INTRODUCTION — Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It can cause bothersome symptoms, and also increases the risk of acquiring serious sexually transmitted infections, such as HIV. It may be difficult to know if discharge is caused by BV or other common vaginal infections, thus a visit with a healthcare provider is recommended in most cases.
CAUSES — BV occurs when there is a complex change in the number and types of bacteria in the vagina. The concentration of lactobacilli, a type of bacteria that is normally predominant in the vagina, becomes reduced. The reasons for the reduction in lactobacilli and overgrowth of other bacteria are not clear. The role of sexual activity in this process is also not clear.
Risk factors — Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection.
SIGNS AND SYMPTOMS — Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present.
Pain during urination or sex, vulvar itching, redness, and swelling are not typical features of the disorder. Occasionally, BV causes an abnormal cervical discharge and easy bleeding (such as after sexual intercourse).
A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis.
DIAGNOSIS — The diagnosis of BV is based upon a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. It can be difficult to know, without an examination and testing, if vaginal discharged is caused by BV or another vaginal infection.
COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. Pregnant women with BV are at higher risk of preterm delivery Untreated BV in a woman who undergoes hysterectomy or abortion can lead to infection of the surgical site. BV increases the risk of acquiring and transmitting HIV. BV increases the risk that a woman will become infected with genital herpes, gonorrhea, or chlamydia. (See "Patient information: Genital herpes" and see "Patient information: Gonorrhea" and see "Patient information: Chlamydia").
TREATMENT — Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV.
There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve.
Metronidazole — The oral regimen for metronidazole is 500 mg twice daily for seven days. Topical vaginal therapy with 0.75 percent metronidazole gel (5 g in the vagina at bedtime for five days) is as effective as oral metronidazole. The choice of oral versus topical therapy depends upon the patient's preference. In general, there are fewer side effects with the topical treatment.
Side effects of oral metronidazole include a metallic taste, nausea, and a temporary lowered blood count. Alcohol should not be consumed during oral metronidazole treatment due to the risk of a serious interaction, which can cause flushing, nausea, thirst, palpitations, chest pain, vertigo, and low blood pressure. Oral metronidazole also interacts with warfarin (Coumadin®), potentially increasing the risk of bleeding. The vaginal gel does not cause these side effects.
Clindamycin — The standard treatment regimen for clindamycin is a 2 percent vaginal clindamycin cream for seven days; this should not be used with latex condoms due to the risk of condom breakage.
Alternate regimens for treatment of BV include oral clindamycin (300 mg twice daily by mouth for seven days) or clindamycin ovules (100 mg intravaginally once daily for three days). A one-day application of clindamycin is also available (Clindesse®).
Sexual partners — It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated.
Relapse and recurrent infection — Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. The explanation for this high rate of recurrence is unclear. Recurrence is likely the result of failure to eliminate the offending bacteria or failure to reestablish the normal levels of protective lactobacilli.
Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days; the United States Center for Disease Control and Prevention suggests a treatment regimen different from the initial or previous treatment regimen (eg, oral treatment if vaginal treatment used previously).
Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen. (See "Patient information: Vaginal yeast infection").
Pregnancy — Pregnant women with BV are at increased risk of preterm birth. However, there is no evidence that screening and treatment of pregnant women who have no signs or symptoms of infection reduces the risk of preterm birth. There may be benefits to screening and treating pregnant women who have symptoms of BV and a history of a previous preterm delivery.
Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments.
PREVENTION — The best way to prevent BV is not known. However, a few basic recommendations can be made. Do not douche. Douching is the use of a solution to rinse the inside of the vagina. Some women douche to feel "clean", although there is no proven benefit of douching. The vagina is normally able to maintain a healthy balance of bacteria; douching can upset this balance and potentially flush harmful bacteria into the upper genital tracts (uterus, fallopian tubes). Limit the number of sexual partners. Women with multiple sexual partners are at higher risk of developing bacterial vaginosis, as well as sexually transmitted infections. Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.
SUMMARY Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. It occurs when there is a complex change in the number and types of bacteria in the vagina (see "Causes" above). Risk factors for BV include multiple or new sexual partners, douching, and cigarette smoking. Although sexual activity is a risk factor for the condition, BV can occur in women who have never had vaginal intercourse. BV is not thought to be a sexually transmitted infection. Approximately 50 to 75 percent of women with BV have no symptoms. Those with symptoms often note an unpleasant, "fishy smelling" vaginal discharge that is more noticeable after sexual intercourse. Vaginal discharge that is off-white and thin may also be present (see "Signs and symptoms" above). A woman with concerns about excessive or foul-smelling vaginal discharge, abnormal bleeding, or vulvar irritation is advised to see a healthcare provider. Self-treatment with over-the-counter products (eg, yeast creams, deodorants) is not recommended without a definite diagnosis (see "Diagnosis" above). BV is diagnosed with a physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the healthcare provider to observe and test vaginal secretions during or immediately after the examination. Treatment is usually recommended for women who have bothersome symptoms from the infection and those preparing for abortion or hysterectomy. Treatment of BV may also reduce the risk of acquiring other STDs, including HIV. For this reason, some experts now support the concept of treating all women with BV (see "Treatment" above). There are two prescription medications used for the treatment of BV: metronidazole and clindamycin. Both medications can be taken in pill form by mouth, or with a treatment inserted inside the vagina. Oral medication may be more convenient, but has a higher rate of side effects. Follow-up testing is not needed if symptoms resolve. It is not necessary to treat the male sexual partner of a woman with BV; there is no evidence that the woman's symptoms or risk of relapse is improved if her sex partner(s) is treated. Approximately 30 percent of women who initially improve with standard treatment have a recurrence of BV symptoms within three months, and more than 50 percent experience a recurrence within 12 months. Relapse can be treated with a prolonged course of oral or vaginal metronidazole or clindamycin for 10 to 14 days. Most women with recurrent BV benefit from suppressive therapy. A long-term maintenance regimen that includes vaginal metronidazole gel twice weekly may be of benefit, although secondary yeast infection can develop with this regimen (see "Relapse and recurrent infection" above). Pregnant women with signs or symptoms of BV infection are usually treated to relieve symptoms. Oral treatment with seven days of metronidazole is preferred over shorter oral regimens or vaginal treatments (see "Pregnancy" above).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Allergy and Infectious Diseases
(www.niaid.nih.gov/factsheets/vaginitis.htm)
Centers for Disease Control and Prevention
(www.cdc.gov/STD/BV/default.htm)
American Social Health Association
(www.ashastd.org/learn/learn_vag_trich_bv.cfm)
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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Schwebke, JR, Desmond, RA, Oh, MK. Predictors of bacterial vaginosis in adolescent women who douche. Sex Transm Dis 2004; 31:433.
2. Gutman, RE, Peipert, JF, Weitzen, S, Blume, J. Evaluation of clinical methods for diagnosing bacterial vaginosis. Obstet Gynecol 2005; 105:551.
3. McDonald, H, Brocklehurst, P, Parsons, J. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev 2005; :CD000262.
4. Riggs, MA, Klebanoff, MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin Obstet Gynecol 2004; 47:796.
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