www.vaginosis.com

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First, what is bacterial vaginosis?

Could bacterial vaginosis be a sexually-transmitted disease?

Why is bacterial vaginosis important?

What are the main symptoms of bacterial vaginosis?

Does vaginal douching truly cause bacterial vaginosis?

How can I find out if I have bacterial vaginosis?

Revised What are the most effective medications for treating bacterial vaginosis and for restoring the normal vaginal bacterial ecology?

New Why yogurts and also probiotics, as adjuctive therapies for bacteria vaginosis, may NOT have failed you after all?

New What are 4 recent reasons why your doctor would do well to avoid prescribing a clindamycin-based product, including the new single-dose vaginal cream Clindesse?

New Which alternative treatments have proved effective in managing vaginosis?

What clues might I be able to use on my own to help me conclude that I simply have a "yeast infection" and not bacterial vaginosis or some other kind of vaginal infection?

When might it be okay to try an over-the-counter vaginal anti-fungal product, such as Monistat and Gyne-Lotrimin, if I think that I might have a vaginal "yeast infection"?

How can I communicate with Dr. Christian to pose questions or to provide feedback regarding this web site?


First, what is bacterial vaginosis1?
Well, first, let's start out with what it is not. Bacterial vaginosis is not an infection. The term "vagin-osis" denotes a changing condition within the vagina. Trichomonas vaginalis and Candida albicans are examples of microorganisms which cause "vagin-itis", or infections of the vaginal tissues, characterized by changes of redness, swelling and tenderness within the vagina. Such symptoms should not be present when a woman simply has bacterial vaginosis.

Bacterial vaginosis is an alteration in the normal healthy bacterial ecology of the vagina
So what is bacterial vaginosis then? It is an alteration in the normal healthy bacterial ecology of the vagina. The bacteria species, which predominate within the normal healthy vagina, are bacteria from the Lactobacillus species. However, the healthy vagina actually exists as a complex micro-environment populated by numerous differing bacterial species existing in a mutually-interdependent relationships with one another. This integrated community of microbial inhabitants also normally includes representative counts of Gardenella vaginalis and of Candida albicans (the proper species name for vaginal "yeasts").

Lactobacillus bacterial species, the normal healthy vaginal colonizer
Lactobacillus species are classified as aerobic bacteria, or bacteria whose growth is favored by aerated, oxygen-rich microenvironments. Lactobacillus bacteria produce micro-quantities of lactic acid, which account for the moderate acidity of normal vaginal secretions. The acidity of the normal vaginal secretions is thought to play a significant role in immune defense as this acidity has the effect of inhibiting the growth of many other microorganisms, which might be introduced within the vagina. Lactobacillus bacteria are also responsible for vaginal micro-quantities of hydrogen peroxide, a compound that also appears to play a prominent role in protecting vaginal lining cells from some kinds of infection.

Gardnerella vaginalis and the other usurping bacterial species that cause bacterial vaginosis
The abnormal condition of bacterial vaginosis is brought about when the normal, healthy bacterial inhabitants of the vagina are supplanted by mixed populations of predominantly anaerobic bacteria. Anaerobic bacteria, as contrasted with the aerobic Lactobacillus species, tend to thrive in closed-off, relatively oxygen-depleted microenvironments. The anaerobic bacteria which have previously been linked to bacterial vaginosis include Gardnerella vaginalis, Prevotella species, Mobiluncas species, Peptostreptococcus species, and Mycoplasma hominis. Important new research has identified a previously unrecognized bacterial species, Atopobium vaginalis, which when present in combination with Gardnerella vaginalis appears to explain why many women are plagued by rapid post-treatment relapses and frequent recurrences. Once these abnormal vaginal bacteria have supplanted the normal vaginal bacterial population, only prescription antibiotics specifically targeted against anaerobic bacteria can be counted on to dislodge them.

The critical importance of vaginal pH in diagnosing bacterial vaginosis
When this characteristic mixed population of anaerobic bacteria has replaced the lactic acid producing Lactobacillus species are the predominant bacterial type inhabiting the vagina, the acidity of the vaginal secretions will become significantly neutralized. The power of the hydrogen atom, or pH, is a scientific notation for quantifying just how strong an acid, or alternatively, just how strong a base a particular solution is. The pH of vaginal secretions is normally between 3.8 and 4.2. Vaginal pH measurements that are above this range and especially those above a cut-off value or 4.5 have been defined as evidence of an abnormal vaginal condition. Some recent research indicates that this abnormal cut-off value, in the case of most African American women, should be set a few tenths of a point higher. Be this as it may, no matter what the starting normal pH, this vaginal pH, if bacterial vaginosis develops, will be significantly increased- that is, the acidity is significantly reduced. In severe cases of bacterial vaginosis, the vaginal pH even be raised close to the neutral value of water, or 7.0. The fact that vaginal secretions in bacterial vaginosis are characterized by a higher pH than normal is an invaluable piece of information in allowing doctors to successfully screen for and treat the important condition of bacterial vaginosis.

