How can bacterial vaginosis (BV) be prevented?

Prevention of Bacterial Vaginosis

The most effective strategies to prevent bacterial vaginosis (BV) include avoiding douching, using condoms consistently, quitting smoking, and considering hormonal contraception, as these measures help maintain normal vaginal flora and pH. 1

Understanding BV Risk Factors

Bacterial vaginosis occurs when the normal hydrogen peroxide-producing Lactobacillus species in the vagina are replaced by high concentrations of anaerobic bacteria. While BV is the most prevalent cause of vaginal discharge or malodor, several risk factors have been identified:

• Sexual activity (women who have never been sexually active are rarely affected) 2
• Multiple sexual partners 2, 1
• Smoking 1, 3
• Douching 1
• Absence of hormonal contraception 1, 3

Evidence-Based Prevention Strategies

Primary Prevention Measures

1. Avoid Douching

   • Douching disrupts the natural vaginal flora and pH balance 1
   • The CDC recommends against this practice as it increases BV risk

2. Sexual Practices

   • Consider consistent condom use during sexual intercourse 1, 3
   • While BV is associated with sexual activity, it is not exclusively considered an STD 2
   • Note: Treatment of male sexual partners has not been shown to prevent BV recurrence 2, 1

3. Lifestyle Modifications

   • Smoking cessation may help reduce BV risk 1, 3
   • Hormonal contraception appears to offer some protection 1, 3

4. For Postmenopausal Women

   • Vaginal estrogen with or without lactobacillus-containing probiotics may help maintain vaginal pH 1

Prevention of Recurrence

BV has a high recurrence rate of 50-80% within one year after treatment 3, 4. For women with recurrent BV, additional strategies may be considered:

1. Probiotic Supplementation

   • Lactobacillus-containing probiotics (particularly L. acidophilus, L. rhamnosus GR-1, and L. fermentum RC-14) at doses of at least 10⁹ CFU/day for 2 months have shown promising results 5, 6
   • Probiotics can be administered orally or vaginally to help restore normal vaginal flora 5, 6

2. Extended Antibiotic Treatment for Recurrent Cases

   • For women with frequent recurrences, extended courses of metronidazole may be considered 4
   • Metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly for 3-6 months is an alternative regimen for recurrent cases 4

Special Considerations

Before Invasive Gynecological Procedures

BV has been associated with complications after gynecologic procedures, including:

• Post-abortion pelvic inflammatory disease (PID)
• Endometritis
• Vaginal cuff cellulitis following hysterectomy
• Complications after IUD placement 2, 1

Treatment of asymptomatic BV before surgical abortion procedures may be reasonable to reduce the risk of post-procedure infection 2, 1.

During Pregnancy

BV during pregnancy is associated with adverse outcomes including:

• Premature rupture of membranes
• Preterm labor
• Preterm birth
• Postpartum endometritis 2, 1

High-risk pregnant women (those with previous preterm delivery) may benefit from screening and treatment for BV, even if asymptomatic 2, 1.

Emerging Prevention Approaches

Research is exploring several novel approaches to BV prevention:

• pH modulation strategies 3, 7
• Biofilm disruption techniques 3, 4, 7
• Vaginal microbiome transplantation 3
• Bacteriophage therapy targeting BV-associated bacteria 7

Common Pitfalls in BV Prevention

1. Treating Male Partners: Despite logical reasoning, treatment of male sexual partners has consistently failed to prevent BV recurrence 2, 1

2. Overuse of Antibiotics: While antibiotics effectively treat acute BV, they do not prevent recurrence and may contribute to antibiotic resistance 3, 4

3. Douching: Often used by women to "clean" the vagina, douching actually increases BV risk by disrupting normal flora 1, 3

4. Ignoring Asymptomatic BV: In high-risk situations (pregnancy with history of preterm birth, before invasive procedures), treating asymptomatic BV may be beneficial 2, 1