Bacterial Vaginosis 101

Bacterial vaginosis (BV) increases the risk of UTIs. In this post, Jessica Lloyd, BHS(N), who runs the project myvagina.com shares her insights on how to diagnose and treat BV.

What is bacterial vaginosis (BV)?

Bacterial vaginosis is an imbalance in vaginal bacteria whereby a few unfriendly bacteria take over your vagina, while normal, healthy flora are displaced and cannot return. Where lactobacilli make your vagina smell like nothing much, BV-related bacteria cause your vagina to smell off, produce an unpleasant discharge, and sometimes itch, or feel sore and irritated.

This change in flora happens because your healthy bacteria have not been able to defend your vagina from a pathogen. Unfortunately, getting properly diagnosed is not as easy as it seems.

The specifics of bacterial vaginosis will vary from woman to woman, and it’s important to understand that the medical diagnosis of BV can also vary among practitioners. BV may be diagnosed with a culture to see which bacteria rule the roost in your vagina, but most women will go home with a prescription for antibiotics, either metronidazole or clindamycin, before the test results have even come back.  This is because the symptoms of BV can be terrible, and the medical treatment – as ineffective as it can be – is antibiotics, which your doctor can instantly prescribe you to A) get you out of their office, and B) hopefully cure your BV.  

Remember, your doctor sees many women like you, and they are crossing their fingers hoping you don’t come back. Recurrent BV often leaves both practitioners and patients without a resolution, and this feels terrible for everyone. Doctors dread recurrent BV.

The current state of BV treatment

Medicine has not yet solved bacterial vaginosis, with antibiotic treatments failing about half the time. This leaves many women, often for years and even decades, with vaginal symptoms that rob them of their confidence and destroy intimacy. BV is a scourge affecting so many women, who are too ashamed to talk about it and are unsure how to cure it on their own.

Women turn to the internet for help with bacterial vaginosis symptoms, finding all kinds of treatments – vinegar, boric acid, hydrogen peroxide, vitamin C, folic acid, vitamin D – and trying them all. Some will find success, temporary or long-lasting, but others will try everything without their symptoms budging.

The issue with these home remedies is that none of them actually deal with the true cause of recurrence in BV: the bacterial biofilm. Another huge elephant in the room is the microbes that are not tested for because they cannot be cultured (won’t grow in a petri dish in a lab). These microbes are often resistant to antibiotics, causing a bigger issue to develop over time. More on this shortly.

The main players in bacterial vaginosis

Gardnerella vaginalis has been the focal point in BV diagnosis for some time now, but it isn’t the only bacteria involved in BV; it’s simply the one you’ll hear about the most. This is because G. vaginalis is often the ringleader of the change in vaginal flora that occurs in bacterial vaginosis.

If you only have G. vaginalis in your vagina (and not much else), your symptoms are likely to be a fishy smell and a watery, greyish discharge. This is what we’ll call ‘classic BV’. Classic BV doesn’t cause inflammation, which is why technically speaking, classic BV doesn’t cause itching, soreness or cramps. In fact, classic bacterial vaginosis can be silent, with no symptoms at all.

Do I have a BV if my symptoms differ?

So what does it mean if you have different symptoms, like itching, sticky yellow or green discharge, or an odor that more closely resembles ammonia, metal, feces, or sour milk? It means you have another bacteria that is either in cahoots with G. vaginalis or a completely different set of bacteria. This is still ‘bacterial vaginosis’, which means ‘an abnormal vaginal environment due to bacteria’. 

The ultimate result is that it doesn’t actually matter which bacteria you have, so long as you can treat them. Knowing your bacteria is a good start (see PCR testing for more information) because then you can tailor the treatments for faster results. G. vaginalis is very common and is tested for by all medical systems to diagnose BV. If you’ve been diagnosed with BV, it’s probably because you tested positive for high growth of G. vaginalis, have low or no healthy flora, have a high pH (over 4.5), and/or unpleasant symptoms that have no other explanation besides a change in flora.

Classic bacterial vaginosis may be quick and easy to treat with a round of antibiotics, if you get lucky. If antibiotics don’t work, you step into recurrent BV territory; recurrent because it seems to keep coming back over and over, despite seemingly effective treatment. The truth is that if your BV is recurrent, it’s because it never went away, likely due to the bacterial biofilm.

Bacterial vaginosis and bacterial biofilms

Recurrent BV can be incredibly difficult to treat using antibiotics, and for a very good reason: many bacteria build a thick biofilm that acts like a shield, keeping good bacteria and treatments out, and ensuring the continued survival of the pathogenic bacteria on your vaginal cells.  The biofilm protects the bad bacterial colony, so just the planktonic (free floating) bacteria were killed by the treatment (if they were susceptible), with the colony of bad bacteria still hiding in the biofilm and remaining unharmed.

