A Comprehensive Guide to Aerobic Vaginitis (AV)

Aerobic vaginitis (AV) is a condition that causes vaginal inflammation and discomfort. Like a lot of vaginal disorders, it’s poorly studied, but there are a few things we know for sure.

For many years, aerobic vaginitis was simply seen as bacterial vaginosis with other organisms present or a form of “inflammatory bacterial vaginosis”, rather than a separate condition. But we now know that aerobic vaginitis is distinct from bacterial vaginosis (BV). 

Both aerobic vaginitis and bacterial vaginosis can cause uncomfortable symptoms like unusual vaginal discharge or an unpleasant smell. However, distinguishing between the two is crucial to receiving appropriate care.

Research suggests 7-12% of women have aerobic vaginitis. Due to how frequently vaginal infections are misdiagnosed, it’s likely that disorders such as aerobic vaginitis are actually more common than research suggests.

What causes aerobic vaginitis?

Both aerobic vaginitis and bacterial vaginosis happen when there's a shift in the vaginal microbiome, specifically a decline in protective Lactobacilli and dysbiosis of the vaginal microbiome.

The main difference between these two conditions is the type of bacteria that causes them. Bacterial vaginosis is caused by anaerobic bacteria — meaning, bacteria that don’t need oxygen to survive, like Gardnerella, Prevotella, and Fannyhessae. Aerobic vaginitis is caused by aerobic bacteria, which are specific pathogens that don’t mind having oxygen around, like E.coli, Staphylococcus aureus, group B Streptococcus (GBS), and Enterococcus faecalis.

Aerobic vaginitis symptoms

The most common symptom of aerobic vaginitis is vaginal inflammation, the key symptom that usually distinguishes aerobic vaginitis from bacterial vaginosis.

Other symptoms of aerobic vaginitis include:

• Sticky, yellow, or green vaginal discharge
• Unpleasant “rotten” smell
• Vaginal redness and swelling around the opening of the vagina
• Pain during sex
• A stinging and/or burning sensation. 

The presence of parabasal or immature epithelial cells is considered a diagnostic feature for the severity of aerobic vaginitis.

A microscopic analysis of vaginal discharge, usually collected using a swab, can be used to diagnose both aerobic vaginitis and bacterial vaginosis.

Advanced DNA-based testing, such as qPCR panels or next-gen sequencing (the technology used to sequence Evvy vaginal microbiome tests), can help identify aerobic bacteria from vaginal samples more accurately and precisely.

How to treat and manage aerobic vaginitis?

Aerobic vaginitis is a condition that really benefits from a tailored approach to treatment since what's most effective can vary based on how severe the infection is and which specific bacteria are involved.

Antibiotics and antimicrobials

While there isn’t a one-size-fits-all solution, there are some antibiotics that tend to do a great job, especially for mild to moderate cases. Commonly prescribed options include clindamycin, kanamycin, and fluoroquinolones, which can be taken orally or used as intravaginal treatments, depending on your specific situation.

Typically, treatment lasts about five to ten days, but if your case is a bit more serious or doesn’t seem to improve, you might need a longer or repeat course of treatment. It’s also worth mentioning that metronidazole, a go-to for bacterial vaginosis, doesn’t work for aerobic vaginitis. So if you notice your symptoms aren’t responding to metronidazole, it might mean that aerobic vaginitis, rather than bacterial vaginosis, is what’s really going on. 

Topical corticosteroids

In more severe or highly inflammatory cases of aerobic vaginitis, topical corticosteroids may be prescribed alongside antibiotics to reduce irritation, redness, and swelling. These are typically used for short durations to avoid thinning of the vaginal epithelium and are especially helpful when inflammation is a major component of the infection.

Probiotics

Probiotics can play a crucial role in recovery and prevention. These can be used during or after antibiotic treatment and often include Lactobacillus species, which help reestablish a healthy vaginal microbiome. Probiotics may be taken orally or used as vaginal inserts and have been shown to reduce inflammation and lower the risk of recurrence.

Vaginal suppositories

In some cases, antibiotic or probiotic suppositories are used directly in the vagina to target infection more locally. These may contain kanamycin or other antimicrobials, depending on the bacteria involved, and are especially helpful for patients who don’t tolerate oral antibiotics well or need localized treatment.

Vaginal microbiome test

Taking a vaginal microbiome test can help tailor treatment to your unique vaginal microbiome. This type of testing identifies the types and quantities of bacteria present, helping clinicians pinpoint whether aerobic vaginitis is caused by specific aerobic bacteria such as E. coli, Streptococcus, or Staphylococcus. Understanding the microbial profile allows for more accurate and effective treatment choices.

So, how long does it take to get over aerobic vaginitis? With the right antibiotic therapy, many mild cases can clear up in about a week, though full symptom resolution may take a bit longer depending on individual response. For more stubborn or chronic cases, treatment could extend over several weeks and might include supportive therapies like probiotics, topical steroids, or hormone-related interventions when appropriate.

Desquamative inflammatory vaginitis and vaginal inflammation

Desquamative inflammatory vaginitis (DIV) is a rare diagnosis often given to people with a severe form of aerobic vaginitis. Desquamative inflammatory vaginitis is also associated with the same list of aerobic organisms (E. coli, S. aureus, group B strep, and Enterococcus faecalis), but it’s characterized by severe vaginal inflammation often accompanied by pain and burning.

