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)
• Diet
• Geographical roots and genetics
• Birth
• 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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Bibliography:

(1) Lev-Sagie A, De Seta F, Verstraelen H, Ventolini G, Lonnee-Hoffmann R, Vieira-Baptista P. The Vaginal Microbiome: II. Vaginal Dysbiotic Conditions. J Low Genit Tract Dis. 2022;26(1):79-84. doi:10.1097/LGT.0000000000000644

(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

(3) Krajčovičová R, Hudeček R. Faktory ovlivňující vaginální eumikrobii. Prakt Gyn 2008; 12(4): 202-211

(4) Unzeitig V, Buček R. Poševní prostředí a jeho mikrobi ální profil. Prakt Lék 1990; 70 (23): 867– 868

(5) Miller L, Patton DL, Meier A, Thwin SS, Hooton TM, Eschenbach DA. Depomedroxyprogesterone-induced hypoestrogenism and changes in vaginal flora and epithelium. Obstet Gynecol. 2000 Sep;96(3):431-9. doi: 10.1016/s0029-7844(00)00906-6. PMID: 10960638

(6) Calzolari E, Masciangelo R, Milite V, Verteramo R. Bacterial vaginosis and contraceptive methods. Int J Gynaecol Obstet. 2000 Sep;70(3):341-6. doi: 10.1016/s0020-7292(00)00217-4. PMID: 10967168

(7) Bradshaw CS, Morton AN, Garland SM, Morris MB, Moss LM, Fairley CK. Higher-risk behavioral practices associated with bacterial vaginosis compared with vaginal candidiasis. Obstet Gynecol. 2005 Jul;106(1):105-14. doi: 10.1097/01.AOG.0000163247.78533.7b. PMID: 15994624

(8) Cherpes TL, Hillier SL, Meyn LA, Busch JL, Krohn MA. A delicate balance: risk factors for acquisition of bacterial vaginosis include sexual activity, absence of hydrogen peroxide-producing lactobacilli, black race, and positive herpes simplex virus type 2 serology. Sex Transm Dis. 2008 Jan;35(1):78-83. doi: 10.1097/OLQ.0b013e318156a5d0. PMID: 17989585

(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

(11) Kotrbová D. Intimní hygi ena. Prakt lék 2007; 3(5): 246– 247

(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

The often ignored power of the vaginal microbiome in a woman’s life.

Take a peek at the party downstairs

Things are very lively down-under, and that is nothing but great! When you hear the word microbiome, you probably think mainly of the community of microorganisms in our gut. However, there are many more such local microbiomes, be it the aforementioned gut microbiome, dermal, oral, or vaginal. Every one of them is distinctive in terms of composition, proportions, and representation of individual species of microorganisms (for simplification, I will hereafter only name bacteria) and has different needs for its life, depending on the different conditions of the inhabited space. Even your left and right hand microbiome differ (for example, if you are left-handed, you perform certain activities with your left hand and leave other, easier activities to your right hand), and it is as unique as the iris or fingerprint. The individual bacterial communities are not hermetically separated from one another, however, they affect each other and communicate. And it makes sense - after all, they all live on the same planet - your body!

The life of a vaginal microbial town is not easy because the vaginal environment changes dynamically based on cyclicity, hormonal changes, or the woman’s stage of life (1). And what if the woman’s cycle is irregular, and so the vaginal microbiome faces sudden changes or its “militia” is weakened for some reason? Although it is not easy to thrive in such uncertainty and throw a quality party, your bacteria do their very best. A partial indicator of such a good and healthy party is the bacterial guestlist, but it is not the only or sufficient indicator. We can tell a lot from the overall health, immunity, and emotional state of the woman, her individual physiology and metabolism, the state of the gut microbiome, hormonal (im)balance, lifestyle, ethnicity, and genetic predisposition. It would definitely be a lot less fun if we knew the guestlist and the exact development of the party, anyway. There are still plenty of confusing aspects, and the research of the vaginal microbiome is still in its infancy (and in our knickers, right?).

Whose presence is a must and what about catering?

As I hinted before, studying the vaginal guestlist is not a piece of cake, partly because it is impossible to cultivate these bacterial strains in Petri dishes or other laboratory equipment (it is such a different environment for vaginal bacteria that they are unable to grow there) and also - as biological research keeps teaching us, gently but adamantly - nothing is quite as simple and clear as we would like (2). And now to the point - what about those guests?

