Awareness of the Vaginal Microbiome and Willingness to Undergo Vaginal Microbiota Transplant.

In a cross-sectional survey conducted in Canada, Crann et al. (2018) reported that 80% of 1,435 respondents experienced adverse vaginal symptoms in their lifetimes. This finding suggests that a vast number of individuals may be affected by vaginal symptoms that could be alleviated through VMT. Researchers are currently exploring the potential of VMT to treat bacterial vaginosis. For example, a research group at Massachusetts General Hospital is actively recruiting participants for VMT following a pilot study in which they characterized a donor screening protocol for VMT collection and storage (Yockey et al., 2022). To test and safely implement VMT in clinical practice, it is critical to understand patient perspectives and concerns when undergoing the treatment, especially because it involves the transfer of a live bio-therapeutic into the vagina. In a survey study conducted in South Africa, Claassen-Weitz et al. (2024) explored the willingness of donors to donate vaginal samples and the factors that affected their willingness. Most donors ( n = 91/106, 86%) were willing to donate a vaginal sample ( Claassen-Weitz et al., 2024 ). In this study, we examined the willingness of patients to undergo VMT. Our aims were to examine awareness of the vaginal microbiome and VMT, willingness to undergo VMT, and factors that influence the decision to undergo the procedure.

We conducted this cross-sectional descriptive survey study in the United States. We used REDCap to design and distribute surveys. For this study, we obtained institutional review board approval from the University of Washington (date: 9/23/24; number: STUDY00021367). This study is presented based on the Checklist for Reporting Results of Internet E-Surveys ( Eysenbach, 2004 ). We recruited participants via ResearchMatch, a national health volunteer registry that was created by several academic institutions and supported by the U.S. National Institutes of Health as part of the Clinical Translational Science Award program ( ResearchMatch, 2025 ). ResearchMatch has a large population of volunteers who have consented to be contacted by researchers about health studies for which they may be eligible. We distributed the online survey through email that was distributed by ResearchMatch. Individuals were eligible if they were 18 years or older and had vaginas. Pre- and post-menopausal participants were included as well as those who did and did not experience vaginal symptoms and/or conditions. Among 5,998 persons contacted via ResearchMatch, 299 agreed to participate in the study. Upon agreeing, respondents were automatically directed to the survey. A total of 226 persons started the survey, and 210 completed it, which represented 3.5% of those initially contacted. Participation was voluntary and no compensation was provided for completing the survey. We collected and managed data using REDCap ( Harris et al., 2019 ). We collected data between October 2024 and January 2025. The research team designed and tested an online survey in English before contacting participants in Research Match. The survey included questions about demographics; menstrual cycle regularity; gynecologic, pelvic, and vaginal symptoms and conditions; and awareness of the vaginal microbiome and VMT. Demographic questions included age, gender identity, and race. Respondents were asked if they had had menstrual cycles in the past 90 days; the regularity of their menstrual cycles (excluding times when they had just started their period, been on the pill or intrauterine device, were pregnant, or were nursing); and their menopause status. Respondents could answer that their menstrual cycle was very regular (you can usually predict when you will start bleeding to within 3–4 days), regular (you can usually predict when you will start bleeding to within 5–7 days), usually irregular (you cannot usually predict when you will start bleeding), always irregular (you can rarely, if ever, predict when you will start bleeding), don’t know, or not applicable. Respondents were given definitions of pre-menopausal, perimenopausal, post-menopausal, and induced menopause while answering stage of menopause ( Harlow et al., 2012 ). Additionally, the survey included questions about whether respondents had experienced a variety of gynecologic, pelvic, and vaginal symptoms in the past 30 days, 6 months, and over their lifetimes, and if so, how frequently and how severe the symptoms were. This was followed by questions regarding how willing they were to undergo VMT for various indications. Respondents who answered that they were unwilling to undergo VMT were asked why. We used open-ended questions to ask what key factors respondents would consider when deciding to undergo VMT and if anything else was important for the research team to know. The end of the survey included a disclaimer stating that the safety and effectiveness of VMT are not yet known, more research is needed, and respondents should not attempt VMT without consulting their health care providers. Using SPSS 30.0.0 software, we conducted descriptive statistics to summarize the quantitative data, primarily measures of distribution and frequency. Qualitative data were primarily comprised of lists and short sentences, which we explored using a process of conventional content analysis ( Hsieh & Shannon, 2005 ). In conventional content analysis, researchers interpret text by developing categories based on the data. Two authors (EK and CM) independently familiarized themselves with the data by reading through open-ended responses multiple times before generating initial codes. They then met to discuss codes and reach a consensus over any discrepancies. This was followed by sorting and grouping the codes into categories. Coders met again to discuss the categories and reached a final agreement on the categories.

