What therapeutic options are there for the dysbiotic vagina?
Today we are welcoming back naturopath, acupuncturist, and vaginal health expert, Moira Bradfield.
Resuming our conversation from Vaginal Dysbiosis: Part 1, where we discussed the vaginal microbiome and how to recognise the various symptoms of infections and dysbiosis. In part 2, Moira takes us deeper into the holistic treatment options to consider when faced with vaginal dysbiosis cases.
Covered in this episode
[00:52] Welcoming back Moira Bradfield
[02:32] Aspects to be aware of when treating vaginal dysbiosis
[05:34] Discussing Candida
[07:50] Using oral probiotics
[12:54] Defining the “normal” vaginal microbiome
[14:28] Lactobacillus iners: pathogenic or not?
[17:23] A crash course on bacteriophages
[21:03] Oestrogen levels and recurring candidiasis
[22:36] Treatments to relieve vaginal inflammation
[26:35] Different strains of probiotics
[28:57] Reestablishing microbial terrain
[30:52] Discussing the use of creams
[35:14] Discussing the use of pessaries
[37:52] Discussing postpartum treatment
[40:07] Discussing the use of herbal and natural remedies
[45:41] Pre and post testing to gauge recovery
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining me on the line today is Moira Bradfield.
Moira has 16 years experience working as a Naturopath both in Australia and overseas. Graduating with a Bachelor of Naturopathy from Southern Cross University 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 University and now incorporates effective oriental protocols in her naturopathic practice. She has travelled to the United Kingdom, Thailand and China as part of her clinical training. She specialises in holistic medical ophthalmology as part of an integrated acupuncture practice on the Gold Coast and maintains a busy private practice in this speciality. She also has a general practice which focuses on complex case presentations and pathologies, including those related to the vaginal microbiome.
Moira is about to embark on PhD studies with a focus on women's health and the vaginal microbiome. She continues to add to her clinical expertise through a practical passion for understanding the client-based specifics of clinical presentations. Moira has lectured in naturopathy both overseas and in Australia in nutrition, pharmacology, and pathology, and is currently a senior lecturer of nutrition at the Endeavour College of Natural Health Gold Coast.
Welcome back to FX Medicine, Moira. How you going?
Moira: Very well. Thanks for having me back again.
Andrew: In part one of our podcast on vaginal dysbiosis we went through presentation, screening, modifiable factors, amongst other things which may impact ladies’ health. Today we'll be delving more into the clinical aspects and treatment of vaginal dysbiosis . So where do we start here? What's the biggest aspect or the biggest issues that we need to be aware of when treating vaginal dysbiosis?
Moira: Well, to start with, I think we need to remember that we're holistic practitioners. And that whilst there's lots of research and there's certainly, you know, a tendency to only focus on that one specific area, that really if we're looking for interrupting the re-occurrence that we're seeing in these particular infections because they are chronic and recurrent, that we need to address things more than just what we're looking at in the vagina itself. And that includes everything from past treatment and response, to looking more systemically, looking at that dysbiosis, looking at hormonal, and what's going on in the endocrine system, is there any issue with blood sugar regulation, and of course, looking at stress levels, and anything that might be depleting an immune response or even affecting a microbiome in its various surfaces in the body.
Andrew: And of course, there's so many aspects to cover here. But I guess the holistic approach to treatment of this might answer why there's such a vast variability in "normal presentations" of the woman's vagina. You know, some women normally have Leukorrhea, some women recurrently suffer from Candida, whereas others only suffer from it transiently, others only in certain situations, maybe antibiotic use or if they're immune depleted. So how do we assess where we should head back to?
Moira: Well, for me that's certainly part of just a general clinical practice. We've talked in our previous podcast about the array of different factors that can influence the microbiome in the vagina. So everything from sexual practices to what they may be using in sanitary, in hygiene practices. We also need to assess hormonal imbalance or hormonal balance for a woman because there's certainly an ebb and flow of infection and breakout associated with where oestrogen levels are. So we would need to be looking at, you know, assessing in a clinical setting like we would at any other time, what's going on with the hormones, how are we establishing perhaps something like oestrogen dominance, and assessing along those ways on an endocrine system, and also looking for the risk of, you know, high blood sugar levels if we're dealing with a candida presentation. So it's not just about that, though it's still important, the specifics of the vagina and the discharge and the amount of discomfort that they may be experiencing. And we do need to assess also those things we were talking about previously. So that comes into that presentation on a holistic basis.
