Recent research on the diagnosis, treatment, and management of bacterial vaginosis (BV) reveals a growing frustration among women affected by this infection. Affecting over 21 million women annually, BV is the most prevalent gynecologic infection in the United States. However, BV remains underdiagnosed in many women, and research shows that just 4 million women undergo treatment for BV.
More than half of patients who are prescribed treatment for BV do not adhere to their full course of therapy due to barriers such as side effects, treatment frequency and duration, and limitations while taking medication. When taking antibiotics, women commonly experience adverse effects like nausea, stomach cramps, and diarrhea. In addition, 50% of women treated for BV experience recurrence within a year. All these issues point to a disease state that is largely misunderstood and in need of better treatment options.
Diagnosis & Treatment
BV is classically defined as an imbalance of the vaginal flora that is characterized by an overgrowth of anaerobic bacteria. Diagnosing bacterial vaginosis is a complex process, requiring point-of-care pelvic exams followed by a wet mount, whiff test, vaginal pH test, FDA-approved polymerase chain reaction testing, or other diagnostic mechanisms.
Further complicating matters to diagnosing BV is that there have been few advancements in this area over the last 30 years. One study on diagnostics comparing Amsel’s criteria and the Nugent score found vaginal pH to be a “relatively poor” predictor of BV. Other research has noted that nearly 30% of patients met the diagnostic criteria of BV but were clinically asymptomatic. “The microbiology of the vagina is complex, posing challenges to efficiently and accurately making a diagnosis,” adds Steven E. Chavoustie, MD, FACOG, CCRP. “This then complicates how BV is treated and managed.”
There is a clear need for better treatment options for BV because, when left untreated, women with the infection face a significantly higher risk of serious health problems. BV increases risks for sexually transmitted diseases, including HIV, HPV, chlamydia, trichimoniasis and pelvic inflammatory disease. BV can also increase the risks for pre-term birth and low birth weight in pregnant women. The infection can also negatively impact reproductive and surgical outcomes.
Poor Awareness & Misunderstanding
There is significant room for improvement in regard to awareness of the signs and symptoms of BV and the serious health consequences among women with the infection (Table). A study that examined the management of BV with an in-depth analysis of 35 patients found that this patient population reported “very poor” levels of awareness about the infection prior to being initially diagnosed, with most reporting they had never heard of BV before. Women in the study reported multiple reasons for a general lack of awareness of BV, including societal stigma that is often associated with vaginal health, misperceptions that the infection is sexually transmitted, or falsely believing that they have a yeast infection.
Both patients and clinicians report that instances of BV have triggered the use of self-imposed remedies like added douching and taking vitamins, probiotics, or over-the-counter vaginal treatments. Women with symptoms of BV often resort to avoiding perfumed soaps, tight clothing, and sexual activity, according results of a recent study. In this same study, women also reported receiving inconsistent medical advice, misdiagnoses, and inappropriate responses from primary care providers, some of whom reported that their healthcare providers were insensitive or dismissive of their condition.
“Misunderstanding the risks, frustration and embarrassment with the symptoms of BV, and the perception that this infection is a reflection of one’s sexual activity often prompts women with BV to delay a clinical diagnosis,” says Dr. Chavoustie. “Physicians need to approach these women with sensitivity and understand the impact that this infection has on their lives, both physically and socially.”
Coming to a Consensus
For a paper published in the International Journal of Gynecology & Obstetrics, Dr. Chavoustie and colleagues issued a consensus statement calling for greater awareness of BV among women and healthcare providers. The statement endorses the adoption of point-of-care tests to improve the diagnosis of BV and emphasizes the need to pay more consideration to treatment efficacy, patient preferences, and tolerability when deciding on how BV should be managed. The paper called for an innovative therapy that would decrease treatment length and reduce side effects to improve patient outcomes.
“Despite BV’s high prevalence, awareness is remarkably low among patients and physicians,” says Dr. Chavoustie. “Underdiagnosis and misdiagnosis, in tandem with poor adherence to treatment, exposes women to serious health risks. We need to raise awareness of this infection, improve how we diagnose BV, and develop and deliver better treatment options to encourage compliance and reduce unpleasant side effects of the therapies we use.”
Chavoustie S, Eder S, Koltun, et al. Experts explore the state of bacterial vaginosis and the unmet needs facing women and providers. Int J Gynaecol & Obstet. 2017;2:107-109. Available at http://onlinelibrary.wiley.com/doi/10.1002/ijgo.12114/full.
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Bilardi J, Walker S, McNair R, et al. Women’s management of recurrent bacterial vaginosis and experiences of clinical care: a qualitative study. PLoS One. 2016;11:e0151794.
Bradshaw C, Morton A, Hocking J, et al. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis. 2006;193:1478-1486.
Hoffman M, Bellad M, Charantimath U, et al. A comparison of colorimetric assessment of vaginal pH with Nugent score for the detection of bacterial vaginosis. Infect Dis Obstet Gynecol. 2017 Feb 15 [ePub ahead of print]. Available at www.hindawi.com/journals/idog/2017/1040984.