Prevalence of Vaginal Infections in Women under Screening to HPV Infection and Cervical Lesions in Brazilian Basic Health Service

Introduction: Vaginal infections and inflammations are re sponsible for the most demand at gynaecology, because the main complains are leucorrhea and vulvovaginitis, there is a specifically interest in cervix cancer prevention. Aim: The aim of this study is to understand the prevalence of vaginal infections cases and cervical lesions, found in women attended at health basic units from Igarapava, São Paulo state, Brazil. Methods: There were analyzed retrospectively 1,071 cas es of cytopathological exams from SUS (Brazilian Unique System of Health) during the period of January 2013 to July 2016, patients from Igarapava city, São Paulo state. Results: Gardnerella vaginalis was the most common ly found microorganism in the four years studied with the highest prevalence in 2014 with 46.8%. This study identified that all cases of Gardnerella vaginalis are associated with Mobiluncus sp. Candida sp should decrease gradually over the years, in 2013 (36.9%) and 2016 (16.9%), as well as the decrease of normal bacterial flora (Lactobacillus) with 11% only in 2016. Trichomonas vaginalis should increase in 2016 (37.5%) compared to 2014 (31.2%), and finally just found two cases of cervical intraepithelial neoplasia grade I. Conclusion: In view of the values obtained from bacterial, fungal and protozoal genital infections, there is a need for a better follow-up of the women screened, both in terms of prevention of these infections, as well as infections relat ed to the development of tumors, knowledge of the signs and symptoms of these infections, as well as specialization courses for professionals to better assist these women, in order to guarantee health and quality of life.


Introduction
Cytopathological exam of the cervical membrane, known as Papanicolaou, was adopted at fifties, as a method which can identify pre-cancerous lesions [1] and consists at observation of exfoliated sloughed off cells from external (ectocervix) and internal (endocervix) part of cervix [2].
More than ever, Papanicolaou has been helping at inflammation and infections detections of the feminine genital tract, evaluating the intensity and the possible etiological causes [3,4].

RESEARCH ARTiClE
Check for updates ISSN: 2643-4008 development, as report in the literature [14,15].In this sense, the present study aimed to verify the prevalence of microorganisms that are normally found in the vaginal and cervical microbiota, in addition to verify the prevalence of agents that cause infections e lesions in vaginal and cervical in women attended to basic health units of Igarapava, SP, Brazil.

Methods
There were analyzed retrospectively 1,071 cases of cytopathological exams from SUS (Brazilian Unique System of Health) during the period of January 2013 to July 2016, patients from Igarapava city, Sao Paulo state, which presents a population of 25,950 citizens, being 12,762 men and 13,163 women.The evaluated populational sample corresponds to 8.14% of feminine people, being 6807 (51.7%) women between 25 and 60 years of age.This study was approved by the Research Ethics Committee from the Faculty of Human Talent, Uberaba, Minas Gerais, Brazil, under the protocol number 0060/2016.

Cervicovaginal samples were analyzed by Cancer
Hospital of Barretos, that has an agreement with Igarapava city.Cytological samples were obtained by collecting cervix-vaginal material performed with the help of an Ayre and cytobrush spatula, or only vaginally for hysterectomized patients.After fixation of the material, the smears were stained by the Papanicolaou method and analyzed under an optical microscope in increments of 100X and 400X, and possibly 1000X for confirmation of the microorganisms.The results were expressed according to the Bethesda System.Data were obtained from database of Municipal Secretary of Health from Igarapava, São Paulo state, where all the information about the exams was collected, such as age of the volunteer and year of sampling.All the women with insufficient sample for analysis were discarded, including all the ages.The therapeutic conducts performed by the medical team were not reported in the database.
The different variables obtained information from the database were tested for normal distribution.When distribution was non normal, nonparametric tests were performed, test of Kruskal-Wallis test, and Dunn's Multiple Comparison Test.The results were expressed as medians and interquartile range (IQR).Proportions were compared using the X 2 test (chi-square), when necessary, by Fisher's exact test.The observed differences were considered significant when the probability of rejection of the null hypothesis is less than 0.05 (5%).

