ORIGINAL RESEARCH ARTICLE: VULVA AND VAGINA
Oral Intake of Lactobacilli Can Be Helpful in Symptomatic
Bacterial Vaginosis: A Randomized Clinical Study
Halyna Reznichenko, MD, PhD,1 Nataliya Henyk, MD, PhD,2 Viktor Maliuk, MD, PhD,3
Tetyana Khyzhnyak, MD,4 Yevhenia Tynna, MD,4 Ihor Filipiuk, MD, PhD,5 Nataliia Veresniuk, MD, PhD,6
Larysa Zubrytska, MD,7 Johan Quintens, MSc,8 Karl Richir, MD,8 and Sergiy Gerasymov, MD, PhD9
Objective: The aim of the study was to explore a role of oral intake of a
mixture of 3 Lactobacillus species in recurrence of bacterial vaginosis (BV).
Materials and Methods: A phase 2 randomized parallel group pro-
spective placebo-controlled study conducted at 7 clinical centers enrolled
18- to 45-years-old women with recent symptomatic BV cured with metro-
nidazole. Within 48 hours after completion of metronidazole therapy, eligible
women received 1 capsule of the verum (5.4 billion Lactobacillus crispatus
LMG S-29995, Lactobacillus brevis, and Lactobacillus acidophilus in
proportion of 60%, 20%, and 20%, respectively), or the placebo supple-
ment 2 times daily for the first 7 days and 1 time daily for the next 8 to
120 days. The primary outcome measure was the percentage of recurrence
of BV, which was defined as 3 of 4 Amsel criteria plus abnormal vaginal
discharge/vulvar odor during 4 months of intake of the test dietary supplement.
Differences between the groups were assessed with Z test for proportions.
Results: One hundred sixty-six women were analyzed in the verum
(82 patients) and the placebo group (82 patients). Recurrence of BV was
documented in 15 (18.3%) of 82 women in the verum group and 27
(32.1%) of 84 in the placebo group (p = .014). Rates of survival without
BV rates were higher in the verum group (Cox F test, p = .018). Both
verum and placebo supplements were well tolerated.
Conclusions: Oral intake of L. crispatus LMG S-29995, L. brevis, and
L. acidophilus can significantly decrease percent of recurrences of BV
in recently treated women and prolong time to recurrence of the disease.
Key Words: vaginosis, bacterial, Lactobacillus, oral intake
(J Low Genit Tract Dis 2020;00: 00–00)
B acterial vaginosis (BV) is the most common cause of vagi-
nal symptoms among women of childbearing age.1 In the
United States, it affects approximately 30% of women and more
1
Zaporizhzhia State Medical University, Zaporizhzhia, Ukraine; 2Ivano-Frankivsk
National Medical University, Ivano-Frankivsk, Ukraine; 3Odessa National
Medical University, Odessa, Ukraine; 4Lviv Community Emergency Care Clin-
ical Hospital, Lviv, Ukraine; 5The 3rd Lviv Community Clinical Hospital, Lviv,
Ukraine; 6Lviv State Center for the Reproductive Health, Lviv, Ukraine; 7Med-
ical Center “MediVit,” Ternopil, Ukraine; 8Vésale Pharma, Éghezée, Belgium;
and 9MedianaStatistics, Lviv, Ukraine
Reprint requests to: Sergiy Gerasymov, MD, PhD, MedianaStatistics, 15-A
Skrypnyka St 22, 79012, Lviv, Ukraine. E-mail: mediana.statistics@gmail.com
H.R., N.H., V.M., T.K., Y.T., I.F., N.V., and L.Z. received personal fees for
clinical visits and data collection; J.Q. and K.R. are employees of Vésale
Pharma and did the conceptualization of the study; S.G. received financial
support for methodology, project administration, supervision, data analysis,
and writing of the article.
The study was supported by Vésale Pharma (Belgium).
The institutional review board status was approved by the Ethical Committee at
Lviv Community Emergency Care Clinical Hospital (Ref. #20-1.1. of
September 28, 2017).
