Women's Health Update: Cytolytic Vaginosis; A Vaginitis You May Not Have Heard About
Cytolytic vaginosis(CV) is the current term for a condition of lactobacilli overgrowth. It is a little recognized but common cause of cyclic vulvovaginal complaints in women of reproductive age. CV is often misdiagnosed as candidiasis and most women have tried many antifungal medications both conventional and alternative, with little or no relief.
CV was first described as a clinical entity by Cibley and Cibley in 1982 and it was initially referred to as Doderlein's cytolysis (DC). They observed that the symptoms of CV were similar to Candida vaginitis, but when viewed under a microscope, there were differences.( 1, 2) The name of Doderlein's was abandoned because these same authors realized that DC only refers to the Doderlein's species of lactobacilli when in fact there are approximately 80 different species of lactobacilli that have been described. CV was then proposed as the more accurate term that described the actual destruction of the epithelial cells caused by the overgrowth of lactobacilli. The experience of Cibley and Cibley was that the majority of the patients referred to them that thought they had chronic vulvovaginal candidiasis actually had CV instead.( 1)
The normal ecosystem of the vagina involves many different organisms that are involved in a system of checks and balances. No other concept in vaginal health is as important as the state of the ecosystem of the vagina. The flora that colonizes the vagina takes place in the birth canal during delivery, and the flora that is established in the newborn girl must therefore consist of the same strains as in the mother. The vaginal environment of a newborn changes during the first month, then again at prepuberty, puberty, during the reproductive years and post-menopausally. Additionally, the cyclic hormonal changes of the menstrual cycle also influence the vaginal ecosystem. It is a variable state throughout a woman's lifetime, but nothing is more key to this ecosystem than lactobacillus. The range of bacterial types isolated is immense, including Staphylococcus species, Garnerella vaginalis, Streptococcus species, Bacteriodes species, Lactobacillus species, Mobiluncus, Candida species, (most commonly Candida albicans), and more. The predominant organism isolated from the normal vagina are members of the Lactobacillus genus. One species of bacteria inhibits another and an elegant combination of pH, vaginal immunity, hormonal activity and the community of organisms that occupy the vagina interact in a manner in which bacterial overgrowth is controlled, unless the well-established mechanism of balance is thrown off by one factor or another.
Factors controlling this defense system include the health of the vaginal squamous epithelium, the dominance of Lactobacilli and the subsequent low or acid pH balance and hydrogen peroxide production, hormonal activity both over our lifetime as well as our monthly cyclic changes, pregnancy, contraceptive devices, feminine hygiene products, and vaginal sexual activity including friction, lubricants, foreign objects, and semen.
It has been proposed that lactobacilli and possibly other bacteria cause the symptoms of CV. Even though we lack full understanding about the exact mechanism of lactobacilli overgrowth, a clinical condition does exist with this overgrowth that manifests as chronic cyclic burning and itching. It appears that this is probably related to an overgrowth of lactobacilli that produces irritating acids.( 1)
Several mechanisms are possible for how Lactobacillus in normal amounts does its remarkable job of controlling the environment. A low vaginal pH is believed to be a primary mechanism controlling the composition of the vaginal micro flora. Lactic acid is produced by the metabolism of lactobacillus and although there may be other ways in which the vagina maintains its normal acidic environment, the role of lactobacilli seems evident. Lactobacilli thrive at an acidic pH of 3.5-4.5 and these values are indeed found in the normal vagina throughout the menstrual cycle.
Lactobacilli have also been shown to interfere with how pathogenic bacteria adhere and colonize the cells of the vagina.( 3) Hydrogen peroxide production is another well-recognized method of antagonism to problematic bacterial populations and there are strains of lactobacilli that produce hydrogen peroxide (H( 2)O( 2)). A lack of H( 2)O( 2) producing lactobacilli predisposes a woman to bacterial vaginosis by allowing the overgrowth of Gardnerella and other anaerobic bacteria. Lactobacilli also act directly as antibacterials( 4) and may function as an immune stimulant locally in controlling microbial levels in the vagina.
But what happens when there is too much Lactobacilli? Several species of lactobacilli ferment both glycogen and glucose to lactic acid, carbon dioxide, alcohol, formic acid, acetic acid, and hydrogen peroxide. It is these acids that cause the problem. When lactobacilli overgrow, toe many acids are produced, causing vulvar irritation and itching.
