Document Type



Doctor of Philosophy (PhD)


Public Health

First Advisor's Name

Purnima Madhivanan

First Advisor's Committee Title

Committee Chair

Second Advisor's Name

Diana Sheehan

Second Advisor's Committee Title

Committee Member

Third Advisor's Name

Tan Li

Third Advisor's Committee Title

Committee Member

Fourth Advisor's Name

Giri Narasimhan

Fourth Advisor's Committee Title

Committee Member


bacterial vaginosis, African American, chalmydia, gonorrhea, longitudinal analysis, latent class analysis, recurrent BV, persistent BV

Date of Defense



Bacterial vaginosis (BV) is a common vaginal dysbiosis among women of reproductive age. Literature presents discordant findings with respect to the predictors of BV and there is a paucity of literature examining the mechanisms by which multiple episodes of BV occur. This dissertation summarized current literature on BV, identified BV incidence patterns over a twelve-month period, and estimated the risk of sexually transmitted infections (STI) among women with episodic and persistent BV. Previously collected randomized clinical trial data were analyzed, where oral metronidazole was the administered treatment. Latent class analysis (LCA) was used to assess BV incidence patterns. Multinomial Logistic Regression was used to estimate adjusted Odds Ratios (adjOR) associated with the predictors of BV incidence patterns. Binary Logistic Regression models were used to estimate adjOR associated with STI acquisition among women with persistent BV compared to episodic BV.

The results of the review identified conflicts in the literature further highlighted what little is known about the etiology and pathogenesis of BV, recurrent BV and persistent BV. LCA illustrated three emergent patterns of multiple cases of BV: persistent (55.9%; 95 % Confidence Interval [CI]: 52.5%-59.3%), recurrent (30.5%; 95% CI: 27.5%-33.7%) and clearance (13.5%; 95% CI:1.3%-16.0%). Compared with belonging to the clearance group, women who had sex with women (WSW) had significantly lower odds of belonging to the persistent class (adjOR: 0.38; 95% CI: 0.22-0.68) and the recurrent class (adjOR: 0.43; 95% CI: 0.23-0.81) than women who did not. Those who were treated with metronidazole had significantly increased odds of being in the recurrent class (adjOR: 1.92; 95% CI: 1.22-3.03) than those who were not treated. Additionally, women with persistent and episodic BV were at increased risk (p= 0.02) of developing an STI. Women without BV did not acquire an STI.

Assessment of BV cases revealed distinct patterns of recurrence and persistence despite treatment with oral metronidazole. These preliminary findings suggest, Metronidazole may not be the most effective treatment to reduce the prevalence of recurrent and persistent cases of BV. More effective treatment of singular episodes of BV may reduce the adverse sequalae of incident STI, we reported associated with recurrent, episodic and persistent BV. The review identified gaps in the literature, which were addressed by the second and third aims.





Previously Published In

Coudray MS, Madhivanan P. Bacterial vaginosis-A brief synopsis of the literature. Eur J Obstet Gynecol Reprod Biol. 2020 Feb;245:143-148. doi: 10.1016/j.ejogrb.2019.12.035.



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