When should bacterial vaginosis (BV) be treated?

When to Treat Bacterial Vaginosis (BV)

All women who have symptomatic bacterial vaginosis require treatment, regardless of pregnancy status. 1 Additionally, treatment should be considered in specific asymptomatic cases due to potential complications.

Treatment Indications for BV

Symptomatic BV

• All women with symptomatic BV should be treated 1
• Symptoms typically include:
  • Abnormal vaginal discharge (homogeneous, white, coating vaginal walls)
  • Fishy odor (especially after adding 10% KOH)
  • Vaginal irritation

Asymptomatic BV

Treatment is indicated in the following scenarios:

1. Before invasive gynecologic procedures:

   • Before surgical abortion 1
   • Consider before hysterectomy 1
   • Consider before other procedures such as endometrial biopsy, hysterosalpingography, IUD placement, cesarean section, and uterine curettage 1

2. High-risk pregnant women:

   • Women with history of preterm delivery 1
   • Treatment may reduce risk of prematurity, premature rupture of membranes, preterm labor, and postpartum endometritis 1, 2

3. Women with irregular vaginal bleeding:

   • Treatment of BV can resolve bleeding disturbances 3

Diagnostic Approach

BV diagnosis requires 3 of the following 4 clinical criteria (Amsel's criteria):

1. Homogeneous, white discharge that coats vaginal walls
2. Presence of clue cells on microscopic examination
3. Vaginal fluid pH >4.5
4. Fishy odor before or after adding 10% KOH (whiff test) 1

Alternatively, Gram stain with Nugent scoring (≥4 indicates BV) can be used 1, 4.

Treatment Options

Non-pregnant women:

• First-line:

  • Metronidazole 500 mg orally twice daily for 7 days 1
  • Metronidazole gel 0.75%, one applicator (5g) intravaginally twice daily for 5 days 1
  • Clindamycin cream 2%, one applicator (5g) intravaginally at bedtime for 7 days 1

• Alternative regimens:

  • Metronidazole 2g orally in a single dose (less efficacious) 1
  • Clindamycin 300 mg orally twice daily for 7 days 1
  • Tinidazole 2g once daily for 2 days or 1g once daily for 5 days 4

Pregnant women:

• Treatment follows special considerations for pregnancy 1
• Metronidazole and clindamycin are safe to use in pregnancy 2

Important Clinical Considerations

1. Recurrence risk: 50-80% of women experience BV recurrence within a year of treatment 5, 6

2. Treatment caveats:

   • Patients should avoid alcohol during metronidazole treatment and for 24 hours after 1
   • Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 1

3. Partner treatment: Treatment of male sex partners has not been shown to prevent recurrence of BV 1

4. Follow-up: Consider test of cure after treatment, especially in high-risk cases 2

5. Untreated consequences: BV is associated with increased risk of PID, endometritis, and vaginal cuff cellulitis after procedures, as well as adverse pregnancy outcomes 1

By following these evidence-based guidelines for treating BV, clinicians can effectively manage both symptomatic cases and prevent complications in high-risk asymptomatic cases.