What is the best way to explain bacterial vaginosis to a patient?

How to Explain Bacterial Vaginosis to a Patient

Tell your patient that bacterial vaginosis is an imbalance in the normal vaginal bacteria—not a sexually transmitted infection—where the healthy bacteria (lactobacilli) are replaced by other bacteria, causing discharge and odor.

What BV Actually Is

• BV occurs when the normal hydrogen peroxide-producing Lactobacillus bacteria in the vagina are replaced by high concentrations of anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis 1
• Emphasize to patients that this is an ecological shift in their vaginal environment, not catching a single "germ" from someone else 2
• The vagina normally maintains an acidic environment (pH less than 4.5), but in BV this becomes more alkaline (pH greater than 4.5), allowing these other bacteria to overgrow 1

Clarifying the Sexual Activity Connection

• Explain that while BV is strongly linked to sexual activity, it is NOT a classic sexually transmitted infection like gonorrhea or chlamydia 3, 2
• Women who have never been sexually active rarely get BV, and having multiple sex partners increases risk, but the exact mechanism remains unclear 3
• Critically, their male partner does NOT need treatment—treating partners has consistently failed to prevent BV recurrence 3, 2
• This distinguishes BV from true STIs where partner treatment is essential 2

Common Symptoms (But Many Have None)

• Up to 50% of women with BV have no symptoms at all 1, 3
• When symptoms occur, the most common are:
  • Thin, white, homogeneous discharge that smoothly coats the vaginal walls 1
  • Fishy odor, especially after sex or during menstruation (this is the hallmark symptom) 1
  • Notably, BV does NOT typically cause significant vulvar irritation or itching—if those are prominent, consider other diagnoses 1

Why Treatment Matters Even Without Symptoms

• BV increases risk for serious complications including pelvic inflammatory disease, preterm birth if pregnant, and increased susceptibility to sexually transmitted infections 1
• The bacteria present in large numbers can cause problems after gynecologic procedures 1
• This is why treatment may be recommended even for asymptomatic women in certain situations (before procedures, during pregnancy) 1

Treatment Expectations

• Standard treatment is metronidazole 500 mg orally twice daily for 7 days, or clindamycin 1
• Be upfront about recurrence: 50-80% of women will have BV return within one year 1, 3
• Probiotics used alongside antibiotics can improve cure rates (risk ratio 1.53) and may be worth discussing as complementary therapy 1
• Again, treating their partner will NOT reduce recurrence rates 3

Key Pitfalls to Address

• Patients often confuse BV with yeast infections—clarify that BV causes fishy odor and thin discharge, while yeast causes thick white discharge and intense itching 1
• Patients may feel stigmatized thinking it's an STI—reassure them it's a bacterial imbalance, not something they "caught" in the traditional sense 2
• Patients may insist their partner needs treatment—firmly explain that multiple studies over decades show this doesn't help and exposes partners to unnecessary antibiotics 3, 2
• The high recurrence rate is frustrating but normal—it reflects the difficulty in permanently restoring the vaginal bacterial balance, not treatment failure 1, 3