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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 41-49

Effect of ingestion of yogurt containing Lactobacillus acidophilus on vulvovaginal candidiasis among women attending a gynecological clinic


1 El Fayoum School in El Fayoum General Hospital, El Fayoum Governorate, Egypt
2 Faculty of Nursing, Cairo University, Cairo, Egypt
3 Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission10-Jan-2017
Date of Acceptance30-Jan-2017
Date of Web Publication13-Jun-2017

Correspondence Address:
BSN Safaa Fares
El Madina El Senaiea, Takseem Nasar, El Fayoum
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_8_17

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  Abstract 

Background
Vaginal infection is the most common complaint during childbearing.
Aim
The aim of the present study was to assess the effect of yogurt intake on relieving symptoms of vulvovaginal candidiasis (VVC).
Design
This study was quasi-experimental in nature.
Setting
The study was conducted at the outpatient gynecological clinic at El Fayoum General Hospital.
Sample
A purposive sample of 200 women with VVC assigned into two groups was used in the study. The first group (control group) received medical care only, whereas the second group (study group) received medical care and yogurt. The researcher determined certain days for the research group and other days for the control group.
Tools
Researcher designed this tool. The first tool was a structure interview and the second was assessment and follow-up schedule for the symptom of VVC.
Results
The findings of our study indicated no statistically significant differences between groups as regards sociodemographic characteristics. The mean age was 27.97±5.73 years in the study group, whereas it was 27.18±5.35 years in the control group. As regards educational level there was no statistically significant difference between groups (χ2=1.754, P=0.15). Regarding monthly income there was no statistically significant difference between groups (χ2=1.245, P=0.21). Moreover, as regards assessment symptom of VVC there was a statistically significant difference between groups.
Conclusion
Yogurt contains probiotic bacteria such as Lactobacillus acidophilus that are beneficial against mucosal candida infections and their beneficial actions by suppressing the growth of candida, and thus yogurt intake can relieve symptoms of VVC.
Recommendation
Yogurt intake (one large cup without sugar daily) can relieve symptoms of VVC.

Keywords: vulvovaginal candidiasis, women, yogurt


How to cite this article:
Fares BS, Abd el Kader S, Abd El Hamid AA, Gaafar HM. Effect of ingestion of yogurt containing Lactobacillus acidophilus on vulvovaginal candidiasis among women attending a gynecological clinic. Egypt Nurs J 2017;14:41-9

How to cite this URL:
Fares BS, Abd el Kader S, Abd El Hamid AA, Gaafar HM. Effect of ingestion of yogurt containing Lactobacillus acidophilus on vulvovaginal candidiasis among women attending a gynecological clinic. Egypt Nurs J [serial online] 2017 [cited 2018 Oct 22];14:41-9. Available from: http://www.enj.eg.net/text.asp?2017/14/1/41/206943


  Introduction Top


Vaginal infection is a medical term used to describe various conditions that cause infection or inflammation of the lining mucosa of the vagina. It is a common problem for women who seek medical care. The most common types of vaginal infection are bacterial vaginosis, vulvovaginal candidiasis (VVC), and trichomonas vaginitis. In the USA, the incidence of bacterial vaginosis is 40–50%; VVC is 20–25%; and trichomonas vaginitis is 15–20% (Sobel, 2013).

Vaginal infection occurs when the vaginal ecosystem is changed by several factors including patient’s age, hormonal status, excessive douching, pregnancy, sexual activity, menstruation, contraceptive methods, antibiotic, certain medication, and presence of disease such as diabetes. Other factors that may increase the incidence of vaginal infection are multiple sexual partners and previous history of sexually transmitted disease (Dawood, unpublished data).

VVC or monilia or yeast infection is caused by an overgrowth of Candida albicans, which is normally present in a harmless amount in the vagina, the digestive tract, and the mouth. The symptoms of VVC are a cheesy white discharge, irritation, intense burning, itching, and redness in the vagina, and may present with pain with urination or intercourse (Dawood, unpublished data; CDC, 2015).

