Presentation notes about Bacterial Vaginosis for medical students, undergraduate doctors and other health allied courses. It was prepared by medical doctor at Free Medicine.

1. BV
BACTERIAL VAGINOSIS
DR. LAITON, MD

2. OUTLINE
1. Introduction
2. Epidemiology
3. Risk Factors
4. Protective Factors
5. Etiology
6. Pathophysiology
7. Clinical Presentation
8. Differential diagnosis
9. Investigations
10. Treatment
11. Complication
12. Prevention
13. References

3. 1. INTRODUCTION
 Bacterial Vaginosis (BV) is a clinical condition
characterized by a shift in vaginal flora away from
lactobacillus species toward more diverse bacterial
species including facultative anaerobes.
 Bacterial Vaginosis (BV) is not a sexual transmitted
infection (STI).
 Other names of BV includes: Anaerobic Vaginositis, Non-
specific Vaginitis, Vaginal Bacteriosis, and Gardnerella
Vaginitis
 This condition was called Bacterial Vaginosis (not
bacterial vaginitis) because it is caused by bacteria and
inflammatory response is lacking. However, BV is the
most common causes of vaginal infection.

4. 1. INTRODUCTION CONT.
 BV is the most common infection encountered in the
outpatient gynaecological settings.
 Typical symptoms of Bacterial Vaginosis is thin, grey,
homogenous vaginal discharge and fishy vaginal odour.
Other symptoms which may be present are vulvar
irritation, dysuria and dyspareunia.
 Wet Mount Microscopy showing clue cells on a saline
smear is most specific criterion for diagnosis of Bacterial
Vaginosis.
 Asymptomatic BV often resolve with treatment, however
symptomatic BV is treatment using antibiotic therapy.
 Antibiotics which are mainly used are Metronidazole or
Clindamycin.

5. 2. EPIDEMIOLOGY
 General population prevalence of BV is high globally
ranging from 23% to 29% across regions.
 Black and Hispanic women have significantly higher
prevalence compared to other racial groups.
 The estimated annual global economic burden treating
symptomatic BV is US $4.8 billion.
 Economic burden of BV is increasing when including costs
of BV-associated preterm births and HIV cases.
BV Cases
(26%)
Non BV Cases
(74%)

6. 3. RISK FACTORS
Risk factors of BV are listed below:
1. Recent antibiotic use
2. Decreased estrogen production of the host
3. Wearing an IUCD
4. Douching, Tub baths, and Bubble baths
5. Intravaginal hygiene products
6. Liquid soaps and body washes
7. Sexual activity
 High frequency of sexual activity
 Multiple sexual partners
 Having new sexual partners
 Early Initiation of sexual intercourse

7. 3. RISK FACTORS
Risk factors of BV are listed below (cont.):
8. Presence of other STIs
9. Prior Trichomoniasis
10. Cigarette smoking
11. Obesity
12. Being single/not married
13. Prior pregnancy
14. History of induced labour
15. Frequency use of sex toys
16. Frequency digital-vaginal sex
17. Frequency use of scented soap
18. Lesbians

8. 4. PROTECTIVE FACTORS
Protective factors of BV are listed below:
1. Abstinence
2. Use of condoms
3. Hormonal contraception (combined and progestin only)
4. Cleaning sex toys between use
5. Use of gloves during digital-vaginal sex
6. Use of probiotics
These protective factors play very minor role in reducing
the risk of BV. Few studies have been conducted, there is no
enough data to be conclusive.