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Could bacterial vaginosis be a sexually-transmitted disease?
While it is understood that bacterial vaginosis is not an infection, the question of whether bacterial vaginosis is or is not a sexually-transmitted disease is currently unsettled. A few of the major points supporting the two opposing theories are presented below.

Arguments Against Bacterial Vaginosis Being a Sexually-Transmitted Disease
  1. Although some of the bacteria which are most commonly associated with bacterial vaginosis (such as Gardnerella vaginalis) can be also isolated from the male genital tract, antibiotic treatment of the male partner of a female with recurring vaginosis does not seem to prevent the woman from continuing to have recurrences.
  2. It also does not appear that a woman who has never had bacterial vaginosis can acquire vaginosis by "seeding" the woman's vagina with a pure inoculum of Gardnerella vaginalis harvested from another woman who has vaginosis.
  3. Bacterial vaginosis has been anecdotally reported in virgins.
Arguments Supposting Bacterial Vaginosis is a Sexually-Transmitted Disease
  1. Bacterial vaginosis appears more common in women who have had 3 or more male sexual partners (or at least one female sexual partner) during the preceding 12-month period.2
  2. Bacterial vaginosis appears less common in women who have most consistently had their male sexual partners use condoms.3
  3. There have been innumerable anecdotal reports of women developing prominent new symptoms of bacterial vaginosis following beginning vaginal sexual relations without condoms with a new male sexual partner.
One possible synthesis theory is that there is some as-yet-unidentified factor (possibly not even bacterial) whose transmission in semen, in menstrual blood flow, or possibly even in saliva, initiates some alteration in the vaginal micro-environment which subsequently favors the growth of the vaginosis-associated bacteria.

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Why is bacterial vaginosis important?
Doctors have recognized the abnormal condition of bacterial vaginosis for decades. However, only within the past couple of decades have medical researchers begun to recognize the association of bacterial vaginosis with a number of serious medical complications of women. Although nothing like a direct causal relationship has been proved for any of these conditions, bacterial vaginosis appears to set women up for the following significant obstetrical and gynecologic problems:
  • first-trimester miscarriage, particularly in women undergoing in-vitro fertilization procedures
  • preterm labor and delivery
  • uterine infections following cesarean-section surgery
  • uterine infections following surgical abortions and
  • acute and chronic tubal infection-- also referred to as pelvic inflammatory disease
Even more startling has been has been the medical research from the past decade which suggests that women with more severe cases of bacterial vaginosis are more easily infected by the AIDS virus, during unprotected vaginal sexual intercourse.

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What are the main symptoms of bacterial vaginosis?
It is critical to appreciate that most women have not a clue that they are affected by this condition, and here we are referring to millions and millions of women. These women might notice a recurring vaginal seepage which they may assume to be nothing important or they may have noticed an unusually strong and "fishy" odor with vaginal lubrication. Still probably millions of woman with bacterial vaginosis objectively have no outward symptoms of this condition. Probably, therefore, only a relative minority of women experience the more dramatic acute presentation of bacterial vaginosis where the discharge quantity is more profuse and the discharge odor is very strong and very obvious. However, this is the presentation that will get women in to see their doctors the most quickly-- particularly if the woman is now noticing these symptoms after beginning sex without condoms with a new partner. Both the discharge and the pungent fishy odor which typify bacterial vaginosis are caused by the growth within the vagina of the hoards of anaerobic bacteria which characterize this disorder. Because so many women notice especially that the this discharge appears only to follow ejaculation of their partner's fresh semen into the vagina, it is only natural to suspect that the partner is transmitting a sexual disease. In the past, the conventional wisdom has been to say that fresh semen does something to intensify the bacterial processes that underlie the vaginosis and to deny that the semen was actually transmitting new boluses of vaginosis bacteria. Be this as it may, it is certainly understandable that many women could unfortunately decide not to see a doctor because they have assumed that the problem lies with their sexual partner and not with themselves.

Vaginosis Discharge The images linked to this section are presented by courtesy of the Seattle STD/HIV Prevention Training Center at the University of Washington. Viewers are advised that descriptions of the so-called classic discharges can be misleading because the discharges due to abnormal vaginal conditions like bacterial vaginosis can appear differently in different women. This point being understood, the classic discharge of bacterial vaginosis is whitish-to-grayish in appearance, is associated with a pungent fishy odor, and has a homogeneous quality similar to milk yet still tends to be adherent within the vagina. The pelvic photograph to the right of this paragraph shows a woman manifesting this classic discharge of bacterial vaginosis.





o Candida Discharge The classic discharge associated with the common Candida "yeast infection" is thicker, white, and curd-like in appearance and is usually associated with vaginal itchiness. The vaginal photograph to the right of this paragraph shows the classic discharge of a Candida vaginitis, commonly referred to as a "yeast infection" Again it must be stressed that while the photograph shows the classic appearance of a Candida albicans vaginitis, other examples in which the discharge is of a more "cheesy" character or altogether absent may also be typical of a "yeast infection" for different women. This is to say that a discharge that does not resemble this classic picture shown here might still be due to yeasts.