Yogurt is an anti-infection agent. It is believed to be a protector against immune-related diseases and bacterial and fungal infections. It helps the immune system to be more resilient. The beneficial bacteria in yogurt are an excellent method to get rid of a vaginal infection. The prevalence of bacterial and VVC infections decrease when the immune system is resilient. The body needs to restore beneficial bacteria and the vagina needs a good balance of healthy flora before VVC gets a foothold, specifically in the sense of a candida where the bacteria can directly destroy candida development. Ingestion of yogurt during and after a course of antibiotics can restore good bacteria in the body and restore a healthy balance of flora in the vagina. Yogurt must contain active live cultures Lactobacillus acidophilus to be effective for vaginal health. Furthermore, sweetened yogurt is detrimental to vaginal health because sugar contains yeast, and yeast thrives off sugar. All sources of sugar should be avoided until the Candida has been eliminated, including fruit and fruit juices, alcohol, and starch (Homayouni et al., 2014).

Mailander-Sanchez et al. (2012) reported that, yogurt containing Lactobacillus spp. was associated with a decreased amount of vaginal yeast (detected by culture), as well as a reduced rate of vaginal discharge associated with yeast infections. They mentioned that, probiotics such as Lactobacillus spp. are beneficial against mucosal Candida infections, and should be considered for women who suffer from recurrent infection. They explain that probiotics exert their beneficial actions by suppressing the growth of candida in various regions of the body and inhibiting candida’s ability to adhere to cell surfaces.

Significance

VVC in Egypt affects 41% of women experiencing vaginal infections. The ignored vaginal infections or improper management can induce maternal complications including endometritis; salpingitis; peritoneal infection; pelvic abscess; temporary or absolute infertility; endometritis; postpartum infection; and urinary tract infection. Whereas during pregnancy they can cause preterm delivery and premature rupture of membranes (Ganjoei, 2005; Dawood, unpublished data).

Recurrent vaginal yeast infections cause the internal vaginal flora to become unbalanced, which may make it harder for the sperm to reach the uterus. Sperm is not killed by overgrowth of candida, but because the infection changes the consistency of the cervical mucus, it may make it more difficult for the sperm to reach the cervical opening. An imbalance in vaginal flora impairs the vaginal mucosa’s ability to fight off other infections or diseases, which may lead to other fertility issues later in life; on other hand, vaginal candida affect fertility by making woman so uncomfortable from itching and slight burning that she will not want to have sexual intercourse (Churchill, 2010).

In Egypt there were few scattered researches assessing the effect of ingestion of yogurt containing L. acidophilus on relief symptoms of VVC. Nurses in all gynecological clinics must be knowledgeable about VVC signs, symptoms, management, and health education. Results of this research will help the nurse as an educator to raise women awareness regarding the management of VVC.


  Aim Top


The aim of the present study was to assess the effect of ingestion of yogurt containing L. acidophilus on relieving signs and symptoms of VVC.

Research hypothesis

Women with vulvovaginal candidiasis who will eat yogurt containing Lactobacillus Acidophilus will have earlier of vulvovaginal candidacies than those who receive medical care only.


  Participants and methods Top


Design

A quasi-experimental design (nonequivalent control group design) was adopted in this research to assess the effects of yogurt on women with VVC. This design requires a pretest and post-test for the study and control groups.

Sample

A purposive sample of 200 (based on the rule of sum number of variables multiplied by a constant, which is 5) women with VVC were recruited to be included in the research. The inclusion criteria were as follows: age not exceeding 35 years and diagnosis of VVC only and not pregnancy. The exclusion criteria have Diabetes Mellitus (DM), sexually transmitted disease, urinary tract infection, and receiving antibiotic for a long time. The sample was divided into two groups. The first group (control group) received medical care only, whereas the second group (study group) received medical care and yogurt containing L. acidophilus. The researcher determined certain days for the study group and other days for the control group.

Setting

The setting of data collection was the outpatient gynecological clinic at El Fayoum General Hospital; this hospital provides free healthcare for outpatients as well as inpatients. The gynecological clinic consists of two rooms for gynecological cases. It provides care for ∼40 women of vaginal infection per day, and refers them to the laboratory unit if needed.

Tools

Two tools were designed and used by the researcher to collect data for this research. The first was a structured interview and the second was assessment and follow-up schedule for the symptoms of VVC.

Structured interview tool included three parts related to (a) demographic data such as age, residence, level of education, marital status, monthly income, and smoking habits; (b) obstetrical, gynecological and medical history that included data related to the number of gravidity, parity and the last date of labor or abortion, types and duration of contraceptive methods if used, medical history including data about chronic disease as hypertension, anemia, allergy, use of medication during current VVC as antibiotic or corticosteroids; and (c) hygienic and personal habits that included data related to the types of underwear, types of toilet, use of public WC, use of towel of discharge, number of shower per week, and use of vaginal douches.

