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Bacterial Vaginosis: How It Presents and How to Manage It

vaginosi batterica

WHAT IS BACTERIAL VAGINOSIS AND WHAT CAUSES IT?

Bacterial vaginosis (BV) is a very common condition among women of reproductive age. When recognized, it can be effectively treated. However, it should not be underestimated, as in some cases it may have clinically relevant consequences.

Bacterial vaginosis is sometimes incorrectly referred to as a “vaginal bacterial infection.” In reality, rather than being caused by a single pathogen, it is a condition of dysbiosis — an imbalance of the normal vaginal ecosystem — associated with alterations in vaginal pH, which under optimal conditions ranges between 3.8 and 4.5.

The vaginal environment is populated by numerous microorganisms that make up the vaginal microbiota and coexist in balance without causing symptoms. Among them are various Lactobacillus species, including Lactobacillus crispatus, which is frequently associated with a balanced vaginal microbiota.

Lactobacillus crispatus contributes to the production of lactic acid and helps maintain an acidic pH, conditions that support vaginal ecosystem stability.

However, when vaginal pH increases and becomes less acidic, this balance may be disrupted. Bacteria normally present in small amounts may then proliferate and become predominant, leading to bacterial vaginosis.

HOW DO YOU GET BACTERIAL VAGINOSIS?

One of the most common questions is: how do you get bacterial vaginosis?

Unlike sexually transmitted infections, BV is not “contracted” from a single external pathogen. Instead, it develops when the balance of the vaginal microbiota is altered.

Under physiological conditions, lactobacilli maintain an acidic and stable vaginal environment. When this balance changes, bacteria normally present in small quantities may overgrow and become predominant.

  • Several factors may contribute to this imbalance:
  • Use of intimate cleansers with an inappropriate pH
  • Frequent vaginal douching
  • Antibiotic therapies that reduce protective lactobacilli
  • Changes in sexual habits or new sexual partners
  • Cigarette smoking
  • Use of intrauterine devices (IUDs), in some cases

The presence of one or more of these factors does not necessarily mean BV will develop, but it may increase the likelihood of dysbiosis.

Bacterial vaginosis is commonly associated with the proliferation of anaerobic bacteria, including Gardnerella vaginalis and, to a lesser extent, other microorganisms such as Atopobium and Prevotella, which become predominant when lactobacilli decrease.

GARDNERELLA: HOW DOES IT DEVELOP?

Gardnerella vaginalis is not necessarily “contracted” like a classic transmissible vaginal infection. It may be part of the vaginal flora in balanced conditions and become predominant when dysbiosis occurs.

Its proliferation is favored by the same factors that alter vaginal microbiota balance — including pH changes, reduction of protective lactobacilli, vaginal douching, and changes in sexual habits.

Therefore, rather than asking “how do you get Gardnerella?”, it is more accurate to understand which conditions promote the loss of vaginal microbiological balance.

GARDNERELLA AND PREGNANCY

During pregnancy, bacterial vaginosis associated with Gardnerella vaginalis requires particular clinical attention.

If left untreated, BV may be associated with an increased risk of obstetric complications, such as premature rupture of membranes and preterm birth. For this reason, in the presence of symptoms or risk factors, medical evaluation is recommended.

SYMPTOMS OF BACTERIAL VAGINOSIS: VAGINAL DISCHARGE AND POSSIBLE COMPLICATIONS

Bacterial vaginosis is not always accompanied by evident symptoms. When symptoms are present, they mainly involve vaginal discharge.

Typical BV discharge is:

  • Abundant
  • White-grayish in color
  • Thin in consistency
  • Associated with an unpleasant odor, often described as “fishy”

These features help distinguish BV from other vaginal conditions, such as candidiasis, which presents with different discharge characteristics.

Less commonly, BV may cause:

  • Vaginal itching
  • Burning during urination
  • Pain during sexual intercourse

POSSIBLE COMPLICATIONS

Beyond local discomfort, untreated bacterial vaginosis may have relevant consequences.

It may be associated with increased susceptibility to sexually transmitted infections in the presence of unprotected intercourse and may contribute to the development of pelvic inflammatory disease (PID). If neglected, PID may increase the risk of ectopic pregnancy and reduce fertility.

During pregnancy, untreated BV may be associated with an increased risk of premature rupture of membranes and preterm birth.

IS BACTERIAL VAGINOSIS TRANSMITTED? IS IT CONTAGIOUS?

Bacterial vaginosis is not classified as a sexually transmitted disease. It is a condition linked to an imbalance of the vaginal microbiota.

However, sexual activity may influence vaginal flora balance. BV has been observed to:

  • Be more frequent in sexually active women
  • Be associated with new or multiple partners
  • Occur following changes in sexual habits

This does not mean that BV is “contagious” in the classical sense, but that sexual activity may temporarily modify vaginal microbiota balance.

HOW TO MANAGE BACTERIAL VAGINOSIS: TREATMENT AND SUPPORT STRATEGIES

Understanding how bacterial vaginosis is treated means distinguishing between management of the acute episode and long-term support of vaginal microbiota balance.

HOW IS BACTERIAL VAGINOSIS TREATED? ANTIBIOTIC THERAPY

In symptomatic cases and during pregnancy, BV is treated with antibiotic therapy, generally based on metronidazole or clindamycin, as prescribed by a physician.

These medications reduce the proliferation of bacteria involved in dysbiosis and typically improve symptoms in the short term.

However, antibiotic treatment addresses the acute episode but does not always ensure stable restoration of vaginal microbiota balance.

RECURRENT BACTERIAL VAGINOSIS: WHY IT MAY RETURN

In some women, BV may recur over time. Recurrences are often associated with:

  • Reduction of protective lactobacilli, particularly species linked to stable vaginal microbiota such as Lactobacillus crispatus
  • Persistent alteration of vaginal pH
  • Ongoing microbiota imbalance

In these cases, antibiotic therapy alone may not be sufficient to durably restore a physiological vaginal ecosystem.

SUPPORT STRATEGIES AND MAINTENANCE OF VAGINAL BALANCE

Alongside medical therapy, strategies aimed at supporting vaginal microbiota balance may be considered:

  • Use of intimate cleansers with an appropriate pH
  • Limiting unnecessary vaginal douching
  • Evaluation of probiotic supplementation containing selected strains of Lactobacillus crispatus, such as strain M247, which has been studied for its potential role in supporting vaginal microbiota rebalancing

Some studies have shown that a vaginal microbiota dominated by Lactobacillus crispatus is associated with greater ecosystem stability. The stable presence of this species is currently considered one of the indicators of vaginal microbiota balance, an area of growing interest in the management of recurrent bacterial vaginosis.

From this perspective, the focus is not exclusively on eliminating the predominant bacterium, but on restoring a physiological and stable vaginal ecosystem over time.

The goal is not to replace antibiotic therapy, but to support the maintenance of physiological vaginal conditions by promoting lactobacilli presence and maintaining an appropriate pH.