A vaginal trichomonas infection can be easily mistaken for bacterial vaginosis because both of these vaginal conditions are associated with discharges with a pungent fishy odor and furthermore because upon diagnostic testing in a doctor's office, both conditions are characterized by elevated vaginal pH readings. The classic discharge associated with a vaginal trichomonas infection is thinner, may appear foamy, and has a yellowish-to-greenish tint or frank coloration. Symptoms accompanying a vaginal trichomonas infection may range from simple vaginal itchiness to vaginal swelling, irritation, burning and other signs of serious inflammation. It should be underscored that as a rule, discharges which are either yellowish or which are associated with genital or pelvic pain cannot be due to bacterial vaginosis or to Candida "yeast infections". Women who experience these symptoms should prompty see their physicians to get tested for sexually-transmitted disease.

This is why it is so important for women to educate themselves as to the true facts regarding bacterial vaginosis. Every day in this country, tens of thousands of women turn to vaginal douche or vaginal perfume products to treat a problem, which quite probably, can only effectively be dealt with by antibiotics prescribed by their doctors.

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Does vaginal douching truly cause bacterial vaginosis?
Numerous past epidemiologic studies have shown that women who douche are more likely to have bacterial vaginosis. However, in recent years, many physicians and medical researchers have begun to question whether this simple observation justifies the oft-repeated admonishment that vaginal douching will lead to vaginosis. Writing in Infectious Diseases in Obstetrics and Gynecology in 2003, Drs. Martens and Monif were among the first physicians to challenge the notion that douching might be a risk to women's health. They wrote: "The theory that douching disrupts the normal vaginal flora and selects for BV has little, if any, microbiologic foundation as it involves the effects of douching."4 Dr. Mustaf had previously demonstrated that women who used a vinegar-and-water-based douche only experienced a transient reduction in vaginal bacterial counts which did not lead to vaginosis.5 So it seems accepting unthinkingly and without medical proof the idea that regular douching causes vaginosis makes about as much sense as accepting the idea that daily use of a mouthwash product causes bad breath!

Of course, it must also be acknowledged that there are a variety of different brands and types of vaginal douches and perfume products. Speaking now specifically of vaginal douche products, there are basically two types: vinegar-and-water-based douches and antiseptic or iodine (Betadine) based douches. It is here interesting here to note that a Betadine douche included in its original Federal Drug Administration application evidence that daily use of their product for 7-10 days could significantly improve the vaginosis symptoms and could even result in a strict microbiologic cure in some women.6 This point made, still the popularity of the vaginal douches and the vaginal perfume products is undoubtedly rooted in misinformation and incorrect understanding on the part of many women as concerns their own bodies. Nevertheless, the point remains that there are no scientific studies that comes close to proving that bacterial vaginosis is caused by vaginal douching. Accordingly, any doctor or nurse who tells women not to douche because it will cause them to develop vaginosis has absolutely no scientific back-up for making this claim. This does not mean that doctors and nurses might not continue to recommend against compulsive vaginal douching on the part of healthy women based on an appropriate concern that excessive douching undoubtedly feeds misconceptions about normal vaginal hygiene in these women.

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How can I find out if I have bacterial vaginosis?
Given the very private and often embaressing nature of bacterial vaginosis, a commercially-marketed home diagnostic kit has been for a long time a needed option. Currently-marketed bacterial vaginosis test cards are primarily intended for use in a doctor's office and tend individually to be expensive. In addition, these bacterial vagiosis test cards are marketed to busy doctors who want a quick yes-or-no answer to the question of whether his or her patient has vaginosis. What these ards obviously do not do is to alert the doctor if there is another condition present. In contrast, home vaginal pH test strips, such as is now being offered through this website, provide a woman with the key determinant as to whether a woman has vaginosis and as well allows women a means of monitoring eradication and recurrence of this condition at home.

Home vaginal pH testing will not mean that a woman will be able to forgo going to a doctor as obviously, even when the test strips strongly suggest vaginosis is present, the woman will still need some sort of confirmation from her doctor's office and of course some prescribed therapy. It is nonetheless impowering for a woman to meet with her doctor already aware of what her vaginal pH is. In addition, it is an unfortunate but sad reality that many primary care physician offices, and even a few gynecologist's offices, that do not keep pH strips on hand in order to test for bacterial vaginosis. Speaking generally, women are certainly more likely to find offices equipped and prepared to evaluate concerns about this condition, if they seek out the services of a board-certified gynecologist. However, I hasten to add that physician assistant and nurse practitioners working out of gynecologists' offices are also usually safe bets. These statements should not be taken to suggest that there are no family practice and internal medicine offices, which are properly equipped and prepared to check for bacterial vaginosis. A woman desiring to have a check with a primary care physician with whom she has an established, trusting relationship is encouraged to check on this question prior to scheduling an appointment.

