Women's Probiotic for Vaginal Health: Essentials You Need to Know

Our understanding of live microorganisms and their habitats has evolved significantly since Leeuwenhoek, the father of microbiology, first discovered “animalcules” (tiny animals) in the late 1600s. Today, we know that trillions of bacteria thrive in and on our bodies, impacting our digestive, immune, reproductive, and urinary tract health, among other functions.

Prioritizing feminine health involves understanding what comprises a healthy vaginal microbiota, especially since vaginal concerns like recurrent urinary tract infections (rUTIs) can impact mental, reproductive, and overall vaginal health in subtle ways. Let's delve into what a healthy vaginal flora looks like, factors that might disturb this unique ecosystem, the role of the estrobolome, practical advice on restoring the vaginal microbiome, and how probiotics can support better health.

The role of Lactobacillus in vaginal health

The vaginal microbiota is a dynamic community of microorganisms that changes throughout a woman's life and menstrual cycle. The female genital tract (vagina, cervix, endometrium, fallopian tubes, and ovaries) hosts roughly 9% of the total microbiota of the female body, with most of it belonging to the Lactobacillus species.

Researchers have been curious about the methods of vaginal and urogenital microbial colonization and have traced back vaginal and urogenital (kidneys, ureters, bladder, and urethra) microbiomes back to the gut via the rectum due to its proximity to the urethra, vaginal opening, and the anus. 

In interesting research conducted by Dr. Siouxsie Wiles and her team, glowing bacteria in mice were used to showcase microbial migration from one mucus membrane to another, in this case from the gut to the vagina.

Lactobacilli play a crucial role in maintaining vaginal health by dominating the vaginal microbiota and producing lactic acid, which helps maintain an acidic pH of 4. This acidic environment inhibits the growth of pathogenic bacteria and fungi, thereby preventing infections. Additionally, Lactobacillus species produce hydrogen peroxide and bacteriocins, further protecting against harmful microbes. 

Protective effects of Lactobacillus

Lactobacillus acts as a keystone species, crucial for sustaining vaginal microbial balance and overall reproductive health. Disruptions in Lactobacillus populations can lead to conditions like bacterial vaginosis and vaginal candidiasis. 

Vaginal epithelial cells and glycogen

The vagina is lined by epithelial cells that release glycogen (a type of sugar stored in cells) as they shed. Resident Lactobacillus species break down glycogen to lactic acid, which acidifies the vagina by lowering its pH and inhibits the growth of pathogens. 

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Vaginal flora and pH balance

Lactobacilli are gram-positive bacteria that dominate a healthy vaginal microbiota. Women of different ages and ethnicities display different types of vaginal bacterial compositions or community state types (CSTs). 

Community state type and composition

Based on the dominance of specific species of lactobacilli, there are five different CSTs:

• CST-I (Lactobacillus crispatus)
• CST-II (Lactobacillus gasseri)
• CST-III (Lactobacillus iners)
• CST-IV (diverse anaerobic composition)
• CST-V (Lactobacillus jensenii)

CST-I, II, III, and V generally display a pH of 4 and are considered to be the more protective CSTs than CST-IV. CST-IV is characterized by a higher diversity of anaerobic bacterial genera Prevotella, Atopobium, Gardnerella, etc., and displaying a higher pH of 5.3 are considered to be more likely to experience bacterial vaginosis.

Additionally, perimenopausal women who belong to CST-III (dominated by L. iners) are more likely to transition to CST-IV postmenopause.

Factors influencing vaginal microbiota

The microbial composition of the vagina can impact local and systemic immune health and local dysbiosis has been implicated in increased susceptibility to sexually transmitted infections, miscarriage, spontaneous preterm delivery, recurrent yeast infections, bacterial vaginosis (BV), and urinary tract infections (UTIs).

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Factors that either lead to a change in vaginal pH balance, or a decrease in beneficial bacteria might induce dysbiosis. A few of these factors include:

Menstruation 

Menstrual blood has a pH of 7.4 which can temporarily raise the pH of your vagina. During the menstruation cycle, while some CSTs remain stable, others might switch to a dysbiotic state (most likely between CST-III and CST-IV). 