9. 5. ETIOLOGY
• BV is known to be synergistic polymicrobial infection.
• Gardnerella vaginalis is thought to have a leading role in the
infection, although the correct aetiology is unknown.
• Other associated bacteria includes:
1. Prevotella
2. Anaerobes
 Mobiluncus
 Bacteroides
 Peptostreptococcus
 Fusobacterium
 Veillonella
 Eubacterium
3. Mycoplasma hominis
4. Ureaplasma urealyticum
5. Streptococcus viridans
6. Atopobium vaginae

10. 6. PATHOPHYSIOLOGY
 The exact pathogenesis of BV is not fully understood.
 BV is thought to be result of a shift in vaginal flora from
lactobacillus species towards more diverse of bacterial
species including facultative anaerobes.
 The shift of vaginal flora causes a reduction in the
hydrogen peroxide-producing lactobacilli, this leads to an
increase in the vaginal pH and overgrowth of Gardnerella
vaginalis and anaerobes.
 Decrease in pH facilitates:
– Adherence of Gardnerella vaginalis to the exfoliating epitheal
cells making clue cells and
– Formation of Gardnerella vaginalis biofilms which can survive
hydrogen peroxide, lactic acid, and high level of antibiotics.

11. 6. PATHOPHYSIOLOGY CONT.
• Anaerobes produce large amount of proteolytic
carboxylase enzymes which break down vaginal peptides
into variety of amines that are volatile, malodorous, and
associated with increased vaginal transudation.
• Production of amines causes further reduction of
lactobacilli which leads to more increase of vaginal pH.
• Anaerobes (mobiluncus) produce amine called
trimethylamine giving the smell of rotting fish.
• Anaerobes also produce succinate (keto-acid).
Production of succinate and absence of lactic acid blunt
the chemotactic response of polymorphinuclear
leucocytes reducing their killing ability.
• This explains absence of cellular inflammatory response.

12. 6. PATHOPHYSIOLOGY CONT.

13. 7. CLINICAL PRESENTATION - HISTORY
 More than 50% of women diagnosed with BV are
asymptomatic.
 Symptoms of BV include the following:
1. Vaginal odour
 Most common and often initial symptom of BV.
 Odour may be recognized only after sexual intercourse.
 The alkalinity of semen may cause a release of volatile amines
from the vaginal discharge and cause a fishy odour.
2. Increased vaginal discharge
 Vaginal discharge are usually thin, homogenous, whitish-grey.
3. Vulvar irritation is less common
4. Dysuria and dyspareunia occur rarely

14. 7. CLINICAL PRESENTATION – P.E.
• Physical Examination is mainly done by Inspection and
Speculum Examination.
• Physical Examination findings include:
1. Vaginal discharge features include the following:
 Most often gray, thin, and homogeneous
 Adherent to the vaginal mucosa
 Small bubbles in the discharge fluid ()
 No pooling of discharge in the posterior fornix ()
2. An increased light reflex of the vaginal walls may be
observed, indicating very wet appearance.
3. No or little evidence of inflammation of vaginal walls.
4. The labia, introitus, cervix, and cervical discharge appear
normal.
5. Any evidence of Cervicitis, check for STIs.

15. COLOR OF VAGINAL DISCHARGE
COLOR INTERPRETATION
WHITE
Healthy
Yeast Infection
YELLOW TO GREEN
Sexual Transmitted Infection
Trichomoniasis
PINK TO RED
Menstruation or Implant bleeding
Cervical Infection or Cervical Polyp
Endometrial or cervical cancer
Vaginal irritation
GRAY Bacterial Vaginosis
CLEAR
Healthy
Ovulation
Pregnancy
Hormonal Imbalance

16. 8. DIFFERENTIAL DIAGNOSIS
 For atypical clinical features of BV, the possibility of a
coinfection is high, such as Vaginal Candidiasis,
Trichomoniasis, Chlamydia infection, Gonorrhoeae, HSV
infection, or an alternative diagnosis.
 Differential diagnosis are as follows:
1. Candidiasis
2. Cervicitis
3. Chlamydial Genitourinary Infections
4. Gonorrhoea
5. HSV Infection
6. Trichomoniasis
7. Vaginal Candidiasis
8. Vaginitis

