Microbial Pathogenesis 136 (2019) 103696

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Microbial Pathogenesis
journal homepage: www.elsevier.com/locate/micpath

Crosstalk between Vaginal Microbiome and Female Health: A review T

a a b,∗
Shagun Gupta , Vipan Kakkar , Indu Bhushan
a
School of Electronics and Communication Engineering, Shri Mata Vaishno Devi University, Katra, India
b
School of Biotechnology, Shri Mata Vaishno Devi University, Katra, India

A R T I C LE I N FO A B S T R A C T

Keywords: Microbiota plays a fundamental role in the overall development and defences of human beings. The majority of
Vaginal microbiome (VMB) indigenous microbiota exists in a mutually beneficial relationship with their hosts, while few of these are op-
Lactobacillus portunistic pathogens that can lead to life-threatening diseases and chronic infections. These microbial com-
Vaginal infections munities constitute the primary defence against infections induced by non-indigenous invasive organisms.
Diagnostics
Female vaginal ecosystem thought to have been shaped over the years by co-evolutionary processes occurring
Pre/probiotics
between the particular microbial partners and the human host. Vaginal secretions contain numerous micro-
organisms and the host provides them nutrients for their growth and development. Disruptions in vaginal as-
sociation with the microbiomes lead to the change in the vaginal environment, which enhanced the risk of
acquiring diseases including sexually transmitted infections, bacterial vaginosis, fungal infections, preterm birth
etc. The focus of this review is on the detailed analysis of vaginal microbiome interplay and its overall impact on
female health. The mutualistic relationship between the vagina and residing microbial species has been well
described. Finally, the recent advancements in the detection of microbiome interactions with the vaginal en-
vironment have been presented.

1. Introduction the genetic profile of all such microorganisms in a combined manner

[3,8–10]. Human genome is basically a segment of the cumulative
“The states of health or disease are the expressions of the success or genome of complex symbiotic, commensal and pathogenic microbial
failure experienced by the organism in its efforts to respond adaptively to association that colonizes and resides inside the human body [11]. The
environmental challenges” [1]. human microbiome consists of almost more than ten thousand diverse
species of microorganisms that populate the human body [6]. Until
– stated by Rene Dubos (Rockefeller University scientist) in 1965
recently, the researchers have studied human microbiome with a pri-
[2].
mary focus on disease states, however, the research trend has now
Indigenous microorganisms play a very crucial role in the overall
shifted with the objective of recognition of innate microorganisms as
maintenance of human health [3]. Multicellular creatures existing as
these indigenous microbes have a fundamental role in regulating
meta-organisms include both the macroscopic host and its commensal
human health [3].
symbiotic microbiota [1]. These complex microbial communities in-
Similar to the gut and mouth which contains numerous different
clude viruses, fungi, bacteria, protozoa etc. [4]. These symbionts have
microbial communities, the female vagina also consists of millions and
an amazing enzymatic capability and have the capability of expressing
trillions of tiny microorganisms including bacteria, viruses, and fungi.
10 fold more unique genes than their host's genome, thus play a crucial
All such microorganisms together make up the vaginal microbiome.
role in governing most facets of host physiology [5,6]. In 2001, the
Among these microbiomes, Lactobacillus is one of the primary bacteria
announcement of revolutionary sequencing of the human genome has
colonising inside a healthy vagina [12] and helps in keeping the vaginal
been made [7]. Undoubtedly, it is one among the notable achievements
environment acidic, thus prevents the thriving of yeast, deadly bacteria
in the physiological and biological worlds, but still it provides only a
and viruses in vagina [13–15]. Some specific types of lactobacilli in-
fractional blueprint of human species [8]. In order to complete this
teract with the host cells and interplay with the genome type of a
blueprint, the next frontier of research is the critical study and analyses
woman in order to boost the production of right mucus and also
of human microbiota (which includes the microorganisms' communities
maintain the acidic environment of the vagina [16]. Such types of
that inhabit the human body [9]) and microbiome (which represents

∗
Corresponding author.
E-mail addresses: sharmasmvdu92@gmail.com, indu.bhushan@smvdu.ac.in (I. Bhushan).

