The dreaded, uncomfortable, annoying, burning, itchy, achy, irritating vaginal infection.
Ladies, we have all been there. And for those unicorns that have never had a vaginal infection such as yeast or bacterial vaginosis, well, you are certainly one of the lucky ones. While a yeast infection or BV is not life-threatening, not fatal, and maybe not an emergency, that does not mean it’s not urgent.
Especially vaginal infections that are chronic or keep returning can be incredibly annoying, painful, and frustrating. It is very accurate that once you have a yeast infection or vaginal infection like BV, it can come back over and over. I have had many patients come to see me because no one could help them with their vaginal issues. Not only is it embarrassing and uncomfortable, but often, doctors will blow off vaginal issues.
Perhaps it was not expressed enough as an issue. As I know it can be challenging to talk about issues ‘downstairs’ to a stranger, doctor, or no doctor. Geez, most women have told me that their mothers and grandmothers would not go near the subject of anything to do with ‘the vagina.’ So can you imagine telling a doctor you have never met that you are in pain, super itchy, tender, uncomfortable, and not-normal discharge is discharging, a lot… takes a lot of courage to say.
As I said, a vaginal infection is not fatal. It might feel like your vagina is on fire, but you will live. Uncomfortably live to say the least. I think it is essential to talk about having a vaginal infection. If you had a sinus infection, no one would bat an eye. If you have an ear infection, that is easy to talk about. It should be the same with vaginal infections.
Bacterial vaginosis (BV) and yeast (candida) infections have nothing to do with hygiene and are not contagious. They can happen for many reasons, just like an ear infection or sinus infection.
So that leads me to a great question from a reader about her issues with vaginal infections. She says she had 6 yeast infections in six months and more months of grief with no relief. I really feel for this woman because that is not how to live life. After all the treatments she has used and put on/in her poor vagina, she is terrified to put anything else near it. I don’t blame her. But what a predicament to be in. I am sure she is not even contemplating being intimate, let alone sexual, when her poor privates are on fire. I’m sure she is constantly worried that darn infection lurks around the corner at every turn.
Here is our reader’s question, which I will answer (we always change the name for privacy).
I am 52. Have Sjogrens and Hashimotos. I have Atrophic Vaginitis. A year ago I started Vagifem for 3 weeks. Yeast infection after. Then I was put on Premarin Cream then yeast again. But I continued with the Premarin. I did this for 6 months and treated 6 yeast infections during this time. Finally I stopped all medications and took a vaginal moisturizer. I did well with this for three months. Then I got another yeast infection or so I thought. This has been a battle for another 2 months. The dr did swabs and everything negative for yeast BV STI. I feel swollen in the vag and when I urinate I feel pain afterward and sitting feels like my vag is hurting. No cystocele or rectocele. I have also reacted to lubes with glycerine or glycol. Now the Dr wants me to start Intrarosa and I am paranoid to start incase I get yeast. Does anyone have any advise as I am at my witts end!
I will answer Melissa’s questions plus:
GSM stands for genitourinary syndrome of menopause. It is a new term that replaces vaginal atrophy. But GSM and vaginal atrophy can be used interchangeably. When a woman enters menopause, her ovaries stop producing estrogen and progesterone. The vaginal cells and tissues respond and maturate to estrogen. So when the estrogen levels drop, you will see changes in the vaginal tissues and cells. Immature vaginal cells are called parabasal cells.
Parabasal cells are like baby vaginal cells. You feed them estrogen, and they will grow into mature vaginal cells. When the estrogen levels drop in menopause, you will see changes in the vaginal tissues. It can cause vaginal dryness, pain with intercourse, and even bleeding from the fragile, thin tissues of the vaginal vault. Also, because there is less lubrication and more fragile tissues, it can alter the biome of the vaginal canal. The vaginal canal/vault has a symbiotic relationship with bacteria, yeast, organisms, and flora. When the vaginal tissues and cells change during menopause, this can disrupt the flora balance increasing the risk of vaginal infections. Also, when this flora is disrupted, it can cause an increase in urinary tract infections (UTIs).
Disrupting the beneficial bacteria can allow e.coli to travel up the urethra to cause a UTI.
