1. health and fitness
2. therapy

LITERATURE REVIEW
ALTERNATIVE THERAPIES EOR
BACTERIAL VAGINOSIS: A LITERATURE
REVIEW AND ACCEPTABILITY SURVEY
Elizabeth K. Boskey. PhD, MPH,
Objective • This article reviews current research into non-antibiotic treatments tor bacterial vaginosis and assesses interest in the
use of alternative therapies for women's health in a non-representative sample of women.
Design • Literature re\iew and online survey.
Subjects • A convenience sample of 192 women was selected
from an online community devoted to the discussion of
women's health.
Results " Data on altemative treatments for bacterial vaginosis
are mixed. Studies have shown both positive and null effects for
probiotic- and lactic acid-based treatments. The results of antiseptic studies were more uniformly positive, but the studies were
Elizabeth R. Boskey, PhD, MPH, CHES, is an adjunct professor
in the Department of Preventative Medicine and Community
Health at the State University of New York Health Science
Center in Brooklyn, NY.
B
acterial vaginosis is characterized by an increase in
the vaginal pM from a healthy, acidic pH of ~4 to a
more neutral pH of >4.5. This change is due to an
overgrowth of anaerobic bacteria and a concomitant
decrease in the number of acid and ll^O^-producing
lactohacilli. which are the microbial guards for vaginal health.'
This understanding of bacterial vaginosis as a disruption in the
normal vaginal ecosystem, as well as recent media coverage of
antibiotic resistance and a growing movement toward "natural"
therapies.' have led to increasing interest in non-antibiotic treatments for bacterial vaginosis.
Most proposed non-antibiotic therapies for bacterial vaginosis fall into two categories—probiotic therapies, which aim to
provide the bacteria to directly supplement or restore a woman's
healthy lactohacillus-dommated flora (eg, lactobacillus capsules
and yogurt-based treatments'"), and acid-restoring therapies
such as BufferGel (Reprotect. Inc. Baltimore, Md) and lactic acid
gels and creams, which aim to make the vagina a hostile environment to the acid-sensitive bacterial vaginosis organisms, thereby
promoting native lactobacillus regrowth.'"'"' Natural antibiotics.
38
generally not placebo-controlled. Women in the survey population were both interested in and experienced with alternative and
complementary therapies for reproductive health problems—
44% of them had used home or natural remedies to treat vaginal
infections or menstrual problems, and only 20% indicated that
antibiotics and antiflingals would be their treatment of choice.
Conclusions • Women are interested in alternative treatments
for women's health problems such as yeast infections and bacterial vaginosis. Although such treatments have been investigated,
further research—particularly in the form of high-quality, randomized, controlled trials—i.s strongly indicated. {Altern Ther
Health Med. 2005;U(5):38-43.)
such as tea tree oil. are being studied for use in treating bacterial
vaginosis and are frequently recommended by word of mouth in
women's communities.'"
This article reviews current research into non-antibiotic
treatments for bacterial vaginosis. Additionally, to assess the
potential for interest in non-antibiotic therapies, a survey was
developed for web-based administration to a convenience sample of women with an expre.ssed interest in vaginal health. A
sample of 192 women was acquired by posting a time-limited
invitation to participate in the survey to an online community
focusing on women's reproductive health.
MATERIALS AND METHODS
Literature Review
A search of the literature for all articles containing the keywords "bacterial vaginosis" and "treatment" was conducted.
Wherever possible, articles that discussed only antibiotic treatment of bacterial vaginosis were eliminated and all other articles
were retrieved and individually reviewed for inclusion. Inclusion
criteria were 1) the article must describe a treatment trial for
bacterial vaginosis—a decision was made to include trials of any
size since alternative therapy trials are frequently small. 2) the
article must include at least one treatment that is not one of the
standard antibiotic therapies for bacterial vaginosis (eg, metronidazole. clindamycin), 3) trials of natural antibiotics (eg, tea tree
oil) were acceptable because they are not part of standard pre-
ALTERNATIVE THEIUPIES, SHPT/OCT 2005. VOL II, NO, 5
Altemative Therapies for Bacterial Vaginosis
scription regimens. Articles that met the inclu.sion criteria were
also drawn from the reference sections of the selected literature.
