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These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
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These are activities that use your work data to ensure quality results.
These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
One dominated by Lactobacillus, says Melbourne fertility specialist, gynaecologist and obstetrician Dr Rebecca Mackenzie-Proctor. “We think Lactobacillus crispatus is the good bacteria that maintains low vaginal pH and shifts things away from a pattern of dysbiosis.”
Antibiotics are the most common cause of dysbiosis anywhere in the body—including the vagina, Dr Mackenzie-Proctor says.
“I see time and time again in my practice women coming in on that vicious cycle—UTI, antibiotics, thrush, more antibiotics, creams and things—and they just can never break that cycle.”
While the gut and vagina may seem distant, bacteria travel between them, she notes.
“We know the load of bacteria that’s in the gut will over time pass out the rectum and then transfer up into the vagina. So when you are disrupting the gut’s microbiome, you’re also disrupting the vagina,” she says.
“In saying that, antibiotics are meant to spread everywhere, so you’re also killing all the bugs in the vagina by using antibiotics.”
Hormones affect the microbiome throughout a woman’s life, she adds.
Before puberty, lower oestrogen levels mean vaginal pH is higher and “changes the bugs that live there,” she says. Rising oestrogen levels during and after puberty increase the glycogen that is an important food source for bugs, she explains. As oestrogen levels drop at menopause, lower glycogen supply means less Lactobacillus.
Dr Sara Whitburn, a GP and Medical Director of Sexual Health Victoria, stresses several factors play a role.
“Yes, antibiotics taken for a range of conditions, like chest or skin infections, can disrupt the vaginal biome. We know people can have thrush if they have broad spectrum antibiotics. But there are also other causes for altered flora.”
“We are starting to see that for bacterial vaginosis, there does appear to be a link for sexual transmission. With bacterial vaginosis and candidiasis, there’s often a change during times of hormonal fluctuation—going from pre-puberty into having regular cycles and also in perimenopause and menopause.”
“We know that there is an evidence-based link with copper IUDs. We’re still waiting for further evidence into hormonal IUDs, but if bacterial vaginosis symptoms are not improving sometimes removing the hormonal IUD can help with management.”
“There’s also a role for biofilm dysfunction, and if people use douching or genital hygiene products that aren’t helpful for genital skin care, that too can be a risk for altered flora.”
Dr Mackenzie-Proctor says the strongest evidence for probiotics is in bacterial vaginosis, noting they’re mostly beneficial in recurrent cases.
“If it’s just one off, you don’t necessarily need to burden them with a long course of treatment. But if they’re having more than two episodes in a three- or six-month period, then I’d be suggesting some probiotics.”
A 2022 systematic review and meta-analysis involving 10 studies and more than 1200 participants found that probiotics reduced BV recurrence by 45% compared to either placebo or metronidazole (14.8 vs. 25.5%). The absolute risk reduction was 12.12%.
Importantly, though, a 2025 narrative review of studies exploring whether probiotics could help prevent recurrent BV concluded that while results so far are promising, current evidence is insufficient to recommend them.
Nor are they included in current Australian STI Management guidelines, Melbourne Sexual Health Centre treatment guidelines or the Therapeutic Guidelines, Dr Whitburn notes.
Rather, guidelines recommend treatment with oral or intravaginal metronidazole or clindamycin as a secondary option.
A Lancet study involving heterosexual couples also found treating the regular male partner with oral and topical antimicrobials can reduce recurrence rate.
Dr Mackenzie-Proctor says there is less evidence for probiotics in UTIs, but more research is underway—with some promising early results.
One recent RCT with 174 premenopausal women who had a history of recurrent UTIs found there were significantly fewer symptomatic UTI recurrences in the three probiotic intervention groups compared with placebo. Overall, the groups that included a vaginal probiotic – both alongside an oral placebo and in combination with an oral probiotic – had significantly lower incidence of symptomatic UTIs compared to the groups that received just the oral probiotic, or the group that received only placebos.
Dr Whitburn stresses that while this is promising, “we still need more well-designed randomised controlled trials to gather the evidence to make clinical change.”
The 2025 European Association of Urology guidelines say evidence for using local or oral probiotics to regenerate vaginal flora and prevent cystitis is weak.
Both experts note there is inadequate evidence to support probiotic use for candidiasis.
A recent literature review of 25 clinical studies and seven systematic reviews reported they yielded “a generally positive yet inconsistent view” of the efficacy of probiotics for vulvovaginal candidiasis, noting a wide range of heterogeneity between studies. The authors concluded fluconazole is more effective than probiotics for this condition, while combining both treatments “seems to reduce recurrence and improve symptoms significantly”.
