Bacterial vaginosis (BV) is the most common vaginal infection in women. It is characterized by vaginal fishy odor, vaginal discharge (usually thin, gray or white or even greenish) and irritation and/or burning and/or itching. Women and practitioners can easily conclude incorrectly that the symptoms are due to a yeast infection, but a test of vaginal pH and an amine test of the discharge confirm the diagnosis. It’s not something you “catch” from someone else, meaning it is not considered a sexually transmitted infection , but rather a result of a displacement of the optimal lactic acid producing lactobacilli in the vagina by the already present, but now over populated anaerobic organisms of BV . There are some potential complications of BV rather than just annoying, including: risk of preterm birth if you have BV during pregnancy, an increased risk for sexually transmitted infections, pelvic inflammatory disease and an increased risk of a pelvic infection post certain pelvic surgeries such as a hysteroscopy or dilation and curettage.
One of the most challenging aspects of BV is that it can easily recur, despite conventional standard of care treatment with antibiotics.
This study was funded by the National Institute of Health to assess whether intravaginal replacement of Lactobacillus crispatus, considered a “good” vaginal bacteria, would reduce the risk of recurrence of BV. This double-blind, placebo-controlled trial was conducted in 228 women who had recently been treated with a common antibiotic for BV, called metronidazole. The women inserted a preparation of Lactobacillus crispatus or placebo for 4 consecutive days during the first week, then twice weekly for 10 weeks.
At week 12, 30% of the women who received the L. Crispatus had a recurrence and 45% of those receiving placebo had a recurrence of BV. At week 24, recurrence rates were 39% for the L. crispatus group and 54% for the placebo group. However, the recurrence rate for 19% of the women was unknown.
Commentary: There have been many good studies of lactobacillus species and strains for BV, and now we can add this one. However, I would want the results to be even better, and as you can see, at 24 weeks, the recurrence rates are higher, implying longer treatment is needed. Recurrence rates are famously high for even a first episode of acute BV making it a challenge for all practitioners and women who are dealing with BV, but even more so for women with recurring BV. About 30% of women experience a recurrence of symptomatic BV within 30 to 90 days, and 70% will have a recurrence within 9 months. Clearly, a more effective approach is needed. While this one organism, L. crispatus is an important consideration, I find that better results could be achieved when incorporating the other research that has been done on other species as well, such as L. rhamnosus and L. reuteri, and in addition, vaginal vitamin C tablets and Boric acid.
Because the recurrence rate is high for a simple case of BV, I can make a compelling case for using an integrative approach with both antibiotics and natural agents. I also prefer to use vaginal antibiotics rather than systemic, for this condition. The overriding concept is to restore normal vaginal ecology with lactic acid producing lactobacilli species to be dominant. A normal vaginal pH is more acidic in the range of 3.5-4.5, that is why you see research on the acidic items of vitamin C, boric acid and lactic acid producing lactobacilli.
: Cohen C, et al. Randomized trial of Lactin-V to prevent recurrence of bacterial vaginosis. NEJM 2020 May 14;382:1906