Data Abstraction
The following data were systematically abstracted from
each study: number of subjects, type of study design, tested compounds, whether a placebo was used, whether the compound
was administered orally or vaginally, study duration, and results.
Survey
Design
The survey was designed using a paid online survey tool—
Survey Monkey (SurveyMonkey.com, Portland, Ore)—which
allows for an unlimited number of respondents, the use of
response-specific skip patterns, and many options for survey
structure. The Institutional Review Board (IRB) approved survey consists of 4 sections: 1) an active consent section that
requires 4 confirmatory an.swers before the participant can
proceed to the main survey; 2) questions about the demographics of study participants and ascertainment ot where the)'
were recruited into the survey: ''•) questions about experience
with vaginal infections or problems and experience with prescribed, over-the-counter, and natural or home remedies; and
4) questions about provider choice for reproductive health
problems and general use of complementary and alternative
medical systems. Participants taking the survey could only go
forward—they could not go back to change previous survey
answers—and could opt out of the survey at any time. Skip
patterns were used to end the survey early for those who did
not consent or who were not eligible {ie. people who have
taken the survey before and male respondents) and to skip
questions that were not relevant to them based on earlier
responses. Answers were not required for reproductive health
questions but were required for the demographic and consent
sections. The investigator's contact information was provided
at the end of the survey in case participants had concerns or
questions.
Recruitment
Survey recruitment was through a post to a woman's
health community on an online journal website (ie, www.livejournal.com). The community had approximately 1,300
members and was monitored by another 700 individuals who
are part of the larger site where the community is located.
The invitation included permission to forward a link to the
survey website to friends.
The survey recruitment post had a disclaimer section written written by the 1KB. with detailed disclosure on possible
issues with anonymity. This was necessary because although
the survey collected no identifying data, it did collect the computer's Internet protocal (IP) address to prevent people from
taking the survey multiple times, and it also left a "cookie" on
the participant's computer. The disclosure included detailed
instructions on how to remove the cookie file from the comput-
Alternative Therapies for R.icterial Vaginosis
er and the survey URL from the web browser's History file. The
survey was available for 3 weeks, and a second post referring
people to the initial recruitment message was placed 4 days
before the study closed.
Analysis
The survey was analyzed by simple descriptive statistics
becau.se of the non-random nature of the sampling procedure.
The survey was intended to demonstrate only whether there is
an interest in alternative therapies for vaginal infections among
a non-representative sample of women with an avowed interest
in women's health.
RESULTS
Literature Review Results
Eighteen studies that examined treatments for bacterial
vaginosis with medications other than commercial antibiotics
were identified. The treatments could largely be broken down
into the 3 categories of antiseptics, probiotics, and acidification devices, but one trial also examined the spermicide
nono\ynol-9 as a treatment regimen. Studies varied in quality,
witb more than half of them having no control group or nonrandomized controls (Table 1). Most studies were small, and
they varied considerably in design. Not surprisingly, because
negative studies are rarely published, most of the available
studies showed a positive effect for the alternative therapies.
Only 3 of the studies bad ambivalent or negative results.'""'
Although design quality was problematic in many of the studies, the results suggest that all 3 main methods—probiotics,
antiseptics, and acidification agents-—^are potentially useful
non-antibiotic therapies for bacteria! vaginosis.
Survey Results
The women who cbose to participate in the survey were
primarily white, college-educated women in their late tetns
and 20s (Table 2), as would be expected based on the recruitment method. The majority of these women (74%) have worried about their vaginal health at one time or another, but
more of them sought advice from a non-healthcare professional than went to a doctor for care. Slightly more than one-third
of the population (39%) had been diagnosed with a vaginal
infection (eg, bacterial vaginosis, yeast infection) or sexually
transmitted disease at some point in the past, and more than
half (60%) of those diagnosed with a vaginal infection were prescribed antibiotics. Most women (56%) saw MDs for tbeir
reproductive healthcare, although a similar number were seen
by nurse practitioners, and a substantial minority (14%) were
unwilling to seek care.
