Prevalence by sexual behavior and identity
Bacterial vaginosis is prevalent among all sexually active women and is even more commonly seen in women who have sex with women (WSW). BV also has been diagnosed in women reporting sexual inexperience, albeit at lower rates than in women reporting sexual experience.2 An analysis of data from the 2001-2004 National Health and Nutrition Examination Survey (NHANES) showed that overall BV prevalence among women aged 14-49 years was 29%.3 For women who reported a history of having a female sexual partner, the prevalence jumped to almost 45.2%.3
In a systematic review and meta-analysis of 43 studies, Fethers et al.4 identified a 1.6 relative risk for BV among women with new or multiple male partners and a 2.0 relative risk among women with one or more female partners during their lifetimes. Evans et al.5 conducted a cross-sectional BV prevalence study of 171 women who identified as lesbian and 189 women who identified as heterosexual in a community setting in the United Kingdom; 354 of the participants had gradable flora. BV was identified in a significantly greater proportion of lesbian women than heterosexual women (25.7% vs 14.4%; adjusted odds ratio, 2.45; 95% confidence interval [CI], 1.25-4.82;P = .009). Concordance of vaginal flora within lesbian sexual partnerships was significantly greater than expected (27/31 couples, or 87%; kappa = 0.63; P <.001). Another recent systematic review of 22 studies of BV and STIs in WSW found that the most frequently reported condition was BV, with a prevalence ranging from 26% to 43%.6
Risk factors for BV
Among all women, risk factors for BV include having new or multiple male sex partners, nonuse of condoms with male partners, having female sex partners, douching, a lack of vaginal lactobacilli, and a history of STIs.5,10 Among WSW, additional risk factors for BV include a higher number of sexual partners, having a female partner with BV, use of a vaginal lubricant, sharing sex toys,
a history of forced vaginal penetration, and engaging in digital-vaginal sex and/or digital-anal sex.6,11-13
Support for bacterial vaginosis as a sexually transmitted infection
The CDC does not classify BV as an STI.1 However, for WSW, BV meets the basic definition of an STI based on the transfer of bodily fluid during sex that contains BV-associated bacteria. Whether or not BV is classified as an STI, it is clearly associated with sexual behavior, and evidence for sexual transmission is growing. In a study of 21 pairs of monogamous female sexual partners, of 11 index women who had BV, 8 (72.7%) had sexual partners who also had BV.14 By contrast, of10 index women who did not have BV, 1 (10%) had a sexual partner with BV. The probability of a partner having BV if the index case also had BV was 19.7 times higher (P <.008).
Finally, although a single pathogen for transmission has not been isolated, a high level of concordance of BV-associated pathogens is observed in monogamous lesbian couples with BV.10,12,16,17
Unmet healthcare needs among women who have sex with women
On the basis of six studies conducted in the 1980s and 1990s that failed to show partner treatment was beneficial, the CDC advises against treating sex partners of women diagnosed with BV.10 However, these studies focused on treatment of male sexual partners, had methodologic limitations, and utilized suboptimal treatments. Research needs to be updated utilizing treatment regimens consistent with the current standard of care.10
No current guidelines specifically address treatment of BV in WSW. Even among women who have biologic evidence of BV, current guidelines recommend treatment only for those who are symptomatic.1 Transmission of infection from asymptomatic women with BV to female sexual partners may be a factor in the higher BV prevalence and high recurrence rate among WSW.3,7 The effectiveness of strategies to reduce transference of vaginal secretions between female sexual partners, as well as treatment of female sexual partners of infected individuals, has not been adequately studied. This information is key to the development of evidence-based guidelines for treatment of BV in WSW.18
