The Vajenda

Some very offensive ads for an offensively named probiotic were making the rounds of late. The product? The “Happy Hoo-Ha,” which the manufacturer Olly claims “supports vaginal health and pH.”

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Actually naming a product for the “Hoo-Ha” is sophomoric enough, but Olly doubled down by advertising this as product as good for your panty hamster. No, not party hamster, panty hamster.

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Sigh.

You feel my eye-roll, don’t you?

Olly has been investing heavily in Instagram influencers to push this crap, so I felt it was worthwhile to explain why this product is the equivalent of flushing $20 down the toilet each month. Well, more than $20, because it’s $19.99 for 25 capsules, and you need to take one a day.

Vaginal Bacteria Primer

The vagina is filled with different types of bacteria. In fact, there are five main bacterial communities (think clubs) in the vagina, called community states. So person A may have an entirely different combination of vaginal bacteria or different community state as compared with person B, and yet they can still both be perfectly healthy. Four of these five community states are dominated by lactobacilli, and one has less lactobacilli.

Overall, the main species of lactobacilli found in the vagina are:

Crispatus
Gasseri
Iners
Jensenii

However, these community states fluctuate, so a snapshot showing how much of each lactobacilli (and other bacteria) are present in the morning will look different from a snapshot taken in the evening. In addition, this might change based on the day of the menstrual cycle. For example, iron in menstrual blood can help some, but not all, bacteria grow, and some bacteria stick to menstrual blood causing numbers to drop because the bacteria is essentially flushed out with menstruation.

How all the bacteria interact to keep the vagina healthy is highly complex. We think that lactobacilli work by way of several mechanisms, including, but not limited to the following:

Fermentation of glycogen (sugar) producing lactic acid, which lowers the pH, affecting how some bacteria grow.
Production of bacteriocins which are substances that can kill bacteria.
Competition with other bacteria and yeast for nutrients.
Prevention of other bacteria and yeast from sticking to cells in the vagina (sticking to the cells is an important step in causing problems). Lactobacilli may accomplish this by sticking to the cells themselves and physically competing for space on the cells, or by releasing substances that prevent adherence.
Modulation of the immune system locally in the vagina.

We Have Yet to Replicate the Phenomenal Power of Vaginal Lactobacilli

There have been quite a few studies looking at probiotics for improving the vaginal ecosystem, where “improving” is typically defined as treating or preventing infections, but sometimes these studies just look at the ability of probiotics taken orally to find their way into the vagina. While there was some early enthusiasm for probiotics with lactobacillus rhamnosus and reuteri, the data hasn’t really panned out. Most of these studies suffer from significant design flaws, often they are too small to detect any meaningful improvement. In addition, the studies that look at whether the vagina actually gets colonized with the lactobacilli in the probiotic typically don’t distinguish between lactobacilli present naturally and that from the supplement.

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Another big issue with probiotic studies is that many probiotics don’t contain what they claim. So what was used in the study may not be what you get, even if you are buying the same product. So buying the product over the counter does not mean you are getting what was actually studied. There is literally no requirement for a probiotic to contain what it claims on the label, and most studies using over the counter products don’t do analysis on what they are studying, so they are trusting the manufacturer.

The best study for vaginal infections and probiotics was published a few years ago in the New England Journal of Medicine and evaluated a product with Lactobacillus crispatus called LACTIN-V for prevention of recurrent BV used in combination with an antibiotic to treat the bacterial vaginosis. At 12 weeks 45% of people who only took the antibiotic had a recurrence versus 30% who took the antibiotic plus probiotic. At 24 weeks those numbers were 54% and 37% respectively. So there definitely was some benefit, but this was a phase 2 study, so more work is needed. LACTIN-V is a powder that is administered vaginally and it is being developed as a pharmaceutical. It is also currently being studied to see if it reduces the rate of acquiring HIV.

This study doesn’t support the use of Olly’s “Happy Hoo-Ha” (I die a little inside each time I type that) because, while promising, it is a phase 2 study. And, more importantly, it’s a different probiotic than found in the “Happy Hoo-Ha”. But this is the kind of data that we need, and if Lactin-V holds up in phase 3 studies, unlike Olly’s “Happy Hoo-Ha”, it will be a useful addition to the medical armamentarium.

