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Perceived Life Stress and Bacterial Vaginosis

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Bacterial vaginosis (BV) is a common vaginal condition produced by overgrowth of anaerobic bacteria. Consequences of the condition may include preterm birth and pelvic inflammatory disease (PID). Because stress can suppress immune function, increased stress might increase the risk of BV. Our objective was to determine whether life stress was associated with risk of bacterial vaginosis in a cohort of nonpregnant women. A total of 411 African American women receiving routine gynecological care were recruited from two New York City hospitals. They were asked to rate the pressure they felt over the last week as a result of change, relationships, sickness, and finances using the Global Assessment of Recent Stress scale. An overall measure of stress was created by summing the responses over the categories. Stress was categorized into low, intermediate, and high tertiles. BV was diagnosed by gram stain score. In almost all domains of life stress, women with high stress were more likely to have BV than those with low stress; however, none of the differences reached statistical significance. Thirty-four percent of women with BV had high overall stress as opposed to 26% of women without BV, giving an adjusted relative risk (RR) of 1.4 (95% confidence interval, 0.95, 2.1). In a cohort of African American women in New York City, perceived life stress showed no clear association with BV. Because of the prevalence of both the exposure and the disease, further study is warranted.
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JOURNAL OF WOMEN’S HEALTH
Volume 14, Number 7, 2005
© Mary Ann Liebert, Inc.
Perceived Life Stress and Bacterial Vaginosis
EMILY W. HARVILLE, M.S.P.H.,
1
MAUREEN C. HATCH, Ph.D.,
2,3
and JUN ZHANG, M.D., Ph.D.
2,4
ABSTRACT
Background: Bacterial vaginosis (BV) is a common vaginal condition produced by overgrowth
of anaerobic bacteria. Consequences of the condition may include preterm birth and pelvic
inflammatory disease (PID). Because stress can suppress immune function, increased stress
might increase the risk of BV. Our objective was to determine whether life stress was asso-
ciated with risk of bacterial vaginosis in a cohort of nonpregnant women.
Methods: A total of 411 African American women receiving routine gynecological care were
recruited from two New York City hospitals. They were asked to rate the pressure they felt
over the last week as a result of change, relationships, sickness, and finances using the Global
Assessment of Recent Stress scale. An overall measure of stress was created by summing the
responses over the categories. Stress was categorized into low, intermediate, and high tertiles.
BV was diagnosed by gram stain score.
Results: In almost all domains of life stress, women with high stress were more likely to
have BV than those with low stress; however, none of the differences reached statistical sig-
nificance. Thirty-four percent of women with BV had high overall stress as opposed to 26%
of women without BV, giving an adjusted relative risk (RR) of 1.4 (95% confidence interval,
0.95, 2.1).
Conclusions: In a cohort of African American women in New York City, perceived life stress
showed no clear association with BV. Because of the prevalence of both the exposure and the
disease, further study is warranted.
627
INTRODUCTION
B
ACTERIAL VAGINOSIS
(BV)
IS A COMMON
condi-
tion among women of reproductive age.
1
It is
caused by an overgrowth of naturally occurring
anaerobic bacteria, particularly Mobiluncus spp.
and Gardnerella vaginalis, and a corresponding re-
duction in Lactobacillus spp., normally present in
high numbers. BV is very common, usually de-
tected in 10%–40% of women worldwide. How-
ever, a majority of women with the bacterial
profile are asymptomatic.
2,3
Prevalence of BV is
reported to be higher among women who have
multiple sexual partners, who have low incomes
1
Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina.
2
Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, New York.
3
Present address: Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of
Health, DHHS, Rockville, Maryland.
4
Present address: Epidemiology Branch, National Institute of Child Health and Human Development, National In-
stitutes of Health, DHHS, Rockville, Maryland.
This study was funded by the National Institute of Allergy and Infectious Disease, National Institutes of Health
(grant R01AI41036). E.W.H. is a Howard Hughes Predoctoral Fellow.
5791_08_p627-633 9/7/05 8:55 AM Page 627
or lower levels of education, who smoke, and
who do not use hormonal contraception.
2–4
As-
sociations with douching have been studied,
but the evidence for causality is mixed.
5
BV has
been associated with serious reproductive conse-
quences: women with BV are 1.4–3 times more
likely to deliver preterm
1,3,6
and approximately 3
times more likely to develop pelvic inflammatory
disease (PID),
7,8
although not every study has
confirmed this.
9
Psychological stress can downregulate im-
mune responses by disrupting neuroendocrino-
logical pathways, and many immune cells re-
spond to signals from stress hormones.
10,11
Stress
has also been associated with decreased defenses
in the mucosal lining of the gastrointestinal
tract.
10
Alterations in the vaginal mucosal im-
mune system have been linked to BV in some
studies.
12
We hypothesize that higher levels of
stress may be associated with a greater preva-
lence of BV.
Research directly linking stress and BV is very
limited. Culhane et al.
13,14
assessed stress in a co-
hort of innercity pregnant women using the Co-
hen Perceived Stress Scale, as well as neighbor-
hood-level variables. They found that higher
perceived stress was associated with an elevated
risk of BV (odds ratio [OR] 1.3, 1.0-1.6); the mean
score on the stress scale was 24.6 in women with
BV compared with 22.2 in women without BV.
Ruiz et al.
15
studied a group of pregnant women
in central Texas, also measuring stress with the
Cohen Perceived Stress Scale, and found no as-
sociation with either BV or chlamydia. No previ-
ous study has attempted to measure the associa-
tion between BV and stress in nonpregnant
women. We examined this association in an in-
nercity African American population.
MATERIALS AND METHODS
African American women seeking outpatient
gynecological care and family planning at Mount
Sinai Medical Center and North General Hospi-
tal in New York City from 1999 to 2001 were re-
cruited for a study of bacterial vaginosis and
douching. All women scheduled for appoint-
ments at the two recruitment sites were ap-
proached in the waiting rooms of the respective
clinics by a study interviewer. Prospective sub-
jects were asked to answer a brief screening form
to determine eligibility. All eligible women were
then invited to participate in the study. Women
were eligible if they were between 18 and 45 years
old, had not had a hysterectomy or bilateral
oophorectomy, were not menopausal, pregnant,
or immediately postpartum, and did not have
certain chronic conditions (diabetes, HIV, auto-
immune disorders). We excluded women with
chronic vaginitis, defined as having been treated
with antibiotics for the same type of vaginitis
within the previous 3 months, as well as women
who had used antibiotics or other medicines with
immunosuppressive effects in the last 3 months.
