Skip to main content
NCBI home page
Communications Medicine logoLink to Communications Medicine
. 2026 Feb 3;6:136. doi: 10.1038/s43856-026-01410-2

The Nugent score is an inappropriate diagnostic tool for neovaginal bacteria in transfeminine people

Reeya Parmar 1, Bern Monari 2, Emery Potter 3,4,5, Jorge Rojas-Vargas 1,6, Hannah Wilcox 1, David Zuanazzi 1, Annabel Poon 1, Ainslie C Shouldice 1, Vonetta L Edwards 2, Yonah Krakowsky 3,4,7, Jacques Ravel 2,✉,#, Jessica L Prodger 1,8,✉,#
PMCID: PMC12976259  PMID: 41634193

Abstract

Background

Many transfeminine people (assigned male at birth with feminine gender identities) undergo vaginoplasty, a surgical procedure constructing a neovagina, typically using penile and scrotal tissue. In cisgender females, gynecological symptoms (pain, discharge, malodor) are often attributed to bacterial vaginosis, which can be diagnosed using Nugent scoring of gram-stained vaginal smears. The Nugent score assesses the abundance of large gram-positive rods versus small or curved gram-variable rods, traditionally for the detection of Lactobacillus, Gardnerella vaginalis, and Mobiluncus, respectively. Although unvalidated, this method is frequently applied to neovaginal samples to diagnose gynecological symptoms and dysbiosis. This study assessed the Nugent score’s utility for diagnosing neovaginal dysbiosis in transfeminine people.

Methods

As a part of the TransBiota study, n = 39 transfeminine participants self-collected neovaginal smears. Smears were Gram stained and Nugent scored, and scores were correlated with data on neovaginal bacterial composition (16S rRNA gene sequencing), neovaginal cytokines (Luminex multiplex immunoassay), and self-reported symptoms.

Results

We show more than 70% of neovaginal smears fell in the 7-10 Nugent score range, indicative of Bacterial Vaginosis in cisgender women. However, scores fail to correlate with the abundance of Nugent-targeted bacteria. Bacteria with similar morphotypes, but not belonging to Lactobacillus, Gardnerella, or Mobiluncus, are highly abundant and prevalent in the neovagina. Nugent score also fails to predict local inflammation or clinical symptoms.

Conclusions

The Nugent score is not an effective tool to identify neovaginal dysbiosis or indicators of health in transfeminine individuals. Clinicians need the development of accurate, evidence-based diagnostic tools for the neovagina.

Subject terms: Clinical microbiology, Microbiome, Cytokines, Diagnosis, Microscopy

Plain language summary

Many transfeminine people undergo vaginoplasty, which creates a vagina (neovagina) from penile tissue. In cisgender women, vaginal symptoms like pain, discharge, or malodor are caused by bacterial imbalance. This can be diagnosed using the Nugent score, which counts bacteria of specific shapes under a microscope. We examined whether this test also works in neovaginas. Data on neovaginal bacteria, inflammation, and symptoms was collected from 39 transfeminine people. The bacteria the Nugent score was designed to detect were rarely present, yet most participants received a score that would indicate bacterial imbalance in cisgender women. These scores also did not align with symptoms or inflammation, showing that the Nugent score is not reliable for neovaginas. Neovagina-specific diagnostic tools are needed to help transfeminine people and clinicians accurately understand and manage neovaginal symptoms.

Parmar et al. assess the Nugent score as a diagnostic tool for neovaginal dysbiosis in transfeminine people with vaginoplasty. Nugent targeted taxa are found to be rare in the neovagina, and Nugent score does not correlate with neovaginal inflammation or symptoms, highlighting the need for neovagina-specific, evidence-based diagnostic tools.

Introduction

Transfeminine individuals (TF) were assigned male at birth and experience a female/feminine gender identity. Numerous communities fall under this umbrella, including transgender women, non-binary, and other gender diverse individuals1,2. Many TF elect to undergo gender-affirming medical care, often through feminizing hormone therapy and/or surgery. Vaginoplasty is a gender-affirming surgery that creates a clitoris, vulva, and vaginal canal. The most prevalent technique is penile inversion vaginoplasty, involving orchiectomy, dissection of the space between the bladder and rectum, and lining the newly formed space with penile and scrotal tissue3. Although less common, sigmoid or peritoneal tissue may also be used to augment the vaginal canal4–6. Penile inversion vaginoplasty results in a vaginal canal that is visually and functionally similar to that of cisgender females (CF) but is lined with skin, a keratinized stratified squamous epithelium with a well-developed stratum corneum, in contrast to the non-keratinized mucosal epithelium of the natal vagina. We use the term “vagina” to refer to the vaginal canal of those born with a vagina, and “neovagina” to refer to the surgically created vaginal canal of TF. Our aim in using two terms is to clinically distinguish between vaginal canals lined with epithelia of different origins.

In 2021, an estimated 20% of TF in the US had undergone genital surgery, with an additional 67% desiring it7. Like CF, TF with vaginoplasty often experiences genital symptoms, including itching, burning, discharge, and malodor; however, the source of these symptoms has not been explored. To address this gap, we performed a study of the neovaginal microenvironments of 47 TF living in Canada8,9. In this study, 56% of participants reported neovaginal symptoms within the past 30 days10. In reproductive-aged CF (rCF), similar symptoms are caused by vaginal infections (i.e., Trichomonas vaginalis, yeast) or by Bacterial Vaginosis or “BV”, which occurs when beneficial Lactobacillus spp. are replaced by a polymicrobial microbiome, including Gardnerella vaginalis, Prevotella spp., Candidatus Lachnocurva vaginae, and other anaerobic bacteria11–13. Lactobacillus spp. play a critical role in rCF vaginal health by producing antimicrobial compounds and lactic acid, which lowers pH and inhibits colonization by pathogens14,15. Even without symptoms, non-optimal microbiomes in rCF are associated with increased susceptibility to sexually transmitted infections, including chlamydia, gonorrhea, HSV-2, and HIV-1, underscoring the importance of the vaginal microbiome in sexual health14–23.

