Probiotics – Innovative Strategy
for Better Vaginal Health
At an evening symposium held by the Obstetrical & Gynaecological Society
of Hong Kong on October 22, 2009, Professor Gilbert Donders from Belgium
discussed the challenges of treating and preventing recurrence of local vaginal
infections, including bacterial vaginosis, candida vaginitis and trichomoniasis.
He explained the importance of maintaining or restoring a normal vaginal flora
dominated by lactobacilli, and explored the role of probiotics containing viable
lactobacilli, like Gynoflor® (DKSH), in the management of vaginitis, particularly as
adjuvant therapy to improve outcomes and reduce the risk of recurrence.
Probiotics as an Alternative Treatment for Vaginitis
Professor Gilbert GG Donders
Department of Obstetrics and Gynaecology
Infectious Diseases in OB/GYN
H Hart Kliniek Tienen
University Hospital Gasthuisberg Leuven
University of Leige
Leige, Belgium
T
he three most frequently occurring vaginal disorders worldwide are trichomoniasis, candida
vaginitis and bacterial vaginosis (BV). However, other conditions that are also important to consider
include aerobic vaginitis (AV), cytolytic vaginosis and mixed infections.
Despite the availability of effective antibiotic treatments, the high recurrence rate of local vaginal
infections shows that the management of these prevalent conditions needs to be improved. Many
patients wish to avoid taking repeated courses of antibiotics, which are often associated with
unpleasant side effects and potentially lead to pathogen resistance problems. Improving clinical
outcomes for women with vaginitis starts with a good understanding of the healthy vaginal
ecosystem.
Understanding the vaginal ecosystem
The vaginal mucosa is composed of basal cells, parabasal cells, intermediate cells
and superficial epithelial cells (Figure 1), which are the cells that desquamate
during a vaginal smear. In healthy women, the vaginal epithelium is lined with
a microflora ecosystem predominated by lactobacilli. These lactobacilli require
an acidic environment (pH 4.0 – 4.5) and they help maintain this acidity
by producing lactate (lactic acid). The lactobacilli convert glycogen
released from desquamating superficial cells into lactose and then
lactate to lower the vagina pH. They also produce bacteriocidal
compounds, including hydrogen peroxide, and compete
with other bacteria for adhesion to the epithelial cells,
thus protecting against an overgrowth of pathogenic
bacteria. Professor Donders explained that a
healthy full-thickness epithelium is essential
for this ecosystem to operate optimally, as
the lactobacilli require an adequate
supply of glycogen from the
proliferation, maturation
and desquamation of
superficial cells. Thus,
the other factor essential
to a healthy vaginal
ecosystem is an adequate
local oestrogen level (Figure 1).
Figure 1. The essential elements of a healthy vaginal
ecosystem
pH=4.3–4.5
Grading disturbances in the
vaginal microflora
Bacterial vaginosis and aerobic vaginitis
BV is characterized by a 100- to 1,000-fold increase
in pathogenic bacteria accompanied by a substantial
decrease in lactobacilli concentrations. However, this
shift in the vagina flora is not associated with leukocyte
infiltration, inflammation, pain, itching, dyspareunia,
vaginal redness or oedema. “BV is not an inflammatory
condition; it can be viewed as an ecological disorder,”
explained Professor Donders.
A diagnosis of BV according to Amsel involves identification of three of the following four criteria:
• Homogeneous grey watery discharge
• F ishy smell (increased after menses or
sexual intercourse)
• pH >4.5
• clue cells on microscopy
Using these criteria and microscopy, BV
can be diagnosed successfully during
the patient consultation.
Mucosa
Intermediate cells
Parabasal cells
Basal cells
High recurrence rates are typical for BV,2 and may be the
result of the development of a therapy-resistant biofilm on
the vaginal epithelium. “This is my major point – it is not
treatment
of BV, but prevention of recurrences of BV that is
pH>4.5
the main issue for clinicians,” Professor Donders commented.