The protocol entailed a brief (10–20 minute) in-
terview administered immediately after the sub-
ject’s agreement to participate and the collection
of additional vaginal swabs during the subject’s
physical examination.
Five hundred eighty-five women were ap-
proached to be screened to determine eligibility.
Sixteen (2.8%) refused to be screened. Of those
who were screened, 9 women (1.6%) refused to
participate, and 134 (23.5%) proved to be ineligi-
ble. The most common reasons for ineligibility
were having diabetes and being HIV positive (21
women for each), as well as being pregnant (15).
Four hundred eleven (96.9%) of the 426 women
who were eligible agreed to participate. Of those,
400 who had complete data on stress and BV com-
prise the sample for analysis.
The structured interview included questions on
sociodemographic characteristics, lifestyle, femi-
nine hygiene, sexual behavior, reproductive his-
tory, and employment. Stress was measured by
the Global Assessment of Recent Stress (GARS)
scale, an instrument designed to evaluate per-
ceived short-term stress, defined as “a feeling of
pressure.”
16
To help the individual assess overall
feelings of stress, participants were first asked to
evaluate stress during the past week in seven dif-
ferent areas of life (work/job/school, interper-
sonal relationships, changes in relationships, sick-
ness or injury, financial, unusual happenings, and
change or lack of change in daily routine). Each
of the eight items in the scale is scored from 0
(none) to 9 (extreme), and examples are given to
help guide the respondents in selecting the
amount of perceived stress or “pressure.” The
GARS scale has been found to be reproducible
(test-retest correlation between r0.69 and r
0.92) and to correlate well with clinical judgments
and with scores from the Holmes and Rahe mod-
HARVILLE ET AL.
628
5791_08_p627-633 9/7/05 8:55 AM Page 628
ified Social Readjustment Rating Scale,
16
which
measures specific life events rather than global re-
sponses. The scale also is significantly associated
with such psychological markers as depression and
anxiety.
16
Significant, although moderate, correla-
tions have also been shown with physiological pa-
rameters, including blood pressure, response to
cold pressor, and changes in immune function.
16
Gynecologists were asked to collect extra vagi-
nal swabs during the pelvic examination. A swab
was placed in a test tube and sent to the Clinical
Microbiology Laboratories at Mount Sinai Med-
ical Center for gram stain analysis, using the sys-
tem of Nugent et al.
17
Briefly, each gram-stained
smear was evaluated for morphotypes: Lacto-
bacillus, G. vaginalis, Bacteroides, Mobiluncus. Each
morphotype except Mobiluncus (score 0–2) was
quantitated from 1 to 4, with Lactobacillus
scored inversely to their quantity. The scoring cri-
terion is a weighted sum of these scores, with BV
defined as a gram stain score 7.
This project was approved by the Institutional
Review Boards at the Mount Sinai School of Med-
icine and North General Hospital.
To avoid small cell counts and to provide a
more convenient summary of the data, a three-
level stress measure (low 0–3, intermediate 4–6,
high 7–9) was created from each stress domain.
A composite measure was created by summing
the categorized responses on all the stress do-
mains. Bivariate analyses were performed, using
stratified analysis to determine the relative risk
of BV for each category of stress, with the lowest
level as a referent. Risk factors for BV were in-
vestigated by examining associations with de-
mographic, sexual, and hygiene factors: age, par-
ity, income, education, recent unprotected sex
(defined as vaginal intercourse without a condom
within the last 24 hours), a new sex partner within
the last 3 months, number of sex partners, mari-
tal status, body mass index (BMI), smoking, use
of hormonal contraception, and frequency of
douching. Chi-square tests were used to deter-
mine statistical significance. Covariates were
modeled in the form listed in Tables 1 and 2.
Potential confounders were assessed for their
association with both exposure and outcome, us-
ing the criteria of relative risk (RR) 2 or p0.15
for association. Variables screened were age, par-
ity, recent new sex partner, number of sex part-
ners, marital status, poverty, education, and use
of hormonal contraception. Douching frequency
was only weakly associated with BV in these data
and so was not considered.
18
Only hormonal con-
traception fit these criteria, so it was included in
the regression model. Each stress variable was
modeled separately. Binomial log-linear regres-
sion was chosen over logistic modeling because
the outcome is common, making RR a better ef-
fect measure than an OR.
RESULTS
The study population comprised African Amer-
ican women of whom 73% were never married
and 82% were parous (Table 1). All except 5 wo-
STRESS AND BACTERIAL VAGINOSIS 629
T
ABLE
1. C
HARACTERISTICS OF
411 N
EW
Y
ORK
C
ITY
A
FRICAN
A
MERICAN
W
OMEN
Characteristic n%
Age, years
a
18–21 28 7
21–25 81 20
25–30 100 25
30–35 78 19
35–40 55 14
40 59 15
Education
b
High school 272 67
High school 137 34
Household income (month)
a
$500 105 26
$500–800 122 30
$800 174 43
Marital status
b
Unmarried 297 73
Married 57 14
Separated, widowed, or divorced 55 13
Smoked in the past 3 months
Yes 137 33
No 274 67
Body mass index (kg/m
2
)
c
20 30 7
20–25 122 30
25–30 103 25
30 152 37
Parity
d
07418
1 149 37
2 185 45
Douching frequency in the last 3 months
e
Never 216 53
Once a month or less 132 32
More than once a month 61 15
a
Missing data on 10 women.
b
Missing data on 2 women.
c
Missing data on 4 women.
d
Missing data on 3 women.
e
Missing data on 2 women.
5791_08_p627-633 9/7/05 8:55 AM Page 629
men were sexually active at some point, and 87%
were sexually active in the last year. One hundred
eight (27%) had BV, defined as a gram score 7.
One hundred nineteen (30%) had a gram score of
4–6 (intermediate), and the remaining 173 had a
gram score 4.
