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 Table of Contents 
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 1  |  Page : 88-92  

Gynecological complaints and their associated factors among women in a family health-care clinic


1 Federal District Health Department, University of Brasilia, Brasilia; Department of Tropical Medicine, University of Brasilia, Brasilia, Brazil
2 Federal District Health Department, University of Brasilia, Brasilia, Brazil
3 Federal District Health Department, University of Brasilia, Brasilia; Department of Tropical Medicine, University of Brasilia, Brasilia; Laboratory of Parasitology and Biology of Vectors of Faculty of Medicine, University of Brasilia, Brasilia, Brazil

Date of Web Publication18-Sep-2017

Correspondence Address:
Mateus de Paula von Glehn
Block 102, Sol Nascente Building, Aguas Claras, Brasilia/Federal District
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4863.214982

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  Abstract 

Aim: The aim of this study was to describe the most common gynecological complaints and possible associated factors among women of reproductive age attended at a family health-care clinic. Methodology: A transversal study conducted with a sample of an outpatient population consisting of women of reproductive age. Pregnant women and minors were excluded. The final sample consisted of women between 18 and 49 years of age. The participants answered a questionnaire in which the complaints of the last 4 weeks were registered. They were examined, had the vaginal pH assessed, and secretion was tested using a 10% potassium hydroxide solution to verify the presence of amine odor (whiff test). Results: Most participants were black or of mixed races. Considering the frequency of complaints, there were no significant differences between white and nonwhite women. There was an association between vaginal pH and discharge complaints as well as unpleasant odor, positive test of amines, smoking, and performing vaginal douches. Conclusions: Vaginal complaints were common among participants; the practice of vaginal douches was also frequent and was associated with higher pH values. The use of hormonal contraceptives was associated with lower pH values. There was no significant association between condom use and gynecological complaints, vaginal pH, or the whiff test.

Keywords: Female genitalia, vaginal discharge, vaginal diseases, vaginal douching


How to cite this article:
von Glehn Md, Sidon LU, Machado ER. Gynecological complaints and their associated factors among women in a family health-care clinic. J Family Med Prim Care 2017;6:88-92

How to cite this URL:
von Glehn Md, Sidon LU, Machado ER. Gynecological complaints and their associated factors among women in a family health-care clinic. J Family Med Prim Care [serial online] 2017 [cited 2018 Dec 18];6:88-92. Available from: http://www.jfmpc.com/text.asp?2017/6/1/88/214982


  Introduction Top


Gynecological complaints are frequent reasons for seeking primary health-care clinics. In addition to being annoying, they can compromise the sexual and reproductive health of women. Among the most common complaints are the abnormal vaginal discharge and pain in the lower abdomen. In general, such complaints are associated with higher vaginal pH values, which are considered normal when below 4.5.[1] The physiological pH is maintained due to the production of lactic acid by bacteria belonging to the vaginal commensal microbiota, in particular, bacteria of the Lactobacillus genus. Glycogen, released by epithelial cells of the vagina, acts as a substrate to lactic acid production.[1],[2],[3],[4]

There are various profiles of vaginal microbiota.[5] Some are more prone to instability, which may lead to noticeable symptoms in women [6],[7] and are generally accompanied by changes in pH values. Some bacterial dysbiosis can use lactic acid as an energy source, which may explain, in part, the elevated pH.[8],[9] In such cases, there is a predominance of polymicrobial flora with anaerobic bacteria producing amines and short chain fatty acids which contribute to distinctive and unpleasant odor.[10] In addition to the different existing standards of vaginal microflora, various genital infections may be associated with pH changes, as well as the appearance and odor of vaginal secretion.[11]

Objective

The objective of this study was to identify and describe the most common gynecological complaints and their association with the vaginal pH, of women of childbearing age attended at a family health-care clinic.


  Methodology Top


A cross-sectional study was conducted between November 2014, and March 2015, in a primary health-care clinic of Estrutural City, one of the administrative regions of the Federal District, Midwest region of Brazil.

Ethics Committee

The study was approved by the Research Ethics Committee of the State Health Department of the Federal District (CAAE 28186514.5.0000.5553).

Sample population

The sample of the present research was part of the participants of a larger study concerning the prevalence of Trichomonas vaginalis conducted in a primary health-care clinic of the Federal District of Brazil. It was selected from an outpatient population, a sample composed of women of childbearing age, except pregnant women and minors. The final sample of the present study consisted of 193 women between 18 and 49 years of age. These women were part of a group of nearly 700 childbearing age women living in the clinic coverage area. Using this number as an indicator of a finite population, assuming a 10% prevalence of infection and a 95% confidence interval (CI), the sample was calculated as 116 participants. Predicting a 20% loss during the time of the study increased this number to 139 women. As data were collected, 219 women were invited regardless of the reason that they had come to the clinic, 201 women agreed to participate, and 193 of them were examined.

