Advances in treating bacterial vaginosis: recognizing sexual transmission and pipeline of therapies

Bacterial vaginosis (BV) is a common vaginal dysbiosis linked to increased risk of HIV, other sexually transmitted infections (STIs), and adverse obstetric outcomes. Standard antibiotic therapy often induces symptom remission, but recurrence rates exceed 50% within 6 months. The purpose of this review is to discuss recent clinical trials that demonstrate improved outcomes when compared to treatment according to current management guidelines and outline potential future therapies.

Strong evidence supporting transmission of bacteria associated with the dysbiotic state of BV between sexual partners has accumulated over time. A recent clinical study (StepUp) demonstrated overwhelming evidence that treating male partners with combined oral and topical antibiotics significantly reduces BV recurrence in their female partners, highlighting the role of sexual transmission. Recent guideline updates reflect these advances: the American College of Obstetricians and Gynecologists now advises partner therapy for recurrent BV, signaling a shift toward partner-inclusive management strategies. In parallel, live biotherapeutic products (LBPs) and vaginal microbiota transplantation (VMT) show promise in restoring a stable, Lactobacillus crispatus-dominant microbiome. Novel approaches targeting metabolic vulnerabilities of BV-associated bacteria and L. iners, and nonantibiotic agents like metastable iron sulfides are in early development.

Several advances in managing recurrent BV have shown promise in improving care of this condition. They represent a shift toward microbiome-informed, durable, and woman-controlled therapies. Strategies combining these along with continued development of promising novel approaches to treatment will be needed to optimize care of patients and reduce global BV burden.