The Nugent score is widely used as a laboratory reference standard for the diagnosis of BV in rCF. The Nugent score is a Gram stain-based scoring system that rates the relative abundance of Gram-positive rods (indicative of beneficial Lactobacillus spp.) vs. small or curved Gram-variable rods (morphotypes of BV-associated bacteria)12,24. Scores from 0 to 3 are considered optimal, 4 to 6 intermediate, and 7 to 10 indicative of BV. The Nugent score is often applied to diagnose TF experiencing genital symptoms; however, the neovaginal microbiota is distinct from the vaginal microbiota25–27, and results from TransBiota, a study conducted by our group to characterize the neovaginal microbiome, suggest bacteria associated with inflammation in the neovagina differ significantly from those in the rCF vagina8. Bacteria associated with neovaginal immune activation include Lawsonella, Howardella, Fusobacterium, and Parvimonas, while higher abundances of Ezakiella, Fastidiosipila, Murdochiella, and Peptoniphilus are associated with reduced inflammation8.

The substantial differences in microbiome composition and associated inflammation found in the rCF vagina and the neovagina raise questions about the utility of the Nugent score as a diagnostic tool in TF. Nevertheless, in the absence of neovagina-specific guidance, neovaginal swabs are often processed and interpreted using Nugent-based frameworks developed for rCF, and these scores are used to guide treatment decisions in some clinical settings, as reported by clinicians providing postoperative vaginoplasty care28. This study evaluated the Nugent score’s relevance as a diagnostic tool for neovaginal dysbiosis by assessing its accuracy in identifying bacteria targeted by the score, and its ability to predict markers of a non-optimal microbiome in the neovagina. We show here that the Nugent score is not a suitable diagnostic tool for neovaginal dysbiosis in TF with penile inversion vaginoplasty, as neovaginal taxa are not targeted by the Nugent score and scores do not correlate with neovaginal inflammation or symptoms.

Methods

Participants

TransBiota was a study investigating the genital microenvironments of trans and other gender diverse people receiving gender-affirming medical care8–10. Eligible TF participants were Canadian residents 18 years or older, who underwent vaginoplasty >1 year prior to study entry. Participants were excluded from the study if they did not meet these criteria. Research ethics board approval was obtained from Western University (REB #115503) and the University of Maryland (IRB #HP-00096952), and all participants provided written informed consent. Participants were recruited online through social media and community groups, healthcare provider referrals, and re-contact of consenting Trans PULSE Canada participants. Trans PULSE Canada used multimodal convenience sampling to perform a national, community-based survey of 2873 trans and non-binary people from all provinces and territories in Canada29. Participants were mailed a study kit containing instructions and self-collection materials. Demographic, behavior, hormone use and symptom data were collected through an online questionnaire. For three consecutive weeks, participants (n = 47) collected three neovaginal sample sets and returned them by mail within 24 h using the provided pre-paid envelopes (samples kept at room temperature by participants until mailing). Participants also self-tested their neovaginal pH at each timepoint by rolling swabs onto a provided pH strip and recording the associated color in REDCap. The current analysis includes the first timepoint for each participant for which there is a corresponding (1) scorable gram-stained slide, (2) microbiome data, and (3) immune analyte data.

All research activities were conducted in accordance with institutional and ethical regulations, and participant data were deidentified prior to analysis.

Microbiota and cytokine analyses

Participants self-collected neovaginal swabs at each timepoint for Nugent scoring, microbiota analysis, and cytokine quantification. Sample collection and analysis of neovaginal microbiota and cytokines have been described in detail elsewhere8. In brief, participants were instructed to insert each swab (Puritan HydraFlock) 5 cm into the neovaginal canal, rotate three times, and place it in the collection media. Swabs for microbiota analysis were collected into 1 ml of Qiagen C2.1 solution. DNA extractions were performed using the MagAttract PowerMicrobiome DNA/RNA kit (Qiagen), and 16S rRNA gene V3-V4 region amplicon sequencing (amplified via two-step PCR) was conducted at the University of Maryland Institute for Genomic Sciences30. Reads were processed using a QIIME-dependent script with DADA2 to generate amplicon-sequence variants (ASVs). Taxonomy was assigned with the RDP naïve-Bayes classifier trained on the SILVA v138.2 16S rRNA database and refined species-level calls with SpeciateIT v2.0.0. ASVs sharing identical taxonomy were collapsed. Core neovaginal bacteria from TransBiota8 are listed in Supplemental Table 1.

Swabs for cytokine analysis were collected into 500 µl of a PBS-based stabilizing buffer, and IL-1α, IL-1β, IL-6, IL-8, MIG, MIP-1β, and RANTES concentrations were quantified on a Luminex MAGPIX system.

Nugent scoring

Participants rolled collection swabs onto positively charged glass microscope slides (USA Scientific) and returned them to Western University in secured plastic cases. Neovaginal smears were heat-fixed and Gram-stained using standard techniques at the University of Maryland25,31,32. In brief, slides were stained with crystal violet (1 minute), iodine mordant (1 min), decolorizing solution (until solution ran clear), and safranin (30 s) at room temperature. Slides were rinsed with running tap water between steps. Slides were observed under a 100x oil-immersion light microscope. For each smear, bacterial morphologies were individually scored in 10 representative fields of view (FOVs) following Nugent criteria24. Scoring of neovaginal smears was performed alongside smears collected from the natal vagina (from a separate study), by a single investigator who was blinded to the origin of the smear. The criteria assign a decreasing score from 0 to 4 for the abundance of Lactobacillus-like gram-positive large rods, an increasing score from 0 to 4 for the abundance of Gardnerella-like short gram-variable straight rods, and an increasing score from 0 to 2 for the abundance of Mobiluncus-like gram-variable curved rods. Scores for each morphotype were summed to yield a total score from 0 to 10 for each FOV. The final mean score across the ten FOVs was calculated for each participant. In rCF, scores of 0–3 are optimal, 4–6 are intermediate, and 7–10 are indicative of BV24.

Statistical analysis

Multiple unpaired Mann–Whitney U nonparametric tests were used to assess differences in Nugent scores between asymptomatic and symptomatic participants. Fisher’s exact test was used to assess differences in bacterial prevalence, and the Mann–Whitney U-test was used to assess differences in relative abundances of neovaginal bacterial taxa between asymptomatic and symptomatic participants. Associations between Nugent score and cytokines (IL-1α, IL-1β, IL-6, IL-8, MIG, MIP-1β, and RANTES) were assessed by Spearman’s correlation. Relationship between neovaginal bacteria taxa and cytokines, as well as bacterial taxa and Nugent score, was also evaluated using Spearman’s correlations. Only taxa with a neovaginal prevalence of >25% were included in analyses.

