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LITERATURE REVIEW
ALTERNATIVE THERAPIES EORBACTERIAL VAGINOSIS: A LITERATUREREVIEW
AND ACCEPTABILITY SURVEY
Elizabeth K. Boskey. PhD, MPH,
Objective This article reviews current research into
non-antibi-otic treatments tor bacterial vaginosis and assesses
interest in theuse of alternative therapies for women's health in a
non-represen-tative sample of women.Design Literature re\iew and
online survey.Subjects A convenience sample of 192 women was
selectedfrom an online community devoted to the discussion
ofwomen's health.Results " Data on altemative treatments for
bacterial vaginosisare mixed. Studies have shown both positive and
null effects forprobiotic- and lactic acid-based treatments. The
results of antisep-tic studies were more uniformly positive, but
the studies were
generally not placebo-controlled. Women in the survey
popula-tion were both interested in and experienced with
alternative andcomplementary therapies for reproductive health
problems44% of them had used home or natural remedies to treat
vaginalinfections or menstrual problems, and only 20% indicated
thatantibiotics and antiflingals would be their treatment of
choice.Conclusions Women are interested in alternative
treatmentsfor women's health problems such as yeast infections and
bacteri-al vaginosis. Although such treatments have been
investigated,further researchparticularly in the form of
high-quality, ran-domized, controlled trialsi.s strongly indicated.
{Altern TherHealth Med. 2005;U(5):38-43.)
Elizabeth R. Boskey, PhD, MPH, CHES, is an adjunct professorin
the Department of Preventative Medicine and CommunityHealth at the
State University of New York Health ScienceCenter in Brooklyn,
NY.
Bacterial vaginosis is characterized by an increase inthe
vaginal pM from a healthy, acidic pH of ~4 to amore neutral pH of
>4.5. This change is due to anovergrowth of anaerobic bacteria
and a concomitantdecrease in the number of acid and
ll^O^-producinglactohacilli. which are the microbial guards for
vaginal health.'This understanding of bacterial vaginosis as a
disruption in thenormal vaginal ecosystem, as well as recent media
coverage ofantibiotic resistance and a growing movement toward
"natural"therapies.' have led to increasing interest in
non-antibiotic treat-ments for bacterial vaginosis.
Most proposed non-antibiotic therapies for bacterial vagi-nosis
fall into two categoriesprobiotic therapies, which aim toprovide
the bacteria to directly supplement or restore a woman'shealthy
lactohacillus-dommated flora (eg, lactobacillus capsulesand
yogurt-based treatments'"), and acid-restoring therapiessuch as
BufferGel (Reprotect. Inc. Baltimore, Md) and lactic acidgels and
creams, which aim to make the vagina a hostile environ-ment to the
acid-sensitive bacterial vaginosis organisms, therebypromoting
native lactobacillus regrowth.'"'"' Natural antibiotics.
such as tea tree oil. are being studied for use in treating
bacterialvaginosis and are frequently recommended by word of mouth
inwomen's communities.'"
This article reviews current research into
non-antibiotictreatments for bacterial vaginosis. Additionally, to
assess thepotential for interest in non-antibiotic therapies, a
survey wasdeveloped for web-based administration to a convenience
sam-ple of women with an expre.ssed interest in vaginal health.
Asample of 192 women was acquired by posting a
time-limitedinvitation to participate in the survey to an online
communityfocusing on women's reproductive health.
MATERIALS AND METHODSLiterature Review
A search of the literature for all articles containing the
key-words "bacterial vaginosis" and "treatment" was
conducted.Wherever possible, articles that discussed only
antibiotic treat-ment of bacterial vaginosis were eliminated and
all other articleswere retrieved and individually reviewed for
inclusion. Inclusioncriteria were 1) the article must describe a
treatment trial forbacterial vaginosisa decision was made to
include trials of anysize since alternative therapy trials are
frequently small. 2) thearticle must include at least one treatment
that is not one of thestandard antibiotic therapies for bacterial
vaginosis (eg, metron-idazole. clindamycin), 3) trials of natural
antibiotics (eg, tea treeoil) were acceptable because they are not
part of standard pre-
38 ALTERNATIVE THEIUPIES, SHPT/OCT 2005. VOL II, NO, 5
Altemative Therapies for Bacterial Vaginosis
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scription regimens. Articles that met the inclu.sion criteria
werealso drawn from the reference sections of the selected
literature.
