How well do you know the vagina?
Arguably one of the most crucial organs due to its role in reproduction, yet, medically, the subject can still discombobulate physicians and patients alike.
Today, we welcome back Moira Bradfield, Naturopath and Acupuncturist, to share her knowledge and passion for demystifying vaginal health.
In Part 1 we review the anatomy, histology and vaginal microbiome and dive into the clinical aspects for recognising potential vaginal infections or dysbiosis, when to refer and how best to support patients.
Covered in this episode:
[00:39] Welcoming back Moira Bradfield
[02:18] Reviewing the vaginal milieu
[05:01] Vaginal histology
[07:05] Defining what is "normal"
[08:51] Scope of practice
[11:22] Normal commensal flora
[14:49] Vaginal dysbiosis
[18:03] Assessments
[21:30] Differential diagnosis
[22:10] Asking the right questions
[23:13] Red flags, alarm bells?
[25:24] Social factors influencing STD incidence
[37:38] Candida: multiple species
[42:43] Resources for practitioners
[45:37] Supporting patients with fears
[47:40] Inviting Moira back for Part 2
Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining me, on the line today is Moira Bradfield for part one, of a two part series on vaginal dysbiosis.
Moira is a Naturopath and Acupuncturist, who's been in clinical practice for 15 years. Graduating with a Bachelor of Naturopathy from Southern Cross Uni in 2001, Moira has worked as a naturopath in a variety of settings, with a wide range of health conditions and disease states. In the pursuit of blending naturopathic medicine with oriental modalities, Moira completed a diploma in Traditional Thai massage in 2004. And in 2010, completed a Master's Degree in Acupuncture through Southern Cross Uni.
She now incorporates effective oriental protocols into her naturopathic practice. She has a passion for considering the energetic principles underpinning nutritional interventions, in client prescription and aligning treatment approaches with constitutional considerations. Moira blends this passion with a solid biochemical and pathological framework to create relevant and effective approaches to health and wellbeing.
Moira has a special interest in holistic medical ophthalmology, working in an integrative service offering acupuncture and naturopathic medicine for people suffering from degenerative eye disorders. Moira has also lectured both overseas and in Australia in nutrition, pharmacology, and pathology, and is currently a senior lecturer in nutrition at the Endeavour College of Natural Health, Gold Coast.
Welcome back to FX Medicine, Moira.
Moira: Thank you, for having me back.
Andrew: This can be a very serious topic because it's often a taboo subject. But the fact of the matter is that bacterial vaginosis causes a great amount of discomfort for many women, and indeed partners. So let's first go into this subject, the vagina and the milieu of the organisms that reside within.
Moira, can you first take us through the normal microbial environment of a vagina?
Moira: I certainly can. And I wanna start by saying as well, I think one of the things that really came across to me when I went into this subject matter, and I did that because I had a lot of clients who were coming in with quite chronic and recurrent infections. But they weren't responding to the normal treatment that I would prescribe for this sort of thing. And so I really wanted to look at why. And what I've discovered when I went into the ‘why’ was there was a lot I didn't know. And there was a lot I didn't know because it's just not taught.
So I'm sure that a lot of the people out there listening can identify with that. That they probably don't have any recollection of learning about the vagina other than its involvement in reproduction. That they are unaware of what constitutes, you know, certainly I know in the common vernacular that the term vagina is used to describe the external genitalia when that's completely incorrect. It's the internal genitalia that we're talking about, so from the vulva up to the cervix. And everything that resides in there in terms of cells, immune function, and of course the microbiome and micobiome which we're gonna touch on as well.
Andrew: Yes, yes.
Moira: And those are things that, you know, just aren't covered in detail. And so if you're not thought them in detail, there's no way that you can screen for them in detail as well. And so you could be overlooking a factor in that person's clinical presentation. That might be the key factor, to turn that particular chronic picture around.
So I wanted to have, get that out there to start with so that when we look at this subject matter, there is gonna be a lot that, you know, you don't know, there's a lot that I don't know. This is still quite new. Traditionally women's health, anyway, when we're talking about reproduction and menstrual cycles, and vaginas, it's been an area that is taboo in medicine historically for us. And so we need to bring that out, the vagina is a part of anatomy. It needs to be talked about. It's a huge part of morbidity for women. We see recurring infections in these women and these are chronic for some women. Like every month, they would experience symptoms.
And you can imagine if you're experiencing those sort of symptoms, that there's a certain amount of fed-upness that you're going to get to.
Andrew: One of the things that really interests me though too, Moira, is the difference in histology. Once you have an understanding of the different types of cells that inhabit, or that make up different tissues in the vagina, the vulva, the cervix. And then you have an understanding of what sort of organisms attach to certain tissues. Then you get a real understanding of the symptoms that you are starting to… being described by these women. And then you get a real understanding of what's happening.
