Cultivating a Healthy Genitourinary Microbiome with Emma Sutherland and Moira Bradfield Strydom

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Cultivating a Healthy Genitourinary Microbiome with Emma Sutherland and Moira Bradfield Strydom

In this week's podcast, Emma Sutherland and academic, Naturopath and Acupuncturist, Moira Bradfield Strydom join together to discuss Moira’s work on the genitourinary microbiome. Together they discuss the clinical challenges of treating recurrent thrush, bacterial vaginosis and the vaginal microbiome and touch on the influence of oestrogen and other lifestyle factors on symptoms. Moira shares her clinical pearls on how to undertake a complete urogenital case history and how to ensure that tracking and testing are done at optimal times within the ever-changing hormonal cycle of a woman, providing us with some great clinical tips for our own practice.  

Covered in this episode

[00:39] Welcoming back Moira Bradfield Strydom
[01:27] Moira’s background and area of interest
[07:18] Moira’s PhD: recurrent thrush
[13:02] Why don’t we know more about this area
[16:07] How oestrogen affects the vaginal microbiome
[20:58] Lactobacilli crispatus 
[24:04] Lactobacilli dominance and IVF success
[28:05] The endometrial microbiome
[30:26] Bacterial vaginosis and preventing recurrence
[34:18] Tracking symptoms and testing pH balance 
[38:01] The role of vaginal microbiome testing in clinic
[40:26] Supporting both the uterine and the vaginal microbiome
[45:22] Foods that influence the vaginal microbiome
[47:02] Balancing different roles and having a successful practice
[52:22] Thanking Moira and closing remarks


Key takeaways 

  • Oestrogen fluctuation can have a considerable impact on the vaginal microbiome, in particular lactobacillus.  
  • Lactobacillus is the dominant bacteria within the vaginal microbiome and influences vaginal pH and susceptibility to infection or dysbiosis.  
  • Lactobacillus crispatus produces lactic acid and hydrogen peroxide and can support the pH control of the vaginal and prevent opportunistic bacteria proliferating. However, the amount of L. crispatus a person needs is individual and may be hereditary and impact fertility and IVF success.  
  • A healthy vaginal microbiome has the ability to modulate inflammation through pathogen inhibition.  
  • The definition of bacterial vaginosis is a loss of lactobacillus. Need to assess why the lactobacillus numbers are reduced and consider hormonal implications or interactions with partners. Symptom tracking for a month can provide insight. 
  • There are many lifestyle factors, including glycaemic load, that can influence the vaginal microbiome and vaginal health. 

Practice pearls 

  • Increased oestrogen can fuel fungal microbes and low oestrogen can fuel bacterial vaginosis or aerobic vaginitis.  
  • There is increased risk of thrush in the mid-luteal phase due to the relationship between oestrogen and progesterone, creating an environment that supports the growth of fungal microbes. 
  • Lactobacillus is influenced by the menstrual cycle, life stage and fluctuations in oestrogen, with oestrogen promoting a healthy lactobacillus population. 
  • Symptom tracking supports the recognition of cycle-related changes and can support lifestyle decisions based on where the client is in the cycle for optimal health. 
  • Vaginal pH testing can be done by the patient using litmus paper strips wiped around the vagina or using a cotton tip. The ideal pH range for the vagina is 3.8-4.5, subtle changes in this may suggest dysbiosis. Caution is needed in atopic or vaginismus patients. 
  • Vaginal microbiome testing is best done while symptomatic, or if asymptomatic, around ovulation. 
  • Screening questionnaires can make taking a complete urogenitary case history easier for the client and practitioner to ensure any tricky questions are not missed. 

Resources discussed in this episode

Moira's website: Intimate Ecology
FX Article: Vaginal Microbiome Composition by Moira Bradfield Strydom
Study: Evidence-based update on Australasian pharmaceutical prescribing approaches for recurrent vulvovaginal candidiasis (Strydom, et al., 2021)
Study: Microbiota in vaginal health and pathogenesis of recurrent vulvovaginal infections: a critical review (Kalia, Singh, & Kaur, 2020)
Study: The vaginal microbiome as a predictor for outcome of in vitro fertilization with or without intracytoplasmic sperm injection: a prospective study (Koedooder, et al., 2019)
Study: Bacterial Vaginosis - A Brief Synopsis of the Literature (Coudray & Madhivana, 2020)

Transcript

Emma: Hi, and welcome to FX Medicine, where we bring you the latest in evidence-based, integrative, functional, and complementary medicine. I'm Emma Sutherland and joining us on the line today to discuss cultivating a healthy genitourinary microbiome is naturopath, acupuncturist, and academic, Moira Bradfield Strydom. Welcome back to FX Medicine, Moira.

Moira: Yeah, it's great to be back. Thank you for having me.

Emma: It's a pleasure. Now, unlike the gut microbiome, a healthy vaginal microbiome is characterised by low diversity of microorganisms, combined with Lactobacilli dominance, as lactobacilli are essential for the production of lactic acid, which maintains optimal pH of around 4.0. 

Now Moira, you've been a frequent guest on the show, and thank you for taking time out to join us again. For those listeners who might not be familiar with your work, can you tell us a little bit about your background, and what led you to this area of interest?

Moira: Yes. So I've been a naturopath for a little while now and coming up on 21 years, and I don't know if I had a choice...

Emma: Right.

Moira: ...to be anything but a naturopath. So I think apart from wanting to be a ballerina at one stage, that's all I wanted to be was a naturopath from very early on. So I went into study straight from high school.

Emma: Wow. Okay.

Moira: And then went straight from university into private practice, at that point.

Emma: Yeah, incredible. But when you were young, what made you interested in becoming a naturopath?

