This site is intended for health professionals only

Bacterial vaginosis: how can nurses help?

Kathy French
RN BSc(Hons) PhD MPhil PGDip Cert Ed
Clinical Director, Brook
Nurse Advisor to the London Sexual Health Programme 

Bacterial vaginosis can recur despite treatment, and the primary care nurse can be a valuable source of information and support for women suffering from this common but distressing condition

Bacterial vaginosis (BV) is associated with an increased risk of sexually transmitted infections (STIs), HIV, post-abortion infection and adverse pregnancy outcomes. It is estimated that the prevalence rate varies from 5% in a group of asymptomatic college students to 12% of pregnant women attending antenatal clinics and of 30% of women undergoing termination of pregnancy in the UK.1

[[Box 1,2 BV]]

BV is a fairly common vaginal infection characterised by the over-production of anaerobic organisms in the vagina and a reduction of the normal lactobacillus. The overgrowth of the vaginal anaerobes increases the pH from less than 4.5 to as high as 7.0, making the pH more alkaline. Some authors, however, have described this as a deficiency of lactobacilli rather than an increase of anaerobes. This is a possibility, as less is known about the subspecies of lactobacillus which thrive in the vagina.2

Women with BV find it a disturbing condition because they feel unclean, are aware of the fishy odour, assume others can smell them and because it often reoccurs despite treatment. However, a woman may have one episode and that is the end of it.

There is much debate as to whether BV is classified as an STI, but it does sometimes occur in adolescent girls who have not been sexually active. Therefore, with the current evidence it is important for nurses to reassure women that they do not have an STI.

BV tends to occur around the time of menstruation when oestrogen levels may be low and the pH higher. This is an important factor when taking a history from a woman complaining about discharge as it could help in the diagnosis.
As mentioned earlier, some women may have a one-off episode that will spontaneously resolve itself; however, BV is a very important public health matter because of its association with the risk of STIs and HIV infection, and with adverse pregnancy outcomes. Additionally, women with recurrent BV suffer considerable distress during the symptomatic phase.  

BV can be detected on routine cervical screening and the nurse needs to explain the condition to women with a positive BV result on a cervical smear, otherwise they may think they have cervical cancer if recalled after the test. This discussion could take place before the smear. For example, women could be told that occasionally minor infections are picked up at the same time and if we ask you to return to speak to the nurse/doctor do not assume you have a serious condition. It is likely that women with BV are aware of their condition but find it difficult to discuss with a health professional. 

Risk factors
The prevalence of BV is much higher in sexually active women than non-sexually active women, black women and women who smoke cigarettes. The literature cites vaginal douching as a possible cause for BV, but the evidence is not conclusive because some women may douche to relieve the constant itching and discharge, and to remove odour.

Investigations
The clinician may be confident enough about the odour and appearance of the discharge to make a diagnosis, but vaginal swabs should be taken to exclude other conditions; for example, chlamydia, gonorrhoea or candida. If BV is present clue cells will appear on the microscopy of wet mount. The pH can be tested in clinic. New swabs are now entering the market that offer results within seconds and can aid in the diagnosis of BV. While these are not widely used yet, they could have application for services who screen women before an abortion, or for woman with a history of pre-term delivery. 

Treatment
Treatment is indicated for:

  • Symptomatic women.
  • Women undergoing some surgical procedures.
  • Women who do not report symptoms may elect to take the treatment and notice beneficial change afterwards.

Caution
Women should be advised to avoid alcohol when taking metronizadole. Cindamycin cream can weaken condoms and should not be used during treatment. No test for cure is needed following treatment for BV.

Vaginal douching
It is important that nurses advise women to avoid douching with soap, shampoo or other vaginal preparations. Frequently, women admit to douching with Dettol and this should be discouraged as these agents can damage the naturally occurring flora in the vagina.

Complications
The prevalence of BV is high in women with pelvic inflammatory disease (PID) and is associated with late miscarriage, pre-term birth and post-abortion endometritis.3 There are no studies linking BV with PID after the insertion of
an intra-uterine device (IUD).

Women seeking abortion should be screened and offered prophylaxis to reduce the risk of post-abortion PID. Three studies investigated whether antibiotics can reduce the risk of infection in women with BV after an abortion and a
Scandinavian study of 231 women demonstrated a reduction in infection rates when oral metronidazole was given before abortion. Additionally, a UK study also found that treating asymptomatic women with BV resulted in a five-fold reduction in late miscarriage and a two-and-a-half-fold reduction in spontaneous pre-term birth.4

[[Table 1 BV]]

In terms of pregnancy, the value of screening for and treating BV in pregnancy have been conflicting but nurses and midwives should seek the opinion of a clinician in the sexual health service if they suspect a woman has BV. 
Metronidazole can enter breast milk and affect the taste; therefore, it is recommended to avoid high doses when breastfeeding and an intra-vaginal treatment is recommended for lactating women.1

Ongoing research
Further research is needed to investigate the possibility of agents other than long-term antibiotics to reduce the recurrence of BV. Some women, once diagnosed, find over-the-counter products, for example, Balance Activ® or Relactagel®, helpful in reducing the recurrence. There is much to learn about the influence of the cyclical changes during the menstrual cycle and the impact those changes have on the lactoballi. Probiotics are now an area of interest for researchers.

Conclusion
BV is a miserable condition for women as well as a public health issue with adverse outcomes. Nurses can help women recognise the condition, reduce the stigma, encourage investigations, assist in the diagnosis and advise on treatment, thereby reducing distress for women.

References

  1. British Association for Sexual Health and HIV (BASHH). National Guidelines for the Management of Bacterial Vaginosis. London: BASHH: 2006.
  2. Hay P. Recurrent bacterial vaginosis. Curr Opin Infect Dis 2009;22:82-6. 
  3. Goldenburg RL, Hauth JC, Andrews WW. Intrauterine infection and preterm delivery. N Engl J Med 2000:342(20):1500-7.
  4. Ugwumadu A, Manyonda I, Reid F, Hay P. Effects of early oral clindamycin on late miscarriage and preterm delivery in asymptomatic women with abnormal vaginal flora and bacterial vaginosis: a randomised controlled treatment for bacterial vagonosis. Lancet 2003 361(9362):983-8

Resource
British Association for Sexual Health and HIV (BASHH)
W: www.bashh.org.uk

Your comments (terms and conditions apply):

"It does not look like it is the norm to have asexual haelth history before a cervical smear test taking from experience" - Sarah Tawonezvi