What is Bacteria Vaginosis?
Bacteria Vaginosis is usually not considered a sexually transmitted disease although it occurs more often in sexually active women than non-sexually active women.
Bacteria Vaginosis is a condition as a result of the replacement of the usual lactobacilli in the vagina with high concentrations of anaerobic bacteria such as Gardnerella Vaginalis, Mycoplasma Hominis, Mobiluncus Species and prevotella species. This results in a rise in PH from the usual 4.5 to as high as 7.0.
Bacteria Vaginosis is usually not considered a sexually transmitted disease although it occurs more often in sexually active women than non-sexually active women.
Bacteria Vaginosis is a condition as a result of the replacement of the usual lactobacilli in the vagina with high concentrations of anaerobic bacteria such as Gardnerella Vaginalis, Mycoplasma Hominis, Mobiluncus Species and prevotella species. This results in a rise in PH from the usual 4.5 to as high as 7.0.
Possible complications of Bacteria Vaginosis
It has been associated with pregnancy related complications such as preterm labor, late miscarriages, premature rupture of membranes and post-delivery endometritis.
It is also associated with pelvic inflammatory disease, vaginal cellulitis post-surgery and endometritis.
Currently there has been more evidence suggesting that Bacteria Vaginosis (lack of lactobacilli) has been associated with an increased risk of HIV contraction with a HIV partner during heterosexual intercourse.
Clinical symptoms and signs of Bacteria Vaginosis
Most people with bacteria vaginosis have no symptoms. If they do have symptoms they may present with an unpleasant fishy smelly thin white homogenous vaginal discharge.
Diagnosis of Bacteria Vaginosis
It is usually diagnosed with Amsel Criteria:
If 3 out of 4 following criteria are present then it is diagnostic of bacteria vaginosis:
It has been associated with pregnancy related complications such as preterm labor, late miscarriages, premature rupture of membranes and post-delivery endometritis.
It is also associated with pelvic inflammatory disease, vaginal cellulitis post-surgery and endometritis.
Currently there has been more evidence suggesting that Bacteria Vaginosis (lack of lactobacilli) has been associated with an increased risk of HIV contraction with a HIV partner during heterosexual intercourse.
Clinical symptoms and signs of Bacteria Vaginosis
Most people with bacteria vaginosis have no symptoms. If they do have symptoms they may present with an unpleasant fishy smelly thin white homogenous vaginal discharge.
Diagnosis of Bacteria Vaginosis
It is usually diagnosed with Amsel Criteria:
If 3 out of 4 following criteria are present then it is diagnostic of bacteria vaginosis:
- PH of vaginal discharge above 4.5
- Thin homogenous white vaginal discharge
- Microscopy of vaginal discharge reveal clue cells
- Odor/Sniff test: positive amine (fishy) smells before or after adding 10% potassium hydroxide solution.
Note that presence of semen, menstruation, douching and cervical secretions may affect the PH of discharge. Trichomoniasis should be excluded.
Culture for Gardnerella Vaginalis is usually not recommended as it is usually present in >50% women.
Indications of treatment
1. All symptomatic women (pregnant or not) should be treated.
2. Pregnant women with no symptoms but at risk preterm labor should be treated.
3. Women with no symptoms before an abortion surgery or gynecological surgeries should be treated as there is a risk of endometritis post-surgery.
Recommended dosage regimes for non-pregnant women
Antibiotics oral metronidazole 400mg twice daily for a week or clindamycin cream intra-vaginally for 7 nights or metronidazole gel intra-vaginally for 5 days may be used for treatment.
Other alternatives are oral tinidazole 2 gram one single dose or clindamycin 300 mg twice daily for 1 week or clindamycin 100 mg intra-vaginally for 3 nights.
When taking metronidazole, patients should not consume alcohol during treatment as well 24 hours after. Clindamycin being oil based it may weaken the latex in condoms and diaphragms.
Treatment regime dosage in patients who are pregnant
Antibiotics oral metronidazole 400 mg twice daily for 1 week or metronidazole 200 mg 3 times daily for 1 week or clindamycin 300 mg twice daily for 1 week.
Intra-vaginal clindamycin cream is not recommended as during the 16-32 weeks of gestation, there has been an association with neonatal infections and low birth weight.