Moira: Gosh, many things I guess. I mean, I grew up in beautiful Hobart in Tasmania. And nature is a big part of being Tasmanian, and so I suspect that had a huge influence on me. Also, in terms of my mother was very big on not always going for more mainstream solutions and looking at how we could possibly support ourselves in other ways, so there was definitely influences in that. And through high school, I did interesting things, like, did some work experience in Goulds Apothecary down there, and I also went into health food shops and sat with some naturopaths. And at the time, was seeing a Chinese herbalist, so lots of different things like that, that sort of cemented that that's what I wanted to do. And just really being inspired by looking for alternate solutions. You know, what else could we be doing? There's got to be other answers.

So, yeah, it's sort of something I haven't reflected on because, as I said, I don't know if I ever wanted to be anything else. And even in the early stages of then going and applying to go to university and get that degree, obviously, I applied for other things as well. But as soon as I found out that I'd got into naturopathy, I unenrolled, because I was in the process of enrolling to be a marine biologist.

Emma: Okay.

Moira: And then I got my acceptance letter. So, it was top of the pick for me to go down that path and really immerse myself in more natural and holistic solutions for healthcare.

Emma: Yeah. And obviously, you have a very curious mind, because I think naturopathy is all about being curious about possibilities and other ways of doing things and other ways of seeing things.

Moira: Yeah, I think so. I mean, yeah, it's interesting, as I've aged, to understand how my mind works more. And there's certainly some very atypical things I've noticed about myself, but I do love a good puzzle. And I love to think expansively, and then to be able to contract and expand on different parts, which I think is a really big part of understanding systemic health care. And looking at it and looking at an individual area, which is often why somebody presents to you, but being able to integrate that and understand how that functions as a whole, as well. So my brain really likes that sort of thought process.

Emma: It certainly is a challenge at times. And you're right, the puzzle is a great analogy for patients.

Moira: Yeah.

Emma: Now, I want to talk to you about your speciality in the area of genitourinary health. Why did you decide to head down that path specifically?

Moira: It sort of presented itself to me. It's not something that I went seeking at all, I had been in private general practice for gosh, maybe 15 years at that point, and had started to see a run of clients in clinic that had unexplainable discharge or recurrent infections, and I found that the approach that I was utilising was not working.

Emma: Okay.

Moira: And so when I went to dig in and think about why, what I realised is there was a whole area of health that I really didn't have a knowledge base in. And so I threw myself into that and realised that as that opened up, that it was something that I was really interested in.
And up until that, I had no interest in specialising or having a special interest in anything. I was a general clinician, and that was good. But this area really ignited my fire. And I think because there are...obviously, I'm a female.

Emma: Yeah.

Moira: And there are aspects of my own health journey that resonated and made sense. And so I dug into that literature. And then I also started to realise that, because it wasn't something that we talked about, or that we learnt about in great detail, that my role as an educator, because I had been in education for a long time at that point was to also, "How can I take this to other practitioners?" Because this is a really important and overlooked part of health, that a huge percentage of our potential clients or patients actually have issues with, and we're not even digging into it, or we're too shy to ask those questions.

Emma: Yeah, and I would definitely say that we are under-educated in this space, when we go through our training. And it is something in clinical practice that patients will come back again and again, with the same symptoms. And you know, we're going to deep dive into all of this, but as a practitioner, it can be very frustrating when you feel your knowledge is not sufficient enough to really help these patients get better results.

Moira: Yeah, definitely. I mean, I think for me, the big realisation is that most of it is not an infection.

Emma: Yeah.

Moira: But it's a huge part of it, so why are we addressing it that way? And throwing lots of anti-microbials at it instead of thinking about it in a restorative way?

Emma: Yeah, it's a very one dimensional way of thinking about it. You're right.

Moira: Yeah.

Emma: Now you're also doing your PhD. So tell us what you're working on. I admire anyone who takes on a PhD.

Moira: Yeah, it's been quite a journey and it's coming to the end of it now. I'm working in the area of recurrent thrush, because of all of the things that I was dealing with in clinic, that one has the least amount of answers. And it certainly is frustrating to see people that have had 10, 15 years of symptoms that come back on a monthly basis and to have had a whole barrage of anti-fungal medications thrown at them both holistically, and pharmaceutically, only to have those symptoms return. 

So I thought, “Gosh, what can I do in this space? This is the biggest area, I think that troubles me that I want more answers to that I think we need to understand better.” And so I ended up, from the genesis of deciding that I wanted to do further study, in meeting my supervisor, who also wanted to do some work with some specific compounds, in terms of recurrent thrush from her background meeting, and it was very... Yeah, it was just one of those things that had all the stars aligned and I ended up going into PhD studies looking at recurrent thrush. 

So we're looking at a number of different factors and certainly doing a PhD through a pandemic has meant we've had to pivot numerous times in how we approach the work. But we're running a clinical trial, I'm seeing if we can reduce the severity and frequency of thrush flares in people who experience recurrent vulvovaginal candidiasis. And we're using an intra vaginal application to do that.

Emma: Okay.

Moira: And then there's been some side projects that have come out of that as well, because one of the papers that we have had published is around the pharmaceutical management of recurrent vulvovaginal candidiasis in Australian guidelines. And what we found was that the treatment, you know, is successful whilst people are on it. But there's a really high relapse rate associated with recurrent thrush once you've stopped some of those longer term Azole therapies. 

And there's also a huge, like many other, I think, female health conditions, there's also delays to diagnosis. There's mismanagement, there are people that feel like they've not been heard. So we've also been involved in some semi-structured interviews, looking at qualitative data to talk to people that have recurrent thrush as a diagnosis and what they've been experiencing and what's come through for them. And there's a lot of uncertainty and feeling like they've just not been listened to, or supported in their journey.

Emma: Yeah.

