What are the preventive measures for recurrent bacterial vaginosis (BV)?

From the Guidelines

To prevent recurrent bacterial vaginosis, it is essential to maintain a healthy vaginal pH and microbiome through several key strategies, including the use of antibiotics as prescribed by a healthcare provider, such as metronidazole (500mg twice daily for 7 days) or clindamycin cream (2% applied intravaginally for 7 days) to treat active infections completely, as recommended by the Centers for Disease Control and Prevention 1.

When considering treatment options, it is crucial to note that the recommended metronidazole regimens are equally efficacious, while the vaginal clindamycin cream appears less efficacious than the metronidazole regimens 1. Alternative regimens, such as metronidazole 2g orally in a single dose or clindamycin 300mg orally twice a day for 7 days, have lower efficacy for BV treatment 1.

To prevent recurrence, consider maintenance therapy with twice-weekly metronidazole gel (0.75%) for 3-6 months, as this can help maintain the acidic environment of the vagina and support beneficial bacteria that prevent overgrowth of the anaerobic bacteria responsible for bacterial vaginosis. Additionally, avoid douching, scented feminine products, and tight synthetic underwear, as these disrupt vaginal flora 1. After sex, urinate and gently clean the genital area, and wear cotton underwear to prevent moisture buildup. Some women find taking probiotics containing Lactobacillus species helpful in maintaining vaginal health, though consuming probiotic-rich foods like yogurt can also be beneficial.

It is also important to note that treatment of the male sex partner has not been beneficial in preventing the recurrence of BV, and follow-up visits are unnecessary if symptoms resolve, but recurrence is not unusual, and patients should return for additional treatment if symptoms recur 1. Boric acid suppositories (600mg inserted vaginally at bedtime for 7-14 days) may help restore vaginal pH, but more research is needed to confirm their efficacy.

In terms of prevention, maintaining a healthy lifestyle, avoiding risky behaviors, and getting regular check-ups can help reduce the risk of developing bacterial vaginosis. However, the current evidence does not support universal screening for bacterial vaginosis in pregnancy, and more research is needed to clarify the issue of screening and treatment in pregnant women 1.

Key strategies to prevent recurrent bacterial vaginosis include:

• Using antibiotics as prescribed by a healthcare provider to treat active infections completely
• Considering maintenance therapy with twice-weekly metronidazole gel (0.75%) for 3-6 months
• Avoiding douching, scented feminine products, and tight synthetic underwear
• Wearing cotton underwear and avoiding sitting in wet clothing
• Taking probiotics containing Lactobacillus species or consuming probiotic-rich foods like yogurt
• Using boric acid suppositories (600mg inserted vaginally at bedtime for 7-14 days) to restore vaginal pH.

From the FDA Drug Label

A randomized, double-blind, placebo-controlled clinical trial in 235 non-pregnant women was conducted to evaluate the efficacy of tinidazole for the treatment of bacterial vaginosis. Therapeutic cure was a composite endpoint, consisting of both a clinical cure and microbiologic cure In patients with all four Amsel's criteria and with a baseline Nugent score ≥4, tinidazole oral tablets given as either 2 g once daily for 2 days or 1 g once daily for 5 days demonstrated superior efficacy over placebo tablets as measured by therapeutic cure, clinical cure, and a microbiologic cure.

The FDA drug label does not answer the question of how to prevent recurrent bacterial vaginosis.

From the Research

Prevention Strategies for Recurrent Bacterial Vaginosis

To prevent recurrent bacterial vaginosis, several strategies can be considered:

• Behavioral modifications:
  • Smoking cessation 2
  • Condom use 2
  • Hormonal contraception 2
• Dietary modifications 2
• Use of non-medical vaginally applied products 2
• Choice of lubricant 2
• Treatments from medical practices outside of allopathic medicine 2

Probiotics and Vaginal Microbiome Transplantation

Probiotics, including Lactobacillus strains, have shown promise in preventing recurrent bacterial vaginosis:

• A study found that a probiotic mixture containing Lactobacillus acidophilus and Lactobacillus rhamnosus, in combination with lactoferrin, significantly improved symptoms and reduced recurrence rates 3
• Vaginal administration of Lactobacillus rhamnosus after metronidazole therapy has been shown to lower the rate of bacterial vaginosis recurrences 4

Antibiotic Treatment and Biofilm Disruption

Antibiotic treatment is currently the mainstay of treatment for recurrent bacterial vaginosis:

• Extended courses of metronidazole treatment (500 mg twice daily for 10-14 days) are recommended for recurrent BV 5
• Biofilm disruption and use of probiotics and prebiotics have shown some promise, but require further study 5

Combination Therapies

Combining oral metronidazole with vaginal clindamycin or a vaginal probiotic has been investigated:

• A study found that combining oral metronidazole with vaginal clindamycin or a vaginal probiotic did not reduce BV recurrence rates 6