Bacterial Vaginosis; a story of good vs evil

his article will be specific to Bacterial Vaginosis but look out for others discussing vaginal health.

Itching! Burning! Change in color! Odor! Vaginal Discharge!

You need someone to take a look! If you take anything away from this is do not use telemedicine for what you think is BV. Get an actual in-person exam, let your Doctor take a look and do some vaginal swabbing.

Let's start off with dispelling some misinformation as many people freak out when they hear BV!

It is not a Sexually Transmitted Infection (STI) so try not to accuse your partner. Instead, it is an overgrowth of one bacteria and lack of lactobacilli; a very important bacteria in our vagina as you will see.  

BV can sometimes be found on pap w/o necessarily looking for/ordering tests for it so to treat or not to treat will depend on whether we are symptomatic or asymptomatic. 

While it is not an STI the bacteria can be spread amongst female partners, unclean sex toys, new partner, and lubricants can contribute (use a plain lubricant best w/o the fun smells & add ons), and douching. Pretty much anything that can change the balance of your bacteria.  

BV symptoms: thin discharge, lots of it, grayish-white and foamy, skim milky and odor “fishy smell.”
Not much of symptoms such as itch/irritation but you can have that from the constant dampness.

When the lactobacillus colonizes the vagina it produces lactic acid suppressing the growth of Gardnerella vaginalis and other bacteria. This overgrowth of various bacteria is what leads to decrease in hydrogen peroxide needed to kill the overgrowth of the bacteria.

Microscope show clue cells (cells covered with bacteria on it). pH paper shows pH of vaginal fluid >4.5 (can also indicate trichomonas which is an STD). In presence of lactobacilli you are creating lactic acid so the normal vaginal fluid pH is<4.5. 

Amsel criteria, Nugent scoring and NAAT (nucleic acid amplificaiton test) are some ways to test for BV.

High recurrence rate, so you need an exam! Your Doctors needs to know if it was BV to begin with so worth confirmation when treating and having to come up with a retreatment plan.

Treatment: Metronidazole pill/vaginal gel are most effective, there are alternatives if you are allergic/can't take Metronidazole but treatment does require prescription.

Do probiotics work? Some promise with nightly intervaginal capsule is an option.

Which one? Intravaginal L. crispatus. NOT oral probiotics! Oral formulations have not shown to be as promising as intervaginal suppositories (closest one I can find w/ L. crispatus was Jarro-dophilus vaginal probiotic). This helps to restor the lactobacillus and provide that more acidic environment to help keep the other bacteria at bay.

Vaginal Boric acid (oral ingestion can cause death, keep away from children) has some promise to decrease recurrence when used in conjunction with prescription treatment.

Treating partners: not recommended and has not shown to be effective.

Why treat BV? It can actually increase your risk for other Sexually Transmitted infections such as gonorrhea and chlamydia. Those with BV and HIV are at higher risk of transmitting HIV to partners due to increase in shedding of virus. It is a risk factor for HSV-2 and reactivation of HPV.  In high risk pregnant symptomatic women it may lead to pregnancy complications such as preterm delivery.

Further reading found:

https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(22)00043-X/fulltext https://www.ncbi.nlm.nih.gov/books/NBK459216/