I guess the point I'm making here is things like, you know, Chlamydia. Chlamydia will not infect the vagina. It infects the cervix because it infects a certain type of cell.
Moira: That's a really great point because certainly, the location, if we're dealing with infection, will also then dictate the symptom that's experienced. So, certainly for things like Chlamydia, gonorrhoea, when we're looking at those as being infections, we're looking at higher up in the reproductive tract. So certainly deep pain on sexual penetration to lower pelvic inflammation, which is very different to some of the things that we might see with a vulvovaginal candidiasis or bacterial vaginosis.
Because where the pain is, if there's pain on intercourse or pain on application of sanitary items, it's much lower down than it is up higher. So those sort of things in clinical case taking are very important as well.
We do see some of these infections coexisting particularly with bacterial vaginosis because it is a risk for other infections. It becomes a risk, quite a serious one, when we look at things like the incidence of HIV infection, and the ability to pass that on.
So you know, it is a thing that we need to be aware of. That this might look like bacterial vaginosis and it probably, you know, many aspects of it seem quite simple but unless we're going and getting specific testing done, we cant necessarily rule out an existing co-infection aligned with that.
Andrew: Yeah. Well, and indeed, another confounding issue is the huge variance of normal. Even normal secretions. You know, some ladies have a lot of leukorrhea and it’s quite normal, it's just a cleansing reaction. Other ladies it's pathological to have that amount. So this is...
Moira: It's a really great point.
Andrew: Yeah, well, yes. So it's this real massive variation. So we need to know what's normal.
Moira: And not to taboo certainly where we're talking about, is part of the perpetuating, well, I guess, a disconnect for females, about what is normal, you know? That we're not exposed to this. It's certainly not always talked about. And there's an awareness that there's a discharge but how much is that? And I guess the point that we need to consider is, yes, it changes throughout the month. I mean, we have hormonal fluctuations and so the amount and the type of discharge will change. But for some women, it is a saturating discharge and that isn't pathological. Where for others, that will be, you know, quite small amounts of discharge which, you know, may be another issue in terms of hormonal, or it can be completely normal as well.
And when we look the anatomy of the vagina, you know, that follows through as well. That there are differences in the length of it, there are, you know, certainly in the shape of it, what trajectory it takes into the body. So all of those things are certainly things that people aren't aware of.
And that extends as well to the external genitalia. That there are differences visually that people obviously are taking to be, you know, not the norm when, in fact, there is a plethora of normal. And it's just not something that's actually educated to, both health professionals and to the common woman out there or the common person who has a vagina. We need to also stipulate that if we're encompassing all people.
Andrew: I think one point I need to make is, for our listeners out there that, you know, it really is outside the scope of our practice to do internal investigations with females. And therefore, it is, I've got to ask you the question, Moira. How do you assess? How do you question the woman regarding their vaginal discharge? What's normal, what's abnormal? And why they're coming to see you?
Moira: So questioning is the way, certainly, I agree. We're not doing internal examination. But there is a requirement to have an open discussion about referral and cross-referral and getting those results. They are really important to treatment. It doesn't mean you can't initiate some sort of intervention and certainly there are common factors for all of these infections that need addressing. But there needs to be a diagnosis particularly for seeing a recurrent. And one of the things that happens out there is self diagnosis, you know, using the internet or just over the counter, you know, self prescription or...
Andrew: Or magazines.
Moira: ...products. Definitely, and products that are going to treat candida or fungal infections. But they have little impact on a bacterial issue.
And so that needs to be something that is addressed and certainly in the questioning of the client. You sometimes see in these recurrent… it's just self medication. And then there has never been some sort of official diagnosis, or if there was, you know, it was five years ago. And things can change because the chronic treatment or self prescription of over the counter medications to treat fungal infections also changes the vaginal milieu of bacteria. And can predispose to bacterial vaginosis.
So where we're seeing a shift in the pH of the vagina, you know, moving towards a more alkaline environment. But we also have some really interesting vaginal issues where it's too acidic, and so we've seen overgrowth of lactobacillus, so cytolytic vaginosis is also something out there that is misdiagnosed. It presents very much like candidiasis, so the discharge is similar, it's thick, it's white, you know, chunky. And it has a similar reach associated with it. But it doesn't respond to treatment, over the counter treatment and it tends to have this fluctuation around the menstrual cycle as well. Where it actually gets better with the menstrual cycle because we see the menses themselves shift the pH up to where will be considered to be a more normal pH for the vagina, which is anywhere between 3.2 and 4.5.
Andrew: Okay. So when we're talking the normal pH, that's a decent variation. And I think part of this is, as you spoke about with cytolytic vaginosis, where there's a lot of the lactobacilli. These are normal inhabitants, these are commensals. So I think we need to firstly go through what are the normal inhabitants?
