The Efficacy of Probiotics in the Treatment of Vulvovaginal Infections

Introduction: Bacterial vaginosis (BV) and recurrent vulvovaginal candidiasis (RVVC) are the most common causes of vaginal infection and discomfort among the female population during reproductive age. Although BV can be treated with oral metronidazole or intravaginal clindamycin, these treatments do not restore the normal vaginal microbiota or provide long-term defensive protection against recurring infections. The current maintenance regimen for those with RVVC is oral fluconazole by mouth daily for 6 months. Of these patients, 30-50% will have a relapse of the disease once the maintenance therapy is stopped. Therefore, this review analyzes whether adjuvating the conventional maintenance therapy of antibiotics or antifungals [C] with a daily probiotic [I] will provide greater relief of symptoms and decreased recurring episodes [O] among premenopausal women [P]. Methods: A literature search was conducted through PubMed and EBCOhost in November 2018. A total of six articles consisting of randomized control trials, prospective cohort, and case-control studies were selected based on their relevance to the research question, publication date, measurement of variables, and results. The study designs and overall outcomes amongst the selected articles were analyzed and compared. Results: All six of the analyzed studies showed a significant increase in the time to recurrence of infection when probiotics were added to the treatment regimen. However, there was not enough statistical evidence supporting an increase in cure rate with probiotics when compared to standard pharmacological treatment. Four of the six trials did demonstrate a statistically significant improvement in symptomatic relief with the use of probiotics. At baseline, three of the studies analyzed antibiotic vs. antibiotic and probiotic and one analyzed antibiotic vs. probiotic. The other two studies analyzed antifungal vs. antifungal and probiotic. Aside from the time to recurrence and symptomatic improvement, the studies did not have uniform comparable outcomes (i.e. Nugent score, Amsel’s criteria, colonization of Lactobacilli). Discussion: Each study presented positive outcomes when probiotics were introduced into the sample population, but the six selected studies used different baseline disease states and different probiotic strains making comparison among outcomes difficult. These criterion in addition to limited use of randomized control trials and lack of long-term follow-up hindered the findings from becoming clinically significant. Overall, there were no adverse side effects to the probiotics and use was generally well-tolerated. This encourages the need for further study and clinical trial. Conclusion: The emergence of probiotic use is an innovative and growing topic in the medical field. Although many people in the holistic community encourage probiotic use for a healthy microbiome, there is limited scientific evidence supporting these claims other than personal testimony. The six studies that were selected for review found significant symptomatic improvement and increased time to recurrence when probiotics were added to their pharmacologic regimen. However, there was not enough statistical evidence supporting the claim that probiotics increased cure rates of vulvovaginal infections. Due to tolerability and increase in symptomatic improvement, providers may consider adjuvating standard treatment options with probiotics, but there is not enough evidence to change standard of practice for vulvovaginal infections