This study was sponsored by Vésale Pharma (Belgium). The sponsor did not
participate in the study design, conduct, analysis, writing, or submission of
the article.
Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on
behalf of the ASCCP. This is an open-access article distributed under the
terms of the Creative Commons Attribution-Non Commercial-No Deriva-
tives License 4.0 (CCBY-NC-ND), where it is permissible to download
and share the work provided it is properly cited. The work cannot be changed
in any way or used commercially without permission from the journal.
DOI: 10.1097/LGT.0000000000000518
Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020
than 4 million women are treated for BV annually.2 Bacterial
vaginosis increases risk of sexually transmitted, pelvic inflam-
matory disease, infertility, spontaneous abortions, and delivery
a premature baby.3–6 It impairs quality of life, has a negative im-
pact on job performance, and impairs intimate partner rela-
tions.7,8 One of the treatment approaches to the symptomatic BV,
recommended by the Centers for Disease Control, includes metroni-
dazole tablets 500 mg taken orally twice a day for 7 days.9 However,
this protocol is associated with 58% recurrence rate with approxi-
mately more than 40% of cases occurring during the first 4 months.10
There is no consensus on the prevention of BV. In a series of
small randomized trials, it has been shown that lactobacilli taken
per os improve vaginal bacterial ecology and decrease recurrence
rate of BV in heterogeneous groups of women.11–14 The rationale
behind the oral use of lactobacilli has served as indirect evidence
for the present understanding that colonic bacteria can translocate
into the vagina.15 Women with BVare less likely to have rectal and
vaginal colonization with Lactobacillus crispatus, a Lactobacillus
species that is often absent in the vaginal microbiota of women
with BV.16 Use of DNA hybridization techniques has shown the
same genetic types of lactobacilli in the rectum and vagina.17,18
The effect of oral use of lactobacilli has not been yet assessed
in a sufficiently powered randomized clinical trial. The objective
of the study was to explore a role of oral intake of a mixture of
3 Lactobacillus species in recurrence of BV, recently treated
with antibiotics.
SUBJECTS AND METHODS
This was a phase 2 randomized (1:1 allocation ratio) inter-
ventional parallel group prospective placebo controlled multicen-
ter clinical study. It was performed from February to August 2018 at
the following 7 clinical settings with gynecology units: 3 public ter-
tiary care city or state hospitals (The 3rd Lviv Community Clinical
Hospital, Lviv; Lviv Community Emergency Care Clinical Hospital,
Lviv; Lviv State Center for the Reproductive Health, Lviv), 3 univer-
sities (Zaporizhzhia State Medical University, Zaporizhzhia; Odessa
National Medical University, Odessa; Ivano-Frankivsk National
Medical University, Ivano-Frankivsk); 1 private clinic (Medical Cen-
ter “MediVit,” Ternopil). All included centers are located in Ukraine.
The study received approval at the ethical committee at the Lviv
Community Emergency Care Clinical Hospital (ref. #20-1.1. of
September 28, 2017). Before enrollment, patients provided signed
informed consent for participation in the trial. The privacy rights
of participants were safeguarded throughout the study and the trial
was fully compliant with the Declaration of Helsinki. The study
was registered at ClinicalTrials.gov (Identifier: NCT03601429).
Women were included in the study if they signed the informed
consent form, were 18 to 45 years old, able to swallow capsules, had
recent BV cured with metronidazole tablets in a dose of 500 mg 2
times daily for 7 days, less than 48 hours after cure of BV, gave spe-
cific consent to communicate intimate history, agreed not to use sper-
micides for 4 months after starting the test dietary supplement (TDS),
and stated the availability of a mobile phone as well as personal avail-
ability throughout the study. Bacterial vaginosis, or its recurrence,
was defined as the presence of 3 of 4 Amsel criteria and one or
1
Reznichenko et al. Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020
combination of self-reported symptoms typical to the disease (vaginal
discharge, vaginal odor).19 Recovery from BV was defined as absence
of all self-reported symptoms plus 3 of 4 negative Amsel criteria.