Use of home remedies and alternative therapies in this
population was high (Table 2). Almost half (45%) of the women
have used home or alternative remedies for vaginal infections
in the past—a slightly higher percentage than those who had
used an over-the-counter yeast infection treatment without seeing a doctor (37%). When asked what their first choice for a
A L T E R N A T I V E T H E K A l M h S . S E P T / O C T 2 0 0 5 , V O L II, N O . 5
39
TABLE 1 Review of ihe Literature on Ndu-Aiitibiotic Treatments for Bacterial Vaginosis
Study
Number of Study Type
Participants
Tested Compounds
Treatment Placebo- Oral/ Length of
Category Controlled Vaginal Foiiowup
Result.s
Reid etal 2001'
10
Feasibility'
L rhaimwsus CR-1 +
Ljcrmcntum RC-14
suspension in milk
Probiotic
No
Oral
4 weeks. OgaiiismsrecoveredfhiiT! thevn^giias
] 2 ueeks of most women. Six women v\ith abiior(3 women) malflorahad resolution within 1 week
Reid etal 2001'
42
Feasibilit)'
study
/. rtmmihmis CR-l +
i.fcwwitum W-\A or
L rlhimmms C,C,
Probiotic
Inactive
Oral
42 days
One treatment group with
from treat- tiR-l/RC-14 had good resolution
ment
of B\' bi' Nugent .scort—all women
were i-linicall\' heaitliv
Chimura 1998''*
16
Trial
Bio-Three
Probiotic
No
Parent etal 1996"
32
Multicenter.
randomized
n.J].Jactobacilli and
Estriol (Gynoflor)
Probiotic
plus estriol
yogurt ivif b L
luidophilux
Probiotic
Pasteurized
yogurt
Trial
Intravaginal yogurt
Probiotic
No
Vaginal 3 days
Treatment led to significant
decreases in vaginal discharge,
redness, and pH as well as a 54%
microbiologic cure rate
Audit
Gynatren vaccine
(/. aclihpliihis lysate)
Probiotic
vaccine
No
Neitber - 6 mo
Potentially effective for reducing
recurrent B\' if used with
metronidazole
Open
randomized
1) Yogurt douche
2) Acetic add tampon
Probiotic, Treatment Vaginal 2 months
and tampon refusals
Both treatments effective at treating
B\'. but yogurt substantially more so
1) Acetic acid ielly
2) Dinoestrol creme
3) ComETiercial yogurt
4} Metronidazole
Probiotic.
acid gel,
hormone
No
Vaginal 1 month
The alternative treatments were
only rarel)' effecti\'e. All were
substantially less effective than
metronidazole
Vaginal 14 days
Prevalence of BV declined
significantly in study population
Shalev et al 1996'
Chimura et al
1995**
20-BV.
Crosso\'er
18-Canditia trial
8 - Both
11
Pattman et al
1994'
Vaginal 3 days
Significant decreases in vaginal discharge, redness, and pi I as well as a
44% rnicrobiologic cure rate
Vaginal 4 weeks
Gynoflor was effective in treatingBV
Oral
6 months. Increase in L aeidopbinlus isolated
in women in treatment group.
Significant decrease in B\' in
treatment group
Neri et al 1993'"
84 pregnant
Fredricsson et al
1987"
61
van deWijgertetal
2001'^
98
Drug safety
trial
BufferGel
Acid gel
No
Boeke et al 1993''
125
Randomized
clinical trial
1) Oral metronidazole
2) Vaginal lactic acid
Acid
suppositor\'
Yes
Hoist et al 1990'*
10 pregnant
Pilot study
Ijctal gel
Acid gel
No
Anderschetal
1986'"'
114-62
withBV
Randomized 1) Oral metronidazole
trial
2} Vaginal lactate gel
Acid gel
No
Wewalka et al
2002'"
70
Randomized 1) Betadine suppositories Antiseptic,
trial
2)/.ij/j.wm capsules.
