Most people with a vagina will experience an infection at some point in their lives; over three in four of us will get a yeast infection while about a third of us at any given point have BV.
But the only thing worse than getting a vaginal infection is having one that won’t go away. In around 30% of cases, bacterial vaginosis (BV) will recur within one month, while a yeast infection comes back within a year up to 28% of the time.
At Evvy, our goal is to break the cycle of infection through better education, testing, and support. By knowing the composition of your vaginal microbiome, you can better understand your risk of infection and take steps towards prevention.
So why do infections come back, and is there any way to prevent this from happening? Here are seven reasons why your vaginal infection may not be going away.
1. You’ve been misdiagnosed
Vaginal infections are extremely common, but they’re also commonly misdiagnosed. Being misdiagnosed actually happens more often than being correctly diagnosed! In a study of 220 people with vaginal symptoms, 61% of BV and 77% of yeast infection diagnoses were incorrect.
What about self-diagnosing?
We aren’t much better at diagnosing ourselves, either. A different study that involved 546 cisgender women showed self-diagnoses of BV were correct only 56% of the time. Even more interestingly, 69% of those who thought they had a yeast infection actually had something else.
One reason why diagnosis can be tricky is because many vaginal conditions have similar symptoms. Abnormal vaginal discharge can be a sign of a yeast infection, but it can also be a symptom of a host of other conditions such as bacterial vaginosis, cytolytic vaginosis, and more. A test is necessary in order to know what bacteria or yeast may be present, which might not be an option if you’re being treated over the phone or getting medications via an online form.
It’s essential to get your symptoms tested properly before taking any medication. Otherwise, you may be treating the wrong thing!
2. You’re taking the wrong medication
Even if you are diagnosed correctly, you may be taking medication that isn’t working on the pathogen (disease-causing microbe) that’s causing your infection.
Identifying the best antibiotic for BV
Antibiotics such as clindamycin and metronidazole are first-line treatments for BV. However, each works better on some strains of bacteria compared to others.
For example, metronidazole has been shown to be less effective than clindamycin for treating both Gardnerella vaginalis and Atopobium vaginae, which are two primary BV-causing bacteria. Meanwhile, metronidazole is more effective than clindamycin against other bacteria, such as Prevotella.
But the type of disruptive bacteria isn’t the only factor when considering what antibiotic might be best. It’s also important to consider whether there are protective bacteria present in the microbiome and how to preserve them.
You may know that some antibiotics can kill off protective bacteria in addition to pathogenic ones. That’s why clinicians often prescribe metronidazole instead of clindamycin, as clindamycin eradicates protective vaginal bacteria called lactobacilli.
However, if you have no lactobacilli present and the bacteria that is present is resistant to metronidazole, then the logic to use metronidazole to preserve lactobacilli doesn’t hold. (This is why our Vaginal Health Test identifies all bacteria and fungi — including the protective types!)
Identifying the best antifungal for yeast infections
Much like BV, yeast infections also respond differently to treatment depending on the type of Candida causing the problem.
While up to 85% of yeast infections are due to overgrowth of Candida albicans, other strains of yeast such as Candida glabrata and Candida tropicalis can be the culprits. Standard antifungal treatment is not as effective on these strains, and longer treatments, different antifungals, or alternative solutions like boric acid may be more effective.
Unless you know which bacteria or yeast you are dealing with, antibiotic or antifungal treatment may feel a bit like trial and error. Tracking your vaginal health with tools like Evvy can help you identify which microbes are most associated with your symptoms and spark conversations about the best treatment options with your doctor.
3. You took antibiotics
Antibiotics are intended to kill disruptive bacteria, but sometimes, they don’t work as well as we’d like or in ways we’d expect.
BV recurrence after antibiotics
Within a month, antibiotics clear up to 85% of bacterial vaginosis cases, yet for over half of these patients, BV will return within 6 months. This is thought to be in part because the antibiotics don’t fully eradicate the pathogenic microbes, leaving BV-associated bacteria to regrow in the vagina following treatment. As mentioned above, certain antibiotics can also eliminate protective bacteria in addition to pathogens — which can leave you vulnerable to another infection.
Antibiotics and yeast infections
If you’re taking antibiotics for any reason (vaginal or not), they can actually increase the chances of a yeast infection developing. Yeast infections are more common in people who are taking antibiotics and, not so fun fact, antibiotics are actually the most frequent and predictable cause of a yeast infection.
