Bacterial vaginosis is a type of vaginal inflammation caused by the overgrowth of bacteria naturally found in the vagina, which upsets the natural balance. Women in their reproductive years are most likely to get bacterial vaginosis, but it can affect women of any age. Bacterial overgrowth in the vagina. Bacterial vaginosis tends to affect women of childbearing age. Activities such as unprotected sexual intercourse or frequent douching can increase a person's risk. In some cases, there are no symptoms. In other cases, there may be abnormal vaginal discharge, itching or odour. BV can clear up on its own. Treatment can include prescription cream, gel or medication. Recurrence within three to 12 months is common, requiring additional treatment. Very common More than 10 million cases per year (India) Treatable by a medical professional Short-term: resolves within days to weeks Requires a medical diagnosis Lab tests or imaging often require

1. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS
MA(PSY)
1

2. VAGINAL ENVIRONMENT
• The Vagina is a dynamic ecosystem that contains
approximately 109 bacterial colony forming units.
• Normal vaginal discharge is clear to white odorless , and
of high viscosity.
• Normal bacterial flora is dominated by lactobacilli –
other potential pathogens present acidic environment
(PH3.8 -4.2) inhibits the overgrowth of bacteria
• Some lactobacilli also produces H2o2 a potential
microbicide
2DR ALKA MUKHERJEE NAGPUR

3.  Bacterial vaginosis (BV) is a polymicrobial infection
characterized by a lack of hydrogen peroxide-producing
lactobacilli and an overgrowth of facultative anaerobic
organisms.
 BV is the most common of vaginal discharge in young
women of reproductive age. Prevalence between 5% &
35% depends on method of screening & the locality
BACTERIAL VAGINOSIS (BV)
3DR ALKA MUKHERJEE NAGPUR

4. DR ALKA MUKHERJEE NAGPUR 4

5. AETIOLOGY
Polymicrobial:
• G. vaginalis (coccobacilli, surface pathogen),
• Anaerobic bacteria
• (Bacteroids, Mobiluncus, Prevotella) & Mycoplasma hominis.
• There is synergistic relationship between the acquired organisms.
They replace lactobacilli
• Their metabolism produces volatile amines & organic acids other
than lactic acids leading to smell & increase pH
• Mobiluncus produce trimethylamine giving the smell of rotting
fish.
• Mobiluncus & Bacteroids produce succinate (Keto-acid) which
raises vaginal pH.
• Absence of lactic acid & the production of succinate blunt the
chemotactic response of polymorphnuclear leukocytes & reduce
their killing ability. This explains absence of cellular inflammatory
response.
5DR ALKA MUKHERJEE NAGPUR

6. PREDISPOSING FACTORS
• 1. Increase vaginal pH:
• Semen, after menstruation when estradiol levels increase.
• 2. Decrease lactobacilli
• Douching, change of sexual partner (change of vaginal
environment), episodes of candida
• 3.Smoking: suppresses the immune system facilitating
infection.
• 4.IUCD:
• 5.Black ethnic groups
• 6.Lesbians
• It is not STD:
• Treatment of the husband is not beneficial in preventing
recurrence of BV.
• Detection of BV in 12% of virgins after menarche.
6DR ALKA MUKHERJEE NAGPUR

7. DR ALKA MUKHERJEE NAGPUR 7

8. PATHOGENESES
• The reason for the alteration in
flora is unclear.
• l.Hormonal changes: the
mechanism is unclear
• 2.Enzymatic changes: Mucinase
& siallidase are elevated in
vaginal discharge of BV. Breaking
down the mucosal barrier
• 3.Bacteriophage ( virus that
infects bacteria)
8DR ALKA MUKHERJEE NAGPUR

9. CLINICAL PICTURE
• Up to half the women diagnosed
with BV are asymptomatic.
• Discharge: thin, homogenous,
whitish-grey, frothy & fishy.
Absence of discharge does not
imply the absence of BV. It is not
accepted as a reliable indicator
on its own as it is neither
sensitive nor specific to
BV.(Deborah et al ,2003)
• Seldom associated with mucosal
inflammation or irritation of the
vagina or vulval itch.
9DR ALKA MUKHERJEE NAGPUR

10. DR ALKA MUKHERJEE NAGPUR 10

11. DIAGNOSIS
1. pH of discharge: 5.7
A low pH virtually excludes n elevated pH is the most sensitive but
least specific as an increase can also associated with menstruation,
recent sexual intercourse, or infection with T. vaginalis
2. Whiff test (amine test). Addition of 10% O to sample of vaginal
discharge produces fishy odor.
It has a positive predictive value of 90% & specificity of 70%
3. Wet film (drop of vaginal secretion & drop of saline):
coccobacilli, borders are indistinct), No WBC.
It is the single most sensitive & specific criterion for BV- , but it is
operator dependent. Debris & degenerated cells may be mistaken
for clue cells & lactobacilli may adhere to epithelial cells in low
numbers.
11DR ALKA MUKHERJEE NAGPUR

