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Will bacterial vaginosis be a problem since I have a Mirena IUD? #221/11

Hi Dr. Hatcher,


I had BV (bacterial viginosis) last month and took the 5 day course of Flagyl. Today I went back and I still have it, so have to repeat the course of antibiotics. I am worried about having a bacterial infection while using the Mirena IUD and have a lot of questions my doctor wasn't able to really answer.


However, it is in the STI (sexually transmitted infection) section on the CDC website. Can you please clarify? The doctor today said that if this course of antibiotics didn't work, we would 'just leave it.' Is that safe?

Here is extensive information on bacterial vaginosis:

21.  Reproductive Tract Infections, Including HIV and Other Sexually Transmitted Infections

Jeanne M. Marrazzo, MD, MPH

Felicia Guest, MPH, CHES

Willard Cates, Jr., MD, MPH


BACTERIAL VAGINOSIS (BV) is a clinical syndrome

BACTERIAL VAGINOSIS (BV) is a clinical syndrome in which several species of vaginal bacteria (including Gardnerella vaginalis, Mycoplasma hominis, and various anaerobes) replace the normal H2O2-producing lactobacillus species and cause vulvovaginitis symptoms. Bacterial vaginosis is a sexually associated condition, but it is not usually considered a specific STI; however, it does occur frequently in lesbians and may represent an STI in this group. Treatment of the male partner has not been found to be effective in preventing the recurrence of BV. Because of the increased risk for postoperative infectious complications associated with BV, screening prior to pelvic surgery is recommended (for example, hysterectomy); some specialists recommend that before performing surgical abortion, providers screen and treat women with BV in addition to providing routine prophylaxis.

Symptoms. Excessive or malodorous discharge is a common finding. Other signs or symptoms include erythema, edema, and pruritis of the external genitalia.

Diagnosis. The presumptive clinical criteria are three of the following four: increased amounts of homogenous discharge; elevated vaginal pH (greater than 4.5); fishy odor on addition of 10% KOH; and identification of clue cells (small coccobacillary organisms associated with epithelial cells) on saline wet mount (>20% of vaginal epithelial cells). Alternatively, a Gram stain of the vaginal discharge can reveal the relative absence of lactobacilli with replace­ment of other anaerobic organisms. Cultures for G. vaginalis, M. hominis, or Mobiluncus are not useful and should not be performed.

Treatment. Patients with symptomatic disease should be offered treatment. The three recommended regimens are metronidazole, 500 mg orally twice daily for 7 days; OR clindamycin cream, 2%, one full applicator (5 g) vaginally at bed time for 7 days; OR metronidazole gel, 0.75%, one full applicator (5 g) vaginally at bed time for 5 days. Two alternatives are oral clindamycin 300 mg two times a day for 7 days; clindamycin ovules 100 mg vaginally at bedtime for 3 days; or single-dose sustained-release clindamycin cream, 2%, one full applicator (5 g) vaginally at bed time. During the second and third trimester of pregnancy, oral metronidazole 500 mg three times a day for 7 days is the preferred treatment. Pregnant women who are at low risk for preterm delivery can be treated with metronidazole gel, 0.75%, one full applicator (5 g) vaginally at bedtime for 5 days.

Potential complications. Secondary excoriation may occur. Recurrent infections are common. Bacterial vaginosis is associated with an increased risk of PID, and may also cause cervicitis. Bacterial vaginosis is associated with an increased risk of adverse pregnancy outcomes, including preterm delivery and low birthweight.

Behavioral messages to emphasize. Understand how to take or use any prescribed medications. Return if the problem is not cured or recurs. Avoid drinking alcohol until 24 hours after completing metronidazole therapy.


Two further notes on February 28, 2011:

An alternative regimen: Tinidazole 2 g qd x 2 or 1 g qd x 5

Management of  recurrences: While there is insufficient evidence recommend partner treatment and this was in both the current and the last CDC Rx guidelines, certainly experienced clinicians, including clinicians who have worked on the CDC guidelines, have done this


I will ask one of the above authors of the chapter quoted above if she thinks re-treatment would be advisable for you.


Apparently partner treatment is not beneficial


To learn more about the advantages and disadvantages of the Mirena IUD or any of the available contraceptives, go to our website: www.managingcontraception.com and click on Choices.  You can also order this wonderful new educational book from our website or by calling 404-875-5001.  Do you have your copy yet?       


Key Words:  bacterial vaginosis, Flagy, treatment, antibiotics. Bacterial infection, Mirena IUD, STI, CDC, safe, reproductive tract infections, HIV, sexually transmitted infections, Dr. Jeanne M. Marrazzo, Dr. Felicia Guest, Dr. Willard Cates Jr., symptoms, diagnosis, complications



Marrazzo JM, Guest F, Cates W Jr. Reproductive tract infections, including HIV and other sexually transmitted infections IN Hatcher RA, Trussell J, Nelson AL. et al Contraceptive Technology 19th edition, pages 533 and 534: Ardent Media Inc. 2008

Posted 7-7-2022, Updated 7-8-2011


Robert A. Hatcher MD, MPH
Emeritus Professor of Gynecology and Obstetrics
Emory University School of Medicine
Atlanta, GA

The directors and owners of this website and any publications and information concerning health matters offered here advise a person with a particular problem to consult a primary-care clinician or a specialist in obstetrics, gynecology, or urology (depending on the problem or the contraceptive) as well as the product package insert and other references before diagnosing, managing, or treating the problem.
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