https://doi.org/10.1016/j.micpath.2019.103696
Received 30 May 2019; Received in revised form 29 July 2019; Accepted 23 August 2019
Available online 23 August 2019
0882-4010/ © 2019 Elsevier Ltd. All rights reserved.
S. Gupta, et al.
lactobacilli are considered to be the healthiest vaginal microbiota
(VMB) or vaginal microflora [17]. Other types of lactobacilli are cata-
strophic in nature. Presence of these harmful strains or lack of dominant
and healthy lactobacillus in vaginal microbiome can put females at a
higher risk of getting infected with sexually transmitted infections
(STIs) [6,18,19] and also enhance the chances of acquiring several
critical conditions like bacterial vaginosis, pelvic inflammatory disease,
preterm birth etc. [13,16,20].
1.1. Composition of vaginal microbiota
Human microbiome study is important for understanding the com-
position of human body; to determine whether all human beings consist
of a core and specific set of microbial communities or they differ from
person to person. It has been speculated that human health alterations
and the risk of acquiring diseases might be correlated with the varia-
tions in the core microbiome [21]. Among the different microbial
species, bacteria are present in a vast group of living beings and carry a
large domain of life in themselves [22]. On the basis of cell shape, cell
wall type, motility, endospore production, energy and oxygen re-
quirements, the bacterial community can be classified biochemically
and morphologically by employing DNA-based tests. According to their
capability of producing energy in the absence and presence of oxygen,
bacteria can also be categorized as anaerobic, aerobic or facultative
anaerobic. Facultative anaerobic bacteria are those that can generate
ATP both in presence and absence of oxygen while obligated anaerobic
bacteria can only survive and perform in anaerobiosis. Staphylococcus,
Lactobacillus, and Escherichia coli (E. coli) are all facultative anaerobic
bacteria. On the other hand, Bacteroides are examples of obligated
anaerobic species. Phylogenetically, bacteria are segregated according
to the analysis of small subunits of ribosomal RNA operons’ nucleotide
sequences, especially variable regions of 16S rRNA, a bacterial specific
ribosomal RNA [22–24]. Presently, bacteria domain is gigantic and is
classified into diverse phyla; however, the whole human microbiota
consists of majority of microbes that can fall under four major phyla:
Bacteroidetes, Proteobacteria, Actinobacteria, and Firmicutes [25–28].
From the comprehensive study of the human vaginal microbial
community, it has been found that in the majority of females the va-
ginal composition is dominated by the Lactobacillus bacterial species
[29]. This group of bacteria acts as protective agents in the re-
productive tract by producing hydrogen peroxide and also release
several compounds like bacteriocins in order to prevent the colonization
of harmful bacteria. However, an appreciable percentage of asympto-
matic and healthy women, harbouring an array of diversified strictly
and facultative anaerobic microbes, have vaginal microbiota that lacks
a sufficient number of Lactobacillus sp. [29]. Thus, it can be concluded
that there are multiple core microbiomes instead of a single core mi-
crobiome for the human vagina [30]. Further, ethnicity is also one of
the major factors contributing to vaginal composition. It has been seen
that the Asian/Caucasian women have significantly higher levels of
Lactobacilli than Black/Hispanic women [31,32]. Though, it is still a
mystery that whether this difference in Lactobacilli levels is due to
genetic factors or related to the hygiene practice variations, specifically
vaginal douching [33,34].
Since the vaginal environment of all females is not same, so the
researchers have observed that there are actually five kinds of microbial
communities (as shown in Fig. 1(A)), known as Community State types
(CST), as per which species of Lactobacillus dominates. The CST I is
dominated by Lactobacillus crispatus (L. crispatus), CST II is dominated
by L. gasseri, CST III is dominated by L. iners and CST V is dominated by
L. jensenli. CST IV lacks Lactobacillus sp. and contains huge amounts of
strict anaerobic bacteria like Megasphera, Prevotella, Gardenella and
Sneathia which are generally associated with BV [31,35,36]. Every
woman in her lifespan is susceptible to transitions from one CST state to
another and the most common transition seen in the majority of cases is
from CST III to CST IV. Each Lactobacillus sp. has its particular weakness
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Microbial Pathogenesis 136 (2019) 103696
and strength, for example, L. iners can be active over a wider pH range,
but are not strong enough to inhibit the growth of strict anaerobes seen
in CST IV. These strict anaerobes multiply over a period of time and the
concentration of lactobacilli falls due to the lack of fighting capability of
L. iners leading to the change in power where the strict anaerobes rule
the roost [31].
The recent studies comparing the composition of vaginal micro-
biome from three vaginal sites viz. cervix, mid-vagina, and introitus
have revealed that the female vagina consists of over 200 phylotypes
and the most predominant belong to the phyla Firmicutes, Bacteroidetes,
Actinobacteria, and Fusobacteria [11,30,37,38]. Fig. 1(B) schematically
summarizes the taxonomic distribution, abundance and prevalence of
these microbial taxa residing in the female vagina in accordance with
the human microbiome projects (HMP) [39–41].
The female vagina in normal situations is acidic in nature i.e. has
low pH value because of the presence of hydrogen peroxide and lactic
acid secreted by Lactobacillus sp. The vaginal microbiome gets disrupted
due to the disturbances experienced by the vaginal environment on a
regular basis like the use of various lubricants, sexual activities, semen,
menstruation, antibiotics and hormonal contraceptives [42–44]. For
instance, in the case of gut bacteria, antibiotics are culpable for elim-
inating the lactobacillus and for providing the opportunity to harmful
microorganisms to thrive and grow [16]. As a consequence of the
prolonged use of antibiotics, Peptostreptococcus anaerobius and Gard-
nerella vaginalis, Atopobium vaginae, Mobiluncus sp. Sneathia, Prevotella
sp., Mycoplasma, Ureaplasma, and numerous uncultivated or fastidious
anaerobes become more active and can cause BV and other associated
disorders due to the decrease in the levels of Lactobacillus [45,46]. Thus,
the health status of a female can be predicted by observing the com-
position of the vaginal microbiome. Vaginal microbiome environment
is also age-dependent [47]. As the reproductive status and physiology of
female changes, the vital functions and microflora in the reproductive
tract also change. From the preliminary evidence, it has been observed
that for the ability to conceive and for a successful pregnancy, the
composition of microflora in whole reproductive tract play a crucial
role [13,48,49],. Further, IVF (In-vitro Fertility) research has shown
that at the time of transfer of the embryo, the type of microorganisms
present in the uterus interplay resulting in the outcome of pregnancy
[13]. Thus, due to constant lifestyle and hormonal changes, the vaginal
microbiome experience dramatic shifts throughout a woman's life.
2. Vaginal microbiota in different conditions
Vast array of microbes reside inside a healthy vagina in the primate
conditions. From the above discussion, it can be noticed that women
from birth till death, undergo tragic deviations in vaginal microbiome
composition, yet the environmental and genetic factors that influence
these variations and the complexities of these microbes need to be
described completely. Due to the inherent variations within and be-
tween females of different ethnic groups, a more refined and sophisti-
cated definition of different bacterial communities found in healthy
women is required. Further, the differences between the individuals
should also be appreciated and taken into account while making the
risk assessments and disease diagnosis [30]. A healthy vaginal micro-
biota is essential in preventing BV and other urogenital conditions like
STIs, UTIs (urinary tract infections), yeast infections etc. Moreover, a
better understanding of vaginal microbiome will help in facilitating the
theranostics of various vagina related diseases [6]. In this section, dif-
ferent cases of variations in the vaginal microbiome have been dis-
cussed.
2.1. Vaginal microbiome of healthy women
The relationship between health, disease and the human microbiota
is a broad, fast-moving, contentious and complex research area. The
microbiota composition variations amongst different individuals are
S. Gupta, et al. Microbial Pathogenesis 136 (2019) 103696

