GPAtlas🧭 When to suspect
Suspect bacterial vaginosis (BV) in a woman with a thin, white–grey, homogenous vaginal discharge that coats the vaginal walls, classically carrying a fishy odour that is worse after intercourse or around menstruation (both raise vaginal pH and release volatile amines). BV reflects a loss of lactobacilli and overgrowth of anaerobes (Gardnerella vaginalis, Prevotella, Mobiluncus), with a consequent rise in vaginal pH above 4.5.
The defining clinical point is what BV is not: it is usually non-inflammatory. Prominent itch, soreness or vulvitis points away from BV and towards candida, trichomonas, or a dermatitis. BV is not classed as a sexually transmitted infection, although it is strongly associated with sexual activity and shares risk factors with STIs. Many cases are asymptomatic and found incidentally (for example, reported on a cervical smear) – these rarely need treatment.
| Feature | Bacterial vaginosis | Thrush (candida) | Trichomoniasis |
|---|---|---|---|
| Discharge | Thin, grey-white, homogenous | Thick, white, "curd-like" | Frothy, yellow-green |
| Odour | Fishy (worse post-coital) | None / yeasty | Offensive / musty |
| Itch / soreness | Usually absent | Prominent | Common (± vulvitis) |
| Vaginal pH | > 4.5 | ≤ 4.5 (normal) | > 4.5 |
Risk factors include new or multiple sexual partners, a female partner, vaginal douching and use of perfumed soaps, shower gels or bath additives, smoking, the presence of a copper IUD, and being of Black-Caribbean or Black-African family origin (higher prevalence).
Source: BASHH 2012
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