Asymptomatic women not undergoing gynaecological procedures

• CKS found no evidence on treating non-pregnant asymptomatic women (who are not undergoing a gynaecological procedure) for bacterial vaginosis (BV).
• Recurrence of BV is frequent; therefore, treating asymptomatic BV will have no impact on the population prevalence in women who are not pregnant [Wawer et al, 1999].
• Treatment of asymptomatic non-pregnant women with an incidental finding of BV is not recommended in current UK guidelines for BV [BASHH, 2006].

Termination of pregnancy

• Bacterial vaginosis is common in some populations of women undergoing elective termination of pregnancy and has been associated with post-termination endometritis and pelvic inflammatory disease (PID).
• Evidence from three RCTs suggests that treating BV with either metronidazole or clindamycin cream before termination may reduce the incidence of subsequent genital tract infection.

Other gynaecological procedures

• There is a lack of evidence to support or refute the treatment of asymptomatic BV before other gynaecological procedures.
• CKS found no studies investigating the possible role of BV, or the management of asymptomatic BV, in the development of PID directly after insertion of an intrauterine contraceptive device (IUD).
• The Faculty of Sexual and Reproductive Healthcare guidance on intrauterine contraception recommends that in asymptomatic women attending for insertion of an IUD, there is no indication to test for, or treat, lower genital tract organisms (such as BV) or to delay insertion until results of such tests are available. Women who are at higher risk of a sexually transmitted infection or who request swabs should be tested for chlamydia and gonorrhoea before IUD insertion [FSRH, 2007].
• Bacterial vaginosis has been associated with an increased incidence of vaginal cuff cellulitis and abscess formation after abdominal hysterectomy, but it is unclear whether this is a problem in UK practice, where many units administer perioperative antibiotics.
• CKS found no studies investigating the management of asymptomatic BV in preventing infection after upper genital tract procedures.
• Expert opinion is divided over treatment of BV in asymptomatic women before other invasive procedures, such as IUD insertion or endometrial biopsy. Some CKS expert reviewers would consider treatment of BV in asymptomatic women in this situation; however, current evidence does not support this approach.
• The British Association for Sexual Health and HIV recommends that treatment is indicated for women undergoing some surgical procedures, but the procedures are not specified [BASHH, 2006].