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How can I confidently know if my vaginal discharge and odor are caused by bacterial vaginosis?

Why would my physician want to shortchange me the testing that I need to determine if I have bacterial vaginosis?

But if my pap smear was all right, doesn't that mean that I don't have bacterial vaginosis?

What tests have to be performed for my doctor to confidently diagnose me with bacterial vaginosis?

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

Welcome to this Bacterial Vaginosis website. This website is derivative of the www.vaginosis.com website, which should be read first. The vaginosis.com website answers basic questions about what bacterial vaginosis represents and about why testing women for bacterial vaginosis is important. That website also presents my views on why women accepting treatment for bacterial vaginosis should begin asking for one of the two brand-name intravaginal antibiotic products rather than continuing to go along with the completely unpalatable oral treatment with the generic metronidazole pill.

Both websites, the vaginosis.com site and the bacterial vaginosis.net site, have been independently authored by me, Dr. James Christian, an internal medicine doctor who has long studied developments in this field. This bacterial vaginosis.net website aims at providing women with a patient orientation guide to the range of testing options that their physicians have at their disposal, but often fail to utilize to check their women patients for bacterial vaginosis. It is my strong belief that women equipping themselves with some basic understanding of these tests constitute the best protection against women with this condition being shortchanged appropriate tests and services.

How can I confidently know if my vaginal discharge and odor are caused by bacterial vaginosis?
Uncovering the cause of a new or recurring vaginal discharge and odor problem is an intensely personal and private matter which is confronted each day by thousands of women worldwide. In fact, a number of investigations have shown that every day millions of dollars are being spent and wasted on over-the-counter anti-fungal creams, vaginal douches and vaginal perfume products which represent misguided and ineffective attempts to treat what is actually bacterial vaginosis. Bacterial vaginosis, or BV, is now known to be by far the most common cause of vaginal discharge and strong odor in all groups of women today. Many of the women affected by this conditon however are stopped by either personal embaressment or else financial considerations from going to see a doctor about their vaginal complaints. Then those women who do go ahead and consult a doctor are more likely than not to encounter physicians who lack appropriate concern and empathy regarding their vaginal complaints and who after one fashion or another end up short-changing these women appropriate testing and treatment services. The vaginal diagnostic packs being offered on my website
www.testyourvagina.com offer women a private home testing option to provide themselves with valuable screening information as to whether they might have bacterial vaginosis and also allow women who have had BV to monitor themselves as to when this frustrating condition is cured or is recurring.

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Why would my physician want to shortchange me the testing that I need to determine if I have bacterial vaginosis?
Doctors today face day-by-day overwhelming demands on their time. Of the procedures that a doctor may be called upon to perform on a given day, none is more time consuming than the stopping to perform an examination for bacterial vaginosis and for the other causes of abnormal vaginal discharge, odor, or irritation. The temptation comes quite naturally for either the doctor or her or his staff to employ stratagems to attempt to spare the physician from having to perform these procedures.

Perhaps the most devious stratagem is for an office triage nurse to try to dissuade a women from using up a valuable doctor's appointment slot by cajoling the woman into agreeing to first try an over-the-counter treatment, such as an antifungal vaginal cream, before calling back for an appointment. Even when the woman has wrestled away an appointment slot from some disapproving office assistant, the same advice might be given by the doctor herself or himself, as she or he is backpedaling out of the examination room in a rush to get to the next patient.

This is very bad advice and very bad medicine. It results in a phenomenon, which may be termed cost shifting. The over-the-counter antifungal cream will almost certainly not resolve the woman's symptoms. So she will be out the money for the over-the-counter treatment. Additionally, she is now facing the necessity that she will have to pay to go back to see the doctor (although hopefully she will have gotten the message by this time to go to see a different doctor). On the other hand, the woman's doctor's office has been saved the expense of the doctor's time and of office materials, which rightly should have been employed more professionally addressing the woman's problem in the first place.

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But if my pap smear was all right, doesn't that mean that I don't have bacterial vaginosis?
The short answer to this question is absolutely not! Pap smears are intended solely to screen for cancerous or pre-cancerous cells of the uterine cervix. Many cell pathologists, whose job it is to read the Pap smears, will append a comment at the bottom of the Pap smear report that an abnormal overgrowth of bacteria, or even Trichomonas bacteria, had been noted on the smear. However, this may occur primarily in the most severe cases and, in any case, cannot be relied upon.

The bacterial overgrowth situation occurring in bacterial vaginosis can also make it very difficult for the cell pathologist to say absolutely that a Pap smear is normal. This is because bacterial vaginosis can be associated with Pap smears, which demonstrate atypical cervical cells (that is, cells that do not definitely appear pre-cancerous, but do appear strange). Some cell pathologists will recommend on the Pap smear report that the patient be treated with an antibiotic and then rescheduled for a follow-up Pap smear within a period of months. If, following one Pap smear, your doctor orders for you an antibiotics treatment, with or without follow-up instructions to schedule another Pap smear in 3 or in 6 months, you are most likely being treated for bacterial vaginosis, whether or not the doctor or the nurse has informed you of this directly.

I am a strong proponent for women obtaining photocopies of their Pap smear reports and for their discussing any abnormalities annotated in the report with their own private doctors. However, I feel this way not simply out of the concern that patients are being urged to take treatments that have not been adequately discussed with their doctors. I also have some concern that many women are not being told at all about these important footnotes at the bottom of their Pap smear reports.

