Bacterial vaginosis (BV) is a common vaginal infection that affects women in their reproductive years. It is caused by the overgrowth of normal bacteria found in the vagina. While many women don’t have symptoms, others can experience unpleasant symptoms as well, such as unusual discharge, itching and a fishy odor.
In this article, I’ll break down exactly what BV is, what causes it, some of its most common symptoms, and the best treatments for the condition.
What are the symptoms of Bacterial Vaginosis?
Most of the time, BV is asymptomatic, meaning that a woman may have the infection and not even realize it. However, many women do experience some common unpleasant symptoms.
Bacterial Vaginosis Symptoms
- Unusual vaginal discharge (thin, and white, gray, or green in color)
- Fishy odor (typically more noticeable during intercourse or during a woman’s period)
- Vaginal itching
- Painful urination
If you’re experiencing any of these symptoms, it’s important to visit your doctor so you can start treatment. It’s not always BV and there’s also a chance you have multiple infection, so meeting with your doctor can help you differentiate the cause of your symptoms and help you get the best treatment for you.
What is Bacterial Vaginosis?
Bacterial vaginosis (BV) is an infection of the vagina usually affecting women of reproductive age. BV is caused by an imbalance in vaginal bacteria. In women with BV, lactobacillus becomes scarce, and other kinds of bacteria (e.g. Gardnerella vaginalis, Ureaplasma urealyticum, Anaerobes, and Mycoplasma hominis) become too plentiful. This is referred to as overgrowth of normal flora.
Women with BV experience a rise in the pH of the vagina. In healthy women who are not in menopause, the vagina is acidic, with a pH of between 3.8 and 4.5. This is due to Lactobacillus species producing lactic acid, which maintains a pH that keeps the critters in check!
Is Bacterial Vaginosis an STI or STD?
Firstly, let’s talk about the difference between a Sexually Transmitted Infection (STI) and a Sexually Transmitted Disease (STD). These terms are often used interchangeably, but they’re technically quite different.
If you have an STI, it means that the infection has not yet developed into a disease. A great example of this is chlamydia. A person with chlamydia has an infection, not a disease—they therefore have an STI. However, chlamydia can lead to pelvic inflammatory disease (PID). If someone with chlamydia develops PID, they then have an STD, because PID is a disease.
Very often, when you use the term “STD”, “STI” is probably more correct.
Examples of STIs:
- Hepatitis B
- Human Immunodeficiency Virus (HIV)
- Human Papillomavirus (HPV)
Even in the literature and online, many sources call the above conditions STDs.
BV is a tricky condition to categorize. It is definitely not an STD, because it is not a disease. But there is also contention around whether or not it is an STI, because of a lack of clear evidence linking sex (including oral sex received by a woman) with BV.
However, sexual activity is certainly a risk factor for BV. One reason for that is because sexually activity that introduces semen into the vagina can shift the pH. Semen is slightly alkaline. Vaginas should be moderately acidic. So when semen enters the vagina, it causes a rise in the vagina’s natural pH, which can lead to the overgrowth of normal bacteria that call the vagina their home. Hello bacterial vaginosis!
In addition, certain lubes can alter vaginal pH leading to BV. Interestingly, there have been multiple studies showing that spermicide does not lead to an increase in BV overgrowth.
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In that sense, we could say that BV is sexually transmitted. However, unlike other STIs, BV can recur even without sexual activity. Like I said, tricky! So it is not strictly sexually transmitted. More on that soon!
One thing we do know is that having BV makes a woman more vulnerable to other STIs, because BV changes the flora of the vagina.
What causes Bacterial Vaginosis?
BV is caused by an imbalance in the flora of the vagina. More specifically, BV is often associated with a decrease in Lactobacillus, a vital good bacteria for a healthy vagina, which is what ultimately leads to bacterial vaginosis symptoms. This is why some women find Lactobacillus suppositories helpful. So what causes this bacterial imbalance? There are a few key culprits.
Risk Factors for Developing BV:
- Intercourse (sex)
- Period blood
- New sexual partner or multiple partners
- Oral and anal sex
- Imbalances in gut flora
Douching Disrupts Healthy Flora
Have you ever been made to feel like your vagina needs assistance in keeping clean? For a long time, women were told that vaginas are inherently dirty, and need to be cleaned. This harmful, sexist message has spread down through the generations. At one point, women were even told to use Lysol to clean their vaginas, to eliminate any odor and keep their husbands happy. Lysol.
While we now know that Lysol is definitely not safe for use inside our bodies, the narrative of “keeping the vagina clean” persists. Let me be clear. Genitals have an odor (yes, a penis can too). Some odors can indicate problems, such as the fishy smell brought on by BV. But healthy vaginas do have a smell and despite what clever marketers tell you, this is normal.
