This protocol was developed for practitioners using Fullscript in the United States and the templates cannot be applied to accounts operating outside of the United States

Protocol development in integrative medicine is not typically a simple process. Individuals require individualized care, and what works for one patient may not work for another.

To establish these protocols, we first developed a Rating Scale that could be used to discern the rigor of evidence supporting a specific nutrient’s therapeutic effect.

The following protocols were developed using only A through D-quality evidence.

Class
Qualifying studies
Minimum requirements
A
Systematic review or meta-analysis of human trials
 
B
RDBPC human trials
2+ studies and/or 1 study with 50 + subjects
C
RDBPC human trials
1 study
D
Non-RDBPC human or In-vivo animal trials
 

Introduction

Whole person care is a person-centered approach to medicine. It goes beyond treating symptoms or isolated conditions, focusing on the interconnectedness of bodily systems and addressing a wide range of factors. These include biological makeup, behavioral habits, environmental factors, and a patient’s personal beliefs, values, and goals. By tailoring care to align with these unique aspects, healthcare providers can create highly personalized treatment plans that address not only physical health but also emotional and mental well-being.

This protocol aims to provide healthcare providers with practical suggestions for labs, supplements, and lifestyle strategies, helping them design personalized whole person care plans for patients looking to prevent or treat vaginal infections and support a healthy vaginal microbiome.

Advanced lab testing provides valuable insight into the root causes of vaginal symptoms, enabling healthcare providers to move beyond symptom management and address the specific imbalances contributing to vaginal concerns.

Hormonal fluctuations, particularly in estrogen levels, play a key role in shaping the vaginal ecosystem. Low estrogen can reduce Lactobacilli and increase vaginal pH, creating conditions that favor bacterial vaginosis (BV). (Wilson 2007) Conversely, high estrogen levels may impair innate immune defenses, promoting Candida overgrowth and recurrent yeast infections. (Sasani 2021) Because estrogen affects the microbiome and immune function differently depending on the pathogen, hormone testing can help identify patterns behind recurring infections. 

Additionally, different types of vaginal infections can cause similar symptoms—such as itching, burning, and abnormal discharge—making diagnosis based on symptoms alone challenging. Vaginal microbiome testing offers a clearer picture by assessing microbial diversity and identifying imbalances between beneficial, pathogenic, and opportunistic organisms. 

When combined with hormone testing, this comprehensive approach helps pinpoint the underlying source of symptoms and supports the development of targeted, personalized treatment plans that address both microbial and hormonal contributors to vaginal health.

Evidence-based supplements can support the pillars of vaginal health, such as hormonal equilibrium, a balanced microbiome, and tissue integrity. Providers can integrate these supplements into customized protocols based on their patient’s needs and goals to treat existing infections and prevent future vaginal health issues.

Lifestyle modifications should be considered foundational for hormonal health, microbial homeostasis, and immune function. Habits that encompass good nutrition, vaginal hygiene, and stress management create a solid foundation that enhances the effectiveness of targeted treatments.

This flexible approach ensures a personalized and comprehensive care plan for optimal results.

How To Use This Protocol

This protocol offers guidance to help healthcare providers integrate labs, supplements, and lifestyle recommendations into their patient care plans. Start by assessing the patient’s unique needs, goals, and health status. Use the labs section to identify potential areas of focus, such as biomarkers for hormone or microbiome imbalances. Finally, incorporate evidence-based supplements and lifestyle strategies to address specific needs and preferences and enhance health outcomes.

Labs

Doctor’s Data Comprehensive Hormone Profile

Ingredients

Lactobacillus Probiotics

Dosing: 1–10 billion CFU for one week (acute treatment) to six months (maintenance) (Cribby 2009)(Chieng 2022)

Supporting evidence:

  • Probiotics are live microorganisms that provide health benefits when consumed in adequate amounts by supporting the balance of beneficial microbes in the gut. (Bodke 2022) 
  • Lactobacillus spp. are the dominant bacteria in a healthy vaginal microbiome responsible for maintaining an acidic environment, preventing the overgrowth of harmful pathogens, and promoting vaginal health through the production of lactic acid and antimicrobial substances. (Mashatan 2023)
  • In a double-blind, randomized, controlled clinical pilot trial, ASTARTE™, an oral probiotic blend containing L. crispatus, L. rhamnosus, L. gasseri, and L. jensenii, was shown to improve bacterial vaginosis (BV) recovery rates when used alongside metronidazole for four weeks. (Laue 2018)
  • In this prospective study, 30 pregnant women with herpes virus infection received a one-week course of oral probiotics—containing L. crispatus, L. rhamnosus, L. gasseri, and L. jensenii—and fructooligosaccharides as part of their prenatal care. Following the intervention, participants showed significant improvements in intestinal and vaginal microbiota, with increased levels of Lactobacillus and Bifidobacterium and reduced colonization by Candida, Staphylococcus aureus, Klebsiella, and other opportunistic pathogens. Clinical symptoms such as bloating, constipation, vaginal discharge, and itching decreased by 2–3 times. Additionally, the rates of placental insufficiency, fetal distress, and pre-eclampsia were reduced by approximately half. No adverse effects were reported. (Anoshina 2016)
  • In a randomized trial, women over the age of 18 with BV were assigned to take either a daily oral probiotic containing L. rhamnosus GR-1 and L. reuteri RC-14 or a placebo for six weeks. After 44 days, 61.5% of the probiotic group restored balance to their vaginal microbiota compared to 26.9% in the placebo group, and more than half (51.1%) of the probiotic group maintained microbial homeostasis after an additional six weeks. (Vujic 2013)
  • Postmenopausal women taking an oral probiotic formula of L. rhamnosus GR-1 and L. reuteri RC-14 had significantly reduced Nugent scores for BV and improvements in menopausal genitourinary symptoms, such as vaginal dryness, sexual dysfunction, and urinary frequency. (Petricevic 2008)
  • This triple-blinded RCT evaluated oral L. acidophilus LA-5 in 40 women with vulvovaginal candidiasis over 60–65 days. The probiotics improved symptoms like itching, discharge, and erythema, especially within the first month, but were less effective than fluconazole in preventing recurrence (19.4% vs. 45.5% negative cultures at day 60). (Mollazadeh-Narestan 2023)

Side effects:

  • While probiotics are generally safe for most individuals, they may pose risks such as sepsis, fungemia, and gastrointestinal ischemia in critically ill patients, immune-compromised individuals, and those in postoperative settings. (Didari 2014)
  • Research indicates that oral probiotic supplementation is generally safe during pregnancy and lactation. (Sheyholislami 2021) While oral probiotics have been more extensively studied, data on the use of vaginal probiotics during these life stages remain limited.

Boric Acid

Dosing: 600 mg inserted vaginally 1–2 times daily for up to four weeks (Müller 2024)(Workowsi 2021)

Supporting evidence:

  • Boric acid, or hydrogen borate, is a weak acid with antifungal and antibacterial properties. (Powell 2019)
  • A review including 14 studies reported that intravaginal boric acid was associated with symptom resolution in 40–100% of women treated for vulvovaginal candidiasis (VVC). (Iavazzo 2011)
  • In a study of 105 women with recurrent BV unresponsive to standard treatments, a combination regimen of oral nitroimidazole for seven days followed by vaginal boric acid for 30 days resulted in symptom resolution in 98.9% of participants. (Surapaneni 2021)

Side effects:

  • Short courses of intravaginal boric acid are generally well tolerated. Mild side effects may include watery vaginal discharge, redness, and burning. (Prutting 1998)
  • Long-term safety data for intravaginal boric acid is lacking. (Müller 2024)
  • Ingesting boric acid can lead to gastrointestinal distress, dermatological reactions, kidney failure, neurological symptoms, and potentially fatal multi-organ failure. (Restuccio 1992)(Webb 2013)(Wong 1964)

Estriol 

Dosing: 1 mg inserted vaginally every night for 14 days before reducing frequency to twice weekly (Dessole 2004) 

Supporting evidence:

  • Declining estrogen levels during menopause lead to a thinning of the vaginal walls and a decrease in the abundance of Lactobacillus spp., altering vaginal pH. These changes may increase the susceptibility to infections and contribute to vaginal symptoms like dryness and discomfort. (Park 2023)
  • Vaginal estriol cream significantly alters the vaginal ecosystem in postmenopausal women with stress incontinence. Specifically, 12 weeks of therapy resulted in reduced vaginal pH and notably increased Lactobacillus and Bifidobacterium growth, especially in women with a Lactobacilli-deficient microbiome pre-treatment. (Moore 2024)

Side effects: 

  • Studies have shown that ultra-low-dose estriol formulations result in minimal systemic absorption; therefore, vaginal estriol is generally considered safe for postmenopausal women. (Delgado 2016)(Sánchez-Rovira 2020) However, providers should assess each patient individually to determine the suitability of vaginal estriol, taking into account personal risk factors, symptom severity, and overall health status.
  • One study reported a transient increase in Candida colonization shortly after initiating treatment with vaginal estriol and Lactobacilli tablets, which returned to baseline levels with continued use. (Donders 2015)

Vitamin C 

Dosing: 250 mg tablet inserted vaginally for six days (Krasnopolsky 2013)

Supporting evidence:

  • In one study, vitamin C tablets inserted vaginally significantly reduced the presence of non-specific vaginitis compared to placebo, in addition to substantially reducing vaginal pH and increasing Lactobacillus concentrations. (Petersen 2004)
  • Women who received prophylactic intravaginal vitamin C therapy after being treated for BV had a significantly lower BV recurrence rate (16.2%) than women who received a placebo (32.4%). (Krasnopolsky 2013)
  • Low-risk pregnant and non-pregnant premenopausal women with vaginal pH ≥4.5 and disrupted Lactobacillus microflora who administered vaginal vitamin C tablets daily for six days, followed by weekly maintenance for 12 weeks, showed a 51.4% normalization to healthy vaginal flora after four months. (Zodzika 2013)