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What tests have to be performed for my doctor to confidently diagnose me with bacterial vaginosis?
Let us first review our definition of bacterial vaginosis. Bacterial vaginosis is the very common vaginal condition where the normal predominant Lactobacillus inhabitants of the vagina have been replaced by a mixed population of anaerobic bacteria that appear to open up the female genital region to a host of other infections and complications.

The Amsel criteria are the universally accepted criteria today for making a diagnosis of bacterial vaginosis. This criteria says that bacterial vaginosis is present if any 3 of the following 4 conditions are present:
    1) Presence of a vaginal discharge, which rather than being watery, is of a milky consistency;

    2) Vaginal acidity, or pH, being above 4.5;

    3) A positive "whiff" test, either unaided or aided by the depositing of a drop or two of potassium hydroxide solution into a teaspoon of the collected vaginal fluid; and

    4) The identification of at least 20% of the cells on a microscopic wet mount as "clue cells".

Let us take these items point by point.

The presence of a vaginal discharge, particularly one that is heavier than normal or one that is associated with a strong repugnant odor, may be the main concern that leads a woman into her doctor's office for a consultation. The woman may or may not be able to tell her doctor whether her discharge fluid has a consistency similar to milk. In any case, the doctor will need to have the woman undressed and prepared for a pelvic examination so that she or he can observe the consistency of the discharge, while simultaneously inspecting the vagina and cervix for clues to sexually transmitted disease. Additionally, whether the discharge fluid either tends to pool at the back of the vagina or tends to more evenly coat the whole length of the vagina a valuable clue as to what is going on, because the discharge of bacterial vaginosis tends to more evenly coat the whole vagina.

Accordingly, it is imperative that women ignore what might appear normal instincts and refrain from douching before they present to their doctors for a vaginal examination. A woman who douches in preparation to going to see her doctor will destroy valuable clues that would have aided her doctor in correctly identifying the cause of her gynecologic problem.

Vaginal acidity can be determined during a pelvic examination by depositing a small sample of the vaginal fluid on a chemical strip or card. The degree of acidity of vaginal secretions, as for any fluid, is scientifically expressed in terms of its pH, which stands for power of the hydrogen atom.

The pH of pure distilled water is set at the neutral value of 7.0. Below this number, the lower the pH value of a solution the more acidic is the solution. For example, the pH of tomato juice is 4.3, the pH of grapefruit juice is 3.2, and the pH of stomach secretions is 0.9. In the normal healthy vagina, the pH of secretions does not rise above 4.5. When the pH within the vagina is found to be above 4.5, it is indicative of the fact that something has happened to the lactic acid -producing Lactobacillus bacteria that normally predominate in the vagina. Accordingly, a vaginal pH above 4.5 is strong circumstantial evidence that bacterial vaginosis is present, although I hasten to add that vaginal infection with the sexually transmitted bacteria Trichomonas can also cause an elevation of the vaginal pH above this value.

The Whiff test is smell test for the presence of amine compounds produced by the anaerobic bacterial population characterizing bacterial vaginosis. The abnormally strong and fishy odor characterizing bacterial vaginosis may, in fact, be the very reason why the woman has come to see the doctor in the first place. This odor might become immediately apparent to the doctor after the vagina has been wedged open by a speculum inserted for the purpose of the vaginal exam. If this odor is not noted at this point, the whiff test is supposed to be performed by the doctor to determine whether depositing a drop or two of potassium hydroxide solution into a teaspoon of collected vaginal secretion will succeed in bringing out this characteristic smell. Unfortunately, in the real practice world of today, few primary care doctors stock fresh bottles of potassium hydroxide in their examination rooms for the purpose of performing the whiff test.

The Wet Mount preparation is simply a microscopic slide that has been made by thinning out a sample drop or two of the vaginal fluid with a drop or two of sterile water. The preparing of the wet mount and the examining of the wet mount under microscopic power are quite time consuming, and for this reason, the wet mount may be skipped by many physicians examining women for vaginal discharges or irritation.

Top Photo: Clue Cells A Clue Cell is the microscopic thumbprint of bacterial vaginosis. Clue cells are collections of vaginal lining cells, which have been shed into the vaginal secretions and which are distinguished by a "ground glass" appearance produced by large numbers of anaerobic bacteria adhering to their surfaces. When a doctor decides not to perform a wet mount, she or he misses the opportunity to cinch the diagnosis of bacterial vaginosis. As important, the doctor does the patient a tremendous disservice as the wet mount might also be used to examine vaginal secretions for fungal or "yeast" infection or for the sexually transmitted bacteria Trichomonas. The image to the right presents a pair of microscopic views of typical "clue cells" in the top photo and normal healthy vaginal cells in the bottom photo. These photographs are presented courtesy of the Seattle STD/HIV Prevention Training Center at the University of Washington.

What follows here is a checklist, which will be useful to take with you when you go to your doctor's office.
    1. Doctor, will you be performing a pelvic exam? If not, why not?

    2. Doctor, will you be measuring my vaginal pH? If not, why not?

    3. Doctor, what is my vaginal pH?

    4. Doctor, will you be performing a wet mount? If not, why not? Isn't it true that you can't tell what problem I have, whether bacterial vaginosis or trichomonas (or "trick", as doctors shorten it to), unless you do a wet mount?

    5. Doctor, if I do have bacterial vaginosis, would you be willing to prescribe a metronidazole vaginal gel rather than give me the pills by mouth?
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