Table 1 presents the demographic and clinical characteristics of the sample. Most respondents ( n = 120, 57.1%) were pre-menopausal. Less than a quarter of respondents ( n = 45, 21.4%) reported a very regular menstrual cycle. Respondents reported their lifetime experience of gynecologic, pelvic, and vaginal conditions ( Table 2 ): urinary tract infection ( n = 148, 70.5%), yeast infection ( n = 148, 70.5%), and bacterial vaginosis ( n = 67, 31.9). Respondents also reported their experience of vaginal symptoms over their lifetime with the top symptoms being: vaginal itchiness ( n = 153, 72.9%), abdominal pain just before or during menstruation ( n = 136, 64.8%) and abnormal discharge ( n = 123, 58.6%). Most respondents ( n = 176, 83.8%) reported awareness of vaginal microbiota. However, only 11.4% ( n = 24) reported awareness of VMT. Most respondents were willing or very willing to undergo VMT for various indications ( Table 3 ), primarily to prevent vaginal infections ( n = 131, 62.4%), reduce risk of sexually transmitted infections ( n = 130, 61.9%), alleviate menstrual pain ( n = 126, 60.0%), and prevent urinary tract infections ( n = 126, 60.0%). For respondents unwilling to undergo VMT ( Table 4 ), the most common reasons were uncertainty over safety and/or risk ( n = 36, 64.3%), never heard of it ( n = 26, 46.4%), lack of research evidence on effectiveness ( n = 20, 35.7%), do not think it will help me ( n = 16, 28.6%), and gross ( n = 16, 28.6%). From 180 open-ended responses, five categories emerged regarding factors that influenced the decision to undergo VMT: Evidence, Procedure Logistics, Health Care Factors, Personal Factors , and Donor Health ( Supplementary Table S1 ). The category Evidence consisted of concerns regarding effectiveness, risks, benefits, and safety. One hundred and twelve respondents (62.2%) expressed interest in research and clinical data and described their desire to weigh the pros and cons of the procedure. For example, a postmenopausal respondent who had not heard of the vaginal microbiome or VMT but had experienced vaginal symptoms such as itchiness, odor, pain, and abnormal discharge, yeast infections, urinary tract infections, and endometriosis noted that “extensive research and studies indicating safety and effectiveness of the treatment” were important for her to consider. Another respondent who suffered from bacterial vaginosis and rated the importance of the vaginal microbiome as a 10 on a scale from 0 to 10 asked “whether there is good science that suggests it is likely to alleviate symptoms.” A 41-year-old pre-menopausal respondent asked, “What are the risks as compared to the rates of success?” The category Procedural Logistics included factors that respondents would consider when deciding to undergo VMT. For 74 respondents, (41.1%) this category represented a variety of procedural factors, such as recovery duration, setting of the procedure (e.g., at-home or in a provider office), pain, and number of transplants required. For example, one pre-menopausal respondent who was aware of the vaginal microbiome but unaware of VMT asked, “how long it would last, how often it would have to be repeated, pain scale, how long I would have to wait to resume sex.” A 29-year-old respondent shared how her experience of sexual assault could influence her willingness to undergo VMT: “certain procedures are difficult, if not impossible, for me to endure, so if this one requires insertion of a larger object to complete the transplant, I would not be willing to undergo it no matter the positive outcome.” Other respondents were