Bacterial Vaginosis: How to stop recurring BV- finally!

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Learn how to stop recurring BV (bacterial vaginosis). BV is caused by an imbalance of bacteria in the vagina, and recurrent BV can be prevented with the use of probiotics, prebiotics, diet, rebalancing the vaginal pH, disrupting the BV biofilm, switching your contraception and other measures.

What is BV (Bacterial Vaginosis)?

Bacterial vaginosis (BV) is a common vaginal infection that occurs when there is an imbalance of bacteria in the vagina. The main symptoms of BV is a strong fish-like odor of the vaginal discharge, vaginal discharge that is greenish, white or gray in color, burning during urination, and irritation around the outside of the vagina.

Bacterial vaginosis is the most common cause of vaginal discharge and odor in women, affecting 29% of women. 

What causes BV (bacterial vaginosis)?

Bacterial vaginosis is a vaginal infection and is caused by an imbalance of pH and bacteria in the vagina. It is a multi-species, biofilm-related vaginal disorder. It can be sexually assisted and sexually transmitted between partners who share their intimate bacterial flora (Muzny 2016).

There are many different types of bacteria that live in the vagina, and they are usually in balance with each other. The healthy vaginal flora is predominated by the hydrogen-peroxide producing lactobacilli, which is responsible for maintaining an acidic environment.

Healthy Vaginal Microflora

Healthy vaginal bacteria that contribute to a healthy vaginal microbiome include a number of species of lactobacilli including:

  • Lactobacilli crispatus,
  • Lactobacilli iners,
  • Lactobacilli gasseri,
  • Lactobacilli jensenii.

These bacteria produce substances such as lactic acid and hydrogen peroxide that maintains a vaginal pH of < 4.5, creating an unfavorable environment for expansion of more harmful bacteria (Tidbury 2020).

Bacterial Vaginosis: How to stop recurring BV

Vaginal Dysbiosis

When the vaginal balance can be disturbed, there is bacterial overgrowth of anaerobic bacteria. In BV the particular harmful anaerobic bacteria that overgrows includes;

  • Gardnerella vaginalis,
  • Prevotella species,  
  • Mobiluncus species,
  • Atopobium vaginae,
  • Bacteroides species.

When lactobacilli is replaced by G. vaginalis and other anaerobic bacteria it promotes a pH that creates an environment that enhances biofilm production.

A biofilm is a thin layer containing a bacterial community that adheres strongly to the vaginal wall. This makes it difficult to eradicate these bacterial with antibiotics or via the immune system. This is why bacterial vaginosis treatment has a high rate of relapse and re-infection.

Bacterial vaginosis Risk Factors

The vaginal bacterial balance can be disrupted for a variety of reasons, including the following risk factors;

  • douching,
  • using scented soaps or bubble baths around the vaginal area,
  • having new or multiple sex partners.
  • diet effects on gut and vaginal microflora
  • repeat use of antibiotics
  • intrauterine device use
  • smoking.

How is BV diagnosed?

Your healthcare provider will ask about your symptoms and medical history. They will also do a physical exam. To confirm the diagnosis, your provider may collect, or ask you to collect a sample of vaginal discharge/vaginal fluid with a swab to test for the presence of bacteria that causes BV.

Sometimes BV can co-exist with or be misdiagnosed as yeast infections. So make sure to test if you have symptoms so you get the correct diagnosis and treatment.

Is Bacterial vaginosis a serious condition?

Bacterial vaginosis can be difficult to eradicate and can have significant effects on quality of life for many women, especially it can negatively affect how women feel about their body, their relationships and sex.

Additionally it leads to serious additional healthy concerns particularly for pregnant women including increased risks of:

Bacterial vaginosis also contributes to increased risk of vaginal infections including

  • pelvic inflammatory disease (Rothman 2003),
  • endometritis/infection of the lining of the uterus (Jacobsson 2002)
  • increased risk of gaining and transmitting several sexually transmitted diseases (Gallo 2012).

How is BV treated? How can you get rid of BV?

