Probiotics, bacteria that are naturally occurring in the body, are often recommended as a treatment for vaginal flora imbalance. Probiotics can help to restore a healthy level of lactobacilli both in the gut and in the vulval-vaginal area particularly after a course of antibiotics. The vaginal flora of healthy premenopausal woman is generally dominated by a number of Lactobacillus species.  For women, this health level of lactobacillus changes during the peri menopause and menopausal years leading to the level of lactobacilli in the vagina decreasing alongside the production of lactic acid and hydrogen peroxide.

Because vaginal lactobacillus species produce lactic and hydrogen peroxide, maintaining the vaginal pH around 4.5 or less and hampering growth of pathogenic bacteria and fungi, they are thus considered protective against vulval vaginal candida (VVC) and bacterial vaginosis (BV). This has increased the interest in the beneficial effect of Lactobacillus species-containing probiotics in restoring and maintaining the vaginal microbiome.

Orally administered probiotics reach the vagina in approximately seven days, Lactobacillus strains administered intravaginally show effects in two to three days.

Are probiotics effective for long term vaginal health?

The effectiveness of probiotics for the treatment of VVC in non-pregnant women was evaluated in 2017 in a Cochrane systematic review. A total of 10 RCTs (1656 participants) investigating the effect of probiotics used by the oral and vaginal route as a complementary therapy to conventional antifungal drugs were included. Probiotics slightly improved the short-term clinical cure rate and reduced the 1-month relapse rate. However, no important impact of probiotic use was observed on long-term clinical cure rate (3-month post-treatment evaluation). Given the low- or very low-quality of the considered studies, the authors emphasized the need for further and better designed RCTs with larger sample size, standardized methodology for probiotic preparation, and longer follow-up. More studies are needed to conclude that taking probiotics orally or vaginally alone will inhibit vaginal candida overgrowth and successfully treat any fungal infections.

In a study published in  Frontiers in Cellular and Infection Microbiology in 2022, it was noted that VVC-positive women with an abundance of the strain of Lactobacillus. iners. can induce a marked increase in biofilm formation by C. albicans. They concluded that this might limit L. iners use in treating vaginal infections.  However biosurfactants extracted from lactobacilli such as iturin, lichenysin and surfactin have the capacity to limit Candida biofilm formation and prevent expansion (Nelson et al., 2020). Lactobacilli can also reduce C. albicans pathogenicity by boosting the local immune system response of human cells.

Notably, several clinical investigations have demonstrated an improvement in the treatment of VVC with or without antibiotic therapy, plus oral or intravaginal probiotic lactobacilli administration. Oral or vaginal administration of three L. crispatus strains can lower the combined scores of two of the most important symptoms in VVC patients, the amount of discharge and the level of itching/irritation (Mändar et al., 2023). In addition to lactobacilli alone, the combination of lactobacilli with antibiotics is also an effective therapy for vaginal Candida infection. By improving the composition of vaginal flora and reestablishing vaginal microecology, probiotic lactobacilli vaginal capsules combined with clotrimazole vaginal tablets can enhance the effectiveness of treatments for simple VVC (Zeng et al., 2023). The combination of L. acidophilusGLA-14, L. rhamnosus HN001, and bovine lactoferrin dramatically improved itching and discharge in VVC patients at 3 and 6 months, and throughout the six-month follow-up, the intervention group had considerably fewer recurrences than the placebo group (Russo et al., 2019b).

The use of probiotics in people who have a health condition of the bowel should always be discussed with their GP or consultant. There are also particular risks associated with supplements that are meant to be used vaginally. There is the risk of introducing other bacteria with insertion – for instance, because of dirty hands or if the tablet wasn’t clean at insertion – as well as the risk of small cuts in the vagina if it’s not inserted correctly and the risk of increased vaginal discharge and change in odour.

There is also the question of cost – both vaginal and oral probiotic supplementation can be expensive. Your gynaecologist, genito urinary medicine doctor or women’s health doctor should advise as to whether their usage is necessary.