Results
The studied population was formed by 1,071 women, with different ages.The results found were divided into six groups, being them composed by women who presented different infections: Gardnerella vaginalis, be conducted in women with age between 25 and 60 years old and sexually active women each three years, after two negative results with one year range [5].
Genital infections and inflammations are responsible for the most demand at gynecology, because the main complains are leucorrhea and vulvovaginitis, there is not a specifically interest in cervix cancer prevention [6].
Vaginal infections are any disease that affects the feminine genital caused by several microorganisms.The most frequents are candidiasis, trichomoniasis, Gardnerella vaginalis, Gonococcus and Chlamydia infections, although Gonococcus and Chlamydia are more related to cervical infections.They can cause simple or grave infections, causing inflammatory cervix disease, cervical cancer, infertility, spontaneous miscarriage and ectopical pregnancy, which can lead to maternal obit [7].
Candida sp. can cause pruritus, dyspareunia, vaginal discharge with whitish color, swollen vulva and vagina, hyperemia, and it can or not cause burning and stinging when urinate [8].Gardnerella vaginalis is characterized by grayish discharge with foul-smelling, without local irritation [9], and Trichomonas vaginalis presents variate symptoms depending of clinical patient conditions and the number of infecting parasites [10].
The presence of microorganisms in the vagina are determined by factors that alter their survival capacity, including vaginal pH, quantity of glycogen for bacteria metabolism, that helps the colonization of pathogenical microorganisms.Several external factors are related to the normal microbiota susceptibility, such as: use of wide spectra antibiotic, period, post-coital, excitation (production of transudate that elevates the vaginal pH), immunosuppression by chemotherapeutic agents, glucocorticoids, immunosuppresses, HIV, menopause, decompensated diabetes, use of vaginal shower, IUD, tie clothes, use of internal absorbent (that cause bacteria proliferation when used for more time than recommended), wrong hygiene habits, pregnancy, trauma after sexual act, oral hormonal contraceptive of high dosage and unprotected sexual relationships [11].
According to Campos, et al. [12], alkaline pH of the vagina is a predisposition for the appearance of HPV genital infections, which is a condition directly related to the neoplasia emerge.pH changes for values higher than 4.5 are easily found in women who presents bacterial vaginosis, being the immunological response in this case and for HPV infection are similar, with an expressive increase of cytokines for both.In this sense many studies in the literature abording immune response in different grades of cervical lesions, thus understanding how the immune system behaviour during HPV infection with or without vaginosis [13].
Thus, because of the clinical importance for women well-being and health, and improve their knowledge about HPV infection and cervical lesions and cancer during the years analyzed, being the highest prevalence found in 2016 with 37.5%.Lactobacillus were found in 620 women during the four years, but it has no clinical significance because vaginal flora is composed mostly by them (Table 4).
There were found bacillus in 246 women, with highest prevalence in 2014 (50%) and coccus were found in 399 women, with highest prevalence in 2013 (71.4%).They are normal components of vaginal ecosystem (Table 4).All the women infected with Gardnerella vaginalis presented associated bacillus.
Regarding to cervical intraepithelial neoplasia, just two cases has been reported in the database.

