Why Does My BV Keep Coming Back?
Why Does My BV Keep Coming Back?
Introduction
"I've taken the antibiotics. It got better. Then a few weeks or months later, the symptoms came back."
This is one of the most common and frustrating stories I hear from women experiencing recurrent bacterial vaginosis (BV). If this sounds familiar, you are not alone.
BV is the most common cause of abnormal vaginal discharge in women of reproductive age, and unfortunately recurrence is extremely common. Many women experience another episode within months of completing treatment.
The good news is that recurrent BV is a recognised clinical challenge and is often more complex than simply having "an infection that won't go away". Understanding why BV keeps returning is the first step towards developing a more individualised approach to management.
What Is Bacterial Vaginosis (BV)?
Bacterial vaginosis occurs when the normal balance of bacteria within the vagina changes.
A healthy vaginal microbiome is typically dominated by beneficial bacteria known as Lactobacillus species. These bacteria help maintain an acidic vaginal environment and support the natural balance of the vaginal ecosystem.
In BV, the number of protective Lactobacillus bacteria decreases and other bacteria become more abundant. This change in the vaginal microbiome is known as vaginal dysbiosis.
Common symptoms of BV include:
Thin grey or white vaginal discharge
A strong or unpleasant "fishy" odour
Symptoms that may worsen after sex
Increased vaginal discharge
Vaginal discomfort or irritation
Some women may have BV without experiencing any symptoms.
Why Is Recurrent BV So Common?
One of the biggest misconceptions about BV is that antibiotics should permanently "cure" the problem.
While antibiotics are an important and evidence-based treatment for BV, recurrence can occur for many reasons. Understanding these contributing factors may help explain why symptoms often return.
1. The Vaginal Microbiome Has Not Fully Recovered
Antibiotics work by reducing BV-associated bacteria. However, treatment does not always restore a healthy Lactobacillus-dominant vaginal microbiome.
In simple terms, the unwanted bacteria may have reduced, but the protective bacteria may not have fully returned. This can leave the vaginal environment vulnerable to recurrent dysbiosis.
Research into the vaginal microbiome has significantly changed how we understand recurrent BV. Rather than focusing only on eliminating bacteria associated with BV, researchers are increasingly investigating how to support long-term vaginal ecosystem balance.
2. Biofilms May Be Protecting BV-Associated Bacteria
One of the most important discoveries in recurrent BV research has been the role of bacterial biofilms.
A biofilm is a structured community of bacteria that attaches to the vaginal lining and surrounds itself with a protective layer. You can think of it as a microscopic shield that may make bacteria less accessible to treatment.
This may help explain why symptoms improve temporarily after treatment but later return.
3. Sexual Activity Can Influence the Vaginal Environment
BV is not traditionally classified as a sexually transmitted infection, but sexual activity can influence the vaginal microbiome.
Factors associated with an increased risk of BV recurrence include:
New sexual partners
Multiple sexual partners
Female sexual partners
Unprotected intercourse
Semen is naturally alkaline and may temporarily increase vaginal pH, which can influence the vaginal environment in some women.
Many women notice their symptoms flare after sex, making this an important part of the clinical history to discuss with a healthcare professional.
4. Hormones and Vaginal pH Can Play a Role
The vaginal microbiome is strongly influenced by hormones.
Oestrogen helps maintain vaginal tissue health and supports the production of glycogen, which provides fuel for Lactobacillus bacteria. Changes in hormone levels may influence vaginal pH, Lactobacillus populations and vaginal tissue health.
This may be relevant during:
Perimenopause
Menopause
Postpartum
Breastfeeding
Certain hormonal treatments
Hormonal influences are often an overlooked contributor to recurrent vaginal symptoms.
5. It May Not Actually Be BV
One of the most commonly overlooked reasons for recurrent symptoms is that the diagnosis may not be straightforward.
Several conditions can cause symptoms that are similar to BV, including:
Aerobic Vaginitis
An inflammatory vaginal condition that can cause burning, irritation, discomfort and abnormal discharge.
Cytolytic Vaginosis
A less recognised condition associated with excessive Lactobacillus activity that can mimic BV or recurrent thrush.
Recurrent Thrush
Recurrent vulvovaginal candidiasis can cause ongoing irritation, discharge and discomfort.
Genitourinary Syndrome of Menopause (GSM)
Hormonal changes associated with declining oestrogen may cause dryness, burning, irritation and recurrent urinary symptoms.
Mixed Vaginal Conditions
Some women may have more than one contributing factor occurring at the same time.
Should I Keep Taking Antibiotics?
Antibiotics remain the recommended first-line treatment for bacterial vaginosis and can be very effective.
However, if BV keeps returning, it may be time to step back and ask a broader question: Why is this happening
Repeated treatment without understanding the underlying factors may not always provide a long-term solution.
A more comprehensive review may consider:
Whether the diagnosis is correct
Previous test results and treatment history
Hormonal influences
Sexual history and triggers
Vaginal microbiome health
Other potential contributing factors
What About Vaginal Microbiome Testing?
There has been increasing interest in vaginal microbiome testing in recent years.
Unlike standard testing, these tests aim to provide a more detailed picture of the bacteria present within the vaginal ecosystem, including Lactobacillus species and other microorganisms associated with vaginal dysbiosis.
For some women with recurrent or complex symptoms, this additional information may provide further insight. However, microbiome testing remains an evolving area of medicine and should always be interpreted alongside:
Symptoms
Medical history
Clinical assessment
Standard investigations
A test result alone does not provide a diagnosis or treatment plan.
When Should You Seek Further Medical Advice?
Consider seeking further assessment if:
BV keeps returning despite treatment
Symptoms are affecting your quality of life
You have repeated courses of antibiotics
You are unsure whether the diagnosis is correct
You experience pelvic pain, abnormal bleeding or other concerning symptoms
You do not need to continue living in a cycle of temporary improvement followed by recurrence.
The Bottom Line
Recurrent BV is common and can be incredibly frustrating.
The reason BV keeps returning is often complex and may involve changes in the vaginal microbiome, bacterial biofilms, hormonal influences, sexual factors or an alternative diagnosis.
Understanding the whole picture rather than repeatedly treating individual episodes may help identify the factors contributing to your symptoms.
How I Can Help
I am Kylie Sayce, an endorsed Nurse Practitioner with extensive clinical experience in sexual and reproductive health and advanced training in the human microbiome.
Over the past three years, I have completed more than 30,000 telehealth consultations, including caring for women experiencing recurrent BV, recurrent thrush, hormonal changes and ongoing vaginal symptoms.
Many women who come to my clinic have:
Had repeated episodes of BV
Completed multiple courses of antibiotics
Been told their tests are "normal"
Seen multiple healthcare providers without finding answers
My approach focuses on understanding your individual history, reviewing previous investigations, considering potential contributing factors and developing an evidence-based management plan tailored to your situation.
If you are struggling with recurrent BV or ongoing vaginal symptoms, you can book a consultation to discuss your symptoms and explore the next steps.
Medical Disclaimer
This information is intended for educational purposes only and does not replace individual medical advice, diagnosis or treatment. If you are experiencing symptoms, please seek personalised advice from an appropriately qualified healthcare professional.
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