Pathophysiology

Vaginal infections are commonly caused by bacterial vaginosis (BV), aerobic vaginosis (AV), cytolytic vaginosis (CV), vulvovaginal candidiasis (VVC), and trichomoniasis.[1–4] Less common causes include foreign bodies, Group A streptococci, toxic shock syndrome, and HIV-related ulceration.[1] The normal vaginal environment, maintained by lactobacilli-producing hydrogen peroxide, has a low pH (3.8-4.2) that suppresses harmful bacteria.[2,4] Oestrogen levels influence the vaginal microbiota by increasing glycogen, which lactobacilli ferment into lactic acid, lowering pH.[2,5]

• BV occurs when lactobacilli are lost, raising pH and allowing anaerobes like Gardnerella vaginalis to thrive, producing a fishy odour and increasing discharge.[1,2] BV is linked to higher risks of HIV, HSV-2, gonorrhoea, and chlamydia.[1]
  
• AV involves a disturbed microbiota with aerobic pathogens replacing lactobacilli, causing significant vaginal leucocytosis and epithelial inflammation with significant discharge. Unlike BV, AV is characterised by red and oedematous vaginal tissue as a result of worsened inflammation.[4]
  
• CV involves overgrowth of lactobacilli, (particularly Lactobacillus crispatus), leading to tissue cytolysis, thick discharge and irritation.[2,6] Often misdiagnosed as VVC due to similar symptoms and pH.[1]
  
• VVC results from Candida overgrowth, causing inflammation, swelling, and discharge, with a normal pH (4.0-4.5).[1]
  
• Trichomoniasis, a sexually transmitted infection caused by Trichomonas vaginalis, leads to malodorous discharge and irritation, with symptoms often appearing around menstruation.[1,7]
  

Identify signs of vaginal infections

The following tables have been modified from the work of Moira Bradfield. For more information regarding vaginal infections and vaginal health see Intimate Ecology or join the Intimate Ecology community.

Table 1: Signs and Symptoms of Common Vaginal Infections

Factors influencing vaginal infections

• Antibiotic Therapy: Broad-spectrum antibiotics can eliminate protective vaginal flora, leading to dysbiosis and infections like BV, AV, and VVC.[1,4,8]
  
• Oestrogen Levels: Oestrogen increases glycogen, promoting lactic acid production and lowering pH, influencing vaginal flora.[2] High oestrogen normalizes BV-associated microbes, while low oestrogen increases BV risk. Oestrogen can also exacerbate CV and VVC symptoms.[8,9]
  
• Oral Contraceptives (OCPs): OCPs, due to their oestrogen content, are linked to increased VVC.[1]
  
• Diabetes Mellitus: Uncontrolled diabetes raises glycogen levels, enhancing Candida proliferation and increasing VVC prevalence.[1] Conditions that feature elevated blood glucose and raised oestrogen levels (i.e. gestational diabetes) have been associated with a greater prevalence of VVC.[10]
  
• Sexual Activity: High intercourse frequency, new or multiple partners, and sharing vaginal sex toys can increase the risk of BV, AV, and VVC.[8,11,12] Male ejaculate alkalinity and sexual practices can disrupt vaginal acidity for six to 17 hours increasing dysbiosis risk.[13]
  
• Impaired Immune Function: Chronic stress, corticosteroids, or compromised immunity correlate with recurrent VVC and Trichomonas infections.[1,12]
  
• Douching/Bidet Use: Frequent douching disrupts vaginal microbial balance, leading to BV and AV.[4,8]
  
• Intrauterine Devices (IUDs): IUDs are associated with BV, AV and VVC.[1,4,12] Its presence can aggravate epithelial inflammation in vaginal infections, and may act as a reservoir for biofilm-forming yeasts.[12]
  
• Spermicide/Condom Use: These contraceptives may disturb vaginal microbiota, with yeasts metabolizing spermicides.[12]
  
• Smoking: Cigarette use is linked to BV, increasing biogenic amines that affect pathogen virulence and contribute to malodour.[14]

Red Flags

• Pregnancy[1,2,12,15,16]
• Cervical dysplasia/low-grade squamous intraepithelial lesions (LGSIL)[17–19]
• Sexually transmitted infections (STIs)[1,4]
• Recurrent in vitro fertilisation (IVF) failure[20]

Treatment Recommendations

Probiotics Lactobacillus rhamnosus (GR-1™) and Lactobacillus reuteri (RC-14™) with liquorice for women’s urogenital health
Dose: 1 capsule daily

L. rhamnosus (GR-1™) and L. reuteri (RC-14™) effectively reduce the growth and adhesion of uropathogens, shown to treat and prevent uUTI.[21] For example, a trial with 252 women suffering from recurrent UTIs, treatment with 2 billion CFU (Colony Forming Units) each of GR-1™ and RC-14™ daily for 12 months achieved similar reductions in UTI recurrence compared to daily prophylactic antibiotics (trimethoprim-sulfamethoxazole). The probiotic treatment induced no antibiotic resistance, compared to 80-95% increased resistance to E. coli with antibiotics.[22] Extra mucosal membrane health is offered by combining with deglycyrrhizined extract of liquorice root (GutGard^® liquorice).[23]

For prevention of recurrent urogenital tract infections and to support women’s overall health and wellbeing

Multistrain Probiotics with B12 and Folate for Women's Multi Benefit Support
Dosage: 1 capsule daily

This multi benefit probiotic formulation harnesses the power of the gut-vaginal axis, gut-brain axis and gut-immune axis to provide daily support for women. For recurrent urogenital tract infections, targeting both gut and vaginal microbiome may offer preventative support.