“For recurrent BV, patients may want to use natural drugs
like probiotics, rather than
repetitive courses of antibiotics,
• Pathogens
with their potential for side effects and resistance induction.”
Aerobic vaginitis (AV) is characterized by smears that are
Intermediate
deficient in lactobacilli,
positive cells
for cocci and parabasal
epithelial cells, and/or positive for vaginal leukocytes.3 The
Parabasal
cellsdamage and/or thinning
presence of parabasal cells
indicates
of the vaginal epithelium (Figure 2). Clinical findings include
Basal cells
genital inflammation, yellow discharge, vaginal dyspareunia
and vaginal ulceration. Aerobic pathogens including group B
streptococci, E coli and Staphylococcus aureus are frequently
cultured.
Abnormal vaginal flora and pregnancy
The relationship
between abnormal vaginal flora (AVF) in
1010
Control
early pregnancy and adverse pregnancy outcomes,
specifically
Plus L acidophilus KS 400
8
increased
10 risk of preterm delivery (PTD), has been clearly
4,5
established.
However, using metronidazole to treat pregnant
106
women with asymptomatic BV or trichomoniasis has shown
104 for preventing PTD; in fact, metronidazole may
no benefit
increase the
risk.6-8
2
10
101 Donders and his colleagues have investigated
Professor
the relationship
between
PTD further
toalbicans
determine
S aureus
E coliAVFG and
vaginalis
P bivia C.
IH11128
which subtypes pose
the most risk in pregnancy.5,9 His
prospective studies have shown that full-blown BV in the
first trimester has less impact on pregnancy outcome than
intermediate types of AVF,5 and that AVF, coccoid-type
AV, staphyloid AV and partial BV are the most important
predictors of PTD.9 Another recent study has shown that AV
before the 17th week of gestation is correlated with placental
Normalinflammation
Flora Index (NFI)
histological
and funisitis.10 Relapse rate
16
2.0
Gynoﬂor®
other types
14
Placebo
These studies show that
of AVF, such as AV,
12.65%
partial1.6BV and mixed infections, may
be more dangerous
in
12
1.4
early pregnancy
than BV. In addition, metronidazole is not the
10
1.2
ideal treatment
for all women with AVF, and certainly not in
7.9%
8 aspecific therapies may
1.0
pregnancy.
Hence, broader and more
0.8
be needed
for AVF in pregnancy, such
as clindamycin and/or
6
0.4
probiotics,
although clinical studies will
be needed to support
4
0.4
such regimens.
1.8
% relapse
Lactobacillary grading using a wet mount and phase-contrast
microscopy is the first investigation Professor Donders uses
clinically; if the vaginal ecosystem is shown to be disturbed,
diagnosis of the infection can then be performed. He encouraged the audience of clinicians to use microscopy in
their daily clinical practice.
Superﬁcial cells
Colony forming units/mL
Increasing LBG (LBG I, IIa, IIb and III) has been shown to
be directly correlated with increasing vaginal pH and
inversely correlated with lactate concentrations.1 In addition,
increasing disturbance of the lactobacillary flora was highly
correlated with the presence of genital micro-organisms,
including Gardnerella vaginalis, Trichomonas vaginalis,
Gram positive cocci (eg, enterococci) and Gram negative rods
(eg, Escherichia coli).
