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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.

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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.

Related:

Originally Appeared on SELF

Bacterial Vaginosis Is The Most Common Vaginal Infection In Women — Here's What You Need To Know

Experts explain what cause bacterial vaginosis and how to treat it. (Photo: Getty Images) (Getty Images/iStockphoto)

Bacterial vaginosis (BV) is the most common vaginal infection in women. According to the Centers for Disease Control and Prevention (CDC), the condition affects nearly 30% of women between 15 and 44 years old. However, BV disproportionately impacts Black women, who have an estimated infection rate of more than 50%.

BV occurs when there's an overgrowth of bacteria, according to the Mayo Clinic, which throws off the natural pH balance of the vagina.

What causes bacterial vaginosis?

Bacterial vaginosis is most often caused by an overgrowth of a common type of bacteria called gardnerella vaginalis. Certain risk factors, such as douching, can disrupt the balance of "good" and "bad" bacteria in the vagina, leading to this overgrowth.

BV can happen to anyone with a vagina, even if you're not sexually active. However, occurrence in those who are not sexually active is rare.

You're at higher risk for getting BV if you're pregnant; have a new sex partner, a female sex partner or multiple sex partners; don't use condoms or dental dams; use douches; or have an intrauterine device (IUD).

There is no foolproof way of avoiding bacterial vaginosis. But you can reduce your risk by not douching, limiting sex partners, using latex condoms or dental dams and wearing cotton or cotton-lined underwear.

What are the symptoms?

Dr. Jennifer Wider tells Yahoo Life, "Sometimes there are no symptoms, but if there are, the most common include an off-white, gray or greenish, watery vaginal discharge [and] a 'fishy' odor that can be strongest during the period or after sex. A less common symptom is itchiness or soreness."

Dr. Kecia Gaither, director of perinatal services at NYC Health + Hospitals/Lincoln in the Bronx points out to Yahoo Life that some people think bacterial vaginosis is a sexually transmitted infection, "hence the stigma," she says. "But it is not."

However, BV can increase your risk of getting a sexually transmitted infection, such as chlamydia or gonorrhea, according to the CDC. That, in turn, can lead to pelvic inflammatory disease. Having BV when you're pregnant also increases the risk of preterm birth (before 37 weeks of pregnancy).

BV is sometimes mistaken for other conditions like a non-viral STI called trichomoniasis, as well as other bacterial infections including chlamydia and gonorrhea.

According to Cleveland Clinic, the most common mix-up occurs between bacterial vaginosis and yeast infections because both are bacterial infections that cause increased discharge. However, there are notable differences between the two infections: discharge with bacterial vaginosis has a fishy smell and is watery in consistency, while discharge from a yeast infection is thick and white with a cottage cheese-like appearance and there isn't a strong odor.

Typically, BV doesn't cause irritation or itchiness, but a yeast infection will. Finally, yeast infections can be treated with over-the counter-medications or with an antifungal medication, while you will need prescription antibiotics for bacterial vaginosis.

How do you treat bacterial vaginosis?

The good news is that bacterial vaginosis is curable. The infection is diagnosed through a sample of vaginal fluid taken through a gynecological exam and sent to a lab. After diagnosis, treatment usually involves a seven-day course of antibiotics. Gaither explains that "multiple therapeutic medications have been utilized for treatment like metronidazole, clindamycin and tinidazole."

However, not finishing the full course of antibiotics can trigger a relapse, according to the U.S. Department of Health and Human Services. Also, in a small percentage of cases, people may need a second treatment. Unfortunately, research shows that BV has a high rate of recurrence — a 2021 study found that BV will recur within six months in more than 50% of cases.

Bacterial vaginosis is thankfully considered a mild infection, but it can make you susceptible to more serious health conditions. If you experience any of the symptoms, don't delay seeing your medical provider.

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Organon's XACIATO™ (clindamycin Phosphate) Vaginal Gel 2% Available Nationwide To Treat Bacterial Vaginosis (BV) In Females Aged 12 And Older

Despite being the most common vaginal condition,1 BV symptoms are often mistaken for a yeast infection2

Organon (NYSE: OGN), a global healthcare company with a focus on women's health, announced that XACIATO™ (clindamycin phosphate) vaginal gel 2% is available by prescription to treat bacterial vaginosis (BV). BV results from an overgrowth of certain bacteria, which upsets the balance of the natural vaginal microbiome (environment) and can lead to symptoms of odor and discharge.3 BV has also been shown to disproportionately affect non-Hispanic Black and Mexican American women.4,5

