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IG Live Recap: The Vaginal Microbiome and Symptoms of Imbalance During Menopause

Mallory Junggren

We recently hosted our fourth Instagram Live session of Bonafide Talks on the topic of the vaginal microbiome and what can happen if/when an imbalance in this delicate ecosystem occurs during perimenopause or menopause.  

During the conversation we covered a variety of topics, including what exactly the vaginal microbiome is and how it differs from other microbiomes in the body, as well as what can happen if there’s an imbalance, symptoms that may present and treatment options to handle them. In case you missed it, we’ve included a recording of this fourth session here, along with a full transcript of the video.

Stay tuned for more Instagram Live sessions!


What is the Vaginal Microbiome?

Sarah: Hi, everyone. Thanks so much for joining the 4th session of Bonafide Talks, which is our Instagram Live series. We’re here with our Chief Medical Officer at Bonafide, and practicing gynecologist, Dr. Alyssa Dweck.

We’re super happy to be here. For those of you who are new, welcome, and thank you for joining. If you missed any of our past sessions, just know that they've been recorded. And you can find them on Instagram and Facebook, along with the transcript on our blog, so you can follow along with the talk.

My name is Sarah, and I'm on the product team here at Bonafide. Today, I'm going to be talking to Dr. Dweck about the vaginal microbiome and how that can change during menopause and perimenopause. We'll also talk about different treatment options – along with why the microbiome changes and answer all your questions about that.

So, doctor. Thanks for being here. Maybe you can introduce yourself.

Dr. Dweck: Absolutely. Hey, Sarah, great to talk to you again. So, Dr. Alyssa Dweck, I am a gynecologist in New York and have practiced for almost 30 years. I see women of all ages, and I am so excited to be here representing Bonafide as Chief Medical Officer to talk about one of the most popular topics now, the vaginal microbiome, so we're going to get right into it.

Sarah: Let's do it! All right, great. Well, so let's start by talking about the vaginal microbiome. Just the basics, because I feel like a lot of people think of the microbiome, and they think of the gut. Right? So, how can we talk about the vaginal microbiome? How does it differ from the gut?

Dr. Dweck: Yeah. So, you know, a microbiome is basically a community and environment of organisms. It would be organisms like bacteria, like viruses, like fungi, and other organisms that all live in harmony together. And so many areas of our body have a microbiome.

We have all heard of the gut microbiome; there's actually a microbiome in the skin; and there's a microbiome in the vagina, which is super special. The incredible organ, the vagina, keeps the microbiome in check, because it contains good bacteria, which are also referred to as lactobacilli, various strains, and other bacteria, in check. They're in perfect harmony and balance and the vagina has mechanisms to do this. In essence, lactobacilli, a good bacterium, produces lactic acid and even hydrogen peroxide to help keep the vagina in an acidic pH. This is what's considered to be helpful.

Sarah: So, it sounds like what you're saying is the vaginal microbiome has specific strains that keep it healthy. And it differs from the gut. And so, I know that the microbiome is pretty delicate, and it can change; I know that during menopause specifically, there are some changes that take place. So, I'm curious if you can explain what happens during menopause or perimenopause that affects the vaginal microbiome?

Dr. Dweck: Absolutely. So, the drop in estrogen that occurs both during perimenopause and during menopause alters the pH of the vagina and alters the number of bacteria, the lactobacilli good bacteria, and therefore the pH changes. So, that's really what's going on in a low estrogen environment. In fact, it seems like the menopausal vaginal microbiome almost mimics an infection called BV or bacterial vaginosis, which we can get into later. But in other words, there's a dysbiosis or imbalance in the usual bacterial community, which can cause symptoms like discharge, odor, itching, irritation, and just not feeling one hundred percent right.

What Causes Imbalances in the Vaginal Microbiome?

Sarah: Okay, that's super helpful. And I was just thinking while you were talking about how it's a very sensitive environment. So, are there other factors that can also influence the microbiome besides just menopause and estrogen levels?