Treating BV with antibiotics is first line treatment. The most common antibiotic used to treat BV is metronidazole (Flagyl). Your healthcare provider may prescribe oral or vaginal metronidazole. You will likely need to take the medicine for 7-10 days. It is important that you take all of the medication, even if your symptoms go away before you finish. If you stop taking the antibiotic too soon, the infection could come back.

Antibiotics such as Flagyl (metronidazole) are effective for 70-85% of women but 50% get a recurrence within 6 months (Sobel 2015).

Alcohol should not be used while taking metronidazole as it can cause unpleasant symptoms such as vomiting, dizziness, nausea, low blood pressure and a fast heart rate.

If you have an allergy or reaction to metronidazole you can use an alternative antibiotic to treat BV such as clindamycin.

When bacterial vaginosis (BV) won’t go away

Approximately 50 percent of women who have been treated for bacterial vaginosis develop recurring bacterial vaginosis infections.

Repeated bacterial vaginosis, failed BV treatment or reinfection with BV are related to:

  • Failure of vaginal tract to be recolonized by Lactobacillus.
  • Recolonization from sexual partner’s genital flora.
  • Altered immune response to support dysbiosis
  • Failure to disrupt the BV biofilm.
  • Antibiotic resistant bacterial vaginosis.

If antibiotics fail to disrupt the biofilm, repeat antibiotics continue to promote a vaginal microflora that is favorable to recurrent bacterial vaginosis.

How to stop recurring BV

Recurring BV can be very frustrating and can affect sense of wellbeing, body image and confidence in relationships and lead to other pregnancy or vaginal health complications.

There are a number of strategies for eradicating recurring BV. These should address disrupting the biofilm, acidifying the vaginal pH, replenishing the vaginal lactobacilli and considering the effect of contraception on the vaginal microbiome.

Bacterial Vaginosis: How to stop recurring BV

1. BV biofilm disruptors

Research around the BV biofilm has shown the need for effective biofilm disruptors for eradicating recurring BV. A number of substances have been identified or are currently being researched for use as biofilm disruptors. These include:

Antiseptics for Bacterial Vaginosis

These have antibacterial activity against a broad spectrum of bacteria and act by disrupting the bacteria cell membrane. Antiseptics used in BV include:

  • povidone iodine
  • hydrogen peroxide
  • chlorhexidine.

One regime includes vaginal tablets containing the antiseptic, dequalinium 10 mg, once daily for 6 days (Dermnet 2022).

Despite these having a seemingly high cure rate, when used for longer periods or repeatedly bacterial resistance emerges (Swidsinski 2015).

Probiotics for BV

Lactobacillus, particularly L. crispatus acts via inhibiting Gardnerella vaginalis from adhering to the vaginal wall cells. They also produce antimicrobial compounds such as:

  • hydrogen peroxide
  • lactic acid
  • bacteriocins.

These lactobacilli bacteria have the ability to incorporate themselves in to the BV biofilm, causing destruction to the biofilm structure and bacterial cell death of the competing harmful bacteria (McMillan 2011).

Diverse oral formulations of lactobacillus have been shown to reduce BV symptoms, and improve the vaginal microbiome profile.

These probiotics have also been shown to reduce the recurrence of BV, and the re-establishment of a healthy vaginal microflora when used in combination with conventional metronidazole antibiotic treatment.

For example Marcone et al treated Group A with standard metronidazole for 1 week only and compared this with Group B, women who also recieved metronidazole for 1 week followed by once weekly vaginal capsule of Lactobacillus rhamnosus (40,000 cfu) for 6 months. At 6 months 96% of women were free of BV compared with 74% of women in group A. Even though probiotic treatment stopped at 6 months the benefit to the vaginal microbiome was stable at 12 months with 91% in group B being BV-free compared to 69% in group A.

2. Vaginal pH imbalance and BV

In bacterial vaginosis, the pH in the vagina is too high due to low numbers of lactobacilli, which enables overgrowth of BV-associated bacteria. Maintaining vaginal pH is essential for reducing BV-associated bacteria and restore the vaginal microflora lactobacilli.

Avoid douching

The vagina is self-cleaning. Water alone is an adequate cleanser for the vulva and vagina.