In addition to the physical symptoms,3 BV can also impact a woman's emotional wellbeing.2 In fact, a 2017 survey among 304 women diagnosed with BV2 found that 79% avoided intimacy with their partner2 and 68% felt self-conscious because of their condition.2 Most women with symptoms of BV require treatment.6 Women with recurrent BV have reported frustration with recurrence after initial treatment,7 with 58% of them experiencing recurrent infection within 12 months.7

XACIATO, pronounced zah-she-AH-toe, is a colorless single-dose vaginal gel that can be applied at any time of day and is formulated with the goal of limiting leakage and increasing vaginal retention time (time spent in place).4 As demonstrated by an in vitro study using clindamycin HCl, the gel increases viscosity (thickness and stickiness) at body temperature and gradually releases clindamycin, over time.4,8

"As a company focused on women's health, we make it a priority to listen to women and their providers, so that we understand their needs and put forward innovative solutions," said Juan Camilo Arjona Ferreira, M.D., Head of Research & Development and Chief Medical Officer at Organon. "What drew us to XACIATO is that it was formulated with specific needs in mind and studied in a patient population that was representative of women with BV."1

XACIATO is contraindicated in individuals with a history of hypersensitivity to clindamycin or lincomycin. Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin, and may range in severity from mild diarrhea to fatal colitis. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. Difficile may need to be discontinued.

"BV is the most common form of vaginitis,1,9 disrupting the lives of approximately 21 million women.1,5 For these women, it's important to consider her individual treatment needs, such as route of administration, cost, adverse events, dosing and duration of treatment,"7,10 said Erica Montes, M.D., Board-Certified Obstetrician and Gynecologist and a Fellow of the American College of OB/GYN. "The availability of XACIATO is important as it's one dose for women experiencing BV and it can be taken at any time of day."

In 2022, Organon and Daré Biosciences completed an agreement whereby Organon will license global rights to XACIATO.

Information about XACIATO, and the eVoucher instant savings coupon for eligible patients, can be found at XACIATO.Com.

About BV

BV is the most common vaginal condition in women of reproductive age in the United States, affecting approximately 21 million women.1,5 The condition results from an overgrowth of certain bacteria, which upsets the balance of the natural vaginal microbiome and can lead to symptoms of odor or discharge.3 BV may self-resolve in up to 30% of women, but most symptomatic women require treatment.6,11 If left untreated, BV may lead to serious complications.2,11 BV has also been shown to disproportionately affect non-Hispanic Black and Mexican American women.4,5

About XACIATO

XACIATO is indicated for the treatment of bacterial vaginosis in females 12 years and older. A single-dose user-filled disposable applicator delivers 5g of vaginal gel containing 100mg of clindamycin.

Selected Safety Information

XACIATO is contraindicated in individuals with a history of hypersensitivity to clindamycin or lincomycin.

Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin, and may range in severity from mild diarrhea to fatal colitis. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibacterial use not directed against C. Difficile may need to be discontinued.

Polyurethane condoms are not recommended during treatment with XACIATO or for 7 days following treatment. During this time period, polyurethane condoms may not be reliable for preventing pregnancy or for protecting against transmission of HIV and other sexually transmitted diseases. Latex or polyisoprene condoms should be used.

XACIATO may result in the overgrowth of Candida spp. In the vagina resulting in vulvovaginal candidiasis, which may require antifungal treatment.

The most common adverse reactions reported in >2% of patients and at a higher rate in the XACIATO group than in the placebo group were vulvovaginal candidiasis and vulvovaginal discomfort.

XACIATO has not been studied in pregnant women. However, based on the low systemic absorption of XACIATO following the intravaginal route of administration in nonpregnant women, maternal use is not likely to result in significant fetal exposure to the drug.

There are no data on the effect of clindamycin on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for clindamycin and any potential adverse effects on the breastfed child from clindamycin or from the underlying maternal condition.

Please see the Prescribing Information, Patient Information, and Instructions for Use.

About Organon

Organon is a global healthcare company formed to focus on improving the health of women throughout their lives. Organon offers more than 60 medicines and products in women's health in addition to a growing biosimilars business and a large franchise of established medicines across a range of therapeutic areas. Organon's existing products produce strong cash flows that support investments in innovation and future growth opportunities in women's health and biosimilars. In addition, Organon is pursuing opportunities to collaborate with biopharmaceutical innovators looking to commercialize their products by leveraging its scale and presence in fast growing international markets.

Organon has a global footprint with significant scale and geographic reach, world-class commercial capabilities, and approximately 10,000 employees with headquarters located in Jersey City, New Jersey.

For more information, visit http://www.Organon.Com and connect with us on LinkedIn, Instagram, X (formerly known as Twitter) and Facebook.

