Sam was on her 3rd trip back to the gynecologist when she realized she could not keep treating her recurrent Bacterial vaginosis (BV) infections with yet another course of medications. She’s already gone through two rounds of a topical treatment and was now on her second round of oral medication. There had to be some underlying reason this was happening.
Hearing about me from a friend, she made an appointment to come see me and together we began to sort out her Root Causes, which for Sam included a recent new relationship that had her going out to dinner and drinking more than usual, using a new brand of condoms with lube, all at the same time she’d recently started a new job which was demanding and stressful and activating her IBS, and also affecting her diet – she was grabbing coffee and a muffin most days for breakfast rather than her usual healthier choices.
Getting the sugar out, reducing the alcohol, telling Sam about a healthier condom and lube choice, and taking care of her gut health, along with a non-antibiotic approach to treating the infection led to a huge turnaround for Sam. Within a week the infection was gone not to return and on top of it, her IBS resolved and she felt more energetic and clear than she had in long time.
BV Treatment Requires Identifying the Real Cause
The mainstay of conventional BV treatment is antibiotics, but as you’ll learn in this article, as my patient Sam did, treatment isn’t foolproof – there’s a high recurrence rate, and on top of this, conventional treatment carries medical risks. Conventional antibiotic treatment is not a long-term solution for BV. It’s a bandaid, albeit sometimes necessary in the short run, for what’s really going on: disruption in the vaginal microbiome, otherwise known as vaginal dysbiosis.
The medical community is having the wrong conversation about bacterial vaginosis. BV is talked about as an isolated gynecological problem and not as an imbalance in the vaginal microbiome – which can be the result of a larger, system-wide imbalance in a woman’s total ecosystem.
But BV is annoying, sometimes uncomfortable, and also carries some risks. So what’s a gal to do?
The answer lies in understanding the underlying cause of BV – disruption in the vaginal microbiome – and removing the triggers and causes of that.
In my recent blog post Vaginal Ecology: What You Need to Know to Keep Things Healthy Down There, I let you into a little secret: I’m a vaginal ecologist. No, I don’t go around gathering samples or looking with binoculars! I study the impacts that determine the health of the diverse microbiome that makes up the vagina – the ecology of the vagina, that is. These include diet, stress, and what goes in there – from toxins in our tampons to who we’re having sex with – and what happens to the greater environment of the body, for example, with antibiotics we might use for infections in general (or that show up in the food chain!).
The medical community is having the wrong conversation about #bacterialvaginosis. The answer isn’t more antibiotics. Read here to learn what we really need to know.
So Wait, Dr. A, What is Bacterial Vaginosis?
BV isn’t, as many women think, an infection with a specific bacteria or yeast. BV refers to an imbalance in the vagina’s own bacterial communities in which the beneficial organisms aren’t as robust, leading to an overgrowth of the less-than-desirable bacteria in the vagina – Gardnerella vaginalis, Mycoplasma hominis, and a few other microorganisms.
BV usually has noticeable symptoms including,
- Thin graying colored discharge
- A strong, unpleasant (often fishy) odor
- Vaginal itching or irritation
It can, however, occasionally be asymptomatic until bigger problems crop up.
Almost 30 percent of women between the ages of 20 and 50 have BV – or more accurately, are in a state of BV – enough vaginal dysbiosis at any given time that their flora is significantly disrupted. Unfortunately, conventional doctors know surprisingly little about how to treat it outside of prescribing antibiotics, which often don’t work, leading to multiple rounds of treatment which may eventually reduce the overgrowth of the annoying bacteria, but don’t help to reset your vaginal ecology – and may wipe out even more good microorganisms along with the symptom-causing ones.
Bacterial Vaginosis Risks
BV does need to be taken seriously. Disruption in the natural ecology of the vagina changes the pH and vaginal mucous, the job of which is to protect us against infections. BV reduces our defense mechanisms and makes us more susceptible to contracting sexually-transmitted infections (STIs), frighteningly, including HIV. It is also associated with abnormal Pap smears, pelvic inflammatory disease (PID) which can cause later fertility problems and ectopic pregnancy, and endometritis (inflammation in the lining of the uterus).
