Written by Mona Fahoum, ND

Reviewed by Kim Ross, DCN

September 4, 2024

Bacterial vaginosis (BV) is one of the most common vaginal conditions seen in clinical practice. It is estimated that 30% of women in the United States experience bacterial vaginosis, though the prevalence worldwide is upwards of 70% (1). For many women, it can mean a simple one-time treatment of medication like clindamycin or metronidazole (2). For others, BV can be a chronic, recurring infection that requires a more holistic and integrative approach to resolve it and address the underlying causes, allowing it to perpetuate itself.

What is BV?
BV is a condition caused by an overgrowth of normal vaginal flora, usually a lack of lactobacilli, and an overgrowth of anaerobic bacteria such as Gardnerella (1). It often presents as a thin, whitish-to-gray, watery discharge with a ‘fishy’ odor (1,3). This discharge may worsen after intercourse. Vaginal itching (pruritis) may be present. Some women also report mild pelvic discomfort, though it is often painless (1).

Urinary pH is used for medical diagnosis and serves as a marker for long-term treatment. An elevated pH of >4.5 is indicative of infection, though it is non-specific to identify BV. On microscopy, there will be clue cells, the positive ‘whiff’ test (a drop of potassium hydroxide mixed with vaginal discharge), and likely a lack of lactobacilli, which allows the infection to grow (4). If you do not have testing available in your office, point-of-care tests are now available for BV (and other infections), and samples can be sent to conventional labs. Consider more advanced testing for those who suffer from chronic vaginal or urinary tract infections with newer technology available that uses qPCR and DNA sequencing to uncover hidden infections and explore microbiome diversity.

Diagnosis of chronic vaginitis is key in solving this condition for patients.

The testing noted above is very helpful given that BV is not the only condition that can be present with a higher vaginal pH and low lactobacilli population. Ruling out aerobic vaginitis, trichomoniasis, and desquamative inflammatory vaginitis is an important exercise in properly managing chronic infection and helping to restore good vaginal flora.

• Aerobic vaginitis will most notably have an odor, but not the fishy amine odor characteristic of BV, and likely will have a thicker, yellow to yellow-green discharge. Burning and dyspareunia (pain during intercourse) can also be present (3). This infection is likely caught on a standard bacterial culture or qPCR testing.

• Trichomoniasis is also characterized by a yellow/green frothy discharge, but very often presents with few symptoms short of vague vaginal discomfort or soreness. The ruling out of gonorrhea and chlamydia should be done simultaneously.

• Desquamative inflammatory vaginitis (DIV) is less understood, but like BV is thought to be an overgrowth of anaerobic bacteria with low lactobacilli populations and resultant higher vaginal pH. This infection appears to be more prevalent in perimenopausal women. On microscopy, clue cells will be absent, but oval immature epithelial cells and leukocytes will be present. Upon exam, a yellowish discharge will be apparent with the presence of vulvar erythematous (redness of the skin and mucous membranes), which may have a bruised-like appearance. Notably, atrophic vaginitis appears similar to DIV on microscopic evaluation (5).

Treatment options – from terrain to eradication and replacement.

In approaching treatment for recurrent BV, clinicians will need to identify the harmful bacterium through testing to eradicate it properly (5). The bacterial overgrowth needs to be treated so that the terrain can be remediated, and beneficial flora can be repopulated. Since 80% of women experience a recurrence within nine months, ongoing support for healthy balance vaginal flora is warranted (1).

After treatment, the pH of the vaginal vault should be supported, which means rebuilding the bacterial microbiome. Lactobacilli are responsible for creating an acidic environment to maintain healthy vaginal pH. Additionally, these beneficial bacteria likely play a role in breaking down the biofilms in which the anaerobic bacteria flourish, helping to break the chronic recurrence cycle. Lactobacillus rhamnosus, Lactobacillus gasseri, and Lactobacillus acidophilus have mounting data in helping to restore pH and reduce biofilms with both oral and vaginal applications (2). More recently, Lactobacillus crispatus CTV-05 has been shown to be beneficial in decreasing the chance of recurrence (1). Additionally, there is data on prebiotic applications, acidifying agents (like lactic acid and vitamin C), and boric acid suppositories (600 mg) for the treatment and restoration of healthy vaginal flora (2,6,7). Sousa et al. published a great summary article on these agents.

Note on ‘normal flora’

There is mounting data on the vaginal microbiome and the differences that are simultaneously present in healthy women of different ethnicities and races. We cannot presume that every microbiome is the same in order to be healthy, nor can we assume certain species are necessary for every individual. For example, lactobacilli are the predominant species in a ‘healthy microbiome’ for most White and Asian women but not necessarily for Hispanic or Black women (8). As clinicians, we will likely have to use some broad-spectrum probiotics due to market availability but will need to be attuned to updates and more customized approaches over time.

