What happens to the vaginal microbiome during dysbiosis and how does it affect our overall wellbeing?
Mum, there’s a micro-bogeyman in the basement!
What if your vaginal microbiome is in disagreement with itself and also with you? A general discomfort of both parties ensues! The discontent souls then create a bogeyman called vaginal dysbiosis, whether they want to or not.
What is dysbiosis? It is any disruption of the laboriously established balance of the individual organisms inhabiting your body. The bogeyman’s thirst for power does not bode well, and if we give such a rascal the space and tools, we cannot act surprised. When speaking of the vaginal microbiome, dysbiosis means a change in the ratio of the predominant microorganisms, in most women Lactobacilli and Bifidobacteria, favouring others instead, for example intestinal ones. There is at least one more catch in this definition, however. Even girls before puberty or women after menopause have a different composition of their vaginal microbiome, usually with a higher number of non-fermentative bacteria, with a more alkaline pH than in women of reproductive age, and they do not necessarily show any symptoms of dysbiosis or susceptibility to it (1).
Whether dysbiosis occurs is determined by the composition of species and stability of your microbial inhabitants. A community that is not resistant enough will succumb even to a minor instability, and that is why every woman is susceptible to changes to a different degree (2). This may be the reason why your friend has never had the slightest problem, but you call a cleaning lady for your nether regions every month. From my personal point of view, however, nothing is unchanging and fixed, and so you can still train your weakened army in many respects.
Why must I of all people have bats in the belfry?
There are many both internal and external factors that have the ability to influence your lady garden down under. Many of them may seem oddly unconnected with one another. They include:
- Age (the life stage of the woman)
- Geographical roots and genetics
- Personal hygiene habits
- Sexual activity and number of sexual partners
- Forms of contraception
- Strength of the immune system
- Mental state
- Hormonal system (the phase of the cycle or hormonal imbalances)
- Medication, supplements, herbs
- Smoking, alcohol, drugs
- Sexually transmitted diseases
- Pathological changes in the cervix
- Vaginal infections and many other, so far undiscovered factors (3).
In the following paragraphs I will present to you the results of several studies. See if you feel identified with any of it, and if perhaps you might take your first action steps towards “debogeyfication” based on these scientific findings.
At the very beginning, we will look at different methods of contraception. Mere minimal effects on the vaginal microflora have been shown in long-term use of spermicide contraception based on nonoxynol-9 (4). On the contrary, the application of depot medroxyprogesterone acetate injections caused long-term lowering of oestrogen levels, according to another study. The preparation caused a reduction of Lactobacilli and thinning of the vaginal epithelium, thus facilitating the development of infection (5). The microbiome was also weakened by the use of an intrauterine device. The opposite effect was observed in the use of condoms and hormonal contraception – the susceptibility to and occurrence of infections was reduced significantly (6). Here I must point out, however, that hormonal contraception carries many other risks, and you can always find other ways besides the pill.
The mechanism of the harmful effects of smoking is quite interesting. Nicotine and cotinine, the toxic substances contained in cigarette smoke, permeate the vaginal fluid of female smokers where their presence subsequently changes the microbial composition and facilitates the development of infections (7).
Another disruptor of the vaginal microbiome is sexual promiscuity, frequent unprotected sexual intercourse, anal sex followed by vaginal penetration, or the presence HSV-2 – serum herpes simplex antibodies (8).
Equally important is your intimate hygiene. Be very careful about vaginal douching, the use of common alkaline soaps (we want our vaginal pH rather acidic, remember?), and generally excessive hygiene. Vaginal douching using water or soap water (which is even more destructive) simply washes out a lot of your microbial resilience in the form of Lactobacilli and other important microorganisms (9). On the other hand, in the treatment of acute or recurring vulvovaginitis, vaginal douching with a benzydamine solution has shown positive results (10). Using tampons for a long time and not changing menstrual pads often enough can also be dangerous. Both can serve as breeding ground for pathogens and these can thus enter your microecosystem (especially via the string of the tampon) (3). Imagine putting up ladders for the enemy to climb over your fortified walls. Make sure you change your sanitary products regularly.
And now, instead of looking into your knickers, I will look directly at them. Do you wear breathable cotton underwear and trousers of looser cuts? Synthetic materials and close-fitting cuts have a negative effect on the acidity of our vaginal environment and its inhabitants (11). This really works the same way as basements. If you do not let air and sunshine in, moulds and other microorganisms assume power, the structure of the walls is weakened, and such a basement can then make troubles for the whole house.
