Endometriosis and inflammatory pathologies
In gynecological practice, endometriosis is viewed as a process of ectopic proliferation of endometrioid tissue. However, inflammatory diseases of the pelvic organs (IDFPOs) rank first in frequency. Their increase is driven by decreased immunity, environmental factors, and changes in sexual behavior.
Anatomically, IDFPOs are divided into pathologies of the lower (vulvitis, colpitis, cervicitis) and upper (endomyometritis, salpingo-oophoritis) divisions. The boundary between them is the internal os of the uterus (ostium uteri internum). Infection can spread passively (ascending, hematogenous, lymphogenous pathways) or actively (on the surface of spermatozoa and trichomonads). Absolute pathogens include gonococci, chlamydia, trichomonads, and Mycoplasma genitalium.
Natural barriers and microecology
Reproductive system health depends on multi-level defense. Mechanical and biological barriers include the closed vulvar cleft, cervical slime (containing lysozyme, immunoglobulins, and macrophages), regular shedding of the functional endometrial layer, and the plastic properties of the pelvic peritoneum.
The primary role in vaginal defense is played by lactobacilli (Döderlein bacilli). They break down glycogen from surface epitheliocytes into lactic acid, creating an acidic environment that is lethal to pathogens. A decrease in estrogen levels (in postmenopause) or iatrogenic factors (unjustified antibiotic use, frequent douching) lead to the death of lactobacilli. This paves the way for the proliferation of opportunistic flora: anaerobes, E. coli, klebsiella, and fungi of the genus Candida.
Lower tract infections: vulvitis and bartholinitis
Vulvitis is inflammation of the external genitalia. In women of reproductive age, it is more commonly secondary (arising against the background of colpitis or cervicitis). Primary vulvitis is typical for endocrine disorders (diabetes mellitus) or trauma. It manifests with itching, edema, hyperemia, and purulent discharge. Treatment includes local antiseptic care, complex antimicrobial drugs intravaginally, and reparative ointments (with retinol, sea buckthorn oil) after the acute process subsides.
Bartholinitis is inflammation of the greater vestibular gland. Blockade of the excretory duct leads to the formation of an abscess with sharp pulsating pain, labial edema, and fever up to 39 °C. At the abscess stage, surgical opening with marsupialization (formation of an artificial duct for secretion outflow) is indicated.
Vaginal infections and dysbiosis
Bacterial vaginosis is a non-inflammatory syndrome (dysbiosis) in which lactobacilli are displaced by obligate anaerobes (Gardnerella vaginalis, Bacteroides spp., Mobiluncus spp.). A characteristic sign is abundant grayish discharge with a "fishy" odor (the result of volatile amine production). Diagnosis is established using Amsel criteria. Treatment is strictly two-stage: eradication of anaerobes (metronidazole, clindamycin) and subsequent colonization of the flora with eubiotics.
Nonspecific vaginitis (colpitis) is true inflammation of the vaginal mucosa. It is accompanied by pain during intercourse (dyspareunia), itching, purulent plaques, and contact bleeding. Upon transitioning to a chronic form, infiltrates of the papillary layer (granular colpitis) may form. Therapy requires the use of local antiseptics (for no more than 3–4 days to avoid disrupting the biocenosis) and systemic drugs. For senile colpitis, local estrogens are additionally prescribed.
Amsel criteria for diagnosing bacterial vaginosis are easily remembered in 4 points: 1) Specific discharge, 2) "Key" cells in the smear, 3) pH shift > 4.5, 4) Positive amine test (fishy odor). The diagnosis is made if 3 out of 4 signs are present.
Class and exam questions
What serves as the anatomical boundary between the upper and lower sections of the genital tract?
The anatomical boundary is the internal os of the uterus (ostium uteri internum).
Why does a specific odor appear in bacterial vaginosis?
The "fishy" odor is caused by volatile amines. They are produced by obligate anaerobes that actively multiply when the number of lactobacilli decreases.
Is it necessary to treat the sexual partner when a woman has bacterial vaginosis?
No, routine treatment of male partners to prevent recurrences in women is impractical. Examination is required only if the man has symptoms of urethritis.
What is the fundamental difference between vaginosis and vaginitis?
Vaginosis is a dysbiosis without a pronounced inflammatory reaction (few leukocytes in the smear). Vaginitis (colpitis) is true inflammation of the mucosa with edema, hyperemia, and a large number of leukocytes.
What else to study on this topic
- Pathophysiological features of endometrioid foci
- Nugent score for assessing a vaginal smear
- Mechanisms of immune defense in cervical mucus
- Specific IDFPOs: gonorrhea, chlamydia, tuberculosis
- Effect of hormonal contraceptives on microflora and barriers
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