By Jandra Mueller, DPT, MS, PHRC Encinitas
Here is the situation, you have irritation down there, you go to your doctor, she performs her exam and tests, she swabs you, then you get the call… your cultures came back negative. Here is what your GYN may have missed.
Many women experiencing pelvic pain, urinary, and sexual dysfunction often have pelvic floor dysfunction. More often than not, there is another underlying condition that may be driving their pain. If you are experiencing pain with intercourse, or pain in your vulva, your doctor may have diagnosed you with vulvodynia. If you have urinary urgency, frequency, and/or pain, your doctor may have diagnosed you with interstitial cystitis/painful bladder syndrome (IC/PBS). Localized provoked vestibulodynia is the most common subset of vulvodynia and the most common cause of dyspareunia (painful sex) AND irritative bladder symptoms. This term simply describes the location of the pain and symptoms, but what is the actual reason why sex hurts? Why are you constantly feeling itchy? Or that you have to pee constantly? If you follow our blog and social media, you may know that combined oral contraceptives (birth control) is a leading cause, but there can be other causes of vulvar pain that may be impacted by the use of oral contraceptives, or can be independent of their use.
When women develop symptoms of pelvic pain they usually go for vaginal swabs and cultures. When these come back negative they go back in, repeat the same swabs and cultures, sometimes again and again, HOPING they are positive. They often aren’t. The standard OBGYN may not be aware of, or believe in some of the other pathogens that have a significant impact on our vulvovaginal tissues. The topics that will be discussed in this blog may be things you haven’t heard of or you wondered if they could be the cause of your symptoms. Here is what you need to know, how to get tested, and what you can do if the tests are positive.
What is normal?
We are bombarded with false information about our vulvas so how in the world is one supposed to truly know what is normal?
Anatomy: First and foremost, women’s vulvas look completely different from one person to the next, especially when it comes to labia. Just because you may have “big lips” does not mean that is abnormal or you need a labiaplasty because women with “small lips” are praised in the media.
Smell: How should your vagina (or vulva) smell? The answer is, that depends on many factors, and to read more about that, check out one of our most popular blogs: “How your vagina is supposed to smell.” For the purpose of today’s blog, it should not smell “fishy.” As Stephanie mentions in her blog, it is assumed by all of the fragrance in hygiene products, that a woman’s natural state is “smelly.”
Color: If you actually look, there should be a nice healthy pink color in the inner tissues, this is true for women that have darker skin color too. Redness, or erythema, especially in certain areas can signify inflammation or irritation or hormonal imbalances. Similarly, pale or white tissue can indicate hormone deficiencies or certain vulvar conditions.
Discharge: This is something many women get hung up on. Vaginal discharge is highly variable. Discharge is caused by mucus production by the cervix and various glands in the vulva. Discharge plays a very important role, and can tell you a lot about the state of your health, and what it looks like depends on many factors, especially in hormonal shifts. A woman may see more discharge if they are on oral contraceptive pills, are pregnant, or around the time of ovulation. The color can range from clear to white and the consistency can change as well. Discharge itself should not cause any itchiness, but if someone feels “wet” all the time, they may have some discomfort, and it should absolutely not smell foul or cause you to be embarrassed. Abnormal discharge is often caused by infection or inflammation. It may be normal looking, or have a change in color, and it may cause itching. Although this is not a complete list, the International Society for the Study of Vulvovaginal Disease (ISSVD) has created a great patient education handout that you can find here, all about discharge.
Ecology: This is something we cannot necessarily see, but we can see the effects or changes in the ecology by our symptoms. Changes in discharge color, frequent or recurrent infections, itching, pain, etc. may be a sign that our microbiome is off or there is an imbalance in the ecosystem of our vagina. Typically, the vagina should be dominated by lactobacillus species, which is impacted by our estrogen levels; however, there are a number of other commensal bacteria (other non harmful bacteria) that make up our vaginal microbiome. The lactic acid and hydrogen peroxide produced by the lactobacillus, keeps the vagina at a lower pH (3.5-4.5), helping to prevent infections or colonization of other, potentially harmful, bacteria. Disruptions in the balance of these bacteria can come from birth control pills, douching or using soap in the vulva/vagina, chemicals in our detergents and feminine hygiene products, the health of our gut, frequent use of antibiotics (even antibiotics used for other infections that have nothing to do with our vulvas), and even in response to semen and even new partners. Did you know, the vagina actually mounts an immune response to your new partner’s penis!? If you have ever experienced a UTI or yeast infection after sleeping with a new partner, this is why. Your pH and your new partner’s pH may not quite agree. Obviously, this improves as your body adjusts, but may be quite concerning and exhausting especially in the new age of online dating and one night stands, one of the many reasons to practice safe sex with new partners and use a condom! Don’t know which to choose? Check out our blog all about condoms! Also, Aviva Romm, MD has a great podcast with founder of Sustain Natural, Meika Hollander, about condom use called: “Why condoms are a women’s issue”.
There are many variables that can cause abnormalcy including hormonal changes, pregnancy, number and exposure to different sexual partners, and medications such as the birth control pill. Other than yeast infections, there are other conditions that affect many women, yet may go undiagnosed, in this blog we will discuss bacterial vaginosis and aerobic vaginitis.
