Vulvovaginitis: Antimicrobial Therapy

Antimicrobial herbs are used as primary treatments in cases of vulvovaginitis when due to infectious causes. For acute infections, they are generally used solely as topical applications. For recurrent cases, external application is combined with oral use. Internal treatment should focus on immune supporting and antimicrobial botanicals, including echinacea, garlic, goldenseal, Oregon grape root, Pau d’arco, astragalus, and various medicinal mushroom species such as maitake and reishi medicinal mushrooms. Also see site for a discussion on adaptogens and immune support.

Numerous herbs have exhibited both broad spectrum and specific antimicrobial activities. Although treatment approaches vary with each of the different infectious causes of vulvovaginitis, antimicrobial herbs are usually applied generically regardless of the infectious agent. There appears to be little, if any risk of resistance with herbal treatments; however, labs specializing in delivering services to complementary and alternative medicine practitioners sometimes do sensitivity and specificity testing for natural agents with screening for vaginal infections. This is unnecessary except in chronic, recurrent, or intractable cases.

Garlic

Garlic is a popular antimicrobial botanical treatment for vaginal infections, effective when applied in fresh whole form. A single clove is carefully peeled and inserted whole at each application, usually at night, and left in during sleep. It is sometimes dipped in a small amount of vegetable oil to ease insertion. It also may be wrapped in a small piece of gauze or with a piece of string with a tail left hanging to ease removal. Otherwise, it can be removed manually. In vitro, garlic has demonstrated antimicrobial effects against a wide range of bacteria and fungi, including E. coli, Proteus, Mycobacterium, and Candida species. In a study by Sandhu et al., 61 yeast strains, including 26 strains of C. albicans were isolated from the vaginal, cervix, and oral cavity of patients with vaginitis and were tested against aqueous garlic extracts. Garlic was fungistatic or fungicidal against all but two strains of C. albicans. In another in vitro study, an aqueous garlic extract effective against 22 strains of C. albicans isolated from women with active vaginitis. At body temperature, garlic had mostly fungicidal activity; below body temperature, the action was mostly fungistatic. Cases of irritation and even chemical burn have been reported after prolonged application of garlic to the skin or mucosa.

Goldenseal, Goldthread, and Oregon Grape Root

Goldenseal, goldthread, and Oregon grape are all herbs that contain the alkaloid berberine, a major active component possessing antimicrobial activity. In vitro studies demonstrate a rational use of the herb for its antibacterial properties. Berberine has demonstrated specific activity against C. albicans and C. tropicalis as well as to a species of trichomoniasis, T. mentagrophytes, among other pathogens. These herbs have been used historically and in modern herbal medicine with good reliability for the treatment of a variety of infectious conditions, both internally and topically. Goldenseal is considered by many herbalists to be the most effective of the three herbs. It is commonly included, as is Oregon grape root, as an ingredient in topical preparations for the treatment of vaginitis, added in powder or tincture form to suppositories or powder inserted vaginally in “00” capsules. Internal use of goldenseal, in addition to specific antimicrobial activity, may enhance immune response via stimulation of increased antibody production and may be suggested for oral use in intractable cases. Goldthread has demonstrated significant antimicrobial activity against a wide range of Candida species.

Oral consumption of these herbs is generally contra-indicated for use in pregnancy. Goldenseal root is an endangered North American plant. Therefore, only cultivated root should be purchased for use. Oregon grape and goldthread can be substituted with confidence.

Note: Berberine-containing herbs stain fabrics a very distinctive yellow color. Patients using any of these herbs in suppositories or other external treatments should be advised to avoid staining towels, clothing, and bed coverings. It is advisable to insert suppositories prior to bed, and to wear a menstrual pad to protect bedding.

Licorice

Licorice root is one of the most widely used herbs for the treatment of a range of inflammatory conditions. It has demonstrated effectiveness as a demulcent in the treatment of oral, gastric, and respiratory tract conditions, including ulcers and inflammation. Although no research was identified on the use of this herb for vulvovaginitis, its effects on other mucosa would seem to substantiate this application. Additionally, licorice alcohol extracts have shown effectiveness against E. coli, and Candida and Trichomoniasis species in vitro. Alcohol extracts can easily be added to suppository blends for topical application.