Lactobacilli
Glycogen
Acidiﬁcation H2O2 Adhesion
Proliferation
NFI change from baseline
Professor Donders emphasized that a
40x magnification phase-contract microscope is an essential tool for physicians
treating women with suspected vaginal infection. “Preparing a vaginal smear slide and using
simple microscopy techniques can quickly provide a great deal of information about the case,”
he said. Lactobacillary grades (LBG) can be determined using simple phase-contract microscopy of
wet mounts in the clinic. The grading categories are:
• G
rade I (normal) – predominance of lactobacilli
without other bacteria
• G
rade IIa (intermediate) – predominantly lactobacilli
but evidence of other bacteria
• G
rade IIb (intermediate) – lactobacilli present but
outnumbered by many other bacteria (eg, cocci)
• Grade III (abnormal) – no lactobacilli, many pathogenic
bacteria
Lactose
Lactate
Estrogens
2
0.2
0
0
C1
C2
Gynoﬂor®
Placebo
Parabasal cells
Basal cells
Figure 2. Diagrammatic comparison of the vaginal ecosystem in bacterial vaginosis (left) and
aerobic vaginitis (right)
pH>4.5
pH>5.0
•
Pathogens
Intermediate cells
Parabasal cells
Basal cells
The role of therapeutic probiotics in vaginitis
Professor Donders outlined the desirable properties of
therapeutic lactobacilli as:
• High adhesion to the vaginal epithelium to effectively
compete with pathogenic bacteria 1010
– L gasseri, L brevis, L acidophilus and 8L rhamnosus
10
display strong epithelial adhesion
106lactic acid,
• Antibacterial activity, via production of
bacteriocins and hydrogen peroxide 104
• Biosurfactants and co-aggregation of bacteria to ensure
102
destruction of the biofilm
BV, metronidazole treatment has been shown to be superior
15-17
pH=4.3–4.5
to probiotic lactobacilli oral and vaginal preparations.
Estrogens
Lactose
Lactobacilli
Mucosa
Colony forming units/mL
% relapse
NFI change from baseline
Colony forming units/mL
Lactate
Professor Donders has conducted a randomized,
single-blind,
active-controlled,
multicentre
pilot study comparing the
Glycogen
Control
Acidiﬁcation
L acidophilus (12
KS 400days) and
H2O2 Adhesion
efficacy of Plus
Gynoflor®
metronidazole
(6 days)
Proliferation
in patients with AVF (n=42) (Donders GGG, et al. Manuscript
submitted,
Based a variety of efficacy parameters,
Superﬁcial2009).
cells
Gynoflor® was non-inferior to metronidazole 1 week after
Intermediate cells
treatment,
but was slightly less effective than the antibiotic
at 1 month. Thus, for a long-term cure, a single course of
Parabasal cells
therapy
with a probiotic is suboptimal, and repetitive courses
101
Basal cells
Gynoflor® vaginal tablets are a therapeutic
lactobacilli
or
interval
therapy may be needed, explained Professor
S aureus
E coli
G vaginalis P bivia C. albicans
preparation containing 0.03 mg estriol and more than
100 Donders.
IH11128
million viable L acidophilus. Estriol is included to stimulate
proliferation and maturation of the vaginal epithelium, which Probiotics in the adjuvant setting
is important to support the growth and survival of lactobacilli. Adjuvant therapy with probiotics is another potential way to
The L acidophilus KS 400 strain included in the product is of improve the outcomes of conventional treatments, perhaps
pH>4.5 cure rates, preventing candidiasis and other
human origin and has been shown to have the properties by improving
desirable for therapeutic vaginal use. It promotes a low abnormalities that may emerge after antibiotic therapy, or
vaginal pH through fermentation of lactose
and glycogen
preventing
recurrences
of BV or candida infections.
Normal Flora
Index (NFI)to
Relapse
rate
• Pathogens
lactic acid, is a strong producer of hydrogen
peroxide and
16
2.0
displays competitive adherence to epithelial
cells.
