The patient presented with intense pruritus and pain. It usually presents with irritation and vaginal discharge A thorough examination is essential in order not to miss the less common causes. 2010 Nov. 282(5):515-9. Advertising on our site helps support our mission. [QxMD MEDLINE Link]. Bacterial vaginosis can be treated with oral or topical metronidazole, oral tinidazole, or oral or topical clindamycin.9 All options offer equivalent efficacy as initial treatments, so the choice may be based on cost and preferred route of administration. Cartwright et al compared the performance of a multiplexed, real-time PCR assay and Affirm VPIII in 102 patients. Nucleic acid amplification tests are usually not performed as point-of-care tests. Women who cannot or do not want to take hormones may decide to use nonpharmacologic therapies, such as herbal treatments. These forms of estrogen all maintain plasma levels well below 30 pmol/L during steady state. Unless a patients serologic status has already been determined, serologic testing should be done concurrently with HSV culture or PCR testing. A systematic review of 16 randomized trials investigating local estrogen treatment of vaginal atrophy found that creams, pessaries, and rings were all similarly effective in relieving the symptoms. Experts reveal proper usage, potential side . Committee on Gynecologic Practice, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, Sign In to Email Alerts with your Email Address. To a second vaginal sample, a small amount of 10% potassium hydroxide should be added, and the examiner should sniff it. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMjE4ODkzMS10cmVhdG1lbnQ=. [Guideline] Huntzinger A. . 13(1):27-42. Patients allergic to nitroimidazoles should be referred for desensitization. 17(3):340-5. This method is inexpensive and provides immediate results in the clinic. Jessian L. Munoz, MD, PhD, is a resident in the institute. Nonculture-based or nucleic acid tests do not require viable organisms, so they allow for a wider range of specimen storage temperatures and time intervals between collection and processing. Role of mannose-binding lectin in the innate defense against Candida albicans: enhancement of complement activation, but lack of opsonic function, in phagocytosis by human dendritic cells. Diagnosis is based on all of the following: At least 1 symptom (ie, vaginal discharge, dyspareunia, pruritus, pain, irritation, or burning), Presence of parabasal cells and leukorrhea on microscopy (a ratio of leukocytes to vaginal epithelial cells > 1:1).36. Patients may report copious green-yellow mucoid discharge, vulvar or vaginal pain, and dyspareunia. 10(2):435-44. It occurs mostly in perimenopausal woman and is often associated with low estrogen levels. . Pyka RE, Wilkinson EJ, Friedrich EG Jr, Croker BP. However, drug interactions with oral usage must be taken into consideration. Vulvitis is often easily cured once you receive the right treatments. 2006 Oct 18. Investigations may be needed to confirm the diagnosis Candidiasis and bacterial vaginosis are the most common causes. Typical presenting symptoms of vulvovaginitis are itching, burning, and abnormal discharge. The examination should be performed with caution, as the vagina may bleed easily. Clin J Pain. Presented at the Virtual IDWeek 2021. Simple tests of vaginal secretions can often determine the diagnosis (Table 2). Although these are not infectious processes, superimposed infections (mostly bacterial and fungal) may also be present and should be treated. They are more expensive and require special equipment with trained personnel. Katz. [Full Text]. These medications are usually most effective against true. During the 28 weeks of follow-up, recurrences occurred in 51% of treated women vs 75% of those on placebo. [51] biofeedback, The condition reflects a microbial imbalance in the vaginal ecosystem, characterized by depletion of the dominant hydrogen peroxide-producing lactobacilli and overgrowth of anaerobic and facultative aerobic organisms such as Gardnerella vaginalis, Mycoplasma hominis, Atopobium vaginae, and Prevotella and Mobiluncus species. Immunoglobulin M (IgM) testing for HSV-1 or HSV-2 is not diagnostic or type-specific and may be positive during recurrent genital or oral episodes of herpes. Enter multiple addresses on separate lines or separate them with commas. This quality limits