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

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.