Andrew: Just thinking about what you mentioned there regarding oestrogen and also candida, for instance, you know, with, let's say an overabundance of substrates for growth of candida. The premise is that candida overgrows in the bowel and move forward because of anatomical closeness of the vagina to the anus. But I have heard from practitioners, for instance, a gastroenterologist has said that he never finds candida overgrowing in the bowel, but it does impact on the vagina. Have you ever done testing like CDSA analysis, perhaps, which might be identifying that there is candida in a stool sample? And I guess, there's still issues on what that stool sample is collecting? Like, is it from higher up or is it from lower down?
Moira: Well, not directly. So but what you are saying is essentially that we can have a dysbiosis that is vaginal that doesn't necessarily have a reflection on the bowel, and vice versa, because we can have certainly bowel-based dybiosis that doesn't result in recurrent infections on a female.
Andrew: Yep. Yeah.
Moira: And we do know that that migration, anus to vaginal migration of microbes, whether they are micro Z's, or bacteria, is part of how we have this, you know, co-environment occurring. There's also as we see, when we're looking at how, you know, just taking something like an oral probiotic affects other sites like breast milk, for example. There's certainly in, you know, there's hypotheses that these things travel to these areas or signalling, you know, population growth in ways other than just direct translocation of microbes.
Moira: So there are other ways that we could be looking at that, and certainly, you know, a preexisting dysboisis in the vagina, and just a normal migration or exposure of a candida species which would exist there, normally, it's just that you don't want the diversity that we see when we have those type of infections occurring, that that's just become an opportunistic like it does in other places in that circumstance because of a depletion of other microbes surrounding it that aren't keeping it in check, that aren't, then, you know, keeping that pH in balance where it shouldn't be for optimal vaginal health.
Andrew: You mentioned something very interesting there, and that was the microbial signalling. So, you know, very much like the interleukin signalling that we can talk about with regards to gut-brain function, for instance, a very interesting area of microbial, or microbiota, microbiome, whichever word you want to use there, the research arm that's heading down that path now. Similarly, are you finding that you can influence women's vaginal microbiota by giving oral probiotics?
Moira: Oh, definitely. And, you know, certainly there is an abundance of research that suggests that's a possibility. Looking at everything from just simply, you know, oral probiotics and tracking the appearance of that particular population in the vagina, towards the using oral treatments in the prevention or cutting the risk of re-occurrence in sufferers. So we have that body of evidence there. We also have a body of evidence that is looking at more direct application of probiotics to the vagina where we're using vaginal tablets or pessaries. So, you know, there's an array of different ways that we can affect the vaginal microbiome. The direction that you take is sometimes dictated by the acuteness of the situation, the chronicity of it, and also the other circumstances surrounding it. Because sometimes, you know, you have an acute presentation, that's what you need to treat. The systemic, more chronic stuff comes on in the background and certainly takes a lot more time to shift. So we could use a vaginal pessary, to get quite a quick shift in the microbiome, but it doesn't necessarily mean that we're going to have an ongoing survival of that population. And in fact, in people who are prone to the re-occurrence of these infections, what they do know is that they're already dominated by a more diverse microbiome in the vagina and of a population group that is more, you know, not just Gardnerella-based, but the Mobiluncus which is the one I can't say.
Andrew: The Mobiluncus, yeah, yeah. I love those people that make up these microbial names.
Moira: Oh gosh, like, I read them but I can't say them.
Moira: You know, that we have that situation and we also have host immunity, you know, immune tolerance and what's going on. And there's some really interesting stuff that's looking at that sometimes immune tolerance is an interesting fact and when we're looking at why aren't we populating long term when we've put the probiotics in and we've done the hard work, you know.
And it can be down to the fact that that immune system already is in play and recognising a particular microbe and it works in reverse in that you're actually not, you know, it's doing its job too well, and the tolerance isn't there and we're wiping out perhaps beneficial populations. And then of course, we have multiple strains, we have the issue of bacteriophages, and how they come into play. And certainly, I mean, I was mentioning to you also is the role of iners in the vaginal microbiome...
Andrew: Yes, yes.
Moira: ...and whether that is in fact, you know, a friend or a foe. And one of the things they do know about iners is that it's got some genes that are quite specific in anti-bacteriophage defence. So, when we see a population such as what we might see in bacterial vaginosis, where bacteriophages may be responsible for that wipe out of lactobacilli, and we also know that that's a really great environment for the the pathogenic strains to grow, that iners could possibly be kicking in because it has anti-bacteriophage capabilities, and in that situation, it becomes the dominant species.