The last thing I will mention is the relation with your overall health. This is because your vaginal microbiome is affected by any weakening of the organism, including autoimmune diseases, chronic infections, tumours, HIV, obesity, cardiovascular diseases or prolonged nutrient deficiency. Let’s look at a specific example – the chronic metabolic disease diabetes mellitus which increases the sugar levels in the vaginal mucous membrane and fluid, lowers acidity and gives more space to infections. In diabetic patients of type 1, Candida infections were 3 times more common than in patients of type 2 diabetes (12).
If the bogeyman also plays a horror (bio)film for you
Biofilm is a structured consortium of pathogenic microorganisms that have settled on your vaginal mucosa and produce their own protective layer of polysaccharides, proteins, and nucleic acids. It is as if an enemy army dug trenches and atomic bunkers, or if Harry Potter put on his invisibility cloak. Your immune system is confused and cannot find and disable the troublemakers so easily because the biofilm is a lot more resistant to the acidic pH, hydrogen peroxide, and also the detection mechanisms of the immune system. Some of these horrific adversaries may be Gardnerella, Atopobium vaginae or the infamous Candida. Getting rid of microorganisms with biofilm is much more difficult, and the infection often comes back soon after curing the symptoms, since the biofilm was preserved (13).
How can the bogeyman complicate your life?
The aforementioned disruptors of the vaginal balance (and many others, so far undiscovered) cause a change in the ratio of the microorganisms. This imbalance culminates in a vaginal infection, often recurrent and complicated, which can leave behind many effects in the form of fertility problems and endometriosis, frequent urinary tract and genital infections, an increased risk of other infections including a susceptibility to sexually transmitted diseases, premature birth, mental health problems, and a lower quality of life of women in general (2).
A vaginal infection usually manifests itself in the form of an unusual colour or consistency of vaginal discharge (careful, though, the consistency of discharge changes naturally throughout the cycle, don’t let it confuse you), itching and burning, smell, the need to urinate, and overall discomfort. This is the moment when you should call pest control. Your gynaecologist will use a series of methods to evaluate if there is a dysbiosis, which pathogen is sitting on the throne of your vaginal kingdom, and what the best acute strategy should be (you will find more information here). At the same time, they should rule out any other risks, such as tumour disease or dermatosis.
It is evident that things do not end with an acute treatment. Why did dysbiosis occur in the first place? Were you more stressed? Did you expose your body to adverse external conditions, change anything in your care, behaviour or diet, or is there a problem elsewhere in your body? In your gut, for example? Next time, try to prevent the dysbiosis from happening, thus breaking the cycle of recurring problems. It is vital for us women to know the behaviour of our basement enemy, so that we can take action so far in advance that they will not be able to penetrate our lady garden at all. Veronika wrote a wonderful article on the topic of prevention, and I am also preparing one, with my own recommendations. At the same time, Terezka put together a very good article about the susceptibility to dysbiosis during menstruation.
So let’s get down (literally) to business, to active steps that will ensure your lady garden will remain a safe space that you can rely on, as it relies on you.
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(2) Hickey RJ, Zhou X, Pierson JD, Ravel J, Forney LJ. Understanding vaginal microbiome complexity from an ecological perspective. Transl Res. 2012;160(4):267-282. doi:10.1016/j.trsl.2012.02.008
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(9) Beigi RH, Wiesenfeld HC, Hillier SL, Straw T, Krohn MA. Factors associated with absence of H2O2-producing Lactobacillus among women with bacterial vaginosis. J Infect Dis. 2005 Mar 15;191(6):924-9. doi: 10.1086/428288. Epub 2005 Feb 8. Erratum in: J Infect Dis. 2005 May 15;191(10):1785. PMID: 15717268
(10) Unzeitig V. Praktické zkušenosti s benzydaminem. Mod. Gynek. Porod. 2001; 10: 382– 385
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(12) de Leon EM, Jacober SJ, Sobel JD, Foxman B. Prevalence and risk factors for vaginal Candida colonization in women with type 1 and type 2 diabetes. BMC Infect Dis. 2002;2:1. doi:10.1186/1471-2334-2-1
(13) Chen X, Lu Y, Chen T, Li R. The Female Vaginal Microbiome in Health and Bacterial Vaginosis. Front Cell Infect Microbiol. 2021;11:631972. Published 2021 Apr 7. doi:10.3389/fcimb.2021.631972