Consider Switching Up Treatment Regimens for Recurrent Bacterial Vaginosis

Jake Remaly

September 29, 2020

Limited data are available to guide treatment of recurrent bacterial vaginosis, but behavioral changes and switching between approved medication regimens may help, according to a presenter at the virtual conference on diseases of the vulva and vagina, hosted by the International Society for the Study of Vulvovaginal Disease.

Dr. Debra L. Birenbaum

Investigational treatments – such as a live biotherapeutic product delivered vaginally or vaginal microbiome transplantation – could someday be additional options if they prove safe and effective. "The current research is emphasizing biofilm disruption and products that will reestablish normal acidic vaginal pH," said Debra L. Birenbaum, MD, assistant professor of obstetrics and gynecology at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

As for home remedies, Dr. Birenbaum and another presenter at the conference, Cynthia Rasmussen, MD, urged caution during a panel discussion.

"I think the vagina knows its business, and the more you mess with it, the more you invite trouble," said Dr. Rasmussen, director emerita of vulvovaginal services at Atrius Health in Burlington, Mass. For instance, tea tree oil, often cited as a home remedy, can be an allergen and very irritating.

"I want to know what women are using, but I try and dissuade them," said Dr. Birenbaum. "I have to be careful what I say, because you'll antagonize patients" if you come out strongly against home treatments. "I try to encourage them not to go by things they read on the Internet, because I think that's where many people are finding their home remedies."

When counseling patients, an analogy shared during the meeting – the vagina is a self-cleaning oven – may help get the point across. "I love the comment," Dr. Birenbaum said. "I've never used that before. I'm going to start saying that."

Possible Causes and Risk Factors

Bacterial vaginosis, also known as vaginal dysbiosis, is the most common cause of discharge in women of reproductive age worldwide. Growth of a biofilm may cause the condition, which is characterized by a shift in vaginal flora from a Lactobacilli-dominant environment to one of other bacterial types.

Risk factors include douching, smoking, sex with an uncircumcised partner, and having multiple sexual partners. Bacterial vaginosis may be associated with various complications and infections, including increased risk of preterm delivery, postpartum endometritis, postabortal infection, Trichomonas, chlamydia, and HIV.

Unlike recurrent yeast, which is characterized by four or more episodes per year, recurrent bacterial vaginosis has no official criteria, Dr. Birenbaum said. However, recurrence of bacterial vaginosis "is extremely common," she said. "Up to 30% of women with [bacterial vaginosis] may recur within 3 months, and up to 50% after 12 months."

Lifestyle Changes and Treatments

Recommendations to use condoms, stop smoking, and not douche are important.

In addition, 11 treatment regimens for four drugs – metronidazole, clindamycin, tinidazole, or secnidazole – are available for the treatment of bacterial vaginosis. For recurrent cases, adjusting and switching between the drugs and modes of delivery may help. If a patient started with vaginal gel, they can try an oral medication, or vice versa.

"There's very little data to guide the optimal therapy for this," Dr. Birenbaum said. "All of this is worth a try to see if you can beat this before this becomes an ongoing issue."

As an example of one possible regimen for recurrent bacterial vaginosis, Dr. Birenbaum suggested that a patient could complete a 2- to 4-week course of oral metronidazole instead of the usual 1-week course. The regimen could incorporate boric acid vaginal suppositories 600 mg nightly for 21 days, followed by metronidazole gel 0.75% (one applicator twice per week for 6 months).

New Therapies May Be on the Horizon

In a randomized, double-blind, phase 2b trial published in the New England Journal of Medicine that included more than 220 participants, patients who received an investigational product containing Lactobacillus crispatus CTV-05 (Lactin-V) were less likely to have recurrent bacterial vaginosis at 12 weeks, compared with those who received placebo (30% vs. 45%).

A product in development known as TOL-463, a boric acid–based vaginal anti-infective enhanced with ethylenediaminetetraacetic acid, may be safe and effective, a phase 2 study published in Clinical Infectious Diseases suggests.

Investigators in the United Kingdom designed a trial to compare lactic acid gel and metronidazole, and the findings published in the Trials journal may clarify inconsistent results from prior studies.

Furthermore, preclinical research in Pathogens and Disease has identified cationic amphiphiles that might help fight the biofilm that is formed with Gardnerella vaginalis in patients with bacterial vaginosis, Dr. Birenbaum said.

Finally, an exploratory study in Israel published in Nature Medicine evaluated vaginal microbiome transplants in five patients, three of whom required repeat transplantation. Four patients had long-term remission, and one had a reduction in symptoms

Dr. Birenbaum is a reviewer for UpToDate. Dr. Rasmussen had no relevant disclosures.

This article originally appeared on, part of the Medscape Professional Network.


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