Results

Of the n = 47 TransBiota participants, 8 were excluded (17%) due to no scorable slides from destruction during heat-fixation from smearing on the incorrect side of the slide; damage to slides during shipping; or insufficient sample for Nugent scoring (defined at <30 bacteria/FOV). Demographics and hormone use from the remaining n = 39 participants included in this study are displayed in (Table 1. Median time on hormone therapy was 5.6 years and median time since vaginoplasty 2.8 years.

Table 1.

Participant demographics

Participants (n = 39)
Age, years (median, range) 39 (26-67)
Ethnoracial Identity (%)
 White 89.7%
 Latin American 2.6%
 Jewish 2.6%
 Mixed ethnicity 5.1%
Months on hormone therapy (median, range) 67 (35–265)
Months since vaginoplasty (median, range) 33 months (12–229 months)
Circumcised prior to vaginoplasty (%) 56.4%
Symptoms, past 7 days (%) 23.1%
 Bleeding 5.1%
 Discharge 5.1%
 Itching/burning 2.6%
 Malodor 12.8%
 Pain 2.6%
pH (median, range) 5.5 (4.5-8)
Open in a new tab

Neovaginal smears contained nucleate and anucleate epithelial cells, with most bacteria clustered near these epithelial cells (Fig. 1a, e). Four slides (10.3%) were visibly bloody with erythrocytes and leukocytes visible by microscopy (Fig. 1b, e). Gram-variable rods and cocci dominated the majority of smears (Fig. 1c, e). Although all smears contained gram-variable straight rods, only 48.7% of slides displayed large gram-positive rods (Lactobacillus-like morphotype), and just three (7.7%) were dominated by large gram-positive rods (Fig. 1d, e).

Fig. 1. Representative images and descriptive characteristics of neovaginal smears.

Fig. 1

Open in a new tab

Self-collected neovaginal smears (n = 39) were heat-fixed, Gram-stained, and observed under a 100x oil-immersion light microscope. Ten fields of view (FOV) were scored per participant; representative FOVs showing a proximity of bacteria to epithelial cells, b abundance of red and white blood cells, c dominance with Gram-variable rods and cocci, and d dominance with Lactobacillus-like morphotype. Descriptive characteristics of neovaginal smears are shown in (e).

The majority of neovaginal smears (71.8%) fell within the BV Nugent range (7–10; Fig. 2a). The most common score was 7 (46.2% of participants), indicating abundant gram-variable rods and minimal Lactobacillus-like rods. Only two participants (5.1%) scored an optimal Nugent score range for rCF (0–3). Lactobacillus showed a moderate negative correlation with Nugent score (Fig. 2b) while Gardnerella and Mobiluncus showed no correlation (Fig. 2c, d).

Fig. 2. Nugent scores and correlation with traditional Nugent-targeted taxa across neovaginal smears.

Fig. 2

Open in a new tab

a Distribution of Nugent scores from n = 39 TF participants. Scores represent the median score per participant over 10 fields of view (FOVs) acquired at 100x oil-immersion magnification. Lower scores from 0 to 3 are considered optimal, scores of 4–6 are intermediate, and higher scores of 7–10 are considered indicative of BV. Spearman’s correlations are shown between the relative abundances of b Lactobacillus (p < 0.03), c Gardnerella (p = 0.67), and d Mobiluncus (p = 0.85) within neovaginal smears and Nugent score.

Nugent score and traditional Nugent-targeted taxa are not associated with neovaginal symptoms

Nine participants (23.1%) reported neovaginal symptoms (malodor, discharge, bleeding, pain/burning) within 7 days prior to sample collection. There was no difference in Nugent scores between symptomatic and asymptomatic participants (Fig. 3a). Additionally, no relationship was observed between prevalence (Fig. 3b) or proportional abundance (Fig. 3c) of the traditional Nugent-targeted bacteria (Lactobacillus, Gardnerella, and Mobiluncus) and the presence or absence of neovaginal symptoms.

Fig. 3. No differences in Nugent score or traditional Nugent-targeted bacteria between symptomatic and asymptomatic participants.

Fig. 3

Open in a new tab

a Median Nugent score did not vary between asymptomatic participants (n = 30) and participants who self-reported neovaginal malodor (n = 5), discharge (n = 2), bleeding (n = 2), or pain/burning (n = 2) in the last 7 days (Mann–Whitney U, asymptomatic participants vs. each symptom, odor: p = 0.1, discharge: p = 0.5, bleeding: p = 0.1, pain/burning: p = 0.3). Comparison of the b prevalence and c relative abundance of Lactobacillus (prevalence: p = 1.0; relative abundance: p = 1.0), Gardnerella (p = 1.0; p = 0.9), and Mobiluncus (p = 1.0; p = 0.9) between asymptomatic and symptomatic participants (prevalences compared by Fisher’s exact test, relative abundances by Mann–Whitney U). Median and interquartile range are shown.

Nugent score is not associated with neovaginal cytokines

Elevated cytokines have been consistently associated with adverse health outcomes, including in the natal vagina, penis, urethra, and rectum16,26,33–38. Therefore, in this paper, we use elevated cytokines as a marker of a non-optimal neovaginal microbiota. Nugent scores were analyzed in relation to pro-inflammatory cytokine concentrations, but no significant correlations were observed (Fig. 4a–g). Representative images are shown of gram-stained smears from one participant with high cytokine levels (87.8 pg/ml IL-1α, 65.4 pg/ml IL-1β, 34.7 pg/ml IL-6, 85.3 pg/ml IL-8, 61.1 pg/ml MIG, 21.7 pg/ml MIP-1β, 33.1 pg/ml RANTES) and one participant with low cytokine levels (83.9 pg/ml IL-1α, 35.6 pg/ml IL-1β, 6.3 pg/ml IL-6, 57.1 pg/ml IL-8, 11.8 pg/ml MIG, 21.7 pg/ml MIP-1β, undetectable RANTES). Both participants had a Nugent score of 7 with neovaginal smears dominated by gram-negative rods (Fig. 4h, i).

Fig. 4. Neovaginal cytokines do not correlate with Nugent score.