It also becomes the dominant species post pharmaceutical treatment as well. So, you know, whether it is there and it has variants that are pathogenic and it's using them as an opportunistic, whether that is there as part of a trending towards dysbiosis, which is also one of the theories that has been pushed around, it's quite interesting, and what it brings back to us is, we know very little, you know. And the more I go into microbes, I like, "Wow, you have that capability, you know, you do that and you can signal that and, you know, you survive in that environment." It's interesting that we can then step back and manipulate that and expect to know and control that as well.
Andrew: There's a, firstly, before I move on, I just want to clarify what I asked last time, because in my last question, I don't think I asked it very well. I was thinking more about the microbial signalling. You measure this? Do you actually see the difference in signalling upon giving an oral probiotic or do you measure symptoms?
Moira: Personally, in clinical measuring symptom recovery...
Moira: ...research, certainly looking at, you know, cytokines of various nature, the presence of T regulatory cells, you know, known expresses in different environments as well. So, I mean, that is there. But again, there's so much interaction going on that it's very hard to pinpoint. And certainly interaction is the spice of life, you know, it's what keeps us pushing forward and creating a homeostasis, which is ultimately where we want to be trending through in this environment.
Moira: It is, you know, and then certainly where we're at with the vaginal microbiome is there's an agreement that there's certainly a Lactobacilli dominant vagina is the epitome of health. But what that is made up of is quite variable.
Moira: So there are identified five different, you know, sub-families that are quite predominant across race, and geographic location. But we know that there are some of those that are more inclined to be in that vaginitis type of area, the ones that have the more pathogenic strains. Because when we're looking at the Lactobacilli species and their ability to produce lactic acid, that is not just, you know, a Lactobacilli species trait. We do have pathogenic strains that can also do that. And therefore, in some circumstances, if we were just going on microbes, and what that looked like, if, unless we're considering symptomatology, we can't necessarily say whether that is actually, you know, an infection or pathogenic state at all. It's just that that's a slightly different variance that usually in many women is expressed in these types of infections, but in a certain asymptomatic female, or a person with a vagina that might actually be anormal for them, and they may not have symptoms associated with it, and therefore, like when we're looking at other pathogens, and in other areas, does that require treatment?
Andrew: Lactobacillus iners, may or may not be pathogenic. Not just a temporal rescuer, so that it sets up the scaffolding for the next, dare I say the word, probiotic organism to come along to then take over the restoration of the normal vaginal microbiota. Is that true? Is that what you're saying? That there may be actually some pathogenic aspect to Lactobacillus iners?
Moira: Possibly. That's, I mean, the jury's still out on it.
Moira: But when we're looking at this environment, you know, that is a species that has a quite a great resilience.
Moira: Because it is associated as well with some of these, particularly bacterial vaginosis, which is where my head is at a lot of the time these days, associated with those type of conditions in health and in disease. One of the factors that when I've been reading around that I do keep coming back to however, is that we are dealing with people who have used pharmaceuticals. So the introduction of metronidazole or clindamycin if we're dealing with resistant species has already happened. So we've already wiped out possibly, if the microbes already weren't there, any base level of the other types of Lactobacilli because they do know about crispatus that, you know, it's possibly wiped out by metronidazole. Iners is resistant to metroniazole. So it's also there because it can be there, like say, you know, an iron-rich and sulphur-rich environment so it exists and survives through menstruation...
Moira: ...which is also characteristic of Gardnerella. So we've got a quite a robust Lactobacillus, but it doesn't necessarily confer some of the other health benefits that the less robust species and the diversity or the balance of those in the, you know, families provide. So it's quite interesting.
Andrew: Yeah, very much so. I'm scratching my head here because I thought "Yep, got it right. I absolutely got it right." I understand that, you know, iners crispatus, jensenii, gasseri, they're very important good guys. Nuh, maybe not. So...
Moira: Well, maybe not. But, I mean, with anything. I mean, you look at the helicobacter debate and ecoli…
Andrew: Yeah, yeah.
Moira: …and the Lactobacillus, you know, there is conferred survival benefit from all of those microorganisms in certain situations. And when you bring it down to homeostasis, that's all our body's trying to do is survive another day. And so how it does that is diverse as well, and right down to our microbes, and what they're signalling and the kind of environment they're trying to stabilise. So, you know, what iners, tends to be that the jury is more on the side that it's actually friendly, and there are circumstances where perhaps it's resistant and then pathogenic, like any of those wouldn't have the ability to be.
