Symptoms, risks, and complications
The classic symptoms of bacterial vaginosis are an abundant, grayish-white, and homogeneous discharge, and a characteristic unpleasant "fishy" odor. This odor is caused by the production of amines (putrescine, cadaverine) by the anaerobic bacteria. However, it is crucial to note that about 50% of women with bacterial vaginosis are asymptomatic. Bacterial vaginosis is often linked to the use of systemic antibiotics that have destroyed some of the lactobacilli, as well as stress and internal vaginal douches. While it is not a sexually transmitted disease, it can be affected by sexual activity, especially with multiple and unprotected partners, as seminal fluid has an alkaline pH of 7.2–8.0, which can alter the vaginal pH and increase the risk. The alkaline pH of seminal fluid raises the vaginal pH to create a more favorable environment for sperm survival and motility. If left untreated, bacterial vaginosis can lead to more serious complications. It increases the risk of contracting other sexually transmitted infections, such as chlamydia. Furthermore, during pregnancy, it is associated with an increased risk of preterm birth and low birth weight.

Diagnosis and principles of treatment
Diagnosis is based on clinical and laboratory criteria. The Amsel criteria, for example, require the presence of at least three of the following elements:
Homogeneous grayish-white discharge coating the vaginal walls.
Vaginal pH greater than 4.5.
Positive "whiff test": the addition of potassium hydroxide to a sample of the discharge produces a strong amine odor.
Presence of "clue cells" under the microscope: vaginal epithelial cells covered with a carpet of bacteria, which makes the cell borders indistinct. The standard treatment involves the use of specific antibiotics, such as metronidazole or clindamycin, administered orally or, preferably, in a topical formulation (creams or vaginal gels). Topical treatment is often preferred to reduce systemic side effects and act directly on the infection site.

Prevention strategies and the challenge of recurrence
The real problem with bacterial vaginosis is the high rate of recurrence, which occurs in about 30% of women within three months of treatment. This is because antibiotics, while eliminating pathogenic bacteria, do not always completely restore the lactobacillus flora. To prevent recurrence, it is essential to focus on restoring the vaginal balance. This includes:
Use of vaginal probiotics: The application of specific Lactobacillus strains (e.g., Lactobacillus crispatus, Lactobacillus rhamnosus) can help restore the acidic pH.
Avoiding risk factors: Stop using internal douches, prefer cotton underwear, and use intimate washes with an appropriate pH. Bacterial vaginosis is a complex alteration of the vaginal microbiota, requiring a thorough understanding for accurate diagnosis and effective treatment. The goal is not only to eliminate the excess bacteria but also to restore the delicate ecological balance that protects a woman's health.

Bibliography
Amsel, R., Totten, P. A., Spiegel, C. A., Chen, K. C., Eschenbach, D., & Holmes, K. K. (1983). Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. The American Journal of Medicine, 74(1), 14-22.
Bhandari, N., & O'Hanlon, S. J. (2016). Recurrence of bacterial vaginosis: a systematic review and meta-analysis of treatment trials. The Journal of Infectious Diseases, 214(1), 1-8.
Donati G. 30 Giu 2009 Human Papilloma Virus (HPV), cancro del collo dell'utero e vaccino: risultati a due anni dall'esordio

Donati G. 18 Giu 2008 Human Papilloma Virus e altre malattie sessualmente trasmesse (MST) un reale problema di comunicazione

Donati G. 17 Dic 2003 Emergenza Malattie Sessualmente Trasmesse Scienzaonline

Muzny, C. A., & Schwebke, J. R. (2020). Biofilms: a critical component of bacterial vaginosis. The Journal of Infectious Diseases, 221(S2), S120-S123.
O'Hanlon, S. J., Moench, T. R., & Cone, R. A. (2013). In vitro studies of the effect of hydrogen peroxide-producing lactobacilli on the growth of Gardnerella vaginalis. Sexually Transmitted Diseases, 40(6), 464-469.

 *Board Member, SRSN (Roman Society of Natural Science) Past Editor-in-Chief Italian Journal of Dermosurgery