[The etiology of leukorrheas in non-pregnant women (apropos of 500 cases of leukorrhea)].
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OBJECTIVE: To evaluate whether the combination of bacterial vaginosis and leukorrhea on microscopic evaluation of a saline wet preparation is associated with cervical infection with Chlamydia trachomatis (C. trachomatis) or Neisseria gonorrhea (N. gonorrhea). METHODS: A cross-sectional study of 598 patients was performed. Nonpregnant patients undergoing a saline wet preparation and microbiologic testing for C. trachomatis and N. gonorrhea were eligible. Providers prospectively collected data from saline microscopic analysis. Bacterial vaginosis was documented based on Amsel's criteria, and ligase chain reaction testing of the endocervix was performed for C. trachomatis and N. gonorrhea. RESULTS: On univariate analysis, young age (less than 25 years), unmarried marital status, black race, and the presence of leukorrhea were all associated with increased rates of testing positive for C. trachomatis and N. gonorrhea (P <.05). We stratified patients into three groups: 1) no evidence of bacterial vaginosis or leukorrhea; 2) evidence of either bacterial vaginosis or leukorrhea, but not both; and 3) evidence of both bacterial vaginosis and leukorrhea. Using logistic regression analysis to control for age, marital status, and race, we found an odds ratio of 3.8 (95% confidence interval 1.3, 11.6) for a positive microbiologic test for either C. trachomatis or N. gonorrhea in women with the combination of bacterial vaginosis and leukorrhea. CONCLUSION: In this group of high-risk women seen in an urgent care facility, the presence of both bacterial vaginosis and leukorrhea was associated with an increased risk of cervical infection. Future prospective studies should evaluate whether empiric treatment of high-risk women with these findings is justified and cost-effective.
OBJECTIVE: To evaluate 1) whether microscopic detection of leukorrhea or bacterial vaginosis identifies patients at high risk for cervical infection with Chlamydia trachomatis or Neisseria gonorrhoeae, and 2) if pregnancy alters the predictive value of these findings. METHODS: Wet-mount screening examination of vaginal discharge was performed on all new patients seen at two resident-staffed clinics serving primarily indigent women. Leukorrhea was defined as >10 white blood cells per high-power field on microscopic examination; Amsel criteria were used to determine the presence of bacterial vaginosis, with a positive clue cell test result defined as >20% of epithelial cells. The diagnoses of C trachomatis and N gonorrhoeae infection were established by deoxyribonucleic acid amplification tests. RESULTS: The study population consisted of 194 women, 118 (61%) of whom were pregnant. Overall, 11% of women had positive cultures for chlamydia or gonorrhea. Although both leukorrhea and clue cells were independently associated with positive cervical cultures, multivariate analysis found that clue cells did not contribute to the predictive value of leukorrhea alone among both pregnant (relative risk [RR] = 15.7) and nonpregnant (RR = 58.7) women. Negative predictive values for the screening test were comparably high (98-100%), independent of pregnancy status. CONCLUSION: Leukorrhea, in the presence or absence of bacterial vaginosis, was strongly associated with cervical infections with C trachomatis or N gonorrhoeae among both pregnant and nonpregnant patients. In settings where patient follow-up is uncertain, on-site screening tests identify women for whom empiric antibiotic therapy for sexually transmitted diseases may be appropriate.
Corynebacterium vaginale was recovered from vaginal-cervical swab specimens in 164 of 288 women with leukorrhea and in four of 30 women without signs or symptoms of lower genital tract infection. The amount and character of the leukorrhea observed in association with C. vaginale infection were variable; in typical cases the discharge had the appearance of a thin paste. In a series of 100 patients studied to determine the apparent causes of leukorrhea, noninfectious causes were inferred in seven patients and no cause ascertained in six. Candida or other yeasts, C. vaginale, and Trichomonas vaginalis were identified alone or in combination in 87 patients; 53 had yeasts, 35 had C. vaginale, and 15 had T. vaginalis.
Among women in South Asia, the complaint of vaginal discharge (often called leukorrhea) is extraordinarily common. From a biomedical perspective, this symptom suggests that reproductive tract infection (RTI) is prevalent in the subcontinent; however, several recent studies provide evidence that the prevalence of RTI is relatively low. Women who do not have RTI frequently report the symptom of vaginal discharge. An anthropological perspective on the cultural meanings of leukorrhea can shed light on this puzzling phenomenon. According to Ayurvedic concepts of health and illness, genital secretions are considered a highly purified form of dhatu, or bodily substance, and loss of this precious substance is thought to result in progressive weakness or even death. Many South Asian women who complain of vaginal discharge also report a variety of somatic symptoms such as dizziness, backache and weakness. The link between unexplained gynaecological symptoms and mental health concerns has been explored by both psychiatrists and anthropologists in South Asia. Leukorrhea may represent a culturally shaped "bodily idiom of distress", in which concerns about loss of genital secretions reflect wider issues of social stress. Problems may arise when a symptom with deep cultural meaning is interpreted in a purely biomedical framework. In the syndromic approach to the treatment of sexually transmitted infections (STIs), health workers are trained to treat women presumptively based on history and a risk assessment, but without clinical or laboratory confirmation of infection. A recent evaluation of this approach demonstrates that many women who complain of vaginal discharge do not have RTI, and are inappropriately treated with antibiotics. It seems likely that women are over-reporting vaginal discharge because of its deep cultural meanings, meanings that need to be understood within an anthropological rather than biomedical framework.
A harmless acid detergent douche solution based on known physiologic and chemical factors was used in clinical trial on 104 patients having leukorrhea of various causes. When used alone or as an adjunct to other forms of therapy there was a favorable response in 81 per cent of patients with infections who were followed. In non-infectious leukorrhea there was probably no shortening of healing; however, there was effective relief of symptoms in 84 per cent of those who were followed. This acid detergent douche solution may have a wide range of use.
Strains of Haemophilus vaginalis were isolated from patients with leukorrhea. The characteristics of the microorganism that permit its laboratory diagnosis and results of the antibiotic-sensibility tests are described.
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