Recurrence is common, but this practical advice can help reduce the risk

Recurrence rate for bacterial vaginosis (BV) is high – greater than 50% after a first infection, says Dr Sara Whitburn, a GP and medical educator with a special interest in menopause, midlife and vulval health.

She offers practical advice to help effectively treat BV and reduce the chance of recurrence.

First, it is important to ask about symptoms. Is the discharge new, abnormal or causing symptoms?

“You only want to test and treat if someone has symptoms. It is important to ask about symptoms if someone is about to have an IUD or is pregnant,” she says.

If someone has a new discharge or a discharge that is watery, malodourous or causes skin discomfort, then consider testing for bacterial vaginosis.

BV may have a watery discharge that can be malodourous (as opposed to the thicker, ‘cottage cheese’ type of discharge more common with thrush).

The next question is to confirm that the discharge is bacterial vaginosis?

A useful tip for diagnosing BV, especially if the discharge is not malodourous, is a quick pH test, Dr Whitburn suggests.

“If you were taking a swab to send away from microbiology and culture, you’d use one of those cotton tip swabs and pop it on the pH stick and if the pH is above 4.5 that does make you feel that it’s much more likely that this person has BV.”

A common bacterial cause that often shows up in the lab results is Gardnerella, but sometimes the results will come back with mixed flora, and Dr Whitburn says it is worth contacting the lab for more information. They may give a grading of low, intermediate, or high of the type and number of bacteria that are associated with bacterial vaginosis, which can help in your diagnosis.

Treating symptomatic cases is especially important during pregnancy, as untreated, symptomatic BV increases the risk of premature birth and other antenatal complications. It is also important to treat symptomatic BV before procedures such as an IUD insertion or where instruments are used in the uterus as having untreated symptomatic BV during these procedures can lead to pelvic inflammatory disease, she warns.

Dr Whitburn says the first line treatment for acute BV is 400mg of oral metronidazole, taken for seven days, but she warns it can make people feel nauseous and it interacts with alcohol.

“You can use topical antibiotics as well, but you often find that people are more likely to have a recurrence of symptoms,” Dr Whitburn explains. But topical treatments can be used if the patient prefers them, or if they are unable to tolerate oral medication, she says. The first line topical is metronidazole 0.75% gel, with a dose of one applicator at night for five days.

Clindamycin is another option. “You can get that as a 2% cream which you can use vaginally each day for seven days, but that one’s not on the PBS (Pharmaceutical Benefits Scheme) so cost can be an issue,” Dr Whitburn says.

Reducing recurrence

Recurrent BV is defined as three or more cases documented by microbiology and symptoms within 12 months.

Effective treatment of acute symptomatic cases is key, followed by a longer period of preventative treatment.

“Once someone has good symptom control from acute treatment, I talk to them about using metronidazole gel two to three times a week, making sure that helps with their symptoms and they feel it is well controlled. If it is, then I ask them to continue that for anywhere between four to six months,” she says.

“If metronidazole gel doesn’t control the symptoms, you can use a nightly boric acid pessary vaginally for three weeks.”

Dr Whitburn says BV is not sexually transmitted, but “sexually related.” New or multiple partners and unprotected penis/vaginal sex can be risk factors for recurrence.

In cases where two ‘vagina owners’ are sexual partners; current guidelines recommend treating both to reduce recurrence.

Treating the male partner is not currently recommended but, the ‘Step Up’ study is investigating if treating male partners in cis heterosexual couples can decrease recurrence. A pilot study of 34 couples showed a reduction in bacterial vaginosis related bacteria in both partners microbiomes when treated with antibiotics. Dr Whitburn explains.

She suggests talking to patients about using condoms, and smoking cessation, as that can also decrease the risk of BV recurrence. Copper IUDs (intrauterine devices) may also be a risk factor, so other contraceptive options may be worth considering, depending on the risk and benefits to that individual patient.

“Some people find that their BV recurrence is decreased if they are on combined oral contraception. Once again, you must make sure it is the safe and appropriate choice for that person,” Dr Whitburn says.

Dr Whitburn recognises that not everyone is comfortable talking about their discharge or the common symptoms of bacterial vaginosis, but she says, “I would always ask if as part of a sexual history if someone has an abnormal vaginal discharge, or if they’re bothered by their vaginal discharge” and then explain that there are treatment options for both acute and recurrent symptoms.