Fig. 1. Composition of vaginal microbiome.

Fig. 2. Vaginal microbiome composition in different female conditions from birth to menopause [58,59].

3
S. Gupta, et al.
constantly increasing our understanding of pathophysiology that un-
derlies a range of diseases, from atopic dermatitis [50] to colorectal
cancer [51,52], affecting distinctive human body parts. In contrast to
the majority of human body sites where the microbial communities
with higher levels are generally presumed as a signature of health
[53,54], the reproductive tract of females is considered healthy in low
microbial diversity cases where only one or few Lactobacillus sp. dom-
inate [30,55,56]. A normal healthy vaginal microbiome is mainly
composed of Lactobacillus sp. that acts as a beneficial barrier by inter-
fering with different uropathogens [57]. It has been suggested by the
well-established paradigm associated with the vaginal health that the
lactic acid and hydrogen peroxide are produced by these beneficial
bacteria which helps in maintaining the low pH environment required
for protection from disastrous pathogens. Moreover, in addition to
acidic pH, the mucous membrane surface is also provided with several
immune mechanisms in normal conditions [6]. Fig. 2 shows the com-
position of the vaginal microbiome in different female conditions from
birth to menopause.
2.2. Vaginal microbiome of reproductive-age women
Due to the augmented estrogen levels, large volumes of glycogen,
lactobacilli's main food source, gets deposited in the vaginal walls. The
new-borns that are still under the effect of high estrogen levels of their
mothers possess acidic pH in lactobacilli colonized vagina but with the
course of time, when this estrogen starts leaving their system, the lac-
tobacilli number starts falling and the vaginal pH environment becomes
neutral [58,60,61]. Women in their reproductive age are more likely to
acquire urogenital diseases owing to the vaginal microbiome imbalance
[62–65]). Vaginal microbiome contains lactobacilli in large amounts just
before menopause and after puberty when chances of reproduction are
highly probable (Fig. 2) Since, the whole vaginal microbiome is affected
by estrogen levels, so, the amplified estrogen levels helps in restoring
the useful vaginal lactobacilli and acidic pH environment during and
ensuing puberty which will deteriorate after menopause [60]. During
the premenopausal period, estrogen promotes vaginal colonization by
lactobacilli that metabolize glycogen, produce lactic acid, and maintain
intravaginal health by lowering the intravaginal pH level [57].
2.3. Menopause and the vaginal microbiome
Postmenopausal women often suffer from hormonal, sexual, as well
as genital symptoms, vaginal infections and climacteric syndromes such
as insomnia, hot flushes, depression etc. [66]. Vaginal microbiome is of
great significance and has a profound effect on the overall quality of a
postmenopausal female's life including sexual health, vaginal dryness,
vulvovaginal atrophy (VVA), etc. Vaginal microbiota is highly affected
when a woman approaches menopause due to the reduction in the le-
vels of estrogen leading to VVA. Several recent studies claim that
around 25–50% of postmenopausal females experience VVA including
the vulvovaginal symptoms of painful sexual intercourse, bleeding after
intercourse, burning on urination, soreness, itching, and untimely va-
ginal discharge with foul odours [67]. The action of estrogen influences
the predominant connection between the menopause and vaginal mi-
crobiota [68]. Indigenous bacterial communities metabolize the gly-
cogen and estrogen helps in the maturation of vaginal epithelium by the
deposition of glycogen which produces the organic acids (primarily
lactate) in order to protect the genital tract. In postmenopausal females,
reduced estrogen secretion results in the depletion of lactobacilli and
increase in the intravaginal pH which in turn increases the colonization
of vagina by harmful microbes (such as Escherichia coli (E. coli), Can-
dida, Enterobacter, Gardnerella etc. as shown in Fig. 2) [57].
The topical estrogen helps postmenopausal women in the treatment
of VVA symptoms but it has been seen that in some cases, hormone
therapy (HT) is contraindicated especially in those with the previous
history of active liver disease, breast cancer, prior venous
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Microbial Pathogenesis 136 (2019) 103696
thromboembolic stroke, or coronary artery disorder [67,68]. Vaginal
lubricants can alleviate some vulvovaginal symptoms, however, such
lubricants have adverse effects on the vaginal microbiome, lamina
propria and vaginal epithelium. Moreover, estrogen therapy has also
been associated with serious side effects like perineal pain, breast pain
and vaginal bleeding, thus non-hormonal alternatives and optimal HT
route and dosage are needed to be explored [68].
2.4. Genetic factors affecting vaginal microbiome
It has been observed that certain genetic mutations interfere with
the production of a hormone named corticotrophin-releasing hormone