primarily concerned with recovery from the procedure: “what is the procedure like, is there recovery?” and asked for information about “healing time, pain level, same day procedure.” Health Care Factors included items such as cost, insurance coverage, provider reliability, and regulation that would influence the decision to undergo VMT. The comments of forty-five respondents (25.0%) were included in this category. Implicated with cost, insurance coverage also played a role in the decision to undergo VMT: “If it can improve my health and is covered by insurance, I would undergo a transplant,” stated a gender nonconforming respondent with irregular periods. One respondent who was very willing to undergo VMT for all presented indications described the importance of the provider: “the experience of my provider in ordering and completing this procedure would be paramount.” A postmenopausal 56-year-old woman underscored that “the experience of the clinician” would be a key factor. Respondents also mentioned a desire to understand the regulatory aspect of the procedure, although it was unclear whether they meant regulation by the Food and Drug Administration or another governing body. Personal Factors centered on the relevancy of the procedure to the respondent’s well-being, including symptom severity, symptom frequency, and personal benefit, i.e. if VMT would alleviate specific symptoms and/or conditions. Fifty-four respondents (30.0%) included personal factors in their responses. A 68-year-old woman who experienced bacterial vaginosis, yeast infections, and urinary tract infections stated that she would be open to VMT “if it would guarantee to prevent future UTIs,” while a 43-year-old woman who also experienced bacterial vaginosis and urinary tract infections wrote, “the severity, inconvenience, and how uncomfortable the condition is” were crucial to consider. A 36-year-old transgender respondent explained that a factor was “the likelihood of it helping alleviate any of the above concerns, and the severity of those concerns in my specific case.” A sub-category of personal factors was the “ick” factor. Four respondents expressed feelings of discomfort and disgust about VMT, for example, “general ickiness about the whole thing!” Others accepted the procedure but acknowledged the general ick: “I’m not squeamish about it.” Another category that emerged was Donor Health, which included factors regarding donor screening, donor selection, and donor microbiota composition. Thirty-five respondents (19.4%) mentioned donor health. The respondent who ranked the importance of the vaginal microbiome as a “10” asked, “How are the donors screened? Will the transplant be from one or multiple donors?” Another postmenopausal respondent brought up the “possibility of getting other diseases from donor.” Overall, respondents questioned “Where the vaginal fluid came from and how well tested it has been” as a central concern for undergoing VMT.

Although most respondents were willing to undergo VMT for a variety of symptoms and conditions, they had a general lack of awareness about VMT. Increasing awareness is a necessary precursor to successful clinical implementation of a promising, alternative treatment to common and highly prevalent vaginal symptoms and conditions. Additionally, addressing key factors that affect an individual’s decision to undergo VMT could accelerate the implementation of VMT, including further clinical research, ensuring insurance coverage, increasing provider education on VMT, and dispelling lingering myths about vaginal microbiota health and cleanliness.