Less is more and strength lies primarily in balance; nobody should gain the upper hand too much. Although there is no such thing as a perfect list of bacterial strains that would distinguish a healthy woman from a woman suffering from an imbalance, it has been shown that a healthy vaginal microbiome is usually characterised by fewer strains in mutual balance than in the very complex gut microbiome. This is mainly due to the richness of nutrients that we send to the gut, while the vaginal microbiome is more monotonous in terms of nutrition and not every bacterial strain can thrive there. On the contrary, an increase in diversity may indicate a vaginal dysbiosis (3). So invite only the most esteemed micro-guests to your vaginal party and pamper them.

We count the Lactobacillus strains among the most common inhabitants of our vaginal microbiome. These probably originally came from the gut microbiome (perhaps it was too crowded for them there, but honestly, this migration did not help a lot…), like the Candida yeast, for example (we will definitely speak more of it in future articles). Studies done on Afroamerican and Hispanic women showed that a healthy vaginal microbiome does not have to consist mainly of Lactobacillus (4). It was also shown, however, that such a non-lactobacillary composition of vaginal microbiome is more susceptible to sexually transmitted diseases and infections; I will only mention one study, but if you want more evidence, do not hesitate to get in touch (5). So you can find different types of viruses, bacteria, and yeast in this magical environment (many microorganisms probably still remain to be discovered), and it does not necessarily indicate a dysbiosis or disease. Future research based on extensive databases could reveal, among other things, more differences between the microbiome of fertile and infertile women, women suffering from frequent vaginal infections and those who don’t, or women who use and don’t use hormonal contraception.

And what do I mean by “monotonous catering”? The bacteria in our womb can feast on the main course of the vaginal menu, which is primarily glycogen (not the only source of nutrients, though), a glucose polymer whose main chef is - hold on to your chef’s hats - oestrogen! It is therefore clear who plays the role of the true “periodic” supervisor of our vaginal party.

Lactobacilli, as well as many other microorganisms, ferment glycogen to lactose and lactate (basically lactic acid) which - together with the epithelial production - creates a specific acidic environment.

Don’t look so sour, where it’s sour, it’s not dour

Really. Acidic pH is beneficial in the context of the vaginal environment as it makes survival more difficult for pathogens that you did not invite to your party, but that would very much like to infiltrate and infect you (3). However, it is also true here that a different composition of bacterial strains leads to different levels of acidity, and that is why African American and Hispanic women have a higher pH than white and Asian women (6).

Two forms of lactic acid are produced during bacterial feasts, and their healthy ratio ensures a stronger immunity of the invited guests (7). Thanks to lactic acid, it is precisely Lactobacillus in the form of probiotics that can protect your party castle from marauders. Since the composition of every vaginal microbiome is unique, however, all we can do is support it, rather than miraculously replace and fix it (such a drastic action would probably have the opposite effect). Lactic acid plays the role of a bouncer at your party - it actively protects you from STDs, such as Chlamydia trachomatis, Trichomonas vaginalis, HIV, herpes simplex virus, or papillomavirus (8), but its other roles remain to be understood. The same as with Lactobacillus, an acidic environment in itself does not guarantee a healthy vaginal microbiome and absence of disease, but it is one of the many indicators that we can take into account and support them.

There is both strength and risk in contact

Not even your private party is a completely isolated world. Guests come and go, their numbers change, as well as their moods, they are affected by the outer world and communicate with it. Most of your worldly activities also influence the fun at the party. As you can certainly imagine, sexual activity has a fundamental effect on your womb (9). I shall describe its action in one of my next articles. Excessive and inconsiderate intimate hygiene is like the irritable gentleman in the apartment above the dancefloor, who does not hesitate to call the police and ruin all the fun. Another long-term saboteur is of course an unhealthy lifestyle based on an unbalanced diet, drinking, or smoking (9, 10). Hormonal contraception is also a huge topic. I feel obliged to write a separate article dedicated entirely to this problem because the consequences of its use can be truly far-reaching and every woman should be aware of it. The overuse of topical vaginal antibiotics, or their use without well-established and proven reasons is an equally problematic (if not even more dangerous) disruptor (11). Other factors that play an important role are your psyche, immunity, hormonal changes and the state of your gut and oral microbiome. In the end, these microbial communities are not far from each other and they share many things (12, 13). 