Professor Donders presented an overview of randomized
Gynoﬂor®
1.8
14
Placebo clinical trials that
12.65%
have assessed the efficacy of
1.6
12
In vitro experiments with L acidophilus
KS 400 have adjuvant lactobacilli Intermediate
therapy (oralcells
or vaginal) in the
1.4
10
demonstrated its ability to produce lactic
acid and rapidly management
of BV; each of the trials found a benefit
1.2
11
7.9% lactobacilli therapy after antimicrobial
reduce the pH of the culture medium,
produce hydrogen of adjuvant
8
Parabasal cells
1.0
11
peroxide, and inhibit the growth of
pathogenic micro- treatment.18-25 In one of the studies, women treated
0.8
6
organisms including G vaginalis, Prevotella
brevia, E coli, for BV, candidiasis or Basal
trichomoniasis
(n=360)
cells
0.4
4
S aureus and Candida albicans (Figure
3).12,13 L acidophilus were
randomized (2:1) in double-blind fashion
0.4
2
KS 400 was also shown to reduce adherence
of G vaginalis, to receive
Gynoflor® or placebo after antibiotic
0.2
13
P brevia and E coli to epithelial cells in culture.
0
0
FigureGynoﬂor®
3. GrowthPlacebo
inhibition of vaginal pathogens in
C1
C2
Treatment in the acute setting
L acidophilus KS 400 in Gynoflor®12,13
C1, follow-up at 3-7 days post-therapy; C2, follow-up atvitro
4-6 weekswith
post-therapy
A small (n=32) multicentre, randomized, placebo-controlled,
clinical trial examined the efficacy of Gynoflor® (1-2 tablets for
1010
Control
6 days) for treatment of BV, including intermediate/partial BV
Plus L acidophilus KS 400
8
10
cases.14 The cure rate (defined as ≤1 of the four Amsel clinical
criteria positive) 2 weeks after the start of therapy was 77% in
106
the Gynoflor® group and 25% in the placebo group (p<0.05).
104
At 1 month, the cure rates were 88% and 22% (p<0.05),
102
respectively. Furthermore, the results showed that after 6
days of Gynoflor® treatment, the lactobacilli were capable of
101
recolonizing the vagina.
S aureus
Although probiotics like Gynoflor® have an interesting potential to improve or cure different conditions in AVF, in full-blown
E coli
G vaginalis
IH11128
P bivia
C. albicans
IH11128
Figure 4. Gynoflor® adjuvant therapy improved the NFI and
reduced relapse rate after treatment for vaginitis24
Relapse rate
2.0
16
1.8
Gynoﬂor®
14
Placebo
1.6
12.65%
12
1.4
% relapse
NFI change from baseline
Normal Flora Index (NFI)
1.2
1.0
0.8
0.4
10
8
7.9%
6
4
0.4
2
0.2
0
0
C1
C2
Gynoﬂor®
Placebo
C1, follow-up at 3-7 days post-therapy; C2, follow-up at 4-6 weeks post-therapy
therapy.24 The primary outcome of the study was the effect
on the Normal Flora Index (NFI), which comprises numbers
of lactobacilli, pathogenic micro-organisms, leukocytes and
vaginal pH. This was used to assess the effect on restoration of
the normal vaginal microflora. Follow-up visits occurred 3 to
7 days and 4 to 6 weeks after the end of the adjuvant therapy.
At both follow-up visits, the NFI had increased significantly
more in the Gynoflor® group than the control group (p=0.002
and p=0.006, respectively) (Figure 4).24 In addition, at the
second follow-up, the relapse rate was lower in the Gynoflor®
group than the placebo group, although the difference was not
statistically significant (Figure 4). Thus, Gynoflor® significantly
enhanced restoration of the vaginal flora after anti-infective
treatment for vaginitis.
Professor Donders said that the available evidence for
using lactobacilli probiotics as adjuvant therapy in vaginitis
shows that, in this setting, probiotics have a prominent
role in enhancing the effect of antibiotic treatment, and
preventing recurrences of BV and emergence of candidiasis
and other types of vaginitis. He also remarked that lactobacilli
probiotics have a role in the treatment of atrophic vaginitis in
menopausal patients. However, patients need to understand
that repetitive courses are required. “Due to its unique
properties, Gynoflor® promises to be a prime candidate for
these applications,” he concluded.