Data collection

A questionnaire, administered by a female trained interviewer, asked the participants about complaints that had occurred during the last 4 weeks. They were subsequently sent for a vaginal pH test and a test of the amines. The pH was measured using a graduated strip every 0.3 units for a range from 3.6 to 6.1 (pH-Fix ®, Macherey-Nagel, Ref. 92130). The test for the detection of amines was performed by adding a drop of 10% potassium hydroxide to a sample of vaginal discharge that had been previously deposited on a glass slide. The test was considered positive with the perception of the characteristic fishy odor. Among the associated factors examined, the race/color variable was considered according to the participants' self-declarations. Since more than half of the women declared that they were brown or black, the race/color variable was grouped into two categories: White and nonwhite. Other factors examined included smoking, methods of contraception, use of vaginal douches, and use of condoms.

Data analysis

Associations between variables were evaluated using Chi-square (χ2), and the odds ratio with 95% CI, used to identify probabilities of occurrence. The differences between proportions were verified with a one-tailed test, which was considered significant when Z-calculated > Z-critical. In the case of a one-tailed curve, an error of 5% yielded a Z-critical value of 1.64.


  Results Top


A total of 219 eligible women were invited to participate in the study. Of these, 201 women agreed, and 193 of them (96%) were examined. The average age of participants was 34 years; most of them were of mixed races (58%). There were 24% white, 13% black, and 4.5% other races.

Among the women interviewed, 78% (157/201) reported at least one gynecological complaint. The most frequent complaints were pain in the lower abdomen (50%); discharge (46%); dyspareunia (34%); unpleasant odor (33%); pruritus (28%); and burning (27%) as shown in [Figure 1].
Figure 1: Distribution of women interviewed according to gynecological complaints (%), 2015

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Complaints of discharge, itching, burning sensation, dyspareunia, and pain in the lower abdomen were more frequent among women who declared themselves to be white. The unpleasant odor was more frequent among nonwhite women. Considering all of the vaginal complaints, there were no significant differences between white and nonwhite women. The proportion of nonwhite women testing positive in the amines test was higher than that of white women, but there was not a significant difference [Table 1].
Table 1: Distribution of women, according to vaginal complaints by race/color, 2015

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Of the 193 women examined, 83 (43%) had pH levels above 4.5. There was an association between higher pH (>4.5) and the result of the amines test. An association was also identified between the pH level and complaints of discharge and unpleasant odor. No associations were found among the other complaints.

Eighty-nine women (44%) had the habit of performing regular vaginal douches. Of these, 30% (27/89) used only water and 70% (62/89) used other substances. There was an association between the performance of vaginal douches and higher pH values. In terms of the use of hormonal contraception, 31% (63/201) reported use, especially the use of pills (62%), in contrast to the use of injected contraceptives (35%). Half of the women said they used condoms, but only 19% (38/201) of them used the prophylactic in all sexual relations. Preference was for the male condom in 93% of cases. There was no association between the consistent use of condoms and vaginal pH values [Table 2].
Table 2: Distribution of women, according to associations between the variables studied and vaginal pH values, 2015

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  Discussion Top


Species of lactobacilli present in the vaginal environment produce, in addition to lactic acid, other substances essential for maintaining the local balance of pH.[12] It is thus possible to hypothesize that an increase in pH is related to a decrease in the quantity or function of these lactobacilli. Such a situation could result in vulnerability to dysbiosis, which results in several of the common gynecological complaints reported in primary health-care clinics.

Most vaginal complaints reported in the present study were more frequently among white women, except for the complaint of unpleasant odor. Nonwhite women had proportionately higher levels of positivity by the test of amines. Research reported in the literature has demonstrated an association between skin color, pH, and genital infections.[13] However, the participation of other variables, biological (race/ethnicity and genetic polymorphisms [14]) or socioeconomic and cultural, such as hygiene, sexual practices, and other activities that could transmit sexual maladies require more investigation.[15],[16]

This study found an association between pH values and the use of hormonal contraceptives, smoking and the practice of vaginal douches. As mentioned above, the substrate for production of lactic acid is glycogen, produced by vaginal epithelial cells that function under the influence of the hormonal status of the individual, especially in terms of estrogen. This may explain, in part, the protective effects exerted by hormonal contraceptives against the appearance of dysbiosis, which has been reported in a recent systematic review with meta-analyses.[17]

Another publication, also applying meta-analysis,[18] described an association between the practice of vaginal douches and changes in the vaginal balance. Our study also found an association between vaginal douches and pH, and it is known that in the case of dysbiosis, these values are generally above 4.5. These associations do not make it possible to identify causes, but a hypothesis to be considered is that vaginal douches actually contribute to an imbalance in vaginal flora.

