Bacterial vaginosis is one of those vaginal conditions that's super common but somehow still feels mysterious. If you've ever wondered, "What exactly is BV?" or found yourself Googling symptoms at 2 AM, we got you covered.

This article is the first in our comprehensive three-part series on bacterial vaginosis. We're covering what BV actually is, how to spot it, and what causes it in the first place.

For the complete picture, check out our companion articles on treating bacterial vaginosis and preventing BV recurrence, because understanding the full story is key to taking control of your vaginal health.

Vaginal microbiome: your body's most important ecosystem

Your vaginal microbiome is basically your body's most sophisticated ecosystem, and it's doing way more than you might think. Picture millions of microorganisms (mostly bacteria) working 24/7 to keep things running smoothly down there.

This microscopic community is your vagina's first line of defense, and when it's thriving, you probably don't even notice it. When it's not? That's when things get interesting.

Lactobacilli's role in vaginal health

At the center of this whole operation are bacteria from the Lactobacillus family, basically the the most valuale players of vaginal health. When these good bacteria are present in healthy numbers, they're doing some pretty incredible things for you. They're creating your vagina's built-in security system.

Lactobacilli produce lactic acid, which keeps your vaginal environment naturally acidic [1]. Research shows this acidity (typically a pH between 3.8 and 4.5, approximately as acidic as tomato juice) makes it nearly impossible for harmful bacteria to establish themselves and cause trouble [3]. It's like having bouncers at the club who only let the right bacteria through the door.

But that's not all these bacterial bodyguards do. Some Lactobacillus strains also produce other protective compounds, like hydrogen peroxide and bacteriocins [2]. Studies show these substances work like natural antibiotics, helping keep potentially problematic bacteria in check and maintaining the delicate balance your vagina needs to stay healthy.

Why Your Vagina's pH Is Actually a Big Deal

We keep mentioning pH, but here's why it matters so much: the pH scale measures how acidic or alkaline something is. Lower pH means more acidic, higher pH means more alkaline. Clinical research confirms that your vagina is naturally designed to be acidic, and this acidity is the cornerstone of its defense system [3].

When your pH rises (becomes less acidic), it's like those bouncers we mentioned going on break. Suddenly, bacteria that normally wouldn't stand a chance can start setting up shop and potentially cause conditions like BV.

What vaginal dysbiosis means?

So, what happens when this carefully orchestrated system gets disrupted? Enters dysbiosis, a fancy term that means the bacterial balance in your vagina has been thrown off. Research shows that when dysbiosis occurs, your protective Lactobacilli population might decrease, while other types of bacteria (often anaerobic ones that thrive without oxygen) can start to overgrow [4].

This shift is exactly what happens in bacterial vaginosis. It's not necessarily about some foreign invader swooping in; it's more about bacteria that are normally present in small, harmless numbers suddenly getting the opportunity to multiply and take over.

That's why understanding dysbiosis is key to understanding BV. It helps us see BV not as some mysterious infection, but as a sign that your vaginal ecosystem needs support to get back to its natural, healthy balance.

Bottom line: Your vaginal microbiome is a complex ecosystem where Lactobacillus bacteria and acidic pH are the main players keeping you healthy. When this balance gets disrupted (dysbiosis), conditions like BV can develop. Think of it as your vagina's operating system needing a reboot.

What Exactly Is Bacterial Vaginosis?

Now that we've covered your vaginal microbiome's normal operations, let's talk about what happens when things go sideways, specifically, when you develop bacterial vaginosis.

Remember that thriving ecosystem we just described? BV occurs when that system gets completely out of whack. It's not typically caused by one specific "bad" bacteria invading your space. Instead, research demonstrates that BV is what scientists call a polymicrobial syndrome, basically meaning it involves a shift in the types and amounts of bacteria that are naturally hanging out in your vagina [5].

Here's what's happening when you have BV:

Your protective Lactobacilli take a major hit. Studies show that the population of those good-guy Lactobacillus bacteria, the ones producing lactic acid and keeping your vaginal pH acidic and healthy, drops significantly [6]. It's like your security team is suddenly getting decimated.