17. 8. DIFFERENTIAL DIAGNOSIS
Vaginitis
Normal pH
Infectious
- Vulvovaginal
Candidiasis
- HSV infection
Non-infectious
- Vulvodynia
- Dermatosis
- Dermatitis
- Physiologic
leucorrhoea
Abnormal pH
Infectious
- Bacterial
Vaginosis
- Trichomoniasis
- Cervicitis
Non-infectious
- Blood
- Semen
- Cervical mucus
- Amniotic fluid
- Vaginal atrophy
- Lichen Planus
- Desquamative
Inflammatory
vaginitis

18. 9. INVESTIGATIONS
 Specimen of choice is vaginal discharge.
 The collection of specimen for diagnosis is ideally
performed during a comprehensive pelvic examination
using a speculum.
 During speculum examination, an evaluation of the
discharge is made by clinician.
 Specimen is collected from the lateral vaginal wall and
posterior fornix with a sterile swab.
 There are two main categories of diagnostic tests for BV:
1. Clinical Criteria (Amsel’s criteria)
2. Laboratory-based testing (Nugent scoring)

19. 9. INVESTIGATIONS CONT.
The following are investigations done in BV:
1. Macroscopic Examination
2. Vaginal pH
3. Whiff Test
4. Microscopic Examination
 Saline Wet Mount (Clue Cells Test)
 Gram stain
 Evaluation of bacteria flora
5. Vaginal Culture
6. Diagnostic Tools
7. Quantitative PCR

20. 9. INVESTIGATIONS CONT.
1. Macroscopic Examination
 This is done during speculum examination, an evaluation of
the discharge is made by clinician.
 Typical features of BV vaginal discharge will be seen (as
mentioned on Physical Examination).
2. Vaginal pH Test
 The use of pH sticks placed on the vaginal wall or The use of a
swap which is touched on pH paper.
 Vaginal pH > 4.5 in 90% of BV cases.
3. Whiff Test
 A drop of 10% potassium hydroxide is placed on a glass slide.
 The swab is then stirred in the 10% KOH and immediate
evaluate for a fishy odour.
 Fishy odour means positive result. It is usually positive in 70%
of BV cases.

21. 9. INVESTIGATIONS CONT.
4. Microscopic Examination
A. Saline Wet Mount
 The swab is immersed into 0.2mL of physiological saline and
put on a glass slide. Glass slide is covered with a coverslip and
examined at 400 magnification with a light microscope.
 Clue cells are identified, that is positive result.
 Clue cells are vaginal epitheal cells covered with bacteria
(coccobacilli) that the peripheral borders are obscured.

22. 9. INVESTIGATIONS CONT.
AMSEL CRITERIA FOR DIAGNOSIS OF BV:
 Amsel Criteria is the most widely accepted clinical criteria
used in diagnosis of BV.
 This clinical diagnosis requires that at least three of the
following four criteria to be met:
1. Homogenous, thin, greyish-white discharge
2. Vaginal pH > 4.5
3. Positive whiff-amine test
4. Presence of clue cells in the vaginal fluid

23. 9. INVESTIGATIONS CONT.
4. Microscopic Examination
B. Gram stain
 Specimen on the slide is stained by standard methods, the
stained slide is read, and number of morphotypes are
evaluated based on a standardized scoring method.
 The current standard scoring method used is Nugent scoring
of gram stained smear for bacterial vaginosis.

24. 9. INVESTIGATIONS CONT.
SCORE
Lactobacillus
morphotype
per field
Gardnerella
morphotype
per field
Curved Bacteria
(mobiluncus)
per field
0 >30 0 0
1 5 – 30 <1 1 – 5
2 1 – 4 1 – 4 >5
3 <1 5 – 30
4 0 >30
NUGENT SCORING OF GRAM STAINED SMEAR FOR BACTERIAL VAGINOSIS:
INTERPRETATION OF NUGENT SCORE:
0 – 3: Normal
4 – 6: Intermediate, repeat test later
7 – 10: Bacterial Vaginosis

25. 9. INVESTIGATIONS CONT.

