Bacterial vaginosis (BV) is a common vaginal condition found in women of reproductive age, estimated to occur in many women. It affects a significant number of women ages 14 to 49, but rates can vary. Untreated BV may increase the risk for health complications, especially in those who are pregnant and sexually active. Natural, holistic approaches may help support the management and recurrence prevention of BV. (2)
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What is Bacterial Vaginosis?
BV is associated with a shift in vaginal flora from the normal predominance of Lactobacilli species of bacteria. It is often linked to increased growth of anaerobic gram-negative bacteria, like Gardnerella vaginalis. Lactobacilli produce hydrogen peroxide, which helps maintain an acidic environment within the vagina, supporting its natural defenses. Anaerobic bacteria produce large amounts of enzymes that break down vaginal peptides into amines, contributing to the characteristic odor of BV. (2, 3)
The connection between sexual activity and BV is not completely understood. However, BV is more common in people who are sexually active with multiple partners, in people whose sexual partner also has BV, and in people who do not use condoms. Other factors that may increase the risk for BV include vaginal douching, cigarette smoking, and sharing sex toys. (4, 5)
BV may reduce the vagina's natural defenses against infections and other pathogens that can access the upper genital tract, potentially increasing the risk for sexually transmitted infections (STIs) like HIV, herpes simplex virus, chlamydia, and gonorrhea. BV and STIs can also be associated with pelvic inflammatory disease (PID), an infection within the uterus, fallopian tubes, or ovaries. (2, 5)
Other complications may be associated with untreated BV. BV in pregnant women has been linked to premature birth and low birth weight babies. BV may also increase the risk of post-surgical infection after procedures like hysterectomy and dilation and curettage (D&C). (5)
Bacterial Vaginosis Signs & Symptoms
BV is often identified using the Amsel Criteria when at least three of the following clinical and microscopic findings are present:
- Homogeneous vaginal discharge
- Vaginal fluid pH greater than 4.5, associated with a reduction in hydrogen peroxide-producing Lactobacilli
- Positive "whiff test": an amine (fishy) odor observed when 10% potassium hydroxide solution is added to vaginal secretions
- Presence of clue cells (at least 20%) on wet mount microscopy: these cells appear fuzzy without sharp, delineated edges
The most common symptoms of BV include a thin vaginal discharge and a malodorous, "fishy" smell. The vaginal discharge typically has a gray-white color but can vary in color and volume. Some individuals may also report vaginal itching, discomfort with urination, and discomfort during sex. However, many individuals with BV may not have any symptoms and only discover it through a routine gynecologic exam. (1)
Causes of Bacterial Vaginosis
Vaginal dysbiosis, an imbalance in the "good" and "bad" bacteria in the vagina, is often associated with bacterial vaginosis. The three main factors that may contribute to the decline in Lactobacillus numbers include intercourse without condoms, douching, and broad-spectrum antibiotics.
Gut dysbiosis can also be related to vaginal dysbiosis. Given their close anatomic proximity, the origin of microorganisms colonizing the cervicovaginal space has been traced to the rectum. Dysbiosis originating in the gut may translocate to the vagina, altering vaginal Lactobacillus dominance.
Hormonal imbalances can also influence the composition of the vaginal microbiome. Estrogen supports vaginal colonization by Lactobacilli, which metabolize glycogen and produce lactic acid, helping to maintain an acidic vaginal environment. Decreased estrogen levels, such as in the post-menopausal state, may deplete Lactobacilli in the vagina and increase vaginal pH, potentially predisposing the vagina to colonization by opportunistic bacteria. Hormonal imbalances can also cause frequent periods; the neutral pH of menstrual blood passing through the vaginal canal can cause vaginal pH to rise, increasing the risk of BV.
Functional Medicine Labs to Test for Root Cause of Bacterial Vaginosis
A vaginosis panel combines microscopic analysis and gram-staining of vaginal secretions to identify gram-negative bacteria and clue cells characteristic of BV. This panel also screens for vulvovaginal candidiasis and Trichomonas vaginalis, other common causes of vaginal symptoms that may occur alongside BV. Antimicrobial susceptibility testing to prescriptive and natural agents is performed for identified bacterial and fungal species to guide effective management recommendations.