Moira: So they are the normal inhabitants and in fact, the lactobacilli species are the inhabitants by which the healthy norm of a vagina is actually graded. So there is in a lot of the research, and there is some that actually challenges this, but the definition of a health lower genital microbiota is predominantly a lactobacilli species. So L. crispatus, jensenii, gasseri, iners. And what we know about those lactobacilli is that they maintain pH or lower pH because they can produce lactic acid.
So that lactic acid and also the production of hydrogen peroxide helps protect colonisation by the other microbes. It promotes vaginal health and it also helps the microbes themselves produce their own antimicrobial compounds.
Because I mentioned the hormonal influences, that in itself changes the pH over a month. But what it does is it keeps it still within a healthy range. We know that oestrogen encourages the production of more lactobacilli, so we certainly see lactobacilli…. actually increases the epithelial cells to be able to express more glycogen essentially. Which is the fuel source that these lactobacilli are feeding on to produce their lactic acid.
So we have this picture of what constitutes a perfect vaginal flora. And anyway, it's still a new science. We're still looking at, you know, for genomapping, the vagina, like the gut, it's not much over a decade of information that we have. We do know that pathogenic strains of bacteria has been identified for many years. And certainly the treatment of the vagina is something that's not new. But this understanding of the microbiome, of the micobiome is something that is quite new and the diversity that that exists as well.
Because when you read research again, it could be anywhere from 50 to 200 different species. So they've been able to...you know, that's a big variance as well. And again, a lot of those are lactobacilli. We certainly do have normal commensal mycoses like Candida albicans. And then we have some that continue to be in there but they should be kept in check. And depending upon too race and culture, some of these changes in bacteria can be quite significant.
So when we look at anaerobes or anaerobic bacteria like Gardnerella vaginalis for example, we know that that's one of the major bacteria that we associate with bacterial vaginosis. It's part of a polymicrobial infection. And so that particular bacteria has been identified in asymptomatic women, so it doesn't necessarily always lead to, you know, that dire BV diagnosis. And we also know that in women of Hispanic origin or of African American origin, that they will have a higher percentage of those anaerobes and still possibly have quite a normal vaginal microbiome. They do have higher susceptibility to dysbiosis but it's not always expressed.
Andrew: Before we get into some descriptions and differential diagnoses, what about recovery of the normal vaginal milieu of organisms? I remember reading a paper where it seemed to be temporal. In other words, one bacilli would come in first and then pass over the baton, if you like, to then, you know, set up the foundations and pass the baton to the next one, and the next one, and the next one. Almost like a relay race. And I thought that was really, really interesting. What's the latest on this?
Moira: So certainly, when we're looking at dysbiosis anywhere, we do understand that in order for our population to be able to come in and to take that residence, there has to be a certain environment that has to exist for it. And certainly this is something we've known with digestive health for a while. So we're looking at making the terrain appropriate for the survival of the species.
So, like that in the vaginal microbiome, there certainly exists that we have to have the species that come in and scaffold the environment, that make the pH correct for it, to optimise the survival of those that are more beneficial.
So certainly if we're looking at strains in the vaginal microbiome, one of the things they do know is that lactobacillus iners is not as useful, I guess, in terms of preventing infections as those other lactobacilli are. And that's because its production of short-chain fatty acids is a little bit more varied, in that, it's not just lactic acid that it produces but it also has butyrate and propionate for example. And so that confers a slightly different environment, but it maybe that it's actually important to allow those other species their opportunity to actually thrive in that particular space.
Andrew: Yeah. And, you know, this to me speaks volumes in just how arrogant I think we try and get with, you know, the magic thing, the magic species. Without really fully understanding how the body uses those species, as you term it, eloquently, ‘scaffolding’. So they actually have a shift, they work in, as a team. They work in tandem if need be or they pass the baton on in other instances.
Moira: Definitely. When we're talking about the vaginal microbiome, as I've mentioned a few times, we're talking about a fluctuation of hormones that affects everything from cells, to glycogenic expression to, you know, immune cell expression on that level. Because we're looking at an environment that has to be, you know, conducive to reproduction. That has to be able to foster and move sperm through it. So it can't...you know, it lowers its pH slightly, it down-regulates its T-cell expression and interleukin expression at certain times of the month. And so you have to have bacteria that can accommodate and still infer immunity or take up some of that role.
So that if we're lowering any one aspect and we're allowing an opening, if you like, to the endometrial tissues, then there has to be some sort of backup.
So I think that complexity is something, you know, we don't understand. And would only be gained by, you know, measuring continuously through a month what microbes exist and how they fluctuate. And certainly only by looking at really large groups of women, which is somewhere, where we're not at, at the moment when we're looking at the vaginal microbiome.
Andrew: What about assessment when something goes wrong? Do we have any standard tests?