(CRH) which plays a crucial role in immunity regulation and in-
flammation thus, the abnormalities in its production may cause an
imbalance in vaginal microbiota and have adverse effects on vaginal
tissues especially during pregnancy [69]. Further, in some individuals,
genetic factors result in the reduced protective vaginal lactobacilli le-
vels than expected and therefore, contribute to an enhanced risk of
getting infected with BV. Earlier researches have reported that black
women are more prone to get BV infections in comparison to their
white counterparts mainly due to the increased number of CRH-related
genetic mutations in black women [70].
2.5. Other factors
Apart from the demographic status of women including age, eth-
nicity and several medical conditions such as previous pregnancy, the
habits and living styles of women also affect the vaginal microbiome
composition. Sanitary and hygiene, sexual and birth control practices
and other lifestyle factors like smoking, drinking can also act as co-
founders in establishing the relationship between the diseases and va-
ginal microbiota [62].
2.5.1. Sexual risk factors
Various sexual factors like having multiple or new sex partners,
unprotected sex, use of sex toys etc. Increase the chances of vaginal
infections and disease acquisition. These factors are briefly explained as
follows:
Multiple Physical Relations: Having physical relationships with mul-
tiple males or females is one of the major risk factors of getting infected
with BV [71]. Intercourse with several partners may result in the
change in vaginal microbiota composition as new partners may in-
troduce certain bacteria or other microbes that a particular female's
body is usually not accustomed to, thus leading to several diseases. In
fact, a 2010 study concluded that having sex with another woman in-
creases your risk of BV by as much as 52% [69,70].
Unprotected Sexual Intercourse: Unprotected vaginal and anal sex is
harmful and may lead to several infections as they remove the pro-
tective barrier that dental dams and condoms usually provide. Frottage
(dry humping), use of shared or unshared sex toys and oral sex in-
cluding masturbation and fingering are one of the dominant reasons for
BV [69]. [70].
2.5.2. Living style and habits
Vaginal health is associated with optimal pH and beneficial micro-
biota but the maintenance of these is a complicated task. Many of the
everyday practices in which a woman is engaged can destabilize this
delicate balance, resulting in either the harmful and bad bacteria
overgrowth or undermining the ability to fight infections. The various
factors that intensify the possibility of developing a vaginal infection
and increase the chances of abnormal discharge include stress, alcohol
abuse, smoking, obesity, deficiency of Vitamin D, hormonal variations,
douching, climatic situations like hot weather, high sugar levels or
diabetes, improper clothing, contraceptives (oral and injectable) and
use of steroids, antibiotics and antibacterial soaps [72,73]. Some of
these factors are described below:
S. Gupta, et al.
Smoking: Smoking is associated with various precarious re-
productive health consequences such as ectopic pregnancy, premature
birth, and several birth defects including low infant weight and so on
[74,75]. Smokers are more prone to bacterial infections [76] and it has
been reported that smoking lowers the two vital Lactobacilli sp. levels: L.
crispatus and L. iners; present in a healthy vagina [73]. The females who
smoke are more prone to BV, Chlamydia trachomatis, herpes simplex
virus type 2 (HSV-2), Trichomonas vaginalis [76]. Further, smoking
also causes the blood vessels constriction which impairs the immunity
to stand against the infections especially when increased blood circu-
lation is required leading to breathing and other heart disorders [73].
Douching: Vaginal douching is the practice of intravaginal cleansing
preferably using a liquid solution. The idea behind practising douche is
to maintain the personal hygiene, to prevent the infections by washing
the vagina with douching products especially after sex or menstruation,
to treat various infections, to prevent pregnancy and for various aes-
thetic reasons [33]. Douching puts the females at exposure to diseases
by stripping the protective vaginal microbiota, thereby permitting the
overgrowth of harmful pathogens [77]. As per the majority of evidence,
the frequent vaginal douching is associated with heightened risks of
ectopic pregnancy, preterm delivery, and reduced fecundity, Chlamydia
Trachomatis ailments, Herpes Simplex type 2 disorders, bacterial vagi-
nosis and pelvic inflammatory diseases [33,34,78]. Thus, it can be
concluded that instead of having constructive outcomes, douching is
actually unsafe and have detrimental effects.
Intrauterine devices (IUDs): Birth control procedures can influence
the vaginal microbiome either by introducing the vaginal environment
with the physical and chemical barriers or by hormone levels mod-
ulation. Intrauterine devices (IUD) are effective in preventing the un-
