How Bacterial Vaginosis Is Treated

CDC Guidance and Alternative Approaches

Bacterial vaginosis (BV) is a common vaginal infection that causes itchiness, vaginal discharge, and a characteristic "fishy" odor. Most cases are uncomplicated and may be treated with prescription antibiotic drugs, taken either orally or with topical creams or gels. BV infections are known to frequently recur, usually within three to 12 months, requiring additional or alternate forms of therapy.

Treatment may also be prescribed during pregnancy to reduce the risk of complications such as low birth weight and the premature rupture of membranes.

Prescriptions

An antibiotic treatment of bacterial vaginosis is recommended for all women with symptoms. Doing so not only helps to eradicate the infection, it reduces a woman's chance of getting a sexually transmitted disease such as gonorrhea, chlamydia, and trichomoniasis.

Preferred Drugs

There are three preferred antibiotic drug regimens recommended by the Centers for Disease Control and Prevention (CDC) for the treatment of BV:

  • Metronidazole 500 milligrams taken orally (by mouth) twice daily for seven days
  • Metronidazole 0.75 percent gel applied once daily for five days using a 5.0-gram disposable intravaginal applicator
  • Clindamycin 2.0 percent cream applied once at bedtime for seven days using an intravaginal applicator

Alternative Drugs

Certain treatments are reserved for second-line therapy if symptoms recur or if a person has a known resistance to a preferred antibiotic. Alternative therapies include:

  • Clindamycin 300 milligrams taken orally twice daily for seven days
  • Clindamycin 100-milligram suppositories applied at bedtime for three days
  • Tindamax (tinidazole) 2.0 grams taken orally once daily for two days
  • Tindamax (tinidazole) 1.0 grams taken orally once daily for five days

Proper Prescription Usage

Whichever treatment you are prescribed, you need to complete the course even if your symptoms clear. Failure to do so may increase the risk of antibiotic resistance.

It is advised that you abstain from alcohol during the course of therapy and for 24 hours after. Drinking may trigger adverse symptoms such as a headache, flushing, rapid heart rate, shortness of breath, nausea, vomiting, and fainting.

To prevent exposure to bacteria and other harmful microbes, you should either refrain from sex or use condoms throughout the course of treatment. While BV is not considered a sexually transmitted infection, potentially harmful microorganisms may be harbored on the male penis, especially under the foreskin. Even a female sex partner poses a risk due either to skin-to-genital or genital-to-genital contact.

Despite these risks, the treatment of a sexual partner is not usually needed.

Common Side Effects

Most are relatively mild. Among them:

  • Oral medications may cause stomach upset, nausea, cold symptoms (a cough, runny nose, sore throat), and a metallic taste in the mouth.
  • Topical antibiotics may cause vaginal itchiness, headache, nausea, cold symptoms, a tingling sensation in the hands and feet, and a metallic taste in the mouth.

Home Remedies

One of the biggest frustrations of treating bacterial vaginosis is the high rate of recurrence. Some studies have suggested that the rate may be as high as 50 percent; others believe that it is much greater. And, this poses a problem given that the repeated use of antibiotics may increase the risk of drug resistance.

To this end, a number of home remedies have been studied in women with recurrent BV symptoms. Chief among these are boric acid and hydrogen peroxide, both of which are relatively inexpensive and easily obtained at the drug store without a prescription.

Here is what we know:

  • Boric acid has been used to treat yeast infections (vaginal candidiasis) for over 100 years. A 2015 study explored its use as a vaginal suppository in women with BV and found that, after 10 days, the rate of infection clearance was similar to that of antibiotics.
  • Hydrogen peroxide, delivered in a 3 percent intravaginal solution, has also been used for generations to treat BV. However, research in 2011 from John Hopkins University showed that the treatment was not able to suppress the specific "bad" bacteria associated with a BV infection, undermining its value in women with recurrent symptoms.

While these remedies are considered safe and affordable, they should not be used without a complete diagnosis and input from your doctor. This is especially true for first-time sufferers, pregnant women, or those with symptoms of a severe infection (including fever, body aches, pelvic and/or abdominal pain, or difficulty urinating).

Pregnancy Recommendations

An active BV infection during pregnancy may increase the risk of preterm birth, low birth weight, the premature rupture of membranes (PROM) and, less commonly, miscarriage.

Oral antibiotics are most commonly prescribed, either clindamycin 300 milligrams or metronidazole 500 milligrams taken twice daily for seven days. Topical antibiotics, by contrast, appear less effective in preventing pregnancy complications.

While most studies show that the use of oral antibiotics can reduce the risk of PROM and low birth weight, the evidence is lacking in their ability to prevent preterm birth.

Antibiotic Resistance

Generally speaking, the risk of antibiotic resistance in bacterial vaginosis is nowhere near as dramatic as one might expect. The is due in part to the types of bacteria involved in BV (which are anaerobic and don't require oxygen) compared to those found in other forms of vaginitis (which are aerobic and do require oxygen).

Aerobic bacteria are found outside the body and more readily transmitted from person to person. These include such well-known types as Staphylococcus aureus, Streptococcus, and Escherichia coli (E. coli). The widespread use of antibiotics to treat these infections has resulted in increasing rates of resistance.

While this is far less common with the bacteria involved in BV, resistance can sometimes occur. It depends largely on the type of "bad" bacteria that can predominate during a BV infection. For example:

  • Metronidazole resistance is believed to be building in response to a type of vaginal bacteria known as Atopobium vaginae. The same is less commonly seen with clindamycin.
  • By contrast, clindamycin resistance has become a growing concern with regards to Prevotella bacterial strains. The same has not been seen with metronidazole.
  • There have also been reports of metronidazole resistance to another common vaginal bacteria known as Gardnerella vaginalis.

But, in the larger scheme, the threat is still considered low and the benefits of treatment far outweigh the consequences.

To this end, antibiotic therapy should never be avoided due to the largely unfounded chance of resistance. In the end, resistance can be avoided by taking your medications completely and as prescribed. Moreover, if symptoms do recur, you should never ignore them but rather get them treated sooner rather than later.

Complementary Medicine (CAM)

Bacterial vaginosis is caused when "good" vaginal flora, called lactobacilli, is depleted, allowing "bad" bacteria to predominate and cause infection. As such, it has been suggested that probiotics, rich in healthy bacteria like Lactobacillus acidophilus, may be useful in replenishing vaginal flora. And, there is some evidence to support this.

2014 review of clinical studies concluded that the daily use of an oral probiotic, either through supplementation or foods like yogurt, may prevent a BV infection or help support antibiotic therapy.

That being said, it is highly unlikely that probiotics on their own can treat a BV infection on their own. The CDC has long questioned the use of probiotics in treating BV, even as a form of adjunctive therapy. That is not to suggest that probiotics have no value; it is simply that there is no proof that probiotic bacteria can translocate from the stomach to the vagina in quantities considered therapeutic.

There has been a similar lack of evidence supporting the use of other natural remedies (such as garlic or tea tree oil) in treating BV.

If you decide to pursue a complementary or alternative form of therapy, it is important to speak with your doctor about the potential risks and benefits. Self-treating and avoiding standard care may lead to a worsening of symptoms and the development of complications, including pelvic inflammatory disease (PID) and preterm birth.

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