Bacterial vaginosis (BV) is the most common cause of abnormal vaginal discharge in women of reproductive age, with a prevalence in North America of 29.2% among women ages 14 to 49.1-3 BV is a condition in which the normal vaginal flora are altered, primarily due to a reduction in hydrogen peroxide–producing strains of lactobacilli. This leads to an elevated vaginal pH and increased levels of proteolytic enzymes (eg, sialidase), organic acids, and volatile amines.4 This change in pH allows an overgrowth of multiple types of anaerobic, mycoplasmic, and gram-negative bacteria.
In most cases of BV, the predominant microbe is the facultative anaerobe Gardnerella vaginalis. However, evidence from recent studies of the pathogenesis of BV suggests that this bacterium forms a biofilm in the vaginal epithelium that serves as a “scaffolding” to which other bacterial species adhere in a symbiotic fashion, colonizing the vagina.5 Though asymptomatic in at least half of affected women,2,6,7 this polymicrobial condition can produce a thin, white, homogenous discharge with a distinct “fishy” odor.
The changes in the vaginal flora seen in BV are associated with serious sequelae, such as preterm delivery, spontaneous abortion, postpartum endometritis, and increased susceptibility to HIV and other sexually transmitted infections (STIs).4,8,9 The polymicrobial nature of BV and its propensity for recurrence make treatment a challenge.
PATIENT PRESENTATION/HISTORY
The most common symptom of BV is increased vaginal discharge, which usually is thin and white or dull gray.4 Some women report a strong fishy odor, especially after sex. Vaginal pain, itching, or burning may also be present, especially if the discharge is copious. Dyspareunia and dysuria are rare, but possible, symptoms. Fever, malaise, and other systemic symptoms are not associated with BV and should prompt the clinician to consider other causes. About half of women with bacterial vaginosis have no symptoms.2,6
The typical finding on physical examination is a homogeneous, off-white, creamy, malodorous discharge that adheres to the vaginal walls and pools in the vaginal vault. There are usually no or minimal signs of vaginal inflammation, and the vulva, labia, and cervix are typically normal. In some cases, BV can lead to cervicitis.6,9,10
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