To make a diagnosis of bacterial vaginosis, a doctor must keep in her or his office a functioning microscope and a set of diagnostic cards or strips designed to measure the acidity of the vaginal secretions or discharge. Another kind of diagnostic card is also available to physicians that detect the presence of amine compounds, which are produced by the anaerobic bacteria that define bacterial vaginosis. These amine compounds produce the pungent, fish-smell odor that characterizes the discharge of bacterial vaginosis. For a useful patient orientation guide aimed at equipping you to intelligently engage your doctor in a discussion about screening and diagnosis issues, please visit www.bacterialvaginosis.net.

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What are the most effective medications for treating bacterial vaginosis and for restoring the normal vaginal bacterial ecology?
Metronidazole and clindamycin are the most commonly prescribed antibiotics for treating vaginosis.
The antibiotics metronidazole and clindamycin are the most often employed approach to ridding the vagina of the group of anaerobic bacteria that cause bacterial vaginosis. Metronidazole is available by prescription either in tablet form or as a topical gel for insertion vaginally (brand name Metrogel-vaginal). The oral formulation of generic metronidazole, or its brand name formulation, Flagyl, are most commonly prescribed at a dose of 500 milligrams twice a day for 7 days.

Special concerns about prescribing clindamycin products for bacterial vaginosis
Clindamycin is available under the brand name Cleocin, both as a 7-day vaginal cream and as a 3-night vaginal suppository (Cleocin vaginal ovules) which has been approved as an equivalent treatment to the 7-day cream. Most recently, a single-dose clindamycin vaginal cream under the name Clindesse has also been released as an equivalent treatment. Clindamycin should not prescribed orally for bacterial vaginosis because of this drug's potential side effect of producing very serious diarrheal diseases and possibly even a life-threatening intestinal infection caused by Clostridium.

Metronidazole, a very bitter pill if your doctor prescribes it
Virtually all patients today being handed prescriptions for metronidazole are cautioned that they may experience severe nausea and vomiting if they attempt to consume alcohol while taking this prescription. On the other hand, probably very few patients are told to expect the metronidazole tablet to have a very bitter metallic taste. Anecdotally, in my experience, the longer the period of time that a patient has to take the pill the more likely she or he is to note the persistence of the bitter after-taste through the entire day. Doctors generally will avoid prescribing oral metronidazole in the first trimester of pregnancy out of concerns that this drug might produce birth defects.

The metronidazole vaginal cream products currently appears the best of a group of not-great antibiotic treatment options
The topical vaginal preparations with either clindamycin or metronidazole avoid these problems. The bacterial vaginosis cure rates of all three products, Cleocin vaginal suppositories or cream, Metrogel-vaginal, and oral metronidazole, were once felt to be the same. One week following completion of therapy with any of these products, approximately five out of six women will find that their bacterial vaginosis has been cured. By four weeks later, one of these initially cured women will experience a recurrence of their bacterial vaginosis. This means that the cure rate has fallen to about 67%; however, it now appears that the four-week cure rate for clindamycin cream products will be significantly less than this figure. Following for even longer periods of time after their initial treatments, women, no matter what the initial drug prescribed, show a definite trend to having their bacterial vaginosis reoccur. Therefore, it may be appropriate for women with this medical problem to receive re-treatments with one of the metronidazole products, as the need arises.

Alternate antibiotic prescriptions which you should question if prescribed for you by your doctor
The antibiotic amoxicillin and the Triple Sulfa vaginal cream product are among other antibiotic treatments still being prescribed by many physicians for their patients with bacterial vaginosis. Studies have demonstrated that these treatments are less effective than metronidazole and clindamycin, and medical authorities in the field of bacterial vaginosis do not recommend that these treatments be prescribed.

Other advantages that metronidazole holds over clindamycin
Metrogel-vaginal holds one theoretical advantage clindamycin vaginal cream. Clindamycin is known to not only kill the bacterial anaerobes that cause bacterial vaginosis, but it will also kill healthy Lactobacillus species surviving in the vagina, as well. Metrogel-vaginal does not kill Lactobacillus species. However, it has not been clinically proved and cannot be assumed that this means that Metrogel-vaginal allows for a more rapid recolonization of the vagina with its normal Lactobacillus inhabitants. Clindamycin vaginal cream is also known to have a potential of damaging condoms, and the product carries a warning that condoms should not be relied on for contraception or sexually transmitted disease protection during its use.

