Examining Women’s Self-Management Strategies for Recurrent Bacterial Vaginosis in New York City

Abstract

Introduction

Bacterial vaginosis (BV) is the most prevalent vaginal condition among women, yet limited data exist on how women manage recurring BV and their perceptions of BV triggers. This study aimed to explore women’s experiences with BV onset and recurrence, the various self-treatment strategies used, and adherence to medication regimens.

Methods

From March 2020-May 2022, we recruited females at birth ages ≥18 years, who had received a BV diagnosis within the past year at one of four New York City Department of Health and Mental Hygiene (NYC DOHMH) sexual health clinics (SHCs) to take part in semi-structured interviews.

Results

A total of 41 women participated, with over half (n=23) from the SHC in the Bronx.

Most women identified as non-Hispanic or Hispanic Black (n=32), and nearly a quarter as bisexual (n=8). Women cited sexual (e.g., partner infidelity) and non-sexual (e.g., diet, perfumed soaps) triggers for BV recurrence. To reduce BV recurrence, women reported engaging in self-management strategies like dietary and hygiene changes, including some practices (e.g., increased douching) that are known to exacerbate BV. Some women reported low adherence to the seven-day metronidazole pill regimen, primarily due to side effects.

Discussion

Findings highlight self-management strategies women use to reduce BV recurrence and indicate further education about which strategies may be helpful or harmful is needed. Some patients may need additional BV medication adherence support for multi-day dosing of oral metronidazole or access to alternate treatment regimens.

SUMMARY

Women attending sexual health clinics engaged in lifestyle modifications, sexual changes, and douching to manage their bacterial vaginosis. Several women reported challenges adhering to multi-day regimens of oral metronidazole.

INTRODUCTION

Bacterial Vaginosis (BV) is the most prevalent vaginal infection for women in their reproductive years, affecting almost 30% of women in the United States.¹ Rates of BV vary among ethnic groups and are highest among non-White women, with 51% prevalence among African American women and 32% among Hispanic women.¹ Additionally, the literature suggests that women who have female sexual partners are more likely to contract BV than heterosexual women.^2,3 Symptoms of BV can include malodorous vaginal discharge, itching of the vulva, pain during urination, and pain during sexual intercourse,⁴ but many women with BV are asymptomatic.¹ If left untreated, BV can increase the risk for adverse reproductive and obstetric outcomes including premature birth, low infant birth weight, the onset of pelvic inflammatory disease (PID), and for acquisition and transmission of HIV and sexually transmitted infections (STIs).^5,6

Despite its adverse outcomes, the etiology of BV remains unknown.⁶ Clinical approaches to managing BV involve antimicrobial treatments, such as nitroimidazoles or clindamycin.⁷ Recommended first-line regimens include oral metronidazole 500 mg twice daily for 7 days, intravaginal 2% clindamycin cream once daily for 7 days, or intravaginal metronidazole gel once daily for 5 days.⁸ Though short-term cure rates of first-line recommended BV regimens approach 80%,⁹ extended studies show recurrence rates exceeding 50% within 6–12 months of treatment.¹⁰ Ineffective long-term treatments and high recurrence rates increase clinic office visits and can lead many women to resort to erroneous self-treatment methods, such as over-the-counter (OTC) vaginal yeast treatments or douching.¹¹

Despite the high prevalence of BV and BV recurrence, studies examining women’s experiences self-managing BV remain limited. Prior studies indicate that women often feel frustrated with the care they receive for BV and engage in self-help remedies on their own,^11,12 yet clinicians rarely ask patients about which self-management strategies they use.¹³ This means clinicians may miss the chance to educate patients about self-management strategies that may be potentially harmful or further exacerbate BV, while also missing learning about potential strategies that could be beneficial to other women. Thus, we aimed to examine women’s experiences of BV recurrence, the types of self-treatment strategies they use, and their adherence to BV medication regimens to inform and improve the clinical management of BV.

METHODS

Study Participants and Setting

Informational study flyers were placed in four New York City Department of Health and Mental Hygiene (NYC DOHMH) sexual health clinics (SHCs) in the following NYC neighborhoods: Morrisania (Bronx), Chelsea (Manhattan), Fort Greene (Brooklyn), and Jamaica (Queens). After completion of standard patient visits at the SHC, an SHC provider presented potentially eligible participants with an informational study flyer. After the provider left the room, participants who were interested in participating in the study provided their contact information on an index card and placed it in a locked box in the SHC. Once every few weeks, research assistants (RAs) from Columbia University visited the SHCs to retrieve the index cards. Potential participants were then contacted by Columbia University RAs to complete eligibility screening and, if found eligible, to schedule an appointment for an interview.

