How to Manage Painful & Recurrent Cytolytic Vaginosis?

Besides bacterial vaginosis, there is another “vaginosis.”

You may be familiar with bacterial vaginosis (BV). Vaginosis means vaginal dysbiosis. Dysbiosis means imbalance of the vaginal microbiome (also called vaginal microbiota or vaginal flora).

The BV-related dysbiosis is caused by a reduction of the friendly Lactobacillus bacteria normally present in the vagina and an overgrowth of anaerobic bacteria, like Gardnerella vaginalis.

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Symptoms of bacterial vaginosis

Common signs and vaginal symptoms include fishy odor, abnormal vaginal discharge, elevated vaginal pH, vaginal itching, burning, and painful sex.

Do you know that there is a different type of vaginosis? It also causes excessive vaginal discharge, itching, burning, and painful sex. But it does not have fishy odor and increased vaginal pH.

What is cytolytic vaginosis?

This other vaginosis is called cytolytic vaginosis (CV) or Lactobacillus overgrowth syndrome or Doderlein’s cytolysis. This condition is less common than bacterial vaginosis (BV) and the yeast disease (or vulvovaginal candidiasis or vaginal thrush).

Cytolytic vaginosis – Lactobacillus overgrowth causes over production of lactic acid, which breaks down vaginal epithelial cells, causing burning and discharge.

Thus, it is lesser known. It can cause similar vaginitis symptoms and are often misdiagnosed as yeast or BV.

Some women with CV are treated for vulvovaginal candidiasis (yeast) or bacterial vaginosis (BV) first. After repeated unsuccessful treatment attempts, their doctors may analyze their conditions again.

When their doctors find that these women’s vaginal Lactobacillus bacteria are increased and their vaginal pH is normal or lower than normal, the condition is diagnosed as CV.

What causes cytolytic vaginosis?

The overgrowth of vaginal lactobacillus bacteria produces increased amount of lactic acid, which causes the vaginal epithelial cells (the vaginal lining skin that covers the vaginal wall) to lyse (break down) and peel off to form discharge. Thus, this condition is called “cytolytic vaginosis.”

Cytolytic is the adjective of cytolysis, which means the lysis (break down) of cells. When excessive amount of lactic acid washes away the exfoliated vaginal lining cells, the underlying vaginal wall tissue becomes exposed without a thick protective cover. It is like desquamative inflammatory vaginitis. The vagina becomes highly sensitive to irritation and feels itching, burning, and discomfort.

What factors cause overgrowth of vaginal lactobacillus is unknown. However, certain factors such as the recent use of antibiotics, high-strength probiotics, or antifungal medications may contribute to CV.

Some women reported that taking the prebiotic lactulose may result in cytolytic vaginosis.

Lactulose – a prebiotic that may cause lactobacillus bacteria to overgrow.

Lactulose is a prebiotic that selectively feeds lactobacilli species in the vagina, which can lead to an abundance of lactobacillus species. This overgrowth can result in cytolytic vaginosis, which in most people will resolve without issue once the food supply (lactulose) is ceased. But for some women, CV does not go away after stopping lactulose consumption.

What are the symptoms?

Excessive acid produced by the overgrowth of Lactobacillus bacteria causes irritation and discharge. The discharge does not have much of an odor, not fishy odor. Otherwise, it has vaginal symptoms like those found in vulvovaginal candidiasis (yeast), bacterial vaginosis (BV), or vaginal trichomoniasis caused by Trichomonas vaginalis (trich), like excessive white and thick discharge, itching, burning, irritation, and painful sex.  

Symptoms are often worse in the luteal phase of the menstrual cycle before the menstrual period. Menstrual flow can help reduce the symptoms, because the menstrual blood helps dilute or flush out the acid produced by overly growing lactobacillus bacteria.

You might recall an occasional regurgitation of gastric juice into the oral cavity. The taste of the acid reflux is very sour, and the gastric acid causes you to feel irritation and discomfort.

Discomforts associated with acid reflux.

Luckily, this happens rarely and transiently, and you can easily spit the acid out or swallow it back in, and rinse the mouth with water to remove the gastric acid. Gastro-Esophageal Reflux Disease, or GERD for short, is acid reflux that occurs regularly. 