You may have even been making the bad bacteria stronger with repeat failed antibiotic treatments. For example, if you didn’t do proper tests (full BV-related bacteria PCR) and your initial antibiotic treatment did not account for the bacteria that didn’t grow in a culture. If the lab didn’t find bacteria, then you cannot account for their resistance or treat them effectively.

Bacterial vaginosis is an STD!

While bacterial vaginosis can and does develop on its own without sexual contact, BV is most definitely also sexually transmitted by both men and women. Many of you will have developed BV after unprotected sex with a new partner.

Yes, it was them.

Women who have sex with women are at greater risk than women who have sex with men – vagina-to-vagina transmission is oh-so-easy, but so is penis-to-vagina transmission. This is because biofilms are very infective, and while a penis isn’t the natural home of these bacteria, with regular contact and especially in uncircumcised men, biofilms can and do exist.

You’ll also be sad to know that you can get BV in your mouth. It might have a different name then, but it’s the same idea, same bacteria, and can result in gum disease. This is why some women report having received oral sex from someone with bad breath and developed BV afterward. It’s not just regular p-in-v sex.

If you have a male sexual partner and have been having sex without a condom, he almost certainly has BV biofilms on his penis and will be reinfecting you and any other women he is coming into unprotected sexual contact with. Men should get a treatment as well, but antibiotics do not work in men and on biofilms, and frequently physicians do not even test men for BV bacteria.

If you have sex with women, the same principle applies. Remember, no symptoms doesn’t mean no BV. You can still be infective. 

Treating BV effectively in men and women

My Vagina, an evidence-based vulvovaginal resource, has the best, most effective non-antibiotic treatments for BV available in the definitive guides to cleaning up the mess left by bacterial vaginosis, Killing BV, for both men and women. My Vagina has the only BV-related treatment guide for men available anywhere in the world.

Provided treatment programs effectively dissolve the bacterial biofilms, kill the liberated bacteria, and recolonize the vagina with healthy flora. The Killing BV books explain BV, why it appears, and offers a handful of effective treatments for each stage to fit your body and budget.

My Vagina’s vulvovaginal specialist naturopaths provide free email support; there is an exclusive BV support section; and any woman who cannot afford to pay the US$7.99 for the book can apply for a payment waiver.

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Practitioners can apply for membership to get access to treatment programs and the research, plus discounts and patient codes so you can provide books and information to clients or patients from any discipline.

Why typical BV treatments don’t work in recurrent BV

You can think of the biofilm as a layer of gum that coats your vaginal walls, hiding lots of different microbes. The biofilm is impervious to the usual BV treatments, both home remedies, and antibiotics.

Antibiotics (usually metronidazole)

Unfortunately, antibiotics do not dissolve or dislodge biofilms and can only target planktonic bacteria in your vagina. Therefore, antibiotics may be useful when used in conjunction with a biofilm-busting program, as the antimicrobial prong in the four-pronged Killing BV approach, but on their own have an unacceptably high failure rate.

Apple cider vinegar or boric acid to re-acidify the vagina

Creating a more acidic environment can’t treat BV because the biofilm protects the hiding colony from pH changes.

Probiotics vaginally or orally

Good bacteria can’t rebuild their colony because they can’t get access to attach to vaginal cells, and can’t create their own healthy biofilms. Good bacteria are blocked by the bad biofilm, like a bug on a window. Good bacteria just won’t survive, since your body will rinse it out with normal vaginal secretions or in your digestive tract.

Taking vitamins (folic acid, B vitamins, vitamin D)

While providing nutrition to your body, vitamins of any kind cannot influence biofilms. Vitamins can help your immune system function optimally, but once a biofilm is in place, it can be incredibly hardy and difficult to dislodge or dissolve without the right tools for the job. These tools do not include vitamins. Simple BV can respond well to vitamin D, but recurrent BV does not.

Hydrogen peroxide to act as a disinfectant

Many of your healthy vaginal microbes produce hydrogen peroxide as a weapon of defense against invading bad bacteria, but sadly it cannot break down bad bacterial biofilms. In a healthy vagina, hydrogen peroxide helps keep bad bacteria and their biofilms out, but if you have BV, you do not have any good bacteria left.

HOT BV TIP: Freshen up for a hot date or some time off from bad smells

Hydrogen peroxide can provide temporary relief from the fishy odor just in time for a hot date or to feel fresh, but only in strengths of six percent. Three percent, which is, unfortunately, the dilution most widely available, is not quite strong enough.

If you can’t find six percent hydrogen peroxide and want to freshen up your vagina while you prepare to do a proper biofilm-busting BV treatment, find 9 or 35 percent food grade hydrogen peroxide and dilute it to six percent.

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