Data AbstractionThe following data were systematically
abstracted from
each study: number of subjects, type of study design, tested
com-pounds, whether a placebo was used, whether the compoundwas
administered orally or vaginally, study duration, and results.
SurveyDesign
The survey was designed using a paid online survey toolSurvey
Monkey (SurveyMonkey.com, Portland, Ore)whichallows for an
unlimited number of respondents, the use ofresponse-specific skip
patterns, and many options for surveystructure. The Institutional
Review Board (IRB) approved sur-vey consists of 4 sections: 1) an
active consent section thatrequires 4 confirmatory an.swers before
the participant canproceed to the main survey; 2) questions about
the demo-graphics of study participants and ascertainment ot where
the)'were recruited into the survey: '') questions about
experiencewith vaginal infections or problems and experience with
pre-scribed, over-the-counter, and natural or home remedies; and4)
questions about provider choice for reproductive healthproblems and
general use of complementary and alternativemedical systems.
Participants taking the survey could only goforwardthey could not
go back to change previous surveyanswersand could opt out of the
survey at any time. Skippatterns were used to end the survey early
for those who didnot consent or who were not eligible {ie. people
who havetaken the survey before and male respondents) and to
skipquestions that were not relevant to them based on
earlierresponses. Answers were not required for reproductive
healthquestions but were required for the demographic and
consentsections. The investigator's contact information was
providedat the end of the survey in case participants had concerns
orquestions.
RecruitmentSurvey recruitment was through a post to a
woman's
health community on an online journal website (ie,
www.live-journal.com). The community had approximately 1,300members
and was monitored by another 700 individuals whoare part of the
larger site where the community is located.The invitation included
permission to forward a link to thesurvey website to friends.
The survey recruitment post had a disclaimer section writ-ten
written by the 1KB. with detailed disclosure on possibleissues with
anonymity. This was necessary because althoughthe survey collected
no identifying data, it did collect the com-puter's Internet
protocal (IP) address to prevent people fromtaking the survey
multiple times, and it also left a "cookie" onthe participant's
computer. The disclosure included detailedinstructions on how to
remove the cookie file from the comput-
er and the survey URL from the web browser's History file.
Thesurvey was available for 3 weeks, and a second post
referringpeople to the initial recruitment message was placed 4
daysbefore the study closed.
AnalysisThe survey was analyzed by simple descriptive
statistics
becau.se of the non-random nature of the sampling procedure.The
survey was intended to demonstrate only whether there isan interest
in alternative therapies for vaginal infections amonga
non-representative sample of women with an avowed interestin
women's health.
RESULTSLiterature Review Results
Eighteen studies that examined treatments for bacterialvaginosis
with medications other than commercial antibioticswere identified.
The treatments could largely be broken downinto the 3 categories of
antiseptics, probiotics, and acidifica-tion devices, but one trial
also examined the spermicidenono\ynol-9 as a treatment regimen.
Studies varied in quality,witb more than half of them having no
control group or non-randomized controls (Table 1). Most studies
were small, andthey varied considerably in design. Not
surprisingly, becausenegative studies are rarely published, most of
the availablestudies showed a positive effect for the alternative
therapies.Only 3 of the studies bad ambivalent or negative
results.'""'Although design quality was problematic in many of the
stud-ies, the results suggest that all 3 main
methodsprobiotics,antiseptics, and acidification agents-^are
potentially usefulnon-antibiotic therapies for bacteria!
vaginosis.
