to the editor: The Information from Your Family Doctor handout regarding bacterial vaginosis1 in the May 1 issue states: “Some women have bacterial vaginosis without any symptoms.” It then poses the question, “Do I have to be treated?,” which is answered with an unqualified “Yes.”
Certainly there are indications to treat asymptomatic bacterial vaginosis: treatment is recommended in pregnant women at high risk for preterm delivery and women undergoing surgical procedures such as abortion and hysterectomy,2 for example; and, by extension, there are instances in which treatment is reasonable, such as prior to transvaginal procedures (e.g., intrauterine device insertion, endometrial biopsy).
However, except in the above circumstances, I am aware of no solid evidence-based recommendation for the treatment of asymptomatic women with bacterial vaginosis; treatment of asymptomatic bacterial vaginosis even in low-risk pregnant women remains controversial.2 Guidelines from the Centers for Disease Control and Prevention state that the “established benefits of therapy for [bacterial vaginosis] in non-pregnant women are to relieve vaginal symptoms and signs of infection and reduce the risk for infectious complications after abortion or hysterectomy.”2 Additionally, the natural history of bacterial vaginosis is such that it may resolve (and recur) spontaneously.3
It is hard to make an asymptomatic patient feel better; we should demand evidence before assuming that the benefits of diagnosis and therapy outweigh their burdens.
in reply:We would like to thank Dr. Fox for calling our attention to this patient education handout. We agree that no evidence has shown that treating asymptomatic bacterial vaginosis improves patient outcomes. Accordingly, the handout did not advocate testing and treatment of asymptomatic women. Rather, its unqualified recommendation to treat was directed to women who present with symptoms that may be relieved by treatment. This patient education handout has been updated on our Web site (https://www.aafp.org/afp/20040501/2193ph.html).