Exclusion criteria included postmenopausal period, unpro-
tected intercourse to achieve pregnancy, breast feeding, sexually
transmitted disease (STD), vulvovaginal candidiasis, diabetes
mellitus, inflammatory bowel disease, alcohol or drug addiction
as suspected by the investigator, absence of a refrigerator in the
home, known moderate to severe disease of any systems, difficulty
in comprehending the study requirements as judged by physician,
mucosal ulcerations, herpes-like lesions, cervicitis during vaginal ex-
amination, treatment of BV with measures other than metronidazole
antibiotic therapy, use of any investigational drug within the previous
30 days, and use of drugs that suppress the immune system.
Screening for STDs included polymerase chain reaction assays
for chlamydiosis, gonorrhea, HIV, and medical records were re-
viewed for genital herpes, papillomatosis. There were no changes
made to the eligibility criteria after the study commencement.
Study chronology is present in the Figure 1.
The patients with symptomatic BV entered metronidazole
treatment period after preassessment of eligibility criteria. Within
48 hours after finishing metronidazole, if a woman had no symptoms
and 3 of 4 negative Amsel criteria, she was invited for the baseline
visit. During this visit, informed consent was documented with a
signed and dated form, vaginal smears were evaluated for Amsel
criteria and Nugent score,20 and recovery from BV was reassessed.
At the end of the baseline visit, the investigator randomly
dispensed the TDS as described hereinafter, provided the 120-day
study diary (120-DSD), and requested participants to report if
symptoms of BV recurred.
Random numbers were generated by the Random Allocation
Software v. 1.0.0 with no restrictions.21 Random allocation imple-
mented sticking the labels with sequential random numbers to and
sequential selection of the packs by the investigator. Random
numbers were generated by the technician who did not participate
in distribution of packs among centers or data analysis. The TDS
looked the same and had the same smell and consistency. Investi-
gators and patients were concealed which type of TDS was given.
The verum group received the TDS with a combination of
lactobacilli in a dose of 5.4 billion (L. crispatus LMG S-29995,
Lactobacillus brevis, and Lactobacillus acidophilus in proportion
of 60%, 20%, and 20%, respectively; Lactogyn, Vésale Pharma,
FIGURE 1. Schematic presentation of the study chronology.
2 © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP.
Belgium) 2 times daily for the first 7 days and 1 time daily for
the next 8 to 120 days continuously after meals. The placebo
group received a similar TDS (maltodextrin) without lactobacilli
in the same manner.
At the baseline visit, women were advised to avoid any foods
or dietary supplements that contained prebiotics or probiotics,
vitamins, or trace elements during intake of the TDS. In the
structured 120-DSD, women recorded TDS intake, symptoms
of BV, and food intolerance events (abdominal distension, ab-
dominal pain, bloating, constipation, diarrhea, nausea, pruritus,
rash, urticaria). A woman was considered compliant with TDS in-
take, if she received more than 90% of the planned number of
doses. The compliance was assessed by counting remaining cap-
sules in bottles returned during the final visit.
On every visit, the investigator asked about symptoms of BV
and performed a standard gynecologic examination, and vaginal
discharge was analyzed for Amsel criteria and Nugent score.
Between the study visits, an SMS notification to switch from
2 capsules to 1 capsule per day dosing mode was sent. Two stan-
dard phone calls were performed to check if any of BV symp-
toms appeared after previous visits, correctness of records in
the 120-DSD, compliance with TDS intake, number of doses missed,
food intolerance events, storage of the TDS, and to remind to
come back for the interim or final visits.
The primary outcome measure was percent of recurrences of
BV in the verum and placebo groups during 16 weeks of interven-
tion. The secondary outcomes were Nugent scores at weeks 0
(baseline visit), 8 (interim visit), 16 (final visit), time to recurrence
of BV, and rates of survival without BV. There were no changes
made to the outcome measures after the study commencement.