probiotic
No
Vaginal 10 days
Patients in botli groups improved both
clinically and subjectively. Betadine
had a stronger long-tenn ertkt
Petersen et al
2002"
180 - 73
with BV
Randomized, 1) Dequaliiiium chloride Antiseptic
double-blind 2) Povidone iodine
No
Vaginal 4 weeks
Both treatments effective in
treating BV
Case study
Antiseptic
No
\'aginal 1 montb
Vaginal flora and pH resolved to
normal after self-treatment
Antiseptic
No
Spermicide
Yes
randomized
Blackwell 1991'"
1
Ison et al 1987-"
79
Tea tree oil. vaginal
pessaries
Randomized, I) X'aginal ClorhexidiTie
single-blind 2) Oral Metronidazole
Richardson et al 278 CSWs Randomized, Nonoxynol-9
2001''
U2BV
double-blind
Both
3 months Lactic add ineffective in treating BV
Vaginal 8 weeks
Both
Botli
Lactal effective in treating BV
8 da\'s
Lactate gel as effective as
metroTiidazole in treating BV.
28davs
Clorhexidine as effective as
metronidazole in treating BV
Vaginal Median 50 weeks
No difference in B\' incidence between
treatment and placebo groups
Artitic in Japanese. B\'-lla(lcrJa! vaginosis; CSVV=tommercial sra workers
40
A L T E R N A T I V E T H E R A P I E S . S E T T / O C T 2 0 0 5 , V O L II, N O . 5
Alteniiitive Therapies for Bacterial Vaginosis
TABLE 2 Survey Responses
}Ustor\ of Vitjiimil Problems ami Remedies (Continued)
Demographic Questions
Age (years)
<17
18-19
20-24
25-29
30-39
40 or older
Skipped
Race
White (non-Hispanic)
Black (non-Hispanic)
Hispanic
Asian/Pacific Islander
,\merican Indian/Alaskan Native
Olher
Skipped
Educational Level
less than high scluHil
High school diploma or GED
Some college
Associates degree
Bachelor's degree
Graduate or Postgraduate
Skipped
n
19
43
83
29
13
2
3
%
9,9
22,4
43.2
15,1
6,8
1.0
1.6
167
1
2
5
2
12
3
870
0.5
1.0
2.6
1.0
6.i
1.6
19
16
91
10
9,9
8,3
474
5,2
4o
7
3
3,6
1,6
143
43
6
74.5
22.4
3,1
71
59
84
53
36
77
3
49,7
41.3
58.7
37,1
25.2
53,8
2.1
54
7
14
109
8
28,1
3,6
7.3
56,8
4,2
39.7
4.9
92,7
2,4
55.7
26,0
3,6
26.0
1.0
11
4.2
16
5,7
78
73
Home ami Aiternative Remediesfor Vaginal Problems
Ever treated a yeast infection with OTC medication?
70
\es
9
Yes—only afrer seeing a healthcare provider
105
No
8
Skipped
Home/natural remedy ever used for women's health?
86
^•es
96
No
10
Skipped
First choice treatment for treating a vaginal infection
39
An antibiotic or antihmgal pill or creme
12
An over-the-counter product that is not an antibiotic
15
,\ probiotic product
47
A natural remed)' \'ou could prepare yourself
6G
"1 don't care what I take as long as it works"
13
Skipped
36,5
4,7
54.7
4,2
44.8
50.0
5.2
20.3
6.3
7.8
24.5
34.4
(S.8
Treatments interested in using (all that apply)
An antibiotic or aotitiingal pill or creme
remedy for a vaginal infection would be, 39% chose a non-traditional therapy (ie. probiotic, non-antibiotic over-the-counter
cemcdy. tiatiiral or home remedy), only 20% cbose an antibiotic
or anti-fungal, and 34% said they would take anything as long
as it worked. When asked whicb therapies tbey would be willing to use. approxitiiatcly (50% were willing to use any therapy
on the list. The population, as a whole, was also reasonably
experienced with alternative therapies in other aspects of their
AltiTiiali\ e Therii|iit's for B:!( itrial Vaginosis
%
60.3
')A l\
History of Vaginal Pmhiems ami Experieme With Remedies
Ever worrietl might have a vaginal infection?