Dr. Dweck: Yes, absolutely. So, we call these ‘disruptors’. There are various disruptors that all of us, you know, experience in our day to day lives, that can cause an imbalance in the microbiome.

So, low estrogen, whether it's because of menopause, perimenopause, or even things like using oral contraception, which is a hormonal medication, can alter the vaginal microbiome. What else can? Well, antibiotics that we commonly take for various infections; steroid use, certain infections that can occur due to using very fragrant products, like laundry detergents or fabric softeners or wipes or body soaps and things that we use in the shower for hygiene every day.

So, we really have to be very mindful of ingredients. Because all of these things can be microbiome disruptors. Sex is another one that we often talk about. So, sex with one partner or multiple partners can predispose someone to an altered microbiome, and condom use can sometimes be really helpful to prevent this.

Sarah: Great, yeah, that's super helpful. And, you know, it's good to know that there's so many different factors that you have to be aware of, and how they can, in fact, impact your microbiome. And one thing stood out to me, you mentioned antibiotics. And I think that might seem a little contradictory to some people. They may think, hey, that's the opposite – antibiotics are good; they only do good things. But how can they disrupt the microbiome, and it sounds like they can cause a little bit of imbalance too?

Dr. Dweck: Yes, because think about it, antibiotics, while we certainly need them to treat infections and whatnot, they can cause an imbalance of bacteria because they not only kill off the bad bacteria, but they may kill off some of the good bacteria. So, it's all a matter of having this harmonious balance of good and bad bacteria.

Taking antibiotics has to be something done in a very thoughtful way, in an effort not to overuse or abuse them and cause antibiotic resistance, but also so that it doesn't cause imbalance of bacteria for too long of a period. I think this really comes into play when people are suffering with recurrent infections. Some people will experience let's just say, one yeast infection, so they go ahead and treat with an antifungal for that yeast infection. And then they end up maybe with a just an imbalance, which can progress to BV as a result of that [yeast] treatment. They then have to be treated with antibiotic to address that secondary infection. And so, it really can become a vicious cycle. The other thing is that people get recurrent infections as a result of resistance. So, there may be resistant strains of bacteria or resistant strains of fungus, that don't necessarily respond well to the medications that are used. And that can also cause a vicious cycle.

What Symptoms Can Present with an Imbalanced Vaginal Microbiome?

Sarah: Let's definitely talk about ways that you can break that vicious cycle. But before that, since we did talk about what imbalances the vaginal microbiome, you talked a little bit about the symptoms that occur from that. But maybe if you could just lay out a few of the main symptoms that someone would say, hey, you know, I might have imbalance, and I'm experiencing these symptoms.

Dr. Dweck: Hundreds and thousands of women are seen every day for what we call vaginitis. That simply means inflammation of the vagina, and it causes symptoms. One very common symptom is discharge. Now, look, all people with vaginas have a little bit of vaginal discharge, and it might vary through the cycle. But most people with vaginas also know when something seems off. So, whether it's the amount, the consistency, the odor, those are things that should be monitored. Number two would be itching, irritation, and a change in the vaginal scents. So again, vaginas usually have a scent, but sometimes it can change and become more of an odor. And people are usually aware that something's not right.

Sarah: Yeah, that's really helpful. Because I feel like you're saying anyone with a vagina knows that different symptoms can happen, but it's good to hear that from you. It's kind of like, if you feel like something feels off or different, that's when it might be an indication that you might have some sort of imbalance.

Dr. Dweck: Exactly. Look, I always like to also preface this by saying bloody discharge, something that's really painful or uncomfortable; these things should be checked out right away just to rule out a bigger problem. But again, your provider can examine you. Checking with your healthcare provider can be helpful to discern even just a mild symptom change.

Sarah: And just to clarify one thing, you mentioned how there's infections like BV and yeast? But also, that some women can just have an imbalance. So, maybe what you can clarify is, is it possible to have all of these symptoms without an infection, and then also with an infection?

