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Sunday, December 11, 2011

Herpes Vaccine? Maybe One Day...

People don't talk about it much because it has such a huge emotional impact, but herpes simplex virus (HSV) is also a huge health problem throughout the world.  As many as 1 in every 5 people has potentially been exposed to HSV, and their immune response to that exposure can be determined with a blood test.  But unfortunately, that immune response in the form of antibodies does not "cure" the virus.  The viral particles live on in the nerve roots and continue to reassert themselves in the form of blisters on the genital skin or cold sores on the lips or mouth off an on throughout that persons lifetime.  Genital herpes, generally caused by HSV type 2 (type 1 causes most fever blisters/cold sores), is clearly more stigmatized, and plenty of people who have this problem don't even realize what it is.  Thus, the cycle of spreading the virus via intimate contact goes on.

How can the cycle be broken?  Since protective barriers such as condoms fail to cover enough skin to do the job, and since many people shed viral particles from their skin even with no visible sores present, the clear choice of how to avoid the problem of HSV exposure would be a vaccination.  Vaccine development has been ongoing and is currently being evaluated as to actual effectiveness in disease prevention.  It appears that the vaccine has more potential effectiveness in women than in men, and the immunity it affords women seems to be we're not there yet.

Those who already suffer with HSV outbreaks would not benefit from a vaccine in any case.  They are left with managing their outbreaks by various measures including decreasing their stress levels and taking a daily dose of a suppressing prescription anti-viral medication.  There are several good choices on the market that have been used for years with success, but clearly, it would be better not to have to deal with this problem at all.

Saturday, December 3, 2011

Bacterial Vaginosis

Riddle me this: what is it that women get that is somewhat like a yeast infection, often confused with a bladder infection and scary for being a sexually transmitted disease?

Answer: Bacterial Vaginosis (BV)

Bacterial vaginosis is actually more commonly found on exam than yeast vaginitis, but the symptoms are distinct and the treatment is 180 degrees different for each.  Bladder infections are not even in the same ballpark, but when a woman gets symptoms in the vulvo-vaginal area, sometimes it's tough to make the call about where the problem resides.  Sometimes the only thing my patient can tell me is that something just isn't right in that area of the body!

But once a person realizes exactly which symptoms go with which problem, it's fairly straight-forward.  For yeast, the hallmark symptom beyond the presence of a discharge is irritation and/or itching.  With bacterial vaginosis, those are not nearly as much in the picture.  There is minimal inflammatory response from the vaginal lining cells (mucosa), and so one of the main symptoms is the volume of watery-gray/white drainage.  Usually, it has an odor that people describe as "fishy" because of the effects of the bacterial metabolism.  That's usually what brings them into my office.

Bacteria are normal in the vagina, but there is a certain type that is native - these are called lactobacilli - they literally are "good" bacteria and help maintain healthy vaginal acidity and prevent the overgrowth of "bad" or non-native bacteria.  Those "bad" ones are really usually from another part of the person's anatomy such as skin and anus/rectum....I know...yuck!  But still, at least they are one's own bacteria, for better or worse.  The trouble comes when there are just too many of the abnormal bacteria such that the lactobacilli can't keep cleaning up.

Some tactics to keep the vaginal pH on the acid side are to use over-the-counter vaginal acidifying products like "Rephresh" - I have no proof that this particular product works, but the concept is sound.  Also, using some type of antibacterial wet-wipe when toileting can reduce the overall bacterial load so close to the vaginal opening.  Some of these products can be irritating and overly drying to the delicate skin in that zone, so you have to be choosy about which product you would use.  Douching is a definite no-go...these "treatments" actually do more harm than good as far as promoting healthy pH and lactobacilli.

Intercourse does play a role in BV in that seminal fluid would potentially change the pH to less acidic and promote the conduction of a woman's own bacteria from a location outside the vagina to the inside.  But strictly speaking, BV is not a sexually transmitted infection like gonorrhea, trichomonas or chlamydia.  We really don't treat the male partner of a woman with even chronic or recurrent bouts of bacterial vaginosis, but we might tell the couple to try using condoms to see if that helps.

Diagnosis of BV happens in the doctor's office (not over the phone) where a simple preparation of cells from a vaginal swab can be analysed with a microscope.  This will reveal whether or not there is overgrowth of abnormal bacterial relative to a less than normal complement of lactobacilli, a mixed infection with yeast or the presence of those pesky (and very strange looking) trichomonads.  The acidity of the discharge can also be directly tested.

Treatment is in the form of cream, gel or tablet depending upon the patient's choice and any allergies to medication that might be present.  I lean toward topical vaginal gel because it tends to hit the problem right at the source without disturbing the whole intestinal tract with antibiotic insult (like diarrhea or nausea).  Also, the topical agent known as Metrogel is supposed to help preserve the "good" bacteria relative to the evil ones!

If BV is a recurrent issue month after month, I sometimes use a monthly regimen of medication timed for use around the menses since that seems to coincide with the onset of odor and discharge.  I have the person use the medication for about 5 days each month on a cyclic basis for several months in a row while they also try the other measures that I mentioned above.

BV is aggressively treated in pregnant women because it has a known association with preterm contractions/preterm labor, but in non-pregnant women (except for those undergoing a gynecological surgery such as hysterectomy), it tends to be more of a nuisance.  There is evidence that the presence of bacterial vaginosis can predispose women to sexually transmitted infections including it's best to treat rather than to simply hope for things to get better on their own.