Several social, hygiene, and sexual factors
were assessed in bivariate analyses for their as-
sociation with risk for BV (Table 2). Use of hor-
monal contraception was inversely related to
risk of BV (21% vs. 31%, p0.03). Being mar-
ried and of higher income were modestly asso-
ciated with a reduced risk of BV, as was having
recent, unprotected sex, possibly explained by
an association with marital status. Women who
smoked were more likely to report high overall
stress (41% vs. 33% at highest level, p0.03),
as were women who used hormonal contracep-
tion (39% vs. 33%, p0.11). Women with more
children also reported more stress (p0.12), as
did women with more sex partners (52% of wo-
men with two or more partners reported over-
all high stress vs. 38% of those with no partner,
p0.20). Income was not significantly associ-
ated with overall stress, although there was a
trend of increased reported financial pressure
with decreased income.
Approximately a quarter of the women re-
ported high levels of stress on any one of the
domains covered by the GARS scale, with fi-
nancial pressures cited most frequently (31% in
the upper tertile) (Table 3). Pressure due to rou-
tine (17%) and sickness (16%) were least often
reported. Thirty-six percent of the women re-
ported high overall stress.
The overall stress score was not associated with
BV (Table 3). Increased reported pressure was as-
sociated with increased rates of BV in the fol-
lowing domains: pressure from routine, change
in relationships, financial pressure, unusual hap-
penings. The summed score of all domains was
also associated with BV. The prevalence ratios
were 1.26 (95% confidence interval [CI] 0.84, 1.88)
and 1.44 (95% CI 0.98, 2.11) for the moderate and
high scores, respectively, compared with that for
the low score. These findings changed very little
after controlling for hormonal contraceptive use,
the one variable identified as a confounding fac-
tor. Results using the original continuous mea-
sure of stress and the gram score as a continuous
variable were similar to the results from the cat-
egorical analysis (data not shown).
DISCUSSION
In this study of African American women in
New York, we did not find any clear association
between stress and BV. For some domains (pres-
sure from routine, changes in relationships, and un-
usual happenings), as well as the sum of all the sub-
scores, the prevalence of BV increased with higher
stress level. In spite of the fact that pressure in sev-
eral domains showed an association with BV and
the sum of the domain subscores also showed an
association, the subjects’ assessment of their over-
all level of pressure was unrelated to the risk of
bacterial vaginosis. This may indicate that respon-
dents had an easier time rating the level of stress
in specific areas of life than the level of pressure
they were feeling overall. Indeed, the overall esti-
mate of pressure was only moderately correlated
with the sum of the domain subscores.
Women in the highest third of the summed
stress score had a 45% higher prevalence of BV
compared with those in the lowest tertile. This is
lower than in one previous study, which reported
an OR of 2.2 (1.1, 4.2) for the most highly stressed
women,
14
although similar to the OR of 1.3 (1.0,
1.6) in a study comparing those above vs. below
the median in perceived stress.
13
Because a high
percentage of African American women are at an
elevated stress level and BV is such a common
disorder, even a modest association could have
significant public health implications.
In this population, BV was inversely associated
with using hormonal contraception, similar to
what has been found in several previous stud-
ies.
2,19,20
Also consistent with other studies is the
inverse association with income,
1,2
although this
was not statistically significant. We did not see
any associations with other suspected risk factors,
such as age, education, or smoking, although the
trends with marital status were in the predicted
direction. This may be in part because we con-
ducted the study in a gynecological clinic instead
of a sexually transmitted disease (STD) or prena-
tal care clinic and limited the study to African
Americans. A strength of the study is the focus
on the population at risk for BV, unselected for
pregnancy or risk of STDs. Another strength is
the excellent participation rate. We used a vali-
dated stress instrument, the GARS, that has been
associated with alterations in immune parame-
ters,
21
including reduced immune response to de-
layed hypersensitivity skin tests.
16
HARVILLE ET AL.
630
5791_08_p627-633 9/7/05 8:55 AM Page 630
STRESS AND BACTERIAL VAGINOSIS 631
T
ABLE
2. A
SSOCIATIONS BETWEEN
B
ACTERIAL
V
AGINOSIS AND
C
OVARIATES
IN
411 A
FRICAN
A
MERICAN
W
OMEN IN
N
EW
Y
ORK
C
ITY
Bacterial vaginosis by gram score
a
Yes No
Characteristic n%n%p
Age, years
b
18–21 4 3.7 24 8.5 0.65
21–25 21 19.6 57 20.1
25–30 28 26.2 66 23.3
30–35 24 22.4 53 18.7
35–40 14 13.1 40 14.1
40 16 15.0 43 15.2
Education
c
High school 67 62.6 196 67.4 0.38
High school 40 37.4 95 32.7
Household income per month
b
$500 27 25.5 74 26.0 0.17
$500–800 40 37.7 81 28.4
$800 39 36.8 130 45.6
Marital status
c
Never married 83 77.6 204 70.1 0.23
Married 10 9.4 46 15.8
Separated, widowed, or 14 13.1 41 14.1
divorced
Smoked within the last 3 months
Yes 37 34.3 97 33.2 0.84
No 71 65.7 195 66.8
Body mass index (kg/m
2
)
d
20 10 9.4 20 6.9 0.81
20–25 29 27.4 88 30.3
25–30 26 24.5 74 25.5
30 41 38.7 108 37.2
Parity
e
0 19 17.9 52 17.9 0.58
1 35 32.7 110 37.9
2 53 49.5 128 44.1
New sex partner in last 30 days
c
Yes 6 5.6 8 2.8 0.22
No 101 94.4 283 97.3
Number of sex partners in last 3 months
e
2 6 5.6 11 3.8 0.72
1 79 73.8 216 74.5
0 22 20.6 63 21.7
Recent unprotected sexual intercourse
c
Yes 11 10.2 45 15.5 0.17
No 97 89.8 245 84.5
Used hormonal contraception in last 3 months
f
Yes 37 34.6 136 46.6 0.03
No 70 65.4 156 53.4
Douching frequency in the last 3 months
c
Never 60 55.6 152 52.4 0.83
Once a month or less 34 31.5 95 32.8
More than once a month 14 13.0 43 14.8
a
Missing data on 11 women.
b
Missing data on 10 women.
c
Missing data on 2 women.
d
Missing data on 4 women.
e
Missing data on 3 women.
f
Missing data on 1 women.
