Recurrent vaginitis is really common, really poorly handled in the traditional medical system, and devastating to self esteem and sexuality
Maria is booked for an urgent fit-in appointment this morning. She declined to state the reason for her visit with our call center. When I enter the room, Maria is sitting on the exam table looking defeated and uncomfortable. I ask what brings her in today, and she states she needs medication for BV.
It’s clear that Maria is used to seeing a provider who would end the visit there and simply send off an antibiotic prescription. However, I’m not that kind of provider. I inquire about the symptoms she’s having, and she endorses the typical watery discharge with fishy odor. I ask Maria if she had an examination and swabs done recently, and she replies that, in over 2 years of going to multiple urgent care clinics for these symptoms, no one has offered to examine her.
I ask her how often she gets these symptoms. Maria pauses, taken aback by the question. “No one ever asks me if I’ve had this before. I have it all the time. Seems like whenever I don’t have my period I have this awful discharge and odor.” Maria states she’s taken antibiotics 8 or 9 times this year.
“Gosh, that must be really difficult, to have symptoms this frequently,” I say. “How is this affecting you?” Maria’s eyes well up with tears and she tells me she feels embarrassed and disgusting. She has a girlfriend but avoids sexual activity because “my vagina doesn’t feel healthy”. Maria feels her girlfriend withdrawing and they’re arguing more. She is scared that the odor is apparent to others, and finds excuses to avoid going out to clubs or playing sports with her friends.
“How about we take collect swabs today to confirm BV, rule out other causes of vaginitis like yeast, give you treatment today and talk about how to restore vaginal balance?” Maria’s face brightens at my suggestion and we proceed with a thorough visit which includes a pelvic examination and extensive counselling.
Vaginitis is treated with oral or vaginal medications. But in more than half of cases, a single treatment is not the end of the story
I encounter recurrent vaginitis frequently in my practice. Vaginitis is the umbrella term for when the healthy balance of microorganisms in the vagina is disturbed. A happy vagina is populated predominantly by Lactobacillus species of bacteria and has an acidic pH.
BV happens when the mix of bacteria or flora shifts so that problematic bacteria like Gardnerella dominate, shifting the pH alkaline and causing a variety of symptoms like abnormal discharge and odor. Bacterial vaginosis (BV) is NOT a sexually transmitted infection (STI).
In more than half of cases, people go on to have multiple episodes, or recurrent BV. While symptoms may differ somewhat from person to person, the common features of every person’s experience of recurrent BV are shame, low self worth and devastated sexual confidence.
What do you do when abnormal vaginal symptoms come back…again and again?
Here’s what the average person with recurrent BV goes through: They live with abnormal vaginal symptoms more days than not.
Symptoms may disappear during a period but then rebound back within a couple of days of their period ending. They have sought care from multiple clinics and urgent care centers without ever having worked with a consistent provider. They’re sick of taking antibiotics all the time. Or they may quietly suffer symptoms without treatment and simply bear the discomfort and shame.
Let me just say that, if recurrent BV happened to those with penises, they would be shouting from the rooftops demanding a cure. There would be plenty of industry interest and an expensive pill advertised through coy banner ads on the subway. But just as people with vaginas tend to be underserved, so it is that recurrent BV is overlooked. BV is a huge issue that deserves more attention and resources.
BV devastates quality of life
A well-done qualitative research study by Bilardi et. al.(1) in Melbourne explores people’s experiences with bacterial vaginosis, finding that this condition “severely impacted on their lives, causing them a great deal of distress and anguish” and “embarrassment and shame”. Those “with a higher number of recurrences and more severe symptoms tended to report a greater impact”. Among study participants, this study found universal confusion “about why they were experiencing recurrent BV and (frustration) about their lack of control over recurrences. “
Why is this study so remarkable? Because it’s rare to find a publication that cares to examine the impact of conditions affecting vaginas on quality of life. I believe that all of us in the medical community should care as much as these clinician researchers at the Melbourne Sexual Health Centre. We must all practice with compassion to inquire about the impact of recurrent BV on quality of life and dedicate time to help people restore vaginal balance.
Here are 7 suggestions for you to consider in your approach to recurrent BV:
1. Remember you’re not alone
BV affects 10-30% of the population in countries like the United States. That’s many millions of people. Even if people aren’t talking about it, recurrent BV is prevalent – I know because it’s one of the most common conditions I see in family practice. We need more talking about it and less judgement.
2. Don’t struggle alone
Find a health care provider who can spend the time with you. I know this is easier said than done. Try asking friends and family for a recommendation. Planned Parenthood provides excellent care. If you’ve never had an examination or it’s been a while, it’s important that your provider do a speculum examination and collect swabs for organisms that cause vaginitis (yeast, BV and trichomonas are the main ones).
At the same time, it’s always good to get updated testing for chlamydia and gonorrhea because you can be infected without symptoms – it’s just one extra swab that takes a second and the treatment is curative.
