Bacterial vaginosis that keeps returning

Bacterial vaginosis is the most common cause of vaginal discharge and odor in women of reproductive age, and one of the most misunderstood. It is not caused by poor hygiene, it is not a sexually transmitted infection, and it is not yeast - though it is treated as yeast constantly, which is one reason it keeps coming back. BV is a disturbance of the vaginal microbiome: the protective lactobacilli thin out and other bacteria take the space. Clearing an episode is usually simple. Keeping it from returning is the real work, and most of this page is about that.

What bacterial vaginosis actually is

A healthy vagina is dominated by lactobacilli, bacteria that produce lactic acid and hold the environment acidic, generally below a pH of about 4.5. That acidity is the main force suppressing the anaerobic organisms that also live there in small numbers. In bacterial vaginosis the lactobacilli decline, those anaerobes expand, the pH rises, and the by-products of their metabolism create the thin gray-white discharge and the odor that becomes more noticeable after sex or around your period. Nothing has been caught and nothing has invaded; a balance already in place has tipped.

This distinction matters because it determines what treatment can and cannot do. An antibiotic knocks down the overgrown anaerobes and resolves the symptoms, but it does not restore the lactobacilli, and in many women they do not re-establish themselves. That is the mechanical reason BV recurs so readily, and why a strategy built on repeated short courses tends to disappoint. It is also why hygiene advice points the wrong way: BV is more common in women who wash the vagina more, not less.

Getting the diagnosis right

The most common error in vaginal symptoms is assuming that discharge means yeast. Surveys of women buying over-the-counter antifungals have repeatedly found that most do not have a yeast infection, and BV is the leading alternative. This is not carelessness, since the symptoms overlap enough that the two cannot be separated reliably without an exam. As a rough guide, yeast itches and produces a thick, odorless discharge, while BV itches little and produces odor; trichomonas can resemble either.

Diagnosis in the office is quick and worth the visit. We check the vaginal pH, look at the discharge, and either examine it under the microscope for clue cells or send a molecular panel that identifies what is present, including yeast species and trichomonas. Getting this right at the outset matters, because the treatments are entirely different and an antifungal used against BV leaves the real problem untreated while weeks pass. If you have been self-treating for months, bring that history; a pattern of failed antifungal treatment is itself diagnostic information.

Treating the episode

Standard treatment is an antibiotic active against anaerobes: a nitroimidazole taken orally or used as a vaginal gel, or clindamycin as a vaginal cream. Oral and vaginal routes have broadly similar cure rates for a first episode, so the choice comes down to tolerance and preference. The oral nitroimidazole can cause nausea and a metallic taste, while vaginal preparations avoid that; clindamycin cream weakens latex condoms and diaphragms while in use. The drug, route and duration are individualized, particularly in pregnancy, so those decisions belong in the consultation rather than on a web page.

Most episodes settle within a week. If symptoms persist past the course, that calls for re-evaluation rather than a repeat of the same prescription, because persistent symptoms after adequate treatment usually mean a second condition is present or the original diagnosis was wrong. Treating a woman who has no symptoms but happens to show a BV flora pattern on a test is generally unnecessary, with the exceptions of pregnancy in certain circumstances and the period before some gynecologic procedures.

When it keeps coming back

Recurrence is the genuine clinical problem with BV. A large share of women finish treatment symptom-free and are back where they started within a few months, which reflects neither a failure on your part nor anything more sinister. The reason is the one described at the top of this page: the antibiotic removed the overgrowth, but the protective lactobacilli did not return, leaving an environment primed to tip again. Recurrent BV is best approached as a chronic condition with a plan, not as unrelated episodes handled at the last minute.

Suppressive regimens

The best-established approach for frequent recurrence is induction followed by suppression: a full course to clear the current episode, then intermittent vaginal gel, commonly twice weekly, for several months. This works reliably while it is being used; some women stay well after stopping and others relapse and need a longer or repeated course, which is worth knowing in advance so a relapse does not feel like a defeat. The trade-off is real, since prolonged antibiotic exposure raises the rate of yeast infections, and an antifungal is sometimes added for that reason. It is a sensible plan for several episodes a year and unnecessary for one.

Boric acid, with the caveat it deserves

Intravaginal boric acid capsules are widely used as an adjunct, alongside or between antibiotic courses, on the rationale that boric acid disrupts the biofilm sheltering the BV-associated bacteria. The honest position is that the evidence base is thin - small studies, inconsistent designs, no large trial that settles the question - so it is not first-line treatment. In practice some women clearly do better with it, and it is inexpensive and usually well tolerated. Two points are not negotiable: it is for vaginal use only and is toxic if swallowed, so keep it away from children, and it should not be used in pregnancy.

What to change, and what to stop worrying about

A short list of habits genuinely influences recurrence, and a much longer list of things women are told to fret over does not. The items below have a defensible rationale behind them. Anything not on the list is probably not worth your attention.

• Stop douching. It strips out lactobacilli along with everything else and is among the most consistent risk factors for BV.
• Wash the vulva with water or a plain unscented cleanser and leave the vagina itself alone - no internal washes, scented products or deodorizing wipes.
• Use condoms where you can. Semen is alkaline, repeated unprotected exposure is associated with recurrence, and condom use with less of it.
• Notice whether episodes track with a new partner or with resuming sex after a gap - a pattern worth knowing even though BV is not transmitted in the ordinary sense.
• Stop smoking if you smoke, since it is associated with disrupted vaginal flora and with recurrence.

BV is not a hygiene failure. The vagina is the one part of the body that does worse the more you wash it, and a great deal of stubborn recurrence is the direct result of well-intentioned effort.

Partners, IUDs and menopause

BV is not classified as a sexually transmitted infection, but sexual activity plainly influences it. The long-standing advice that male partners need no treatment has been challenged by recent work suggesting that treating them may reduce recurrence in some couples, so this is an area where practice is genuinely shifting. We would rather tell you where the evidence sits than recite a rule that may not hold. Between female partners, flora concordance is high and treating both is reasonable.

Two other situations come up often enough to name. A copper or hormonal IUD is associated with a modest increase in BV and persistent discharge for some women; that is usually manageable with a suppressive plan and only rarely a reason to remove a device you otherwise want, but it deserves mention if your symptoms began after insertion. After menopause the picture changes, because low estrogen reduces the glycogen lactobacilli depend on and the flora shift for hormonal reasons. Vaginal estrogen then often does more than another antibiotic course would.

Why this is worth treating properly

Beyond the symptoms, BV carries two associations worth stating plainly rather than burying. Losing the acidic, lactobacillus-dominant environment increases susceptibility to sexually transmitted infections, including HIV, chlamydia and gonorrhea, and raises the risk of infection after gynecologic surgery. In pregnancy, BV is associated with preterm birth and late miscarriage, which is why symptomatic BV is treated in pregnancy without hesitation, although screening women who have no symptoms has not been shown to prevent preterm birth. Neither association is cause for alarm; both are reasons to treat BV as a real condition rather than a pharmacy-aisle nuisance.