Comparative costs of the different antibiotic products
Prescriptions for oral metronidazole are a popular thing in this age of tight management of prescription drug costs. The generic tablets are extremely cheap. Pharmacy retail prices for the three brand-name topical treatments are approximately $45 for the Cleocin vaginal suppository 3-pack and $60 to $70 for either Cleocin vaginal cream or Metrogel-vaginal. In contrast, the price for a seven-day course of twice-a-day generic metronidazole is around $13. Women with fixed-copay prescription plans may not think they need be concerned with their costs, but they are mistaken. The physician who writes for their prescription may also be aware of these price differences and may use this knowledge to select the product based primarily on cost concerns rather than on what the woman might desire in terms of personal preference.

It is a bit perplexing to me professionally how any physician could be either unknowing or so uncaring as to prescribe to a patient-- without so much as a warning-- so unpalatable a pill as metronidazole should be well-known to be. Neither should a good doctor neglect to ask his or her patients whether they have previously experienced the nausea, abdominal pain, or even vomiting that are well-associated with oral metronidazole before unthinkingly scribbling out a new prescription for oral metronidazole. This would be an especially sad omission if the primary reason why the doctor prefers to prescribe metronidazole tablets is so as to assist the patient's insurance prescription plan in making a few extra dollars of profit.

My wish is that women patients, by virtue of the knowledge base provided by this web site, can feel more confidant and more comfortable about broaching with their doctors the possibility that they might have bacterial vaginosis. I also hope that familiarity with the treatment dilemmas surrounding bacterial vaginosis will ready women patients to hand back quickly-scribbled prescriptions for oral metronidazole and to be brave enough to then to ask the doctor whether he or she will allow the time for a more serious and in-depth discussion of other treatment options.

A vaginosis treatment flow chart is presented at the end of this section which highlights several key points about antibiotic management of this condition.
  1. Treatment for bacterial vaginosis should be initiated on each new occasion only after this diagnosis has been confirmed both by vaginal pH testing and by a wet-mount examination of vaginal secretions to rule-out co-existing vaginal infections.
  2. Once treatment is begun, the woman patient should be strongly encouraged to require any current or reason sexual partner to faithfully weara condom during vaginal intercourse. This precaution should be continued for a minimum of one month, and optimally for three months, while the woman continues to check herself for vaginosis recurrence. This precaution is long-overdue in view of the strong epidemiological evidence linking bacterial vaginosis to sexual transmission.
  3. A metronidazole gel product-- either Metrogel-vaginal or the newer Vandazole gel-- should be prescribed as first-line therapy for any first diagnosis of bacterial vaginosis. It should also also be prescribed as first-line therapy for any woman who has been successfully treated with a metronidazole gel product in the past and who did not experience a recurrence of this condition within several months of this treatment.
  4. Clindesse should not be prescibed for this condition, nor should any other clindamycin-based products, while the important scientific questions concerning clindamycin's true effectiveness and this drug's potential for harmful ecological after-effects are better settled. click here to skip to the next question and a more in-depth discussion of why use of Clindesse should be avoided).
  5. Based on the recent groundbreaking research that Gardnerella vaginalis not just coats, but appears tightly adherent to the vaginal surface epithelial cell in the manner of a biofilm7, oral metronidazole considered for longer than the standard 7-day course, may be appropriate for some women patients who initially responded to metronidazole gel and then relapsed after a few months. The principle here is that an oral medication might be more effective at attacking a built-up bio-film at its roots with boosted antibiotic blood levels at the vaginal epithelial cell level.
  6. For women patients who cannot take or cannot tolerate oral metronidazole, a small study has suggested that cefadroxil (brand name of Duricef) might have a equivalent killing power for vaginal anaerobic bacteria, as does metronidazole.8
  7. Alternative medical therapies, in particular probiotic products, should be considered to aid in restoring the normal healthy Lactobacillus species within the vagina. Another recent study found that women who combined taking metronidazole orally for 7 days with a Lactobacillus-containing capsules twice a day for 30 days had twice the cure rate of the control group of women who only received the 7-day course of oral metronidazole.9One commercially-available product is the plain variety of Dannon's DanActive Probiotic Dairy Drink, which women should discuss with their doctors whether this product might be tried as a douche.
  8. Polymerase Chain Reaction (or PCR) testing for trichomonas should be performed for women who immediately recur following treatment with metronidazole gel. A recent study has demonstrated that PCR testing found that PCR testing is far more accurate in identifying trichomonas than simple swab cultures. PCR testing might also be performed for Atopobium vaginae as the presence of this bacteria within a Gardnerella vaginalis biofilm appears to be a very good predictor for the most severe and resistant cases of vaginosis.
  9. The final recommendation is to not give up searching until you find that informed, concerned, and open-minded doctor, physician assistant, nurse practitioner who is willing and able to work patiently with you to manage chronic resistent disease.
Please click the link to the below to download the flow chart containing my BV treatment recommendations.
BV Treatment Recommendations

