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Bacterial vaginosis - Management
Basis for recommendation

Recurrence of symptoms

  • Up to 30% of women with an initial response to treatment have a recurrence of symptoms within 3 months [Sobel, 1997]. The reasons for this are unclear.
  • There are few published studies evaluating the optimal approach in women with frequent recurrences of bacterial vaginosis (BV).

Avoidance of vaginal douching and possible irritants

  • Vaginal douching has been identified as a risk factor for BV [Alfonsi et al, 2004].
    • A cross-sectional study of 1200 women found that recent douching significantly increased the risk of BV approximately two-fold.
  • In the absence of evidence to refute or support women with recurrent episodes of BV avoiding vaginal douching, this recommendation is based on expert opinion [BASHH, 2006].

Possible management options

  • Evidence on the management of recurrent BV is insufficient to make recommendations for primary care. Options that have been studied include:
    • Oral metronidazole before and/or after menstruation.
    • Intermittent use of metronidazole vaginal gel.
    • Use of lactobacillus (orally or intravaginally).
    • Vaginal acidification with intravaginal acetic acid or lactic acid gel.
  • Given that BV can often be asymptomatic, it may be difficult to distinguish recurrent BV from persistent BV or treatment failure, and adequate treatment of the current episode is therefore essential.

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