Treatment of Asymptomatic Bacterial Vaginosis
Asymptomatic bacterial vaginosis in a woman of reproductive age does not require treatment unless she is undergoing surgical abortion or other high-risk invasive procedures. 1, 2, 3
When NOT to Treat Asymptomatic BV
Routine asymptomatic BV should not be treated in non-pregnant women because the principal goal of therapy is to relieve vaginal symptoms and signs of infection, and treatment is only indicated for symptomatic disease. 1
The CDC explicitly states that asymptomatic non-pregnant women should not receive treatment unless they are undergoing surgical abortion or other high-risk invasive procedures. 2, 3
Follow-up visits are unnecessary if the patient remains asymptomatic. 2, 3
Critical Exceptions: When Asymptomatic BV MUST Be Treated
Before Surgical Abortion
All women with asymptomatic BV must be treated before surgical abortion procedures because treatment with metronidazole substantially reduces post-abortion pelvic inflammatory disease (PID). 1, 3
BV has been associated with endometritis, PID, and vaginal cuff cellulitis after invasive procedures such as endometrial biopsy, hysterectomy, hysterosalpingography, IUD placement, cesarean section, and uterine curettage. 1
Before Other Invasive Gynecologic Procedures
- Consideration should be given to treatment before procedures such as hysterectomy, endometrial biopsy, hysterosalpingography, IUD placement, and uterine curettage, though the evidence is less definitive than for surgical abortion. 1, 3
Special Population: High-Risk Pregnant Women
High-risk pregnant women (those with previous preterm delivery) who have asymptomatic BV may be evaluated for treatment because treatment might reduce the risk for prematurity. 1
However, expert opinion remains divided on this recommendation, with some experts believing more information is needed before routinely treating asymptomatic BV in pregnancy. 1
Treatment of BV in high-risk pregnant women may reduce the risk of preterm delivery. 2, 3
Treatment Regimens If Indicated
If treatment is warranted based on the above criteria:
First-Line Options for Non-Pregnant Women
- Oral metronidazole 500 mg twice daily for 7 days (highest efficacy at 95% cure rate) 2, 3
- Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days 2, 3
- Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 2, 3
Important Precautions
- Patients using metronidazole must avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction. 2, 3
- Clindamycin cream is oil-based and may weaken latex condoms and diaphragms. 2, 3
Partner Management
- Routine treatment of male sex partners is not recommended because it has not been shown to influence a woman's response to therapy or reduce recurrence rates. 2, 3