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Of 715 adequate Pap smears, 7 revealed cancer, 4 high-grade squamous intra-epithelial lesions (SIL) and 15 low-grade SIL. Clinical algorithms had very low sensitivity and predictive values for cervical infection, but over half the women with symptoms of malodorous vaginal discharge, signs of abnormal vaginal discharge, or both, had bacterial vaginosis or trichomoniasis. Women with selected symptoms and signs of vaginal infection could benefit from standard metronidazole therapy. Entre los síntomas declarados figuraba flujo vaginal anormal (29,3% y 22,9%, respectivamente). De las 715 pruebas de Papanicolaou realizadas, 7 revelaron la presencia de cáncer, y en 4 y 15 casos se detectaron lesiones intraepiteliales escamosas de grado alto y de grado bajo respectivamente. Movimiento Manuela Ramos carried out initial qualitative research in 240 women's community-based organizations (CBOs) throughout Peru using participatory techniques for reproductive health self-assessments (1). Women in 16 of 18 rural districts identified vaginal discharge as one of their three most important reproductive health problems. All women from CBOs (called mother's clubs) within these villages were invited to participate. Local ReproSalud teams reported total active membership of these 18 CBOs as 944; of these, 754 (80%) participated.
Approximately 21% were illiterate, just over half had primary education, and education duration averaged 5 years.
The midwife then examined their vulva, perineum, vagina, and cervix, and palpated for adnexal and cervical motion tenderness. During speculum examination, the midwife collected vaginal and endocervical samples and blood for laboratory testing. She also mixed vaginal fluid 1:1 with saline to detect motile trichomonads and clue cells, and with 10% potassium hydroxide (KOH) to detect fungal hyphae by microscopic examination and amine-like odour.
Vaginal fluid smears were evaluated by Gram's stain for fungal elements and Nugent's score (2).
To test for Trichomonas vaginalis she inoculated vaginal fluid into InPouch TV tests for microscopic examination before and after incubation at 37 ºC for 24 and 48 hours. She stained and examined cervical specimens for Gram-negative diplococci and quantitated neutrophils within cervical mucus. The swabs were tested for Chlamydia trachomatis and Neisseria gonorrhoeae, using Roche Molecular Diagnostics reagents, and for human human papilloma virus (HPV) DNA types 6, 11, 16, 18 and human beta-globin, using Merck's multiplex type-specific PCR assay.
We offered counselling and partner treatment for trichomoniasis, syphilis seropositivity, and MPC or Gram stain indicative of gonorrhoea, and referred pregnant women to the nearest health centre.
Local ReproSalud representatives provided referrals and financial and logistic support for treating all women with abnormal Pap smears requiring treatment. A higher percentage of jungle residents perceived that their partners had engaged in these activities compared with Andean and coastal residents.

