Practical strategies for acute and recurrent vaginitis
Self-diagnosis and treatment are out, and meticulous, in-office diagnosis is in—and there is new hope for women with chronic candidiasis: maintenance fluconazole.
BV is diagnosed by finding at least 3 of the following Amsel criteria:
- abnormal gray discharge
- vaginal pH of more than 4.5
- positive amine test
- more than 20% of epithelial cells are clue cells
Susceptibility to other infections
In nonpregnant women, BV has been linked to infections of the reproductive tract, including pelvic inflammatory disease, postprocedural gynecologic infections, and acquisition of HIV.5 Treating BV prior to abortion or hysterectomy appears to substantially lower the risk of postoperative infection.18 Treatment also helps resolve concurrent mucopurulent cervicitis.19 However, we lack evidence that BV treatment decreases the risk of pelvic inflammatory disease or HIV.
First-line treatment
The number of approved treatment options has increased (TABLE 2). Although clindamycin may have greater in vitro resistance,5 all the listed agents have comparable clinical efficacy and safety.20-22
Topical agents often cost more than generic oral metronidazole, although the latter is often associated with GI symptoms.
TABLE 2
Bacterial vaginosis treatment options
| DRUG | FORMULATION | DOSE PER DAY | DURATION |
|---|---|---|---|
| Clindamycin | 2% cream | 5 g | 7 days |
| 2% single-dose cream | 5g | 1 day | |
| 100-mg ovules | 100 mg | 3 days | |
| 300 mg oral | 300 mg bid | 7 days | |
| Metronidazole | 0.75% gel | 5 g | 5 days |
| 500 mg oral | 500 mg bid | 7days |
When BV recurs
After treatment, bacterial vaginosis recurs in as many as 30% of women within 3 months.23 A number of explanatory theories have been proposed:
- persistent pathogenic bacteria
- reinfection from exogenous sources, including a sexual partner
- failure of normal lactobacillus-dominant flora to reestablish itself
In support of the first theory, Sanchez and colleagues24 found a lower risk of recurrence after treatment with high-dose (500 mg) intravaginal metronidazole plus nystatin, compared with standard metronidazole gel. (See “High-dose treatment [and maybe condoms] improved cure rate,”.)
The same study suggested a possible link to exposure to exogenous pathogens: Women who used condoms after treatment had a lower risk of recurrence than women who did not. However, other randomized trials evaluating treatment of the partner have shown no benefit in preventing recurrent BV.
Similarly, recolonization with lactobacillus supplements using nonvaginal strains failed to show a clear benefit.23
Benefits of maintenance therapy
Some women with recurrent BV appear to improve with low-dose maintenance antibiotic therapy. In a recent study of low-dose metronidazole gel (0.75%),25 women with recurrent BV were given a 10-day course to clear that episode, then randomized to maintenance metronidazole (1 applicator twice a week) or placebo for 4 months. Seventy percent of the treatment group remained free of infection, compared with only 34% of theplacebo group. After an additional 4 months of observation, 39% of the treatment group remained free of BV compared with 18% of the placebo group.
Although these findings demonstrate significant improvement with maintenance therapy, the relapse rate remained relatively high. A high rate of VVC was also noted: Almost 60% of women required antifungal therapy at some point during the study.
Vaginitis: A way of life
SANDRA’S CASE
At minimum, symptom control
After careful evaluation and vaginal cultures, you diagnose Sandra with candidiasis infection with the C glabrata species and prescribe 600-mg capsules of intravaginal boric acid—taking care to warn her that they are for intravaginal use only, not to be taken orally—which completely relieve her symptoms for several months.
Although the candidiasis eventually recurs, the symptoms are not as severe and resolve again with more boric acid capsules.
For patients like Sandra, vaginitis may be an inescapable fact of life.
Fortunately, as our understanding of vulvovaginal conditions has improved, more effective evaluation and treatment enable us to establish clearer diagnoses and choose therapies that—at a minimum—keep symptoms under control.
Dr. Nyirjesy serves on the speakers bureau for 3M and KV Pharmaceuticals and consults for 3M, KV Pharmaceuticals, Presutti Laboratories, and Personal Products Worldwide. He also has received grant support from Presutti Laboratories.
Dr. Sobel serves on the speakers bureau for 3M, KV Pharmaceuticals, Merck, and Pfizer, and consults for Pfizer, Presutti Laboratories, and Vicuron. He also has received grant support from Fujisawa Pharmaceuticals, Johnson & Johnson, and Presutti Laboratories.