A 43% recurrence rate of BV for the first 3 months after
acute manifestation of the disease has been shown previously.10
Assuming 20% absolute reduction due to use of the TDS, sample
size was calculated as of 83 women per arm (166 two arms) with
1-β error 0.80 and type 1 error based on 0.05 hypothesis for a
2-tailed distribution. Although the sample size was calculated
based on the previously mentioned reference, the time frame
was extended to 4 months as another study showed 2 distinct
waves of recurrences at weeks 8th and 16th.22 There were no in-
terim analyses and stopping guidelines in this study.
Absolute number and percent were used to describe race, ed-
ucation, marital status, employment, smoking status, gynecologic
Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020
diseases, features of intimate habits, food intolerance events, items
of Amsel criteria, and range for Nugent score. Mean and standard
deviation described age, time to recurrence of BV. Normality of
data was assessed with Kolmogorov-Smirnov test. Difference be-
tween the groups in percent data was assessed in Z test for propor-
tions and between the means in 2-tailed t test for independent
variables. Kaplan-Meier plot was used to describe survival with-
out BV, and Cox F test assessed significance in survival rates in
the groups. p values of less than 0.05 were considered significant.
Tests were performed with the Statistica 9 (StatSoft., Inc, Tulsa,
OK) software package.
The study was supported by Vésale Pharma (Belgium). The
sponsor did not participate in the study design, analysis, construc-
tion, or decision as to the submission of the article.
RESULTS
Four hundred forty-eight women with BV were enrolled in
the prestudy metronidazole treatment. All women had 4 of 4 pos-
itive Amsel criteria for BV before antibiotic therapy. Forty-five
women of 276 excluded (16%) failed to achieve a cure of BV with
metronidazole (see Figure 2).
At the baseline visit, 172 women were cured of BV and ran-
domly allocated to the verum or placebo supplementation. Dur-
ing the study, 3 women were lost to follow-up with no further
wish to participate. Three women were excluded from analysis
because of poor compliance with TDS intake, use of spermicide,
or antibiotic. Enrollment of patients was stopped when data from
166 women could be evaluated for the study purposes.
The verum and placebo groups were comparable on major
demographic and medical characteristics (see Table 1).
Most participants were young women, half of them gradu-
ated university. The remainder had secondary education with a
small portion being current students or having interrupted uni-
versity education. Approximately, the half of the study popula-
tion was married, one tenth divorced, and approximately 20%
lived single. Employment status was variably reported, but most
FIGURE 2. Flow diagram of the participants.
© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP.
Lactobacilli in Bacterial Vaginosis
of women were employed full-time. History of BV, genital
papillomatosis, and abnormal cervical cytology were similar
in both groups. History of STD is not mentioned in the Table 1
as it was negative in all women, serving an exclusion criterion.
Almost all women had one male sexual partner. Women reported
more than one male partner or female partner very rarely. Preg-
nancy control measures were comparable in the groups.
At baseline visit, all included women had no symptoms and 3
of 4 negative Amsel criteria (see Table 2).
At the baseline visit, no women had clues cells in the vaginal
smear. Few women occasionally presented with one of other
Amsel criteria. Most of the participants had Nugent score 0 to
3 with no significant difference between groups on all the pa-
rameters. At the interim visit, the verum and the placebo groups
were disproportional in number of patients with each positive
Amsel criterion, except for amine test. Bacterial vaginosis was
diagnosed 3 times less often in the verum group that was associ-
ated with greater proportion of women with Nugent score 7 to 10
in the placebo group. At the final visit, BV recurred more often
in the placebo group, in which the number of women with
Nugent score 0 to 3 was also lesser.
The mean (SD) time to recurrence of BV was 97.3 (26.7) days
in the verum group versus 74.7 (27.7) days in the placebo group
(p = .014). Survival analysis showed that women in the verum
group survived longer without BV than did controls (see Figure 3).
Cox F test showed that time dependence of survival rates
was significant (p = .018).
