Recurrent bacterial vaginosis — What works?
The next patient in your exam room is a 23-year-old woman who is experiencing her third episode of symptomatic bacterial vaginosis (BV) in six months. Which of the following strategies would you recommend?
- Treat with a 10-day course of vaginal metronidazole, then suppressive metronidazole gel on a biweekly basis for six months.
- Use condoms as much as possible.
- Douche with acetic acid to improve vaginal pH.
- Eat a lot of yogurt to replenish vaginal lactobacilli.
- Treat her male partner with a week of oral metronidazole.
- Refer her to a new health care provider.
The first two answers are the most effective strategies, according to BV experts.
Addressing recurrent bacterial vaginosis is a challenge for many family planning providers, says Jeanne Marrazzo, MD, MPH, associate professor in the Division of Allergy and Infectious Diseases in the University of Washington Department of Medicine and the medical director of the Seattle STD/HIV Prevention Training Center, both in Seattle. Marrazzo presented information on recurrent BV at the recent Contraceptive Technology conference.1
"Basically, the challenges are that some women simply don't respond to the usual antibiotics, or more commonly, respond briefly then relapse," observes Marrazzo. "We really don't know what predicts relapse."
New drug for BV
Bacterial vaginosis is the most prevalent cause of vaginal discharge or malodor, according to the Centers for Disease Control and Prevention (CDC); however, more than 50% of women with BV are asymptomatic.2 Clinical criteria require three of the following symptoms:
- homogeneous, thin, white discharge that smoothly coats the vaginal walls;
- presence of clue cells on microscopic examination;
- pH of vaginal fluid above 4.5;
- a fishy odor of vaginal discharge before or after addition of 10% potassium hydroxide, known as the whiff test.2
Until now, clinicians have had two drugs to treat BV, metronidazole and clindamycin. Now you can add a new drug to the list: tinidazole (Tindamax, Mission Pharmacal, San Antonio). The Food and Drug Administration just approved the drug for treatment for BV; it already carries indications for trichomoniasis, the intestinal infections giardiasis and intestinal amebiasis, and amebic liver abscess.
For treatment of BV, tinidazole is administered as 1 g (two tablets) once daily for five days or 2 g (four tablets) once daily for two days. Other regimens, which are included in the CDC's 2006 Sexually Transmitted Diseases Treatment Guidelines include:
- metronidazole 500 mg orally twice a day for seven days;
- or metronidazole gel, 0.75%, one full applicator (5 g) intravaginally, once a day for five days;
- or clindamycin cream, 2%, one full applicator (5 g) intravaginally at bedtime for seven days.2
Alternate treatments listed in the guidelines include:
- clindamycin 300 mg orally twice a day for seven days;
- or clindamycin ovules 100 mg intravaginally once at bedtime for three days.
What causes recurrence?
What are the factors that lead to recurrent BV? Research continues to focus on this subject, but sexual transmission and reinfection may play in a role in some women, says Jack Sobel, MD, chief of the Division of Infectious Diseases and professor of medicine at Wayne State University School of Medicine.
"Whether in fact it is due to failure to establish a lactobacillus-dominant flora or whether it is due to the fact that we do not eradicate the abnormal or the original offending agent with our therapy, I believe a major factor is that the treatment with clindamycin and with metronidazole is simply not potent enough to eradicate the agent," he comments.
More metronidazole may be effective. Sobel and a research team have looked at suppressive antibacterial therapy using metronidazole vaginal gel in a longer treatment regimen. Results from research published in 2006 indicates that suppressive therapy with twice-weekly metronidazole gel achieves a significant reduction in the recurrence rate of bacterial vaginosis; however, secondary vaginal candidiasis is common.3 Sobel is now looking at a more complex regimen for recurrent BV, and he says other agents are being researched with promising results. Data have not yet been published, he says.
Give women the following information when counseling on recurrent BV, Marrazzo advises:
- Abstain from vaginal sex during treatment.
- Don't douche — with anything!
- Use of condoms during the first month following treatment probably will reduce risk of recurrence.
- Clean sex toys — or use condoms — between use on one sexual partner and another.
- Avoid vaginal insertion following anal insertion of fingers or penises.1
References
- Marrazzo J. Managing women with vulvovaginal complaints; an interactive case-based discussion. Presented at the Contraceptive Technology conference. Washington, DC; March 2007.
- Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006; 55(RR-11):50-52.
- Sobel JD, Ferris D, Schwebke J, et al. Suppressive antibacterial therapy with 0.75% metronidazole vaginal gel to prevent recurrent bacterial vaginosis. Am J Obstet Gynecol 2006; 194:1,283-1,289.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content