Metronidazole when used in the first trimester of pregnancy has not shown to have harmful effects on the fetus. It may enter breast milk and affect the taste of milk hence high doses should be avoided during lactation period.
Oral Clindamycin will cross over and enter breast milk hence it is not recommended in lactating mums. In such cases, intra-vaginal clindamycin may be more appropriate.
Currently there are no recommendations to screen for bacteria vaginosis in pregnant women who do not have any symptoms. However, for women who are undergoing termination of pregnancy, screening and treatment of bacteria vaginosis will reduce the incidence of endometritis.
Recommended treatment for recurrent bacteria vaginosis
1. Maintenance use of acetic acid vaginal gel following unprotected sexual intercourse and during menstruation.
2. Oral metronidazole 400 mg twice daily for 3 days at start of menstruation and at end of menstruation. One dose of oral fluconazole 150 mg may be given if the patient has candidiasis too.
3. Metronidazole gel twice weekly for a period of 4 to 6 months can be used as suppressive therapy.
Long term maintenance therapy is not recommended.
Prevention of bacteria Vaginosis
Patients should be advised to avoid use of shower gel/shampoo/antiseptic agents for genitalia area and vaginal douching during shower.
Follow up
As long as symptoms have resolved in non-pregnant women, follow up is not necessary. However for pregnant women, a follow up one month later to evaluate clearance is necessary. So far no clinical presentation is seen in male partners so screening and treatment of male partners are not recommended. Some studies have suggested a higher incidence in lesbian partners but so far no recommendation for screening.
Culture for Gardnerella Vaginalis is usually not recommended as it is usually present in >50% women.
Indications of treatment
1. All symptomatic women (pregnant or not) should be treated.
2. Pregnant women with no symptoms but at risk preterm labor should be treated.
3. Women with no symptoms before an abortion surgery or gynecological surgeries should be treated as there is a risk of endometritis post-surgery.
Recommended dosage regimes for non-pregnant women
Antibiotics oral metronidazole 400mg twice daily for a week or clindamycin cream intra-vaginally for 7 nights or metronidazole gel intra-vaginally for 5 days may be used for treatment.
Other alternatives are oral tinidazole 2 gram one single dose or clindamycin 300 mg twice daily for 1 week or clindamycin 100 mg intra-vaginally for 3 nights.
When taking metronidazole, patients should not consume alcohol during treatment as well 24 hours after. Clindamycin being oil based it may weaken the latex in condoms and diaphragms.
Treatment regime dosage in patients who are pregnant
Antibiotics oral metronidazole 400 mg twice daily for 1 week or metronidazole 200 mg 3 times daily for 1 week or clindamycin 300 mg twice daily for 1 week.
Intra-vaginal clindamycin cream is not recommended as during the 16-32 weeks of gestation, there has been an association with neonatal infections and low birth weight.
Metronidazole when used in the first trimester of pregnancy has not shown to have harmful effects on the fetus. It may enter breast milk and affect the taste of milk hence high doses should be avoided during lactation period.
Oral Clindamycin will cross over and enter breast milk hence it is not recommended in lactating mums. In such cases, intra-vaginal clindamycin may be more appropriate.
Currently there are no recommendations to screen for bacteria vaginosis in pregnant women who do not have any symptoms. However, for women who are undergoing termination of pregnancy, screening and treatment of bacteria vaginosis will reduce the incidence of endometritis.
Recommended treatment for recurrent bacteria vaginosis
1. Maintenance use of acetic acid vaginal gel following unprotected sexual intercourse and during menstruation.
2. Oral metronidazole 400 mg twice daily for 3 days at start of menstruation and at end of menstruation. One dose of oral fluconazole 150 mg may be given if the patient has candidiasis too.
3. Metronidazole gel twice weekly for a period of 4 to 6 months can be used as suppressive therapy.
Long term maintenance therapy is not recommended.
Prevention of bacteria Vaginosis
Patients should be advised to avoid use of shower gel/shampoo/antiseptic agents for genitalia area and vaginal douching during shower.
Follow up
As long as symptoms have resolved in non-pregnant women, follow up is not necessary. However for pregnant women, a follow up one month later to evaluate clearance is necessary. So far no clinical presentation is seen in male partners so screening and treatment of male partners are not recommended. Some studies have suggested a higher incidence in lesbian partners but so far no recommendation for screening.
