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Evidence Based

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This article contains scientific references. The numbers in the parentheses (1, 2, 3) are clickable links to peer-reviewed scientific papers.

Your Guide to Using Probiotics for BV (Bacterial Vaginosis)

Written by Dr. Ruscio on August 28, 2022

Written by Dr. Ruscio on August 28, 2022 — Reviewed by Hannah Hamlin

How to Help Bacterial Vaginosis with Friendly Bacteria

• What is Bacterial Vaginosis|
• Probiotics for BV|
• Antibiotic Pros and Cons|
• How to Choose a Probiotic|
• Diet for BV|
• Vitamin C and BV|
• Recap|

Most women know what it’s like to experience an annoying and uncomfortable vaginal infection. Thrush (caused by a Candida yeast infection) is perhaps the most familiar of these, but bacterial vaginosis (caused by bacteria) is also very common, affecting 30% of females aged 14–49 in the US at least once [1].

The good news is that taking probiotics for BV is a simple step that can bring great results. In this article we’ll look at what triggers bacterial vaginosis (BV), how probiotics can help to treat and prevent it and other ways to encourage good vaginal health.

What is Bacterial Vaginosis?

Bacterial vaginosis (BV) is vaginal inflammation caused by an overgrowth of normal vaginal bacteria [1].

In a healthy vagina, “good” lactic acid-producing bacteria occur in bigger numbers than the “bad” bacteria known as anaerobes. If anaerobe pathogens, such as Gardnerella vaginalis grow out of hand, this upsets the balance of microorganisms in your vagina, causing symptoms of BV infection [2].

Signs of BV include [1]:

• A thin, gray or white vaginal discharge with a fishy odor
• Painful urination and urinary tract infections
• Pain during sex
• Vaginal itching

Frequent vaginal douching and recent antibiotic use are among the factors that can increase the risk of getting a BV infection. Women who smoke cigarettes, have multiple or a recent new sex partner (particularly another woman), or have an IUD contraceptive device fitted are also more prone to BV. Females are at higher risk around the time of their monthly period, as well as after menopause due to hormonal changes [1, 3, 4].

For most healthy women, a one-off episode of BV is of no serious consequence, but under certain circumstances it can be more worrying. Specifically, the presence of BV increases the risk of [1]:

• Acquiring a sexually transmitted infection (STI)
• Early delivery of the baby in pregnant women

Probiotics for BV

Research suggest that probiotics — supplements of beneficial live bacteria —have many beneficial effects for vaginal health that include [5, 6, 7, 8, 9]:

• Balancing the vaginal microbiota
• Reducing the levels of inflammatory substances such as interleukin and cytokines
• Helping keep the vagina acidic, and therefore inhospitable to many harmful bacteria
• Producing substances such as bacteriocins and hydrogen peroxide, which can help to prevent harmful bacteria from growing

Clinical studies show that probiotics can work both with antibiotics, and alone, for the treatment of BV and to reduce recurrent bacterial vaginosis.

Studies of antibiotics and probiotics together:

• In a systematic review/meta-analysis (i.e. high quality cumulative data) the best treatment/cure rates for bacterial vaginosis were found when high-dose oral probiotics and antibiotics were used together. However, probiotics alone were as good as antibiotics alone [10].
• In a study in which probiotics were administered after a course of antibiotics (both given vaginally), the followup probiotics led to fewer recurrences of bacterial vaginosis compared with antibiotics followed by placebo [11].

However, if you would prefer to avoid antibiotics, you may get excellent results, often with fewer downsides, by using  probiotics alone. 

Studies of probiotics alone:

• In one systematic review/meta-analysis, probiotics given with or without antibiotics significantly increased the cure rate of bacterial vaginosis. Probiotics also reduced BV recurrence rate, especially when used for a longer period of 1 to 3 months [12].
• Another systematic review found that oral and vaginal probiotics (lactobacilli) were better than placebo for BV treatment but not conclusively better than antibiotics. For BV prevention, long-term vaginal lactobacilli were better than oral or vaginal antibiotics [13].
• As well as being effective for curing and preventing bacterial vaginosis oral probiotics were also effective against yeast infections, urinary tract infections, and HPV [14].
• Probiotics were safe and useful for women for even pregnant women with BV [5].