Symptoms of CV usually mimic those of vulvovaginal candidiasis. The most common symptom is itching, but vulvar burning, dysuria, and entry dyspareunia are often present as well. Cyclical and recurrent symptoms typically occur during the luteal phase and worsen premenstrually, increasing in intensity and severity until the onset of menses. Once the onset of menstrual flow occurs, the blood raises the vaginal pH and there is often dramatic relief of symptoms.( 1)
The physical exam is not particularly different from candida vulvovaginitis. The vulva may appear red and slightly swollen. There may be a small amount of white and slightly clumpy discharge. The vulvar tissues may be a little tender with discomfort during the speculum exam. The cervix, vagina, uterus and adnexae are normal unless there is also some other kind of co-infection. Even the pH of the vagina is normal in CV.
Diagnosis of CV is improved if the clinician has a high degree of suspicion of the condition. The history and physical exam basically mimics candida vulvovaginitis. The key is in the microscopic exam: 1) false clue cells with agglutination of lactobacilli to epithelial cells; 2) few white blood cells; 3) cytolysis of epithelial cells with pale or bare nuclei/cytoplasm and poorly defined cell borders; 4) absence of yeast, trichomonas, bacterial vaginosis, or other organisms.( 1)
Repeat microscopic exams that reveal the same findings is confirmation of CV. As you know, each episode of vaginitis symptoms may be due to a different cause.
The goal of therapy is aimed at reducing the overgrowth of lactobacilli and providing relief of symptoms. Use of antifungal agents, both conventional and alternative, should be discontinued because these agents may contribute to the recurring nature of the condition. Use of lactobacilli in the form of yogurt, supplements and suppositories should be stopped. It may also be wise to discontinue use of tampons because unimpeded menstrual flow acts much like an alkalinizing agent, raising the vaginal pH and inhibiting the overgrowth of lactobacilli.
Baking soda sitz baths offer relief by removing irritating acid secretions from contact with the vulvar tissues and also just a local soothing effect to excoriated tissue from itching. Mix 2 to 4 tablespoons of baking soda in 1 to 2 inches of warm bath water. Sit in the sitz bath twice a day for 15 to 20 minutes. Wash the tub after each use. Baking soda douches should be reserved for women whose symptoms do not respond to the sitz baths. This is because douching removes vaginal secretions and can disrupt the desired organisms in the vagina and create further problems in maintaining an ecological balance. Consider douching with baking soda once or twice a week during symptomatic phases when the sitz baths do not provide relief. Mix 1 to 2 teaspoons of baking soda in a pint of warm water and gently douche either in the bathtub or over the toilet.
Cytolytic vaginosis may coexist with candidiasis and may need to be managed by combining therapy for both. Using the local antifungal agent in the morning and the baking soda gentle douche in the evening for seven days would be an appropriate regime that may need to be repeated monthly in the premenstrual phase of the cycle.
Other recommendations may prove prudent:
Reduce dietary sugar.
Avoid soap in the genital area. Instead, wash with plain water, use pure unscented mineral oil on cotton balls as a cleanser
Wear white, all cotton underwear and launder with mild soap and hot water, rinsing thoroughly.
Avoid sexual intercourse during symptoms and initial therapy. Oral sex should also be avoided during symptomatic periods because bacteria in the partner's mouth may be irritating to the vulva.
As women and clinicians become aware of CV, women with cyclic vulvovaginitis will receive better health care and be managed more appropriately. With improved diagnosis of this condition and accurate treatment, fewer women will experience cyclic recurrences of their vaginitis. Success is especially seen when the wrong treatments are discontinued and something as simple as using menstrual pads are used instead of tampons. Treatment approaches to treat CV must be modified as necessary and practitioners must recognize the individual needs of each patient and be willing to be creative and somewhat experimental, utilizing the basic concepts and understanding of CV that we have discussed here.
(1.) Cibley J, Cibley J. Cytolytic vaginosis. Am J Obstet Gynecol 1991; 165: 1245-1248(supple 2).
(2.) Kaufman R, Friedrich E, Gardner H. Benign diseases of the vulva and vagina (ed 3). Chicago, III, Year Book Medical, 1989: 371-418.
(3.) Chan R, Bruce A, Reid G. Adherence of cervical, vaginal and distal urethral normal microbial flora to human uroepithelial cells and the inhibition of adherence of gram-negative uropathogens by competitive exclusion, J Urol/1984; 131: 596-601.
(4.) Andersson R, Daeschel M, Hassan H. Antibacterial activity of plantaricin SIK-83, a bacteriocin produced by Lactobacillus plantarum, Biochimie 1988; 70:381-90.
Townsend Letter for Doctors & Patients.
By Tori Hudson