Other bacteria seize the opportunity to multiply. As your Lactobacilli numbers dwindle, other bacteria (particularly anaerobic ones that love low-oxygen environments) start throwing their own party. Clinical research identifies common players in BV, including Gardnerella vaginalis, Prevotella species, Atopobium vaginae, and Mobiluncus species, amongothers [7].

Here's the thing: many of these bacteria can actually be present in a healthy vagina in small amounts. The problem isn't their existence, it's when they overgrow and start dominating the ecosystem.

So, BV is essentially vaginal dysbiosis, an imbalanced ecosystem where your protective forces are weakened and the potentially disruptive bacteria take over. Research confirms that this shift leads to changes in your vaginal environment, including an increase in pH (making it less acidic), which creates an even more favorable environment for BV-associated bacteria to thrive [8]. It's like a snowball effect that keeps getting worse.

Is BV a common condition?

If you've ever experienced BV or think you might have it, here's something that might make you feel better: you are far from alone. CDC data shows that BV is actually the most common vaginal condition in women of reproductive age [9]. We're talking about a condition that affects a significant number of women at some point in their lives. It's more common than yeast infections, even though it gets way less airtime.

The silence around BV can make it feel isolating, but understanding just how prevalent it is can be pretty reassuring. You're not broken; you're not doing anything wrong. You're dealing with something that millions of other women experience.

Is BV a STI?

It's complicated. This is probably one of the most confusing aspects of BV, so let's clear it up. The short answer: BV isn't a sexually transmitted infection (STI) in the traditional sense, like chlamydia or gonorrhea. Research demonstrates that you don't "catch" BV from a partner the way you would catch other STIs [10].

However, and this is where it gets a bit complicated, sexual activity is definitely a known risk factor for developing BV. This is likely because sex can introduce new bacteria or alter your existing vaginal microbiome and pH. For example, semen is alkaline, which can temporarily raise your vaginal pH and potentially create an environment where BV-associated bacteria can thrive.

‍

Studies show that having new or multiple sexual partners is associated with an increased risk of BV [10]. But it's more about the disruption of your unique vaginal ecosystem rather than catching a specific bug from someone else.

This is crucial to understand without any stigma attached: BV is about bacterial imbalance, not a reflection of your hygiene habits or sexual choices. It's a medical condition that can happen to anyone with a vagina, regardless of their sexual activity level.

 BV isn't your typical infection; it's more like an ecosystem disruption where your vagina's good bacteria (Lactobacilli) get outnumbered by other bacteria that normally hang out in small numbers. And while sex can definitely trigger it, BV isn't an STI that you "catch" from someone else.

What triggers BV?

Now that you understand what BV is - a microbiome disruption rather than a simple infection - let's dive into what can actually trigger this imbalance. Spoiler alert: there's usually not just one culprit, but understanding these factors can help you identify potential risks and take steps to protect your vaginal health.

The Most Common BV Triggers

BV rarely has a single, obvious cause. Instead, various factors can mess with your vaginal ecosystem's delicate balance, potentially setting the stage for BV to develop.

1. Sexual Activity

While BV isn't an STI, research demonstrates that sexual activity is definitely associated with increased BV risk [10]. This includes having new sexual partners or multiple partners. Here's what's happening: semen has an alkaline pH that can temporarily neutralize your vagina's natural acidity, potentially creating conditions where BV-associated bacteria can thrive.

Using condoms can help minimize this pH disruption, which is one reason why barrier methods might reduce BV risk. It's not about the sexual activity itself being "dirty"; it's purely about the chemical changes that can occur.

2. Douching & Those "Fresh Feeling" Products: Hard Pass

Studies show that vaginal douching is basically evicting all your good bacteria along with the bad [11]. When you douche, you're washing away the beneficial bacteria that work so hard to maintain your vaginal balance.

Those scented soaps, "feminine washes," and fragranced sprays? They're doing you zero favors either. Your vagina is literally designed to clean itself (seriously, it's incredible), and these products disrupt its natural process. The marketing might be convincing, but the science says: hard pass.