To be eligible for participation, participants had to be SHC patients who 1) were female at birth, 2) were at least 18 years old, 3) were proficient in English or Spanish, and 4) were diagnosed with BV at an SHC in the past year. BV diagnosis at the SHCs were determined using Amsel criteria. Rapid trichomonas testing is used in the SHCs prior to making any diagnosis of BV. Because neovaginas have different microbiomes than cis vaginas and may require different BV treatment and management strategies,¹⁴ we did not include transwomen in this study. We aimed to recruit at least half of our sample from African-American women and at least 15% of our sample from women who have had sex with another woman in the past year. Recruitment occurred from March 2020 to May 2022. (During the COVID-19 pandemic, the SHCs were closed or providing limited sexual health services. Thus, the study was paused for recruitment from April 2020 to December 2021.)

Interview Procedures

Prior to the COVID-19 pandemic lockdowns (March 2020), interviews were conducted in-person by a trained RA in a private room at Columbia University School of Social Work. Interviews were recorded on an audio recorder and uploaded to Columbia University’s secure LabArchives system. During the COVID-19 pandemic (January-May 2022), interviews were conducted online via Zoom by a trained RA. Interviews were recorded via Zoom and saved to LabArchives. Each interview lasted approximately 30–60 minutes. Prior to the start of the interview, RAs completed informed consent processes and answered any questions participants had. To protect confidentiality, participants provided oral informed consent and the RA certified consent by signing and dating the consent form. All participants received $60 in the form of an egift card or pre-loaded debit card.

Participants were assigned a unique numeric study ID. Prior to each interview, a brief survey was administered containing items on sociodemographics and recent behaviors related to BV (e.g., number and sex of sexual partners, contraceptive use). Subsequent semi-structured interviews contained questions about BV infection history and symptoms, clinical care experiences, perceived factors associated with BV, and self-management and treatment approaches. Recorded interviews were transcribed verbatim and any potentially identifying information was removed. Transcripts were stored on LabArchives.

Analysis Procedures

Qualitative data were coded and analyzed by trained RAs using NVIVO software (version 12). Thematic analysis was conducted using an a priori coding framework based on key domains followed by open-coding to capture emergent themes. A collaborative process of building the codebook and coding the data involved several steps. First, the primary investigator and the RAs read through the same interview excerpts and constructed a codebook for an initial round of coding. Second, the RAs independently coded a second set of identical transcript excerpts to check reliability in the application of codes across transcripts and further refine the codebook. The RAs coded a third set of identical transcript excerpts to finalize the codebook. Coding responsibilities were then divided between the RAs, with each interview coded by at least 2 RAs. Descriptive statistics of sociodemographic information were calculated using SPSS 28.0.

RESULTS

A total of 41 women participated in the interviews. Sociodemographic data are presented in Table 1.

Table 1:

Participant Sociodemographics (N=41)

Variable	N (%)
Recruitment Site
Bronx	23 (56.1%)
Brooklyn	8 (19.5%)
Manhattan	9 (21.9%)
Queens	1 (2.4%)
Race/Ethnicity
Non-Hispanic Black	27 (65.9%)
Hispanic Black	5 (12.2%)
Non-Hispanic White	2 (4.9%)
Non-Hispanic Asian	2 (4.9%)
Hispanic, Race unspecified	5 (12.2%)
Sexual Orientation
Heterosexual	33 (80.5%)
Bisexual	8 (19.5%)
Age, mean±SD	31.6±8.5

Women’s Perceptions of Triggers for BV Onset and Recurrence

Women reported both sexual and non-sexual triggers for the onset and recurrence of BV (Table 2). Triggers for the onset of BV were defined as triggers the women noticed at their first experience of BV. Triggers for recurrent BV were defined as triggers women felt contributed to subsequent cases of BV. They identified sex with regular, new, and multiple male partners, partner infidelity, and condomless sex as sexual triggers for BV. Many women attributed their BV to partner factors, particularly lack of good hygiene by partners. Several expressed frustration that they had been told by providers men could not have BV because they attributed their BV onset or recurrence to their partner. For non-sexual triggers, participants identified factors such as diet, the use of perfumed soaps and hygiene products, and underwear choices as potential BV triggers. A number of women also thought the use of birth control impacted BV recurrence.

