Vaginal Microbiome & pH: The Role of Lactobacilli

The vaginal microbiome is a complex, dynamic ecosystem of bacteria, viruses, fungi, and other microorganisms that live in and on the vagina. Far from a passive bystander, this microbial community plays a central role in maintaining vaginal health, influencing everything from pH balance and susceptibility to infections to fertility, pregnancy outcomes, and broader reproductive well-being. For most reproductive-age women, a healthy vaginal microbiome is dominated by Lactobacillus species that produce lactic acid and keep the environment acidic. This article explains how that ecosystem works, what "healthy" can actually look like, how dysbiosis may affect women's health, and what scientific evidence says about probiotics, natural remedies, and testing.

What is the Vaginal Microbiome?

The vaginal microbiome refers to the collection of microorganisms—primarily bacteria—that colonize the vaginal environment. Unlike the gut, where hundreds of bacterial species coexist, a healthy reproductive-age vagina tends to be far less diverse, usually dominated by one or two species of Lactobacillus. This relatively simple bacterial community is one of the most studied aspects of women's health because of the outsized influence it appears to have on infection risk and reproductive outcomes.

When scientists describe the vaginal microbiome, they often group it into categories based on which species dominate. These categories are called Community State Types (CSTs), a framework introduced through landmark research led by Jacques Ravel and colleagues. CSTs help researchers and clinicians describe patterns of vaginal flora rather than assuming a single "ideal" composition.

The Players: Lactobacillus crispatus, Lactobacillus iners, and Others

Several Lactobacillus species commonly dominate vaginal flora:

• Lactobacillus crispatus — Often considered the most protective species. It is strongly adapted to the vaginal environment and produces high amounts of lactic acid in the form of the D-isomer, which research suggests is particularly effective at deterring pathogens.
• Lactobacillus gasseri and Lactobacillus jensenii — Other beneficial lactic acid-producing species that also contribute to an acidic environment.
• Lactobacillus iners — A more complex and somewhat paradoxical species. It is common but appears less robustly protective than L. crispatus, and it can persist in transitional states, including near dysbiosis. Some research suggests L. iners may act as a "colonizer-in-waiting" rather than a stable protector.

Some women have a microbiome that is not Lactobacillus-dominant at all—classified as CST-IV—and instead contains a more diverse mix of anaerobic bacteria, including Gardnerella, Atopobium, Prevotella, and others. Importantly, CST-IV is not automatically "abnormal"—many women live with it without symptoms—but it is often associated with higher risk of certain conditions.

The Role of the Environment

The vaginal environment is shaped by the interaction between the host and its microbes. Estrogen thickens the vaginal epithelium and increases glycogen content, which Lactobacillus species ferment into lactic acid. Hormonal changes across the menstrual cycle, throughout pregnancy, and during menopause influence which bacteria thrive. Sexual activity, hygiene practices, and the immune system also shape the ecosystem.

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Because so many factors interact, the vaginal microbiome is best thought of as an ecosystem rather than a checklist of "good" and "bad" bacteria. That framing is important for understanding why symptoms and test results don't always align perfectly, and why what's "normal" can vary enormously from woman to woman.

The Crucial Link Between Lactobacilli and Vaginal pH

One of the most important functions of Lactobacillus species is their ability to acidify the vagina. A healthy vaginal pH typically falls between 3.8 and 4.5, which is distinctly more acidic than most other body sites. This acidity is a first-line defense against pathogens.

How Lactic Acid Protects the Vagina

Lactobacillus species convert glycogen released by vaginal epithelial cells into lactic acid. As lactic acid accumulates, the vaginal pH drops, creating an environment that is inhospitable to many harmful bacteria, yeasts, and viruses. Research suggests that lactic acid does more than just lower pH—it may also act directly on immune cells and interfere with pathogen adhesion.

There are two forms of lactic acid: the D-isomer and the L-isomer. Studies indicate that L. crispatus produces the D-isomer, and a Lactobacillus-dominant environment with higher D-lactic acid content is generally associated with greater protection against conditions like bacterial vaginosis and sexually transmitted infections.

