When you have a vagina, there’s a good chance you’ll experience itchiness, irritation, discharge, and odors at some point in your life. When you do, those symptoms may range from no big deal to really annoying to needs-attention-now.
When this happens, most of us think one thing: yeast infection. And while that may be the case—a whopping 75% of women will get a yeast infection at some point in their lives, and almost half of all women will have two or more, according to the U.S. Department of Health & Human Services Office of Women’s Health—there’s another possible explanation for your symptoms that’s actually much more common than yeast infections and much less talked about: bacterial vaginosis (BV).
“When I see patients with vaginal symptoms like irritation, itchiness, and unusual discharge, almost all of them assume they have a yeast infection,” says Maren Rae Oser, CNM, RN. “But about half of these cases are actually BV.” According to the Centers for Disease Control and Prevention (CDC), about 30% of women ages 14-49 will have BV at some point in their lives, and the prevalence increases based on a woman’s number of sexual partners.
Considering how common BV is—and the complications it can cause if it goes undiagnosed—it’s important that more women understand what it is, why it happens, and what to do about it.
What is Bacterial Vaginosis?
In an ideal world, your vagina will have a healthy mix of yeast and bacteria. Just like the balance of good and bad bacteria in your gut microbiome that keep everything from your immune system to your digestion working optimally, the good bacteria in your vagina are responsible for keeping out extra yeast as well as unwanted, bad bacteria.
When this balance of bacteria is on point, you have a healthy, happy, irritation-free vagina. However, when the number of good bacteria drops, you can get an overgrowth of bad bacteria. The result? BV.
Why Does BV Happen?
Unfortunately, experts don’t know exactly what causes BV. However, there are a handful of scenarios that tend to disturb this delicate balance of bacteria and yeast that live inside the vagina and can make BV more likely:
Wiping back to front.
When you use the bathroom, it’s crucial to wipe from front to back. (Yes, even if you haven’t pooped!) This reduces your chances of dragging bacteria from your butt into your vagina, which can cause an infection, says Oser.
Sex with a new partner or multiple partners.
Sex with someone new, as well as having multiple partners, can contribute to women getting bacterial vaginosis—and it’s even more likely if you’re not using condoms. (One study found that sexual contact with new and multiple male and female partners was associated with an increased risk of BV, while condom use was associated with a decreased risk.) Changes in the vaginal pH as a result of exposure to semen or saliva can also contribute to BV.
Douching or using products to clean your vagina.
The simple truth is that your vagina is self-cleaning! Using soap, bath gel, or even some products specifically designed to “cleanse” the vagina (a.k.a. douching) can increase your odds of upsetting your vaginal pH and bacterial balance. Instead, only clean the skin on the outside of your vagina and in the creases around the area with a gentle soap and water, and no more than once a day.
Having a sexually transmitted infection (STI).
If you have an STI, you might be more likely to get BV. Research shows those with genital herpes have a 55% higher risk of getting infected with BV, and chlamydia, gonorrhea, trichomoniasis, and HIV have also been shown to be risk factors.
Related: Should You Get the HPV Vaccine?
A dysregulation of the bacteria in the gut may be a sign that the balance of bacteria in your vagina is dysregulated, too. This can be caused by a number of factors, including a poor diet (consuming too much sugar and alcohol, and having poor blood sugar regulation can all result in an overgrowth of “bad” bacteria), antibiotic use, chronic stress, and more.
The Complications BV Can Cause
BV messes with the natural pH of your vagina, which can lead to problems. Here’s how it works: Your good bacteria (called Lactobacillus) pump out lactic acid, which keeps the vagina at a low, acidic pH that discourages other bacteria, yeast, and viruses from thriving. BV changes this healthy pH balance, which reduces the protective benefits of your vagina’s mucus. Unfortunately, this makes you more prone to developing a sexually transmitted infection (STI).
Not only that, but this alkaline pH is an environment where STIs can thrive, making them more likely to move up into your uterus, fallopian tubes, and ovaries, adds Oser. If you get pregnant, this can be especially dangerous because it increases your risk of preterm labor. If BV isn’t treated, it also increases your risk of pelvic inflammatory disease (PID).
How to Spot BV
These are some of the most common signs of this vaginal infection:
Pain, itching, or burning in or around the vagina
A strong, fish-like odor that’s especially strong after sex
A burning sensation when you urinate
A thin white or gray vaginal discharge
If you’re dealing with vaginal irritation, itchiness, or a smelly discharge, you might assume you’re dealing with a yeast infection and try to treat it yourself with an over-the-counter medication. The smarter move is to call your doctor, who will take a sample of your discharge and either send it to a lab or test it right there in the office. “We look for a thin, whitish grey discharge that covers the walls of the vagina, a pH greater than 4.5, a positive ‘whiff test’ (which literally means checking to see if the discharge smells like fish after exposure to a solution called KOH), and we examine the discharge under a microscope to look for BV cells,” says Oser. “Your healthcare provider needs to see at least three of these criteria to diagnose BV.”