3. Your Menstrual Cycle

Research confirms that your vaginal pH naturally fluctuates throughout your menstrual cycle [21]. During menstruation, your pH rises (becomes less acidic), which can create an environment where BV-associated bacteria can flourish more easily.

Some women notice BV symptoms recurring around their period for exactly this reason. It's not that periods cause BV, but the natural pH changes can sometimes tip an already vulnerable ecosystem over the edge.

4. IUDs

Some studies suggest a potential association between copper intrauterine devices (IUDs) and increased BV risk[8]. The research isn't definitive, but if you have an IUD and experience recurrent BV, it might be worth discussing with your healthcare provider. This doesn't mean IUDs are bad, just that they might be one factor to consider in your personal BV puzzle.

5. Antibiotics

Here's an ironic twist: while antibiotics are often prescribed to treat infections, they can also kill off beneficial bacteria in the process. This collateral damage can sometimes disrupt your vaginal microbiome, potentially leading to conditions like BV.

It's not that you should avoid necessary antibiotics, but understanding this connection can help you take proactive steps (like considering probiotics) when you need antibiotic treatment.

6. Wardrobe Choices

Wearing tight underwear or pants made from synthetic materials can create a warm, moist environment that may alter your vaginal microbiome. Cotton underwear and looser-fitting clothes allow for better air circulation, which your vaginal ecosystem appreciates.

Who's at Higher Risk for BV?

While any woman can develop BV, certain factors are associated with higher risk:

1. Age and Reproductive Status

BV is most common in women of reproductive age, particularly those between 15 and 44 years old. This timing isn't coincidental; it corresponds with peak hormonal activity and often increased sexual activity.

2. Demographic Variations

Studies have shown variations in BV prevalence among different racial and ethnic groups [9]. The reasons for these differences are complex and likely involve a combination of biological, environmental, and socioeconomic factors. This isn't about one group being more or less "clean"; it's about complex interactions between genetics, environment, and access to healthcare.

3. Smoking

Research demonstrates that cigarette smoking has been associated with increased BV risk [9]. The exact mechanism isn't fully understood, but it may relate to how smoking affects immune function and vaginal blood flow. Just another item on the long list of reasons why smoking isn't doing your body any favors.

4. Stress

High stress levels can impact your immune system and potentially disrupt your vaginal microbiome. While we can't eliminate stress from our lives entirely, practicing stress-reduction techniques may support overall vaginal health. Your mental health and vaginal health are more connected than you might think.

Why BV reoccurs?

Here's one of the most maddening aspects of BV: its tendency to come back. Clinical studies show that about 50% of women treated for BV will experience a recurrence within a year [12]. That's not a failure on your part; it highlights the importance of not just treating immediate symptoms, but also addressing the underlying microbiome imbalance and identifying your personal triggers.

This high recurrence rate is exactly why understanding your individual risk factors is so important. What triggers BV for your friend might not be the same as what triggers it for you. Paying attention to patterns, like whether your BV tends to occur after your period, after sex, or during stressful times, can help you and your healthcare provider develop a more targeted prevention strategy.

What are the symptoms of BV?

When your vaginal microbiome shifts into dysbiosis mode, your body usually sends some pretty clear signals that something's off. Recognizing these signs can help you seek appropriate care and get back to balance sooner. But here's the thing: BV symptoms can vary wildly from person to person, and sometimes there are no symptoms at all.

The Most Common Signs of BV

1. That Distinctive Discharge

BV typically causes:

- Thin, watery discharge that's nothing like the thick stuff you'd see with a yeast infection. We're talking about discharge that's much thinner than your usual consistency.

- Gray or off-white color that's definitely not your normal discharge color. This grayish tint is actually one of the more reliable clues that you might be dealing with BV rather than another type of vaginal condition.

- Smooth consistency without clumps or chunks. Unlike yeast infections, which often cause cottage cheese-like discharge, BV discharge tends to be uniform and smooth.

