Effects of Flourish HEC Vaginal Care System on Vaginal Microbiome in Women With Recurrent Bacterial Vaginosis

The vaginal microbiome interacts with vaginal epithelial cells and host immune cells in varying ways depending on the presence of particular species. Presence of high quantities of Lactobacillus species, which are considered healthy, downregulate pro-inflammatory markers and upregulate anti-inflammatory markers. On the other hand, BV-associated bacteria such as Gardnerella vaginalis, Atopobium (Fannyhessea) vaginae, Prevotella bivia, Mobiluncus curtisii and others, are associated with increased pro-inflammatory markers and reduced anti-inflammatory molecules. The investigators predict that improving the vaginal microbiome by using an over-the-counter vaginal care system will increase levels of Lactobacillus species, reduce levels of BV-associated bacteria, and improve vulvovaginal symptoms of BV.

Bacterial vaginosis (BV) is a common dysbiosis of the vaginal microbiome causing vaginal odor, discharge, discomfort, or even vulvovaginal pain. In some women, BV is asymptomatic; there is some evidence to support the concept that asymptomatic BV results from repeated instances of BV that damage the vaginal lining so extensively that the body is no longer able to generate symptoms, and as such, asymptomatic BV represents a more advanced disease state as compared with symptomatic BV. Whether symptomatic or asymptomatic, BV is known to affect the vaginal epithelium, disrupting intercellular adhesions and increasing susceptibility to infections, including HIV, HSV, and perinatal infections leading to sequelae such as late miscarriage, preterm labor, preterm premature rupture of membranes, and preterm delivery. Symptomatic BV can interfere profoundly with quality of life, causing embarrassment, itching, pain, and challenges with intimacy. The standard of care for treatment of BV is metronidazole, clindamycin, or rarely other antibiotic. Repeated use of antibiotics is used out of necessity for symptomatic women, but many women and healthcare providers are hesitant to use antibiotics repeatedly due to side effects and risk of development of antibiotic-resistant organisms. An alternative method of preventing and/or treating BV is therefore desirable.

An 11-week pilot study of similar, though less informative, design was recently conducted. Women with recurrent BV were recruited to use the Flourish® Vaginal Care System [using aloe-based Restore gel instead of hydroxyethylcellulose (HEC)-based BioNourish gel which is part of the Flourish HEC Vaginal Care System] for 11 weeks. Primary outcomes were vaginal fluid pH and whether or not women had BV recurrence. By the end of the study, the average vaginal fluid pH had fallen from mean (SD) of 4.54 (0.53) at week 0 to 4.08 (0.40) at week 11. At baseline, 30% of women had active BV. (These women were treated with standard of care oral metronidazole). The number of BV-positive women steadily declined until 5 weeks, at which point no woman had BV. There was no recurrence of BV in any woman through the end of the study.

Although this 11-week study is promising, the short time frame provides only limited information about BV recurrence, and there was no control group included. However, considering what has been published, we might have expected up to half of the women to have had a recurrence of BV during this time. By developing this new randomized controlled study with a longer time frame, we will have more certainty about whether prevention of BV recurrence is a feasible aim for a double-blind placebo-controlled randomized controlled trial in the future.

The present study will also expand upon the previous trial by providing data about the vaginal microbiome of women before and after use of the Flourish HEC Vaginal Care System. Historically, Amsel criteria (presence of 3 out of 4 of: thin grayish-white discharge, positive whiff test with addition of KOH to vaginal fluid, vaginal pH >4.5, and presence of >20% clue cells on wet mount microscopy of vaginal smear) or Nugent scoring (scoring method based on Gram stained vaginal fluid) were used to diagnose BV. More recently, existing data about changes in the vaginal microbiome during BV have been used to develop the commonly used clinical BV tests such as Aptima BV test (Hologic), SureSwab BV and Vaginitis test (Quest Diagnostics), Affirm VPIII test (BD Diagnostics), and others. Recently, next-generation sequencing (NGS) has been used to examine more thoroughly the complement of bacteria found in women with or without symptomatic BV. These studies shed some light on what would constitute a healthy microbiome if the Flourish HEC Vaginal Care System is successful at establishing a healthy colony of lactobacilli. However, the investigators are not aware of any studies that have examined changes in the entire vaginal microbiome using NGS before and after use of a vaginal probiotic suppository. This is important because the pre-NGS techniques used are limited in their ability to detect species. Some bacteria are resistant to traditional culture techniques and may have been missed in earlier culture-based studies. PCR-based tests are limited because they are used to assess presence or amount of specific targets which have been selected using information from culture-based studies. The Evvy Vaginal Microbiome Test using metagenomic sequencing, a type of NGS technology, is superior because it is able to detect every bacterial and fungal species present at a level of 0.1% of the microbiome or higher. Only rare species would be missed. While these rare species may be important for seeding following events that disrupt the vaginal microbiome (like antibiotic use), they likely have a small effect on day-to-day health.