Protective Vaginal Ecosystem

The vaginal microbiota provide a first line of defense in the reproductive tract

pH -3.8-4.5

Lactobacilli (Doderlein bacillus) 
The dominant inhabitants & the cornerstone of vaginal health

Ravel J. Translating the vaginal microbiome: gaps and challenges. Genome Medicine. 2016;8:35.
 Normal Vaginal Microbial Ecosystem
When pH is altered, restoration of microbiota is very important
•Human vagina microbial ecosystem •Other less common bacterial species
most often dominated by found in the vagina includes
• L. crispatus  •Prevotella 
• L. jensenii, •Megasphaera 
• L. gasseri, • Atopobium vaginae
• L. iners, 
•Peptostreptococcus 
• L. acidophilus,
•
•staphylococcus spp 
L. fermentum,
• L. plantarum, •Streptococcus spp.
• L. brevis, •Gardnerella vaginalis
• L. salivarius, • Sneathia 
• L. casei, • Bacteroides spp
• L. vaginalis
• L. reuteri
• L. rhamnosu

This indigenous microbiota protect against pathogenic organisms, responsible for

1. Bacterial vaginosis, Yeast infections, Sexually transmitted infections (STI),&
2. Urinary tract infections, and pre-term delivery, miscarriage, Pelvic inflammatory disease
Sarah Cribby, “Vaginal Microbiota and the Use of Probiotics,” Interdisciplinary Perspectives on Infectious Diseases, vol., 2008
 The changing pH physiology of vagina over a lifetime

Vaginal epithelium
thickens and
intracellular glycogen
production begins.
Cervicovaginal
Puberty secretions are
produced, and vaginal
fluid becomes acidic
Estrogen stimulation
causes the thickness,
glycogen content, and
parakeratosis of the
vaginal epithelium .
Lactobacillus species
predominate in the vaginal Reproductive age
flora (92%) and vaginal pH
is acid.

The elevated vaginal pH

Vaginal epithelium is thin associated with pregnancy is
and fragil and vaginal pH probably due to the increased
is about 7 becuase the volume of the of mucous
low frequency of secretion. Mucous has high ph
lactobacilli. The decrease of and this might reduce vaginal
estrogen and acidity favoring bacterial
progesterone levels colonization
Pre-menarche results in decrease of Pregnancy
vaginal secretions and in
the thinning of the pregnancy the
vaginal epithelium. pH value is
Lactobacilli decrease and
Endogenous factors on physiology vaginal pH rise. These usually 4
Estrogens. modification make vagina
more susceptible to
Menstrual cycle infection.
Pregnancy
Vaginal infections Menopause
Farage M, Maibach H. Lifetime changes in the vulva and vagina. Arch Gynecol Obstet. 2006 Jan;273(4):195-202.
 Vaginal pH
• pH in healthy women during the child
bearing period is about 3.8- 4.5
• The new-born pH value-5.7, &
• Children : between 6-8
• At puberty: falls to 4
• During pregnancy the pH value : usually 4
• After the menopause the pH rises to 7

Doderlein’s Bacillus is almost the only organism which will grow at pH of 4-4.5
As the pH rises, pathogenic microorganisms are able to thrive

Shaw's Textbook of Gynecology E-Book 2014. By V. G. Padubidri, Shirish N Daftary

 The loss of Lactobacilli is linked to

Relatively High vaginal pH (>4.5)

Associated with an overgrowth of bacteria

Infections Adverse Reproductive Infertility

• Bacterial vaginosis
• Vaginal candidiasis
• Trichomoniasis
• Cervicitis
• STD
• Cervical dysplasia
Outcomes •Tubal infertility
• Preterm labour •Ectopic pregnancy
• Low birth weight •Pelvic inflammatory
• Amniotic fluid infection disease (PID)
• Chorioamnionitis •Reduced sperm motility
• PROM and viability