Moira: And then the third project that we're running is a microbiome study. So we're looking at vaginal and gastrointestinal microbiomes of people that have recurrent thrush who have used oral fluconazole therapy either for maintenance, so longer term periods, or four times or more in the last 12 months. And comparing that to people who are essentially healthy controls, to see if there are differences in the microbiome because there's no long term data on what the impacts of these pharmaceuticals are on those microbiome sites. And there's also some disparities when we look at microbiome research between what constitutes healthy or whether there are bacterial shifts associated with these, primarily what we believe are fungal conditions. And there's not necessarily any data on the gut microbiome people that have recurrent thrush either, despite, you know, long held beliefs, that Candida is in the gut, and that's why it ends up in the vagina, etc. So we were looking at statistics of carriage as well for Candida on a gut level, as well as obviously microbiome trends in the gut as associated there.

Emma: I think I cannot wait for your research to be released, I'm already incredibly fascinated. And I think that recurrent thrush to me, it's a little bit like endometriosis, in as far as patients come in, and they feel that they haven't been heard. They're being misdiagnosed, and they're frustrated as anything with this recurrent set of symptoms that they're experiencing. So anything that sheds light in this space is going to make profound impacts on the experience these women have.

Moira: Yeah, I hope so because they deserve it. And, there's certainly aspects of recurrent thrush that makes it look like more of a syndrome than an infection, but we still see it being treated as episodic infections, rather than looking at a whole basis of it. So there's certainly factors associated with things like allergy, there are genetic components that they're identified, there are certainly hormonal risk points, as well. And those things are not often acknowledged or explained to people, and we don't necessarily have the interventions, particularly in a medication sense that can come in and even impact those things. 

So there's lots of gaps in the understanding of what constitutes it, which also leads into why it's often overlooked as a diagnosis, because sometimes people have symptoms without the culturable microbe and that's part of that diagnostic criterion as well. And sometimes people don't have the full extent of symptoms, they can have an ongoing irritation or an erythema, but they don't have a discharge, or they have a discharge, but they don't have those other classic inflammatory signs. And that all still fits under the banner of recurrent, or chronic even, vulvovaginal candidiasis because there's a spectrum of severity that goes with recurrent thrush as well.

Emma: With this whole subject being such a pain point, literally, for so many women, why do you think that it hasn't been identified before as an important area of study? I mean, it just kind of baffles me in a way, that it hasn't been highlighted before now.

Moira: Yeah, I mean, it is baffling. And there are certainly some heroes working in that space, and have been in that space for a long time, doing research and doing, you know, looking at case studies and things like that over long periods of time. So it is there, but I think it's chipping away in the background. 

And from a clinical practice perspective, when we look at mainstream medicine, a lot of these very recurrent pictures are not something that are seen in some aspects of hospital based gynaecology, for example. So it's more of a private practice point. And so it's about what is on the radar, and what the burden of that is, as well. And now, we're only just obviously coming to this new understanding of what microbiome health is. And we have a lot more information on bacterial microbiome health than we do fungal microbiome health. And that fits into that. And there are various factors and obstacles and understanding the fungal microbiome in terms of just testing, and databases, and all of those other things.

So we've got...it's a journey, and it's improving every year, I see more and more, and we get really excited about how many people are interested in this. And we've seen more startups who are interested in it, but it's, it's one of those things, I guess it still falls under that banner of women's health and there are acknowledged areas in that. And from a research perspective, and now from running a clinical trial, there's a lot of obstacles when you're dealing with people that have menstrual cycles and you're dealing with vagina health.

Emma: Yeah.

Moira: Because we're timing an intervention with somebody's menstrual cycle, and you've got to wait for it to come around, and then you got to recruit them in at the right time. And then obviously, things happen like sex and morning after pills, etc.

Emma: Yeah.

Moira: So there's lots of possible reasons why it's too hard.

Emma: Yeah, I can... I mean, a lot of research has been done on male rodents and males for a reason. Because as women we have these fluctuating hormones and all these other things that can happen. So I can just imagine the logistics are massive.

Moira: Yeah, totally. And particularly when you're looking at longer term studies as well because a lot can happen over nine months of using an intervention or following people. So it becomes really problematic. And when you've got something that's much more predictable and consistent to research, and that's generally safer, I think in terms of that perspective. But it's also because it's probably not talked about. So the severity of it, it's not that well acknowledged, because even the people that have it, are reluctant to talk about it and to talk about its impacts because of various levels of taboo associated with it.

Emma: Yeah, it definitely is a topic that you have to have some very direct questions with, when you're working with women so that you get the answers that you need. 

Now, I'd really love to discuss how oestrogen affects the vaginal microbiome. I mean, clinically, we see this at different points of the menstrual cycle, with patients more likely to get outbreaks of thrush during their period, and then less likely to get outbreaks around ovulation. But how does oestrogen fit into that and the susceptibility for infections?

Moira: Yeah, so oestrogen is probably one of the most important hormones to consider when we're talking about vaginal microbiome health. And its relationship is to the cellular health in terms of how many, what the density of epithelial cells are within the vaginal space, and therefore the expression of glycogen, which is the fuel that via some amylases becomes a fuel for those lactobacillus bacteria. So their survival is dependent upon good levels of oestrogen, good cell-expression of glycogen. 

So when we look at lactobacillus or lactobacilli microbes, we talk about them as a very overarching concept as being associated with vaginal health. And as an area, as a microbiome, we have less diversity because we seem to see dominance of lactobacillus and some low level microbes. And that's good. And that's eubiosis as far as the vagina is concerned, for most people, there are exceptions.

So this oestrogen rhythm that we have, we see as being really important to correlate to lactobacillus. So, when we have stages of life or even stages of the menstrual cycle, where oestrogen may be lower, then theoretically lactobacillus may be challenged or their numbers may not be as robust, or they may not be fed as well, essentially.

