December 2022
This month, we chat with Melissa Rietz, CNP, RYT-200, IF, on her integrative approach to treating Bacterial Vaginosis (BV), the most common vaginal condition affecting women, and her thoughts on future research needed to explore the connection between BV and the vaginal microbiome.
Melissa Rietz, CNP, RYT-200, IF, is an advanced practice clinician trained at the University of Michigan with more than 25 years in the field of sexual trauma and women’s health. She has practiced for the past two decades as a social worker, RN, Sexual Assault Nurse Examiner (SANE), and Family Nurse Practitioner. Her commitment is to create spaces of healing for women in the clinic setting and she has dedicated her life to service as a healer, educator, and mentor. Melissa believes that with an integrative, intentional, and individualized plan of care women can reclaim their innate ability to heal.
SHWI: This month we’re focusing on understanding Bacterial Vaginosis (BV), an oftentimes difficult-to-treat condition and one of the most common types of vaginal infections. How do you treat BV—especially recurrent BV—differently than other healthcare providers?
A focus on listening to patients and ensuring that they feel heard, valued, and respected is what sets me apart from other providers in the management of recurrent bacterial vaginosis. This is a condition that can be very challenging to treat, and I rely heavily on the patient to provide me with the information necessary to proactively manage this condition. I work alongside the patient to uncover how lifestyle factors, past traumas, and the ability to perform the recommended treatment protocols are impacting her capacity to heal from the condition. When a woman is comfortable under my care, and she trusts my capacity as a provider she is much more likely to follow the treatment advice, which is essential for resolution of BV.
A patient may not be clear about the recommended treatment plan at the time of the visit which is why it is necessary to write out the protocol, provide resources so that she can explore information on her own time, and uncover any barriers she might have to acquiring the products necessary for healing. I take the additional time to discuss these barriers with the patient and ensure that she has everything she needs to complete the treatment needed for resolution.
I have been working full-time in the clinic for decades and have noticed that within the medical profession we often place band-aids over conditions when what is really needed is to uncover the root of the concern. In the treatment of BV specifically the first step is to explore the underlying cause which may be vaginal dryness, an overloaded stress response, exposure to agents that cause reactivity of the vaginal tissue, etc. Until I have the chance to sit with a patient and listen to her history and her current living environment, I will be unable to guide her towards a treatment plan that is individualized for her healing.
SHWI: BV can have further implications if not properly addressed, such as being more susceptible to STIs and even pelvic inflammatory disease (PID). What do you wish women knew about BV and vaginal health?
Women need to know that their personal experience is unique and that it may take time to fully treat BV and balance the vaginal microbiome. The time required for management is often frustrating, and I find that when we set up realistic expectations women are better able to stick to the regimen. I would also want them to know that they can always ask for a second opinion if they are not satisfied with the care they are receiving, I would remind them that they are the consumer and that they deserve to be seen and heard.
In terms of vaginal health specifically I wish women were aware of the toxic products that are sold so liberally at their local pharmacy. I would want them to choose with ease the products that will not disrupt the delicate balance of the vaginal tissue. I wish for them to understand the importance of the vaginal microbiome and why the selection of products is so essential to overall health of the vulva and vagina.
SHWI: How can healthcare providers empower women to understand—and take proactive measures towards—their own vaginal health?
Healthcare providers have a profound responsibility to ensure that women are empowered to share their sexual health history in an environment that is trauma informed. They should allow for the time that is required to establish trusting and therapeutic relationships and encourage questions from the patients they serve. The use of anatomical images to facilitate greater understanding of the anatomy and vaginal health helps to bridge the gap that exists between providers and patients. Requesting teach back, particularly when treating a vaginal concern such as BV can be instrumental to successful treatment and complete resolution of symptoms. BV can be incredibly challenging to treat if there is a lack in communication and providers have not performed an in-depth health history to include lifestyle considerations.
Women should be encouraged to expect a therapeutic partnership with their healthcare providers, and I believe that this proactive measure alone would significantly reduce the burden placed on women as they advocate for their vaginal health.
SHWI: From a scientific standpoint, there is still so much to learn about BV. What research on BV do you think needs to be explored? Have you heard of any new research or treatments on the horizon?
BV is now understood to be not only one condition, but more of an umbrella state within which other conditions are included. This greater understanding of the disease state will in my opinion ultimately lead to a better understanding of how to diagnosis and treat BV. There is ongoing investigation into the role of the vaginal microbiome and the influence this has on the development of BV. I believe that this is the next evolution of research in vaginal health. The role of Lactobacilli is not yet understood, particularly the role and influence of Lactobacilli iners. L. iners was a hot topic during the recent Annual International Society for the Study of Vulvovaginal Disease (ISSVD) meeting in Dublin and we continue to lack data as to the role that this form of Lactobacilli may have in the disruption of the vaginal microbiome and increased susceptibility for BV in certain patient populations. We do know that L. iners increases during menses, is related to higher levels of proinflammatory factors, and that it seems to co-habitate with BV-associated G. vaginalis.
Whether to treat asymptomatic BV is another area being studied and as we expand our understanding, we will be better able to standardize treatment protocols in these oftentimes murky patient scenarios. As clinicians when we have a positive finding, we are apt to treat with medication, however if we find that these asymptomatic patients do not require treatment as this is simply a variant of their unique microbiome, we can avoid unnecessary administration of antibiotics.
BV is a condition that is prone to recur and can become chronic, making the study of preventative measures of the highest priority and an area that warrants further exploration.There remains ongoing debate about the role of probiotics as a tool in the prevention of recurrent infections. There is hope that probiotics may help to reinstate balance of the vaginal microbiome and there are now multiple products available to women over the counter. While we do not yet have the hard data to back the use of these products currently, with ongoing research there is great promise in this area.
References
Ding C, Yu Y, Zhou Q. Bacterial Vaginosis: Effects on reproduction and its therapeutics. J Gynecol Obstet Hum Reprod. 2021 Nov;50(9):102174. doi: 10.1016/j.jogoh.2021.102174. Epub 2021 Jun 2. PMID: 34087449.
Lev-Sagie, Ahinoam MD1,2; De Seta, Francesco MD3,4; Verstraelen, Hans MD, MPH, PhD5,6; Ventolini, Gary MD, FACOG7; Lonnee-Hoffmann, Risa MD, PhD8,9; Vieira-Baptista, Pedro MD10,11,12. The Vaginal Microbiome: II. Vaginal Dysbiotic Conditions. Journal of Lower Genital Tract Disease: January 2022 - Volume 26 - Issue 1 - p 79-84 doi: 10.1097/LGT.0000000000000644
Muzny CA, Schwebke JR. Asymptomatic Bacterial Vaginosis: To Treat or Not to Treat? Curr Infect Dis Rep. 2020 Dec;22(12):32. doi: 10.1007/s11908-020-00740-z. Epub 2020 Nov 13. PMID: 33814990; PMCID: PMC8015387.
Zheng N, Guo R, Wang J, Zhou W, Ling Z. Contribution of Lactobacillus iners to Vaginal Health and Diseases: A Systematic Review. Front Cell Infect Microbiol. 2021 Nov 22;11:792787. doi: 10.3389/fcimb.2021.792787. PMID: 34881196; PMCID: PMC8645935.