5791_08_p627-633 9/7/05 8:55 AM Page 631
On the other hand, stress is a difficult concept to
measure, and no single scale can capture every-
thing. There was no measure of specific life events,
coping styles, social support, or biomarkers of
stress in this study. It is possible that a more de-
tailed stress measurement would reveal stronger
associations or would provide a more definitive
finding of no association. Our sample size was
somewhat limited; we had approximately 80%
power to detect an RR of 2, and the observed as-
sociations were more modest. Only one variable
was found to have a potential confounding effect,
and adjusting made no material difference to the
results. However, there is the potential for unmea-
sured confounding, perhaps by health habits or
day of menstrual cycle. The sample is one of con-
venience, and results cannot be generalized to wo-
men who do not use gynecological services.
Especially valuable in further research would
be a prospective cohort study of women who are
BV free at the start. In view of the modest risks
observed, larger samples will be needed to en-
sure adequate statistical power. As a cross-sec-
tional study, this research cannot distinguish be-
tween factors that predict incidence of BV and
factors that predict duration or between cause
HARVILLE ET AL.
632
T
ABLE
3. A
SSOCIATIONS BETWEEN
R
EPORTED
P
RESSURE AND
B
ACTERIAL
V
AGINOSIS
IN A
G
ROUP OF
411 A
FRICAN
A
MERICAN
W
OMEN IN
N
EW
Y
ORK
C
ITY
Bacterial vaginosis by gram score
a
Yes No Unadjusted Adjusted
b
Domain n%n%RRCIRRCI
Pressure from routine
0–3 49 45.4 150 51.4 1 1
3–6 37 34.3 96 32.9 1.13 (0.78, 1.63) 1.07 (0.74, 1.55)
7–9 22 20.4 46 15.8 1.31 (0.86, 2.00) 1.24 (0.81, 1.89)
Pressure from change in relationships
0–3 43 39.8 138 47.3 1 1
3–6 34 31.5 83 28.4 1.22 (0.83, 1.80) 1.19 (0.80, 1.75)
7–9 31 28.7 71 24.3 1.28 (0.86, 1.90) 1.28 (0.87, 1.90)
Financial pressure
0–3 38 35.2 102 34.9 1 1
3–6 32 29.6 107 36.6 0.85 (0.56, 1.27) 0.83 (0.55, 1.25)
7–9 38 35.2 83 28.4 1.16 (0.79, 1.69) 1.15 (0.78, 1.67)
Pressure from unusual happenings
0–3 52 48.2 162 55.5 1 1
3–6 33 30.6 86 29.5 1.14 (0.79, 1.66) 1.09 (0.75, 1.60)
7–9 23 21.3 44 15.1 1.41 (0.94, 2.12) 1.38 (0.92, 2.07)
Relationship pressure
0–3 37 34.3 115 39.4 1 1
3–6 43 39.8 100 34.3 1.24 (0.85, 1.80) 1.24 (0.85, 1.81)
7–9 28 25.9 77 26.4 1.10 (0.72, 1.67) 1.11 (0.73, 1.70)
Sickness/injury
0–3 58 53.7 168 57.5 1 1
3–6 32 29.6 76 26.0 1.15 (0.80, 1.66) 1.09 (0.75, 1.58)
7–9 18 16.7 48 16.4 1.06 (0.68, 1.67) 0.99 (0.63, 1.56)
Pressure from work
0–3 40 37.0 117 40.1 1 1
3–6 47 43.5 113 38.7 1.15 (0.80, 1.65) 1.14 (0.80, 1.64)
7–9 21 19.4 62 21.2 0.99 (0.63, 1.57) 1.00 (0.63, 1.58)
Overall estimate of pressure
0–3 34 31.5 83 28.4 1 1
3–6 37 34.3 106 36.3 0.89 (0.60, 1.32) 0.85 (0.57, 1.26)
7–9 37 34.3 103 35.3 0.91 (0.61, 1.35) 0.93 (0.62, 1.37)
Sum of reported stress
7–11 39 36.1 135 45.9 1 1
11–14 32 29.6 81 27.7 1.26 (0.84, 1.88) 1.30 (0.87, 1.95)
1437 34.3 77 26.4 1.44 (0.98, 2.11) 1.39 (0.95, 2.05)
a
Missing data on 10 women for bacterial vaginosis and on 1 woman for stress measurements.
b
Adjusted for use of hormonal contraception in the last 3 months.
5791_08_p627-633 9/7/05 8:55 AM Page 632
and effect. It may be argued that women with BV
might be more inclined to report stress due to the
BV symptoms, but in our data, the women with
and without BV reported a similar stress level due
to “sickness/injury.”
African American women are at higher risk of
preterm birth, have a higher prevalence of BV, and
are under greater stress in many ways than women
of other racial/ethnic groups.
22
Stress has been as-
sociated with preterm birth in some studies, al-
though the association is not found consistently.
23
A connection between stress and BV is plausible
biologically and would provide an important link
between the social and medical epidemiology of
preterm birth.
24
Further research, using a larger
sample and more extensive measurements of
stress, should attempt to pursue this line of inquiry.
ACKNOWLEDGMENTS
We thank Dr. Tonja Nansel for her helpful com-
ments on the manuscript.
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Address reprint requests to:
Emily W. Harville, M.S.P.H.
Department of Epidemiology
University of North Carolina at Chapel Hill
CB 7435
Chapel Hill, NC 27599-7435
E-mail: ewh@unc.edu
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... Penelitian menunjukkan BV memiliki hubungan konsistensi yang tinggi dengan tingkat stres psikososial (Nansel et al., 2006;Harville, et al., 2005;Culhane, et al., 2002;Culhane, et al., 2001). Penelitian yang dilakukan oleh Paul, et al (2008) bahwa stres akibat peristiwa dalam kehidupan berhubungan secara signifikan dengan tingginya prevalensi BV pada wanita ras Amerika-Afrika sebesar 5,6% dibandingkan dengan kondisi normalnya yaitu 3,9% (p < 0,001) dan pada wanita Amerika kulit putih sebesar 4,1% dibandingkan dengan kondisi normalnya yaitu 2,1% (p < 0,001). ...
... Penelitian yang dilakukan oleh Paul, et al (2008) bahwa stres akibat peristiwa dalam kehidupan berhubungan secara signifikan dengan tingginya prevalensi BV pada wanita ras Amerika-Afrika sebesar 5,6% dibandingkan dengan kondisi normalnya yaitu 3,9% (p < 0,001) dan pada wanita Amerika kulit putih sebesar 4,1% dibandingkan dengan kondisi normalnya yaitu 2,1% (p < 0,001). Harville, et al (2005) menemukan bahwa 34% wanita yang memiliki tingkat stres tinggi mengalami BV dan 26% wanita dengan stres tinggi tetapi tidak mengalami BV. Namun, tidak ada perbedaan signifikan secara statistik. ...
