Bacterial vaginosis (BV) is the overgrowth of unfriendly bacteria in your vagina, resulting in bad smells, unusual discharge and/or a shift in pH to over 4.5. This can often be resolved either temporarily or permanently after using antibiotics, boric acid, or other non-antibiotic treatments.

Recurrent or chronic BV

Then there’s next level BV, where it never seems to go away, or it always seems to come back. This is called recurrent or chronic BV. This type of BV can be very troublesome to treat, and have many contributing factors to it that create complexities that aren’t fully understood. (Our unique treatment programs address the bacterial biofilms, reduce inflammation and recolonise.)

What BV is and isn’t

BV is not an infection, but an imbalance. Think of a bus you are going to work or school on, and 15 rowdy eight-year-olds get on board. The ratio of loud kid to quiet adult is off, but there is nothing technically ‘wrong’ with this – it’s just a change in who’s around. You do not have an infection, but an imbalance in the microbes that have been allowed to take over your vagina.

The balance went out for a reason, or maybe several reasons, so correcting this can take a lot more than a round of antibiotics. Understanding what’s happening to your body is key, but difficult, since nobody teaches us this stuff. Your vagina is not an isolated piece of your machinery; your vagina is supported by your entire body.

Things that can throw your body out of microbial balance

  • Low immunity – you can’t fight off pathogens adequately, particularly the nastier kinds
  • Low oestrogen levels or disrupted hormones – you need oestrogen to feed your good bacteria
  • Introduced species – you may have caught a virulent form of BV off a sexual partner, or another microbe that threw the balance off (read the science that supports this)
  • Naturally low levels of healthy flora (lactobacilli) – some ethnic groups have naturally low numbers, leaving a gap in defences (women of African descent, Latin Americans)
  • Digestive problems and low-quality diet – constipation, diarrhoea, gas, bloating – anything that disrupts your flora upstairs can cause trouble downstairs, including crappy food
  • Stress – stress hormones (cortisol) block the action of oestrogen in your vaginal cells, starving your healthy bacteria, and have a huge impact on your immune system function and digestion

How your vaginal microbes join forces to cause BV

Bacterial vaginosis produces a fishy or foul odour and unusual discharge, but you may have a diagnosis of BV and have all sorts of non-classic-BV symptoms such as itching, pain, or yellow/green discharge. Each of you experiences BV a bit differently, because everyone has different sets of bacteria present.

Think of your different species of vaginal microbes as having personalities, and each personality in your vagina creates a different symptom. The specific group of microbes together create a unique set of symptoms, just like personalities at a party.

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 like antibiotics.

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.

Bacterial vaginosis can be very quiet, appearing only on a test. If you have itching, swelling, soreness or other symptoms, it means you probably have extra bacteria floating around that may not include G. vaginalis at all.

In fact, many women have microbes from the digestive tract like E. coli or E. faecalis, which is known as aerobic vaginitis. These aerobic bacteria cause inflammation – itching, soreness, swelling, green/yellow discharge. These microbes are extremely antibiotic resistant, so antibiotic treatment often fails.

Non-classic-BV symptoms can include ammonia odour, green or yellow discharge, itching (which may 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 chronic bacterial vaginosis, which makes treating it sometimes complex (and annoying). That’s why it’s now being known more frequently as vaginal dysbiosis, which means vaginal microbial imbalance.

The biofilms issue

Recurrent bacterial vaginosis may linger due to 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.

Symptoms of ‘classic’ bacterial vaginosis

Symptoms of bacterial vaginosis, aerobic vaginosis or other vaginal microbial imbalances or infections

  • Itching
  • Redness
  • Soreness
  • Pelvic pain
  • Pain during or after sex
  • Cramping
  • 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)
  • Rawness
  • Symptoms alleviated during period

Fishy vagina smell

Diagnosis of bacterial vaginosis and why getting properly tested is key for curing BV

Regular culture

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. Your doctor may also do what’s known as a wet mount or a wet prep, where they examine your vaginal fluids under a microscope in the office.

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’.

PCR testing

A culture cannot detect 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/UTI/lactobacilli test. A PCR test looks for microbial DNA, and can detect even a dead species. No growing required.

It is a superior test, but PCR tests can only find what the test asks for. If you don’t ask, it won’t tell. This is why the full panel is required.

Testing your pH (acidity levels)

To have bacterial vaginosis, your pH will also be too high – you can test this at home using pH strips. If your vaginal fluids have a pH higher than 4.5, you may have BV. A healthy vaginal typically sits between a pH of 3.5-4.5. This is because healthy lactobacilli produce lactic acid, so the vagina is naturally acidic.

If you are low in lactobacilli, other microbes that do not like a such an acidic pH may have taken over.

Figuring out if you have BV

A vagina that is low in lactobacilli and high in G. vaginalis or other BV-related bacteria is a vagina considered to have BV, generally speaking, but you can have low levels of lactobacilli and have no symptoms and not have bacterial vaginosis. You may also not have G. vaginalis present.

