By Dr. Colin Michie FRCPCH
Vaginosis is a common condition caused by changes in the microbes normally resident in the vagina. It is not always reported by sufferers, is often recurrent and causes concern to women of all ages, including after menopause. Vaginosis needs to be treated.
The many millions of micro-organisms cohabitating with us make up a busy world. We depend on them, but are only beginning to understand some of these tiny tenants. Once thought to be sterile, the womb contains a distinctive pattern of non-human organisms, found in larger numbers in the lower genital tract, the vagina. These microbial communities play critical roles in reproductive health, including fertility and the smooth progress of pregnancies. A healthy vaginal microbiome includes over a hundred different types of microbe, usually dominated by large numbers of Lactobacilli.
Lactobacilli make lactic acid and other products creating an acidic local environment. They protect the vaginal lining against invasive microbes such as Candidal fungi and anaerobes – bacteria that do not require a great deal of oxygen. Lactobacilli contribute to the characteristics of normal vaginal secretions. Oestrogens support them by providing a food source, glycogen, in vaginal mucosal cells which are broken down in each menstrual cycle by progesterone – crucial endocrine links to vaginal health.
Lactobacilli appear frequently on supermarket labels as starter cultures for acid-fermented probiotic foods. Lactic acid helps foods last longer, preventing spoilage – yoghurt or cheese from milk, or sauerkraut from cabbage. It can make them more digestible, as with miso from soya beans or sourdough maize breads in West Africa. Lactic acid enhances flavours, as with coffee beans, Scotch bonnets and other pickles. Acid fermentation adds to the flavours in ginger beer, mauby, wines and ciders. Many foods are prepared using symbiotic cultures that include beneficial yeasts together with Lactobacilli. On the farm Lactobacilli contribute to the fermentation of silage, enhancing the milk provided by cows eating it. Fermented foods in our diets probably have many benefits for gut and brain health.
Healthy vaginas have robust microbial defences. They do not require specific care. Disinfectant douches, gummies, sweeties or other “lifestyle” modifications are not necessary! However, if vaginal Lactobacilli diminish in number, other bacteria (including species of Gardnerella and Atopobium) take over, becoming more numerous. They form defensive layers or biofilms, distorting the healthy ecosystem. This dysbiosis causes vaginal secretions to become watery and grey, with a fishy odour. This characteristic malodorous problem is vaginosis.
Vaginosis may be sexually transmitted. It can follow sexual activity, although is less frequent if condoms are used. Vaginosis has been described in those with low levels of vitamin D or with limited access to clean water and flushing toilets. Cases have been linked to using copper intrauterine devices too, or rarely in women taking testosterone supplements. Vaginosis is not caught from a toilet seat or swimming pool.
Vaginosis itself does not sound dangerous – it usually does not cause pain or itching. But it brings many risks. Vaginosis makes it much easier to catch sexually transmitted infections. Many pathogens find it easier to invade, Including papillomaviruses that can cause cervical cancer, the HIV virus, syphilis, chlamydia and pelvic inflammatory disease. Vaginosis during pregnancy is linked to miscarriage, early rupture of the membranes and preterm labour. These complications affect the sufferer, the next generation, the wider family – all large emotional and economic burdens. Vaginosis rarely disappears on its own – it needs treatment.
Vaginosis is under-reported in women after menopause. As oestrogen levels fall, Lactobacilli disappear and vulvovaginal atrophy develops, limiting sexual activity and reducing the quality of life. Local vaginal treatments with oestrogen creams protect Lactobacilli and reduce the risks of vulvovaginal atrophy and vaginosis. Laser therapies offer a second-line approach that can treat some successfully.
Traditional herbal treatments are commonly used for vaginosis. Mexican poppy, oregano, garlic or lemongrass are recommended. Boric acid vaginal suppositories are useful disinfectants. They are helpful in preventing recurrence of vaginosis, because boric acid tends to spare Lactobacilli and treats Candidal infections too. These various approaches are thought to remove smell-producing microbes by breaking their defensive biofilms. Biofilms need removing, because within them bacteria and fungi become resistant to antimicrobials. Approaches with probiotic Lactobacilli in live cultures, or products such as royal jelly, logically should support local Lactobacilli. However, their value from formal trials is not clear. Improving and re-balancing microbial communities is the subject of a great deal of study – in the gut and skin too. We need to learn how to keep those beneficial bug tenants happy.
Short-course treatments with the antibiotics metronidazole or clindamycin are effective for vaginosis. Treating a regular sexual partner may reduce recurrence too. If your vaginal secretions develop an abnormal smell, it is worth seeking advice from a local healthcare centre.
Dr. Colin Michie specialises in paediatrics, nutrition, and immunology. Michie has worked in the UK, southern Africa and Ghaza as a paediatrician and educator and was the associate Academic Dean for the American University of the Caribbean Medical School in St. Maarten a few years ago. Useful resources: nhs.uk/symptoms/vaginal-discharge and cdc.gov/bacterial-vaginosis/about/index.html.