Prolonged contact with perfumed and/or blood-saturated tampons and pads due to the higher pH of menstrual blood may affect the pH balance of the vagina. Additionally, most tampons are made of cotton and cotton blends. Cotton plants tend to store heavy metals like lead and cadmium, as well as pesticides like glyphosate (probably carcinogenic according to WHO). Tampon use has also been studied for its potential to raise inflammation markers in the body. A study including 150 tampon users links tampon use during menstruation with increased oxidative stress and inflammation markers and slightly higher blood mercury levels.

Sexual activity 

Unprotected sex may also lead to temporary changes in the vaginal pH and allow pathogens to proliferate. Semen is alkaline (7.2 to 7.8) which can neutralize the vaginal acidic environment, allowing pathogens to thrive and gain a foothold before the local microbiome can reestablish the acidic environment. 

Similar to the vagina, the penis hosts several microbes that may end up disturbing the vaginal environment. The use of scented lubricants might alter the pH of the vagina as well as introduce bad bacteria, like G. vaginalis, in case of unprotected sex. 

Douching and cleansers

Douching and cleansers can lead to abrupt changes in the local microbial population that may result in increased inflammation, which increases the risks of all genitourinary infections, including UTIs. 

Antibiotics

A thriving Lactobacillus population keeps the local yeast population in check by competing for space and resources, and antibiotics use can deplete this protective bacteria population, leaving the vagina vulnerable to chronic yeast infections.

Antibiotics after infections or surgery can wipe out large parts of your overall microbiome, including the vagina. Additionally, infections like UTIs are becoming recurrent (three or more infections in a year) due to increasing antibiotic resistance.

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Gut microbiome, estrogen, and Lactobacillus as you age

As we'd discussed earlier, lactobacilli depend on glycogen from epithelial cells for their growth. However, the level of glycogen in epithelial cells itself depends on estrogen levels in the body. Estrogen synthesis and release primarily occurs in the ovaries, but your estrobolome, a subset of your gut microbiota, also plays a role in how much active circulating estrogen you have. 

The estrobolome and estrogen recycling in the gut microbiome

The estrobolome refers to the collection of gut microbiota capable of metabolizing estrogens, and it plays a pivotal role in regulating the levels of circulating estrogens.

Estrogen Recycling Process

The liver binds estrogen, making it water-soluble for excretion via bile into the intestines. In the gut, however, certain bacteria produce the enzyme β-glucuronidase, which unbinds estrogen, allowing it to be reabsorbed into the bloodstream. The recycled estrogen can then circulate in the body and exert its effects.

A balanced estrobolome is crucial for maintaining optimal estrogen levels. Dysbiosis in the gut microbiome can disrupt this process, leading to either an excess or deficiency of estrogen, which can impact conditions such as obesity, polycystic ovary syndrome (PCOS), breast cancer, and endometriosis.

Menopause, vaginal microbiome, and urobiome

Menopause is associated with a stabilized CST IV (bacterial dominance other than lactobacilli) and a higher pH, which makes post-menopausal women more susceptible to infections such as UTI and BV. 

UTI is also one of the most common infections in individuals with high blood sugar and type 2 diabetes and displays an increasing incidence with age in adult women. 

1. coli-induced urinary tract infections are suspected to originate in the gut, believed to be due to the proximity of the female urethra and the anus. Some evidence suggests that vaginal microbiomes can harbor urogenital pathogens like E. coli. E. coli can reside in the vaginal microbiome after a bout of UTI and can cause recurrent UTI after the initial infection has subsided. 

The most common treatment for UTIs is antibiotic therapy, but 20-30% of women will develop a recurrent infection within 6 months. Repeated antibiotic therapy can lead to the development of antibiotic resistance. D-mannose is a naturally occurring sugar found in fruit and vegetables that has been studied and found to be effective in disrupting E. coli adhesion to the urinary tract. 