Moira: I can take you through the crash course. They're certainly something that when I first encountered bacteriophages, I was like, "What? How can... No, that's crazy." But it did actually explain a lot of things. So when we're dealing with bacteriophages, we're dealing with very small viruses, essentially, that infect bacteria. And in terms of the microbiome, certainly there are bacteriophages, again, that our immune system will learn to have tolerance to and don't necessarily have catastrophic effects. And when I first came across bacteriophages is when I was looking at the sexual transmissional factors, or how does sex affect these microbiomes specifically?
And one of the hypotheses that came up in there, and I must say that the work around bacteriophages is still very early. But one of the hypotheses that came up is that we're not actually introducing a pathogen, in the case of BV, we're not actually crossing over the Gardnerella, what we're introducing from say perhaps male to female is a bacteriophage colony. So we're having a colony of that, well, you know, the introduction of something that could come in and pretty much wipe out the Lactobacilli colony and therefore creates...
Moira: ...the dysbosis that allows an opportunistic infection to thrive and survive. And then I went down into it further, and it was, you know, A, quite scary but also made sense, because when we see, I think we talked in our last podcast about how in a relationship that is established between a sexual partnership, that among female, particularly partnerships, that the longer that that has occurred, the less likely there is to be this risk of recurrence. But certainly, when we look at that, if you are constantly being exposed, and the immune system has no tolerance to that, and also has, you know, things in play that are protective against it, whereas if we're going to a new partner, and then they're introducing a bacteriophage where there's actually no resistance to that or that the immune system isn't primed, ready for that, then that has the capability to come in and actually wipe out that colony.
Andrew: Wow, does that answer the old, you know, theory if you like, of ping pong infections? For instance, the female was treated for thrush and would have sexual intercourse with partner, partner would then get symptoms of thrush and pass it back and forth between each other. And so, you know, there was this time certainly with bacterial vaginosis where both partners were treated simultaneously. Is that of relevance?
Moira: It certainly is. It offers insight into that, but we still need to, I mean, being ever holistic, we still need to consider that, if you had a really robust colony and, you know, and great pH and good lactic acid production, and good hydrogen peroxide production, then perhaps that bacteriophage would never get the chance to do what it does.
Moira: So it comes back to terrain always comes back to terrain. But it is interesting in the sense as I mentioned before, because iners has the genes, and they're called CRISPR genes…
Moira: “clustered regularly interspaced short palindromic repeats,” which are an anti-bacteriophage defence systems essentially. So, as a Lactobacilli, they have the ability to protect us against that. And that's one of the reasons why we see it in those environments that are already dysbiotic, whether it's representative of a shift to dysbiosis or response to a shift to dysbiosis, because of a phage, and that's quite possibly, you know, gives us some insight into that as well.
Andrew: One other point you mentioned earlier which I'd like to cover before we really move on to the aspects of treatment which are relevant and which work, is oestrogen levels. So when you're looking at treating a woman who has recurrent, let's say vaginal candidiasis, because it's an easy topic to get our head around, the theory is that the oestrogens cause an increase in glycogen and that the Candida feeds off that. Am I correct in that or is it other factors?
Moira: That's certainly one of the biggest factors in an oestrogen dominant picture. So, you know, that pattern of outbreak is often around that point where oestrogen isn't peaking, you know, so the first part of the cycle into ovulation. And, you know, and I had someone remark to me the other day, you know, that that's, they get that regular Candida around ovulation, which is quite normal. And I sort of looked and went, "Mm-mm, is that though? Is that normal, or is that actually telling us that there's something going on with those levels at that point in time, along with everything else?"
So, I mean, it is indicative and, and certainly, in my experience where especially, I mean, especially early on when I first started getting into this area is that playing around with the oestrogen levels, but also the metabolites, is sometimes the key to breaking that cycle. If you've done everything else to the terrain and looked at all other systemic and risk factors, both, you know, lifestyle, etc. So shifting and stabilising that can have a big impact, particularly in the Candida species.
Andrew: So now to move on to treatment, I've got to ask the question here, we spoke about terrain. And it just seems that if the terrain is not setup for healthy homeostatic or homeostasis, then whatever treatment you're going to impart is going to be short lived and transient.
Moira: Yeah, definitely.
Andrew: That said, you know, you mentioned that, for instance, certain pathogenic species may produce high amounts of lactic acid, so maybe that isn't the answer to treat with. Traditionally, there's been treatments used, which encompass things like yoghurt, even acetic acid from vinegar, or dilute vinegar, I should also say. Where do you find the relevance of these? And indeed, where do you find the relevance of muco- or trophorestorative treatments to aid in restoring or relieving inflammation of the vagina?