Table 2:

Triggers for BV onset and recurrence (N=41)

Potential Sexual Causes	Illustrative Quotes
Sex with new partner	So I got a new boyfriend and maybe my vagina got shocked or it can’t adapt. I don’t know, I’m really not sure. But I’m pretty sure it was because it was a new boyfriend. (Hispanic, heterosexual (history of sex with women), age 27 -- 1095) Me and my boyfriend broke up and that’s when I got with the guy who gave me BV, I know he gave it to me, and me and him stopped talking after that because I was like ‘you’re dirty’. I got back with my boyfriend and now I feel like he has it now. (Non-Hispanic Black, heterosexual, age 31 -- 1001)
Sex with multiple partners	Definitely sex. Having more than one partner. And having sex with more than one partner back to back. And I mean like let’s say… today is Friday, I have sex with somebody. Let’s say Sunday I’ll have sex with someone else. Then by Monday, I’ll notice BV starts to come on. Like I already know it’s going to happen. And that’s even with a condom. (Non-Hispanic Black, heterosexual, age 40 --1039) I was having sex with multiple men so maybe that’s how I got it. (Non-Hispanic Black, bisexual, age 27 -- 1100)
Condomless sex	We always used condoms and as soon as we stopped using condoms this [BV] happened. (Non-Hispanic Black, heterosexual, age 29 -- 1027) I was a little more sexually active with my partner around that time, and we didn’t use condoms. So I think that sometimes the man’s semen could throw off the balance also. (Non-Hispanic Black, bisexual, age 27 -- 1060) I believe that it is sperm that does it to me because every time I happen to have unprotected sex, I happen to get BV. (Non-Hispanic Black, heterosexual, age 41 -- 1122) Whenever my partner would ejaculate inside me, I would get BV. So, I felt like it was without protection, it was probably the sperm that counteracted with whatever bacteria and it would cause BV. Because lately I would say the last three episodes I’ve had would be directly after that. (Hispanic, heterosexual, age 31 -- 1015)
Sexual practices	We just assumed it was coming from us not using condoms to using them. Because neither one of us was trying to have children at the time, so we started using condoms again. I mean I wasn’t doing anything with anybody else, I can only believe what he was telling me. (Non-Hispanic Black, heterosexual, age 41 -- 1085) Now I noticed that every time I use Durex condoms I end up with it. (Non-Hispanic Black, heterosexual, age 23 -- 1013) He wanted to have oral sex and vaginal sex so I feel like the germs got into my vagina (laughing) from the oral sex but I’m not sure. It wasn’t a very tidy sex. (Non-Hispanic White, heterosexual, age 33 -- 1158) If during sex a man touches my anus and then uses the same hand or finger to go to my vagina, definitely with that. Um, or just maybe my dirty fingers in general. (Non-Hispanic Black, heterosexual, age 23 -- 1013)
Partner infidelity	My partner was infidel and him straying away from me. I think that’s what happened. (Non-Hispanic Black, heterosexual, age 50 -- 1003)
Poor sexual hygiene	Dirty individuals. People who don’t wash up are nasty. You know, men who are uncircumcised, don’t know how to wash properly... (Hispanic, heterosexual, age 36 -- 1005) …maybe something to do with hygiene. I know one time I had it because I had intercourse more than one time in a day, and then I wasn’t cleaning. (Hispanic Black, heterosexual, age 37 -- 1081) Because if they have sex with somebody and then they use no condom that girl’s discharge is all on you. [They] don’t wash [their] penis and go back to another woman. I mean it is going to create an imbalance. (Non-Hispanic Black, heterosexual, age 19 -- 1076)
STIs	I personally think that the Chlamydia triggered the BV. (Hispanic, heterosexual (history of sex with women), age 27-- 1125) I had chlamydia one time, I had PID- pelvic inflammatory disease, and those things led to me finding out about BV and the PH balance and things like that. I would come in for the odor- but I think the first time I went in it was PID. And then it was [trichomoniasis]. You know, they was saying that [trichomoniasis] was like BV at one time, where they couldn’t diagnose it as a sexually transmitted disease. (Non-Hispanic Black, heterosexual, age 35 -- 1121)
Potential Non-Sexual Causes
Yeast infection	I don’t know if the BV resulted in the yeast infection or the yeast infection resulted in the BV but they were definitely right next to each other, right on top of each other, they were almost like instantly started feeling itchy for a couple of days, and then I started getting discharge, and then I’m like mmm my PH balance is being a little weird, let me check myself out… Yeast infections can cause it. (Hispanic, heterosexual (history of sex with women), age 27 -- 1125)
