Bacterial vaginosis (BV) is a common and often irritating infection of the vagina, caused by an imbalance of natural bacteria that normally maintain a healthy vaginal microbiome. With similar symptoms to yeast infections, BV is sometimes misdiagnosed and incorrectly treated. And even when treated with the correct medication, as many as 50% of patients experience recurring BV infections within a year.
How is BV Diagnosed?
To diagnose BV, your healthcare provider will typically perform a pelvic exam to check for vaginal discharge, pelvic inflammation, or pain, and also discuss your sexual history. If they suspect BV, the Amsel Criteria and the Nugent Score are the two recognized methods of diagnosing the condition.
Diagnosis using the Amsel Criteria is typically inexpensive and provides immediate confirmation of bacterial vaginosis in the clinic. The Nugent Score provides a more precise diagnosis through laboratory tests, and patients generally wait a few hours to a few days for results.
In some cases, both the Amsel Criteria and the Nugent score are used to confirm a diagnosis of BV.
The Amsel Criteria for Diagnosing BV
The Amsel Criteria are a set of diagnostic measures used by healthcare providers to identify bacterial vaginosis, with three out of the following four criteria confirmed for a diagnosis.
- Altered Vaginal Discharge
A thin, white, or gray, watery vaginal discharge
- Changes in Vaginal pH (you can also test for this at home)
A vaginal pH higher than 4.5 (compared to the normally mildly acidic pH of 3.8-4.5)
- ‘Whiff Test’
Detection of a fishy odor after adding a few drops of potassium hydroxide (KOH) to a sample of vaginal fluid
- ‘Clue cells’
Vaginal epithelial cells coated with bacteria are identified under a microscope
The Nugent Score for Diagnosing BV
The Nugent Score involves sending a sample of vaginal fluid to a lab for testing, where it is transferred to a microscope slide and stained with a dye (Gram stain) that highlights the types of bacteria present.
In normal vaginal fluids, friendly bacteria such as lactobacilli are more abundant; however, an increase in unfriendly bacteria such as Gardnerella vaginalis and other anaerobes is typical with a BV infection.
The results are then applied to the Nugent Score system, which ranges from 0-10.
0–3 = Normal (healthy lactobacilli are dominant)
4–6 = Intermediate (mixed bacteria indicating a possible bacterial imbalance)
7–10 = Bacterial Vaginosis (less lactobacilli and an overgrowth of harmful bacteria, including Gardnerella vaginalis)
How is Bacterial Vaginosis Treated?
The good news is that BV is treatable with prescription antibiotics to reduce the overgrowth of harmful bacteria and restore the bacterial balance in the vaginal microbiome. Antibiotics such as Metronidazole and Clindamycin are considered first-line treatments for BV. Some studies show that an antibiotic known as Tinidazole is more powerful for recurring BV infections; however, it cannot be taken indefinitely.
Unfortunately, as many as 50% of women are reported to suffer from a recurring BV infection within a year. For this reason, a natural remedy that can be taken in conjunction with antibiotic treatment for BV is also recommended.
What Else Can Be Taken with Antibiotics to Prevent Recurring BV Infections?
Although it is not fully understood why some BV infections return, a few underlying factors are believed to be involved. Taking antibiotics, for instance, reduces the overgrowth of harmful bacteria such as Gardnerella vaginalis, but also destroys friendly bacteria like lactobacilli. This can result in a lowered immune system or an unrestored vaginal microbiome that leaves patients susceptible to further infection.
In women who are genetically prone to producing more Gardnerella vaginalis, BV infections can recur numerous times. Hormone changes during pregnancy, perimenopause, and menopause are also underlying causes of recurring BV infections due to the impact low estrogen levels can have on the production of friendly bacteria in the vaginal microbiome.
However, due to its natural antibacterial, antifungal, and antiviral properties, studies show that when boric acid suppositories are used in conjunction with antibiotic treatment, recurring BV was prevented in 92% of women who were prone to repeated infections.
