From the Guidelines
Recurrent bacterial vaginosis (BV) develops when there is repeated disruption of the vaginal microbiome, allowing harmful bacteria to overgrow while beneficial lactobacilli decrease. This imbalance can occur due to several factors including frequent douching, multiple sexual partners, new sexual partners, lack of condom use, and intrauterine devices, as noted in studies such as 1. Hormonal changes during menstruation or pregnancy can also trigger recurrence. Some women may have bacterial biofilms that protect harmful bacteria from treatment, leading to persistent infection. Genetic factors may make some women more susceptible to recurrent BV. Incomplete treatment of previous BV infections can also contribute, as remaining bacteria may multiply once treatment stops, a concept supported by guidelines such as those found in 1 and 1. To reduce recurrence risk, avoid douching, use condoms consistently, complete the full course of prescribed antibiotics (typically metronidazole 500mg twice daily for 7 days or clindamycin cream 2% for 7 nights), and consider probiotics containing lactobacilli. Some doctors may recommend maintenance therapy with metronidazole gel twice weekly for 3-6 months for women with frequent recurrences. The underlying mechanism involves disruption of the protective acidic environment created by lactobacilli, allowing anaerobic bacteria like Gardnerella vaginalis to flourish, creating the characteristic discharge and odor of BV, as described in 1. Key factors to consider in managing recurrent BV include:
- Avoiding practices that disrupt the vaginal microbiome
- Completing full treatment courses to prevent recurrence
- Considering supplemental therapies like probiotics for prevention
- Maintaining open communication with healthcare providers about symptoms and treatment outcomes, especially given that follow-up visits are not necessary if symptoms resolve, but women should be advised to return for additional therapy if symptoms recur, as suggested by 1 and 1.
From the Research
Recurrent Bacterial Vaginosis (BV) Development
Recurrent bacterial vaginosis is a common issue among women, with studies indicating that 50-80% of women experience a recurrence within a year of completing antibiotic treatment 2. Several factors contribute to the development of recurrent BV, including:
- Persistence of residual infection
- Resistance to antibiotics
- Reinfection from male or female partners
- Formation of a biofilm that protects BV-causing bacteria from antimicrobial therapy 3
- Poor adherence to treatment among patients with genitourinary infections, leading to resistance
Causes of Recurrence
The exact etiology of BV remains controversial, which has impeded significant advances in diagnosis, treatment, and prevention 4. However, research suggests that the following factors may contribute to the recurrence of BV:
- Failure to reestablish acidic pH and the lactobacillus-dominated commensal flora after antibiotic treatment 5
- Inability to eradicate polymicrobial biofilms 5
- Antibiotic resistance 3
Treatment and Prevention Strategies
Current treatment options for recurrent BV include:
- Extended courses of metronidazole treatment
- Metronidazole vaginal gel
- Alternative strategies such as probiotics, prebiotics, and acidifying agents 5
- Antimicrobial substances, including other antimicrobials, antiseptics, and natural compounds 5 Studies have shown that combination pharmacotherapy regimens, including oral nitroimidazole and vaginal boric acid, may be effective in preventing recurrence 6. Additionally, behavioral modifications such as smoking cessation, condom use, and hormonal contraception may also help prevent recurrence 2.