Dr. Dweck: Yes. So normally, we check for infection with a culture, sometimes by just doing a vaginal pH screen, sometimes by looking at the vaginal secretions under a microscope, so that we really can figure out what's going on.

But you know, symptoms can sometimes not be suggestive of an overall infection, but just a mild imbalance. And this is what’s primarily occurring during menopause, where the pH is changing a little bit. And the environment of bacteria and the ecosystem is changing just a little bit. But it's not enough to qualify as an actual infection. So, antibiotics or antifungals really may not be the best management strategy here. Because you may end up creating more of a vicious cycle. Odor, discharge, itching, irritation, these things can occur even without infection, but just due to a slight alteration.

What Treatment Options Are Available for Addressing Vaginal Microbiome Imbalances?

Sarah: Okay, that's super interesting. And that leads me into my next question and topic because I wanted to talk about the management of the symptoms. And so maybe you can talk a little bit more about how there's different approaches, if you, for instance, have an infection. How do you treat them and how do you manage it after versus maybe if you know, you're negative on culture, but you are having these symptoms. Let's talk through some different treatments.

Dr. Dweck: Well, the first time somebody has symptoms that are a little bit concerning, I do think it deserves a healthcare provider visit just to get a good history and see what habits may be going on that might be contributing to this. Also, to do some cultures or to take a look under the microscope and see what's going on.

In general, infections are treated with an antifungal or an antibiotic. However, I think getting to the root of what might be causing the imbalance in the first place is so important. So, it's really vital to look at all products that people are using, you know, inquire about sexual habits and whether condoms are being used.

Think about other medical issues that might be in part responsible, like diabetes, or something along that line, which can predispose people to certain infections, particularly yeast. Certain medications might give symptoms of concern. So, these are things that might be able to be tweaked a little bit. The other thing is what can we do for prevention, especially for people who are suffering with recurrent infection? And what I normally will recommend is a probiotic geared specifically towards vaginal health.

So obviously, you know, we know a lot about Clairvee®, which is the probiotic that Bonafide makes. And this is a wonderful probiotic that has clinical studies behind it to suggest that it really helps to rebalance the microbiome in the vagina, and can help with prevention of recurrent symptoms, not necessarily related to infection, including odor.

What to Look for When Choosing a Vaginal Probiotic for Vaginal Health

Sarah: Okay, yeah, that's really helpful. And I know that there are a lot of different probiotics, and maybe it's hard to choose, or distinguish between a few. So maybe, are there some things you can list, just to clarify, what's good to look for, and, what makes a good probiotic and, and also, why it's important to look for things, like specific strains for the microbiome? Maybe just connecting back to that, because we talked about how it's really different to the gut.

Dr. Dweck: So, look, the strains are important, the amount of probiotic that's physically present in the supplement is really important. Clairvee, for example, specifically has lactoferrin included in the blend of probiotic with the live strain. So, this helps to maintain its viability throughout the GI tract, because this is an oral supplement that's taken for 15 days of each month. So, we know it's well studied. And that's what resonates with me the most as a physician, is that it's been studied for safety and efficacy.

But, you know, other lifestyle measures may be helpful for prevention, like getting out of wet workout clothes right away, like avoiding sitting in a wet bathing suit for long periods of time. And again, noting the other lifestyle habits that we talked about before.

Sarah: Yeah, that makes sense and is really helpful. One thing I've noticed is that there are so many different products for the vaginal microbiome, especially for vaginal odor and things like that. And so, it gets kind of hard to know what's good to do and what's not good to do to support your microbiome.

Maybe you could talk about what not to do, or what you don’t want in a product for vaginal health.

Dr. Dweck: Look, some people can use any product with no problem at all. So, I want to just put that out there. But things that are highly fragrant often cause microbiome disruption and sensitivity; things that are flavored, like particular lubricants that might be flavored or scented, that's something that causes irritation and disruption for lots of people. Gynecologists typically frown on the habit of douching, because that can really alter the microbiome and cause some symptoms.

