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    Dr. Hohner - Script for Metronidazole & Related Questions
    sabine48 posted:
    Hello again!

    I am back with more questions, hope you can help! At my last gyn visit, my gyn did a genital culture with the following results back in June because of problems I'd been having with discharge worsening and itching causing me to make the appointment to see what was going on. The test results came back below:


    I was told my culture showed an over growth of the good bacteria in the vagina that is caused by a pH imbalance and to make sure I maintain a low carb diet, and was prescribed the Metronidazole as well as being advised to start a daily dose of Acidophilus.

    I initially tried Acidophilus alone which did not seem to take care of the problem so I stopped. The problem seems exacerbated apprx. a week, week and a half before the end of my active (white) BCP's (Ogestrel) and the start of my period, the discharge is heavier and I have itching!

    I will be 50 very soon and wonder if this could be hormonal related or due to a switch in BCP's a little more than a year ago, from the Lo/Ovral to the Ogestrel 0.5/50?

    I had problems with excess bleeding between periods (then having used Lo/Ovral for years without incident) which caused me to be anemic prior to being prescribed the higher dose BCP (Ogestrel) to stop the excess bleeding which has worked.

    I am wondering, should I use this RX (Metronidazole) at any time of taking my white pills or during the later two weeks the problem is worse? It does not really specify when to use it in the directions only how much to use and how often. It's a five day dose of vagnial cream.

    I was advised to take the Acidophilous on a daily basis regardless of symptoms. My gyn said, "I do see this more in patients that are eating a carb heavy diet." Also, she says, make sure I am not using Always brand pads when on my cycle, that is the only brand I like & use! I didn't get to ask, what she thinks is wrong with Always pads? Do you know of a better brand? I mentioned in the past on the boards that I use panti liners and most often Always pads because of slight discharge, this brand seemed to draw the moisture (or discharge) away from my vaginal area into the pad better than others. Since the discharge is worse during the above mentioned times, I would like very much to know what brand is advisable?

    Thank you for your time!
    Jane Harrison Hohner, RN, RNP responded:
    Dear Sabine: Let's take overgrowth of lactobacilli first. Your GYN is correct, an overgrowth of the beneficial, hydrogen peroxide producing bacteria can create a discharge accompanied by burning/irritation/itching. Vaginal pH is acidic (which is usually good), but it may have a pH even more acid than normal. Another name for this condition is cytolytic vaginitis. Here's a citation on this from the National Library of Medicine site:

    Am J Obstet Gynecol. 1991 Oct;165(4 Pt 2):1245-9.

    Cytolytic vaginosis.

    Cibley LJ, Cibley LJ.

    Department of Obstetrics and Gynecology, Boston University School of Medicine, MA.

    Cytolytic vaginosis, a not uncommon condition, is frequently misdiagnosed because it is confused with Candida. Many practitioners rely on their clinical judgment alone rather than the use of high-quality microscopes and the results of a wet smear. Compounding the problem of misdiagnosis is that patients assume that their symptoms are caused by a yeast infection, which results in telephone requests for medication from their physicians instead of an office consultation. Cytolytic vaginosis is characterized by pruritus, dyspareunia, vulvar dysuria, and cyclical increase in symptoms more pronounced during the luteal phase {PREMENSTRUAL PHASE-JHH>. Diagnostic criteria include a high risk of suspicion; the absence of Trichomonas, Gardnerella, or Candida on wet smear; an increased number of lactobacilli; a paucity of white blood cells; evidence of cytolysis; and the presence of discharge; and a pH between 3.5 and 4.5. Treatment entails use of sodium bicarbonate douches.

    I have not heard of your GYN's clinical observation that this is linked to high carb intake. The beneficial bacteria prefer an acidic environment. After menopause (no estrogen) the vaginal pH becomes alkaline. I do not know if going to a higher dose estrogen pill would increase the beneficial bacteria--it does not seem likely.

    In my clinical experience the balance of the vaginal ecology usually returns in time. I have prescribed baking soda douches or baking soda in a bath tub for symptom relief. I have not personally used the vaginal metronidazole gel to treat this. Metrogel will definitely change the balance of vaginal bacteria. In terms of when to use your Metrogel it can be done at any time, the change may be more dramatic if used when the symptoms are worst.