wanted pregnancy but at the same time can double the risk of infections
like BV [79,80]. Such devices directly influence the presence and ab-
sence of two vaginal bacteria; L. gasseri and Sneathia, resulting in the
depletion of the useful bacterium within the vaginal microbiome. Use of
copper and hormone IUDs can increase the levels of Candida fungi
without altering the bacterial composition [81–84].
3. Different vaginal infections
Vaginal infections are often caused by an imbalance in vaginal
microbiota [57] and can range from superficial skin infections to life-
threatening diseases. For example, during pregnancy, an infection
caused by streptococcus can lead to lethal new-born conditions and
bacterial vaginosis may result in preterm birth [58,60]. Such infections
require prompt theranostics including efficient and timely diagnosis
followed by appropriate treatment. If they are not diagnosed and
treated promptly, it can lead to chronic vaginitis, pelvic inflammation,
infertility and endometriosis [85]. In this section, various vaginal in-
fections and diseases are discussed.
3.1. Bacterial vaginosis (BV)
Bacterial vaginosis (BV) is an ecological disorder of vaginal micro-
biome in which the normal microbiota balance gets disrupted resulting
in anaerobic bacteria overgrowth. BV occurs when certain harmful
bacteria (Gardnerella vaginalis, Prevotella and Morbiluncus bacteria
strains, Atopobium vaginae, etc.) present in the vagina get the opportu-
nity to thrive. It is associated with several critical health issues in-
cluding preterm birth, poorer pregnancy outcomes [86], acquisition of
sexually transmitted infections (e.g., Chlamydia trachomatis, HIV, Neis-
seria gonorrhoeae, and HSV-2) and other vaginal disorders [11,45,71],
however, BV itself is not considered as STI or STD because a foreign
pathogen (like HIV virus or syphilis bacterium) is not involved. Common
symptoms of BV are thin white vaginal discharge, itchiness, unpleasant
odour (as mentioned in Fig. 3), pain and burning sensation [90]).
Women in their reproductive age are at higher risks of getting infected
with BV due to practising unprotected intercourse and douching,
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Microbial Pathogenesis 136 (2019) 103696
having multiple sex partners and other harmful lifestyle factors
[73,91–94]Further, varied BV rates are observed in individuals be-
longing to different ethnic groups having different vaginal microbiota.
Therefore, BV can be considered as a multifactorial disease mediated by
a complex interplay of microbial, host and environmental factors
[30,43,95,96].
BV mainly occurs at higher vaginal pH (> 4.5) with more alkaline
vaginal conditions due to numerous colonies of anaerobic bacteria in
the vagina than lactobacilli, as frequently reported in postmenopausal
women [57]. In both pre and postmenopausal females, this BV infection
has been observed to have poor gynaecological and obstetric health
outcomes. It is generally cured by using antibiotics but the recurrence
rate is higher usually within a year of treatment.
3.2. Cytolytic Vaginosis
Cytolytic Vaginosis is also known as Doderlein's cytolysis or
Lactobacillus overgrowth syndrome. In normal situations, the female
vagina consists of a large number of Lactobacillus which helps in
maintaining the acidic pH environment and produces lactic acid and an
antiseptic agent called hydrogen peroxide. But the growth of these
Lactobacilli in abundant amounts leads to a situation of Cytolytic
Vaginosis. The Lactobacilli overgrowth causes lysis of epithelial cells of
the vagina resulting in itching, vulval irritation (pruritus vulvae),
burning or inflammation (vulvodynia and dysuria) and painful sexual
intercourse (dyspareunia) [97]. It is often misdiagnosed as an infection
caused by yeast. According to the preponderance statistics, the patients
suffering from diabetes mellitus (high blood glucose) are more sus-
ceptible to this infection and its symptoms are prominent during high
progesterone and estrogen levels occurring in the luteal stage of men-
struation [58].
3.3. Vulvovaginal candidiasis (VVC)
Vulvovaginal candidiasis (VVC) is the second-most common and
frequent vaginal infection after BV and is caused by Candida sp. In
contrast to BV, VVC manly affects premenopausal females having lower
vaginal pH values (< 4.5) [57]. Almost 75% of fertile females experi-
ence this infection once in their whole lifespan. VVC caused by Candida
albicans (C. albicans) species is termed as uncomplicated VVC (as shown
in Fig. 3) and is observed in generally non-pregnant women resulting in
mild to moderate infections which can be treated by all antifungal
therapies [98]. Non- C. albicans candidiasis cause chronic and recurrent
complicated VVC. Females in their childbearing age, exogenous es-
trogen using postmenopausal females and immuno-compromised fe-
males are at higher risks of acquiring complicated VVC [57,99].
Common symptoms of VVC include inflammation, edema, cheese-like
thick vaginal discharge, dysuria and pruritus [100]. Although the exact
causes of VVC have not yet been identified, increased estrogen levels,