Survey ResultsThe women who cbose to participate in the survey
were
primarily white, college-educated women in their late tetnsand
20s (Table 2), as would be expected based on the recruit-ment
method. The majority of these women (74%) have wor-ried about their
vaginal health at one time or another, butmore of them sought
advice from a non-healthcare profession-al than went to a doctor
for care. Slightly more than one-thirdof the population (39%) had
been diagnosed with a vaginalinfection (eg, bacterial vaginosis,
yeast infection) or sexuallytransmitted disease at some point in
the past, and more thanhalf (60%) of those diagnosed with a vaginal
infection were pre-scribed antibiotics. Most women (56%) saw MDs
for tbeirreproductive healthcare, although a similar number were
seenby nurse practitioners, and a substantial minority (14%)
wereunwilling to seek care.
Use of home remedies and alternative therapies in thispopulation
was high (Table 2). Almost half (45%) of the womenhave used home or
alternative remedies for vaginal infectionsin the pasta slightly
higher percentage than those who hadused an over-the-counter yeast
infection treatment without see-ing a doctor (37%). When asked what
their first choice for a
Alternative Therapies for R.icterial Vaginosis ALTERNATIVE
THEKAlMhS. S E P T / O C T 2 0 0 5 , V O L II, N O . 5 39
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TABLE 1 Review of ihe Literature on Ndu-Aiitibiotic Treatments
for Bacterial Vaginosis
Study Number of Study Type Tested Compounds Treatment Placebo-
Oral/ Length ofParticipants Category Controlled Vaginal
Foiiowup
Result.s
Reid etal 2001' 10 Feasibility' L rhaimwsus CR-1 + Probiotic No
Oral 4 weeks. OgaiiismsrecoveredfhiiT! thevn^giiasLjcrmcntum RC-14
] 2 ueeks of most women. Six women v\ith abiior-suspension in milk
(3 women) mal flora had resolution within 1 week
Reid etal 2001' 42 Feasibilit)' /. rtmmihmis CR-l + Probiotic
Inactive Oral 42 days One treatment group withstudy i.fcwwitum W-\A
or from treat- tiR-l/RC-14 had good resolution
L rlhimmms C,C, ment of B\' bi' Nugent .scortall womenwere
i-linicall\' heaitliv
Chimura 1998''* 16 Trial Bio-Three Probiotic No Vaginal 3 days
Significant decreases in vaginal dis-charge, redness, and pi I as
well as a44% rnicrobiologic cure rate
Parent etal 1996" 32 Multicenter. n.J].Jactobacilli and
Probioticrandomized Estriol (Gynoflor) plus estriol
Vaginal 4 weeks Gynoflor was effective in treatingBV
Shalev et al 1996' 20-BV. Crosso\'er yogurt ivif b L18-Canditia
trial luidophilux
8 - Both
Probiotic Pasteurized Oral 6 months. Increase in L aeidopbinlus
isolatedyogurt in women in treatment group.
Significant decrease in B\' intreatment group
Chimura et al1995**
Pattman et al1994'
11 Trial Intravaginal yogurt Probiotic No Vaginal 3 days
Treatment led to significantdecreases in vaginal discharge,redness,
and pH as well as a 54%microbiologic cure rate
Audit Gynatren vaccine Probiotic(/. aclihpliihis lysate)
vaccine
No Neitber - 6 mo Potentially effective for reducingrecurrent
B\' if used withmetronidazole
Neri et al 1993'" 84 - Open 1) Yogurt douche Probiotic,
Treatment Vaginal 2 months Both treatments effective at
treatingpregnant randomized 2) Acetic add tampon and tampon
refusals B\'. but yogurt substantially more so
Fredricsson et al1987"
61 1) Acetic acid ielly Probiotic. No Vaginal 1 month The
alternative treatments wererandomized 2) Dinoestrol creme acid gel,
only rarel)' effecti\'e. All were
3) ComETiercial yogurt hormone substantially less effective
than4} Metronidazole metronidazole
van deWijgertetal 98 Drug safety BufferGel2001'^ trial
Acid gel No Vaginal 14 days Prevalence of BV
declinedsignificantly in study population
Boeke et al 1993'' 125 Randomized 1) Oral metronidazole Acid Yes
Both 3 months Lactic add ineffective in treating BVclinical trial
2) Vaginal lactic acid suppositor\'
Hoist et al 1990'* 10 - Pilot study Ijctal gelpregnant
Acid gel No Vaginal 8 weeks Lactal effective in treating BV
Anderschetal 114-62 Randomized 1) Oral metronidazole Acid
gel1986'"' withBV trial 2} Vaginal lactate gelWewalka et al 70
Randomized 1) Betadine suppositories Antiseptic,2002'" trial
2)/.ij/j.wm capsules. probiotic
No Both 8 da\'s Lactate gel as effective asmetroTiidazole in
treating BV.
