Bacterial vaginosis is a common condition that is often a source of shame and stigma. New treatment approaches that target the vaginal microbiome may help to keep this persistent condition at bay.
Bacterial vaginosis is a common but stigmatised condition. New treatments targeting the vaginal microbiome may help prevent recurrence. Photo: Deon Black
Bacterial vaginosis (BV) is a common and distressing vaginal problem, affecting around 35% of women globally.
“It’s highly prevalent, and in African populations, especially in eastern and southern Africa, prevalence is much higher. In some sub-populations at a higher risk for BV, like female sex workers or smokers, it can be around 60%,” says Serah Gitome, a clinical research scientist at the Kenya Medical Research Institute (KEMRI) who is researching the vaginal microbiome in African women.
BV is caused by an imbalance of the bacteria in the vagina. Symptoms can include pain, itching, burning, and an unpleasant discharge with a strong fishy odour; and although only about half of women with BV experience these symptoms, there is a significant amount of stigma associated with the condition due to this smell and discharge, and a taboo on talking about it.
“Because of the odour, the discharge, and the recurrent nature, it can be stigmatising, especially when it comes to sexual relations. Women worry that their partners might go off with someone else because of this problem, and there is the suspicion that it might be a sexually transmitted infection (STI),” Gitome says.
“We know that it’s not, but women often avoid or delay seeking treatment because of self-stigma or perceived stigma from healthcare providers. They also worry that people will think it’s a reflection of their standards of hygiene.”
Until recently, research has been largely neglected and doctors have been left using treatments dating back to the 1980s. Thankfully, that is now beginning to change.
An awkward and persistent problem
The current treatment is a course of antibiotics, yet compounding the stigma is the fact that BV will reoccur in 50 to 70% of women. Recurrent BV has been linked to a greater risk of contracting HIV and STIs.
“I went on repeated courses of antibiotics, but it kept coming back. I felt a lot less confident, I was worried people could smell the discharge, and I felt uncomfortable.”
“Women stop wanting to go and talk about this problem that never seems to go away. They are at a loss and so it does affect their mental health and is associated with stress and depression,” Gitome says.
“It also puts women at a higher risk of getting infected with HIV and other sexually transmitted infections, which, as we know, in Africa, are still big problems, and women are bearing the burden of these conditions.”
Harriet Jones*, a trainee solicitor in the UK, was diagnosed with BV at the age of 22 after repeated visits to the doctor. “I went travelling before going to university and after I came home I noticed an unpleasant, smelly discharge. It was embarrassing and I felt awkward talking to the doctor about it,” she says.
“At first, they thought it was pelvic inflammatory disease, but eventually, they worked out it was BV. I went on repeated courses of antibiotics, but it kept coming back. I felt a lot less confident, I was worried people could smell the discharge, and I felt uncomfortable with things like wearing leggings at the gym.”
At university, Jones’s BV persisted. On a summer holiday in the US, she came across an article about a probiotic supplement claiming to restore balance in the vaginal microbiome. “I decided to try it and it worked straight away. It was such a huge relief,” she says.
Yet most women are unaware that their vagina has a microbiome, or even that a microbiome imbalance is the reason for BV.
Unlocking the vaginal microbiome
The vaginal microbiome, which contains millions of microorganisms, is a critical determinant of vaginal health. A healthy vaginal microbiome is dominated by a few good bacteria which control the bad bacteria. But if the good bacteria start to reduce, then conditions like BV can emerge.
“The way that I take care of a woman with BV is the same way that I was trained 30 years ago. In most cases, we use these inexpensive antibiotics from the 1980s.”
Oestrogen helps keep the microbiome healthy, so when oestrogen levels drop during menstruation, some women get BV. Others are triggered by spermicides. Multiple partners can also lead to increased risk, as can the practice of ‘douching’, where the vagina is unnecessarily cleaned.
Jones has worked out that the alkaline spermicide in condoms disrupts the pH balance in her vagina, as does her period. “Around the time of my period I’ll take a week of probiotics, which usually keeps the BV at bay,” she says.
Although probiotic supplements are emerging, there are no new licensed products beyond antibiotics for healthcare professionals to treat BV.