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Why yogurts and also probiotics, as adjunctive therapies for bacterial vaginosis, may NOT have failed you after all?
The obvious point of which doctors, other health care professionals, and knowledgeable patients need to be aware is that all yogurts are not created equal. In order for yogurt or the numerous so-claimed Lactobacillus-containing pro-biotic capsules to effectively saturate the gasto-intestinal and genital tracts, these products must contain literally billions of live active cultures and the bacterial species must be ones with known affinities for these human tracts. Unfortunately, the sad reality in 2007 is that American consumers are themselves likely wasting billions of dollars on yogurt and pro-biotic products which are not federally regulated and which their manufacturers offer consumers no proof that their products contain are as potent or as pure as they claim. With particular regard to yogurt products, numerous grocery-store yogurts products today carry the "Live & Active Cultrues" seal of the National Yogurt Association (NYA), an organization which is working to establish standards for commercial self-reporting of culture production-methods and live-culture counts. Unfortunately, a yogurt company only has to vouch that it is conforming to the high standards of the NYA and there is no industry-wide testing authority which can independently check what a producer is claiming. Even a July 2005 Consumers Report article on probiotics which ended with a recommended 18 supplements and 9 yogurt products have recently come under attack. A 2006 Center for Medical Consumers, Inc. article has reported that Dr. Mary Ellen Sanders, President of the International Scientific Association for Probiotics and Prebiotics, had criticized the conclusion of the Consumer Reports article that the recommended products actually contained the one billion probiotic units which are felt to be the minimum counts that are required for produce positive results, particularly intestinally. So were to turn and who to believe now? Actually, the same Center for Medical Consumers, Inc. article had reported that one product of the Consumer Reports list did meet with Dr. Sanders' approval, based on the knowledge available to her by sitting on the scientific advisory board on this product's maker. This product is Dannon's DanActive[TM] yogurt drink, which is marketed nationally in a number of different flavors, including a plain one which may later show some promise as a douche product. DanActive[TM] has identified that this 100-milliliter yogurt drink contains ten billion active Lactobacillus casei. Such products as this are usually recommended to be taken twice a day for maximum benefits. However, my reporting here on this one commercially-available product should not be taken as a ringing endorsement of this product by me as yet. I plan on conducting some additional research and this mention of this product may removed if my additional research finds that the product is actually not what it claims or is materially changed by new production methods. I also will be researching other yogurt products and probiotic capsules. So please check back periodically! For now, at least we have something to possibly work with.

What are 4 new reasons why your doctor would do well to avoid prescribing a clindamycin-based product, including the new single-dose vaginal cream Clindesse?
Not just patients, but doctors as well, are attracted to single-dose therapies. Patients like the idea of taking care of just a single treatment and then being well under way to being cured. Doctors too find comfort in the knowledge that their patients are much more likely to comply with a single-dose treatment than with a multiple-dose regimen which must be taken over several days. However, the key is obviously that the new single-dose therapy must be equally effective to an alternative multiple-dose therapy. Of particular interest, the new product Clindesse contains the same 2% clindamycin phosphate product as does the 7-day Cleocin vaginal cream prduct. However, Clindesse makes use of a sustained-release formulation which allows Clndesse to match the clindamycin vaginal drug concentration of the daily Cleocin cream applications.

The problem comes when Clindesse and other clindamycin-based products have been compared with metronidazole-based products in recent studies. There are four reasons why doctors should be entertaining new doubts about whether clindamycin-based vaginal products are the best treatments that they can prescribe for their patients, these being as follows.
  1. Based on the results of a number of clinical studies which looked at clindamycin cream products, the Center for Disease Control and Prevention (CDC) has stated that the vaginal clindamycin cream appears less efficacious than the metronidazole regimens10. Furthermore, a recent clinical study performed for the Clindesse Investigators Group found that only 42% of enrolled study participants were judged to have had a strict microbiologic cure with Clindesse at 21-30 days post-treatment11.
  2. Unlike what occurs with treatment with metronidazole, treatment of bacterial vaginosis with clindamycin appears to be associated with the subsequent emergence of multiple-antibiotic resistance among vaginal anaerobic bacteria12. Clindamycin resistance rose from 17% at baseline to 53% after therapy with the clindamycin product (Cleocin vaginal ovules), and importantly, 80% of the women who were noted to have clindamycin resistance following therapy continued to harbor clindamycin resistance 90 days after their treatment. This last finding certainly suggests that giving a woman a second prescription for clindamycin within 90 days of a first is ill-advised.
  3. Clindamycin resistance in vaginal anaerobic bacteria also to have a very important spill-over effect on intrapartum antibiotic prophylaxis of Group B Streptococcus, a threatening bacteria in late pregnancy13. When clindamycin resistance is fostered in vaginal anaerobic bacteria, these anerobic bacteria appear to rapidly develop resistance to the group of chemically-related antibiotics called macrolides, which includes erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax). The fear here is that in exchange for a partially successful treatment of bacterial vaginosis with clindamycin, a woman experiencing problems later with a pregnancy threatened by Group B Sreptococcus could then find that this usually-effective group of macrolide antibiotics is no longer effective for her.
  4. As previously discussed, clindamycin, again unlike metronidazole, has antibiotic activity not just against the anaerobic bacteria associated with bacterial vaginosis, but also against any subsisting healthy Lactobacillus species which, were it not for the clindamycin, could have been on its way to regaining its position of dominance within the vaginal flora.