6
 Journal of Pharmacy & Bioallied Sciences. 2011;3(4):496-503.
 Importance of Testing vaginal pH 
• An elevated pH suggests Bacterial
vaginosis or Trichomonas vaginitis
• Vulvovaginal candidiasis is generally
detected in a normal vaginal pH range
(<4.7)
• Studies have recommended screening
for increased vaginal pH during
pregnancy, & even shown its usefulness
in lowering preterm birth rates
 AMSEL Criteria

• Intravaginal pH is one of the important criteria used for diagnosing

bacterial vaginosis (Amsel criteria)
• Presence of 3 out of four criteria shows diagnosis of Bacterial Vaginosis:
1. Increased homogeneous thin vaginal discharge;
2. pH of the secretion greater than 4.5;
3. Positive Whiff test: Amine odor when potassium hydroxide 10% solution is
added to a drop of vaginal secretions;
4. Presence of clue cells (>20%) in wet preparations

8
EvaNew Gloves
(Test Glove with pH Indicator)
 EvaNew Gloves
(Test Glove with pH indicator)

•An absorbing pad on the index finger

of gloves: To collect the vaginal fluid
•The pH indicator specifically located
on the thumb to avoid the contact of
any chemical agent with the vagina
•The pH indicator will change color
when the index finger having absorbing
pad is pressed against thumb for few
seconds

EvaNew Glove is an easy-to-use test for the measurement of vaginal pH

values, identifying women at risk of vaginal infection, prompting early
intervention.
HOW TO TEST VAGINAL PH USING
EVANEW GLOVES
Interpretation of Result
•Healthy Vaginal Ecosystem: pH between
3.8-4.5 in absence of any sign or symptom
•Candida Infection: pH between 3.8-4
associated with whitish discharge and
symptoms such as itching, burning etc
•Bacterial vaginosis: pH > 4.5 associated
with vaginal discharge malodorous or not
•Trichomonas Vaginalis: pH > 4.5
associated with vaginal discharge, itching,
burning
• Mixed Infection: If the vaginal pH
>4.5 with curdy white discharge with
itching burning, then its mix of BV and
candida. pH < 4.5 with same clinical
symptoms is only candidiasis.
Merck
Certificate of Accuracy Of pH strip
 Indications & Usage
• Diagnosis of Vaginal Infections e.g.
1. Bacterial Vaginosis
2. Trichomoniasis
3. Vaginal candidiasis
4. HPV and other Infections of the genito-urinary tract
• Identify women at risk of premature Birth,
PROM, amniotic fluid infections in order to
prevent Preterm labor
 Precautions while Interpreting Result

• False-positive result (elevated vaginal pH)

– may also occur due to alkalinization of the vagina by blood, semen, soap and
antiseptic solutions

• False-negative result
– in the detection of premature rupture of membranes may occur due to decreased
efflux of amniotic fluid as the time between membrane rupture & testing increases
• Antibiotic therapy or infections of the vagina can lead to elevated
vaginal pH which could be interpreted falsely as the presence of
amniotic fluid
• pH testing cannot distinguish amniotic fluid from urine in instances
where there is the possibility of urine contamination

The positive & negative predictive value of vaginal pH as a diagnostic tool is 100% and
92.5% respectively (Mania-Pramanik et al, 2008)
Clinical Evidence
 Summary of clinical trials of EvaNew Gloves
Trial Design No. of patients Key Results
1
An elevated vaginal pH was better
-Vaginal pH predictor of PTL (likelihood ratio
assessed Predicting [LR]- 3.7) and early PTL (LR- 1.7).
using test preterm A shortened CL was significantly
Matijevic R,
Int J Gynaecol gloves &
labor in a correlated with PTL (LR]weighted
Obstet. 2010 low-risk by prevalence- 2.7) but not with
cervical length cohort of 316 early PTL (LR-0.8).
ct;111(1):41-4.
(CL) by pregnant Conclusion: An elevated vaginal
transvaginal women pH is better predictor of early PTL
USG than a shortened CL in this cohort
of pregnant women at low risk.