Professor Craig Cohen is a gynaecologist in the Department of Obstetrics, Gynaecology, and Reproductive Sciences at the University of California, San Francisco, who has spent much of his career studying BV and the vaginal microbiome.
“Historically, there’s been a lack of investment in healthcare for cisgender women, especially when it comes to reproductive health,” he says. “The way that I take care of a woman with BV is the same way that I was trained 30 years ago. In most cases, we use these inexpensive antibiotics from the 1980s, and it recurs in anywhere from 50 to 70% of women within a year.
“With antibiotics, you may be getting rid of the organisms that are causing BV, but you’re not replenishing the optimal vaginal microbiome. That’s where live biotherapeutics and probiotics come in.”
Research and development at last
For women in LMICs, the development of an affordable, accessible treatment for BV could be transformative. Photo: jarmoluk
As the gut microbiome has become a hot topic in the last few years, researchers are finally turning their attention to the vaginal microbiome, and many studies are underway.
“There have been more papers published on the vaginal microbiome in the last two years than there have been since the beginning of time,” says Adam Power, a scientist and director of a new UK-based company, VJJ Health, which has just launched a new probiotic and pH test kit for vaginal health. A similar product, a vaginal probiotic suppository called Seed, has just been launched for consumers in the US.
“It’s great that we’re going to have African population-based data because that has been missing. It’s an area of research that has been neglected for so long.”
Cohen points out that supplements are not medically regulated or licensed. He has been working with a company to develop an FDA-approved live biotherapeutic. In 2020 they published the results of a phase 2b trial that showed a lower incidence of recurrence of bacterial vaginosis than placebo at 12 weeks. They are now seeking more resources to conduct phase 3 trials.
For women in lower- and middle-income countries (LMICs) in particular, the development of an affordable, accessible treatment for BV—such as the one Cohen is researching—could be transformative in reducing stigma and could help to alleviate rates of HIV infections. Yet part of the problem with delivering it is that much of the research has been done on Caucasian women.
“There are some live biotherapeutic products in development. The challenge is that they are formulated with isolates of the probiotic L. crispatus from Caucasian women. Research tells us that how BV presents in African women may be slightly different. They are at greater risk and may have a slightly different make-up of bacteria,” Gitome says.
Gitome is part of the Vaginal Microbiome Research Consortium (VMRC), which is made up of primarily African researchers and was set up to exchange ideas, leverage resources, and carry out microbiome research studies.
“I’m excited about all the research that’s going on now in Africa on the vaginal microbiome. It’s great that we’re going to have African population-based data because that has been missing. It’s an area of research that has been neglected for so long.”
From stigma to empowerment
Dr Jo Bailey is a consultant gynaecologist working for the UK’s NHS; she also serves as a medical advisor to VJJ Health. She says the women with BV whom she sees have usually gone through rounds of antibiotics and the condition keeps recurring. “Now I recommend they try the probiotics and I’ve had good feedback,” she says.
Bailey will usually start her patients on antibiotics and use the probiotics to try and prevent the BV from recurring. “I suggest they take it for two to three months to see how they respond. We test the pH before and after treatment to see how it’s changed.”
Bailey hopes that the research will continue to grow and that more alternatives to antibiotics will be discovered.
“I think it’s about educating women and healthcare professionals. We shouldn’t be looking at BV as an infection. We don’t acquire it like we do pneumonia, for example—these are bugs that are already in the vagina, but are out of balance. It’s about education and saying, there’s an alternative to antibiotics,” she says.
“In a world where we’re worried about antibiotic resistance, surely harnessing the body’s natural defences has got to be a good thing. An affordable treatment could have enormous health possibilities globally.”
Ultimately, when it comes to getting rid of the stigma associated with BV, it’s crucial to focus on education, communication, and prioritising and funding research to prevent recurrence.
“Overcoming taboos and talking about BV is vital,” Bailey says. “Think back to when even talking about breast cancer was taboo and look where we are now—we’re talking about menopause, we’re putting women’s health on the national and research agendas.
“It’s taken a very long time, and tenacious people, but we’re on the precipice of really understanding BV.”
*Name changed at interviewee’s request
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