Unfortunately, if a woman has CV, her overproduced lactic acid is like GERD. The acid is produced consistently and does not go away easily and may consistently cause irritation and discomfort inside the vagina.

Misdiagnosis is common

Cytolytic vaginosis is almost always misdiagnosed at first as vulvovaginal candidiasis (the yeast disease) or bacterial vaginosis (BV) because their symptoms are very much alike.

Nearly all CV cases are misdiagnosed as yeast or BV at first

However, after using different antifungal and/or antibiotic drugs, or self-care products failed to clear the discharges and other discomforts, doctors may perform a lab test or examine the Pap smear under a microscope and achieve a diagnosis of cytolytic vaginosis.

What are unique features of cytolytic vaginosis?

While CV has many common features as vulvovaginal candidiasis (yeast) or bacterial vaginosis (BV), and vaginal trichomoniasis, like discharges, itching, burning, and painful sex, it has several unique features.

  • Yeast or Trichomonas vaginalis is absent in the culture test or under the microscopy.
  • Lactobacillus bacteria are abundant in the smear.
  • Vaginal pH is low at 3.5 – 4.5. Yeast: pH 4.0-5.0; BV: pH >5.0  
  • Discharge is odorless (no rotten fishy odor or any unpleasant odor)
  • Cyclic symptoms: worsen in the luteal phase of the menstrual cycle before the menstrual period, relieve during menstruation (menstrual blood dilutes and flushes acid out), reappear after menstruation.
  • Common Lactobacillus species found in CV in the lab test may include L. crispatus, L. gasseri, and L. jensenii.

A doctor is needed to examine yeast, Trichomonas, BV, and Lactobacillus, and order a lab test, but for the detection of vaginal pH and odor, you can do it yourself.

If you were diagnosed with yeast or BV, but you have tried multiple different treatment products, but all have failed, you may consider the possibility of CV. You can measure vaginal pH and detect if your vaginal discharge has an fishy odor.

How to measure vaginal pH?

You can find several different pH testing kits designed for testing vaginal pH on Amazon. These kits have two basic components: pH paper strips and a color chart with corresponding pH values. Some kits may also include Q-tips, but most do not as Q-tips are a common household item.

A vaginal pH strip kit

To measure vaginal pH, insert a Q-tip into the vagina and hold it against the wall of your vagina for five seconds to allow it to absorb moisture. Withdraw the wet Q-tip and press it against the pH paper strip until it is fully wet.

Wait for a few minutes for the color on the pH paper strip to develop. This step may take up to five minutes, depending on the kit. Compare the color of your pH paper strip to the colors on the chart. Write down the number.

Note, you must compare the color while the paper strip is wet. After it becomes dry, the color changes and it may no longer be accurate.

If your pH is below 4.5, you may rule out BV as BV often has a higher pH. But you cannot rule out yeast yet.

How to check vaginal odor?

A typical symptom of BV is unpleasant fishy odor.

If your discomfort is caused by BV, you may smell an odor like rotten fish. The odor is so bad that you may never forget about it. The odor will make your underwear smell too, and you cannot hide it.

Since CV does not have an odor, you can check the smell with a Q-tip or a cotton swab.

Once you sampled your vaginal secretion with the Q-tip or cotton swab, you can smell it for the presence of any odor. If you do not smell anything unpleasant, you do not have a BV-associated fishy odor.

BV has a fishy odor, but CV does not.

If you have a pH below 4.5 and you do not smell fishy odor, your condition may not be bacterial vaginosis (BV).

Can discharge tell CV apart from vulvovaginal candidiasis (yeast)?

Yeast infection may have a low pH without apparent odor. Thus, you may need to check other things to rule out yeast.

Both CV and yeast cause discharge. Women with CV often have thick and white, or clumpy cottage cheese-like discharge. This is like yeast. Therefore, using discharge alone cannot distinguish CV from yeast.

In a doctor’s office, under a microscope, the vaginal secretion of cytolytic vaginosis does not show white blood cells involved in immune responses, but they are in the vaginal secretion of women with yeast infections. Typical yeast cells are not found in the discharge of cytolytic vaginosis. But in yeast infection, you can see the candida yeast cells in the discharge. But this may need a doctor to provide the diagnosis.

