The goal of this clinical trial is to learn about the vaginal microbiome in premenopausal women with recurrent bacterial vaginosis (BV). The main questions it aims to answer are:

• Does using a specific vaginal care system reduce recurrence of BV?
• How does using this vaginal care system change the vaginal microbiome and pH over time?

Participants will:

• Have their vaginal microbiome and pH tested in several ways at three timepoints: the start of the study, 12 weeks later, and 24 weeks after the start of the study
• Answer questionnaires about vulvovaginal symptoms at each of these three timepoints
• Use a specific vaginal care system at home for 24 weeks, consisting of an intimate wash, a vaginal moisturizing gel, and a vaginal probiotic suppository, if assigned to the intervention group

Researchers will compare the group using the vaginal care system with a control group that does not use the system to see if using the system reduces risk of BV recurrence or changes the vaginal microbiome, pH, or symptoms.

The vaginal microbiome interacts with vaginal epithelial cells and host immune cells in varying ways depending on the presence of particular species. Presence of high quantities of Lactobacillus species, which are considered healthy, downregulate pro-inflammatory markers and upregulate anti-inflammatory markers. On the other hand, BV-associated bacteria such as Gardnerella vaginalis, Atopobium (Fannyhessea) vaginae, Prevotella bivia, Mobiluncus curtisii and others, are associated with increased pro-inflammatory markers and reduced anti-inflammatory molecules. The investigators predict that improving the vaginal microbiome by using an over-the-counter vaginal care system will increase levels of Lactobacillus species, reduce levels of BV-associated bacteria, and improve vulvovaginal symptoms of BV.

Bacterial vaginosis (BV) is a common dysbiosis of the vaginal microbiome causing vaginal odor, discharge, discomfort, or even vulvovaginal pain. In some women, BV is asymptomatic; there is some evidence to support the concept that asymptomatic BV results from repeated instances of BV that damage the vaginal lining so extensively that the body is no longer able to generate symptoms, and as such, asymptomatic BV represents a more advanced disease state as compared with symptomatic BV. Whether symptomatic or asymptomatic, BV is known to affect the vaginal epithelium, disrupting intercellular adhesions and increasing susceptibility to infections, including HIV, HSV, and perinatal infections leading to sequelae such as late miscarriage, preterm labor, preterm premature rupture of membranes, and preterm delivery. Symptomatic BV can interfere profoundly with quality of life, causing embarrassment, itching, pain, and challenges with intimacy. The standard of care for treatment of BV is metronidazole, clindamycin, or rarely other antibiotic. Repeated use of antibiotics is used out of necessity for symptomatic women, but many women and healthcare providers are hesitant to use antibiotics repeatedly due to side effects and risk of development of antibiotic-resistant organisms. An alternative method of preventing and/or treating BV is therefore desirable.

An 11-week pilot study of similar, though less informative, design was recently conducted. Women with recurrent BV were recruited to use the Flourish® Vaginal Care System [using aloe-based Restore gel instead of hydroxyethylcellulose (HEC)-based BioNourish gel which is part of the Flourish HEC Vaginal Care System] for 11 weeks. Primary outcomes were vaginal fluid pH and whether or not women had BV recurrence. By the end of the study, the average vaginal fluid pH had fallen from mean (SD) of 4.54 (0.53) at week 0 to 4.08 (0.40) at week 11. At baseline, 30% of women had active BV. (These women were treated with standard of care oral metronidazole). The number of BV-positive women steadily declined until 5 weeks, at which point no woman had BV. There was no recurrence of BV in any woman through the end of the study.

Although this 11-week study is promising, the short time frame provides only limited information about BV recurrence, and there was no control group included. However, considering what has been published, we might have expected up to half of the women to have had a recurrence of BV during this time. By developing this new randomized controlled study with a longer time frame, we will have more certainty about whether prevention of BV recurrence is a feasible aim for a double-blind placebo-controlled randomized controlled trial in the future.