\'es
No
Skipped
If yes, what was done? (n=143) (all that apply)
Went to the doctor
Sought ad\ ice from family/friends
Sought ad\ ice from the Internet
Bought over the lounter remedy
Used a home/natural remedy
Waited for symptoms to go away
Other/Skipped
Ever tliagnosed with a vaginal infection/STD?
Yes—vaginal infection
Yes—sexually transmitted disease
\es—both (not concurrently)
No
Skipped
n
If diagnosed, prescribed antibiotics? {n=68)
41
Yes
27
No
If antibiotics prescribed, were the\' taken? (n=41)
2
No
38
Yes
1
[lon't Remember
Providers seen for reproducti\e health care (all that apply)
107
MD—OB/GYN specialist
50
Ml")—Other
7
Nurse Midwite or Midwife
50
Nurse practitioner
2
Osteopath
6
CAM Provider
8
No practitioner-—uninsured
7
No practitioner—uncomfortable
11
No practitioner—other
15
Other Practitioner/L'nknown Type
14
Skipped
An over-the-counter product that is not an antibiotic
A probiotic product
A natural remedy you could prepare yourself"
"I don't care what 1 take as long as it wtirks"
Skipped
108
112
112
125
85
13
56.3
58.3
58.3
65.1
44.3
6.8
tnedieal care (Table 3). Althougb ]^7% of the women stated tbat
they used tio complementary or alternative tberapies, 31% used
dietary supplements, and approximately 10% used aromatherapy, naturopathy, homeopathy. Reiki, therapeutic massage, and
chiropractic services.
Types of bome remedies for vaginal probletiis used by participants were diverse (Table 4). The most common therapy by
far was yogurt—either applied vaginally or ingested. Yogurt and
ALTERNATIVE THERAPIES, SEPT/OCT 2005, VOL, 11, N O , 5
4!
I/VBLE 3 Types of Complementary and Alternative Medicine (CAM)
Providers and Practices L'sed by Survey Participants
CAM providers or products used (all tbat apply)
None
Acupuncture
Osteopathic medicine
Cbiropractic medicine
Homeopathy
Naturopatbic medicine
Aromatherapy
Therapeutic massage
Ayurvedic tberapy
Qigong
Reiki
Therapeutic touch
Dietary supplements (not prescribed by an Mi))
Other oriental medicine system
Other CAM practice not listed
Skipped
n
%
71
8
3
20
24
22
29
19
1
1
15
2
60
4
11
30
37.0
4.2
1.6
L0.4
12.5
11,5
15,1
9.9
0.5
0.5
7.8
1.0
31.3
2.1
5.7
15.6
acidophilus tablets were used in an attempt to replenish healthy
vaginal flora. Herbal teas were the second tnost common therapy—when their use was indicated, it was usually for either pain
relief or as an emmenagogue. Non-bacterial acidfying remedies
also were common, as was garlic—one of the more frequently
discussed home remedies for a yeast infection. Both acidification
treatments and garlic are intended to make the vaginal and urinary environments more hostile to non-healthy flora. Although
normal vaginal flora thrive at low pH, the bacteria associated
with bacterial vaginosis do not, and garlic has established
antimicrobial properties. Alternative pain relief tlierapies also
were frequently used to relieve menstrual cramping.
DISCUSSION
The literature on non-antibiotic therapies for bacterial
vaginosis is mixed. Whereas sotiie studies show these therapies
to be useful, others find no effect, and the overall study quality
is poor. Probiotics,''" acidification agents.'- " '^ and antiseptics'"'"-"all show promise for treating bacterial vaginosis
through clinical studies and have a firm theoretical basis for
why they should be effective. Some studies have found these
agents to be ineffective, however, and it is important that highquality, clinical trials be pursued."''
