Bea, a 35-year-old woman, presents at the clinic as a new patient with a complaint of bad-smelling vaginal discharge— again. She states that she just wants a cure that lasts. She tells the nurse practitioner (NP) that she has been treated countless times for BV over the past several years, with temporary relief before the odor and discharge return.
What additional information would be helpful for the NP to obtain?
Bea tells the NP that she has been treated for BV 3 times in the past year, each time with oral metronidazole for 7 days. Her symptoms resolve for a month and then recur when she has a period. The odor is worse after sex. Bea is married and in a monogamous relationship with her husband of 10 years and knows that BV is not a sexually transmitted infection (STI), but she wonders whether he should be treated. Bea admits to douching after sex sometimes to try to eliminate the odor. She is in good health overall, is of normal weight, does not smoke, and is on no medications. She has had no abnormal Pap test results and has never had an STI. Her husband had a vasectomy 3 years ago. They do not use condoms.
A pelvic exam reveals a malodorous thin gray discharge at the vaginal introitus and adhering to the vaginal walls. No erythema or lesions are noted. Vaginal pH is >5.0 and a wet prep shows clue cells, no yeast buds/hyphae, no trichomonads, and no lactobacilli. A potassium hydroxide (KOH) whiff test result is positive. A diagnosis of BV is made based on the presence of at least three Amsel’s criteria: homogeneous thin gray/white discharge, positive whiff test result with 10% KOH, vaginal pH >4.5, and clue cells on microscopy.4 A confirmatory test is not needed. Diagnosis based on identification of Gardnerella vaginalis on vaginal culture is insufficient; G. vaginalis is detected in up to 55% of healthy asymptomatic women.5 Based on Bea’s history and exam findings, the NP does not order any STI tests.
What is the recommended treatment plan?
The NP acknowledges Bea’s frustration with her recurring symptoms. The NP explains that although data on treatment for recurrent BV are not conclusive, several options have been cited in the literature based on limited studies. The NP and Bea develop a treatment plan but agree that they will consider other options as needed. The plan is to treat the current BV infection with metronidazole 500 mg orally twice daily for 7 days, followed by 0.75% metronidazole gel intravaginally twice weekly for 4 months to reduce the risk for recurrence, with cessation of vaginal douching.