If the vaginal PH is too alkaline, lactic acid pessaries are also available.

More about oral probiotics

Fluconazole tablets can be purchased over the counter in any pharmacy or prescribed by the GP. They can be taken either as a single dose or for longer under the guidance of a GP or physician.

Prescription oral anti fungal medication

Both Fluconazole and Itraconazole can be prescribed. Be aware that these medications are contra-indicated against Warfarin and should not be taken if using statins, antibiotics classed as macrolides, SSRI antidepressants or medications for irregular heart beat. Always discuss existing medications, possible contra-indications, recommended dosage and length of usage with your practitioner or GP.

If taking oral fungal medications, it is recommended that liver function is checked regularly via a GP blood test. This is particularly important for those taking oral medications for longer than four weeks. Oral anti-fungals can affect liver function.

Be aware that oral fungal medications work best in an acidic environment so if taking protein pump inhibitors (PPIs) for excess stomach acid, antacids or other stomach acid reducing medications, take oral fungal medications well away from these.

Nystatin powder

Another alternative treatment is to take Nystatin powder, this is usually prescribed by a doctor and can be taken orally if suffering systemic candida issues alongside vaginal candidasis.  Note that Nystatin Powder is not suitable for the treatment of vaginal thrush.

Within the Multi-Gyn product range there is Multi-Gyn active gel (formerly known as Bio-fem active gel) for Bacterial Vaginosis and there is Multi-Gyn Floraplus for thrush. Both of these gels can be purchased over the counter from pharmacies or online.

Within the Salcura Natural Skin Therapy range Topida intimate topical spray has found favour with a number of Chronic UTI sufferers for helping to alleviate the symptoms of Thrush

The Chronic Urinary Tract Infection Campaign (CUTIC) has secured an affiliate partnership with the manufacturers of Topida Intimate Spray. They are kindly offering a 15% discount on everything purchased directly from their website. Just add the code CUTIC15 to your order. Please note this is applicable to UK and Eire customers only.

Clotrimazole or Canestan cream

Canesten is the branded product and also contains more of the active ingredient at 2%, but is more expensive. Clotrimazole only contains 1%. These can be purchased at any pharmacy or on prescription from the GP. If you have vulval vaginal issues please check if any additives may cause irritation before usage.

There are also intra-vaginal pessaries such as clotrimazole or canesten pessaries, econazole and miconazole. These work in a similar way to the cream, but can cause burning, vaginal dryness and further irritation to some, again use with caution if you are very sensitive.

Nystatin cream and pessaries

Vaginal candida cases related to non-candida albicans species can be treated by Nystatin intra-vaginal pessaries or cream — Nystatin is the only licensed alternative to azole therapy.  Please note that in the UK at present it is unlicensed and would need to be purchased overseas.

The probiotic VSL3 can also be mixed with a small amount of water, just enough to make a paste and inserted in the vagina which can help to relieve and treat thrush.

Boric acid pessaries

Boric acid is a white, crystalline chemical substance that has anti-fungal and antiviral properties. It is used in various prescription pharmaceutical products and is also available without a prescription in some countries. Vaginal boric acid capsules are a treatment option for vaginal yeast infections, particularly infections that can’t be cured by anti-fungal yeast infection medicines. If you are pregnant, do not use vaginal boric acid treatment.

When used in capsules as a vaginal suppository, boric acid is known to sometimes cause skin irritation so again if vaginal or vulval tissues are sensitive please discuss with either a pharmacist or appropriate practitioner before purchasing for treatment. Be aware that if taken orally or used on an open wounds boric acid is toxic. Keep boric acid out of the reach of children.

How to apply topical medications

Apply a pea sized dose to those areas where the itching is most intense. Ensure that any application to the anal region is the last area treated to prevent any bacteria being transferred to the vulva and around the urethral entrance.