Moira: We do, in the sense of diagnostics. So there's two main diagnostic tests that are used, one is the clinical-based one and the other is a lab-based one.
So we've got the Nugent score, which is a Gram stain based on morphology and the existence of different strains under the microscope. And that attributes a score of risk essentially. And one of the interesting thing that research also tells us about that score of the Nugent, is that the higher the score, the more likely we are to see recurrent episodes in a female. So we see that a score of nine to ten for example, which is consistent with really high amounts of Gardnerella species, and also morphotypes with mobiluncus species as well. That's a really complex vaginal flora, a really strong anaerobic environment, and more likely to be a recurrent infection when we're looking at bacterial vaginosis.
So that is something that is available. The issue with the Nugent score is that there has to be a skill applied to it when we're looking at scoring, in those categories. Because certainly, normal lactobacilli give you very low scores and as you move up into the considered anaerobes that are responsible for bacteria vaginosis, we get much higher score. So you have to be trained in that and you have to be able to score appropriately.
The other way that we can also, the clinical criteria I guess and this is an in-clinic test that can be performed by doctors at this point, is the Amsel criteria. And so the Amsel criteria, generally there has to be either two to three out of four criteria present to have a positive BV score. And they are things like vaginal secretions with a pH of greater than 4.5, a fishy odour which is best elicited when they mix the secretion with a 10% potassium hydroxide solution. A rate of about 20% of microscopically observed vaginal epithelial cells. Which are coated bacteria which they're aptly named the clue cell. And typically, the white skim milk-like vaginal discharge that we see in BV.
So if women are presenting with the said two or three of those criteria, then that's a positive for BV. And enough, you know, it's 90% effective and enough to go forth with treatment as a marker.
Andrew: Yes. And indeed, it's the putrescine, isn’t it?…and the cadaverine which give off the fishy odour?
Moira: It is. And I wanna point out too, I think that that fishy odour which is characteristic of some of the infections, parasitic and bacterial, of the vagina is not always elicited unless they add that potassium hydroxide solution.
So if we're in BV, the owner of the vagina doesn't necessarily smell that. It is, it can be there, and that amine, you know, degradation essentially what it is, with cells dying, isn't always present. So it's not always characteristic of it. And with BV, it can also be one of the symptoms that we associate with trichomoniasis. So a parasitic infection. So having that there isn't always a BV diagnosis either.
Andrew: And I've often got confused between the differential diagnosis of those two. So trichomoniasis is an archaea, right, a parasite?
Moira: A parasite, yes.
Andrew: A parasite. How would you differentially diagnose trichomoniasis versus Gardnerella?
Moira: So, with all of it, if we're dealing with a vaginal discharge, the type of vaginal discharge is very characteristic and gives off the first clues essentially.
So the difference between the vaginosis and the trichomoniasis, is in the vaginosis as I've mentioned in that Amsel criteria, we have a very thin white milky or watery discharge, not in large amounts of it as well. With trichomoniasis, it is still thin but it can be quite fluffy and bubbly. And it tends to be a yellow to green colour. Which sometimes we see in vaginosis, slight amounts of green but it shouldn't be there in large amounts.
Andrew: So when would you be alerted to that there's an issue, that there's a need to be questioning your patient? Would it always be upon presentation that they see that there's a problem? Or/and I guess following on from that, what line of questioning do you take?
Moira: So for me, I mean certainly as I mentioned, the presence of a vaginal discharge. But when we do a general system-based screen, if there's anything that comes up that's suggestive of pelvic inflammatory disease. If there a past episodes of infections or Candida-type presentations? It's worth screening and digging into it.
And certainly as well, it's always something I think that because that taboo exists, people aren’t always questioned about, people aren't comfortable talking about, so if you can go into it on the right level, you tend to get a lot of information. And then if you're uncovering it, what I've seen with these women who it is a chronic, they're happy to talk about it. And they want to know what factors they can modify to make that better.
But certainly, if you're seeing symptoms in those areas, you need to be screening effectively to see if there are modifiable factors.
Andrew: Are there any alarm bells that would ring with you when, for instance, a patient presents with some sexual dysfunction, whatever that be, and then there's a secondary question upon asking where, for instance, sexual practices like multiple partners or a new partner.
Is there any alarm bells that ring for you there, that you go down a certain line of questioning?
Moira: Yeah, there is. I mean those certainly, new partners, changing your partners, are risks for a lot of different infections. Whether we're looking at bacterial vaginosis, which isn't classified as an STI. Although there are aspects that suggest that it's certainly a pathobiont. You know, we're looking at it being involved in sexual activity.
Right through to obviously being, you know, STIs that need to be addressed. From mild right through to severe. And so certainly, if we've got, you know, not just ‘it’ each but if there are any lesions, if there is blood, if there's pain on intercourse, if there's pain on urination. Those sort of things are the red flags that we need to look at. So even, you know, spotting throughout the month, that's something new that needs to be looked at as well.
