBFvM2

By:  Letouzey V1, Bastide S2,3, Ulrich D1, Beccera L1, Lomma M2, de Tayrac R1, Lavigne JP4,5.

• 1Department of Obstetrics and Gynaecology, Nîmes University Hospital, Nîmes, France.
• 2Department of Biostatistics, Epidemiology, Public Health and Bio-informatics, Nîmes University Hospital, Nîmes, France.
• 3EA2415 University of Montpellier 1, Montpellier, France.
• 4Department of Microbiology, Nîmes University Hospital, Nîmes, France.
• 5National Institute of Health and Medical Research, U1047, University of Montpellier, Nîmes, France. 

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A Cross-Sectional Study of Bacterial Vaginosis, Intravaginal Practices & HIV Genital Shedding; Implications for HIV Transmission & Women's Health

Bacterial vaginosis (BV) is associated with an increased risk of HIV transmission, and intravaginal practices (IVP) are an important risk factor for developing BV. The relationship between IVP, BV and HIV lower genital shedding, responsible for HIV transmission, has not been examined in women receiving antiretrovirals in Zambia.

Setting: Community Health Center in Lusaka, Zambia.

Participants were HIV-infected women receiving antiretroviral therapy and engaging in IVP (n=128). Participants completed audio computer-administered self-interviews to assess IVP and underwent a vaginal examination. BV was diagnosed using Nugent criteria. HIV-1 lower genital shedding was assessed by measuring HIV-1 RNA in cervicovaginal lavages.

Most women engaged in IVP daily (114, 89.0%) and 81 (63.3%) of the participants had BV. HIV-1 genital shedding was detected in 18 (14.2%) participants. BV was associated with daily use of IVP and weekly use of traditional medicines for IVP. The only factor associated with HIV-1 lower genital shedding was plasma viraemia. Neither IVP nor BV were associated with HIV shedding.

Despite the frequency of IVP and high prevalence of BV, plasma viraemia was the primary factor associated with HIV lower genital shedding. These findings support early initiation of antiretrovirals as an HIV prevention tool. Given adverse health outcomes associated with BV, the association between frequent IVP and BV, and the powerful local norms and traditions encouraging IVP, there is a need for studies assessing culturally tailored interventions to decrease BV in high-prevalence settings.

Full article at:  http://goo.gl/EmtqVd

By: Alcaide ML1, Chisembele M2, Malupande E2, Arheart K3, Fischl M1, Jones DL4.

• 1Division of Infectious Diseases, University of Miami, Miller School of Medicine, Miami, Florida, USA.
• 2University of Zambia, University Teaching Hospital, Lusaka, Zambia.
• 3Department of Epidemiology and Public Health, University of Miami, Miller School of Medicine, Miami, Florida, USA.
• 4Department of Psychiatry and Behavioral Sciences, University of Miami, Miller School of Medicine, Miami, Florida, USA. 

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Prevalent Bacterial Vaginosis Infection - A Risk Factor for Incident Sexually Transmitted Infections in Women in Durban, South Africa

The association between bacterial vaginosis (BV) and incident sexually transmitted infections (STIs) in a cohort of high-risk women from Durban, South Africa was investigated in this study. 

We undertook a secondary analysis of the Methods for Improving Reproductive Health in Africa trial that assessed effectiveness of the latex diaphragm and lubricant gel on HIV prevention among women. During study visits, urine specimens were collected for testing for Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis. The presence of BV was based on vaginal pH and wet mount test assessments. The association between BV and the risk for incident STIs was determined using Cox proportional hazards model. Prevalence of BV was 31% in a cohort of 435 women tested at baseline. Among these women, BV was significantly associated with incident Trichomonas vaginalis (14.6 per 100 PY, p = 0.03) and Chlamydia trachomatis infections (15.8 per 100 PY, p = 0.04). BV remained a significant predictor for Trichomonas vaginalis infections even after adjusting for potential confounders such as age and marital status (HR: 1.60, 95% CI: 1.00, 2.57, p = 0.04). 

Our study showed an association between baseline BV infections and incident Trichomonas vaginalis and Chlamydia trachomatis infections. Women with BV infections should be counselled on the use of condoms and the risk of new STIs.

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By: Abbai NS1, Reddy T2, Ramjee G3.

• 1HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa Nathlee.abbai@mrc.ac.za.
• 2Biostatistics Unit, South African Medical Research Council, Durban, South Africa.
• 3HIV Prevention Research Unit, South African Medical Research Council, Durban, South Africa Department of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.  

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Prevalence Of & Risk Factors for Bacterial Vaginosis among Women of Reproductive Age Attending Cervical Screening in Southeastern Brazil

To determine the prevalence of and risk factors for bacterial vaginosis.