Also, estrogen can help tone the urethra (the tube from your bladder to the outside world). When the estrogen levels drop in menopause, the urethra can become more lax, allowing easier access for the e.coli to cause a UTI. And it can cause urinary leakage, also called urinary stress incontinence. You know, jumping jacks, coughing, sneezing, laughing, exercising, anything you are putting a little strain on the bladder can cause a little leakage. I like the new term GSM, even if it is a mouthful to say, genitourinary syndrome of menopause. It explains that more can happen to the vaginal vault and urinary tract than just vaginal dryness.
Vagifem is a estradiol vaginal insert. It is used for GSM/vaginal atrophy. There are three estrogens that we make in our bodies, estrone (E1), estradiol (E2), and estriol (E3).
Estradiol is the most potent form of estrogen. It is a beautiful hormone and helpful in many areas, from brain health to bone density. But estradiol can be too strong in some cases. Ideally, estradiol applied vaginally should only stay localized to the vaginal tissues to help with GSM.
But I have found that my patients taking Vagifem, had elevated levels of estradiol in their blood when they were not taking any systemic hormone replacement. That may be unsafe for women who should not be on estrogen therapy. This is why I do not prescribe vagifem. Estradiol, in many cases, can to too strong for the vaginal vault and can cause yeast infections. That is why women will get a yeast or bacterial infection very shortly after using estradiol vaginally.
First off, I do not prescribe Premarin in any form. Not just for the ethical (or really unethical) sourcing of it (google it, you will be horrified). But also because it is not bio-identical. I only use bio-identical estrogen (estriol and estradiol) for hormone replacement. Premarin is not estradiol but is even stronger. Premarin cream can (like estradiol vaginally) can disrupt the flora of the vaginal vault making it easy to get a yeast or bacterial infection.
There are vaginal moisturizers and lubricants and each are different from each other. A vaginal moisturizer increases the water in the vaginal cell. They often have hyaluronic acid in them to increase the water content in the cell. A vaginal lubricant sits on the surface of the tissues to relieve friction. A lubricant would be used during intercourse and a moisturizer would be used regularly to help the tissues retain more moisture. Both are helpful with GSM but sometimes the benefit is minimal depending on the severity.
Most of us have heard of BV and a vaginal yeast infection. One of course is an overgrowth of bacteria and the other is yeast. Bacterial vaginosis is a overgrowth of garderella species. Garderella is a bacteria that is non-pathogenic in our vaginal canals. But when it grows like crazy, it can cause BV.
Garderella will propagate when the pH of the vaginal canal becomes more alkaline. The vaginal vault likes to be in a more acid state. That is why the beneficial bacteria of the vaginal canal have names like lactobacillus acidophilus. That is why probiotics that have Lactobacillus reuters and Lactobacillus rhamnosus are really popular for women. They help to keep the vaginal vault more acidic to help prevent BV.
A yeast infection is an overgrowth of candida. Candida albican is the main fungus that causes a yeast infection. Yeast infections can happen in the mouth (called thrush), and I have even seen yeast under the creases of the breasts, in the ear, anally as yeast can grow anywhere that is moist.
The symptoms of yeast and BV are similar but also quite different. BV:
Interrosa is a vaginal insert that is made of DHEA. DHEA is an amazing hormone. It is a hormone that is mainly made from the adrenals glands and systemically is more of a masculine hormone, but can help with energy, drive, immune system and much more. I give lots of women DHEA supplements. Now us ladies should take lower doses of
DHEA systemically/orally. But it has so many benefits. Interrosa is a vaginal insert of DHEA. There are studies that show that vaginal DHEA can be helpful for dryness. I have also seen literature that shows that vaginal DHEA can help with libido. Honesty, at this time, I have not found that vaginal DHEA helps with libido, but I am open to it.
Sjogrens could be its own series of blogs and podcasts. But I do want to touch on this as Sjogren’s can make GSM/vaginal atrophy symptoms so much worse. It is a connective tissue autoimmune syndrome that causes dryness. You will see dryness in the eyes, skin, and pretty much any mucous membrane. Vaginal tissues are a mucous membrane that can be affected in Sjogrens. Making the vaignal tissues more dry, increasing the risk of disrupting the vaginal flora and pH, this increasing the chance for vaginal infections.
I deal with Hashimoto’s all the time. It is more common than you think. Hashimoto’s is an autoimmune syndrome where the immune system makes antibodies to attack the thyroid. Eventually this will cause the thyroid hormones to drop becoming hypothyroid. The main Hashimoto’s antibodies are thyroid peroxidase antibody (TPO), and thyroid peroxidase antibodies (TGab). If one or both of these are elevated then you have Hashimoto’s.