I wanted to really point to a study that we presented at the North American Menopause Society regarding odor because this is such a common issue. Some people do complain of genital or vaginal odor without any obvious infection. And we studied Clairvee, in light of this, and women noticed an improvement in their odor as soon as two weeks and an even more significant improvement after four weeks, which is something that really resonated with me and with our audience.

Sarah: Yeah, for sure. I know it’s something a lot of women struggle with. And yeah, and it can impact their quality of life and things like that.

Dr. Dweck: And self-confidence. Don't ever dismiss that, because that's super important.

Can the Vagina Correct Imbalances in the Microbiome On its Own?

Sarah: That also made me think of another question, when you were just talking about all these different treatment options. I feel like you can read online that the vagina is self-cleaning. So, would you just say it can solve all its own problems, or what's the story there?

Dr. Dweck: Well, it's designed to be, you know, like a self-cleaning oven. We often talk about that. But again, this goes back to the natural lactobacilli that are producing lactic acid that are keeping the vagina in a good acidic pH range; for you science buffs out there, 3.8 to 4.5 is in the acidic range. And that's how it maintains itself. But sometimes it is overwhelmed by disruptors that are in our everyday lives. It needs a little bit of help.

Sarah: It sounds like there's a lot of different things out there that can disrupt it. So, it makes sense to use something consistently to kind of help it be in balance and probiotics can help in that area. Awesome.

So, I think something else that probably a lot of people are curious about is how to approach this with your doctor. I feel like this could be a sensitive topic, kind of similar to the other topics you’ve talked about on Instagram Live. So, maybe any advice that you have, from your perspective.

How to Talk to Your Healthcare Provider about Symptoms of Vaginal Microbiome Imbalance, Like Vaginal Odor

Dr. Dweck: I feel like just being direct and as detailed as possible is very important. These days, there's so much reading and information that's top of mind; here we are speaking about the vaginal microbiome so that people coming into see their healthcare provider should be comfortable saying, “I am here because I'm concerned about a vaginal odor”, or “I am here because I'm concerned about a discharge that seems a little bit off for me, or an irritation or itch.” And then, of course, a great healthcare provider is going to elicit further information and get a good history so they really can get to the bottom of things. But being direct is my recommendation. I can guarantee your healthcare provider has heard this question before.

Sarah: Exactly! So yeah, that's good to know. A lot of people are experiencing it and practitioners are knowledgeable about it. So, it makes sense to just ask them and be direct as you can. Okay, great. I think we've covered everything. Is there anything else that you feel like we need to touch on a little bit further?

Dr. Dweck: No, no, I'd love to get some questions addressed because I see that there are several.

Common Questions About the Vaginal Microbiome and Symptoms Like Vaginal Odor and Discharge

Sarah: Alright, let's go into our question component. Alright, let's see here. Okay, one question we have is from someone whose never experienced a lot of discharge. But now, she said she thinks she’s perimenopausal, but is not sure. She seems to have discharge a lot more and isn't really sure what's going on. So, I was curious are changes to discharge normal during the time of perimenopause?

Dr. Dweck: Yeah, it's not unusual. I don't want to call it normal. And I don't want to call it abnormal, but it's not an uncommon concern that I see in the office. I think the big deal is to elicit the characteristics of the discharge, again; is it a bloody? Is it green or a different color? Is there itching or irritation associated? Is there a foul odor associated? Is it just, you know, related to a particular time of the cycle?

But in general, this is somebody who I would say, you know, if you have concerns, go in and get it checked out – a culture will likely be done, perhaps something called a wet mount, which is an evaluation of secretions under the microscope. And, you know, we'll figure out whether there's an infection or just a slight change. But the change in hormone levels that occurs during perimenopause may be leading to this and it may just be physiologic.

Sarah: That makes sense. And it sounds like, if you feel any changes that are making you uncomfortable, if you feel uncomfortable at all, why not see a doctor…it can't hurt? Okay, very helpful.

