From the Guidelines
Clue cells on a Pap test result are a definitive indicator of bacterial vaginosis (BV), and treatment should be initiated promptly to prevent complications. Bacterial vaginosis is a common vaginal infection caused by an overgrowth of bacteria that disrupts the normal vaginal flora, as described in the American Academy of Pediatrics clinical report 1. The presence of clue cells, which are bacterial-covered epithelial cells, is a key diagnostic criterion for BV. Treatment typically involves a 7-day course of metronidazole 500mg orally twice daily, or metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days, as outlined in the guidelines 1. Some key points to consider when treating BV include:
- Avoiding alcohol consumption with metronidazole, as it can cause severe nausea and vomiting
- Using condoms during treatment to prevent transmission to sexual partners
- Completing the full course of antibiotics, even if symptoms resolve quickly, to prevent complications such as pelvic inflammatory disease and pregnancy complications
- Being aware of the symptoms of BV, which include thin grayish-white discharge with a fishy odor, although many women are asymptomatic The diagnosis of BV can be confirmed through a wet mount preparation, which can be performed immediately in the office if a microscope is available, or through other tests such as pH testing and whiff testing, as described in the American Academy of Pediatrics clinical report 1.
From the Research
Clue Cells on Pap Result
- Clue cells are an accepted clue to the diagnosis of bacterial vaginosis, characterized by epithelial cells heavily covered with adherent bacteria 2
- The presence of clue cells on a Pap result may indicate bacterial vaginosis, which is a common cause of vaginitis worldwide and is associated with serious reproductive health outcomes, including increased risk of preterm birth, sexually transmitted infections, and pelvic inflammatory disease 3
- However, not all clue cells are true clue cells, as some may be pseudo clue cells, which are epithelial cells mechanically entrapped in bacterial masses, and the composition is unrelated to the epithelial cell surface 2
- The diagnosis of bacterial vaginosis is typically made based on the presence of clue cells, as well as other clinical criteria, such as a thin, white, yellowish, homogeneous vaginal discharge, and a pH of the vaginal fluid greater than 4.5 4, 5, 6
Treatment and Management
- The current and only FDA-approved treatment regimens for bacterial vaginosis are antibiotics, such as metronidazole and clindamycin 3
- Treatment of bacterial vaginosis during pregnancy should focus on the elimination of symptoms, and data on adverse pregnancy outcomes for women with bacterial vaginosis remain insufficient to recommend treatment of asymptomatic patients 4
- Behavioral modifications, such as smoking cessation, condom use, and hormonal contraception, may also help in the management of bacterial vaginosis 3
Diagnosis and Differential Diagnosis
- A pelvic exam should be performed for any woman presenting with vaginal discharge to confirm the diagnosis and rule out an upper tract infection 6
- The differential diagnosis of vaginal discharge includes physiologic discharge, vaginitis, cervicitis, and pelvic inflammatory disease (PID) 6
- Vaginitis is inflammation of the vagina, most commonly caused by bacterial vaginosis (BV), vulvovaginal candidiasis, and trichomoniasis infections 6