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Patient education: Bacterial vaginosis (Beyond the Basics)

Patient education: Bacterial vaginosis (Beyond the Basics)
Literature review current through: Jan 2024.
This topic last updated: Sep 14, 2022.

INTRODUCTION — Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge. Additional symptoms of BV include vaginal odor and a burning sensation. BV also increases the risk of acquiring sexually transmitted infections, such as HIV. Anyone with symptoms that could be related to BV should be evaluated by a health care provider. (See "Patient education: Vaginal discharge in adult women (Beyond the Basics)".)

BACTERIAL VAGINOSIS CAUSES — BV occurs when there is a change in the number and types of bacteria in the vagina. Lactobacilli are a type of bacteria that are normally found in the vagina. In people with BV, the concentration of lactobacilli is reduced while the numbers of other bacteria increase. The reason for these changes is not known.

RISK FACTORS — Sexual activity is the main risk factor for BV. Although BV is not yet considered a sexually transmitted infection, it is more common in people who have multiple sex partners, in people whose sex partner also has BV, and in people who do not use condoms. BV can be spread through sharing of sex toys, oral-genital contact, and fingers. Other risk factors for BV include douching and cigarette smoking.

Options to reduce the risk of BV include regularly using condoms, washing sex toys after every use, and using hormonal contraception (if appropriate).

SIGNS AND SYMPTOMS — People with classic symptoms often describe an unpleasant and "fishy smelling" vaginal discharge that is off-white and thin. Burning or itching may be present. Some people find that the odor is more noticeable after sexual intercourse with male partners, as well as during, and immediately after, their period. However, approximately 50 to 75 percent of people with BV have no symptoms.

Pain during urination or sex, redness, and swelling are not typical.

If you have concerns about abnormal vaginal discharge, abnormal bleeding, or vulvar irritation, see a health care 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 on physical examination and laboratory testing. The physical examination usually includes a pelvic examination, which allows the health care provider to observe and test vaginal secretions. Health care providers can look at the vaginal discharge under a microscope or use laboratory tests.

Without an examination and testing, it can be difficult to know if vaginal discharge is caused by BV, another type of infection (such as a yeast infection), or both. People being tested for BV are also typically offered tests for sexually transmitted infections, including gonorrhea, chlamydia, and trichomonas.

TREATMENT — Treatment of BV is recommended for people with symptoms and people who are having surgery such as hysterectomy (even if they have no symptoms).

BV is treated with antibiotics. The medications most commonly used are metronidazole and clindamycin. These medications are available in oral and vaginal forms. Oral pills may be more convenient to use but may cause more gastrointestinal side effects.

Newer medications that are taken by mouth include secnidazole and tinidazole; however, these drugs may be more expensive and are not more effective than metronidazole or clindamycin. If symptoms improve after treatment, a follow-up visit is not necessary.

Metronidazole — Metronidazole, taken over multiple days, is one of the most effective treatments for BV. Metronidazole is available as an oral pill or vaginal gel; the choice of pill or gel is based on the person's preferences. The oral pill is taken twice daily for seven days. The gel is inserted into the vagina at bedtime for five days. Both treatments work equally well. A single-dose gel is also available, but it is not yet known if the one-day treatment works as well as the multiple-day treatments.

People using oral or vaginal metronidazole may experience a metallic taste, nausea, and a temporarily lowered blood count. Metronidazole pills also interact with the anticoagulant medication warfarin (brand name: Jantoven) and can potentially increase the risk of bleeding. The vaginal gel causes fewer gastrointestinal side effects.

Clindamycin — Clindamycin is available as an oral pill or vaginal cream or gel. The vaginal cream is inserted into the vagina at bedtime for seven days. Other vaginal treatment options include a one-day vaginal clindamycin cream or gel and three-day vaginal suppository. Clindamycin cream should not be used with latex condoms due to the risk of condom breakage.

Clindamycin can also be taken by mouth, 300 mg twice daily, for seven days. Some experts prefer vaginal clindamycin because of concerns that oral clindamycin can increase the risk of gastrointestinal infection and diarrhea.

UNIQUE PATIENT GROUPS

People planning vaginal surgery — People who are having surgery that involves the vagina should be treated if BV is present, even if they do not have symptoms.

Sex partners — Treating sex partners does not improve a person's symptoms or lower the risk of the infection coming back. Female sex partners of a person with BV can also develop BV. Female sex partners should be tested if they develop abnormal vaginal discharge. Consistent use of condoms by all sex partners can reduce the risk of BV.

