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    Recurrent vulvovaginitis: Tips for treating a common condition

     

    Suppressive therapy has been shown to keep women in an asymptomatic state. This is typically done with monthly metronidazole. It is important to also counsel patients regarding lifestyle changes. Eliminating contact irritants such as douching and other irritating products will allow the vaginal ecosystem time to heal. The use of suppressive therapies seems to work while the medications are being used, but may not affect the rate of recurrence once stopped. Acidification of the vagina has not been shown to reduce recurrence rates and in fact, may worsen symptoms of irritation.9

    The addition of probiotics is currently being evaluated as a way to keep the vaginal flora balanced and is a promising method of preventing the recurrence of BV. Using exogenous human bacteria to restore a normal flora seems to be a reasonable way to decrease BV, especially when used in conjunction with standard therapy.13 Probiotics have not been shown to definitively help decrease recurrence rates, but many studies show promise. The optimal route of administration, oral or vaginal, the appropriate strain, and correct dosing are all areas that would benefit from further study.12

    Another treatment option involves the addition of boric acid to an oral nitroimidazole.14 Early studies have been promising, but more rigorous studies are needed.

    While treatment of the partners of affected women has not been shown to help, sexual intercourse does appear to have a role in the disease process. It is not that BV is clearly a STI, but sexual risk factors certainly contribute to its transmission.15 There is evidence to support the use of condoms to decrease risk of recurrence. Risk of concordant infection is high in women who have sex with women and partners should be counseled about symptoms and seeking treatment when they occur.8

    Currently, there is an unacceptably high rate of recurrence for BV. Some behavioral changes can decrease this risk, but other therapies are necessary to improve both the quality of life of those affected and decrease future health risk associated with the disease.

     

    Merida Miller, MD
    Dr. Miller is Associate Professor of Obstetrics and Gynecology, University of Iowa, Iowa City.

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    • Dr. Neil S. Gladstone
      I appreciated Dr. Miller's discussion of a common and vexing problems for both patients and clinicians. For 45 years, I have seen more unhappy patients with BV than any other condition including malignancies. At least with cancer, there is hope of a cure. With BV it never goes away. The two most important tools for the clinician in diagnosis BV are pH paper and a microscope. After the history, which is predictable, and after my vaginal exam. I do a pH on the discharge taken from the upper aspects of the vagina. The pH helps to direct what comes next. If the pH is in the acidic range the differential diagnosis is either Candida (yeast) or leucorrhea. If the patient presents with a history suggestive of yeast and she has a "Typical" cottage cheese discharge, and we are not dealing with multiple recurrences, I elect to treat with either topical or oral agents. For problem cases I will use a NAAT testing procedure. If the pH is in the alkaline range, I do a wet smear. If there is no evidence of Trichomands and with presence of Clue Cells, I make the diagnosis of BV. My treatment is two fold: I take the time needed to explain to the patient what are the triggers for BV, that the bacteria that cause the BV symptoms are residents of the vagina and can not be totally eliminated, and the change in pH temporarily eliminates the beneficial action of Lactobacillus. In this environment it is the anaerobes that were listed in the article that predominate. I encourage all patients to use condoms at all times and to use tampons to get rid of menstrual blood as quickly as possible. Instead of continually prescribing Metronidazole or Clindamycin orally, I use Boric acid vaginal suppositories 600 mg for at least one week. Patients do not like the topical antibiotics as the perception these measures do not work. They are unhappy because the oral antibiotics do not work because the "infection" keeps reoccurring, I never reference BV as a STI,but I also talk about keeping the environment of the vagina healthy by keeping out the offending substances and restoring the pH. The suppositories help with Candida as well. One part of therapy most clinicians especially non OBGYNS fail to do is to use a steroid and antifungal topical combination for the skin of the vulva. This maneuver provides relief for the irritated itchy skin. Each patient gets a written information about BV and I always offer to discuss the diagnosis with reluctant partners. This approach is not the panacea for BV , but I think it is more successful than the manner most people treat BV.This is anecdotal information, but I think it would merit someone with the time and patients to do a RCT. Also, I am very liberal in ordering STI panels including the use of NAAT panels. Neil S Gladstone, MD, FACOG,CCD

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