Your Guide to Using Probiotics for BV (Bacterial Vaginosis) - Dr. Michael Ruscio, DC

Does your gut need a reset?

Yes, I'm Ready

Do you want a second opinion?

Yes, I Need Help

Do you want to start feeling better?

Yes, Where Do I Start?

Your Guide to Using Probiotics for BV (Bacterial Vaginosis)

How to Help Bacterial Vaginosis with Friendly Bacteria

Key Takeaways:

  • Bacterial vaginosis (BV) is a type of vaginal infection caused by an imbalance in good and bad bacteria
  • Symptoms occur when healthy lactobacilli, which produce lactic acid and keep the vaginal tract acidic, are overrun by less beneficial bacteria.
  • Probiotics are supplements of live friendly bacteria, and include the type that keeps the vagina healthy
  • Probiotics are of proven benefit in BV and can work with or without antibiotics
  • They can help not just with a current bout of BV but also to prevent recurrences

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?

Menstrual pain woman with stomachache

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

Your Guide to Using Probiotics for BV (Bacterial Vaginosis) - How%20Probiotics%20Work Landscape L

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 can 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

Your Guide to Using Probiotics for BV (Bacterial Vaginosis) - 3%20Categories%20of%20Probiotics %2016%20x%209 %20Landscape L

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

Buddha bowl dinner with boiled egg, chickpea, fresh tomato, sweet pepper, cucumber, savoy cabbage, red onion, green sprouts, spinach leaves, blueberry, walnuts, chia and quinoa

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.

➕ References
  1. Kairys N, Garg M. Bacterial Vaginosis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. PMID: 29083654.
  2. Bacterial vaginosis – Symptoms and causes – Mayo Clinic [Internet]. Available from: https://www.mayoclinic.org/diseases-conditions/bacterial-vaginosis/symptoms-causes/syc-20352279
  3. Verstraelen H, Vieira-Baptista P, De Seta F, Ventolini G, Lonnee-Hoffmann R, Lev-Sagie A. The vaginal microbiome: I. research development, lexicon, defining “normal” and the dynamics throughout women’s lives. J Low Genit Tract Dis. 2022 Jan 1;26(1):73–8. DOI: 10.1097/LGT.0000000000000643. PMID: 34928256. PMCID: PMC8719517.
  4. Kim J-M, Park YJ. Probiotics in the prevention and treatment of postmenopausal vaginal infections: review article. J Menopausal Med. 2017 Dec 29;23(3):139–45. DOI: 10.6118/jmm.2017.23.3.139. PMID: 29354612. PMCID: PMC5770522.
  5. Afifirad R, Darb Emamie A, Golmoradi Zadeh R, Asadollahi P, Ghanavati R, Darbandi A. Effects of Pro/Prebiotics Alone over Pro/Prebiotics Combined with Conventional Antibiotic Therapy to Treat Bacterial Vaginosis: A Systematic Review. Int J Clin Pract. 2022 Apr 21;2022:4774783. DOI: 10.1155/2022/4774783. PMID: 35685517. PMCID: PMC9159122.
  6. Wu S, Hugerth LW, Schuppe-Koistinen I, Du J. The right bug in the right place: opportunities for bacterial vaginosis treatment. npj Biofilms and Microbiomes. 2022 May 2;8(1):34. DOI: 10.1038/s41522-022-00295-y. PMID: 35501321. PMCID: PMC9061781.
  7. Lackie JM. H. In: The dictionary of cell & molecular biology. Elsevier; 2013. p. 287–319. DOI: 10.1016/B978-0-12-384931-1.00008-8.
  8. O’Hanlon DE, Moench TR, Cone RA. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS ONE. 2013 Nov 6;8(11):e80074. DOI: 10.1371/journal.pone.0080074. PMID: 24223212. PMCID: PMC3819307.
  9. Juven BJ, Pierson MD. Antibacterial effects of hydrogen peroxide and methods for its detection and quantitation †. J Food Prot. 1996 Nov;59(11):1233–41. DOI: 10.4315/0362-028X-59.11.1233. PMID: 31195444.
  10. Chen R, Li R, Qing W, Zhang Y, Zhou Z, Hou Y, et al. Probiotics are a good choice for the treatment of bacterial vaginosis: a meta-analysis of randomized controlled trial. Reprod Health. 2022 Jun 13;19(1):137. DOI: 10.1186/s12978-022-01449-z. PMID: 35698149. PMCID: PMC9195231.
  11. Cohen CR, Wierzbicki MR, French AL, Morris S, Newmann S, Reno H, et al. Randomized Trial of Lactin-V to Prevent Recurrence of Bacterial Vaginosis. N Engl J Med. 2020 May 14;382(20):1906–15. DOI: 10.1056/NEJMoa1915254. PMID: 32402161. PMCID: PMC7362958.
  12. Liu HF, Yi N. A systematic review and meta-analysis on the efficacy of probiotics for bacterial vaginosis. Eur Rev Med Pharmacol Sci. 2022 Jan;26(1):90–8. DOI: 10.26355/eurrev_202201_27752. PMID: 35049024.
  13. Tidbury FD, Langhart A, Weidlinger S, Stute P. Non-antibiotic treatment of bacterial vaginosis-a systematic review. Arch Gynecol Obstet. 2021 Jan;303(1):37–45. DOI: 10.1007/s00404-020-05821-x. PMID: 33025086.
  14. Hanson L, VandeVusse L, Jermé M, Abad CL, Safdar N. Probiotics for treatment and prevention of urogenital infections in women: A systematic review. J Midwifery Womens Health. 2016 May;61(3):339–55. DOI: 10.1111/jmwh.12472. PMID: 27218592.
  15. Wei K, Chen T. [Vaginal microbiota transplantation for treatment of bacterial vaginosis: a review]. Sheng Wu Gong Cheng Xue Bao. 2021 Nov 25;37(11):3820–7. DOI: 10.13345/j.cjb.210163. PMID: 34841787.
  16. Wang Z, He Y, Zheng Y. Probiotics for the Treatment of Bacterial Vaginosis: A Meta-Analysis. Int J Environ Res Public Health. 2019 Oct 12;16(20). DOI: 10.3390/ijerph16203859. PMID: 31614736. PMCID: PMC6848925.
  17. Li C, Wang T, Li Y, Zhang T, Wang Q, He J, et al. Probiotics for the treatment of women with bacterial vaginosis: A systematic review and meta-analysis of randomized clinical trials. Eur J Pharmacol. 2019 Dec 1;864:172660. DOI: 10.1016/j.ejphar.2019.172660. PMID: 31562865.
  18. Huang H, Song L, Zhao W. Effects of probiotics for the treatment of bacterial vaginosis in adult women: a meta-analysis of randomized clinical trials. Arch Gynecol Obstet. 2014 Jun;289(6):1225–34. DOI: 10.1007/s00404-013-3117-0. PMID: 24318276.
  19. Krasnopolsky VN, Prilepskaya VN, Polatti F, Zarochentseva NV, Bayramova GR, Caserini M, et al. Efficacy of vitamin C vaginal tablets as prophylaxis for recurrent bacterial vaginosis: a randomised, double-blind, placebo-controlled clinical trial. J Clin Med Res. 2013 Aug;5(4):309–15. DOI: 10.4021/jocmr1489w. PMID: 23864922. PMCID: PMC3712888.

Need help or would like to learn more?
View Dr. Ruscio’s, DC additional resources

Get Help

Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!