Fig. 4

Open in a new tab

Self-collected neovaginal smears from transfeminine participants (n = 39) were heat-fixed, Gram-stained, and observed under a 100x oil-immersion light microscope. Cytokine concentrations in neovaginal swabs were measured by multiplex immunoassay (Luminex). Spearman’s correlations were used to assess associations between Nugent score and a IL-1α, b IL-1β, c IL-6, d IL-8, e MIG, f MIP-1β, and g RANTES. Representative images of Gram-stained neovaginal smears from participants with low (h) and high (i) cytokine levels. Images have been cropped for visualization.

Bacteria with Nugent-targeted morphotypes in the neovagina

Part of the Nugent score’s diagnostic power in rCF comes from inadvertently taking into account the presence of other inflammatory gram-variable rods (e.g., Fannyhessea vaginae, Ca. Lachnocurva vaginae, Sneathia vaginalis) in addition to the traditional Nugent bacteria (Gardnerella and Mobiluncus). This study was designed with the consideration that the Nugent score may have utility in the neovagina due to the potential inadvertent detection of other inflammatory gram-variable rods. Therefore, bacteria with similar morphotypes to the traditional Nugent score bacteria were considered in this analysis. A comprehensive description of neovaginal bacterial communities of TransBiota participants has been previously published8. A summary of the most prevalent neovaginal bacteria (>25% prevalence) are listed in Fig. 5, separated by the morphotypes targeted by Nugent scoring.

Fig. 5. Neovaginal bacterial prevalence, relative abundance, and association with cytokines and Nugent score.

Fig. 5

Open in a new tab

Taxa scored by Nugent criteria (Lactobacillus, Gardnerella/Fannyhessea, and Mobiluncus) at the start of each morphotype category. Bacterial taxa with a prevalence of >25% are included. Median relative abundance is measured among prevalent participants, and the interquartile range are shown. Bacterial prevalence and relative abundance were measured from neovaginal swabs (n = 39) using 16S rRNA gene sequencing. Cytokine concentrations were measured from swab eluent by multiplex immunoassay (Luminex). Spearman’s correlations were used to assess associations between taxa and IL-1α, IL-1β, IL-6, IL-8, MIG, MIP-1β, RANTES, and Nugent score. Spearman’s correlations p values are shown in Supplemental Table 3.

Traditional Nugent-targeted taxa (Lactobacillus, Gardnerella, and Mobiluncus) frequently appeared in the neovagina, but at low relative abundance (Fig. 5). Several other taxa detected in the neovagina had similar morphologies to Nugent-targeted genera. Lawsonella clevelandensis is a large gram-positive rod that can have a similar appearance to Lactobacillus spp. on Gram staining39,40. Lawsonella clevelandensis (87.2% prevalence; 0.3% median abundance) outnumbered Lactobacillus (64.1%; 0.2%). Lawsonella abundance positively correlated with IL-1α, IL-1β, IL-8, and RANTES (p < 0.05), whereas Lactobacillus showed no correlation with cytokines, and correlated with lower Nugent scores (Fig. 5; p < 0.03). Three participants exhibited predominantly large rods; two had low Nugent scores of 2 (72.6% Lactobacillus relative abundance) and 3 (58.0% Lactobacillus relative abundance), and one scored 4 (16.5% Lactobacillus relative abundance), owing to mixed morphotypes.

Gardnerella vaginalis, was detected in 33.3% of samples at a median relative abundance of 0.4%. Fannyhessea vaginae (formerly Atopobium vaginae), although not a traditional Nugent bacterium, is also a BV-associated rod and may contribute to the diagnostic power of the Nugent score in rCF41. Fannyhessea was detected in 28.2% of samples at a median relative abundance of only 1.7%. Short straight rods in the neovagina were more likely to be Hoylesella (previously Prevotella; 97.4% prevalence, 9.7% relative abundance), Prevotella spp. (92.3%; 8.5%), or Porphyromonas spp. (97.4%; 8.3%). Prevotella was positively associated with increased cytokines (IL-1α; p < 0.01), while Gardnerella, Fannyhessea, Porphyromonas, and Hoylesella had no significant correlation. None had significant correlations with the Nugent score.

Mobiluncus, the gram-variable curved rod traditionally targeted by Nugent scoring, was detected in 76.9% of samples at 0.8% median relative abundance. Other abundant neovaginal curved rods included Varibaculum (92.3% prevalence, 2.6% abundance) and Campylobacter (89.7%; 1.7%). Abundances of Campylobacter were inversely correlated with neovaginal cytokines (IL-1β, IL-8; p < 0.05) while Mobiluncus and Varibaculum showed no significant correlation with cytokines. Both Mobiluncus (p < 0.02) and Campylobacter (p < 0.02) correlated with higher Nugent scores.

Of note, in addition to F. vaginae, BV-associated Ca. Lachnocurva vaginae (formerly BVAB1; curved rod) and Sneathia vaginalis (curved Gram-negative rod) possess similar morphotypes to traditional Nugent bacteria and may contribute to the diagnostic power of the Nugent score in rCF42. However, both were absent from neovaginal samples.

As noted in Fig. 1E, many neovaginal smears contained a high abundance of cocci, which are not considered by Nugent criteria. Based on V3-V4 16S rRNA gene sequences, 4/10 core neovaginal bacteria have morphotypes not considered during Nugent scoring (Supplemental Table 1). Peptoniphilus, Ezakiella, and Anaerococcus are all gram-positive cocci. Of these, Ezakiella is associated with reduced neovaginal cytokines (IL-8, MIG, p < 0.05), while Anaerococcus is associated with increased cytokines (IL-6, MIG, MIP-1β; p < 0.05) (Fig. 5).

Discussion

This study provides strong evidence that the Nugent score is not suitable as a clinical diagnostic or reference standard for neovaginal dysbiosis in TF with penile inversion vaginoplasty. Most neovaginal bacteria belong to taxa not targeted by the Nugent score, and the score does not associate with predictors of a non-optimal genital microbiome, including neovaginal symptoms and cytokines.