... Ha sil a nal isis st at ist i k a nt a r a st res pada k uesioner Self Reporting Q u e st i o n n a i r e b e r hu bu ng a n s e c a r a signifikan dengan kejadian BV ( p value < 0,05). Hal ini sejalan dengan penelitian dari Nansel et al (2006), Harville et al (2005), Culhane et al (2002) dan Culhane et al (2001) yang menunjukkan BV memiliki hubungan konsistensi yang tinggi dengan tingkat stres psikososial. ...
Article
Introduction: Bacterial Vaginosis (BV) is a common vaginal condition produced by overgrowth of anaerobic bacteria. Stress can alter women’s reproductive health in many ways; one of them is increasing the risk for bacterial vaginosis. In facing stressful life conditions, resilience plays an important role to maintain optimal function and prevent traumatic experience.Methods: This research was an analytical observational study with cross sectional design. Questionnaires were given to 104 women in reproductive age between November 2013 and January 2014. Resilience and stress were assessed using The Connor-Davidson Resilience Scale (CD-RISC) and Self Reporting Questionnaire respectively, and bacterial vaginosis status was diagnosed using Amsel’s criteria. Statistical analysis was performed using chi square test and multiple logistic regressions.Results: Bivariate analysis showed significant relations between resilience (p=0,005), stress (p=0,002), frequency of sexual intercourse within 1 week (p= 0,015) and the bacterial vaginosis incidence. Multivariate analysis showed stress was the most influential factor OR=3,9 (95% CI=1,478–10,562).Discussion: Resilience and stress were significantly with increased risk of having bacterial vaginosis.
... 55 There is also a link between perceived stress and BV. 58,59,71 In pregnant women, higher Nugent scores are associated with higher levels of perceived stress, even after adjusting for socioeconomic and behavioral varia bles. 58,59 Nansel et al. 60 tracked women over time and found that not only was perceived stress associated with developing BV (odds ratio (OR) = 1.29; 95% confidence interval (CI)), but women had 1.28 greater odds of get ting BV with a 1point increase in their perceived stress score. ...
Article
Full-text available
Recurrent urogenital infections such as bacterial vaginosis, vulvovaginal candidiasis, and urinary tract infections have a high prevalence and pronounced psychosocial impact. However, no review has compared the psychosocial impacts across infection types. This narrative review discusses the impact of common recurrent urogenital infections on psychosocial aspects, including quality of life, stress, mental health, sexual health, work productivity, race and ethnicity, and satisfaction of medical care. Validated questionnaires show that women with recurrent vulvovaginal candidiasis and urinary tract infections have decreased scores on all aspects of quality of life. Those with recurrent vulvovaginal candidiasis and urinary tract infections show lower mental health scores compared to the general population, with increased risk of anxiety and depression. Recurrent urogenital infections affect sexual relationships and intimacy, including avoidance due to symptoms or as a method of prevention. Recurrent infections also increase medical cost and negatively affect work productivity, leading to a combined estimated cost of over US$13 billion per year. There are clear effects of racial inequality involving minority populations that affect diagnosis, treatment, prevalence, and reporting of recurrent urogenital infections. Satisfactory medical treatment improves quality of life and mental health in those suffering from these conditions. Research evaluating psychosocial aspects of recurrent urogenital infections is variable and is not comparable across vulvovaginal conditions. Even so, psychosocial factors are important in understanding contribution and consequence of urogenital infections. Education, awareness, normalization, community support, and access to care can help to alleviate the negative implications of recurrent urogenital infections.
... One study involved the experiences of the male partners of women with BV. Sixteen studies were included, [7,11,[16][17][18][19][20][21][22][23][24][25][26][27][28][29] of which twelve studies regarding emotional health, [7, 16-22, 24, 25, 27-29] five on sexual health [7,11,16,18,23,27], and four involving social health [7,11,16,26,27]. Nine out of sixteen manuscripts reported on studies that were conducted in the US, four were conducted in Australia, the three remaining studies were carried out in India, Kenya, and the UK. ...
Article
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Background Bacterial vaginosis (BV) is a condition that, if symptomatic, is characterized by discharge and odor, with high recurrence rates even when treated. This study aims to review what literature exists on the association between BV and the emotional, sexual, and social health of women. Methods MEDLINE, Embase and Web of Science databases were searched from inception until November 2020. Studies reporting an association between women’s emotional, sexual and/or social health and symptomatic BV in a qualitative and/or quantitative manner were included. Selected studies were divided in three categories, i.e. reporting on the emotional, sexual and/or social association. All studies were critically evaluated and discussed. Results Sixteen studies were included. Concerning emotional health, we found eight studies that calculated the association between stress and BV, in four this was statistically significant. Four qualitative studies on emotional health showed that the severity of the symptoms influenced the impact on women’s lives. All studies on sexual health reported that many women experienced an impact on their relationship and sexual intimacy. Results for social life ranged from no association found to most of the study population showing avoidance behavior. Conclusion This review shows that symptomatic BV can be associated with diminished emotional, sexual, and social health, but there is too little evidence to state the extent of this association.
... There is some evidence that vaginal microbiome composition varies by individual levels of psychosocial stress and other social factors (17)(18)(19)(20)(21), and there is increasing awareness that these factors are not purely a result of individual choices or behaviors, but are also represented by differences in experienced social context, including the residential neighborhood context (22,23). It is therefore plausible that where someone lives could affect the health of the vaginal microbiome. ...