So we need to go into it, not thinking that everything's BV. And not thinking that everything is thrush essentially. Because these symptoms I mentioned before can coexist but there's also, they're inevitably common. And we're seeing a trend unfortunately in the population where there's now a higher rate of STIs appearing in women over 40.
Andrew: Yes.
Moira: And the theory around that is, you know, possibly that there is a lowered risk of pregnancy and so therefore safe sex practices aren't being taken up. And/or women exiting marriages and then entering into new relationships, and you know, certainly have missed that big period of, you know, STI scares essentially. And then we also have really young populations as well that are now at high risk of STI’s. Certainly alarmingly the rates of Chlamydia have risen in really young age groups. So we see that there are certainly at risk age groups and then there's everything in between that.
Andrew: I have to ask a controversial question here, and that is about the HPV vaccination program. Has the successful HPV vaccination program in young women led to excess promiscuity with the mindset that they think they're protected from “STDs", when really, they're only protected from HPV and not other infective agents like, for instance, bacterial vaginosis, candidiasis if you wanna put it, and even herpes?
Moira: It's possibly a factor. I do think that there's a range of social factors as well that are involved in that rise in STIs that we're seeing in younger groups. And that possibly maybe part of that mindset. We've also got the influence of media. I know we've talked about pornography before, you know, those sort of things where they're exposed to them at much higher rates than any of the generations previously. And what they are seeing, particularly in pornography is sex that doesn't involve the use of condoms, oral sex that doesn't involve the use of condoms. So those sort of things. As in behaviours that sometimes are the only behaviours that they're seeing sexually, so they're modelling from that as well. So to put it down to just, you know, the HPV which I'm sure is at the back of their mind as well. And then there's also too, you know, there's a whole lot of misunderstanding in early sexual development, about, you know, “you can't catch an STI in your first time”, and all sorts of things that are perpetuated as wives tales.
Andrew: Really?
Moira: Oh, definitely, just Google it.
You know, you find that there is many factors that are possibly adding to that burden. And, you know, certainly the way that education is delivered, may be part of that as well. So I don't want to say yes, I don't wanna say no. I'm saying it's one of many factors.
Andrew: Anything else that we need to cover on bacterial vaginosis?
Moira: Oh, so many. Yes.
Andrew: How many hours?
Moira: So we've talked a little bit about hormones and certainly I mentioned the oestrogen increases lactobacilli. So that’s actually protective for bacterial vaginosis, but can be predisposing for Candida, to have higher oestrogen levels. So we've got these little switch there that's interesting.
Then we've got obviously the oral contraceptive pill which has always been something we've associated with that. And again, depending upon the amounts and what's going on, it can be a risk and also will affect the gut microbiome which is essentially, you know, we have that transference via… it’s a rectal migration to the vagina, to see how we get some of that bacteria in there, so we're constantly re-adding to that particular microbiome.
The use of sanitary items is an interesting one. So we have, you know, all sorts of risks associated I guess, with what type of sanitary item you're using. Whether that's creating, you know, a damp environment, whether that's actually an inserted sanitary item. How clean is that? If you're using vaginal cups, have they being disinfected appropriately, because they also are a breeding ground particularly in Candida? It's one of the factors that I've noticed in females.
What were some of the other interesting things? So dysbiosis, I don't think we need to go into from a gut-base level. I think that's quite self explanatory for most people.
Andrew: What about the issue that, you know, quite commonly males are asymptomatic? And so therefore, the female doesn't know that they're at risk?
Moira: Which is a very good one. So certainly sex has a big impact on predisposing for a lot of different infections. And with bacterial vaginosis and vulvovaginal candidiasis. There's some interesting research that says that, you know, it is passed between the two. And we certainly see when they've studied couples who have unprotected sex that there is a homogenising of the microbiome between those two sides in couples. There's also when we look at females who have sex with other women. They're a very high risk population for some of the factors that we've discussed in terms of the use of barriers and contraceptive barriers particularly for that group.
And then there's a higher risk as well with digital penetration and oral sex versus penile penetration. So even though unprotected penile penetration, in terms of predisposing the owner of the vagina to a bacterial vaginosis, and that maybe because they're passing Gardnerella back and forth, but it also maybe because, you know, having sperm inside the vagina will shift the pH as well to a more alkaline pH. And in an environment, in a terrain that is already predisposed or on the verge of recurring infection all the time, that might be enough just to tip it over.
Andrew: Tip it over, yeah, yeah. You raise a very valid point about general hygiene measures, you know, digital penetration. Has that person washed their hands first? It's simple things to me as a registered nurse and to you as somebody who's in the healthcare field. But to the lay person, is very not often obvious.