Emma: Yeah.

Moira: And so infection risk for bacteria becomes higher or a dysbiosis risk for bacteria becomes higher, at those stages. So when we look at premenstrual, menstruation, and then early, obviously, until oestrogen starts to peak again, those time points become more common for people, for example, if you have bacterial vaginosis, because the oestrogen and the lactobacillus equation when we have BV or bacterial vaginosis that is characterised by loss of lactobacillus and an overgrowth of facultative anaerobic microbes, so things like Gardnerella, for example. 

So we can think about oestrogen over a lifespan where we have pre-puberty, then the microbiome will be different and not as lactobacillus dominated. We move into more oestrogen dominant stages of life, pregnancy, menstruation, so there'll be more lactobacillus overall. And then as we move towards perimenopause and menopause, we start to see that relationship decline because the oestrogen declines and the lactobacillus are not as prevalent or they start to disappear. And the microbiome becomes more diverse.

So we have these sort of macro/micro situations, we have stage of life journeys, and then we have a menstrual cycle itself. So understanding that rhythm of hormones helps us to understand possible fluctuations that can occur, particularly in people that already have symptoms, because their disorder becomes more pronounced at different stages, because there usually are some sort of hormonal rhythm issues as well for those people.

Emma: Yeah, and I think a great point here is discussing those very facts with patients so they can really understand why their body is more susceptible at certain points in their lifespan or their menstrual cycle. And they can really become more empowered in that, rather than feeling like they're at the whim of these symptoms randomly.

Moira: Yeah, totally. And, I mean, tracking, symptom tracking is one of the most important things you can do for people to recognise their own rhythms and risk points, and helps you to A, identify what could be going on and helps you to also apply any prophylactic therapy. If you're looking to stop a cycle of recurrency, you start by addressing it right before or in that time period, we're then moving into a riskier period for them. So understanding those patterns, and they previously may never have been aware of those patterns, can really help to empower them because they might know, "Oh, it's safer to have sex at this time of the month,” because I generally don't get symptoms then and it's only when I start to see that rhythm changing, either less oestrogen in the case of things like bacterial vaginosis or aerobic vaginitis or more oestrogen, which can become a fuel for fungal microbes.
So with thrush, we see ovulation through to mid-luteal, sort of being a riskier time point where it's actually not just the oestrogen, but it's the relationship between the oestrogen and the progesterone. And what that does in that situation to influence or create an environment that's more favourable to some of those more fungal based microbes.

Emma: Right. Well, talking about microbes, let's dive in. I would love you to tell us a little bit about lactobacilli crispatus. So a 2020 review stated it was widely regarded as the best marker for vaginal microbiome health due to its proficiency in producing lactic acid and hydrogen peroxide. But can you tell us a little bit more about this bacteria?

Moira: Yeah, I mean, it is one of those ones that people tend to focus in on as being the one they have to have. Well, I mean, it is an important microbe, and it is probably the king of lactic acid and hydrogen peroxide production, which means its environmental control in terms of pH, and inhibition of other opportunistic microbes is much better than some of the other lactobacillus species that can inhabit that space. But when we look at it, not everybody will be able to hold lactobacillus crispatus in their microbiome, nor should they be able to because we also know with microbiomes, that there are a vaginal microbiomes that...there are different categories, I guess, they're called community state type, so they’re different profiles that people can fit into, and they refer to the most dominant type of lactobacillus that they might have, or a lack of lactobacillus dominance for some of those community state types.

So we seem to have a lot of research that's focusing in on lactobacillus crispatus, both in supplemental form, and in general, in terms of native carriage of this as a species associated with different health traits, like being able to conceive, for example, or being less likely to have a fungal infection, or less likely to have bacterial vaginosis. But it's not the everything, I think, because there are also some research that suggests some lactobacillus crispatus may be problematic or that too much of it is also a problem because we see this significant lack then for shifting of diversity in the other direction. And so there's a condition called cytolytic vaginosis, where some of the newer research coming through suggests that it may be a lactobacillus crispatus overgrowth.

Emma: Wow.

Moira: And there are different reasons why people may end up with a lot of this, like it can be...they believe it's hereditary, in that you can have crispatus coming through generations of people from obviously your mother and your grandmother, etc. And that's a really strong and robust microbiome. But sometimes we see this microbe turn up in excess, because there's been over treatment, or there's been a loss of some of those other more diversifying microbes within the microbiome. 

So it's interesting, and I think it's going to be a watch this space, because we have some conflicting information about crispatus in both general health and then special subsets as well, of research in terms of fertility, or with the work we're doing in terms of recurrent thrush, for example, crispatus is something that we're focusing in on for that very reason, in terms of overtreatment, and is that moving through and becoming more of a cyto loop type picture.

Emma: It's just so fascinating, but it also, once again, reinforces that point that it is about balance, when it comes to any kind of microbiome. Heading into this interview, I was reading a 2019 study on around 300 women that showed an increase rate of IVF success if they had more than 60%, lactobacillus crispatus. But, as you say, it's not always a good thing to have too much. But what do you think is the actual mechanism here of how that impacts IVF success?

Moira: Yeah, there's been a few studies around crispatus and IVF and what's on the catheter chip, for example, when they do the embryo transfer. And the lactobacillus crispatus situation is very interesting, because I think when we look at one of those research papers that suggests that if you actually have higher amounts, that there's a less chance of implantation.

Emma: Okay.

Moira: Whereas less than 60, and lactobacillus dominance is actually conducive to achieving pregnancy. And I think when we look at the type of people who are in need of assisted reproductive technologies, there's a whole array of different health conditions that have led them there.

Emma: Yeah.