If you have bacterial vaginosis, antibiotics are a valid option to clear up symptoms. But it’s best to read the pros and cons section below (and then discuss with a trusted clinician) before deciding if they are right for you.

What we can confidently say is that probiotics are safe, helpful and have few side effects, so might actually be the better option for many people. 

Either way, probiotic supplements are a good choice for BV whether you take antibiotics or not. 

Antibiotics for BV: Pros and Cons

Doctors typically prescribe the antibiotics clindamycin or metronidazole for treatment of bacterial vaginosis, taken orally or as a gel inserted into the vagina [1].

The main benefit of antibiotics is that they usually act quickly and effectively for acute BV symptoms, such as itching and vaginal discharge.

However, for between one in ten and one in five women, symptom improvement is not so fast and antibiotic treatment may need to go on longer [1].

Even when symptoms do resolve with antibiotics, up to 80% of women experience a recurrence sometime in the future for which another course of antibiotics will usually be prescribed [1].

Antibiotics can also disrupt the acidity of the vagina, increasing the likelihood of recurrent BV [15].

Probiotics help get you out of this vicious cycle, by correcting underlying microbial imbalances in both the gut and reproductive (genital) tract.

How to Choose Probiotics for BV

We’ve established that probiotics can be of great help for BV, but which type, what dosage, and how often?

Research doesn’t pinpoint one particular strain as being markedly better than another.

Any probiotic is likely to be better than none, but research does provide a few pointers for their use in BV. In one research review [10]:

• Oral probiotics were found to be better than vaginal probiotics (delivered via suppositories)
• High-dose probiotics delivered better results than low-dose probiotics

The cumulative data from other studies on probiotics and BV suggests that: 

• An effective daily dosage appears to be in the range of at least 100 million to 1 billion CFU (coliform forming units) [10, 16, 17, 18].
• Lactic acid-producing lactobacillus species are probably the most relevant as they account for over 50% of the species naturally present in the healthy vagina of a woman of reproductive age [3]. The commonest probiotic lactobacillus strains successfully used in studies include [1]:
  • Lactobacillus crispatus (L. crispatus)
  • L. reuteri RC-14
  • L. fermentum
  • L. gasseri
  • L. rhamnosus GR-1
  • L. acidophilus

From my clinical experience of women experiencing repeated vaginal infections, taking several probiotic strains at the same time to cover all “good bacteria” bases is actually the best idea.

This is especially the case given we find that women who are more prone to BV are also likely to be experiencing gut bacteria imbalance too.

In fact, the gut and vaginal microbiome in females share similarities and are in continuous communication with each other.

The full implications of this aren’t understood, but at its most basic, healthy gut = healthy vagina.

Diet for BV

Beyond consuming probiotics for BV, there’s not a lot of research on diet for the condition, but it makes sense to eat healthily in order to promote a diverse and healthy microflora.

This means including plenty of whole, unprocessed foods, identifying and avoiding any foods you might be sensitive to, and including plenty of lean proteins, fruits and vegetables for nutritional completeness.

Many of our patients find that a Paleo-style diet (with similarities to the type our ancestors would have eaten) works well for them. You can get extra gut benefits by including fermented food, such as kimchi, kefir and kombucha that encourage good microbes to grow in the gut.

Vitamin C and BV

Some research shows that vitamin C (ascorbic acid) can be another treatment option for BV, and it can actually be administered vaginally to help directly restore the acidity of the vagina. This research has largely been sponsored by vitamin C manufacturers so should be treated with caution, but nonetheless seems promising.  In a clinical trial of 142 European women with BV, intravaginal use of silicone-coated 250mg vitamin C tablets reduced BV recurrence by nearly 50% [19].

Probiotics and BV: A Recap

Bacterial vaginosis is caused by bacterial balances in the vagina, and can often recur, especially after initial treatment with antibiotics. Probiotics are a better solution to clear BV over the longer term, backed up by a diet of minimally processed foods to create a healthier microbiome.

For more information on how a healthy gut microbiome can affect many aspects of your wellbeing including reproductive health, check out my book Healthy Gut, Healthy You.

The Ruscio Institute for Functional Medicine has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.