Assessment and follow-up schedule for signs and symptom of VVC included symptoms of VVC and its severity assessed by a Likert scale (no, simple, moderate, severe, and morbid severe).

Tools validity

The tools used in the study were submitted to a panel of five experts in the field of maternity nursing and obstetric medicine to test the content validity. Modification was carried out according to the panel judgment on clarity of sentences and appropriateness of content.

Ethical consideration

For ethical reason, an official permission was taken from research ethical committee at the Faculty of Nursing, Cairo University, to approve the tools and the research. Every woman was informed about the purpose of the research and its importance. The researcher emphasized that participation in the research was voluntary; furthermore, anonymity and confidentiality were assured through coding the data. Written consent was taken from the women who accepted to participate in the research.

Pilot study

A pilot research was carried out on 10% of the total sample to check clarity of items and determine the feasibility of the research. According to the results of the pilot research, modification was required to the Likert scale from three items (simple, moderate, severe) to five items (no, simple, moderate, severe, morbid severe) because some women did not present with all the symptoms of VVC. The sample included in the pilot research was excluded from research sample.

Procedure

Data were collected through a period of 6 months, from October 2013 to March 2014, on a total number of 200 women with VVC. Data were collected through four phases: (a) interview, (b) assessment, (c) implementation, and (d) follow-up and evaluation.

Preparatory phase

An official permission to conduct the proposed research was obtained from the hospital administrators, and healthcare providers were informed orally about the purpose, importance, and benefits of research. The researcher met the women at the outpatient gynecological clinic and obtained their acceptance to be recruited in the research. The researcher determined some days for the study group and other days for the control group. After obtaining a written consent from women the researcher started to collect data through the following.

Interviewing phase

Each woman was interviewed to collect data related to personal data, level of education, marital status, personal and hygienic habits, medical history, and obstetric history. The researcher faced each woman, asked her questions in simple Arabic language, and recorded each answer using the structured interview tool. Each interview lasted for about 30 min.

Assessment phase

The researcher assessed signs and symptoms of VVC as cheesy white vaginal discharge, burning sensation during urination, vaginal itching, redness and edema of vulva, and pain with intercourse, and documented the data using the assessment and follow-up schedule for signs and symptom of VVC tool.

Implemental phase

The researcher gave one cup of yogurt 200 ml (Johaina Yogurt Company in Upper Egypt) containing L. acidophilus without sugar to each woman of the study group every day until 2 weeks in addition to medical treatment.

Follow-up and evaluation phase

The researcher asked each woman about suitable time to call her by telephone every day to be sure of her compliance and followed up the signs and symptoms of VVC for 2 weeks. All women returned back to the outpatient gynecological clinic after 1 week from the first visit and their degree of relief from the signs and symptoms of VVC was evaluated.


  Results Top


The findings of this quasi-experimental study are presented in three sections. The first includes the description of the sample. The second section includes obstetrical, gynecological, and medical history. The third section includes the effect of yogurt on VVC.

Section 1: description of the sample

This section includes the description of the women as regards age, educational level, marital status, monthly income, residence, and hygienic and personal habits.

The age range was 18–35 years old with a mean age 27.97±5.73 years for women in the study group compared with 27.18±5.35 years for women in the control group. About half of the women (59% and 47%) in the study and control groups were in the age category 30–35 years. Regarding the educational level, more than one-fourth of the women (27%) in the study group could not read and write compared to 25% in the control group. Regarding marital status, nearly three-quarter of women were married (73%) in the study group compared with 61% in the control group, and minority (6%) in the study group compared with none in the control group were divorced. A high percentage of women (76%) had income ranging between 500 and 1000 EGP (Egyptian pound) in the study group compared with more than two-third (68%) in the control group. No statistically significant differences were found between the groups as regards age, educational level, marital status, and income ([Table 1]).
Table 1: Distribution of women in both groups as regards personal data

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Regarding residence, 75 and 25% in the study group were living in urban and rural areas, respectively, compared with 66 and 33%, respectively, in the control group. The χ2-test indicated that, there was no statistically significant difference between the groups. In relation to smoking habits, 96% of women did not smoke in the study group compared with 99% in the control group. No statistically significant difference was found between the groups.