It’s also important to note that many women—a staggering 84%, according to one study—won’t experience any symptoms when they have BV. Which means there are plenty of women who don’t know they have BV, and it’s only discovered during an annual exam. Even more reason to schedule your annual GYN appointment!
How to Treat BV
While BV can go away on its own, it’s a good idea to make an appointment with your doctor if you’re experiencing any symptoms. If you’re diagnosed with BV, your doctor will likely discuss the following treatment options, says Oser:
This is a vaginal gel that you insert at bedtime for five nights. Warning: This medication can be messy! After you insert the gel, it becomes white and chunky when it sticks to the vagina wall—which will eventually create discharge that looks a lot like a yeast infection.
This is an antibiotic cream that can be used at bedtime for one week and may be less messy than Metronidazole.
In addition to a gel, Metronidazole also comes in a pill form that you take twice a day for a week. While it isn’t as messy as the gel, it can cause some unpleasant GI side effects. If you do give this option a try, it’s really important to steer clear of alcohol completely while you’re taking it to avoid vomiting or severe gastrointestinal effects.
If you take an antibiotic, make sure to finish the treatment as your doctor prescribed, even if your symptoms start to improve, says Oser. “If you don’t finish the course of medication, you’ll increase your odds of recurrence,” she says. That said, it’s important to understand that BV recurrence is common (15 to 50 percent of women treated with metronidazole for BV experience a return of symptoms within three months!) and can be treated with a longer course of antibiotics and/or a different treatment than what you tried the first time.
For many women with recurrent BV infections, getting to the root cause of the issue is key—and taking a holistic approach with the help of an integrative practitioner can prove very helpful. According to Aviva Romm, MD, a midwife, herbalist, and author of Hormone Intelligence, there are six key steps to restoring your vaginal ecology:
Balance your blood sugar.
“Bad” bacteria in both your gut and vagina thrive on sugar, which means that if you keep your sugar intake low (which in turn will balance out your blood sugar), you’ll help support a healthy microbiome and optimal vaginal ecology.
Restore a healthy microbiome.
An imbalance in your gut flora is a known root cause of vaginal infections, including yeast infections and BV. Following a protocol to fix intestinal dysbiosis can not only help treat a current BV infection, but it can also put an end to recurring bouts of BV. Dr. Romm’s 4R Protocol is always a part of her treatment plan in patients with recurrent BV.
Have smart sex.
If you have sex with men, there are two important points to remember: First, semen is alkaline, which changes the naturally acidic pH of the vagina and creates a ripe environment for BV. Second, penises carry their own bacteria that can disrupt the balance of bacteria in and around your vagina (a.k.a. your vaginal ecology). However, it’s also important to keep in mind that rates of BV are high among women who have sex with women. Saliva can trigger BV, because the pH of the mouth is so different than vaginal pH. So, if you’re dealing with persistent BV, take a break from sex for a couple weeks until your vaginal ecology is back on track. When you do have sex again, use a condom (choose a brand that doesn’t contain a lubricant, which can make BV worse), opt for lubricants made from natural ingredients and no preservatives, and clean your sex toys (which can be another source of recurrent BV).
Avoid scented bath products and douching.
Douching—even with natural products—increases your odds of BV, according to research. What’s more, the fragrances in soaps, body washes, bath bombs, and other products can disrupt your vaginal ecology and make BV more likely. Remember, your vagina is self-cleaning! Washing the outside of your vagina with an all-natural soap and water no more than once a day (if that) is ample.
Choose “greener” period products.
Just like those synthetic fragrances in your bath products can disrupt your vaginal ecology, so can pads, tampons, and other period products. If you notice that BV is consistently problematic for you after your period, Dr. Romm suggests switching to a reusable menstrual cup.
Avoid unnecessary antibiotics.
Considering up to 80% of all antibiotics used in the U.S. go into our animal products, it’s a good idea to opt for organic meat, poultry, and dairy. And if you’re prescribed a round of antibiotics, finish your prescription in full (not finishing the course as prescribed can lead to antibiotic resistance) and take a high-quality probiotic every day for up to three months afterward.
In addition to these steps, Dr. Romm recommends a natural BV protocol that can be effective at stopping BV in its tracks. She recommends following this protocol for one week, during which time you avoid all forms of sex:
Take zinc (30 mg/day), vitamin E (400 IU/day), and vitamin A (up to 10,000 units/day, except in pregnancy) in your diet and multivitamin—all of which are essential when it comes to healing the vaginal tissue that gets irritated and inflamed in BV infections.
Insert one capsule of Women’s Pro-Flora or a probiotic-containing L. rhamnosus and L. reuteri each morning and take one capsule orally as well.
Use an herbal suppository each evening that contains goldenseal (or berberine, an active ingredient from goldenseal) and essential oils, which are antimicrobial. You can buy a good quality, pre-made vaginal suppository from Vitanica. Or, follow Dr. Romm’s instructions for making your own here.