Article
Full-text available
Introduction The vaginal microbiome is a dynamic ecosystem that is important for women's health. Its composition has been associated with risk for menopausal symptoms, sexually transmitted infections, gynecologic cancer, and preterm birth. Conventional risk factors for a vaginal microbiome linked with these adverse health outcomes include sexual behaviors, hygiene practices, individual social factors, and stress levels. However, there has been limited research on socio-contextual determinants, and whether neighborhood context modifies the association with individual socioeconomic factors. Methods Socioeconomically diverse pregnant African American women in Atlanta, Georgia (n = 439) provided residential addresses and first trimester vaginal swab samples, which underwent sequencing, taxonomic classification, and assignment into mutually exclusive CST (community state types) via hierarchical clustering. Linear probability models were used to estimate prevalence differences (PD) for the associations of neighborhood factors with vaginal microbiome CST and to evaluate for additive interaction with maternal level of education, health insurance type, and recruitment hospital. Results Factors such as higher (vs. lower) maternal education, private (vs. public) insurance, and private (vs. public) hospital were associated with higher prevalence of Lactobacillus-dominant vaginal microbiome CSTs typically associated with better health outcomes. When considering the joint effects of these individual socioeconomic status and residential neighborhood factors on vaginal microbiome CST, most combinations showed a greater than additive effect among the doubly exposed; however, in the case of local income homogeneity and local racial homogeneity, there was evidence of a crossover effect between those with less-advantaged individual socioeconomic status and those with more-advantaged individual socioeconomic status. Compared to women at the public hospital who lived in economically diverse neighborhoods, women at the private hospital who lived in economically diverse neighborhoods had a 21.9% higher prevalence of Lactobacillus-dominant CSTs, while women at the private hospital who lived in less economically diverse neighborhoods (the doubly exposed) had only an 11.7% higher prevalence of Lactobacillus-dominant CSTs, showing a crossover effect (interaction term p-value = 0.004). Discussion In this study, aspects of residential neighborhood context were experienced differently by women on the basis of their individual resources, and the joint effects of these exposures on vaginal microbiome CST showed a departure from simple additivity for some factors.
... My work builds on an eclectic precedent, with leucorrhea having captured the attentions of scholars and practitioners across the social sciences and medicine. Medical and public health scholarship overwhelmingly evaluates leucorrhea in terms of its clinical etiologies (Bhatia and Cleland 1995;Patel et al. 2005;Harville, Hatch, and Zhang 2005;Karasz and Anderson 2003), and explores how traditional beliefs and 'misconceptions' concerning its sources and effects can be corrected through culturally competent treatment protocols (see Kaur and Kapoor 2014;Patel 1998). In ways that preclude deeper examinations of the traditional beliefs and ethno-etiologies associated with leucorrhea, much of this work adheres to biomedical logics, and places primary emphasis on the need to clinically or epidemiologically isolate its causes. ...
Article
Full-text available
In Gilgit, capital of the Gilgit-Baltistan region in northern Pakistan, leucorrhea – vaginal discharge known in the vernacular as safaid pani, or ‘white water’ - serves as both a medical diagnosis and signifier of the chronicity of the reproductive, social, and emotional burdens endured by women. While ethnomedical providers explained safaid pani as resulting from relatively benign forms of ‘weakness’, which required minimal dietary or ethno-botanical recourse, allopathic physicians approached discharge as evidence of numerous pathologies that necessitated protracted and sometimes also expensive treatments. Physicians’ clinical assessments were not solely biomedical, but also integrated informal folk and formal ethnomedical theories of causation. Clinical diagnoses that affirmed leucorrhea as a pathophysiology substantiated women’s belief that it was proof of the destructive effects of sustained social inequity, peril, and distress on the body, and the uterus in particular. Women and their treating providers recognized the power of the (dys)functional uterus to not only threaten women’s reproductive wellness but also their social, marital, and familial status, which hinged on their ability to become pregnant and give birth, to sons especially. Because of the ailing uterus’s expansive importance, weeping wombs served as a potent source for women’s claims making and calls for attention and care.
... Epidemiologic studies have identified persistent exposure to stress as a risk factor for BV, independent of confounders (19,(44)(45)(46)(47)(48), although some studies have had inconclusive or null findings regarding this association (49)(50)(51). However, we are aware of only 2 studies that investigated stress in relation to the vaginal microbiota, one in a mouse model and one with a sample of only 21 participants (47,48). ...
Article
Vaginal microbiota provide the first line of defense against urogenital infections primarily through protective actions of Lactobacillus spp. Perceived stress increases susceptibility to infection through several mechanisms, including suppression of immune function. We investigated if stress was associated with deleterious changes to vaginal bacterial composition in a subsample of 572 women in the Longitudinal Study of Vaginal Flora, sampled from 1999 through 2002. Using Cox proportional-hazard models, both unadjusted and adjusted for sociodemographics and sexual behaviors, participants who exhibited a 5 unit-increase in Cohen’s perceived stress scale had greater risk (aHR=1.40, 95% CI 1.13-1.74) of developing molecular bacterial vaginosis (BV), a state with low Lactobacillus abundance and diverse anaerobic bacteria. A 5-unit stress increase was also associated with greater risks for transitioning from the L. iners-dominated community state type (26% higher) to molecular-BV (aHR=1.26, 95% CI 1.01-1.56) or maintaining molecular-BV from baseline (aHR=1.23, 95% CI 1.01-1.47). Inversely, women with baseline molecular-BV reporting a 5-unit stress increase were less likely to transition to microbiota dominated by L. crispatus, L. gasseri, or L. jensenii (aHR=0.81, 95% CI 0.68-0.99). These findings suggest psychosocial stress is associated with vaginal microbiota composition, inviting a more mechanistic exploration of the relationship between psychosocial stress and molecular-BV.
... The condition of vaginal microbiota depends on hygienic skills, sexual behavior, stress, as well as on physiological or pathological fluctuations in the level of female hormones [15]. Since the basis of BV is the uncontrolled growth of anaerobic bacteria [19] and the reduction of vaginal colonization resistance [10], the authors [11] hypothesized the suppression of immune function by stress, which increases the risk of BV. A higher prevalence of BV has been found in women with high levels of general stress. ...