Hydrogen Peroxide and Other Protective Mechanisms

Many Lactobacillus species also produce hydrogen peroxide, which can inhibit the growth of catalase-negative bacteria such as Gardnerella vaginalis. Additionally, lactobacilli produce bacteriocins and compete for adhesion sites on the vaginal epithelium, making it harder for pathogens to establish a foothold. These mechanisms work in combination rather than in isolation, reinforcing the value of a robust, Lactobacillus-dominant community.

What Happens When pH Rises

When Lactobacillus populations decline or are displaced, lactic acid production drops, and pH rises. A less acidic environment allows anaerobic bacteria to overgrow, which can lead to conditions like bacterial vaginosis. A rise in pH also appears to make the vaginal environment more permissive to certain pathogens, including those responsible for sexually transmitted infections. That is why pH is often used as an accessible marker of vaginal ecology—though it is a marker, not a diagnosis in itself.

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What Does a Healthy Vaginal Microbiome Look Like?

If you search for "healthy vaginal flora," you will often see Lactobacillus dominance presented as the gold standard. That framing is broadly useful, but it oversimplifies the science. A healthy vaginal microbiome is not a single fixed pattern—it is a dynamic balance shaped by age, hormones, ethnicity, geography, sexual history, and immune function.

Lactobacillus Dominance vs. Other Community State Types

Research consistently shows that Lactobacillus-dominant communities—especially those dominated by L. crispatus—are associated with lower rates of bacterial vaginosis, STI acquisition, and pregnancy complications. However, CST-IV (the "diverse, non-Lactobacillus" state) is present in a substantial proportion of healthy women, particularly in certain populations. A landmark study found that vaginal microbial communities vary significantly by ethnicity, with Black and Hispanic women more likely to have non-Lactobacillus-dominant communities compared with white and Asian women. These patterns likely reflect a mix of genetic, hormonal, environmental, and social factors rather than any inherent pathology.

Diversity Is Not Automatically Bad

In the gut, higher diversity is generally considered favorable. In the vagina, the story is different—and more nuanced. Lactobacillus dominance is protective, but "diversity" in the vaginal microbiome is not a reliable indicator of disease on its own. Some women with CST-IV have no symptoms and no clinical infection. Others with the same community develop bacterial vaginosis. Context matters enormously.

A Dynamic Balance, Not a Fixed State

The vaginal microbiome changes across the menstrual cycle, shifts during pregnancy, and transforms with menopause as estrogen declines and Lactobacillus populations naturally decrease. It can also shift temporarily after antibiotic use, sexual activity, or hormonal changes. The idea that there is one static "healthy" composition is therefore not supported by current science.

Why "Vaginal Flora Imbalance" Is Not a Diagnosis

People often use the phrase "vaginal flora imbalance" to describe symptoms like unusual discharge or odor. While imbalance is real, the term is not a clinical diagnosis. Different imbalances have different causes, different implications, and different treatments. Symptoms alone cannot reliably distinguish bacterial vaginosis, yeast infections, trichomoniasis, or simple community shifts. That is why clinicians rely on laboratory testing to identify what is actually happening.

Vaginal Dysbiosis: An Imbalance in the Microbiome

Vaginal dysbiosis describes a disruption of the normal microbial community—typically a loss of Lactobacillus dominance and an overgrowth of anaerobic bacteria. Dysbiosis is not a single condition; it is a broad umbrella that includes bacterial vaginosis (BV), intermediate flora states, and other compositional shifts.

Common Causes of Vaginal Dysbiosis

Many factors can disrupt the vaginal ecosystem:

• Antibiotic use — Broad-spectrum antibiotics can reduce Lactobacillus populations alongside their intended targets.
• Douching and harsh cleansers — These can wash away protective bacteria and alter pH, and are consistently linked to higher BV risk.
• Hormonal changes — Puberty, pregnancy, menopause, and hormonal contraceptives all influence the microbial environment.
• Sexual activity — New sexual partners can introduce new bacteria; semen has a higher pH, which can temporarily reduce acidity.
• Immune variation — Immune function plays a role in keeping the ecosystem balanced.
• Certain hygiene products — Scented products, spermicides, and some lubricants may disrupt the microbiome.

Bacterial Vaginosis and Gardnerella

Bacterial vaginosis is the most common form of vaginal dysbiosis in reproductive-age women. It is characterized by a shift away from Lactobacillus dominance and a rise in anaerobic bacteria—most prominently Gardnerella vaginalis, along with Atopobium vaginae, Prevotella, and others. BV is often accompanied by a thin, grayish discharge and a fishy odor, but many women with BV are asymptomatic.

