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Use of Lactobacillus for the Treatment of Vulvovaginitis
Source: Jeavons HS. Prevention and treatment of vulvovaginal candidiasis using exogenous Lactobacillus. J Obstet Gynecol Neonatal Nurs 2003;32:287-296.
Abstract: The author reviewed literature examining exogenous Lactobacillus therapy for vulvovaginal candidiasis and discusses recommendations for clinical practice and future research. Computerized searches on MEDLINE and CINAHL were done in November 2000, September 2001, and March 2002, with search terms including Lactobacillus, acidophilus, Candida, and yeast infections. Relevant English-language articles from the past 10 years were included in the analysis, and unique or seminal studies included where pertinent. Data are organized under the following headings: endogenous Lactobacillus, exogenous Lactobacillus, Candida, studies of intravaginal Lactobacillus therapy for vulvovaginal candidiasis, studies of oral Lactobacillus therapy for vulvovaginal candidiasis. The author concluded that vaginally administered or orally ingested Lactobacillus is able to colonize the vaginal ecosystem. Controlled intervention studies regarding the effect of such colonization on vulvovaginal candidiasis are promising but few. These studies had small numbers of participants, were inconsistent in the form of Lactobacillus used, and reported conflicting results. Further randomized controlled trials involving large numbers of women are imperative. In the meantime, health care providers should discuss potential benefits with affected patients while clarifying the current lack of conclusive evidence. Without further research into currently available sources and brands of Lactobacillus and without governmental regulation of supplements and their contents, however, it is difficult to make recommendations regarding appropriate product choice.
Comments by Mary L. Hardy, MD
Vaginitis or symptoms of vaginal irritation account for millions of office visits a year and Candida sp. are the most common etiologic agents identified. Effective oral and topical therapies exist for fungal vulvovaginitis, but treatments are not universally effective. Patients commonly turn to over-the-counter (OTC) remedies, including alternative therapies such as probiotics, for relief especially of chronic symptoms. Dr. Jeavons suggested in her recent review that therapy with Lactobacillus "represents low risk of therapeutic resistance and side effects, low financial cost, and greater appeal for women who prefer natural methods for their health maintenance." Her recent article reviews the research on the use of exogenous Lactobacillus for treatment and prevention of vulvovaginal candidiasis (VVC) and makes clinical recommendations regarding appropriate clinical use.
A recent study focused on the use of OTC and complementary and alternative medicine (CAM) therapies for chronic vaginal symptoms.1 Most patients thought they had candidiasis and 74% treated with OTC anti- fungal preparations. About half as many patients (42%) used the following CAM therapies, in descending order of frequency of use: acidophilus pills orally (50%), yogurt orally (20.5%), yogurt vaginally (18%), vinegar douche (14%), boric acid (14%), and acidophilus pills vaginally (11%). Significantly, less than a third of the women (28%) actually had candidiasis and those women who were correct in their self diagnosis were twice as likely to have used CAM therapies. Patients also were less likely to disclose use of CAM products than OTC products to their health care provider.
Lactobacillus sp. have been used to treat or prevent a variety of conditions such as urinary tract infections, traveler's diarrhea, C. difficile, and other bacterial diarrheas as well as VVC.2 In normal vaginal flora, a complex mixture, Lactobacillus is the most commonly identified species. However, L. acidophilus, the species most commonly available commercially, is not the only species present in healthy vaginal flora and may not be the dominant species in vivo. The use of active lactobacillus cultures is biologically plausible as there are a number of mechanisms by which lactobacilli can prevent overgrowth of potentially pathogenic species of yeast and bacteria. First, they all produce lactic acid as a byproduct of glucose metabolism, thus acidifying the vagina. Some species produce hydrogen peroxide or other antibacterial compounds and compete with pathogens for binding sites in vaginal epithelium.
According to Dr. Jeavons’ review, evidence does exist that exogenously provided Lactobacillus sp. can colonize the vagina when given either orally or intravaginally both in dairy products as well as dietary supplements. Most supplementation needs to continue chronically to sustain continued colonization. Several species have been tested and have shown that a relatively long duration of treatment is necessary, on the order of 2-6 months. There is likely a difference in effect based on species chosen and possibly on vehicle of delivery (yogurt-based bacteria were shown in one trial to be less likely to adhere to the vaginal wall). Some studies have also looked at the rate of rectal colonization to determine if vaginal bacteria are seeded into the vagina from the rectum (probably) and if the action of the bacteria in the colon on yeast populations there is definitive for vaginal colonization (unclear from present data). Clinical evidence at this point is insufficient to answer these questions definitively.
Most clinical testing of exogenous Lactobacillus is concerned with the ability of these bacteria to relieve current symptoms (with or without a confirmed diagnosis of VVC) and to prevent recurrent attacks. The data are generally scanty as reported by Dr. Jeavons, but encouraging. Most studies had problems with small numbers of subjects, inadequate controls, or lack of blinding, as well as high attrition rates. Encouragingly, one well-done recent trial examined recurrent episodes of VVC in HIV-positive women who were treated weekly for an average of 21 months with placebo, clotrimazole, or L. acidophilus administered vaginally.3 The women in the acidophilus group had only half the risk of developing VVC compared to the placebo group. This reduction in risk is excellent compared to the 60% reduction in risk of the clotrimazole-treated group in these immunocompromised patients. Additional clinical research is urgently needed to clarify how to use these probiotic foods and products to effectively treat patients.
For practicing clinicians, relevant information can be gleaned from this review. First, there is a plausible biologic rationale for the use of exogenous Lactobacillus sp. Prophylaxis is probably a better indication for these products than acute treatment, although there is no evidence of toxicity in acute care. Clinical evidence, while not yet sufficiently strong for a firm recommendation, is encouraging. Given, the low toxicity and relatively low cost of these interventions (especially the yogurt), including this therapy in the options discussed with patients is reasonable. In fact, for patients with chronic symptoms or recurrent infections, it is recommended that clinicians actively solicit information about their patients’ use of CAM therapies, since patients may not volunteer this information.
Patient adherence may be a limiting factor for the use of probiotic products or foods with active cultures. Treatment may need to be of long duration. Clinical trials documented that large numbers of patients failed to adhere to the clinical regimens. Oral therapies were better tolerated than topical or intravaginal products. Choice of a commercial product should be made based on the amount of live bacteria of an appropriate species the product provides. Some products have been reported to be contaminated with other bacteria than the target organisms. Yogurt preparations generally have been found to contain single species and can be therapeutically useful. So in summary, for patients with recurrent symptoms or repeated infections of VVC, the choice of an appropriate product given for a sufficient amount of time represents a reasonable addition to the clinical armamentarium in this area.
Dr. Hardy is Medical Director Cedars-Sinai Integrative Medicine Medical Group Los Angeles, CA.
1. Nyirjesy P, et al. Over-the-counter and alternative medicines in the treatment of chronic vaginal symptoms. Obstet Gynecol 1997;90:50-53.
2. Elmer GW, et al. Biotherapeutic agents: A neglected modality for the treatment of prevention of selected intestinal and vaginal infections. JAMA 1996;275: 870-876.
3. Williams AB, et al. Evaluation of two self-care treatments for prevention of vaginal candidiasis in women with HIV. J Assoc Nurses AIDS Care 2001;153: 740-743.