them for testing treatment success; if performed too early, they may detect nonviable organisms. Although vulvovaginitis has several possible causes, the typical presenting symptoms are similar regardless of the cause: itching, burning and vaginal discharge. Infections C. albicans can cause acute, recurrent and chronic symptoms that always involve the vagina and may also spread to the vulva. Treatment for recurrent disease. Saline microscopy (Figure 2) with the addition of 10% KOH may reveal the characteristic fungal elements, but its sensitivity is only 50%. Bergeron C, Moyal-Barracco M, Pelisse M, Lewin P. Vulvar vestibulitis. Bergeron S, Binik YM, Khalif S, Pagidas K. Vulvar vestibulitis syndrome: a critical review. Vulvovaginal candidiasis can be clinically diagnosed on the basis of cottage cheese-like clumpy discharge; external dysuria (a burning sensation when urine comes in contact with the vulva); and vulvar itching, pain, swelling, and redness. [48], Interest in isoflavones escalated after observation that Asian women, who consume a much higher quantity of isoflavones than do Western women, experience fewer menopausal symptoms. 36(1):33-51, viii. Evaluating vaginal secretions with simple office-based tools is often sufficient for diagnosis, although DNA testing is also available. Vaginal examination may reveal a pale mucosa that lacks elasticity and rugation. Hydrocortisone cream is a common medication used to treat eczema. DNA tests. 325(7364):586. Oestrogen causes the lining of the vagina to mature and to contain glycogen, a substrate on which C. albicans thrives. Mannose-binding lectin gene polymorphism, vulvovaginal candidiasis, and bacterial vaginosis. Oteseconazole is an oral antifungal approved in April 2022 specifically to reduce the incidence of recurrent vulvovaginal candidiasis (RVVC) in females with a history of RVVC in women who are NOT of reproductive potential (ie, biological females who are postmenopausal or have other reasons for permanent infertility). Nov 2006. [QxMD MEDLINE Link]. Chen J, Geng L, Song X, Li H, Giordan N, Liao Q. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Saline microscopy may show parabasal cells and a paucity of epithelial cells (Figure 4). Potassium hydroxide 10% added to a vaginal sample and microscopy performed at 40 magnification reveals yeast. 2013 Jun. [42] Serum estrogen is slightly increased but usually remains in the menopausal range. A comparative study of safety and efficacy of continuous low dose oestradiol released from a vaginal ring compared with conjugated equine oestrogen vaginal cream in the treatment of postmenopausal urogenital atrophy. Healing was noted to be prolonged, and complications such as scarring and further pain led to the general abandonment of this technique. Maturitas. Do not use leave-on moist wipes, antiperspirants or other cosmetics in the vulva. 155, 1008-1012. Prim Care. Mosby; Elsevier; 2007. A number of trials have used alpha interferon and have noted some success with it. [Full Text]. 2007 Apr. Drug interactions may occur with simultaneous use of calcium channel antagonists, warfarin, cyclosporine, oral hypoglycemic agents, protease inhibitors, theophylline, and rifampin, to name a few. [49]. 351(9):876-83. Obstet Gynecol. Although it is more expensive than testing for the Amsel criteria, it is commonly used in private offices because it is simple to use, gives rapid results, and does not require a microscope.6 Insurance pays for it when the test is indicated, but we know of a patient who received a bill for approximately $500 when the insurance company thought the test was not indicated. (Figure 6). If the culture is positive, the patient should be treated with fluconazole 150 mg orally every 3 days for 3 doses.14, Patients with recurrent episodes (3 or more in 12 months) should follow initial treatment with maintenance therapy of weekly fluconazole 150 mg orally for 6 months.15. Atrophic vaginitis. Preparations for intravaginal administration of butoconazole, clotrimazole, miconazole, and tioconazole are available OTC. Saline microscopy. Unless a patients serologic status has already been determined, serologic testing should be done concurrently with HSV culture or PCR testing. We do not endorse non-Cleveland Clinic products or services Policy. Infection of the minor vestibular gland. 74. High-potency topical steroids are the mainstay of therapy for lichen disease. 