Introduction:
Bacterial vaginosis (BV) is one the most common causes of vaginal discharge and odor in women of childbearing age. The term “vaginosis” implies no redness, pain, or inflammation but the term “vaginitis” is a general term used to describe inflammation, pain, redness, itching, odor, and discharge. Most vaginitis is caused by bacterial vaginosis, vaginal candidiasis (also known as vaginal yeast infection), vulvar candidiasis (also known as a vulva yeast infection), or Trichomonas vaginitis.
Important points regarding bacterial vaginosis (BV):
Risk factors for BV include smoking, African American heritage, douching, sexual activity, and use of intrauterine contraceptives (1). BV occurs when a reduction in the normal lactobacillus flora of the vagina results in an increase of acidity of the vagina and anaerobic bacteria are promoted. These anaerobes cause the odor and discharge. There are several different anaerobic bacteria which cause BV, the most commonly known one is Gardnerella vaginalis. A gynecology evaluation is the ideal approach to proper diagnosis and treatment which is especially important in pregnancy since BV and vaginitis increases the risk of preterm labor. A vaginal yeast infection may be accurately recognized by women with prior experience in this condition. If self-treatment by using an over the counter antifungal medication does not result in clearance of vaginitis symptoms, proper diagnosis should be pursued by a gynecologist. Diagnosis is critical to determine accurate treatment which is best accomplished by a gynecologist.
Probiotics and vaginal yeast infections:
Studies outlining the use of probiotics for vaginal yeast infections have yielded mixed results.
Lactobacillus and yeast infections:
A review of available clinical trials by Falagas, M. E et al showed that the effectiveness of a probiotic called Lactobacilli (including Lactobacillus acidophilus, Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC-14) for the treatment of recurrent vulvovaginal candidiasis (’yeast infection’) in women is limited. According to the author, some studies support the effectiveness of lactobacilli in preventing the growth of harmful bacteria (C. albicans) and others do not. (2)
Use of lactobacillus (yogurt) for the treatment of bacterial vaginosis in 11 women aged 20 to 60 was effective. After 3 days of intravaginal application of 5 ml of commercial yogurt (pH 4.3 +/- 0.2) vaginal discharge, redness, and pH were significantly improved. There was 29 bacteria strains detected total. Following the 3 days of treatment, all 14 strains of the gram negative bacteria were no longer present. Overall 6/11 or 54.5% of bacterial vaginosis cases were completely resolved and 3 cases were partially improved. (3)
Probiotics, vaginal infection, and preterm labor:
A review of 4 studies by Othman M et al use pooled results from 2 studies to assess whether probiotic use can affect the rate of preterm delivery. Out of the 4 studies, the author excluded 2 of them because there was no data available in one and another was not complete. The 2 included studies included one that supplemented mothers who were 34 weeks pregnant with oral fermented milk (essentially yogurt). A second study used yogurt intravaginally starting in early pregnancy. The conclusion of the author was that the use of probiotics in the form of fermented milk or yogurt in pregnancy, either by oral route or by intravaginal application, reduced the risk of genital infection by 81%. There was not enough evidence for using probiotics to reduce the incidence of preterm labor. (4)
Boric acid and yeast infections:
Boric acid may be used to treat vaginal yeast infections using a 600 mg capsule intravaginally each bedtime for 7-14 nights. Rash and redness of the skin or vagina has been reported. Boric acid should not be taken by mouth, it should be avoided in pregnancy or women of child-bearing age, avoid on broken skin, and should not be given to children.
