Bacterial Vaginosis: Causes, Symptom and Treatment

Bacterial Vaginosis Summary

Summary

  1. Bacterial vaginosis (BV) is an imbalance of vaginal bacteria, leading to increased harmful bacteria.
  2. Common symptoms include vaginal discharge with a fishy odor, itching, and discomfort.
  3. Treatment involves antibiotics like metronidazole and promoting healthy vaginal flora.

Introduction

Bacterial vaginosis (BV) is the leading cause of unusual vaginal discharge in women who can have children.

This condition happens when there is a disruption in the natural bacteria in the vagina, leading to certain bacteria, mainly Gardnerella vaginalis and anaerobic bacteria, being more present than lactobacilli, the healthy bacteria typically found.

This change can cause symptoms like a strong vaginal smell, discharge, and irritation, although some women may not show any symptoms.

BV is often seen as an issue with the vaginal environment instead of a typical infection, as it results from an overgrowth of the body’s own microbes rather than germs from outside.

Although BV is not called a sexually transmitted infection (STI), it appears more often in sexually active women. It can be uncomfortable, but antibiotics usually treat it.

If untreated, BV can raise the risk for other issues, including STIs, pelvic inflammatory disease (PID), and pregnancy-related complications like preterm labor and low birth weight.

Causes

The precise reason for bacterial vaginosis is not known, but it relates to a disturbance in the vaginal bacteria. Typically, various bacteria live in the vagina, with Lactobacillus species being the most common.

These help keep a low pH, which stops harmful germs from growing. In BV, the Lactobacillus decreases, and anaerobic bacteria like Gardnerella vaginalis, Atopobium vaginae, Mobiluncus, and Prevotella species grow more.

Several factors can lead to this imbalance:

  • Sexual Activity: While BV is not called an STI, it is seen more in sexually active women. It can relate to having many sexual partners, vaginal douching, and unprotected sex, but it can also happen in women who do not engage in sexual activity.
  • Antibiotic Use: Broad-spectrum antibiotics for other infections can disturb the natural balance of vaginal bacteria, raising the chance of developing BV. They reduce Lactobacillus species, which allows anaerobic bacteria to grow more.
  • Hormonal Changes: Shifts in hormone levels during pregnancy, menstruation, or menopause can change the vaginal environment, increasing the likelihood of BV. Pregnant women are especially prone to BV and its risks.
  • Douching: Douching is the process of cleaning the vagina with water or other solutions and is linked to a higher risk of BV. It can disturb the natural bacteria balance and eliminate protective ones like Lactobacillus.
  • Immune System Factors: Women with weakened immune systems, such as those with HIV or diabetes, may find it easier to develop BV, as a weakened immune system can hinder the body’s ability to manage vaginal bacteria properly.
  • Smoking: Smoking cigarettes is recognized as a risk factor for bacterial vaginosis. Chemicals in tobacco might change the vaginal bacteria and weaken the immune response to bacterial growth.

Symptoms

Bacterial vaginosis can have various symptoms, but some women may not show any signs at all.

When symptoms appear, they may include:

  • Vaginal Discharge: The primary symptom of BV is unusual vaginal discharge. This discharge is typically thin, gray or white, and has a fishy smell, which can become stronger after sex. The amount of discharge may increase but is usually not painful or irritating.
  • Odor: A common “fishy” smell is often linked with BV. This odor results from amines, which are compounds released by the growth of anaerobic bacteria. The smell might become more noticeable. after sexual activity or at the day’s end.
  • Vaginal Irritation: Some women may feel mild itchiness or irritation at the vaginal opening, but pain and burning usually are not common signs of BV.
  • Pain during Urination: Some women with BV may feel slight pain or discomfort while urinating, due to vaginal lining irritation, even though this is not usual.
  • Pelvic Pain: Severe pain is not a common sign of BV, but rare cases may show lower belly discomfort, which could mean a serious issue like pelvic inflammatory disease (PID).

Risk Factors

Many aspects can raise the chances of getting bacterial vaginosis:

  • Sexual Activity: BV occurs more often in sexually active women, especially if they have many partners or don’t use condoms. While BV isn’t an STI, sexual activity seems to change the vaginal flora in a way that makes women prone to it.
  • Age: BV is most frequent in women of childbearing age, mainly those aged 15 to 44. After menopause, BV cases usually lessen due to changes in the vaginal environment and hormone levels.
  • Pregnancy: Pregnant women are at higher risk for BV, which can cause issues during pregnancy, such as preterm labor and low birth weight. Many pregnant women with BV do not show symptoms, so screenings are important.
  • Douching: Douching is linked to a higher risk of BV as it disrupts the natural vaginal balance and changes the pH.
  • Antibiotic Use: Antibiotics can lower Lactobacillus in the vagina, making women more prone to BV. Broad-spectrum antibiotics especially alter the normal microbial balance.
  • Smoking: Smoking can increase the risk of BV by changing the vaginal flora and affecting immune function.
  • Underlying Health Issues: Women with immune-suppressing conditions like diabetes or HIV are at a higher risk for BV. Additionally, those with prior STI histories may also be more vulnerable to BV.