A cross-sectional study of women aged 14-54 years attending 18 primary healthcare units in Botucatu, Brazil, for cervical screening was undertaken between September 1, 2012, and January 31, 2013. Data on sociodemographics, sexual behavior, and medical history were obtained by interview. Vaginal swabs were taken to classify the vaginal flora according to the Nugent scoring system. Candida sp. hyphae and infection by Trichomonas vaginalis were also evaluated by microscopy and culture, respectively. Stepwise logistic regression analysis was performed to identify risk factors independently associated with bacterial vaginosis.

Among 1519 women included in analyses, 30.1% had bacterial vaginosis. Variables independently associated with bacterial vaginosis were a single marital status, partner infidelity, abnormal discharge in the previous year, and concurrent trichomoniasis. Current use of hormonal contraception, luteal phase of menstrual cycle, higher income, and vaginal candidiasis all had protective effects.

The prevalence of bacterial vaginosis in the study population is high. The epidemiological data provide evidence of the sexual transmissibility of bacterial vaginosis.

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By: Marconi C1, Duarte MT2, Silva DC3, Silva MG4.

• 1Department of Pathology, Botucatu Medical School, Univ Estadual Paulista, Botucatu, São Paulo, Brazil.
• 2Department of Nursing, Botucatu Medical School, Univ Estadual Paulista, Botucatu, São Paulo, Brazil.
• 3Department of Health of Botucatu Prefecture, Botucatu, São Paulo, Brazil.
• 4Department of Pathology, Botucatu Medical School, Univ Estadual Paulista, Botucatu, São Paulo, Brazil. Electronic address: mgsilva@fmb.unesp.br.  

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A Cross-Sectional Study on the Relationship of Age, Gestational Age & HIV Infection to Bacterial Vaginosis & Genital Mycoplasma Infection

Pregnant women are especially at risk of developing complications when infected with reproductive tract infections (RTIs). The objective of this study was to determine the prevalence of bacterial vaginosis (BV) and genital mycoplasmas in pregnant women and investigate the associations between BV, genital mycoplasmas, HIV infection, age and gestational age.

220 pregnant women older than 18 were included in the study and provided self-collected vaginal swabs.

BV and genital mycoplasma colonisation and/or infection in women of differing age, gestational period and HIV status.

The prevalence of BV was 17.7%, intermediate vaginal flora (IVF) 15%, and the overall prevalence of genital mycoplasmas was 84%. BV was significantly associated with HIV infection with an OR of 2.84. However, BV was inversely associated with gestational age with an OR of 0.08 for second trimester pregnancies and an OR of 0.03 for third trimester pregnancies using the first trimester as reference. IVF was significantly associated with HIV infection with an OR of 2.7 but not with age or gestational age. Genital mycoplasmas were not significantly associated with age, gestational age, HIV status, BV flora or IVF.

The high infection rate of genital mycoplasmas and the association of BV with HIV found in this study reiterate the importance of screening for these RTIs in high-risk groups such as pregnant women.

Table 2

Distribution of BV, IVF and genital mycoplasmas across three age categories in pregnant women attending antenatal care

Reproductive tract infection	Age category
	18–24 years (n=49) (Reference)		25–34 years (n=120)			>35 years (n=51)			Total (n=220)
	Prevalence (%)	OR	Prevalence (%)	OR and 95% CI	p Value	Prevalence (%)	OR and 95% CI	p Value
BV	10 (20.4)	1	20 (16.7)	1.21 (0.42 to 3.48)	0.726	9 (17.6)	1.15 (0.32 to 4.06)	0.831	39
IV flora	6 (12.2)	1	18 (15)	1.25 (0.44 to 3.54)	0.679	9 (17.6)	1.54 (0.47 to 5.15)	0.475	33
M. genitalium	9 (18.4)	1	16 (13.3)	0.78 (0.29 to 2.09)	0.615	8 (15.7)	1.27 (0.41 to 3.93)	0.674	33
M. hominis	26 (53.1)	1	63 (52.5)	0.56 (0.28 to 1.12)	0.102	22 (43.1)	0.69 (0.30 to 1.62)	0.398	111
U. parvum	42 (85.7)	1	81 (67.5)	0.81 (0.38 to 1.73)	0.583	34 (66.7)	1.72 (0.63 to 4.74)	0.291	157

• BV, bacterial vaginosis; IVF, intermediate vaginal flora.

Full article at: http://goo.gl/jmKFdz

By: Redelinghuys MJ1, Ehlers MM2, Dreyer AW3, Lombaard H4, Olorunju SA5, Kock MM2.

• 1Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa.
• 2Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa Department of Medical Microbiology, Tshwane Academic Division, National Health Laboratory Service, Pretoria, South Africa.
• 3Centre for Tuberculosis, National Institute for Communicable Diseases, Johannesburg, South Africa.
• 4Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa.
• 5Biostatistics Unit, South African Medical Research Council, Pretoria, South Africa.  

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