Modern aspects of the treatment of bacterial vaginosis in women of childbearing age

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Introduction. Genital infections are widespread among girls and women. This is due to the fact that microorganisms that are conditionally pathogenic and are normally present in the body may, under certain conditions, exhibit pathogenic properties. One of these significant diseases is bacterial vaginosis. This is a polymicrobial inflammation, which is characterized by a violation of the microflora (dysbiosis) of the female body's vagina: there is a decrease in the number of lactobacilli Lactobacillus spp. and an increase in opportunistic anaerobic microorganisms Gardnerella vaginalis, Megasphaera spp., Atopobium vaginae, Dialister spp., Streptococcus viridians, Mycoplasma spp. They form a pathogenic biofilm on the mucosa, which can interfere with the formation of the therapeutic effect of drugs. Mechanism of disease development: Lactobacilli (Lactobacillus spp) of the healthy vaginal ecosystem, under the influence of female sex hormones-estrogens, convert glycogen into lactic acid during glycolysis, providing an acidic environment in the genital tract of women (pH 4.0-4.5). With a lack of lactobacilli, Lactobacillus spp. the acidic environment shifts to an alkaline one, which promotes the division and growth of pathogenic microorganisms, mainly Gardnerella vaginalis. Gardnerella vaginalis synthesizes and secretes the enzyme vagolysin, which destroys the epithelial cells of the vaginal mucosa and has a toxic effect on the microflora of the female genital tract. A marker of this disease is excess carbohydrates due to cytolysis of the vaginal epithelium. Bacterial vaginosis is not a threat to women's lives, but it can cause such things as premature birth, pelvic organ abscesses, and endometritis. The causes of bacterial vaginosis are changes in the structure of the vaginal mucosa (for example, injury, the influence of pathogenic microflora, lack of barrier methods of contraception, frequent change of sexual partners, non-compliance with personal hygiene rules, the use of intrauterine devices, hormonal changes, and termination of pregnancy). The clinical picture is represented by copious secretions (about 15-20 ml) of gray color with a "fishy" odor; unpleasant sensations in the form of discomfort, burning in the area of the external genitalia; soreness during urination, sexual intercourse. Edema, dryness, and changes in the color of the mucous membrane are not observed in bacterial vaginosis. [1, 2].
The purpose of the work. The study of modern approaches to the treatment of bacterial vaginosis among women of the reproductive period.
Materials and methods of research. More than 30 literature sources were analyzed: scientific articles, dissertations, statistical data on approaches to the treatment of bacterial vaginosis.
The results of the study. It has been established that the therapy consists of 2 stages, which include:
1. Taking antibacterial agents that contribute to the disruption of the division and growth of pathogenic microorganisms
2. Taking medications necessary to restore the growth and development of lactobacilli.
Among the antibacterial agents used are Metronidazole, Tinidozole, Clindamycin-Vertex, Dequalinium chloride, Rifampicin.
Metronidazole is an antimicrobial, antiprotozoal drug, a derivative of 5-nitroimidazole. The reduced 5-nitro group interacts with the DNA of microorganisms, reducing the rate of nucleic acid synthesis, which leads to the death of microflora. The drug has a high bioavailability (about 80%), accumulates in the vaginal secretions, thereby prolonging the effect (due to the delayed release of the active substance, the duration of action of the drug increases). It is used in the form of tablets at a dose of 400-500 mg 2 times a day for 5-7 days, in the form of a gel (0.75%) 1 time a day for 5 days and in the form of vaginal suppositories (0.5 g before bedtime for 5 days). Side effects from the genitourinary system are cystitis, candidiasis, red-brown urine staining; from the digestive system - intestinal colic, nausea, vomiting. Contraindications to use are pregnancy (1st trimester), lactation, liver failure, kidney failure.