1996 Jan. 174(1 Pt 1):85-92. Nonspecific tests (e.g., Tzanck smear, direct immunofluorescence) are neither sensitive nor specific and should not be relied on for diagnosis. [40]. Determining the cause is key to successful treatment. All Rights Reserved. Treatment involves use of 2 percent intravaginal clindamycin or 10 percent intravaginal compounded hydrocortisone cream for four to six weeks. A double-blind, placebo-controlled trial. BMJ. Mild topical steroids such as hydrocortisone cream are often combined with intermittent oral fluconazole. Cochrane Database Syst Rev. This medication is used to treat a variety of skin conditions (such as insect bites, poison oak /ivy, eczema, dermatitis, allergies, rash, itching of the outer female genitals, anal itching . If pH paper, KOH and a microscope are unavailable, other point-of-care tests can be used for specific conditions as discussed below. Turner ML, Marinoff SC. J Infect Dis. Jill M Krapf, MD, MEd, FACOG, NCMP, IF is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, American Congress of Obstetricians and Gynecologists, International Society for the Study of Vulvovaginal Diseases, International Society for the Study of Womens Sexual Health, North American Menopause SocietyDisclosure: Nothing to disclose. To date, studies have shown no overall difference in the in vitro activity and clinical efficacy of the various azole topical agents, used in the treatment of uncomplicated cases (see Table 1, below). Woodruff and Parmley developed the original surgical mode of treatment, describing a U-shaped excision of the posterior hymenal ring 0.5 cm on each side of the hymen, starting 0.5 cm below the urethra on each side. Management of candidiasis. Challenges in diagnosing vulvovaginitis are many and include distinguishing contact from allergic dermatitis, recognizing vaginal atrophy, and recognizing a parasitic infection. The liquid-based Pap test is more accurate for microscopic diagnosis, and its results can be used to determine if treatment is needed (sensitivity 60 percent to 90 percent; specificity 98 percent to 100 percent). Accessed: August 22, 2013. * Vaseline or 1% hydrocortisone ointment to use 2-3 times daily. You may also have an abnormal vaginal discharge. 3rd ed. Dermatol Clin. 2008 May. Because the etiology of pain in vulvar vestibulitis is neuropathic, research has focused on pharmacologic treatment that addresses neuropathic pain. Diagnosis. This article reviews the diagnosis and treatment of many common and less common infectious and noninfectious causes of vulvovaginitis, the use of special tests and the management of persistent cases. If endogenous estrogen levels are high, they exhibit antiestrogenic effects; however, in postmenopausal women in whom levels are diminished, they are found to exhibit estrogenic properties. This website also contains material copyrighted by 3rd parties. [QxMD MEDLINE Link]. In addition to medical treatment, studies have shown that ingested sucrose and lactose may support and promote the growth of yeast. Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Biggs WS, Williams RM. Lichen sclerosus is a benign, chronic, progressive dermatologic condition characterized by marked inflammation, epithelial thinning and distinctive dermal changes accompanied by pruritus and pain. It is contraindicated in females of reproductive potential and in pregnant females because of the risk for embryofetal toxicities. Additional treatment can include antihistamines and sodium bicarbonate sitz baths. Patients who are not cured with single-agent therapy may benefit from compounded clindamycin and hydrocortisone, with estrogen added to the formulation for hypoestrogenic patients. Heavy vaginal discharge may also be normal. Initial treatment. Infection should be considered and treated as needed. 2012 Jan. 16(1):24-9. However, most of the common antifungals may not be effective against non-albicans Candida. CD001500. A predominance of immature cells indicates a hypoestrogenic state. Reichman et al11 treated women with oral metronidazole or tinidazole 500 mg twice a day for 7 days, followed by vaginal boric acid 600 mg daily for 21 days. Adverse effects also can include nausea, abdominal pain, and headaches. Lillegard JB, Sim RB, Thorkildson P, Gates MA, Kozel TR. Numerous studies have used different treatment regimens; treatment usually is selected based on clinician preference. The pH can help determine likely diagnoses and streamline further testing (Figure 1). Patients may report copious green-yellow mucoid discharge, vulvar or vaginal pain, and dyspareunia. A side effect of therapy is vulvovaginal candidiasis, which should be treated as needed. [QxMD MEDLINE Link]. Ferri. Inhibition of CYP51 results in accumulation of 14-methylated sterols, which may be toxic to fungi. In rare cases, black cohosh can cause stomach upset. 