The relationship between smoking and imbalance of the vaginal flora has also been shown in other studies,[19],[20] and the basis for this association appears to be the reduction of the Lactobacillus vaginal flora. Unlike results reported by other author,[7],[21] hormonal differences among the women of the present study occurred between the first and second phase of the menstrual cycle. These changes may explain the vaginal microbiota. It has been shown that high estrogen levels contribute to the higher stability of the vaginal ecosystem.[22]

Among the women studied, there was no significant association between vaginal pH values and the phase of the menstrual cycle. The imbalance of the vaginal environment can also occur, however, as a result of sexual intercourse,[23],[24] and it is possible that various sexual practices may have different local influences. However, none of the practices here examined were associated with the pH values.

Regular use of condoms has been recommended as protection against the development of an imbalance of vaginal flora.[25] Still, for those of our sample, condom use was not associated with vaginal pH although the analysis may have been limited by the fact that <1/5 of the women used condoms regularly.

In summary, imbalance of the vaginal microbiota is a complex situation, subject to the interference of many variables, biological, social, and cultural. This imbalance can be evaluated indirectly by measuring the pH and testing for amines, thus making it possible to administer procedures that can improve the quality of primary health care.


  Conclusions Top


Analysis of the information given by the women of the present study, in comparison with research reported in the literature, resulted in the following conclusions: the number of women having at least one complaint was high, with nearly 80% of participants; the practice of vaginal douches was quite widespread, even though not recommended; higher pH values and positive results from the test of amines were associated with reports of discharge and complaints of unpleasant odor; the proportion of nonwhite women who tested positive for amines was significantly greater than the proportion of white women.

Financial support and sponsorship

Logistical support from the Federal District Health Department and Laboratory of Parasitology and Biology of Vectors of Faculty of Medicine, University of Brasília.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Frobenius W, Bogdan C. Diagnostic value of vaginal discharge, wet mount and vaginal pH – An update on the basics of gynecologic infectiology. Geburtshilfe Frauenheilkd 2015;75:355-66.  Back to cited text no. 1
    
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Donati L, Di Vico A, Nucci M, Quagliozzi L, Spagnuolo T, Labianca A, et al. Vaginal microbial flora and outcome of pregnancy. Arch Gynecol Obstet 2010;281:589-600.  Back to cited text no. 2
    
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Turovskiy Y, Sutyak Noll K, Chikindas ML. The aetiology of bacterial vaginosis. J Appl Microbiol 2011;110:1105-28.  Back to cited text no. 3
    
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Mirmonsef P, Hotton AL, Gilbert D, Burgad D, Landay A, Weber KM, et al. Free glycogen in vaginal fluids is associated with Lactobacillus colonization and low vaginal pH. PLoS One 2014;9:e102467.  Back to cited text no. 4
    
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Ravel J, Gajer P, Abdo Z, Schneider GM, Koenig SS, McCulle SL, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A 2011;108 Suppl 1:4680-7.  Back to cited text no. 5
    
6.
Verstraelen H, Verhelst R, Claeys G, De Backer E, Temmerman M, Vaneechoutte M. Longitudinal analysis of the vaginal microflora in pregnancy suggests that L. crispatus promotes the stability of the normal vaginal microflora and that L. gasseri and/or L. iners are more conducive to the occurrence of abnormal vaginal microflora. BMC Microbiol 2009;9:116.  Back to cited text no. 6
    
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Gajer P, Brotman RM, Bai G, Sakamoto J, Schütte UM, Zhong X, et al. Temporal dynamics of the human vaginal microbiota. Sci Transl Med 2012;4:132ra52.  Back to cited text no. 7
    
8.
Macklaim JM, Fernandes AD, Di Bella JM, Hammond JA, Reid G, Gloor GB. Comparative meta-RNA-seq of the vaginal microbiota and differential expression by Lactobacillus iners in health and dysbiosis. Microbiome 2013;1:12.  Back to cited text no. 8
    
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Yeoman CJ, Thomas SM, Miller ME, Ulanov AV, Torralba M, Lucas S, et al. A multi-omic systems-based approach reveals metabolic markers of bacterial vaginosis and insight into the disease. PLoS One 2013;8:e56111.  Back to cited text no. 9
    
10.
Srinivasan S, Morgan MT, Fiedler TL, Djukovic D, Hoffman NG, Raftery D, et al. Metabolic signatures of bacterial vaginosis. MBio 2015;6. pii: E00204-15.  Back to cited text no. 10
    
