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Bacterial vaginosis (BV) is an infection that develops when there is an imbalance of good bacteria and bad bacteria in the vaginal environment. BV symptoms include:
- A thin white or gray vaginal discharge
- Pain, itching, or burning in the vagina
- A strong fish-like odor, especially after sex
- Burning when urinating
- Itching around the outside of the vagina
- Elevated vaginal pH
To address this common vaginal infection, antibiotics can be prescribed to quickly and effectively clear an infection. But if your BV keeps coming back, it can disrupt your life in many ways including:
- Sexual health
- Physical health
- Mental health
- Social interactions(1)
Recurrent BV is very common and can be a huge source of frustration for women of all ages. Here at Interlude, our medical team is here to help you prevent recurrent BV infections. In this article, we’ll cover what treatments are backed by research so that you can get on a faster track to relief.
Antibiotics for BV
If you currently have BV symptoms, treatment is recommended to relieve symptoms and also to reduce your risk of other infections. Antibiotics are the first-line treatment for BV.
Antibiotics work by killing off the bad bacteria in the vaginal environment. The CDC recommends either metronidazole or clindamycin antibiotics for BV. The standard doses are:
- Metronidazole 500 mg orally 2 times/day for 7 days
- Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days
- Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days
What to do if BV comes back
Even with successful antibiotic treatment, recurrent BV infections are common. Up to 50% of women report a repeat BV infection within 3–6 months.(1)
For the first repeat BV infection, retreatment with the same antibiotic regimen is probably the way to go.(2) But if you’re prone to multiple BV recurrences, then you may want to try other preventative strategies.
How to stop BV infections permanently
Figuring out how to prevent BV symptoms from coming back can be overwhelming. Antibiotics, vaginal estrogen, probiotics, and boric acid are all treatments that might help prevent recurrent BV symptoms.
Antibiotics are unlikely to stop BV infections permanently. If you want to stop BV infections permanently, you may need to try an alternative treatment such as vaginal estrogen or probiotics to promote good bacteria in the vaginal environment.
Antibiotics for recurrent BV
For women with multiple repeat BV infections, antibiotics can help prevent future infections. Emerging research shows that the following regimens may prevent recurrent symptoms:
- Antibiotic regimen: 0.75% metronidazole vaginal gel or 750mg metronidazole vaginal suppository (twice weekly for three months). This regimen will stop BV while using the regimen, but it won't stop BV infections permanently. Once you stop the regimen, BV symptoms will probably come back.(3,4)
- Antibiotic and boric acid regimen: 500mg oral metronidazole (2 times/day for 7 days) followed by vaginal boric acid (for 21 days) and 0.75% metronidazole gel (twice weekly for 4-6 months). This regimen is promising because it might cure recurrent BV - and not just suppress it - but more research is needed. One of the weaknesses of this regimen is that it was only studied in younger women, so future research should include more perimenopausal and postmenopausal women.(5)
- Antibiotic and probiotic regimen: 500mg metronidazole (twice daily for 7 days) with probiotics plus lactoferrin (2 capsules/day for 5 days followed by 1 capsule/day for 10 consecutive days).(6)
Whenever you treat BV with antibiotics, there is a risk of wiping out the good bacteria along with the bad bacteria. And the lack of good bacteria might lead to ongoing BV infections. This highlights the importance of promoting good bacteria in the vaginal microbiome to stop BV from coming back.
Vaginal estrogen therapy
Vaginal estrogen works by restoring healthy levels of good bacteria in the vaginal microbiome. It’s available in a variety of formulations, including vaginal estrogen cream, vaginal estrogen suppositories, and a vaginal estrogen ring.
If you’re in perimenopause or postmenopause, then vaginal estrogen rather than antibiotics is probably the best way to combat an elevated vaginal pH or unusual vaginal odor .
What does menopause have to do with vaginal health? When estrogen levels decline during menopause, the lack of estrogen in the vaginal environment can lead to a decline in good bacteria and a higher proportion of bad bacteria and this can lead to BV symptoms like an elevated vaginal pH, vaginal odor, itching and burning, and pain during urination.
Treatments like vaginal estrogen cream are associated with an increase in the levels of good bacteria in the vaginal microbiome.(7,8) This suggests that for many women, treatment with vaginal estrogen, rather than antibiotics, is the best way to promote a healthy balance of good and bad bacteria.
Vaginal estrogen is available by prescription, and we offer it here at Interlude. Vaginal estrogen is highly effective at treating many vaginal and urinary symptoms that can happen around the time of menopause - including vaginal dryness, painful sex, frequent UTIs, and urgency.
Probiotics for women
Probiotics work by delivering good bacteria to the vaginal environment either by taking an oral pill or inserting a vaginal suppository.
Recent studies suggest that probiotics may help prevent BV when combined with antibiotics.(9,10) However, probiotics alone are not shown to prevent BV.
Probiotics are available over the counter, and if you’re thinking of trying probiotics for BV we recommend trying a probiotic that contains lactoferrin.
Boric acid vaginal suppositories
The idea behind boric acid for BV is that a boric acid suppository can be inserted vaginally to help remove biofilms that might be harboring bad bacteria or limiting the effectiveness of antibiotics.
Research has shown that boric acid in combination with antibiotics may help prevent BV.(5,11) It’s possible that boric acid suppositories on their own can prevent BV, but more research is needed.(5,12)
You can buy boric acid vaginal suppositories over the counter, but as with any vaginal health supplement or over-the-counter product, it’s always a good idea to review with a medical professional before using this treatment.
What not to do
- Douching: This may seem like a good idea, but washing the inside of the vagina can increase your risk of recurrent BV infections. The vagina is self-cleaning and douching is never recommended.
- High-dose Vitamin D supplements: These are not likely to help with BV. Save your money on supplements like this.(13)
Is it BV or something else?
BV symptoms can be very similar to other conditions, and this can make it difficult to determine if it’s BV or something else like a UTI, yeast infection, STI, or the genitourinary syndrome of menopause that’s causing your symptoms.
Other conditions that are similar to BV include:
- Sexually transmitted infection (STI): Sores on genitals, burning painful discharge, partner having symptoms of an STI.
- Yeast infection: White cheesy discharge, redness or itching in and around the vagina.
- UTI: Burning with urination, pain in the lower back near kidneys, frequent urination, feeling unable to fully urinate.
- Genitourinary syndrome of menopause (GSM) or vaginal atrophy: Vaginal dryness, pain with intercourse, frequent UTIs, urgency to pee, vaginal odor, itching and burning in and around the vagina.
Getting the help you need
If you have an active BV infection or want to prevent recurrent BV infections, then you should get help from a medical professional, such as a board-certified doctor here at Interlude. We offer a range of doctor-prescribed treatments to help you protect your vaginal and urinary health for the years to come.