Nugent scoring in rCF relies on the eubiotic nature of Lactobacillus spp. predominance, and vaginal polymicrobialism as dysbiotic. However, Lactobacillus spp. predominance in the neovagina is very rare8,27,28,43, potentially due to differences in carbon sources available in the rCF vagina and TF neovagina. Vaginal epithelial cells in rCF are rich in glycogen and constantly shed into the vaginal lumen15,44,45. In contrast, neovaginal epithelium derived from penile-skin lacks glycogen despite exposure to estrogen levels similar to rCF, and is instead soft-cornified with a lipid-rich extracellular matrix15,44–47. In rCF, vaginal Lactobacillus spp. metabolize glycogen products to produce lactic acid with anti-inflammatory properties, inhibiting colonization by non-lactobacilli, including pathogens48,49. In our cohort, Lactobacillus rarely dominated and showed similar abundance in symptomatic and asymptomatic TF. Future research is warranted to determine if the neovaginal epithelium can support Lactobacillus predominance, and if this confers any benefit.

Further, there is no evidence that neovaginal microbiomes rich in gram-variable rods are necessarily dysbiotic. Neovaginal abundances of traditional Nugent morphotypes Gardnerella and Mobiluncus were not different between symptomatic and asymptomatic TF and did not correlate with increased cytokines. While the relationship between neovaginal inflammation and sexual health outcomes has not been adequately explored, genital inflammation is strongly correlated with negative health outcomes in cisgender individuals16,26,33–36. In rCF, Mobiluncus and Gardnerella are positively associated with vaginal cytokines such as IL-1β and IL-833,50–52. Instead, in the neovagina, Campylobacter, a more abundant curved rod, showed negative correlations with cytokines. More abundant short gram-variable rods such as Hoylesella (predominantly H. timonensis and H. buccalis, both previously Prevotella), Porphyromonas and Dialister lacked any association with inflammation, while Fenollaria correlated inversely with cytokines. Other bacteria that normally contribute to the diagnostic power of the Nugent score in rCF (Fannyhessea, Sneathia vaginalis, Ca. L. vaginae) showed no correlation to cytokines or were absent from the neovagina. These data suggest that gram-variable rod abundance on neovaginal smears does not provide interpretive information on neovaginal health.

Lawsonella abundance correlated strongly with inflammation, yet Nugent scoring classifies Lawsonella morphotypes under the “beneficial rod” category. Likewise, pro-inflammatory cocci such as Anaerococcus lay outside the Nugent framework. These findings are consistent with a study by Weyers et al. examining neovaginal cytology, reporting that, despite over 50% of participants being diagnosed with BV, no correlation was observed with neovaginal inflammation53. Additionally, Weyers et al. noted a significant presence of inflammatory cells in the neovagina. In our study, we frequently observed blood cells, suggesting participants may be experiencing epithelial erosion. Between 7 and 39% of patients experience neovaginal hypergranulation tissue that can significantly impact quality of life54–56. Future research may investigate if RBCs present on neovaginal smears may be an indicator of current or developing hypergranulation tissue.

Nugent scoring of neovaginal smears risks misdiagnosis and promotes futile antibiotic use. Nearly all neovaginal smears in this study fell outside the optimal Nugent range (0–3), indicating most would be classified as dysbiotic and indicative of BV. BV in rCF is commonly treated with metronidazole, which spares Lactobacilli but is bactericidal for BV-associated anaerobes, including Gardnerella57,58. As such, metronidazole reduces non-optimal bacteria, providing an opportunity for Lactobacillus spp. to become dominant. However, in the neovagina, bacteria associated with both high and low inflammation are susceptible (or likely susceptible) to metronidazole59–63, and therefore this antimicrobial is unlikely to selectively deplete non-optimal taxa or to promote an optimal neovaginal microbiota the way it can in the natal vagina. TF who receive a Nugent score in the BV range may feel distress or use products or home remedies aimed at treating BV and restoring Lactobacilli in rCF. TransBiota participants who used diverse solutions for douching (povidone-iodine, soapy water, and vinegar) were more likely to have high abundances of inflammation-associated bacteria8. Many also reported using oral probiotics or probiotic suppositories designed for rCF when experiencing neovaginal symptoms, and referred to having BV in their questionnaires10. Additional research is urgently needed to better characterize the causative agents of neovaginal inflammation and symptoms, and to design effective diagnostic tools to identify them in a clinical setting. However, these findings apply chiefly to mature penile-skin-lined neovagina, and microbial dynamics might differ in bowel-segmented or peritoneal graft neovaginas.

In contemporary rCF practice, BV is more commonly diagnosed using clinical criteria (e.g., Amsel) or NAAT-based assays than by Nugent scoring alone, with Gram stain-based Nugent scoring primarily serving as a laboratory reference standard. While this paper did not evaluate Amsel criteria or NAAT tests, the findings of this study are likely to have implications for these diagnostics as well. For the Amsel criteria, the requirement for a vaginal pH >4.5 is unlikely to be informative in the neovagina, because neovaginal pH clusters around 5.5, within the normal range for keratinized skin8,64. Further research is needed to determine whether the remaining Amsel components (homogeneous discharge, amine odor, and clue cells) have diagnostic value in this population. NAAT-based BV tests are also unlikely to provide interpretable information about neovaginal bacteria because, like the Nugent score, they target organisms associated with BV in rCF (e.g., Gardnerella vaginalis, Atopobium vaginae, BVAB2, Megasphaera type 1) alongside Lactobacillus species (e.g., L. crispatus, L. jensenii). Like the Nugent score, the algorithmic outputs of existing BV NAATs are therefore unlikely to predict symptoms or local inflammation in TF.

This study’s mail-in methodology enabled broader participation, but resulted in some limitations. Some smears were unusable due to inadequate sampling or slide damage during shipping. Both sampling and assessment of symptoms were not clinically supervised. Additionally, although participants were asked to report a history of STIs, participants were not tested for concurrent STIs at the time of their sampling. This study also did not address sampling location within the neovaginal canal; while participants were instructed to collect swabs 5 cm into the neovaginal canal, sampling depth may have varied between participants, and microbiomes vary by distance from the introitus.

Participants were recruited through Trans PULSE Canada, our study Facebook page, Ontario-based clinicians with trans-focused practices, and the two publicly funded vaginoplasty centers in Canada; as such, this convenience sample likely over-represents transfeminine people who are engaged in gender-affirming care and connected to community or clinical networks, and should not be viewed as population-representative. However, this selection is unlikely to affect our main conclusion that Nugent scoring is not a valid indicator of neovaginal health, as that inference rests on the discordance between Nugent scores and local inflammation/symptoms. In addition, although participants were asked to refrain from inserting anything into their neovagina 24 h prior to sampling, variable practices outside this window may have introduced variability65,66. Unmeasured behavioral or hormonal variables may also confound associations.