26. 9. INVESTIGATIONS CONT.
4. Microscopic Examination
C. Microscopic Evaluation of the bacteria flora
 This is done to examine the evidence of changes in overall
bacterial predominance.
 The healthy vagina has a predominance of lactobacilli (large
gram-positive rods).
 The flora of a patient with BV changes to become dominated
by coccobacilli, reflecting an increase in growth of Gardnerella
vaginalis and other anaerobes. No PMNs are observed.

27. 9. INVESTIGATIONS CONT.
4. Vaginal Culture
 Vaginal culture is not done routinely and has no utility.
 G vaginalis is 100% of vaginal culture of symptomatic BV and
70% of vaginal cultures of asymptomatic BV.
 Vaginal cultures helps to exclude other infectious aetiologies
such as Trichomonas spp, C trachomatis, and N gonorrhoea.
 In recurrent BV cases that have not resolved with standard
regimens, cultures may be appropriate.
5. Diagnostic tools
 FemExam is one of diagnostic tool, not used a lot due to
variable in sensitivity (38 - 90%) and specificity (12.5 – 97%).
 There are other female self-test cards in the market.
6. Quantitative PCR
 It is useful in the evaluation of BV treatment response and the
risk of preterm birth in pregnant women.

28. 9. INVESTIGATIONS CONT.
Examples of Vaginitis Self-Test Kit in the market

29. Clinical Elements
Bacterial
Vaginosis
Trichomoniasis
Vaginal
Candiasis
Symptoms
Vaginal odour + +/- -
Vaginal discharge
Thin, gray,
homogenous
Green-yellow White curdlike
Vulvar irritation +/- + +
Dyspareunia - + -
Signs
Vulvar erythema - +/- +/-
bubbles in vaginal fluid + +/- -
Strawberry cervix - +/- -
Microscopy
Saline wet mount
Clue cells + - -
Motile protozoa - + -
KOH test
Pseudohyphae - - +
Whiff test + +/- -
pH > 4.5 > 4.5 < 4.5
Differences between Infectious Vaginitis:

30. 10. TREATMENT
 Benefits of Treatment includes:
1. Relief of symptoms
2. Reduction of postoperative infection
3. Reduction of the risk of acquiring STIs
 Inpatient care is not necessary for patient with BV.
 Surgery is not indicated for BV.
 Antibiotics are the mainstay of therapy for BV, mainly
Metronidazole and Clindamycin.
 Alternative antibiotics are Tinidazole and Secnidazole.
 Asymptomatic women with confirmed BV do not need
treatment.
 Uncomplicated cases typically resolve after standard
antibiotic treatment .

31. 10. TREATMENT CONT.
 Treat BV occurring in pregnant women to reduce the risk
of pregnancy-associated complications related to
infection.
 Treatment before transvaginal procedures, caesarean
delivery, total abdominal hysterectomy, or insertion of an
IUD is also recommended.
 Studies of topically applied and orally administered
yogurt or lactobacilli preparations and probiotics, which
are used to help re-establish the lactobacilli population in
the vagina, have demonstrated inconsistent results.
 BV that does not resolve after one course of treatment
may be cured by giving a second course of the same
agent or by switching to another agent.

32. 10. TREATMENT CONT.
 Some women with recurrent BV may benefit from
evaluation or treatment of G vaginalis colonization in
their sexual partner (controversial).
 Testing for other infections (e.g., N gonorrhoeae, C
trachomatis, or herpes simplex virus infection) may be
appropriate .
 Therapy with metronidazole or clindamycin may alter
the vaginal flora and predispose the patient to
development of vaginal candidiasis .
ON THE NEXT PAGES IS THE ALGORITHM
OF THE INITIAL TREATMENT OF BV

33. 10. INITIAL TREATMENT OF BV
Has the diagnosis been confirmed based
on any of the following:
1. Amsel Criteria
2. Gram stain
3. Commercial Test
Does the patient have
symptoms? OR Is the patient
about to have a transvaginal
surgery or procedure?
Test before treating
YES NO

