Whether you just received a diagnosis of bacterial vaginosis (BV) or have struggled with recurrent bouts of BV for ages, you’re likely on the hunt for a fix. 

Bacterial vaginosis is a vaginal infection caused by an imbalance in the bacteria that make up your vaginal microbiome. Essentially, healthy vaginal bacteria are replaced by disruptive “bad” bacteria, creating an infection.

“Okay, easy”, you may be thinking. “I just need to kill off the bad bacteria and everything will go back to normal!”

Unfortunately, it’s not quite that simple. With the many bacterial vaginosis treatment options on the market, it’s hard to know what will help: will this new medication or that new supplement shift your vaginal microbiome to a healthier, protective state, or will it keep you stuck in the endless cycle of having bacterial vaginosis over and over again?

Read on to learn about BV medication, including the most common pharmaceutical treatments for bacterial vaginosis and how they affect your vaginal health.

What is bacterial vaginosis?

Before we dive into the treatment options, it's important to understand what causes bacterial vaginosis.

Bacterial vaginosis is a common vaginal infection caused by an imbalance of bacteria in the vagina. Normally, the vagina contains a healthy balance of different types of bacteria, with Lactobacilli being the most dominant.

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In bacterial vaginosis, there is a decrease in Lactobacilli and an overgrowth of harmful bacteria, such as Gardnerella and Prevotella. This imbalance disrupts the vaginal pH, leading to symptoms such as abnormal vaginal discharge that may be thin, grayish-white, and have a strong fishy odor. Many women don't experience any bacterial vaginosis symptoms.

Bacterial vaginosis isn't considered a sexually transmitted infection (STI), but it's more common if you're sexually active. Having unprotected sex, multiple sex partners, or a new sex partner make you more likely to develop BV. Other behaviors, such as smoking or douching, can put you at an increased risk of developing bacterial vaginosis.

It's important to consult a healthcare provider for proper BV diagnosis and treatment if you suspect you have an infection. Treatment usually involves prescription antibiotics to restore the natural balance of bacteria in the vagina and alleviate uncomfortable symptoms. Below, we take a look at the available treatment options for bacterial vaginosis.

Metronidazole

Brand name: Flagyl®

Type of medication: antibiotic 

Class: nitroimidazoles

Administration route: oral (pills taken by mouth) or intravaginal (gel applied internally)

Antibiotic medications are commonly prescribed to treat bacterial infections, and bacterial vaginosis is no exception. Metronidazole is an antibiotic used to kill anaerobic bacteria (bacteria that don’t require oxygen to survive) and other microbes that can cause infections.

It’s been tested and found to be effective against several bacterial species that are associated with bacterial vaginosis, including: 

No antibiotic medication can always wipe out every bacterial species at once. Some BV-related bacteria are resistant to metronidazole (i.e., metronidazole won’t kill them), including: 

However, there’s some good news: Lactobacilli species, the “good” bacteria that are the most common in healthy vaginas, are also resistant to metronidazole. This means that treatment with metronidazole will get rid of the disruptive, or “bad” bacteria while sparing your healthy Lactobacilli. 

Guidelines by the Centers for Disease Control and Prevention (CDC) currently recommend that metronidazole be given either orally (as pills) or via intravaginal administration to treat BV. If your healthcare provider prescribes metronidazole for your BV, they may recommend one of the following courses:

  • 500 mg pills taken twice a day for seven days
  • A full applicator of 0.75% gel applied inside the vagina once daily for five days

While these are common recommendations, recall that your healthcare provider must take your unique medical history and sensitivities into account when determining the correct treatment regime for you.

Clindamycin

Brand name: Cleocin®

Type of medication: antibiotic 

Class: lincomycins

Administration route: oral (pills taken by mouth) or intravaginal (tablets inserted or cream applied internally)

Clindamycin is another antibiotic commonly used to treat BV. It works by slowing and sometimes stopping the growth of bacteria. Similar to metronidazole, clindamycin is effective against several bacterial species that can cause bacterial vaginosis, including:

  • Gardnerella
  • Atopobium  
  • Some Mycoplasma species
  • Megasphaera

Despite this list, clindamycin isn’t a silver bullet against BV-related bacteria. For example, it is not as effective against Prevotella species that can contribute to bacterial vaginosis. Clindamycin can also kill off the protective (Lactobacilli) bacteria along with the disruptive bacteria, which may contribute to bacterial vaginosis coming back again later.

Both vaginal and oral clindamycin should be taken for seven days. Alternatively, your provider may recommend using clindamycin “ovules”, which are basically little pills you place inside the vagina and allow to dissolve. Ovule treatment takes just three days.

Tinidazole

Brand name: Tindamax®

Type of medication: antibiotic + antiprotozoal 

Class: nitroimidazole

Administration route: oral (pills taken by mouth)

Tinidazole is an antibiotic that can kill protozoa (microscopic single-celled animals). It belongs to the same class of antibiotics as metronidazole and is also effective against many of the bacteria involved in bacterial vaginosis. 

Tinidazole can kill Gardnerella vaginalis, a bacterial strain commonly associated with bacterial vaginosis. 

However, less is known about how well it works against other specific BV-related species. As the research on BV treatment progresses, we may learn that tinidazole can also act against other problematic bacterial strains.

Like metronidazole, tinidazole does not kill Lactobacilli, the protective bacteria of a healthy vaginal tract. Researchers have also shown that it may cause fewer negative side effects on the GI tract, making it an attractive alternative to metronidazole in some cases.

To treat bacterial vaginosis, your provider may prescribe tinidazole to be taken orally for two or five-day courses. Though less convenient, longer courses of treatment appear to be more effective against bacterial vaginosis than shorter ones.

