Should a female's sexual partner be tested and treated for bacterial vaginosis (BV) if she experiences multiple episodes?

Testing and Treatment of Sexual Partners for Recurrent Bacterial Vaginosis

Treatment of male sexual partners is not recommended for women with recurrent bacterial vaginosis (BV), as it has not been shown to prevent recurrence or improve clinical outcomes. 1, 2

Evidence Against Partner Testing and Treatment

• The Centers for Disease Control and Prevention (CDC) clearly states that treatment of male sex partners has not been shown to alter the clinical course of BV in women or reduce recurrence rates 3, 4
• High-quality evidence from randomized controlled trials demonstrates that antibiotic treatment of sexual partners, compared to placebo, does not increase the rate of clinical or symptomatic improvement in women with BV during the first week, between the first and fourth week, or after the fourth week of treatment 2
• Low-quality evidence suggests that antibiotic treatment of partners does not lead to lower BV recurrence rates in women but does increase the frequency of adverse events (primarily gastrointestinal symptoms) reported by sexual partners 2
• Despite the exchange of bacteria between partners during sexual activity, partner treatment trials have failed to demonstrate efficacy in preventing BV recurrence 5

Understanding BV and Its Recurrence

• BV is characterized by replacement of normal hydrogen peroxide-producing Lactobacillus species with high concentrations of anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis 4, 1
• BV is the most prevalent cause of vaginal discharge and malodor, with up to 50% of women with BV being asymptomatic 1
• Recurrence rates are high, with 50-80% of women experiencing BV recurrence within one year of treatment 6, 7
• Recurrence may be due to multiple factors including:
  • Persistence of residual infection
  • Formation of biofilms that protect BV-causing bacteria from antimicrobial therapy
  • Resistance to antibiotics
  • Possible reinfection 6, 5

Risk Factors for BV

• Multiple sexual partners increase the risk of BV 1, 8
• New sexual partners also increase the risk 1
• Sexual activity is a significant risk factor, as women who have never been sexually active are rarely affected 1
• Other risk factors include African-American ethnicity, low socioeconomic status, and previous history of preterm birth 1
• Additional risk factors include exposure to semen, prior trichomoniasis, intrauterine device usage, smoking, and frequent use of scented soap 8

Management Strategies for Recurrent BV

• Recommended treatment for recurrent BV consists of an extended course of metronidazole (500 mg twice daily for 10-14 days) 6
• If ineffective, metronidazole vaginal gel 0.75% for 10 days, followed by twice weekly application for 3-6 months, is an alternative regimen 6
• Probiotics containing Lactobacillus species may help maintain healthy vaginal flora when used as complementary therapy with antibiotics 1, 9
• Meta-analyses show that probiotic supplementation significantly improves BV cure rates when used alongside antibiotics 9

Clinical Pitfalls to Avoid

• Unnecessarily treating sexual partners, which exposes them to medication side effects without clear benefit 1, 2
• Assuming BV is always symptomatic, when up to 50% of cases are asymptomatic 1
• Failing to consider other prevention strategies such as condom use, smoking cessation, and hormonal contraception that may help reduce recurrence 7
• Overlooking the importance of treating BV before invasive gynecological procedures to reduce the risk of post-procedure infections 4

In conclusion, while BV is associated with sexual activity and multiple partners increase risk, the current evidence does not support testing or treating male sexual partners of women with recurrent BV.