Bacterial Vaginosis (BV) is a condition that affects one in four people with a vagina globally. While some experience no symptoms, others may find they have unusual, odorous discharge or vaginal itching, and it is associated with an increased chance of miscarriage and premature birth.
Until recently, BV was considered a condition that developed as the result of an imbalance in vaginal flora. However, in one of the most significant breakthroughs in decades, it is now considered to be sexually transmissible – making male-partner treatment a vital consideration. The research has already led to an update to the Australian STI Management Guidelines for use in Primary Care, which now outlines how and when to treat partners of people with BV.
The groundbreaking study was led by Professor Catriona Bradshaw and Dr Lenka Vodstrcil at the Melbourne Sexual Health Centre, who found treating both the male and female in a closed heterosexual relationship for BV significantly reduced the rates of BV reoccurring.
During the study, only 34.7 per cent of women in the group where both partners were treated for BV experienced BV return, compared to 63.2 per cent of women in the group where only the woman was treated.
Speaking to ASHM, Professor Bradshaw says that for decades, treatment strategies were only directed to women.
“Women have been exposed to often repeated courses of antibiotics directed at them and still have high rates of recurrence. What we’ve shown is that sexual transmission of BV bacteria is responsible for a very significant proportion of what we call BV recurrence.
“By treating men, we have shown that we can greatly improve BV cure for women, and this is the first treatment strategy that really has made very significant inroads into improving BV cure for women,” she says.
The study was not the first to attempt to link partner treatment to a reduction in BV recurrence, but it was the first to successfully demonstrate it. As to why other studies were unsuccessful, Professor Bradshaw says there were a number of reasons.
“When we looked at the other studies, there have been eight other studies, seven of the studies have only used oral therapies in men, and we believed that you needed to use a combination of oral and topical antimicrobials.
“We felt the oral agent didn’t really, or wouldn’t be likely to, achieve good clearance of BV bacteria just sitting on the skin and under the foreskin, and that would need a topical agent,” says Professor Bradshaw.
She explains that a previous study that did use a topical agent to clear BV bacteria on the skin used an alcohol-based wash, which was unsuccessful and likely quite inflammatory.
Additionally, other studies in the field did not feature robust enough interventions for male treatment, were not well-equipped to adequately measure adherence, or were methodologically flawed in another way.
“The conclusion was that really, it wasn’t that male partner treatment didn’t work, it was the fact that these studies weren’t well designed and able to address that research question,” explains Professor Bradshaw.
“This was the first study to use a combination of an oral and a topical antibiotic that really were relevant to the types of bacteria that you see in BV.”
She explains that her study also significantly emphasised to participants the importance of maintaining a closed, or monogamous, relationship for the duration of the study.
“We put huge amounts of effort into explaining to couples why we only wanted couples who were in closed relationships in this trial, and what happens when there are other concurrent partners who are untreated, which will erode the intervention,” she says.
“You have to have monogamy from the point of the intervention to the point of measuring the outcome, and you need the outcome not just to be two weeks down the track or three weeks, but three months.”
As a result of the study, the STI Guidelines now recommend concurrent partner treatment for male-female couples in ongoing relationships be implemented when a woman presents with BV.
“When a woman has an ongoing male partner, you have a very key opportunity to prevent women entering a cycle of highly recurrent entrenched BV. So consider male partner treatment early for women that have an ongoing male partner,” says Professor Bradshaw.
Explaining it to patients and getting males on board is easier than one might think, she states.
“I think the misconceptions are really around it’s just too hard: men won’t do it, I can’t do it, I don’t know how to do. We’ve got all the resources.”
“You can see men face to face. You can do telehealth with men, you don’t need to actually have that appointment [in person]. It’s very amenable to a telehealth appointment as well, so there’s lots of different models that you can do this.”
Professor Bradshaw says that when she sees a woman in clinic presenting with BV with an ongoing male partner, she texts her the link to the BV in Focus website and tells the woman to look at the pages detailing what partner treatment involves and how to have the conversation with a partner. Then she suggests the couple sit down and chat about it when they’re next together. She says the result is often that male partners come into their appointment equipped with information, and ready to share the responsibility of treatment.
“In our qualitative studies, women felt incredibly isolated, bore the burden of BV, and were trapped in this cycle of recurrent BV with the emotional and financial responsibility of repeatedly attending healthcare professionals, and that [partner treatment] broke that cycle for men and women.”
“It became a shared responsibility, and they universally reported that the inconvenience of a week of antibiotics was nothing compared to the inconvenience of the repeated cycles of recurrent BV.”
Per the guidelines, partner treatment for BV is ideally completed simultaneously. But if that’s not possible or the woman is not in an ongoing relationship, it’s crucial healthcare practitioners consider BV like any other sexually transmissible infection (STI) and emphasise the importance of abstaining from sex during treatment or using barrier methods.
“Make sure treatment is synchronous, or at least women don’t have unprotected sex before their male partner is treated. So do consider it like you would an STI, you have to time treatment and consider reinfection.” says Professor Bradshaw.
“Individuals need to use condoms with partners, it’s an important part of it because for women who don’t have an ongoing partner, condoms prevent acquiring BV or at least substantially reduce that risk of acquiring it,” she explains.
Reframing BV as an STI is also important in discussions with patients.
“It’s important to say that BV itself is sexually transmissible and that the bacteria can be exchanged during sex.”
“The way I approach it with patients is this: I say, ‘When you have close contact with someone, you exchange good and bad bugs. That can be shaking hands, sharing a drink, kissing, and obviously sex. You’ve got good bugs going in both directions, bad bugs going in both directions, and BV is a consequence of some of the bad bugs being exchanged.’”
Professor Bradshaw asserts that partner treatment does not prevent all cases of BV recurring, but that these findings, and the resulting updates in the Australian guidelines, mark a significant moment in women’s health and a big step forward for the future research and understanding of BV.
