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.

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).

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 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.

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.

Who may get CV?

The female hormone estrogen supports glycogen synthesis in vaginal cells. When these cells exfoliate, glycogen is released to support the growth of vaginal lactobacilli. To get CV, a woman needs to have a high estrogen level. Thus, only women in the reproductive age, like 15 - 45, may get CV.

Prepubescent girls and postmenopausal women may not get CV because they have a lower level of estrogen.  There is one exception, if a postmenopausal woman is heavily supplemented with estrogen, like taking hormone replacement therapy or bioidentical hormone, CV may still occur because the naturally reduced estrogen level after menopause is restored by hormone supplementation.

Recently, a 70 year-old woman not on hormone supplement had vaginal burning and discharge. She asked if her condition was caused by CV. We explained to her that she could not get CV because her estrogen level was low after menopause.

Thus, two factors, your age and whether you are on hormone supplement, may help you rule out the possibility if your vaginal discomfort is caused by CV. 

On the other hand, if you are taking estrogen supplement and also suffer from CV, it means that you may be taking too much estrogen. Weaning estrogen supplement may heal your CV naturally. Also, estrogen supplement promotes cancer risk. It is good for your health to wean estrogen even if you do  not have CV.

How to diagnose CV?

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.

However, after using different antifungal and/or antibiotic drugs, or self-care products failed to clear the discharges and other discomforts, CV may be suspected. 

A gynecologist may perform a lab test or examine the Pap smear or a wet swab slide under a microscope. When the doctor sees a lot of Lactobacillus bacteria,  the diagnosis of cytolytic vaginosis can be achieve. The microscopic diagnosis can be further confirmed by a DNA test like Evvy.

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.

We recommend this Pelvana brand because it is easier to read. Other brands are cheaper but may be a waste of money because it is hard to separate their colors of pH 4.5 and pH 5.0.

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.

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.

How to distinguish CV from vaginal lactobacillosis?

Vaginal lactobacillosis (VL) is caused by an overgrowth of a lactobacillus-related bacterial species, Leptothrix vaginalis​​. Its cell shape is an elongated filamentous rod, 3-5 times longer than that of a Lactobacillus cell.  

Previously, it was thought to be a subtype of Lactobacillus acidophilus. It is now classified as Leptothrix vaginalis. It is a relative of Lactobacillus. 

Its overgrowth produces increased amount of lactic acid, which causes damages to the vaginal lining cells similar to cytolytic damages seen in CV. Therefore, CV and VL have similar clinical symptoms.

Using Pap smear and a wet mount slide, the long-rod shaped Leptothrix vaginalis bacteria associated with VL can be observed under a microscope.

Cytolytic vaginosis (CV) and vaginal lactobacillosis (VL) are mostly considered together as the Lactobacillus overgrowth syndrome. Therefore, these two diseases are related and may be treated by same approaches.

How to distinguish CV from 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.

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.

Other labs also provide vaginal microbiome test that can detect CV:

- www.juno.bio

- www.ombrelab.com

- https://microgendx.com

The test costs from $85 to $150 per test. It is expensive. You may want to shop around and do a comparison. You may ask them if their test is covered by medical insurance, Medicare, Medicaid, or HSA account.

If you have predominantly Lactobacillus species (close to 100%) in the vaginal sample and you have discomforts like pain, irritation, burning, itching, and/or discharge, some may be cottage cheese like charge, you may have CV.

Lactobacillus iners is a bad apple in the family of Lactobacillus. It is often associated with an increased risk of vaginal infection. If you see a high number of L. iners in your lab test, most likely you have a vaginal dysbiosis like BV or AV. If the population of L. iners is close to 100%, you may developed a special type of CV. L. iners secrete a cytolysin called inerolysin that kills your vaginal lining skin cells and cause burning and discharge.   

Major symptoms of CV include intensive itching, burning, and discharge. CV is often misdiagnosed at first. After treatment failure for BV or yeast, lab diagnosis may discover CV.

Once diagnosed, the doctor may provide treatment. Your doctor may also refer you to a specialist in women’s health or infectious diseases.

There is no treatment products specifically for CV a doctor can prescribe. Some doctors may prescribe antibiotics. Unfortunately, antibiotic overuse often causes yeast infection or BV or no effect at all, further complicate your condition.

