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Finding bacterial vaginosis on a swab is a common reason for an end-of-day phone call. Luckily, the conversation is usually quick and efficient: check if the person is pregnant, ask if they have any symptoms, reassure them that this is not sexually transmitted (although see below), and send a prescription to the pharmacy if indicated.
While preparing a recent GPnotebook TV video, I gained interesting insights into research about the potential role of treating both the woman and her partner in recurrent bacterial vaginosis (the video will be available soon).
It also threw up an interesting question: Does bacterial vaginosis have similar traits to sexually transmitted disease and do we need to start thinking of it as such? When the GPnotebook page on this condition was recently updated, I was keen to read more about this, and any other new developments on the topic.
Bacterial vaginosis is a form of vaginitis caused by an overgrowth of mixed anaerobic organisms, including Gardnerella vaginalis, Prevotella species, Mycoplasma hominis, and Mobiluncus species, which are typically present in small amounts in most women. When these bacteria increase in number, the normal lactobacilli flora of the vagina may be disrupted, vaginal pH can rise above 4.5, and bacterial vaginosis can develop.
Although often asymptomatic, it is a leading cause of abnormal vaginal discharge in women of reproductive age, typically presenting with a fishy odour. In pregnant women, it increases the risk of preterm birth, while in non-pregnant women undergoing post-gynaecological surgery, it can lead to infectious complications.
The prevalence of bacterial vaginosis is variable, with studies indicating it may be affected by behavioural and sociodemographic factors. There is ongoing discussion in the literature about whether bacterial vaginosis can be sexually transmitted, as new evidence has emerged on this topic that has muddied the waters regarding the previous belief that it was not related to sexual intercourse.
Current research provides perspectives on whether bacterial vaginosis should be categorised as a sexually transmitted infection (STI). Early studies identified cases of bacterial vaginosis among individuals without any prior sexual activity, supporting the position that bacterial vaginosis is not a traditional STI. However, more recent research showed an association between bacterial vaginosis and sexual behaviour – specifically, increased rates of bacterial vaginosis associated with vaginal intercourse. As a result, bacterial vaginosis is now sometimes described as “sexually associated” rather than strictly “sexually transmitted”. Interestingly, some evidence also indicates that regular condom use may contribute to lowering bacterial vaginosis prevalence.
This point certainly adds new perspectives to that evening phone call and is a good reminder to ask about the sexual health history in all women presenting with vaginal discharge or other gynaecological symptoms.
The GPnotebook page on the treatment of bacterial vaginosis, found here, has also been recently updated and is a helpful resource, especially if used to complement our Irish antimicrobial prescribing guidelines. In addition to summarising initial management options (oral or vaginal metronidazole or vaginal clindamycin), it highlights the management of bacterial vaginosis in pregnancy.
This updated page also includes some entirely new information for me on another product being used in some countries to treat bacterial vaginosis. This medication is called dequalinium chloride and acts as a surface antiseptic agent. In 2015, a vaginal tablet formulation was licensed for the treatment of bacterial vaginosis. It works by increasing bacterial wall permeability and decreasing bacterial enzyme activity, leading to cell death.
It is cited to be a possible alternative treatment option for bacterial vaginosis in the following situations:
After reading this, I was interested to find out if dequalinium is currently relevant to Irish general practice? Sadly, the answer to this question seems to be “No”. On looking into it, I could not find it as a licensed product here in Ireland, as a listed product on pharmacy websites, or in our own antimicrobial guidelines. It is useful, however, to be aware of it and to keep an eye out for it in the future, and it is always positive to see agents coming down the line that might reduce antibiotic usage.
Finally, the GPnotebook page on treating bacterial vaginosis also contains some fascinating information about a trial looking at the effect of male partner treatment in women with recurrent bacterial vaginosis.
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