BV is not a sexually transmitted infection in the classical sense, but it is more common in sexually active women and is associated with having new partners and lack of condom use. Recurrence is common—over half of women treated for BV experience a recurrence within a year, which researchers increasingly link to the persistence of biofilm-forming bacteria and slow restoration of Lactobacillus dominance.

How Dysbiosis Increases STI Risk

A Lactobacillus-depleted vaginal environment is associated with higher susceptibility to several infections, including HIV, herpes simplex virus, Chlamydia trachomatis, Neisseria gonorrhoeae, and human papillomavirus (HPV). The mechanisms are multiple: loss of lactic acid reduces pathogen inhibition, higher pH may make epithelial tissue more vulnerable, and inflammation associated with dysbiosis may compromise mucosal barriers. Notably, these are associations in observational studies—causal pathways are plausible but complex.

The Vaginal Microbiome's Impact on Women's Health

The vaginal microbiome's influence extends well beyond local infection risk. Research over the past two decades has linked vaginal microbial composition to pregnancy outcomes, fertility, gynecological cancers, and more. Some of these connections are well-established; others remain areas of active investigation.

Pregnancy and Preterm Birth

Perhaps the strongest body of evidence links vaginal dysbiosis to adverse pregnancy outcomes, including preterm birth and premature rupture of membranes (PPROM). Studies suggest that a non-Lactobacillus-dominant vaginal microbiome in early pregnancy is associated with a higher risk of preterm delivery. The mechanisms proposed include ascending infection and inflammation, but causality has not been definitively established in randomized trials. This is an area where microbiome composition is a risk marker rather than a proven direct cause.

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Fertility and IVF

Vaginal microbiome composition has also been associated with outcomes in in-vitro fertilization (IVF) and assisted reproduction. Some studies have found associations between Lactobacillus dominance and higher implantation rates, while others have produced mixed results. Importantly, the more established fertility-microbiome link involves the endometrial microbiome rather than the vaginal microbiome, and this field is still emerging. Any implication that shifting vaginal flora will improve fertility is not supported by robust clinical evidence.

HPV and Cervical Cancer

Research suggests that vaginal dysbiosis may be associated with increased HPV persistence and, by extension, cervical dysplasia risk. Several studies have found that women with Lactobacillus-depleted microbiomes are more likely to have persistent HPV infections, though the causal direction remains an open question. HPV vaccination, routine cervical screening, and appropriate follow-up remain the most reliable tools for reducing cervical cancer risk.

General Reproductive Health

Beyond pregnancy and cancer, the vaginal microbiome has been linked to urinary tract infections, pelvic inflammatory disease, and possibly endometriosis-related inflammation. Most of these relationships are associations rather than proven causal pathways, and research is ongoing.

Can Probiotics Balance the Vaginal Microbiome?

Probiotics are among the most popular and most heavily marketed interventions for vaginal health. The scientific picture is more nuanced than product labels suggest. Some strains and delivery methods show promise; others lack convincing evidence.

What Probiotics Are

Probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit. Several strains have been studied for vaginal health, most commonly Lactobacillus rhamnosus GR-1, Lactobacillus reuteri RC-14, Lactobacillus crispatus CTV-05, and Lactobacillus acidophilus KS-13. The effects are strain-specific—research on one strain cannot be assumed to apply to another, even within the same species.

Oral vs. Vaginal Probiotics

Oral probiotics are convenient but face a questionable journey: they must survive stomach acid, colonize the gut, and then migrate to the vagina—a hypothesis with some supporting evidence but inconsistent results. Vaginal probiotics (suppositories or capsules inserted into the vagina) deliver strains directly to the target environment. Direct delivery shows more consistent evidence for temporary colonization, but persistence is often short-lived. For BV recurrence prevention, some studies suggest vaginal L. crispatus CTV-05 may reduce recurrence risk, but larger, high-quality trials are needed.

A Balanced Critique of Probiotic Marketing

Many probiotic products on the market make claims not supported by clinical evidence. Common issues:

• Strains incorporated in products are often not the same strains that showed efficacy in clinical trials.
• Doses vary widely, and many products do not meet label claims for viable colony-forming units (CFUs).
• Strain identity is sometimes vague, making it impossible to verify whether the product contains the tested organism.
• Marketing often conflates gut microbiome benefits with vaginal microbiome benefits, which are distinct.

