Bacterial Vaginosis and Desquamative Inflammatory Vaginitis

by Jorma Paavonen, M.D., Ph.D., and Robert C. Brunham, M.D.

N Engl J Med. 2018 Dec 6;379(23):2246-2254

In an opening paragraph the article says, “This review focuses on bacterial vaginosis and desquamative inflammatory vaginitis... Not discussed in this review are trichomoniasis and vulvovaginal candidiasis, two other common causes of vaginal symptoms.” If they were to add Atrophic Vaginitis, that’s FIVE types of vaginitis. So they did better than most articles that suggest there are only four types of vaginitis. They added desquamative inflammatory vaginitis (DIV) but they still fail to recognize two other types, that are much more common than DIV. And the authors equate DIV with the European term aerobic vaginitis which is incorrect. That’s an obvious sign the authors lack experience in actually evaluating patients with vaginitis. Aerobic vaginitis is the european term for what I coined in the literature published in the United States as Inflammatory Vaginitis (IV). Also, using quantitative wet preparations, there is a spectrum of severity; mild inflammatory vaginitis, moderate inflammatory vaginitis, severe inflammatory vaginitis and at the extreme worst end being DIV where white blood cells (wbc’s) are present in clusters and sheets, often toxic appearing. The wbc pattern in mild to moderate IV tend to be agranulocyte dominate. Moderated to severe IV tend to be granulocyte dominate. Severe IV and DIV usually have “toxic” appearing neutrophils. Another category is non-inflammatory vaginosis (NV), this is in the same spectrum as BV but lacks clue cells and pH is variably elevated but shows a dominance of anaerobic bacteria, lack of wbc’s and low lactobacilli concentration. So if one adds trichomonas, lactobacillosis, and mobiluncus, and divides yeast vaginitis into two groups, albicans and non-albicans then that makes TWELVE types of vaginitis; NOT four or five that most articles site.

The authors are correct about the following statements: 1) “During a woman’s reproductive years, the vaginal microbiome appears to be principally influenced by the effects of estrogen on vaginal epithelial cells, the predominance of lactobacilli, and low pH.” 2) “The vaginal microbiome can also be transiently influenced by several other factors, such as use of antimicrobial agents, sexual activity, and menses.” Others include all the factors that can alter estrogen production by the ovaries AND a genetic variant in some women with high estrogen demand vaginal mucosa. 3) “Desquamative inflammatory vaginitis is a newly recognized clinical syndrome characterized by persistent purulent vaginal discharge and vaginal erythema, often with submucosal cervico- vaginal petechiae.” While it may be “newly recognized” it was described the the medical literature over 30 years ago but still most authors who write articles on vaginitis don’t include it among the differential. 4) Clinical manifestations of desquamative inflammatory vaginitis include purulent vaginal discharge and a strong inflammatory reaction. The vaginal discharge is homogeneous and yellowish, with no fishy smell. Vulvar irritation and vaginal mucosal erythema with ecchymotic lesions or erosions are present in severe cases.” Notice the phrase “vulvar irritation,” in other words it is one of the causes of vulvodynia. They just don’t quite put two-and-two together. Of course there are a lot more correct statements in the article, just not pertinent to my practice dealing with vulvodynia, chronic bacterial infections, recurrent yeast infections, chronic discharge and odor. In my clinical experience, BV has never been implicated in these conditions. BV is an acute polymicrobial vaginal dysbiosis that readily responds to metromidazole or clindamycin with underlying healthy vaginal mucosa conditions.