Does bacterial vaginosis (BV) require treatment?

Treatment of Bacterial Vaginosis (BV)

All women who have symptomatic bacterial vaginosis require treatment, while asymptomatic BV generally does not require treatment except in specific high-risk situations. 1

Diagnostic Criteria for BV

• BV is diagnosed when at least three of the following four Amsel criteria are present:

  • Homogeneous, white, non-inflammatory discharge that smoothly coats the vaginal walls 1
  • Presence of clue cells on microscopic examination 1
  • Vaginal fluid pH greater than 4.5 1
  • Fishy odor of vaginal discharge before or after addition of 10% KOH (positive whiff test) 1

• Alternatively, Gram stain can be used to determine the relative concentration of bacterial morphotypes characteristic of BV 1, 2

Treatment Indications

Symptomatic BV

• All women with symptomatic BV require treatment, regardless of pregnancy status 1
• The principal goal of therapy is to relieve vaginal symptoms and signs of infection 1

Asymptomatic BV

• Generally, asymptomatic BV does not require treatment 1, 2
• Exceptions where treatment of asymptomatic BV is indicated:
  • Before surgical abortion procedures to reduce post-abortion PID 1
  • Before hysterectomy or other invasive gynecological procedures to reduce risk of postoperative infectious complications 1, 2
  • High-risk pregnant women (those with history of preterm delivery) to potentially reduce risk of prematurity 1, 3

Treatment Regimens

First-Line Treatment 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, 4

Alternative Regimens

• Tinidazole 2g orally once daily for 2 days (FDA-approved for BV) 5
• Tinidazole 1g orally once daily for 5 days 5
• Metronidazole 2g orally in a single dose (lower efficacy at 84% compared to 7-day regimen) 4, 6

Special Considerations

Pregnancy

• All symptomatic pregnant women should be treated because BV is associated with adverse pregnancy outcomes including premature rupture of membranes, preterm labor, preterm birth, and postpartum endometritis 1, 4
• Oral metronidazole or clindamycin are recommended for pregnant women 1
• A follow-up evaluation one month after treatment completion is recommended for pregnant women to verify effectiveness 1

Important Clinical Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 1
• Clindamycin cream is oil-based and might weaken latex condoms and diaphragms 2, 4
• Treatment of male sex partners has not been shown to prevent recurrence of BV and is not recommended 1
• Recurrence is common, with 50-80% of women experiencing recurrence within a year of treatment 7, 8

Clinical Pitfalls to Avoid

• Treating asymptomatic women unnecessarily exposes them to medication side effects without clear benefit 2, 4
• Failing to treat before invasive gynecological procedures may increase risk of post-procedure infections 1, 2
• Not recognizing that BV is associated with increased risk for acquiring STIs and HIV 1, 7
• Overlooking the high recurrence rate of BV after standard treatment, which may necessitate extended treatment regimens in some cases 7, 8