Response to antifungal treatment

If your condition is caused by yeast, it may respond well to antifungal treatment, like Monistat-3. However, if it is caused by CV, it may not respond to antifungal treatment. This may be a good indicator to separate CV from yeast.

Yeast infection will respond to antifungal treatment, like the commonly used antifungal.

How to distinguish cytolytic vaginosis (CV) from aerobic vaginitis (AV)?

Aerobic vaginitis is It is characterized by a decrease in vaginal lactobacillus along with inflammation, vaginal atrophy, and the presence of predominantly aerobic bacteria. The aerobic bacteria are from fecal contamination, such as the E. coli bacteria.

Since vaginal atrophy occurs mostly in postmenopausal women, women with AV are often older and postmenopausal. Conversely, to produce sufficient lactic acid in the vagina, women must have sufficient supply of vaginal glycogen, which is supported by sufficient estrogen. Therefore, to develop CV, women are often younger and premenopausal, except for older women who are on estrogen supplement.

The most convincing diagnosis is a lab test. Women with AV will show fecal bacterial like E. coli, while women with CV will show dominant Lactobacillus species.

How to distinguish cytolytic vaginosis (CV) from lichen sclerosus?

Lichen sclerosus is a rare, chronic skin disorder, usually of the genital and anal areas. It causes small patches of skin to become thin and colorless. It occurs more often in women over 40 years of age.

Common signs and symptoms include:

  • Redness
  • Itching
  • Discomfort or pain
  • Smooth white patches on the skin
  • Blotchy, wrinkled patches
  • Tearing or bleeding
  • In severe cases, bleeding, blistering or ulcerated sores
  • Painful sex

A major difference is that lichen sclerosus does not show vaginal discharge, but CV commonly shows abnormal vaginal discharge.

Can I order a lab test to confirm CV diagnosis?

You can order a vaginal microbiome test from a company called Evvy.

The Evvy vaginal microbiome test kit.

If the test result shows that your vaginal Lactobacillus species is dominant (could be one species or multiple species but collectively their percentage is over 95%) and you have CV-like symptoms such as discharge, itching and burning, but no fishy odor, you may have CV.

This test can help you confirm the CV diagnosis from a doctor’s office if your doctor did not order a lab test.

How is cytolytic vaginosis treated?

Cytolytic vaginosis is a relatively rare condition affecting women’s vaginal health. The market is relatively small. There has not been a commercial self-care product dedicated to treating CV. In doctor’s offices, a commonly prescribed medication is Clindamycin cream. It can suppress the overgrowth of vaginal Lactobacillus bacteria to provide relief.

The antibiotics may be effective, but a problem with the antibiotic cream is that after vaginal lactobacillus bacteria are wiped out by the antibiotics, yeast infection may occur.

There are some self-care treatment methods for reducing the overgrowth of Lactobacillus bacteria and the acid produced by these bacteria.

  • Avoid probiotics or any products containing Lactobacillus, like yogurt.
  • Avoid certain prebiotics like lactulose. Lactulose is also used as an osmotic laxative that treats constipation and liver problems. If you have CV and need to use a laxative, avoid lactulose, and try other laxatives instead.
  • Baking soda sitz bath.
  • Baking soda capsules or tablets. You can find these on Amazon.
  • Change tampon to pads for menstrual hygiene.
First add baking soda. Second, pour warm water to mix baking soda

Please do not try the baking soda methods unless you are certain that your condition is CV. Stop using the product as soon as you find relief.

Baking soda is around 8.4 on the pH scale, slightly above the neutral mark of 7. It may cause burning in some women. Repeated use or overuse of the baking soda capsules, tablets, douche or sitz bath may disrupt the vaginal microbiome and cause bacterial vaginosis (BV), yeast infection, and/or pelvic inflammatory disease (PID).

If you encounter any difficulty, we suggest that you consult with a doctor who understands CV. Since CV is relatively new and not well known to the medical community, not all doctors are familiar with CV and can help you find a best solution.

Does baking soda cause side effects?

Based on the literature report, about one half of women with CV can find relief after using baking soda sitz bath or baking soda capsules or tablets as vaginal inserts.

Baking soda can raise vaginal pH and reduce the acidity related symptoms caused by CV. However, it does not eliminate the cause of CV, overgrowth of the Lactobacillus bacteria. This may explain why about one half of women with CV do not respond well to baking soda treatment. 