Moira: That's a really great question. And certainly those things that are more traditionally used like that, the vinegar douches, or using lactic acid, or fermented whey, are all very useful in an acute symptoms where they're not necessarily, unless you address those underpinning systemic factors, going to result in preventing reoccurrence. And that's certainly, you know, where we're at with these people. Most of the people I see are already in a recurrent state, which is suggestive that those other factors need to be addressed. If it's a once off, never had ever in my life before this has happened, I had this medication, then sometimes that acute local treatment will get you through and, you know, homeostasis should be restored because the vitality is there in the individual to do that.
Andrew: Got you.
Moira: But in that other stage, you need to certainly give them relief, you know, because depending upon what's going on, it can be very uncomfortable for them. But then the undercurrent of treatment should go on for much longer. And abuse, as I mentioned earlier, it's addressing the why, and certainly the cornerstone of that, for most practitioners should be looking at dysbiosis in other sites and gut because that is our main part of where we're getting that feedback from.
But then certainly, what is affecting that? And that's where it becomes systemic, obviously. Is there hormonal aspects associated with that? And certainly, even in oestrogen dominance, the gut needs to be addressed. Where's the stress and immunity side of it going on? What can we do to correct that? And then we might see that when we introduce the lactobacilli colony, that they have a much longer longevity associated with that.
The other thing I would want to say though, is even when we're using local treatments, a lot of the research when we start looking at probiotics intravaginally, or even orally, is that we're not just doing a short period of time. It's often you know, post treatment for a number of months up to six months before we see an establishment, and I don't think clinically that that's actually going on. There's a tendency to sort of, you know, treat five days, six days...
Andrew: Like a of course of antibiotics, yeah.
Moira: Yeah, you know and move away from it. Whereas we are looking at longer term. And even just a baseline probiotic in at risk people is much more preferred then having to go back to Fluconazole, metronidazole, those type of treatments so that we don't have to wipe out microflora repetitively. There's lots of things that are available, and there's certainly self management techniques, and controlling for all of those things that are, you know, not necessarily associated, but the risk factors, which is obviously not just with oestrogen, but their sexual habits.
And sometimes, you know, it means abstinence around a period of time until we can establish a balance of restoration, a balance in the terrain, because otherwise you just coming in and disturbing a microbiome that's already at risk, that's already on the edge of, you know, falling into dysbiosis.
Andrew: So you, just mentioning a few of those species and strains, you know, it seems like the list is ever growing. You know, years ago there was the Lactobacillus rhamnosus GR-1 combined with the Lactobacillus reuteri RC-14. But then you've got Lactobacillus reuteri CRL 1324. That's been used in a mouse model, you've got Fermentum LF 10, Acidophilus LA 02, there’s…the list is ever growing. Do you find practically, clinically, that you must use one of these strains, or do you find that that just gives you more confidence to therefore treat?
Moira: A bit of both. So certainly, when there are research strains available and readily available, I will go there with them, and I do see really great results with them. And when we're looking at the Rhamnosus GR-1, and Lactobacillus reuteri RC-14, you know, there is quite a lot of research in candidiasis, in vaginal dysbiosis, and in bacterial vaginosis where we see benefit from that with and without mainstream treatment.
There is also a lot of research where strain isn't specific and there is benefit associated with just introducing lactobacilli species. So again, it depends on how long has this situation been there? What's been tried in the past, because you will find that most women would have self-treated somewhere along the line with a probiotic. And what is that probiotic? And therefore, you know, going forth along on that track is,"Did that work for you? Did you see benefits?" "No." "Maybe let's go with a more specific strain that we know will have an impact." Because some of those, you know, the research tells us particularly with BV and reoccurrence that a probiotic intervention, either post pharmaceutical treatment, but also prophylactically can, you know, stop reoccurrence by up to 50%, 60%, which is pretty significant when we're looking at women that are having five to six, to more outbreaks, monthly outbreaks reoccurring. And again, if you're having a monthly outbreak, and your treatment of choice is pharmaceutical, then all you're doing is decimating over and over again.
Moira: So if you get something that can hold and prevent that from happening, what you're doing is buying time in terms of, you know, recolonising and correcting terrain as well.
Andrew: So when we're looking at treatment, you know, I think we've covered in previous podcasts the issue of correcting an iron deficiency and, indeed, when we're talking holistically about uncovering the reasons why they're iron deficient. I guess, what I want to ask now is when you're talking about returning the normal terrain, what treatments do you find most useful?