Many WSW lack knowledge about the risk of BV and STIs, their symptoms and transmission, and their treatment.20 For example, myths about oral or intravaginal probiotics curing BV still exist. In addition, WSW may hesitate to disclose their same-sex sexual attraction, behaviors, and/or identities to their HCPs, which can inhibit HCPs’ ability to offer nonjudgmental communication, counseling, and appropriate treatment.5
Addressing unmet needs
In addition to improving awareness of WSW’s healthcare needs and educating HCPs about how to effectively communicate with WSW, WSW need additional education about BV risk factors, symptoms, and means of transmission. For instance, WSW should be counseled about the use of barrier devices such as dental dams and female condoms; hygienic practices for the use of sex toys, including anything used for vaginal penetration; signs and symptoms of STIs and BV; and avoiding contact with a sexual partner’s menstrual blood or genital lesions.6
Healthcare providers should consider whether BV should be classified as an STI, which carries an inherent stigma, when discussing 22 September 2019 A Supplement to Women’s Healthcare NPWomensHealtHcare.com the condition with WSW. More important is for HCPs to discuss what is known and not known about transmission of BV between female sexual partners, along with risks and benefits of specific treatment regimens. BV has an adverse impact on quality of life and a potentially adverse sequelae. Although no current studies of partner treatment in WSW are available, it seems reasonable to offer treatment to asymptomatic female sexual partners who test positive for BV, especially in cases of recurrent BV. One day, guidelines will evolve to enable better understanding of BV in WSW so that best practices can be implemented.
1. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.
2. Verstraelen H, Verhelst R, Vaneechoutte M, Temmerman M. The epidemiology of bacterial vaginosis in relation to sexual behaviour. BMC Infect Dis. 2010;10:81.
3. Koumans EH, Sternberg M, Bruce C, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis. 2007;34(11):864-869.
4. Fethers KA, Fairley CK, Hocking JS, et al. Sexual risk factors and bacterial vaginosis: a systematic review and meta-analysis. Clin Infect Dis. 2008;47(11):9-12.
5. Evans AL, Scally AJ, Wellard SJ, Wilson JD. Prevalence of bacterial vaginosis in lesbians and heterosexual women in a community setting. Sex Transm Infect. 2007;83(6):470-475.
6. Takemoto MLS, Menezes MO, Polido CBA, et al. Prevalence of sexually transmitted infections and bacterial vaginosis among lesbian women: systematic review and recommendations to improve care. Cad Saude Publica. 2019;35(3):e00118118.
7. Bradshaw CS, Morton AN, Hocking J, et al. High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence. J Infect Dis. 2006;193(11):1478-1486.
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9. Copen CE, Chandra A, FeboVazquez I. Sexual behavior, sexual attraction, and sexual orientation among adults aged 18-44 in the United States: data from the 2011-2013 National Survey of Family Growth. National Health Statistics Reports. 2016 Division of Vital Statistics; no. 88. Hyattsville, MD. cdc.gov/nchs/data/nhsr/nhsr088.pdf
10. Muzny C. Should partners of women with bacterial vaginosis be treated? Contemp Ob/Gyn. 2018;(suppl):1-4. http://contemporaryobgyn.net/sites/default/files/legacy/mm/digital/media/Contemporary%20OBGYN%20Lupin_FINAL_pages.pdf
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14. Berger BJ, Kolton S, Zenilman JM, et al. Bacterial vaginosis in lesbians: a sexually transmitted disease. Clin Infect Dis. 1995;21(6):1402-1405.
15. Vodstrcil LA, Walker SM, Hocking JS, et al. Incident bacterial vaginosis (BV) in women who have sex with women is associated
with behaviors that suggest sexual transmission of BV. Clin Infect Dis. 2015;60(7):1042-1053.
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R, et al. Characterization of the vaginal microbiota among sexual risk behavior groups of women with bacterial vaginosis. PLoS One. 2013;8(11):e80254.
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19. American College of Obstetricians and Gynecologists. Health care for lesbians and bisexual women. ACOG Practice Bulletin No. 525. May 2012; reaffirmed 2016.
20. Wilson J. Managing recurrent bacterial vaginosis. Sex Trans Infect. 2004;80(1):8-11.