Updated: Feb 13
It Smells, It Hurts, and We Want it Gone
The 'Bacterial' in BV
Bacterial Vaginosis (BV) is considered an “ecological disorder” of the vagina – it's literally an overgrowth of any – and usually many – of the non-Lactobacillus bacteria of the vagina.
(The right Lactobacillus bacteria strains are our defenders. We want lots of them, beating down on everything else that shows up.)
BV is the most common disorder in vaginas of reproductive age. It's not a Sexually Transmitted Infection, although it can have links with sexual activity.
These pie charts show a healthy vaginal microbiome on the left, and a picture of BV on the right. The healthy microbiome has loads of Lactobacilli; the microbiome causing unpleasant symptoms has loads of everything but Lactobacilli. (Every case of BV is different, this is just one possibility.)
Up to half of all cases of BV are not recognised because symptoms are not strong enough to make women acknowledge something isn't right here. But even if it's more a passing annoyance than a significant problem, it can still be affecting your health.
Can we create a healthier environment for our vaginal bacteria? Yes, we can. But let's identify the problem first.
The Symptoms of BV
Itch or irritation
Urgency (urgent need to pee)
Discomfort during or after passing urine
Low-level symptoms interspersed by flares
Flares may include abdominal swelling
Discharge is often plentiful, watery and persistent
Discharge is commonly white or grey, and may have a fishy smell
Discharge may be green or yellow if aerobic bacteria (eg E.coli or E.faecalis) are responsible
Intercourse (or medical exam) may cause irritation or pain, often described as burning, chafing or stinging which gets worse as the act continues. Women may notice bleeding or pink discharge afterward, and vulval swelling/puffiness may persist afterward.
Less common symptoms that still could indicate BV include itching worsening at night, an ammonia odour, and menstruation easing the vaginal symptoms.
The HUGE Health Impacts of BV
Aside from being irritating, uncomfortable and potentially embarrassing, BV is a serious health concern.
Although the details are still under study, BV has an association with preterm delivery, amniotic fluid infections, chorioamnionitis, pelvic inflammatory disease (PID), cervicitis and increased susceptibility to infection with STIs.
The loss of natural protection in the vagina makes the woman two to three times more likely to be infected with STIs such as Gonorrhoea, Chlamydia, Trichomonas, HSV-2 and HIV.
It has been established that BV can also contribute to recurrent urinary tract infections (UTIs). The UTI may be effectively treated with antibiotics, but the vagina can act as a reservoir of bacteria which can reinfect the bladder, allowing a new UTI to develop.
If Bacterial Vaginosis exists in a woman who has an IUD inserted, or has a termination of pregnancy, or some other form of instrumented vaginal procedure, she has a much higher than normal risk of developing Pelvic Inflammatory Disease as a result of the procedure. Despite this being well known medically, there is no current medical recommendation for women to be screened or treated for BV before these procedures.
Get a Diagnosis - If You Can
The most common way of diagnosing BV in a doctor’s rooms is using Amsel’s Criteria. If a woman has three of the following four criteria, BV is diagnosed:
Thin, grayish-white discharge that smoothly coats the vaginal walls.
Vaginal pH greater than 4.5.
Positive whiff-amine test, defined as the presence of a fishy odour when a drop of 10 percent potassium hydroxide (KOH) is added to a sample of vaginal discharge (sometimes odour is assessed without adding KOH)
Clue cells on saline wet mount (slide for microscope). For a positive result, at least 20 percent of the epithelial cells on wet mount should be clue cells. The presence of clue cells diagnosed by an experienced microscopist is the single most reliable predictor of BV
If available, lab tests using DNA technology can be used to identify the microbes in a sample. This means BV can be diagnosed even if not enough of the above criteria are met. However, this technology is more expensive and less accessible, so it isn't used often.
Recent advances in technology have made it possible to identify many more types of bacteria, which has allowed a much greater understanding of the complexity and variety of Bacterial Vaginosis. One woman’s case of BV might involve an overgrowth of one specific problematic bacteria, or of any number of different bacteria. The next woman’s case could involve a different set of bacteria altogether.
Unfortunately, the average woman is not being assessed or diagnosed using DNA technology, and she is frequently not being diagnosed or treated at all.
Make BV Less Likely
There are common factors amoungst women who don't get BV. This list is drawn from decades of studies. You are less likely to get BV if you:
Have a high BMI – obese women have a 20% lower risk, possibly due to higher estrogen levels (but being overweight has other risks, so this isn't a treatment strategy)
Have Asian ancestry (too late to change your parents!)
Use Estrogen via the combined Oral Contraceptive Pill or from vaginal estrogen creams – but these unfortunately promote Thrush
Eat a nourishing diet
Have good general health
Don't Invite BV in!
Just like the previous list, some of these factors can't be changed to improve your chances. Understanding where the risk comes from might make the "why me" a little easier to deal with.
These factors are known to increase the likelihood of developing BV:
Women having sex with women (not sure why, may relate to exposure to bacteria that men don't tend to carry)
Recent antibiotic use
High frequency of sexual contact
History of more sexual partners
Douching (washing inside the vagina)
The copper IUD or Mirena IUS (birth control devices)
For the love of your vagina, if you douche, STOP IT. It's the easiest thing on that list to change.
Management of BV
Medically, the recommended treatment for diagnosed BV is a course of antibiotics. This is likely to be effective, particularly in the short term, but many women find BV recurs.
In fact, it has a nasty habit of coming back again, and again, and again.
There are a range of alternative treatments, many of which can be used alongside prescribed antibiotics for a more effective result. These are aiming to support a lasting change in the microbiome.
Potential management options include
specific acid therapies
the right probiotics
properly formulated Calendula products
(Articles detailing each of these are scheduled, starting with one on lifestyle strategies and nutrition coming up 7 days after this post. Watch for this whole series on the blog!)
Some of the "home remedies" you might find on the internet that DO NOT WORK and may cause actual harm include lysol, hydrogen peroxide, and sticking raw garlic in your vagina. So don't.
Check out the rest of the series on Vaginal Health HERE!
Top image of woman is by Abigail Keenan on Unsplash
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