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Lichen Sclerosus and Bacterial Vaginosis: What’s the Difference

Lichen Sclerosus and Bacterial Vaginosis: What’s the Difference


Misdiagnoses are, unfortunately, a common part of many of our journeys to getting a proper diagnosis. Some common misdiagnoses that people with lichen sclerosus get are yeast infections, herpes, menopause/GSM, psoriasis, and vitiligo. Part of our strategy in creating a world where folks with LS get diagnosed sooner involves raising awareness about LS and vulvar health in general. With that, today we are going to be discussing lichen sclerosus and bacterial vaginosis. In particular, we are going to be discussing the differences between the two in terms of signs, symptoms, diagnosis, and treatment.


*This post is evidence-based; I draw on the medical literature to share what you need to know about lichen sclerosus and bacterial vaginosis. Importantly, what I share is my interpretation of the science and data.

**The information contained in this blog post is up-to-date at the time of publication. 

***If this post is helpful to you, we’d love your support so we can continue providing important education like this. Make a donation today, volunteer with us, or share our posts in your support groups.

What is Bacterial Vaginosis (BV)

Bacterial vaginosis is a common condition that occurs when there is an imbalance of the bacteria normally found in the vagina. BV is not a sexually transmitted infection.

To understand this imbalance, it is important to know what vaginal flora is. Vaginal flora refers to the different microorganisms–mainly bacteria–that naturally live in the vagina. This flora is important for maintaining a healthy vagina. The main bacteria in the vagina is of the lactobacilli species. In fact, lactobacilli bacteria make up approximately 90-95% of total vaginal bacteria (Bautista et al., 2016; Coudray and Madhivanan, 2020).

Graphic design image of a blue, gloved hand holding a sample under a microscope, highlighting a number of bacteria.

A quick note: many online posts use the terms vaginal flora and vaginal microbiome interchangeably. However, while they are similar, there is a difference. Specifically, the vaginal flora refers to the species of microorganisms and bacteria present in the vagina. On the other hand, the vaginal microbiome not only includes the vaginal flora but also the genetic material and overall environment in which they live.

Back to the Imbalance

With bacterial vaginosis, there is an overgrowth of opportunistic bacteria and a decrease in the healthy lactobacilli bacteria. Common opportunistic bacteria include Prevotella, Gardnerella, and Mobiluncus species (Holzman et al., 2001;  Joesoef et al., 1999; Lambert et al., 2013). 

You can think of these opportunistic bacteria as being overambitious. They come into the healthy vaginal environment and want to take it over and be the main species. And in doing so, they can cause an imbalance in the vaginal flora.

Another way to think of it is that the number of harmful bacteria increases, and the number of beneficial bacteria goes down.

Signs and Symptoms of Bacterial Vaginosis

Signs and symptoms of bacterial vaginosis include:

  • Abnormal discharge–may have a white/gray color–which can sometimes have a fishy odor
  • Increased vaginal PH
  • Vaginal itching
  • Vaginal irritation (sometimes people report vaginal burning)
  • Some cases are asymptomatic (Redelinghuys et al., 2020)

Who Gets BV?

BV typically affects people with vaginas who are of reproductive age (Coudray and Madhivanan, 2020; Bautista et al., 2016). 

How common BV is depends on geographical location. For example, the prevalence of BV can range anywhere from 20-60%, depending on the country. Indeed, BV prevalence is highest in Sub-Saharan Africa (Kenyon et al., 2023). Unfortunately, no studies have explored what makes certain geographical locations have a higher prevalence of BV.

Graphic image design of a globe and different landmarks from across the world representing the fact that BV prevalence differs depending on geographical location.

How is Bacterial Vaginosis Diagnosed?

BV is diagnosed either by Amsel’s criteria (a scoring system) or laboratory testing using the Nugent score (Bautista et al., 2017). Amsel’s criteria tends to be more popular, as it’s faster (can be done in-office), cheaper, and less resource-heavy. 

With Amsel’s criteria, three of the following factors must be present for a positive score (aka for a BV diagnosis). First, there must be increased discharge that may have a fishy odor. Second, a vaginal PH of 4.5 or higher must be detected. Finally, the presence of clue cells present in the discharge when examined under a microscope (Klatt et al., 2010; Menard, 2011) Now, it is normal for clue cells to be present in vaginal discharge, so for a BV diagnosis, the % of clue cells must pass the threshold of ‘normal clue cells present’. If all three are present, the doctor will make a diagnosis of bacterial vaginosis.

