Up to 75% of women will experience a vaginal yeast infection in their lifetime, so it's understandable why many women will assume they have a yeast infection when they begin to experience vaginal symptoms. However, other conditions can present with similar symptoms, and one study showed that only about one-third of women are correct when they self-diagnose vaginal yeast.
Bacterial vaginosis is actually the most common cause of vaginal discharge worldwide. This article aims to bring attention to this prevalent women's health concern and provides a sample treatment protocol that healthcare providers can adapt for their own use in clinical practice.
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What Is Bacterial Vaginosis?
Bacterial vaginosis (BV) is one of the most common types of vaginal infections in women of reproductive age, characterized by an imbalance in the vaginal flora. In the United States, BV affects 21 million women.
What Causes Bacterial Vaginosis?
The vaginal microbiome is the community of microorganisms predominantly composed of various species of Lactobacillus. Lactobacillus bacteria maintain a healthy vaginal environment by producing lactic acid, which lowers the pH of the vagina to around 4.5. This acidic environment is inhospitable to many pathogenic microorganisms, thus providing a natural defense against infections.
BV occurs when there is a disruption in the normal distribution of bacteria within the vagina: Lactobacillus concentrations are reduced, while other types of anaerobic bacteria, such as Gardnerella vaginalis, begin to overgrow (14).
Several factors have been identified as potential contributors to the development of BV by disrupting the normal balance of the vaginal microbiome. These include:
- Antibiotics
- Vaginal douching
- Use of spermicides
- Hormonal changes
- Sexual intercourse
BV is more common in people who are sexually active, have multiple sex partners, whose sex partner has BV, and do not use condoms. Despite these risk factors, it's important to note that BV is not classified as an STI. (14, 23)
Bacterial Vaginosis Signs & Symptoms
Because BV often doesn't cause any symptoms, many people won't know they have it (31).
When they do occur, the main symptoms of BV include:
- Thin vaginal discharge that looks white, gray, green, and/or foamy
- Strong, fishy vaginal odor
- Vaginal itching
- Pain or burning with urination and during sex
How to Diagnose Bacterial Vaginosis
Without a physical exam and laboratory testing, it's hard to know if BV or another vaginal infection is causing your symptoms. Anyone who suspects they have BV should schedule an appointment with their doctor to ensure the appropriate tests are conducted.
Step 1: Use the Amsel Criteria
A diagnosis of BV is typically presumed based on patient-reported symptoms and is confirmed by obtaining a vaginal swab and preparing a wet mount slide. A vaginal wet mount is a test where your doctor places a sample of discharge on a glass slide, mixes it with a salt solution, and examines it under a microscope.
According to the Amsel Criteria, BV can be diagnosed when at least three of the following criteria are met:
- Homogenous vaginal discharge is present
- Vaginal fluid pH is greater than 4.5
- "Whiff test" is positive: an amine (fishy) odor is noted when 10% potassium hydroxide solution is added to vaginal secretions
- Clue cells are visualized on wet mount microscopy
If you have three or more confirmed episodes of BV in 12 months, you will be diagnosed with recurrent BV.
Step 2: Order Labs to Understand the Root Cause of BV
Your doctor may also recommend ordering additional labs to identify predisposing factors to infection (especially in patients with recurrent BV) and personalize treatment options. These lab results can help doctors personalize treatment recommendations to improve patient outcomes and prevent BV recurrence.
Comprehensive Vaginal Assessment
Various tests can provide a comprehensive evaluation of the vaginal environment. While a pelvic exam and wet mount assist in diagnosing BV, they don't identify the causative bacterial pathogen, nor do they rule out the presence of other infections, such as vulvovaginal candidiasis, that can cooccur with BV.
The following panels are available to rule out other infections and identify specific dysbiotic shifts in the vaginal microbiota that predispose an individual to opportunistic bacterial overgrowth:
- Vaginosis Profile by Doctor's Data
- STD Panel, Comprehensive by Access Med Labs
- Vaginal BiomeFx by Microbiome Labs
Comprehensive Hormonal Assessment
Estrogen stimulates Lactobacillus growth and promotes the health of vaginal tissues. When estrogen levels are low, Lactobacillus populations decrease, and vaginal tissues become thinner and drier. These changes create a favorable environment for anaerobic bacteria to overgrow. (21, 25)
One study also found that irregular vaginal bleeding was a significant risk factor for recurrent BV, further supporting the notion that hormonal imbalances play a role in BV etiology.