- Often more abundant than your usual discharge. You might notice that you're producing more discharge than you typically experience, which can be concerning if you're not sure what's causing it.

Seeing these changes doesn't automatically mean BV, but they're definitely worth paying attention to and potentially discussing with a healthcare provider.

2. The Telltale Odor

Many women with BV notice a strong, fishy odor, especially after sex or during menstruation. Research shows this happens because the anaerobic bacteria involved in BV produce compounds called volatileamines, which become more noticeable when they interact with alkaline fluids like semen or menstrual blood [8].

This odor is often the symptom that prompts women to seek care, and understandably so; it can be embarrassing and concerning. But it's important to know that this odor is a medical symptom, not a reflection of your hygiene or anything you're doing wrong.

3. Mild Discomfort

Some women experience mild itching, burning, or irritation in the vaginal area when they have BV. However, these symptoms are typically much less severe than what you might experience with a yeast infection or certain STIs.

If you're experiencing intense itching or burning, BV might not be the culprit; those symptoms are more commonly associated with yeast infections or other conditions.

What if there is no symptoms?

Here's something that might surprise you: studies demonstrate that many women with BV don't experience any symptoms atall [8]. This "asymptomatic BV" can only be detected through testing during routine gynecological exams.

This silent nature is one reason why BV can sometimes go undiagnosed and untreated for extended periods, potentially leading to other health concerns over time. It's also why regular gynecological check-ups are so important; your healthcare provider might catch something you didn't even know was there.

BV vs. Everything Else: How to Tell the Difference

Different vaginal conditions can have overlapping symptoms, which can make self-diagnosis pretty tricky. Here's how BV typically differs from other common vaginal conditions:

BV vs Yeast Infections

Unlike BV, yeast infections typically cause a thick, white, cottage cheese-like discharge. Itching is usually much more pronounced with yeast infections, and there's typically no fishy odor. If you're dealing with intense itching and thick, chunky discharge, you're probably looking at a yeast infection rather than BV.

BV vs Trichomoniasis

This STI can cause frothy, yellow-green discharge with a strong odor, often accompanied by more significant irritation, itching, and sometimes pain during urination or sex. The discharge color and intensity of symptoms are usually different from what you'd see with BV.

BV vs Chlamydia

‍

Chlamydia is an STI that might cause abnormal discharge, but it’s more likely to cause pelvic pain, pain during sex, or unusual bleeding. Discharge with chlamydia can appear normal, or yellowish in colour rather than the grayish color typical of BV.

BV vs Gonorrhea

Gonorrhea is an STI that often causes an abnormal discharge, but the discharge is more likely to be greenish in colour. Gonorrhea infection is also associated with painful sex, stomach pains and unscheduled bleeding.

When to Actually Worry and Seek Care

While BV itself isn't typically dangerous, it's important to seek medical care if you experience:

-       Any new or unusual vaginal symptoms that persist for more than a few days. Your body knows what's normal for you, so trust those instincts when something feels off.

-       Symptoms that keep coming back, even after treatment. Recurrent BV can be frustrating, but there are strategies to help break the cycle.

-       Vaginal discharge accompanied by fever, pelvic pain, or pain during sex. These symptoms might indicate a more serious condition that needs immediate attention.

‍

-       Unusual vaginal symptoms during pregnancy. BV during pregnancy can potentially lead to complications, so it's crucial to get checked out if you're pregnant and experiencing symptoms.

What to expect from BV testing?

If you're experiencing symptoms that might be BV, or if you're just concerned about your vaginal health in general, getting a proper diagnosis is a crucial step. Understanding what happens during the diagnostic process can help you feel more prepared and empowered when you visit your healthcare provider, here's what to expect:

1. The Medical History Deep Dive

Your provider will ask about your symptoms, how long you've been experiencing them, and any factors that seem to trigger or worsen them. They'll also ask about your sexual history, previous vaginal infections, and any treatments you've already tried.

This might feel invasive, but this information helps them understand the context of your symptoms and rule out other potential causes. Be honest, your healthcare provider has heard it all before, and accurate information leads to better care.

