Lost Balance
Vaginal dysbiosis is an enormous physical and psychological burden for many women. The vaginal flora becomes unbalanced and unfavorable microbial populations gain the upper hand. If the disorder progresses, it can have a massive impact on quality of life. But how exactly does bacterial vaginosis develop and how can it be treated effectively?
According to global studies, 5-10% of all women of childbearing age suffer from bacterial vaginosis. Worldwide, the proportion is even estimated at around 25%. Pregnant women in Germany in particular are frequently affected, at around 20%. The level of suffering is high – not only because of physical discomfort, but also because many women withdraw from social life due to the symptoms.
What is bacterial vaginosis?
Bacterial vaginosis is a special form of advanced vaginal dysbiosis. The balance of the vaginal microbiome becomes unbalanced and microbial populations that are unfavorable for the body can gain the upper hand.
The vaginal flora is a finely tuned interplay of different microorganisms, above all lactobacilli, which ensure a stable, protective environment by lowering the pH value. Bacterial vaginosis, on the other hand, is dominated by anaerobic bacteria such as Gardnerella, Prevotella and Atopobium. Yeast fungi can also multiply excessively. This clinical picture is referred to as vulvovaginal candidiasis, which is characterized by a strong colonization with Candida. Bacterial vaginosis and fungal infections are different sides of the same coin – they can occur individually, sequentially or simultaneously.
The main causes of bacterial vaginosis
Bacterial vaginosis can be favored by various factors. If you are aware of these, you can often actively counteract them in advance and prevent dysbiosis
1. Antibiotics
Broad-spectrum antibiotics can severely disrupt the bacterial balance in the body. They not only destroy the pathogenic germs, but also the protective bacteria – such as the important lactobacilli. As a result, the pH value in the vagina rises, the healthy environment is upset and opportunistic germs have an easy time of it.
Ironically, antibiotics are used to treat bacterial vaginosis – without the accompanying build-up of flora, this can lead to a vicious circle.
Tip: Only use antibiotics when really necessary. Support the natural flora by taking probiotics at the same time or afterwards.
2. Hormonal fluctuations
Oestrogen ensures that the vaginal epithelium produces glycogen, a nutrient that benefits the lactobacilli. If the oestrogen level drops, e.g. due to hormonal changes before menstruation, after childbirth, during breastfeeding or during the menopause, this nutrient is missing. The lactobacilli retreat as they find fewer nutrients, the pH value rises and unfavorable bacteria can spread.
Interestingly, hormonal contraception appears to have a certain protective function here: According to studies, women who take the pill are less likely to be affected, presumably because their hormone levels are more stable.
Tip: Pay attention to oestrogen levels and consider biodentic hormones in consultation with your doctor if you have hormonal disorders. These natural hormones are often absorbed transdermally via patches.
3. Sexual partner
Sex alone does not cause bacterial vaginosis. However, changing partners means contact with different microbiomes and this can affect your own balance. Sperm itself also has an alkaline effect (pH value approx. 7) and raises the acidic pH value of the vagina.
Important: Bacterial vaginosis is not a classic sexually transmitted disease, but foreign microorganisms can destabilize the flora.
Tip: Condoms reduce the risk of dysbiosis. They don’t prevent all effects, but they do significantly more than unprotected intercourse. Frequently changing partners is not problematic per se, but an awareness of microbial interactions helps. Mental factors such as fear of dysbiosis or other illnesses also have a negative impact on the immune system and can increase the risk of bacterial vaginosis.
4. Intimate hygiene
Excessive hygiene, especially vaginal douching, does more harm than good. Water, soaps or antiseptic solutions flush out protective bacteria and disrupt the natural balance. Studies show that douching is associated with a higher rate of bacterial vaginosis. Perfumed intimate hygiene products or aggressive washing lotions are also counterproductive.
The vagina is a self-cleaning organ. Warm water is sufficient – at most mild, pH-acidic lotions for the outer vulva area.
Tip: Less is more. Clean gently – on the outside, not the inside – and do not use aggressive products. Panty liners should be unscented and breathable.
5. Nutrition
What we eat not only influences our intestinal microbiome, but the vaginal flora also reacts sensitively to nutrients, deficiencies and excesses. An unbalanced diet low in vitamins and minerals increases the risk of dysbiosis. Studies show links between bacterial vaginosis and a lack of vitamins A, C, D, E, beta-carotene, folic acid or calcium.
A diet high in sugar, especially foods with a high glycaemic load, also has a negative effect: It favors the proliferation of yeast fungi and shifts the microbial balance. A high-fat diet also appears to have a negative impact.
Tip: A high-fiber, plant-based diet with plenty of fruit and vegetables has a protective effect. Supplement vitamins in a targeted manner, especially A, C, D and E. Reduce sugar, alcohol and highly processed foods as much as possible.
6. Stress and psychological factors
Chronic stress has a variety of effects on the body – and the vaginal flora is not spared either. A permanently elevated cortisol level weakens the immune system, making it easier for opportunistic germs to gain a foothold. In addition, stress is often accompanied by unhealthy factors: poor sleep, an unbalanced diet, more nicotine or alcohol. These are all strains on the fragile balance of the flora.
Tip: Mental stability, regular relaxation and targeted stress management not only strengthen your well-being, but also your vaginal defenses. Mindfulness exercises not only help to promote inner balance, but can also reduce the likelihood of bacterial vaginosis.
7. Environmental factors
Environmental toxins can also severely disrupt the vaginal environment. Chemicals in cosmetics, chlorinated swimming pool water or disinfectants in the intimate area affect the microbial balance. Even cigarette smoke has been proven to have a negative effect on the flora.