For consumers, the most responsible approach is to look for products that state the specific strain designation (e.g., L. rhamnosus GR-1), include clinical evidence in their own labeling, and are produced by manufacturers with third-party testing. Probiotics are generally well-tolerated, but they are not a substitute for prescribed treatments when a clinical infection is present.

What Probiotics Likely Can and Cannot Do

Current evidence supports that certain probiotic strains may modestly reduce recurrence of BV when used as an adjunct to antibiotic therapy, and may support restoration of Lactobacillus populations after antibiotics. Evidence is weaker for treating active BV as monotherapy, preventing STIs, or improving fertility. Claims of "balancing" the microbiome without specific evidence should be read with healthy skepticism.

How to Balance Vaginal pH Naturally: Evidence-Based Practices

One of the most common questions women ask is how to keep their vaginal flora balanced. While the microbiome is influenced by many factors beyond personal control, several habits have meaningful evidence behind them. The overarching principle is less is more—the vagina is largely self-regulating, and most interventions should support, not interfere with, that regulation.

Hygiene Practices That Support Vaginal Flora

• Avoid douching. Douching is consistently associated with bacterial vaginosis and pelvic inflammatory disease. It disrupts the natural acidic environment and flushes out protective Lactobacillus.
• Use plain water or gentle, unscented cleansers on the vulva. The inside of the vagina does not need cleaning. Soaps, washes, and "feminine hygiene" products marketed for internal use are usually unnecessary and sometimes harmful.
• Wipe front to back after using the toilet to reduce transfer of gastrointestinal bacteria to the vulva and vagina.
• Change out of wet clothing promptly after exercise or swimming and avoid prolonged contact with damp swimwear.

Clothing and Breathability

Wearing breathable, cotton underwear and avoiding tight, non-breathable clothing can help maintain a healthy moisture balance. Data on this is limited and largely observational, but it is a low-risk practice with plausible benefits.

Sexual Health Practices

• Condom use is associated with lower BV recurrence and reduced STI risk.
• Semen has a relatively high pH and can transiently shift the vaginal environment after unprotected intercourse. This is normal and usually self-corrects.
• Some lubricants and spermicides can disrupt flora. Water-based, pH-balanced, osmolality-appropriate products are generally considered lower risk.

Diet and Vaginal Health

Evidence on diet and the vaginal microbiome is less mature than for the gut microbiome, but several themes emerge. Diets rich in fiber and fermented foods may support a diverse gut microbiome, which, through immune and metabolic pathways, could indirectly influence vaginal health. Very high sugar intake has been linked to an increased risk of yeast infections. Some studies have explored whether specific nutrients (like vitamin D or probiotics via diet) affect vaginal flora, but results are mixed. Overall, a balanced diet is a reasonable supportive practice, not a targeted vaginal treatment.

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Hormonal Considerations

Because estrogen drives glycogen availability for Lactobacillus, hormonal status strongly shapes the vaginal microbiome. During perimenopause and menopause, Lactobacillus populations often decline and pH may rise. Local low-dose vaginal estrogen (prescribed by a clinician) can help restore vaginal epithelium and support a healthier environment. This should always be discussed with a healthcare provider.

Complementary Approaches

Some women explore boric acid suppositories, vitamin C tablets, or herbal remedies for BV recurrence. Boric acid has evidence for reducing recurrence in some studies and is sometimes used clinically, but it should be discussed with a clinician—it is not appropriate for all situations and has safety considerations. Other remedies have limited evidence and should be approached with caution.

When to See a Healthcare Provider

Self-care and lifestyle habits can support vaginal health, but they are not a substitute for professional evaluation when something is off. Knowing when to seek care is an important part of health literacy.

Symptoms That Warrant Medical Attention

Consult a clinician if you experience any of the following:

• Unusual discharge, especially with a strong odor (fishy, yeasty, or otherwise abnormal)
• Vaginal itching, burning, or irritation that doesn't resolve within a few days
• Pain during urination or intercourse
• Pelvic pain or pain that radiates to the back
• Fever or systemic symptoms
• Recurrent symptoms (three or more episodes per year) suggestive of recurrent BV or yeast infections
• Symptoms during pregnancy, or any new symptoms that concern you
• Bleeding between periods or after sex

What a Clinician Will Evaluate

A proper diagnosis typically involves a symptom history, visual exam, pH measurement, and laboratory testing (such as a whiff test, wet mount microscopy, or NAAT testing for specific organisms). Bacterial vaginosis is diagnosed using clinical criteria (Amsel criteria) or molecular testing, not just symptoms.

