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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 4  |  Page : 1397-1400

Prevalence of aerobic bacterial vaginosis among chronic copper T380 intrauterine device users


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Amiriyah General Hospital, Alexandria, Egypt

Date of Submission30-Nov-2018
Date of Decision25-Dec-2018
Date of Acceptance30-Dec-2018
Date of Web Publication31-Dec-2019

Correspondence Address:
Ahmed A K Nasef
Al Hanovil, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_368_18

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  Abstract 

Objective
To determine the prevalence of bacterial vaginosis (BV) among chronic copper T380 intrauterine device (IUD) users.
Background
There are two gold standards used to diagnose BV: Amsel clinical criteria and laboratory-based Nugent gram-staining evaluation. IUD may affect the normal vaginal microbiota system causing BV.
Materials and methods
The present study was conducted at Al Amiriyah General Hospital, Family Planning Clinic, Gynecology Department, after informed consent was taken from them. It was approved by the research ethics committee at Faculty of Medicine, Menoufia University. One hundred female patients came for routine checkup on their intrauterine contraceptive device and fulfilled the inclusion criteria. Samples of the vaginal discharge were obtained with two dry cotton-wool-tipped swabs from the lower third of the vaginal wall. For the first swab, wet mount preparation for examination of clue cells, measurement of vaginal pH, and Whiff test were performed to fulfill Amsel criteria. The second swab was gram stained by a microbiologist and assessed using Nugent's criteria. The outcome measures positive culture of aerobic BV and positive Amsel criteria.
Results
It was found that age group above 30 years old had the highest prevalence of BV and there was no statistically significant relation between use of douche and Amsel criteria.
Conclusion
There was a statistically significant association between diagnosis of BV and age group above 30 years using copper IUD for more than 1 year.

Keywords: bacterial, copper T380, device, intrauterine, vaginosis


How to cite this article:
El AttiSaleh SA, SaifAlnasr IA, Nasef AA. Prevalence of aerobic bacterial vaginosis among chronic copper T380 intrauterine device users. Menoufia Med J 2019;32:1397-400

How to cite this URL:
El AttiSaleh SA, SaifAlnasr IA, Nasef AA. Prevalence of aerobic bacterial vaginosis among chronic copper T380 intrauterine device users. Menoufia Med J [serial online] 2019 [cited 2020 Jan 17];32:1397-400. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1397/274265




  Introduction Top


The normal vaginal microbiological system is a unique and dynamic system and continually fluctuates under the environmental changes and physiological conditions. The vagina of a healthy fertile woman harbors an extensive number of bacteria, of which lactobacilli predominate [1].

Lactobacilli undergo physicochemical interaction with the vaginal epithelium, which helps in the colonization of the lactobacilli and biofilm formation within the mucosal and the epithelial layer of the vagina. The biofilm consists of the bacterial cell layer(s) and the secretory components from the vagina [2].

The prevalence of bacterial vaginosis (BV) varies according to age, race or ethnicity, education, and poverty [3]. BV occurs in as many as 25% of women attending gynecologic outpatient clinics, in 10–40% of pregnant women, and in 24–37% of women attending sexually transmitted disease clinics [4].

There are two gold standards used to diagnose BV. The first diagnostic method is Amsel clinical criteria and the second one is the laboratory-based Nugent gram-staining evaluation [5].

An intrauterine device (IUD) is a small contraceptive device which is T shaped and may contain copper or levonorgestrel which is inserted into the uterus. They are long-acting, reversible contraceptive methods with a high efficacy of birth control. Failure rate of hormonal IUDs is approximately 0.2%, whereas with copper IUDs is approximately 0.8% in first year of its use [6].

The aim of this study is to determine the prevalence of BV among copper T380 IUD users.


  Materials and Methods Top


The study was conducted in Family Planning Clinic in Gynecology Department at Al Amiriyah General Hospital in Alexandria on 100 female patients who came for routine checkup on their IUD and fulfilled the inclusion criteria. The inclusion criteria were as follows: had been using IUD for at least 1 year, were sexually active, were not pregnant, and presented with abnormal vaginal discharge or odor.

Sample size calculation

Sample size was calculated based on a previous study by Ihsan and Jabuk [7], which studied the prevalence of aerobic BV among intrauterine contraceptive device users women in Hilla city, 2014, by using MedCalc Software, (Amazon, Acacialaan 22 8400 Ostend, Belgium), assuming area under receiver operating characteristic to be 0.80, an alpha of 0.05 and power of study 90.0%. A minimum sample size required to detect prevalence of aerobic BV among chronic copper T380 IUD users was 100 participants for this study.