The list of factors that contribute to your vaginal health and disease is staggeringly long, so I take it upon myself to at least mention all of them. Not because I want to scare you, but to give you a clue - that even apparently unrelated activities and physiological processes can directly or indirectly affect the course of the party downstairs, and so it is a good idea to be conscious of your actions. Just as we are starting to realise many things that relate to the gut microbiome, so should the awareness of the vaginal microbiome increase as well. Nobody wants any unnecessary trouble at a party.

When love and truth prevail and come to light

What do I mean by this “Summer Meditations” headline? Childbirth! This is the reason why the vaginal microbiome should be of interest not only to women, but also to our partners and men in general. Not only does the health of your partner’s womb affect the whole sexual relationship and the man’s health, vaginal microbiome also marks the very begging of our arrival into this world, no matter our gender. In natural birth, the body and mouth of the baby are populated with the mother’s vaginal, dermal, oral, and gut microbiome - the baby receives great equipment for life. Babies delivered by C-section, by contrast, are populated mainly with skin microbiome and their equipment is therefore significantly poorer. This is why something called vaginal seeding is performed in many parts of the world. It is a practice in which a newborn baby is swabbed with its mother’s vaginal fluids (14). Here, too, caution and more studies are advisable. Our feminine intuition tells us that we have been adapted to natural childbirth over the millennia, and so the baby benefits more from the riches of its mum’s vaginal microbiome. I need to emphasise, however, that many caesarean sections are inevitable and have saved countless lives. The question is the context we provide during childbirth - not only microbial contact, but also the relative physical and mental wellbeing of the mother. Everything is alright, as long as we respect life and health.

In my next articles, I will explore the dynamic changes in the vaginal microbiome within the menstrual and life cycles, the possible imbalances and their solutions, and the overall prevention and support of the vaginal environment.

Send some loving attention to the party and read the continuation of this MicroWorld story just as carefully. Read you soon, Sys.

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Bibliography:

(1) Gajer P, Brotman RM, Bai G, et al. Temporal dynamics of the human vaginal microbiota. Sci Transl Med. 2012;4(132):132ra52. doi:10.1126/scitranslmed.3003605 

(2) Human Microbiome Project Consortium. Structure, function and diversity of the healthy human microbiome. Nature. 2012;486(7402):207-214. Published 2012 Jun 13. doi:10.1038/nature11234

(3) Vaginal microbiome. V. Buchta. Ústav klinické mikrobiologie FN a LF UK, Hradec Králové, přednostka doc. MUDr. H. Žemličková, Ph. D. Ceska Gynekol. 2018; 83(5): 371-379

(4) Ravel J, Gajer P, Abdo Z, et al. Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A. 2011;108 Suppl 1(Suppl 1):4680-4687. doi:10.1073/pnas.1002611107

(5) Brotman RM, Bradford LL, Conrad M, et al. Association between Trichomonas vaginalis and vaginal bacterial community composition among reproductive-age women. Sex Transm Dis. 2012;39(10):807-812. doi:10.1097/OLQ.0b013e3182631c79 

(6) Huang B, Fettweis JM, Brooks JP, Jefferson KK, Buck GA. The changing landscape of the vaginal microbiome. Clin Lab Med. 2014;34(4):747-761. doi:10.1016/j.cll.2014.08.006

(7) O'Hanlon DE, Moench TR, Cone RA. Vaginal pH and microbicidal lactic acid when lactobacilli dominate the microbiota. PLoS One. 2013;8(11):e80074. Published 2013 Nov 6. doi:10.1371/journal.pone.0080074

(8) Aldunate M, Srbinovski D, Hearps AC, et al. Antimicrobial and immune modulatory effects of lactic acid and short chain fatty acids produced by vaginal microbiota associated with eubiosis and bacterial vaginosis. Front Physiol. 2015;6:164. Published 2015 Jun 2. doi:10.3389/fphys.2015.00164

(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) Brotman RM, He X, Gajer P, et al. Association between cigarette smoking and the vaginal microbiota: a pilot study. BMC Infect Dis. 2014;14:471. Published 2014 Aug 28. doi:10.1186/1471-2334-14-471 

(11) Vallor AC, Antonio MA, Hawes SE, Hillier SL. Factors associated with acquisition of, or persistent colonization by, vaginal lactobacilli: role of hydrogen peroxide production. J Infect Dis. 2001 Dec 1;184(11):1431-6. doi: 10.1086/324445. Epub 2001 Oct 30. PMID: 11709785