As you read above, estriol is one of the three estrogen we make. Estriol is a very gentle form of estrogen. I love using estriol for GSM and vaginal atrophy. By helping correct the GSM it will help prevent and lower the risk for UTIs and vaginal infections. Estriol vaginally will not enter the bloodstream like vaginal estradiol can. Because it is gentle estriol is much more likely to cause any yeast infections or change the pH making one more susceptible to BV. Estriol can come in suppositories, cream, vaignal inserts. But it typically comes from a compounding pharmacy. Meaning they can make any filler, binder, dose and vehicle for administration we want. We do have many readers and listeners from outside the U.S. that tell us that estriol is available without prescription where they live. But working with patients in the U.S. I usually will prescribe it from a compounding pharmacy.
Melissa started with the vagifem (estradiol vaginal insert). And quickly after that she noticed the yeast infections starting. The estradiol was too potent for her vaginal vault, which triggered a yeast infection. This also goes for the Premarin cream that she tried. It was way too strong for her vaginal vault and disrupted the flora and pH causing these frequent infections. Also Melissa mentions that she was tested for STIs. STI stands for sexually transmitted infections. It is the new replacement term for STD, sexually transmitted disease. Which is a much better name, because they are not diseases but infections. Kathy was negative for STIs and also for BV and yeast. I do know the STI testing is accurate. But swabs and testing for yeast and BV are not always accurate. I believe Kathy’s vaginal vault is in complete dysbiosis. Her flora was off, so the beneficial bacteria was so low it could not compete with more pathogenic bacteria. And the pH of her vaginal canal was disrupted causing a perfect environment for bacterial vaginosis to flourish.
It sounds like the vaginal moisturizer was helpful for several months. Which is encouraging. The increase in the water content of the cell helped to balance the flora of the vaginal vault temporarily. But because of the advanced GSM the moisturizer was not enough to keep the infections at bay.
I think something that would be safe and gentle for Melissa is to take a woman’s vaginal probiotic. A probiotic that has Lactobacillus reuteri and Lactobacillus rhamnosus.
Taking it orally would be great for Kathy. But also using an old-school method of poking little holes in the probiotic capsule and inserting it vaginally to try and repopulate with beneficial bacteria and changing the pH to a more acidic environment.
I really feel like Melissa was dealing with more chronic BV. I know I don’t have all the information but from her description it sounds like chronic BV. She says it is burning and she feels pain with urination (no UTI). BV is pretty notorious for being chronic with the symptoms waxing and waning. With this in mind, I would consider trying to work on her pH. Another great way of doing this is to use boric acid vaginal capsules. This is also a ‘old-school’ method of making the vaginal vault more acidic. I know people get concerned about the ‘acid’ part. But boric acid is a very gentle, healthy treatment for the vaginal canal. I also use boric acid vaginal capsule for UTIs, they work great, for prevention and treatment (but that would be another topic).
Honestly, I do not think the interrosa is going to be helpful or Kathy. I still think she is going to be still suffering from the GSM symptoms and the chronic infections (BV is my thought). Melissa mentions that she has Sjogren’s and Hashimoto’s. Both of these can considerably contribute to GSM/vaginal atrophy. Sjogren’s can cause dry mucous membranes. Hence, Melissa’s GSM, altered vaginal biome/flora. And Melissa says she has Hashimotos. Which means she is most likely hypothyroid and on thyroid medication. Hypothyroid can also cause dry tissues, from constipation to dry hair, skin and nail and even contribute to dry vaginal/mucous membranes.
My additional thoughts for Melissa would be to implement estriol vaginally. I know she might be apprehensive at this point of letting anything near her vagina. But estriol vaginally could help to feed the vaginal cells to create more resiliency, hydration and rebalance the pH for the proper flora to propagate. It is not the infections that we want to eradicate. The goal is to change the environment so that the infections cannot flourish.
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Episode 052 – What Biest Ratio is Best for Menopause?
This is such helpful information. I have often wondered who 80:20 is good for and who 50:50 is good for.
One thing I'm still confused by is the estrogen weight gain component. You said that estrogen (as well as menopause in general) could be the cause of her weight gain. I can relate. I was very thin my whole life, now 53 and about 30 lbs overweight. But you also said she might benefit from getting her estrogen balanced, and she was not using enough.