Bacterial vaginosis can be especially dangerous for pregnant women, who face increased risk of second-trimester miscarriage or preterm labor. After giving birth, women with bacterial vaginosis are at greater risk for postpartum endometritis.
Important: Pregnant women should always seek conventional treatment for BV, though the recommended lifestyle changes can improve treatment outcome and prevent recurrence. If you have persistent infection or abdominal pain with BV, conventional care is the most appropriate for treating acute infection. However, all of the preventative steps in this article still apply and can help prevent recurrence.
Then What Causes Bacterial Vaginosis?
BV is the result of disruption in the body’s local (vaginal) or broader microbial (usually gut) ecosystem. It can be due to local disruptions in the vaginal ecosystem, or more global exposures in the body that in turn affect vaginal ecology.
Common causes of general and local ecosystem disruption include:
- Gut dysbiosis
- High sugar diet, alcohol consumption, or poorly controlled blood sugar
- Exposure to synthetic chemicals and fragrances that upset beneficial bacteria or vaginal pH
- Antibiotic use
- Changes in the vaginal pH that can happen with age
- Changes in the vaginal pH as a result of exposure to semen or saliva (women in heterosexual and same sex relationships are therefore both susceptible and can ‘ping-pong’ the infection between partners).
Getting An Accurate Diagnosis
Getting an accurate diagnosis from your midwife, APRN, doctor, or other licensed practitioner is important. BV diagnosis requires meeting at least three of the following four Amsel’s criteria which can be detected with a vaginal exam and painless swab of vaginal fluids: thin, grayish-colored discharge; (healthy discharge is white in color and more viscous), a vaginal pH greater than 4.5; positive whiff test, and the presence of “clue cells” in vaginal fluid.
Conventional Treatments Can Have Unintended Consequences (though may sometimes be necessary)
The conventional treatment for bacterial vaginosis is the antibiotic metronidazole, which can be taken orally or applied topically to the vagina, or clindamycin.
A sample of the side-effects that can occur with metronidazole include:
- Disturbances of the gut such as diarrhea, nausea, vomiting, or abdominal pain
- Inflamed and sore mouth
- Loss of appetite
- Severe swelling of lips, face or tongue (angioedema)
- Shaky movements and unsteady walk (ataxia)
- Skin rashes or itching
- Pain in the muscles or joints
- Darkening of the urine
- Visual disturbances
- Depressed mood
- Liver disorders
- Disorder of the peripheral nerves called peripheral neuropathy that causes weakness and numbness (on prolonged or intensive therapy)
- Decrease in the number of white blood cells in the blood (leucopenia)
If using an antibiotic, I recommend always trying topical treatment first as this is less likely to cause serious medication side-effects.
Metronidazole has an 80 percent cure rate within 4 weeks, but the recurrence rate is disproportionately high: 15 to 50 percent of women who treat BV with metronidazole experience a return of symptoms within 3 months.
One theory about why the recurrence rate is so high after a course of antibiotics is that the drugs kill the bad bacteria, but they don’t promote recolonization with good bacteria. Without some encouragement from topical or oral antibiotics, it’s tough for good bacteria like Lactobacillus to get a foothold – and the bad bacteria just take over again.
In my practice, if a patient isn’t pregnant or experiencing symptoms of BV complications, for example, abdominal pain, I recommend trying natural treatments first. They are healthier and less likely to cause recurrent infections, though admittedly, they do require a bit more work than just filling a prescription.
8 Ways to Prevent & Treat BV Naturally
Lifestyle choices and overall health are major factors in helping prevent and treat bacterial vaginosis because they are the steps that restore healthy vaginal ecology – in other words, they get to the Root Causes of dysbiosis.
Here are the key steps to restoring your vaginal ecology:
1. Balance your blood sugar. Trouble-making gut and vaginal microorganisms thrive on sugar, so keeping sugar intake low and blood sugar balanced are two of the best things you can do to support whole-body ecology and vaginal ecology. The primary dietary culprits are the added sugars found in most processed foods and the refined grains in most breads, pastas, and baked goods. At the same time, even natural sugars can add up. The dollop of honey in your morning tea or the dash of maple syrup on mashed sweet potatoes can cause blood sugar spikes for some women. The sugar in alcohol is a major trigger for BV, too. So if you’re working to prevent or treat BV, and especially if you struggle with persistent BV, watch the amount of sugar you eat, both added and natural, and know that even small amounts of sugar can add up. It’s smart to avoid alcohol entirely when you’re treating BV and trying to keep it from recurring, and then keep it to small amounts only if you’re susceptible and notice an association between alcohol intake and recurrence.