 (12) Petricevic L, Domig KJ, Nierscher FJ, Krondorfer I, Janitschek C, Kneifel W, Kiss H. Characterisation of the oral, vaginal and rectal Lactobacillus flora in healthy pregnant and postmenopausal women. Eur J Obstet Gynecol Reprod Biol. 2012 Jan;160(1):93-9. doi: 10.1016/j.ejogrb.2011.10.002. Epub 2011 Nov 15. PMID: 22088236

(13) El Aila NA, Tency I, Claeys G, et al. Identification and genotyping of bacteria from paired vaginal and rectal samples from pregnant women indicates similarity between vaginal and rectal microflora. BMC Infect Dis. 2009;9:167. Published 2009 Oct 14. doi:10.1186/1471-2334-9-167

(14) Clemente JC, Dominguez-Bello MG. Safety of vaginal microbial transfer in infants delivered by caesarean, and expected health outcomes. BMJ. 2016 Mar 31;352:i1707. doi: 10.1136/bmj.i1707. PMID: 27033374

 How does a healthy vaginal microbiome make us stronger, and why are we more susceptible to dysbiosis before menstruation?

(5 minutes of reading)

One of our meta topics at Syster is resilience. This is also one of the topics of this article, albeit in a slightly unusual attire. The vaginal microbiome. A healthy and happy vaginal microbiome is one of the basic pillars of a strong immune system of a healthy and happy woman. And a woman with a strong immune system is a resilient woman. In this article you will learn in what ways a healthy vaginal microbiome makes us more resilient and why some of us are more susceptible to such ailments as bacterial vaginosis around our period. At the end, we will share some tips for supporting your microbiome. 

PS: If you tend to blush when you read the word vagina, you’re in for a wild ride. You have been warned! :)

The vaginal microbiome

The vaginal microbiome is a population of microorganisms (bacteria, viruses, yeast) that live in a vagina. These microorganisms communicate with each other using something called quorum sensing. You can imagine it as a sort of “Internet for bacteria”. It allows them to perceive their environment, readily adapt to every situation and regulate their numbers and behaviour as needed (1). The vaginal microbiome is a unique kingdom that differs greatly from the gut microbiome. The gut microbiome loves diversity. It can be made up of up to 200 different species of bacteria. The vaginal microbiome, on the other hand, is somewhat of a minimalist. It prefers fewer species - usually only 1 to 5 different bacteria species (although in a small number of women, it can be as many as 25). Most of the time, they live in harmony. Everyone knows their role, and in a healthy European woman’s vagina, Lactobacilli are in charge.

Dysbiosis - Now I am in command!

The vaginal microbiome continually evolves and fluctuates in accordance with the changes in other aspects of our life. I refer you to Kristie’s article, where she describes such ups and downs in the life of a vagina. A healthy vaginal microbiome cannot really be defined, as it means something different to every woman. However, in most cases, there should be a Lactobacillus on the throne. Lactobacilli cooperate with the immune system and check continually if there is any threat of health complications. Their speciality are sexually transmitted diseases or complications related to pregnancy, such as miscarriage or ectopic pregnancy. It is also their responsibility to defend their leading position to prevent dysbiosis. There is an incessant game of thrones going on in the vaginal microbiome. The Lactobacilli are not the only ones interested in governing, and if such unwanted intruders as Streptococcus, Atopobium, Gardnerella, or Prevotella become overabundant, dysbiosis ensues (2). This can lead to a bacterial vaginosis or candidiasis. Whew. (We will look at the various symptoms of dysbiosis in another article.)

What makes the ruler happy?

So it is very important to us that our vaginal microbiome be happy. You definitely know the saying “good food, good mood”. Well, sure, but what does the vaginal microbiome eat? The vaginal microbiome feeds on cervical mucus. Cervical mucus is produced all the time, but its consistency and amount change depending on the phase of the menstrual cycle. I am sure you have noticed that sometimes the consistency resembles egg whites, it is transparent and stretchy, sometimes the mucus is thick and creamy. The hormone oestrogen contributes significantly to the production of cervical mucus and - what is important - makes it rich in glycogen. Glycogen is especially popular with the rulers of the Lactobacillus genus, and in processing it, they produce metabolites (something like by-products), for example, lactic acid and hydrogen peroxide (H2O2) (3, 4). “Acid? Peroxide? What?!” Now you might be thinking about the peroxide your hairdresser uses to bleach your hair. If you have ever found bleached spots on your favourite underwear, it is precisely due to the peroxide contained in our cervical mucus. We should forgive the bleached underwear, though, because the presence of this compound together with lactic acid in our cervical mucus is very important. It helps to maintain an acidic environment in the vagina, prevents microbial invasion, supports the immune system, reduces inflammation, maintains tissue homeostasis, and boosts our ability to resist certain infections (3, 4).