Moira: And with that comes a history as well of treatment and antimicrobial use and all of these other things that we need to consider in addition to hormonal issues. So it's an interesting thing to evaluate. And I was looking at that 2019 study and sort of trying to understand because they had this, almost opposing thing where they were talking about, lactobacillus iners also being associated with pregnancy outcome. And iners is another one of those things that we don't really...well, we have an opinion on it that it's a lactobacillus, and therefore it has some benefit. But it tends to show up when there's transitioning going on, or it's a bit of a rescuer. So we don't know if it's actually good or bad, or what its deal is, and possibly, it's all of those things depending upon strain specificity of it.

Emma: Yeah.

Moira: But overall, when we look at lactobacillus dominance, it doesn't necessarily matter which microbe it is, although there are also some other ones that are less like jensenii. Their mechanism is that the ability of them to produce lactic acid and hydrogen peroxide is about environmental immune control, that their production of metabolites and bacteriocins are about inhibition of pathogens, and therefore, a decrease of inflammation within that area. So all of these things are conducive, obviously to successful pregnancy and not immune activation at that point, as well. 

So overall, a healthy microbiome, as I said, largely in this space, is lactobacillus dominant and pH regulated, etc. But I suspect when we look at that opposing result, where they were talking about over 60% lactobacillus crispatus having a slight reduction in pregnancy outcome, then it may also be because we know, looking at pH, and what role that can play around pregnancy, and that natural fluctuation of pH around different points of the menstrual cycle for obviously, helping sperm and egg meet each other, etc.

Emma: Yeah.

Moira: So there's lots of things I think, that we don't fully understand. And sometimes focusing in on these singular microbes can mean we miss the bigger picture, but it is nice, those sorts of studies that do the whole microbiome profile, because we get to see these sort of traits and shifts. And it gives us this understanding that obviously, we don't want people if they're already in that situation, and having issues with reproduction, that we don't want them to have other types of anaerobes dominating their microbiome. And that generally, they need to have Lactobacillus at a good amount to have that stability and to have that healthy microbiome to be able to enhance their outcomes.

Emma: Yeah. And looking at endometrial receptivity and the microbiome, is there a role there for dysbiosis and inflammatory changes in driving progesterone resistance? I mean, I truly realised we're just at the tip of the iceberg on all of this. Over the next few years, we're going to see so much more information coming through, but what are your thoughts on the microbiome and the endometrial receptivity side of things?

Moira: Well, yeah, it's a great question. And I mean, it's not something I've spent a lot of time thinking about, because my space is not necessarily fertility driven all the time.

Emma: Yeah.

Moira: But I do think that when we look at the endometrium, and what we know, on a microbiome level of both the endometrial microbiome and the vaginal microbiome is that they are connected in an upstream from the vagina to the endometrium.

Emma: Yeah.

Moira: And that they have common traits amongst them, and that we certainly have inflammation in situations like endometriosis, for example, where there are microbiome profiles of the endometrium that are inflammatory and driven by microbes that are not conducive, as well, to implantation and fertility. So within that, when we look at what we know about endometrial receptivity and progesterone resistance, that there are these common markers of inflammatory changes and of T cell reactions, and the suggestion that that sort of resistance is aligned with hallmarks of some endometriosis pictures as well, I think that the microbiome is definitely implicated. I just don't think we have the details of how exactly at this point, and that even the research on the endometrial microbiome talking about its role in fertility is still in its infancy. But I mean, it's certainly going to be an interesting space to watch. And as it comes to light, I'm looking to be both excited, and amazed and also, “Mm, I thought so.”

Emma: I'm sure that's going to be the case. It is a fascinating area, because it's constantly evolving as the research comes out, and just like your PhD is going to contribute an enormous amount of data to our knowledge bank. We're constantly learning in this space.

Moira: Yeah, so interesting.

Emma: Yeah, yeah. Now looking at bacterial vaginosis, it is treated with antibiotics which are effective for short term relief, but a 2020 review showed that 25% of women experience a recurrence within four weeks, and up to 50% of women experience a recurrence within three months. So as a clinician, you know, how can we get better results for our patients? Because those stats are horrid, they're really so poor. I mean, how can we get better results for our patients?

Moira: They are poor. And bacterial vaginosis is one of the, well it is the most commonly clinical presenting genital urinary infection out of all of them. So thrush is the second, even though most people who will talk about thrush will tell you that they've had thrush, but may not be able to identify that they've had BV.

Emma: Yeah.

Moira: The trick, I think as clinicians in how we can get better results for our patients, is to recognise those statistics and understand that a once off occurrence of BV is likely to result in a recurrence. And if they're not treated effectively, or consider the whole microbiome and the influences on that microbiome that led them to that outbreak or that issue in the first place, then we're not going to get long term results. So the key with addressing recurrency in BV is to consider the lactobacillus situation.

Emma: Okay.

Moira: Because the definition of BV is a loss of lactobacillus, this tipping of the seesaw where we have the overgrowth of facultative anaerobes, like Gardnerella vaginalis, or Atopobium, or Prevotella, and this decrease of lactobacillus or disappearance in some cases as well. And so, even though a lot of the research tells us when BV is treated with metronidazole, for example, we see a recovery of lactobacillus quite quickly. The longer term research tells us that that also doesn't hold for people.

Emma: Okay.

Moira: And so we need to assess the why. The why did this person end up there? What is in their lifestyle that might be influencing the vaginal microbiome? What sort of hormonal factors could be going on? And addressing as many of those touch points as possible, including partners, because we also know with BV, particularly recurrent BV, that if they have a male or a female partner, those things need to be considered. And when it comes down to male partners, there's actually some really interesting research where you can predict bacterial vaginosis incidents by the penile microbiome of a male partner.

Emma: Fascinating.

