Bacterial vaginosis: a narrative review of concepts and best practices

Bacterial vaginosis (BV) is a multifaceted condition characterized by an imbalance of the vaginal microbiota. This disruption includes not only Gardnerella vaginalis but also a range of anaerobic bacteria, with clinical outcomes varying according to the specific bacterial composition. This review aims to provide an updated overview of the concepts, diagnosis, and management of BV.

We conducted a search on MEDLINE (Medical Literature Analysis and Retrieval System Online), Google Scholar, and Scopus for publications in English, prior to September 2025, using the keywords [vaginal microbiota] OR [vaginal microbiome] OR [vaginosis] OR [bacterial vaginosis] OR [dysbiosis] AND [vagina] AND [diagnosis] AND [treatment]. We also reviewed the references of the articles obtained through our literature searches.

BV is characterized by a shift from aerobic to anaerobic microbiota. Anaerobic bacteria and their metabolites can significantly impact the local immune response, resulting in various complications in women's reproductive health. Although most affected individuals remain asymptomatic, dysbiosis may negatively influence pregnancy outcomes and elevate the risk of sexually transmitted infections. Diagnosis is traditionally based on the Amsel criteria and Nugent Score. More recently, nucleic acid amplification tests, particularly those utilizing multiplex platforms, have been implemented to identify bacterial species such as Gardnerella, Fannyhessea, and Sneathia. Bacterial composition and the presence of biofilm are critical factors influencing treatment outcomes. Alternatives to conventional antibiotic therapy, including biofilm-disrupting agents and probiotics, are essential for addressing persistent and recurrent BV.

BV has long been recognized, and diagnosis has traditionally been based on Amsel's criteria and Nugent's score. While new diagnostic tools have offered valuable insights, they have also introduced new questions about this complex condition. Metronidazole remains the primary treatment, although adjuvant therapies, such as biofilm disruption and probiotics, are often required. Further large-scale, in-depth studies are needed to address ongoing uncertainties.