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Bacterial vaginosis

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Bacterial vaginosis

Bacterial vaginosis is the most common cause of abnormal vaginal discharge, affecting 23%–30% of reproductive-aged people

Bacterial vaginosis is caused by a disrupted vaginal microbiome balance. Symptoms include itch, dysuria, and a thin, grey discharge with a “fishy” odour, particularly after coitus. Risk factors include smoking and unprotected intercourse, including oral sex.1,2

Bacterial vaginosis is associated with other medical risks

It increases susceptibility to sexually transmitted infections such as HIV, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, human papillomavirus, and herpes simplex virus.1 Bacterial vaginosis in pregnancy increases risks of miscarriage, preterm premature rupture of membranes, preterm labour and delivery, chorioamnionitis, and postpartum infections.3 Screening for and treatment of bacterial vaginosis is recommended in pregnant people at increased risk of preterm birth between 12 and 16 weeks, even if asymptomatic.3 Routine screening in asymptomatic females, pregnant or not, is unnecessary.1,2

Diagnosis is usually made after a culture of vaginal discharge

Vaginosis is presumed with 3 of the following criteria: thin homogeneous discharge; vaginal pH higher than 4.5; positive “whiff test” (a “fishy” odour after application of 10% potassium hydroxide solution to the discharge); and vaginal discharge microscopy showing clue cells (vaginal epithelial cells covered in gram-negative bacteria).3

First-line treatment regimens have comparable cure rates of 70%–80%

Topical treatment options include metronidazole gel 0.75% (5 g/applicator) once per day for 5 days, or clindamycin cream 2% (5 g/applicator) at bedtime for 7 days. Another treatment option is oral metronidazole 500 mg twice daily for 7 days. Avoiding alcohol consumption during treatment is no longer recommended.1,4

Recurrence rates at 6 months after treatment are higher than 50%

Partner treatments have not proven to be preventive. Recommendations for prevention of recurrence based on expert opinion (low level of evidence) include a trial of alternating vaginal and oral treatments; boric acid (contraindicated in pregnancy) 600 mg vaginal capsules nightly for 21 days after antibiotics; vaginal metronidazole gel twice weekly; or intrauterine device removal.1,4,5

Footnotes

  • Competing interests: Amanda Selk is the past president of the Society of Canadian Colposcopists, past president of the North American branch of the International Society for the Study of Vulvovaginal Disease, and a board member of the International Federation of Cervical Colposcopy and Pathology (all positions unpaid and outside the submitted work). No other competing interests were declared.

  • This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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