Scoping review of the association between bacterial vaginosis and emotional, sexual and social health | BMC Women’s Health

We obtained a total of 1105 unique citations by searching the MEDLINE, Embase and Web of Science Core Collection databases. A total of 1069 studies were excluded based on title and/or abstract alone, leaving 36 studies for full text evaluation (Fig. 1; Additional file 1). Of these, eight were studies about vulvovaginal diseases, but did not present separate data for BV. Eleven studies did not include any information about sexual, social, or emotional health in relation to BV. One study involved the experiences of the male partners of women with BV. Sixteen studies were included, [7, 11, 16,17,18,19,20,21,22,23,24,25,26,27,28,29] of which twelve studies regarding emotional health, [7, 16,17,18,19,20,21,22, 24, 25, 27,28,29] five on sexual health [7, 11, 16, 18, 23, 27], and four involving social health [7, 11, 16, 26, 27]. Nine out of sixteen manuscripts reported on studies that were conducted in the US, four were conducted in Australia, the three remaining studies were carried out in India, Kenya, and the UK. The studies included were very heterogeneous in terms of study population, study goal and methodology.

Flowchart of the study selection

Emotional health

Of the twelve studies we included in the category ‘emotional health’, eight studies specifically addressed stress as a determinant of BV (Additional file 6). Four of these studies found a statistically significant association between stress levels and BV [20, 24, 25, 29]. Nelson and colleagues assessed the level of stress separately in women with symptomatic and asymptomatic BV [25] and reported significantly lower mean stress levels in women with asymptomatic BV compared to symptomatic BV. Because of the cross-sectional nature of these studies [19,20,21,22, 25, 28, 29] except one, [24] no meaningful inferences can be made about the direction of these associations.

Another four studies involving emotional health were reported in five manuscripts that obtained data on emotional health and BV (Table 1) [7, 16,17,18, 27]. Two studies specifically included women suffering from recurrent episodes of BV [7, 17, 27]. Two studies used questionnaires to obtain data, [18, 27] of which one also conducted interviews [27]. Two studies only reported qualitative data out of interviews and did not report the number of women who suffered an impact [7, 16, 17].

In all four studies, most of women experienced a moderate or severe emotional impact of BV on their lives. Women expressed feeling acutely stressed and experiencing increased sensitivity and depression when having an episode of BV [16, 27] and feeling relieved when they did not [7]. Most women felt embarrassed, self-conscious, and uncomfortable [7, 16, 27]. Many expressed feelings of shame and disgust, adversely impacting their self-esteem and confidence [7, 16]. They suffered from the societal stigma around sexuality and STIs. For some women, having recurrent BV led to worrying thoughts about long-term (reproductive) sequelae [7]. Women who experienced BV, especially recurrent episodes of BV, generally felt frustrated and confused [7, 16, 17, 27]. The interviews of the qualitative studies showed different reasons for this frustration and confusion. First, although women tried different treatments and (expensive) self-help remedies, most of them did not perceive any amelioration of the symptoms and frequency of recurrences [7, 16, 17]. Second, women did not know what triggered their symptoms and felt having no control over it. Some women believed they would always have BV and there was no remedy for it [7, 16, 17]. Third, a lot of women just wanted answers for the questions they had regarding BV, however they felt that clinicians themselves had little knowledge on the causes and treatment options [17]. This inadequacy and inconsistency of clinical information built to the frustration and distress of these women [17]. Fourth, women were frustrated because the psychosocial impact of BV was often not recognized by people around them [17].

Sexual health

Five studies reported on sexual health and BV [7, 11, 18, 23, 27] and are summarized in Table 2. Two studies specifically included women suffering from recurrent episodes of BV [7, 27]. Four studies used questionnaires regarding symptoms, practices, and impact [11, 18, 23, 27]. Two studies collected qualitative data by interviewing women [7, 27].

Four studies found that BV symptoms had an impact on women’s sexual lives and sexual intimacy. In the prospective cohort study of Mehta and colleagues, the score of the Sexual Quality of Life Questionnaire decreased with 8,27 points on a scale of 100 when BV diagnosis (assessed with Nugent score) concurred with recent sexual activity, and this decrease was more likely to increase with age [23].

The qualitative study of Bilardi and colleagues reported that the degree of the impact on women’s sexual health was associated with the severity of the symptoms and the frequency of recurrences [7]. Interviews conducted in the qualitative studies, found that women were very self-conscious, embarrassed about having vaginal odor and feared that sexual partners may notice their symptoms, especially during oral sex [7, 27]. This resulted in not being able to relax and enjoy sex, negatively affected sexual self-esteem, sexual confidence and levels of intimacy with partners [7]. Women frequently associated their sexual attractiveness with a non-odorous vagina [7]. Most women with symptomatic BV demonstrated avoidance behavior, such as avoiding certain sexual positions and practices, particularly oral sex, and planned sexual activity after genital hygienic practices or abstained from sex altogether [7, 27]. A slight improvement of sexual enjoyment was observed one month after treatment with antibiotics [11]. Some women worried about infecting their partners when having sexual intercourse [7]. Interestingly, women did not think that their disease could have been transmitted from their partner and did not doubt their partner’s fidelity [7]. Bilardi and colleagues observed no differences in the impact of BV on sexual health between heterosexual women and women who have sex with women [7]. In general, women in relationships experienced greater support and encouragement compared to single women [7].

Social health

Four studies reported on social health and BV and are summarized in Table 3 [7, 11, 26, 27]. Two studies included women suffering from recurrent episodes of BV [7, 27]. One study quantified the social impact with a social integration score based on the level of engagement in four activities: religious activities, participation in a community/voluntary group, social outings to meet friends and/or relatives, and hosting friends and/or relatives [26]. In two studies, a combination of questionnaires and interviews were used to obtain data, [11, 27]. Only one of the four studies primarily relied on interviews [7].

The proportion of women with BV affecting their social lives varied between the studies. In the cross-sectional study of Patel and colleagues, no statistically significant association was found between the social integration score and BV as assessed by the Nugent score [26]. Other studies reported that BV impacted social health and was associated with the severity of the symptoms and the frequency of recurrences [7, 27]. Bilardi and colleagues reported that only a minority suffered from social consequences of BV, [7]. whereas Payne and colleagues found more than half of the women reported a negative impact on work attendance, job performance and productivity, and relationships with coworkers [27]. The type of employment was shown to influence the impact of BV on social interactions on the work floor [7]. Women working in close contact with other people, such as teachers, health-care workers and especially sex workers, were more likely to suffer an impact on their work life [7, 16]. Shame and fear that others may detect their symptoms were important contributing factors [7, 27]. Avoidance behavior was common, ranging from avoiding side-by-side contact with colleagues to absenteeism. Women reported being reluctant to use public restrooms and tended to engage in frequent feminine hygienic practices, including douching [27]. Additionally, some women limited social interactions or avoided going out altogether [7, 27].