Vaginal microbiome and menopause

As the levels of estrogen rise and fall through a woman’s life cycle, so do lactobacilli and their protective effects in the vagina. As girls hit puberty and start producing estrogen, Lactobacillus begins to thrive. Throughout the childbearing age, a woman might see shifts in her primary CSTs based on external factors. Menopause can be a challenging time as estrogen levels and glycogen drop and bring with it a range of vaginal and urinary discomfort, including vaginal dryness and recurrent infections.

Studies propose that there are similarities in the urinary tract and vaginal microbiomes due to their proximity and a similar drop in Lactobacillus species in these ecosystems post-menopause.

Some studies report estrogen replacement therapy may lead to a Lactobacillus resurgence and a reduction in the recurrence of urinary tract infections, bacterial vaginosis, and yeast infections.

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Vaginal dysbiosis and Infections

Vaginal dysbiosis has been linked with multiple urogenital and reproductive conditions, some of which include pelvic inflammatory disease (PID), preterm delivery and low birth weight, postpartum and postabortal endometriosis, etc.

Common infections associated with CST-IV and vaginal dysbiosis include bacterial vaginosis (symptomatic and asymptomatic), vaginal candidiasis (yeast infection) and aerobic vaginitis (AV).

Bacterial vaginosis (BV)

Approximately, 29% of women ages 14-49 are estimated to have bacterial vaginosis in the USA. Symptoms of BV include gray, white, or green vaginal discharge, foul (fishy) smelling vaginal odor, vaginal itching and burning during urination. Treatments generally include antibiotics (metronidazole), but the effectiveness of such treatments is low and relapse is common.

Here's how antibiotics interact with your immune system and affect healthy bacteria.

BV is characterized by the depletion of lactobacilli and an increase in anaerobes such as Atopobium vaginae, Megasphaera spp., Prevotella spp., and Sneathia spp. BV is also associated with an increased risk of contracting STIs such as N. gonorrhea, C. trachomatis, T. vaginalis, HSV, HPV, and HIV, and other infections such as pelvic inflammatory disease, endometritis, chorioamnionitis, and amniotic fluid infection.

Vaginal yeast infection (VVC)

The vaginal mycobiota (fungal population) is dominated by C. albicans and is kept in check by a thriving Lactobacillus population. As Lactobacillus abundance goes down post-menopause, C. albicans might grow uninhibited.

Researchers hypothesize that the presence of symptomatic or asymptomatic BV and the resultant lack of lactic acid can act as a precursor to vaginal yeast infection. 

Probiotic supplements for vaginal and urogenital health

As discussed earlier, estrogen drives glycogen accumulation and vaginal epithelial cell maturation. Probiotic species of Bifidobacterium can produce an enzyme called β-glucuronidase in the gut, which helps free up estrogen from its bound form and makes it reusable by estrogen receptors.

Gut dysbiosis and inflammation have been linked with a decrease in gut microbial diversity and a reduced expression of β-glucuronidase which has been associated with a reduction in free estrogen in blood circulation. Similarly, increased activity of β-glucuronidase has been associated with type-2 diabetes and increased circulating estrogens in the body. 

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Hypo or low estrogen levels have been associated with obesity and PCOS (polycystic ovarian syndrome), a reproductive hormonal (endocrine) disorder. Hyper or high estrogen levels due to a higher expression of β-glucuronidase have been associated with breast cancer, endometriosis, and endometrial cancer.

This study of nearly 5,000 women found a correlation with probiotic intake, including Lactobacillus and Bifidobacteria species that may help regulate sex hormones like estrogen and testosterone in pre- and post-menopausal women. 

“The findings indicated that there were associations between probiotic intake and sex hormone levels in premenopausal and postmenopausal women. For premenopausal women, probiotic intake was positively associated with estradiol (E2) levels. On the contrary, in postmenopausal women, probiotic intake was inversely associated with total testosterone (TT) levels.”