Poor diet and exercise	I started to exercise without underwear, so that could be a factor [for BV]. My eating habits were really poor. I was eating meat and stuff like that. And just not having a good diet, and I wasn’t douching. Those were the factors I noticed. (Non-Hispanic Black, heterosexual, age 29 -- 1027) For now, right now because I know it’s not my partner, it’s my diet. For example, I have been going on vacation back to back. So that’s kind of like bad eating, a lot of alcohol, stuff like that. (Non-Hispanic Black, heterosexual, age 29 -- 1027) Sugar, I’ve noticed, so I stay away from sugar. (Hispanic, heterosexual, age 31 -- 1015)
Use of perfumed soaps and hygiene products	I had been getting ready for a sexual encounter and then I stupidly enough sprayed a perfume in the area, around my vagina and so I’m pretty sure that’s what led to that. (Non-Hispanic Black, heterosexual, age 23 -- 1013) At first, I thought it was the soap. So I just switched soaps, and that worked a little bit. (Hispanic Black, heterosexual, age 29 -- 1002) Pads, certain kinds of pads you wear… I used to wear pantyliners. I stopped wearing those because they said those could be a factor too. (Non-Hispanic Black, heterosexual, age 32 -- 1074) I feel like it could be the pads, the pads and the tampons. That’s why I stopped using tampons. If I do have to use one, I am trying the organic ones. (Non-Hispanic Black, heterosexual, age 31 -- 1120)
Underwear choices	Wearing tight underwear, wearing no underwear, wearing jeans that I just bought from a store…like just doing things that you’re not really thinking that can cause anything… (Non-Hispanic Black, heterosexual, age 30 -- 1103) Certain types of panties you wear... I do wear colorful panties – lace. Like I said, I’ll wear the stuff that gives it to you. (Non-Hispanic Black, heterosexual, age 32 -- 1074) And I know you get BV from many different reasons. Like underwear. There’s many different factors that can cause you to have BV... (Non-Hispanic Black, bisexual, age 27 --1060)
Douching	Douching…And I think that was it, that was really it. That’s what I remember. (Hispanic, heterosexual, age 30 -- 1054)
Birth control	The ring definitely caused me to have BV more consistently for sure. (Non-Hispanic Black, heterosexual, age 30 -- 1103) I think them IUDs can cause [BV], too. It can make bacteria come in there. Anything foreign in your body can give you BV. (Non-Hispanic Black, heterosexual, age 50 -- 1003) I got a Powerguard IUD put in. It was the first IUD I had ever put in. And literally maybe a couple months later, that was the first time I got BV. (Non-Hispanic Black, heterosexual, age 27 -- 1096) I think the most I have BV related experience is when I have my birth control. I think that is an important thing because it changes my environment for my uterus. (Non-Hispanic Asian, heterosexual, age 27 -- 1130)
Incomplete BV medication adherence	It’s like you take pills for 7 days. I never really finished them…I don’t really like taking medicine… But I’ve only finished the medicine twice honestly. Like I said, that’s probably why it keeps coming back. (Non-Hispanic Black, heterosexual, age 32 -- 1074)
Period	I was also towards the end of my period and I think that did contribute…I heard you are more at risk towards the end of your period because of the hormones. (Non-Hispanic Asian, Bisexual, age 31 -- 1113) Sometimes I can feel that something is going to happen during my period...I don’t know if I am making it up in my head. I’ll feel maybe like a tingle or something… (Non-Hispanic Black, bisexual, age 25 --1006) I learned that when you get your menstrual cycle, it kind of dormants everything. (Non-Hispanic Black, heterosexual, age 29 --1027)
Stress	I would say stress… Sometimes I be thinking it is what I eat or just stress in general, because that is probably the most that has changed. Like my stress level has definitely gone up. (Non-Hispanic Black, heterosexual, age 41 --1085) My diet has been horrendous. I haven’t been eating vegetables or fruits. I’ve been highly stressed out with work. Not getting enough sleep. So I feel like it’s a mixture of those. (Hispanic, heterosexual (history of sex with women), age 27 --1125)
Unsure	[I first had BV] when I was really young. I wasn’t sexually active then and I didn’t really have a complete understanding of sexual health, so to go to the doctor and then they say, ‘Oh, you have BV, I’m going to give you medicine’, and I’m just like, ‘But I don’t have sex, so how did I get that? (Non-Hispanic Black, bisexual, age 25 -- 1006) But there’s been other instances where I am not sexually active for a few months and I still have BV and I don’t know what went wrong or what I did differently… (Hispanic, heterosexual, age 28 -- 1114)

Several women reported incomplete medication adherence as a factor contributing to BV recurrence. Reasons for BV medication non-adherence include forgetting to take the pills, finding it too difficult to take the pills, disliking the taste, wanting to socialize and drink alcohol, and managing comorbidities (Table 3).

