Solve the Medical Riddle: She Has Embarrassing Symptoms “Down There” After Making Love, Fourth Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.

The first week of this riddle, the patient reported her symptoms to her gynecologist. The doctor gave her a complete examination using the components of the classic S-O-A-P notes, which are as follows:

S=Symptoms or Chief Complaint

O=Objective Findings

A=Assessment or Analysis

P=Treatment Plan or Recommendation

The second week, the doctor reported on the results of Sybil’s tests. Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will reveal the actual diagnosis. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Crystal S. nailed it! Sybil did indeed have bacterial vaginosis. The “fishy” smell is a dead giveaway. I would have done a simple acid test of vaginal discharge when I suspected that, but it doesn’t help in older women since their vaginal discharge usually alkaline anyway.

Bacterial vaginosis (BV) is the cause of over 50 percent of all cases of vaginitis. The condition was originally called “nonspecific vaginitis.” In 1984, a team of researchers coined the current term. Bacterial vaginosis has prevalence of 10% in younger women and about 6% in postmenopausal women, often without symptoms at all. Then you suddenly have sex. The semen is alkaline, so the healthy lactobacillus levels that produce acid decline too much. Consequently, colon or BV bacteria take over. Also, lack of estrogen with menopause means less glycogen (sugar) produced by the vaginal cells. Glycogen is important fuel for healthy lactobacillus, so that’s another risk factor for BV. Some women use lactic acid gel to aid in treatment in order to reduce acidity and restore healthy low pH. Others might take a vaginal antibiotic tablet before and after their period if they’re still menstruating.

What’s interesting is that a vasectomy is no protection against BV because the semen is still alkaline, which raises pH and further crowds out or kills off acid-producing lactobacilli.

Also of note, postmenopausal women have markedly declining estrogen levels that not only lower glycogen production but also mean that the lining cells thin out. Often, the result is cracks in the vagina wall that allow colon and other bacteria to break through and lead to infection.

BV may go away on its own, but any woman with symptoms should schedule a doctor visit. Untreated BV can cause pelvic inflammatory disease or chronic pelvic pain. Also, BV may increase the risk of infections after hysterectomies.

Warning: Do not douche! Douching can actually cause BV and also make it worse by upsetting the balance of healthy and harmful bacteria. Some doctors do recommend vaginal douches with the lactobacillus bacteria, the kind found in live cultures of yogurt, to restore normal pH balance. However, studies have shown that this practice is no better than a placebo.

Medications for Bacterial Vaginosis

• Flagyl/Metrogel vaginal suppository
• metronidazole gel, 0.75 percent, one full applicator (5g) intravaginally, once a day for 5 days
• clindamycin cream, 2 percent, one full applicator (5g) intra- 
vaginally at bedtime for 7 days. (Warning: Clindamycin cream is oil-based. That means it could weaken diaphragms and latex condoms for up to five days after you stop using the medication.) 
in addition, here are the commonly prescribed antibiotics for BV. if your doctor suggests one of these, why not ask whether a topical remedy can be substituted?
• metronidazole 500 mg orally twice a day for 7 days
• Flagyl/Metrogel in pill or gel form, 500 mg twice a day for 7 days. 
(avoid drinking any alcohol during treatment and for twenty- four hours after your last dose. Combining even small amounts of alcohol with flagyl can make you very sick to your stomach, and may even cause vomiting.)
• clindamycin 300 mg orally twice a day for 7 days
• clindamycin ovules 100 mg intravaginally once at bedtime for 3 days

In Sybil’s case, the vaginal suppository did the trick. Her gynecologist was pleased since the most targeted and least systemic treatment is best because it doesn’t cause secondary problems by disturbing the natural balance of bacteria.

Needless to say, Sybil was relieved to have the condition cured. Here’s what she said: “By the time my boyfriend got back from his business trip, I was almost better. I leveled with him about what was going on, and he was very sympathetic. He went for STD and HIV testing, as my doctor had recommended. That made me very happy. He didn’t freak out at all! We waited for the test results, and my BV was totally gone when we found out he’s completely healthy. I was a little leery about having sex again, but what happened was that my body seems to have gotten used to his semen! My doctor says that’s pretty common. Anyway, Cliff and I have been together now for six months. He’s a keeper! My grandchildren really will be getting a step-grandfather. Cliff proposed last week when we were on vacation together in the Cayman Islands. So romantic! We told my kids after we got back and they cried for joy. I can’t believe I’m getting a second chance at love and marriage – and a good time in bed as well!”

Come back to ThirdAge.com next Thursday when we’ll introduce a new medical riddle!

Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Please visit DrSavard.com.