Another question came in about being embarrassed about vaginal smell. And she was saying she feels can smell herself more than normal and is nervous to be around other people. We talked about confidence and things like that. So, she feels like her hygiene hasn't changed. She's saying, you know, what's going on here?

Dr. Dweck: Boy, I hear this question literally every day in practice. So, look, a horrific, horrible foul odor might be related to a forgotten tampon. So, I'm just going to get that off my chest, because we do see that in the office from time to time.

Most of the time, when somebody senses a foul odor, it’s not recognizable to the outside world. So just for reassurance; but BV or bacterial vaginosis is an imbalance of the bacteria in the vagina, and it typically causes a fishy odor. This is something that can be treated with an antibiotic, and then even maybe prevented by using a probiotic, over time, to prevent this from occurring again, and eliminate the offending factor. Sometimes using a condom can also help before prevention. So, I think this is something that should be checked out.

Sarah: Yeah, that's really helpful. And then another question came in; is there a way to test if your microbiome is imbalanced at home? Which I feel like is a really good question, and probably a lot of women will find it useful to understand and take away something new.

Dr. Dweck: Yeah, I think that this is a question that's going to evolve over time in terms of response. So, right now, we certainly have the capability of doing at home pH testing of the vaginal cavity. And again, we've mentioned a couple of times that the normal pH is acidic. So, this is something that can be depicted by a simple test. The thing is, is that there are a lot of things that can alter the vaginal pH, including menstruation or any other blood, in addition to, you know, ejaculates. So, if somebody's had recent intercourse without a condom, but also possibly has an infection, they can do a pH test which may give a little bit of information that can be elicited at home. Right now, and on the horizon, likely are many, many at home tests that are called microbiome tests. And they essentially let people know what the community of organisms is that normally live in their vagina, because everybody's a little individual this way.

Then once you establish what is normal for you, you can test again and again and again and see if there is any abnormality or change, when you have symptoms. The issue here is we're not 100% sure how to manage results, yet, without knowing whether there's a specific infection involved. But it could be very, very helpful in future for people to sort of get data on themselves and monitor themselves. And eventually, I think this will be really, really ready for primetime.

Sarah: And that's interesting what you're saying, there's obviously bacteria that are more prominent in every woman's vagina, but it can be slightly different between individuals. So, in the future, that could be really interesting to measure yourself in real time.

Dr. Dweck: And just to go into that a little more, when I say communities of bacteria, you know, the lactobacilli come in many, many different strains. And we are finding out that different people have a different majority of strains. So that's something that we're learning more and more about over time, okay.

Sarah: And you mentioned pH. So that is a test that is easily done at home?

Dr. Dweck: You can easily get pH paper, what's also called litmus test paper, and you can test at home. Again, I think it's riddled with a lot of false positive results for various reasons. So, you do have to be careful with interpretation. The standard is to do cultures in an office, in the healthcare setting, to really depict what might be going on – and also doing the microscopic exam.

Sarah: Okay. Okay. Good to know. And that kind of relates to another question that I have coming in because it's specific about infections. A woman is saying she's 43 years old, and she is getting feels like she's getting BV every month now specifically during her period. That didn't used to happen and she’s just curious why it's happening now. And if there's anything to do to prevent that.

Dr. Dweck: Recurrent BV is very frustrating for both the patient and practitioner; figuring out what is the root cause of these infections popping up. And in this particular case, it almost sounds like it's cyclical and related to the menstrual cycle.

So, if it's right after menses, it could be the menstrual hygiene products that are being used that are actually causing a little disruption. Again, we advise using the least absorbent tampons as appropriate for flow, we advise, you know, changing them out on a frequent basis, we advise non-fragrant products of course, when it comes to tampons.