Are Probiotics Recommended for Any Vaginal Health Issues?

Nope.

Here’s the run down…

Vaginal yeast infections: there is really no data at all to support their use here, so no guidelines recommend them. Vaginal colonization with lactobacilli doesn’t even appear to change with yeast infections.

Bacterial vaginosis: some low quality studies suggest a benefit, but other studies do not. The LACTIN-V product holds promise, but it is not available over the counter as currently it is being developed as a prescription. But regarding over the counter probiotics, after 20+ years on the market people deserve better than this dismal data. As such, the CDC does not recommend probiotics for prevention of treatment of bacterial vaginosis and the latest Cochrane review does not support their use for this indication either.

Eradication of group B strep from the vagina: Group B strep is a bacteria in the vagina that can cause serious problems for a newborn, so when present during pregnancy treatment with antibiotics at delivery is recommended. A 2020 review of the sparse data that was available at the time showed no good evidence to support the use of probiotics to reduce GBS colonization of the vagina and two recent randomized double-blinded placebo controlled trials, one published in Nature in 2020 and the other published in 2021 in The Journal of Maternal-Fetal & Neonatal Medicine showed no change in group B strep colonization with probiotics.

Prevention of recurrent urinary tract infections: A Cochrane review showed no benefit versus placebo, but again, review of the studies was hampered by their low quality. I know, I sound like a broken record here, but 20+ years of probiotics should be yielding more than some low quality studies considering it’s a multi-billion dollar industry. It’s almost as if the manufacturers aren’t interested in evaluating the effectiveness of their product (that is written in sarcasm font).

A multi billion dollar industry, and this is the state of the data.

So What About The Panty Hamster Product?

Well, besides the offensive advertising and zero data supporting the usefulness of their product? Well, of all the bad data that we have, the absolute worst results seem to be with lactobacillus acidophilus, which is one of the ingredients AND Olly actually states their product “is not intended to diagnose, treat, cure, or prevent any disease.” We should really take them at their word!

Also, “clinically-studied” is a meaningless term, like “ph balance” and “panty hamster”.

Don’t you think that when a company asks for $19.99 every 25 days they should have some data showing that it works? Would you pay $19.99 a month for Internet service that was not intended to give you Internet service or for a bus ticket for a bus route that was not intended to get you to your destination?

I mean…

Also, and this is a big one, there is no data to show that probiotics can “support vaginal health” or “pH balance”.

Supporting vaginal health is a made up phrase. Breathing supports vaginal health, because not being dead is good for your vagina. What concrete part of vaginal health is Olly’s “Happy Hoo-Ha” supporting? I must have missed it somewhere in the literature…

And pH. Le sigh. Most of the studies that look at probiotics and the vagina, such as they are, don’t even measure pH. And the pH isn’t balanced, it simply is what it is. It is low when people have no symptoms and when they have yeast, and it is elevated when they have bacterial vaginosis and trichomonas, and during menopause if vaginal estrogen isn’t used. Vaginal pH is the result of the bacterial communities, estrogen, and the immune system. Vaginal pH can’t be changed easily. For example, ejaculate raises the pH temporarily, and within hours it is restored to an acidic range.

What Olly is doing is taking this very complex biological process, vaginal pH, and acting like they have some magic knowledge about it, when they don’t.

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What we do recommend for the vaginal pH is trying to use vaginal products, for example, lubes, that have a pH that approximate the vagina, 3.8-4.2. That’s it.

If commercial probiotics did something helpful for the vagina we’d recommend them. When probiotics first hit the market in the 1990s I recommended them all the time. It was a great hypothesis and I though, “We’ll get good data soon.” Ha!

But they didn’t help my patients with complex vaginal conditions and we are now almost 30 years later, plenty of time for some good studies…except the manufacturers of probiotics, companies like Olly, don’t seem interested in using their profits to prove their products work. In addition, almost everyone who comes to see me for their complex vaginal condition has taken probiotics, and yet they are still coming to see me for their complex vaginal condition.

