The ultimate guide to bacterial vaginosis (BV)

A cute bacteria hitching a ride on a fish as per bacterial vaginosis.

Bacterial vaginosis (BV) is the overgrowth of disruptive bacteria in the vagina, which can result in odour, unusual discharge and a shift in vaginal pH. BV may be asymptomatic, only found during health testing for other reasons.

A premenopausal healthy vaginal microbiome tends to be made up largely of protective bacteria such as lactobacilli, a lactic-acid-producing bacteria that fight pathogens and keep infections away.

If you’ve been diagnosed with BV, sadly, you’re not alone!

The Center for Disease Control (CDC) says BV is the most common vaginal issue in ages 15-44 – a whopping 30% get BV each year.

When lactobacilli dominance is disrupted, the vaginal pH can rise allowing other types of bacteria to grow and cause an imbalance (known in medicine as vaginal dysbiosis).

This vaginal bacterial imbalance can contribute to symptoms like vaginal odour, irritation, itching, burning and unusual vaginal discharge. ‍But, up to 84% of those with a BV diagnosis won’t get any symptoms.

Understanding why BV occurs

In some uncomfortable news, the CDC also says that we don’t know why BV develops. Why some of us and not others? My Vagina is working on the how and why of BV, alongside some of the best minds in the medical field.

A BV vagina – a bus full of noisy, smelly, rude kids

BV is not an infection, but an imbalance. You’re on a bus when 15 rowdy, rude eight-year-olds get on board. There is nothing technically wrong with this – it’s just a change in who is on the bus.

BV is a change in bacterial species in your vagina.

There is an umbrella term for this change in species: vaginal dysbiosis. Dysbiosis means a microbial imbalance, or simply put, the wrong bugs in the wrong place.

Vaginal dysbiosis appears in many forms, including yeast infections and aerobic vaginitis (AV).

Why does the balance shift?

Your vagina is not an isolated piece of your machinery; it is supported by your entire body. There are lots of reasons why the balance of your vaginal flora may change for the worse, including:

How your vaginal microbes join forces to cause BV

Each of you experiences BV a bit differently because everyone has different bacterial communities. Think of your different species of vaginal microbes as one of the kids on the bus, with its own personality.

BV is often caused by a bacteria called Gardnerella vaginalis, but there are many other culprits. Who is the bully on your bus?

G. vaginalis is a big ‘un because this bacteria is a great ringleader, but your vaginal microbes may be being led by the likes of E. coli or other bacteria that run in different circles to G. vaginalis.

G. vaginalis or E. coli, or whoever the bully on your bus is, recruits bacteria that help make them stay dominant. The characteristics of the ringleader will determine what sort of symptoms experienced.

What is a bacterial biofilm?

Many bacteria build biofilms. Think of it like a perspex case that covers the vaginal cells, protecting the bacteria from treatments and other bacteria (antibiotics).

If your vagina has a lot of biofilm, symptoms may disappear temporarily as the treatments kill bacteria, but there are always more hiding under the safety of the biofilm, so BV returns, whether in a day or a week or a month.

Symptoms of bacterial vaginosis

Remember, your symptoms will depend largely on what bacteria you have present.

For example, a G. vaginalis dominant vaginal microbiome is likely to have a fishy odour, and watery, grey discharge without inflammation. Add Prevotella or Ureaplasma, and you may start getting inflammation.

Meanwhile, an E. coli dominant vagina is likely to be inflamed, burn, and have yellow-green discharge.

Get a comprehensive vaginal microbiome test to find out what’s growing in your vagina. A culture isn’t enough, and a PCR test is only just passable. You want NGS testing, such as from Juno Bio.

  • Itching
  • Redness
  • Soreness
  • Swelling
  • Pelvic or vaginal pain
  • Pain during or after sex
  • Cramping
  • White, grey, yellow, green, clumpy, thick or bloody discharge
  • Odour – fishy, foul, rotten meat, faeces, off-smelling, or like ammonia or vinegar
  • Rawness
  • Symptoms worse during period
Fishy vagina smell

How BV is diagnosed

Regular swab and culture

Every country does BV diagnosis a little bit differently, but the main method (somewhat useful but now outdated compared to a comprehensive vaginal microbiome test), is a culture: growing bacteria on a petri dish to determine the dominant growth of bacteria or yeast.

