Is bacterial vaginosis an STD?
STD stands for sexually transmitted infection.
The symptoms of bacterial vaginosis (BV) are often most prominent after sex. What does this mean? Is bacterial vaginosis an STD?
The answer is complicated.
No, is the classic response. It is not sexually transmitted in women who have sex with men (WSM). Even though the symptoms seem related to intercourse, it is not an STD.
The answer is maybe in women who have sex with women (WSW).
Virgins can also have bacterial vaginosis.
What are the symptoms?
BV is the most common vaginal infection, and often patients are not aware of it. BV is frequently a coincidental finding on routine cervical smear testing (PAP smears).
A distressing fishy vaginal smell is the overriding symptom that concerns patients.
Women often delay coming to the doctor because they feel embarrassed.
Sometimes, their sexual partner is the only person to notice the smell.
The odor might come and go. In other cases, it is overwhelming; patients worry that people in their work environment might notice it.
A thin-greyish discharge and itching can accompany this. There is usually no pain, redness, or irritation.
Many women are confused as to what is a normal discharge and what should concern them. The video below will help you decide.
What kind of infection is BV?
Essentially it is an overgrowth of normal vaginal anaerobic bacteria. Usually, they make up about 10 to 40% of the microbiome.
They are kept in check by the dominant lactobacilli. Lactobacilli produce lactic acid and keep the vaginal pH low. The acidic environment is not ideal for anaerobic bacteria.
Terminology
- Low pH = Acidic environment
- High pH = Alkaline environment
- Anaerobic = living without oxygen
What causes BV?
The causes are not known.
Anything that upsets the pH balance of the vagina or kills the lactobacilli could be a trigger.
The theories have been investigated.
Unprotected sex in WSM
“You are telling me that sex is a cause. Is bacterial vaginosis an STD? You said it is not.”
Distressed patient
Semen is alkaline. The theory is that during unprotected intercourse, semen entering the vagina cancels out the acidic environment. Lactobacilli numbers drop, and anaerobic BV-causing bacteria flourish. 2
Higher BV incidence is associated with multiple male partners and having a new partner.
However, trials treating male sexual partners of BV positive patients show mixed results in infection recurrence. Most agree that antibiotic treatment for male partners is not beneficial. 9,10,11
Intrauterine device (IUD)
IUDs are a known risk factor.
Hormonal fluctuations
Low estrogen around menstruation time causes a more alkaline environment. Women may report a fishy smell after their period. This might pass as the cycle continues and estrogen levels climb again. 1,4
Lower baseline estrogen levels are present during menopause and with combined oral contraceptive (COC) use. These may predispose to BV in some women.
Vaginal douching
Rinsing inside the vagina with soap or even water increases the chance of BV.
This could be due to
- a pH change using alkaline soaps,
- the bactericidal effect on lactobacilli, and decreased lactic acid production. 1,3
The vagina is self-cleaning, no cleaning is required.
Ethnicity
Your race may play a role. 1
Black and Hispanic women might be more prone to BV. They have a higher pH and fewer competing lactobacilli than their White and Asian counterparts. 1
| ETHNICITY | LACTOBACILLI % OF MICROBIOME |
|---|---|
| Black Hispanic | Approximately 60% |
| Asian White | 80 to 90% |
What about WSW?
The rate of BV in WSW is high, between 25 and 50%. 7,8
The association between BV and exposure to increased numbers of female partners and a female partner with BV, together with a high concordance of BV between female sexual partners in published studies, supports the concept that BV is likely sexually transmitted between women.
Forcey, D. S. et al. 7
This is not conclusive data, but suggestive. 7,8 It would be of value to screen female sexual partners of BV positive patients.
How can I treat it?
You need to see a doctor for an antibiotic.
You can drink tablets or use intravaginal cream. Treatment success and the chance of a recurrent infection are the same with either option. 5
The treatment choice depends on
- your medical history,
- personal preference, medication cost, and
- availability of the options.
Ladies who are trying to fall pregnant, who are pregnant or breastfeeding, should consult their OBGYN.
Metronidazole tablets
Take metronidazole tablets twice a day for 7 to 10 days.
You must take it after meals and drink no alcohol during the course.
Intravaginal antibiotic cream
This is either metronidazole or clindamycin cream at night for 5 to 7 nights.
- The side effects are less severe but the same as the oral equivalents.
- The creams can cause drug interactions; this is why you need to consult with a doctor.
- The cream may leak and be messy.
- Insert the cream into the vagina with an applicator. Some patients are not comfortable with this. If you can use tampons, it shouldn’t be a challenge.
How can I prevent BV?
Exclude possible triggers
BV is often recurrent.
Read through the theoretical causes and change what you can.
- Use condoms during sex.
- Remove the IUD.
- Avoid douching and using soap in the vaginal area.
- Talk to your doctor if the trigger is low estrogen. Consider stopping your COC, starting hormone replacement therapy, or using intravaginal estrogen.