The second way to diagnose BV is by using the Nugent scoring system in a laboratory. First, your doctor will swab the vaginal discharge, package it up, and send it to the lab for testing. Once at the lab, the lab technician will do a gram stain of the sample. Gram-staining involves adding color to the sample to help differentiate between different types of bacteria. It helps the technician see what bacteria are present in any sample. Once the sample is stained, the technician will determine whether BV is present by following the Nugent scoring system. Scoring a 7 or higher indicates the presence of BV (Redelinghuys et al., 2020).

What about at-home testing?

There are different at-home tests on the market. According to Dr. Corey Babb, these tests definitely have their place. However, it is important to research the type of test and the company before purchasing. Be mindful that some tests will simply list out all of the bacteria found but won’t provide any insights into which bacteria is good and which is the problem bacteria. Therefore, some tests require an expert healthcare provider to help interpret and make sense of the data. 

Learn more about at-home testing by watching my live with Dr. Corey Babb.

I (Jaclyn) can’t personally make any recommendations for at-home tests, as I have never used one or researched them thoroughly. However, if you are based in the USA, you may consider the Evvy Vaginal Health Test. Evvy was created by scientists, doctors, and designers and is backed by an all-star medical advisory board. Their Vaginal Health Test tests for all opportunistic/disruptive and protect bacteria and microbes relating to aerobic vaginitis, bacterial vaginitis, cytolytic vaginosis, STIs, recurrent UTIs, yeast infections and more. The test provides detailed results and personalized insights; you can order a treatment based on your results. They also offer 1:1 coaching from start to finish.

Learn more and get the Evvy Vaginal Health Test here.

How is BV treated?

The gold standard treatment for bacterial vaginosis is oral antibiotics. A gold standard treatment is the first treatment healthcare providers will recommend, usually because it has the most evidence-based research behind it regarding safety and efficacy (how well it works). In the United States, the most common antibiotic is Metronidazole (Coudray and Madhivanan, 2020; Joesoef et al., 1999). Sometimes, the use of probiotics is recommended alongside antibiotics (Bradshaw & Sobel, 2016; Kumar et al., 2011).

Image of a an orange pill bottle with an RX label representing antibiotic treatment for BV.

The second-line treatment is a topical antibiotic preparation. This preparation comes in an applicator that allows you to insert and distribute the medication into the vagina. 

What about Complicated Bacterial Diagnosis?

This blog post is more of a general overview, so we won’t go into complicated cases of BV (for example, BV that doesn’t resolve after treatment or chronic BV). Briefly, however, there are instances where people either get chronic BV infections or have a case that does not resolve/respond to the gold standard treatment. These cases often require a vulvovaginal specialist. First, the specialist needs to perform specialized testing to determine the individual cause. Once the individualized causes and strains are identified, then the specialist can move forward with appropriate treatment. For example, in some cases, people have a strain that is resistant to ‘azole’ types of medication (e.g., Metronidazole, which is the gold standard BV treatment). These cases often respond better to Clindamycin.

Dr. Babb talks about personalized testing and treatments that are sometimes necessary for complicated cases in this live, which you can listen to here.

Differences between Lichen Sclerosus and Bacterial Vaginosis

Fortunately, lichen sclerosus and bacterial vaginosis have some pretty big differences. For example, lichen sclerosus affects the vulva, and BV affects the vagina. Second, BV is associated with abnormal vaginal discharge; LS is not associated with any discharge or changes to discharge. 

However, it is possible to have bacterial vaginosis alongside lichen sclerosus. 

What to do If You Think You Have Both Lichen Sclerosus and Bacterial Vaginosis

If you suspect you have bacterial vaginosis, we recommend calling your healthcare provider to do a clinical exam. 

Can You Still Treat with Steroids or Calcineurin Inhibitors While Treating Bacterial Vaginosis

We at LSSN get this question often, and it’s a great question.

