Abstract
An office visit for bacterial vaginosis (BV) is often billed with a “low complexity and low medical decision-making” code. However, as Fought and Reyes so eloquently display in their “Characterization and Treatment of Recurrent Bacterial Vaginosis,” this is not the case for up to 50% of women. 1,2 This review describes the complex microbiological and physiological characteristics that impact, mostly hinder, successful treatment of these women, and outlines the available and potential treatment options, most of which still require better studies, outcomes data, and evidence-based recommendations. They recognize that recurrent BV has significant impact on women's psychological well-being, self-esteem, interpersonal and sexual relationships, and medical and societal costs. Their review helps to uncover why BV deserves respect.
It also reads as a history of our understanding of the disease. Gardnerella vaginalis, which remains paramount on the stage of BV actors, is no longer a lone player, and, in fact, has been fragmented into clades, each with its own characteristics. The background players of Atopobium vaginae, Mobiluncus, Bacteroides, Proventalla, and others are now BV-associated bacteria and have been moved from behind the scenes to stand side by side with Gardnerella. A strong reinforcer of the pathological microbiome, the biofilm, has been identified. Finally, the Lactobacilli strains, which have always been considered the protectors of the vagina have been found to not been created equal in their contribution to vaginal health 2 –4 Overall, the microscopic level of complexity of BV has increased, but has our response? Clinically, 50% of our patients have a recurrence of BV after initial treatment, many of these frequent or prolonged. Our medication options can be expensive, cumbersome, unpleasant, have unwanted side effects, and require abstinence from intercourse or alcohol in many instances. Our thoughts have turned to treat recurrent BV by affecting the overall vaginal milieu (in addition to, or instead of, medications) and many of these approaches are well described in this review. This review gives many of us who treat these recurrent cases ideas for new regimens, although we still yearn for more supportive data.
Our patients, however, are not waiting for the data; they are seeking relief. Industry has certainly recognized this need and pharmacy shelves are filled with products such as oral and vaginal pre- and probiotics, vaginal acidifiers and douches, and odor-relieving products and wipes. Many of these products may be harmless, but they may be irritating and allergenic, or they may be harmful. Well-conducted placebo-controlled studies of these products will help us determine their role in treatment of recurrent BV. Until that data are available, our obligation to our patients is not only to provide recommended and standard treatment but also to recognize these products, explain their limitations, and counsel regarding their safe use. This review provides insight to aid in this counseling.
The addition of a single dose oral medication without alcohol interaction is a welcome newcomer to the world of BV. Its overall impact and effect on recurrent cases is yet to be seen. But even more welcoming is the attention paid to this disruptive disorder. For the women who suffer and the providers who care for them, these microbiome revelations provide promise of new and innovative treatments against this formidable foe.