11.
Brotman RM, Klebanoff MA, Nansel TR, Yu KF, Andrews WW, Zhang J, et al. Bacterial vaginosis assessed by gram stain and diminished colonization resistance to incident gonococcal, chlamydial, and trichomonal genital infection. J Infect Dis 2010;202:1907-15.  Back to cited text no. 11
    
12.
Aldunate M, Srbinovski D, Hearps AC, Latham CF, Ramsland PA, Gugasyan R, et al. Antimicrobial and immune modulatory effects of lactic acid and short chain fatty acids produced by vaginal microbiota associated with eubiosis and bacterial vaginosis. Front Physiol 2015;6:164.  Back to cited text no. 12
    
13.
Nomelini RS, Carrijo AP, Adad SJ, Nunes AA, Murta EF. Relationship between infectious agents for vulvovaginitis and skin color. Sao Paulo Med J 2010;128:348-53.  Back to cited text no. 13
    
14.
Giraldo PC, Babula O, Gonçalves AK, Linhares IM, Amaral RL, Ledger WJ, et al. Mannose-binding lectin gene polymorphism, vulvovaginal candidiasis, and bacterial vaginosis. Obstet Gynecol 2007;109:1123-8.  Back to cited text no. 14
    
15.
Cherpes TL, Hillier SL, Meyn LA, Busch JL, Krohn MA. A delicate balance: Risk factors for acquisition of bacterial vaginosis include sexual activity, absence of hydrogen peroxide-producing lactobacilli, black race, and positive herpes simplex virus type 2 serology. Sex Transm Dis 2008;35:78-83.  Back to cited text no. 15
    
16.
Paul K, Boutain D, Manhart L, Hitti J. Racial disparity in bacterial vaginosis: The role of socioeconomic status, psychosocial stress, and neighborhood characteristics, and possible implications for preterm birth. Soc Sci Med 2008;67:824-33.  Back to cited text no. 16
    
17.
Vodstrcil LA, Hocking JS, Law M, Walker S, Tabrizi SN, Fairley CK, et al. Hormonal contraception is associated with a reduced risk of bacterial vaginosis: A systematic review and meta-analysis. PLoS One 2013;8:e73055.  Back to cited text no. 17
    
18.
Amaral RL, Gonçalves AK, Rodrigues HM, Lima PH, Prudêncio TL, Santiago N, et al. Relationship between vaginal douching and bacterial vaginosis, sexually transmitted diseases and HIV infection: A systematic review. J Bras Doenças Sex Transm 2013;25:183-9.  Back to cited text no. 18
    
19.
Bradshaw CS, Walker SM, Vodstrcil LA, Bilardi JE, Law M, Hocking JS, et al. The influence of behaviors and relationships on the vaginal microbiota of women and their female partners: The WOW health study. J Infect Dis 2014;209:1562-72.  Back to cited text no. 19
    
20.
Brotman RM, He X, Gajer P, Fadrosh D, Sharma E, Mongodin EF, et al. Association between cigarette smoking and the vaginal microbiota: A pilot study. BMC Infect Dis 2014;14:471.  Back to cited text no. 20
    
21.
Srinivasan S, Liu C, Mitchell CM, Fiedler TL, Thomas KK, Agnew KJ, et al. Temporal variability of human vaginal bacteria and relationship with bacterial vaginosis. PLoS One 2010;5:e10197.  Back to cited text no. 21
    
22.
Romero R, Hassan SS, Gajer P, Tarca AL, Fadrosh DW, Nikita L, et al. The composition and stability of the vaginal microbiota of normal pregnant women is different from that of non-pregnant women. Microbiome 2014;2:4.  Back to cited text no. 22
    
23.
Jespers V, Menten J, Smet H, Poradosú S, Abdellati S, Verhelst R, et al. Quantification of bacterial species of the vaginal microbiome in different groups of women, using nucleic acid amplification tests. BMC Microbiol 2012;12:83.  Back to cited text no. 23
    
24.
Santiago GL, Tency I, Verstraelen H, Verhelst R, Trog M, Temmerman M, et al. Longitudinal qPCR study of the dynamics of L. crispatus, L. iners, A. vaginae, (sialidase positive) G. vaginalis, and P. bivia in the vagina. PLoS One 2012;7:e45281.  Back to cited text no. 24
    
25.
Ma L, Lv Z, Su J, Wang J, Yan D, Wei J, et al. Consistent condom use increases the colonization of Lactobacillus crispatus in the vagina. PLoS One 2013;8:e70716.  Back to cited text no. 25
    


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    Tables

  [Table 1], [Table 2]



 

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