Bacterial vaginosis is a condition in which certain organisms, especially Gardnerella predominate. These and other anaerobic bacteria can create an elevated pH of >4.5, There can be a resulting discharge that is typically gray, thin and malodorous, sometimes with itching. This condition can be stubborn and difficult to eradicate. In contrast, with a healthy vaginal microbiome, lactobacillus organisms predominate and create an acidic pH of 3.5-4.5.
The way the question is stated includes the assumption that the husband’s alkaline semen “causes” the anaerobic environment and bacterial vaginosis. This is not exactly true – the alkaline semen can temporarily disrupt the vaginal biome and help Gardnerella grow – but if the vagina is healthy and has enough good bacteria, healthy semen will not cause infections.Â
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First there must be a correct diagnosis. Typically a physician can do vaginal swab tests that can detect vaginosis and also vaginal yeast, the main other cause of vaginal discharge. There are also tests for other organisms such as mycoplasma, ureaplasma, staph, strep and others. It is possible to have more than one organism causing infection at the time and each may need to be treated appropriately.
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Therapies for bacterial vaginosis typically include either the antibiotic metronidazole or clindamycin. For very stubborn infections, the oral form of the medication might work better. Sometimes after antibiotic treatment a yeast infection can occur. This can be avoided by pretreatment with an oral antifungal such as fluconazole. Vaginal metronidazole or clindamycin gel can be effective treatments for BV.
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One time treatment may be sufficient for eradicating mild BV. But for more stubborn BV, treatment over several months may be needed. At the beginning of the cycle just after the period, the number of all organisms is much lower. It is easier to markedly reduce the concentration of bacteria at that time. So after a one-time treatment of oral or vaginal clindamycin or metronidazole, typically lasting 5-7 days, it is helpful in following months to use a one day vaginal dose right after the menses of one of these two antibiotics (either cream, gel or vaginal tablet). The hope is that for the remainder of the cycle the concentration of Gardnerella will remain low. After six months of this type of one-day-a month there can be long lasting effects.
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There also needs to be attention to building up good bacteria in the vaginal microbiome, mainly lactobacillus. Oral probiotics daily can help. They need to be of sufficient strength with at least 25 billion CFUs *colony forming units). There are newer forms of vaginal probiotics, although not as much is known about treatment results. Also the vaginal flora are very affected by intestinal flora. If there is constipation, irritable bowel syndrome or other conditions that can be associated with abnormal microbial organisms. Intestinal health needs to be taken into consideration.
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Finally, in some cases, the male partner may need antibiotic treatment also to achieve good results for the woman. There are not straightforward ways to test men for the organisms causing vaginal infections (exceptions: chlamydia and gonorrhea). So most of the time therapy for the main is “empirical” – based on the woman’s diagnosis. Mary Davenport, MD
