Among Indian women, poor psychological well-being is a strong risk factor for the complaint of abnormal vaginal discharge, but reproductive tract infection (RTI) is not.1 In a community-based survey, women who had high scores on a structured instrument for the measurement of common mental disorders (such as depression and anxiety) and those who had numerous medically unexplained physical symptoms (such as tiredness and body aches) had an elevated risk of reporting abnormal vaginal discharge. However, women who had RTIs were not significantly more likely than others to report abnormal discharge.
Researchers surveyed nonpregnant women aged 18-50 years living in Goa, India, between November 2001 and May 2003. Women were randomly selected to participate; those who did not meet inclusion criteria were replaced with women from the same or neighboring households. During interviews, women were asked about socioeconomic factors and about two types of psychosocial factors—those related to gender disadvantage and social support (spousal relationship, autonomy and social integration) and those related to mental health (common mental disorders and unexplained physical symptoms). Common mental disorders, such as depression and anxiety, were assessed with the revised Clinical Interview Schedule (possible range of scores, 0-57), and unexplained physical symptoms were assessed with a scale measuring complaints such as pain and tiredness (possible range of scores, 0-20); for both, higher scores indicate poorer mental health. The women were also asked if they had experienced abnormal vaginal discharge and certain other gynecologic symptoms in the past three months. Vaginal swabs and urine specimens were collected and assayed for diagnosis of five RTIs (chlamydia, gonorrhea, tricho- moniasis, bacterial vaginosis and candidiasis).
Analyses were based on 2,494 women. The majority were Hindu (75%), were married (70%) and worked as homemakers (67%). Eighty-six percent were literate (i.e., able to read and write). Substantial proportions lived in homes that had a toilet (41%) and piped water (44%). However, 33% of women said that their family was in debt, and 32% felt they had trouble making ends meet.
Overall, 15% of the women said that they had recently experienced abnormal vaginal discharge. Sixty percent of these women also reported recently experiencing other gynecologic symptoms—genital itching (reported by 40%), genital sores or blisters (13%), nonmenstrual pain in their lower abdomen (30%) and pain or burning during urination (20%). When women were asked what they believed was causing their abnormal vaginal discharge, the leading cause given was stress and emotional factors, cited by 37% of women. Other perceived causes were excess heat in the body (35%) and infection (31%).
A first multivariate analysis tested associations between socioeconomic factors and a report of abnormal vaginal discharge, using a significance level of p<0.1. In this analysis, the odds of reporting a discharge were higher among women who had experienced hunger in the past three months than among those who had not (odds ratio, 1.8), for women living in homes that did not have a toilet than for other women (1.3), and among women participating in the study as replacements than among randomly selected women (1.4). In contrast, odds were lower among 30-50-year-olds than among 18-24-year-olds (0.4-0.9), and among illiterate women in comparison with literate women (0.6).
A second multivariate analysis tested associations between psychosocial, reproductive and infectious factors, and a report of abnormal vaginal discharge, taking into account the preceding factors and using a significance level of p<0.1.
With respect to gender disadvantage and social support, married women had elevated odds of reporting abnormal discharge if they had been verbally or sexually abused by their husband (odds ratios, 1.4 and 1.9, respectively) or if they were concerned that their husband was having an extramarital relationship (3.5). Women who had medium or low scores for social integration had higher odds than their counterparts with high scores (1.2). Compared with women who had high levels of autonomy, those who had low levels were more likely to report abnormal discharge (1.2).
In terms of mental health factors, women's odds of reporting abnormal discharge increased with their score for common mental disorders and with the score for unexplained physical symptoms. Finally, with respect to reproductive and infectious factors, odds were higher among women who had ever been pregnant than among those who had never been pregnant (1.3), among users of intrauterine devices relative to nonusers (1.9) and among women in whom any RTI was diagnosed in comparison with others (1.3).
A final, composite multivariate analysis that included the preceding factors showed six variables to be independent risk factors for a complaint of vaginal discharge (p<0.05 for each). Compared with women who had a score of zero for common mental disorders, women who had higher scores were more likely to report abnormal vaginal discharge; the odds ratio was 1.6 among women with a score of 5-8 and 2.2 among women with a score greater than 8. Similarly, compared with women who had a score of less than 2 on the scale for unexplained physical symptoms, women with a score of 4-7 had an odds ratio of 3.0 and women with a score of 8 or greater had an odds ratio of 6.2. In addition, odds were higher among IUD users than among nonusers (1.9), and among women participating as replacement subjects than among those who had been randomly chosen (1.3).
In contrast, illiterate women had lower odds than literate women (0.5), and 30-50-year-olds had lower odds than 18-24-year-olds (0.3-0.6). In this analysis, RTIs were not associated with a report of abnormal vaginal discharge.
Complaints of vaginal discharge, the researchers contend, may be an example of medically unexplained symptoms that are influenced by psychosocial factors and vary with cultural context. They acknowledge that women agreeing to participate differed from those declining in some key respects, which may limit the generalizability of the results. Nonetheless, the researchers assert, the findings suggest that modification of the current approach of syndromic management of vaginal discharge is warranted. "In the absence of diagnostic tests," they conclude, "we recommend screening of all women with the complaint of vaginal discharge for psychosocial difficulties and providing appropriate care for such difficulties, simultaneously with the syndromic approach for the treatment of RTIs."
The author of an accompanying commentary2 cautions that the observed associations may have other explanations. The stigma associated with vaginal discharge may undermine psychological well-being, she points out. Or vaginal discharge and psychological distress may have a common cause, such as husbands' extramarital sexual relationships and wives' limited power to negotiate condom use and other protective measures in that situation. "A better understanding of directions and pathways of influence is required—so that women with complaints that are non-infectious in aetiology are offered psychosocial interventions," she concludes.—S. London
1. Patel V et al., Why do women complain of vaginal discharge? A population survey of infectious and psychosocial risk factors in a South Asian community, International Journal of Epidemiology, 2005, 34(4): 853-862.
2. Jejeebhoy S, Vaginal discharge and stress: a commentary on directions of influence, International Journal of Epidemiology, 2005, 34(4):862-863.