Bacterial vaginosis (BV)
Bacterial vaginosis (BV) is the overgrowth of unfriendly bacteria in your vagina, resulting in bad smells, unusual discharge and/or alkaline pH over 4.5.
Classic BV produces a fishy odour and discharge, but because it does not technically cause inflammation (according to its medical definition), there will be no itching, soreness or redness. As you may be experiencing, this isn’t always true: you may have a diagnosis of BV, but have all sorts of non-classic-BV symptoms.
Bacterial vaginosis is often caused by a bacteria called Gardnerella vaginalis, but this bacteria often has ‘friends’ that it uses to help build its home and defences, which may contribute to other symptoms you may be experiencing. The ‘home’ it makes is what’s known as a bacterial biofilm – think of it like a perspex case that covers it, protecting the bacterial colonies from treatments.
These ‘friends’ often don’t cause BV on their own, but are known as ‘BV-related bacteria’. Not everyone has BV-related bacteria, but there is always a ringleader.
Classic BV can be very quiet, but pungent. If you have itching, swelling, soreness or other symptoms, it means you have more than just G. vaginalis or you do not have BV at all.
There are many crossover bacteria that can co-exist together to create a unique set of symptoms. It’s this set of symptoms that will give you clues as to what’s lurking, and therefore what to get tested for or what treatments to choose.
For example, your vaginal odour may be more like rotten meat or a bit off, metallic or vinegary, rather than fishy. This matters – it may mean you have aerobic vaginitis or other BV-related bacteria.
Non-classic-BV symptoms can include an ammonia odour, green or yellow discharge, itching (which be worse at night), your period soothing your symptoms instead of exacerbating them, and a lack of response to typical treatments. There are many variables to BV, which makes treating it sometimes complex (and annoying).
Symptoms of ‘classic’ BV
- Fishy odour
- Alkaline pH over 4.5 (learn how to test yourself at home)
Symptoms of BV+, AV or other vaginal microbial imbalances or infections
- Pelvic pain
- Pain after sex
- White, yellow, green, clumpy, thick or bloody discharge
- Odour is rotten or off (not fishy) or like ammonia or vinegar
- A test may come back with no results (testing for the wrong thing)
- Symptoms alleviated during period
Diagnosis of BV
Your initial doctor’s visit is likely to include a swab that is sent for culturing – that is, the lab grows your vaginal bacteria to see what emerges.
A culture cannot find some BV-related bacteria, because some are hard to grow in these conditions, so a PCR test is also recommended, with a full BV/AV/lactobacilli test.
There are grades of flora, so you may have a result that is indicative of BV, or not, or perhaps you will get the result of ‘intermediate flora’.
To have BV, your pH will also be too high – you can test this at home using pH strips. If your vaginal fluids look higher than 4.5 pH, you may have BV.
A vagina that is low in lactobacilli and high in G. vaginalis is a vagina considered to have BV, generally speaking, but you can have low levels of lactobacilli and have no symptoms and not have BV.
Usually BV – whether it is truly BV or not – is treated using standard antibiotics that may or may not work, either temporarily or over the longer term. This lays the groundwork for recurrent vaginal problems that are resistant to many types of treatment, while also knocking out some of your healthy gut flora.
The doctor will usually prescribe metronidazole, an antibiotic, which works about half the time in a woman’s first-time case of BV. Other antibiotics may be prescribed depending on the level of testing done.
You can get rid of BV many non-antibiotic ways, but your doctor can only prescribe antibiotics, so it may pay to see a BV-specialist healthcare practitioner who can offer you effective non-antibiotic treatments. Antibiotics do not break down the bacterial biofilm that is often involved in recurrent BV, so is ineffective.
First thing to ensure is proper testing and exclude STIs, then make a treatment decision based on your results and research into BV.
How BV works in your vagina
An overgrowth of bad bacteria causes your vaginal environment to become hostile to your healthy bacteria, lactobacilli.
The bad bacteria use various weapons to take over your vagina: they create a more alkaline environment, stop your cells from being able to defend themselves, and many of them create a sticky antibiotic-resistant biofilm to keep safe from treatments, including antibiotics.
