Treatment of Bacterial Vaginosis in Transgender Men on Testosterone Therapy
Treat bacterial vaginosis in transgender men on testosterone therapy with the same standard regimens used for cisgender women: oral metronidazole 500 mg twice daily for 7 days remains the first-line treatment, with topical alternatives available if oral therapy is not tolerated. 1, 2
First-Line Treatment Recommendations
The standard treatment approach does not change based on testosterone therapy or gender identity—only symptomatic disease requires treatment. 3, 1
Preferred oral regimen:
- Metronidazole 500 mg orally twice daily for 7 days achieves 95% cure rates and remains the gold standard 3, 1
- Patients must avoid all alcohol during treatment and for 24 hours after completion to prevent disulfiram-like reactions 1, 4
Alternative topical regimens (particularly useful if vaginal examination is distressing or oral therapy not tolerated):
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally twice daily for 5 days 1, 2
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1, 2
- Note that clindamycin cream is oil-based and weakens latex condoms and diaphragms 1, 4
Alternative Treatment Options
For compliance concerns or patient preference:
- Metronidazole 2g orally as a single dose has lower efficacy (84% vs 95%) but may be appropriate when adherence is uncertain 3, 1
- Clindamycin 300 mg orally twice daily for 7 days is another alternative 1, 2
Special Considerations for Transgender Men
Gender-affirming care principles:
- Testosterone therapy does not alter the treatment regimen for bacterial vaginosis—standard protocols apply 1, 2
- Topical intravaginal treatments may be preferred if vaginal examination or self-administration causes gender dysphoria 1, 2
- The oral route avoids vaginal contact entirely and may be more acceptable to some patients 3, 1
Important clinical context:
- Testosterone-induced vaginal atrophy may increase susceptibility to BV, but treatment efficacy remains unchanged 1, 2
- Symptomatic relief is the primary treatment goal, as partner treatment is not recommended regardless of partner gender 3, 4
Management Pitfalls to Avoid
Do not treat sexual partners:
- Routine treatment of sex partners (regardless of gender) does not influence cure rates, relapse rates, or recurrence 3, 4
- This applies equally to male and female partners 4
Allergy considerations:
- For metronidazole allergy, clindamycin cream is the preferred alternative 3, 1
- Patients allergic to oral metronidazole should NOT use metronidazole gel vaginally 3, 1