Use of anti-bacterial soaps in the vulval area is associated with an increased risk of BV. If you do need to use a wash, use an intimate soap/wash designed for pH suitable for the vulva.

Avoid Bubble Bath

Bubble bath can negatively influence the vulval pH.

Vitamin C for BV

Vaginal vitamin C (ascorbic acid) can be used to encourage the restoration of the normal vaginal lactobacilli. Use 250mg vaginal ascorbic acid once per night for 7 days and twice weekly for 6-12 weeks to prevent recurrence.

Boric acid suppositories for BV

Boric acid suppositories are helpful for reducing pH in BV. Insert boric acid 600 mg vaginal capsules or pessaries daily for 14 days, and twice weekly for 6–12 months to prevent a recurrence.

Lactic acid pH-balancing gels

Intravaginal Lactigel™ or Gynofit™ are lactic acid-based vaginal gels formulated to reduce vaginal pH. Use one of these gels once per night for 7-14 nights.

3. Replenish healthy vaginal lactobacillus

Probiotics as discussed above are one strategy to replenish a healthy vaginal microflora. It is also important to consider diet which influences gut and vaginal microflora (Bardin 2022).

Chronic BV Diet

Women who consume diets high in fats are at increased risk of BV and more difficult to treat BV (Neggers 2007). Fats are found in high levels in meats, full-fat dairy and processed foods such as fries, doughnuts etc.

Women who consume diets higher in folate, vitamin A and calcium have a reduced risk of difficult to treat BV (Neggers 2007). These nutrients are found in abundance in plant foods such as leafy greens, carrots, pumpkin, bell peppers and fortified soy milk.

In an Iranian study, women who consume an “unhealthy dietary” pattern had a 2x increased risk of developing BV compared to women who score low on the unhealthy dietary pattern (Noormohammadi 2022). The “unhealthy dietary” pattern was characterized as a dietary pattern containing sugars, solid oils, sweets and desserts, red meats, fried potatoes, refined grains, organ meats and sweet drinks.

Women who had the lowest risk of developing bacterial vaginosis were women who consumed an “Ovo-vegetarian diet”. These women had a 16% reduced odds of developing BV compared to non-ovo-vegetarian consumers. The “Ovo-vegetarian diet” was characterized by a diet high in green, yellow and starchy vegetables, other vegetables, beans, whole grains and egg.

Diets rich in plant fibers are likely to reduce the risk of BV infections by affecting the microflora through more Lactobacillus-dominant profiles and positively impacting vaginal health (Shivakoti 2020).

Taken together much of the research on what promotes a healthy microbiome suggests a whole food plant based diet. A diet containing diverse plant foods provides diverse plant fibers and prebiotics, that are foods for the healthy bacteria in our microbiome.

Some excellent dietary prebiotics to incorporate into your diet include:

  • Chicory root – this contains inulin, comes in the form of a coffee-like drink.
  • Dandelion greens – also a great source of inulin
  • Jerusalem artichoke – inulin
  • Garlic, leeks and onions are rich in inulin and fructooligosaccharides (FOS)
  • Asparagus – inulin
  • Barley and oats – beta-glucan and resistant starch
  • Apples – pectin.

Consuming these foods regularly helps establish and maintain a healthy microbiome.

Vaginal prebiotics

Applying prebiotic gels directly in the vagina promotes the growth and establishment of healthy lactobacilli communities that can disrupt the BV biofilm.

Zeng et al demonstrated that a combined prebiotic vaginal gel of sucrose and 0.75% metronidazole showed a more rapid restoration of vaginal microflora than those without the prebiotic in their treatment.

Coste et al likewise demonstrated that prebiotic gel (GOS prebiotic-6%, equivalent to a minimum of 300 mg of oligosaccharide and the trifolium pratense extract-2%) use for 16 days after a week of oral antibiotics was able to maintain and restore normal vaginal microflora.

4. BV and birth control

BV and IUD use

Many women who use and IUD have no problems with BV.

If you do get BV and IUD is your contraceptive method, it can sometimes be hard to eradicate. This is because when intrauterine contraceptive devices are used, BV-associated bacteria biofilms can develop on the IUD and the IUD strings. This means that despite using antibiotics, these will not be able to eradicate the G. vaginalis and other BV bacteria who have created a biofilm on the IUD and strings.

