What is the treatment for asymptomatic bacterial vaginosis?

Treatment of Asymptomatic Bacterial Vaginosis

For non-pregnant women with asymptomatic bacterial vaginosis, routine treatment is generally not recommended unless the patient is undergoing invasive gynecologic procedures such as surgical abortion or hysterectomy. 1

General Principles for Asymptomatic BV

• The principal goal of BV therapy is to relieve vaginal symptoms and signs of infection, which are absent in asymptomatic cases 1
• Asymptomatic BV is common, with approximately 50% of women with BV meeting clinical criteria but having no symptoms 1
• Routine screening and treatment of asymptomatic BV in the general population is not currently recommended 2

Special Situations Where Treatment of Asymptomatic BV is Indicated

Pre-Surgical Considerations

• Treatment should be given to women with asymptomatic BV before surgical abortion procedures to reduce post-abortion PID 1
• Consider treatment before hysterectomy and other invasive gynecological procedures due to increased risk of postoperative infectious complications 1
• BV has been associated with endometritis, PID, and vaginal cuff cellulitis after procedures such as endometrial biopsy, hysterectomy, and IUD placement 1

Pregnancy Considerations

• High-risk pregnant women (those with history of preterm delivery) who have asymptomatic BV may be evaluated for treatment to potentially reduce risk of prematurity 1, 3
• However, there is insufficient evidence to recommend routine screening and treatment of asymptomatic BV in all pregnant women 1, 2

Treatment Regimens When Indicated

When treatment of asymptomatic BV is indicated, the recommended regimens are the same as for symptomatic BV:

First-Line Options

• Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1, 3
• Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 1, 3
• Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1, 3

Alternative Options

• Tinidazole 2g orally once daily for 2 days (therapeutic cure rate 27.4%) 4
• Tinidazole 1g orally once daily for 5 days (therapeutic cure rate 36.8%) 4
• Metronidazole 2g orally in a single dose (lower efficacy at 84% compared to 7-day regimen) 1, 3
• Clindamycin 300 mg orally twice daily for 7 days 1, 3

Important Clinical Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1, 3
• Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 1, 3
• Follow-up visits are unnecessary if no symptoms develop 1, 3
• Routine treatment of male sex partners is not recommended as it has not been shown to reduce recurrence rates 3, 5

Potential Benefits of Treating Asymptomatic BV

• Some research suggests treatment of asymptomatic BV may reduce the risk of acquiring other STIs, including chlamydia 2
• Some women with "asymptomatic" BV may actually have symptoms they don't recognize as infection 2

Pitfalls and Caveats

• Despite treatment, recurrence rates of BV are high, with up to 50% of women experiencing recurrence within 1 year 6, 7
• The formation of polymicrobial biofilms in BV may contribute to treatment failures and recurrence 6, 7
• Some women may have unrecognized symptoms and would benefit from education about normal versus abnormal vaginal discharge 2
• The exact etiology of BV remains controversial, which has impeded significant advances in diagnosis, treatment, and prevention 7