Understanding Bacterial Vaginosis (BV) Symptoms and Treatment

Written by

Pamela Nieto, PhD

Medically reviewed by

Nicole Calloway Rankins, MD, MPH

Reviewed by

Nicole Calloway Rankins, MD, MPH

Scientifically reviewed by

Nicole Calloway Rankins, MD, MPH

Last updated on

August 20, 2024

A young woman with her hair wrapped in a towel, sticking her tongue out at her reflection in a mirror

Summary

Bacterial vaginosis (BV) is a very common disruption of the vaginal microbiome, and the cause is unknown.
Untreated BV may increase your risk of pelvic inflammatory disease, infertility, and preterm birth, and make you more prone to getting a sexually transmitted infection.
BV is treated with antibiotics. While treatment is often successful, about 15-58% of women experience another episode of BV, something known as recurrent BV. There are things you can do to support your vaginal microbiome and stop BV from coming back.

Get deep insights into your vaginal microbiome with our mess free, at home test. Learn more

Bacterial vaginosis (BV) is an overgrowth of unfriendly bacteria.

In a typical healthy vaginal community, Lactobacillus are in charge. These protective bacteria like to dominate in numbers, and while they may be fine with other microbes hanging around, they rarely like to share space with unfriendly bacteria.

In bacterial vaginosis (BV), unfriendly bacteria such as Gardnerella vaginalis, Fannyhessea vaginae (also known as Atopobium vaginae), Prevotella, and others steal the microphone from Lactobacillus and use it to create a disrupted environment, with an increased pH [1]–[3].

Unfortunately, what causes BV is unknown. Some factors that may contribute to it are:

Having a vaginal community that is naturally low in Lactobacillus (CST 4)
Hormone changes
A high number of sexual partners
Smoking
Poor personal hygiene
Douching
Antibiotics [4]–[7]

Some scientists believe BV should be considered a sexually transmitted infection [8], but this is a controversial topic. Sharing microbes through sex can certainly alter your vaginal microbiome, but it’s not absolutely necessary to have sex to get BV.

If you have BV, you’re not alone

You may have had or currently have BV. Or maybe you have had it more than once. There’s nothing to be ashamed of because BV is one of the most common vaginal infections in women.

In fact, one in three women gets BV at some point in their lives and approximately 29% of women in the US have BV [9].

Common BV symptoms

One way to know if you have BV is to pay attention to your vaginal discharge. BV discharge is characterized by:

A fishy odor
Thin texture
Milky white or grayish color

Other common BV symptoms are:

A burning sensation in your vagina
Pain during sex or urination

A shocking fact is that 84% of women diagnosed with BV have no symptoms at all [10]. But not having any symptoms doesn’t mean you’re free from all the BV-associated complications.

These asymptomatic cases are more likely to be detected with molecular techniques such as metagenomic sequencing, the technology we use in Tiny Health microbiome tests.

How BV is diagnosed

BV is often diagnosed by the Amsel criteria [11]. If you have three out of four Amsel criteria, your clinical provider will diagnose you with BV. These criteria include:

A thin white-grayish vaginal discharge
A fishy smell
Clue cells (these are vaginal epithelial cells covered in bacteria) on microscopic examination
A pH higher than 4.5

A second way of diagnosing BV is by using the Nugent criteria. This involves putting a vaginal fluid sample into a microscope slide, staining it, and looking at it under a microscope [11]. The presence and numbers of different bacteria are then used to calculate a score and diagnose or rule out BV.

The problem is that this method is much more cumbersome and it usually requires sending your sample to a laboratory.

Finally, a third way of diagnosing BV is through molecular diagnostic techniques. These may be more expensive, but provide a better picture of the vaginal microbiome. Plus, this type of testing isn’t affected by the subjective interpretation of your provider. Our Vaginal Health Test can detect all the bacteria that are part of your vaginal microbiome at a very detailed level.

Changes in your vaginal microbiome during BV

One characteristic of BV is low levels of Lactobacillus [12]. There is, however, one particular species that doesn’t mind hanging out with the BV gang: Lactobacillus iners [13]. While this species is considered protective, it doesn’t protect as well as other Lactobacillus.

Vaginal communities dominated by L. iners (CST 3) may be less stable and often transition to BV-like communities over time.

Gardnerella vaginalis is a key player in BV. While it’s usually present in small amounts in healthy vaginas [14], when its numbers increase, it pushes out protective Lactobacillus and creates a shield called a ‘biofilm’, which helps bacteria survive [15]–[17]. Other bacteria like Prevotella bivia and Fannyhessea vaginae join G. vaginalis to strengthen the biofilm and seek shelter within it [15]–[18].

Additionally, several other bacteria can be linked to BV, including Megasphaera, Dialister, Mobiluncus, Sneathia amnii, Sneathia sanguinegens, Porphyromonas, Aerococcus, UBA629 sp005465875 (also known as Candidatus Lachnocurva vaginae), Eggerthella, and Peptoniphilus [3], [19].

BV and its associated complications

Untreated BV may increase your risk of other vaginal, urinary, and sexually transmitted infections. It may also contribute to the development of inflammatory conditions that can threaten fertility or lead to pregnancy complications [20], [21].