As regards hygienic and personal habits, more than two-third of women in the study group used cotton underwear (67%) compared with 53% of women in the control group. There was a statistically significant difference between the two groups. In relation to use of towel for discharge, more than half of the women used towel for discharge (59%) in the control group. Regarding to use of the vaginal douche, more than half in the study group (58%) used vaginal douche compared with 71% in the control group. As regards showers per week, 83% of the women in the study group mentioned taking a shower one to three times per week compared with nearly two-third (61%) in the control group taking a shower one to three times per week. A statistically significant different between the two groups was found. Near half (42%) of the women in the study group used public WC compared with 40% of women in the control group. No statistically significant differences between the two groups were found as regards use of towel for discharge, use of vaginal douche, and number of showers per week ([Table 2]).
Table 2: Distribution of women in both groups as regards their hygienic and personal habits

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Section II: obstetrical, gynecological, and medical history

Regarding parity, 41% of the women in the study group compared with 42% in the control group were para 1–2, whereas 3% in the study group compared with 10% in the control group were grand multipara. No statistically significant difference was found between the two groups. Nearly half of the women in both groups used contraceptive methods; 38% of women who used contraceptive methods in the study group used intrauterine device compared with 34% in the control group ([Table 3]).
Table 3: Distribution of women in both groups as regards previous obstetrical and gynecological history

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In relation to previous vaginal infection, 92% of the women in the study group had previous infection compared with 57% in the control group. There was a statistically significant difference between the two groups. About two-thirds of the women in the study and control group used medication during previous infection ([Table 4]).
Table 4: Distribution of women in both groups as regards previous history of infection

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Regarding medical history, 92% of the women did not have hypertension in the study group compared with 79% in the control group. Nearly one-quarter (24%) had anemia in the study group compared with 39% in the control group. There were statistically significant differences between the two groups as regards hypertension and anemia ([Table 5]).
Table 5: Distribution of women in both groups as regards assessment of cheesy vaginal discharge

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Section III: the effect of yogurt on signs and symptoms of vulvovaginal candidiasis

Regarding complaints of cheesy vaginal discharge, during the baseline assessment, 49% of the women in the study group complained of moderate amount of cheesy vaginal discharge compared with 39% in the control group. No statistically significant difference between the groups was found. After 1 week from using yogurt, 20% of the women in the study group complained of moderate amount of cheesy vaginal discharge compared with 38% in the control group; a statistically significant difference between the groups was found. After 2 weeks from using yogurt, 1% of the women in the study group complained of moderate amount of cheesy vaginal discharge compared with 25% in the control group; a statistically significant difference between the groups was found ([Table 5]).

In relation to complaints of burning sensation, during the baseline assessment, 39% of the women in the study group complained of a moderate degree of burning sensation compared with 31% in the control group. No statistically significant difference between the groups was found. After 1 week from using yogurt, 8% of the women in the study group complained of a moderate degree of burning sensation compared with 33% in the control group, with highly statistically significant difference between the groups. After 2 weeks from using yogurt, none of the women in the study group complained of a moderate degree of burning sensation compared with 22% in the control group, with a statistically significant difference between the groups ([Table 6]).
Table 6: Distribution of women in both groups as regards assessment of burning sensation

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Regarding complaints of vaginal itching, during the baseline assessment, 20% of the women in the study group complained of a moderate degree of vaginal itching compared with 28% in the control group. A statistically significant difference between the groups was found. After 1 week from using yogurt, 5% of the women in the study group complained of a moderate degree of vaginal itching compared with 30% in the control group, with a highly statistically significant difference between the groups. After 2 weeks from using yogurt, 1% of the women in the study group complained of a moderate degree of vaginal itching compared with 13% in the control group, with no statistically significant difference between the groups ([Table 7]).
Table 7: Distribution of women in both groups as regards assessment of vaginal itching

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As regards complaints of redness and edema of vulva, during the baseline assessment, 10% of the women in the study group complained of a moderate degree of redness and edema of vulva compared with 19% in the control group. A statistically significant difference between the groups was found. After 1 week from using yogurt, none of the women in the study group complained of a moderate degree of redness and edema of vulva compared with 19% in the control group, with a highly statistically significant difference between the groups. After 2 weeks from using yogurt, none of the women in the study group complained of a moderate degree of redness and edema of vulva compared with 8% in the control group, with a statistically significant difference between the groups ([Table 8]).
Table 8: Distribution of women in both groups as regards assessment of redness and edema of vulva