diabetes mellitus, immunocompromised status, and prolonged admin-
istration of antibiotics are some of the suggested reasons for VVC de-
velopment [101].
3.4. Vaginal microbiome in gynaecological cancer
Uncontrolled growth and scattering of abnormal cells originating
from the female reproductive organs are the reasons for gynaecological
cancer development. Such types of cancer generally don't affect the
whole reproductive system but commonly certain parts like ovary,
cervix etc. get affected [102]. Various types of gynaecological cancer
can be observed depending on the affected reproductive organ as shown
in Fig. 4 [103].
Sexually active and young females are generally at higher risks of
acquiring human papillomavirus (HPV) which causes several genital
infections [32]. In most of the cases, such infections are clear, transient
and inactive without ever causing disease, however, persistent
S. Gupta, et al.
Fig. 3. Various vaginal Infections. A) Bacterial Vaginosis (BV); vagina infected with Gardnerella vaginalis abundance [59]; B) Candidiasis (VVC, Vaginal yeast
infection) [58,87,88]C) Trichomoniasis: a STI caused by trichomonad parasite [70,89].
Fig. 4. Different types of Gynaecological Cancers affecting the specific female
reproductive organ [103].
infections if left untreated, results in premalignant cervical in-
traepithelial neoplasia (CIN) which can further undergo invasive
transformations leading to malignant cervical cancer. Various factors
that influence genital HPV acquisition by a woman and its natural
clearance rate include CST number, sexual behaviour, HPV strains pa-
thogenicity and her immuno-competence to prevent, fight and clear
infection [102]. Recent studies have suggested that the presence or
absence of genital HPV and the associated CIN severity depend on
certain vaginal microbiome signatures but such associations are not
much useful in providing the temporal relationship information or
about ascertain effect and cause [32,102,104].
Though it is plausible that the cervical carcinogenesis is influenced
by, or influences, vaginal microbiome, but the importance of vaginal
microbiota in the etiology of other gynaecological cancers is uncertain
[102]. For example, in the case of ovarian cancer, it is well known that
salpingectomy or hysterectomy with tubal litigation and ovarian con-
servation can reduce the risk. It can further be speculated that this risk
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Microbial Pathogenesis 136 (2019) 103696
reduction mechanism is related to the conduit's surgical disconnection
between the vagina, with the sterile upper genital tract and having the
rich bacterial ecosystem [104].
Champer et al. [105], in their study, have highlighted the function
of vaginal microbiota in endometrial carcinogenesis. The common
factors such as obesity, use of oral contraceptives, hormonal fluctua-
tions, hysterectomy and reproductive history affect the chances of en-
dometrial cancer by disrupting the microbiome [104,105].
3.5. Sexually transmitted infections
Female reproductive tract is composed of a large number of mi-
crobial species and there is much likelihood of pelvic infections to
prevail [106]. Majority of such pelvic infections are sexually trans-
missible. Various catastrophic vaginal microbes; including anaerobic
bacteria, Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pal-
lidum, group B streptococci, Mycobacterium tuberculosis, human papillo-
mavirus (HPV), human immunodeficiency virus (HIV), cytomegalovirus,
herpes virus, and hepatitis B virus; are potential sources of STIs and have
the capability of producing fatal sequelae [107]. In the following sub-
section, Trichomoniasis, and vaginal microbiome and HIV connotation
have been discussed.
3.5.1. Trichomoniasis
Trichomoniasis or Trichomonal Vaginitis (abbreviated as ‘trich’) is a
type of STI and can occur in both teenage and adult females. The single-
cell parasite causing this disease is known as trichomonad. This parasite
can also affect the penis of males and in females; it affects vagina, ur-
inary bladder and urethra. The patients infected with this parasite have
frothy yellow-grey-green vaginal discharge with a foul odour as speci-
fied in Fig. 3 [89]. Other symptoms include painful urination and sexual
intercourse, vaginal soreness, redness, burning and irritation [89,108].
While having sexual intercourse, the use of latex condoms is the most
effective way of preventing this STI [89].
3.5.2. The vaginal microbiome and HIV risk
Disturbances in the vaginal microbiome and imbalance in the va-
ginal microbiota composition might aggravate a woman's vulnerability
to HIV. It has been observed that diverse vaginal microbial differences
and the key bacteria concentrations are associated with greater jeo-
pardy of acquiring HIV infection through several potential pathways
such as through HIV inducing factors production, inflammation, or by
disrupting chemical and physical barriers to HIV [109]. Further, the
other vaginal infections like BV, which is characterized by complex
S. Gupta, et al. Microbial Pathogenesis 136 (2019) 103696