34. 10. INITIAL TREATMENT OF BV
Does the patient have symptoms?
(vaginal discharge + vaginal odour)
OR
Is the patient about to have a vaginal
surgery or procedure?
Is the individual
pregnant or lactating?
Observe and do not treat:
 BV often resolves without
treatment
 Treatment with antibiotics can
result in vaginal yeast infections
YES NO

35. 10. INITIAL TREATMENT OF BV
• Oral Metronidazole 500 mg BID for 7 days OR
• Vaginal metronidazole 0.75% gel 5 g OD for 5 days OR
• Vaginal Clindamycin 2% cream 5 g OD for 7 days
Neither
• Oral Metronidazole 500 mg BID for 7 days OR
• Oral Metronidazole 250 mg TID for 7 days OR
• Oral Clindamycin 300 mg BID for 7 days
Pregnant
• Oral Metronidazole 500 mg BID for 7 days OR
• Oral Clindamycin 300 mg BID for 7 days
Lactating

36. 10. TREATMENT CONT.
For further understanding, treatment session is further
divided into the following:
A. Nonpregnant symptomatic patients
B. Nonpregnant asymptomatic patients
C. Pregnant symptomatic patients
D. Pregnant asymptomatic patients
E. Lactating patients
F. Patients undergoing gynaecologic procedures
G. Sexual partner of patient with confirmed BV
H. Recurrent BV patients

37. 10. TREATMENT CONT.
A. NONPREGNANT SYMPTOMATIC PATIENTS:
 Nonpregnant symptomatic patient are treated by oral
or vaginal formulations of Metronidazole and
Clindamycin.
 Many patients consider oral medication to be more
convenient than vaginal dosing, but oral medication
causes more systemic side effects, such as headache,
nausea, abdominal pain, and Clostridioides.
 Oral metronidazole is commonly used, and
metronidazole is less commonly associated with
Clostridioides difficile infection compared with
clindamycin.
 Alternative medications includes Tinidazole and
Secnidazole.

38. 10. TREATMENT CONT.
A. NONPREGNANT SYMPTOMATIC PATIENTS:
DRUG OF CHOICE
Metronidazole 500 mg PO BID for 7 days OR
Metronidazole 0.75% gel 5 g PV OD for 5 days OR
Clindamycin 2% cream 5 g PV OD (at bedtime) for 7 days
ALTERNATIVE THERAPY
Clindamycin 300mg PO BID for 7 days OR
Clindamycin ovule 100mg PO OD for 3 days OR
Tinidazole 2 g PO 0D for 2 days OR
Tinidazole 1 g PO 0D for 5 days OR
Secnidazole 2 g packet PO single dose

39. 10. TREATMENT CONT.
B. NONPREGNANT ASYMPTOMATIC PATIENTS:
 Nonpregnant asymptomatic patients do not require
antibiotic treatment.
 Treatment is typically avoided since patients often
spontaneously improve over a period of time and any
antibacterial therapy can be followed by symptomatic
vaginal yeast infection.
 Exception:
1. Patients undergoing gynaecologic procedures or surgery that
involved the vagina.
2. Patients more susceptible to acquiring STIs including HIV and
HSV infection (controversial).

40. 10. TREATMENT CONT.
C. PREGNANT SYMPTOMATIC PATIENTS:
 Pregnant individuals with symptomatic BV are treated
to relieve bothersome symptoms.
 Oral therapy is preferred because some data indicate
oral treatment is more effective against potential
subclinical upper genital tract infection.
 Some guidelines allow the use of oral and vaginal
formulations same as nonpregnant symptomatic
patients. Example: CDC Guideline.
 Metronidazole should be avoided during the first
trimester because it can cross the placenta and become
tetratogenic (controversial).

