Clarifying the complexity of bacterial vaginosis: Using targeted testing to identify causes and STD coinfections

Vaginitis, an inflammation or infection of the vagina, is the most common reason for women to seek medical care worldwide, and most women experience an episode at least once in their lifetimes.¹

Research shows high rates of sexually transmitted infections (STIs) in women seeking care for symptoms of vaginitis and bacterial vaginosis (BV), and several studies have found an increased incidence of STIs among women with BV compared to those without, indicating strong associations of STIs with these conditions.¹

BV shares similar symptoms with several STIs, however, which can make accurate diagnosis and treatment challenging. Understanding the range of targeted diagnostic tools available can help you clarify the complexities to screen vaginitis cases thoroughly for coinfections—and treat infections more promptly and effectively.

In this article:

Clinical challenge | Why it matters | Ordering recommendations | Interpreting test results | Next steps | Supporting resources

Clinical challenge: Focused diagnosis and treatment of bacterial vaginosis and coinfections with shared symptoms

In the US, BV occurs in one-third of adult women—which equates to approximately 22 million patients.² Symptoms of vaginal discharge are the cause for approximately 10 million clinical office visits a year.²

BV is the most common cause of vaginitis, accounting for about 40%-50% of cases, with yeast infection and trichomoniasis making up the rest.³

This common condition typically presents with symptoms including abnormal vaginal discharge, pain, itching, and irritation. These symptoms are typically nonspecific and overlapping with other infections—and up to 25% of patients with vaginitis have coinfections.⁴

Shared symptoms create the need for thorough, targeted testing

According to guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC), evaluation for vaginitis should include medical history, physical examination, and testing of vaginal discharge.^5,6

The 2 primary testing approaches are

• Clinical testing, including pH measurement, potassium hydroxide whiff test, and microscopy
• Laboratory testing, most commonly nucleic acid amplification tests (NAATs) 

While clinical testing is faster than laboratory testing, it requires equipment and trained providers.⁷ By comparison, laboratory testing is more accurate than clinical testing, especially for detecting coinfections.^4-8

The CDC recommends that all women with BV be tested for HIV and other STIs.⁹

Why it matters: Using targeted diagnostic tools can support more prompt diagnosis and management of STI coinfections

While recent CDC statistics show some progress in reducing the incidence of STIs in the US, the overall burden of these cases remains substantial.¹⁰

Research has shown that nearly 1 in 5 women with BV or Candida vaginitis (CV, yeast infection) was found to be coinfected with an STI, and women diagnosed with BV had a significantly higher prevalence of STIs (26.3%) compared to those without BV (12.5%).¹

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are the 2 most commonly reported notifiable diseases in the US, and are among the most prevalent of all STDs.¹⁰ Left untreated, they may affect the upper reproductive tract, as both diseases are associated with cervicitis and pelvic inflammatory disease (PID).¹¹

The importance of identifying coinfections

The high incidence of STI coinfections associated with vaginitis makes it important to identify its cause in order to provide targeted, effective treatment. Undiagnosed or improperly treated STIs can lead to serious, life-changing complications, including PID and infertility.^11,12

The CDC recommends STI testing in women with BV based on clinical context and risk, with particular attention to chlamydia, gonorrhea, and trichomoniasis when indicated.^5,13

The persistently high rate of STIs in the US represents an opportunity to improve treatment and outcomes through more thorough diagnostic testing. Definitive testing is the only way to ensure you’re treating the right infection—or multiple infections.

Ordering recommendations: Specialized diagnostic panels to identify causes of vaginitis and potential coinfections, including STIs

Quest offers a variety of high-sensitivity tests with the option for clinician-collected or patient-collected vaginal swab specimens. For patients with symptoms of vaginitis, order a targeted NAAT such as transcription-mediated amplification (TMA) based on the predominant syndrome.

Ordering guide

Recommended tests: Advanced vaginitis and vaginosis TMA tests

Using the most focused test that covers the leading suspected diagnosis is recommended when symptoms are typical, as it lowers the chance of extraneous data. 

A combined vaginitis panel such as SureSwab^® Advanced Vaginitis, TMA or SureSwab^® Advanced Vaginitis Plus, TMA is recommended when the presentation is broad and the exam is equivocal.

SureSwab^® Advanced Bacterial Vaginosis (BV), TMA

• Test code: 10016
• CPT^® code: 81513*

SureSwab^® Advanced Bacterial Vaginosis (BV), CT/NG, TMA

• Test code: 10123
• CPT codes: 87494, 81513*

SureSwab^® Advanced Candida Vaginitis (CV)/Trichomonas vaginalis (TV), TMA

• Test code: 10029
• CPT codes: 87481 (x2), 87661

SureSwab^® Advanced Candida Vaginitis (CV), TMA

• Test code: 10121
• CPT code: 87481 (x2)

SureSwab^® Advanced Vaginitis Plus, TMA

• Test code: 10120
• CPT codes: 81513*, 87481 (x2), 87661, 87494

SureSwab^® Advanced Vaginitis, TMA

• Test code: 10119
• CPT codes: 81513*, 87481 (x2), 87661

Note: Each of the component tests may also be ordered individually.  

Related tests

Chlamydia trachomatis RNA, TMA, Urogenital

• Test code: 11361
• CPT code: 87491*

Chlamydia/Neisseria gonorrhoeae RNA, TMA, Urogenital

• Test code: 11363
• CPT code: 87494

Neisseria gonorrhoeae RNA, TMA, Urogenital

• Test code: 11362
• CPT code: 87591*

Trichomonas vaginalis RNA, Qualitative, TMA

• Test code: 19550
• CPT code: 87661

Mycoplasma genitalium, rRNA, TMA

• Test code: 91475
• CPT code: 87563

Mycoplasma genitalium rRNA, NAAT with Reflex to Macrolide Resistance

• Test code: 18456
• CPT codes: 87563, 87999

* CPT code is subject to a Medicare Limited Coverage Policy and may require a signed ABN when ordering.

Interpreting test results: Applying TMA test results to effective treatment for vaginitis and potential coinfections

For SureSwab vaginitis assays, results are interpreted against the reference range included on the lab report. Results should be interpreted in the context of symptoms and examination.

BV is reported as negative/positive, and the test yields a qualitative pattern-based result.

The BV/CT/NG panel adds chlamydia and gonorrhea reported as detected/not detected, and yields STI results. Chlamydia and gonorrhea are generally treated as clinically actionable infections.

Candida and Trichomonas vaginalis tests produce results as detected/not detected, and provide organism detection results. Positive findings may reflect colonization for Candida and BV-associated flora, while trichomoniasis is generally treated as a clinically actionable infection.

Next steps: Management strategies and follow-up recommendations for positive bacterial vaginosis test results

Because normal vaginal flora varies among individuals, test results should be considered together with clinical evaluation to diagnose or rule out BV.^16,17 Guidelines recommend that women with BV be tested for HIV and other STIs.⁷

In the case of positive BV results, treatment should follow standard bacterial vaginosis CDC guidelines.

Supporting resources