Among the 210 respondents, only 24 (11.4%) were aware of VMT. This may be because VMT is a new treatment approach, stigma around the vagina, or the normalization of prevalent/common vaginal symptoms. Additionally, the novelty of VMT and its experimental nature may have contributed to the lack of awareness among respondents. As seen in Table 4 , almost half of the respondents who were unwilling to undergo VMT selected “never heard of it” as a reason why. However, the general awareness of the vaginal microbiota and its reported importance is a promising precursor to an increased awareness of the role of the vaginal microbiota in various vaginal symptoms and conditions. Awareness is the first step to the implementation of novel and invasive treatments such as VMT that harness the protective powers of a healthy and balanced vaginal microbiota. Self-reported rates of vaginal and pelvic conditions over respondents’ lifetimes closely mirrored the national rates ( Bautista et al., 2016 ). Almost 70% of respondents experienced at least one yeast infection, and one-third experienced at least one case of bacterial vaginosis. Nationally, the prevalence of bacterial vaginosis is between 23% and 51% depending on race/ethnicity ( Bautista et al., 2016 ). Vaginal dysbiosis is associated with yeast infections (the overgrowth of yeast) and bacterial vaginosis (the overgrowth of anaerobes) as well as aerobic vaginitis and cytolytic vaginosis. Vaginal dysbiosis was also associated with an increased risk of sexually transmitted infection, pre-term birth, infertility, pelvic inflammatory disease, endometriosis, menstrual pain, and polycystic ovary syndrome, but the causal direction is yet to be determined ( Chen et al., 2021 ; Han et al., 2021 ). When the vaginal microbiome is dominated by Lactobacillus crispatus and other species of Lactobacillus , it may be protected against microbial infections and disorders of dysbiosis ( Bautista et al., 2016 ). The high prevalence of vaginal symptoms and conditions highlights the need for novel and more effective treatments and patient education that stresses the importance of not accepting vaginal symptoms as typical or expected. Given the sensitive and personal nature of transferring vaginal fluid and live vaginal microbiota to another human’s vagina, it is crucial to consider the reasons respondents gave to not to undergo VMT. Almost one-third of respondents who were unwilling to undergo VMT stated “gross” as a reason. More than half the United States population have vaginas, but there is still a stigma surrounding the vagina and its cleanliness ( Jenkins & O’Doherty, 2020 ). This stigma and the novelty of VMT may be contributing factors to the low awareness. Identifying and exploring factors that influence the decision to undergo VMT is necessary for implementation of the procedure in clinical settings in the future. Of the 5,998 individuals we contacted via ResearchMatch, only 3.5% ( n = 210) completed the survey, and they did so without compensation. Uncompensated respondents who have already opted into a research registry may have characteristics that set them apart from the general population, such as a greater interest in medical research, greater engagement in personal health, and/or higher education. These characteristics may make the sample more open to new therapies, such as VMT. The survey was conducted in English, which led to the exclusion of non-English speakers. Most of the respondents were White. Bacterial vaginosis is more common among people of color ( Holdcroft et al., 2023 ). Therefore, the sample may not be representative of patients most in need of better and alternative treatments for bacterial vaginosis. Educational programs may increase public and provider knowledge on the vaginal microbiome and VMT to improve vaginal health. Findings suggest decision-making can be influenced by multiple factors that were represented by our identified categories: Evidence, Procedure Logistics, Health Care Factors, Personal Factors , and Donor Health . These insights can guide clinical counseling, protocol design, and policy development to ensure VMT is accessible, acceptable, and tailored to patient needs. Additional research regarding the efficacy of VMT is needed before implementation in clinical settings. Nurses can anticipate that patients will ask about the long-term safety of VMT and can be prepared to discuss the current state of the research, including the current lack of efficacy. Nurses can facilitate shared decision-making regarding not only VMT, but also treatment for vaginal disorders to ensure that patient values and background such as history of assault and concerns about VMT are respectfully incorporated into conversations. Beyond VMT, additional work is needed to de-stigmatize vaginal health ( Bohren et al., 2022 ). To address these concerns, nurses can ask patients questions such as: “Do you have any concerns about your vaginal health?” Alternatively, they can educate patients that vaginal symptoms are not normal by saying, “Some individuals experience vaginal itchiness or pain during or after sex or an unusual odor from the vagina. These symptoms are not typical. Are you experiencing any of these symptoms?” Understanding patient perspectives about VMT lays the foundation for patient-centered future research and clinical practices. The high prevalence of vaginal and pelvic conditions suggests a need for more effective and sustainable treatment. Future researchers should explore clinical outcomes of VMT administration and patient concerns and priorities. In this study, we examined willingness to undergo VMT among a sample of online volunteers. Future researchers should explore the perspectives of racially and ethnically diverse patients, incorporate measures of history of sexually transmitted infections and urinary tract infections, and investigate donor willingness and concerns. Furthermore, the barriers to adopt VMT emphasize the need for rigorous clinical trials, transparent communication, and patient-centered education to build trust and acceptance.