Moira: It's varied again, you know, what's going on? So, I guess, I mean, in certainly a good restoration of gut, and microbe associated with gut is important, down regulating inflammatory cytokines is also very important in a systemic sense, and correcting hormones. So, I mean, all of that will always go on in the background, and certainly the treatments for that are so diverse that perhaps, you know, that's a whole another series of podcasts.
So those things are imperative, and they need to be assessed. The local stuff, you know, the more specific stuff for the vagina, things that you know, you can use acutely and also long term depending upon the intervention, but most of the time, you can use them both in multi. And in fact, there are several products out there that lend themselves to using them in a variety of different ways. So things like using capsules as pessaries and vice versa, using them all as a baseline and then using them as post treatments intravaginally throughout the month, you know, possibly making pessaries certainly in clinics that have herbal components or that have, you know, ferment components associated with them is also very important. And then looking as well, depending upon what type of infection you're actually dealing with, at what's out there. So it's looking at like the vitamin C pessaries or the boric acid pessaries and then just talking about things like the recurrent Candida.
Moira: I haven't used slippery elm. Although I guess, one of the things that we need to acknowledge particularly for using any of those other things that might be a bit of acidic. So with any of the, I mean, boric acid or vitamin C, when, or even using a probiotic as a pessary, there comes a time, or a number of hours after first inserting where you have a letdown of powdery greasy stuff.
Moira: And certainly if we've got any irritated tissues whether they're on the vulva or external, having that leak onto those tissues can be very painful particularly in the candida situation. So using some of those more topical creams, either externally on the vulva or even inserted again into pessaries is certainly something that I would do. And you know, over the years of, you know, making pessaries, there's been combinations with Calendula and with goldenseal, you know, and using this sort of microbials or using a lovely vitamin E-based cream to then use it as a carrier if you're using essential oils to treat serious infections. Although over the years I've sort of moved away because, from herbal interventions, apart from some specific recurrent things into using sort of more things that are associated with easy access, kitchen cupboard medicine type stuff as well.
Moira: So certainly, in acute situations, not just having probiotics on hand, but, you know, knowing how to do a 30% apple cider vinegar douche or having fermented whey, you know, frozen into little pessaries in the fridge all ready to go. So those sort of things become sort of the mainstay of treatment for me in an acute setting, because the baseline's already underpinning it.
Andrew: Yeah. Well, one of the, I guess, the let's call it a learning curve that I went through was with regards to cream bases. Do you find the various different cream bases can have either an ill effect or a positive action on the soothing aspect of the irritation that occurs with these sort of infections?
Moira: Most definitely. And it is very hard these days to find a commercial cream that is pure. And so we do move towards using things now like coconut oil, and then having to refrigerate and solidify it. But certainly, for those reasons we talked about when we were looking at lubricants in the first podcast, you know, osmolarity and effect on pH can, might mean that it's not necessarily the best thing to be doing in that environment at that point in time.
So it is a delivery vehicle, but it's not always the best delivery vehicle. And then there also might be certain contraindications surrounding, again, you know, you can tell somebody to not have sex in that situation in an acute phase, but these things happen. And so, certainly they may not be suited to use certain condoms and certain types of birth control.
Andrew: There was a practitioner who used to advocate the use, with very successful outcomes, of using a weak Calendula cream as a lubricant, because it was something that was natural, it had trophorestorative actions as well as anti-microbial actions, and it was something that was quickly applied in the heat of the moment, shall we say. So it was quite useful in certain situations. But you find that every now and again it can actually be deleterious?
Moira: Yeah, definitely. I do. And then of course, we're also dealing with not just those sort of considerations, but we're also dealing with the mess. Yeah.
Moira: And then, I mean, for some interventions, you're adding, then suggesting that they use a panty liner or a pad, which also then creates a different environment down there in terms of breathability...
Moira: ...which might be counterproductive to what you're actually trying to achieve. Whereas with some of the probiotic pessaries, there is a let down and it's a gritty, white, powdery let down, but it doesn't necessarily require, you know, the use of a liner.
Moira: So that's a consideration in that sense.
Moira: Definitely. And I think, you know, certainly having a handout that informs them of what to expect and when to expect it. So generally with a pessary we're looking at 24 to 48 hours before we see that powdery let down. And in certain circumstances I've learned through trial and error, there might be some other things you need to consider. So for example, in a postmenopausal vagina, where they may not be the lubrication, I've had a circumstance where a pessary has popped out a couple of days later unchanged, so it's still in capsule form.