2. The Examination

Your providor may want to visually examine your genitals for signs of infection or inflammation. They'll look for characteristic discharge and other physical indicators of BV or other conditions. The clinician may use a speculum to visualise the vagina and cervixor perform a pelvic examination.

If you're nervous about intimate exams, that's completely normal. Don't hesitate to ask your provider to explain what they're doing as they go, or to request a slower pace if you need it.

3. Sample Collection for Testing

Your provider will use a cotton swab to collect samples of your vaginal discharge for further examination. These samples are used for several different diagnostic tests that can help confirm whether you have BV.

How BV Gets Diagnosed?

Several methods can be used to diagnose BV, and your provider might use one or a combination of these approaches:

1. Amsel's Criteria

This is a common clinical method that requires at least three of the following four criteria to be present for a BV diagnosis:

1.    Thin, gray, homogeneous discharge coating the vaginal walls, basically, that characteristic grayish discharge we talked about earlier.

2.    Vaginal pH greater than 4.5, which means your vagina is less acidic than it should be for optimal health.

3.    Positive "whiff test", this involves adding a drop of potassium hydroxide (KOH) to a sample of your vaginal discharge. If there's a fishy odor when this happens, it's considered a positive test.

4.    Presence of "clue cells" under microscopic examination, which are vaginal cells that are covered with BV-causing bacteria, giving them a stippled or granular appearance that's visible under a microscope.

2. Nugent Score

This method is considered the gold standard for BV diagnosis in research settings. It involves examining a Gram-stained sample of your vaginal discharge under a microscope and scoring the relative amounts of different bacterial shapes. A score of 7-10 indicates BV, 4-6 is intermediate (meaning you're in a gray area), and 0-3 is considered normal.

While this method is highly accurate, it's more commonly used in research settings than in typical clinical practice because it requires specialized laboratory equipment and expertise.

3. Molecular Testing

Newer diagnostic methods include DNA tests that can detect the specific bacteria associated with BV. These tests are becoming more widely available and can be particularly useful in complex cases or when other testing methods give unclear results.

These molecular tests can sometimes provide more detailed information about your vaginal microbiome, which can be helpful for developing targeted treatment strategies.

Can you test for BV at home?

While visiting a healthcare provider is the most reliable way to diagnose BV, there are some at-home testing options available:

1. pH tests

These over-the-counter tests measure the pH of your vaginal discharge. While they can't definitively diagnose BV, an elevated pH (above 4.5) might suggest BV or another vaginal infection. These tests can be a useful first step, but they're not a substitute for professional medical evaluation.

2. Complete home test kits

Some kits allow you to collect a vaginal swab at home and send it to a lab for analysis. These can be convenient, especially if you have difficulty accessing healthcare or prefer the privacy of testing at home.

However, it's important to note that while at-home tests can provide some useful information, they don't replace professional medical care. If you're experiencing persistent or concerning symptoms, consulting with a healthcare provider is still recommended.

Ruling out other conditions

Since various vaginal conditions can have similar symptoms, your healthcare provider will also consider other possible causes during the diagnostic process. They might test for:

·       Yeast infections, which can sometimes be confused with BV but have different treatment approaches.

‍

·       Sexually transmitted infections like trichomoniasis, chlamydia, or gonorrhea, which can cause similar symptoms, but require different treatments.

‍

·       Less common conditions like cytolytic vaginosis (an overgrowth of lactobacilli), inflammatory vaginitis, or allergic contact dermatitis.

‍

Proper diagnosis is crucial for effective treatment, so your provider may test for multiple conditions to ensure they're addressing the right issue.

‍

What If your test results are unclear?

‍

Sometimes, test results can be inconclusive or fall into that intermediate category. This doesn't mean you're imagining your symptoms or that nothing is wrong; it just means your vaginal microbiome might be in a transitional state.

‍

In these cases, your healthcare provider might recommend retesting after a certain period, trying empirical treatment based on your symptoms, or using additional testing methods to get a clearer picture of what's happening.