Table 3:

Reasons for Non-adherence to BV Medication (N=41)

	Illustrative Quotes
Symptoms improved	I seen it clearing up. I didn’t see any more of the symptoms so I wanted to hold on to the medicine for another occasion but that doesn’t work (quiet laugh). (Non-Hispanic Black, heterosexual, age 29 -- 1009) This month I just took two [pills] and it [BV] was gone… But I think if I want to have sex with my partner and it [BV] comes back, I can just pop another pill. (Non-Hispanic Black, heterosexual, age 60 -- 1045) The scent went away, so I just assumed I was good. But that wasn’t what I should’ve did. (sort of laughs) (Non-Hispanic Black, heterosexual, age 41 -- 1122)
Challenging life circumstances/difficulty taking pills	I forgot why I did that, I think skipped one day or two days and then I took it and didn’t take it all the way, I was going through a lot of stuff with my husband, that separation...it was a lot. (Non-Hispanic Black, heterosexual, age 50 -- 1003) To have to take two a day is a lot. For seven days, it’s a long time….Too much stress for the pill. That’s why I always tell my doctor to just give me the cream because with the cream, you only have to use it once at nighttime. You come home from work, take a shower, put it in, boom. It’s over. (Non-Hispanic Black, bisexual, age 27 --1060)
Forgot to take the pills	There was one time where I forgot my last pills and I got BV again maybe a week or two after that. (Non-Hispanic Black, heterosexual, age 23 -- 1013) I will miss a day because I forgot to take it then I remember the next day. Just to take three pills and then don’t take the rest, no…because it says you are supposed to take all of them for the 7 days. (Non-Hispanic Black, heterosexual, age 35 -- 1145) I wouldn’t say stop, but I would mess up the regimen because you’re supposed to take it twice a day. And I would forget sometimes because it was working. It was working in two days and I would honestly forget after because I’d think I’m good now. (Non-Hispanic Black, Bisexual, age 25 -- 1163)
Desire to drink alcohol	To drink (laughter). To drink yeah. (Non-Hispanic Black, heterosexual, age 29 --1027) Because I wanted to drink… (Non-Hispanic Black, heterosexual, age 31 -- 1120)
Dislike the taste of pills	Cuz I don’t like the way it tastes for one, and I just don’t like taking pills at all, so… Nah, it’s not a chewable. It’s one you swallow, but if you don’t swallow it fast enough, you start to taste it. It starts to dissolve. (Non-Hispanic Black, heterosexual, age 32 -- 1074) Yes…[laughter] I hate those pills, those pills are so annoying…they taste like pure hell and I’m just like uhhhh god I can’t… (Non-Hispanic Black, heterosexual, age 30 -- 1103)
Managing comorbidities	I get a yeast infection, even with the cream. I think it’s the medicine itself. It just always gives me a yeast infection, after all the time, it never fails. I don’t like taking it so I just don’t. I don’t even waste my time anymore taking the pills. (Non-Hispanic Black, bisexual, age 27 -- 1100) That was very stupid of me when I was taking the BV pills… I was trying to outsmart the nurse because they gave me a 2 weeks prescription. I had to take it two times and then one time a day. And then the first time I had it [prescription] I took it for 15 days and my yeast infection came back and I was trying to outsmart it. I was like maybe I only need 10 days of the pills, so I don’t kill my healthy bacteria that much in my vagina. But it doesn’t work like that, so I ended up still having to finish that pill then get the yeast infection again, then take the yeast infection medication. (Non-Hispanic Asian, heterosexual, age 27 -- 1130)
Didn’t have health insurance	There’s been times when I didn’t have insurance, so I had to pay for medicine, so I would take 2 pills during every occurrence to see if I could, nip it in the bud, stop it short. (Non-Hispanic Black, heterosexual, age 35 -- 1121)