Unfortunately, women are often made to feel ashamed of their natural scent, and turn to douches and scented washes to “clean” themselves. Good hygiene is of course important. But the vagina is magical. It is self-cleaning, so there is absolutely no need for douching.
In fact, douching causes an imbalance in the vaginal flora, as well as a disruption to its natural pH. Yes, douching makes it harder for harmful critters to grow! Both of which are recipes for BV.
And BTW, those scented lady labia wipes are also not doing you any favors. These can disrupt healthy flora and introduce endocrine disruptors to this sensitive mucosal tissue.
If you're struggling with bacterial vaginosis symptoms then it is a good idea to step away from these practices.
How Am I Supposed to Clean My Vagina?
There’s never really a reason to clean your vagina (the internal structure). Your vulva, the outer portion of your genitals doesn’t really need more than water.
Intercourse (especially unprotected)
In a perfect world, vaginas and semen would have the same pH, but trust me when I say that nature doesn’t get it wrong. Unfortunately, semen isn’t the same pH and can make us susceptible to BV and yeast infections. Semen is actually mildly alkaline, so during unprotected sex, semen slightly raises the pH of the vagina.
While this is usually a temporary change for the vagina, it is sometimes enough to encourage the growth of both beneficial and unhealthy bacteria. An acidic environment keeps the growth of these nasties at bay, so maintaining a moderately acidic vagina is important.
Antibiotics kill the harmful bacteria that cause infections. However, they also kill the good bacteria that we need to stay healthy. This lack of good bacteria can destroy the acidic environment of the vagina, which can lead to bacterial vaginosis. Remember, those Lactobacillus species make acid that keeps the whole ecosystem in check.
Consider a probiotic if you require antibiotic treatment.
This is another weird, ironic quirk of our bodies. In an ideal world, period blood would be acidic and match the pH of our vaginas, since the blood passes through the vagina as it leaves the body. But, like semen, period blood is slightly alkaline. Therefore, it can alter the pH of the vagina, potentially leading to BV.
Your blood must maintain a specific pH in order for enzymes and other metabolic processes to function optimally. The pH of blood is just above 7 and tightly regulated. A pH of 7 is considered neutral, so your blood is slightly alkaline. The lower the pH, the more acidic, which is why your vagina is considered acidic at a pH less than 7.
How is BV Diagnosed?
BV must be diagnosed by a medical professional. During a pelvic exam, a doctor will usually check for four things in order to diagnose BV.
- Thin discharge that is white, grey, or green in color
- Fishy odor with KOH test
- Elevated vaginal pH
- Presence of clue cells
Your doctor may also want to perform a physical exam, which may include a speculum exam to visualize your cervix. I know it’s never fun, but it is an important exam to rule out other possible causes of your symptoms.
My Discharge Smells Bad, but Not Like Fish
This doesn’t necessarily mean it is not BV. It does mean that you need to make an appointment with a doctor to rule out any serious infections.
How is Bacterial Vaginosis Treated?
I’m going to review several treatment options available, including pharmaceutical and natural treatments. Remember, the best way to know what you’re dealing with and the best treatment is to speak with your doctor.
What Antibiotics Treat Bacterial Vaginosis?
Bacterial vaginosis symptoms are treated in non-pregnancy women with antibiotics, specifically metronidazole or clindamycin. They both work equally well, and the medication prescribed usually depends on which is more accessible, and which is more cost-effective.
These antibiotics can be taken orally (in a tablet or capsule), or in gel/cream form inserted directly into the vagina. Deciding how to take the antibiotic is usually dependent on the patient, but oral use of antibiotics does come with more side effects, such as nausea.
Because antibiotics can lead to further unfavorable shifts in both your vaginal ecology and gut microbiome, it is wise to use caution with these medications. They are sometimes necessary to get you relief, but if you find that you need a monthly dose of antibiotics to keep your vagina happy then it is time to bring in more support. Check out the upcoming section on natural treatments.
Metronidazole for the Treatment of BV
Metronidazole is a medication your doctor may recommend in either an oral or vaginal form. Whether it is vaginal or oral treatment, alcohol should not be consumed during treatment or for one day after following treatment.
Other side effects to be aware of are nausea, metallic taste, and tingling in the hands and feet. It is not uncommon to have digestive upset when using the medication orally, which is why your doctor may recommend vaginal dosing instead.
Clindamycin for the Treatment of BV
As mentioned, clindamycin is another antibiotic that is used in the treatment of BV. It is important to note that using clindamycin vaginally has been associated with increased bacteria resistance to this antibiotic following treatment. We don’t see similar resistance with metronidazole.
If you experience diarrhea, abdominal pain, or fever while using this medication it is important to contact your doctor. Using both oral and topical clindamycin can make you susceptible to overgrowth of bacteria in the colon leading to inflammation and digestive symptoms.
