Research Findings

Other articles and reports may be found in the bibliography section
JM Marrazzo1 , L Koutsky1, K Stine1, K Agnew1, D Eschenbach1, S Hillier2 University of Washington1, Seattle WA & University of Pittsburgh,2 Pittsburgh PA, USA “Bacterial Vaginosis and Vaginal Lactobacilli in Women Who Have Sex with Women” From conference STIs at the Millennium: Past Present and Future, A joint Meeting of the ASTDA & MSSVD, Baltimore, MD. 3-6 May 2000
This is available in a modified format below.

Marrazzo JM, Koutsky LA, Agnew K, Stine K, Hillier S. “Prevalence and Microbiology of Bacterial Vaginosis in Lesbians.” Thirteenth Meeting of the International Society for STD Research, Denver, CO, July 1999.
This is available in a modified format below.

Marrazzo JM, Koutsky LA, Stine K, Kuypers J, Grubert T, Galloway D, Kiviat N, Handsfield HH. “Genital HPV Infection in Women Who Have Sex With Women.” Journal of Infectious Disease, Dec 1998, pages 1604-1609.
The report on the Lesbian-Bisexual Women’s Study pilot project.

Marrazzo JM, Stine K, Handsfield HH, Kiviat NB, Koutsky LA. “HIV-Related Risk Behavior in a Community-Based Sample of Women Who Have Sex With Women.” XI International Conference on AIDS, Vancouver, Canada, July 7-12, 1996 [abstract #c2483].

Prevalence and Microbiology of Bacterial Vaginosis in Lesbians

Abstract

Marrazzo JM1, Koutsky LA1, Agnew K1, Stine K1, Hillier S2. University of Washington, Seattle, WA, and University of Pittsburgh, Pittsburgh, PA, U.S.A.

Objective: Bacterial vaginosis (BV) has been reported to occur commonly in lesbians. We studied the epidemiology and microbiology of BV in a self-selected group of women who reported sex with women (WSW).

Methods: WSW who reported sex with women in the previous year were eligible. Sexual history was obtained, and vaginal fluid samples collected for wet mount, pH measurement, anaerobic and aerobic cultures, and measurement of H2O2 production. BV was diagnosed by Gram stain (Nugent criteria). Couples were defined by report of monogamy for >3 preceding months.

Results: 68 subjects were examined, of whom microbiology results were available for 52. Of these, 14 (26.9%) had Gram stain scores consistent with BV, 9 (17.3%) were scored as intermediate, and 29 (55.8%) had normal Gram stains. Only 7.1% of subjects with BV reported douching in the previous 6 months, and 42.8% reported never having douched. The median time to last sex with a man among subjects with BV was 4 years; 4 subjects with BV reported never having had sex with a man. Lactobacilli were detected in 50% of all subjects; of these women, 52% had H2O2-producing strains (overall prevalence of subjects with H2O2-producing strains, 36%). 14 couples (28 women) were enrolled. Overall, 79.6% of couples were concordant for the presence or absence of BV (4 couples (28.6%) BV+/BV+; 6 (42.9%) BV-/BV-; 3 (21.4%) BV+/BV-).

Conclusions: Bacterial vaginosis is common in lesbians in the absence of douching or prior or recent sex with men, suggesting that other risk factors for BV exist. The low prevalence of H2O2-producing lactobacilli in these women may account for the high prevalence of BV in this population. Monogamous couples tend to be concordant for the presence or absence of BV. Reasons for these findings, including current sexual practices and characterization of Lactobacilli strains, require further investigation.Bacterial vaginosis (BV) is a condition in which)-producing lactobacilli which overgrowth of commensal anaerobic flora dominates the hydrogen peroxide (H2O2 predominate in the healthy vagina. In heterosexual women, BV is associated with douching and new sex partner.
BV confers an increased risk of preterm delivery, low birth weight, and postpartum / postabortal endometritis.
BV prevalence reportedly high in women who report sex with women (WSW) (29% to 33%) relative to that in prenatal clients (16%) and STD clinic clients (25%).
Female couples had a high concordance for the presence or absence of BV in some studies.
The Institute of Medicine has identified lesbian health as a priority area for research.
Objectives
To study the prevalence and microbiology of BV in WSW and its association with prior or concurrent sex with men, douching history, and sexual behavior with current female partners, by:

Obtaining extensive sexual history
Studying vaginal flora, particularly lactobacilli
Defining the occurrence of BV within couples
Methods
Study Population

Women who reported sex with another women within the prior year
Female couples who had been monogamous for >3 prior months
Study Protocol:

Standardized questionnaire
Physical examination with collection of vaginal fluid
Vaginal fluid assessed with Gram stain, wet mount, pH, KOH, aerobic and anaerobic cultures
Characterization of lactobacilli by H2O2 production
BV defined by Gram stain (Nugent scale)
Association of BV with subjects’ characteristics measured by chi squared analysis, Fisher’s exact test (for proportions) or analysis of variance (for means)
Results
Characteristics of Study Subjects (%)

*included increased or malodorous discharge, or vaginal itching or burning

Association of BV with Subjects’ Characteristics

(1) SP=sex partner
(2) OR for absence of BV (computed w/ Fisher’s exact test because no cases of BV occurred in women reporting no receptive digital-vaginal or oral-vaginal sex) = 0.7; 95% C.I., 0.6, 0.8

Characteristics of Vaginal Fluid

N (%)
Mean (+/- sd) vaginal pH 4.4 (+/-0.4)
Results of Gram stain score
Normal 46 (58)
Intermediate 10 (13)
BV 23 (29)
Presence of any lactobacilli 40 (51)
Presence of H2O2-producing lactobacilli 24 (31)
Other clinical vaginitis
Trichomoniasis 1 (1.3)
Candidiasis 15 (19)
Study of Couples: 15 couples
5 (33%) concordant for BV
7 (47%) concordant for no BV
3 (20%) discordant for BV
Overall, 12 of 15 couples (80%) were concordant for the presence or absence of BV.
G. vaginalis and U. urealyticum were recovered in high numbers (>105 from all couples concordant for the presence of BV.
Due to difficulty with growth media, the presence of genital mycoplasmas in vaginal fluid cultures could not be assessed.
Characteristics of Couples by BV Status

(1) Defined as flora >105 cfu/g
(2) Gardnerella culture performed on 9/10 subjects
(3) Vaginal fluid cultures performed on 13/14 women
(4) Data on sexual history with women available for 8/10 BV+/BV+, 3/6

BV+/BV-, and 13/14 BV-/BV- couples. P <0.05 for comparison of all means to those for couples concordant for normal flora.

Limitations

Subjects were largely asymptomatic volunteers who may not be a representative sample of WSW; findings may not be generalizable to all WSW. This is especially relevant given that 38% of subjects were part of monogamous partnerships.
Small numbers in some subgroups did not allow for multivariate analysis, and detailed sexual history was not available for some couples.
Almost all subjects practiced some sexual behaviors of particular interest (digital-vaginal and orovaginal sex), which precluded meaningful analysis of the relationship of these practices to the presence of BV.
Similarly, few women reported recent sexual activity with men, behavior that would be of comparative interest in terms of association with current BV.
Difficulty with mycoplasma culture media precluded an accurate assessment of the possible role these organisms may play in BV in this

Conclusions

BV was common in our sample of WSW, and was significantly associated with report of ever having participated in receptive digital-anal sex.
BV occurred independently of prior or current sex with males and douching history
Overall prevalence of lactobacilli was low compared to other samples of heterosexual women studied in STD clinic settings.
Of subjects with lactobacilli cultured, few had H2O2-producing strains.
Female couples had a high concordance for the presence or absence of BV(80% overall), but numbers of couples were too small to allow for thorough comparison of behaviors that might be associated with the occurrence of BV.
Vaginal flora associated with BV in WSW are likely to be similar to that associated with BV in heterosexual women, but further study is warranted.

Areas for Further Study

Accrual of additional WSW should expand numbers and ability to more precisely define risk of BV by above characteristics, particularly among couples and women of color, and allow for multivariate analyses
Enrollment of a concurrent control group of heterosexual women for direct comparison of lactobacilli characteristics
Further characterization of lactobacilli by biotyping and presence of bacteriophage, especially within couples
Longitudinal study of the natural history of BV in WSW
Effect of treating sex partner (regardless of BV status) on BV recurrence

Funding Sources

NIH (NIAID), Lesbian Health Fund, 3M Pharmaceuticals