This is why proper testing is imperative. You don’t want to go for a culture, only to be told there’s nothing wrong, when there clearly is.

Usually bacterial vaginosis 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.

Each unsuccessful treatment (often for the wrong bacteria) makes the untested-for microbes stronger and more resistant.

Treating BV effectively

The doctor will usually prescribe metronidazole, an antibiotic, which according to plenty of research, works about half the time in a first-time case of BV. Other antibiotics may be prescribed depending on the level of testing done and your doctor’s preferences and experiences.

There are also many non-antibiotic methods that are extremely effective, but your doctor can only prescribe antibiotics, so it may pay to see another type of 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 may be ineffective. Long-term antibiotic use is detrimental, and should be avoided where possible.

First thing to ensure is proper testing and exclude STIs, then make a treatment decision based on your results and research into BV. There are many ways to treat BV but many of them are simply not strong enough to break the biofilms and facilitate the recolonisation required, with the right kinds of healthy flora.

The below treatments are worth trying, but keep in mind that the bacterial biofilm of these very hardy bacteria requires specialised tools to break down.

And, whatever you do, do it for longer! BV is not going to be cured overnight, so do at least a week, if not two. Sometimes months of ongoing treatments are required to shift the vaginal environment. Many times taking a good hard look at your diet and lifestyle choices, and overall health, may be in order. Don’t underestimate the impact your overall health has on your vagina. It matters.

The most common non-antibiotic treatments for BV are:

  • Boric acid vaginal capsules
  • Vinegar douches
  • Vitamin C vaginally
  • Probiotics vaginally and orally

Here at My Vagina, we specialise in BV, and have developed our own effective, non-antibiotic treatment programs. We fully back our treatments with free email support – you are all unique snowflakes, and we help you all the way, if you need it.

My Vagina’s effective non-antibiotic treatment programs

Log into the Killing BV Support Section

Log into the Killing BV: Guide for Men Support Section

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 less acidic 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 bacterial vaginosis 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 cling film over your vaginal cells that provides a safe haven for many types of bacteria. This is why BV is known as a polymicrobial (many microbes) condition. One of the main culprits in BV is understood to be Gardnerella vaginalis, but this microbe is far from the only major player. In fact, in many types of BV, G. vaginalis may not be present at all.

Many microbes create biofilms, including your healthy lactobacilli species. 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 bacterial vaginosis ‘returning’ time and again because it never really goes away. Antibiotics, probiotics and home remedies do not get rid of the biofilm.

Bacterial vaginosis 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 cases

Bacterial vaginosis can recur over a lifetime despite multiple treatments. It can be difficult to find a doctor who really understands bacterial vaginosis, and thus can test you thoroughly and stop prescribing you the wrong antibiotics repeatedly. You should seek specialist vulvovaginal doctors 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 vaginal dysbiosis often, so chronic BV is more likely to be 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 vaginal dysbiosis.

How do you know if you have BV?

Vaginal dysbiosis symptoms caused by G. vaginalis are pretty specific – vaginal odour may be your first clue (but this can be caused by some sexually transmitted infections – gonorrhoea, trich) – plus unusual 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 precise causes of odour and discharge

Because each set of bacteria do things differently in your vagina, symptoms vary depending on the microbes present. This means that the odours and discharge will all have a nature to them that is distinct between  each of you (due to natural variations in your biology) and distinct between microbes.

For example, the specific fishy odour associated with BV is caused by a chemical reaction of molecules in your vagina that results in the production of trimethylamine (TMA). This is the exact same molecule that causes old (dead) fish to smell fishy. You can read more about the exact reaction here.

But, if you have Enterococcus faecalis, the odour may be more like faeces and you may get yellow or green discharge. Some bacteria cause distinct inflammation (itching, pain, swelling), while others do not.

Your discharge will vary depending on the microbes too, so for example if you have G. vaginalis present, your discharge will be sort of greyish and watery. This is caused by enzymes that the bacteria excrete breaking down your naturally-produced vaginal mucous. This makes it less viscous (watery). This may also be one of the reasons that bacterial vaginosis can trigger preterm birth – the mucous plug that holds the fluid in the womb gets broken down by the enzymes.

Itch, pain and redness, or other signs of inflammation are due to irritation and damage to your vaginal cells caused by bacteria and biofilms.

Who gets BV?

Bacterial vaginosis 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 you can get BV whether you 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.

Learn more about vaginal dysbiosis and pH here

The symptoms you are experiencing are caused by your vaginal environment becoming an unfriendly home to your good microbes.

My Vagina’s effective non-antibiotic treatment programs

Jessica Lloyd - Naturopathic Practitioner, BHSc(N)

Jessica Lloyd - 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)
Read more about Jessica and My Vagina's origin story.