12. DR ALKA MUKHERJEE NAGPUR 12

13. • 4.Gram stain
90% sensitivity, highly sensitive & specific lactobacilli).
Scoring systems which weight numbers of lactobacilli & numbers of G
vaginalis & Mobiluncus. It is simple & objective method. However the
cost & need for microscopist.
• 5.Rapid tests:
• Diamine test: rapid, sensitive & specific Proline
aminopeptidase1test(PivActivity test Card)
• .A card test for detection of elevated pH & trimethylamine
(FemExam test card)
• DNA probe based test for high concentration of G. vaginalis (Affirm
VP Ill) may have clinical utility.
• 6. Pap. smear: clue cells. Limited clinical utility þeçause ngtnþwn—
sensitivity
• Culture: It is not recommended as a diagnostic tools because it is
not specific
13DR ALKA MUKHERJEE NAGPUR

14. DR ALKA MUKHERJEE NAGPUR 14
'Amsel's criteria

15. DR ALKA MUKHERJEE NAGPUR 15

16. GYNAECOLOGICAL
 PID:
The microorganisms of BV & PID are similar. There is 10
fold-increased risk of PID in females with BV
 Tubal infertility: 1/3 of women with tubal factor
infertility had BV compared to 16% of
 Post-hysterectomy vaginal cuff infection.
 Uretheral syndrome.
 HIV susceptibility infection. The presence of BV
increases susceptibility to HIV infection
 BV is not associated with CIN
16DR ALKA MUKHERJEE NAGPUR

17. OBSTETRIC
• 1. Miscarriage: Women with BV had a higher rate of first trimester
miscarriage than those With norma vagina flora.
Recurrent first trimester miscarriage has not been associated with BV.
The incidence of late miscarriage (13-23 w) is higher in women with
BV.
• 2. Postabortal sepsis- The use of antibiotic prophylaxis before
surgical termination of pregnancy demonstrates a protective
effect.
• 3. Preterm labour - The earlier in pregnancy that BV is detected
the greater the risk of PTL.
Treatment of high risk, BV positive pregnant women has resulted
in reduction of PTL by 40-50%.
• 4. Bactraemia after instrumental delivery
• 6. Chorioamnionitis.
• 7. Postpartum endometritis, post cesarean wound infection
17DR ALKA MUKHERJEE NAGPUR

18. A. NON PREGNANT BENEFITS OF TREATMENT:
• Relieve vaginal
• Reduce the risk for infectious complications after
hysterectomy or abortion.
• Reduction of other infectious complications eg. HIV, STD
Indications For treatment
• Symptomatic women (grade A recommendation).
• Women undergoing some surgical procedures(grade a
recommendation).
18DR ALKA MUKHERJEE NAGPUR

19. RECOMMENDED REGIMENS (CDC,2002)
 Metronidazole 500 mg orally twice a day for 7 days,
 OR
 Metronidazole gel 0.75%, one full applicator
 (5g) intravaginally, once a day for 5 day
 OR
 Clindamycin cream 2%, one full applicator (5g) intra-vaginally at bed
time for 7 days
 Alternative regimens (CDC,2002) Metronidazole 2 g orally in a single
dose,
 OR
 Clindamycin 300 mg orally twice a day for 7 days
 OR
 Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days.
19DR ALKA MUKHERJEE NAGPUR

20. • Notes:
• The recommended metronidazole regimens are equally
effective Metronidazole Gel is more— expensive than tablets
• The vaginal clindamycin is less effective than the
metronidazole regimens.
• 'The alternative regimens have lower efficacy for BV.
• No data support the use of non-vaginal lactobacilli or
douching for treatment of BV.
• 'Clindamycin cream or oral is preferred in case of allergy or
intolerance to metronidazole.
• 'Theoretically, Metronidazole has an advantage because it is
less active against lactobacilli than clindamycin.
• 'Conversely, clindamycin is more active than metronidazole
against most of the bacteria associated with bacterial
vaginosis
20DR ALKA MUKHERJEE NAGPUR

21. FOLLOW UP
• Follow-up visits are unnecessary if symptoms resolve.
• Another recommended treatment regimen may be used
to treat recurrent disease.
• Management of husband is not recommended
21DR ALKA MUKHERJEE NAGPUR

22. B. PREGNANT NATURAL HISTORY:
• 'BV is present in upto 20% of pregnant women depending on
how often the population is screened.
• 'The majority is asymptomatic.
• 'It may spontaneously resolve without treatment, although
the majority is likely to have persistent infection later in
pregnancy.
• Recommended regimen Metronidazole 500 mg orally three
times a day for 7 days
• 'Existing data do not support the use of topical agents during
pregnancy
• Evidence from three trials suggests an increase in adverse
events (e.g. prematurity & neonatal infection), particularly in
newborns, after use of clindamycin cream (McGregor et
al,1994; Joesoef et al,1 995; Vermeulen et al,1999).
22DR ALKA MUKHERJEE NAGPUR

23. • Multiple studies & met analysis have not
demonstrated a consistent association between
metronidazole during pregnancy & teratogenic
or mutagenic effects in new borns (Caro-Paton
et al, 1997).
23DR ALKA MUKHERJEE NAGPUR

