The vaginal microbiome is a central determinant of women’s sexual, reproductive, and obstetric health. An optimal cervicovaginal microbiome is typically dominated by Lactobacillus species that produce lactic acid and other metabolites essential for maintaining epithelial integrity and mucosal immunity. In contrast, a non-optimal vaginal microbiome, characterized by reduced Lactobacillus abundance, increased microbial diversity, and overrepresentation of anaerobes such as Gardnerella, Prevotella, and Fannyhessea, is a significant risk factor for a wide range of adverse outcomes. These include increased acquisition of sexually transmitted infections (including HIV), elevated inflammation, higher susceptibility to genital tract infections, and substantially increased risk of preterm birth and other gynecological and obstetric complications. Despite the burden of disease associated with non-optimal vaginal microbiomes, current treatments are not efficacious. Antibiotics provide only temporary relief, recurrence rates remain unacceptably high, and no therapeutic currently restores or reliably maintains an optimal vaginal microbiome. This gap underscores a critical need for innovative strategies rooted in the ecological principles governing this unique mucosal environment. Advances in our understanding of vaginal microbial ecology have enabled the rational design of live biotherapeutic products (LBPs) engineered to restore and stabilize Lactobacillus-dominated communities. Several LBPs have progressed from preclinical development to clinical trials. In this presentation, the ecological rationale, design principles, and translational pathways underlying these novel interventions will be discussed, with a particular focus on the development and clinical evaluation of LBPs for the prevention of recurrent bacterial vaginosis. Together, these efforts illustrate how ecological insight can be transformed into next-generation therapeutics that address long-standing unmet needs in women’s health.