2006 Sep 21. Typical presenting symptoms of vulvovaginitis are itching, burning, and abnormal discharge. All that itches is not yeast. Centers for Disease Control and Prevention. Sensitivities range from 76 percent to 100 percent, making these tests more suitable for screening and testing of asymptomatic women, in whom the concentration of organisms may be lower. It is a diagnosis of exclusion, and some patients may have a superimposed bacterial infection. [47]. Patients with recurrent bacterial vaginosis despite therapy should be referred to a vulvo-vaginal or infectious disease specialist. (P=.034). He noted that calcium oxalate crystals released in urine might act as an irritant in the development of vulvar vestibulitis. DNA tests. In a study of 109 patients with symptoms of vulvovaginitis, the Affirm VPIII was found comparable to saline microscopy when tested on residual vaginal samples. Atrophic vaginitis. . Affirm VPIII (BD Diagnostics, Sparks, MD) is a nonamplified nucleic acid probe hybridization test that detects Trichomonas vaginalis, Candida albicans and G vaginalis. Diagnosis. Once symptoms improve, continuation of treatment at decreased intervals is necessary for maintenance. Balanitis. This was followed by twice-weekly vaginal metronidazole gel for 16 weeks. Halperin R, Zehavi S, Vaknin Z, Ben-Ami I, Pansky M, Schneider D. The major histopathologic characteristics in the vulvar vestibulitis syndrome. Data are limited, however, and no information is available on toxicity. If these treatments are unsuccessful, the patient should be referred to an infectious dis ease specialist or gynecologist who specializes in vulvovaginal disorders. Lichen planus Vulvovaginal lichen planus, a subtype of lichen planus, is characterized by erosive, papular, or hypertrophic lesions on the vulva, with or without vaginal involvement. [QxMD MEDLINE Link]. J Sex Med. [QxMD MEDLINE Link]. It is intended to be used continuously for 90 days and can be used during sexual intercourse. Practice-Changing Data on Low ER+ Breast Tumors? Courtesy of Centers for Disease Control and Prevention (CDC). Triamcinolone ointment (0.1%) applied twice daily can help in irritant contact dermatitis. Horowitz BJ. Copyright 2023 The Cleveland Clinic Foundation. Reichman et al treated women with oral metronidazole or tinidazole 500 mg twice a day for seven days, followed by vaginal boric acid 600 mg daily for 21 days. A case report. Severe lesions can be treated with wet compresses of aluminum acetate solution for 30 minutes several times per day. Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. I've used it before. If you log out, you will be required to enter your username and password the next time you visit. 1997 Apr. 10 percent KOH whiff test and microscopy. [QxMD MEDLINE Link]. Liu F, Liao Q, Liu Z. Mannose-binding lectin and vulvovaginal candidiasis. The Vaginal Maturation Index is an indicator of the maturity of the epithelial cell types being exfoliated; these normally include parabasal (immature) cells, intermediate, and superficial (mature) cells. These can make her symptoms worse. Patients are also advised to wear loose-fitting, nonocclusive clothing and cotton underwear to avoid providing the warm, moist climate in which Candida tends to thrive. [46], Black cohosh (Cimicifuga racemosa) is marketed as a precursor of progesterone that has estrogenlike effects. [QxMD MEDLINE Link]. Horowitz BJ, Edelstein SW, Lippman L. Sexual transmission of Candida. A thorough history and physical examination are always warranted. 