Tip: Make sure you wear breathable cotton underwear and avoid synthetic fabrics if possible. Change wet clothes quickly after swimming. Only use chlorinated baths in moderation, as less is often more.
Why does bacterial vaginosis return so often?
For many women, bacterial vaginosis is particularly frustrating because it keeps recurring despite successful treatment. In fact, 50-80% of those affected experience a relapse within 6 to 12 months of standard antibiotic treatment. The reason: often only the acute imbalance is treated but not the underlying causes. The healthy vaginal flora can only regenerate with difficulty and often not permanently without targeted support.
In addition, certain pathogens, above all Gardnerella vaginalis, form resistant biofilms on the vaginal mucosa. These protect the bacteria from complete elimination by antibiotics. Even if only a few survive, they are sufficient to provoke a new dysbiosis.
Another problem is recolonization after therapy. The lactobacilli must return quickly and in sufficient numbers to stabilize the bacterial balance. However, Lactobacillus iners is often the first to return as a pioneer colonizer, a species that is present quickly but does not protect as effectively as L. crispatus, for example. This means that although the vagina is colonized with lactobacilli, it is often the wrong ones that do not ensure a lasting balance. The fast-growing L. iners occupy the niche, preventing other Lactobacillus species from colonizing, but only generating an unstable flora that can quickly become unbalanced. This phenomenon of L. iners dominating after treatment also seems to be the reason why bacterial vaginosis is often difficult to cure.
The important role of the sexual partner
The sexual partner can also play a role. Many men often carry Gardnerella on the mucous membrane of the penis without any symptoms. This can lead to a so-called “ping-pong effect”, i.e. despite treatment, the infection is transmitted again. However, even routine treatment of the partner usually has no positive effect because Gardnerella on the penis quickly gains the upper hand again and is transferred to the vagina even before it is fully overgrown with the right lactobacilli.
In many cases, it is therefore preferable to use condoms for some time after co-treatment of the partner so that the lactobacilli flora can regenerate in peace without being harassed again by Gardnerella.
In principle, classic antibiotic treatment should be viewed critically. It rarely eliminates all bacteria completely. Surviving germs can quickly multiply again. But even in the case of complete eradication, recolonization is a game of chance and depends on many factors.
A new course of antibiotics for a completely different set of symptoms, such as dental treatment, can weaken the lactobacilli again. Chronic stress at work can also quickly upset the delicate balance. In addition, bacterial vaginosis makes the vagina more susceptible to fungal infections, the treatment of which in turn leads to bacterial vaginosis.
The doctors’ dilemma
In addition, many diagnostic procedures are outdated. Standard cultures often overlook relevant pathogens, meaning that therapies come to nothing. New diagnostic tools, however, can help to detect even hard-to-detect colonizers. However, they are only used in a few cases by the treating physician. Instead, a “one-size-fits-all” solution is recommended, which is inadequate for many women. This is often due to a lack of time, unfamiliarity with the new methods, a “we’ve-always-done-it-this-way” attitude and also for billing reasons. Doctors often find themselves in a dilemma: they have to provide a solution quickly and cheaply, but bacterial vaginosis requires a more in-depth consultation, a more detailed analysis and more complex treatment.
Conclusion
Bacterial vaginosis is a challenge, but not unsolvable. With patience, precise diagnostics and a holistic approach tailored to the individual causes, it can be treated sustainably.
In the next article, we will show you how you can stabilize your vaginal flora in the long term and restore a healthy balance.
Bibliography and further reading
Han, Y., Liu, Z., & Chen, T. (2021). Role of vaginal microbiota dysbiosis in gynecological diseases and the potential interventions. Frontiers in Microbiology, 12, 643422. https://doi.org/10.3389/fmicb.2021.643422
Lehtoranta, L., Ala-Jaakkola, R., Laitila, A., & Maukonen, J. (2022). Healthy vaginal microbiota and influence of probiotics across the female life span. Frontiers in Microbiology, 13, 819958. https://doi.org/10.3389/fmicb.2022.819958
Liu, P., Lu, Y., Li, R., & Chen, X. (2023). Use of probiotic lactobacilli in the treatment of vaginal infections: In vitro and in vivo investigations. Frontiers in Cellular and Infection Microbiology, 13, 1153894. https://doi.org/10.3389/fcimb.2023.1153894
Moore, K. H., Ognenovska, S., Chua, X.-Y., Chen, Z., Hicks, C., El-Assaad, F., te West, N., & El-Omar, E. (2024). Change in microbiota profile after vaginal estriol cream in postmenopausal women with stress incontinence. Frontiers in Microbiology, 15, 1302819. https://doi.org/10.3389/fmicb.2024.1302819
Morsli, M., Gimenez, E., Magnan, C., Salipante, F., Huberlant, S., Letouzey, V., & Lavigne, J.-P. (2024). The association between lifestyle factors and the composition of the vaginal microbiota: A review. European Journal of Clinical Microbiology & Infectious Diseases, 43, 1869-1881. https://doi.org/10.1007/s10096-024-04915-7
Reid, G. (2018). Promising prebiotic candidate established by evaluation of lactitol, lactulose, raffinose, and oligofructose for maintenance of a Lactobacillus-dominated vaginal microbiota. Applied and Environmental Microbiology, 84(5), e02200-17. https://doi.org/10.1128/AEM.02200-17
Valeriano, V. D., Lahtinen, E., Hwang, I.-C., Zhang, Y., Du, J., & Schuppe-Koistinen, I. (2024). Vaginal dysbiosis and the potential of vaginal microbiome-directed therapeutics. Frontiers in Microbiomes, 3, 1363089. https://doi.org/10.3389/frmbi.2024.1363089