Studies looking into the BV-associated bacteria biofilm on intrauterine devices have found that around 28% of removed IUDs have BV-associated biofilm if analyzed by culture method, but 76% when analyzed by PCR-rRNA analysis (Adam 2018).

If you are experiencing recurring BV with IUD use, that is getting hard to treat, it may be a good idea to change contraceptive methods. Have your IUD removed, treat the BV, restore the vaginal microflora before trialling another IUD.

Can latex condoms cause BV?

The good news is No, condoms do not cause BV. In fact using condoms reduces the risk of developing BV by up to 45% (Hutchison 2011). However do be careful with spermicide coated condoms may have an effect on the vaginal microbiome.

BV and oral contraceptive pills

Using estrogen-containing oral contraceptives is associated with a reduced risk of BV (Shoubnikova 2007, Bradshaw 2012).

If you need to remove an IUD while treating BV, both estrogen-containing contraceptive pills and condoms are a great alternative.

5. Bacterial Vaginosis and Sex

Women who are sexually active are at increased risk of developing BV over their lifetime. BV can be transmitted during sex via the sharing of intimate flora with your sex partner.

It is thought that the sharing of bacteria can occur from the penis to the vagina or from one female sex partner to another. The sharing of intimate microflora can disrupt the delicate balance of bacteria in the vagina, leading to the establishment of BV-associated bacteria, the development of biofilm and establishment of symptoms of infection.

Bacterial Vaginosis: How to stop recurring BV

Sex with bacterial vaginosis

  1. To minimize the risk of BV, use condoms, especially if you change partners frequently or have multiple sex partners.
  2. Consider an estrogen-containing oral contraceptive.
  3. If you have bacterial vaginosis consider using condoms until your treatment is complete.

Bacterial vaginosis and oral sex/anal sex

Recent anal sex or sex toy use both more than double the risk of developing bacterial vaginosis (Bardin 2022).

To minimize the risk of BV with anal sex change condoms before going from anal to vaginal sex.

Ensure that sex toys are frequently washed. Ensure that anything to be placed in the vagina that has been in the anus is pre-washed with soap and warm water.

However the frequency of sex, oral sex and lubricant used does not increase the risk of developing BV (Bardin 2022).

Frequently asked questions about Bacterial Vaginosis

Can BV affect pregnancy?

BV can be experienced by women who are pregnant. It can be treated during pregnancy with antibiotics. Metronidazole is considered sate during pregnancy even during the first trimester. It can also be used during breastfeeding.

Untreated BV can increase the risk of premature birth, low birth weight babies, miscarriage and early IVF pregnancy loss.

A clinical trial screened women for BV between 13 and 20 weeks of pregnancy (Lamont 2003). The women were randomized to treatment of BV with vaginal antibiotic cream or placebo cream. The study found a 60 percent reduction in preterm birth in the treatment groups compared with the women in the placebo group .

Should women be screened for BV before having an abortion?

It is recommended that women who are undergoing a surgical abortion are screened for BV and treated if the infection is present to reduce the risk of infection of the uterus (endometritis) (Hay 2012).

Is bacterial vaginosis an std (sexually transmitted disease)?

The question of whether bacterial vaginosis is an STD is still being researched. There is certainly sharing of BV associated bacteria between sex partners (Muzny 2019).

Does BV increase the risk of sexually transmitted infections?

Bacterial vaginosis is associated with an increased risk of many STIs including: chlamydia, gonorrhea, herpes, HIV and trichomoniasis. It is also associated with the development of pelvic inflammatory disease (PID) (Ness 2005).

Can men get bacterial vaginosis?

Men do not get bacterial vaginosis. They can be colonized with BV-associated bacteria such as Gardnerella vaginosis and they can share it with their partner and contribute to their being colonized with BV-causing bacteria.

Men can get non-specific urethritis (infections of the urethra) that is associated with G. vaginalis (McCormick 2021).

Hopefully you have found some great tips about how to stop recurring BV so you can enjoy great vaginal health.

Dr Deborah Brunt Kale Berri Health

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