Baking soda can be easily overused to cause serious side effects.

Baking soda is a mild base with pH 8.4. If you underuse it, the effect may be short-lived. CV symptoms may come right back after you stop using it.

Because overuse may cause burning and irritation, it is often not overused among women who are sensitive to burning or irritation. In these women, baking soda is ineffective due to underuse.

But for women who are less sensitive to the irritation caused by baking soda, they may overuse it and suffer serious side effects. If you overuse baking soda despite of irritation, it may function as an antiseptic to wipe out the normally protective vaginal lactobacillus bacteria entirely. It is difficult to restore a normal vaginal flora once it is lost. You may suffer from repeated yeast infection or bacterial vaginosis as a result of elimination of vaginal Lactobacillus bacteria.

We do not recommend off-label use of baking soda for CV relief

Many women with CV have tried baking soda and got vulva burning and pelvic pain. Pelvic pain may be caused by Pelvic inflammatory disease or PID. It is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. If PID occurs, about 1-in-10 with the condition may develop infertility. It can be more difficult to manage and it is too great a health risk to take when there is a safer alternative for CV treatment.

Baking soda capsule, tablet, douche, or sitz bath may cause PID

It is unknow why baking soda capsule, tablet, douche or sitz bath may cause PID. Here is a plausible explanation. Normally, Lactobacillus is the first line of defense for woman’s pelvic cavity. The problem with CV is the overgrowth of Lactobacillus that produces too much acid. Overuse of baking soda can completely wipe out Lactobacillus. When women lose the first line of defense, pelvic infection may occur.

Instead of completely wiping out vaginal Lactobacillus, a good CV treatment should just reduce the overly grown Lactobacillus to a moderate level. This will help relieve CV symptoms and also assure a reasonable presence of vaginal Lactobacillus as a good health defense system for women.

NeuEve CV-Ease, the first dedicated self-care product for CV relief

For women with CV but not responding to baking soda, there have been no suitable products for them. We have developed a special formula called CV-Ease.

Vaginal lactobacillus bacteria are normally protective against yeast infection or bad bacteria associated with bacterial vaginosis. Only the “overgrowth” of these lactobacillus bacteria may cause harm. The ideal treatment strategy for relieving CV should not completely wipe out these protective vaginal lactobacillus bacteria. It should just limit their “overgrowth” to avoid causing harm. Therefore, using baking soda to treat CV is not an ideal strategy. It can be easily overused to cause unintended consequences.

When the vagina loses the natural protection offered by lactobacillus bacteria, yeast infection, and/or bacterial vaginosis (BV) may occur. The result can be worse than CV itself, because without the lactobacillus protection, the vagina is more susceptible to some more serious infections, like HIV.

NeuEve CV-Ease works differently from baking soda or antibiotic cream. CV-Ease provides a milder buffer to neutralize lactic acid produced by CV. It also partially suppresses the overgrowth of the vaginal Lactobacillus bacteria. It just reduces the number of the Lactobacillus bacteria from overly dominant to moderately dominant. It does not eliminate lactobacilli, thereby restoring the balance of the normal vaginal microbiome. Additionally, it does not use antiseptic ingredients like baking soda. it uses all natural, food-grade ingredients and is safe.

CV Ease, the first self-care product dedicated to relieving CV-associated symptoms.

NeuEve CV-Ease is the first dedicated self-care product for CV relief. It is not yet listed for sale to the public. If you have CV and have tried baking soda without effect, you can contact us at help@neueve.com to inquire about CV Ease.

Disclaimer: This article is for information purposes only. It is about natural products, nutrients, and/or methods for managing vaginal discomfort (not a true infection or disease). It is not medical advice for the treatment of any diseases.

About the author

Dr. Renjie Chang's medical and pharmaceutical experience:
- OB-GYN in the Peking Union Hospital in China
- a faculty member of OB-GYN at University of Oklahoma Health Sciences Center
- drug developer at the Abbott Laboratories in Chicago
- Founder of Lavax, Inc, where she developed an innovative vaginal microbicide for preventing sexually transmitted disease with grants from NIH and Gates Foundation
- Founder of NeuEve, an all-natural women's health company

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