No Vaginal 10 days Patients in botli groups improved
bothclinically and subjectively. Betadinehad a stronger long-tenn
ertkt
Petersen et al 180 - 73 Randomized, 1) Dequaliiiium chloride
Antiseptic2002" with BV double-blind 2) Povidone iodineBlackwell
1991'" 1 Case study Tea tree oil. vaginal Antiseptic
pessaries
No Vaginal 4 weeks Both treatments effective intreating BV
No \'aginal 1 montb Vaginal flora and pH resolved tonormal after
self-treatment
Ison et al 1987-" 79 Randomized, I) X'aginal ClorhexidiTie
Antisepticsingle-blind 2) Oral Metronidazole
No Botli 28davs Clorhexidine as effective asmetronidazole in
treating BV
Richardson et al 278 CSWs Randomized, Nonoxynol-9 Spermicide
Yes2001'' U2BV double-blind
Vaginal Median -50 weeks
No difference in B\' incidence betweentreatment and placebo
groups
Artitic in Japanese. B\'-lla(lcrJa! vaginosis; CSVV=tommercial
sra workers
4 0 A L T E R N A T I V E T H E R A P I E S . S E T T / O C T 2
0 0 5 , V O L II , N O . 5 Alteniiitive Therapies for Bacterial
Vaginosis
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Demographic Questions
Age (years)
-
I/VBLE 3 Types of Complementary and Alternative Medicine
(CAM)Providers and Practices L'sed by Survey Participants
CAM providers or products used (all tbat apply)
NoneAcupunctureOsteopathic medicineCbiropractic
medicineHomeopathyNaturopatbic medicineAromatherapyTherapeutic
massageAyurvedic tberapyQigongReikiTherapeutic touchDietary
supplements (not prescribed by an Mi))Other oriental medicine
systemOther CAM practice not listedSkipped
n
7183
202422291911
152
604
1130
%
37.04.21.6
L0.412.511,515,19.90.50.57.81.0
31.32.15.7
15.6
acidophilus tablets were used in an attempt to replenish
healthyvaginal flora. Herbal teas were the second tnost common
thera-pywhen their use was indicated, it was usually for either
painrelief or as an emmenagogue. Non-bacterial acidfying
remediesalso were common, as was garlicone of the more
frequentlydiscussed home remedies for a yeast infection. Both
acidificationtreatments and garlic are intended to make the vaginal
and uri-nary environments more hostile to non-healthy flora.
Althoughnormal vaginal flora thrive at low pH, the bacteria
associatedwith bacterial vaginosis do not, and garlic has
establishedantimicrobial properties. Alternative pain relief
tlierapies alsowere frequently used to relieve menstrual
cramping.
DISCUSSIONThe literature on non-antibiotic therapies for
bacterial
vaginosis is mixed. Whereas sotiie studies show these
therapiesto be useful, others find no effect, and the overall study
qualityis poor. Probiotics,''" acidification agents.'- " '^ and
antisep-tics'"'"-"all show promise for treating bacterial
vaginosisthrough clinical studies and have a firm theoretical basis
forwhy they should be effective. Some studies have found
theseagents to be ineffective, however, and it is important that
high-quality, clinical trials be pursued."''