Boric acid vs. fluconazole: In a randomized, open-label trial by Ray D et al revealed that boric acid was more effective for the treatment of C. glabrata yeast infection than fluconazole. Women with diabetes and vulvovaginal candidiasis (’yeast infection) were randomized to receive either a single 150 mg oral dose of fluconazole or 2 weeks of 600 mg/day boric acid intravaginally. Of the 111 women the specific organism causing the yeast infection were C. glabrata in 61.3%, and C. albicans in 28.8%. Results show that among patients with C. glabrata infection, 63.6% of boric acid recipients and only 28.6% of those given a single dose of fluconazole had the infection clear at day 15. In conclusion, boric acid was more effective for the treatment of C. glabrata yeast infection than fluconazole. (5) Another study by Sobel JD et al confirmed these findings. Researchers report clinical improvement in 81% and a negative infection test result in 77% of women (n=60) with symptomatic Torulopsis glabrata vaginitis treated with vaginal boric acid (600 mg intravaginally per night for 14 consecutive nights). (6)
Concerns about the use of boric acid: Intravaginal boric acid should not be taken during pregnancy to avoid potential risk to the unborn child. A pregnancy test should be taken before using this agent. According to Fail PA et al, exposure of the unborn child to boric acid during pregnancy is minimal and the link between boric acid exposure to birth defects is only a theory. It is believed by the author of the study that only a limited amount of boric acid is absorbed in the vagina unless there is severe vaginal damage. (7) A retrospective case-control study conducted in Hungary found a weak non-significant link between boric acid and major birth defects. The authors concluded that vaginal boric acid treatment during pregnancy may be linked to malformations. (8)
Conclusion: Bacterial Vaginosis, Vaginitis, and Vaginal Candidiasis
- A gynecology evaluation is the ideal approach to proper diagnosis and treatment of this condition which is especially important in pregnancy since it increases the risk of preterm labor. Diagnosis is critical to determine accurate treatment which is best accomplished by a gynecologist.
- The use of probiotics in the form of fermented milk or yogurt in pregnancy, either by oral route or by intra-vaginal application, reduced the risk of genital infection by 81% during pregnancy according to 1 study. There was not enough evidence for using probiotics to reduce the incidence of preterm labor in the same study.
- 3 days of intra-vaginal yogurt application at a dose of 5 ml was effective for the treatment of bacterial vaginosis in women aged 20 to 60.
- Studies outlining the use of probiotics for vaginal yeast infections have yielded mixed results, and therefore over the counter antifungal medication or intra-vaginal boric acid suppository is likely more effective.
- Boric acid taken for 2 weeks at an intra-vaginal suppository dose of 600 mg/day was more effective for the treatment of C. glabrata yeast infection than a single oral 150 mg dose of fluconazole. Boric acid should not be taken during pregnancy or women of child-bearing age to avoid potential risk to the unborn child. Boric acid may be used to treat vaginal yeast infections using a 600 mg capsule intravaginally each bedtime for 7-14 nights. Rash and redness of the skin or vagina has been reported. Boric acid should not be taken by mouth, it should be avoided in pregnancy, avoid on broken skin, and should not be given to children.
References:
1.Morris M, Nicoll A, Simms I, Wilson J, Catchpole M. Bacterial vaginosis: a public health review. BJOG. 2001 May;108(5):439-50. http://www.ncbi.nlm.nih.gov/pubmed/11368127
2.Falagas, M. E., G. I. Betsi, et al. Probiotics for prevention of recurrent vulvovaginal candidiasis: a review. J Antimicrob Chemother 2006; 58(2): 266-272. http://www.ncbi.nlm.nih.gov/pubmed/16790461
3.Chimura T, Funayama T, Murayama K, Numazaki M. [Ecological treatment of bacterial vaginosis]. [Article in Japanese]. Jpn J Antibiot. 1995 Mar;48(3):432-6. http://www.ncbi.nlm.nih.gov/pubmed/7752457
4.Othman M, Neilson JP, Alfirevic Z. Probiotics for preventing preterm labour. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005941. http://www.ncbi.nlm.nih.gov/pubmed/17253567
5.Ray D, Goswami R, Banerjee U, et al. Prevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis. Diabetes Care 2007; 30:312–7. http://www.ncbi.nlm.nih.gov/pubmed/17259500
6.Sobel JD, Chaim W: Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis. 1997 Apr; 24(4): 649–652. http://www.ncbi.nlm.nih.gov/pubmed/9145739
7.Fail PA, Chapin RE, Price CJ, Heindel JJ. General, reproductive, developmental and endocrine toxicity of boronated compounds. Reprod Toxicol. 1998;12(1):1–18. http://www.sciencedirect.com/science/article/pii/S0890623897000956
8.Acs N, Bánhidy F, Puhó E, Czeizel AE. Teratogenic effects of vaginal boric acid treatment during pregnancy. Int J Gynaecol Obstet. 2006 Apr;93(1):55-6. http://www.ncbi.nlm.nih.gov/pubmed/16530197