Moira: Yeah, that's right. And it certainly takes the spontaneity out of it. If you have to have a three part disinfecting regime before you actually engage in a sex act. So, but it is for people again who are prone to and we're talking about recurrent issues. Because with bacterial vaginosis, the recurrence of that is really high. So depending upon the population group, it's anywhere up to a 60% chance of reoccurrence after the first episode which is, you know, alarming...
Andrew: Huge.
Moira: ...considering the treatment as well, the standard treatment that's available. So for those people who have had that experience, who are having it recurrently, these are the things that you can modify while you try and stabilise that microbiome. You know, it is hygiene practices for themselves and for their partner. It maybe avoidance of oral sex while you are stabilising the microbiome.
For females, female sex is about using, you know, appropriate barrier methods which, you know, notoriously are very hard to access, which is interesting as well for females. You know, and then we move into the area of lubricant. So that's a really...
Andrew: I was just gonna ask that, because I was just gonna ask about even just friction, upsetting the barrier, upsetting the terrain.
Moira: Definitely. You know, we've got some issues when, you know, certainly cell damage is an issue. And then for people to possibly… one of the things that we know is lactobacilli is associated with vaginal lubrication naturally. So we know in postmenopausal women who have decreased lactobacilli, they're more at risk of vaginal atrophy. You introduce a lactobacilli species, you have an improvement in lubrication.
So when we have that poor lubrication and then there's a need for the use of a lubricant, we have some issues as well. Because lubricants notoriously are not amazing things. They've got some pretty harsh chemicals in them. And the two considerations that we have to have with the lubricant is, is the pH gonna match the vaginal pH?
Which means that you have to have one around that, you know, three and a half to four and a half range. But also the osmolarity is important. So important in fact that the World Health Organisation has put out a standard of what a lubricant osmolarity should be. And most of the ones on the market don't meet it. So now you're looking at...
Andrew: Really?
Moira: Yeah, you're looking at issues of hyper and hypo osmolarity. So we're either exploding cells because they're swelling up, particularly we're dealing with water-based lubricants here, which is the majority of the ones in the market. Or you're shrivelling a cell because of displacement of water out of it.
Andrew: Yeah.
Moira: And that is causing a whole lot of issues as well, because then you are effectively making that terrain and, you know, that vagina, a risk as well. And it's a risk for multiple things, it's a risk for bacterial infection but also therefore, the transmission of other STIs like HIV when you start damaging cells like that.
Andrew: Yeah. What about even the simple stuff, i.e. time, preparation, foreplay?
Moira: Yup, definitely. I mean we're talking about, again, appropriate lubrication.
Andrew: Yeah, that's right. You know, even like the stressed mum. They've got so many things on their mind and the man just needs the time and the place sort of thing, you know. Very simple for a man to be prepared for sex, but it takes a heck of a lot more for a woman, particularly if they're just rundown.
Moira: Yeah, it's true. And there's an alarming trend that I see in clinic with these women. When we start discussing sex and the impact that it has on their vaginal microbiome, because many of them express that they just relent. You know, that there is a, "My husband wants sex. I just choose to do it so that he's happy, so that I can get on with my day."
Andrew: It's easier, yeah.
Moira: And, you know, ultimately they're all tired. Generally, they're all mothers, they're multi...you know, working and they're busy, and picking up their kids. And so the act of sex isn't high on their agenda because from a reproductive point of view which is how...that body is why? Why would you be thinking about having children while you're in that level of stress? But then the partner obviously, that's the whole different thing there, you know? Procreation is the thing, you know, definitely.
Andrew: But I think it's something that really needs to be addressed, and you know, for our listeners out there, it's a subject that, yes, it's taboo, yes, it's uncomfortable. And if you can become comfortable with this line of questioning and exploring these sorts of areas with your female patients. But even if you bring the partner into the practice to talk about this sort of thing about, "Hey, mate, listen. You know, stack the dishwasher, do the washing up, do the cooking.” Thinking about myself, looking at myself in the mirror here, Sorry Lea. You know, that it gives the woman time to have a breather and therefore that load of stress is taken off. So you know, we want to talk about nervous systems, the sympathetic nervous system is no longer activated. The parasympathetic nervous system can come into play. Guess what's there?
Moira: Definitely, and it's a big issue. And I think for practitioners, if they're not comfortable in that domain, then you should be thinking about referring that to a sexologist, to a psychologist, to a counsellor who deals in that area. Because certainly, you can mention that but it is a big discussion and you're bringing in often, you know, another person to have that discussion with. Sometimes what that uncovers is discontent for partners, is disgust for partners as well, and those are certainly emotions that practitioner may or may not be equipped to deal with.
