BV

Question 1

what is the commonest cause of abnormal vaginal discharge in women of childbearing age:

1. Chlamydia
2. Gonorrhoea
3. TV
4. BV
5. Mycoplasma Genitalium

Answer 1

Answer: 4 - BV

Question 2

What is the name of the dominant bacteria in the healthy vagina?

Answer 2

Lactobacilli

Question 3

what is the normal pH of the vagina

a) - <4.5
b) 4.5-6.0
c) 6.0-8.0
d) 7.0

Answer 3

a) < 4.5 pH

Question 4

what happens to the pH in BV?

Answer 4

it increases to above 4.5; usually between 4.5-6.0 in BV

Question 5

What bacteria predominant the vaginal flora in BV?

1. Lactobacilli
2. Mycoplasma genitalium
3. Mycoplasma hominis
4. Gardnerella vaginalis
5. Atopobium
6. Mobiluncus spp
7. Prevotella spp

Answer 5

Gardnerella vaginalis or atopobium are in abundance in the vaginal flora in BV
but mycoplasma hominis, mobiluncus and prevotella are also anaerobic bacteria that can be found in women who have BV

Question 6

Describe the pathophysiology of BV

Answer 6

BV results due to an imbalance in the bacteria that are normally present in the vagina flora. The imbalance is caused due to a rise in the pH above 4.5 which leads to a depletion in the ‘healthy’ bacteria - the lactobacilli and an overgrowth of anaerobic bacteria specifically garnderella and atopobium.

BV is not a sexually transmitted infection.

Question 7

What symptoms might a woman with BV present with?

Answer 7

change in their vaginal discharge - white colour,
a/s with an offensive odour
not normally a/s with itch or vaginal irritation
can re-occur

up to 50% of women may be assymptomatic

Question 8

what are the three diagnostic criteria that can be used to diagnose BV

Answer 8

Amsel criteria and Hay/Iyson criteria

Nugent criteria

Question 9

List the risk factors for developing BV

Answer 9

1. vaginal douching - washing with soaps/showergels/ perfumed products
2. smoking
3. recent change in sexual partner
4. presence of an STI e.g, CT/HSV
5. receptive cunnilingus (receptive oral sex)
6. black race

Question 10

what are the four criteria that make up the Amsel criteria; how many need to be fulfilled to diagnose BV?

Answer 10

(1) Thin, white, homogeneous discharge
(2) Clue cells on microscopy of wet mount
(3) pH of vaginal fluid >4.5
(4) Release of a fishy odour on adding alkali (10% KOH)

need a minimum of 3 out of 4 of the criteria to diagnose BV

Question 11

Describe the Hay/Iyson staging for diagnosing BV

Answer 11

Three grades
grade 1, 2 and 3

Grade 1 (normal flora) : no evidence of BV - abundance of lactobacilli; normal flora

Grade 2 (Intermediate) : lactobacilli reduced in number but still present with the addition of anaerobic bacteria e.g, gardneralla

Grade 3 (BV) : no lactobacilli present, anaerobic bacteria predominate

Question 12

what is the first line treatment for BV?

Answer 12

Metronidazole 2grams stat
or

Metronidazole 400mg BD for 5-7 days

or

Intravaginal metronidazole gel (0.75%) once daily for 5 days (A)

or

Intravaginal clindamycin cream (2%) once daily for 7 days (A)

Question 13

for first line treatment options for BV what is the % of women that are cured based on the RCT evidence

Answer 13

achieves up to 70-80% cure rate after 4 weeks

Question 14

what are alternative treatment options if metronidazole or clindamycin is not suitable for the treatment of BV?

Answer 14

Tinidazole 2 grams stat PO, or clindamycin 300mg BD for 7 days

Question 15

Do women need to avoid alcohol with topical metronidazole?

Answer 15

Yes - for the duration of treatment and for 48 hours after completion

Question 16

Do women need a TOC following treatment for BV?

Answer 16

NO - it isn’t an STI as long as symptoms resolve; if they don’t advise them to return for repeat testing and repeat Rx

Question 17

For women that have recurrent BV how would you manage their symptoms?

Answer 17

The evidence for management of recurrent BV isn’t very strong. No good RCTs that have compared different treatment modalities. Options are:
1. metronidazole 0.75% gel pessaries use twice weekly for a period of 3-4 months, evidence shows on stopping treatment women can go on to develop recurrences again - also this can cause vulvo-vaginal thrush

or

2. Probiotic pessaries, used on day 1-7 and 15-21 again for a period of 3-4 months, symptoms can recur on stopping treatment

advise on avoiding soap products/ vaginal douching, use a soap substitute

Question 18

What is the guidance on treating asymptomatic pregnant women who are found to have BV incidentally?

Answer 18

Insufficient evidence to suggest treatment of BV in asymptomatic pregnant women
there is a very small risk that BV could cause pre-term

Question 19

how would you manage a postnatal female with BV who is currently BF

Answer 19

Avoid high doses of metronidazole; metronidazole can enter the breast milk and alter the taste as can oral clindamycin
guidelines recommend intra-vaginal Rx e..g metronidazole 0.75% pessary od for 5 days or clindamycin 2% cream for 7 days

Question 20

when treating BV what are the general principles you should advise a patient

Answer 20

avoid washing with soaps and vaginal douching, use a soap substitute e.g. E45 cream

Question 21

What are the potential complications of acquiring BV in pregnancy?

Answer 21

late miscarriage, premature rupture membranes, preterm birth, postpartum endometritis (1B)

Question 22

describe the Nugent criteria

Answer 22

The Nugent score is derived from estimating the relative proportions of bacterial morphotypes to give a score between 0 and 10.

<4 is normal,
4-6 is intermediate,
>6 is BV.