Treatment of Asymptomatic Bacterial Vaginosis Detected on Pap Smear
Asymptomatic bacterial vaginosis (BV) detected on a Pap smear does not require treatment in most cases, as the principal goal of BV therapy is to relieve vaginal symptoms which are absent in asymptomatic cases. 1
General Approach to Asymptomatic BV
- Routine treatment of asymptomatic BV is not recommended as approximately 50% of women with BV meeting clinical criteria have no symptoms 1
- The Centers for Disease Control and Prevention guidelines clearly state that the principal goal of therapy is to relieve vaginal symptoms and signs of infection 2
- Without symptoms, treatment is generally unnecessary for most women 2
Special Situations Where Treatment IS Indicated
Treatment of asymptomatic BV should be considered in the following specific scenarios:
- Before surgical abortion procedures: Treatment with metronidazole has been shown to substantially reduce post-abortion PID 2, 1
- Before invasive gynecological procedures: Consider treatment before hysterectomy, endometrial biopsy, IUD placement, or other invasive procedures due to increased risk of endometritis, PID, or vaginal cuff cellulitis 2, 1
- Pregnant women with history of preterm birth: High-risk pregnant women with asymptomatic BV may benefit from treatment to potentially reduce risk of prematurity 1, 3
Treatment Regimens When Indicated
If treatment is warranted based on the special situations above, the following options are recommended:
First-Line Options:
- Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 1, 4
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 1, 4
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1
Alternative Options:
- Metronidazole 2g orally in a single dose (lower efficacy at 84% compared to 7-day regimen) 1, 4
- Clindamycin 300 mg orally twice daily for 7 days 1, 4
Important Clinical Considerations
- Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1, 4
- Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 4
- Follow-up visits are unnecessary if no symptoms develop 1
- Routine treatment of male sex partners is not recommended as it has not been shown to reduce recurrence rates 1, 5
- BV has a high recurrence rate (up to 50% within one year), even after successful treatment 6
Pitfalls and Caveats
- Avoid unnecessary treatment of asymptomatic BV as it may contribute to antibiotic resistance 7
- Do not assume that BV on Pap smear requires treatment in all cases - this is a common misconception 1
- Remember that culture of G. vaginalis is not recommended as a diagnostic tool because it is not specific and can be isolated from vaginal cultures among half of normal women 2
- When BV is detected on Pap smear, confirm the diagnosis using clinical criteria (Amsel's criteria) or Gram stain (Nugent score) before considering treatment in special situations 2, 8
- For pregnant women, metronidazole is contraindicated during the first trimester; clindamycin vaginal cream is the preferred treatment during this period 2