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.