Moira: So this is a translocation thing that's going on between partners. So the restoration of lactobacillus or making that vaginal microbiome resilient and robust again post antibiotic treatment, or if when we're looking at recurrency, as a treatment in itself, is really key to breaking the cycle of BV, because it will just keep shifting out. 

So, for me that it means that I generally will address sexual interaction and modify that while we can so that we're limiting that disturbance factor. Anything that will disturb pH, because once we disturb PH, it's also an opportunity for these microbes to increase so that includes ejaculative sex or lubricants. Or if they are douching, or irrigating, that may not be the best thing for them at that time. Using soaps, for example, assessing workout gear, underwear, I mean, so many things in just lifestyle orientated stuff can impact recovery. It's not necessarily the only thing, but it's going to make it harder if they keep flipping back into disorder. 
And then looking at where it occurs in a cycle, if they have a menstrual cycle. Because again, that helps to understand what microbial shifts could be going on and their relationship to hormones and whether that needs to be addressed for an individual.

Emma: And do you think that tracking, generally, tracking for three months is a good amount of time to see some patterns? It would just be good to have a timeframe that we can give to patients upfront of how long we would like them to track their symptoms for to find some patterns.

Moira: Generally, within a month, you've got a pretty good data set to understand. And in my experience, most people are happy to continue to track ongoing because it's interesting for them and then they also become empowered because they can see that pH drop... I mean sorry, rise above 4.5 which generally is moving into dysbiosis and BV territory.

Emma: Yeah.

Moira: So they can understand to act as well, if you've given them strategies that they can utilise at home to move things back into range really quickly, then they can do that because they've seen it move out. So it means it doesn't progress because the microbiome just needs to be continuously shifted back, reminded that it needs to be in range.

Emma: Yeah.

Moira: So to prevent the cycle from occurring, we need to give it time to recover. We need the endogenous or native lactobacilli to be able to grow back up and to be able to stabilise. And that doesn't happen if you're constantly moving into BV, or you're challenging the pH on a regular basis. So tracking is a really useful, cost effective tool that's empowering for people. And that certainly you need to consider nervous system burden, because it's not for everyone. But in those people, I mean, ideally for pH for the first month, I ask people to do it daily, but not everyone is going to do that. And I don't know if I would, because I'm not that sort of person.

Emma: Yeah.

Moira: But ideally, then test when you have symptoms. Test, at least in the follicular or luteal phases, at least once if you can. If you feel a need, or have a discharge, notice an odour, test.

Emma: Yeah.

Moira: Because it's going to give you that pattern so that you understand as well.

Emma: And a clinical question, what is the most efficient way for a woman to test her pH balance? How does she actually do it?

Moira: Oh, just with the… You can get different types of litmus pH paper. It needs to be low range. So it needs to cover essentially the ideal pH range for a vagina, which is anywhere from 3.8 to 4.5. But it also needs to go above that. And it needs to be at least point five increments so that you can get those subtle shifts of point five to understand them.

Emma: Okay.

Moira: Because there is a difference between 4.5 and 5 when we're looking at vaginal pH. So if you go from four to five on your scale, you're going to miss that. And then generally just, either if it's a roll or a strip, you just...there's two different ways, I tend to advise people to do it. They can use little cotton tips and do a self-swab and apply that to the paper.

Emma: Okay.

Moira: Although, that's not always super effective for conditions where there is less discharge, or it's a pasty or a dryer discharge, which tends to fall into that recurrent thrush picture more than anything.

Emma: Okay.

Moira: Otherwise, they can fold the paper and scoop it around the inside of the vaginal canal, and then read the paper from there. And again, that may not be appropriate for people that have vaginismus or if they're highly reactive, and highly atopic as well. You need to be really aware of what people's triggers are before you get them to do any of those things. But it can be quite straightforward. For people that have quite significant vaginismus or vulvodynia but are seeing pelvic physiotherapists, I will often just get them to be that that's part of that visit to that pelvic physio...

Emma: Okay.

Moira: ...that they get their pH done and recorded while they're doing all the other exams.

Emma: Yeah. Well, super useful clinical tips there, Moira. Thank you.

Moira: Okay.

Emma: Now, I'd like to talk about the role of vaginal microbiome testing in clinic. So you know, what are your thoughts on it? And when is the most appropriate day of the cycle to test?

Moira: Yeah, I mean, vaginal microbiome testing is a very useful tool for us, particularly in atypical presentations, recurrent presentations that aren't responding to therapy. Or if they're people that have been told that everything's normal, when it's clearly not.

Emma: Yeah.

Moira: Then there's a good role for vaginal microbiome testing, because we get an insight into microbes that possibly aren't culturable, or are not reported upon in standard Gram stain culture and microscopy. So it can be useful to understand that, and it can also be useful to understand the vaginal microbiome in both health and disorder. So you get a baseline essentially, of what microbes are there. And then by understanding pH fluctuations, you can make some judgements around what could be shifting and changing over the course of a menstrual cycle...

Emma: Okay.

Moira: ...based on what you already know is living within that microbiome. But generally, if we're going to get the most bang for our buck with the vaginal microbiome test, it does relate to what the most appropriate day of the cycle is to test and then is dependent upon the individual.

Emma: Okay.

Moira: So for me, I get people to test when they're symptomatic. Because that's the shift I want to understand in most people. Unless they're coming to me for general maintenance, or for example, fertility and they're not necessarily symptomatic, then you would be testing around, you know, when you're trying to conceive.

Emma: Okay.

Moira: Around ovulation or mid-cycle, or sometimes even just understanding an early cycle. So there's not necessarily a right and wrong, but for people that have recurrent imbalance or infection tendencies you want to test when they're symptomatic, so that you can get a snapshot of what's going on in disorder for them.