Samples of the vaginal discharge were obtained with two dry cotton-wool-tipped swabs from the lower third of the vaginal wall.

Wet mount preparation for examination of clue cells, measurement of vaginal pH, and application of amine test (Whiff test) were performed on the first swab to fulfill Amsel criteria.

The first swab was spread on a clear glass slide for wet mount preparation; the slide was examined by a microbiologist for detection of clue cells.

  1. Vaginal pH was measured directly in the discharge on the removed speculum by dipping a pH indicator strip with a scale graded from 1 to 14, including distinct color key for each value
  2. Amine test (Whiff test) was performed after removal of the speculum by adding two drops of 10% potassium hydroxide to the posterior lip of the speculum. The release of fishy odor means positive amine test result.


The second swab was spread on a clear glass slide for gram staining; the slides were left to dry in air and then transferred to the microbiologist. Slides were fixed by heating and stained by gram stain. This was assessed using Nugent's criteria. The slides were gram stained, which require the application of four reagents in the following order: violet dye, iodine solution, decolorizing agent, and the counter stain.

Gram-stained slide was assessed by a microbiologist using the Nugent scoring system as follows.

Morphotype were counted as the average number of bacteria under oil immersion (×1000 magnification).

  • 0, no morphotype present
  • 1+, less than 1 morphotype present
  • 2+, 1–4 morphotype present
  • 3+, 5–30 morphotype present
  • 4+, more than 30 morphotype present.


The amount of each morphotype detected on the smear was graded and then allocated a score. Scores of three columns were added and interpreted as follows:

  • A slide with a total score of 7 was interpreted as 'BV'
  • A slide with a total score of 4–6 was interpreted as 'intermediate flora'
  • A slide with a total score of 0–3 was interpreted as 'normal flora' (non-BV).


Statistical analysis

The data were collected and entered into the personal computer. Statistical analysis was done using statistical package for social sciences (version 20) software (SPSS Inc., Chicago, Illinois, USA; IBM SPSS for Windows, IBM Corp., Armonk, New York, USA). Mean and SD for categorized numerical data percent used to show the results, and X 2 test for comparison between qualitative data. P value lower than 0.05 is considered statistically significant.

The outcome measures were positive culture of aerobic BV and positive Amsel criteria.


  Results Top


In the current study, the age of the patients ranged from 17 to 43 years, with mean value of 28.86 ± 6.092. Duration of marriage ranged from 2 to 22 years, with mean value of 6.89 ± 4.426. Employed cases were 43 (43%). Duration of the use of IUD ranged from 0 to 10 years, with mean value 4.74 ± 3.404 and parity 3.00 + was higher with 36 (36%) cases [Table 1].
Table 1: Characteristic features of the studied group

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In the current study, the relation between age group and Amsel criteria was as follows: negative Amsel criteria was seen in 22 (28.2%) cases and positive was seen in two (9.1%) cases in the age group below 25 years. At age group 25–30 years, there were 32 (41%) negative Amsel criteria cases and six (27.3%) positive Amsel criteria cases. At age group above 30 years, there were 24 (30.8%) negative Amsel criteria cases and 14 (63.6%) positive Amsel criteria cases [Table 2].
Table 2: Age group in relation to Amsel criteria

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The relationship between the duration of use of IUD and positive Amsel criteria was as follows: negative Amsel criteria was seen in 36 (46.2%) and positive in 10 (45.5%) at 1 year. At 2 years, there were 24 (30.8%) negative Amsel criteria cases and seven (31.8%) positive Amsel criteria cases. At more than 3 years, there were 18 (23.1%) negative Amsel criteria cases and five (22.7%) positive Amsel criteria cases [Table 3].
Table 3: Duration of use of intrauterine device in relation to Amsel criteria

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Relation between Amsel criteria and different symptoms

The relation between vaginal discharge and Amsel criteria was as follows: negative Amsel criteria were seen in 62 (79.5%) and positive in 0 (0.0%) in the absence of vaginal discharge. In the presence of vaginal discharge, there were 16 (20.5%) negative Amsel criteria cases and 22 (100%) positive Amsel criteria cases. Amsel criteria in relation to presence of purities were as follows: negative Amsel criteria were seen in 54 (69.2%) cases and positive in nine (40.9%) cases in the absence of pruritis. In the presence of pruritis, there were 24 (30.8%) negative Amsel criteria cases and 13 (59.1%) positive Amsel criteria cases. The relation between Amsel criteria and presence of pelvic pain was as follows: negative Amsel criteria were seen in 67 (85.9%) cases and positive in 20 (90.9%) cases in the absence of pelvic pain. In the presence of pelvic pain, there were 11 (14.1%) negative Amsel criteria cases and two (9.1%) positive Amsel criteria cases. The relation between presence of vaginal dyspareunia and Amsel criteria was as follows: negative Amsel criteria were seen in 64 (82.1%) cases and positive in 18 (81.8%) cases in the absence of vaginal dyspareunia. In the presence of vaginal dyspareunia, 14 (17.9%) were negative Amsel criteria cases and four (18.2%) positive Amsel criteria cases [Table 4].
Table 4: Relation between Amsel criteria and different symptoms