    Only a few published studies have addressed the problems of "sanitary napkin contact dermatitis". A case series of 28 women were reported to have developed marked irritation of their vulva after using a specific type of pad (Always?). The irritation abated when this brand of pad was not used, and appeared again among the few women who decided to resume use of Always pads (Eason, 1996). A Japanese physician demonstrated dermatitis in some pad users that was curable by switching to tampons (Wakashin, 2007). It was postulated that a combination of wet conditions, and friction, could expose thin skin to normally occurring bacteria.

    Bottom line, there is no clear data suggesting that one sanitary pad is a better choice. It would be a matter of what works best for the individual woman.

    sabine48 replied to Jane Harrison Hohner, RN, RNP's response:
    Hi Jane,

    Thank you so much for your in depth information. I have found it very helpful in better understanding my diagnosis.

    How might I find out more about the backing soda douche (is this found OTC)? Do you think it is advisable to go ahead with the Metrogel? It wasn't a must as she did mention trying the Acidophilus first but it hasn't taken care of the problem on its own.

    Is it advisable to continue on the Acidophilus? If so, indefinitely or how long might be advisable for someone like myself? My gyn. mentioned it would not hurt to take the Acidophilus indefinitely but I'm not a pill taker and the only pill I ever really take is my BCP daily or an ibuprophen if necessary at certain times of the month when I have migranes.

    Would like to hear your thoughts on these whe you have time.

    Thank you very much!
    sabine48 replied to sabine48's response:
    Sorry, should have checked my spelling, baking soda!
    Jane Harrison Hohner, RN, RNP replied to sabine48's response:
    Dear Sabine: Acidophilus is reputed to be excellent for bowel flora, and has no reported ill effects. You should ask your GYN how long they would expect you to take it.

    You should also ask about the use of baking soda douches ( 1 tea per quart warm water) 3x per week for a couple of weeks. Douching is not routinely recommended so I would check with your GYN for any contraindications. Baking soda in bath water can be tried for external irritation.

    If symptoms persist, and are bothersome, the Metrogel should be used. Historically an other antibiotic vaginal cream (clindamycin) has been used for the same purpose. Metrogel may be the better choice.

    sabine48 replied to Jane Harrison Hohner, RN, RNP's response:
    Thank you Jane,

    When you shared in your clinical experience that 'the balance of the vaginal ecology usually returns in time', can I take that to mean symptoms often go away on their own? I guess my next question is, how long can one expect the symptoms to last? I'm guessing it varies with each individual, is that correct? Do you know of a time frame one might experience this at the longest?

    I was also wondering if I used the metrogel if I could expect more of the same thing again a short time down the road? I really would hope that would not be the case but the question does come up for me.

    Perhaps I need to inquire about the baking soda douches or using baking soda in the tub for symptom relief instead. I know it's up to me to decide whether or not I use the metrogel yet if it just comes back it seems to defeat the purpose.

    You mentioned not having personally used the vaginal metronidazole for treating this condition (I think that is how you meant it), can you tell me if you think the problem can/does resolve itself without? I guess I'm trying to think of a way to talk myself out of it if it doesn't guarantee to rid of the problem or if you yourself feel it is not advisable for this particular problem.

    I'm not sure what you can answer by way of my questions but anything additional you are able to shed light on would be most appreciated as your help has been in the past.

    Thank you,
    sabine48 replied to sabine48's response:
    Can you also please answer the following for me?!

    Is it possible that I can spread this to my partner? If so, what should we do to avoid the possibility?

    Thank you!
    Jane Harrison Hohner, RN, RNP replied to sabine48's response:
    Dear Sabine: There is no risk to your partner. This is just a transient overgrowth of the "good" vaginal bacteria. As in "too much of a good thing"!

    Things that are a normal variant of vaginal ecology (eg overgrowth of yeast, BV bacteria, or beneficial lactobacilli) can resolve over time. Some women seem to be more vulnerable to getting certain types of over-growths (ie recurrent yeast infections, relapsing of BV despite antibiotics, etc.).

    I wish I could tell you specifically about how long it would take to change back, but your are correct, it varies considerably. The overall rule for such things is treat if the symptoms are bothersome to the woman or if there is some risk (eg BV has been linked to preterm labor and post-op GYN surgical infections).


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