2006 Jun 1. In considering treatment, distinguishing between sporadic and recurrent episodes of vulvovaginal candidiasis is of great importance. A Phase 3, Randomized, Double-Blind Study to Evaluate the Efficacy and Safety of Oteseconazole (VT-1161) Oral Capsules versus Fluconazole and Placebo in the Treatment of Acute Vulvovaginal Candidiasis Episodes in Subjects with Recurrent Vulvovaginal Candidiasis (ultraViolet). Reportedly successful regimens for refractory trichomoniasis include 14 days of either: Oral tinidazole 500 mg 4 times daily plus vaginal tinidazole 500 mg twice daily29, Oral tinidazole 1 g 3 times daily plus compounded 5% intravaginal paromomycin 5 g nightly.30, HSV (HSV-1 and HSV-2) causes lifelong infection. Eriksen PS, Rasmussen H. Low-dose 17 beta-estradiol vaginal tablets in the treatment of atrophic vaginitis: a double-blind placebo controlled study. Hydrocortisone (0.5-1%) and fluorinated corticosteroids in lotions or creams may help to reduce symptoms of contact dermatitis. Allergic dermatitis, also contactant-induced, but immunologically mediated. Favorable response was gauged by improvement of clinical symptoms, such as dyspareunia. Sobel et al13 documented successful treatment of non-albicans Candida using boric acid and flucytosine. Part 1: Symptoms and their correlates. Copyright 2017 The Cleveland Clinic Foundation. [QxMD MEDLINE Link]. A one-year multicenter study of efficacy and safety of a continuous, low-dose, estradiol-releasing vaginal ring (Estring) in postmenopausal women with symptoms and signs of urogenital aging. This article reviews the diagnosis and treatment of many common and less common infectious and noninfectious causes of vulvo-vaginitis, the use of special tests, and the management of persistent cases. Phytoestrogens are naturally occurring plant sterols that have estrogenic and antiestrogenic effects in humans. A small study of menopausal Thai women demonstrated that only 27% of them reported menopausal vasomotor symptoms, as opposed to 85% of Western women. Cyclic vulvovaginitis refers to recurrent thrush or thrush-like symptoms related to the menstrual cycle. FIGURE 4. Comprehensive Gynecology. FIGURE 3. 2006 Jan. 92(1):43-7. Other nonhormonal therapies include vaginal moisturizers and lubricants. Studies, although limited, have demonstrated small increases in vaginal superficial cells with the ingestion of isoflavone. Ferri's Clinical Advisor 2009. [34]. Episodic or continuous suppression therapy may be needed for patients experiencing more than four outbreaks in 12 months. [QxMD MEDLINE Link]. Trichomonas can cause itching and an offensive discharge. Patients who do not respond to treatment should be referred to an infectious disease specialist and undergo a viral culture with sensitivities. Nachtigall et al compared the effect of a moisturizer (Replens) with that of conjugated estrogen cream (Premarin) in a randomized 12-week trial with 30 patients and found that, although both agents were effective, estrogen therapy was more effective in restoring vaginal elasticity and reversing vaginal atrophy. 1992 Apr 21. The recommended dosage is for a maximum duration of 6 months. Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine Edema, fissures, and excoriations may be seen on examination of the vulva. FIGURE 2. Treatment for recurrent disease. SUMMARY Vulvovaginitis is a commonly encountered problem in general practice. 2009 Mar. Patients with persistent itching despite treatment should be referred to a specialist to search for another cause. Diagnosis. Before puberty, your child isn't making estrogen, which means the skin around their vulva is thin. Azole compounds, found in antimycotic drugs, are believed to block ergosterol production, allowing topical antimycotics to achieve cure rates in excess of 80%. 91(4):572-6. Similar results have been reported with estrogen vaginal tablets. PCR was much more sensitive (97.7% vs 58.1%) but less specific (93.2% vs 100%), with culture serving as the gold standard. [38, 39]. Contact dermatitis is classified into two types: Irritant dermatitis, caused by the destructive action of contactants, e.g., urine, feces, topical agents, feminine wipes. 2005. Desquamative inflammatory vaginitis is a chronic vaginal disorder of unknown cause. Am J Obstet Gynecol. Potassium hydroxide 10% added to a vaginal sample and microscopy performed at 40 magnification reveals yeast. Fungal culture remains the gold standard for diagnosis and is needed to determine the sensitivity of specific strains of Candida to therapy. 