Frequently used to eliminate recurring yeast infections caused by an overgrowth of fungus, Boric Acid suppositories can also destroy harmful bacteria, restore a healthy vaginal pH, and microflora after infection.
Boric Balance Suppositories from female health experts Intimate Rose are 100% natural and provide quick relief from the itching, burning, and unpleasant odor associated with BV (and yeast infections) within 24 hours. They are ideal for women who are sensitive to antibiotics, prone to recurring BV infections, or experiencing BV due to hormone changes during perimenopause or postmenopause.
Regrettably, Boric Acid Suppositories are not safe for use during pregnancy.
Can You Prevent BV?
Yes, BV can be prevented by paying attention to daily vaginal hygiene, making some lifestyle and clothing changes, and being mindful of the genitals during and after sexual activity.
Refrain from using douching or fragranced hygiene products to clean the vagina, as they are never necessary or recommended for vaginal cleanliness. Once the vaginal microbiome is healthy, the vagina acts as a self-cleaning organ, requiring only a clean washcloth with warm water (unscented soap is optional) to ensure daily freshness.
Change out of wet swimsuits or damp gym as soon as possible to prevent humid conditions around the vagina where bacteria can thrive. For the same reason, it’s wise to skip the hot tub or jacuzzi and switch from synthetic underwear to cotton briefs.
If you are prone to BV infections, using a condom can prevent vaginal pH changes that upset the vaginal microbiome. Urinating after sex, and washing the female genitals (as described above) can also ensure that any harmful penile bacteria are flushed.
Thoroughly drying the vagina after washing will also help to prevent a moist environment where bacteria can overgrow. Rather than rubbing sensitive vaginal skin dry, pat it gently with a clean towel.
Although research is ongoing, early studies suggest that probiotics (particularly those containing lactobacilli) could also help women who are prone to recurring BV infections maintain a healthy vaginal microbiome.
Should Sexual Partners Get Tested for BV?
Although sexual activity is believed to contribute to the bacterial imbalance that results in BV, particularly with multiple partners, it is not considered an STI, and treatment is normally focused on the person with the infection. Male sexual partners do not suffer from BV or require treatment; however, BV can be shared between female sexual partners.
If you have BV and one or more female sexual partners, it would be wise for them to get checked.
Conclusion
Bacterial vaginosis (BV) can be diagnosed by a healthcare provider using the Amsel Criteria and/or the Nugent Score. The Amsel Criteria are a set of four guidelines, of which three must be present for a BV diagnosis. The Nugent Score is determined from a microscopic examination of vaginal fluids for an increased growth of Gardnerella vaginalis and other anaerobes.
Once diagnosed, BV is normally treated with antibiotics; however, over 50% of women experience recurring BV infections within one year. To prevent recurring BV infections, female health experts advise taking Boric Acid Suppositories with antibiotic treatment.
Besides quick relief from BV itching and odor within 24 hours, Boric Acid Suppositories help restore the natural balance of bacteria in the vaginal microbiome. Something that antibiotics cannot achieve, but is fundamental to healing from BV.
References
Centers for Disease Control and Prevention - About Bacterial Vaginosis (BV) - https://www.cdc.gov/bacterial-vaginosis/about/
National Library of Medicine - Clinicians’ use of Intravaginal Boric Acid Maintenance Therapy for Recurrent Vulvovaginal Candidiasis and Bacterial Vaginosis - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878170/
National Institutes of Health - Bacterial vaginal flora in relation to changing oestrogen levels - https://pubmed.ncbi.nlm.nih.gov/17524189/
National Institutes of Health - Bacterial Vaginosis in Postmenopausal Women - https://pmc.ncbi.nlm.nih.gov/articles/PMC10438897/
Dr. Barb DePree, M.D., has been a gynecologist and women’s health provider for almost 30 years and a menopause care specialist for the past ten.