Forward-Looking Statements

Some statements and disclosures in this press release are "forward-looking statements" within the meaning of the safe harbor provisions of the U.S. Private Securities Litigation Reform Act of 1995, including, but not limited to, statements regarding product development and commercialization plans for XACIATO. Forward-looking statements include all statements that do not relate solely to historical or current facts and can be identified by the use of words such as "may," "expects," "intends," "anticipates," "plans," "believes," "seeks," "estimates," "will," or words of similar meaning. These forward-looking statements are based on our current plans and expectations and are subject to a number of significant risks and uncertainties. If underlying assumptions prove inaccurate or risks or uncertainties materialize, actual results may differ materially from the forward-looking statements.

Risks and uncertainties that may affect our future results include, but are not limited to, an inability to fully execute on the nationwide commercialization plans for XACIATO; our product development and commercialization plans within the United States or internationally; an inability to adapt to the industry-wide trend toward highly discounted channels; changes in tax laws or other tax guidance which could adversely affect our cash tax liability, effective tax rates, and results of operations and lead to greater audit scrutiny; an inability to execute on our business development strategy or realize the benefits of our planned acquisitions; efficacy, safety, or other quality concerns with respect to marketed products, including market actions such as recalls, withdrawals, or declining sales; political and social pressures, or regulatory developments, that adversely impact demand for, availability of, or patient access to contraception and fertility products; general economic factors, including recessionary pressures, interest rate and currency exchange rate fluctuations; general industry conditions and competition; the impact of the ongoing COVID-19 pandemic and emergence of variant strains; the impact of pharmaceutical industry regulation and health care legislation in the United States and internationally; global trends toward health care cost containment; technological advances; new products and patents attained by competitors; challenges inherent in new product development, including obtaining regulatory approval; the company's ability to accurately predict its future financial results and performance; manufacturing difficulties or delays; financial instability of international economies and sovereign risk; difficulties developing and sustaining relationships with commercial counterparties; dependence on the effectiveness of the company's patents and other protections for innovative products; and the exposure to litigation, including patent litigation, and/or regulatory actions.

The company undertakes no obligation to publicly update any forward-looking statement, whether as a result of new information, future events or otherwise. Additional factors that could cause results to differ materially from those described in the forward-looking statements can be found in the company's filings with the Securities and Exchange Commission ("SEC"), including the company's Annual Report on Form 10-K for the year ended December 31, 2022 and subsequent SEC filings, available at the SEC's Internet site (www.Sec.Gov).

1 Bacterial vaginosis statistics. Centers for Disease Control and Prevention. Last reviewed February 10, 2020. Accessed October 19, 2023. Https://www.Cdc.Gov/std/bv/stats.Htm

2 Understanding women's experiences with bacterial vaginosis. American Sexual Health Association. Accessed October 19, 2023. Https://www.Ashasexualhealth.Org/understanding-womens-experiences-with-bacterial-vaginosis/

3 Bacterial vaginosis - CDC basic fact sheet. Centers for Disease Control and Prevention. January 5, 2022. Accessed October 19, 2023. Https://www.Cdc.Gov/std/bv/stdfact-bacterial-vaginosis.Htm

4 Mauck C, Hillier SL, Gendreau J, et al. Single-dose bioadhesive clindamycin 2% gel for bacterial vaginosis. Obstet Gynecol. 2022;00:1–11. DOI: 10.1097/AOG.0000000000004805.

5 Koumans EH, Sternberg M, Bruce C, et al. The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis. 2007;34(11):864-9.

6 Bacterial vaginosis. Centers for Disease Control and Prevention. July 19, 2021. Accessed October 19, 2023. Https://www.Cdc.Gov/std/treatment-guidelines/bv.Htm

7 Muzny CA, Kardas P. A Narrative Review of Current Challenges in the Diagnosis and Management of Bacterial Vaginosis. Sex Transm Dis. 2020 Jul;47(7):441-446. Doi: 10.1097/OLQ.0000000000001178. PMID: 32235174; PMCID: PMC7294746.

8 Mondal P, Hemant AH, Johnston TP. Evaluation of TRI-726 as a drug delivery matrix. Drug Dev Ind Pharm. 2011;37(8):995-1001. Doi:10.3109/03639045.2011.555913

9 Paladine HL, Desai UA. Vaginitis: diagnosis and treatment. Am Fam Physician. 2018;97(5):321-329.

10 Chavoustie SE, Eder SE, Koltun WD, et al. Experts explore the state of bacterial vaginosis and the unmet needs facing women and providers. Int J Gynaecol Obstet. 2017;137(2):107-109.Doi: 10.1002/ijgo.12114.

11 Kairys N, Garg M. Bacterial vaginosis. NCBI Bookshelf. Updated July 4, 2023. Accessed October 5, 2023. Https://www.Ncbi.Nlm.Nih.Gov/books/NBK459216/

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