Nineteen (23.2%) of 82 women from the verum and 17
(20.2%) of 84 women from the placebo group missed at least
one dose of the TDS (not significant [NS]). The mean (SD) num-
ber of doses missed was 2.1 (1.3) and 2.4 (1.6) in the verum and
placebo groups, respectively (NS). All evaluable women received
more than 90% of the course dose and were assumed compliant.
Both verum and placebo TDS were tolerated well. In the
verum group 1 (1.2%) of 82 women had abdominal pain and 1
(1.2%) of 84 women had constipation. In the placebo group, a
3
Reznichenko et al. Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020

decreased the number of recurrences of BV. Previous studies dif-

TABLE 1. Baseline Characteristics of the Study Participants fered by a smaller sample size (22–60 patients), a shorter-term
(7–28 days) application of lactobacilli, variations in inclusion
Verum group Placebo group
criteria (pregnant with herpetic infection, transsexual, postmeno-
(n = 82) (n = 84)
pausal undergoing breast cancer chemotherapy), or simultaneous
Age, mean (SD), y 31.1 (7.0) 30.4 (6.9) a initiation antibiotic therapy with lactobacilli.11–14 In all listed tri-
BMI, mean (SD), kg/m2 27.7 (4.9) 28.0 (5.0) als, benefits were achieved independently of the type of the proto-
Education, n (%) col and included decrease in BV incidence, reduction of
Secondary 33 (40.2) 39 (46.4) b symptoms, and improvement of vaginal bacterial ecology.
A total dose and daily dosing of lactobacilli across the studies
University 42 (51.2) 42 (50.0)
were also different. Kaufmann et al.11 administered lactobacilli
Other 7 (8.5) 3 (3.6) 2.5  109 CFU x 2 times daily for 7 days (total dose 35 billion);
Marital status, n (%) Anoshina et al.12 400  109 CFU x 1 time daily for 7 days (total dose
Single 17 (20.7) 22 (26.2) 280 billion); Marschalek et al.13 2.5  109 CFU x 2 times daily for
Married 56 (68.3) 51 (60.7) 14 days (total dose 70 billion); Laue et al.14 1.25  109 CFU x
Divorced 9 (11.0) 11 (13.1) 2 times daily for 28 days (total dose 70 billion). In our study,
Employment status, n (%) lactobacilli were provided in a total dose of approximately 686 bil-
Unemployed 22 (26.8) 14 (16.7) lion, which was higher than the total dose in the previous studies.
Part-time 13 (15.9) 11 (13.1) Double daily dosing during the first week could potentially have
Full time 47 (57.3) 59 (70.2) helped faster restore vaginal colonization, and our longer-lasting
supplementation could have increased chance of colonization;
Smokers, n (%) 11 (13.4) 16 (19.0)
however, this effect was not specifically evaluated. However, re-
Medical history, n (%) peat use of Nugent score, which is based on counting the number
BV 48 (58.5) 42 (50.0) of morphotypes potentially beneficial or pathogenic bacteria, al-
Candidiasis 60 (73.2) 59 (70.2) lows us to speculate that long-term oral use of lactobacilli can in-
Genital papillomatosis 2 (2.4) 2 (2.4) fluence vaginal microecology and increased concentration of
Abnormal cervical cytology 8 (9.8) 7 (8.3) large gram-positive rods, supposed to be of Lactobacillus genus.
