NHS gastroenterology registrar Victoria Nicholas on what probiotics can and can't do for women's health, and why food comes first.
Key Takeaways
The benefits of probiotics are strain-specific as different strains have different effects.
Women's gut and vaginal microbiomes have distinct roles in health.
A food-first approach remains the best foundation for a healthy gut, with probiotics potentially providing additional support in specific situations.
Evidence is strongest for specific strains and health goals, and probiotics should complement rather than replace a balanced diet or appropriate medical treatment.
If you are pregnant or have a medical condition, seek medical advice before starting supplements.
Victoria is a medical doctor and NHS gastroenterology registrar in London, having graduated with a first-class degree from the University of Nottingham in 2016 before completing her general medical training in North West London. She holds a Master's in Genomic Medicine from Imperial College London, deepening her understanding of the molecular basis of health and disease. Alongside her clinical work, Victoria competes as a professional padel player for Great Britain, bringing a unique dual perspective to gut health and athletic performance.
The International Scientific Association for Probiotics and Prebiotics (ISAPP) defines probiotics as "live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.". They include bacteria and yeasts and are found in some fermented foods and supplements. Probiotics are different from prebiotics. Prebiotics are substances, usually dietary fibres, that are utilised by microorganisms and help support a healthy microbial community.
Each probiotic has three parts to its name: the genus, species and strain. The strain is particularly important because closely related bacteria can behave very differently. For example, Lactobacillus rhamnosus GG has been extensively studied for digestive health, but another strain of Lactobacillus, Lactobacillus rhamnosus, cannot be assumed to have the same effects. This is why research findings cannot be generalised across all probiotics.
Not all fermented foods contain probiotics – often live cultures have been killed following the fermentation process and some foods contain live cultures but are not proven to be probiotic micro-organisms.
The microbiomes of the gut, reproductive tract and skin are shaped by hormones and environmental exposures such as diet and medications. Fluctuations in oestrogen and progesterone which occur throughout the menstrual cycle, pregnancy and menopause can influence microbial communities.
The estrobolome describes bacterial genes involved in oestrogen metabolism. Research suggests interactions between hormones and microbes may influence reproductive and metabolic health, although many associations do not prove cause and effect. Microbial communities may also modulate hormone metabolism through enzyme pathways creating a bidirectional hormone-microbiome axis.
The gut microbiome has been associated with conditions including obesity, insulin resistance, PCOS and inflammatory bowel disease, but it remains unclear whether microbial changes contribute directly to disease or occur as a consequence.
Unlike the gut, where greater diversity is generally considered beneficial, a healthy vagina typically has lower microbial diversity with Lactobacillus species being dominant. Lactobacilli produce lactic acid which helps maintain an acidic environment that limits growth of potentially harmful organisms.
The original concept of probiotics was that beneficial bacteria would permanently replace harmful microbes. In reality, many probiotic strains only survive temporarily in the gut while interacting with resident microbes and the immune system.
Therefore supporting the existing microbiome through diet is essential. Foods rich in prebiotic fibre include onions, garlic, leeks, oats, barley, bananas, apples, beans, lentils and asparagus. Eating a wide variety of plant foods provides different types of fibre that nourish different bacterial species.
Fermented foods containing live cultures include live yoghurt, kefir and kimchi. Not all fermented foods contain live microorganisms, so products should be checked individually.
Bacterial vaginosis is an imbalance of vaginal bacteria leading to abnormal discharge. It affects around one in three women at some point and is associated with reduced Lactobacillus dominance.
Theoretically, probiotic Lactobacillus strains may support vaginal health by producing lactic acid and other antimicrobial substances, helping to maintain a lower vaginal pH and creating an environment that is less favourable to bacteria associated with bacterial vaginosis. Some strains may also compete with potentially harmful bacteria for adhesion to the vaginal epithelium and interact with the local immune system. These are proposed mechanisms and do not necessarily translate into a measurable clinical benefit. Some evidence suggests that certain Lactobacillus strains may support restoration of vaginal microbial balance after bacterial vaginosis treatment, but evidence remains mixed and probiotics should not replace recommended medical treatments.
Irritable bowel syndrome (IBS) is a common digestive disorder characterised by recurrent abdominal pain, bloating and changes in bowel habit (diarrhoea or constipation, or both). It affects women almost twice as often as men.
There are several proposed mechanisms by which probiotics could theoretically influence IBS symptoms: modifying the composition and activity of the gut microbiome, producing short-chain fatty acids and other metabolites, reducing the growth of potentially harmful bacteria, and influencing gut-brain signalling and immune responses. However, these mechanisms are complex and vary between strains. There is some evidence that probiotics may improve symptoms in some people with IBS, but effects are strain-specific and modest, and evidence for improving bloating specifically remains less clear.
Probiotics are identified by their genus, species and strain. Different strains have different properties and health effects, even when they belong to the same species. A product containing Lactobacillus is therefore not automatically equivalent to another Lactobacillus product.