Conclusions

The Nugent score is an ineffective tool for predicting neovaginal dysbiosis in TF with penile inversion vaginoplasty. Bacteria traditionally targeted by the Nugent score are rare in the neovagina, while other taxa with similar morphotypes are abundant. Nugent scores did not correlate with inflammation or symptoms in the neovagina. Using the Nugent score on neovaginal smears may result in misdiagnosis, inappropriate antibiotic use, and misplaced efforts by TF and clinicians to “correct” neovaginal microbiomes, possibly disrupting an optimal microbiome. These findings highlight that vaginal dysbiosis differs fundamentally between rCF and TF and underscore the need to establish evidence-based neovaginal diagnostics.

Supplementary information

Transparent Peer Review file (375.7KB, pdf)
Supplemental Material (187.4KB, pdf)

Acknowledgements

The authors would like to thank Jason Hallarn and Greta Bauer for their contributions establishing TransBiota. This work was supported by the Canadian Institute of Health Research [PJT 180322] and the National Institutes of Health [R21 AI157912]. J.L.P. is supported by the Canada Research Chairs Program [CRC-2020-00175]. A.C.S. is supported by a Canada Graduate Scholarship from the Canadian Institute of Health Research. This research was undertaken, in part, thanks to funding from the Canada Foundation for Innovation [CFI 42343]. The funders played no role in study design, data collection, analysis and interpretation of data, or the writing of this manuscript.

Author contributions

Conceptualization: J.R., J.L.P., Y.K., and E.P. Methodology: R.P., B.M., H.W., and D.Z. Formal analysis: R.P. and J.R.-V. Interpretation: R.P., J.R.-V., B.M., J.R., and J.L.P. Writing: R.P. and J.L.P. Editing: R.P., B.M., E.P., J.R.-V., H.W., D.Z., A.P., A.C.S., V.L.E., Y.K., J.L.P., and J.R. Funding acquisition: J.R. and J.L.P.

Peer review

Peer review information

Communications Medicine thanks Hans Verstraelen, Christina A. Muzny, David N. Fredricks and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. A peer review file is available.

Data availability

The cytokine, microbiome, and Nugent scoring datasets used in this study are available in GitHub at github.com/prodgerlab/TransBiota/tree/main/Nugent_scoring_paper67. All relevant data are available from the authors upon request (Jessica Prodger: jprodge@uwo.ca).

Code availability

GraphPad Prism 8 and R Studio (version 4.3.2) were used to create graphs and perform statistical analyses. All source codes used to analyze the data and generate the figures presented are available in GitHub at github.com/prodgerlab/TransBiota/tree/main/Nugent_scoring_paper67.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

These authors contributed equally: Jacques Ravel, Jessica L. Prodger.

Contributor Information

Jacques Ravel, Email: jravel@som.umaryland.edu.

Jessica L. Prodger, Email: jprodge@uwo.ca

Supplementary information

The online version contains supplementary material available at 10.1038/s43856-026-01410-2.

