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How to Treat Recurrent Bacterial Vaginosis, According to Ob-Gyns

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Imagine this: You’re on a tropical getaway…but between the persistent vaginal itching and irritation you’re feeling, you’re in sweatpants instead of a bikini. Recurrent bacterial vaginosis doesn’t care about your plans, whatever your life looks like at the moment. If you’re dealing with symptoms like fishy odor, watery gray discharge and burning, pain, or irritation of the vulva, and this isn’t the first time you’ve experienced these issues recently, it’s likely you have a bacterial vaginosis (BV) infection that won’t quit.

BV can commonly recur, especially if you never really treat the underlying cause, which is an overgrowth of the bacteria Gardnerella vaginalis. It’s naturally found in the vagina and doesn’t always cause problems—but sometimes, it can get too feisty.

Here, ob-gyns share everything you should know about recurrent BV and how to kick it to the curb for good.

What causes recurrent BV?

If you tend to have three or more BV infections in a year, that’s the threshold for recurrent bacterial vaginosis, Suzanne Bovone, MD, a board-certified ob-gyn at Pediatrix Medical Group in San Jose, California, tells SELF. For the infections to warrant an official diagnosis of recurrent BV, they all need to be confirmed by a lab or your doctor, Dr. Bovone says.

There are a few reasons BV infections can recur, but it’s not unusual for BV to come back a few times. One study found that 58% of cases among the 121 participants recurred even after treatment. Stubborn cases along those lines are often not the person going through them’s “fault,” Kameelah Phillips, MD, a board-certified ob-gyn based in New York City, tells SELF: You can follow all the courses of treatment and take all the precautions, and BV can still come back. But why?

Whatever the cause, recurrent BV comes from a consistent imbalance of “good” and “bad” vaginal bacteria.

It might make more sense to think of BV as a “state of affairs” rather than an infection, Mary Jane Minkin, MD, clinical professor of obstetrics, gynecology, and reproductive sciences at Yale University School of Medicine, tells SELF. It’s ideal to have a balance of “good bacteria,” or lactobacilli (a common bacteria found naturally in the vagina and found in probiotics) and “bad bacteria,” or Gardnerella vaginalis. (While it may seem counterintuitive, an overgrowth of lactobacilli can also lead to a yeast-infection-like condition called cytolytic vaginosis. It’s a delicate dance down there!) “The good lactobacilli make acid, which tends to keep the bad bacteria away,” explains Dr. Minkin. When there’s not enough acidity, it can throw off your vaginal pH and cause an overgrowth of harmful bacteria, a.k.a. a BV infection. Here’s what might be throwing things out of whack and contributing to your stubborn BV.

Washing your vagina

Certain products used around or inside the vagina, like douches or cleansers (and especially ones that contain fragrance), can alter your vaginal pH and contribute to BV. They tend to strip away the lactobacilli that help maintain a balanced, acidic pH in the vaginal microbiome and might allow infection-causing bacteria to flourish.

So put down the soap—you don’t need anything fancy to wash with, given that your vagina is self-cleaning. One of the most important things to remember: “The vagina does have a natural odor, and many products try to make you think any odor is bad,” says Dr. Bovone. Using products to mask that natural scent could give you the illusion of making the vagina “cleaner” or “healthier,” but the opposite ends up being true. And if it leads to a BV infection, you might ultimately have to deal with a pungent scent that’s way more pronounced—and unpleasant.

Sex (sorry!)

While BV is not a sexually transmitted infection (STI), the bacteria that sometimes causes it can be passed between sexual partners. Sex can lead to BV when the natural chemistry or pH balance of a partner’s genitals is different from what your vagina is used to, and so, contact between the two changes your vaginal microbiome. Annoyingly, you might encounter (and get BV from) the bacteria that causes issues every single time you have unprotected sex with even one partner whose pH isn’t gelling with yours: “The BV-associated bacteria can be passed back and forth,” Dr. Phillips says. “Having a consistent sexual partner can increase the risk for recurrent BV.” Sex-related BV can also arise when you have a new sexual partner, or multiple partners, especially ones whom you’re having unprotected sex with.

Other lifestyle factors

There are some other less-expected habits that might have something to do with BV that won’t leave you alone. For instance: Smoking cigarettes can also up your chances of getting BV more frequently, says Dr. Phillips. According to research published in Nature, smoking can alter the vaginal microbiome and contribute to deficiencies in lactobacilli bacteria. It could be that cigarettes cause a continuous bacterial imbalance that makes you vulnerable to infections, making it an even better idea to quit if you smoke.

While this is what we know so far about common BV culprits, exactly why some people have recurring cases more so than others, in terms of the root causes, isn’t an open-and-shut case just yet. “We need additional research to pinpoint exactly which other lifestyle factors are most likely to contribute to recurrent BV,” Dr. Phillips explains.

How to take care of yourself in a recurrent BV cycle

Don’t self-diagnose.

A lot of the time, people with BV might not be familiar with it, and so mistake it for a yeast infection or urinary tract infection (UTI), which have similar symptoms—think itchiness and irritation. But trying to self-diagnose sometimes leads people to start taking OTC yeast infection treatments while their BV bacteria is raging, which doesn’t help—and sometimes leads to a more uncomfortable infection, for a longer time, or one that just keeps coming back. This means you have to be sure of what you’re actually dealing with.

It is a possibility that you can have both infections at once, but it’s best to see an ob-gyn or go to a sexual health clinic to confirm what’s going on. “While BV is the most common cause of abnormal vaginal discharge, it’s possible that people may have a co-infection with yeast or other bacteria that can complicate diagnosis,” Dr. Phillips adds.