anaerobic bacteria present in the vagina, also subsidize HIV transmis-

[116,117,121,122])

[116,117,123,124]
[89,108,116–119]
[98,99,116–119]
sion [110,111]. A recent study showed that young South African fe-

[116,117,125])
[116,117,120]
[86,116–119]
males with highly diverse vaginal microbial communities had plentiful

References
genital CD 4- positive T-cells in an activated state and thus were at four-
fold higher risks of acquiring HIV when compared to the females with
less diverse and L. crispatus dominated vaginal microbiome [111,112].
Moreover, the relative abundance of various other bacterial taxa (like

Antigen- testing or Culture using Swab, Pap test Or

Microscopy and Culture, Pelvic examination using

Microscopy, Pelvic examination using Speculum,
examination using Speculum, pH tests and other

Urine Test or Using vaginal Swabs for other lab-

Sneathia sanguinegens, Mycoplasma, Prevotella melaninogenica, Prevotella

Biopsy, Hysteroscopy, Transvaginal ultrasound,

bivia, and Veillonella montpellierensis) also increases the HIV risk [109].

Culture and Microscopy techniques, Pelvic

Environmental, genetic and behavioural factors are also responsible for

Speculum, pH tests and other lab-tests

worsened HIV risk by affecting the vaginal microbiome. For instance,

Conventional Diagnostic Techniques

for the hygiene purposes, the uses of various vaginal products and for
increasing the sexual pleasure by dry vaginal secretions, all such

pH tests and other lab-tests.

practices can change the vaginal pH and have been reported to be as-

Pap Test, HPV DNA test

sociated with several vaginal infections resulting in inflammation,
disruption of vaginal-epithelial barrier and so on [113].

a urine Lab-test
4. Detection of vaginal microbiome

Speculum
lab-tests.

tests.
Since the 1800s, many exclusive studies on the vagina and asso-
ciated microbiome have specified that bacterial communities reside

Blood-tinged red or dark brown, pus-like vaginal discharge with a foul odour.
Pelvic pain, dark brown, reddish brown or red and watery vaginal discharge,
Painful sexual intercourse, burning sensation when urinating with abnormal
inside the vaginal cavity. Initially, scientists used conventional techni-

intercourse, burning sensation during urination, frequent urination, lower

Thin, pus-like white or yellow vaginal discharge with a foul fishy odour,
White, thick, crumbly, cottage-cheese like vaginal discharge followed by
ques such as gram staining, light microscopy etc. In order to observe the

urination and sexual intercourse, vaginal soreness, redness, burning and

Frothy yellow-grey-green vaginal discharge with a foul smell. Painful
vaginal microbial composition. As the technology advances, culturing

Creamy, watery and slightly green vaginal discharge. Painful sexual

techniques and PCR (Polymerase Chain reaction) came into existence

Pelvic or lower abdominal pain with abnormal vaginal bleeding

with which researchers can detect and identify various microbial spe-
cies inhabiting the vagina in a more accurate and efficient way. Though

vaginal irritation and burning sensation during urination

the culturing techniques provide accurate results but are very slow and
time-consuming and only a fraction of microbial species recognized till
date has been cultured successfully in the laboratories. Moreover, such
methods are not suitable in the current scenario for differentiating

vaginal discharge and unpleasant odour

normal and abnormal vaginal microbiome [114], so new techniques are

abdominal pain, sore throat and fever

needed to be developed for deeper taxonomic resolutions and for

painful intercourse with bleeding

functional analysis at the genomic level [11]. On the other hand, PCR
technique provides highly sensitive results rapidly but is complicated
Causative agents and Symptoms of various vaginal infections with Conventional diagnostic methods.

and limited by false-positive and false-negative results.

Non-culture based modern techniques have exposed a dynamic and
complex system to the world which is dominated by lactobacilli sp.
vulval itchiness

[114]. Further, the understanding of complexity and diversity of va-

Symptoms

ginal bacterial microbiota has been expanded due to the evolution of

irritation
molecular-based techniques [67]. In recent years, the microbes’ com-
position and functional space analysis have been revolutionized by
sequencing technologies. 16SrRNA cloning and sequencing, a culture-
independent method, can identify a vast range of vaginal microbiota
STI status

Rarely

and can also detect the uncultured taxa, however, this technique is
[116]

Yes

Yes

Yes

Yes
No

No

restricted by low-throughput and high cost. Hence, this method is

usually utilized for analyzing only smaller sample sizes. The emerging
Morbiluncus bacteria strains, Atopobium vaginae

next-generation sequencing can further be explored in order to char-

acterize a huge array of taxonomic species alternatively and effectively
that otherwise would not be possible to detect with previously existing
Gardnerella vaginalis, Prevotella and

methods [115].
Neisseria gonorrhoeae bacterium

Human papillomavirus (HPV)

Different vaginal associated infections with the causative agents and

symptoms have been described in Table 1. Table 1 also summarizes
Chlamydia trachomatis

various conventional diagnostic techniques used for the detection of

Yeast (Candida sp)

these vaginal disorders.

