Letter to the Editor
To the Editor
Madhivanan and colleagues1 raise 2 questions regarding my systematic review of randomized controlled trials of male sex partner treatment to improve bacterial vaginosis (BV) outcomes2: (1) whether the review is necessary and (2) whether the review was properly conducted.
Randomized controlled trials assessing the efficacy of male sex partner treatment to improve BV outcomes showed no strong effects.3–8 These trials are the basis for the Centers for Disease Control and Prevention9 and World Health Organization10 guidelines, which do not recommend male sex partner treatment for women with BV. Considering the weight these trials carry and their divergence from observational data, Potter11 reviewed the trials to assess the evidence for male partner treatment. He dismissed 4 of the trials as invalid, with cursory, nonstandardized reporting of methodological concerns. Potter details the trial by Mengel et al.5 because of its suggested advantage in treating male partners and the trial by Vutyavanich et al.7 because he found it “difficult to fault,” despite nonreproducible recruitment and screening methods, lack of power calculation, and unreported or unclear randomization and blinding methods. Thus, my systematic review is necessary because (1) it addresses a pertinent scientific and clinical question that has not been answered and (2) it surpasses Potter’s review by systematically selecting and reviewing articles with standardized, objective criteria; generating risk ratios with precision estimates to facilitate quantitative comparison across trials; providing post hoc power estimation; and providing unbiased interpretation. None of these trials provide conclusive evidence regarding the efficacy of male sex partner treatment for women with BV.
Madhivanan et al. question the validity of my review. The search criteria were limited to fit the objective: to review randomized controlled trials of male sex partner treatment for BV, as stated in the title. Thus, it is perplexing why Madhivanan et al. highlight my exclusion of the articles by Larsson et al.,12 Eschenbach et al.,13 Hagstrom et al.,14 Hovik,15 and Jerve et al.16 These studies included male partner treatment, but none included a male partner control group; thus, the effect on BV outcomes in women cannot be estimated. To minimize potential bias in extraction, I used a standardized review approach, completing the 25-item CONSORT checklist for each article (Supplemental Content, http://links.lww.com/OLQ/A68), along with the PRISMA flow diagram and table (Supplemental Content, http://links.lww.com/OLQ/A69), with both available to reviewers at submission. With regard to the potential bias introduced by having a single reviewer, this could be said of any single-authored article, including that by Potter. Despite this, there are numerous examples of highly cited systematic reviews in high-impact journals that are single authored.17–20 The extraction dates were inception through May 2011. The inclusion criteria as reported in methods were as follows: English language publications of studies with randomization of male sex partner treatment for women with BV. No studies meeting these criteria were excluded.
I hope that like Madhivanan and colleagues, others continue to question whether male sex partner treatment affects BV outcomes because these 6 trials are inconclusive.
Supriya D. Mehta, MHS, PhD
Division of Epidemiology and Biostatistics
University of Illinois at Chicago
1. Madhivanan P, Baretteo GA, Revawala A, et al. Where are we with partner treatment in bacterial vaginosis? A critical appraisal of the latest systematic review. Sex Transm Dis 2013; 40: 518.
2. Mehta SD. Systematic review of randomized trials of treatment of male sexual partners for improved bacteria vaginosis outcomes in women. Sex Transm Dis 2012; 39: 822–830.
3. Swedberg J, Steiner J, Deiss F, et al. Comparison of single-dose vs one-week course of metronidazole for symptomatic bacterial vaginosis. JAMA 1985; 254: 1046–1049.
4. Vejtorp M, Bollerup A, Vejtorp L, et al. Bacterial vaginosis: A double blind randomized trial of the effect of treatment of the sexual partner. Br J Obstetr Gynaecol 1988; 95: 920–926.
5. Mengel M, Berg A, Weaver C, et al., and the Bacterial Vaginosis Study Group. The effectiveness of single-dose therapy for patients and their partners with bacterial vaginosis. J Fam Pract 1989; 28: 163–171.
6. Moi H, Erkkola R, Jerve F, et al. Should male consorts of women with bacterial vaginosis be treated? Genitourin Med 1989; 65: 263–268.
7. Vutyavanich T, Pongsuthirak P, Vannareumol P, et al. A randomized double-blind trial of tinidazole treatment of the sexual partners of females with bacterial vaginosis. Obstet Gynecol 1993; 82: 550–554.
8. Colli E, Landoni M, Parazzini F, et al. Treatment of male partners and recurrence of bacterial vaginosis: A randomised trial. Genitourin Med 1997; 73: 267–270.
9. Centers for Disease Control and Prevention, 2010. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep 2010; 73: (RR-12): 1–110.
11. Potter J. Should sexual partners of women with bacterial vaginosis receive treatment? Br J Gen Pract 1999; 49: 913–918.
12. Larsson P-G, Brandsborg E, Forsum U, et al. Extended antimicrobial treatment of bacterial vaginosis combined with human lactobacilli to find the best treatment and minimize the risk of relapses. BMC Infect Dis 2011; 11: 223.
13. Eschenbach DA, Critchlow CW, Watkins H, et al. A dose-duration study of metronidazole for the treatment of nonspecific vaginosis. Scand J Infect Dis 1983; 40: 73–80.
14. Hagstrom B, Lindsted J. Comparison of two different regimens of metronidazole in the treatment of non-specific vaginitis. Scand J Infect Dis 1983; 40: 95–96.
15. Høvik P. Nonspecific vaginitis in an outpatient clinic. Comparison of three dosage regimens of metronidazole. Scand J Infect Dis 1983; 40: 107–110.
16. Jerve F, Berdal TB, Bohman P, et al. Metronidazole in the treatment of non-specific vaginitis (NSV). Br J Vener Dis 1984; 60: 171–174.
17. Stewart LA. Chemotherapy in adult high-grade glioma: A systematic review and meta-analysis of individual patient data from 12 randomized trials. Lancet 2002; 359: 1011–1018.
18. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care 2004; 27: 1218–1224.
19. Hodnett ED. Pain and women’s satisfaction with the experience of childbirth: A systematic review. Am J Obstet Gynecol 2002; 186: S160–S172.
20. Ioannidis JP. Contradicted and initially stronger effects in highly cited clinical research. JAMA 2005; 294: 218–228.