Of these, 387 described having specific symptoms or diagnoses: 243 had experienced vaginal discharge, 55 vulvar itching or pain, 34 lower abdominal pain or pelvic inflammation, 31 urinary symptoms, 15 cervical ulcer or inflammation, 4 ovarian infection, 3 genital ulcers, and 2 dyspareunia. Of those seeking help, only 29% obtained treatment, and most of this was self-medication. Overall, 76.9% either spontaneously volunteered symptoms or reported elicited symptoms possibly related to RTIs. Overall, of 748 tested for both BV and trichomoniasis, 49.5% (370) had either vaginal infection by any criterion. Of the 27 HPV-positive women, 24 had Pap smears, of which only two were interpreted as low-grade SIL (one HPV 6 and the other HPV 6 and 16) and two as invasive cancer (both HPV 16-positive). Abnormal vaginal discharge on examination (including especially yellow colour or liquid, homogenous consistency) was significantly associated with BV or TV.
However, easily-induced cervical bleeding and clinical diagnosis of MPC were significantly associated with endocervical infection. Neither low abdominal pain, nor diagnosis of pelvic inflammatory disease in 11 women (1.5%), was associated with endocervical infection. 1 shows the relationships between spontaneous complaints of vaginal discharge, elicited symptoms of malodorous discharge, signs of abnormal vaginal discharge, and test results for vaginal and cervical infections.
Symptoms and signs of abnormal vaginal discharge showed no relationship to cervical infections. By contrast, the prevalence of BV, TV, or both ranged from 31% of those with no such symptoms or signs, to 75% of patients with spontaneous or elicited symptoms, plus signs. Thus, the algorithm has little utility for managing either infection in the settings and populations studied. This included 47% with spontaneous or elicited complaints of vaginal discharge, and 49% with spontaneous or elicited complaints of lower abdominal pain. The women's symptoms had little potential for use in algorithms for managing cervical infection. Although the signs of MPC and risk factors were significantly associated with cervical infection, the sensitivity and PPV of the Peruvian algorithm was too low to warrant its use in this setting, even with speculum examination and microscopy. Nonetheless, studies of women belonging to CBO's offer advantages of feasibility, low cost, low respondent refusal rates and a potentially direct link between research and subsequent utilization of resulting improvements in services (7). This is analogous to the question posed A— not uncommonly A— in clinical practice: "I know this test is ineffective, but can you advise me on how to use it in my practice?".
In clinical settings that serve women who are seeking care specifically for symptoms of RTIs and who have substantially higher prevalences of cervical infections, pelvic examination can yield better correlations with actual infections. For example, in primary health care, gynaecology, or STD (sexually transmitted disease) clinic settings, signs of MPC or pelvic inflammatory disease are more likely to reflect incident cervical infection (2, 17, 18), often yielding positive predictive values high enough to warrant treatment (with benefits outweighing the costs and adverse effects of medications, other programme costs, and increased pressure for selection of antimicrobial resistant pathogens) (2, 17, 18). Even among these rural Peruvian women, the very high prevalence of BV or trichomoniasis (57%) associated with symptoms of malodorous vaginal discharge or with signs of vaginal discharge suggest the potential clinical benefit of metronidazole treatment (although recurrences of BV following metronidazole therapy, (22) and the need to treat male partners to minimize recurrences of vaginal trichomoniasis (28), currently limit this strategy).

This suggestion is particularly relevant, not only because of the obstetrical and gynaecological complications of BV and trichomoniasis and possible associations of vaginal infections with susceptibility to HIV acquisition (22), but especially in view of the ReproSalud self-assessment study, in which women in 16 of 18 districts listed vaginal discharge as one of their top three reproductive health problems. Formal evaluation of the benefit of metronidazole therapy in relieving such perceived symptoms in rural women seems warranted.
ReproSalud teams helped to implement these changes and advised women in their communities of the significance of symptoms of vaginal discharge, advising appropriate health care seeking. Nonspecific vaginitis: diagnostic criteria and microbial and epidemiological associations.
Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. Alternative study designs for research on women's gynaecological morbidity in developing countries. An epidemiological survey of female reproductive health states: gynecological complaints and sexually transmitted disease. Control of sexually transmitted diseases for AIDS prevention in Uganda: a randomized community trial. Unrecognized sexually transmitted infections in rural South African women: a hidden epidemic. Comparing women's report with medical diagnoses of reproductive morbidity conditions in rural Egypt. A study of field-based methods for diagnosing reproductive tract infection in rural Yunnan province, China. Problems, solutions and challenges in syndromic management of sexually transmitted diseases. Risk assessment, symptoms, and signs as predictors of vulvovaginal and cervical infections in an urban US STD clinic: implications for STD algorithms. Syndromic approach to detection of gonococcal and chlamydial infection among female sex workers in two Philippine cities.
Psychosexual functioning in symptomatic and asymptomatic women with and without signs of vaginitis. The meaning of RTIs in Vietnam A— a qualitative study of illness representation: collaboration or self regulation? Targeted intervention research studies on sexually transmitted diseases (STD) methodology, selected findings and implications for STD services delivery and communications.
A double-blind study of the value of treatment with a single dose tinidazole of partners to females with trichomoniasis.

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