Revolt - Susceptibility to dysbiosis before menstruation

So in great part, a healthy acidic vaginal environment (pH ideally 4-4.5) in women of reproductive age is governed by Lactobacilli, oestrogen and glycogen. And now, Systers, hold on tight because this is going to get super interesting!

Just before menstruation, the oestrogen levels decline → we know that oestrogen is very important to the production of mucus and its glycogen content → the decrease of oestrogen therefore creates a short supply outage during which our good bacteria do not get as much food → less food = less power, and the otherwise mighty genus of Lactobacillus can be weakened (ayayay!) → this affords a wonderful opportunity for other bacteria that have so far been a minority; they start reproducing and - “Woohoo, now it’s time for us to party!” → this party is no fun for us, though, as it may lead to dysbiosis and the onset of an infection or inflammation (5). Menstruation can also cause an imbalance when the usually abundant Lactobacilli are reduced due to bleeding. Some Lactobacilli can agglutinate to red blood cells and leave the vagina with them (6, 3). The bacteria lurking nearby now have an opportunity to seize the throne. And a bacterial vaginosis will soon follow. 

How can I know that a revolt is afoot?

Even though dysbiosis can occur out of the blue, it is usually not without a cause. Learn to recognise what normal cervical mucus means to YOU. If you feel that something is not quite right, observe, note down the changes, and ask questions. Your body will tell you. The natural resilience of your vaginal microbiome may be weakened or disrupted by a number of factors. We can look for the triggers in our everyday habits (intimate hygiene practices, contraception, smoking) or biological variables (hormones, the resilience of our immune system). Tracking the symptoms, especially if they are just starting, will help you and your gynaecologist identify the triggers. 

The basic questions may be as follows:

How can you describe the change?

• Do you experience uncomfortable itching?
• Where and with what intensity?
• Did you notice an unusual smell of your cervical mucus?
• Did you notice an unusual consistency of your cervical mucus?
• Pain during or after sex?

What are the circumstances?

• Have you started taking new medication or antibiotics?
• Do you use scented soaps or shower gel for your intimate hygiene?
• Do you have a new sexual partner?
• New sexual practices or unprotected sex?
• New underwear? Sexy lingerie can really irritate our vaginal microbiome. 
• Change of diet?
• Are you a diabetic and have to watch your blood sugar levels?
• What phase of your menstrual cycle are you in?
• Do you feel stressed or anxious, which may have weakened your immune system?

As I mentioned at the beginning, a healthy happy microbiome is a part of a resilient woman. The game of thrones is a tough game. You can either debilitate or support your army in its battle. Assume responsibility, observe and record. Take active care of your vaginal microbial inhabitants. How? You will find out in the next article!

PS: Do not underestimate the signals of your body and talk to your trusted gynaecologist about any unusual changes.

Bibliography: 

1. Yang, M. et al., 2020. Effects of natural products on bacterial communication and network-quorum sensing. BioMed Research International, 2020, pp.1–10. 
2. Chen, X. et al., 2021. The female vaginal microbiome in health and bacterial vaginosis. Frontiers in Cellular and Infection Microbiology, 11. 
3. Amabebe, E. & Anumba, D.O., 2018. The vaginal microenvironment: The physiologic role of Lactobacilli. Frontiers in Medicine, 5. 
4. Kovachev, S., 2017. Defence factors of vaginal lactobacilli. Critical Reviews in Microbiology, 44(1), pp.31–39. 
5. Aldunate, M. et al., 2015. Antimicrobial and immune modulatory effects of lactic acid and short chain fatty acids produced by vaginal microbiota associated with eubiosis and bacterial vaginosis. Frontiers in Physiology, 6. 
6. Farage, M.A., Miller, K.W. & Sobel, J.D., 2010. Dynamics of the vaginal ecosystem—hormonal influences. Infectious Diseases: Research and Treatment, 3.