Having BV may increase your risk of:

Pelvic inflammatory disease (PID). BV could make you about three times more likely to develop asymptomatic PID [22].
Infertility. High levels of G. vaginalis or F. vaginae could decrease your chances of getting pregnant after in vitro fertilization [23].
Recurrent implantation failure (RIF). Gardnerella, Fannyhessea, and Prevotella are high in women that experience RIF [24].
Preterm birth (PTB). Compared to healthy women, pregnant women diagnosed with BV are about twice as likely to experience PTB [25], [26]. Also, having BV-associated bacteria such as Gardnerella, Prevotella, Fannyhessea, Sneathia, and Megasphaera may significantly increase the risk of PTB [27]–[35].
Viral sexually transmitted infections. Compared to women with a negative diagnosis, women diagnosed with BV are 1.6-2.6 times more likely to be infected with Human immunodeficiency virus (HIV), Human papillomavirus (HPV), or Herpes simplex virus 2 (HSV-2) [36]–[38].
Bacterial sexually transmitted infections. Compared to women with a negative diagnosis, women diagnosed with BV are 1.4-2.0 times more likely to get chlamydia, gonorrhea, or trichomoniasis [39], [40].

That’s a pretty long list of complications. The good news is that BV can be treated and there are things you can do to prevent it from coming back.

BV treatment

BV is treated with antibiotics. If you suspect you may have BV, it’s very important to always get a diagnosis from your provider, never do antibiotics on your own. This is especially relevant if you are pregnant or breastfeeding. Depending on your pregnancy trimester, some antibiotics for BV may be harmful for your baby. Your provider will help you choose the appropriate treatment.

These are the most common antibiotics used to treat BV:‍

Metronidazole (Flagyl, Metrogel-Vaginal, others). Comes as a pill to take orally or as a topical gel that you apply into your vagina.
Clindamycin (Cleocin, Clindesse, others). Comes as a cream that you apply into your vagina.
Tinidazole (Tindamax). Comes as a pill to take orally.

The bad news? BV-associated bacteria build such a strong biofilm that they are not easy to get rid of with antibiotics.

Depending on the country, 15-58% of women experience recurrent BV [41]–[43]. This occurs when symptoms are alleviated by antibiotics but return soon after the treatment is finished, and this can happen more than one time [13], [14]. This may also happen because bacteria like F. vaginae can be resistant to antibiotics like metronidazole [44].

Another thing to consider is that, while antibiotics for BV are intended to eliminate BV-associated bacteria, they can also impact other beneficial bacteria like Lactobacillus. Because of this, an alternative treatment may be a good idea.

Alternative treatments for BV include:

Vaginal Lactobacillus probiotics. These can be used together with antibiotic treatment to increase success and replenish Lactobacillus levels [45], [46]. You may also want to try probiotics alone, especially if you experience recurrent BV that doesn’t fully improve with antibiotic treatment. Some clinical trials in non-pregnant women have shown that probiotics can be effective in treating BV [47], [48].
Vaginal Lactobacillus suppositories. There are several studies showing that these are effective at restoring Lactobacillus levels, and may help reduce the episodes of BV [49]–[54]. If you’re pregnant, ask your provider before trying vaginal suppositories. Some brands may contain boric acid, which should not be used during pregnancy.
Vaginal vitamin C tablets. One of the characteristics of BV is a higher vaginal pH. Vaginal vitamin C tablets have a special formulation that slowly releases vitamin C in your vaginal canal. This helps lower the pH, which inhibits the growth of unfriendly species and supports beneficial Lactobacillus [55]–[59]. These tablets can be used along with a Lactobacillus probiotic to help with colonization. Some Lactobacillus suppositories contain vitamin C (also known as ascorbic acid).
Essential oil suppositories. If you are not pregnant, essential oil suppositories are another alternative that may help relieve BV symptoms. However, it’s important to mention that these have only been tested in laboratory experiments. If you choose to use them, always do so with the guidance of your provider. Dr. Aviva Romm also shares her go-to homemade suppository essential oil blend for addressing BV.

When shopping for a vaginal probiotic or suppository, you may want to look for high-performing and well-researched vaginal strains. When you take a Tiny Health vaginal test we recommend products whose strains have been proven to be effective in clinical trials.

Reduce the risk of BV

Luckily, there are things you can do to support your vaginal microbiome and reduce the risk of developing BV. A few include:

Eating fermented foods such as yogurt, kefir, and pickles
Wearing cotton underwear and loose fitting clothes
Consuming probiotics
Avoiding douching or using harsh soaps or wipes
Wiping from front to back when using the bathroom

Following these measures is especially important if you have a certain vaginal microbiome type called Community State Type (CST) 4, which features low levels of Lactobacillus. Don’t know what type of vaginal community you have?

Our Tiny Health vaginal test can help you identify yours and provide a detailed report with personalized tips to optimize your vaginal health.

Get valuable insights into your vaginal microbiome

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Written by: Pamela Nieto, PhD

Dr. Pamela Nieto has over 10 years of experience in basic research and gut and vaginal microbiome test development.

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Reviewed by: Nicole Calloway Rankins, MD, MPH

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Medical Advisor; Practicing OB/GYN Hospitalist Physician, Creator and Host of The All About Pregnancy & Birth Podcast

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