Bacterial vaginosis: many questions--any answers?

Bacterial vaginosis, a common disorder among young women, is associated with adverse reproductive health outcomes. This review summarizes our current understanding of bacterial vaginosis and where future research should be focused. Recommendations for prevention, diagnosis, and treatment in both nonpregnant and pregnant populations are discussed.

Little progress has been made in understanding the causal factors. The results of several large prospective studies have shown that racial differences persist for rates of bacterial vaginosis even when other known risk factors are controlled for. Studies of the gene-environment interaction that examine the genetic aspects of immune response may explain racial differences and why some but not all women with bacterial vaginosis experience complications. Trials to prevent preterm birth by the treatment of bacterial vaginosis in pregnancy are disappointing. Resistance to clindamycin by bacterial vaginosis-associated anaerobic organisms has also been documented. New technology to provide rapid point-of-care diagnostic testing for bacterial vaginosis has emerged.

To understand the vaginal ecosystem and its role in reproductive health and disease, we will need to study not only the microflora but also the host-immune response. Currently recommended treatment options for bacterial vaginosis are associated with high rates of recurrence. A new concern is the development of macrolide resistance to vaginal anaerobic flora when clindamycin is used as treatment. Further studies are still needed to determine whether prevention or control of bacterial vaginosis, particularly approaches that rely not on antibiotic treatment but on the maintenance of a healthy vaginal ecosystem, can reduce adverse health outcomes.