2. Heal your gut and bring in good organisms. Gut flora imbalance, called intestinal dysbiosis, is commonly a Root Cause of chronic or recurrent vaginal infections, including BV, but also yeast infections. Rebalancing your gut flora can go a long way to preventing and halting recurrent vaginal infections. The 4R Protocol is always a part of the treatment plan in my practice when there is recurrent BV, and especially if my patient also has IBS, chronic constipation, IBD, or other symptoms of gut imbalances.
Repopulating both your gut and your vagina with the good organisms that support healthy vaginal ecology is key to kicking the BV problem. How can you do this? Take a high-quality probiotic daily, specifically one that contains Lactobacillus reuteri and Lactobacillus rhamnosus, two especially vagina-friendly species. You can find options for probiotics in my online dispensary right here (and there’s no obligation to purchase – you can just have a peek and see what I use in my practice). As you’ll learn below, using this same probiotic vaginally can also help to reset your vaginal ecology.
Probiotic-rich foods include live active culture yogurt, sauerkraut and other lacto-fermented vegetables, kimchi, and miso.
3. Practice healthy sex. If you have sex with men, know that penises carry their own bacteria that can disrupt vaginal ecology. Semen also changes the pH of the vagina, creating a ripe environment for BV. Condoms have been proven to help prevent BV so even if you’re got your birth control otherwise covered – having your man ‘wrap it up’ can go a long way to protect you from infection and reinfection. The good (and amusing) news is that some experts suspect that the vaginal microbiome can adapt to the bacteria on familiar penises. But when it’s a new penis in the neighborhood, a the vagina will mount an immune defense that triggers inflammation and wham – that causes vaginal changes that increase BV, too.
Choosing the right condom is essential because some condoms contain lubricants that can make BV worse. Same with the preservatives in many commercial lubricants. I recommend Sustain brand condoms and lubricants; they are some of the safest, most vagina-friendly products on the market.
Wait – same sex lovers aren’t outta’ the woods here. Oral sex can trigger BV because the pH of the mouth is so different than the pH of the vagina. Research also suggests that rates of BV are significantly higher among women who have sex with women. So it’s important to be aware of BV no matter the gender of your partner and, if you’re wrestling with persistent BV, it can help to take a temporary break from sex for a couple of weeks while you get that flora back on track.
Sex toys are yet another source of recurrent BV so keep them clean, even with a regular dip in boiling water, and don’t share them with your partner if you’re passing BV back and forth.
4. Your vagina is self-cleaning. Don’t douche. Douches should be avoided at all costs because they disrupt the natural vaginal ecology. Regular douching – even with natural products – has been shown to double the risk of developing vaginitis. Also, avoid scented products: That includes soaps, toilet paper, and menstrual products. The fragrances in these products are extremely detrimental to vaginal ecology and do more to trigger bacterial vaginosis than keep it at bay.
5. Go green with your period products. If BV is a persistent problem particularly after your period and you use menstrual pads, change your pad more often, try switching to tampons, or consider switching to a reusable menstrual cup. Also, beware of the toxins in conventional products which can alter pH and cause inflammation (and which do get absorbed systemically, too!). Opt for organic pads and tampons only. That’s what I’ve used for three decades – our health is worth the extra money.
6. Sad but true, say goodbye to thongs. If you’ve ever worn a thong, you know that it can start to feel like you’ve got a tightrope down there. But that uncomfortable feeling isn’t the only problem with this sexy underwear: Because thongs inevitably ride up, bacteria from the anus can use that thin strip of fabric as a literal tightrope to travel to the vagina. Instead wear boy shorts, briefs, or bikinis, all of which are way more sexy when you think about the tightrope! Whatever underwear you choose, make sure the crotch has a cotton lining (which is more breathable than other materials).
