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abstract & commentary
Synopsis: There is no evidence to suggest that treatment of women with asymptomatic bacterial vaginosis is warranted in the nonobstetrical practice of medicine.
Source: Schwebke J. Am J Obstet Gynecol 2000;183: 1434-1439.
Bacterial vaginosis is probably responsible for more cases of vaginal discharge in the United States than any other condition. Clinical criteria (Amsel) and laboratory criteria (Nugent) are commonly used to make the diagnosis. However, among women without symptoms there is a relatively high prevalence of Amsel and/or Nugent positive cases of bacterial vaginosis. It is not clear whether women who have a clinical or laboratory diagnosis of bacterial vaginosis, but who do not have symptoms, should be treated.
The purpose of this study was to determine the extent to which women who fulfill the criteria for the diagnosis of bacterial vaginosis, but remain asymptomatic, represent individuals with "poor symptom recognition."
The source of participants for this study was a sexually transmitted disease (STD) clinic in Alabama. To be eligible for entry a woman must have no symptoms of vaginal discharge or odor, but the clinical criteria for the diagnosis of bacterial vaginosis were met. Women who agreed to participate were given a standardized questionnaire, were told that they had bacterial vaginosis, and were randomized to receive either a placebo or vaginal metronidazole gel. The women were examined at two and four weeks following entry into the study. Exclusion criteria included symptomatic women, women with an STD, and women who had been treated with antibiotics in the recent past.
Seventy-five women were originally enrolled in the study, but 15 were dropped because of the diagnosis of an STD. A few losses to follow-up occurred. Fifty-four women completed all study visits.
At the end of one week of treatment, nine of 26 women who received active drug had normal clinical findings compared to one of 28 women who received the placebo. Three of the nine women who had successful treatment relapsed by the time of the second follow-up visit. Interestingly, the number of women who remained free of symptoms or who reported improvement of symptoms in retrospect was equal in the two groups.
Schwebke suggests that the clinical diagnosis of bacterial vaginosis represents a continuum rather than a specific disease, and that asymptomatic women should probably not be treated.
Comment by Kenneth L. Noller, MD
It has been interesting to watch the evolution of the disease we now call "bacterial vaginosis" over the past 30 years. When I was a medical student and resident such cases were called "nonspecific vaginitis." Of course, we all remember the years this problem was known as Gardnerella vaginitis or hemophilus vaginitis. While the clinical criteria of Amsel have helped to standardize the way the diagnosis is made, we are not closer to understanding the disease than we were a generation ago.
It is clear that women who meet the clinical criteria for bacterial vaginosis have a decrease in lactobacilli and a relative increase in gram-negative organisms, probably along with many other changes. The concept that bacterial vaginosis represents a continuum is quite appealing. There are many women who meet some or all of the clinical criteria for the diagnosis, but who have absolutely no symptoms. Contrarily, there are many women who have a perfuse, malodorous vaginal discharge which certainly represents the extreme far end of the spectrum. For clinicians, the quandary is who and when to treat.
It has always been my philosophy that only women who have a symptomatic vaginal discharge should be treated. (This opinion might need to change if the patient is pregnant and the data suggesting an association between preterm labor and bacterial vaginosis holds up.) In general, I do not like giving medication to asymptomatic women, and when treating bacterial vaginosis it is well known that the relapse rate is extremely high. Thus, it has never seemed to make good sense to treat asymptomatic patients routinely.
Schwebke seems to have a similar philosophy to mine. The purpose of this study, though, was to determine whether women who were treated might "think back" and decide that, "in retrospect I guess I did have a bad discharge and/or odor." The results of this study found no such association. That is, treatment did not cause women to suddenly decide they were now better. I like this study. But, maybe that is because it reinforces my personal bias.