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 douche.
• Baking soda capsules or tablets.
• Change tampon to pads for menstrual hygiene.

Warning: Although baking soda may provide temporary relief, repeated use may cause serious side effects that can be more harmful than CV itself. 

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.

How is vaginal lactobacillosis treated?

If your CV-like symptoms are caused by vaginal lactobacillosis (VL), another disease of the Lactobacillus overgrowth syndrom, treatments often use broad spectrum antibiotics. 

These include 500 mg of amoxicillin-clavulanate given orally every 8 h for 7 days or 100 mg of doxycycline every 12 h for 10 days. Vaginal nifuratel may also be used.

Warning: Severe side effects have been reported after using amoxicillin-clavulanate or doxycycline. 

Additionally, some of our customers have used these antibiotics to treat VL. As soon as they stop taking these drugs, their VL symptoms come back. After repeated use, some customers reported that BV and/or yeast occurred and were difficult to clear.

Apparently, these drug can kill a broad range of bacteria including beneficial Lactobacillus bacteria. When overused, they may break the balance of the normal vaginal microbiome. Therefore, we do not recommend using any antibiotics to treat VL when a safer and more effective option is available. 

‍Does baking soda cause side effects?

Based on the literature report, about one half of women with CV may 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 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.

Baking soda use may cause PID and infertility

Many women with CV have tried baking soda and got vulva burning and pelvic pain. The worst side effect may be from baking soda douche. The reason is that douching itself, regardless if you use baking soda or plain water, can cause serious health damages. The US government scientists at NIH and the entire medical community are against douching, because douching reduces woman's resistance to infections and have been linked to BV (bacterial vaginosis), PID (pelvic inflammatory disease), and STI (sexually transmitted infections). 

Pelvic inflammatory disease or PID is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Pelvic pain is the common symptom. If PID occurs, about 1-in-10 women 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.

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 sexually transmitted infections including 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.

NeuEve CV-Ease is the first dedicated self-care product for CV relief. It may also work for vaginal lactobacillosis (VL), because VL is similar to CV in vaginal cytolytic damages. It is now listed for sale on Amazon.com. If you have CV, you can purchase CV Ease on Amazon or from our website.

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.

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Customer feedback after using CV Ease

 
"The product helps me so much I really wish I could use it every night! The symptom relief I have the day after is more than anything else has given me. Obviously I have hope this is going to work bc I keep purchasing more! I’m not sure what the other ladies are saying or how long they’ve had CV. I was diagnosed in August but believe I had CV since June. I just don’t think after having the condition for almost 7 months that 9-12 days of treatment are going to cure me. Does that make sense? Slow and steady wins the race is how I look at it and I fully believe I need to receive treatment nonstop for quite sometime to overcome this imbalance. That is why I would love to see it be used more often & for longer. I can’t help but feel like if I used it more frequently & for a lengthy duration that it would end this mess bc again, this product is AMAZING!"

"The CV-Ease product has definitely improved my cytolytic vaginosis symptoms. I feel clean and have no symptoms of cytolytic vaginosis as of today. I am clear! The CV-Ease side effects for myself were a very light itch nothing unbearable and the suppository discharge. I did not experience burning either irritation. The experience has been a positive one for me and I can finally say I feel free and clean! I am happy as a customer and glad to express that I purchased two CV-Ease packs to have one as a backup in my refrigerator. Thank you for creating the product, Dr. Renjie Chang!"

"Thank youuu! It is a lil irritation so I’m gunna continue the half suppository every other day but I’m noticing no cottage cheese discharge anymore so that’s definitely a good sign! Thank you Renjie! You are a life saver ."

"I am currently using this product and I will smell it for 2 days after. It’s not an unpleasant odor, just slightly herbal in my opinion. I too have received AMAZING results since starting use on December 13. I am eager to see if I have even less symptoms as I enter into a second full monthly cycle. So very thankful for this product!"

"Okayy perfecttt thank you so much!! Very happy with the product so far! 💕 Have a blessed day!"

"Hello! Wanted to let you know I’m over a month out and have had 2 periods without any treatment and my CV is still kept at bay!! I do still have CV-Ease in the fridge in case I need it. :)"