Intimate history As with our study, all referenced intervention studies used
Male partners 0, n (%) 0 (0.0) 3 (3.6) L. crispatus strains.11,13,14 Interest in this Lactobacillus species
1 80 (97.6) 78 (92.9) stems from the earlier epidemiologic finding that L. crispatus is
>1 2 (2.4) 3 (3.6) the most common commensal flora in vagina of healthy women.23
Choice of L. crispatus for formulation was prompted by its direct
Female partners, n (%) 2 (2.4) 0 (0.0)
relationship to BV. When L. crispatus was present in the rectum
Estrogen pills, n (%) 10 (12.2) 11 (13.1) and vagina, BV was diagnosed in 9% of women, whereas its ab-
Condoms, n (%) sence increased prevalence of BV up to 44%.18 Domination of
Never 22 (26.8) 30 (35.7) L. crispatus was effective in suppression of BV-associated anaer-
Occasionally 44 (53.7) 39 (46.4) obes. More than other lactobacilli, L. crispatus produced lactic
Always 16 (19.5) 15 (17.9) acid and other antimicrobial substances.24
Withdrawal, n (%) We documented variable but significantly fewer number of
Never 34 (41.5) 35 (41.7) women with vaginal discharge, clue cells, or increased pH at the
Occasionally 37 (45.1) 40 (47.6) follow-up visits. Similar variability was found in the study by Laue
Always 11 (13.4) 9 (10.7)
et al.,14 who reported Amsel criteria separately and noted their un-
even change of the individual items to the intervention. Investiga-
Spermicide, n (%)
tors did not find significant change in pH of vaginal discharge,
Never 69 (84.1) 70 (83.3) whereas amine tests were more likely negative in the verum group.
Occasionally 12 (14.6) 11 (13.1) Another discrepancy in the referenced article occurred along assess-
Always 1 (1.2) 3 (3.6) ment of Nugent score, which was not different between the groups
Intrauterine device, n (%) at the end of intervention at the background of significant decrease
Never 76 (92.7) 77 (91.7) of clue cell positive smears.14 At the interim visit, we found signif-
Occasionally 3 (3.7) 5 (6.0) icant decrease in percent of smears with Nugent score 7 to 10 and
Always 3 (3.7) 2 (2.4) insignificant increase smears with the score 0 to 3 in the verum
group, and vice versa during the final visit. This discrepancy could
Difference between the groups is not significant on every item of the table. be resolved with the modified Nugent criteria, when scores 4 to 6
a
Difference between the group means in the 2-tailed t test for indepen- were used in combination with presence of clue cells for diagnosis
dent variables. of BV. This approach allowed us to find significantly less preva-
b
Difference between the groups in the z test for proportions. lence of BV in the verum group at both interim and final visits (data
not shown). The selected Amsel criteria together with clinical man-
total of 6 intolerance events were documented by one for every ifestation of BV consistently showed statistical difference between
item (bloating, abdominal pain, nausea, distension, pruritus, con- the groups at every follow-up visit.
stipation). The intensity of the events was mild or moderate with In our study, the verum supplementation with lactobacilli
no consistent relationship attributed to the TDS. prolonged mean time to recurrence of BV by 22.6 days. Similarly,
in the study by Bohbot et al.25 who performed vaginal applications
of lactobacilli for 14 days immediately after metronidazole ther-
DISCUSSION apy and for 14 days after the end of 3 consecutive menstruation
Our study showed that 4-month oral use of lactobacilli, circles (approximately 3.5 months), time to recurrence was longer
started immediately after a cure by antibiotic therapy, significantly by 24.6 days in the verum group. In the mentioned study, the

4 © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP.
Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020 Lactobacilli in Bacterial Vaginosis

TABLE 2. Cumulative Number (Percent) of Women With Amsel Criteria and Nugent Score During the Study Visits

Prestudy Visita −9 Day Baseline 0 Week Interimb 8th Week Finalc 16th Week
Verum group Placebo group Verum group Placebo group Verum group Placebo group Verum group Placebo group
(n = 82) (n = 84) (n = 82) (n = 84) (n = 82) (n = 84) (n = 82) (n = 84)
Amsel criteria, n (%)
Vaginal discharge 82 (100) 84 (100) 3 (3.7) 4 (4.8) 4 (4.9) 16 (19.0)* 16 (19.6) 35 (41.7)*
Clue cells 82 (100) 84 (100) 0 (0.0) 0 (0.0) 3 (3.7) 13 (15.5)† 15 (18.3) 26 (31.0)
Amine test 82 (100) 84 (100) 1 (1.2) 3 (3.6) 5 (6.1) 13 (15.5) 14 (17.1) 21 (25.0)
pH > 4.5 82 (100) 84 (100) 2 (2.4) 3 (3.6) 3 (3.7) 15 (17.9)* 17 (20.7) 30 (35.7)†
BV, n (%)d 82 (100) 84 (100) 0 (0.0) 0 (0.0) 5 (6.1) 16 (19.0)† 15 (18.3) 27 (32.1)†
Nugent score, n (%)
0–3 NAe NA 79 (96.3) 80 (95.2) 67 (81.7) 65 (77.4) 50 (61.0) 38 (45.2)†
4–6 NA NA 3 (3.7) 4 (4.8) 13 (15.9) 7 (8.3) 19 (23.2) 27 (32.1)
7–10 NA NA 0 (0.0) 0 (0.0) 2 (2.4) 12 (14.3)* 13 (15.9) 19 (22.6)
a
Visit before metronidazole therapy.
