Bacterial Vaginosis – Cause, Symptoms, Treatment and Prevention

Bacterial vaginosis is the most common vaginal infection for women of childbearing age- even more common than candidiasis. (1)

One in every four women is affected by the condition, making it a top reproductive health concern. (2)

Due to this occurrence, it is necessary to understand its impact on sexual health, quality of life and self-esteem. In this article, we explain what bacterial vaginosis is, its cause, symptoms, diagnosis, medical treatment, simple home remedies and how to prevent it.

What is bacterial vaginosis?

Bacterial vaginosis as its name suggests is an infection of the vagina that is caused by bacteria. The vagina has bacteria (primarily genus Lactobacillus) that protect against infections by producing lactic acid, hydrogen peroxide, and other substances.

When there is a disruption of normal flora, the healthy bacteria is depleted, allowing the harmful ones to proliferate. (3) This imbalance can be precipitated by hormonal changes, sexual activity, and hygiene habits.

Does sex contribute to bacterial vaginosis?

Although little is known about the role that sex plays in spreading bacterial vaginosis, statistics show that its risk increases with the number of sexual partners that a woman has. Moreover, bacterial vaginosis rarely affects women who are not sexually active.

Again, although bacterial vaginosis is not a sexually transmitted infection (STI), the act of sexual intercourse undermines the vaginal microflora by introducing new microbes that alter the pH and strip away the good bacteria. (4) Consequently, having multiple sexual partners increases the opportunities for inoculation of more and more destructive bacteria.

Surprisingly, it is not essential for a male partner to be treated if a woman has bacterial vaginosis unlike in candidiasis and STIs. However, in the case of where a woman has a female sexual partner, then there is a high chance that the other partner will also have bacterial vaginosis and hence the need for both partners to be treated. (5)

Having bacterial vaginosis also increases the chances of contracting a sexually transmitted infection. (6) That is because the infection disrupts the protective layer of the vagina, making it easier for other microorganisms to reach deeper layers.

Who is at a higher risk of getting it?

Any woman can get bacterial vaginosis but the risk increases (7) in case of:

  • Having multiple sex partners
  • New sex partner that introduces microorganisms that the body is not accustomed to
  • Douching
  • Sharing sex toys
  • Pregnancy
  • Poor vaginal health
  • Use of Intrauterine Devices (IUDs)

Contrary to common belief, rarely do women get bacterial vaginosis from toilet seats, swimming pools, and bedding. (8)

What are the signs and symptoms of bacterial vaginosis?

A significant number of women (about 80%) (9) do not know that they have bacterial vaginosis because they do not notice any symptoms.

In case of symptoms, one may notice:

  • An abnormal thin whitish or gray vaginal discharge with a strong fishy or musty smell (this is the main sign). The odor gets worse at around the time of menstruation or after unprotected sexual intercourse.
  • Pain, itching, or burning in the vagina
  • Burning sensation when urinating
  • Itching in and outside the vagina (may or may not be present)

Vaginal candidiasis (popularly known as thrush) and bacterial vaginosis are at times confused for each other. While candidiasis is caused by a yeast known as candida, bacterial vaginosis is an imbalance of vaginal bacteria.

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The significant difference lies in their manifestations. For thrush, the discharge is thick and white with a yeasty smell, as opposed to thin watery grayish/white discharge with a fish-like odor in bacterial vaginosis. Moreover, itchiness is more pronounced in thrush.

How is it diagnosed?

Health care providers primarily rely on the presenting symptoms of the infection, history taking, physical examination, and laboratory tests to make a diagnosis and rule out the possibility of an STI.

History taking

For the history taking, the clinician will want to know whether one has had past vaginal infections including STIs.

Vaginal examination

Vaginal examination is done to visually examine the vagina. During the examination, the doctor can take a specimen sample to test overgrowth of bacteria. The most frequent test that is then performed is the pH test, to assess the acidity of the vagina.

The health care provider uses a cotton swab to take a sample of the vaginal discharge then measures with a pH strip paper. A reading of above 4.5 means that the vagina is less acidic than it should be, a strong indicator of a bacterial infection. (10)

Pelvic examination

A pelvic exam is not a must, but a clinician may consider doing it examine the vagina and cervix. A speculum is inserted to slightly hold the vagina open for the procedure to be comfortably done.

The doctor then examines the reproductive canal and gets a sample of the vaginal discharge that is taken to the lab for further examination. When checked under a microscope, the lab tech will be looking out for “clue cells” that cover the vaginal cells. (11)

Once the above tests have been done, the Amsel criteria (12) is then used to make a diagnosis. The criteria require that there should be at least three of the following:

  • Thin, whitish or grayish homogeneous vaginal discharge
  • Clue cells on microscopy
  • pH of vaginal fluid that is more than 4.5
  • Release of a fish-like odor when a drop of potassium hydroxide (KOH) is added to vaginal fluid on a microscope slide.

Home test kits

Home test kits to look for changes in vaginal acidity and byproducts of bacterial vaginosis are also available. The test kits are particularly crucial for differentiating between a yeast infection and bacterial vaginosis, which are commonly mistaken for each other.

The test kits are used by inserting the tip of the kit into the vaginal canal, just like a tampon. After a few seconds, the tip changes color depending on the acidity of the vagina. If there is a pH shift, then there is a possibility of bacterial vaginosis.

How is bacterial vaginosis treated?

Sometimes bacterial vaginosis goes away on its own without treatment. However, it is vital to be checked and treated when one experiences the symptoms. It is also necessary to address the infection in order to lower the risk of STIs and in pregnancy, to reduce the risk of low birth weight and premature rupture of membranes.