2
Pregnant women In Erfurt an overall decrease of
Hoyme UB,  performed self- 381 women
measurements of
prematurity from 7.68 to 6.81%
Huebner J. IN and a reduction of cases ≤ 32
Gynecol Obstet their vaginal pH Prematurity
by means of test
Preventional wks. from 3.22 to 2.39% was
Invest. gloves twice a
 2010;70(4):286 week in order to campaign observed
-90. screen for any 2000 Significant reduction of early
disturbances in prematurity from 1.58 to 0.99% was
the vaginal milieu seen respectively (p < 0.001).
18
 Summary of Indian clinical trials of EvaNew Gloves

Trial Design No. of patients Key Results

Vaginal pH >4.5 by
-cross-sectional 270 women with In detecting BV
Hemalatha R. study  complaints of pH strips: Sensitivity 72% & specificity
Indian J Med -to assess the white discharge, -60%
3 Res. 2013 utility of pH strip and symptoms pH Glove: Sensitivity 79% & specificity
Sep;138 (3):354- vs. pH glove attending a 53 %.
9. for screening government pH gloves are equally suitable for
hospital screening women with BV on outpatient
women for BV
basis.

MN ALAM*,
Cross-sectional •Both pH glove and pH strip are equally
ALOK comparative study
BHARDWAJ, to check the 50 subjects suitable for screening women with BV on
MQ HODA, efficacy of pH Strip pregnant as
an outpatient basis.
4 CHITRA GUPTA & pH Gloves for well as non-
Int J Pharm Detection of pregnant •Vaginal pH determination is relatively
Pharm Sci, Vol Bacterial Vaginosis women
in a Tertiary Care sensitive, but less specific in detecting
7, Issue 7, 187-
Hospital
189 May 2015 women with BV
19
Why EvaNew Gloves?
• For Quick, Easy &Reliable assessment of vaginal pH during OPD
check up
• Available with accurate Merck pH paper for instant pH check
• Vaginal infections can be detected and treated at earliest
• Patient can get the specific prescription in the same visit
• Culture test report takes at least 3-4 days for which patient need
to wait and revisit the Dr to get prescription
• Can be carried out at home by the patient herself
• Helps a woman decide if she needs to visit a medical
professional
EVANEW TABLETS
(Vaginal Tablet)
 
 EvaNew Tablets

• Composition
– Each effervescent rapid release vaginal
tablet of EvaNew ™ contains at least 109
viable lactobacilli:
o L. salivarius subsp. Salicinius
o L. Plantarum
o L. Brevis

– Excipients: Lactose monohydrate, corn

starch, adipic acid, sodium bicarbonate,
ascorbic acid, magnesium stearate,
stearic acid, colloidal silicon dioxide
  Selection of Vaginal Lactobacillus Strains

• Strains are selected due to their:

– Ability to adhere to epithelial cells displacing vaginal pathogens
– Enzymatic characteristics (Sphingomyelinases, Arginine-
deiminase)

– Produced high levels of H2O2

– Co-aggregated with pathogens &

– Inhibited the growth of G. Vaginalis

1. Mastromarino P. J Appl Microbiol. 2002;93(5):884-93.

2. De Seta F. Eur J Obstet Gynecol Reprod Biol. 2014 Nov;182:136-9.
 EvaNew strain Characteristics

PRODUCTION ARGININE
CO-
OF H2O2 ADHESION DEIMINASE
AGGREGATION
ACTIVITY

L. plantarum ++ + + -
L. salivaris
subsp. salicinius ++ - + -
L. brevis
(CD2) - + - ++

Mastromarino P et al. J Appl Microbiol. 2002;93(5):884-93.

 EvaNew Tablets: Mechanism of action
• Proposed direct & indirect anti-pathogenic mechanisms of
lactobacilli include:
– Production of lactic acid & bacteriocins that directly kill or
inhibit bacterial and viral pathogens,
– Formation of microcolonies that adhere to the epithelial
cell receptors and form a physical barrier against pathogen
adhesion,
– Stimulation of host Defense Mechanisms against
pathogens
 Mechanism of Action
L salivarius subsp. salicinius
L. plantarum