Article
Full-text available
Annotation. The stress objective marker is the neuro-hormonal stress-implementing system stress and the increase the cortisol and prolactin levels in the blood, leading to the “distress syndrome” formation. Aim – to establish the stress effect, revealed according to the level of stress- implementing hormones, in particular cortisol and prolactin, on the progression of vaginal bacterial dysbiosis and the bacterial vaginosis (BV) development. During the study there were used the data taken from 298 women, who were divided into the following groups according to the Opportunistic pathogenic microflora index (OPMI) and normobiota index (NBI): normocenosis (n=53), dysbiosis I (n=128) and II degree (n=117) among the latter 83 patients with NBI>1 lg GE/sample were identified, in which BV was established. Molecular genetic studies of the epithelium scraping from the vagina posterolateral wall were carried out by Polymerase chain reaction (“DNK-Technologiia” LLC, RF). Facultative and obligate anaerobes, myco- and ureplasmas, and yeast-like fungi were quantified. The cortisol and prolactin blood levels were identified. For statistical analysis, the Statistica 10 software (StatSoft, Inc., USA) was used. Catch out that the blood cortisol content with dysbiosis progression compared with the normocenosis has changed in two-phase: it was increased with I degree dysbiosis (1.2–1.4 times; p<0.01) and decreased with II degree dysbiosis and BV (1.5 times; p<0.001). So, with respect to the classical concept of the General adaptive syndrome of G. Selye, the first dysbiosis development stages can be considered as reaction of “anxiety”, while the development of BV is a reaction of “exhaustion”. The blood prolactin content compared with normocenosis with dysbiosis was increased, which was most expressed in BV (1.5 times; p <0.001). It also reflected the stress response development with increased central nervous system stress. The blood hormones content has relation with BV-associated microbiota indexes: prolactin was positively related with NBI, and cortisol was negatively related to the number of Atopobium vaginalis. Thus, according to the data obtained, BV can be attributed to the stress pathology with the "distress syndrome" development and the content of cortisol and prolactin in the blood can be considered as marker factors for hormonal regulation disorder.
... And anatomical factors and finally the presence of foreign bodies within the reproductive methods (Hodoglugil et al., 2000). Also play life pressure (Harville et al., 2005) and the incidence of some diseases a major role in the incidence of infections of genital infection such as diabetes or immunosuppression (Minkoff et al., 1999). The treatment of some drugs also plays an important role in the incidence of infection such as the treatment of antibiotics and hormonal drugs (Opaneye, 1999;Kurowski et al., 2000). ...
Article
Full-text available
We conducted a study aimed at determining the prevalence of Microorganism vaginosis. Microorganism-associated with genital secretions in married women in The Adwaniyah city, Iraq. We collected 60 samples from women with genital secretions in married women. Vaginal swabs were collected BV-associated bacteria (Gardnerella vaginalis, anaerobic bacteria, staphylococcus aurus, E. coli, N. gonorrhoeae and Candida albicans) cultures; and swabs were collected for culture and Staphylococcus aurus PCR. The results of the present study showed that the highest percentage of Staph. aurus bacteria was (13.3%) of (8) isolates, followed by G. vaginalis with (10%) of (6) isolates, E. coli and N. gonorrhoeas with (6.67%) each of (4) isolates. The species then remained at (5%) of the (3) isolates. The results of the present study showed that after fungal samples, the highest percentage of Candida albicans was recorded, with (31.67%) of (19) samples were isolated and another species (26.67%) of the (16) isolates were fungal isolates.
Article
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There are 150 million women worldwide using combined or progestogen-only hormonal contraceptive methods who may be at risk of sexually transmitted infections (STIs). Previous systematic reviews that have sought to establish whether there is an aetiological association between hormonal contraceptive methods/use and STIs have been limited in their methods and have mixed findings. We sought to update these reviews using appropriate control groups. We undertook a systematic review following the PRISMA guidelines and meta-analysis to examine the association between the use of all hormonal contraceptive methods and the acquisition of STIs (Neisseria gonorrhoeae, syphilis/Treponema pallidum, Chlamydia trachomatis, herpes simplex virus, and Trichomonas vaginalis) and/or bacterial vaginosis in literature published between 2005 and 2020. We analysed the effect of hormonal contraceptive methods/use separately on the prevalence, incidence and recurrence of STIs. A total of 37 studies were included in this review that reported 61 associations, in which 27 prevalence, eight incidence and two recurrence studies provided 43, 16, and two associations, respectively. We observed a positive association between hormonal contraceptive methods/use and the risk of chlamydia and herpes but a negative association for trichomoniasis and vaginosis. A negative but statistically insignificant association was observed between hormonal contraceptive methods/use and gonorrhoea. Hormonal contraceptive methods/use influences a woman's risk of STIs/ bacterial vaginosis, but the risk may differ depending on the type of STI. These findings should be contextualized carefully, particularly when formulating practice guidelines and policy, as the effects of hormonal contraceptive methods/use on the risk of STIs varied in direction when analysed separately by STI.
Article
Around the world, more than 175,000,000 women are diagnosed every year with gynaecological disease, in many cases contributing to high morbidity and mortality. For this reason, knowledge of the composition of the vaginal microbiome and its variations represents a real health challenge, as this is key to improving therapeutic management. This review traces the history of the poorly known vaginal microbiome and focuses on the latest findings concerning this ecosystem. Studies in the past decade have targeted complex bacterial communities within the vagina. However, due to the development of technology and the emergence of next generation sequencing (NGS), the exact definition of the vaginal microbiome has changed and can no longer be linked solely to the presence of bacteria. In order to reach a global view of the vaginal microbiome, it is essential to take into account all microorganisms that the vagina harbours, including fungi, viruses, archaea, and candidate phyla radiation. Although these communities represent only a minimal percentage of the vaginal microbiome, they may act as modifiers of its basic physiology and may play a key role in the maintenance of microbial communities, as well as metabolic and immune functions. Studies of the complex interactions between these different microorganisms have recently begun and are not yet fully understood. Results to date indicate that these microbial communities together constitute the first line of defence against infections. On the other hand, the slightest disturbance in this microbiome may lead to disease. For this reason, enhanced knowledge of these associations is critical to better identify predispositions to certain illnesses, which may open new therapeutic avenues. Currently however, only the tip of the iceberg is understood and current research on this ecosystem is revolutionising our knowledge and understanding of human health and disease.
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The purpose of the study was to examine intercenter variability in the interpretation of Gram-stained vaginal smears from pregnant women. The intercenter reliability of individual morphotypes identified on the vaginal smear was evaluated by comparing them with those obtained at a standard center. A new scoring system that uses the most reliable morphotypes from the vaginal smear was proposed for diagnosing bacterial vaginosis. This scoring system was compared with the Spiegel criteria for diagnosing bacterial vaginosis. The scoring system (0 to 10) was described as a weighted combination of the following morphotypes: lactobacilli, Gardnerella vaginalis or bacteroides (small gram-variable rods or gram-negative rods), and curved gram-variable rods. By using the Spearman rank correlation to determine intercenter variability, gram-positive cocci had poor agreement (0.23); lactobacilli (0.65), G. vaginalis (0.69), and bacteroides (0.57) had moderate agreement; and small (0.74) and curved (0.85) gram-variable rods had good agreement. The reliability of the 0 to 10 scoring system was maximized by not using gram-positive cocci, combining G. vaginalis and bacteroides morphotypes, and weighting more heavily curved gram-variable rods. For comparison with the Spiegel criteria, a score of 7 or higher was considered indicative of bacterial vaginosis. The standardized score had improved intercenter reliability (r = 0.82) compared with the Spiegel criteria (r = 0.61). The standardized score also facilitates future research concerning bacterial vaginosis because it provides gradations of the disturbance of vaginal flora which may be associated with different levels of risk for pregnancy complications.
