September 2024
Dr. Rachel Rubin is a board-certified urologist and sexual medicine specialist. She is one of only a handful of physicians with fellowship training in sexual medicine for all genders. Dr. Rubin is a clinician, researcher, and passionate educator. In addition to being the former education chair and current Director-at-Large for the International Society for the Study of Women’s Sexual Health (ISSWSH), she serves as associate editor for the journal Sexual Medicine Reviews.
Q: How important is the vaginal microbiome in the cases you see in your office?
I think the vaginal microbiome is unbelievably important for vaginal health, but also urinary health. And we know that when you can create an acidic environment, you decrease inflammation, you decrease irritation, you improve lubrication, you decrease your risk of urinary tract infections. And it is such a delicate system, and understanding it better is so important. What is it about sex that throws off people's microbiome? Well, we know semen is super basic and that we should be able to counteract that basic material, but some people can't and it trips them up to getting infections constantly.
We know that hormonal changes, whether it's menopause or birth control or lactation can really alter the microbiome and really make women more susceptible to infections as well. So we love the hormonal approach. We love understanding the probiotic space, which is kind of not very understood at the moment. And so there aren't a lot of products I can recommend right now. And I hope that changes in the very near future.
Q: What happens when the microbiome isn’t able to maintain a low pH? And why is it that some women have that situation just natively and other women can never get back to that situation?
I would say I do have certain patients where no matter what I throw at them seem to maintain a pH of seven and a half and we can't quite figure out how to break the cycles. So we are in desperate need of tools, more tools in our toolbox. And really, the diagnostic tools become extremely challenging because I think as we don't even all agree on what makes a real UTI that needs to be treated or what types of bacteria in the vagina need to be treated and what is over treatment and what's too many antibiotics. And so I think there are just more questions than there are answers at this point.
Q: One thing that I recently heard about UTIs is that the presumption was that 80% of the time it was E. coli. And now we're finding out that it's actually only 30 % of the time E. coli, that it's all these other bugs. And so people are frequently not even getting the right antibiotic, right?
It’s even more complicated than that because we didn’t always have PCR tests that analyze things at such a microscopic level. In reality, we don’t fully understand the implications. For instance, standard cultures might indicate less than 10,000 mixed vaginal or urinary flora, but what does that really mean?
When does it signify something that requires treatment, and when does it not? If we test everyone, will we always find something? Is there an element of normalcy in that? The challenge in our practice is determining when the presence of certain organisms necessitates treatment. The way we were taught in school might not align with the realities we face every day, and this is something we grapple with constantly
Q: So fundamentally, a UTI infection has a level of gravity compared to bacterial vaginosis. While bacterial vaginosis might cause mild symptoms like an odor, UTIs often present with intense symptoms that can escalate quickly and become quite alarming for many women.
Which is why I'm so fiercely wanting to prevent UTIs as much as possible because many, many women die every year of urinary tract infections, which is why vaginal hormones are so effective and helpful and really great microbiome supporters. And so it's really when that's optimized and people are still getting infections, I mean, this is where it's so important that we understand the microbiome. Because I think people aren't using vaginal hormones in their most optimum optimized way.
Q: So are vaginal hormones something you can give women who are still cycling, or do they need to be postpartum?
Absolutely. So, think about it. We give women birth control pills, which are powerful agents that can actually hurt the microbiome of the bladder. And so there is probably a role for using vaginal hormones in women on birth control. It needs to be studied more, but vaginal hormones don't change the systemic blood levels of estrogen. So you can add them for anybody, right? We use them in lactating women. We use them in pre -menopausal. It's just that this approach isn’t studied or advertised enough.
Q: So potentially, in terms of prevention, let's just think about the prevention and the maintenance of a healthy microbiome. We know that a low pH, like you said, creates less inflammation and less symptoms and less ability for bad bacteria to live there. But for UTIs, what's your protocol?
I think everybody needs vaginal hormones. Again, if these are people on birth control pills, try to get them on different things like IUDs and things like that. I try to get them off birth control. I try to get their hormones as optimized as possible. Vaginal hormones we know are super lactobacilli promoters and we know they work to lower the pH and sustain it. I'm a sex doctor, so they're great for orgasm and arousal. mean, is vaginal hormones, whether it's estrogen or DHEA.
I would recommend DHEA for everyone because it contains androgen, and we know that tissue relies on androgens just as much as it does on estrogen. To me, that's the baseline. All the other things—D-Mannose, cranberry, probiotics—are like the finishing touches and can be beneficial. But for me, I want everyone to have the foundational elements of hormones.
Q: Endocrinology is one of the least understood areas of medical science. I suspect many doctors also don't think about vaginal estrogen just as an example for any woman who is menopausal or perimenopausal.
We're working on it. It's going to be a long time. You know, we have a little bit of leeway in the American Urological Association guidelines on recurrent UTIs. says very distinctly in peri and postmenopausal women, you should use it. That word peri, it's four letters, but it is an important four letters because peri menopause is everyone before menopause, right. So there's no reason not to is the point.
Q: Where does perimenopause start?
Well, I’d say it likely begins in your 30s, honestly, in your late 30s or maybe even earlier for some people. It's similar to puberty in that it spans a significant period—about 10 years or so.
Q: Would you recommend hormonal treatment for women in their 20s with recurrent issues?
I would definitely recommend it; it’s completely safe. DHEA or its analogues are entirely safe to use. There are many reasons why women in their 20s might need additional hormones. They may exercise excessively, have disordered eating, experience PCOS with fluctuating hormones, or be on birth control pills. The notion that premenopausal or reproductive women don’t experience hormonal imbalances is simply misguided.