At-Home pH and Microbiome Testing

At-home tests—rangng from simple pH strips to mail-in microbiome sequencing—have gained popularity. They can provide useful information, especially for women trying to understand their patterns. However, they have important limitations:

• pH strips only indicate acidity, not the organisms present.
• Microbiome sequencing describes relative abundance but cannot, on its own, diagnose infection.
• Results can vary from day to day and across cycle phases.
• No at-home test replaces clinical evaluation when symptoms are present.

For women interested in understanding their own microbiome patterns over time, a personalized microbiome analysis can serve as an educational tool. It may help illuminate how your microbiome shifts across lifestyle, cycle, and health changes, and can support more informed conversations with a healthcare provider. It should never be interpreted as a diagnosis or used to delay professional care when symptoms are present.

When to Seek Urgent Care

Seek urgent care for severe pelvic pain, high fever, signs of toxic shock syndrome (sudden fever, rash, dizziness, muscle aches with tampon use), or any rapidly worsening symptoms.

Key Takeaways

• The vaginal microbiome is typically dominated by Lactobacillus species in reproductive-age women, and this dominance supports an acidic, protective environment.
• Lactobacillus produces lactic acid (and often hydrogen peroxide), which lowers vaginal pH to around 3.8–4.5 and discourages pathogen growth.
• Community State Types (CSTs) help describe patterns of vaginal flora, and "healthy" is not a single fixed composition—CST-IV is present in many healthy women.
• Vaginal dysbiosis, including bacterial vaginosis, is characterized by loss of Lactobacillus and overgrowth of anaerobes like Gardnerella, but not all dysbiosis causes symptoms.
• Vaginal microbiome composition has been associated with pregnancy outcomes, STI risk, HPV persistence, and fertility, though association is not the same as causation.
• Probiotics show promise for some outcomes (such as post-antibiotic recovery and BV recurrence), but evidence is strain-specific and often inconsistent.
• No douching, gentle external cleansing, condom use, and breathable clothing are low-risk practices that support vaginal health.
• At-home microbiome tests can offer educational insight but do not replace clinical diagnosis when symptoms are present.
• Seek professional care for unusual discharge, persistent itching, pain, or recurrent symptoms—especially during pregnancy.

Frequently Asked Questions

How can a woman tell if her pH is off?

Some signs that pH may be elevated include unusual or fishy odor, thin grayish discharge, irritation, or a feeling of imbalance. However, symptoms are not a reliable indicator of pH on their own—many women with elevated pH have no symptoms, and many symptoms have causes unrelated to pH. A pH strip or clinical test provides more useful information than symptoms alone, but neither replaces an exam when symptoms are present.

Can taking Lactobacillus get rid of BV?

Probiotics alone are generally not considered an effective standalone treatment for active bacterial vaginosis. The standard of care is prescription antibiotics such as metronidazole or clindamycin. Some evidence suggests certain Lactobacillus strains—especially when used as vaginal suppositories after antibiotic treatment—may reduce recurrence risk. Probiotics should be discussed with a clinician as a possible adjunct rather than a substitute for prescribed therapy.

What does it mean to have high Lactobacillus levels?

High Lactobacillus levels, especially L. crispatus dominance, are generally associated with a healthy, protective vaginal environment. That said, "high" is relative and depends on the specific species, the test used, and the individual's baseline. Some women with Lactobacillus dominance still experience symptoms, which points to the importance of context rather than assuming high levels automatically mean "healthy."

What are the health risks of a high diversity, non-Lactobacillus microbiome?

CST-IV and other non-Lactobacillus-dominant states are associated with higher rates of bacterial vaginosis, STI acquisition, and some pregnancy complications. However, many women with these communities have no symptoms and no clinical problems. Diversity alone is not a reliable indicator of disease, and interpretation requires context about symptoms, medical history, and other clinical factors.

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Are at-home vaginal microbiome tests reliable?