41. 10. TREATMENT CONT.
C. PREGNANT SYMPTOMATIC PATIENTS:
DRUG OF CHOICE
Metronidazole 500 mg PO BID for 7 days OR
Metronidazole 250 mg PO TID for 7 days OR
Clindamycin 300mg PO BID for 7 days
TOPICAL THERAPY
Metronidazole 0.75% gel 5 g PV OD for 5 days OR
Clindamycin 2% cream 5 g PV OD (at bedtime) for 7 days

42. 10. TREATMENT CONT.
D. PREGNANT ASYMPTOMATIC PATIENTS:
 Asymptomatic pregnant individuals are recommended
to be treated to reduce the risk of pregnancy-associated
complications related to infection (controversial).
 Asymptomatic pregnant individuals with previous
preterm births may benefit from treatment.
 When treatment is indicated, oral therapy is used.
 Trials suggest that oral clindamycin given early in
pregnancy is an effective therapy.
 Topical clindamycin given in the second half of
pregnancy is less effective and even associated with an
increase in low birth weight and neonatal infection.

43. 10. TREATMENT CONT.
D. PREGNANT ASYMPTOMATIC PATIENTS:
DRUG OF CHOICE
Metronidazole 500 mg PO BID for 7 days OR
Metronidazole 250 mg PO TID for 7 days OR
Clindamycin 300mg PO BID for 7 days
 Metronidazole should be avoided during the first trimester because it can
cross the placenta and become tetratogenic (controversial).
 Topical clindamycin given in the second half of pregnancy is less effective
and even associated with an increase in low birth weight and neonatal
infection.

44. 10. TREATMENT CONT.
E. LACTATING PATIENTS:
 Lactating individuals with confirmed BV and symptoms
are offered treatment while asymptomatic individuals
do not require treatment as asymptomatic BV can
resolve, just like in nonpregnant individuals.
 The preferred treatment for lactating individuals is:
Metronidazole 500 mg PO BID for 7 days
 Oral clindamycin is a reasonable therapeutic choice,
however clindamycin has the potential to cause adverse
effects on the breastfed infant's gastrointestinal flora.
 Infants of patients treated with oral clindamycin should
be monitored for diarrhoea, candidiasis (thrush, diaper
rash) or rarely blood in the stool indicating possible
antibiotic-associated colitis.

45. 10. TREATMENT CONT.
E. LACTATING PATIENTS:
 Maternal metronidazole use is linked to more loose
stools and more candidal colonization in metronidazole-
exposed infants.
 It is recommended that maternal receiving the 2-gram
one-time dose, should interrupt breastfeeding, express
and discard their milk for 12 to24 hours.
 For lactating individuals who are administered Tinidazole
or Secnidazole, interruption of breastfeeding is
recommended during treatment and for three days after
the last dose.

46. 10. TREATMENT CONT.
E. LACTATING PATIENTS:
DRUG OF CHOICE
Metronidazole 500 mg PO BID for 7 days OR
Clindamycin 300mg PO BID for 7 days
TOPICAL THERAPY
Metronidazole 0.75% gel 5 g PV OD for 5 days OR
Clindamycin 2% cream 5 g PV OD (at bedtime) for 7 days
ALTERNATIVE THERAPY (INTERRUPT BF)
Tinidazole 2 g PO 0D for 2 days OR
Tinidazole 1 g PO 0D for 5 days OR
Secnidazole 2 g packet PO single dose

47. 10. TREATMENT CONT.
F. GYNAECOLOGIC PROCEDURE OR SURGERY:
 For individuals with confirmed BV (with or without
symptoms), antibiotic treatment is given prior to
transvaginal procedures or surgery to prevent
postprocedure infection (cuff infection after
hysterectomy, endometritis after termination).
 The medication treatment options are the same as for
symptomatic nonpregnant females.
 Transvaginal procedures or surgery includes pregnancy
termination, dilation and curettage, hysterectomy,
insertion of an IUD.
 Treatment before caesarean delivery or total abdominal
hysterectomy is also recommended.

48. 10. TREATMENT CONT.
F. SEXUAL PARTNER OF CONFIRMED BV PATIENT:
 Sexual activity is a risk factor for transmission.
 The data do not support treatment of asymptomatic
sexual partners of individuals with confirmed BV.
 Antibiotic treatment of the sexual partners does not
increase the rate of clinical or symptomatic improvement
for the index patients nor did it reduce the rate of
recurrence during a four-week study period.
 Individuals with documented BV infection should
encourage sexual partners who have a vagina to be
aware of the signs and symptoms of BV given the high
risk of concordant infection (25 to 50 percent).

