Everything you need to know about bacterial vaginosis (BV) but might not want to ask

Recurrent yeast infections and a related gynecological condition – bacterial vaginosis, or BV – aren’t dangerous. But they’re an uncomfortable nuisance. If you experience these vaginal infections with any frequency, you might be desperate for a solution.

BV affects one third of reproductive-aged women, and recurrence is common, according to a recent study published in The New England Journal of Medicine. That’s around 24 million women in the U.S. who have experienced BV.

We spoke with Dr. Maria D’lorio, an OB-GYN who recently joined Novant Health WomanCare in Winston-Salem, about BV, how it’s treated and what you can do to prevent it.

Is bacterial vaginosis the same thing as a yeast infection?

They’re actually different types of vaginitis, or vaginal infections. They can present with similar symptoms, such as vaginal discomfort, itching, pain and unusual vaginal discharge. But they’re caused by two different organisms.

BV is caused by an overgrowth of a bacteria called Gardnerella vaginalis. A small amount of these bacteria can be a normal part of the vaginal microbiome, but imbalances in vaginal microflora can cause an overgrowth and lead to symptoms.

The vaginal microflora are the bacteria inside the vagina dominated by lactobacilli, which helps maintain vaginal health by inhibiting the growth of yeast and other nuisance organisms. These healthy bacteria work best at certain pH, or acidity, levels.

Yeast infections are an overgrowth of yeast organisms – most commonly, Candida species. These infections are most often isolated incidents. A small percentage of patients may experience infections recurrently, which is typically defined as three or more within a year.

What are the symptoms?

The most common are:

• A change in vaginal discharge. For BV, discharge is commonly described as grey or pale yellow. Yeast infections most commonly have a thick white discharge, like cottage cheese. Most importantly, discharge is atypical for the woman at that part of her cycle. It’s normal for vaginal discharge to change during a regular menstrual cycle and can become thicker or stickier around ovulation.
• Foul-smelling vaginal odor, most often described as a fishy smell.
• Vaginal and vulvar discomfort or irritation, especially during sex.

What do women need to know about the condition?

When I discuss vaginitis with my patients, the discussion always touches on personal hygiene. Many women mistakenly believe they need to take extra steps to clean their vagina, but I tell patients that the vagina is a self-cleaning system with a delicate pH balance that helps keep the unique microflora happy and healthy.

There’s no need to clean inside the vagina. In fact, vaginal douching should be completely avoided. Infections are often caused by using products, like douches, which aren’t necessary to begin with. They can throw off the vaginal pH and allow an overgrowth of organisms like Gardnerella.

Instead, I recommend cleaning the vulva with warm water only. You can clean the outside of the area (outside the labia majora, between the thighs) with gentle, non-scented soaps and warm water.

Changes to our diet or environment can affect vaginal microflora and pH just as they can our gut microbiome. But we don’t fully understand what those changes are.

Taking antibiotics to fight infections elsewhere in the body will affect the vaginal microflora, and it’s very common to have vaginitis – like BV or yeast infections – after taking a course of antibiotics.

How common is BV?

Very common. I treat about five to 10 patients with it every week. The majority of these cases resolve with simple treatment. (See below.) However, some patients have recurrent infections that require further follow-up.

Can BV be prevented? How?

There are a few things I recommend to prevent infection or re-infection.

• Properly clean and care for the vulva and vagina, as I mentioned earlier.
• Wear breathable cotton underwear and change underwear after working out or swimming to help prevent changes in the pH due to sweat or moisture build-up.
• Allow the area to breathe by wearing loose-fitting shorts or pants (as opposed to tight-fitting yoga pants or bike shorts) and don’t wear underwear to bed.
• Some women find that their vaginal microbiome is irritated by semen or some brands of lubricant. If that’s the case, try alternative lubricants or condoms.
• If you need to take a course of antibiotics for an infection – and you’re susceptible to BVs – we can try to prevent one. I most commonly recommend a boric acid vaginal suppository. Love Wellness is my go-to brand. Boric acid comes in small pills, available over the counter, which can be inserted in the vagina – after sex, for example – and help to correct changes to the vaginal pH. Boric acid can be toxic when ingested, so be sure to follow the instructions for insertion.

How is BV treated?

The traditional treatment is an antibiotic called metronidazole, which comes in two forms – a pill and a vaginal cream. Both work to treat the infection, although the pill takes seven days compared to three days for the cream. For most patients, either form of metronidazole will clear up symptoms in short order.

Some newer vaginal creams – such as Nuvessa – can clear infections with just one dose, but insurance coverage for these is spotty.

How do you treat those rare cases of repeated infections that require follow-up?

If symptoms persist despite patients trying boric acid and changing their hygiene habits, I recommend a vaginal probiotic to help improve the vaginal microbiome. Again, Love Wellness brand is a good option.

If infections continue, I recommend further testing to see if there’s an unusual type of organism causing the symptoms that we can target.

How is BV diagnosed?

Sometimes just discussing symptoms is enough to make a presumed diagnosis. To reach a definitive diagnosis, you need a pelvic exam.

Are there risks to leaving BV untreated?

Risks in women who aren’t pregnant are minimal. But if left untreated, you can continue to have fishy vaginal odor and irritation. Most patients find those intolerable.

It’s rare for BV to progress to a serious infection that spreads to other areas or organs. But in pregnant patients, there’s an association between untreated BV and preterm labor, so we always recommend treatment.

BV’s not considered a sexually transmitted infection (STI), right?

Totally unrelated. It’s not considered an STI, and it’s not associated with risk of other STIs.

A study in The New England Journal of Medicine suggests that treating the male sexual partners of women who get recurring BVs can help. What are your thoughts?

That study, which looked at partner treatment for BV in monogamous couples, showed a lower rate of recurrence for patients whose male partner was treated versus patients whose partner wasn’t treated.

Yet, a third of patients whose partners were treated still had a recurrence. So, I don’t think this study gives a complete picture.

For my patients with recurrent symptoms who have a monogamous sexual partner, I discuss treatment of their partner. But treating the partner can be technically difficult because the patient’s partner isn’t also a patient of the OB-GYN. So, the partner needs to pursue treatment with their own doctor. Since this is a relatively new finding, many doctors may not be familiar with partner treatment, so I always offer to discuss it with their partner´s PCP to help coordinate.

Anything else you want to say on the topic?

Since I’ve found some patients to be hypervigilant about vaginal odor and discharge, I want to add that some vaginal odor and discharge is totally normal. Vaginal odor doesn’t always indicate an infection or problem.

The most important thing is to know your body, including your vagina, and to notice – and consult your doctor – when you notice changes.