The present study will also expand upon the previous trial by providing data about the vaginal microbiome of women before and after use of the Flourish HEC Vaginal Care System. Historically, Amsel criteria (presence of 3 out of 4 of: thin grayish-white discharge, positive whiff test with addition of KOH to vaginal fluid, vaginal pH >4.5, and presence of >20% clue cells on wet mount microscopy of vaginal smear) or Nugent scoring (scoring method based on Gram stained vaginal fluid) were used to diagnose BV. More recently, existing data about changes in the vaginal microbiome during BV have been used to develop the commonly used clinical BV tests such as Aptima BV test (Hologic), SureSwab BV and Vaginitis test (Quest Diagnostics), Affirm VPIII test (BD Diagnostics), and others. Recently, next-generation sequencing (NGS) has been used to examine more thoroughly the complement of bacteria found in women with or without symptomatic BV. These studies shed some light on what would constitute a healthy microbiome if the Flourish HEC Vaginal Care System is successful at establishing a healthy colony of lactobacilli. However, the investigators are not aware of any studies that have examined changes in the entire vaginal microbiome using NGS before and after use of a vaginal probiotic suppository. This is important because the pre-NGS techniques used are limited in their ability to detect species. Some bacteria are resistant to traditional culture techniques and may have been missed in earlier culture-based studies. PCR-based tests are limited because they are used to assess presence or amount of specific targets which have been selected using information from culture-based studies. The Evvy Vaginal Microbiome Test using metagenomic sequencing, a type of NGS technology, is superior because it is able to detect every bacterial and fungal species present at a level of 0.1% of the microbiome or higher. Only rare species would be missed. While these rare species may be important for seeding following events that disrupt the vaginal microbiome (like antibiotic use), they likely have a small effect on day-to-day health.

A 2019 meta-analysis found that vaginal probiotics for BV are safe and effective, though the authors noted a need for studies with larger numbers of women. Similarly, a Cochrane review noted there is insufficient evidence for or against recommending use of vaginal probiotic in BV, and recommended larger, well-designed trials. One study that pre-dates next-generation sequencing found that use of a Lactobacillus acidophilus probiotic vaginal suppository was effective at treating BV but only until a woman's next menses. A randomized, placebo-controlled trial providing two species of Lactobacillus for two months showed that the probiotic restored a normal microbiome in women who used the supplement, but not in controls. It did not follow women beyond the end of the study, but interestingly, the authors suggested that an at-home kit - similar to the one used in the present study - would allow women to take control of their own health. The present study has a six-month time period and has the additional advantage over all other studies that the probiotic is part of a larger system that restores vaginal pH to the correct level to allow for growth of Lactobacillus spp., and to suppress growth of pathogens. This pH adjustment is accomplished with the use of racemic lactic acid, which has been shown to be important for vaginal health vs. use of only L-lactic acid. We believe this is the first randomized controlled study of a vaginal probiotic suppository which also encourages growth of those bacteria by establishing a healthy vaginal luminal environment.

The original Flourish® Vaginal Care System, with slightly different vaginal moisturizer (with aloe), has recently been shown in a clinical study to reduce vaginal pH from 4.81 (unhealthy, elevated) to 4.05 (healthy) and prevent recurrence of bacterial vaginosis over a 10-week study period1. The proposed study uses a newly formulated product that is gentler (no aloe) because the study population is likely to have high sensitivity based on inclusion criteria involving tissue trauma.

The investigators hypothesize that regular use of the Flourish HEC Vaginal Care System can improve the vaginal microbiome and lower vaginal pH, which will thereby prevent recurrence of bacterial vaginosis in women with recurrent BV and improve their vulvovaginal symptoms.

Inclusion Criteria:

1. Cis-gender women between ages 18 and 52
2. Premenopausal
3. Clinically diagnosed with BV twice in the past six months or three times within the past year (by provider-determined criteria)

Exclusion Criteria:

1. Known allergies or sensitivities to any ingredients of the Flourish HEC Vaginal Care System
2. Immunosuppressed or otherwise immunocompromised
3. Vaginal infection at the start of the study other than bacterial vaginosis or yeast infection (these may be treated prior to starting the protocol)
4. Recent (within past 3 months) use of any antibiotics except for treating BV
5. Surgery within the past 3 months
6. Pregnant or trying to conceive during the trial
7. Lactating women
8. Recent (within past 3 months) usage of any Good Clean Love® (GCL) products
9. Sexual trauma history causing psychiatric or mental health disorders which may be triggered by questions related to vulvar or vaginal health, by pelvic exams, or self-application of vaginal products