September 2020
SHWI medical advisor Dr. Cathy Yi joined us for to explore the role of vaginal biomes in successful treatment of conditions like lichen sclerosus, desquamative inflammatory vaginitis (DIV), and bacterial vaginosis (BV). Dr. Yi is a board certified gynecologist specializing in pelvic medicine. Her interests and expertise are in treating endometriosis, vulvar and vaginal disorders, female sexual dysfunction, myo-fascia disorders of the pelvic floor, menopausal symptoms, and incontinence.
Dr. Cathy Yi is a board certified gynecologist specializing in pelvic medicine. Her interests and expertise are in treating endometriosis, vulvar and vaginal disorders, female sexual dysfunction, myo-fascia disorders of the pelvic floor, menopausal symptoms, and incontinence. Her surgical expertise is in minimally invasive surgery - laparoscopy, hysteroscopy, and diVinci robot procedures. Cathy has been practicing for more than 25 years and received her medical degree from SUNY at Buffalo and trained for residency at Sinai Hospital of Baltimore Maryland in obstetrics and gynecology. Her interest in pelvic medicine has evolved from a general Ob/Gyn practice to a gynecologic practice focusing on these conditions of the pelvis which are often under treated.
SHWI: As a gynecologist who specializes in vulva vaginal disorders, please share your experience with how undiagnosed and untreated bacterial vaginosis impacts women’s long term vaginal health.
Unrecognized and untreated bacterial vaginosis makes a woman feel embarrassed, unclean, and miserable. In addition, this condition has been associated with increased risk of surgical infections, sexually transmitted diseases, delayed post-op wound healing, urinary discomfort, UTIs, vaginal pain, and pain with sex.
At the beginning of my career in the 1990s (and even today), BV was felt to be a non-pathogenic condition and therefore professional societies did not endorse treating BV if found incidentally, like on a pap smear, unless the woman complains of symptoms. Recently, evidence and research is emerging linking BV to surgical site infections, increased risk of acquiring STD, HIV, HPV, genital Herpes, as well as preterm births, and post-op infections. BV is a terrible condition and in my experience, not a benign condition to ignore but should be actively sought out and treated. Furthermore, once a woman gets BV, it often recurs and is hard to clear.
SHWI: Why do you think that many vaginal conditions flare up? How do you think maintaining the health of the vaginal biome affects these flare ups?
Vaginal conditions such as DIV or BV may be from disruption of the vaginal environment that promotes inflammation or overgrowth of problematic or unhealthy bacteria such as in the case of BV or vaginitis.
BV can occur with normal activity such as menstruation as well as intercourse. Menstrual blood and seminal fluid increase the vaginal pH to become higher than normal and lose its acidity. Use of personal lubricants such as K-Y Jelly may destroy vaginal skin due to its high osmolality. Friction on the vaginal skin such as using tampons, pessary to reduce pelvic organ prolapse, vaginal sex, using personal lubricants, douching, or hygiene products that are not similar in property to the vagina pH or vaginal osmolality all disrupt the vaginal biome.
Even antibiotics used to treat BV can reduce helpful lactobacilli and cause yeast infection, for example. On the other hand, cross contamination with bacteria from the gut origin such as E.Coli or Enterococci can also pose a problem to the vaginal space, but this is not a common problem.
Maintaining the healthy vaginal biome and acidic vaginal pH is effective in reducing flare-up of DIV and LS in my patients and it is important in reducing BV infections. Just as gut microbiome and digestive flora are felt to be important in promoting healthy GI function, the vaginal microbiome is becoming an important consideration in treating these conditions.
SHWI: Many advanced vaginal conditions are hard to treat, and complex. How do you go about unwinding and looking at the multiple layers to get to a positive treatment outcome?
These conditions seem to share common symptoms and after treating these conditions, I find that it is not difficult to recognize their common presentation. Often these women will have seen many providers on multiple occasions and treated multiple times for BV, yeast, and UTIs with no improvement, and very often distraught. They may have tested positive at times for yeast, BV, or UTI but not consistently in a way that their symptoms are resolved. Therefore, despite treatment with antibiotics or antifungal agents, often they fail treatment because they were not diagnosed correctly.
On a side note, menopausal women may have vaginal problems from lack of vaginal estrogen support and have a condition recognized as genital syndrome of menopause whose symptoms are vaginal skin sensitivity, painful sex, and recurrent UTIs. They may require local vaginal estrogen cream to restore moisture, elasticity and relieve dryness.
So with a good history from the patient and understanding of the vaginal and vulvar skin problems, it is not very hard to help women get better. Providers should familiarize themselves with these conditions and have an understanding of the vaginal biome. Also,educating the patient will allow better patient engagement and improved compliance with treatment. In my experience, the treatment and compliance improves when patients understand their condition.
I also encourage restoring and maintaining the vaginal biome as an important goal in improving their symptoms. It has been the key to my successful management of these conditions. Using the Balance wash and the Restore vaginal moisturizing gel, for example, from Good Clean Love, has allowed me to simplify their treatment to these agents once initial symptoms are addressed. Their flare-ups seem to occur less often with less severity.
My patients are encouraged and happy using these products - I start on the Balance wash with conventional treatment. I also ask about any change in their skin care products that can be a source of irritation or allergy and stop their use of commercial lubricants such as K-Y Jelly or Astroglide, which are hyperosmolar and cause vaginal skin irritation. In their place, I recommend coconut oil, olive oil, or Almost Naked, a personal lubricant from Good Clean Love that is iso-osmolar and non-irritating to the vagina.
SHWI: Within your patient population of desquamative inflammatory vaginitis and lichen sclerosus, what other kinds of treatments have you found to be helpful, in addition to standard of care?
Desquamative inflammatory vaginitis and lichen sclerosus are not easily diagnosable or treated. Lichen sclerosus is an inflammatory condition involving vulvar and perineal skin causing itching/ irritation/scarring, and usually requires topical steroid application for treatment. For DIV, which is a condition recognized by profuse vaginal discharge, vaginal and vulvar pain, painful sex, and increased vaginal pH, treatment is multimodal with vaginal steroid - hydrocortisone acetate suppository and Clindamycin cream. Evidence is still being established for optimal treatment. Both DIV and lichen sclerosus require proactive management to prevent recurrence after treating acute symptoms. LS is also associated with increased risk of skin cancer in the vulva.
Conventional treatments, while effective, are still steroids and antibiotics that alter the natural vaginal environment. Adding Balance moisturizing wash, Restore vaginal gel, and a lactobacilli probiotic like BiopHresh, seem to reduce irritative discharge and symptoms. These products offer significant benefits for my patients. Some of my patients were able to dramatically reduce and even discontinue their conventional treatments using as needed for flare-ups.