Dr Mackenzie-Proctor says European research is exploring probiotics used intravaginally for chronic endometritis and subfertility—with promising results.
“We know that by treating chronic endometritis, we have a better outcome for many patients that have recurrent implantation failures or recurrent miscarriages,” she says.
“Australia is taking a bit longer just because we haven’t had access to the actual vaginal preparations. But we would normally say give a course of 14 days of an antibiotic, mainly doxycycline, and then follow that up with two weeks of a vaginal probiotic. That’s a very common regime a lot of European fertility groups are doing.”
Safety profiles have been studied alongside clinical outcomes, she adds, with no concerns noted.
Probiotics are not created equal, Dr Mackenzie-Proctor says.
“The best probiotic is, first of all, the one you take,” she stresses, noting products that need to be kept cold often end up in the back of the fridge.
“And no one’s taking them. So chances are you will not complete the course. So I suggest avoiding those ones.”
For vaginal health, look for products with high levels of Lactobacillus crispatus—but not a lot of different strains.
“Having more different strains within your probiotic doesn’t mean it’s going to do a better job, because they compete against each other for food,” she explains. “So then you’ll either lose diversity or you’ll lose a particular one that might be the one that you need.”
Products in vacuum-sealed packaging are quite stable at room temperature, she says, and patients should be advised to keep probiotics in a low-moisture environment.
She uses various products, including one from practitioner-only brand Activated Probiotics specifically for the vaginal microbiome—and one patients can take while on antibiotics.
“The way that works is that it adheres to sites along the gut and the lining to stop the impact of the antibiotic affecting the gut itself. So that’s a really useful way of preventing this problem in the first place. If you can take an antibiotic and this probiotic at the same time, you may not need the vaginal probiotic afterwards.”
Most people find an oral probiotic easier to take, but it must get from the mouth to the vagina via the gut, Dr Mackenzie-Proctor says.
“So that takes a lot longer, needs a higher dose, whereas in the vagina it’s much more directed, it’s shorter courses.”
For people with recurrent bacterial vaginosis, she recommends a three-monthly treatment cycle.
“So if you have your period, don’t use the probiotics at that time because you already get a change in the vaginal pH with the blood. Once your period’s finished, then you can use it for two weeks, and then next period, use it for two weeks. Doing that for up to three months can be helpful for some patients.”
Vaginal preparations are typically used 10 nights in a row after a period, she adds, but may be more difficult for some patients—such as women with arthritis—to use.
Being alkaline, semen decreases Lactobacillus in the vagina by increasing its pH, she explains.
“And it can increase, for some people, pathogens in the vagina. So I have the odd patient who actually has a considerable thrush following intercourse.”
This is tricky to manage, especially when you want patients having sex to conceive, but oral or vaginal probiotics may help, she says.
Lifestyle factors also affect vaginal bug balance, Dr Mackenzie-Proctor notes.
“People still are using a lot of scented soaps and things around the vagina. And in the age of active wear, everyone’s walking around in tight pants. If people are having recurrent vaginal infections, consider changing their clothing—having periods of time wearing dresses or skirts or free-flowing things. And the same with sleep habits. I say to people, don’t sleep in underwear, give the vagina a chance to breathe.”
It’s also important for patients to manage stress and cease smoking if necessary, she adds.
Dr Whitburn stresses there’s not enough evidence to recommend a low-yeast or low-sugar diet for recurrent candidiasis. “But we do know that if you have type 2 diabetes and you have glycosuria, or even high blood sugar levels, you are at risk for having candidiasis. So a healthy diet is supportive for your metabolic health, and one of the benefits of decreasing your risk of diabetes is to decrease your risk of having vaginal thrush or oral thrush.”
For genital skin care, she agrees avoiding soap is key, and patients can wash with just water or a hypoallergenic soap substitute such as Cetaphil. They should also avoid tight trousers, douching, perfumes, patterned and dye toilet paper, and should use cotton sanitary products.
Dr Mackenzie-Proctor says reduced oestrogen levels due to perimenopause, excessive exercise, or stress can affect bacterial balance, and some patients may need hormonal therapy.
Dr Whitburn agrees vaginal oestrogen “certainly has a role to play for vaginal health, vaginal flora, and also for decreasing UTIs in people who show genitourinary symptoms of menopause or genitourinary symptoms of lactation.”
“However, I wouldn’t use vaginal oestrogen unless there were signs of hypo-oestrogen in the vaginal area,” she cautions.
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