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Women's sexual health guide · 2026
Bacterial vaginosis is the most common cause of vaginal discharge and one of the most frequently misdiagnosed, in both directions.
Bacterial vaginosis (BV) is a shift in the vaginal microbiome away from lactobacilli towards a mixed anaerobic flora, including Gardnerella vaginalis. It is not classified as a sexually transmitted infection, although sexual activity influences risk. Diagnosis has traditionally used Amsel criteria or Nugent scoring on a Gram stain; molecular panels are now widely offered. The key interpretive point is that Gardnerella is present in many women without BV, so a positive PCR alone does not establish the diagnosis — symptoms and the overall flora pattern do. Recurrence within a year is common and is the main clinical challenge.
| Not an STI | BV is a microbiome shift, not a transmitted infection, though sexual activity affects risk |
|---|---|
| Traditional diagnosis | Amsel criteria or Nugent score on Gram stain |
| Molecular panels | Useful, but a Gardnerella positive alone is not diagnostic |
| Main symptom | Thin grey-white discharge with a fishy odour, often worse after sex |
| Recurrence | Common within 12 months; a management plan matters more than the first prescription |
| Price | Listed on the MedEx STD and STI testing page and the lab test catalogue |
A healthy vaginal microbiome is usually dominated by lactobacilli, which produce lactic acid and keep the pH low. In BV, lactobacilli decline and a mixed anaerobic community expands, raising the pH and producing volatile amines — the source of the characteristic odour.
Gardnerella vaginalis is central to the biofilm involved, but it is also detectable in many women with a normal microbiome and no symptoms. That is why a PCR reporting Gardnerella present is not, by itself, a diagnosis of BV.
Roughly half of women with BV have no symptoms. Where symptoms occur, the classic picture is a thin, homogeneous grey-white discharge with a fishy odour that is often more noticeable after sex or during menstruation. Itching and soreness are more typical of candida than of BV.
Amsel criteria — three of four: characteristic discharge, vaginal pH above 4.5, a positive amine (whiff) test, and clue cells on microscopy.
Nugent score — a standardised Gram stain score, often treated as the reference standard.
Molecular panels — quantify BV-associated organisms and lactobacilli. These correlate reasonably with Nugent scoring and are convenient, particularly with self-collected swabs, but need interpreting as a pattern rather than as individual positives.
What is not a diagnosis: a single organism reported present on a multiplex STI panel. If your panel flagged Gardnerella, Mycoplasma hominis or Ureaplasma without a clinical assessment, review it with a clinician before treating — the same principle covered in the STI PCR panel guide.
Persistent or recurrent discharge deserves a full assessment, not a repeat course.
Treatment is with metronidazole or clindamycin, oral or intravaginal, prescribed by a clinician. Asymptomatic BV found incidentally does not usually require treatment outside specific situations such as before some gynaecological procedures or in pregnancy where indicated.
Recurrence within 12 months is common, and it is the main reason BV frustrates people. Contributing factors include persistence of the biofilm, reintroduction of BV-associated organisms, and behaviours that disturb the microbiome.
Measures that help:
Beyond symptoms, BV is associated with increased susceptibility to HIV and other STIs, with pelvic inflammatory disease, with post-procedural infection, and in pregnancy with preterm birth. That is why persistent or recurrent BV deserves a proper plan rather than repeated single courses.
It is also worth being clear about what BV is not. It is not a reflection of hygiene — if anything, over-washing makes it worse. It is not a sexually transmitted infection in the conventional sense, and male partners do not routinely require treatment, although evidence on partner treatment in recurrent cases continues to evolve.
Where discharge is persistent or recurrent, a combined assessment covering BV, candida, trichomonas and the recognised STIs gives a clearer answer than testing one at a time — arrange through the MedEx sexual health service or discuss a broader functional testing approach for recurrent cases.
No. BV is a shift in the vaginal microbiome rather than a transmitted infection, although sexual activity influences risk. Male partners do not routinely require treatment.
Not on its own. Gardnerella is detectable in many women with a normal microbiome and no symptoms. Diagnosis depends on symptoms plus the overall flora pattern, using Amsel criteria, a Nugent score or a quantitative molecular panel.
Classically a thin, homogeneous grey-white discharge with a fishy odour that is often more noticeable after sex or during menstruation. Itching and soreness point more towards candida.
Recurrence within 12 months is common, driven by biofilm persistence and reintroduction of BV-associated organisms. Stopping douching, avoiding scented internal products, condom use and longer suppressive regimens all help.
Usually not, outside specific situations such as before certain gynaecological procedures or in pregnancy where indicated. Discuss with a clinician.
It is associated with increased susceptibility to HIV and other STIs, pelvic inflammatory disease, post-procedural infection and, in pregnancy, preterm birth. That is why recurrent BV deserves a proper management plan.
Confusing panel result? Have it read before starting antibiotics.
Medical disclaimer: This article is general health information and does not replace medical advice, diagnosis or treatment. Laboratory reference ranges differ between laboratories and results must be interpreted alongside your symptoms, medicines and medical history. Speak with a qualified clinician before starting, stopping or changing any treatment. Service details, inclusions and prices can change — confirm them with MedEx before booking.
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