You can and should continue to treat your lichen sclerosus alongside BV. In most cases, BV treatment involves oral antibiotics (taken by mouth), so it wouldn’t interfere with your topical LS treatments. However, even if you are prescribed a topical treatment for BV, like topical metronidazole gel, you can still continue treating your LS. That is, because BV affects the vagina, the topical treatment is inserted into the vagina, and your LS treatment is applied to the vulva, not the vagina, so the two won’t interfere with the other. If you are still worried, you can absolutely apply one treatment in the morning and one in the evening, although the healthcare providers I consulted said it is unnecessary.

Learn more about BV in my Instagram Live with Dr. Corey Babb here.

Conclusion on Lichen Sclerosus and Bacterial Vaginosis

In sum, lichen sclerosus and bacterial vaginosis have important differences. BV affects the vagina (not the vulva) and involves discharge. LS affects the vulva (not the vagina) and does not involve discharge. However, it is possible to have LS and bacterial vaginosis. In this blog, we review what BV is, the signs and symptoms, and how it is diagnosed and treated. We highlighted the importance of continuing your LS treatment even when you are treating BV.

Let us know if you have had BV and LS and what your experience was like in the comments below. 

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Reach Out to Me

Whether you are debating booking a support call with me, have a quick question, or want to share something related to my content, I can be reached via:

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1.Coudray MS, Madhivanan P. Bacterial vaginosis—A brief synopsis of the literature. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2020;245:143-148. doi:https://doi.org/10.1016/j.ejogrb.2019.12.035

2.Bautista CT, Wurapa E, Sateren WB, Morris S, Hollingsworth B, Sanchez JL. Bacterial vaginosis: a synthesis of the literature on etiology, prevalence, risk factors, and relationship with chlamydia and gonorrhea infections. Military Medical Research. 2016;3(1). doi:https://doi.org/10.1186/s40779-016-0074-5

3.Ranjit E, Raghubanshi BR, Maskey S, Parajuli P. Prevalence of Bacterial Vaginosis and Its Association with Risk Factors among Nonpregnant Women: A Hospital Based Study. International Journal of Microbiology. 2018;2018:1-9. doi:https://doi.org/10.1155/2018/8349601

4.Bradshaw CS, Sobel JD. Current Treatment of Bacterial Vaginosis—Limitations and Need for Innovation. Journal of Infectious Diseases. 2016;214(suppl 1):S14-S20. doi:https://doi.org/10.1093/infdis/jiw159

5.Holzman C, Leventhal JM, Qiu H, Jones NL, Wang JY. Factors Linked to Bacterial Vaginosis in Nonpregnant Women. 2001;91(10):1664-1670. doi:https://doi.org/10.2105/ajph.91.10.1664

More References

6.Joesoef MR, Schmid GP, Hillier SL. Bacterial Vaginosis: Review of Treatment Options and Potential Clinical Indications for Therapy. Clinical Infectious Diseases. 1999;28(s1):S57-S65. doi:https://doi.org/10.1086/514725

7.Lambert JA, John S, Sobel JD, Akins RA. Longitudinal Analysis of Vaginal Microbiome Dynamics in Women with Recurrent Bacterial Vaginosis: Recognition of the Conversion Process. PLoS ONE. 2013;8(12):e82599. doi:https://doi.org/10.1371/journal.pone.0082599

8.Kenyon C, Colebunders R, Crucitti T. The global epidemiology of bacterial vaginosis: a systematic review. American Journal of Obstetrics and Gynecology. 2013;209(6):505-523. doi:https://doi.org/10.1016/j.ajog.2013.05.006

9.Redelinghuys MJ, Geldenhuys J, Jung H, Kock MM. Bacterial Vaginosis: Current Diagnostic Avenues and Future Opportunities. Frontiers in Cellular and Infection Microbiology. 2020;10. doi:https://doi.org/10.3389/fcimb.2020.00354

10.Menard JP. Antibacterial treatment of bacterial vaginosis: current and emerging therapies. International Journal of Women’s Health. Published online August 2011:295. doi:https://doi.org/10.2147/ijwh.s23814

11.Klatt TE, Cole DC, Eastwood D, Barnabei VM. Factors associated with recurrent bacterial vaginosis. PubMed. 2010;55(1-2):55-61.

12.Pal K, Roy S, Behera B, Kumar N, Sagiri S, Ray S. Bacterial vaginosis: Etiology and modalities of treatment-A brief note. Journal of Pharmacy and Bioallied Sciences. 2011;3(4):496. doi:https://doi.org/10.4103/0975-7406.90102

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