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The vaginal wall is composed of four layers:1. Its lining is a mucous membrane
of squamous epithe-
lial cells. (Types of epithelium are described and illus- trated in Chapter 1, Table
1-7.) This layer thickens and thins in response to hormones, particularly estrogen.
The squamous epithelial membrane is continuous with the membrane that covers
the lower part of the uterus. In women of reproductive age, the mucosal layer is ar-
ranged in transverse wrinkles, or folds, called rugae (singular, ruga) that permit
stretching during coitus and childbirth.
The upper part of the vagina surrounds the cervix, the lower end of the uterus (see
Figure 22-5). The recessed space around the cervix is called the fornix of the
vagina. The pos- terior fornix is deeper than the anterior fornix because of the
angle at which the cervix meets the vaginal canal. In most women this angle is
about 90 degrees. A pouch called the cul- de-sac separates the posterior fornix and
the rectum.
Its elasticity and relatively sparse nerve supply enhance the vaginas function as
the birth canal. During sexual arousal the vaginal wall becomes engorged with
blood, like the labia mi- nora and clitoris. Engorgement pushes some fluid to the
sur- face of the mucosa, enhancing lubrication. The vaginal wall does not contain
mucus-secreting glands; rather, secretions drain into the vagina from the
endocervical glands or enter from the vestibule, from the Bartholin and Skene
glands.
Two factors help maintain the self-cleansing action of the vagina and defend it
from infection, particularly during the reproductive years: (1) an acid-base balance
that discourag- es the proliferation of most pathogenic bacteria and (2) the
thickness of the vaginal epithelium. Before puberty, vaginal pH is about 7
(neutral) and the vaginal epithelium is thin. At puberty, the pH becomes more
acidic (4 to 5) and the squa- mous epithelial lining thickens. These changes are
maintained until menopause (cessation of menstruation), at which time the pH
rises again to more alkaline levels and the epithelium thins out. Therefore,
protection from infection is greatest during the years when a woman is most likely
to be sexually active. Between puberty and menopause, vulnerability to in- fection
varies somewhat with cyclic changes in pH and epi- thelial thickness. Both
defenses are greatest when estrogen levels are high and the vagina contains a
normal population of Lactobacillus acidophilus, a harmless resident bacterium that
helps maintain pH at acidic levels. Any condition that causes vaginal pH to rise,
such as douching or use of vaginal sprays or deodorants, low estrogen levels, or
destruction of L. acidophi- lus by antibiotics, lowers vaginal defenses against
infection.
Mc Cance (858-860)
Vaginitis is infection of the vagina. The major causes of vagi- nitis are sexually
transmitted pathogens (see Chapter 24) and Candida albicans. The incidence of
sexually transmitted vagi- nitis remains highest in young women 15 to 24 years of
age.72
The development of vaginitis is related to loss of local de- fense mechanisms, such
as skin integrity, immune reaction, and particularly vaginal pH. The pH of the
vagina depends on cervical secretions and the presence of normal flora that help
maintain an acidic environment. A neutral or alkaline pH normally occurs before
puberty, after menopause, and dur- ing pregnancy. The acidic nature of vaginal
secretions during the reproductive years provides protection against a variety of
sexually transmitted pathogens. Therefore, variables that alter the vaginal pH or
the bactericidal nature of secretions (see Chapter 22) may predispose a woman to
infection. These variables include douching; use of soaps, spermicides, femi- nine
hygiene sprays, or deodorant menstrual pads or tampons; and conditions
associated with increased glycogen content of vaginal secretions, such as
pregnancy or diabetes. Antibiotics often destroy normal vaginal flora, facilitating
overgrowth of C. albicans, causing a yeast vaginitis.
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The pH of the normal vaginal secretions is 4.0 to 4.5; the acidic pH is due to lactic
acid, which is produced by from glycogen by Lactobacillus species and by vaginal
epithelium under the control of estrogen. The acidic environment is hostile to growth
of pathogens (bacterial and viral) and inhibits adherence of bacteria to vaginal
squamous epithelial cells.
Under the influence of estrogen, the normal vaginal epithelium cornifies and
produces glycogen, which acts as a substrate for lactobacilli, thereby protecting
women against infection from a number of pathogens. In contrast, the endocervix is
lined with columnar epithelium and is more susceptible to infection with certain
pathogenic organisms. These differences explain, in part, why cervicitis occurs in the
absence of vaginitis and vice versa.
In premenarchal and postmenopausal women in whom estrogen levels are low, the
vaginal epithelium is thin and the pH of the normal vaginal secretions is 4.7 or more.
The higher pH is due to reduced colonization of lactobacilli and less glycogen in
epithelial cells. (See "Clinical manifestations and diagnosis of vaginal atrophy".)