At-home tests vary widely in methodology and quality. pH strips are useful for basic screening, and sequencing-based tests provide a detailed description of relative bacterial abundance. However, they have important limitations: results can vary day to day, they cannot diagnose infection on their own, and interpretation requires context. They are best viewed as educational tools that support, not replace, clinical evaluation.

Can diet affect the vaginal microbiome?

Evidence on diet and the vaginal microbiome is less developed than for the gut. Some studies suggest that high sugar intake may increase yeast infection risk, and diets rich in fiber and fermented foods may indirectly support immune and metabolic health. There is no specific "vaginal diet" proven to change flora, but balanced nutrition is a reasonable supportive practice.

Does douching help or harm vaginal flora?

Douching is consistently associated with harm—higher rates of bacterial vaginosis, pelvic inflammatory disease, and disrupted pH. It removes protective Lactobacillus and can introduce pathogens. Avoiding douching is one of the most evidence-supported ways to protect vaginal flora.

Can the vaginal microbiome change over time?

Yes. The vaginal microbiome shifts across the menstrual cycle, during pregnancy, after menopause, with hormonal contraceptive use, sexual activity, antibiotics, and lifestyle changes. These shifts are normal and generally self-regulating, but persistent or symptomatic changes warrant medical evaluation.

Is vaginal microbiome testing covered by insurance?

Coverage varies widely and depends on the specific test, indication, and provider. Some clinical tests for BV or yeast are covered when medically indicated, while direct-to-consumer sequencing tests are usually paid out-of-pocket. Check with your insurer and clinician before ordering.

How long does it take for Lactobacillus to return after antibiotics?

Recovery times vary considerably from person to person—some women see Lactobacillus rebound within weeks, others take months, and some experience recurrent dysbiosis. The trajectory depends on hormonal status, baseline microbiome, immune function, and recurrence history. Some clinicians recommend probiotics as supportive during recovery, though evidence is mixed.

Can stress affect the vaginal microbiome?

Chronic stress is associated with changes in immune function and the gut microbiome, and emerging research suggests it may also influence the vaginal environment indirectly. The evidence is not yet robust enough to establish a clear causal pathway, but stress reduction remains a reasonable element of general health.

What is the difference between the vaginal and gut microbiome?

The gut microbiome is highly diverse and contains hundreds of bacterial species, while a healthy vaginal microbiome is far less diverse and typically dominated by Lactobacillus. The two ecosystems interact through immune and metabolic pathways, but they should not be treated as interchangeable—strategies that support gut health may or may not benefit vaginal health.

Conclusion

The vaginal microbiome is one of the most influential—and most misunderstood—aspects of women's health. In most reproductive-age women, a Lactobacillus-dominant community produces lactic acid that keeps vaginal pH low and hostile to pathogens. This basic mechanism underlies much of what we know about vaginal protection against infections, STIs, and certain pregnancy complications. Yet the science is also clear that "healthy" is not a single pattern; Community State Types vary across individuals, life stages, and populations, and diversity alone is not a reliable sign of disease.

When symptoms appear, they do not always reveal what is happening at the microbial level. Two women with similar discharge or odor can have very different underlying microbiomes and diagnoses. That is why clinicians rely on testing, not symptoms alone, and why at-home microbiome tests—while increasingly accessible and informative—are educational tools rather than diagnostic substitutes. Women interested in understanding their own patterns can use microbiome testing to build a clearer picture of their vaginal ecology over time, but this information is most valuable when paired with professional guidance and appropriate medical evaluation. By combining evidence-based hygiene, thoughtful lifestyle choices, and informed conversation with healthcare providers, women can support the vaginal ecosystem that protects them throughout their lives.

Keywords

vaginal microbiome, Lactobacillus, Lactobacillus crispatus, Lactobacillus iners, Lactobacillus rhamnosus, vaginal pH, vaginal flora imbalance, bacterial vaginosis, vaginal dysbiosis, Community State Types, CST-IV, lactic acid, hydrogen peroxide, glycogen, estrogen, preterm birth, HPV, cervical cancer, IVF, fertility, probiotic strains, vaginal probiotics, natural remedies, microbiome diversity, vaginal microbiome test, personalized microbiome analysis, douching, vaginal hygiene, women's health, reproductive health, STI risk, clinical research