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  Discussion Top


There was a statistically significant relation between age and Amsel criteria (P < 0.05), and it was found that age group above 30 years old had the highest prevalence of BV. and there was a statistically significant association between diagnosis of BV and this age group. These results are in accordance with Ihsan and Jabuk [7], where the age group 20–40 years had the highest prevalence of BV followed by the age group above 40 years.

In this study, there was no statistically significant relation between duration of use of IUD and Amsel criteria (P > 0.05), but the percent of positive Amsel criteria decreased with increasing duration of use. This was in accordance with the study done by Ihsan and Jabuk which showed the relationship between the duration of use IUD and positive culture. During the first year, more than 21 (42%) users had positive culture. The negative culture (no growth results) reached up to two (4%) among the IUD users, most of them were during the first year of use. The percent of pathogenic swabs decrease with increasing duration of use. These findings are supported by the study done by Sayeste et al. [8], which showed high percentage of potentially pathogenic bacteria among IUD users during the first year after insertion with significant decrease of this type of bacteria after 36 month of IUD use.

In the current study, the relation between different symptoms and Amsel criteria was as follows: regarding vaginal discharge, there was a highly significant relation between vaginal discharge and Amsel criteria; all negative vaginal discharge cases showed negative Amsel criteria (P < 0.05). This may be explained by that the increase in pH rapidly releases amines, for example, trimethylamine, which are dissolved in the discharge as an acid when the pH is low. According to the study done by Ihsan and Jabuk, there were only nine (18%) women in the study had no symptoms and this results is similar to results of the current study. The most frequently reported symptom was the presence of abnormal vaginal discharge (a total of 50 women). Regarding pruritis, there was a statistically significant relation between pruritis and Amsel criteria (P < 0.05), as negative Amsel criteria were seen in 54 (69.2%) and positive in nine (40.9%) at negative pruritis. At positive pruritis, there were 24 (30.8%) negative Amsel criteria cases and 13 (59.1%) positive Amsel criteria cases. This could be attributed to presence of mixed infection, as presence of pruritis is pathognomonic to candidal infection. Regarding pelvic pain and dyspareunia, there was no statistically significant relation between pelvic pain or vaginal dyspareunia and Amsel criteria (P > 0.05).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Witkin S, Linhares I, Giraldo P. Bacterial flora of the female genital tract: function and immune regulation. Best Pract Res Clin Obstet Gynaecol 2007; 21:347–354.  Back to cited text no. 1
    
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Allsworth J, Peipert J. Prevalence of bacterial vaginosis: 2001-2004 National Health and Nutrition Examination Survey data. Obstet Gynecol 2007; 109:114–120.  Back to cited text no. 3
    
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Nelson D, Bellamy S, Nachamkin I, Ruffin A, Allen-Taylor L, Friedenberg F. Characteristics and pregnancy outcomes of pregnant women asymptomatic for bacterial vaginosis. Matern Child Health J 2008; 12:216–222.  Back to cited text no. 4
    
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Eriksson K, Forsum U, Bjørnerem A, Platz-Christensen J, Larsson P. Validation of the use of Pap-stained vaginal smears for diagnosis of bacterial vaginosis. APMIS 2007; 115:809–813.  Back to cited text no. 5
    
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Hurt K, Joseph E. The Johns Hopkins manual of gynaecology and obstetrics. 4th ed. Baltimore, MD: Department of Gyneacology and Obstetrics, The Johns Hopkins University School of Medicine; 2012. 232.  Back to cited text no. 6
    
7.
Ihsan S, Jabuk A. Prevalence of aerobic bacterial vaginosis among intrauterine contraceptive device users women in Hilla city. J Babylon Uni/Pure Appl Sci 2014; 9:1–9.  Back to cited text no. 7
    
8.
Sayeste D, Ayşegül K, Sinan M. The association between copper containing IUCD and bacterial vaginosis. Cent Eur J Publ Health 2006; 14:138–140.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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