Discussion
Vaginal infections are characterized by vaginal flora modifications, where the flora mostly compound by Lactobacillus is substituted by other etiological agents [16].
In this study, we observed the high prevalence of infections by Gardnerella vaginalis, especially during the year of 2014.The results are similar to the ones found in other studies, such as the one described by Coser, Rodrigues [17], where they found high prevalence of Gardnerella vaginalis.According to Silveira, et al. [18], this bacterium is the cause of 90% of asymptomatic vaginal infections.Mitra, et al. [19] also reported that this bacterium is common in women during their fertile age, occurring due to an increased vaginal microbiota proliferation.
Candidiasis in an infection caused by a commensal fungus.In this study, it was the second most prevalent infection, the opposite of found by Ribeiro, et al. [20], who found Candida sp. as the main microorganism, found in 54.3% of the studied population.The age range is according to Boatto, et al. [21], who found the prevalence in women of 18 to 34 years old; it is according to Candida sp., Trichomonas vaginalis, normal flora (Lactobacillus), presence of coccus and bacillus.The groups are presented at Table 1.
The average age of the patients was 38.9 years old, being 38.5 years old in 2013, 38.7 in 2014, 40.8 in 2015 and 37.7 in 2016 (Table 2).The age range who performed cytopathological exam the most was 15 to 30 years, with statistical significance.Gardnerella vaginalis was the most prevalent, affecting a total of 154 women, followed by Candida sp, affecting 65 women (Table 3).
The year with highest prevalence of Gardnerella vaginalis was 2014 (46.8%), while women presenting normal flora was 36.1%.In 2015 there was a number decrease of Gardnerella vaginalis infection cases (  The relevant register of Gardnerella vaginalis and Candida sp.highlights the necessity of adopting a clinical approach in order to improve the women well-being.About the Trichomonas vaginalis, even with low numbers compared to other studies, it is extremely important the counseling by health professionals in order to clarify doubts about the prevention, transmission and treatment.
However, this study was limited about the information related to: education, use of contraceptive use, number of sexual partners, number of children and miscarriage, sociodemographic profile, smoking and use of alcohol, and the treatment that was provided if any for those women that had pathogenic vaginal microorganisms detected, due to a lack of registration at the used resource.
It is important to say that only two cases of NIC I were found, so the prevalence could not be discussed, as well possible mistakes at sampling and diagnostic process.Besides, it is important to realize more studies about this theme, in order to scientifically help other intervention proposals to prevent cervix cancer from vaginal infections and STDs.
Mendes, et al. [22] as well, who found 21 to 30 years old.This study is according to Adad, et al. [23], who found Candida sp. as the second most prevalent infection in women.
Trichomoniasis is caused by Trichomonas vaginalis, and it is considered a non-viral sexually transmitted disease (STD) most common in the world, with 250 to 350 million new cases identified each year [24].Among the evaluated women, there were identified 16 cases (1.5%), different of other studies, where De Carli and Machado [25] evaluated 500 women and found a prevalence of 29.4%.Adad, et al. [23] studied trichomoniasis in 20,356 patients, and found 10%, 17.3%, 9.8% and 3.4% during the years of 1968, 1978, 1988 and 1998 respectively.
Rosset, et al. [26] correlated trichomoniasis with the herpes genital virus showing that the inflammatory response induced by Trichomonas vaginalis leads to an infiltration of defence cells (leucocytes, lymphocytes and macrophages) in the uterine mucosa, causing hemorrhagic spots, allowing the straight access for the virus.Lupi [27] described that its transmission occurs through mucous surfaces and it is easier when the immunologic system is suppressed.
In this study, we identified 57.9% of lactobacillus, 23% of bacillus and 37.3% of coccus.Campos, et al. [28] analyzed cytologic exams and identified the following prevalence: 35.2% of lactobacillus, 56.8% of bacillus and 42.2% of coccus, saying that variety of bacteria are found in asymptomatic women normally, being part of the flora.Silva, et al. [29] as well noticed at their study that microbiological agents very common in the cervix are bacillus (52.8%), coccus (45.5%) and lactobacillus (32.6%).
Looking at the age range of the participants, we noticed that 19 cytopathologic exams were performed in women under 14-years-old.According to Medeiros, et al. [30] the early initiation at sexual life increases the risk of cervical cancer, because the cervical epithelium transformation zone is more proliferative during the puberty and adolescence, being susceptible to modifications mainly by HPV.Studies performed by Wang and Song [31] and Lu and Cols [32], reported that vaginal microbiota imbalance is positively correlated with HPV infection, thus vaginal microbiota changes can predict the development and prognosis of cervical lesions, and HPV outcome.

Conclusion
The prevalence shows that measures should be taken in order to follow and orientation about the infections prevention.
We identified the necessity of encouraging third age women to conduct cytopathologic exam periodically and annually, because only 127 women over 60-years-old were submitted to the exam during a four-year period.

Table 1 :
11.7%), being 7.1% in 2016.Candida sp.infections were 36.9% in 2013, decreasing to 30.8% in 2014 and to 16.9% in 2016.Trichomonas vaginalis infections presented the lowest rate found in women, being only 16 cases found Distribution of the infectious agents registered in the cytological examination of the uterine cervix.

Table 2 :
Representation of medians and interquartile range (IQR), as well as the representation of means and standard deviations (SD).

Table 3 :
Distribution of infectious agents registered in the cervical cytology exam in each age class interval.

Table 4 :
Distribution of infectious agents.No cytological examination of the uterine cervix in year of occurrence records.