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ALTERNATIVE TREATMENT TREATMENT SPECIFICS TREATMENT EFFECTIVENESS
Lactobacillus-concentrated yogurt douche Ten ml of a Lactobacillus-concentrated yogurt product was used as a daily douche for 7 days; then following waiting for a week, a repeat 7-day treatment was given. At 6 weeks following the 2nd treatment, 19 of 23 first-trimester pregnant women with BV remained without clinical symptoms of discharge, odor, abnormal pH or "clue cells" on vaginal wet mount.14
Hydrogen peroxide douche Nightly douche with 2 Tbsp sterile 3% hydrogen peroxide solution for 7 days. In this non-placebo-controlled study, 89% of women with recurrent BV had no return of vaginal odor during the 3-month study.15
Hydrogen peroxide + Betadine douche Daily douching with a 3% hydrogen peroxide + 15% NaCl + 10% providone iodine mixture for 10 day, each douching followed by a thorough cleansing of vaginal wall with a small gauze. Both the discharge and odor were eliminated for the 12 months this one adolescent girl was followed after this treatment; the girl had a history entering the study of recurrent BV which had failed metronidazole treatment.16
Maintenance acetic acid vaginal gel Study participants were instructed to apply the Aci-Jel product intra-vaginally nightly for 3 nights following a recognized triggering event (such as a period ending or simply renewing vaginal sex). In study participants who did not drop out because of considering gel use too messy, BV recurrences dropped from 4.4 per woman/year to 0.6 per woman/year.18
Polycarbophil-based acidifying vaginal gels such as RepHresh Polycarbophil gel applied intra-vaginally 3 times a week for four weeks. Few of the 17 study participants reported resolution of their vaginal odor or discharge complaints at the end of week 4 of the study. Furthermore, six of the 17 study participants complained of either relapsing or continued symptoms of BV by the end of week 6 or after study completion and subsequently requestd antibiotics for treatment.17


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What clues might I be able to use on my own to help me conclude that I simply have a "yeast infection", and not bacterial vaginosis or some other kind of vaginal infection??
A number of clinical studies into this question have concluded that there is no distinctive set of physical symptoms or signs the average woman can use to reliably and accurately self-diagnose that she is having a vaginal yeast infection versus some other kind of vaginal infection or disturbance. As an example of this point, one study that looked at the ability of women to independently and correctly self-diagnose a vaginal yeast infection found that these women were wrong 67% of the time19.

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When might it be okay to just try an over-the-counter vaginal anti-fungal product, such as Monistat and Gyne-Lotrimin, if I think I might have a vaginal "yeast infection"?
The direct simple answer to this question is NEVER! This is almost always a wrong idea. As discussion in an earlier section, Candida albicans, the species name for yeasts is a normal inhabitant of the healthy vagina. A vaginal infection, produced by a virulent overgrowth of these yeast microorganisms, under most circumstances, should be considered a very serous event, rather than a common one as most women have been led to believe. Speaking from a statistical point of view, a yeast infection should not be the first consideration to enter a woman's mind when she is faced with explaining to herself why she is experiencing a vaginal discharge or other vaginal irritation. Of course, given the ready availability of over-the-counter anti-fungal creams, it is easy to understand why thousands of woman each year think first to go out and purchase one of these products. Unfortunately, the overwhelming majority of these women are only engaged in deluding themselves and also are only delaying the toll that will eventually have to be paid when the real cause of their vaginal conditions become clear. The immune system of a normal healthy woman should encounter little difficulty in handling vaginal overgrowths of yeast microorganisms. Indeed, so unusual is it for a young healthy woman to be plagued by recurrent yeast infections that the Center for Disease Control in Atlanta now recommends that such young women be tested for infection with the AIDS virus in an attempt to explain this failure of their immune systems.

One clinical study has concluded that women with definite documented Candidal vaginal infections tend as a whole to be college-aged or younger, to employ condoms rather than other contraceptive methods during vaginal intercourse, or to have completed treatment with an oral antibiotic within the previous 15 to 30 days20. Diabetic women and women having to take oral steroid medication for conditions as severe asthma are particularly susceptible to Candidal vaginal infections. Women who abuse over-the-counter vaginal anti-fungal products set themselves up for persistent vaginal infections, which in these cases may well be caused by anti-fungal resistant strains of yeast microorganisms. To sum up, a woman who wants to think first that she might have a "yeast infection" and who rushes out to buy an over-the-counter anti-fungal cream when she begins to experience any type of vaginal irritation or the start of any vaginal discharge is most likely only making her condition worse.