- Screen and treat female sexual partners.
Probiotic lactobacilli supplements
Probiotics might be the breakthrough in BV prevention.
Studies have shown that probiotics shorten the duration and decrease symptom intensity of BV. 6
They are available over the counter.
The cost could be a drawback as probiotics are expensive. Patients would need to calculate the cost of consultations, investigations, and prescribed treatments versus the price of a daily probiotic.
- Oral probiotics reach the vagina in 7 days.
- Intravaginal probiotics take effect in 48 hours.
Currently, in South Africa, intravaginal probiotics are not readily available.
Summary
- Bacterial vaginosis is not an STD in women who have sex with men.
- Bacterial vaginosis might be sexually transmitted in women who have sex with women.
- BV is common; you are not alone.
- Most patients are not aware that it is present.
- Asymptomatic BV usually requires no treatment.
- Symptomatic BV requires antibiotic treatment.
- Not definite causes have been identified, but many theories exist.
- Probiotics might help in the prevention of BV.
References
- Chen, Y., Bruning, E., Rubino, J., & Eder, S. E. (2017). Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Women’s health (London, England), 13(3), 58–67. https://doi.org/10.1177/1745505717731011
- Mngomezulu, K., Mzobe, G. F., Mtshali, A., Osman, F., Liebenberg, L. J. P., Garrett, N., Singh, R., Rompalo, A., Mindel, A., Karim, S. S. A., Karim, Q. A., Baxter, C., & Ngcapu, S. (2021). Recent Semen Exposure Impacts the Cytokine Response and Bacterial Vaginosis in Women. Frontiers in immunology, 12, 695201. https://doi.org/10.3389/fimmu.2021.695201
- Hutchinson, K. B., Kip, K. E., Ness, R. B., & Gynecologic Infection Follow-Through (GIFT) Investigators (2007). Vaginal douching and development of bacterial vaginosis among women with normal and abnormal vaginal microflora. Sexually transmitted diseases, 34(9), 671–675. https://doi.org/10.1097/01.olq.0000258435.34879.da
- Wilson, J. D., Lee, R. A., Balen, A. H., & Rutherford, A. J. (2007). Bacterial vaginal flora in relation to changing oestrogen levels. International journal of STD & AIDS, 18(5), 308–311. https://doi.org/10.1258/095646207780749583
- Sobel, J. D., Schmitt, C., & Meriwether, C. (1993). Long-term follow-up of patients with bacterial vaginosis treated with oral metronidazole and topical clindamycin. The Journal of infectious diseases, 167(3), 783–784. https://doi.org/10.1093/infdis/167.3.783
- Liu, P., Lu, Y., Li, R., & Chen, X. (2023). Use of probiotic lactobacilli in the treatment of vaginal infections: In vitro and in vivo investigations. Frontiers in cellular and infection microbiology, 13, 1153894. https://doi.org/10.3389/fcimb.2023.1153894
- Forcey, D. S., Vodstrcil, L. A., Hocking, J. S., Fairley, C. K., Law, M., McNair, R. P., & Bradshaw, C. S. (2015). Factors Associated with Bacterial Vaginosis among Women Who Have Sex with Women: A Systematic Review. PloS one, 10(12), e0141905. https://doi.org/10.1371/journal.pone.0141905
- Evans, A. L., Scally, A. J., Wellard, S. J., & Wilson, J. D. (2007). Prevalence of bacterial vaginosis in lesbians and heterosexual women in a community setting. Sexually transmitted infections, 83(6), 470–475. https://doi.org/10.1136/sti.2006.022277
- Plummer, E. L., Vodstrcil, L. A., Doyle, M., Danielewski, J. A., Murray, G. L., Fehler, G., Fairley, C. K., Bulach, D. M., Garland, S. M., Chow, E. P., Hocking, J. S., & Bradshaw, C. S. (2021). A prospective, open-label pilot study of concurrent male partner treatment for bacterial vaginosis. mBio, 12(5). https://doi.org/10.1128/mbio.02323-21
- Schwebke, J. R., Lensing, S. Y., Lee, J., Muzny, C. A., Pontius, A., Woznicki, N., Aguin, T., & Sobel, J. D. (2021). Treatment of Male Sexual Partners of Women With Bacterial Vaginosis: A Randomized, Double-Blind, Placebo-Controlled Trial. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 73(3), e672–e679. https://doi.org/10.1093/cid/ciaa1903
- Amaya-Guio, J., Viveros-Carreño, D. A., Sierra-Barrios, E. M., Martinez-Velasquez, M. Y., & Grillo-Ardila, C. F. (2016). Antibiotic treatment for the sexual partners of women with bacterial vaginosis. The Cochrane database of systematic reviews, 10(10), CD011701. https://doi.org/10.1002/14651858.CD011701.pub2
A valuable article!
It is such a common and debilitating illness that ladies need to talk about.