Bacterial vaginosis, or BV, is not an infection itself, but it is more of a state of being. BV is a change in the ecology of your vagina or a dysbiosis, an imbalance in the microbes living in you. According to the CDC, bacterial vaginosis, or BV, is the most common cause of vaginal symptoms among women aged 14-49 years old, with a prevalence of 29.2%. That is about one in every three to four women! It is defined according to the presence of clinical symptoms and increased vaginal pH, typically greater than or equal to 4.5, white adherent discharge that contains certain cells (by a swab test), and a fishy odor. Many women are asymptomatic; however, if you have BV, you are at an increased risk of pelvic inflammatory disease (PID), sexually transmitted (STIs) in addition to HIV infection, and preterm delivery in pregnant women.
Aerobic vaginitis, or AV, is similar to BV in that there is a disruption in the ecology of the vagina, specifically the lactobacillus dominance. However, in AV, there are more extreme inflammatory consequences from the change in the bacteria in the vulva. It is reported in some studies to affect 5-24% of women reporting vaginal complaints. AV can sometimes be misdiagnosed as BV, which can lead to incorrect treatment and may have more severe risks including progression to a more severe condition called desquamative inflammatory vaginitis and can increase the risk of complications during pregnancy as well as fetal risk factors.
Common causes of both BV and AV
There can be many factors that influence the make-up of our vaginal ecosystem, including the health of your GI tract. If you have been experiencing abnormal vulvar changes or symptoms and have a diagnosis or suspect IBS, in addition to treating your vulvar symptoms, working with a provider to improve your gut health is necessary. Other factors include diets high in sugar, alcohol, poor blood sugar control, exposure to chemicals and fragrances in hygiene products or our detergents, antibiotic use, aging, birth control pills, hormonal fluctuations and changes in the pH as a result of exposure to semen or saliva.
While these conditions are not the result of sexually transmitted diseases, there are some risks including exposure to many sexual partners, or if you are at risk for another reason, sexual intercourse including oral sex, may put you at higher risk. The reason for this is that our bodies have different ecosystems throughout our skin, mouth, GI tract, and genitourinary tract. When you have a high number of sexual partners, you are being exposed to that partner’s own ecosystem which may or may not be compatible with yours. So opposite sex as well as same-sex partners have their risks.
The diagnosis is made by a medical professional, more than likely your OBGYN, but could also be your primary care doc, naturopath, nurse practitioner, etc. They should do a thorough history and physical exam looking for changes in tissue appearance, presence of a fishy odor, and will perform a swab which will help determine presence or absence of specific cells, inflammatory markers or infection. In addition, there are swabs that can be used to look at the general patterns of bacteria in the vagina to better understand the ecology and may explain why something just isn’t quite right down there and help you understand preventative measures as well as review treatment options. Note that not all MDs perform these specialized swabs and you may need to seek out a vulvar specialist. One reason these types of swabs are not routinely performed, is because as of right now, they are not always accepted in conventional medical practices. However, these things can be a part of understanding someone’s pelvic pain. Hence, there may be a call that all your tests were “negative”, because the issues we mention here were not considered.
Treatment and prevention
If you go to your standard OBGYN, first-line therapies that are offered are antibiotics which may be appropriate initially and may not cause harm, depending on your history of antibiotic use. However, there are unintended consequences of using antibiotics, especially if this is a recurrent issue. This includes changes to your gut microbiome, possibly furthering the imbalance, antibiotic resistance, and many others. Of course, if this is your first experience, your doctor may suggest this, and it may absolutely be appropriate. However, this may just be a band-aid and lifestyle changes still should be considered in addition to antibiotics (sometimes we need band-aids). Luckily, there are topical vaginal antibiotics that can be used and this may cause less unintended side effects. However, if you are pregnant, you should consider antibiotics as there are risks during this time if this is ongoing.
There are natural methods to treating AV and BV as well, which include the use of herbal therapies, and high-quality probiotics taken either orally, or in suppository form used straight in the vagina. I am not talking about yogurt here, although you may have heard of a friend that used yogurt to heal their BV, or you may find this as a hot topic in online forums. Yes, there are studies out there that have looked at this and without taking a deep dive into them, they look promising! However, most of the studies out there are low quality and in the scientific community, these would not be accepted as good evidence. Anecdotally, there are some women that swear by this, but again, many of these women have actually not been tested first to know if this is actually the issue. There are many factors to consider if opting for this option which the internet cannot teach you. So, the bottom line is: please don’t put yogurt in your vagina. Play it safe, get tested, and opt for the oral or suppository probiotics and work with a practitioner that understands how to treat you naturally. These options will have a higher number of beneficial bacteria, it is less messy, and likely more effective.
Painful intercourse and vulvar pain are not uncommon conditions and there can be several reasons for these symptoms. In addition to myofascial causes and hormonal birth control, the state of your vaginal ecosystem is an important factor in your overall health, and understanding this is crucial. A significant amount of women suffer from BV and AV and standard antibiotics are often not enough, although they may be helpful short-term or in certain situations like pregnancy. Working with a provider and understanding your risk factors is important and can help you to maintain a healthy vagina (and vulva)!
These are only two of the potential causes of your vulvar issues, as mentioned earlier, there are others, stay tuned for part 2!
Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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