Vulvovaginitis and breast cancer

Among patients receiving standard or high-dose chemotherapy for breast cancer, vulvovaginitis is a frequent reason for referral to the Gynecologic Oncology Center. Vulvovaginitis can occur during or after chemotherapy and is thought to result from an alteration in the vaginal ecosystem due to loss of normal ovarian function. Specifically, myelosuppressive chemotherapy can cause loss of normal ovarian function, which in turn can lead to a decrease in the vaginal epithelial glycogen content and an increase in the vaginal pH, and myelosuppressive chemotherapy can also cause neutropenia. Both higher pH and neutropenia may facilitate the pathogenic behavior of bacteria, fungi, and protozoans coincidentally present in the vagina.

Vaginal infections are usually accompanied by a discharge that is troublesome and noticeable to the patient. Patients describe the discharge as being increased, offensive, and associated with itching or a "burning" sensation at the introitus or urethra. The discharge resulting from vaginal infections is different from the normal physiologic discharge that many women experience, which is white but sometimes leaves a brownish stain on underclothing. More than one type of vulvovaginal infection can be present at the same time, and therefore a careful work-up is essential.

Bacterial Vaginosis
Bacterial vaginosis is the most frequent type of vaginal infection, accounting for approximately 50% of all cases of vaginitis.

Bacterial vaginosis was previously also known as Corynebacterium vaginalis infection and subsequently as Gardnerella vaginalis infection after H. L. Gardner, the clinician who first described it. The pathologic state is believed to involve multiple bacteria, and the incubation period is usually 5-10 days.

The following bacteria are commonly found in the vagina (approximate frequencies of specific infections are shown in parentheses): gram-positive rods such as diphtheroids (40%); gram-positive cocci such as Staphylococcus epidermidis (55%), S. aureus (5%), ?-hemolytic streptococci (20%), and group D streptococci (55%); gram-negative organisms such as Escherichia coli (30%) and Klebsiella species (10%); and anaerobics such as Bacteroides species (40%), Clostridium species (20%), Peptococcus species (65%), and Peptostreptococcus species (35%).

Women with bacterial vaginosis usually complain of a fishy malodorous discharge. The odor becomes more pronounced after intercourse and during the menstrual cycle because the alkalotic environment present at these times leads to the production of aromatic amines. The discharge is usually dark gray, with low viscosity and homogeneous consistency, and is primarily localized and adherent to the vaginal walls. Pruritus is not a common complaint. Three out of the following four criteria should be met before bacterial vaginosis is diagnosed: (1) there is a white or gray vaginal discharge of homogeneous consistency; (2) the pH of the discharge is greater than 4.5; (3) there is an amine-like odor when the discharge is mixed with potassium hydroxide (also known as a positive finding on a whiff test); and (4) at least 20% of the vaginal epithelial cells examined on the wet mount are "clue cells"-cells covered with clusters of cocco-bacilli, which give the cells a granular appearance.