Douching is the best-studied risk factor for bacterial vaginosis. A recent multicenter cross-sectional study of 1200 women assessed douching practices and found that recent douching increased the risk of bacterial vaginosis twofold (odds ratio=2.1; 95% confidence interval, 1.3–3.1).6 Evidence for the other risk factors listed in Table 2 is based on smaller studies or expert opinion.7,8
For women who continue to have recurrent or unresolved vaginal symptoms not explained by candidiasis or sexually transmitted infections such as trichomoniasis, consider less common causes such as atrophic vaginitis, chemical/irritant vaginitis, allergic vaginitis, Behçets disease, desquamative interstitial vaginitis, or erosive lichen planus vaginitis.9
TABLE 1
Amsel criteria for diagnosis of bacterial vaginosis
| Patient must have 3 of the 4 criteria for diagnosis. |
|
| Source: Based on Amsel et al 1983.11 |
TABLE 2
Risk factors for bacterial vaginosis
| Use of vaginal foreign bodies, perfumed soaps, or douching |
| Cigarette smoking |
| Intrauterine device |
| New male sexual partner |
| Sex with another woman |
| No condom use (trend toward association) |
| Source: Based on Marrazzo et al 20027; CDC 2002.8 |
Recommendations from others
No organizations have developed guidelines for treating recurrent bacterial vaginosis. In 2002, the Association for Genitourinary Medicine and the Medical Society for the Study of Venereal Diseases released national guidelines on the management of bacterial vaginosis,10 which generally agrees with the previously described CDC recommendations.
CLINICAL COMMENTARY:
Take a detailed history, make sure clinical findings support the diagnosis
Jon O. Neher, MD
Valley Medical Center, Renton, Wash
Patients with recurrent bacterial vaginosis are often embarrassed, frustrated, or angry with the failure of prior medical therapy. Our challenge is to listen empathetically and avoid blaming the patient for the failure. It is critical to take another detailed history (again reviewing sexual and perineal hygiene habits), consider an expanded differential, and make sure clinical findings continue to support the diagnosis. A discussion about the (current lack of) evidence on pharmacologic therapy for recurrent cases must also be included in the visit. A collaborative plan of action will help the patient regain a sense of control over her health.