Emma: Yeah, I think it’s a fairly new area in clinical practice, and a lot of practitioners out there may not have started doing this or maybe a little unsure. But I think that gives us some really clear clinical guidelines that we want to test our patients when they're symptomatic, especially if they're getting recurrent symptoms. But if they're coming in for generalised support, and possibly preconception, then around ovulation is going to be the best time for them to do that microbiome testing.

Moira: Yeah, yeah, that's what I've worked out pretty fast.

Emma: Beautiful. Now I want to discuss some simple and some practical tips to support both the uterine and the vaginal microbiome, what are some tips that you can share with us?

Moira: I think that when we're looking at it from a clinic perspective, or we're talking to clients around it, the best tip is to actually have the discussion. And then to go into a lot of lifestyle stuff. I mean, most people, when they have recurring issues will tell you, "I've done all the things, I've changed my underwear, I don't wash with soap, etc." So a lot of that is generally covered. 

But there is a lot of other things and the nitty-gritty detail that you need to understand, so you can help somebody modify and identify what their risks may be. So things like lubricant, for example, and ensuring that your lubricant is pH or is molecule correct, so it's not damaging to the environment or damaging to your cells.

Emma: Yeah.

Moira: Because a lot of people aren't aware of that. And sometimes even if they are using barrier methods, they may not be aware that some barrier methods have casein in them. And that could be problematic if they have issues with dairy proteins.

Emma: Yeah.

Moira: Or if they are atopic, that can also be a problematic factor.

Emma: Okay.

Moira: So some of those really practical things that are not even involving ingested therapies or vaginally applied therapies, it's just about what you're doing every day that could be challenging this environment. And I think because we have this higher use now, workout wear, for example, that's an area that probably needs to be explored a little bit more directly as well, because most people will say, "Oh, I've changed my underwear, and it's all natural." But then they're putting themselves into some semi-recycled plastic bottle lycra pants, and and that's not breathable, and they're in that and they're sweating. And that can be a challenge for them in different circumstances.

Emma: Yeah.

Moira: So those sort of things. And then, of course, we need to also be brave enough to ask questions around sexual habits to people...

Emma: Yeah, yes.

Moira: ...to understand that as well. Because there are certainly practices that maybe people are not aware of that they could be doing or not doing that could be challenging the environment. And we're never going to know about those unless we ask about it. So we have to be aware and certainly encourage people to be more mindful of their genitourinary and sexual health. And even things like STI screening, for example, is something that a lot of people will not have done regularly, or it had, particularly in older age group, it may not have crossed their mind that that's something that they need to even consider, that once the risk of pregnancy is decreased, sometimes the flag to go and get an STI screen also disappears.

So these sort of things are just discussions that we can do to look after the microbiome, I mean, anything potentially, that is shifting or changing the environment needs to be screened for, because if you don't change those things, then anything you're doing is not going to necessarily have...well, it's going to be harder to get that change you need in that space.

Emma: Yeah, there's so many factors there. But some really, really good tips. And I think you're right, in clinical practice, no amount of information is too small or no question should not be asked. So because sometimes we just have to have those really honest conversations with our patients, too, because sometimes they might not want to discuss their sex life with you. But it is important.

Moira: Yeah, it is important. And I think there's various ways to approach that. I mean, even though people come to me specifically for help with their genitourinary health, I have a screening questionnaire that also asks a lot of those questions already, so that I understand where they're at, and what type of partner or partners that they have, etc. So that, you know, A, we're not sort of limited. I mean, they know I'm going to be asking those sort of questions. And I do always let people know, I'm going to be asking you some very personal questions, and I do apologise, but the need for me to know means that I can help you. So often, even just explaining that and because it's such a new territory for so many people, and that they have not even been brave enough to discuss their vaginal symptoms most of the time.

Emma: Yeah.

Moira: And then you're there asking them about what sort of sex they're having, and how many people they're having it with, and what type of lubricant they're using...

Emma: Yeah.

Moira: ...or what their hygiene factors are around that. It can be a bit confronting, so you do need to ease into it. But I think that most people appreciate that really frank discussion as well, because they're probably worrying at the back of their mind, "Is there something that I'm doing?" I mean, a lot of people are looking for the factor or blaming themselves, and there are things to be found, but sometimes to find nothing is also confirms some of those diagnostic pathways as well.

Emma: Yeah. So I think the pre-frame is a great idea and explaining to them that, you know, the information that you're asking for could be very helpful in determining what treatment you're going to recommend for them. 

What about foods that can influence the vaginal microbiome? What foods should we be eating?

Moira: Yeah, I mean, gosh, when we look at this at a research level, there's not a lot of information. There's certainly links between glycaemic load in diets and vaginal microbiome. So, looking at that overall healthy diet, and we do know that even though the vaginal microbiome is an independent microbiome site, it does still interact with the gastrointestinal on some levels, it's not probably to the extent you would think and that they're not so similar that you can predict one microbe in one space to the other. But their relationship is still linked in terms of anything that you would do to support microbial health for the gastrointestinal system will improve microbial health for the vaginal microbiome.

So getting people to clean up their diets, and to remove anything that you think might be a problem food or a glycaemic trigger, is really important. And then sometimes in specific genitourinary disorders, you're looking for, going down rabbit holes and looking at things like oxalates, for example, but it tends to be something that I don't do straightaway, because that sort of restriction or elimination diet is a pretty big change. And if it's not necessary, then it's not necessary. So whole food diets are probably my answer to that, and abundant colours, and polyphenols, and plant fibres, and anything really, that you would associate with microbial health in other sites.

Emma: Yeah, that's very sound advice. And I do like the angle of the glycaemic load and just watching those blood sugar levels as well. 

Now, you have quite a lot of different roles, you're in clinical practice, you're in research, you're in education. How do you balance those three hats that you wear?