‍

Let's bust some myths about BV

‍

When it comes to BV, there's a lot of misinformation floating around that can lead to confusion, unnecessary shame,or completely wrong self-care approaches. Let's clear up some of the most persistent myths about this condition.

‍

Myth #1: "BV means I'm not clean enough"

‍

Reality check: Research clearly demonstrates that BV is NOT caused by poor hygiene. In fact, excessive cleaning, especially with harsh soaps or douching, can actually increase your risk of developing BV by disrupting your natural vaginal balance.

‍

BV is about bacterial imbalance in your vaginal microbiome, not about how often you shower or what soap you use. Many women with excellent hygiene habits experience BV, while others with less rigorous routines never do. Your vaginal microbiome is influenced by hormones, genetics, sexual activity, stress, and many other factors that have nothing to do with cleanliness.

‍

The vagina is designed to clean itself through natural processes, and too much intervention often does more harm than good. So if you're dealing with BV, please don't blame yourself or think you need to scrub harder; that's not the solution.

‍

Myth #2: "BV is STI"

‍

Reality check: While sexual activity can trigger BV, it's not classified as a sexually transmitted infection (STI). Unlike STIs such as chlamydia or gonorrhea, BV isn't caused by a specific pathogen that gets passed from one person to another.

‍

Sexual activity can disrupt your vaginal environment and introduce new bacteria, potentially triggering BV in some women. This is why BV is more common in sexually active women and those with new or multiple partners. However, studies show that women who have never been sexually active can also develop BV, though it's less common.

‍

The key difference is that BV is about your individual vaginal ecosystem getting out of balance, rather than catching a specific infection from someone else.

‍

Myth #3: "I can cure BV with yogurt"

‍

Reality check: While some yogurts do contain beneficial bacteria (probiotics), simply eating yogurt or applying it vaginally is not a proven treatment for BV. And here is why it's problematic:

 - Most yogurts contain Lactobacillus strains that are different from those naturally found in the vagina. Your vaginal microbiome has specific bacterial strains that work best in that environment.

‍

 - The concentration of probiotics in yogurt typically isn't high enough to effectively colonize your vaginal environment and outcompete the bacteria causing BV.

‍

 - Applying food products vaginally can introduce other substances (like sugars) that might cause irritation or even feed harmful bacteria.

‍

 
Though If you're interested in probiotic approaches to vaginal health, it's better to use products specifically formulated for this purpose, like targeted vaginal probiotics that contain appropriate strains in therapeutic concentrations.

The following product information is provided for informational purposes only and represents the manufacturer's descriptions and intended uses. It is not intended to diagnose, treat, cure, or prevent any disease. Always consult with a qualified healthcare professional before starting any new supplement or treatment regimen, especially if you have underlying health conditions or are pregnant or breastfeeding. Individual results may vary.

Products like Neycher's BV Away (specifically formulated for bacterial vaginosis) and Vaginal Synbiotic are designed specifically for vaginal health, containing targeted bacterial strains along with prebiotics to nourish them, a more scientifically sound approach than DIY yogurt treatments.

‍

Myth #4: "Once my symptoms disappear, I'm cured"

‍

Reality check: The disappearance of symptoms doesn't necessarily mean the underlying microbiome imbalance is fully resolved. This is one reason why BV has such frustratingly high recurrence rates, up to 50% within a year after treatment [12].

‍

Complete resolution often requires finishing the full course of prescribed treatment, even if symptoms improve earlier, considering follow-up measures to restore vaginal pH and beneficial bacteria, and identifying and addressing personal triggers to prevent recurrence.

‍

Think of BV treatment like taking antibiotics for strep throat; you need to complete the full course even if you feel better after a few days.

‍

Myth #5: "BV will just go away on its own if I wait"

‍

Reality check: While mild cases of BV can and do resolve without treatment, many cases persist or worsen over time if not addressed. Research shows that untreated BV can lead to an increased risk of acquiring STIs (including HIV), cause complications during pregnancy, including preterm birth, and increase the risk of developing pelvic inflammatory disease (PID).