The following panels measure female reproductive hormones to screen for hormonal imbalances that can contribute to suboptimal vaginal health:
- Female Hormone Panel by BostonHeart Diagnostics
- DUTCH Cycle Mapping + Sex Hormone Metabolites (Dried Urine) by Precision Analytical (DUTCH)
Intestinal Microbiome Analysis
Intestinal dysbiosis can contribute to recurrent BV. The gastrointestinal tract can act as a reservoir for bacteria implicated in BV. Given the proximity of the vagina to the anus, these bacteria can migrate from the gut to the vagina, disrupting the normal balance of vaginal microbiota.
Intestinal dysbiosis can weaken immune defenses, making the vaginal area more susceptible to infection, and promote systemic inflammation that fosters pathogenic bacterial growth. Additionally, because the gut microbiota influences estrogen metabolism, dysbiosis can disrupt estrogen levels, affecting the vaginal epithelium and reducing the growth of protective lactobacilli. (7)
The following stool tests are excellent options to screen for intestinal dysbiosis and gastrointestinal infections:
- GI-MAP by Diagnostic Solutions
- BiomeFx by Microbiome Labs
- GI Effects Microbial Ecology Profile - 1 day by Genova Diagnostics
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Treatment Plan for Bacterial Vaginosis
Effective treatment protocols for BV alleviate symptoms, prevent recurrences, and reduce the risk of associated health complications.
Step 1: Eradicate Bacterial Overgrowth
Here's Why This Is Important:
It is recommended to treat BV to resolve vaginal symptoms and prevent complications associated with untreated infections (discussed in more detail below).
How Do You Do This?
First-line therapies for treating BV include seven-day courses of oral or intravaginal metronidazole or intravaginal clindamycin. Evidence has not suggested that one option is significantly more effective than another. (22)
Inserted vaginally, boric acid has been used for over a century to treat vaginal infections. Boric acid promotes a healthy vaginal pH and can disrupt biofilms produced by bacteria, which can contribute to BV recurrence. Studies show that intravaginal boric acid (600 mg for 2-3 weeks), used alone or with antibiotics, is an effective treatment option for BV. (1, 34)
Step 2: Prevent Reoccurrence
Why Is This Important?
Up to 80% of patients will experience a recurrence of BV within nine months of completing initial antibiotic treatment.
How Do You Do This?
Diets high in refined carbohydrates and sugars can disrupt the natural balance of the intestinal and vaginal microbiomes, leading to dysbiosis. By limiting the intake of refined carbohydrates and sugars and increasing the intake of fiber-rich foods, it is possible to prevent the development of dysbiosis and maintain a healthy microbiome.
Certain dietary components have been associated with a decreased risk of severe BV. Reducing dietary fat and eating adequate folate, vitamin A, and calcium protect against BV. (19)
- Folate-Rich Foods: fruits, vegetables, grains, and legumes
- Vitamin A-Rich Foods: liver, fish, eggs, dairy products, and orange/yellow vegetables
- Calcium-Rich Foods: dairy products, bone-in fish, cruciferous vegetables, and tofu
Probiotics are beneficial bacteria that can help restore and maintain a balanced vaginal microbiome.
- Probiotic-rich foods like yogurt, kefir, sauerkraut, and kimchi can introduce beneficial bacteria to the gut, improving intestinal and vaginal health.
- Probiotic supplements, specifically those containing Lactobacillus rhamnosus, Lactobacillus reuteri, and Lactobacillus acidophilus, can be used orally and intravaginally during and after antibiotic therapy to increase the cure rate and prevent infection recurrence. (10, 18, 30, 32)
Vitamin C's acidic and antimicrobial properties have been shown to restore the acidic pH and promote a healthy vaginal environment. One study found that 250 mg of intravaginal vitamin C reduced BV recurrence by nearly 50%.
The Risks of Untreated Bacterial Vaginosis
Untreated BV can lead to several health complications, including increased risk of:
- Contracting a sexually transmitted infection (STI), such as HIV, HSV, chlamydia, or gonorrhea
- Infection after gynecological surgery
- Pelvic inflammatory disease (PID)
- Pregnancy-related complications, such as preterm birth and low birth weight
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Key Takeaways:
- BV is a common vaginal infection that affects millions of women and often reoccurs after treatment.
- Adding additional nutritional and supplemental therapies to antibiotic treatment can address the root causes of BV, enhance eradication rates, and prevent infection recurrence.
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