What is the clinical significance of abundant clue cells on a Pap test in an asymptomatic woman on oral contraceptives (OC)?

From the Guidelines

The patient should be treated for bacterial vaginosis with either oral metronidazole 500 mg twice daily for 7 days, metronidazole gel 0.75% intravaginally once daily for 5 days, or clindamycin cream 2% intravaginally at bedtime for 7 days. The diagnosis is based on the presence of abundant clue cells on her Pap test, which are epithelial cells coated with bacteria that are pathognomonic for bacterial vaginosis 1. Despite the patient being asymptomatic without vaginal discharge or odor complaints, treatment is still recommended as bacterial vaginosis can increase the risk of acquiring sexually transmitted infections and can cause complications if the patient becomes pregnant.

Key points to consider in the management of this patient include:

• Bacterial vaginosis results from an imbalance in vaginal flora with overgrowth of anaerobic bacteria and reduction in protective lactobacilli.
• The patient should be advised that bacterial vaginosis can recur, and she should return if symptoms develop.
• Her male partner does not require treatment as there is no evidence that treating partners reduces recurrence rates.
• She can continue her oral contraceptive during treatment, but should be advised that if using the metronidazole gel or clindamycin cream, these can weaken latex condoms for up to 72 hours after application. The USPSTF recommendation statement addresses screening for bacterial vaginosis in asymptomatic women, and while this patient is not pregnant, the presence of clue cells on her Pap test is sufficient to diagnose bacterial vaginosis 1.

From the Research

Diagnosis and Treatment of Bacterial Vaginosis

• The patient's Pap test results show abundant clue cells, which is a characteristic finding in bacterial vaginosis (BV) 2, 3, 4, 5, 6.
• BV is a common and treatable condition, with effective treatments including oral and intravaginal metronidazole and clindamycin, as well as oral tinidazole 2, 3, 4, 5, 6.
• The recommended treatment for BV includes oral metronidazole (500 mg twice daily for 7 days) or intravaginal metronidazole gel (0.75% twice daily for 5 days) 3, 5, 6.
• Alternative treatment options include clindamycin vaginal cream (2% once daily for 7 days) and oral tinidazole (1 g daily for 5 days) 3, 4, 5.
• Recurrent BV is a common problem, and extended treatment courses or alternative treatments may be necessary 2, 4.

Treatment Considerations

• The patient's symptoms and physical examination findings are consistent with BV, and treatment should be initiated accordingly 2, 3, 4, 5, 6.
• The patient's use of oral contraceptives is not a contraindication to treatment with metronidazole or other antibiotics 3, 5.
• The patient's monogamous relationship with a male partner does not require treatment of the partner, as data do not support routine treatment of male sex partners 3, 5.

Treatment Options

• Oral metronidazole (500 mg twice daily for 7 days) is a recommended treatment option for BV 3, 5, 6.
• Intravaginal metronidazole gel (0.75% twice daily for 5 days) is an alternative treatment option with similar efficacy to oral metronidazole and fewer gastrointestinal side effects 6.
• Clindamycin vaginal cream (2% once daily for 7 days) and oral tinidazole (1 g daily for 5 days) are also effective treatment options for BV 3, 4, 5.