And there are, I know obviously from my association with a sexologist, I know that there are certainly exercises and programs that can be run through with that type of relationship, with that sort of sexual dynamic, that can improve that quite considerably. And sometimes it's the male partner not even being aware that, that is what the female is doing, that they're just saying yes just to get it over and done with. And certainly, that is not what sex should be about.
Andrew: No, that's right. Now, can I ask then, seeing as you brought it up, you're association with the sexologist and she obviously will be counselling many, many couples...people, not just couples. Is she finding a whole throng of infectious issues with people who have sexual function issues?
Moira: Not necessarily infectious issues interestingly. There's certainly a lot of psychological issues causing, I mean, it's a differential for her. But certainly there's psychological issues causing pain on intercourse for example. And certainly getting to underpinning this, we're looking at sexual trauma and everything that that could bring up in a relationship as well.
So most of her domain is in that area from my discussions with her. But it is certainly something that it is common. And certainly, I know that they are educated to be able to recognise that as well because that is a point of referral.
Andrew: Now, vulvovaginal candidiasis. Species; you know, we all talk about Candida albicans, very common. Everybody knows about it. There's ads on TV. What they don't speak about is the other species, Candida glabrata, Candida tropicalis, I think there's another one that I keep forgetting.
Moira: Albicans fungi.
Andrew: There you go. So what's the prevalence? Where are the prevalence, you know, with regards to climate? And indeed, you know, partnership or relevance for different groups of women? What's happening here? What's the spread of this infection?
Moira: So when we're talking recurrence of the vaginal candidiasis, those are the strains that we're generally dealing with. Unfortunately they're the ones that the common, you know, anti-fungal, imidazole, miconazole, clotrimazole don't deal with. And so they're 10 times less sensitive in fact to those anti-fungal agents. So they are the ones that hang around, that are going to flare up at the, you know, drop of a hat. And there are also some cases of really nonspecific, even moving on, I was reading a case the other day of a baker that ended up with a Saccharomyces thrush. And, you know, so there are some really obscure mycoses as well that's showing up as being, you know, ineffectively treated with over the counter medications essentially.
With those type of mycoses, we're always dealing with, you know, slightly warmer climates, certainly with the tropicalis for example. And the glabrata out of all of those is probably the most common of the non-typical Candida species that we actually deal with. And there have been some really effective clinical trials with treatment interventions looking at how you might actually treat those.
Andrew: Okay. But how would you know that it is candidiasis versus other disorders, for instance, viral agents? What do we need to be aware of regarding differential diagnosis here?
Moira: We need to make sure that we're asking the right questions. And certainly when we're differentially diagnosing a vaginal discharge, you have to ask the questions about the character of it, about the occurrence of an itch. Where the itch is? How itchy it is? Is there an odour associated with it?
Andrew: Lesions.
Moira: Lesions, you're right. And certainly the circumstances around the onset of that. And has there been antibiotics, has there been a change in the relationship? What's going on? Is there a diabetic with blood sugar levels? Is there a steroid in play? You know, so those sort of things are part of your case history. But certainly, you have to ask the right questions.
And that's why before I mentioned that generally, unless I've got it on a piece of paper that this is a positive for this particular infection. Then I'm not necessarily believing of it because we are dealing with...which is awful, we're dealing with the self-reported diagnosis of somebody who has nothing else to go other than the fact that they're itchy and they have a discharge. And that's commonly associated with being thrush.
In fact, you know, the misdiagnosis of bacterial vaginosis for thrush is very common but they have two very different presentations. And so then when we throw in to play things like herpes or trichomoniasis, or gonorrhoea, or a Chlamydia, or even just dermatitis. What we're actually, you know, doing is confusing all of that into one big thing which is I've got a discharge and I have an itch, therefore it must be thrush. And so you have to ask those questions.
Andrew: Yes. Indeed I picked up a case where it wasn't thrush. And I'm so glad that this lady got assessed. I felt horrible for her because it turned out that she was diagnosed with herpes from a new partner, who had played around on her. But I'm thankful that she was caught in the net and appropriately treated without being inappropriately treated because we didn't know. And I think that's so important to be able to, you know, assess differential diagnosis and to always have these alarm bells running in your brain about what it could be.
Moira: Definitely. Having a good idea of what each of those actually looks like clinically because, you know, herpes is one that's often misdiagnosed as candida by the person that has it. And certainly, no one wants to have their first thought and think, "Oh that's herpes." You know, and the perception as well of what herpes is, it can be very different to what it actually is. So you know, it's not a huge clusters of vesicles or it can be very small or just, you know, sort of, you know, a soreness and not even a visible lesion. And it can be very itchy or painful to touch. And then you might find that there's a discharge but the discharge is very different to thrush. It's thinner and watery, much like that of bacterial vaginosis. So we have some similarities and again, you sort of need to look at it medically, to take a swab, to have it looked at, to get that big diagnosis because it's very different treatment. And certainly one in a much bigger diagnosis than the other.