In regard to sexual activity, many people will notice that they develop symptoms of BV after sexual activity. And this could be related to exposure to ejaculate. So, using a condom, at least for a period of time may help to break the cycle and prevent recurrent infection. Using a probiotic may be a helpful thing in this particular case as well. But, you know, I think again, ensuring that there's no medical issue that needs to be addressed would be very helpful. From time to time, we will do a regimen like antibiotics for a particular diagnosed infection once a month for a couple of months, add a probiotic to help with prevention, and try to break this vicious cycle.

Sarah: Yeah, that's helpful. And I feel like that's good to know, if someone who's experiencing these types of symptoms in a cyclical way to be aware that it may be related to your period or some sort of sexual activity, and that there's things you can do consistently, like, taking a probiotic, but also being aware, during those times, you know, maybe not to use a scented type of menstrual product and keep a calendar of symptoms in an app. Everybody, you know, seems to keep an Apple calendar of some sort, especially regarding their cycle, because a pattern may be recognized and really help with management of this.

Dr. Dweck: Yeah, that can be really helpful.

Sarah: Definitely. Okay, great. So, another question we had coming in was about the concept of using gut probiotics and vaginal probiotics. So, if someone is already taking a gut probiotic, for instance, can they also take a vaginal probiotic?

Dr. Dweck: Yeah, this is a little controversial. And I would say, for the most part, it would have to be individualized based on the particular person. Some people are using gut probiotics for kind of more significant issues, like irritable bowel syndrome or whatnot. And I surely wouldn't want to interfere with that type of management. In general, you know, nobody wants to overload on too many strains or too, too much of a probiotic, which could potentially not be a great thing. But I think this needs to be individualized. Okay?

Sarah: That's good to know. So maybe, you know, ask your healthcare provider about that. Okay, another question that we have coming in; so, this kind of relates to what we talked about before, someone was saying that she has been tested multiple times for an infection and results keep coming back negative, but they’re still noticing vaginal odor, it's bothering her, what can she do?

Dr. Dweck: Yeah, I would have to assume that this might be due to a hormone change that is causing less lactobacilli in that vagina but not enough to, you know, turn into an infection. So, again, a probiotic, such as Clairvee, which has been studied for just this issue, might be really helpful, in this particular case. There are people who also use boric acid, specifically in the form of a suppository in the vagina to help with this issue. And we do have good information that this could be helpful either with an oral probiotic, or as a separate alternative.

Sarah: Yeah. And it's interesting you said that because I was just looking at another question coming in about boric acid suppositories, specifically reading that they're really good for pH and stuff like that, but I think they can be a little bit scary sometimes for someone to use just because it's a kind of a strong remedy.

Dr. Dweck: Yes, I mean, listen, this is boric acid, that kills roaches, so I can understand people feeling a little bit hesitant. However, this has been used for years and years and years with good results. Very important; this caveat – absolutely no oral ingestion of boric acid, ever. That's a reason to call poison control. Some people use boric acid vaginally along with an oral probiotic. Some people will use boric acid just, you know, around the time of menses to assist with odor, but it's a very reasonable alternative. And remember, boric acid is in the acidic range, it's an acid. So, it helps to re-acidify the vaginal canal.

Sarah: That's, that's good to know, that you can use it, maybe, you know, as another type of treatment option. Okay, let me just see if there's any other questions coming in. All right, I think we covered everyone's questions. So, this was great, and we covered a lot of ground.

Dr. Dweck: I think we did. And you know, this is such an exciting topic, because we are literally knee deep in research about the vaginal microbiome and really stay tuned for much more information to come out in the future!

Sarah: Yeah, yeah. It's a really amazing area of study; obviously, there's a lot of questions and a lot of people who are struggling with different symptoms. I'm glad we're able to talk about this and provide some info, and things like that. So hopefully, you know, everyone found this helpful. And just a reminder that this session is being recorded, and it will be available in the upcoming weeks on our Instagram and Facebook.

And, if we didn't get to your question, please, please feel free to DM us. Know we're always here to help and we want to be able to get back to you and answer your questions. So, thanks for being here!

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