Get evaluated by a health care provider to get the most accurate diagnosis, says Dr. Phillips—and find a new one if you’re not getting good answers or helpful treatment as things stand.

Give health care providers all the info they need to make a complete diagnosis.

Bacterial STIs can also be strikingly similar to BV, symptom-wise. The condition can look a lot like trichomoniasis, which usually comes with funky-smelling discharge and itchiness, or Mgen, which causes unusual or smelly discharge, burning when you pee, and vulvar pain or discomfort. To avoid a misdiagnosis, Dr. Bovone recommends that providers test for all STIs, especially those with bacteria and parasites as vectors, or which come with symptoms of vaginal itching and discharge with an off odor (like gonorrhea and chlamydia). “We see it all, and can reassure you what is normal. And if anything is off, we can help,” says Dr. Bovone.

Ask a doctor to test you for BV specifically, too. Dr. Phillips starts appointments with a verbal screening to clarify her patients’ symptoms, then takes a vaginal swab sample to send out to a lab for analysis. Once she knows what’s actually going on, she’s able to devise a treatment plan.

When a doctor prescribes you treatment, follow their instructions and stick with it for the whole time you’re supposed to—even if your symptoms get better.

Depending on the infection and the clinic, you might be given the option of oral or vaginal antibiotics (often, clindamycin or metronidazole) to treat BV. To target recurrent BV, Dr. Bovone explains that doctors might prescribe a longer course of treatment than they would for a one-off case, such as using an antibiotic for seven to 10 days, plus a weekly dose of a vaginal antibiotic gel for four to six months afterward to prolong the treatment. There are also newer treatments, including a clindamycin vaginal gel called Xaciato that can be applied like a tampon to deliver a strong single dose of medication.

BV can come creeping back if you veer off course with a prescribed treatment, such as not taking all of the antibiotics every day or stopping before the intended date, even if it seems like your symptoms are clearing up. “Inadequate treatment is a setup for a recurrence: BV is a disruption of the normal vaginal flora, and that flora needs to be re-established,” says Dr. Bovone. It can become unclear whether the recurrence is a reinfection, or if the infection never really cleared in the first place. So, even if you’re feeling better, don’t stop taking medication before the set end date, or else you might risk a BV infection creeping back.

Keep things moisturized.

One way to keep your vaginal pH as close to acidic (and infection-free) as possible is to make sure there’s enough lubrication on a day-to-day basis. Vaginal dryness, which can happen due to lower estrogen levels during menopause or during a period of breastfeeding, among other things, can lead to a less acidic pH, according to Dr. Minkin. She recommends a vaginal moisturizing gel like Replens to help with dryness.

Get a doctor’s opinion before you use OTC suppositories, like those containing boric acid.

You may have heard of boric acid suppositories and other over-the-counter treatments that purportedly balance the vaginal microbiome. No matter what, you should speak with your health care provider to confirm you have BV before trying these out, Dr. Phillips says. From there, you should know that boric acid supplements are not FDA-approved, and that the jury’s still out about whether boric acid on its own can help with BV. (SELF has a full rundown of how boric acid affects your vagina, including if you have a bacterial or yeast infection.)

Your ob-gyn probably won’t prescribe boric acid alone to treat acute BV, since it’s a homeopathic remedy and has not been proven to be more effective than prescription antibiotics. That said, there’s a chance your gyno might recommend it as a maintenance treatment for acidifying the vagina and keeping recurrent BV away. Studies show it can lead to some irritation of the vagina, though, so it may not work well for everyone. And you shouldn’t use boric acid supplements if you’re pregnant or trying to conceive, because there’s not enough research to show that it won’t cause harm to a fetus.

If you decide to give boric acid a try with your ob-gyn’s blessing, a typical cycle of treatment is 30 days (you shouldn’t use it for longer than that, which can lead to even worse irritation). To avoid contact irritation to your partner’s skin or damage to condoms or diaphragms—both of which can be caused by boric acid—it’s best to hold off on having penetrative or receptive oral sex while you’re using it, Dr. Bovone advises.

Err on the side of not using products in or near your vagina.

Double-check with your gyno before trying any over-the-counter products that could alter your pH and send you into a BV spiral. “You don’t need any vaginal wash. This will disrupt the normal bacteria and create more issues,” says Dr. Bovone. The vagina is meant to be self-cleaning, thanks to vaginal discharge sweeping out any bacteria, and will regulate its own pH and natural odor, as SELF previously reported.

And, hate to say it, but…don’t have sex until you get to the bottom of things, and use protection whenever possible when you do.

This might seem like a given, but don’t have penetrative sex or receive oral sex, even with barrier protection, during your antibiotic treatment. If you do, it can throw things off course as your pH is settling back into its normal groove. Once you finish the whole course of medication and your vagina seems calm again, you’re good to go.

If your partner’s pH is potentially the X factor here: Whether your partner has a penis or vagina, using condoms or dental dams might be able to decrease spread of the bacteria until you get the overall imbalance under control.

Take a breath—and don’t beat yourself up about this.

We know, BV is not a good time—especially when you have life events that involve bikinis! wedding days! beach vacations! or simply getting laid! And it can be particularly difficult to get to the bottom of the recurrent cases. But don’t be ashamed—this is SO common, and there are effective treatments available to you. It just takes a bit of trial and error—and patience. With the right help (and perhaps a thorough audit of the products you use near your vagina), you’ll figure it out.

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Originally Appeared on SELF