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As regards complaints of pain during intercourse, during the baseline assessment, 2% of the women in the study group complained of a moderate degree of pain during intercourse compared with 12% in the control group. A statistically significant difference between the groups was found. After 1 week from using yogurt, none of the women in the study group complained of a moderate degree of pain during intercourse compared with 13% in the control group, with a highly statistically significant difference between the groups. After 2 weeks from using yogurt, none of the women in the study group complained of a moderate degree of pain during intercourse compared with 9% in the control group, with a statistically significant difference between the groups ([Table 9]).
Table 9: Distribution of women in both groups as regards assessment of pain with intercourse

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  Discussion Top


This research presents important findings related to the effects of ingestion of yogurt containing L. acidophilus on VVC. The findings of the present research accept the hypothesis that women with VVC who eat yogurt containing L. acidophilus experience relief from the symptoms of VVC earlier than who receive medical care only.

The findings of this research documented that, after 2 weeks from starting ingestion of yogurt containing L. acidophilus, more than three-quarters of the women in the study group had no complaint of cheesy vaginal discharge compared with less than one-quarter in the control group. In addition, a high percentage of women in the study group had no complaints of vaginal itching and burning sensation during urination compared with about two-third in the control group. In addition, almost all women in the study group had no complaints of edema of vulva and pain with intercourse compared with more than three-quarter in the control group. There were statistically significant differences between the two groups. These results were in agreement with AbdElmonem et al. (2012). They examined the use of bee-honey and yogurt mixture in comparison with itraconazole for treating patients with VVC during pregnancy. Their findings documented that, 87.8% compared with 72.3%, respectively, showed improvement in the symptoms of VVC. Therefore, itching, secretions, and redness of the vulva and vagina significantly decreased in the consumer group of bee-honey and yogurt mixture compared with the itraconazole group.

In the same context, Fazel et al. (2011) compared the effect of vaginal cream mixed with yogurt and honey compared with clotrimazole on the symptoms of VVC. The results of their research demonstrated a significant reduction in the signs and symptoms of vaginal candidiasis after using the vaginal cream of yogurt and honey for 7 days in more than three-quarter of women compared with two-thirds of the clotrimazole group.

Moreover, these results were in agreement with Mailander-Sanchez et al. (2012). They reported that yogurt containing Lactobacillus spp. was associated with a decreased amount of vaginal yeast (detected by culture), as well as a reduced rate of vaginal discharge associated with yeast infections. They mentioned that probiotics such as Lactobacillus spp. are beneficial against mucosal candida infections, and should be considered for women who suffer from recurrent infection. They explained that probiotics exert their beneficial actions by suppressing the growth of candida in various regions of the body and inhibiting candida’s ability to adhere to cell surfaces.

Similarly, Martin and Duru (2007) conducted a double-blind, randomized placebo-controlled study using probiotic Lactobacillus spp. as an adjunctive therapy to fluconazole in the treatment of yeast vaginitis and bacterial vaginosis. They reported that, oral administration of two well-documented strains of lactobacilli given to women with recurrent yeast vaginitis, followed by standard therapy with fluconazole, results in a significant reduction in the recurrence rate of the disease. Yeast vaginitis is a very commonly affecting premenopausal female disease prevalent in the age group 21–30 years in Nigeria. In most of these women, recurrent rate of vaginal candidiasis with empiric therapy stands between 70 and 80%. In addition, resistance to antifungal agents is increasing at an alarming speed. The healthy vaginal environment is composed mainly of lactobacilli and when these organisms are suppressed overgrowth of a large number of pathogens occur, including yeasts.

Moreover, a study conducted by Jonne (2003), examining yogurt and vaginal health, support our results. He reported that yogurt is effective for treating vaginal infections, and may be more effective than the typical treatments used for candida infections. In his research he examined two types of treatment (metronidazole and yogurt containing L. acidophilus). His results showed that, the group that received metronidazole built a resistance to the antifungal, but the group that was treated with yogurt containing L. acidophilus had a decreased prevalence of candida colonization and vaginal infections.