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The integrity of the immunoglobulins in vaginal washings of patients with bacterial vaginosis was examined to answer the question of the lack of immune response against Gardnerella vaginalis cytolysin. Clinically diagnosed patients (n = 100) were recruited and their vaginal washings examined by Western blotting. Many showed IgA and IgM partially or extensively degraded. According to the degradation pattern, the patients were subdivided into 4 subsets, from intact (score 0) to completely degraded IgA (score + 3). Statistical analysis of the data showed a correlation between IgA degradation and absence of immune response to G. vaginalis cytolysin. The extent of IgA degradation correlated also with the sialidase (but not with the prolidase) activity level. All women showed intact IgG and human serum albumin and no trypsin-like activity. Patients with bacterial vaginosis having high sialidase activity and extensive IgA degradation in their secretions could incur more dangerous infections and adverse pregnancy outcomes.
Article
The Global Assessment of Recent Stress (GARS) Scale was developed to assess current stress perception. Most measurements of environment are derived from life event scales that capture amount of stress or change associated with stressful events that have occurred over the past six to twenty-four months. A scale that provides a more immediate estimate of stress is needed when physiological tests and perceived stress are studied together. The GARS has been subjected to a series of studies concerning its reliability, validity, and factor structure. Results suggest that it may be a useful instrument for helping individuals assess their current feelings of stress.
Article
In this review of articles on prenatal stress, anxiety, development, and reproductive health outcomes in pregnancy, the focus is on recent research in which the relationships among the major types of stressors, anxiety, and development, on the one hand, and maternal, fetal, and neonatal problems or complications, on the other hand, were examined. Available and effective treatment measures, although limited, are introduced and discussed at length in a follow-up article. Recommendations for policy development based on current research and treatment methods and directions for future research and treatment studies are presented in a third article.
Article
We present an assessment of studies published in the last decade that consider the relationship of stress and social support to preterm delivery or fetal growth retardation. Included in the review are all reports on the direct effects of stressors or psychological distress; the indirect effects of stressors or distress through health behaviours such as smoking; and the direct and buffering effects of social support. Although an important stimulus for recent stress research has been the attempt to explain racial and social class differences in birth outcome, the recent data show that stressful life events during pregnancy, though more common in disadvantaged groups, do not increase the risk of preterm birth. In contrast, intimate social support from a partner or family member appears to improve fetal growth, even for women with little life stress. Questions unanswered by the research to date are whether elevated levels of depressive symptoms affect pregnancy outcome, either directly or by encouraging negative health behaviours, and whether chronic (vs. acute) stressors are harmful. Additional research is also needed to determine whether psychosocial factors interact with specific clinical conditions to promote adverse pregnancy outcomes. Focusing on intimate support and how it benefits pregnancy outcome could lead to the design of more effective interventions.
Article
The objective of this study was to determine whether the clinical diagnosis of bacterial vaginosis is associated with objective evidence of acute upper genital tract infection. Women who either met the Centers for Disease Control and Prevention's minimal criteria for acute pelvic inflammatory disease or had other "nonclassic" signs of upper genital tract infection (i.e., atypical pelvic pain, abnormal uterine bleeding, or cervicitis) were evaluated with either an endometrial biopsy or a laparoscopy with endometrial and fimbrial biopsies for objective evidence of upper genital tract infection. Bacterial vaginosis was considered present if three of the four following criteria were found: (1) homogeneous gray-white vaginal discharge, (2) vaginal pH > 4.5, (3) positive "whiff" test result, and (4) the presence of > 20% of epithelial cells classified as clue cells. Patients were considered to have upper genital tract infection if they had histologic, microbiologic, or laparoscopic evidence of upper tract infection. One hundred sixteen women were evaluated between August 1993 and March 1997 with complete evaluations. Objective evidence of upper tract infection was present in 56% (14/25) of women with the clinical diagnosis of bacterial vaginosis compared with 30% of women (27/91) who did not meet the clinical criteria (p = 0.015). Using logistic regression to control for confounding variables, we found that the presence of bacterial vaginosis was associated with a threefold increased risk of upper genital tract infection (adjusted odds ratio = 3.0, 95% confidence interval 1.2 to 7.6). Bacterial vaginosis is associated with an increased risk of objective evidence of acute upper genital tract infection. Future prospective studies are needed to determine whether treatment of bacterial vaginosis can reduce the risk of ascending infection.
Article
Bacterial vaginosis (BV) is characterized by dramatic changes in the vaginal ecosystem. Women without evidence of vaginal infection may exhibit transient changes in their flora. We prospectively followed up women by using diaries and self-obtained vaginal smears to correlate behaviors with changes in flora. The majority of women (38/51, 78%) had significant, although transient, changes. Behaviors associated with unstable flora were a history of BV, a greater number of partners, and more frequent episodes of receptive oral sex. Only the latter remained significantly associated in the multivariate analysis. Variables that were associated with day-to-day variability in the flora included use of vaginal medication, menses, greater number of partners, spermicide use, more frequent vaginal intercourse, and less frequent use of condoms. Only a minority of women (11/51, 22%) maintained a “normal” lactobacillus-predominant flora. Factors associated with instability of the flora are similar to those epidemiologically associated with BV.
Article
Stress alters immune function and affects different immune cell populations in different ways. The authors examined whether psychological stress has different effects on the production of macrophage, T-helper 1(Th1) cell, and T-helper 2(Th2) cell-derived cytokines. Forty-two college students were recruited and their blood was sampled on the day they were to take a stressful academic examination and again 4 weeks after the examination. The stress from the academic examination significantly increased IL-1 beta, IL-6, and IL-10 and decreased IFN-gamma production. These findings suggest that examination stress may increase Th2 cell-mediated humoral immunity and macrophage activities and may decrease Th1 cell-mediated cellular immunity.