Andrew: So one of my favourite textbooks with regards to microbiology in general is Cedric Mims. And I guess I'll put this reference up on the FX Medicine website. There was also a pharmacist that I met once that had this fantastic differential diagnosis table, not that it was exhaustive but it was a really good clue-finder, if you like.
What other resources can you elucidate for us that practitioners can get a hold of?
Moira: Certainly, I see some really great web-based resources for Australian clinicians which is...and I will have to find the name and give it to you as well. Which is a differential page for general practitioners and there is one section that's specifically for vaginal discharge. And goes into that as alarm symptoms, and then has standardised treatment protocols as well for prescriptions, in terms of medical prescription for bacterial vaginosis, for gonorrhoea, for trichomoniasis. So it's a really great resource that I find. I've cut and pasted tables and I have them in a folder, and they're there for me because I like paper unfortunately for the resources because they don't disappear. So we can pop that up as well.
But it is, you know, having a great differential diagnosis textbook, whether that is, you know, a specific gynaecological text. Because you will find certainly in the text that teach pathology in school, they don't have really developed gynaecological sections in them unfortunately. And they tend to only be dealing with, you know, menstrual irregularity, not infectious disease. So it is an important thing to be familiar with.
But certainly, as you said, you know, making up your own tables, having something that is a quick reference guide. Making sure you ask the right questions to get the right information about that particular discharge and when it occurs, and what it feels like? Those are the things that we need to know about.
And as I said before, when we were talking about pain on intercourse, you know, the location of the infection itself. But if you're dealing with superficial dyspareunia, I can never say that word, that's why I'm talking intercourse. We're dealing with, you know, candidiasis, dermatitis, sometimes things like lichen planus. And then if we're dealing with deeper pain on intercourse, it can be Chlamydia, it can be gonorrhoea. It can also be other genital tract infections.
So those are the things that we need to know about and we can then maybe tick things off. And as I said, go forth with treatment. While you’re waiting for a swab to come through, while are you looking at them to go and just touch base with their GP. And certainly demystifying that. I do meet a lot of women who haven't been to their GP who've got chronic vaginal symptoms. And they haven't been because they're scared they're going to get a diagnosis of an STI like herpes.
Andrew: Really?
Moira: And understandable.
Andrew: Yes, the fear preventing treatment.
Moira: Yeah, definitely. Which, you know, occurs in, you know, seemingly in intelligent women.
Andrew: Okay. So how do you address that? If somebody's got the fear that they don't want to go and visit a practitioner because they're scared of a diagnosis that they might get. How do you reassure them that it's the appropriate thing to do to actually make sure that it isn't?
Moira: It's an interesting question. And I guess it depends upon the person and their level of fear. Sometimes working through the consequences of what an untreated infection means, is a way of going about it. Sometimes, that can make things a lot worst when we're talking about infertility and permanent scarring for example.
Or, certainly, letting people know that you're supporting them to go and get that test, and then there's always something that you can do around that to make that better, depending upon what that diagnoses is. Because some things are there forever when we're talking about viral infections in that area. But there's certainly lots of interventions that you can go forth with, that will reduce reoccurrence.
That might mean, that they can avoid, you know, lifelong therapy to stop those flare ups or recognising those particular factors. So it is about knowing your client and taking them through on that journey. Also, you know, making sure they have support networks around them. You know, referring them to an appropriate place. Sometimes, I'd find that there are reluctance is that they don't really want their doctor to be aware of that. And we certainly have a lot of really great sexual health clinics in Australia. You know, some of them have ‘pee and flee’, which essentially means you can go in, do a really quick test, and then they only call you back if there's an issue. So if you don't hear from them that's a great thing.
So there are those sort of resources available. And often going to the clinics that are specifically sexual health clinics, means that you can get that diagnosis on the spot. So you know, that they can experience the clinician going into the next room to use their microscope and then to come back in and prescribe treatment on the spot which is really great. Because you're not waiting. Because sometimes the worry of waiting is actually worst than receiving a diagnosis.
Andrew: Salient points all, and thank you so much for alerting us to those points which may not be infectious in nature like dermatitis. It's really, I love speaking with you because you have this breadth of knowledge which includes not just the topic we're talking about, but what the patients experience.
So Moira, thank you so much for taking us through this, you know, topically charged subject today. And I might just tell our listeners that in part two of this, we'll be talking about clinical considerations and treatment of these infections. But it's really important that we covered all of these issues regarding what it is and what it might be. Because we're talking about the health of the patient, aren't we?
Moira: We definitely are and a very important area that can have really big repercussions.
Andrew: Moira, thank you so much for joining us on FX Medicine today.
Moira: Thank you, for having me.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.
Additional Resources
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