Tinidozole is an antibacterial agent that inhibits the synthesis of bacterial genetic material and causes damage to it. It has a very high bioavailability (about 100%). This leads to the widespread use of this drug. During the metabolism of Tinidazole in the liver, derivatives of substances are formed that enhance the effect of the drug. When taking this drug, there will be dry mouth, fatigue, and itchy skin. The main contraindication is the 1st trimester of pregnancy and lactation. During the 2nd and 3rd trimesters, Tinidazole should be taken with caution and in cases where the benefit to the pregnant woman outweighs the risk to the fetus. The drug is taken orally as a tablet, 2 g 1 time per day for 3 days or 1 g 1 time per day for 5 days.
Clindamycin, a lincosamide group drug that binds to the 50S subunit of the ribosome and inhibits microbial protein synthesis, is widely used in gynecology. It is rapidly absorbed into the gastrointestinal tract, has a high penetrating ability into the fallopian tubes, the vaginal mucosa, and wound surfaces. It is applied intravaginally in the form of a cream 2% 5.0 once a day (at night) for 3-7 days and in the form of tablets (0.3 g 2 times a day for a week). It has the shortest (3-day) intravaginal course of treatment. Side effects from the genitourinary system are vulvovaginitis, menstrual disorders; from the nervous system-headache, from the skin-itching, rash.
Dequalinia chloride is an antiseptic agent that has an antibacterial, bacteriostatic effect against Gram-positive and Gram-negative microorganisms. It is used for frequent recurrences of vaginosis for 6 days 1 time a day in the form of a tablet before bedtime.
Rifaximin is a broad-spectrum antibiotic. By inhibiting the synthesis of RNA and the enzyme RNA polymerase, it suppresses the reproduction of bacteria that cause bacterial vaginosis. It has a good ability to bind to plasma proteins (about 89%), which is more effective against microorganisms. Taking this drug can lead to impaired vision, menstrual cycle, and urticaria. Apply Rifaximin daily for 5 days at 0.025 grams. [3, 4].
Comparing the drugs used in antibiotic therapy, it was found that Dequalinium chloride is the most effective remedy in the fight against bacterial vaginosis. It actively counteracts Gardnerella vaginalis, Megasphaera spp., Atopobium vaginae and other pathogens, and, unlike Metronidazole and Clindamycin, is active against fungi of the genus Candida. Metronidazole is more effective in the form of tablets and vaginal suppositories, while Clindamycin is more effective in the form of vaginal cream and tablets. Chlorhexidine and iodine preparations have no proven efficacy. Povidone-iodine can cause allergic reactions.
The next step is to prescribe therapy to restore the vaginal microflora. At the same time, vitamin C, lactic acid and probiotics are used. Vaginorm-C (the active substance is ascorbic acid) is used to lower the pH of the vagina by inhibiting the reproduction and growth of microorganisms. It helps to restore the natural acidic environment of the female genital tract (it is used in the form of tablets 1 time a day before bedtime for 6 days). Lactic acid (Lactagel) is sometimes used as monotherapy, which is a natural biological antiseptic and immunocorrector (used intravaginally as a gel to maintain vaginal acidity at the end of a course of antibiotics, 1 tube 1 time a day for 4-5 days). Of the probiotics, Vagilak (1 capsule with meals), Lactoginal (1 vaginal candle 1 time a day) and Triogenal (1 capsule each morning and evening intravaginally) are used [5].
In the treatment of bacterial vaginosis, it is necessary to refrain from sexual activity, as well as to stop using products intended for intravaginal administration (for example, tampons, syringes).
Conclusion. Proper treatment of bacterial vaginosis in women of reproductive age is achieved through the use of antibiotic therapy and the subsequent use of drugs that restore normal vaginal microflora.

About the authors

Snezhana Olegovna Popova

Burdenko Voronezh State Medical University

Author for correspondence.
Email: snezhana.popova.2006@mail.ru
ORCID iD: 0009-0009-6184-2360
Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

Sofia Sergeevna Kolesnikova

Burdenko Voronezh State Medical University

Email: skolesnikova1@mail.ru
ORCID iD: 0009-0001-9815-6366
Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

Mariya Yurievna Leshcheva

Burdenko Voronezh State Medical University

Email: pantera7695@mail.ru
ORCID iD: 0000-0002-9696-3893
Russian Federation, 10 Studencheskaya str., Voronezh, 394036, Russia

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