What is the treatment for vaginal dysbiosis?

Treatment of Vaginal Dysbiosis

The treatment for vaginal dysbiosis depends on the specific type, with bacterial vaginosis requiring metronidazole 500 mg orally twice daily for 7 days as first-line therapy, while cytolytic vaginosis requires sodium bicarbonate douches to increase vaginal pH. 1, 2

Types of Vaginal Dysbiosis and Their Treatments

Bacterial Vaginosis (BV)

• BV results from replacement of normal H2O2-producing Lactobacillus with anaerobic bacteria, G. vaginalis, and Mycoplasma hominis 1
• Diagnosis requires three of the following: homogeneous white discharge, presence of clue cells, pH > 4.5, and fishy odor with KOH test 1
• Treatment options:
  • First-line: Metronidazole 500 mg orally twice daily for 7 days (95% cure rate) 2
  • Alternative: Metronidazole gel 0.75%, one full applicator (5g) intravaginally once daily for 5 days (53-57% cure rate) 3
  • Alternative: Clindamycin cream 2%, one full applicator (5g) intravaginally at bedtime for 7 days 1
• Patients using metronidazole should avoid alcohol during treatment and for 24 hours afterward due to potential disulfiram-like reaction 2
• Treatment of male sex partners is not recommended as it has not been shown to prevent recurrence 1, 2

Vulvovaginal Candidiasis (VVC)

• Caused by Candida albicans or other yeast species 1
• Presents with pruritus, vaginal discharge, soreness, and dyspareunia 1
• Associated with normal vaginal pH (≤4.5) 1
• Treatment options:
  • Topical azoles: Butoconazole, clotrimazole, miconazole, or terconazole for 1-7 days 1
  • Oral option: Fluconazole 150 mg as a single dose 1
• Oil-based creams and suppositories may weaken latex condoms 1

Cytolytic Vaginosis

• Caused by excessive growth of hydrogen peroxide-producing lactobacilli 4
• Associated with very acidic vaginal pH (typically <4.0) 4
• Treatment:
  • Sodium bicarbonate (baking soda) douches or sitz baths: 30-60g in 1 liter of warm water, used 2-3 times weekly for 2 weeks 4
• Antibiotics would worsen this condition by further promoting lactobacilli overgrowth 4

Emerging Treatments: Probiotics

• Probiotics show promise for treating and preventing recurrence of bacterial vaginosis 1, 5, 6
• Most effective strains include:
  • Lactobacillus rhamnosus TOM 22.8 (10×10^9 CFU/day for 10 days) has shown significant improvement in Nugent scores and vaginal pH 6
  • Combinations of L. acidophilus, L. rhamnosus, and L. reuteri have improved vaginal dysbiosis in asymptomatic women 5
• Meta-analyses show probiotics can improve cure rates when combined with standard antibiotic therapy for BV 1, 7
• Administration can be oral or vaginal, with minimal side effects reported 8, 6

Special Considerations

• During pregnancy, consult with an obstetrician before using any vaginal treatments 4
• For recurrent BV, longer treatment courses or combination therapy may be needed 2
• Self-medication with OTC preparations should only be advised for women previously diagnosed with VVC who experience the same symptoms 1
• Clindamycin cream is oil-based and may weaken latex condoms and diaphragms 2

Common Pitfalls to Avoid

• Misdiagnosis between different types of vaginal dysbiosis can lead to inappropriate treatment 4
• Using antibiotics for cytolytic vaginosis will worsen the condition 4
• Treating asymptomatic Candida colonization is unnecessary, as 10-20% of women normally harbor yeast in the vagina 1
• Failure to differentiate BV from other causes of vaginitis (Trichomonas, Chlamydia, gonorrhea) can lead to treatment failure 3