Lactobacillus overgrowth syndrome (cytolytic vaginosis)
When lactobacillus overgrows, it can look and feel like a yeast infection, but doesn’t respond to antifungals. This can go on for a long time undiagnosed.
While lactobacillus is one of the most helpful (identified) microorganisms in the human vaginal tract, it isn’t always good news if this generally-friendly bacteria get out of control. Usually unless there is a factor that is perpetuating the problem, it is easy to get back under control.
How do I know if I have cytolytic vaginosis?
If everything else that could cause vaginal discharge – trichomoniasis, sexually transmitted infections, bacterial vaginosis, and yeast infection – has been ruled out, cytolytic vaginosis should be evaluated and investigated.
This is particularly true when a suspected (untested) yeast infection doesn’t respond to antifungals, over and over, and when probiotic use makes the problem worse. Cytolytic vaginosis tends to be cyclic, as the food supply relies heavily on oestrogen to stimulate glycogen. This means symptoms will get worse at certain times, as a pattern.
How cytolytic vaginosis works
Cytolytic vaginosis is also called lactobacillus overgrowth syndrome or Doderlein’s cytolysis, and is characterised by an overgrowth of Lactobacilli. This overgrowth actually damages the vaginal cells and results in the cell wall rupturing and the cell dying.
Cyto means cell, and lytic means death – cytolytic vaginosis is therefore a condition involving the disintegration of the vaginal cell wall.
Normal functioning of lactobacillus in the vagina
A healthy vagina has an abundance of lactobacillus species that work to ward off invaders like E. coli, Candida albicans and glabrata, and various other species like Gardnerella vaginalis. Lactobacilli produce hydrogen peroxide and lactic acid, among other bacteriocins, in their normal daily war against all things not vagina, including HIV.
Lactobacillus do a great job, using glucose as a food source, taken from the vaginal wall and provided by the action of oestrogen.
In a normal vagina, the presence of low numbers of Lactobacilli has been shown to have a protective effect against yeast infections by blocking the adhesion of the yeasts to the vaginal walls as they compete for nutrients. Some women in their fertile years, however, may develop an overgrowth of Lactobacilli, which alone (or sometimes with other bacteria) can cause damage to the vaginal walls that results in the cells dying. This causes vaginal discharge.
This discharge is then misdiagnosed as a yeast infection and antifungals are prescribed. Women with diabetes (any kind) may have an overabundance of glycogen (vaginal glucose) due to blood sugar dysregulation, which feeds the Lactobacilli and allows their overgrowth. Symptoms may also increase during the luteal phase (the part of the cycle post-ovulation until the first day of the period), which is where oestrogen rises, possibly causing more glycogen to be excreted and feeding the lactobacillus.
Symptoms of cytolytic vaginosis
- The signs and symptoms are much like a yeast infection
- Painful sex or penetration attempts (dyspareunia)
- Cyclical increase in symptoms (in the luteal phase after ovulation)
How often is cytolytic vaginosis diagnosed?
While it isn’t usually the primary focus of a doctor’s visit, there are some stats available. In one study (Cerikeioglu et al 2004)1, 210 women with vaginal discharge and other symptoms that looked like a yeast infection were examined, and 15 of them were found to have cytolytic vaginosis.
Another study (Wathne et al 1994)2, found around five in 101 women had cytolytic vaginosis.
It is estimated that while yeast infections comprise up to 30 per cent of all gynaecological complaints associated with discharge, cytolytic vaginosis makes up between five and seven per cent of those in the same patient population. It is considered a significant clinical condition.
Diagnosis of cytolytic vaginosis
A yeast infection and BV must be excluded by further investigations. This is done by testing the following:
- Normal pH is found in cytolytic vaginosis (3.5-4.5)
- Leukocytes (white blood cells involved in immune responses) are not observed in cytolytic vaginosis, whereas they are in yeast infections
- Typical yeast cells are not found
- Bacterial vaginosis is excluded by pH tests and the whiff test (BV presents with an alkaline vagina, more than 4.5)
- Negative culture results in sabouraud dextrose agar (SDA) (for testing for certain fungi)
To diagnose cytolytic vaginosis, the following must be true:
- Increased lactobacilli numbers
- No Trichomonas, Gardnerella or Candida on a wet mount
- Few white blood cells
- High suspicion
- pH between 3.5 and 4.5
Treating cytolytic vaginosis
Reducing lactobacilli numbers can be done by elevating the vaginal pH using a sodium bicarbonate douching solution or suppository. This should help to restore the natural balance after three weeks, however if symptoms worsen, stay the same or become different, cease treatment and seek re-evaluation.
Cytolytic vaginosis douche bicarb treatment mixture
- 1-2 tablespoons of baking soda (sodium bicarbonate)
- 4 cups of warm water
Douche twice-weekly for one week on, one week off, for three weeks.
Cytolytic vaginosis suppository bicarb treatment mixture
- Empty vegetable capsules (not gelatin), size 0 or 1 is fine
- Fill with baking soda
Insert one capsule deep into the vagina twice a week for one week on, one week off, for three weeks.
When should I see results from the bicarb treatment?
Each of you will be a bit different, but the treatment period is over several weeks and therefore the results will also be over several weeks – but, you should feel some relief immediately.
Don’t overdo this treatment, as you don’t want to go in the other pH direction too far and leave your vagina open to other pathogens. Avoid probiotics and milk kefir (anything containing lactobacilli) for your treatment time, and make sure you evaluate why this has been allowed to occur.
If you are not sure, seek the help of a qualified, experienced healthcare provider who is knowledgeable about bacteria and women’s health. Your naturopath may be a good place to start, as you get way more time with your practitioner than your regular GP.
What do I do if I don’t respond to the bicarb?
Testing and treatments is haphazard at best, with this condition not even necessarily an official condition. Researchers are still learning about it, and therefore many doctors are unaware of how to test for or treat lactobacillus overgrowth. We spend so much time trying to get these good bacteria to proliferate and make themselves at home, it is somewhat counterintuitive to now see them as the enemy.
We suggest you see a practitioner who either knows about cytolytic vaginosis or is willing to learn, who wants to help you. This is easier said than done, but there are many types of practitioner out there. It doesn’t have to be a doctor.
A naturopath, herbalist, acupuncturist, or nutritionist may be able to shed some light on what they think is going on, and help restore balance.