Moira: Yeah, oh, that's a really great question. I think that I'm very good at segmenting.

Emma: Okay.

Moira: And they are all related, obviously. But I'm mindful of what I do on what days. And I'm not in full time clinical practice, because I am in full time PhD.

Emma: Yeah.

Moira: So I have set times that I do things and I am very mindful as well not to promise things I can't necessarily deliver.

Emma: Okay.

Moira: So I've gotten much better at that. And I also don't put pressures on myself to, for example, deliver a treatment plan, straightaway. I have a set amount of hours or days that you will get this through on this day, if you see me on this day.

Emma: Okay.

Moira: So that I allow myself time to do that. I do, however, make sure that… I mean, I do work hard. I get up early in the morning, and I will do work in the morning or edit or do some referencing and do those sort of things. So being aware of what tasks I have, and just chipping away at them, essentially, is how I bring it all together. And yeah, I mean, there's also outsourcing what you're not good at...

Emma: Yeah.

Moira: ...and not being afraid to say no. And knowing where your boundaries are, are all really important things as well.

Emma: Yeah. And I must say, it takes a few years of clinical practice to work out how to do those, setting boundaries, saying no. So, it takes time to become good at that side of work as well. 
Now, for those new graduates or practitioners that are looking to build their clinical practice, what's one tip that you would give them to build a successful clinical practice? Because clearly, you are very successful, Moira.

Moira: Wow, thank you. It took a while. And I think that that's okay. You don't need to know everything straight away. I don't think you ever need to know everything. There's always the internet. And there's always books, and there's always good mentoring that you can access.

Emma: Yes.

Moira: But I do think you need to be aware that you need to put in effort to be a success at anything. And also that there's a whole lot of mindset associated with this profession particularly, and what it means to make money from it or to be successful. And there are lots of different ideas around that. And some of them are not true. So you need to be okay, and work through those blocks and think about what you really want. I mean, I think at the core of it, we get into this job because we want to help people and we want to help people heal and travel along their life journey.

And I think that that's a really wonderful thing to go into a job for. But we also as humans need to survive, and we need to make a living and if you want to do that in the job that you love, you also need to be okay with that. So there's, you know, I don't know. It took a while to work through that. I think, I mean, I remember not being very good at rebooking people.

Emma: Okay.

Moira: Or asking for money for my services and you have to sort of be okay with those things.

Emma: Yeah, you do. You absolutely do because we want to stay in clinical practice. And that means we have to be able to pay our mortgages, our rent, or whatever it is, we need to be able to do that as well.

Moira: Yeah. And there's wonderful things out there now to support us, certainly booking systems and automation, and all those sort of things that once upon a time, I had a big huge diary on my desk that I would scribble in and write people's names on, and it was all very manual. And now it's all very automatic. And so I can take myself out of a lot of those uncomfortable situations that maybe previously, I was not very good at. So I think that's also a really important part of building practice, as well is identifying which bits make you squeamish and really examining the why, of it.

Emma: Yes. Yeah.

Moira: But also being aware that in terms of this particular career, or profession, or trajectory, that you've chosen, that let it evolve, because I certainly don't think I would ever be here. I remember speaking to somebody once and they told me, "Oh, you'll be in women's health," and I was like, "No, I won't, that's the last area I want to be in." We went through only, personal fertility journey, etc. And even at the end of that, I didn't want to have a bar of doing any of it.

Emma: Yeah.

Moira: That this area excited me and it took a while to find me. So don't feel like you have to niche straightaway. But if there is an area that you enjoy, just work away at that and it doesn't mean that you limit yourself to not seeing other types of people, because I certainly still have diverse patients and they're not all female. And, things constantly surprised me that end up across my desk. So you're not limiting yourself by deciding you want to sort of work in one area, but you also don't have to just work in one area.

Emma: Well, we are all very glad that you are working in that one area and being that person at the front that we can all learn from. So thank you, Moira, for joining us today...

Moira: Of course.

Emma: ...and taking us through how we can best support the genitourinary microbiome. I mean, it's definitely an area that has been somewhat a bit taboo in the past and that so many practitioners don't have a lot of knowledge in this area. So thank you so much for sharing simple, practical and actionable tips with us today.

Moira: Well, it's been my pleasure. Thank you for having me.

Emma: Thank you everyone for listening today. Don't forget that you can find all the show notes, transcripts and other resources from today's episode on the FX Medicine website. I'm Emma Sutherland and thanks for joining us we'll see you next time.


About Moira Bradfield

Moira is a naturopath and acupuncturist who has been in clinical practice for 16 years. Graduating with a Bachelor of Naturopathy from Southern Cross University in 2001, Moira has worked in a variety of settings with a wide range of health conditions and disease states. She blends naturopathic medicine with Oriental modalities including acupuncture. Moira has a specialised interest in Holistic Medical Ophthalmology, working in an integrative service offering acupuncture and naturopathic medicine for people suffering from Degenerative eye disorders. Moira has lectured 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.


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Emma Sutherland
Emma Sutherland is a successful mum, author and clinical naturopath. Her mission in life is to inspire women to get their Mojo back and to help families raise vibrantly healthy children. Emma is a fully qualified Naturopath, having completed four years of training in Herbal Medicine, Nutrition and Homoeopathy as well as a Bachelor of Health Science. She has over 17 years of experience in treating women and children at every life stage. Her busy clinic provides her with many clinical insights as well as keeping her finger on the pulse of patient led trends. Her friendly personality results in a unique ability for people to feel comfortable and listened to. Emma’s daughter, Sophia, is her greatest teacher and constantly pushes her to do better and be better. Emma is passionate about always learning and discovering new concepts and strategies that she can apply to her clinical practice. And let’s not forget her number one value in life is fun!