In the same context, the findings of a study by Hilton et al. (2003) supported our results; they examined ingestion of yogurt containing L. acidophilus as prophylaxis for candida vaginitis. Their sample consisted of 33 women with recurrent candida vaginitis; the women ate yogurt for 6 months of the research period. They found that, a three-fold decrease in infections was seen when patients consumed yogurt containing L. acidophilus. They concluded that a daily ingestion of 8 oz of yogurt containing L. acidophilus decreased both candida colonization and infection.

Reid et al. (2003) investigated the ability of orally administered lactobacilli to reduce the vaginal colonization and infection by candida. They conducted a randomized trial in 64 healthy women in the age range 19–46 years without any urogenital infections in the year before the study. After 4 weeks, 32 of the studied women received orally lactobacilli, whereas the other 32 women received placebo. Cultures of the vaginal swabs of the studied women 4 weeks after orally administered lactobacilli showed a significant increase in vaginal lactobacilli (P=0.01) and a significant reduction in yeast (P=0.01) in the lactobacilli-treated compared with the placebo-treated women.


  Conclusion Top


Yogurt contains L. acidophilus, which is beneficial against mucosal candidal infections and exerts its beneficial actions by suppressing the growth of candida. Therefore, yogurt intake can provide relief from the symptoms of VVC.

Recommendations

Based on the findings of this research, the following are recommended:
  1. Raise awareness of women about the importance of ingestion of yogurt daily without sugar to treat VVC.
  2. Health training for the medical staff to add yogurt with routine medical treatment for vaginal candidiasis to reach good results.
[11]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
AbdElmonem A, Rasheed S, Mohamed A (2012). Bee-honey and yogurt: a novel mixture for treating patients with vulvovaginal candidiasis during pregnancy. Arch Gynecology Obstet 286:109–114.  Back to cited text no. 1
    
2.
CDC (2015) Genital/vulvovaginal candidiasis (VVC). Available at: http://www.cdc.gov/fungal/diseases/candidiasis/genital/. [Accessed 13 Jul 2005]  Back to cited text no. 2
    
3.
Churchill (2010) Botanical Medicine for Women’s Health, Livingstone Press, Aviva Romm. Available at: http://natural-fertility-info.com/candida-fertility.html. [Accessed 13 Jul 2005]  Back to cited text no. 3
    
4.
Fazel N, Hashemian M, Ramezani M, Akaberi A (2011). Comparison of honey with clotrimazole alone and mixed on candidial vaginitis. IJOGI 14:48–54.  Back to cited text no. 4
    
5.
Ganjoei TA (2005). Risk factors for bacterial vaginosis in women attending a hospital in Kerman, Islamic Republic of Iran. Available at: http://www.emro.who.int/emhj/1103/11_3_2005_410_415.pdf. [Accessed 13 Jul 2005]  Back to cited text no. 5
    
6.
Hilton E, Isenberg HD, Alperstein P, France K, Borenstein MT (2003). Ingestion of yogurt containing Lactobacillus acidophilus as prophylaxis for candidal vaginitis. Ann Intern Med 116:353–357.  Back to cited text no. 6
    
7.
Homayouni A, Bastani P, Ziyadi S, Mohammad-Alizadeh-Charandabi S, Ghalibaf M, Mortazavian AM, Mehrabany EV (2014). Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Low Genit Tract 18:79–86.  Back to cited text no. 7
    
8.
Jonne G (2003). Yogurt & vaginal health. Available at: http://www.livestrong.com/article/yogurtvaginalhealth/325230. [Accessed 13 Jul 2005]  Back to cited text no. 8
    
9.
Mailander-Sanchez D, Wagener J, Schaller M (2012). Potential role of probiotic bacteria in the treatment and prevention of localised candidosis. Mycoses 55:17–26.  Back to cited text no. 9
    
10.
Reid G, Charbonneau D, Erb J, Kochanowski B, Beuerman D, Poehner R, Bruce AW (2003). Oral use of Lactobacillus rhamnosus GR-1 and Lactobacillus fermentum RC-14 significantly alters vaginal flora: randomized, placebo-controlled trial in 64 healthy women. FEMS Immunol Med Microbiol 35:131–134.  Back to cited text no. 10
    
11.
Sobel J (2013). Approach to women with symptoms of vaginitis. Available at: http://www.uptodate.com/…/approach-to-women-with-symptoms-of-vaginitis [Accessed 3 October 2013]  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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