Pregnant people — Pregnant people with BV are at increased risk of preterm birth. However, there does not appear to be a benefit to routinely testing and/or treating all pregnant people for BV. Pregnant people with symptoms of infection should be tested; some experts also recommend testing pregnant people who have a history of a previous preterm birth.

Pregnant people with symptoms of BV infection are treated; oral therapy with metronidazole or clindamycin is preferred over vaginal treatments.

RELAPSE AND RECURRENT INFECTION

Relapse — Relapse or repeat BV infections are common. For people who initially improve after initial BV treatment, approximately 1 in 3 will have a recurrence of BV symptoms within three months, and more than half will have a recurrence of symptoms within 12 months. Symptoms may return because of a new infection or relapse (return) of the prior infection. Possible reasons for relapse of BV include if treatment is stopped early, if medication is not used correctly, if BV was not completely treated, or if the normal level of protective lactobacilli bacteria did not return. The role of lactobacilli is discussed above. (See 'Bacterial vaginosis causes' above.)

People who develop repeat BV symptoms should be evaluated to confirm that BV is the cause. Physical examination and testing of vaginal discharge are repeated.

People with a confirmed relapse of BV are retreated with an antibiotic. The antibiotic can be the same as the initial treatment or one that hasn't yet been used (for example, the person might try a vaginal medication instead of an oral pill). Some people find it helpful to use a longer course of medication after initial antibiotic treatment. This involves completing the course of antibiotics, then using metronidazole gel intravaginally twice a week for four to six months.

Recurrent BV — Recurrent BV is considered as having three or more confirmed episodes of BV in 12 months. People with recurrent BV are again treated with an antibiotic as discussed above. (See 'Treatment' above.)

After finishing the antibiotic, people with recurrent BV are offered "maintenance therapy." The best way to do this is not known as there are not a lot of studies on giving longer treatment. Options for maintenance therapy include:

Inserting metronidazole gel in the vagina twice a week for four to six months.

Starting intravaginal boric acid (inserted into the vagina) at the same time as the antibiotic and continuing it for 21 to 30 days. Boric acid is toxic if taken by mouth (orally), and can cause death. It should be stored safely where children cannot reach it.

Using intravaginal boric acid a few times a week to control symptoms (see cautions above regarding safe storage).

Other treatments are also being studied. Clindamycin (oral or vaginal) is not usually recommended as a long-term treatment. Probiotics do not prevent recurrence of BV.

LOWERING THE RISK OF RECURRENCE — While the best ways to reduce the risk of BV coming back are not known, a few basic steps can be helpful, including:

Finish the entire course of treatment for BV, even if the symptoms resolve after a few doses.

Use condoms correctly and consistently for all types of sexual activity.

Consider hormonal birth control if you want to prevent pregnancy. Some studies suggest that using birth control pills that contain an estrogen and progestin reduces the risk of recurrent BV. It is not known if other types of hormone-containing birth control, such as skin patches, vaginal rings, or intrauterine devices (IUDs), are helpful for this.

Do not douche. Douching is the use of a solution to rinse the inside of the vagina. 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 and fallopian tubes).

COMPLICATIONS — BV itself is not harmful, although it has been associated with some health problems. For example:

Pregnant people with BV are at higher risk of preterm delivery. (See 'Pregnant people' above.)

Untreated BV in a person who undergoes hysterectomy or abortion can lead to infection of the surgical site.

BV increases the risk of becoming infected with and spreading HIV.

BV increases the risk of becoming infected with genital herpes, gonorrhea, or chlamydia. (See "Patient education: Genital herpes (Beyond the Basics)" and "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Vulvovaginal yeast infection (The Basics)
Patient education: Bacterial vaginosis (The Basics)
Patient education: Vaginal discharge (The Basics)
Patient education: Probiotics (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Vaginal discharge in adult women (Beyond the Basics)
Patient education: Genital herpes (Beyond the Basics)
Patient education: Gonorrhea (Beyond the Basics)
Patient education: Chlamydia (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Bacterial vaginosis: Clinical manifestations and diagnosis
Acute cervicitis
Desquamative inflammatory vaginitis (DIV)
Vaginitis in adults: Initial evaluation
Pelvic inflammatory disease: Pathogenesis, microbiology, and risk factors
Screening for sexually transmitted infections

The following organizations also provide reliable health information.

National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

National Institute of Allergy and Infectious Diseases

     (www.niaid.nih.gov/diseases-conditions/std-research)

Centers for Disease Control and Prevention

     (www.cdc.gov/STD/BV/default.htm)

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Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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