Probiotics and Pelvic Pain
The best probiotic for women can be challenging to choose from among the many options. For women with pelvic pain, the choice can be even more challenging. As health and wellness professionals who support women with pelvic pain, we have to educate ourselves about the research on the best strains, and their mechanisms of action to better support our clients and patients.
The Best Probiotic for Women with Pelvic Pain: Strains
When we consider the best probiotic for women with pelvic pain, it’s important to remember that there is significant interaction between pelvic pain and mood disorders in women. In women with pelvic pain, common mental health comorbidities found in one study were depressive episodes (42%), dysthymia (54%), social phobia (36.5%), agoraphobia (8.5%) and panic disorder (7.3%) (Castro, et al., 2009.)
A variety of probiotic strains have been studied for the improvement of visceral pain. In animal models with chronic stress, the strains Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 have been found to attenuate the Hypothalamic-Pituitary-Adrenal (HPA) axis stress response (Ait-Belgnaoui, et al., 2018) This calming of the HPA axis stress response can help with mood disorders in both rats and humans (Messaoudi, et al., 2011.)
The same combination of strains – L. helveticus and B. longum – have been found to be effective in animal models to regulate glucocorticoid negative feedback on the HPA axis, and by that mechanism, reducing stress-induced visceral pain (Ait-Belgnaoui, et al., 2018.) Using a single probiotic strain (either B. longum or L. helveticus) was found to be less effective in reducing visceral pain in the stressed mice.
Other strains have also been found to be useful for attenuating depressive symptoms in humans, and these may also be useful for reducing pelvic visceral pain. These strains include, L. acidophilus, L. casei, B. bifidum, and B. longum (Wallace & Milev, 2017.)
In many of these studies, combinations of probiotic strains are more effective than individual strains. For example, VSL #3, a combination of L. acidophilus, S. thermophilus L. plantarum, B. longum (reclassified as B. lactis), L. paracasei, B. breve, L. delbrueckii subsp. Bulgaricus (reclassified as L. helveticus), has been found to reduce National Institute of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scores in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) plus diarrhoea-predominant irritable bowel syndrome (D-IBS) (Vicari, et al., 2017.)
The combination of probiotic strains in VSL#3, has been shown to have protective effects against development of visceral hypersensitivity in the neonatal maternal separation animal model of stress-induced pain. In one study, a gene expression modulation mechanism is proposed because TPH1, tryptophan hydroxylase 1, the gene for the enzyme responsible for synthesizing serotonin, a key neurotransmitter involved in IBS treatment, was found to be markedly up-regulated by the neonatal maternal separation imposed on the animal models, and this effect was reversed by the VSL#3 intervention (Distrutti et al., 2013).
Bifidobacterium infantis and B. lactis have both been found to reduce visceral pain and hypersensitivity in animal models (Agostini, et al., 2012, Johnson, et al., 2011, McKernan, et al., 2010.) Lactobacillus species, including L. reuteri, L. acidophilus, and L. paracasei, have also been found to attenuate visceral pain via a variety of mechanisms in animal models, including by inducing opioid and cannabinoid receptors, modulating the stress response and improving intestinal permeability (Eutamene, et al., 2007, Kamiya, et al., 2006, Rousseaux, et al., 2007.)
The Best Probiotic for Women with Pelvic Pain: Adverse Effects
The great news is that there are very rarely found to be any significant adverse effects with the use of any of these well-tested probiotic strains. Occasionally mild digestive complaints occur, and are easily reduced or eliminated by reducing the probiotic dose, or changing to use a different strain or combination of strains.
The Best Probiotic for Women with Pelvic Pain: Recommended Products
In my practice, I commonly use a few specific probiotic combination products for women with chronic pelvic pain conditions. Most of these women also have comorbid mood and/or gastrointestinal symptoms, which I consider when choosing which product to recommend.
The Gut Institute BIFIDO|MAXIMUS
Clinically, I find that this supplement can sometimes increase constipation. Start with ¼ – ½ of the full dose, and then increase slowly. Also, useful for clients struggling with chronic diarrhea in addition to pelvic pain and/ or fecal incontinence.
This is a high quality probiotic that includes many of the strains that are well studied to improve pelvic visceral pain, vulvovaginal dysbiosis, and related GI and mood symptoms via a variety of mechanisms – Lactobacillus rhamnosus, Bifidobacterium bifidum, Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus plantarum, Lactobacillus salivarius, Bifidobacterium longum, Streptococcus thermophiles, Lactobacillus bulgaricus, Lactobacillus paracasei, Bifidobacterium lactis, Bifidobacterium breve
I like this product for those with very sensitive stomachs. It is similar to ProBiota 12, but has a few distinct strains that are less irritating to those with sensitive digestive systems, or significant food sensitivities.