Comprehensive DNA-based vaginal microbiome testing

A lab culture is the process of taking a vaginal fluid sample, sending it to the lab, and seeing which bacteria or fungi grow over a set period of time, say 12 or 24 hours.

Vaginal culture cannot detect some BV-related bacteria, because some microbes are hard to grow in these conditions. The dominant strains of bacteria will appear, while others will be dismissed as unimportant – which isn’t always true.

A comprehensive vaginal microbiome test looks for microbial DNA/RNA, and can detect the genetic material from even a dead microbe.

Polymerase chain reaction (PCR) tests can only find what the test asks for. If you don’t ask, it won’t tell. This is why the more comprehensive NGS tests are preferable.

Testing vaginal pH (acidity levels)

In BV, vaginal pH may be above 4.5, indicating an abundance of unprotective non-lactobacilli species. You can, and should, regularly test your vaginal pH at home using correctly measured vaginal pH strips.

The vaginal fluids of a someone getting regular periods typically sits between a pH of 3.8-4.5, however, prepubertal girls and those in menopause tend to have a still-healthy pH of 5.0 or higher. This higher pH is due to the absence or low levels of lactic-acid-producing lactobacilli, and it does NOT indicate infection, vaginal dysbiosis or BV unless there are symptoms.

The absence of lactobacilli does not mean the presence of problematic bacteria, but it can mean increased susceptibility to imbalances. This is also true in people without symptoms, but who naturally have a non-lactobacilli dominant vaginal microbiome (or Community State Type 4).

Effectively treating BV

BV can be resolved with appropriate treatment, which may be antibiotics, non-drug treatments or a combination of multiple treatment strategies.

The most common medical treatment for BV is antibiotics, usually metronidazole or clindamycin. There are loads of at-home treatments online, which My Vagina explains the value of (or lack thereof), such as apple cider vinegar, tea tree oil, yoghurt, boric acid and others.

Many of these are options worth trying – they are cheap and unlikely to cause further problems. Straightforward drug-free treatments can be found in our unique, comprehensive guide on treating BV, Killing BV and in My Vagina’s shop.

If your BV won’t go away, you may benefit from an appointment with one of My Vagina’s qualified, experienced naturopathic practitioners. Working out why BV keeps coming back over and over is important, while providing tailored practitioner-only treatments.

Antibiotics can work well, but there are some key problems with repeated antibiotic use, including antibiotic resistance, damage to the overall microbiome, a poor cure rate, and feeling unwell while taking them.

Recurrent BV

Recurrence rates after standard medical treatment with antibiotics (usually metronidazole or clindamycin) are unacceptably high, leaving many with chronic symptoms.

Chronic BV is a blight, slowly destroying self-esteem, intimate relationships and sometimes, sadly, clothes. But luckily western medicine isn’t the only one plugging away at solving BV! My Vagina is on it.

My Vagina’s unique, effective Killing BV system

Here at My Vagina, we specialise in treating BV and take treatment failures seriously. We know how horrible BV is – we’ve had it too.

We also take antibiotic resistance seriously – considered a global health emergency by the World Health Organisation. Our treatments are antibiotic and hormone free, using nature-based ingredients and a holistic approach to microbial imbalances.

Understanding how and why BV develops is the key to unlocking its driving factors in your body. All BV is not created equal.

Download Killing BV and join the tens of thousands of others who have benefited greatly from the effective treatments.

Enjoy exclusive membership to the support section for plenty more information and tips and tricks. Start your drug-free journey to a healthy, happy, BV-free vagina guided by one of the world’s very best and only vulvovaginal specialist naturopaths, Jessica Lloyd.

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Jessica Lloyd - Vulvovaginal Specialist Naturopathic Practitioner, BHSc(N)

Jessica is a degree-qualified naturopath (BHSc) specialising in vulvovaginal health and disease, based in Melbourne, Australia.

Jessica is the owner and lead naturopath of My Vagina, and is a member of the:

  • International Society for the Study of Vulvovaginal Disease (ISSVD)
  • International Society for the Study of Women's Sexual Health (ISSWSH)
  • National Vulvodynia Association (NVA) Australia
  • New Zealand Vulvovaginal Society (ANZVS)
  • Australian Traditional Medicine Society (ATMS)
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