1.Medical treatment

The standard medical treatment for bacterial vaginosis is a course of antibiotics that can be taken orally, as a cream, gel or suppository. The three preferred antibiotics for treatment of bacterial vaginosis are

  • Metronidazole 500mg, 14 tablets taken orally for seven days twice daily
  • Metronidazole (0.75%) 40g applied two times a day for 5 to 7 days
  • Clindamycin cream (2%) 40g applied once daily at bedtime for one week
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When on metronidazole tablets, alcohol should be avoided as it can cause side effects such as heart palpitations, headaches, hot flushes, shortness of breath, nausea, and vomiting. (13)

If the symptoms persist after treatment with either of the above antibiotics, the doctor may consider other stronger antibiotics like clindamycin or tinidazole tablets.

When antibiotics are prescribed, the dose should be completed to prevent antibiotic resistance, regardless of improvement of the symptoms- as it does not always mean that the infection has completely gone. Some bacteria causing the infection may survive and reproduce. These bacteria then gain resistance to that specific antibiotic. That means that if the infection reoccurs, it will be more challenging to treat. (14)

Even without antibiotic resistance, bacterial vaginosis infection is known to recur within 4 to 12 months. For this reason, medical treatment should be combined with simple home remedies.

2.Home remedies

Boric acid

Boric acid can eliminate bacteria on the lining of the vagina, after treatment with antibiotics. (15) It is administered as a capsule that is inserted into the vagina before bedtime for 7 to 14 days. Overall, boric acid is safe but should only be used vaginally and not orally.

Cooling probiotic tampons

Probiotic tampons act locally to restore the vaginal flora. They can be purchased or homemade. To make one at home, freeze unflavored plain yogurt in a tampon applicator then insert it into the vagina. The cooling sensation temporarily soothes the discomfort that comes with bacterial vaginosis. (16) Probiotic tampons also facilitate the healing of an active infection when used together with antibiotics.

Apple cider vinegar

Apple cider vinegar can help balance vaginal pH. To make this remedy, add two tablespoons of apple cider vinegar in one cup of clean water and use it to rinse the vulva twice daily. Alternatively, add apple cider vinegar into bathing water.

Are there any complications?

In most instances, bacterial vaginosis has an excellent prognosis when properly treated. Therefore, complications are not common. However, if not treated it can cause certain health problems including

  • Pelvic inflammatory disease (PID), a serious infection of the reproductive organs including the uterus, fallopian tubes, and ovaries. If untreated, PID can result in infertility.
  • Being more susceptible to HIV, genital herpes, chlamydia and gonorrhea

In pregnancy, (17) untreated bacterial vaginosis poses the risk of:

  • Preterm birth
  • Premature rupture of membranes (PROM)
  • Miscarriage
  • Low birth weight

Can bacterial vaginosis be prevented?

Prevention bacterial vaginosis primarily relies on changing modifiable risk factors. Many of the prevention practices focus on maintaining the optimal pH of the vagina and increasing the ability of the body to fight infections.

Steps to take to lower the chances of getting bacterial vaginosis include:

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Practice safe sex by using condoms correctly and consistently. Avoid flavored and scented condoms. They contain sugars and chemicals that potentially cause irritation to the vaginal mucosa and throw off the pH balance. Even worse, some research studies have shown that they are not as safe as regular condoms. (18) Also, limit the number of sexual partners.

Maintain proper vaginal hygiene to sustain optimal vaginal health by cleaning it with a washcloth, mild soap (or none) and clean water. After a shower, dry it off gently in slow motion, avoiding going deep into the vaginal tract. In addition, wipe from front to back after using the toilet, to avoid introducing bacteria from the anal region.

Avoid changing the physiologic environment of the vaginal lumen by

  • Not douching to avoid upsetting the natural balance of bacteria. Some women claim that douching helps to get rid of unpleasant smells, prevents STIs and pregnancy, and clean away menstrual blood. However, health experts have demonstrated through research that douching is not effective for any of these purposes. Instead, the products used not only disturb the normal microbial balance and inflame the skin but also force the pathogens up through the vaginal tract to the cervix and uterus.

The reality is that the vagina has a mild odor, which is normal. If the smell is too strong and unpleasant, seeking the help of a health professional is more helpful than douching.

  • Use of mild soap. Harsh and scented soaps contain chemicals that deplete vaginal flora and irritate the vaginal epithelium, creating a conducive environment to facilitate infections.
  • Regularly change tampons and pads. Even though tampons and pads are sterile and clean objects, be mindful of the duration that it is left in the sensitive areas. Failure to do so not only increases the risk of bacterial vaginosis but also Toxic Shock Syndrome (TSS), a deadly complication of staphylococcal bacterial infection. (19)
  • Use cotton underwear that is breathable and non-constricting. The natural fibers of cotton wick moisture away as compared to other synthetic materials which trap moisture and heat, providing an excellent breeding ground for bacteria and yeast.

Take a diet that is rich in fruits and vegetables and low in sugars, fats and highly refined carbs. This kind of diet supports the immune system by aiding in detoxification and boosting immune cell function. Brightly colored fruits and vegetables and green, leafy vegetables are particularly the best for infection prevention.  (20) Other foods to consider are those with antibacterial properties like garlic, coconut oil, apple cider vinegar, and manuka honey.

Take probiotics daily is another helpful trick. They contain the healthy L. acidophilus bacteria and are also food for healthy bacteria. The best way to get probiotics is to eat fermented foods such as cultured vegetables, dairy products, kefir, sour cream, and yogurt. read more about 14 Best Probiotic Rich Foods You Should Be Eating More