Secnidazole

Brand name: Solosec® 

Type of medication: antibiotic

Class: nitroimidazole

Administration route: oral (granules taken by mouth)

Secnidazole is an antibiotic in the same class as metronidazole and tinidazole, and it, too, works by stopping bacterial growth. However, unlike its cousins, it’s typically taken orally in a single dose.

Secnidazole is effective (and ineffective) against similar sets of bacterial species as metronidazole and tinidazole. It also spares the beneficial Lactobacilli strains that help maintain vaginal health.

This medication comes in the form of granules you sprinkle on soft food like yogurt to ingest. Typically, only one dose of these granules is required to treat bacterial vaginosis.

Boric acid

The only non-prescription option on this list, boric acid is a white powder made from borax, a naturally occurring mineral. It’s composed of the elements boron, hydrogen, and oxygen.

Boric acid has antimicrobial and antifungal properties, suggesting that it may be a useful addition to the treatment regime for people with recurrent BV. It hasn’t been studied as much as the medications we’ve discussed, so we don’t have a reliable breakdown of the BV-related bacterial species it can and can’t impact. 

However, some research suggests that boric acid may help break down the biofilms which protect harmful bacteria and allow bacterial vaginosis to return after antibiotic treatment. 

By breaking down these biofilms, boric acid may allow an antibiotic like metronidazole to be more effective. When used to help treat BV, the CDC recommends that boric acid be placed intravaginally as a suppository (in capsule form). Boric acid cannot be taken orally (by mouth).

Additionally, a new boric acid-based medicine called TOL-463 is currently in development. TOL-463 combines boric acid with a chemical called EDTA that can help break down biofilms further to improve treatment effectiveness.

Initial results are promising, though additional research will be necessary to determine the most effective way to use TOL-463 to help treat recurrent BV.

FYI, generally, boric acid prescribed by a doctor tends to be more pure and less likely to cause adverse reactions than boric acid purchased OTC or online. So if you're going to use boric acid, always try to get it prescribed by a healthcare provider.

Treating BV: Timeframes and expectations

As we’ve discussed, the initial treatment timeframes for the various bacterial vaginosis medications vary, though most can be completed in a week or less. It’s important to complete the entire treatment you’re prescribed for bacterial vaginosis, even if your symptoms go away before you complete it. This is one way to help prevent bacterial vaginosis from coming back.

Unfortunately, up to 50% of people who are diagnosed with BV will experience a recurrence within one year. 

If your BV symptoms return after an initial round of treatment, it’s important to consult with your medical provider. If this is the first time your BV has recurred, or if the first round of treatment simply didn’t work, they may recommend a second round of the same course of medication. 

However, if your bacterial vaginosis keeps coming back, it’s typically time to try an alternative medication and administration route (i.e., an intravaginal gel instead of oral pills). 

While additional rounds of pharmaceutical treatment can be effective in knocking out recurrent BV, they often require much longer courses lasting several weeks or months. Additionally, the protection these medications provide often disappears when you stop taking them, and the bacterial vaginosis can come right back, again.

How Evvy can help with BV  

What’s a person with BV to do? First things first: if you’re struggling with stubborn, recurrent bacterial vaginosis, take a deep breath and know you’re in the right place. Evvy is working to break down barriers in our understanding of the vaginal microbiome and its role in recurrent BV. 

Whether or not you have bacterial vaginosis, taking an Evvy test will help you understand the makeup of your vaginal microbiome, which can help you determine if your vaginal microbiome is dominated by bacteria associated with bacterial vaginosis, and if so, which types. This can help you and a healthcare provider choose the most effective treatment (including an antibiotic) against your microbes based on existing research and your health history.

Our vaginal healthcare platform ensures you receive a clear plan for your next steps in care. If you’re eligible for clinical care, it can link you with a healthcare provider affiliated with Evvy. These professionals are trained to review your test results and determine the most suitable care based on your specific symptoms. They may also suggest research-supported supplements to help restore your microbiome to a protective state.

With an Evvy Membership, you can easily monitor changes in your microbiome and track your body’s response to different treatment regimes. Knowledge is power: the better you understand your unique microbiome, the more accurately you can tailor your care to keep it healthy.

We know that searching for an effective care for vaginal symptoms can be overwhelming. We’re here to provide you with up-to-date research on treatments and personalize your care so you feel supported at every step.  

FAQ

What is the best medication for BV?

The first-line treatment for bacterial vaginosis is antibiotics like metronidazole or clindamycin. These can as pills you take by mouth or a vaginal cream. Your doctor will decide which option is best based on how severe your BV symptoms are and your medical history. It's super important to follow their advice closely and finish the entire course of medication, even if you start feeling better sooner. This ensures that the infection is completely cleared and lowers the likelihood of it coming back.

Can I get BV medication over the counter?

Medication specifically for bacterial vaginosis isn't available OTC. Antibiotics such as metronidazole or clindamycin require a prescription from a healthcare provider. The only OTC options available are boric acid suppositories, but we need more research to know how effective they are in treating BV. Boric acid suppositories prescribed by a healthcare provider tend to be purer and less likely to cause side effects than those purchased OTC.

Can BV clear up on its own?

Sometimes it can, especially if it's a mild case and not causing noticeable symptoms. But here's the thing: even if the symptoms seem to get better on their own, the imbalance of bacteria in your vagina might still be there, so we wouldn't recommend chancing it. Untreated BV can lead to recurrent infections and other health problems, including pelvic inflammatory disease (PID), pregnancy complications (such as preterm birth or low birth weight), and a higher risk of sexually transmitted infections. So, if you're noticing any signs like unusual vaginal discharge or vaginal odor, it's a good idea to chat with your healthcare provider.

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