Can probiotics (Probiotic Bacteria) be used to treat yeast infections or bacterial vaginosis (BV)?

Probiotics for Yeast Infections and Bacterial Vaginosis

Probiotics show promising results for treating bacterial vaginosis but have limited evidence for treating yeast infections. 1, 2

Bacterial Vaginosis (BV)

Efficacy of Probiotics for BV

• Meta-analysis evidence shows that probiotic supplementation can significantly improve the cure rate in adult BV patients (risk ratio 1.53; 95% CI 1.19–1.97) 1
• Probiotics appear particularly effective in European populations and with short-term follow-up 1
• Combination therapy shows better outcomes:
  • Oral metronidazole/probiotic regimen (OR 0.09,95% CI 0.03 to 0.26) 1
  • Probiotic/estriol preparation (OR 0.02,95% CI 0.00 to 0.47) 1

Standard Treatment vs. Probiotic Approach

• First-line treatment for BV remains metronidazole 500mg BID for 7 days (95% cure rate) 3
• Alternative treatments include metronidazole gel 0.75% intravaginally once daily for 5 days or clindamycin cream 2% intravaginally at bedtime for 7 days 3
• The high recurrence rate (50-80% within one year) after antibiotic treatment is a significant issue 2
• Probiotics may help address this recurrence problem by restoring beneficial Lactobacillus species 2, 4

Probiotic Recommendations for BV

• Most effective strains: Lactobacillus acidophilus, Lactobacillus rhamnosus GR-1, and Lactobacillus fermentum RC-14 4
• Recommended dosage: at least 10 CFU/day for 2 months 4
• For recurrent BV: Consider probiotics as an adjunct to extended antibiotic treatment 5
• Vaginal administration may be more effective than oral administration as it allows direct replacement of healthy microbiota 4

Yeast Infections (Vulvovaginal Candidiasis)

Efficacy of Probiotics for Yeast Infections

• Limited evidence supports probiotics for treating vulvovaginal candidiasis 6
• First-line treatment remains topical azoles or fluconazole 150mg single dose 3
• Saccharomyces cerevisiae-based probiotics are being investigated as novel agents but are not yet proven effective 7

Clinical Decision Algorithm

1. Diagnosis:

   • Measure vaginal pH (>4.5 suggests BV, ≤4.5 suggests yeast infection) 3
   • Assess discharge characteristics:
     • BV: Homogeneous, white, thin discharge with fishy odor
     • Yeast: White, thick, "cottage cheese-like" discharge with minimal odor 3

2. Treatment:

   • For BV:

     • First use standard antibiotic treatment (metronidazole or clindamycin) 3
     • Add probiotic therapy (preferably containing L. acidophilus, L. rhamnosus GR-1, and L. fermentum RC-14) 4
     • For recurrent BV: Consider extended course of metronidazole plus probiotics 5

   • For Yeast Infection:

     • Use standard antifungal treatment (topical azoles or oral fluconazole) 3
     • Probiotics not recommended as primary treatment due to insufficient evidence 6

Important Caveats

• Probiotic strains do not appear to colonize the vagina long-term; benefits may only last during the dosing period 6
• Quality of evidence varies significantly across studies with high heterogeneity 6
• Probiotics appear safe with no major adverse effects reported 6
• Behavioral modifications that may help with BV include smoking cessation, condom use, and hormonal contraception 2
• For postmenopausal women, vaginal estrogen with lactobacillus-containing probiotics may help maintain vaginal pH 3

Practical Considerations

• Patients using metronidazole should avoid alcohol during treatment and for 24 hours after 3
• Clindamycin cream can weaken latex condoms and diaphragms 3
• Patients should abstain from sexual intercourse until treatment is completed 3
• Follow-up visits are generally not needed unless symptoms persist or recur 3