3. Channel your inner detective and make a list
The most powerful tool that we have to determine what’s causing BV is a list that you create to try to find a correlation between your symptoms and all the products you’re exposed to. BV is caused by an imbalance in the normal microbial balance of the vagina. Any chemical, perfume, or other irritant can throw off the balance, and it can be a different thing for everyone. Here are examples from my practice of products that my patients have identified as the cause of their recurrent BV:
- A different detergent brand (I ask people if they’ve switched brands because of a sale)
- Using toilet paper at their job (BV symptoms resolved once they started bringing their own TP to work)
- New sex partner (while BV is not an STI, having sex with a new partner may be a factor. Maybe a different chemical composition of semen, type of lube, condoms or sex toy used, how they’re used, how they’re cleaned or different sex positions)
- Stopped or started a contraceptive method (for some, a particular method may be associated with vaginitis. Copper IUDs may be associated with higher rates of BV than if a hormonal IUD or no IUD is used)
Consider making a list like this, which makes a temporal (time) link between products you tried/started/stopped with the trend in your vaginal symptoms:
Track your symptoms along with any changes in products or exposures. Then look back on this list and take note of any patterns. Try eliminating all products (“Zero Therapy” – see below) and then reintroduce them one by one to see how BV symptoms trend. Your provider is an important partner in the detective work required to identify the potential contributors to BV, so feel free to bring your list to your provider to review together.
After a few months, you should notice some interesting trends which may point to products or exposures that you should change or avoid. Remember, every person is unique, and a product that causes no problems for one person can cause imbalance for another person.
I always take the opportunity to state that vaginal douches are never to be used. They’re almost always going to throw off your healthy vaginal balance. They’re simply unnecessary. Your vagina is a wonderful self-cleaning entity. The normal rhythm of discharge and odors is something to be embraced, not shamed. Just say NO to douches of any kind. When bathing, use a mild unscented soap (or no soap at all!), and gently cleanse the vulvar (outer) area with a flat hand/pads of your fingers, avoiding any scrubbing.
4. Take a “zero therapy” break
When you’re faced with recurrent abnormal vaginal symptoms, you are always on high alert and, let’s face it, you’re taking medication frequently! You are hypersensitive to any hint of discharge or odor and you immediately jump to take treatment.
If you experience the return of mild discharge after taking treatment, I advise taking a few days without doing anything. We call that “Zero Therapy”, which means doing nothing to see if the body just needs us to chill so that it can find its own balance. Observe to see whether the discharge follows the normal, healthy vaginal discharge pattern. Only if your symptoms continue to escalate into clearly abnormal territory should you begin another course of treatment. It’s important for your piece of mind to break the cycle of repeat treatments if they’re not needed.
5. Switch up oral and vaginal treatment options
Let’s take the case of metronidazole, the most commonly prescribed antibiotic for BV treatment (for those allergic, there are alternatives). Metronidazole is prescribed in a 7-day course if taken orally and a 5-day course if administered vaginally. If you’ve been treated with the oral preparation and you feel it may not be working as well, talk to your provider about switching to the vaginal preparation, and vise versa.
6. BV prevention and maintenance of healthy vaginal balance
Once you’ve restored vaginal balance i.e. abnormal discharge and odor have resolved, it’s important to maintain healthy balance by avoiding any of the chemical/scents/irritants that you identified as problematic from your detective work (above). Stick to a “less is more” approach when it comes to genital hygiene. Use unscented, mild products. Avoid anything marketed to “keep you fresh” – corporations create the perception of a problem just to take our money. The vagina is plenty fresh all by itself! If I haven’t said it enough, don’t douche. Ever.
There is some evidence for the use of boric acid 600mg vaginal capsules inserted vaginally. A prospective randomized controlled trial (i.e. a kick-ass high quality study) is in the works. To restore the vagina’s normal pH balance and microbial mix, I advise my patients try a boric acid 600mg vaginal capsule inserted vaginally every night. Why? Because it’s a non-prescription product available online or at health stores – I like it when my patients have the freedom and choice to access a relatively inexpensive product over-the-counter. How long do you use it? We don’t know because the kick-ass high quality study hasn’t yet been published. Expert opinion says anywhere from 10-21 days or longer. I tell patients that, if boric acid vaginal capsules work for them, they can use this intermittently as needed for as long or as short a time as they need to restore their balance. This can be used in addition to the prescription medications mentioned above.
7. Love your Vagina!
This last point is the most important. When I first encounter patients who have been struggling with recurrent BV for a while, they feel utterly broken in terms of their sense of health, self, and their sexual functioning. I want everyone to know that BV does not define you or your vagina. With the tools above, it’s possible to identify culprit irritants that, once eliminated, no longer mess with your balance. Don’t hide in the shadows. Seek out a caring health care provider who will partner with you on this treatment journey. And if you’ve done all of the above and are still struggling with abnormal vaginal symptoms despite eliminating all potential irritants, ask for help. A referral to a gynecologist is then necessary to rule out other conditions affecting vaginal wellness.
In my experience, most people are able to come up with a solution and beat BV once they become informed and step into their confidence. Let’s confront the silence and shame of BV. Let’s declare our refusal to remain at the mercy of BV. Let’s step into our power with our own plan of action to optimize conditions for healthy vaginal balance.
- Bilardi, J. E., Walker, S., Temple-Smith, M. et al. (2013). The Burden of Bacterial Vaginosis: Women’s Experience of the Physical, Emotional, Sexual and Social Impact of Living with Recurrent Bacterial Vaginosis. PLoS ONE, 8(9). doi: 10.1371/journal.pone.0074378