Self-Management Strategies

Participants with frequent BV recurrence reported making several lifestyle changes to try and prevent recurrence (Table 4). These included dietary changes, such as reducing meat consumption and increasing consumption of fruit and vegetables or even switching to a vegan diet. Others reported drinking more water and decreasing soda and/or alcohol consumption. Other participants reported switching to unscented hygiene products and/or using vaginal suppositories. Such participants often became engaged in overall holistic wellness modifications to eat more healthfully, drink more water, cut back on toxins and scented products, exercise more and wear more breathable material. Several participants felt these modifications were helpful in managing BV, though it is difficult to determine which of the modifications were most helpful. Other women reported changing their sexual behaviors, such as using condoms more or abstaining from sex. Many participants reported douching either currently or previously to reduce BV. Most reported douching increased the frequency or severity of BV and subsequently stopped douching. However, a few women were unaware that douching can exacerbate BV or still believed that douching was important for cleanliness.

Table 4:

Self-Management Strategies of BV (N=41)

Diet modifications	Illustrative Quotes
Dietary changes/Increased water intake	Try to eat a little more healthier…fruits. Just trying to stay with the same foods that I am eating. I try my best not to try anything new… (Non-Hispanic Black, heterosexual, age 41 --1085) I take all natural products, vitamins, water. I drink water everyday. Fiji specifically. Everyday and eat good. Eat a lot of vegetables. Fruits, oranges, apples, mangoes, grapes. (Hispanic, heterosexual, age 36 --1005) I try to drink a lot of water. I try to drink healthy…like green juice, cranberry juice… (Non-Hispanic Black, bisexual, age 27 --1060)
Oral supplements
Probiotics	Now I use probiotics along with the one for your stomach and the one for your PH but I realized it costs so much… That was the only thing that kept BV away, the one for your stomach and the one for your vagina, but they both were oral. When you use it every day for 30 days, you literally don’t have BV. (Hispanic Black, bisexual, age 41 -- 1090) I take probiotics daily because I know I am a frequent receiver of it, and that kind of calms everything down. (Hispanic, heterosexual, age 31 -- 1015)
Natural supplements	I started to look up actual oils you can either drink or take. I think one of them was oil oregano, tea tree oil, that was helpful. So I tried it. It did work…Just continuously literally I’d have to drink oil oregano three times a day and it completely killed it. That was really good for me. (Non-Hispanic Black, heterosexual, age 29 --1027) I found granola that has probiotic in it so I’ve been eating that to see if it will help. (Hispanic Black, heterosexual, age 29 -- 1002) Oh! One other thing I do is I'll take a shot of apple cider vinegar. I don’t know if that’s real. But it does something! (Non-Hispanic Black, bisexual, age 25 --1006)
Hygiene modifications
Unscented hygiene products	I changed the laundry detergent ‘cuz I think my vagina is very sensitive to strong stuff. Soap that has smells…I can’t use…even though I don’t put soap down there, even if it touches it a little bit…if it has perfume in it, it’s like a wrap. So I tried to change my soaps and use more soap that doesn’t have as much perfume or [unscented] laundry detergent. When I stopped using certain soaps and switched my laundry detergent, I definitely saw improvement. (Non-Hispanic Black, bisexual, age 27 --1060) I use unscented everything. I make sure the sensitive skin, like the soap, the panty liners. I also take probiotics daily. (Hispanic Black, heterosexual, age 37 -- 1081) At first, I was using Dove cucumber fragrance, now I am just using no fragrance, sensitive skin. (Hispanic Black, heterosexual, age 29 -- 1002)
Changes of underwear	Obviously I had to start wearing cotton panties when I was working out. And then I just decided to have a vegan lifestyle. (Non-Hispanic Black, heterosexual, age 29 --1027) I am wearing cotton panties, I have like 100 panties… I switched to cotton panties instead of Victoria Secret. I wear those occasionally. I don’t do thongs…I straight do cotton now and I haven’t been having too much of a problem either. (Hispanic Black, bisexual, age 41 -- 1090)
