The roles of intestinal dysbiosis and permeability (leaky gut syndrome) should not be overlooked in the etiology of chronic or intractable cases of vaginitis. The body’s ability to maintain control over the volume of microorganisms present in the intestinal and vaginal tracts is intimately connected to the health of the bowel and bowel flora. If the body is unable to sustain a healthy balance of microorganisms, those that normally inhabit our bodies without causing harm can overproliferate or migrate, becoming pathogenic. This is often the case with chronic vaginal infections. Further, when the body is in a chronic state of immune-mediated response and inflammation, normally controlled organisms may become opportunistic. Thus, a first line of botanical treatment for chronic vaginal infections, especially candidiasis, is improving the integrity of the bowel mucosa and helping to restore normal bowel flora. The former is done with many of the same anti-inflammatory, antimicrobial, and vulnerary herbs already mentioned, and a few additional botanicals. The most important of these include chamomile, marshmallow root, calendula, slippery elm, goldenseal, Oregon grape root, Dioscorea villosa (wild yam), and licorice root. These may be administered as teas, tinctures, or capsules. Essential fatty acids of both the omega-3 and -6 varieties should be supplemented for their anti-inflammatory action. Probiotics (see the following) are useful in restoring gut flora and can be taken as a supplement or as live, active culture yogurt.
Nutritional Considerations: Lactobacillus / Yogurt
The goal of treatment with lactobacillus supplements or yogurt, taken orally or applied vaginally, is recolonization of the vagina (and bowel with oral intake) with adequate numbers of healthy flora capable of controlling and resisting pathogenic infection. The success of this treatment requires products that contain the proper lactobacillus species and that these species be active. Additionally, oral yogurt therapy requires the survival of lactobacilli through the GI system and digestive processes, as it is thought that vaginal recolonization occurs as a result of migration of the microorganisms from the anus to the vaginal introitus. Effective oral and topical yogurt therapy also requires that the lactobacilli be able to adhere to the vaginal epithelium. L. acidophilus is poorly adherent to the vaginal walls, and it also is not a major rectovaginal species. Although two clinical trials have demonstrated significant efficacy with oral and / or topical use, the use of other species of lactobacillus, such as L. crispatus, L. jensenii, L. rhamnosus, and L. fermentum, may be more effective. A randomized crossover study with a washout period by Shalev et al. studied the effects of oral yogurt prophylaxis on a group of women (n = 46) with bacterial vaginosis (n = 20) and candidal vaginitis (n = 18) or both (n = 8). The study showed a significant decrease in bacterial vaginosis and no significant decrease in candidal infection. Only 28 participants were still enrolled in the study at 4 months and only 7 completed the protocol. In an open crossover trial by Hilton et al., a randomized group of women (n = 33) with recurrent vulvovaginal candidiasis were assigned to either a 6-month protocol of daily oral intake of L. acidophilus containing yogurt or a yogurt-free diet. A threefold decrease was seen in candidal infections, substantiated by wet mount and potassium hydroxide. Interestingly, although only 13 women completed the yogurt treatment, 8 women in the yogurt arm refused to switch over to the yogurt-free diet. Patients with lactose intolerance may experience GI complaints from oral yogurt intake. Topical treatment of bacterial vaginosis with yogurt has been evaluated in several studies. In an unblinded study of 84 pregnant women with bacterial vaginosis a program of yogurt douching twice daily for 7 days (n = 32) compared with acetic acid tampons (n = 20) or no treatment (n = 20), it was found after 2 months of treatment 88% of women in the yogurt group and 38% of women in the acetic acid group compared with 5% of women in the no treatment group were bacterial vaginosis free. A multi-center, placebo-controlled RCT looking at the effects of lactobacillus vaginal tablets combined with estrogen as a delivery agent on bacterial vaginosis demonstrated a 75% cure rate at 2 weeks and an 88% cure rate at 4 weeks compared with a 25% and 22% respective cure rates at corresponding times in the placebo group.
Empiric evidence from herbal and midwifery practice suggests that live active culture yogurt may be more effective than acidophilus tablets or capsules, although any of the options is potentially effective. It is also provides some immediate relief of burning and itching to inflamed tissue. The easiest way to apply it is in the shower, placing one foot on the edge of the tub and using two fingers to insert the yogurt vaginally and around the vulva. Do not place fingers back in the yogurt after applying; rather place the appropriate amount (2 to 3 tbs) in a small container. The yogurt should be left on for 3 to 5 minutes, and then rinsed off, repeating up to two times daily depending upon the severity of the infection and irritation. Repeat for up to 2 weeks, although treatment is often effective within several days.