Anytime you are using a topical medication in the vagina there is a risk that it will make condoms ineffective. Be sure to ask your doctor if this medication can be used with latex condoms. It’s really best to avoid sex while treating the infection, but just in case, you should know the risks.
Natural Treatments for Bacterial Vaginosis Symptoms
1. Don’t Douche, Skip the Scent, Be Gentle with Your Vagina
Your vagina will tend to itself and while the odor may make you feel like you need to lend some assistance, you don’t. Douching is a risk factor for developing BV. And as I mentioned above, scents and harsh personal care products used internally can do more harm than good.
Hydrogen Peroxide for BV
Ok, so I definitely just said don’t douche and now I’m going to talk about some common at home treatments that can help. Again, you want to work with a doc before diving into treatments. There are some things you can DIY, but gynecology isn’t one of them.
Hydrogen peroxide has been used for years (ages even) for the treatment of BV and it proves to be pretty effective in some studies. What we don’t know is if it can shift the flora too much and leave you susceptible to other infections.
In a small 2003 study it was found that the use of hydrogen peroxide decreased odor and eliminate signs and symptoms of BV. However, in a randomized control trial, a single treatment with hydrogen peroxide was found to be less effective than a single dose of metronidazole.
Apple Cider Vinegar for BV
I feel like ACV is up there with coconut oil in how it is recommended for just about everything. Can apple cider vinegar treat BV? The answer is, there really isn’t any evidence it can, but let’s talk about how it might seem like a viable treatment because it is definitely something you’ll find on the internet.
Firstly, ACV is antimicrobial, but it appears to be only against certain strains like E. coli, Candida albicans, and Staph aureus. These organisms may or may not be the cause of your symptoms and being specific matters when it comes to clearing infection.
ACV is also acidic due to the presence of acetic acid. This may help shift your vaginal pH, but I wouldn’t recommend it over getting those Lactobacilli to do their job because that is how you naturally maintain your pH.
Some women report symptom relief from making a sitz bath with ACV. If it makes you feel better, there isn’t much harm that we know of in doing this. But as to whether you should douche with it? I wouldn’t advise it.
What About Vaginal Steaming for BV?
I know so many ladies who love this self care routine and done safely (read: no steam burns) this practice can be a way for women to take some time to pamper their lady parts. But with regards to clearing bacterial vaginosis or any other microorganism growing in the vagina, the evidence just isn’t there.
I know some women claim that certain herbs steamed can be beneficial to their vaginal health and I’m not saying they are wrong. What I am saying is that we don’t have sufficient studies to support this and we don’t understand if some herbs used that have antimicrobial properties could actually disrupt the flora further.
Eucalyptus, oregano, even lavender have antimicrobial properties, which may prove to be beneficial in a steam in future research. However, as it stands, this is not regarded as a treatment for this condition.
2. Eco Friendly Period Products
Good for the environment and good for your vagina! #winning If you’re struggling with recurrent BV, consider making the switch.
You may have heard that it doesn’t matter if your period products are organic, but as more information is coming to light we are understanding that non-organic products can contain glyphosate and other environmental toxins. Not only can your vagina absorb these toxins, the toxins themselves can disrupt vaginal flora.
3. Support Healthy Vaginal Ecology
This may come as a bit of a surprise, but supporting your gut health can support your lady parts too! The gut and vagina share organisms and as I’ve found many times in my practice, we can’t totally clear recurrent vaginal infections until we’ve addressed the gut.
Make sure you’re eating in a way to support hormones and gut health. Consider taking a probiotic daily, especially if you’re currently on antibiotics or have recurrent infections. And be sure to address any gut issues you may have, especially leaky gut.
4. Get Your Blood Sugar in Check
Blood sugar imbalances cause hormone imbalances and all of the above can make you more susceptible to BV. This is not to say if you eat sugar then boom, you’ll have an infection. But it is part of the bigger picture of overall health. If you’re struggling with chronic BV or yeast infections, this is a good area to have your doc check out.
5. Vitamin C Suppository
During my clinical rotations at a homeless youth clinic vitamin C suppositories were one of our go to treatments for BV because of access and it being a low cost treatment. I’ve also used vitamin C suppositories within my clinical practice for women can’t or don’t want to use pharmaceutical interventions. I’ve found great success with this treatment, especially in recurrent BV cases.
In a randomized, double-blind, placebo-controlled clinical trial it was found that recurrence of BV in women treated with vaginal vitamin C was substantially lower than those in the placebo group at 3 months and 6 months of treatment. This study used 250 mg of ascorbic acid (vitamin C) for 6 days every month over the course of 6 months and concluded that this treatment drops the risk of repeat BV by half!
Another randomized, double blind, placebo controlled clinical trial also found that vitamin C was effective in the management of BV.