49. 10. TREATMENT CONT.
G. RECURRENT BACTERIAL VAGINOSIS:
 Approximately 30% of patients with initial responses to
therapy have a recurrence of symptoms within 3
months, and more than 50% experience a recurrence
within 12 months.
 The explanation for this high rate of recurrence is
unclear.
 Recurrence more likely reflects a
1. Failure to eradicate the offending organisms
2. Failure to re-establish the normal vaginal flora
3. Formation of biofilms which are more difficult to eradicate
4. Treatment failure due antimicrobial resistance
5. Nonadherence to medications

50. 10. TREATMENT CONT.
G. RECURRENT BACTERIAL VAGINOSIS:
 The only interventions proven to reduce development or
recurrence of BV are chronic suppressive therapy and
circumcision of male partner.
 Symptomatic recurrent BV should be treated initially with
a seven-day course of oral or vaginal metronidazole or
clindamycin (alternate between the two antibiotics).
 Alternative treatment: vaginal boric acid suppositories
for 30 days can be used as an induction regimen
simultaneously or to follow seven-day oral antibiotic
treatment.
 The treatment regimen may be the same or different
from the initial or previous treatment regimen.

51. 10. TREATMENT CONT.
G. RECURRENT BACTERIAL VAGINOSIS:
FIRST CHOICE
Oral or Vaginal Metronidazole or Clindamycin for 7 days as in
treatment of symptomatic nonpregnant patients.
ALTERNATIVE THERAPY
Oral Metronidazole or Clindamycin for 7 days PLUS
Vaginal boric acid 600 mg PV OD (at bedtime) for 30 days.
Oral Metronidazole or Clindamycin for 7 days FOLLOWED BY
Vaginal boric acid 600 mg PV OD (at bedtime) for 30 days
N.B: Vaginal boric acid alone is ineffective. Boric acid can cause death if taken
orally. Boric acid should not be used by individuals who are pregnant or
attempting conception.
Sexual partners of patients treated with vaginal boric acid have reported skin
irritation after exposure.

52. 10. TREATMENT CONT.
G. RECURRENT BV – LONG-TERM SUPPRESIVE REGIMEN:
 After initial induction therapy, most individuals with a
history of recurrent infection benefit from suppressive
therapy to maintain an asymptomatic state.
 Patient with more than 3 documented episodes of BV in
the previous 12 months should be offered a long-term
suppressive regimen consisting of maintenance
metronidazole vaginal gel.
 Long-term clindamycin regimens, oral or topical, are not
advised because of toxicity (oral) and lack of documented
efficacy (topical).

53. 10. TREATMENT CONT.
G. RECURRENT BV – LONG-TERM SUPPRESIVE REGIMEN:
 Metronidazole Monotherapy:
– Metronidazole gel 0.75% or an oral nitroimidazole for 7 to 10
days followed by twice-weekly dosing of metronidazole gel for
more than three months (treat for four to six months).
– In Metronidazole Monotherapy, secondary vaginal candidiasis
was a common side effect.
 Combination Therapy followed by suppression therapy:
– Oral nitroimidazole for 7 days and vaginal boric acid 600 mg
once daily at bedtime is begun at the same time and continued
for 21 days.
– Follow-up a day or two after their last vaginal boric acid dose; if
they are in remission, immediately begin metronidazole gel
twice weekly for four to six months as suppressive therapy.

54. 10. TREATMENT CONT.
G. RECURRENT BV – LONG-TERM SUPPRESIVE REGIMEN:
METRONIDAZOLE MONOTHERAPY
Oral or Vaginal Metronidazole for 7 to 10 days FOLLOWED BY
Twice-weekly dosing of Metronidazole gel for more than three
months (four to six months).
COMBINATION FOLLOWED BY SUPPRESSION THERAPY
Oral Metronidazole or Tinidazole for 7 days AND
Vaginal boric acid 600 mg once daily at bedtime for 21 days.
If patient is in remission, begin:
Twice-weekly dosing of Metronidazole gel for more than three
months (four to six months).