References

  • 1.James, S. E., Herman, J., Keisling, M., Mottet, L. & Anafi, M. 2015 U.S. Transgender Survey (USTS): Version 1. ICPSR - Interuniversity Consortium for Political and Social Research 10.3886/ICPSR37229.V1 (2019).
  • 2.Coleman, E. et al. Standards of care for the health of transgender and gender diverse people, version 8. Int. J. Transgend. Health. https://pmc.ncbi.nlm.nih.gov/articles/PMC9553112/ (2022). [DOI] [PMC free article] [PubMed]
  • 3.Papadopulos, N. A. et al. Quality of life and patient satisfaction following male-to-female sex reassignment surgery. J. Sex. Med.14, 721–730 (2017). [DOI] [PubMed] [Google Scholar]
  • 4.Jun, M. S., Gonzalez, E., Zhao, L. C. & Bluebond-Langner, R. Penile inversion vaginoplasty with robotically assisted peritoneal flaps. Plast. Reconstr. Surg.148, 439–442 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Castanon, C. D. G. et al. Laparoscopy assisted peritoneal pull-through vaginoplasty in transgender women. Urology166, 301–302 (2022). [DOI] [PubMed] [Google Scholar]
  • 6.Salgado, C. J., Nugent, A., Kuhn, J., Janette, M. & Bahna, H. Primary sigmoid vaginoplasty in transwomen: technique and outcomes. Biomed. Res. Int.2018, 4907208 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Tristani-Firouzi, B. et al. Preferences for and barriers to gender affirming surgeries in transgender and non-binary individuals. Int. J. Transgend. Health23, 458–471 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Rojas-Vargas, J. et al. The neovaginal microbiota, symptoms, and local immune correlates in transfeminine individuals with penile inversion vaginoplasty. Cell Rep. 44, 116546 (2025). [DOI] [PMC free article] [PubMed]
  • 9.Monari, B. et al. The vaginal microbiota, symptoms, and local immune correlates in transmasculine individuals using sustained testosterone therapy. Cell Rep. 44, 116632 (2025). [DOI] [PMC free article] [PubMed]
  • 10.Hallarn, J. et al. Gynecological concerns and vaginal practices and exposures among transfeminine individuals who have undergone vaginoplasty. J. Sex. Med.20, 1344–1352 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.O’Hanlon, D. E., Gajer, P., Brotman, R. M. & Ravel, J. Asymptomatic bacterial vaginosis is associated with depletion of mature superficial cells shed from the vaginal epithelium. Front. Cell Infect. Microbiol.10, 106 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Ma, B., Forney, L. J. & Ravel, J. Vaginal microbiome: rethinking health and disease. Annu. Rev. Microbiol.66, 371–389 (2012). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Eschenbach, D. A. et al. Diagnosis and clinical manifestations of bacterial vaginosis. Am. J. Obstet. Gynecol.158, 819–828 (1988). [DOI] [PubMed] [Google Scholar]
  • 14.Martin, H. L. et al. Vaginal lactobacilli, microbial flora, and risk of human immunodeficiency virus type 1 and sexually transmitted disease acquisition. J. Infect. Dis.180, 1863–1868 (1999). [DOI] [PubMed] [Google Scholar]
  • 15.Mirmonsef, P. et al. Free glycogen in vaginal fluids is associated with Lactobacillus colonization and low vaginal pH. PLoS ONE9, e102467 (2014). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Masson, L. et al. Defining genital tract cytokine signatures of sexually transmitted infections and bacterial vaginosis in women at high risk of HIV infection: a cross-sectional study. Sex. Transm. Infect.90, 580–587 (2014). [DOI] [PubMed] [Google Scholar]
  • 17.Masson, L. et al. Inflammatory cytokine biomarkers to identify women with asymptomatic sexually transmitted infections and bacterial vaginosis who are at high risk of HIV infection. Sex. Transm. Infect.92, 186–193 (2016). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Norenhag, J. et al. The vaginal microbiota, human papillomavirus and cervical dysplasia: a systematic review and network meta-analysis. BJOG127, 171–180 (2020). [DOI] [PubMed] [Google Scholar]
  • 19.Brotman, R. M. et al. Bacterial vaginosis assessed by Gram stain and diminished colonization resistance to incident gonococcal, chlamydial, and trichomonal genital infection. J. Infect. Dis.202, 1907–1915 (2010). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Cauci, S. et al. Interrelationships of interleukin-8 with interleukin-1beta and neutrophils in vaginal fluid of healthy and bacterial vaginosis positive women. Mol. Hum. Reprod.9, 53–58 (2003). [DOI] [PubMed] [Google Scholar]
  • 21.Wiesenfeld, H. C., Hillier, S. L., Krohn, M. A., Landers, D. V. & Sweet, R. L. Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae and Chlamydia trachomatis infection. Clin. Infect. Dis.36, 663–668 (2003). [DOI] [PubMed] [Google Scholar]
  • 22.Peters, S. E. et al. Behaviors associated with Neisseria gonorrhoeae and Chlamydia trachomatis: cervical infection among young women attending adolescent clinics. Clin. Pediatr.39, 173–177 (2000). [DOI] [PubMed] [Google Scholar]
  • 23.Cherpes, T. L., Meyn, L. A., Krohn, M. A., Lurie, J. G. & Hillier, S. L. Association between acquisition of herpes simplex virus type 2 in women and bacterial vaginosis. Clin. Infect. Dis.37, 319–325 (2003). [DOI] [PubMed] [Google Scholar]
  • 24.Nugent, R. P., Krohn, M. A. & Hillier, S. L. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of gram stain interpretation. J. Clin. Microbiol.29, 297–301 (1991). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Ravel, J. et al. Vaginal microbiome of reproductive-age women. Proc. Natl. Acad. Sci. USA108, 4680–4687 (2011). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Prodger, J. L. et al. Penile bacteria associated with HIV seroconversion, inflammation, and immune cells. JCI Insight6, e147363 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Birse, K. D. et al. The neovaginal microbiome of transgender women post-gender reassignment surgery. Microbiome8, 61 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Mora, R. M., Mehta, P., Ziltzer, R. & Samplaski, M. K. Systematic review: the neovaginal microbiome. Urology167, 3–12 (2022). [DOI] [PubMed] [Google Scholar]
  • 29.Scheim, A. I., Coleman, T., Lachowsky, N. & Bauer, G. R. Health care access among transgender and nonbinary people in Canada, 2019: a cross-sectional survey. CMAJ Open9, E1213–E1222 (2021). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Holm, J. B. et al. Ultrahigh-throughput multiplexing and sequencing of >500-base-pair amplicon regions on the Illumina HiSeq 2500 platform. mSystems4, e00029–19 (2019). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Ravel, J. et al. Twice-daily application of HIV microbicides alters the vaginal microbiota. mBio10.1128/mbio.00370-12 (2012). [DOI] [PMC free article] [PubMed]
  • 32.Gajer, P. et al. Temporal dynamics of the human vaginal microbiota. Sci. Transl. Med.4, 132ra52 (2012). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Mitchell, C. & Marrazzo, J. Bacterial vaginosis and the cervicovaginal immune response. Am. J. Reprod. Immunol.71, 555–563 (2014). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Chen, X., Lu, Y., Chen, T. & Li, R. The female vaginal microbiome in health and bacterial vaginosis. Front. Cell. Infect. Microbiol. 11, 631972 (2021). [DOI] [PMC free article] [PubMed]
  • 35.Arnold, K. B. et al. Increased levels of inflammatory cytokines in the female reproductive tract are associated with altered expression of proteases, mucosal barrier proteins, and an influx of HIV-susceptible target cells. Mucosal Immunol.9, 194–205 (2016). [DOI] [PubMed] [Google Scholar]
  • 36.Prodger, J. L. et al. Chemokine levels in the penile coronal sulcus correlate with HIV-1 acquisition and are reduced by male circumcision in Rakai, Uganda. PLoS Pathog.12, e1006025 (2016). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Nakase, H., Sato, N., Mizuno, N. & Ikawa, Y. The influence of cytokines on the complex pathology of ulcerative colitis. Autoimmun. Rev.21, 103017 (2022). [DOI] [PubMed] [Google Scholar]
