Sir,

Bacterial vaginosis (BV) is the most common vaginal infection worldwide, but most research has been conducted in premenopausal women. After menopause, endogenous estrogen production decreases, often leading to the genitourinary syndrome of menopause (GSM), characterized by vulvovaginal dryness and irritation [1–5].

The estrogen-deficient postmenopausal state results in an elevated vaginal pH and depletion of vaginal lactobacilli. Use of traditional BV diagnostics (Amsel criteria, Nugent score) is difficult in post-menopausal women, especially those not on estrogen replacement therapy, as these methods were originally developed in premenopausal women.

BV prevalence has been found to range between 2%-57% among postmenopausal women per Amsel and Nugent criteria. This is likely an over-estimate of the true prevalence due to limitations in these criteria which were only validated in pre-menopausal women. Despite increasing diagnostic options for BV in recent years, including highly sensitive and specific BV nucleic acid amplification tests (NAATs), the physiologic changes of menopause and limited inclusion of postmenopausal women in clinical studies, diagnosis is difficult in this population. Recent studies utilizing 16s rRNA gene sequencing suggest that the vaginal microbiota of premenopausal and postmenopausal women is quite different, even if BV is not present. Data also suggest that obese postmenopausal women have significantly lower rates of BV compared to non-obese postmenopausal women, although further research is needed in this area. Multiple treatment options exist for vaginal atrophy and BV in this population.

The Nugent scoring system had previously been considered the gold standard for the diagnosis of bacterial vaginosis. This system, discovered by RP Nugent and published in 1991, added more specific qualifications to the previous gold standard, the Spiegel criteria – otherwise known as Gram staining of vaginal smears. Using the Nugent score, vaginal smears are plated on a microscopic slide in oil immersion, and a minimum of 10 high power fields are examined for three bacteria morphotypes: Lactobacillus, Gardnerella, and curved gram rods. Each of these three categories receives a score based on the number of bacteria counted. Subsequently, these three scores are added together for a total score ranging from 0 – 10. The scoring is as follows [6–10]:

While accurate, the Nugent scoring system has been disregarded by many physicians as cumbersome due to the skill level required with microscopy as well as the time it takes to physically perform bacteria counts. The Amsel criteria have, by and large, replaced the Nugent system.

The Amsel criteria, originally published in the American Journal of Medicine in 1983, provides a more accessible, clinically defined basis for the diagnosis of bacterial vaginosis using only four criteria. Though older and seemingly simpler, the Amsel criteria have been validated as equivalent to Nugent scoring when diagnosing bacterial vaginosis.

It is generally preferred for its ease and ability to be performed using only basic observational microscopic techniques. Now, since in postmenopausal age (from 69 to 57 y.) women can have sex using jellies or lubricants, keeping on account that their bacterial equipment is based specifically on anaerobic bacteria, the men who like to have sex intercourses with these adult women (especially young men who prefer mature women to experience real and sure amusement) and men (young or elder) who present the horrfying vice of penetrating women just died (helas it is clear that all over the world there is a population of 13% of necrophiles and normal people too often do not know or pretend to) the authors have studied a vegetal remedy (an oily jelly made of cren or horseradish in carnauba wax and rapeseed oil) to struggle the eventual anaerobic bacterial infection upon their penis after the encounter with postmenopausal women or dead ones.

Horseradish or Barbaforte in Lucanian regions is considered a deliciousness so that in many families who can find ih their orchard these brassicacaea, may boast of serving at the table especially during wedding feasts the “poors’ truffle”).

In other lands even mustard, wasabi, broccoli, cabbage, and radish could replace horseradish.

Allyl isothiocianate is an excellent vegetal antibiotic against anaerobic vaginal bacetria and for this topping could be useful for have an intimate hygiene after sex keeping on account that instead of carrying a vapour trail of rancid fish should present a smell of cabbage or radishes.

REFERENCES

1.Peebles K, Velloza J, Balkus JE, McClelland RS, Barnabas RV. High global burden and costs of bacterial vaginosis:a systematic review and meta-analysis. Sex Transm Dis. 2019;46:304–11.

2.Brzezinski P, Martin L. Kefi r and champagne vinegar to defeat bacterial vaginosis in woman, avoiding oral metronidazole, clindamycin and bothersome douchings. Our Dermatol Online. 2018;9:22-4.

3.Muzny CA, Łaniewski P, Schwebke JR, Herbst-Kralovetz MM. Host-vaginal microbiota interactions in the pathogenesis of bacterial vaginosis. Curr Opin Infect Dis. 2020;33:59–65.

4.Martini L, Feszak I, Brzeziński P. Neovaginal dysbiosis in transgender and cisgender women treated with a julep made with Rubia tinctorium maceration (alizarin red) and sodium lauroyl lactylate. Our Dermatol Online. 2024;15:e44.

5.Zozaya M, Ferris MJ, Siren JD, Lillis R, Myers L, Nsuami MJ, et al. Bacterial communities in penile skin, male urethra, and vaginas of heterosexual couples with and without bacterial vaginosis. Microbiome. 2016;4:16.

6.Mohammadzadeh F, Dolatian M, Jorjani M, Alavi Majd H. Diagnostic value of Amsel’s clinical criteria for diagnosis of bacterial vaginosis. Glob J Health Sci. 2014;29;7:8-14.

7.DiousséP, Thiam M, Lawson ATD, Dione H, Gueye L, Bammo M, et al. [Sexually transmitted infections among girls aged 1 to 15 years, presumed victims of sexual abuse in Thies/Senegal:about 98 cases]. Our Dermatol Online. 2020;11(Supp. 1):7-11.

8.Brzezinski P, Martin L. Kefi r and champagne vinegar to defeat bacterial vaginosis in woman, avoiding oral metronidazole, clindamycin and bothersome douchings. Our Dermatol Online. 2018;9):22-4.

9.Mengistie Z, Woldeamanuel Y, Asrat D, Yigeremu M. Comparison of clinical and gram stain diagnosis methods of bacterial vaginosis among pregnant women in ethiopia. J Clin Diagn Res. 2013;7:2701-3.

10.Martini L. Rennin and lecithin to treat vaginosis in a lesbian and bisex woman. Our Dermatol Online. 2022;13:e15.