If too low a dose made her gain weight, won't an increased dose cause more weight gain? I have heard other podcasts and read articles that in menopause, we gain weight because our estrogen falls. Estrogen seems to be blamed for weight gain, whether it's high or low. Can you help clarify? There's something I'm not understanding. Thank you! Tracy
Often estrogen has been the scapegoat for weight gain. I'm sure you have heard too much causes weight gain. Too little can pack on the pounds. It can be pretty confusing. So which is it? Is too much estrogen causing my pants to become uncomfortably tight? Or is it too little estrogen that has given me the gut I never had?
Well, it’s not that simple. Estrogen levels do have a hand in weight gain and weight loss. But it is not the only variable. It really is the combination of the balance of estrogen with other hormones in your body. To name a few main players, progesterone, insulin, and cortisol, as well as enzymes, lipoprotein lipase (LPL), and hormone-sensitive lipase (HSL). Okay, I know that sounds vague and doesn't answer the question. Let's back up a bit and look at what women are saying about estrogen.
As soon as menopause hits, women complain that they are instantly 15-30 lbs heavier. Not because of diet or lifestyle. It's like menopause adds an unwanted 15-30 lbs overnight. Then some women are on hormone replacement therapy, taking estrogen, and are horrified because the HRT caused them to gain 10 lbs in a month. So what is it? Did the lack of estrogen in menopause cause that 20 lb weight gain? Or did that hormone replacement estrogen create rolls that were never there? Well, actually, both are true. Before you throw out your jeans in favor of high-waisted yoga pants, let’s learn about the other players in weight gain.
Progesterone will buffer estrogen. Estrogen does like to grow things'. That is why in puberty, you grow breasts and hips. Progesterone helps to balance some of the growth' that estrogen can cause. That is why in perimenopause, when the progesterone drops and the estrogen is running the show, the weight gain begins. That is also why when a woman starts estrogen therapy for menopause but not enough progesterone, there is weight gain.
‘Doc, I really don't feel like myself. I think it's my hormones. Could it be my hormones? Can you test my hormones?'
How many times have I heard new clients tell me this story? They go to see their GP, Gyno, or Internist, asking to have their hormones tested. Only to be told that there is no testing for hormones. Or that it's not necessary to test hormones. Only to leave feeling dismissed, with no answers to why they do not feel well.
While I understand that your GP, Gynocologist, and Primary Care Physician are not the jack of all trades,’ there are many tests for hormones. There are blood tests, urinary testing, and even saliva testing. The more difficult part of hormone testing is the interpretation. The basic lab values assigned by the labs are very vast, and without experience and training, it can be quite difficult to determine if there is a hormone imbalance.
If you are feeling like you have a hormone imbalance or having symptoms concerning your hormones, below is a list of common hormones to be tested and why. Because blood lab testing is so popular, I am going to stick to blood testing. Later we will have more labs and interpretations for urine and saliva.
To start, blood testing is just a look at one moment in time with respect to your hormone levels. In a menstruating woman, her hormone levels are changing every day. But in a menopausal woman where the ovarian function has ceased, her hormone levels are going to be pretty level day to day. So in a female that is still having her period, I like to try and aim for getting the blood drawn around day 12 and/or day 21. In a 28-day cycle, the estrogen will surge around day 12, and the progesterone will surge on day 21. This can give us better insight into her levels of progesterone and estrogen. In a menopausal woman that has not had a period or has sporadic periods with common menopausal symptoms, I will have her draw her blood any time of the month.
FSH and LH:
FSH stands for follicle-stimulating hormone, and LH stands for luteinizing hormone. These are not actually hormones. They are stimulating hormones.' Meaning both the FSH and LH are released from the pituitary gland (in your brain) in response to estrogen and progesterone production. The FSH and LH work in what is called a negative feedback loop.’ Meaning if the levels of estrogen and progesterone are high, then the FSH and LH are low. In turn, if the estrogen and progesterone levels are low, then the FSH and LH are high. It is like when you want your husband to take out the garbage. If he doesn't, you might raise your voice until he does. It is the same with all stimulating hormones. If the ovarian production of hormones is low, as in menopause or perimenopause, the FSH and LH levels will look high.
Estradiol and Progesterone:
Always test estradiol to get specific results for estrogen levels. Estradiol is much more specific for estrogen levels than simple total estrogens. Ideally, in a menstruating woman having the blood test around day 21 will give you insight if that woman is ovulating. It will so give you insight if there is progesteron