Probiotics for the treatment of vulvovaginal candidiasis in nonpregnant women: a systematic review and meta-analysis of randomized controlled trials.

Abstract

Vulvovaginal candidiasis and recurrent vulvovaginal candidiasis significantly impair women's quality of life and psychological well-being. Although numerous randomized controlled trials have explored probiotics as alternative or adjunctive therapies, their clinical efficacy remains inconclusive. This meta-analysis systematically assessed the therapeutic value of probiotics for these infections among nonpregnant women. Cochrane Library, PubMed, Embase, ClinicalTrials.gov, and Web of Science were searched from inception to October 12, 2025. Eligible studies were randomized controlled trials enrolling nonpregnant women with vulvovaginal candidiasis or recurrent vulvovaginal candidiasis. Three comparisons were analyzed: 1) probiotics combined with antifungal drugs vs antifungal drugs (with or without placebo), 2) probiotics alone vs antifungal drugs, and 3) probiotics alone vs placebo. The primary outcomes were cure and recurrence rate. Relative risk and 95% confidence interval were calculated using the Mantel-Haenszel method. Random-effects or fixed-effects models were applied depending on heterogeneity assessed by the chi-squared test. Fourteen studies met the inclusion criteria. In comparison 1, according to low and very low certainty evidence, combination therapy significantly improved short-term (<1 month) mycological cure (relative risk=1.19; 95% confidence interval, 1.03-1.36; P=.02) and clinical cure (relative risk=1.41; 95% confidence interval, 1.14-1.74; P=.001) and reduced 6-month recurrence (relative risk=0.20; 95% confidence interval, 0.05-0.83; P=.03), with no long-term benefit (P>.05). For recurrent vulvovaginal candidiasis, combination therapy improved the 3-month combined mycological and clinical cure rate (relative risk=8.00; 95% confidence interval, 2.06-31.07; P=.003), with no sustained effect (P>.05). In comparison 2, probiotics alone had no short-term difference from antifungal drugs (P>.05), whereas antifungal therapy achieved higher long-term mycological cure (relative risk=0.52; 95% confidence interval, 0.32-0.85; P=.009; very low certainty evidence). In comparison 3, probiotics alone significantly improved the 6-month mycological cure of recurrent vulvovaginal candidiasis compared with placebo (relative risk=12.64; 95% confidence interval, 1.77-90.01; P=.01; low certainty evidence). Evidence of very low and low certainty indicates probiotics combined with antifungal drugs provided a potential adjunctive strategy to enhance conventional antifungal therapy, while probiotics alone showed limited efficacy compared with antifungal drugs but may be a beneficial alternative or preventive option in selected cases. Future high-quality trials are warranted to define optimal probiotic strains, treatment durations, and long-term outcomes.