THE VAGINAL MICROBIOME: ON RECURRENT ISSUES
The vaginal microbiome is an incredibly resilient, yet sensitive environment that is important for our health and fertility. A ‘healthy’ vagina is dominated by Lactobacillus species, whose role is to acidify the vaginal environment. Oestrogen feeds lactobacillus; consuming glycogen to make lactic acid. This helps to protect against invading organisms and maintain a healthy microbiome. The environment will fluctuate throughout a woman’s menstrual cycle, as it is under the influence of oestrogen, and it will change throughout a woman’s life (menstruating vs. menopausal).
Recurrent issues of the vaginal microbiome can really impact a woman’s quality of life, self esteem, and confidence. From a health and fertility perspective, vaginal issues can be a disaster for increasing risk of STI transmission, endometriosis, pelvic inflammatory disease, HPV, infertility, adverse pregnancy outcomes and preterm birth. Though, many women either suffer in silence or feel they have exhausted all their options. The three most common conditions are bacterial vaginosis (BV), aerobic vaginitis (AV), and vulvovaginal candidiasis (thrush).
BACTERIAL VAGINOSIS (BV)
BV is characterised by low or no levels of lactobacilli and high levels of anaerobic microbes (i.e. Gardnerella, Prevotella, Atopobium, Eggerthella, Prevotella). Ordinarily the pH is high, meaning the vagina is less acidic and able to hold up its line of defence against invading organisms. Symptoms are usually a watery, thin, grey discharge that smells fishy. It’s not usually inflamed and sore, but it can be if Prevotella is there. Ordinarily antibiotics will be used that are not lactobacilli sparing, further accentuating lactobacilli loss. Regardless of whether the anaerobes are cleared or not, we need to get lactobacilli back in there!
AEROBIC VAGINITIS (AV)
AV is a more painful, inflamed condition characterised by lowered lactobacilli and increased aerobic microbes (i.e. enterococcus, E. coli, strep B and staph)—anaerobic bacteria can also be present. Symptoms include off coloured discharge, usually gushy/leaky that doesn’t smell fishy but can smell offensive (i.e. meaty). Hallmark feature is pain on entry to the introitus—with a tampon, or during intercourse. Usually found in a low oestrogen environment, so particularly common in peri and postmenopausal women, but can also happen at low oestrogen times in the menstrual cycle and whilst breastfeeding.
VULVOVAGINAL CANDIDAISIS (THRUSH)
Thrush is characterised by presence of candida species in the vagina. Lactobacilli can be normal. In comparison to acute thrush that is cottage cheesy and copious in discharge amount, really itchy etc, recurrent thrush can present a little differently. Recurrent thrush is considered 3-4 episodes or more in a year that are unrelated to antibiotics. It could just be an itch that doesn’t go away, there could be pain or dryness, and discharge is white and usually thicker. It can worsen around ovulation and then in the luteal phase aligned with oestrogen spikes.
RECURRENT ISSUES
Some women would have experienced one of the above before, and found the condition to go away more or less on its own. This is great! Having a once off infection that the vagina clears means the vaginal environment is healthy. But what happens when this doesn’t go away? Unfortunately, 80% of bacterial vaginosis cases will reoccur within 3 months of antibiotic treatment. At which point, another round of antibiotics might be given, or a woman will be labelled as a resistant case. The most horrible part of vaginal issues is feeling like you get to the end of the road in terms of treatment. However, there is so much more to be done!
The first step is understanding what is actually going on. What microbes are present? For candida, being able to distinguish between albicans and glabrata (the treatment strategies are different). For BV and AV being able to know what bacteria we are working with. Sometimes, we will be able to obtain this from a high vaginal swab. Though, for persistent cases and ones that are characterised by a mixed presentation (BV and candida can coexist) it can be really useful to do a vaginal microbiome map. This also gives a nice breakdown of the levels of lactobacillus. There is one type of lactobacillus that can actually cause some chaos if it’s too high!
TREATMENT GOALS
Once we have the information we need, we can treat specifically to ensure we are addressing the right species and presentation. Our goals might be:
Support immune system function. Check vitamin D status!
Reduce inflammation with topical and/or oral support for mucus membranes.
Consider douche to increase pH in the vagina.
Consider vaginal insertions with specific treatment for microbes (i.e. herbal pessary or tampon, targeted probiotics and nutraceuticals.
Address oestrogen status with oral and/or topical support.
Stop over-cleaning the vagina or washing with soap.
Improve sex practices that might be contributing to infection.
Create protocols for trigger zones to avoid infection taking hold (i.e. post-sex).
Address biofilms (protective barrier microbes create around themself).
GENERAL RECOMMENDATIONS
Some general advice that might be useful to begin, though please take this with a grain of salt as it’s best to test, not guess. Always, always spot test first before you go gung-ho with something in the vagina.
Olive and Bee is a really love protective intimate cream that can be nice for inflamed vaginas. Sea Buckthorn oil is also really lovely.
Use a pH protective lubricant, like Bed Intentions.
Support lactobacillus growth by drinking green tea (3 cups daily), supplementing with lactulose (directly feeds lactobacilli in the vagina) - start very small with your dose, and taking an oral probiotic that contains Lactobacillus rhamnosus, reuteri, and/or crispatus. Please note strain specific treatment is dependent on what’s presenting.
Apple cider vinegar (ACV) can be great to swash in the vagina during a shower if you are prone to pH issues after sex, before/after your period etc. This is not appropriate if there is any inflammation. However, ACV can be a complete game changer for women with vagina issues. If we keep the pH at a good level, then lactobacilli can thrive and keep the pesky microbes at bay.
Download my Caring for your Vagina handout that has some additional info for supporting a healthy, happy vagina.
If you’re feeling deep in the throes of recurrent vaginal issues, please reach out. Once we crack the code and start repairing the vaginal microbiome, a healthy, happy vagina will be in reach. There is always something to be done. Don’t give up!
