This month, we talked with clinician, researcher, and educator Susan Kellogg-Spadt about treating vulvar pain and what we're learning about the connection between vulvovaginal conditions and the vaginal biome.
Susan Kellogg-Spadt is the Director of Female Sexual Medicine at The Center for Pelvic Medicine in Bryn Mawr, Pennsylvania. In this capacity, Dr. Kellogg performs direct patient care, consultative services as a vulvovaginal and pelvic pain specialist, researcher, educator, sexual dysfunction clinician, and therapist. She is a Fellow of the International Society for the Study of Women’s Sexual Health where she serves as the Chair of the Fellowship Committee and a member of the Board of Directors. She is on the Executive Board of the National Vulvodynia Association.
SHWI: How did you become interested in women’s sexual health and especially recurrent vaginal infection?
Susan Kellogg-Spadt: I have dedicated my career to women's sexual health and have a particular expertise in sexual pain syndromes. My interest in vaginal infections has been through that lens. So many of my patients have had recurrent yeast infections just before the onset of developing provoked vestibulodynia, a chronic condition that negatively affects their intimate lives and relationships.
SHWI: As a nationally recognized expert in pelvic and vulvar pain, and sexual dysfunction, how do you approach the treatment of these conditions in non-surgical ways?
SKS: Certainly there are a number of non-surgical mainstays to the care of a vulvar pain patient. One is to be certain that the patient, whenever possible, remains infection-free while we are treating them. We accomplish this by reviewing their personal care products, recommending organic and hypoallergenic products, performing microscopy at every visit, and performing vaginal cultures when indicated.
Next, we assess the role that their pelvic floor muscles may be playing in their pain and refer them to pelvic floor physical therapy (PT). We work with the PTs by prescribing muscle relaxants, and occasionally giving trigger point injections and Botox.
We also refer pain patients for mindfulness and cognitive behavioral therapy (CBT) care so that they are better able to emotionally manage their condition. We make recommendations about the form of birth control they use, and we prescribe medications and creams that quiet abnormal nerve fire and modulate inflammation.
SHWI: What are the most common and difficult-to-treat conditions that you face every day?
SKS: Long-standing cases of vulvodynia – in which the burning pain has extended beyond the vulva and has become a chronic regional pain syndrome – are some of the most common conditions we see, as well as PGAD/GPD (persistent genital arousal syndrome/genito-pelvic dysesthesia), a debilitating condition associated with persistent, unrelenting and unwanted sensations of genital arousal that is not associated with sexual interest or desire and is associated with significant negative psychosocial impact.
SHWI: For both doctors and patients, the most daunting issue is resolving infections in a conclusive way. What do you think needs to happen in treatment to reestablish vaginal biome health?
SKS: Health care providers are moving away from “reactive treatment” – providing repeated RX for symptoms with antibiotics and antifungals – and moving toward the use of products that proactively support the biome in terms of pH balance, moisture, and probiotic population. A healthier baseline biome is a preventative way to address repeated infections.
SHWI: As an instructor to other gynecologists, what are the most important changes in approach to recurrent vaginal issues that you would like to see happen in the wider gynecological community?
SKS: I would like to see complaints of “vaginal infection” worked up properly—with cultures, specific subtypes of candida and bacteria identified, and sensitivities to various medications identified before clinical recommendations are made for species-specific treatment. Then, I'd like to see tests of cure performed after treatment to assure the provider and the patient that the infection is gone. If there is no infection, but symptoms are present, I'd like to see a comprehensive work-up for other causes of symptoms. Most importantly, I'd like to never hear of a provider who told a female patient who is suffering that she is imagining her symptoms.
SHWI: What do you believe is some of the most important recent research that has been done in the last five years in support of women's vaginal and reproductive health?
SKS: We have moved away from considering vaginal bacterial composition as “one size fits all” to considering that “normal” may be different for different women—depending on geography, ethnicity, and culture. As a result of the research that looked at rRNA gene sequences in various asymptomatic women, it was determined that several kinds of vaginal biomes exist; the majority are dominated by Lactobacillus, while others are composed of anaerobic organisms. In addition, we have new pilot research that suggests that the biome composition of vulvar pain patients may differ from that of control women who have no pain.
To read Dr. Kellogg-Spadt’s publications, visit researchgate.net and search: Susan Kellogg Spadt.
And to read more interviews with leading women’s healthcare practitioners, as well as the latest on women's health clinical trials and research, check out The Biome Blog.