‍

Given these potential complications, it's generally not worth the risk to just wait and see if BV resolves on its own.

‍

Myth #6: "Natural treatments don't work for BV"

‍

Reality check: While antibiotics remain the standard first-line treatment, research demonstrates that certain natural approaches can be effective, particularly for prevention and as complementary treatments.

‍

Evidence-based natural approaches include pH-balancing treatments like boric acid [18], targeted probiotics designed specifically for vaginal health [15], and lifestyle modifications to support vaginal microbiome health.

‍

The key is using evidence-based natural approaches rather than unproven home remedies. Not all "natural" treatments are created equal, and some can actually make things worse.

‍

Conclusion

‍

Many misconceptions about BV stem from stigma and misinformation that have been passed down through generations. Understanding the fact that BV is a common microbiome imbalance, not a reflection of your hygiene or sexual behavior, can help reduce shame and lead to more effective treatment approaches.

‍

BV is a medical condition that deserves proper medical attention and evidence-based treatment. You don't need to suffer in silence or try to fix it with questionable home remedies.

‍

References

[1] Petrova, M. I., Lievens, E., Malik, S.,Imholz, N., & Lebeer, S. (2015). Lactobacillus species as biomarkers andagents that can promote various aspects of vaginal health. Frontiers inPhysiology, 6, 81. https://pmc.ncbi.nlm.nih.gov/articles/PMC4373506/

[2] Delgado-Diaz, D. J., Tyssen, D.,Hayward, J. A., Gugasyan, R., Hearps, A. C., & Tachedjian, G. (2020).Distinct immune responses elicited from cervicovaginal epithelial cells bylactic acid and short chain fatty acids associated with optimal and non-optimalvaginal microbiota. Frontiers in Cellular and Infection Microbiology, 10,628699. https://pubmed.ncbi.nlm.nih.gov/31998660/

[3] Saraf VS, Sheikh SA, Ahmad A, GillevetPM, Bokhari H, Javed S. (2021). Vaginal microbiome: normalcy vs dysbiosis.Archives of Microbiology, 203(7):3793-3802. https://pubmed.ncbi.nlm.nih.gov/34120200/

[4] Han, Y., Liu, Z., & Chen, T.(2021). Role of vaginal microbiota dysbiosis in gynecological diseases and thepotential interventions. Frontiers in Microbiology, 12, 643422. https://pmc.ncbi.nlm.nih.gov/articles/PMC8249587/

[5] Redelinghuys, M. J., Geldenhuys, J.,Jung, H., & Kock, M. M. (2020). Bacterial vaginosis: Current diagnosticavenues and future opportunities. Frontiers in Cellular and InfectionMicrobiology, 10, 354. https://www.frontiersin.org/journals/cellular-and-infection-microbiology/articles/10.3389/fcimb.2020.00354/full

[6] Muzny, C. A., Taylor, C. M., Swords, W.E., Tamhane, A., Chattopadhyay, D., Cerca, N., & Schwebke, J. R. (2019). Anupdated conceptual model on the pathogenesis of bacterial vaginosis. Journal ofInfectious Diseases, 220(9), 1399-1405. https://pubmed.ncbi.nlm.nih.gov/31369673/

[7] Onderdonk, A. B., Delaney, M. L., &Fichorova, R. N. (2016). The human microbiome during bacterial vaginosis.Clinical Microbiology Reviews, 29(2), 223-238. https://pubmed.ncbi.nlm.nih.gov/26864580/

[8] Kairys, N., & Garg, M. (2023).Bacterial vaginosis. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459216/

[9] Workowski, K. A., Bachmann, L. H.,Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J.M., & Bolan, G. A. (2021). Sexually Transmitted Infections TreatmentGuidelines, 2021. MMWR. Recommendations and reports, 70(4), 1–187. https://www.cdc.gov/std/treatment-guidelines/default.htm

[10] Bradshaw, C. S., & Sobel, J. D.(2016). Current treatment of bacterial vaginosis - Limitations and need forinnovation. Journal of Infectious Diseases, 214(suppl_1), S14-S20. https://pubmed.ncbi.nlm.nih.gov/27449869/