55. 10. TREATMENT CONT.
G. RECURRENT BV – LONG-TERM SUPPRESIVE REGIMEN:
 Intravaginal L. Crispatus (LACTIN-V)
– Intravaginal treatment with Lactobacillus crispatus is a
promising therapy to follow the initial course of metronidazole.
– This approach is promising both:
1. For eliminating Bacterial Vaginosis and
2. For restoring Lactobacillus colonization
– In addition, the product is not commercially available, and study
results should not be extrapolated to other probiotic remedies.
 Treatment:
Vaginal metronidazole for 7 days followed by
Intravaginal LACTIN-V once daily for 11 weeks.

56. 10. TREATMENT CONT.
OTHER LESS STUDIES TREATMENT:
1. Combination of metronidazole and fluconazole
2. Treatment with lactobacillus - Exogenous lactobacillus
recolonization with 30 days of oral probiotic
Lactobacillus rhamnosus and Lactobacillus reuteri in
addition to seven days of metronidazole therapy.
3. Vaginal microbiome transplant
4. Vaginal boric acid with EDTA
(ethylenediaminetetraacetic acid) for bacteria that
forms biofilms.

57. 11. COMPLICSCATIONS
• GYNAECOLOGICAL COMPLICATIONS
1. Psychological Disturbances
2. Increase risk of STIs including HIV and HSV
3. Bacteraemia
4. PID and UTI
• OBSTETRIC COMPLICATIONS
1. Preterm delivery and LBW
2. Premature labour due to choriamnionitis
3. Late term miscarriage
4. Postpartum fever, endometritis and salpingitis
• POSTOPERATIVE COMPLICATIONS
1. Wound infection
2. Vaginal cuff infection

58. 12. PREVENTION
1. Use of condoms
2. Hormonal contraceptives
3. Avoid douching, tub baths, and bubble baths
4. Avoid the use of feminine hygiene products (
vulvovaginal products)
5. Avoid the use of liquid soaps and body washes
6. Cleaning sex toys between use
7. Use of gloves during digital-vaginal sex
8. Use of probiotics
9. Limiting number of sex partners
10. Avoid thongs and tight nylon tights

59. 13. CONCLUSION
• The BV prevalence is high globally, with concomitant high
economic burden and marked racial disparities in
prevalence.
• Research to determine aetiology, prevention, and
treatment strategies are urgently needed to reduce the
burden of BV among women.
• Women with recurrent BV reported psychological and
social impacts on their self-esteem, sexual relationship,
and quality of life.
• Support and acknowledgement of impacts of BV on
women life are required when managing women with
recurrent BV.

60. 14. REFERENCES
1. Williams Gynaecology Third Edition
2. Dutta’s Textbook of Gynaecology Eighth Edition
3. Bacterial Vaginosis. eMedicine:
https://emedicine.medscape.com/article/254342-overview
4. Bacterial Vaginosis. Uptodate (2021):
https://www.uptodate.com/contents/bacterial-vaginosis-
treatment/print
5. Bacterial vaginosis. CDC (2021):
https://www.cdc.gov/std/treatment-guidelines/bv.htm
6. Bacterial vaginosis, Wikipedia (2021):
https://en.wikipedia.org/wiki/Bacterial_vaginosis
7. Bactrial Vaginosis – Global burden. Stdjournal (2019):
https://journals.lww.com/stdjournal/Fulltext/2019/05000/High_G
lobal_Burden_and_Costs_of_Bacterial.5.aspx

61. “Do not cry over spilled milk.
By this time tomorrow, it will be free yoghurt.
Compliments to Lactobacillus bulgaricus”
TAHNK FOR LISTENING. ANY QUESTION?