In 1959, investigators examined a group of 113 New York City women, an unknown number of whom showed evidence of cervical or vaginal infection (19). The researchers quantified the discharge by swabbing the entire vagina during the course of an examination and measuring the weight change in the swab. The mean vaginal discharge was 0.76 g for all patients, 1.0 g for women with vaginal infection, and 0.50 g for women who had douched the day before the examination. The mean weight of vaginal discharge increased among women who were periovulational.
Another study evaluated a group of 27 women who had no vaginal symptoms and considered their discharge normal (20). The investigator provided the women with tampons to wear for eight hours and then mail to the investigator in a plastic container. Discharge was quantified by the weight change in the tampon. In this study, mean discharge was 1.55 g/8 hr, with a standard deviation of 0.6. Lowest values for discharge weight were obtained on day 7 of the cycle (1.38 g/8 hr) and day 26 (1.37 g/8 hr), and the highest value was on day 14 (1.96 g/8 hr); there was also a midcycle increase in discharge.
Another study of multiple aspects of the menstrual cycle evaluated 10 women who had undergone a thorough medical examination to exclude both medical and gynecologic disease (21). The researchers studied the subjects throughout the menstrual cycle and evaluated cervical mucus production during a speculum examination in terms of quantity (measured in milliliters), viscosity, and spinnbarkheit. Cervical mucus increased from 2.68 mL during the follicular cycle to 3.97 mL during midcycle and declined to 2.13 mL during the luteal phase. Viscosity showed an inverse pattern, decreasing at mid-cycle and increasing to a maximum in the luteal phase. Spinnbarkheit was maximal at midcycle, specifically on the day before the luteinizing hormone surge, dropping dramatically in the luteal phase.
The observation that variation in cervical secretions was associated with changes in vaginal discharge led the Australian physician John Billings to study vaginal secretions as a way of predicting ovulation (22,23). Billings studied several hundred women using self-report, often correlated with biochemical markers of ovulation, and described a typical pattern of vaginal discharge based on the changes in cervical mucus. The pattern began with a postmenses "dry period" followed by a period of discharge attributable to increasing production of cervical mucus. The discharge resulting from this mucus was initially opaque and sticky. At the time of ovulation, the discharge was stretchy, wet, and slippery (reflecting spinnbarkheit), becoming opaque and tacky later on in the cycle. The typical pattern might be altered by infection or semen. The "ovulation method" or "Billings ovulation method" is promoted either for the purpose of family planning or for that of infertility treatment (24).
A more recent study did not find a periovulational increase in vaginal fluid (25). The researchers studied 74 women (24 with evidence of "asymptomatic BV") by evaluating symptoms and physical examination findings at days 1 to 5, 7 to 12, and 19 to 24 of the menstrual cycle. They estimated the amount of vaginal discharge by instilling the vagina with 3 mL of phosphate-buffered saline using a pipette, removing all fluid, and estimating the increase in the aspirate. Discharge was graded as scant (<1mL), normal (1 to 3 mL), or copious (>3 mL). Discharge volume increased over the three phases of the study; cervical mucus was greatest during days 1 to 5. "Most" subjects had white or clear discharge; women with yellow discharge were excluded from the study, but about 10% of the women had yellow discharge later. The discharge from 65 women had a "normal" consistency, the discharge from eight women was judged homogenous, and one woman had a curdy discharge. Forty-eight subjects had a discharge that was pooled; 24 had a diffuse discharge, and two had a patchy discharge.
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