1989 Mar. Mucoid or purulent discharge may be seen. Allergic dermatitis, also contactant-induced, but immunologically mediated. Saline microscopy shows increased parabasal cells and leukorrhea (Figure 3). Table 1. Lifestyle and home remedies. A 2-week interval is recommended between the end of treatment and retesting.25, Nonamplified tests such as Affirm VPIII and the Osom Trichomonas Test (Sekisui Diagnostics, Lexington, MA) are 40% to 95% sensitive, depending on the test and reference standard used, and 92% to 100% specific.26,27. Vaginal secretions should be analyzed in the following order: Testing the pH. All rights reserved. [QxMD MEDLINE Link]. They then bind with and activate human estrogen receptors. Postmenopausal vaginal atrophy and atrophic vaginitis. Pandit L, Ouslander JG. Help your child remember to not wear tight-fitting clothes or undergarments. The vaginal pH is usually elevated. Interferon therapy for condylomatous vulvitis. Systemic diseases, such as eczema and psoriasis, may also present with gynecologic symptoms. Non-albicans Candida may be azole-resistant, and fungal culture and sensitivity should be obtained. Bacterial vaginosis causes a non-irritating discharge. Vulvar and vaginal symptoms are most commonly caused by local infections, but other causes must be also be considered, including several noninfectious ones (Table 1). Studies, although short-term, have not demonstrated an association between the use of unopposed estrogen and the risk of endometrial proliferation and possible subsequent endometrial carcinoma. The Replens increased elasticity over a longer period of time. Culture. Taking a 25 mg Benadryl tablet at night can reduce . Although an optimal regimen has not yet been established, treatments include ketoconazole (400 mg/day), itraconazole (50-100 mg/day), fluconazole (100 mg/wk for 6 wk), and clotrimazole (500-mg vaginal suppositories once per wk). Eur J Obstet Gynecol Reprod Biol. It has been linked to preterm delivery, intra-amniotic infection, endometritis, postabortion infection, and vaginal cuff cellulitis after hysterectomy.3 It may also be a risk factor for human immunodeficiency virus (HIV) infection.4. Foxman B, Muraglia R, Dietz JP, Sobel JD, Wagner J. Treatment can be continued indefinitely, although safety data for treatment beyond 1 year have not been established. Uncomplicated cases can be managed with prescription or over-the-counter topical or oral antifungal medications for 1 to 7 days, depending on the medication.9 However, most of the common antifungals may not be effective against non-albicans Candida. In a study of patients with symptomatic vaginitis, Affirm VPIII detected Candida in 11 percent of samples, whereas microscopy detected it in only 7 percent. Fertil Steril. Ayton RA, Darling GM, Murkies AL, Farrell EA, Weisberg E, Selinus I, et al. 2006 Apr. 588-596. 1987 Jun. [QxMD MEDLINE Link]. 1997 Oct. 314(4):228-31. Vulvovaginal candidiasis is the second most common cause of vaginitis. An oral estrogen regimen can also be used. The incidental finding of T vaginalis on a conventional Papanicolaou (Pap) smear has poor sensitivity and specificity, and patients diagnosed with T vaginalis by conventional Pap smear should have a second test performed. Presenting symptoms include vulvar or vaginal pain and dyspareunia. A randomized, multicenter, double-blind study by Kroll et al that included 550 sexually active postmenopausal women with moderate-severe dyspareunia reported that lower-dose estradiol vaginal cream (0.003%) dosed three applications/week reduced the level of dyspareunia, decreased vaginal pH, and improved vaginal cytology when compared to the placebo. Table 1. 9500 Euclid Avenue , Cleveland , Ohio 44195 | 800.223.2273 | TTY 216.444.0261, Hormone Therapy for Prevention Requires a Nuanced Approach, Race and Ethnicity Affects Care for Patients with Endometriosis, The Art and Science of Diagnosing Vaginitis, Vaginal boric acid 600 mg daily for 14 to 21 days, Flucytosine in 15.5 percent vaginal cream, intravaginally administered as 5 g for 14 days, Amphotericin B 50 mg vaginal suppositories for 14 days, Oral metronidazole 500 mg twice a day for seven days, Oral metronidazole or tinidazole, 2 g daily for five days, Oral tinidazole 500 mg four times daily plus vaginal tinidazole 500 mg twice daily, Oral tinidazole 1 g three times daily plus compounded 5 percent intravaginal paromomycin 5 g nightly, At least one symptom (i.e., vaginal discharge, dyspareunia, pruritus, pain, irritation or burning), Presence of parabasal cells and leukorrhea on microscopy (a ratio of leukocytes to vaginal epithelial cells > 1:1).