There are over the counter vitamin C based suppositories that you can talk with your doctor about to see if it is the best treatment for you.
Can BV clear up on its own?
BV is considered a mild infection of the vagina, and in some women, it certainly can and does go away on its own. However, if left untreated, BV can cause more serious health problems.
Untreated BV leaves you vulnerable to:
- Increased risk of miscarriage or preterm labor
- Pelvic infection
- Increased risk of contracting STIs (such as gonorrhea and HIV)
It’s best not to assume symptoms are BV and to meet with your doc because again, it could be something else or something else could be accompanying the BV.
Can I treat BV at Home?
Using the above natural therapies, it is possible to treat BV at home. However, I can’t stress enough to be sure that you are dealing with BV and to meet with your doctor to discuss the best treatments.
In terms of prevention, that’s 100% at home habits to keep your vagina happy and healthy.
How Can I Prevent Bacterial Vaginosis?
There are a few steps you can take to reduce your risk of getting BV.
1. Do Not Douche
Douching has no benefits for your vagina. It may cause the vagina to smell “clean”, but it wreaks havoc on its beneficial bacteria and its healthy acidity.
2. Keep Vaginal Bacteria Balanced
By maintaining an optimal balance between good and bad bacteria, you will create an inhospitable environment for BV. You can do this by not using harsh, heavily fragranced soaps to clean the outside of the vagina, and by wearing breathable cotton underwear.
3. Abstain From Sex
😆 Semen can be a problem. Semen from multiple partners can be a problem. But avoiding sex…mmm…now we have a major problem. 😂
Ok, now seriously. This is a recommendation made to women with BV and it lives all over the internet. But let’s be real, abstaining from sex isn’t an option for most women (for whatever reason) who are experiencing BV. It is best, however, to abstain from sex while treating a vaginal infection.
If you are going to continue having sex, consider using a condom to avoid exposure to ejaculate while you help restore the normal ecology in your vagina.
If you have multiple partners, definitely use a condom. I know, I sound like a mom. I am a mom. But this sincerely comes from the place where all the knowledge I’ve acquired about medicine lives. As a doctor, please, consider a condom.
Consider Changing Up Your Lube
It could be you’re using something that has antimicrobials in it to prevent bacterial contamination (a good thing) and yet, for you and your vagina’s needs, you may need to switch.
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As a friendly reminder in the infection arena:
- Pee after sex.
- Don’t change orifices without being mindful about what bacteria (and other organisms) you’re transferring from one area to another.
- Please be mindful to properly clean sex toys.
Can I Get BV from My Boyfriend?
While your boyfriend’s semen can make you more susceptible, your boyfriend isn’t actually giving you BV. It is well recognized that new partners or having multiple partners can put you at increased risk.
Can I Get BV from Oral Sex?
Saliva can shift the pH of the vagina, so it is possible this could leave to bacterial imbalance and cause BV.
BV in pregnancy
Untreated BV can cause problems during pregnancy, so it’s important to see a doctor if you are pregnant and suspect that you have BV. Anytime you have any concerns about what may be growing in your vagina in pregnancy please go straight to your doctor and get it checked out.
Can BV cause miscarriage?
According to this study of women undergoing in vitro fertilization (IVF), BV significantly increases the risk of miscarriage in the first trimester, compared to women with normal vaginal flora.
Does BV harm the baby?
BV can cause a woman to go into preterm (early) labor, and can also cause low birth weight in the baby. Neither of these conditions are ideal for a healthy baby. However, underweight babies and premature babies often can and do still grow up to be very healthy.
How Can I Treat BV Naturally During Pregnancy?
Use some of the tips above like maintaining a healthy gut, considering a probiotic, avoiding douching and harsh chemicals on the vagina, and eat to optimize your gut flora and blood sugar. When it comes to treating BV naturally, it is vital to see a medical professional in order to get rid of the infection as quickly as possible, and therefore avoid some of the potential risks to the pregnancy.
How to Stop Recurring BV Infections Permanently
- Practice good sex hygeine and consider condoms
- Resolve any underlying gut issues
- Consider vitamin C and probiotics both orally and vaginally
- If you’re douching, stop
- Balance your hormones
- Meet with your doctor to discuss individual risk factors
BV is easily treated, but must not be ignored
Bacterial vaginosis is common in sexually active women of reproductive age. Many women do not experience symptoms, and the infection resolves itself in a few days.
However, women also experience several uncomfortable symptoms, and should seek the advice of their chosen medical professional as soon as possible. BV is successfully treated with oral or intravaginal antibiotics.
If left untreated, BV can cause pelvic infections, lead to a greater risk of contracting STIs, and cause miscarriage or preterm labor in pregnant women. So, while it is not necessarily a serious health condition, it is definitely not one that should be ignored.
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