By: Mary Schroeder, ND, LAc

How to Cultivate Your Microbiome,

Part II: Vaginal Flora

If you have recurrent vaginal infections, you’ve likely been on a rollercoaster of antibiotic and antifungal medications, only to have the familiar symptoms return a month later. This tale is all too common, and can leave patients and doctors stumped and frustrated. Luckily, the burgeoning field of microbial research has spurred a paradigm shift in gynecology and may provide the missing link to sustained yoni health: the vaginal microbiome. 

The vagina, just like our gut, skin, and urinary tract, is home to an ecosystem of bacteria and fungi that have a symbiotic relationship with humans. In exchange for nutrients, these microbes help maintain a stable vaginal environment and ward off pathogens.^1,2 Recent advances in microbial identification have granted us a deeper understanding of vaginal microbes and how to foster resilience in this delicate and essential ecosystem. In this article, we have distilled key findings in vaginal ecology as well as ways your can work with, rather than against, your vaginal microbes. 

Queens of the Realm

Unlike most other ecosystems, in the vaginal microbiome, less diversity is key. The healthiest vaginal kingdoms are dominated by just one or two bacterial species.² In the majority of vaginal ecosystems, Lactobacilli play this leading role. While the most common species are Lactobacillus iners, Lactobacillus crispatus, Lactobacillus jensenii and Lactobacillus gasseri, the identity of these key species can vary widely from person to person and among racial and ethnic groups.^1,2 In one study, as many as 20% of healthy, asymptomatic subjects had microbiomes dominated by non-lactobacillus species; this estimate reached as high as 40% in black and Hispanic women.¹ 

These queen species of the vaginal microbiome have a mutually beneficial relationship with their human hosts. In response to estrogen stimulation, the vaginal walls produce glycogen, as well as an enzyme, alpha-amylase, that breaks it down into digestible morsels for the bacteria. ^2,3 In turn, the dominant species produce lactic acid to maintain an acidic environment that they, and they alone, can thrive in. They also produce chemical weapons like bacteriocidins and hydrogen peroxide to kill off their competitors and maintain their hegemony.² Through these defense mechanisms, resident microbes help protect their human hosts from a variety of bacterial, fungal and viral infections, including gonorrhea, chlamydia, HIV, and candidiasis.²

Landscape Disturbances

Hiking through the old growth rainforests of the Olympic National Park, my eyes inevitably gaze up to the giant arms of the Sitka Spruce, Western Red Cedar, Doug Firs, and Western Hemlock. Their expansive limbs house whole communities of cascading epiphytes, lungwort and licorice fern, and create a dappled sunlight that allows specific species to grow beneath them, like deer fern, queen’s cup, hooker’s bells. Here, it is clear that the ancient trees help define the landscape, and that without them, very different species would thrive. 

In the vaginal microbiome, the dominant bacterial species define the landscape and therefore define the ecosystem. The lactic-acid-producing bacteria create an acidic environment, with a pH of between 4.0 and 4.5, keeping other bacterial in check.¹ Living among these dominant species are many others that are considered “normal” in smaller quantities, but that become problematic in larger quantities. 

For example, Gardenerella vaginalis is a normal member of the vaginal ecosystem in small numbers. However, when the vaginal acidity decreases, G. vaginalis is able to flourish. As its population blooms and dies, it creates the fishy-smelling discharge and itching that are the main symptoms of bacterial vaginosis (BV). While G. vaginalis is the most common culprit in BV, there are many species that can overgrow and cause symptoms when pH rises.² Similarly, Candida species, are considered normal resident fungi when their populations are kept in check. When the resident vaginal microbiome is weakened from antibiotic use, or when a woman’s blood sugar is elevated, these fungi can overgrow and cause the itching, burning, and thick, curdy discharge characteristic of a yeast infection. 