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How can I communicate with Dr. Christian to pose questions or to provide feedback regarding this web site?
I intend to periodically update this web site with breaking developments in this field. You are welcome to email your questions and comments to me at drchristian@vaginosis.com. Please type in either "vaginosis" or "BV" in the subject line to help me in distinguishing your questions from junk mail. Also please feel free to resubmit questions if, because of time constraints, I fail to respond to your email within 7 days. Also brevity is appreciated.

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BIBLIOGRAPHY
  1. This web site has been independently written entirely by myself, Dr. James Christian, an internal medicine physician who has long studied and reported developments in the fields of bacterial vaginosis and vaginitis. This web site was last updated February 20, 2007.
  2. Smart S, Singal A, Mindel A. Social and Sexual Risk Factors for Bacterial Vaginosis. Sexually Transmitted Infections Journal February 2004; 80(1): 58-62.
  3. Ibid.
  4. Martin M, Monif G. Douching: A Risk to Women's Healthcare? Infectious Diseases in Obstetrics and Gynecology 2003; 11: 135-137.
  5. Monif G, Thompson J, Stephens H, Baer H. Quantitative and Qualitative Effects of Providone-Iodine Liquid and Gel on the Aerobic and Anaerobic Flora of the Female Genital Tract. American Journal of Obstetrics and Gynecology 1980; 137: 432-438.
  6. Martin M, Monif G. Op. cit., 136.
  7. Swidsinski A, Mendling W, Loening-Baucke V, Ladhoff A, Swidsinski S, Hale L, Lochs H. Adherent Biofilms in Bacterial Vaginosis. Obstetrics & Gynecology November 2005; 106(5-Part 1): 1013-23.
  8. Wathne B, Hovelius B, Holst E. Cefadroxil as an Alternative to Metronidazole in the Treatment of Bacterial Vaginosis. Scand J Infect Dis. 1989; 21(5): 585-6.
  9. Anukam K et al. Augmentation of Antimicrobial Metronidazole Therapy of Bacterial Vaginosis with Oral Probiotic Lactobacilus rhamnosus GR-1 and Lactobacillus reuteri RC-14: Randomized, Double-Blind, Placeba Controlled TRial. Microbes and Infection 2006; 8: 1450-1454.
  10. Treatment of BV. Sexually Transmitted Diseases Treatment Guidelines 2002. MMWR 2002; 51: 43.
  11. Beigi RH, Austin MN, Meyn LA, Krohn MA, Hillier SL. Antimicrobial Resistance Associated with the Treatment of Bacterial Vaginosis. American Journal of Obstetrics and Gynecology October 2004; 191(4): 1130-1132.
  12. Faro S, Skokos C. The Efficacy and Safety of a Single Dose of Clindesse Vaginal Cream versus a Seven-Dose Regimen of Cleocin Vaginal Cream in Patients with Bacterial Vaginosis. Infectious Diseases in Obstetrics and Gynecology September 2005; 13(3): 155-160.
  13. Ibid.
  14. Tasdemir M, Tasdemir I, Tasdemir S, Tavukcuoglu S. Atlernative Treatment for Bacterial Vaginosis in Pregnant Patients; Restoration of Vaginal Acidity and Flora. Archives of AIDS Research 1996; 10(4): 239-41.
  15. Cardone A, Zarcone R, Borrelli A, Di Cunzolo A, Russo A, Tartaglia E. Utilisation of Hydrogen Peroxide in the Treatment of Recurrent Bacterial Vaginosis. Minerva Ginecol. December 2003; 55(6): 483-92.
  16. Papanikolaou EG, Tsanadis G, Dalkalitsis N, Lolis D. Recurrent Bacterial Vaginosis in a Virgin Adolescent: A New Method of Treatment. Infection December 2002: 30(6): 403-4.
  17. Wu JP, Fiedling S, Fiscella K. The Effect of Polycarbophil Gel (ReplensTM) on Bacterial Vaginosis: A Pilot Study. European Journal of Obstetrics & Gynecology and Reproductive Biology 2006; 1-5.
  18. Wilson J, Shann S, Brady S, Mammen-Tobin, Evans A, Lee R. Recurrent Bacterial Vaginosis: The Use of Maintenance Acidic Vaginal Gel Following Treatment. International Journal of STD & AIDS 2005; 16: 736-38.
  19. Weisberg M, Summers P. Patient Self-diagnosis of Vulvovaginal Candidiasis. Female Patient 1996; 21: 60-64.
  20. Eckert L et al. Vulvovaginal Candidiasis: Clinical Manifestations, Risk Factors, Management Algorithm. Obstetrics & Gynecology 1998; 92(5): 757-765.
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