Differential Diagnosis

Many conditions can show symptoms like bacterial vaginosis, making it important to tell BV apart from other reasons for abnormal vaginal discharge:

  • Yeast Infections: Yeast infections (candidiasis) can lead to vaginal discharge, itching, and irritation. Unlike BV, yeast infections often come with thick, white, “cottage cheese-like” discharge, and the vaginal pH is typically normal or slightly acidic. A KOH (potassium hydroxide) test or vaginal culture can tell the difference between yeast infections and BV.
  • Trichomoniasis: Trichomoniasis, an STI caused by Trichomonas vaginalis, can also cause discharge and irritation. However, the discharge is generally frothy and yellow or greenish, and the smell may not be as fishy as with BV. Microscopic tests or PCR testing can confirm the diagnosis.
  • Chlamydia and Gonorrhea: These STIs can cause discharge, pain during urination, and pelvic pain, but usually lead to more severe symptoms, such as dysuria (painful urination), irregular bleeding, and pelvic discomfort. They are diagnosed through urine tests or cultures.
  • Cervicitis: Inflammation of the cervix can bring about abnormal discharge, often with pain during sex or urination. Cervicitis can result from infections like chlamydia, gonorrhea, or herpes, requiring STI testing.
  • Pelvic Inflammatory Disease (PID): PID is an infection in the reproductive organs that can cause pelvic pain, fever, and abnormal discharge. PID usually accompanies additional symptoms like abdominal pain and fever and can lead to complications if not treated.
Bacterial Vaginosis Differential Diagnosis
Differential Diagnosis Definition Symptoms Treatment
Bacterial Vaginosis (BV) An imbalance in vaginal bacteria leading to overgrowth of harmful bacteria. Thin, grayish discharge with a fishy odor, itching, and mild irritation. Antibiotics like metronidazole or clindamycin; probiotics to restore healthy flora.
Yeast Infections Overgrowth of Candida fungus in the vagina, disrupting normal balance. Thick, white, “cottage cheese-like” discharge, intense itching, and burning sensation. Antifungal treatments such as fluconazole or topical creams.
Trichomoniasis An STI caused by the protozoan Trichomonas vaginalis. Frothy, yellow-greenish discharge, genital irritation, and sometimes a mild odor. Metronidazole or tinidazole for both the patient and their partner(s).
Chlamydia and Gonorrhea STIs caused by bacteria (Chlamydia trachomatis and Neisseria gonorrhoeae). Discharge, painful urination, and pelvic discomfort; sometimes asymptomatic. Antibiotics such as azithromycin for chlamydia and ceftriaxone for gonorrhea.
Cervicitis Inflammation of the cervix, often linked to infections like STIs. Abnormal discharge, pain during sex, and urinary discomfort. Treatment of the underlying infection, often antibiotics or antivirals.
Pelvic Inflammatory Disease (PID) Infection of the reproductive organs, often a complication of untreated STIs. Pelvic pain, fever, abnormal discharge, and abdominal tenderness. Broad-spectrum antibiotics and, in severe cases, hospitalization.

Investigation

Diagnosing bacterial vaginosis mainly relies on clinical observations and laboratory tests. Tests:

1. Clinical Criteria (Amsel’s Criteria):

To diagnose BV, a doctor can look for at least three of these four signs:

  • A thin, grayish-white discharge from the vagina.
  • A fishy smell, especially after sex.
  • Vaginal pH higher than 4.5.
  • Clue cells (vaginal cells covered in bacteria) seen under a microscope.

2. Gram Staining:

Checking vaginal fluid with a Gram stain is a clear way to diagnose. Finding more Gardnerella vaginalis and other anaerobic bacteria along with fewer Lactobacillus species confirms BV.

3. Nucleic Acid Amplification Tests (NAATs):

These tests effectively find Gardnerella vaginalis and other bacteria linked to BV. They are increasingly used in clinics.

4. Vaginal Culture:

This test is not used often but may be done when there is uncertainty or if other infections need to be excluded.

Treatment

Bacterial vaginosis can be treated with antibiotics, which often clear symptoms. However, many women see it return and may need more treatments.

1. Antibiotics:

  • Metronidazole: This is the main treatment for BV. It can be taken as a pill for seven days or as a gel for five days.
  • Clindamycin: This is another treatment available in oral form or as a cream applied inside the vagina. It is for patients who cannot take metronidazole.
  • Tinidazole: Similar to metronidazole, this drug is used for treating BV and is usually given as a single dose.
  • Probiotics: Some research hints that probiotics, especially Lactobacillus, might help restore good bacteria in the vagina. More studies are needed to confirm if they work alone or with antibiotics.

2. Partner Treatment:

Partners usually do not need treatment for BV since it is not a sexually transmitted infection. If BV keeps coming back, treating both partners might help prevent re-infection.

3. Lifestyle Modifications:

Women with BV should stop douching because it can upset the natural bacteria balance and cause BV to return. Using condoms can help lower the chance of getting BV again.

4. Follow-up:

Regular check-ups may be needed to see how well the treatment is working and check for BV returning. Women with more than three episodes of BV in a year might need long-term therapy or further checks.

Conclusion

Bacterial vaginosis is a common and treatable problem affecting many women, especially those who can get pregnant. While not an STI, its symptoms can be upsetting and may cause issues if not treated.

Quick diagnosis and proper antibiotic treatment are essential for managing BV. Women should also learn about ways to prevent it, like avoiding douching and safe sexual practices.

Regular follow-up is vital, especially for those with recurring BV. With the right treatment, women can manage bacterial vaginosis and lessen the risk of complications.

References
  1. McMillan, A., & Badgwell, D. (2016). “Bacterial Vaginosis: Diagnosis and Treatment.” Journal of Clinical Microbiology, 54(4), 895-900.
  2. Centers for Disease Control and Prevention (CDC). (2015). Bacterial Vaginosis. Available at: https://www.cdc.gov/std/bv
  3. Sobel, J. D. (2000). “Bacterial Vaginosis.” Clinical Infectious Diseases, 30(3), 503-510.
  4. Simoes, J., & Vinturini, G. (2014). “Probiotics in the Treatment of Bacterial Vaginosis.” Journal of Clinical Microbiology, 52(9), 3141-3147.
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