Like aerobic vaginitis, desquamative inflammatory vaginitis is diagnosed via a microscopic analysis of vaginal discharge. The doctors are looking for signs of vaginal inflammation rather than bacterial load.

The cause of desquamative inflammatory vaginitis is controversial, while aerobic bacteria are commonly present, DIV could also be caused by anything that results in high levels of vulvar and vaginal inflammation. That is why other causes of inflammation (like sexually transmitted infections, lichen planus, or severe vaginal atrophy) need to be ruled out first.

Treatment for desquamative inflammatory vaginitis focuses on decreasing inflammation and can include clindamycin, steroids, or estrogen. Currently, there have been no randomized controlled trials to determine which treatments are best.

Risks associated with aerobic vaginitis and abnormal vaginal flora

Aerobic vaginitis is also associated with a higher risk of other health consequences including:

• Pelvic inflammatory disease (PID)
• Sexually transmitted infections (STIs)
• Human papillomavirus (HPV) and cervical cancer
• Infertility
• Adverse pregnancy outcomes (miscarriage and preterm birth)
• Neonatal issues
• Urinary tract infections (UTIs). 

Additionally, major Pap smear abnormalities can occur in the context of aerobic vaginitis, impacting pregnancy outcomes and maternal health.

Pregnant women are also at risk for complications if S. agalactiae (Group B Streptococcus) is one of the bacteria involved in an aerobic vaginitis infection. In non-pregnant women, Streptococcus agalactiae is a common and benign member of the vaginal microbiome. However, all pregnant women are tested for GBS between 36-37 weeks because it may cause side effects for newborns. If GBS is detected during your third-trimester test, rest assured that when treated, the risk of transmission drops to almost zero.

The vaginal microbiota plays a significant role in pregnancy outcomes. An imbalance in this microbiota can lead to adverse outcomes such as preterm delivery and stillbirth. Understanding and managing the complex composition of the vaginal microbiota is crucial for maternal and neonatal health.

How can I prevent aerobic vaginitis?

While it is important to understand the differences between aerobic vaginitis and bacterial vaginosis, the preventive measures come down to the same thing: maintaining a healthy vaginal microbiome.

Some general rules of thumb include:

• Using barrier methods such as condoms and dental dams during sex
• Wiping front to back
• Changing your period products within the recommended time frame
• Avoiding douching and feminine hygiene products, which can cause an imbalance in your microbiome (vaginal dysbiosis)
• Maintaining good hygiene around sex, such as washing sex toys often. 

Most importantly, it’s good practice to keep in mind the different activities and life events that can cause a shift in the microbiome and put you at an increased risk of aerobic vaginitis. Some risk factors include:

• Sex 
• Hormonal fluctuations (e.g. birth control, pregnancy, and menopause)
• Your period
• Smoking‍
• Stress. 

Get aerobic vaginitis care with Evvy

Care at Evvy isn’t just treatment. Built with leading OB-GYNs, it’s the first-ever platform for vaginal healthcare that combines state-of-the-art vaginal microbiome testing, prescription treatment, and 1:1 coaching to create personalized care as unique as your vaginal microbiome. Experience vaginal health care with Evvy today.

FAQ

What is aerobic vaginitis?

Aerobic vaginitis is a type of vaginal infection characterized by inflammation and an imbalance in the vaginal microbiome, where healthy lactobacilli are reduced and replaced by abnormal vaginal flora, specifically harmful aerobic bacteria such as Escherichia coli, Staphylococcus aureus, or Streptococcus species. This condition can affect women of any age, but it happens more often in postmenopausal women or those who have recently taken antibiotics. Aerobic vaginitis often causes redness, burning, irritation, yellowish discharge, and sometimes an unpleasant odor. It can also lead to vaginal dryness and discomfort during sex. This condition is sometimes mistaken for other infections — like bacterial vaginosis — because of overlapping symptoms, but it requires a different treatment approach. To diagnose aerobic vaginitis, doctors usually look at samples of vaginal discharge under a microscope. They check for signs of inflammation and specific bacteria.

What's the difference between bacterial vaginosis and aerobic vaginitis?

The main difference between bacterial vaginosis and aerobic vaginitis is the bacteria that cause the infections. Bacterial vaginosis is caused by anaerobic bacteria, such as Gardnerella, which don’t need oxygen to survive. On the other hand, aerobic vaginitis is caused by aerobic bacteria, including E. coli, Staphylococcus aureus, group B Streptococcus (GBS), and Enterococcus faecalis, which don’t mind being exposed to oxygen environments. Bacterial vaginosis and aerobic vaginitis also cause similar but different symptoms. While they both cause abnormal vaginal discharge, bacterial vaginosis is associated with watery, gray discharge with a fishy odor, while aerobic vaginitis discharge tends to be yellow or green and can have a “rotten” smell.

How is vaginitis treated?

Vaginitis is an umbrella term used to describe an inflammation of the vagina. It can have many different causes, which means that treatment for vaginitis depends on what's causing it. Common treatments include antifungals (in the case of a yeast infection), antibiotics (in the case of a bacterial infection), steroids (for skin conditions), and hormone treatments (for vaginitis linked to menopause).

​​What is an aerobic bacterial infection?

An aerobic bacterial infection is one caused by bacteria that grow when oxygen is present.