Oregano and Thyme

The antimicrobial properties of essential oils have been known since antiquity. In vitro testing of essential oils against a wide variety of microorganisms, showed thyme and oregano to possess the strongest antimicrobial properties among many herbs that were tested. Thyme essential oil has also found to be specifically effective against Candida spp. Direct application of undiluted oil (neat oil) is not recommended as it is too caustic to the skin and sensitive mucosa. Rather, a small amount of essential oil can be added to suppository blends, diluted tincture may be added to peri-washes and sitz baths, and tea of these herbs may be used as a base to which other herbs may be added for peri-washes and sitz baths.

Tea Tree

Tea tree oil is derived from the leaves of the tea tree, a native to Australia with a history of use of the leaves for the treatment of colds, coughs, and wounds by indigenous Australians, who spoke of healing lakes in which leaves of the tree had decayed. The medical use of the oil as an antiseptic was first documented in the 1920s, and led to its commercial production, which remained high throughout World War II. Legend has it that it was provided to Australian soldiers fighting in World War II for use as an antiseptic and that harvesters were exempt from enlisting. Reports of the effectiveness of tea tree oil appeared in the literature from the 1940s through the 1980s, with a significant increasing interest in the medical value of tea tree oil seen in the 1990s to the present, corresponding with interest in complementary and alternative medicine generally. Current research, presented in a thorough review by Carson et al., supports its use as an antibacterial and antifungal, as well as an anti-inflammatory. Limited studies have been done on tea tree oils use as an antiviral, but a few trials have indicated possible activity against enveloped and non-enveloped viruses. A broad range of bacteria have demonstrated in vitro susceptibility to tea tree oil, including those known to be associated with bacterial vaginosis. A case report in which a woman successfully self-treated with tea tree oil-containing suppositories also supports the use of tea tree oil in bacterial vaginosis. At concentrations lower than 1%, tea tree oil may be bacteriostatic rather than antibacterial. Several studies have demonstrated efficacy against C. albicans; however, to date no clinical trials have been done. A rat model of vaginal candidiasis supports the use of tea tree oil for vulvovaginal candidiasis. The organisms on which numerous tea tree oil antifungal studies have focused. Two studies demonstrated antiprotozoal activity of tea tree oil, one specifically supporting anecdotal evidence that tea tree oil is effective against T. vaginalis. The mechanisms of antimicrobial action are similar for bacteria and fungi and appear to involve cell membrane disruption with increased permeability to sodium-chloride and loss of intracellular material, inhibition of glucose-dependent respiration, mitochondrial membrane disruption, and inability to maintain homeostasis. Perhaps what has attracted the most interest about this herb is that it has demonstrated activity against antibiotic-resistant bacteria. It has been used in Australia since the 1920s has not led to the development of resistant strains of microorganisms, nor have studies that have attempted to induce resistance with the exception of one case of induced in vitro resistance in Staphylococcus aureus.

Usnea

Usnea lichens have a history of use that spans centuries and countries from ancient China to modern Turkey, from rural dwellers in South Africa to modern day naturopathic physicians and herbalists in the United States. The lichen is rich in usnic acid, which has demonstrated in vitro antimicrobial activity against bacteria, viruses, protozoa. Additionally, it exhibits anti-inflammatory and analgesic activity. Alcohol extract may be added to a suppository blend or diluted in water or tea (1 tbs tincture / cup of liquid) for use as a peri-wash or in sitz baths.

Uva Ursi

Uva ursi is used by midwives as a topical antiseptic and astringent to relieve vulvar and urethral irritation associated with vulvovaginitis. Leaf preparations have shown antimicrobial activity against C. albicans, S. aureus, E. coli, and other pathogens. For vulvovaginitis, it is used topically as a peri-rinse or in sitz baths.