b
Cumulative number of recurrences diagnosed between the baseline through the interim visits.
c
Cumulative number of recurrences diagnosed between the interim through the final visits.
d
At least 3 of 4 of Amsel criteria plus 1 or 2 symptoms (vaginal discharge, valvular odor).
e
Not assessed.
Difference between the groups in the Z test for proportions (*p < .01, †p < .05).

recurrence rates, 16 (41.0%) of 39 patients in the placebo group
versus 8 (20.5%) of 39 patients in the verum group, were some-
what greater than these in our study, 27 (32.1%) of 84 patients
in the placebo versus 15 (18.3%) of 82 patients in the verum
group, respectively.
The strength of our study was its randomized double-blind
controlled prospective parallel group design with involvement of
7 clinical centers and predefined sample size. This allowed ade-
quate evaluation of a primary outcome measure, a percent of re-
currences of BV in the verum and placebo groups. The most
meaningful limitation of our study was use of less strict criteria
to diagnose BV compared with others. In the present study with di-
etary supplement, BV was defined as at least 3 4 Amsel associated
with symptoms, whereas recent guidelines for industry issued by
the Food and Drug Administration recommended to consider 4 of
4 criteria for reliable diagnosis of BV.26 After re-evaluation of the
database, we found that before commencement of metronidazole
treatment, all patients had 4 of 4 Amsel criteria being positive.
The same guidelines suggested definition of clinical cure as nor-
malization of vaginal discharge, a negative whiff test, and absence
of clue cells on microscopic examination of the saline wet mount.
We defined cure after metronidazole therapy as absence more
than 3 of any 4 Amsel criteria and symptoms of BV that are not
in complete accordance with Food and Drug Administration
recommendations for evaluation of drugs. Another limitation
of the study was also the absence of microbiological end points

FIGURE 3. Kaplan-Meier plot of survival without symptomatic BV. Dash line and triangle marks denote the verum group. Solid line and round
marks denote the placebo group.

© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the ASCCP. 5
Reznichenko et al. Journal of Lower Genital Tract Disease • Volume 00, Number 00, Month 2020
describing evolution of the colonic and vaginal flora before and
during follow-up visits. Indeed, 2 of 4 trials exploring oral use
of lactobacilli in BV, incorporated such an analysis and reported
the increase in lactobacilli count in vagina.11,12 At the same time,
we measured morphotypes of bacteria that might serve a surrogate
end point instead of detailed identification of bacterial species.
Another limitation was absence of description of types (vaginal,
oral, anal) and frequency of sexual activity that also might be dif-
ferent in the groups and influence the study outcomes.27 Long-
term benefits of probiotic supplementation remains unknown as
follow-up for women was 4 months, as we targeted at the early re-
currences of BV at the background of the short-term TDS intake.
We did not assess benefits of probiotic supplementation after ces-
sation of TDS intake.
CONCLUSIONS
The results of this study indicate that 4-month use of
lactobacilli in a dose of 5.4 billion, L. crispatus LMG S-29995,
L. brevis, and L. acidophilus in proportion of 60%, 20%, and
20%, respectively, is safe, decreases significantly rates of exacer-
bations of BV, and prolongs time to the recurrence in fertile
age women.
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