Genetic mutation

Diagnostic methods used for detection of several vaginal microbial

Trichomonad

communities, as summarized in Table 1, are mostly laboratory-based

procedures which are costly, time-consuming, laborious and require
Agent

etc.

highly skilled practitioners. Thus, it is necessary to design rapid, por-

table, real-time, low-cost, point-of-care (POC) and sensitive microbial
Endometrial cancer
Bacterial Vaginosis

detection tools. Current research scenario has entered into the gen-
Cervical cancer
Trichomoniasis

eration of biosensors [126–129]and lab-on-chip platforms [130] owing

to the recent developments in nanotechnology and VLSI (very large
Chlamydia
Gonorrhea
Disease

scale integration). A biosensor is an analytical device which comprises a

Table 1

VVC

bio-recognition component for separating the biomarker and a physi-

cochemical transducer for converting the biological signal into

7
S. Gupta, et al.
analyzable form. Due to the possibility of integration of various fields
like microfluidics, biosensing, electronics etc. on a single chip, the lab-
on-chip POC platforms can be designed for the complete pathogenesis
of various vaginal diseases [129–133]). Rapid diagnostic platforms
along with on-time appropriate treatment are indispensable for the
complete theranostics of vaginal infection. In the next section, the
benefit of prebiotics and probiotics as vaginal infection therapeutics
regimens has been explained briefly.
5. Effect of probiotics and prebiotics on vaginal communities
As discussed in the previous sections, vaginal microbiome with
lactobacilli abundance is a sign of health and is found in the majority of
healthy women. In the cases with an imbalance in vaginal microbiota,
the beneficial lactobacilli sp. Is in fewer amounts, thus the chances of
acquiring the vaginal diseases and infections get increased. In such si-
tuations in order to maintain the healthy vaginal microbiota balance,
additional dietary supplements known as probiotics are advised [134].
Probiotics are basically propitious microorganisms which usually con-
tains the L. genus species. Researchers have reported that in approxi-
mately 82% of cases suffering from vaginal microbiota imbalance, the
supplementations with oral L. fermentum and L. rhamnosus can restore
the VMB. An important advantage of using such probiotics is that they
can be taken for longer time periods, thus are beneficial especially after
combative regimens of antibiotic therapy [135]. Probiotics help in
maintaining the healthy vaginal microbiome environment by altering
the intravaginal microbe composition, by promoting the proliferation of
beneficial microbial communities, and by preventing the vaginal in-
fections especially in postmenopausal duration. Probiotics are also
useful in reducing the symptoms of various vaginal infections (such as
inflammation, vaginal discharge, foul odour, etc.), and are thus helpful
in the prevention and treatment of VVC and BV [57]. Though vaginal
and oral probiotics have shown great potential and initial studies have
complemented the previous research findings concerning the effects of
probiotics in menopausal conditions and in preserving vaginal micro-
biome composition, but still, additional trials are mandatory for de-
termining the bacterial therapeutics’ efficacy in modulation and re-
storation of vaginal homeostasis [67].
Other than probiotics, prebiotics are also utilized to enhance the
production of useful bacteria residing inside the human body.
Prebiotics are carbohydrates that are generally not digestible such as
families of gluco-oligosaccharide (GOS), fructo-oligosaccharide (FOS)
etc. They have the capability of modulating the microbial composition
and can have microbiota independent immuno-modulatory effects
[136]. Their use in the gastrointestinal tract is well available in the
literature and recently, several in-vitro and few in-vivo studies have
suggested the proof of concept of prebiotics in the vagina [32]. Both
GOS and FOS families help in the growth of L. jensenii, L. crispatus, and
L. vaginalis [137]. Moreover, in a synbiotic environment, if prebiotics
are used with probiotics, they may augment their growth and enhance
their bacteriocin production [32,138]. Thus, both pre and probiotics
play a crucial role in the treatment of many female vaginal diseases
including cancers.
6. Conclusion
It can be concluded from the above study, that the vaginal micro-
biome plays an imperative role in maintaining the overall health of a
female. The dynamics of vaginal microbial communities over the phy-
siological phases of a female's life span gives an insight into the mu-
tualistic relationship between the female host and its vaginal micro-
biota. Despite their significance, surprisingly diminutive knowledge is
there about how these microbial species articulate a dynamic ecosystem
in response to environmental turbulences by interacting with each
other and with their host. For example, it is well-known fact that mi-
crobial interactions are responsible for developing infertility (such as
8
Microbial Pathogenesis 136 (2019) 103696
tubal damage) but it is not crystal clear that actually microbiome in-
terplay is behind the outcome of fertility or not. So, a proper under-
standing of vaginal microbiome composition in different situations and
the awareness of various factors affecting such composition is required
in order to ameliorate the disease diagnostics. Utility of modern-omic
techniques and development of portable and efficient on-chip diag-
nostic platforms for the early detection of various vaginal infections and
for the investigation of variations in vaginal microbiota are the current
frontier of research in this field. Further, the adaptation of more per-
sonalized regimens for the better treatment of vaginal disorders can be
proven useful in order to boost female health.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://
doi.org/10.1016/j.micpath.2019.103696.
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