0.03 mg, which is very low. It is 30 times
lower than the dose in preparations used
to treat vaginal dryness, and we use those
regularly in such patients. The intravaginal
administration ensures that serum levels of
estriol are almost zero. I use Gynoflor® for young
women, older women, and in pregnancy; it is safe
for all these women.
Q – If Gynoflor® is safe in hormone-dependent
tumours, why does the product information list it as
a contraindication?
Professor Donders: Gynoflor® has been in the market for
many years, and this contraindication is a ‘left-over’ of
the way drugs were classified. If a drug was categorised as
a hormone, it was automatically listed as contraindication
in hormone-related cancers. But over the years, we have
learned that estriol has no effect on breast cancers. I
believe that this contraindication should be removed from
the drug leaflet, but obviously this will require the support
of appropriate clinical studies.
Q – What stain should be used when performing
microscopy examination of smears?
Professor Donders: No stain is needed. The important thing is
to use a phase-contrast microscope, not a light microscope.
The superiority of phase contrast has even been proven in a
controlled trial.
Q – Is sexual activity contraindicated while using Gynoflor®?
Professor Donders: It is probably better to avoid sexual
activity during any intravaginal drug therapy, but if
sexual activity is planned, it would be best to administer
Gynoflor® afterwards. But sexual activity is not a formal
contraindication.
References
1. Donders GG, et al. Am J Obstet Gynecol 2000;182:872-878. 2. Bradshaw CS, et al. J Infect
Dis 2006;193:1478-1486. 3. Donders GG, et al. Br J Obstet Gynaecol 2002;109:34-43.
4. Donders G, et al. Am J Perinatol 1993;10:358-361. 5. Donders G, et al. Prenat Neonat
Med 1998;3:588-593. 6. Carey JC, et al. N Engl J Med 2000;342:534-540. 7. Klebanoff MA,
et al. N Engl J Med 2001;345:487-493. 8. Odendaal HJ, et al. South Afr Med J 2002;92:231234. 9. Donders GG, et al. Br J Obstet Gynaecol 2009;116:1315-1324. 10. Rezeberga D, et
al. Acta Obstet Gynecol Scand 2008;87:360-365. 11. Schoeni M, et al. SAZ 1988;126:139142 [in German]. 12. Kanne B, et al. Jatros/Gynaekologie 1986;2:11-28 [in German].
13. Data on file; DKSH. 14. Parent D, et al. Arzneimittelforschung 1996;46:68-73.
15. Anukam KC, et al. Microbes Infect 2006;8:2772-2776. 16. Hallén A, et al. Sex Transm
Dis 1992;19:146-148. 17. Fredricsson B, et al. Gynecol Obstet Invest 1989;28:156-160.
18. Anukam K, et al. Microbes Infect 2006;8:1450-1454. 19. Neri A, et al. Acta Obstet
Gynecol Scand 1993;72:17-19. 20. Shalev E, et al. Arch Fam Med 1996;5:593-596.
21. Reid G, et al. FEMS Immunol Med Microbiol 2001;32:37-41. 22. Reid G, et al. FEMS
Immunol Med Microbiol 2003;35:131-134. 23. Reid G. J Med Food 2004;7:223-228.
24. Özkinay, et al. Br J Obstet Gynaecol 2005;112:234-240. 25. Larsson PG, et al. BMC
Womens Health 2008;8:3.
Conclusion
Probiotics may have a role in the treatment of BV when antibiotics are contraindicated, although repeated applications
may be necessary. The aspecific actions of lactobacilli probiotics mostly likely provide coverage against AV, partial BV and
mixed AV/BV, which can be difficult to treat successfully with
traditional therapy. The largest role for lactobacilli probiotics
is in the prevention of recurrence in patients with recurrent
BV and candida, through restoration of the normal vaginal
microflora. The role of these agents in the prevention of pregnancy complications warrants investigation.
Q&A session
Q – Is Gynoflor® safe for use in patients with oestrogendependent cancers?
Professor Donders: Definitely. The dose of estriol is only
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