Women are interested in non-antibiotic therapies for vagi-nal
infections. Only 20% of survey respondents preferredantibiotics;
most would be happy using any therapy that waseffective; and more
than one-third indicated a preference for aprobiotic. natural,
ornon-aiitibiotic therapy. Almost half of thepopulation had, in
fact, used home or natural remedies to treatvaginal or menstrual
problems in the past^more women thanhad purchased over-the-counter
treatments with or withoutphysician approval. Even many of the
women who did not indi-cate a preference for a non-antibiotic
therapy would be willing
TABLE 4 Types of Home or Natural Remedies Used by
SurveyParticipants for Vaginal or Menstrual Problems*
Yogurt:Acidophilus
tablets:Boric:Vinegar:Cranberry:Garlic:Heating:
Herbal teas:
Herbs and essential oils:
Intoxicants:
Special baths and rinses;
Supplements:
Therapies:
Either eaten or applied vaginally (n=48)Eaten or inserted
(n=4)Acid vaginal suppositories (n-2)When specified, as a rinse or
douche (n=6)Juice or pills (n= Hi)Either eaten or inserted
(n=13)Pads, packs, hot baths, andcompresses (n-10)ttickiding
parsleyteinmenagogue), thyme,tansy (pregnanc)
teniiination/emmena-gogue), raspberr)', ginger, chamomile,molasses,
and peppermint (n=23)Including black cohosh, blue
cohosh,pennyroyal, evening primrose oil, dong quai,Chinese herbs,
yarroiv. calendula oil.tea tree oil (n=9)Alcohoi, marijuana
(n=2)Epsom sa!t, oatmeal, baking soda,peroxide (n=8)Lysine (for
1ISV-1 outbreaks), calcium, mag-nesium, vitamin C (emmenagogue)
(n=5)Massage, acupuncture (n=2)
"Number of women mentioning the llierapy is in parenthesis. Most
commonreasons for use of therapies, when given, were cramps, yeast
infections, and uri-nary tract iiifectiDiis, When a specific use,
olher than the above, was meiilioiiedfor a therapy, it is listed in
paremhests.
to use oneequivalent numbers of women were willitig to
useantibiotics, probiotics. home remedies, and
over-the-counter,non-antihiotif therapies.
Current use of alternative therapies for general health inthis
population was similar to (hat seen in a national survey in1997.'
Approximately 42% of the study population used at leastone such
therapy, with tnore than a third of the populationusing dietary
supplements that ha\'e previously been reportedto be frequently
used by women." Interestingly, these womenused a wide range of home
remedies for their reproductivehealth problems. Although this is
partially explained by thesource of the population being a woman's
health communitywhere several of these treatments are discussed,
the frequencyof use is surprising. The most common therapies used,
yogurtor acidophilus. garlic, and cranberry, are easily prepared
orpurchased, and do have some scientific basis for effect.'"'^
'^
The biggest limitation to this study is the non-representa-tive
source of the survey population and the relatively low-response
rate. However, the survey does show a strong interestin natural and
alternative therapies by women in this sampleand will hopefully
help to provide an impetus to futureresearch in this area.
High-quality clinical trials of non-antibi-otic tberapies for
vaginal infections need to be conducted.There is a market for these
treatmentsthey just need to betested and developed.
42 AIJFRNATIVE THERAPIES, SErT/OCT 2005, VOI, 11, NO, 5
Alternative Therapies for Bacterial Vaginosis
-
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lonrrolliiig the popiiialion of vaginal
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D.M. Davis RB, Ediier SL. et al. Trends in alternative mediiine u\e
in ihe
United Stales. 1090-1997: results ofa tiilliiw-up naiional
survey. JAMA. 1998;
Reid tl. Brute AV\', leaser N, et al. Oral probiotics ran
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