Patients with recurrent BV infection may benefit from a more extensive microfloral evaluation of the vagina and gut with specialty vaginal and intestinal microbiome analyses. A lack of Lactobacillus and overgrowth of anaerobic bacteria (e.g., Gardnerella vaginalis, Mycoplasma hominis, and species of Mobiluncus, Bacteroides, Peptostreptococcus, Fusobacterium, Veillonella, Eubacterium, and Clostridium) is a characteristic microbial pattern in recurrent BV. (6)
Serum and urine tests can measure sex hormones (estrogen, progesterone, testosterone) and their metabolites to comprehensively evaluate possible hormonal imbalances contributing to irregular menstrual cycles and vaginal dysbiosis.
Doctors may also consider ordering a complete STI panel for patients at risk for STI exposure. Risk factors include being young (age 15-24), having multiple sex partners, having unprotected sex, and having sex while under the influence of drugs or alcohol.
Conventional Treatment for Bacterial Vaginosis
Treatment is often recommended for all symptomatic women with antibiotic therapy. First-line treatment options may include an oral or topical course of metronidazole or clindamycin. All options are generally considered safe and comparably effective. Oral antibiotic therapy has been shown to reduce pregnancy-associated morbidity, whereas topical treatments have not. (1)
Functional Medicine Approaches for Bacterial Vaginosis
Approaches to managing bacterial vaginosis may include: supporting a healthy vaginal pH, promoting immune response, encouraging microfloral balance, reducing inflammation, and supporting antimicrobial activity.
Nutrition for Bacterial Vaginosis
A well-balanced, healthy diet rich in whole foods and low in fat, sugars, processed foods, and alcohol may support overall health, reduce inflammation, support hormonal balance, and encourage microbiome homeostasis.
Diets high in refined carbohydrates and sugars may contribute to negative dysbiotic patterns within the intestinal and vaginal microbiomes. Limiting the intake of refined carbohydrates and sugars may help support a balanced microbiome.
Dietary folate, vitamin A, and calcium intake may support vaginal health. Good food sources of folate include a wide variety of fruits, vegetables, grains, and legumes. Vitamin A-rich foods include liver, fish, eggs, dairy products, and orange/yellow vegetables. Dairy products, bone-in fish, cruciferous vegetables, and tofu are high in calcium. (7)
Supplements for Bacterial Vaginosis
Oral and vaginal probiotics may effectively support antimicrobial therapies to manage BV and support its recurrence prevention. Strains of Lactobacillus, acidophilus, rhamnosus, fermentum, and reuteri are commonly used to promote vaginal health. (8-10)
Vitamin C is known for its beneficial effects on the immune system, and research suggests that vaginal administration of vitamin C may support Lactobacillus growth and help maintain a healthy vaginal pH.
Natural Options for Bacterial Vaginosis
Boric acid has been used for over one hundred years to support vaginal health, such as in cases of BV and candidiasis. Some studies suggest that intravaginal boric acid used in addition to antibiotic therapy may be effective in managing BV. (11-13)
Tea tree oil has been studied for its potential to support the management of trichomoniasis, candidiasis, and other vaginal conditions. Given its broad-spectrum antimicrobial properties, diluted intravaginal tea tree preparations have been explored for BV management.
Goldenseal and Oregon Grape Root contain a compound called berberine, which is known for its antimicrobial properties. Research suggests that berberine may support vaginal health by reducing inflammation and improving clinical symptoms.
Prevention for Bacterial Vaginosis
Support a healthy vaginal microbiome by avoiding vaginal douching, which can alter the natural balance of bacteria, and avoiding vaginal contact with anything that has touched the anus (e.g., toilet paper, fingers, sex toys) (14).
Cotton wicks away moisture. Cotton or cotton-lined underwear may help create a dryer vulvovaginal environment and support bacterial balance. (14)
Minimize vaginal irritation by using unscented soaps, tampons, and pads (5).
Use condoms when engaging in sexual activity and wash sex toys after every use (5).
Summary
Bacterial vaginosis is a common vaginal condition associated with a shift in the healthy vaginal flora. Although not considered an STI, BV is more common in sexually active individuals. Antibiotic therapy is often recommended for all symptomatic people. For some, BV may recur after treatment. Specialty testing can help identify chronic imbalances in the vaginal and intestinal microbiomes and hormonal fluctuations that may contribute to recurrent BV. Lifestyle habits promoting good vaginal hygiene, dietary choices, and natural supplements may help support a healthy vaginal microbiome and reduce the likelihood of BV recurrence.
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