Cleaning (frequent showers, use cleaning wipes or sprays, steaming)	I definitely shower often. When I’m home, I don’t wear anything because I’m not trying to be irritated, I’m just trying to let it breathe out. Mainly just trying to shower more and give it air but the smell doesn’t go away. (Non-Hispanic Black, heterosexual, age 41 --1085) (Laugh) The only thing I could say is I just shower. The shower, I just take the shower hose and try to flush out (laugh) without actually putting anything in there just (shhhhh water sounds)… and just let the water run through your vaginal area. (Non-Hispanic Black, heterosexual, age 40 -- 1039) Constantly going to the bathroom with wipes to clean and [I] have spray…It’s helpful but it is still very uncomfortable and very embarrassing. I don’t feel like myself. (Hispanic Black, heterosexual, age 29 -- 1002)
Douching
Stopped douching due to increased severity or advised by the doctor	I learned the hard way that I can’t really use douching. I used to always have chronic yeast infections. I didn’t know that my body is sensitive. So what little bit of good bacteria is in there [vagina] definitely needs to stay there [laughs]. (Hispanic Black, heterosexual, age 37 -- 1081) I was douching but my doctor told me that can be the cause of it… Because when I didn’t douche it was worse. If I douche; it felt better, it smelled better. If I didn’t; it flared up crazy… Well I don’t anymore since my doctor told me not to. It’s only been a week. (Non-Hispanic Black, heterosexual, age 31 -- 1001)
Douching for cleanliness or to reduce odor	I douched. I thought nothing was wrong with douching until my doctor told me it was bad. But the old fashion remedies like vinegar and water I liked that. Just to make sure it’s clean like once a year, I don’t see anything wrong with that. Make sure it’s clean down there… I used to do that, I vinegar douche, yup I used to. I haven’t done it since.... I should do it. (Non-Hispanic Black, heterosexual, age 50 -- 1003)
Biologics
Boric acid	Boric acid pills. I take those as well…I like boric acid pills more because with Acromona they do leave a heavy discharge. I don’t want to say discharge but they both leak and Acromona is heavier. (Hispanic, heterosexual, age 30 -- 1054) Boric acid supplement, if I'm not mistaken iťs maybe a 600 mg supplement. Iťs a suppository so you have to stick it inside of your vagina. I usually wash my hands before I do it. I'll place it at the opening with my hand, but then I take a vibrator or something to push it up cuz I feel like my finger doesn’t push it far enough. (Non-Hispanic Black, bisexual, age 25 --1006) These pills that I take, I get them from Target. I would use these PHD boric acid vaginal suppositories. I was using these tablets from Honey Pot, and it would say it’s good for BV and yeast infections and it really do work really good. Instead of me going to the clinic, I’ll get that. (Non-Hispanic Black, bisexual, age 27 -- 1100)
Other substances (yogurt, garlic, tea tree oil, coconut oil)	I’ve tried the tea tree oil. Actually I poured it in a thing. I put it in the freezer. And it made a little cold suppository and I stuck it in there. It gave me some kind of relief. (Hispanic, heterosexual, age 36 --1005) Garlic, yogurt… I’ve tried douching, but I don’t douche. (Non-Hispanic Black, heterosexual, age 29 -- 1088) I tried the yogurt, it was just such a disaster because I wasn’t doing it right at first, I didn’t get the right type of yogurt… I definitely tried garlic, I tried the garlic, I tried coconut oil. That really helped. (Non-Hispanic Black, bisexual, age 27 -- 1100)
Changes in sexual behaviors
Sex with condoms	I try very hard to make sure that condoms are used. Honestly to prevent other things, but after that experience where I felt strongly my BV occurred after not using a condom, I try to make sure that is happening. (Hispanic, heterosexual, age 28 -- 1114) Instead of using durex, which I think causes BV for me sometimes, I stuck to using Trojan ultra-thin, which has been really good for me. (Non-Hispanic Black, heterosexual, age 23 -- 1013)
Abstinence	I stopped having sex for a couple weeks. Recently my boyfriend and I had sex. I was a little shy about the fact that I still noticed some smell. But it didn’t bother him and I… (pause) I feel like it’s going away, but I’m worried that it’s going to get worse again. I guess I wanted to have sex with my boyfriend and that’s why I overlooked the fact that I still have some symptoms. But I don’t know if it’s going to cause a problem. I should probably douche or something like that. I just don’t know what to do. (Non-Hispanic White, heterosexual, age 33 -- 1158) Pft, don’t have sex boo boo. That’s something I’ve actually changed. Yes ma’am. (Non-Hispanic Black, heterosexual, age 60 -- 1045) Well I stopped having sex for like a year. I just stopped having sex. That’s why it was such a long time that I hadn’t had it because I hadn’t had sex in a long time. (Hispanic, heterosexual (history of sex with women), age 27 --1125)