  • 38.Li, W. et al. Genome-wide identification and expression profiling analysis of the mitochondrial calcium uniporter gene family under abiotic stresses in Medicago sativa. Plants13, 3176 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Bell, M. E. et al. Lawsonella clevelandensis gen. nov., sp. nov., a new member of the suborder Corynebacterineae isolated from human abscesses. Int. J. Syst. Evol. Microbiol.66, 2929–2935 (2016). [DOI] [PubMed] [Google Scholar]
  • 40.Morton, A. B., Boyle, E., Pettengill, M. A. & Gancher, E. The brief case: strictly anaerobic and staining acid fast. J. Clin. Microbiol.61, e0015022 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Muzny, C. A. et al. Identification of key bacteria involved in the induction of incident bacterial vaginosis: a prospective study. J. Infect. Dis.218, 966–978 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Srinivasan, S. et al. More than meets the eye: associations of vaginal bacteria with gram stain morphotypes using molecular phylogenetic analysis. PLoS ONE8, e78633 (2013). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Weyers, S. et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol.9, 102 (2009). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Cruickshank, R. The conversion of the glycogen of the vagina into lactic acid. J. Pathol.39, 213–219 (1934). [Google Scholar]
  • 45.Dinh, M. H., Okocha, E. A., Koons, A., Veazey, R. S. & Hope, T. J. Expression of structural proteins in human female and male genital epithelia and implications for sexually transmitted infections. Biol. Reprod.86, 32 (2012). [DOI] [PMC free article] [PubMed]
  • 46.Krakowsky, Y. et al. The effect of gender-affirming medical care on the vaginal and neovaginal microbiomes of transgender and gender-diverse people. Front. Cell. Infect. Microbiol.11, 769950 (2022). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Dekker, J. J. M. L., Hage, J. J., Karim, R. B. & Bloemena, E. Do histologic changes in the skin-lined neovagina of male-to-female transsexuals really occur? Ann. Plast. Surg.59, 546–549 (2007). [DOI] [PubMed] [Google Scholar]
  • 48.Hearps, A. C. et al. Vaginal lactic acid elicits an anti-inflammatory response from human cervicovaginal epithelial cells and inhibits production of pro-inflammatory mediators associated with HIV acquisition. Mucosal Immunol.10, 1480–1490 (2017). [DOI] [PubMed] [Google Scholar]
  • 49.Delgado-Diaz, D. J. et al. Lactic acid from vaginal microbiota enhances cervicovaginal epithelial barrier integrity by promoting tight junction protein expression. Microbiome10, 141 (2022). [DOI] [PMC free article] [PubMed]
  • 50.Joseph, A. et al. Intrauterine colonization with Gardnerella vaginalis and Mobiluncus mulieris induces maternal inflammation but not preterm birth in a mouse model. Am. J. Reprod. Immunol.90, e13749 (2023). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Campos, A. C. C., Murta, E. F. C., Michelin, M. A. & Reis, C. Evaluation of cytokines in endocervical secretion and vaginal pH from women with bacterial vaginosis or human papillomavirus. ISRN Obstet. Gynecol.2012, 342075 (2012). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Anahtar, M. N. et al. Cervicovaginal bacteria are a major modulator of host inflammatory responses in the female genital tract. Immunity42, 965–976 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Weyers, S. et al. Cytology of the ‘penile’ neovagina in transsexual women. Cytopathology21, 111–115 (2010). [DOI] [PubMed] [Google Scholar]
  • 54.Potter, E. et al. Hypergranulation management following penile inversion vaginoplasty. Can. Fam. Physician70, 456–461 (2024). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Hontscharuk, R., Alba, B., Hamidian Jahromi, A. & Schechter, L. Penile inversion vaginoplasty outcomes: complications and satisfaction. Andrology9, 1732–1743 (2021). [DOI] [PubMed] [Google Scholar]
  • 56.Potter, E. et al. Patient reported symptoms and adverse outcomes seen in Canada’s first vaginoplasty postoperative care clinic. Neurourol. Urodyn.42, 523–529 (2023). [DOI] [PubMed] [Google Scholar]
  • 57.Verwijs, M. C., Agaba, S. K., Darby, A. C. & van de Wijgert, J. H. H. M. Impact of oral metronidazole treatment on the vaginal microbiota and correlates of treatment failure. Am. J. Obstet. Gynecol.222, 157.e1–157.e13 (2020). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Goldstein, E. J. C., Tyrrell, K. L. & Citron, D. M. Lactobacillus species: taxonomic complexity and controversial susceptibilities. Clin. Infect. Dis.60, S98–S107 (2015). [DOI] [PubMed] [Google Scholar]
  • 59.Diop, K., Raoult, D., Bretelle, F. & Fenollar, F. ‘Ezakiella massiliensis’ sp. nov., a new bacterial species isolated from human female genital tract. New Microbes New Infect.15, 16–17 (2017). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 60.Cobo, F., Pérez-Carrasco, V., García-Salcedo, J. A. & Navarro-Marí, J. M. New anaerobic bacteria causing infection: bacteremia due to Murdochiella asaccharolytica. Anaerobe79, 102697 (2023). [DOI] [PubMed] [Google Scholar]
  • 61.Dahlen, G. & Preus, H. R. Low antibiotic resistance among anaerobic Gram-negative bacteria in periodontitis 5 years following metronidazole therapy. Anaerobe43, 94–98 (2017). [DOI] [PubMed] [Google Scholar]
  • 62.Shilnikova, I. I. & Dmitrieva, N. V. Evaluation of antibiotic susceptibility of Gram-positive anaerobic cocci isolated from cancer patients of the N. N. Blokhin Russian Cancer Research Center. J. Pathog.2015, 648134 (2015). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Goldenberger, D. et al. Emerging anaerobic and partially acid-fast Lawsonella clevelandensis: extended characterization by antimicrobial susceptibility testing and whole genome sequencing. Clin. Microbiol. Infect.25, 1447–1448 (2019). [DOI] [PubMed] [Google Scholar]
  • 64.Lambers, H., Piessens, S., Bloem, A., Pronk, H. & Finkel, P. Natural skin surface pH is on average below 5, which is beneficial for its resident flora. Int. J. Cosmet. Sci.28, 359–370 (2006). [DOI] [PubMed] [Google Scholar]
  • 65.Muthusamy, S., Varghese, J., Raveendran, V., Ezilarasan, K. & Easow, J. Evaluation of interobserver reliability of Nugent score for diagnosis of bacterial vaginosis. Indian J. Sex. Transm. Dis.39, 120 (2018). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Mohanty, S., Sood, S., Kapil, A. & Mittal, S. Interobserver variation in the interpretation of Nugent scoring method for diagnosis of bacterial vaginosis. Indian J. Med. Res.131, 88–91 (2010). [PubMed] [Google Scholar]
  • 67.prodgerlab. TransBiota/Nugent_scoring_paper. GitHubhttps://github.com/prodgerlab/TransBiota/tree/main/Nugent_scoring_paper (2025).

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Transparent Peer Review file (375.7KB, pdf)
Supplemental Material (187.4KB, pdf)

Data Availability Statement

The cytokine, microbiome, and Nugent scoring datasets used in this study are available in GitHub at github.com/prodgerlab/TransBiota/tree/main/Nugent_scoring_paper67. All relevant data are available from the authors upon request (Jessica Prodger: jprodge@uwo.ca).

GraphPad Prism 8 and R Studio (version 4.3.2) were used to create graphs and perform statistical analyses. All source codes used to analyze the data and generate the figures presented are available in GitHub at github.com/prodgerlab/TransBiota/tree/main/Nugent_scoring_paper67.

Articles from Communications Medicine are provided here courtesy of Nature Publishing Group

RESOURCES