Olly isn’t just interested in mining your vagina for cash. They have a whole stable of unproven products with remarkable claims. Take their Metabolism Gummy Rings (no, I didn’t make that name up, I have more self respect than that), which are a scammy mix of apple cider vinegar, vitamin B12, and chromium. I asked Dr. Spencer Nadolsky, a physician who specializes in treatment of obesity and lipid disorders, about these gummies and he told me, “there is no evidence that this supplement will increase your metabolism let alone help you lose any clinically meaningful amount of weight”. You may need a vitamin B12 supplement if you are vegan or have issues absorbing nutrients, but there are cheaper products that don’t contain apple cider vinegar.

What is ultimately the most frustrating about companies like Olly Wellness, and they are not the only ones, is that after only 6 years in business they were rumored to have been acquired for tens of millions of dollars (and possibly more). That’s right. They have no product that has been shown in studies to be beneficial and they made a small fortune for what essentially amounts to a slick marketing claim for scammy wellness products. So don’t tell me these companies can’t afford the research or that they are kind and Big Pharma is evil. The company that bought Olly Wellness, Unilever, generated $62 billion in revenue in 2021 from brands like Axe, Dove, Hellmans and Ben and Jerry’s. If they were really interested in helping people instead of cashing in on distress, they could have used just a tiny fraction of that money to conduct some quality clinical trials. Except, the fastest way to generate cash is pretty products for wellness with dubious claims and the downside of a high quality clinical trial is it might prove that your product doesn’t actually work. I guess it is safer to be able to claim you don’t know either way.

If you want reduce your risk of vaginal infections, this is what we know about vaginal health:

If you partner with someone with a penis, use a condom.
If you partner with someone with a penis, male circumcision is associated with a 40-60% lower rate of bacterial vaginosis.
Don’t smoke.
Practice antibiotic stewardship, meaning make sure any antibiotic prescription that you get is truly needed and that it is not a broad spectrum antibiotic (if that is possible with the condition you have). For example, if you have a bladder infection, the antibiotic nitrofurantoin is a narrow spectrum antibiotic and is not associated with yeast infections. Many people receive antibiotics for viral infections, so you want to make sure you really need them. The risk of developing a yeast infection after taking antibiotics can be as high as 20-30% depending on the study.
Try to maintain a healthy diet, because that is good for your health overall and your vagina is part of you.
And if you have recurrent symptoms and you are not getting help with your own provider, ask for a referral to a specialist in vulvar and vaginal conditions.

Oh…and sugar doesn’t cause yeast infections. So have a slice of cake if you want.

References

Farr, A., Sustr, V., Kiss, H. et al. Oral probiotics to reduce vaginal group B streptococcal colonization in late pregnancy. Sci Rep 10, 19745 (2020). https://doi.org/10.1038/s41598-020-76896-4
Schwenger EM, TejaniAM, Loewen PS. Probiotics for preventing urinary

tract infections in adults and children. Cochrane Database Syst Rev 2015.
Mary Sharpe, Vibhuti Shah, Tatiana Freire-Lizama, Elizabeth C. Cates, Kory McGrath, Iuliana David, Sara Cowan, Janaya Letkeman & Emily Stewart-Wilson (2021) Effectiveness of oral intake of Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 on Group B Streptococcus colonization during pregnancy: a midwifery-led double-blind randomized controlled pilot trial, The Journal of Maternal-Fetal & Neonatal Medicine, 34:11, 1814-1821.
Jois, R.S., Tan, J.K. and Silva, D. (2020), Do probiotics in pregnancy reduce the risk of group B streptococcal colonisation?. J Paediatr Child Health, 56: 1468-1472. https://doi.org/10.1111/jpc.15021.
Cohen CR, Wierzbicki MR< French AL, et. al. Randomized Trial of Lactin-V to Prevent Recurrence of Bacterial Vaginosis. N Engl J Med 2020; 382:1906-1915.
Bradshaw CS, Sobel J. Current Treatment of Bacterial Vaginosis—Limitations and Need for Innovation. JID 2016:214 (Suppl 1).
CDC STI Treatment guidelines 2021 https://www.cdc.gov/std/treatment-guidelines/vaginal-discharge.htm