Moira: So, in those circumstances, certainly wetting it a little bit before insertion is a consideration. The interesting flip side to that is that the lactobacilli has certainly been shown to improve lubrication. So, you know, perhaps doing some more specific oral population work before going in with that, if it's not an acute situation. And then another circumstance where using probiotic pessaries in a pregnant female will, obviously, as with all females, the position of the cervix changes depending upon where hormones are at. Getting a frantic text message asking me, "Is it possible that I have inserted the capsule right up into my cervix?”
Moira: “I can't find it, it's disappeared." And certainly we worked through that. And it wasn't an issue in the end and there was a letdown. But because the cervix was just so close to the vaginal opening, and she'd been a little bit too enthusiastic...
Andrew: Right. Right.
Moira: ...with pushing it up in there that it had actually, you know, gone up more into the mons and the squishiness of it that time.
Moira: But, you know, she still had a plug in place and there wasn't any other risk of infection. But, you know, those are things, I guess, to be mindful of on a clinical setting.
Andrew: Yes, that's a very relevant safety aspect too. Can I give you one more?
Andrew: Always be very mindful, particularly when using a vaginal microbial pessary, a probiotic pessary, to inform your patient to read the instructions, that it is not an oral probiotic.
Moira: Before they've done any harm.
Andrew: Well, the report was, "Jeepers, it tasted powdery." That, was it. I think the lesson is, please be specific with your instructions, take time to inform them, particularly when it looks like it would be given via the usual oral route. But it's not. It's a pessary.
Moira: Yeah, definitely.
Andrew: Very interesting that you mention age there, because obviously, we do have changes in the... I say we. Women do have changes in the vaginal mucosal lining with age, and even after bearing children, things like that. So how do you vary your treatment when you're dealing with women recovering from pregnancy, from childbirth, and postmenopausal, perimenopausal women? What are their specific sort of needs with regards to changes in therapy?
Moira: I mean, if we start off with postpartum group, I guess, is the considerations there if we're doing any type of oral therapy is, obviously, are they breastfeeding, and what impact is that going to have if we're introducing some sort of therapeutic into play? So we certainly are going to be a little bit more restrictive in terms of antimicrobials if we're using those orally to correct any sort of dysbosis. The other aspect of that is if they've had vaginal delivery, there's obviously, and depending upon how soon postpartum it actually used, again, we may have some issues in terms of retaining pessaries if that's what you're going to be introducing.
Interestingly, in, because of what well, I was mentioning earlier about the iron rich environment that comes with menstruation and also bleeding and Gardnerella survival, is that if we've got somebody that has a history of reoccurrence, I mean, hopefully it's been dealt with during pregnancy to ensure an appropriate microbiome for birth. But also in that postpartum period, depending upon the female and the way that they've given birth, the length of time therefore that they bleed could also be putting them at risk. So certainly, there is a huge variability in postpartum bleeding from days to weeks to months. And you need to be considerate about that would actually be changing that environment as well. You do have a different chemical rhythm going on in the background, obviously, and the oestrogen aspect of it is slightly different. But certainly that iron rich environment and the pH of the vagina is very different postpartum than it would be in a menstruating female as it fluctuates through the month.
Andrew: Okay. So just on the last sort of note, herbs, you know. To me, a critical inclusion in prescription because you can vary it with each changing visit, changing presentation. But what sort of herbs do you use, and what do you find most clinically relevant for treating vaginal dysbiosis and infections?
Moira: So, I mean, we've already mentioned some of the things that we would use more locally if we were using creams or pessaries. To that list, I guess I'd want to mention good old garlic and using whole cloves, and which is a great kitchen cupboard remedy, you know, at short notice.
Moira: Certainly when we're looking at allicin you know, the ability of that to affect microbial balance, and to..looking at biofilms is pretty important. So, you know, inserting it, some people like to, you know, to add a bit of string it, I didn't find that that's really that necessary, it tends to work its way out anyway. And so actually inserting a whole clove of garlic into the vagina and...
Moira: ...yeah, depending upon the level of inflammation. So if we're dealing with a Candida where you tend to get that really, you know, raw, red mucosa, it's that pure clove, but not with any nicks or crushing. If it's a little bit, you know, less than sort of more chronic and not having that super acute presentation…
Moira: …you can slightly bruise it. And it does tend to, you know, after about six to eight hours, a little bit of downward pressure and it pops itself back out again. And being mindful as well that if there is discomfort associated with it, then it's probably not an appropriate, but it has been used for very long period of time as a quite traditional remedy in that sense.
Moira: And we do see research, not intravaginal as such, but certainly we see research looking at garlic tablets, and in decreasing the incidence of BV and quite moderate cure right, I guess, associated with it. So around about 60% using garlic tablets, but...
