One of the most common questions from the Evvy community is “Why do I keep getting BV?”. 

Dealing with recurrent bacterial vaginosis (BV) can be really frustrating, but you're not alone in this. Bacterial vaginosis is a stubborn infection, and in 50% of cases, it comes back within three months of successful (!) treatment. 

There are many reasons why bacterial vaginosis might keep coming back, from lifestyle habits to factors outside your control. Some people are just more prone to BV than others, but researchers aren’t sure why.

So, why does your bacterial vaginosis keep coming back, and is there a way to stop it? Here are some reasons you might be dealing with recurrent BV and what you can do to prevent it.

What is BV?

Bacterial vaginosis is the most common vaginal infection in women aged 15-44. It affects almost 30% of people with vaginas each year, according to the Centers for Disease Control (CDC).  

Bacterial vaginosis can develop anytime there is an imbalance in your vaginal microbiome. Normally, "good" bacteria like Lactobacilli keep your vaginal pH acidic and prevent infections, but when levels of Lactobacilli decrease, other bacteria can overgrow — this is referred to as “dysbiosis”.

The exact cause of bacterial vaginosis remains unclear, but the infection is mostly associated with the overgrowth of anaerobic bacteria (bacteria that grow without oxygen) like Gardnerella and Prevotella, among others. 

Another thing that remains unclear is why some women are more prone to bacterial vaginosis than others, but research shows there are certain risk factors, including:

BV symptoms 

Not everyone who develops bacterial vaginosis will have symptoms. Up to 84% of people with bacterial vaginosis may not experience anything at all. Sometimes, symptoms are so mild they’re barely noticeable. When they do occur, the most common bacterial vaginosis symptoms include:

  • watery, gray vaginal discharge 
  • an abnormal amount of vaginal discharge
  • a strong, foul, or fishy vaginal odor that is more noticeable after sex
  • very rarely, vaginal itching, and pain or burning when you pee or have sex.

Abnormal vaginal discharge, a strong vaginal odor, and discomfort can be signs of a condition other than bacterial vaginosis. These symptoms are similar to those of a sexually transmitted infection (STI), so it’s important to see your healthcare provider if you're experiencing any of them.

Recurrent symptoms? Meet Evvy's at-home vaginal microbiome test, approved by leading OB-GYNs.
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Why does my BV keep coming back?

It's not unusual for bacterial vaginosis to return after it has been successfully treated, but the exact reasons for this are not entirely clear. 

Recurrent bacterial vaginosis is when you have more than three symptomatic infections in one year, and it often happens within the first few months after the initial treatment. Here are some possible reasons why your bacterial vaginosis might keep coming back — besides just bad luck.

You were misdiagnosed 

Despite being so common, bacterial vaginosis is often misdiagnosed. Surprisingly, misdiagnoses happen more frequently than correct ones! In a study of 220 people with vaginal symptoms, 61% of BV diagnoses were incorrect. We're not much better at self-diagnosing ourselves, either. Another study involving 546 women found that self-diagnosis of bacterial vaginosis was correct only 56% of the time. 

Bacterial vaginosis shares symptoms with plenty of other infections, including aerobic vaginitis, pelvic inflammatory disease (PID), and the STI trichomoniasis. 

Treatment didn’t work

Even with the right diagnosis, your medication might not be effective against the specific bacteria causing bacterial vaginosis.

Common antibiotics like clindamycin and metronidazole are often the first choice for treating bacterial vaginosis. However, each antibiotic may work better on certain bacteria strains than others.

For example, metronidazole may not be as effective as clindamycin in treating Gardnerella and Atopobium vaginae, two of the main bacteria responsible for BV. On the other hand, metronidazole may be more effective than clindamycin against other bacteria, such as Prevotella. Additionally, certain antibiotics may also kill off good bacteria along with harmful ones, which can leave you susceptible to another infection.

While antibiotics can clear up to 85% of bacterial vaginosis cases within a month, over half of these patients may experience a recurrence within six months. This could be because the antibiotics don't completely eliminate BV-associated bacteria, allowing them to grow back in after treatment. 

One reason why your bacterial vaginosis might be tough to treat is the formation of a biofilm in your vaginal microbiome. Biofilms are like protective shields that bacteria create, making it harder to get rid of them with treatments like antibiotics. This could be why bacterial vaginosis often comes back, but we're still learning about the exact role of biofilms in vagina infections.

Another factor to consider is whether you completed the entire course of antibiotics. It's not uncommon for people to stop taking antibiotics once their symptoms go away, but it's very important to finish the whole treatment — even if you start feeling better. 

You’re sexually active

While bacterial vaginosis can develop even if you're not sexually active (it's not an STI), having sex can trigger BV. Research shows that having unprotected sex, sex with a new partner, or sex with multiple partners increases the likelihood of developing bacterial vaginosis.

There are a few reasons why sex is a risk factor for BV:

  • Men have BV-associated bacteria on their penis and in semen, which can be passed on during unprotected sex.
  • Semen is slightly alkaline, which can increase vaginal pH and create an environment for harmful bacteria to thrive.
  • Women in same-sex relationships can also transmit bacterial vaginosis to their partners. Research shows that women who have sex with other women are more likely to have bacterial vaginosis compared with women who only have sex with men.