Terrain

Beyond and intertwined with the microbiome is the terrain to support healthy tissues and immune function. In part, this is related to vaginal hygiene as far as reducing exposures to infection via protected intercourse, preventing cross-contamination (i.e., wiping front to back), and not using perfumed products or douches that will alter the normally acidic pH of the vaginal vault.

In our more mature patients, we must also consider hormonal impacts on the microbiome, lubrication, and friability. The impact that peri and postmenopausal hormone changes have on both the gastrointestinal and vaginal microbiome as well as overall tissue health should not be ignored and should be part of our treatment plans. The postmenopausal decline of estrogen has been connected to a decrease in lactobacilli, increasing the vulnerability of this population of women (9). Supporting hormone balance with FemmenessencePRO would be an appropriate consideration.

Additionally, we need to support healthy tissues through good nutrition, including a focus on the following:

1. Whole foods

2. Greens and other plants for their rich nutrient profile and prebiotic fibers

3. Detoxification support

4. Hydration

5. Avoiding processed foods

Especially for women who have trouble consuming enough greens, add pH Quintessence PRO as part of their plan. Three capsules are the equivalent of 2 servings of greens, provides gentle detox support, and can improve gut motility.

Additionally, vaginal hyaluronic acid or estradiol, may be part of maintaining a healthy terrain to treat and stop recurrent BV.

Treatment Plan Considerations

• Infection prevention: personal hygiene, cotton underwear, avoiding perfumes, using condoms while undergoing treatment.

• Initial treatment with CDC guidelines: Metronidazole oral/vaginal or clindamycin vaginal

• Treatment and Biofilm disruption: Boric Acid or Vitamin C suppositories 

• Tissue Health: Hyaluronic acid or local estradiol if any atrophy is present

• Probiotics specific to the vaginal vault: Lactobacillus crispatus, gasseri, reuteri, jensenii and rhamnosus.

• Full body support: pH QuintessencePRO for gut motility, detoxification, and balanced pH.

• Full body hormone support: FemmenessencePRO, choosing the appropriate option based on the woman’s stage of life.

• FemmenessencePRO HARMONY:Premenopaual women

• FemmenessencePRO PERI: Perimenopausal women

• FemmenessencePRO POST: Postmenopausal women

Conclusion

In practice, we see patients suffer from chronic BV (or Candida and other infections) all too often. They have seen multiple providers and likely had multiple rounds of medications that have no doubt further impacted the ‘normal’ flora of both the gut and vaginal vault. They are often left to feel hopeless and broken. We can significantly impact these patients by being excellent diagnosticians and then doing the deep dive to address the entire system.

Recurrent infection treatment plans need to include all the above elements, and when we help correct nutrition, support gut function, support pH, and promote a healthy microbiome, we can stop the recurrent BV so they can take control of their health again.

References:

1. Kairys N, Carlson K, Garg M. Bacterial Vaginosis.; 2024. PMID: 29083654

2. Sousa LG V, Pereira SA, Cerca N. Fighting polymicrobial biofilms in bacterial vaginosis. Microb Biotechnol. 2023;16(7):1423-1437. doi:10.1111/1751-7915.14261

3. Donders GGG, Bellen G, Grinceviciene S, Ruban K, Vieira-Baptista P. Aerobic vaginitis: no longer a stranger. Res Microbiol. 2017;168(9-10). doi:10.1016/j.resmic.2017.04.004

4. Kelly KG. Tests on Vaginal Discharge.; 1990. PMID: 21250131

5. Hildebrand JP, Carlson K, Kansagor AT. Vaginitis.; 2024.PMID: 29262024

6. Powell A, Ghanem KG, Rogers L, et al. Clinicians’ Use of Intravaginal Boric Acid Maintenance Therapy for Recurrent Vulvovaginal Candidiasis and Bacterial Vaginosis. Sex Transm Dis. 2019;46(12):810-812. doi:10.1097/OLQ.0000000000001063

7. Krasnopolsky VN, Prilepskaya VN, Polatti F, et al. Efficacy of vitamin C vaginal tablets as prophylaxis for recurrent bacterial vaginosis: a randomised, double-blind, placebo-controlled clinical trial. J Clin Med Res. 2013;5(4):309-315. doi:10.4021/jocmr1489w

8. Ravel J, Gajer P, Abdo Z, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A. 2011;108 Suppl 1(Suppl 1):4680-4687. doi:10.1073/pnas.1002611107

9. Muhleisen AL, Herbst-Kralovetz MM. Menopause and the vaginal microbiome. Maturitas. 2016;91:42-50. doi:10.1016/j.maturitas.2016.05.015