Moira: ...then we do know a lot about... Orally, yes. We do know a lot of about it, in terms of just general dysbiosis and how it actually works in microbial imbalance. And so it's quite cornerstone in that oral part of my treatment protocol if we're looking to go through and sort of have a bit of a clean out. So it's a very effective remedy in that sense, and, you know, quite well tolerated, not a huge amount of side effects associated with it. So it's something I quite confidently use in those type of treatment protocols. I know that when we're talking about just general dysbiosis, you know, the treatment of that has come quite diverse. And we can choose to, you know, use quite specific herbs and then we have to consider about how specific are they for certain microbial populations? Are we using quite a wide brush to deal with a very small problem?
Moira: And, you know, that's all a consideration as well. We don't want to be wiping out anything that is beneficial. So again, some of those things would be a little bit more local if we were dealing with an acute flare, and then using appropriate. And for that reason, I mean, a lot of the probiotics that we have have the ability to address biofilm and, you know, quite significantly. So there's not always the requirement to go in with a bit of a wipe out of everything. You can sort of manipulate it, quietly and subtly. But certainly if we were to go down that ,know, there's the research there for goldenseal or, any of the berberine containing herbs, interestingly, and also things like basil. So we have, you know, the ability to use those, and there are certainly products out there that combine things like that that we can use successfully as well.
Andrew: Did you say basil or holy basil?
Moira: Holy basil.
Andrew: Holy basil, got you.
Moira: And then, I mean, if we step away for a little bit from things like BV and Candida, but, and look at things like trichomoniasis which we talked a bit about in our first podcast, you know, there is some interesting research surrounding that and biochemical, so…and many of the same things, generally that we would use for BV because the two exist, are used quite a lot with trichomoniasis. We see benefit for with trichomoniasis, as well herbally. So there's some in vitro, in vivo, and the research looking at that. And there's some case studies as well with using things like myrrh for trichomoniasis. And interestingly, there's some quite scary statistics of prevalence of trichomoniasis in places like the United States. So certainly in those populations, it's going to be an area where there is, they're looking for more and more interventions because metranidazole has many issues, you know, there seems to be quite severe side effects with that type of intervention.
Moira: And this is a really common reoccurrent issue as well.
Andrew: Why are they finding more of an issue of trichomoniasis in the USA? Is it just because they're looking for it? I mean, Australia has a dearth of statistics on this sort of thing.
Moira: I have no idea. I don't know whether it's the population, and certainly the risk of unsafe sex, which is, an increasing issue…
Moira: …in our population surprisingly, or whether there are other factors at play. There's certainly when we're looking at socioeconomic factors, you know, there are clusters that would be associated with that in a certain region in Australia when looking at Indigenous communities unfortunately in trichomoniasis infection, so that would be a huge part of that I would imagine. And then, you know, obviously that everything that goes with that.
Andrew: Moira, I love the way that you always treat the terrain and always ask why something's happening, and you always treat the person not the disease. There's obviously so much to learn here. So we'll be putting up some resources on the FX Medicine website. I guess, as a round up, though, what do you find the relevant or the importance of pre and post testing to be with regards to your ladies in determining how they're recovering from these infections?
Moira: That's a really great question. Part of that is dependent upon the underlying factors. So certainly with things like oestrogen dominance, they would be retesting, even you know, stress and the markers of what's going on there'd possibly retesting. Where it comes down to the microbial or we're dealing with an infectious level is dependent upon what we're dealing with. So certainly in situations, and not huge part of my clinical practice, but in situations when there's been trichomoniasis, retesting is pretty important.
And so that's part of that. Certainly we do chronic BV and chronic candida, symptom pictures alone are able to guide that. So you certainly, you know, what symptoms are available, or what symptoms are showing themselves, and how often are they reoccurring, if at all, should be the marker that you're actually on the right track, and that the dysbiosis is being corrected for that individual. And so on that very local vaginal level, that's where I would sit with that, and then the systemically depending upon what specifically I'm actually measuring. So, you know, all of the array of functional and mentoring testing is available to us through thyroid levels, you know, blood sugar levels, oestrogen levels, and if I do go down the path of looking at CDSAs and things like that, then we can certainly retest for different aspects of that depending upon what showed up initially.
Andrew: Moira Bradfield, I love speaking with you on FX Medicine, because you always bring so many aspects of care into the topic that we're talking about and you wake me up to make me think about other aspects that I might not have otherwise thought of. So thank you very much for taking us through the health of the vagina and treating vaginal dysbiosis on FX Medicine.
Moira: Thank you for having me. It's always a pleasure to be on FX Medicine.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.