When treating these bacterial and yeast infections, it is important to not only cull the overgrown populations, but to also address the underlying shifts in the landscape that set the stage for the infection in the first place. Two major landscape features allow for stable vaginal communities: acidity and estrogen. Since estrogen stimulates the vaginal walls to secrete glycogen, which bacteria convert into lactic acid, its presence has a major influence on the vaginal landscape. When the pH or estrogen levels change, so does the microbiome.

The vaginal ecosystem changes drastically throughout a woman’s life, largely due hormonal shifts.³ At times when estrogen is relatively low, such as around the time of menstruation or after menopause, the acidity of the vagina decreases, leaving women more vulnerable to vaginal infections.^3,4  It is very common for women to have altered vaginal flora after bleeding, as many menstrual products can harbor bacteria, and since blood can decrease the acidity of the vagina. This can cause a transient change in vaginal odor that is considered normal, but more significant shifts in the resident microbes can lead to recurrent bacterial vaginosis. 

Other factors that can affect the vaginal pH and cause disturbances in the vaginal landscape include spermicides, a new sexual partner, semen, douching and smoking.^2,3 Exposure to antimicrobials can also disturb stability of the vaginal community by killing the lactic-acid producing species.² 

Ecological Restoration

Often, the disturbances in the vaginal landscape seen in BV are short-lived and the bacterial community can re-establish itself without intervention. For most, the best thing you can do for your vagina is to leave it alone and let the ecosystem re-establish. However, many women experience persistent symptoms or recurrent infections, often associated with menses, menopause and frequent antibiotic use. 

Conventional treatment can involve antibiotics such as metronidazole gel or clindamycin cream. Unfortunately, recurrence of bacterial infections after treatment is common. An estimated 15-30% of patients have a recurrence of symptoms 1-3 months after antibiotic therapy; 70% of patients experience a recurrence within 9 months.²

If you are struggling with recurrent infections, it may be time to restore your vaginal ecology and landscape. Here are some helpful tips to help maintain your vaginal environment on a daily basis:

• Ditch the douching. Just like our eyes and mouth, our vaginas have a mucosal layer that keeps our tissues healthy and happy. You would never clean your eyes with soap, so why would you do that to your vagina? For cleaning your labia, or the outer-bits, use just water or a gentle, fragrance free soap. Be careful with “natural” soaps that contain a high concentration of essential oils; even Dr. Bronner’s can be caustic to vaginal and labial tissues. 
• Let your fanny breathe. Synthetic materials in panties can be irritating and can decrease airflow to our ladybits. Thongs are particularly troublesome because they can drag microbes from back to front. These fecal microbes don’t necessarily colonize the vagina, but they can alter the balance of the vaginal ecology and increase the risk of bacterial vaginosis. If you are going for a seamless look, try out seamless panties or boyshorts. For greater breathability and less irritation, go for bleach-free cotton materials. 
• Avoid antibiotics when possible. There is certainly a time and a place to take antibiotics, as they can save your life in the face of a serious infection. And yet, as we discover more about the benefits of our resident microbes on our health, as well as the rise of antibiotic-resistant pathogens, the medical community is shifting to prescribe antibiotics more conservatively. Consult with your healthcare provider any time you are considering using an antibiotic. 
• Vaginal probiotics. You have probably heard of ingesting probiotic supplements and foods, but did you know that you can use probiotics vaginally as well? Vaginal probiotics can help repopulate your queen species and crowd out pathogens after a disturbance to your resident flora. Look for creams and suppositories that contain some of the more common dominant vaginal species (Lactobacillus iners, Lactobacillus crispatus, Lactobacillus jensenii and Lactobacillus gasseri). If you are prone to bacterial vaginosis, it is smart to use a vaginal and oral probiotics for up to three months after taking antibiotics. 
• Choose your menstrual products wisely. Many commercial menstrual products contain bleach and fragrances that can degrade the vaginal microbiome and irritate vaginal and labial tissues. Opt for bleach and fragrance free pads and tampons, or consider re-useable products like menstrual cups, discs and absorbent panties. If you are using re-usable products, be sure to change and clean them regularly to avoid a build-up of bacteria. 
• Balance your blood sugar. Spikes in blood sugar can contribute significantly to vaginal bacterial and yeast overgrowth. If you are prone to vaginal infections, avoid refined sugar and simple carbohydrates and keep your consumption of “natural” sugars, like maple syrup, honey and dried fruit in low quantities. Alcohol is another sneaky source of extra sugar; consider limiting drinking or going sober if you are prone to vaginal infections. 
• Practice smart sex. Novel skin and oral bacterial populations from new sexual partners can disrupt your vaginal flora. Interestingly, expert opinion suggests that vaginal ecosystem often adapts to these new microbes over time. Semen, and many spermicides and lubricants can decrease the acidity of the vagina, setting the stage for vaginal infections. If you are noticing changes in odor or discharge after sex, consider using condoms and inserting a vaginal probiotic within half an hour after intercourse. Opt for condoms without spermicides, which alter the acidity of the vagina. In addition to raising the pH of the vagina, many lubricants contain parabens and sugars that feed unwanted vaginal organisms. An ideal lubricant is one that has added acids as well as aloe vera gel, which is soothing to mucous membranes and is safe to use with latex condoms. Lastly, sex toys can be another source of re-infection with undesirable microbes. Be sure to clean your sex toys with a gentle, fragrance-free soap after each use. 
• Herbal antimicrobials. With significant symptoms of bacterial vaginosis and vaginal candidiasis, herbal antimicrobials can be helpful in preventing and treating bacterial and fungal overgrowth. Oregon grape root and goldenseal both contain berberines, a type of molecule well known for it’s antifungal and antibacterial activity.⁴ Caprylic acid is an extract from coconut oil that we commonly use to treat and prevent vaginal Candida infections.⁵ Garlic has shown also action against Candida spp, as well as E. coli and another of other vaginal pathogens.⁴ Since all of these herbs and extracts can be caustic to vaginal tissues, we generally recommend that you use them in a vaginal suppository form, combined with a carrier like coconut oil. 
• Vaginal estrogen. After menopause, decreased estrogen can cause both lowered vaginal acidity and vaginal dryness, both of which can set the stage for vaginal dysbiosis. Using small amounts of estrogen in suppository form can help support vaginal tissues, as well as glycogen stores that feed lactobacilli. This local, low-dose form of estrogen replacement is generally considered safe and does not increase your risk for estrogen-dominant cancers. 

If you are concerned about your vaginal health and looking for ways to support your internal landscape, consider consulting the naturopathic physicians at Prosper Natural Health. We use comprehensive microbiome testing and a wide range of low-force interventions to diagnose and treat the root cause of a wide range of vaginal conditions. 

Sources:

1. Ma B, Forney LJ, Ravel J. Vaginal microbiome: rethinking health and disease. Annu Rev Microbiol. 2012;66:371-89. doi: 10.1146/annurev-micro-092611-150157. Epub 2012 Jun 28. PMID: 22746335; PMCID: PMC3780402.
2. Huang B, Fettweis JM, Brooks JP, Jefferson KK, Buck GA. The changing landscape of the vaginal microbiome. Clin Lab Med. 2014;34(4):747-761. doi:10.1016/j.cll.2014.08.006
3. Brotman RM, Shardell MD, Gajer P, Fadrosh D, Chang K, Silver MI, Viscidi RP, Burke AE, Ravel J, Gravitt PE. Association between the vaginal microbiota, menopause status, and signs of vulvovaginal atrophy. Menopause. 2014 May;21(5):450-8. doi: 10.1097/GME.0b013e3182a4690b. PMID: 24080849; PMCID: PMC3994184.
4. Romm AJ. Botanical Medicine for Women’s Health. St. Louis, MO: Elsevier; 2018.  

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