• 1 billion CFU/d Lactobacillus plantarum (CLEPIUS™ Lpla33™) decreases stress scores by 10% in 4 weeks and reduces digestive bloating by 44% in 8 weeks.[24]
  
• 1 billion CFU/d Bifidobacterium animalis ssp lactis (BB-12™) boosts bowel movement frequency by 33% in 4 weeks and strengthens immunity in just 14 days.[25,26]
  
• 1 billion CFU/d each of Lactobacillus rhamnosus (GR-1™) and Lactobacillus reuteri (RC-14™) taken orally, breaks through resistant biofilms that cause recurrent urinary tract and vaginal infections.[27,28] Assists in the management and prevention of bacterial vaginosis and urinary tract infections.[21,29,30]
  
• Activated vitamins B12 and folate are included to support cellular energy production.[31,32]

Additional recommendations

For restoration of gastrointestinal dysbiosis after antibiotic therapy

Strain Specific Probiotics for Gut Microbiota Restoration and Support
Dose: 1 capsule daily

Highly researched probiotic strains, Lactobacillus rhamnosus (LGG^®), Saccharomyces cerevisiae (boulardii) (SB), Bifidobacterium animalis ssp lactis (BB-12^®) have demonstrated the ability to disrupt pathogenic bacteria, protect commensal groups and encourage restoration in the event of disruption, enhance gastrointestinal mucosal integrity, and have a beneficial impact on gastrointestinal function.[33,34]

If vaginal infection is suspected or associated with compromised immunity

Cordyceps, Coriolus and Reishi for Immune Stimulation
Dose: Acute: 1 level metric teaspoon (2.7 g) to 125 mL water 3 times daily for 5 days

Traditionally, the mushrooms in Cordyceps, Coriolus and Reishi for Immune Stimulation have been used to strengthen and enhance the immune system.[35–37] They can support resolution of chronic, latent or recurrent infections.

Mushrooms and Astragalus for Immune System Support
Dose: 1 tablet twice daily

Polysaccharides in both mushrooms and astragalus may enhance and regulate immunity via interaction with the intestinal microbiome and gut associated lymphoid tissue (GALT). Astragalus also increases the number and activity of T-regulatory cells and modulates inflammatory pathways.[38]

Vitamin D3
Dose: 1000IU (25 mcg) daily

Vitamin D has been shown to play an important role in regulating the immune system. By inducing the innate immune system, vitamin D enhances the response to both bacterial and viral agents.[39]

High Bioavailability Zinc with Vitamin C
Dosage:
• Children 4 to 8 years: Acute: Add ¼ metric teaspoon (0.95 g) to 100 mL water once daily with food;
• Children 9 to 13 years: Acute: Add ¼ metric teaspoon (0.95 g) to 100 mL water twice daily with food; Children 9 to 13 years: Maintenance: Add ¼ metric teaspoon (0.95 g) to 100 mL water once daily with food.
• Adults and children over 14 years: Acute: Add ½ metric teaspoon (1.9 g) to 200 mL water twice daily with food; Adults and children over 14 years: Maintenance: Add ½ metric teaspoon (1.9 g) to 200 mL water once daily with food.

Zinc and vitamin C to support the development, function and mediation of immune cells required for defence against infections.[40]

AHCC^® Lentinula edodes (Shiitake) extract and Ginger
Dosage: Take 2 capsules twice daily.

AHCC^® Lentinula edodes (Shiitake) extract and ginger enhance immune function and surveillance, to support the immune system against HPV infections.[41,42]

Lifestyle recommendations

Basic hygiene for vaginal infections:[2]

• Avoid scented soaps and feminine hygiene products.
  
• Avoid douching (as this may introduce new pathogens).
  
• Avoid tampons (until patients are symptom-free for 6 months); if using a menstrual cup, ensure sterilisation with each use.
  
• Avoid the use of sterilised wipes or steroid creams (unless prescribed).
  
• Wear cotton underwear, and change underwear if wet (i.e. after exercise or swimming).
  
• Avoid restrictive or tight-fitting clothing.
  
• Perform monthly vulvar self-examination.
  
• Avoid or limit sexual activity until symptoms are clear, or alternatively use condoms. Sexual activity should be appropriately adapted until patient experiences significant improvements. This includes ensuring hygiene practices are followed, such as limiting digital penetration, oral sex, unprotected sex, use of unsanitised toys, some personal lubricants and some condom types.
  
• Sleep without underwear.
  
• Patients should keep vaginal area as dry as possible during infection.
  
• Avoid excessive exercise, which may lead to excessive sweating/moisture in this area if this worsens symptoms.

Dietary suggestions

Dietary patterns high in refined starches, sugar, and saturated and trans-fatty acids, poor in natural antioxidants and fibre from fruits, vegetables, and wholegrains, and poor in omega-3 fatty acids may cause an activation of the innate immune system. This may reduce the body’s immune defences as a result of excessive production of proinflammatory cytokines associated with a reduced production of anti-inflammatory cytokines. Current evidence suggests that the Mediterranean diet protects against several diseases associated with inflammation and immune activation.[43]

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