[11] Cottrell, B. H. (2010). An updatedreview of evidence to discourage douching. MCN: The American Journal ofMaternal/Child Nursing, 35(2), 102-107. https://pubmed.ncbi.nlm.nih.gov/20215951/

[12] Sobel, J. D., Kaur, N., Woznicki, N.A., Boikov, D., Aguin, T., Gill, G., & Akins, R. A. (2019). Prognosticindicators of recurrence of bacterial vaginosis. Journal of ClinicalMicrobiology, 57(5), e00227-19. https://pubmed.ncbi.nlm.nih.gov/30842235/

[13] Chen, Y., Bruning, E., Rubino, J.,& Eder, S. E. (2017). Role of female intimate hygiene in vulvovaginalhealth: Global hygiene practices and product usage. Women's Health, 13(3),58-67. https://pubmed.ncbi.nlm.nih.gov/28934912/

[14] van Eijk, A. M., Zulaika, G.,Lenchner, M., Mason, L., Sivakami, M., Nyothach, E., Unger, H., Laserson, K.,& Phillips-Howard, P. A. (2019). Menstrual cup use, leakage, acceptability,safety, and availability: A systematic review and meta-analysis. The LancetPublic Health, 4(8), e376-e393. https://pubmed.ncbi.nlm.nih.gov/31324419/

[15] Reid, G., Bocking, A., &Laniewski, P. (2003). The potential for probiotics to prevent bacterialvaginosis and preterm labor. American Journal of Obstetrics and Gynecology,221(6), 477-487. https://pubmed.ncbi.nlm.nih.gov/14586379/

[16] Carlson, J. L., Erickson, J. M.,Lloyd, B. B., & Slavin, J. L. (2018). Health effects and sources ofprebiotic dietary fiber. Current Developments in Nutrition, 2(3), nzy005. https://pmc.ncbi.nlm.nih.gov/articles/PMC6041804/

[17] Klebanoff, M. A., Nansel, T. R.,Brotman, R. M., Zhang, J., Yu, K. F., Schwebke, J. R., & Andrews, W. W.(2010). Personal hygienic behaviors and bacterial vaginosis. SexuallyTransmitted Diseases, 37(2), 94-99. https://pubmed.ncbi.nlm.nih.gov/19823112/

[18] Abbe, C., & Mitchell, C. M.(2023). Bacterial vaginosis: a review of approaches to treatment andprevention. Frontiers in Reproductive Health, 5, 1100029. https://www.frontiersin.org/journals/reproductive-health/articles/10.3389/frph.2023.1100029/full

[19] O'Hanlon, D. E., Moench, T. R., &Cone, R. A. (2013). Vaginal pH and microbicidal lactic acid when lactobacillidominate the microbiota. PLoS One, 8(11), e80074. https://pubmed.ncbi.nlm.nih.gov/24223212/

[20] Swidsinski, A., Mendling, W.,Loening-Baucke, V., Swidsinski, S., Dörffel, Y., Scholze, J., Lochs, H., &Verstraelen, H. (2008). An adherent Gardnerella vaginalis biofilm persists onthe vaginal epithelium after standard therapy with oral metronidazole. AmericanJournal of Obstetrics and Gynecology, 198(1), 97.e1-97.e6. https://pubmed.ncbi.nlm.nih.gov/18005928/

[21] Amabebe, E., & Anumba, D. O. C.(2018). The vaginal microenvironment: The physiologic role of lactobacilli.Frontiers in Medicine, 5, 181. https://pubmed.ncbi.nlm.nih.gov/29951482/

[22] Forcey, D. S., Vodstrcil, L. A.,Hocking, J. S., Fairley, C. K., Law, M., McNair, R. P., & Bradshaw, C. S.(2015). Factors associated with bacterial vaginosis among women who have sexwith women: A systematic review. PLoS One, 10(12), e0141905. https://pmc.ncbi.nlm.nih.gov/articles/PMC4682944/