This is my choice for clients who have excessive Lactobacillus strains on stool or organic acids testing. This can sometimes happen for clients who have been using commercial yogurts or single strain lactobacillus supplements in high doses over time. This formula contains Bifidobacterium bifidum, B. longum, B. lactis, B. breve
This is a great option for women with pelvic pain, especially if combined with vulvovaginal issues like chronic yeast, chronic BV, or vulvar pain.
This product contains more lactobacillus strains to optimize the vulvovaginal environment. Strains in this product: Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus rhamnosus, Lactobacilus gasseri, Lactobacillus casei, Lactobacillus salivarius, Lactobacillus plantarum, Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium longum
This is a prebiotic fiber to support the growth and thriving of Lactobacillus and Bifidobacterium species.
Agostini S, Goubern M, Tondereau V, Salvador-Cartier C, Bezirard V, Leveque M, et al. (2012) A marketed fermented dairy product containing Bifidobacterium lactis CNCM I-2494 suppresses gut hypersensitivity and colonic barrier disruption induced by acute stress in rats. Neurogastroenterol Motil, 24:376–e172.10.1111/j.1365-2982.2011.01865.x
Ait-Belgnaoui, A., Payard, I., Rolland, C., Harkat, C., Braniste, V., Théodorou, V., & Tompkins, T. A. (2018). Bifidobacterium longum and Lactobacillus helveticus Synergistically Suppress Stress-related Visceral Hypersensitivity Through Hypothalamic-Pituitary-Adrenal Axis Modulation. Journal of Neurogastroenterology and Motility, 24(1), 138–146. http://doi.org/10.5056/jnm16167
Castro, M, Kraychete, D, Daltro, C, Lopes, J, Menezes, R, Oliveira, I (2009) Comorbid anxiety and depression disorders in patients with chronic pain. Arq Neuropsiquiatr, 67(4):982-5.
Distrutti, E., Cipriani, S., Mencarelli, A., Renga, B., & Fiorucci, S. (2013). Probiotics VSL#3 Protect against Development of Visceral Pain in Murine Model of Irritable Bowel Syndrome. PLoS ONE, 8(5), e63893. http://doi.org/10.1371/journal.pone.0063893
Eutamene H, Lamine F, Chabo C, Theodorou V, Rochat F, Bergonzelli GE, et al. Synergy between Lactobacillus paracasei and its bacterial products to counteract stress-induced gut permeability and sensitivity increase in rats. J Nutr (2007) 137:1901–7.
Johnson AC, Greenwood-van Meerveld B, Mcrorie J. Effects of Bifidobacterium infantis 35624 on post-inflammatory visceral hypersensitivity in the rat. Dig Dis Sci (2011) 56:3179–86.10.1007/s10620-011-1730-y
Kamiya T, Wang L, Forsythe P, Goettsche G, Mao Y, Wang Y, et al. Inhibitory effects of Lactobacillus reuteri on visceral pain induced by colorectal distension in Sprague-Dawley rats. Gut (2006) 55:191–6.10.1136/gut.2005.070987
McKernan DP, Fitzgerald P, Dinan TG, Cryan JF. The probiotic Bifidobacterium infantis 35624 displays visceral antinociceptive effects in the rat. Neurogastroenterol Motil (2010) 22(1029–35):e268.10.1111/j.1365-2982.2010.01520.x
Messaoudi, M, Lalonde, R, Violle N, Javelot, H, Desor, D, Nejdi, A, Bisson, JF, Rougeot, C, Pichelin, M, Cazaubiel, M, Cazaubiel, JM (2011) Assessment of psychotropic-like properties of a probiotic formulation (Lactobacillus helveticus R0052 and Bifidobacterium longum R0175) in rats and human subjects. Br J Nutr, 105(5):755-64. doi: 10.1017/S0007114510004319.
Rousseaux C, Thuru X, Gelot A, Barnich N, Neut C, Dubuquoy L, et al. Lactobacillus acidophilus modulates intestinal pain and induces opioid and cannabinoid receptors. Nat Med (2007) 13:35–7.10.1038/nm1521
Vicari, E., Salemi, M., Sidoti, G., Malaguarnera, M., & Castiglione, R. (2017). Symptom Severity Following Rifaximin and the Probiotic VSL#3 in Patients with Chronic Pelvic Pain Syndrome (Due to Inflammatory Prostatitis) Plus Irritable Bowel Syndrome. Nutrients, 9(11), 1208. http://doi.org/10.3390/nu9111208
Wallace, C. J. K., & Milev, R. (2017). The effects of probiotics on depressive symptoms in humans: a systematic review. Annals of General Psychiatry, 16, 14. http://doi.org/10.1186/s12991-017-0138-2