To reduce the risk of bacterial vaginosis (including recurrent BV) after sex, it's best to use barrier methods like condoms or dental dams. According to a study, consistent condom use can decrease the risk of bacterial vaginosis by 45%.

You have a period

As if periods couldn't get any worse, they may make you more susceptible to vaginal infections like bacterial vaginosis during your period. ​​The hormonal changes during your menstrual cycle, particularly the fluctuating estrogen levels, can impact the normal balance of bacteria in your vagina. During your period, estrogen levels are at their lowest, leading to higher bacterial diversity and fewer protective Lactobacilli bacteria in your vaginal microbiome.

Also, the presence of menstrual blood can raise the pH level in your vagina, throwing off the bacterial balance. Normally, the pH level inside your vagina is acidic (between 3.8 to 4.5), but menstrual blood is more neutral (7.4), which can change your natural pH balance and allow BV-associated bacteria a chance to grow.

You’re a smoker 

We know you don't need us to remind you that smoking is bad for your health, but here's another reason to consider quitting: some research suggests that smoking might reduce the levels of protective bacteria in your vaginal microbiome and increase the risk of bacterial vaginosis. 

Researchers are still studying the link between smoking and BV risk, but one possible explanation is that smoking could change levels of estrogen, which in turn can harm the growth of Lactobacilli in the vagina. Another reason might be a chemical in cigarette smoke that has been found in the vaginal secretions of smokers, which can change the DNA in the good bacteria, possibly leading to lower levels of these bacteria in the vaginal microbiomes of smokers.

You use douches

Not only is vaginal douching ineffective and unnecessary, but it can disrupt the normal balance of your vaginal flora and increase your risk of bacterial vaginosis. Research shows that women who douche regularly are five times more likely to develop BV than women who don't douche. 

Douches can flush out both good and bad bacteria, which may do more harm than good. They can also push harmful pathogens further up the reproductive tract, increasing the risk of infections.

Remember: your vagina is self-cleaning!

You don’t have enough “good” bacteria

Some people don't have enough protective bacteria in their vaginal microbiome, making them more likely to develop bacterial vaginosis. 

Most vaginal microbiomes fall into one of five general categories known as "Community State Types” (CSTs). Your CST is determined by the dominant microbes in your microbiome, and it can affect your symptoms, infections, and overall health.

A Type 4 CST is characterized by a low abundance of lactobacilli and a high diversity of other bacteria — specifically, BV-associated bacteria like Gardnerella vaginalis, BVAB-1, and Atopobium vaginae. This can lead to vaginal dysbiosis and a less stable vaginal environment, making you more prone to recurrent bacterial vaginosis.

Understanding these variations can help in finding the most effective treatments and maintaining a healthy balance of bacteria in the microbiome. The good news is that the vaginal microbiome is highly dynamic, and you can move from one CST to another.

BV treatment 

Antibiotics like clindamycin, metronidazole, tinidazole, and secnidazole are the first-line treatment for bacterial vaginosis. Currently, there isn't any evidence that "natural" or home remedies can clear up BV (regardless of what you may have seen floating on social media). 

While antibiotics can clear up to 85% of BV cases within a month, the infection may come back within six months for over half of the patients. 

It's also worth considering that not all antibiotics work the same for everyone. Some may work better for certain strains of bacteria, while others may not. Understanding the specific bacteria in your microbiome can be helpful when battling recurring infections.

As discouraging and frustrating as that sounds, it's crucial to address bacterial vaginosis. Untreated BV is linked with various health issues, including: 

How to prevent BV

The exact cause of bacterial vaginosis is still unclear, so there's no foolproof way to stop it from coming back (sorry). That said, making a few changes to your daily habits and reducing certain risk factors can really help lower the chances of getting BV as often.

  • Don’t use douches
  • Wipe front to back after going to the toilet
  • Don’t leave tampons or menstrual cups in longer than recommended
  • Use barrier methods like condoms or dental dams during sex
  • Cover sex toys with a condom during partnered sex, too 
  • Wash sex toys and menstrual cups after each use
  • Quit smoking.

FAQ

Why do I keep getting BV with the same partner?

Research has found that women in a committed relationship with a man are two to three times more likely to have recurrent bacterial vaginosis. Sex can increase the risk of BV for a few reasons — and no, BV isn't always a sign of cheating. Semen can alter the vaginal pH, which creates a better environment for bad bacteria and other pathogens to grow. Studies also show that even though men can't get bacterial vaginosis, they can pass on BV bacteria to people with vaginas during sex. Women can also pass on bacterial vaginosis to their female partners during sex. The best way to prevent bacterial vaginosis after having sex is to use barrier methods like condoms or dental dams. 

How do I get rid of BV permanently?

That’s the million-dollar question. Currently, antibiotics are the only effective treatment for bacterial vaginosis. Although antibiotics can treat BV, they don’t always stop it from coming back. Recurrence rates are really high, partly because the exact cause of BV is still unknown. 

What are the biggest causes of BV?

Bacterial vaginosis is caused by an overgrowth of “bad” bacteria in the vagina. The exact cause is unknown, but research has found that factors like having unprotected sex, sex with multiple partners, smoking, and using vaginal douches can all put you at higher risk of developing BV.