This is why BV can be unresponsive to antibiotics and keep on reappearing, no matter what you do.
What is a bacterial biofilm?
A biofilm is like a film of wax or clingfilm over your vaginal cells that provides a safe haven for many types of bacteria, which is why BV is known as a polymicrobial (many microbes) – condition. The main culprit in BV is understood to be Gardnerella vaginalis, but this microbe is far from the only major player. Many microbes create biofilms, including lactobacilli, which are your good bacteria. Biofilms aren’t bad in and of themselves, but they complicate your treatments when the wrong biofilms are in place.
The biofilm is what keeps BV ‘returning’ time and again because it never really goes away. Antibiotics, probiotics and home remedies do not get rid of the biofilm, which is why BV can seem impossible to get rid of.
BV is curable, but you need to use different tools, which we explain in detail in our book on removing the biofilm and curing your BV for good, Killing BV.
Typical treatments for BV and why they don’t work on recurrent BV
BV can recur over a lifetime despite multiple treatments. It can be difficult to find a doctor who really understands bacterial vaginosis, and will test you thoroughly and stop prescribing you the wrong antibiotics repeatedly. You should seek specialist vulvovaginal doctors out if you have BV that just won’t go away, and demand better testing and more thoughtful treatments.
Remember, your doctor only has a short time with you and is busy, so find a doctor who likely deals in BV often, so it’s more on their radar.
You may have tried apple cider vinegar, hydrogen peroxide, lactic acid, vitamin C, vitamin D, vitamin B, folic acid, probiotics and yoghurt. In Killing BV, we explain why these treatments have continually failed, and provide you with a dedicated treatment plan to get rid of your BV.
How do you know if you have BV?
BV symptoms caused by G. vaginalis are pretty specific – the fishy vaginal odour is your first clue (but this can be caused by some sexually transmitted infections – trich or gonorrhoea), plus the distinctive discharge.
But, you may have watery discharge, no discharge, no smell, or no symptoms (asymptomatic). You could have been diagnosed with BV via a swab taken at your doctor’s office. The test will come back high for G. vaginalis and you will have a higher than normal pH.
The precise cause of your symptoms – fishy odour and discharge
The odour is caused by a chemical reaction of molecules in your vagina that results in the production of trimethylamine (TMA), which is the exact same molecule that causes fish to smell like fish. You can read more about the exact reaction here.
The watery discharge is caused by enzymes that the bacteria excrete breaking down your naturally-produced vaginal mucous. This causes it to become watery. It is also why BV can trigger preterm birth – the mucous plug that holds the fluid in the womb gets broken down by the enzymes.
Any itch is due to irritation and damage to your vaginal cells caused by the bacteria and biofilm.
Who gets BV?
BV is one of the most common vaginal infections in the world, and affects all populations almost equally, though women of African descent naturally have fewer protective lactobacilli in their vaginas and are more prone to BV than other groups of women.
Children do not get BV, but past puberty, any woman can get BV whether they are sexually active or not – while BV can and often is sexually transmitted (those biofilms again), it isn’t always.
The BV-causing bacteria may naturally reside in the vagina, but when the balance of good bacteria is off for whatever reason and your cellular immunity is down, the bad bacteria can overgrow from something as slight as a pH change (think semen, menstrual blood), causing an imbalance.
BV is not an infection per se, but an imbalance of bacteria (vaginal dysbiosis) that results in symptoms, which all depends on what specific bacteria you have. They all have different natures.
The biofilm causes recurrent BV
Recurrent BV is caused by the sticky bacterial biofilm, which blocks your friendly microbes from controlling the lion’s share of your vaginal surface area. The planktonic bacteria may be killed off by antibiotics, but the biofilm remains.
Women often think that their BV is ‘coming back’ all the time, especially after sex where semen enters the vagina or a menstrual period. This happens because both semen and menstrual blood have an alkaline pH, but men can be passing the infection back to their female partners all the time too. We’ve written a book just for men, Killing BV: Guide for Men, so this cycle can be interrupted and both partners can be treated for BV-related bacteria and biofilms.
The symptoms you are experiencing are caused by your vaginal environment becoming an unfriendly home to your good microbes.