Recurrent Vaginosis by Michael East, MD
When a woman presents with an irritating or painful vaginal discharge that may also have an offensive odour, the most common diagnosis turns out to be either acute Candidiasis or an overgrowth of Gardnerella vaginalis. Simple treatment with anti-fungal agents for the former or Tinidazole or Metronidazole l for the latter usually resolve the problem swiftly and completely. In other words the solution is often simple. Where things become difficult however is when a woman represents with several episodes of recurring discharge and/or irritation within a short timeframe that seems to be refractory to the normal treatments described above. Obviously swabs must be taken with a view to screening for a sexually transmitted disease but by the time the discharge has become a chronic complaint, the swabs are usually returned showing ‘normal vaginal organisms’ possibly with some microscopic evidence of bacterial vaginosis but generally no one organism leading the field, in short it has become a non-specific chronic vaginosis. The organisms involved are the normal organisms but they are simply out of balance usually due to the demise in dominance of acidophilus.
Acidophilus or lactobacillus prefers an acid environment and it in turn excretes acid as a waste metabolite, thus helping to (a) preserve its own environment, and (b) make the vaginal environment less hospitable to an overgrowth of other organisms such as Candida and Gardnerella vaginalis. The vagina then ought to be considered akin to a micro ecosystem.
Management Solution
The management solution for persistently occurring non-specific vaginosis is to restore the vaginal acidity. The best way to do this is not through using preparations such as Aci-jel which can very quickly be buffered and neutralised but instead to increase the acid production within the vagina by using twice weekly estrogen cream or similar product such as Vagifem. Oestrogen achieves an increase in the vaginal acidity, improves the epithelial resistance to infiltration of organisms that should be retained within the cavity of the vagina, not within the epithelial wall of the vagina, and it also increases IgA antibody secretion into vaginal mucus. All of the above tends to keep the population of Candida and Gardnerella at low levels and promote the correct environment for acidophilus/lactobacillus to become the dominant organisms once again and thereby ‘policing’ the vaginal environment. The vaginal oestrogen approach can be used even in teenage women and is not simply a management for post menopausal women. Obviously post the menopause the treatment should be continued ad infinitum but for premenopausal women then usually the management is simply carried out as a three month course. Some women during the transition part of their lives in their fourth decade may also however need to continue twice weekly oestrogen ad infinitum before the menopause has actually occurred should their symptoms relapse following cessation of an initial three month course. When instituting a three month course of estrogen cream it is also a good idea to prescribe a two day course of Tinidazole at 500mg b.d. for two days (warn against concurrent alcohol use) in conjunction with Fluconazole, 150mg stat, followed by 50mg daily for six days.
In addition I would advise checking the serum zinc level by requesting a serum zinc assay. The normal range quoted 10-17umol/L. The range quoted by various laboratories can differ but I would advocate that if a woman is found to have a level of 10umol/L or lower then a two-week course of 250mg zinc sulphate tablets, one daily, should be instituted, followed by over-the-counter self prescribing of zinc thereafter on an ongoing basis (such usually contributes around 15mg of elemental zinc.) This advice cannot be presented as hard scientific data, it has simply been an observation made over the years. Zinc is a trace element requirement within the diet and it is very rare that one can become zinc deficient due to dietary intake. Nonetheless many women with recurring vaginal irritation/discharge issues are found in my experience to have low levels of zinc and anecdotally report improvement in the symptoms following zinc replacement. Zinc replacement will not help if the zinc level has not been shown to be low. One cannot produce hard scientific support for this approach however but it has simply been a clinical observation of mine over many years of clinical experience in treating this difficult problem.
