By Amanda Stuart, PT, DPT, PHRC West Los Angeles
The vagina, like the gut, hosts its own ecosystem of microorganisms, known as the Vaginal Microbiome (VMB). When there’s a disruption in this ecosystem (dysbiosis), it can lead to various infections affecting genital and reproductive health. These infections may include bacterial vaginosis (BV), aerobic vaginitis (AV), cytolytic vaginosis, vulvovaginal candidiasis (yeast infections), and sexually transmitted infections (STIs). In this week’s blog, we will discuss how imbalances in the microbiome play a role in these conditions and the latest evidence.
Recently, the human microbiome has been the focus of several areas of research, while it is in its infancy, we are starting to learn more about the role these invisible organisms have on our health. Before diving into changes, we need to understand what a ‘healthy’ environment looks like.
Oftentimes people initially associate the word “microbiome,” with gut health or maybe even the skin’s ecosystem. In this instance, the vaginal microbiome is just as important to overall well-being and deserves equal acknowledgment. This complex community of microorganisms plays a crucial role in maintaining vaginal health, preventing infections, and supporting reproductive and sexual health.
Composition of a Healthy VMB:
- Dominated by lactobacillus bacteria, which produce lactic acid and bacteriocins, this maintains a healthy acidic pH which reduces risk of these conditions.
- Studies show that lactobacilli and the resulting acidic pH of the vagina promote a healthy epithelial barrier, inhibiting the colonization of harmful microbes.
Host Factors affecting the VMB:
- Genetic factors, including racial background, can influence the composition of the VMB.
- Different Lactobacillus species, like L. crispatus and L. iners, have varying effects on the VMB and susceptibility to infections.
- L. crispatus is associated with lower risks of infections like bacterial vaginosis and vulvovaginal candidiasis, while L. iners may coexist with bacteria linked to dysbiosis.
Bacterial Vaginosis (BV):
- BV involves the displacement of Lactobacilli by anaerobic bacteria like Gardnerella vaginalis.
- BV-associated bacteria produce biofilms that disrupt the vaginal mucosal and epithelial barriers, increase the vaginal PH and produce enzymes that enhance their ability to colonize.
- Treatment with Metronidazole is initially successful but recurrence is common at a rate of 50% within as little as 12 weeks to 12 months.
- Introducing L. Crispatus following Metronidazole treatment has been shown to decrease recurrence by 15% at week 12.
Vulvovaginal Candidiasis (Yeast):
- Vulvovaginal Candidiasis often occurs when the vaginal environment is altered by antibiotic treatment, hormonal changes, metabolic disease, immunological incompetence, sexual activity or other conditions that permit yeast, mainly Candida species (spp.), to colonize the female reproductive tract.
- L. Crispatus dominance is associated with lower risks of Candida colonization.
- Treatment involves antifungal medication such as Fluconazole, Nystatin, etc.
Aerobic Vaginitis:
- Aerobic Vaginitis is typically associated with purulent discharge, vaginal itching, dyspareunia and an inflamed vaginal wall.
- Similar to BV, this condition presents with a reduction of vaginal Lactobacilli.
- The bacteria most frequently encountered in aerobic vaginitis include group B streptococcus (GBS), E. coli and Staphylococcus aureus.
- A combination of antibiotics and probiotics are commonly used for treatment.
Closing Thoughts:
Now that I’ve discussed certain characteristics of both a healthy and unhealthy vaginal microbiome, let’s conclude with talking about how to address the dysbiosis that can occur:
- Low-dose transvaginal topical estrogen has shown to be effective at engendering a more optimal Lactobacillus-rich microbiome while not increasing the risk of estrogen-sensitive cancers.
- Probiotics, combined with antibiotics or antifungals and estrogen therapy, may improve the vaginal microbiome balance and vaginal health.
- It is important to note that Cytolytic Vaginosis would be the exception in that probiotics would not be warranted as this is caused by an overgrowth of Lactobacilli.
- Other treatments like Statins and vitamin D may also be beneficial.
- Vaginal Microbiome transplants from healthy donors have shown promise in treating recurrent BV but come with risks and challenges.
Composition of the Vaginal Microbiome in Vaginitis
Condition Vaginal Microbiome Features
Cytolytic vaginosis |
Overgrowth of Lactobacillus spp. |
Bacterial vaginosis |
Enrichment of Atopobium vaginae, BVAB1, BVAB2, BVAB3, Gardnerella vaginalis, Mobiluncus spp., Mycoplasma spp., Porphyromonas spp., Prevotella spp., Sneathia spp., and Ureaplasma spp.; depletion of Lactobacillus spp. |
Vulvovaginal candidiasis |
Normal to BV-like vaginal microbiome; colonization by Candida albicans, Candida glabrata, Candida parapsilosis, Candida tropicalis, or Candida krusei. |
Trichomoniasis (STI) |
BV-like vaginal microbiome; invasion by Trichomonas vaginalis |
Aerobic vaginitis or desquamative inflammatory vaginitis |
Depletion of Lactobacillus spp.; frequent detection of aerobic, enteric bacteria, e.g., E. coli, Enterococcus spp., Staphylococcus spp., and Streptococcus spp. aBVAB1, “Candidatus Lachnocurva vaginae”; BVAB2, Lachnospiraceae BV-associated bacterium 2; BVAB3, Mageeibacillus indolicus. |
Understanding the intricacies of the microbiome extends beyond just gut health—it’s a holistic view of the human body’s interconnected systems, including those critical to pelvic health. The vaginal microbiome, for instance, plays a pivotal role in preventing infections and maintaining overall reproductive wellness. Incorporating prebiotic foods into your diet can support these beneficial microorganisms, fostering a balanced and healthy microbiome throughout the body. By raising awareness and promoting education on this topic, we can empower individuals to make informed decisions about their health and recognize the importance of a balanced vaginal microbiome. Understanding this often-overlooked aspect of health is essential for holistic wellness.
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Check out our recently published e-book titled “Vulvodynia, Vestibulodynia, and Vaginismus,” designed to empower and inform individuals on their journey towards healing and understanding.
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