Postmenopausal women can be more prone to vaginal health concerns due to a reduction in gut bacteria diversity associated with age and estrogen decline. A review suggests that probiotics Lactobacillus and Bifidobacteria) could potentially restore impaired phytoestrogen activation—freeing up plant estrogen (phytoestrogens in soy and red clover) to act on estrogen receptors in the body— to benefit conditions such as osteoporosis.

Probiotic recommendations for post-menopausal women included Lactobacillus casei, L. rhamnosus, and L. reuteri. Trials that included probiotic supplements of L. acidophilus, L. paracasei, and L. crispatus, propose that oral probiotics can enhance recovery rate and relieve symptoms of BV and vaginal yeast infections. 

Looking to support your vaginal health or simply tired of recurrent UTIs? Try our proprietary probiotic blend, Sugar Shift® that comes enriched with beneficial probiotic strains like L. plantarum (TBC LP-36™), L. paracasei, and L. reuteri (PCR07) associated with diverse and robust gut and vaginal health. These strains help convert glucose and fructose into mannitol, a powerful free radical scavenger! 

Probiotic Supplements — which strains should you look for?

These strains have been shown to enhance recovery rates and relieve symptoms of BV and vaginal yeast infections.

Recommended Probiotic Strains:

Lactobacillus casei

Lactobacillus rhamnosus

Lactobacillus reuteri

Lactobacillus acidophilus

Lactobacillus paracasei

Lactobacillus crispatus

Suggestions on Restoring the Vaginal Microbiome

Restoring the vaginal microbiome is essential for maintaining vaginal health and preventing infections. Here are some practical steps:

1. Probiotic Supplements: Take probiotics that are specifically formulated for vaginal health. Look for supplements containing strains like Lactobacillus rhamnosus, Lactobacillus reuteri, and Lactobacillus crispatus. These strains have been shown to enhance the recovery rate and relieve symptoms of BV and vaginal yeast infections.
2. Diet and Nutrition: A balanced diet rich in fiber, fruits, and vegetables supports overall microbiome health. Foods like yogurt, kefir, and fermented vegetables contain natural probiotics that can benefit vaginal health.
3. Avoid Douching and Harsh Cleansers: Douching and using scented or harsh cleansers can disrupt the natural balance of vaginal bacteria. Stick to mild, unscented soaps for cleaning the external genital area only.
4. Safe Sexual Practices: Use protection during sex to prevent the introduction of pathogenic bacteria and maintain a stable vaginal pH. Avoid using scented lubricants, which can disrupt the vaginal microbiome.
5. Manage Antibiotic Use: While antibiotics are sometimes necessary, they can disrupt the balance of bacteria in the vagina. If you need to take antibiotics, consider taking probiotic supplements to help restore your microbiome.
6. Hydration: Staying well-hydrated helps maintain overall health, including vaginal health. Drink plenty of water to support your body's natural processes.
7. Wear Breathable Underwear: Choose cotton underwear and avoid tight-fitting clothing that can create a moist environment conducive to bacterial growth.
8. Regular Check-ups: Regular gynecological check-ups can help detect and address any imbalances in the vaginal microbiome early on.

Maintaining a healthy vaginal microbiota is crucial for overall feminine health. Understanding the role your diet, lifestyle, and age can have on the Lactobacilli population and how probiotics can help support your gut and vaginal health moving forward!

Frequently Asked Questions:

Do probiotics help feminine odor?

Vaginal malodor is generally associated with vaginal dysbiosis and if it smells fishy, then it might be a symptom of bacterial vaginosis. Research supports that probiotics that include strains like Lactobacillus acidophilus, L. acidophilus, and L. rhamnosus may help improve vaginal microbiota.

Do women's probiotics help with BV?

Studies suggest oral probiotics may help establish a healthy vaginal microbiota and help with bacterial vaginosis (BV).

How long does it take for probiotics to work for BV?

Oral probiotics may take up to seven days to begin affecting the vagina and work for BV.  Changes will depend on several factors including diet, medications, and sexual activity.