Women are interested in non-antibiotic therapies for vaginal infections. Only 20% of survey respondents preferred
antibiotics; most would be happy using any therapy that was
effective; and more than one-third indicated a preference for a
probiotic. natural, ornon-aiitibiotic therapy. Almost half of the
population had, in fact, used home or natural remedies to treat
vaginal or menstrual problems in the past^more women than
had purchased over-the-counter treatments with or without
physician approval. Even many of the women who did not indicate a preference for a non-antibiotic therapy would be willing
42
TABLE 4 Types of Home or Natural Remedies Used by Survey
Participants for Vaginal or Menstrual Problems*
Yogurt:
Acidophilus tablets:
Boric:
Vinegar:
Cranberry:
Garlic:
Heating:
Either eaten or applied vaginally (n=48)
Eaten or inserted (n=4)
Acid vaginal suppositories (n-2)
When specified, as a rinse or douche (n=6)
Juice or pills (n= Hi)
Either eaten or inserted (n=13)
Pads, packs, hot baths, and
compresses (n-10)
Herbal teas:
ttickiding parsleyteinmenagogue), thyme,
tansy (pregnanc) teniiination/emmenagogue), raspberr)', ginger, chamomile,
molasses, and peppermint (n=23)
Herbs and essential oils: Including black cohosh, blue cohosh,
pennyroyal, evening primrose oil, dong quai,
Chinese herbs, yarroiv. calendula oil.
tea tree oil (n=9)
Intoxicants:
Alcohoi, marijuana (n=2)
Epsom sa!t, oatmeal, baking soda,
Special baths and rinses; peroxide (n=8)
Lysine (for 1ISV-1 outbreaks), calcium, magSupplements:
nesium, vitamin C (emmenagogue) (n=5)
Massage, acupuncture (n=2)
Therapies:
"Number of women mentioning the llierapy is in parenthesis. Most common
reasons for use of therapies, when given, were cramps, yeast infections, and urinary tract iiifectiDiis, When a specific use, olher than the above, was meiilioiied
for a therapy, it is listed in paremhests.
to use one—equivalent numbers of women were willitig to use
antibiotics, probiotics. home remedies, and over-the-counter,
non-antihiotif therapies.
Current use of alternative therapies for general health in
this population was similar to (hat seen in a national survey in
1997.' Approximately 42% of the study population used at least
one such therapy, with tnore than a third of the population
using dietary supplements that ha\'e previously been reported
to be frequently used by women." Interestingly, these women
used a wide range of home remedies for their reproductive
health problems. Although this is partially explained by the
source of the population being a woman's health community
where several of these treatments are discussed, the frequency
of use is surprising. The most common therapies used, yogurt
or acidophilus. garlic, and cranberry, are easily prepared or
purchased, and do have some scientific basis for effect.'"•'^^'
The biggest limitation to this study is the non-representative source of the survey population and the relatively lowresponse rate. However, the survey does show a strong interest
in natural and alternative therapies by women in this sample
and will hopefully help to provide an impetus to future
research in this area. High-quality clinical trials of non-antibiotic tberapies for vaginal infections need to be conducted.
There is a market for these treatments—they just need to be
tested and developed.
AIJFRNATIVE THERAPIES, SErT/OCT 2005, VOI, 11, NO, 5
Alternative Therapies for Bacterial Vaginosis
14.
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Light For Health
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21-
22,
23.
There is no area of
our mental and
bodily functioning
that the sun does
not influence. ... We
were not designed to
hide from it in
houses, offices,
factories and schools.
Sunshine, reaching us
through our eyes and
our skin, exercises a subtle
control over us from birth
to death, from head to tail."
Department of Education,
Alberta, Canada,
February 1992
"Mal-illumination"
is linked to
malabsorption,
fatigue, tooth
decay, depression,
anxiety, stress,
seasonal affective
disorder (SAD),
suppressed
immune function,
strokes, hair loss,
skin damage,
alcoholism, drug
abuse, Alzheimer's
disease, cancer,
and loss of muscle
tone and strength.
Light For Health'
800-468-1104
847-459-4455
www.lightforheaith.com
Alternative Therapies for Bacieria! Vaginosis
Light isn't just for SAD
(Seasonal Affective Disorder) anymore!
ALTERNATIVE THERAPIES. SEPT/OCT 2005. VOL. 11. NO. 5
43