Frustratingly, science still doesn’t fully understand why antibiotics cause yeast infections — which is one of the questions Evvy is hoping to answer with our vaginal health research!
4. Disruptive microbes have formed a biofilm
Like all of us, bacteria are just out here trying to survive. One of their strategies is forming what’s called a biofilm, where they attach to the surface of an environment and form a protected community there. Bacteria in a biofilm are able to survive in this self-sustaining structure, making it harder to eradicate them.
The ability of BV-causing bacteria to potentially form a biofilm may explain in part why BV has such a high recurrence rate. However, the exact role that biofilm plays in the development of BV is still somewhat unclear.
Candida also has the ability to form biofilms, which can make your yeast infection resistant to treatment with antifungals, too.
Based on your unique vaginal microbiome, Evvy’s personalized reports can help you determine whether or not the microbes in your vaginal are prone to producing biofilm that enables resistance and/or recurrence.
5. Sex is disrupting your vaginal microbiome
While neither BV nor yeast infections are considered sexually-transmitted infections, certain sexual behaviors can create conditions that trigger them again and again. (Kind of a buzzkill, we know!)
The jury is still out on how exactly sex and BV are linked, but associations have been made between BV and new partners, multiple partners, and inconsistent or lack of condom use.
There’s also a possible link between reinfection and staying with the same sexual partner before and after treatment. Research has shown that infection was two to three times more likely to come back for cisgender women with ongoing cis male partners. For sex between people with vulvas, BV has also been associated with new partners, having a partner with BV, and receptive oral sex.
Interested in learning more about the connection between sex and the microbiome? Read more here!
6. Your hormone levels are in flux.
Shifts in hormone levels can affect the vaginal microbiome—and in some cases, make it more susceptible to infection.
Wondering how this happens? It often comes down to estrogen levels. That’s because estrogen promotes the production of a sugar called glycogen. Glycogen acts as the main form of sustenance for protective bacteria called lactobacilli, which help maintain a healthy vaginal pH and keep pathogens at bay. When there is less estrogen present, there is less glycogen to feed the lactobacilli, which leaves an opportunity for BV-causing bacteria to overgrow.
On the other hand, glycogen is also food for yeast cells, so estrogen levels that are higher than normal can encourage Candida to multiply—bringing on a yeast infection.
That’s right — not enough estrogen could create an opportunity for BV, while too much estrogen could encourage a yeast infection (we really can’t win…!)
As our hormones change throughout the month, as well as when we get pregnant, give birth, and go through menopause, the risk of bacterial or yeast infections change. This also happens when switching birth controls or dealing with a hormonal condition or imbalance. If you are managing consistent or recurring hormonal changes, vaginal issues may follow suit.
This is just the tip of the iceberg regarding all the ways hormones can influence the microbiome but you can read more about this relationship here.
7. You’re going through menopause.
An individual enters menopause when they have gone 12 consecutive months without a menstrual cycle (the time leading up to this, when cycles start to dwindle, is known as perimenopause). The menstrual cycle is the main source of reproductive hormones. As these hormones decline during menopause, there is an increased risk for certain vaginal infections.
Remember how estrogen feeds protective bacteria who keep pathogens in check? Lowered estrogen means less protective bacteria and therefore a less acidic, more vulnerable vaginal environment—which can invite BV-causing bacteria to overgrow.
A lack of estrogen can also cause atrophy or thinning of the vaginal tissue which can impact the physical structure of the reproductive system, leading to an increased risk of UTIs. When the vaginal environment is disrupted in this way, it opens the door for bacteria such as E. coli to colonize and travel up into the urethra, causing infection. Sometimes, the bacteria hang around in the vaginal microbiome and travel upwards now and again, potentially leading to recurrent bladder infections.
While yeast infections are generally less common during menopause, a common menopause treatment, estrogen-containing hormone replacement therapy (HRT) is considered a risk factor for yeast infections.
Get the answers you need
Our bodies may feel like a mystery, but that’s only because we don’t have all the information we need to understand them. Evvy’s Vaginal Health Test can tell you what the composition of your vaginal microbiome is, why it matters, and how to improve your vaginal health for good.