24. • Indications
• 1 . All symptomatic pregnant women should be tested &
treated.
• 2.Asymptomatic pregnant women at high risk for PTL (
previous history), should be screened early in pregnancy &
treated (Cochrane library,2002)
• Asymptomatic pregnant females at low risk for PTL: Data are
adverse outcomes of pregnancy.
• One trial, using oral clindamycin demonstrated a reduction in
PTL & postpartum infectious complications (Hay et al, 2001).
• Oral clindamycin early in the second trimester significantly
reduced the rate of late miscarriage & PTL in general obstetric
population (Ugwumadu et al, 2003).
24DR ALKA MUKHERJEE NAGPUR

25. • How to screen for BV ? (Gierdingen et al,
• 2000) Ask about determined frequently during
pregnancy. If pH > 4.5 ( BV or TV in 84%), do wet mount.
• Follow-up of pregnant women One month after
treatment to evaluate whether therapy was effective is
recommended.
25DR ALKA MUKHERJEE NAGPUR

26. LACTATION
• C. •Metronidazole enters breast milk & may affect its
taste. Recommendation avoiding high doses if breast
feeding.
• Small amounts of clindamycin enter breast milk.
• It is prudent therefore to use an intravaginal treatment
for lactating women (Grade C recommendation)
26DR ALKA MUKHERJEE NAGPUR

27. ANTIBACTERIAL TREATMENT FOR BV AND
ITS CONSEQUENCES
• Therapy with metronidazole or clindamycin alter the
vaginal flora and predispose the patient to development
of vaginal candidacies
• Increased number of recurrences of BV When the
synthetic antimicrobials are used
• Use of antibiotics may be attributed to the development
of antimicrobial resistance mechanism within the
microbes.
• Antibiotics can not restore the vaginal micro flora and
fight against lactobacilli setback.
27DR ALKA MUKHERJEE NAGPUR

28. RECURRENCE
• 20 % recurrence rate after 1 month
• Recurrence may be a result of persistence of BV –
associated organisms and failure of lactobacillus flora to
re-colonize.
• Data do not support yogurt therapy or exogenous oral
lactobacillus treatment .
• Under study : vaginal suppositories containing human
lactobacillus strains
28DR ALKA MUKHERJEE NAGPUR

29. PROBIOTICS
• Studies have suggested that the presence of H2O2 -
producing vaginal lactobacilli may protect against BV.
• In-vitro studies have suggested that certain specific
strains of lactobacilli are able to inhibit the adherence
of Gardnerella vaginalis to the vaginal epithelium
and/or produce H2O2, lactic acid and/or bacteriocins,
which inhibit the growth of bacteria causing BV.
29DR ALKA MUKHERJEE NAGPUR

30. DR ALKA MUKHERJEE NAGPUR 30
DIFFERTIAL DIAGNOSIS

31. FOR D/D DIAGNOSTIC TESTS
• A sample of the vaginal discharge should be obtained for gross
microscopic - Wet – Mount Preparation
 Motile trichomonads (Trichomoniasis)
 Increase and number of polymorphonuclear cells
(trichomoniasis)
 Clue Cells(Baterial vaginosis)
 Fungal hyphae (Vulvovaginal candidiasis)
 Round parabasal cells (atrophic vaginitis)
 Whiff Test : A positive whiff test is suggestive of bacterial
vaginosis
 Litmus Testing for Ph
 Ph > 4.5 : Bacterial vaginosis. Trichomoniasis , altrophic
vaginitis – NL PH : nl Vaginal dischrage . Vulvoaginal
candidiasis
31DR ALKA MUKHERJEE NAGPUR

32. HOW CAN BACTERIAL VAGINOSIS BE
PREVENTED ?
• It is known that BV is associated with having a new sex
partner or having multiple sex partners.
• The following basic prevention steps can help reduce
the risk of upsetting the natural blance of bacteria in the
vagina and developing BV.
• Be abstinent
• Limit the number of sex partners.
• Do not douche unless prescribed by your doctor.
• Use all of the medicine prescribed for tretment of BC,
even if the signs and symptoms go away.
32DR ALKA MUKHERJEE NAGPUR

33. DR ALKA MUKHERJEE NAGPUR 33

34. TAKE HOME : BACTERIAL VAGINOSIS
• Characterized by a pungent vaginal “ fish – like “ order and a
thin , off – white / gray, homogenous , discharge that coats
the vaginal wall.
• usually cause dysuria , dyspareunia , pruritus or vaginal /
vulavar inflammation.
• The best initial test is microscopic examination.
• Diagnosis is supported by the presence of clue cells on wet
mount.
• Other supportive finding include a vaginal ph > 4.5 and a
positive whiff – amine test
• Treated with either metronodazole or clindamycin for seven
days.
• Routine screening and treatment of all pregnant women with
asymptomatic bacterial vaginosis is not recommended
34DR ALKA MUKHERJEE NAGPUR

35. 35DR ALKA MUKHERJEE NAGPUR