Side effects: 

  • According to clinical studies, the most common side effects of intravaginal vitamin C are localized itching and irritation. (Zodzika 2013)

Lifestyle Recommendations

Nutrition

Carbohydrates

  • Higher glycemic load and glycemic index foods are associated with an increased risk of BV. (Noormohammadi 2022)(Thoma 2011)
  • According to one study, reducing sugar intake was one of the most impactful lifestyle changes that reduced the risk of future infections in women with recurrent VVC. (Donders 2011)
  • Individuals should focus on replacing simple carbohydrates with complex carbohydrates to increase the abundance of Lactobacillus spp. in the vaginal microbiome. (Miller 2024) Examples of easy swaps include: 
    • Brown rice instead of white rice
    • Whole fruits instead of fruit juice
    • Oatmeal instead of processed breakfast cereals (Ferretti 2017)

Fiber

  • Higher fiber intake has been associated with a lower prevalence of BV characterized by a low-Lactobacillus profile, suggesting that dietary fiber may help maintain a Lactobacillus-dominant vaginal ecosystem. (Shivakoti 2020) 
  • One study found that individuals eating an ovo-vegetarian diet, comprised of high-fiber foods like vegetables, beans, and whole grains, had a lower likelihood of BV infection. (Noormohammadi 2022) 
  • Dietary sources of fiber include: 
    • Whole fruits and vegetables: Apples, pears, citrus, carrots, broccoli, peas, cucumbers, celery
    • Whole grains: Wheat, barley, oats
    • Legumes: Lentils, chickpeas, red beans
    • Nuts and seeds: Flax, psyllium, sunflower, cashews, almonds, walnuts (Ioniță-Mîndrican 2022) 

Vitamins and Minerals

  • Certain nutrients may play a role in maintaining a healthy vaginal environment and preventing dysbiosis: (Neggers 2007)
    • Folate: Green leafy vegetables, broccoli, Brussels sprouts, beans (Chan 2013)
    • Vitamin A: Liver, mackerel, sweet potato, green leafy vegetables, squash (McEldrew 2023) 
    • Vitamin E: Vegetable oils, nuts, seeds, green leafy vegetables, fortified cereals (Rizvi 2014)
    • Calcium: Dairy products, almonds, sesame seeds, chia seeds, kale, broccoli, watercress (Cormick 2019)

Fat

High dietary fat intake, particularly saturated and monounsaturated fats, has been associated with an increased risk of BV. Reducing dietary fat intake may lower the risk of developing BV. (Neggers 2007)

  • Dietary sources of saturated fat:
  • Dietary sources of monounsaturated fats:
    • Vegetable oils
    • Red meat and poultry
    • Dairy products
    • Nuts and seeds (Zong 2018)  

Vaginal Hygiene

Maintaining good vaginal hygiene involves avoiding practices that disrupt the natural balance of bacteria and yeast. 

  • Avoid douching and vaginal steaming, which can deplete Lactobacilli and increase the risk of BV.
  • Avoid using intravaginal products like petroleum jelly, perfumed soaps, and spermicides that can irritate vaginal tissues and disrupt the natural pH of the vagina. 
  • Clean the external genital area with mild soap and water. Avoid using harsh soaps, scented products, or antiseptics inside the vagina to avoid irritating the vaginal tissues and disrupting the natural flora.
  • Wear breathable cotton underwear and avoid tight-fitting clothes to reduce moisture buildup, which can promote yeast growth.
  • Change tampons and pads regularly during menstrual periods. (Brown 2013)(Chen 2017)(Klebanoff 2010)

Stress Management

  • Increased stress is associated with a higher risk of BV, characterized by reduced Lactobacillus spp. and an increase in anaerobic bacteria. This is likely due to stress-induced immune suppression and hormonal changes, such as elevated cortisol levels, which can disrupt the healthy vaginal ecosystem. (Amabebe 2018)(Nansel 2006)(Turpin 2021)
  • Chronic stress is also linked to recurrent VVC, with affected women often showing signs of chronic stress, including blunted cortisol responses, that impair immune function. (Akimoto-Gunther 2016)(Ehrström 2005)
  • Stress-related hormonal changes, such as increased prolactin, may compromise the vaginal epithelial barrier, increasing susceptibility to infections. (Li 2015)
  • These findings suggest that implementing mindfulness-based stress-reducing practices into daily routines could help maintain a healthy vaginal microbiota, prevent infection, and promote overall vaginal health. (Khoury 2013)(Najiabhary 2023)

Patient Resources

Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

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