DISCUSSION

All women in our study had tried various self-help remedies and made lifestyle modifications in an effort to manage symptoms or prevent future BV recurrence. Some women reported learning from their physicians that douching exacerbates BV and subsequently ceased douching. Other women stated they felt douching was an important hygiene practice and engaged in douching to try to minimize BV symptoms or prevent recurrence. A significant amount of evidence exists indicating the adverse effects of douching on the vaginal microbiome.¹⁵ Our findings indicate that further efforts may be needed to change cultural beliefs and practices around douching and that informing patients about the negative impacts of douching may be inadequate to change behavior. Our findings also suggested that holistic lifestyle changes may benefit some women with BV, though further research is needed to verify the extent to which such measures may be beneficial, if at all. For example, a number of women reported that switching to non-scented soaps and perfumes seemed to alleviate BV symptoms. There is little empirical data to support the association between use of perfumed soaps and sprays with BV. In the Longitudinal Study of Vaginal Flora, greater use of feminine hygiene sprays, douching, powder on genitals, and use of nylon underwear were associated with BV; however, in the adjusted models, only douching remained significantly associated with BV.¹⁶ Further research is needed on the impact of various hygiene practices on the vaginal microbiome. Other women reported switching to diets with more fruits and vegetables and less processed foods, which they felt reduced their BV recurrence. Women from other qualitative BV research studies also report the role of diet in self-managing their BV symptoms,^11,17 however, few large scale studies exist examining the efficacy of dietary changes on BV recurrence. One study examining the effects of the Mediterranean Diet (MD) on BV found that high adherence to the MD was not associated with lower odds of BV in the adjusted model, though the association was of borderline statistical significance.¹⁸ However, greater consumption of vegetables, fish, and legumes were significantly associated with lower odds of BV.¹⁸ Given the limited long-term effectiveness of existing pharmacological treatments on BV, providers may wish to inform patients that making certain lifestyle changes, such as using unscented hygiene products and incorporating dietary modifications, may help reduce BV symptoms and recurrence, though data supporting these modifications are limited.

There are a number of treatment options for BV, including single dose and multi-day dosing oral therapies as well as topical therapies, that have been approved by the U.S. Food and Drug Administration (FDA).¹⁹ However, the 7-day 500mg per day dosage of oral metronidazole is recommended by the U.S. Centers for Disease Control (CDC) for treatment of BV (even though it is not FDA approved) as it is inexpensive and therefore often the treatment of choice in low-income settings.²⁰ Many of the women in our study were on this treatment regimen, and some reported challenges with oral metronidazole adherence. Some women took only a few days of metronidazole until their symptoms subsided, saving the rest of the prescription for their next BV recurrence. Others cited side effects commonly reported in the literature (e.g., bad taste, nausea),²¹ desire to save money, or wanting to drink alcohol as reasons for non-adherence. Non-adherence to metronidazole increases the risk for BV recurrence. Other research has found that women believe oral metronidazole to be more effective in treating severe BV symptoms, yet often still prefer using vaginal gel treatments due to lower side effects and greater ease with a once per day application.¹⁷ In their discussions of BV medication options with their patients, clinicians should discuss the importance of completing the full treatment regimen and inquire about patients’ abilities to adhere to different medication options as well as explore costs and ability to pay. For patients who cannot tolerate or adhere to a multi-day dosing regimen of oral metronidazole, prescription of alternate BV medication regimens may be warranted, though some women may need additional financial support to obtain these regimens.

Strengths of this study include the in-depth data collected on different aspects of women’s experiences treating BV and accessing clinical care for BV. Data were collected from primarily racial/ethnic minority women in four boroughs of NYC. A limitation of this study is that women were only recruited from an urban area and thus, findings may not be generalizable to women living in other areas (e.g., rural areas or different regional areas) where women’s experiences accessing BV care and personal strategies for managing BV may differ.

CONCLUSION

In summary, women engage in a number of dietary and hygiene modifications, oral supplementation, use of vaginal suppositories and douching, and changes in sexual behaviors to manage their BV. Women found some of these strategies beneficial, and clinicians may wish to present dietary, lifestyle, and sexual behavior changes as potential self-management strategies to supplement BV treatment. Increased education is also needed to increase women’s knowledge about the use of self-management approaches that may be exacerbating recurrences, such as douching. For women who would have difficulty adhering to a multi-day dosing regimen of oral metronidazole, clinicians may wish to prescribe topical or single dose therapies when feasible.