↑ H2O2-producing Lactobacilli ↑ Lactic acid ↓ pH

↓ Catalase-negative bacteria

↓ G. vaginalis ↓ Anaerobic bacteria ↓ Mobiluncus

↓ Epithelial exfoliat. ↓ Polyamines

↓ CLUE( bacterial) CELLS ↓ VAGINAL DISCHARGE ↓ UNPLEASANT ODOR

 Mechanism of Action
L salivarius subsp. Salicinius & L. brevis CD2
L. plantarum

Sphingomyelinase
Sphingomyelinase Arginine Deiminase

↑ Ceramide

↓ VIRAL INFECTIONS ↓ Epithelial exfoliation ↓ Polyamines

↓ CLUE CELLS ( bacterial) ↓ VAGINAL DISCHARGE ↓ UNPLEASANT ODOR

EvaNew
Tablet

28
 Indications & Usage
• Prevention of Common
vaginal infections –
– Bacterial vaginosis (BV),
– Aerobic vaginitis,
– Vulvovaginal candidosis
(Yeast vaginitis) 
– Trichomoniasis
• Prevention of Recurrent UTIs
• To improve reproductive
health:
– Improve the fertilization
chances
– Prevention of preterm birth
 EvaNew Treatment Regimen
• Dosage:
– 1 tablet intra-vaginal at bedtime for 8 days
– Every month preferably from 8th day of menstruation
for 3 months
• Directions for use
– Use at bed-time for 8 days
– Wash your hands with soap
– Remove the tablet from the pack
– Do not break or crush the tablet
– Insert the tablet inside the vagina with the middle
finger while lying in a recumbent position
 Warnings and Precautions

• Do not use if the packaging is broken or

damaged
• Avoid douching during treatment
• Do not ingest (Only for Vaginal Use)
• Avoid intra-vaginal antibiotics during
treatment
• Compatible with condoms and other
physical barrier methods without any
interference in intercourse
• No major side effect or over dosage has
been reported
Clinical Evidence
 Summary of clinical trials of EvaNew Tablet
Trial Design No. of patients Key Results

Hemalatha R.Eur J
1 Clin Microbiol Infect Subjects randomized 67 patients with The lactobacilli tablet was better than
to receive bacterial vaginosis
Dis. 2012
(BV) the pH tablet in preventing BV in healthy
Nov;31(11):3097-
105.
-1 EvaNew Tablet subjects
or Vaginal pH tablet Vaginal tablets containing lactobacilli a
inserted into the cure rate of nearly 80 %; whereas 20 %
vagina daily at of the subjects did not clear BV 
bedtime for 8 days •The pH tablet: Induced resolution of BV
& restoration of normal vaginal flora in
74% and 26 % did not clear BV 

2 Mastromarino P Double-blind 34 women with BV •All of the patients in the Lactobacillus-

Clin Microbiol randomized placebo- were enrolled
treated group (n = 18) were free of BV,
Infect. controlled.
 2009 Jan;15(1):6 as compared with only 2 patients (n=16)
1 EvaNew tablet free of BV placebo-treated women (p
7-74. daily/7days or or
placebo 
<0.001).
Follow-up at 14 days
• In the treatment group, the total
after the end of the number of symptomatic patients and the
treatment intensity of their symptoms, in particular
vaginal malodour, were significantly
reduced at both follow-up visits
33
 Summary
EvaNew Gloves to DIAGNOSE ‘&’ EvaNew Tablets to NORMALISE the vaginal pH

• Tablet maintains healthy vaginal flora thereby preventing infection and colonization by
vaginal pathogens like Gardnerella vaginalis, Chlamydia,HSV-2 and HIV-1
• EvaNew tabs can improve the chances of fertilization in women
EvaNew Tablet
Activity against bacterial vaginosis Yes
Activity against Chlamydia & Trichomonas Yes
Activity against HSV-2 & HIV-1 Yes
Arginine deiminase activity (helps control Foul odour) Yes
Sphingomyelinase activity Yes
(generates ceramide maintaining membrane integrity)

Positive Effect on sperm motility Yes

Treatment regimen 8 days/ month for 3 months
Route of administration Vaginal (Local dosage for specific action)