7. Take antibiotics only when necessary. Antibiotics save lives, to be sure. But up to 70 percent of the antibiotics prescribed in the United States are unnecessary. Consult with your healthcare provider carefully any time you’re considering taking antibiotics and avoid them when they aren’t necessary. When antibiotics are necessary, take a high-quality probiotic daily for up to 3 months afterward. Ok, and here’s another crazy thing – up to 80 percent of all antibiotics used in the US are going into our meat – and this has been associated with a variety of resistant infections in humans! So if you struggle with BV that just won’t go away or keeps coming back, try going organic with meat, dairy, and poultry for 3 months and see if this helps.
8. Finally, if you do have BV, consider treating naturally:
In addition to all of the important steps for prevention above, the plan below can help to stop a BV infection in its tracks.
Remember if you’re pregnant, within a few months postpartum, are having persistent infection (it doesn’t clear up within a few days of natural treatment), or you develop abdominal pain, fever, or other symptoms, get conventional treatment promptly!
Dr. Aviva's Protocol for Treating BV
There are a variety of all-natural botanical interventions that can be effective against BV. Here’s my daily protocol.
You’ll want to follow this for one week, and avoid sex (all forms) during this time:
- Make sure you’re getting zinc (30 mg/day), vitamin E (400 IU/day), and vitamin A (up to 10,000 units/day, except in pregnancy when only up to what’s in your prenatal vitamin) in your diet and multivitamin – these are essential for healing the vaginal tissue that gets irritated and inflamed in BV infections.
- Each morning insert one capsule of Women’s Pro-Flora or a probiotic containing L. rhamnosus and L. reuteri. Treating BV using topical yogurt applications is also an option. While it’s widely disputed, one study found that 88 percent of women who applied (unsweetened, live, active culture) yogurt internally to the vagina twice a day for a minimum of seven days remained BV-free two months after the study. In my practice, I find that combined vaginal and oral use of probiotic capsules is as effective and easier. In a pinch, however, for example if you’re traveling, the yogurt is a reasonable go-to.
- Take 1 capsule of the above probiotic orally each day as well.
- Each evening use an herbal suppository. Suppositories that contain goldenseal (or berberine, an active ingredient from goldenseal) and essential oils are antimicrobial. A note of caution: berberine-containing supplements have a strong yellow color that can stain underwear or sheets.
You can purchase a good quality pre-made vaginal suppository from Vitanica, or you can make your own using this recipe that’s been tried and true in my practice for over 30 years. I recommend purchasing your supplies online from Mountain Rose Herbs for convenience. Once you learn to make this, it’s easy – and if you make a full batch, you’ll have enough for a week of treatment and then some.
Here’s my go-to suppository blend for treating both vaginal yeast and BV infections. I use this suppository in my practice for pregnant patients, but check with your midwife or doctor first.
- 1 cup cocoa butter
- 1/2 cup coconut oil
- 3 Tbs calendula oil
- 1/4 tsp thyme essential oil
- 1/4 tsp lavender essential oil
- 1/4 tsp tea tree essential oil
- 4 Tbs comfrey root powder finely ground (safe for short term topical use)
- 2 Tbs goldenseal root powder
To prepare the suppositories:
- Melt the cocoa butter and coconut oil together in a saucepan. When melted remove the pan from the burner.
- Add the powdered herbs and mix well.
- Add all of the herbal oils and blend well.
- Stir well and pour into the suppository mold (see below). Refrigerate until firm. Insert vaginally 1 per night for 7 days; repeat if needed.
- Always wear a sanitary pad while you sleep with the suppository in place. It will melt and will otherwise stain bedding or undies!
- Results are typically seen within several days, however you may treat up to a week and repeat if necessary.
- Suppository molds can easily be prepared at home by using aluminum foil that has been folded several times lengthwise, and then widthwise, to form a trough approximately 8 inches in length and 1/2 inch in width. Alternatively, suppository molds can be purchased online. The base of the suppository is a combination of coconut oil and cocoa butter, to which is added the desired combination of medicated oils, powdered herbs, and tinctures. This mixture is then poured into the mold, refrigerated to harden, cut into pieces the size of the patient’s pinky finger, and inserted as needed.
The key to successful natural treatment? Remembering that optimal vaginal ecology depends on optimal whole-body ecology. So focus on nutrition (balanced blood sugar), gut health, and vaginal health!