Can Anything Prevent Recurrent Bacterial Vaginosis?

Anne M. Teitelman, PhD, CRNP, MSN


January 14, 2010


What are the best treatment options and prevention messages for my patients with recurrent bacterial vaginosis infections?

Response from Anne M. Teitelman, PhD, CRNP, MSN
Assistant Professor, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania; Nurse Practitioner, University of Pennsylvania Hospital, Philadelphia, Pennsylvania


Defining Recurrent Bacterial Vaginosis

Bacterial vaginosis (BV) is a polymicrobial disease that occurs when the protective peroxide-producing lactobacilli of the vagina are eliminated, permitting an overgrowth of anaerobes and other pathogens, such as Gardnerella vaginalis and Mycoplasma hominis.[1,2] Because the etiology and pathogenesis of BV are not completely understood, treatment for BV is not always effective, resulting in high recurrence rates.[3] Recurrent BV is generally defined as 3 or more episodes of BV per year, and one study found that 6-month recurrent rates were as high as 80%.[2] Given the treatment challenges and the fact that BV is the most common vaginal infection for women of reproductive age, the disease causes great frustration for both patients and providers.[4]

The symptoms of BV include a foul-smelling ("fishy") vaginal discharge, which may be accompanied by pruritus, although more than 50% of patients are asymptomatic.[2] The most common method of diagnosis is the Amsel criteria, which include the following:

  1. A white, homogenous discharge that is adherent to the vaginal walls;

  2. A vaginal pH of greater than 4.5;

  3. A positive amine "whiff" test; and

  4. Presence of clue cells.

If at least 3 of the criteria are present, the patient has a positive BV diagnosis. The Nugent criteria, which detect BV by Gram staining, may also be used and are preferred for most clinical trials.[1,2] BV infection is known to increase a woman's risk for pelvic inflammatory disease and susceptibility to sexually transmitted infections, including HIV.[2] BV also increases the risk for postsurgical infection after gynecologic procedures,[3]spontaneous abortion, preterm labor and low birth weight, and postpartum and postabortion endometritis.[1]

Treatment Options

The most common initial treatment for BV is one of the following:

  • 7-day oral 500-mg metronidazole regimen;

  • 5-day intravaginal 0.75% metronidazole gel (once daily at bedtime); or

  • 7-day intravaginal 2% clindamycin cream (once daily at bedtime).[5,6]

These treatments generally show immediate symptomatic improvement (7-14 days after beginning treatment), with recurrence rates of 30% at approximately 2-3 months after treatment, and the risk for recurrence increases with time.[3]

Supplemental Treatments

Because of the high recurrence rates associated with BV, research to explore other, mostly supplemental, treatment options is underway. However, to date, insufficient large-scale studies have been completed to warrant any conclusive clinical recommendations.

Acidification. A bacterial biofilm has been shown to be present in the vaginal mucosa of patients with BV, but not in that of control patients. The bacterial biofilm is thought to facilitate the growth of infecting pathogens by increasing their adherence to the vaginal wall and creating a physical barrier against medications.[4] Therefore, acidification to destroy the biofilm has been considered as a potential method for reducing BV recurrence. Reichman and colleagues[7] looked at the effectiveness of applying topical boric acid to the vagina after nitroimidazole therapy (the class of drugs that includes metronidazole). Cure rates ranged from 88% to 92% after weeks 7 and 12, and 87%, 78%, and 65% after weeks 12, 16, and 28, respectively. By 36 weeks after treatment, a 50% rate of recurrence was noted. No adverse reactions were reported with the use of the boric acid.[7]

Probiotics. An inability to regenerate sufficient lactobacilli after treatment may be a cause of BV recurrence, and several researchers have looked into probiotic therapy as an adjunct to traditional antimicrobial treatment. Thulkar and associates[8] found that using 0.75% metronidazole gel in conjunction with probiotics (Ecoflora; Tablets India Ltd, Chennai, India) was associated with a 100% cure rate after 4 weeks, 75% cure rate after 8 weeks, and 62.5% cure rate 12 weeks after treatment (vs 75%, 50%, and 37.5%, respectively, using the gel alone).

Long-term metronidazole gel application. Sobel[3] found that applying topical metronidazole gel twice weekly for a period of 4-6 months after oral antibiotic therapy achieved moderate reductions in recurrence rates but was an expensive and bothersome process for the patient.

Long-term, high-dose metronidazole suppositories. Although no large long-term studies have been conducted, a study from Peru and reported by Sobel[3]showed that long-term administration of high-dose (500 mg) metronidazole vaginal suppositories was more effective than 0.75% metronidazole gel. However, it is important to note that the suppositories used in this study also contained nystatin and were aimed at reducing Candida albicans in mixed infections.

Prevention of Bacterial Vaginosis

Recently in clinic, I have seen several clients with recurrent BV. Some of them claim to follow the vaginal hygiene measures we suggest (eg, wipe front to back, cotton underwear, no douching, no feminine products, use a mild soap). A couple of patients have mentioned that they thought they got BV with one particular partner and not with others. Therefore, prevention messages are important.

Prevention Messages

Although BV is not considered to be a sexually transmitted disease, it has a similar epidemiologic profile to other sexually transmitted infections in that it has been shown to be associated with new and multiple male and female sexual partners.[1,9] Therefore, preventing unprotected sexual encounters may also reduce the incidence and recurrence of BV. Although the treatment of male partners is not recommended, women should be evaluated, and if BV is present, should receive treatment.[2]However, it is uncertain whether most recurrences are the result of reinfection or relapse.[3] One study showed that 6 months of consistent condom use resulted in reduced occurrences of BV in persons without BV at baseline but also concluded that male condoms protected against first occurrence, but not recurrence, of BV.[10]

Patient education in conjunction with suggested treatments:

  • Partner management: reduce the number of partners;

  • Use of condoms or dental dams;

  • Avoidance of douching; and

  • Education regarding BV signs and symptoms.[2]


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