Prevention of Bacterial Vaginosis
For women with recurrent BV, the most effective prevention strategy is probiotics containing Lactobacillus species combined with behavioral modifications, while treating male sexual partners provides no benefit and should not be done. 1
Evidence-Based Prevention Strategies
Probiotic Supplementation
- Probiotics containing Lactobacillus species are recommended to maintain healthy vaginal flora and prevent BV recurrence. 1
- Meta-analyses demonstrate that probiotic supplementation significantly improves BV cure rates when used as complementary therapy with antibiotics. 1
- The mechanism works by restoring hydrogen peroxide-producing Lactobacillus species that protect against anaerobic bacterial overgrowth. 2
- After antibiotic treatment, beneficial strains like L. crispatus often fail to recolonize the vagina naturally, which explains the 50-80% recurrence rate within one year—probiotics address this gap. 3
Behavioral Modifications That Work
- Avoid vaginal douching and chemical irritants (regular soap, vaginal products) as these disrupt the protective vaginal ecosystem and trigger microbial shifts. 2
- Use condoms consistently during sexual activity, as multiple and new sexual partners significantly increase BV risk. 1
- Consider hormonal contraception, which may provide protective effects. 3
- Smoking cessation should be encouraged as smoking is associated with increased BV risk. 3
Menstrual Hygiene Considerations
- BV recurrence correlates with menstrual cycles due to hormonal changes affecting vaginal pH. 1
- Change tampons and pads frequently during menstruation to reduce BV risk. 1
- For women with recurrent BV, avoiding tampons entirely may be beneficial. 1
What Does NOT Work
Partner Treatment
- Treating male sexual partners does not prevent BV recurrence and is not recommended. 4, 1
- Multiple clinical trials demonstrate that a woman's response to therapy and likelihood of relapse are unaffected by treating her sex partner(s). 4
- This is true even though sexual activity is a significant risk factor—women who have never been sexually active rarely develop BV. 1, 2
Special Populations Requiring Screening
Before Invasive Procedures
- Screen and treat asymptomatic BV before surgical abortion or hysterectomy to prevent serious ascending infections including post-abortion pelvic inflammatory disease, vaginal cuff cellulitis, and endometritis. 4, 2
- Consider screening before other invasive gynecologic procedures (IUD placement, hysterosalpingography) though evidence is less robust. 4, 2
- Up to 50% of women with BV are completely asymptomatic, so absence of symptoms does not eliminate complication risk. 1, 2
Pregnancy
- All symptomatic pregnant women should be tested and treated for BV due to associations with premature rupture of membranes, preterm labor, preterm birth, and postpartum endometritis. 4
Understanding Why Prevention Is Difficult
The Biofilm Problem
- BV bacteria form biofilms that protect them from antimicrobial therapy, contributing to persistence and recurrence. 5, 3
- This explains why standard antibiotic treatment provides short-term cure but fails to provide consistent long-term cure for many women. 3
The pH and Microbiome Disruption
- Loss of acidic vaginal pH (normally 3.8-4.2) to pH >4.5 both results from and perpetuates loss of protective Lactobacillus dominance. 2
- BV represents ecological disruption rather than infection with a single pathogen—it is vaginal dysbiosis, not a traditional infection. 2
Common Pitfalls to Avoid
- Do not assume BV is always symptomatic—up to 50% of cases are asymptomatic, requiring a high index of suspicion in high-risk populations. 1, 2
- Do not treat sexual partners routinely—this wastes resources and has no evidence of benefit. 4, 1
- Do not rely on antibiotics alone for recurrent BV—combine with probiotics and behavioral modifications for better long-term outcomes. 1, 3
- Do not use non-vaginal lactobacilli or douching—these have no supporting data and douching actively harms the vaginal ecosystem. 4, 2