Elsevier

Women's Health Issues

Volume 14, Issue 1, January–February 2004, Pages 14-18
Women's Health Issues

Article
Acceptability of a self-sampling technique to collect vaginal smears for gram stain diagnosis of bacterial vaginosis

https://doi.org/10.1016/j.whi.2003.12.001Get rights and content

Abstract

To diagnose asymptomatic bacterial vaginosis (BV), self-sampled vaginal smears were collected during a study of risk factors for preterm birth in African American women. More than 90% of those women who were willing to participate in the interview portion of the study were also willing to provide a self-sampled vaginal smear. The smears are an acceptable and efficient way of detecting BV in an urban minority population.

Introduction

Bacterial vaginosis (BV) is a significant public health problem. Depending on the population, it has been found to have a prevalence of between 15% and 30% in nonpregnant women in the United States, with African American women being particularly at risk (Goldenberg et al., 1996, Holzman et al., 2001). During an episode of BV, the typically dominant vaginal bacteria, lactobacilli, decrease markedly in number and a polymicrobial mix of other organisms, including Gardnerella vaginalis, mycoplasma, and various anaerobes, dramatically increase in concentration with a concomitant increase vaginal pH. Typical symptoms include an abnormal vaginal discharge or a fishy odor after sex (owing to the volatilization of the bacterial amines in the presence of the high-pH semen); however, many cases of bacterial vaginosis are asymptomatic. BV is associated with an increased risk for many serious upper genital tract problems, including pelvic inflammatory disease and cervical intraepithelial neoplasia (McNicol et al., 1994, Paavonen et al., 1987). Pregnant women with BV are at increased risk for preterm birth, amniotic fluid infection, and endometritis (Hillier et al., 1988, Gravett et al., 1986, Holst et al., 1994). Furthermore, recent domestic and international studies have shown that BV is a significant risk factor for acquisition of HIV (Cohen et al., 1995, Hillier, 1998, Martin et al., 1999, Sewankambo et al., 1997, Taha et al., 1999).

One of the difficulties with research involving BV is the frequency of recurrence even after successful treatment. Full resolution, or partial resolution, may be difficult to assess when a patient is seen in an office visit only once every 3 months if her flora are changing on a monthly, or even weekly, basis. Furthermore, these recurrent episodes, even when asymptomatic, may contribute to future health problems (Hay, 2000) Unfortunately, owing to difficulty in obtaining repeated samples, only a few studies have been able to effectively assess changes in women's vaginal flora over time (Hay, Ugwumadu, & Chowns, 1997).

As part of an ongoing prospective cohort study of preterm birth in African American women in Baltimore City, self-sampled vaginal smear specimens are collected in the prenatal clinic. The self-samples are collected privately by the patients following verbal and written instructions from our interviewers. This protocol could be easily adapted to a home setting for daily, weekly, or monthly monitoring of women's vaginal flora. The purpose of this substudy was to determine whether vaginal self-sampling techniques can be a useful adjunct to both basic and clinical research—for example, when clinician compliance to research protocols is low or when women are reluctant to receive an internal examination. The analysis presented here assesses whether the self-smear protocol for BV was acceptable to this relatively high-risk population by assessing willingness to provide smears. Because one of the concerns of the study investigators was that comfort with one's own body could vary by age, willingness was analyzed by age. Smear quality was also qualitatively assessed to determine whether these samples were an acceptable substitute to physician-provided samples, which were difficult to obtain in the overarching study.

Section snippets

Methods

Women were recruited into the overarching study during a prenatal care visit between week 22 and week 28 of gestation. All eligible women—pregnant, African American, Baltimore City residents—receiving care at one of the study clinics were invited to enroll. The women in this substudy were those enrolled from November 2001 (the start of the self-sampling protocol) through the end of June 2003.

After women consented to provide a self-sampled smear, they were given two sterile-wrapped Dacron (or

Results

The study population consists of the first 306 women enrolled in an ongoing prospective cohort study after the self-sampling protocol was initiated. Participants were all pregnant, African American, Baltimore City residents receiving care at one of three outpatient clinics associated with Johns Hopkins Hospital, and were between the ages of 13 and 40 with approximately one quarter of the women under the age of 20.

The self-sampling procedure was highly acceptable to women. Willingness to provide

Discussion

Women are very interested in self-sampling techniques for the diagnosis of vaginal infections (Mercer et al., 1995, Serlin et al., 2002). Diagnosis based on self-obtained vaginal samples has previously been reported for bacterial vaginosis, Chlamydia, group B Streptococcus infection, and human papillomavirus (Coutlee et al., 1997, Domeika and Drulyte, 2000, Domeika et al., 1999, Mercer et al., 1995, Sturm et al., 2002, Wiesenfeld et al., 1996) However, these sampling procedures have not

Acknowledgements

The prospective cohort study under the auspices of which this research was done was funded by NIH Grant #1R01HD038098. Elizabeth Boskey was funded to work on this study as a postdoctoral fellow under NIH Grant #1F32HD40718.

Elizabeth Boskey is a biophysicist and epidemiologist interested in the role of the vaginal flora in women's reproductive health.

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