One reason probiotic research can appear confusing is that studies often use different strains, doses, treatment durations and patient populations. Two studies investigating "probiotics" may actually be testing completely different organisms, making results difficult to compare. This is why high-quality systematic reviews often conclude that more research is needed.
Two strains that have been relatively well studied are Lactobacillus rhamnosus GG (LGG) and Lactobacillus acidophilus NCFM. LGG is one of the most studied and strongest evidence relates to gastrointestinal uses, including reducing antibiotic-associated diarrhoea risk in some populations. Lactobacillus acidophilus NCFM has primarily been studied for digestive health. Some studies suggest it may support improvements in abdominal symptoms in people with IBS, although evidence is limited and effects appear modest.
Hormonal changes across the menstrual cycle can influence gut function. Progesterone may slow gut motility during the luteal phase, contributing to constipation and bloating in some individuals.
During pregnancy, changes to the gut and vaginal microbiomes are normal. Alterations in the vaginal microbiome may be associated with conditions such as bacterial vaginosis and thrush, while colonisation with group B streptococcus (GBS) is common during pregnancy and can have implications for the newborn during birth. Although probiotics have been investigated as a potential way of reducing GBS colonisation, current evidence is insufficient to recommend them for this purpose.
Some research suggests probiotics during pregnancy and infancy may modestly reduce eczema risk in infants at higher allergy risk, but evidence for preventing food allergy remains uncertain.
As oestrogen levels fall during menopause, Lactobacillus populations often decline and vaginal pH increases. This may contribute to changes in the vaginal environment, including vaginal dryness and irritation, and may be associated with an increased susceptibility to some vaginal and urinary symptoms.
Probiotic supplements are available in many forms including capsules, powders and liquids, as well as containing a wide variety of strains and doses.
Traditionally, probiotics are measured using colony-forming units (CFU), which estimate the number of viable microorganisms capable of growing under specific laboratory conditions. More recently, alternative approaches have been explored to quantify viable microorganisms. One such approach is viable fluorescent units (VFU), which uses fluorescence-based methods to assess viable cells, along with digital PCR (dPCR) which can provide additional molecular quantification. These approaches may offer advantages over traditional culture-based methods, but methodologies and definitions are still evolving.
It is important to look beyond the CFU or VFU count, as more is not necessarily better. When choosing a supplement, look for products that clearly state the strain, the number of viable microorganisms at the end of shelf life and recommended storage conditions. The evidence supporting the specific strain for your particular health goal is more important than simply choosing a product with the highest number of bacteria.
Checklist for choosing a probiotic:
Probiotics are generally well tolerated in healthy individuals. However, people who are severely unwell, immunocompromised or taking immunosuppressive medication should seek medical advice before using them as they could lead to a severe infection.
Persistent changes in bowel habit, unexplained weight loss, bleeding, or any symptoms that are significantly affecting your quality of life should always be discussed with a healthcare professional.
Women do not necessarily need probiotics. Many people naturally have healthy gut and vaginal microbiomes and probiotics may not provide any benefit in such cases. Some specific strains may provide support in particular situations depending on individual circumstances, but they are not a replacement for a balanced diet or medical treatment.
Certain Lactobacillus strains may support a Lactobacillus-dominant vaginal microbiome and may be useful as an adjunct following treatment for bacterial vaginosis, but evidence remains inconsistent.
There is evidence that some probiotics can support an improvement in global symptoms and abdominal pain associated with irritable bowel syndrome (IBS). However the effect on bloating is less clear. A time-limited trial of around four weeks may be reasonable if symptoms are troublesome, but treatment should be stopped if there is no benefit.
Neither is universally better but a food-first approach is usually recommended because fermented foods can provide live microorganisms alongside other beneficial nutrients, while a fibre-rich diet supports the beneficial bacteria already living in the gut. at defined doses and may be useful when there is evidence for a particular health goal.
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Although the gut and vaginal microbiomes are distinct ecosystems, they do not function independently. The gut microbiome influences immune function, inflammation and hormone metabolism, all of which can affect vaginal health. Diet, antibiotics, stress and hormonal changes may therefore have effects beyond the digestive system.
Recurrent UTIs are common in women and there has been much interest in the preventative role of probiotics.
Theoretically, probiotic Lactobacillus strains may help prevent recurrent UTIs by supporting the normal vaginal microbiome, producing antimicrobial compounds, lowering vaginal pH and competing with uropathogenic bacteria such as Escherichia coli for adhesion to the vaginal epithelium. These mechanisms could potentially reduce colonisation by harmful bacteria, although evidence remains insufficient to determine whether probiotics reliably prevent recurrent UTIs, and more research is needed.
Although probiotics are being investigated as a way of supporting vaginal health after menopause, evidence remains limited and they should not replace established treatments such as local vaginal oestrogen where indicated.
For most healthy pregnant individuals, probiotics appear to have a good safety profile. However, evidence for preventing pregnancy complications is limited and anyone who is pregnant should discuss supplements with their midwife or healthcare professional.
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