Women suffering from recurring vaginitis may also be burdened by feelings of frustration, anxiety, and depression.
Vaginitis is a common, short-term, and treatable condition, affecting more than three million women in the U.S. each year. Despite it being a “common” ailment, the aggravating symptoms of vaginal inflammation, including discharge, itching, and pain, can cause significant distress for some women.
Even after treatment, most women with the condition will experience a recurrence of the same uncomfortable condition
within 6 months.
Dr.
Aimée Gould Shunney, an integrative naturopathic physician who specializes in women’s health, has seen patients with a dozen recurrent “infections” in a year. She’s also noticed a pattern of women entering her practice who are prescription fatigued and wish to heal the root cause of the condition.
“Terms like dysbiosis, vaginal microbiome, and pH imbalance, these are not generally used by most practitioners,” she said. “We’re still telling patients they have an infection, and we’re ending the discussion there. In a sense, that’s the old story.”
The stigma of recurring vaginal infection may insinuate having “caught” a contagion, when in fact, there are women who aren’t sexually active and who are monogamous, who regularly suffer from these symptoms. Researchers can
explain the cause of many cases of vaginitis but some remain elusive. Seemingly shrouded in secrecy, vaginitis is an area of women’s health with slowly emerging new knowledge—while it is a curable condition, not all are being cured.
Vaginitis is an umbrella term for inflammatory vaginal disorders, though there are three main types—bacterial vaginosis (BV), yeast or candida infections, and trichomoniasis. All occur due to an imbalance of flora, the colony of bacteria living in the vagina.
“How many times can you treat somebody with an antibiotic or an antifungal without saying there are actually some other things going on here we need to look at?” Shunney said. “Especially with bacterial vaginosis, it’s really not an infection at all. It is a dysbiosis or an imbalance of the flora in the vagina.”
For some women, a change in discharge and a fishy odor alert them of an imbalance in their bodies. But other symptoms—a high pH level and cells covered with bacteria—are silent ones. Adding to the complications, Candida overgrowth can persist without a change in pH, and many women are asymptomatic, which puts them and others at risk. Women who have BV are more susceptible to sexually transmitted diseases and
complications in pregnancy and gynecologic surgery.
Bacterial vaginosis can also be painful, itchy, and difficult to manage. Often women find themselves silently taking their frustrations to pharmacy shelves. Ironically, most of what they find are products that simply mask or even exacerbate symptoms.
Douches, perfume-laden creams, and chemical ingredients in many feminine care products can further aggravate the vaginal pH balance and perpetuate the very symptoms women are desperate to eradicate.
The Role of pH Levels
A measurement of acidity, pH plays a role in the body’s defenses against pathogenic invasion. Various microorganisms thrive, and others die, depending on the pH of their environment. Vaginal pH is a barometer for a disease state, a gauge that typically indicates unhealthy bacteria and yeast have multiplied.
Doctors who use pH testing along with clinical examinations are more likely to
accurately diagnose women, but the development of at-home pH tests can empower women to monitor their own health. Vaginal pH is prone to change—not just throughout a woman’s lifetime, but also ebbing and flowing through the three phases of the menstrual cycle. Knowing what can disrupt pH and learning how to track it can help women to be proactive, especially when faced with risk factors.
pH is measured on a scale from zero to 14, with zero being the most acidic and seven representing neutral.
Normal vaginal pH for women of childbearing age is slightly acidic, ranging from 3.8 to 5.0. An elevated pH can indicate pathogens—unless a woman is
menopausal when it can suggest either bad bacterial overgrowth or, more likely, the lack of estrogen, which gets depleted when women stop menstruating.
“The natural pH of the vagina is acidic,” said
Dr. Anna Cabeca, triple board-certified OB-GYN. “It has to be acidic to protect us from harm. It needs to prevent bacteria and sperm from getting into our womb.”
Thin, translucent liquid, called vaginal fluid, forms a protective barrier in the vagina to prevent unhealthy bacteria from invading the body. From this fluid, pH value is measured; it is influenced by a number of factors such as:
Antibiotics—A common treatment for BV, antibiotics kill the overgrowth of infection-causing bacteria but also the good ones that keep the environment acidic. According to a 2015
study published in the Journal of Infectious Diseases, antibiotics dramatically and rapidly change pH, and BV-causing bacteria levels typically return just as rapidly after a course of antibiotics. The same
effect often occurs when women stop taking antifungals for yeast infections. This complication is one reason a
study is underway to determine if treating the sexual partners of women with recurrent BV can make a difference.
Douching—Cleaning out the vagina may seem like a pragmatic approach, but it washes away the protective vaginal fluid, which can knock the flora out of balance.
Studies have shown douching increases BV risk and can lead to pregnancy complications, cervical cancer, and pelvic inflammatory disease (PID), caused by the ascension of bacteria into the upper reproductive tract. PID can infect and scar fallopian types, ovaries, and uterine lining leading to infertility, chronic pelvic pain, ectopic pregnancy, and other conditions that could require surgery. A
recent study in Nature Microbiology linked chemicals found in the vagina, presumably from personal care products, with spontaneous preterm birth in pregnant women.
Sexual activity—Semen has a pH value of 8.0, so unprotected intercourse creates a more alkaline environment putting women at risk of pathogenic susceptibility. The increased pH level can remain elevated for 10 to 14 hours after intercourse, according to a 2015
study published in the Journal of Infectious Diseases.
Menstruating—Menstrual blood is slightly alkaline and can increase vaginal pH levels. In women and girls with irregular periods, vaginal mucosal disorders are more common which puts them at
risk for vaginitis.
Aging—Estrogen plays a factor in the acidity of vaginal fluid, so it’s typically the culprit for older women with infections, which can include urinary tract infections. Women in menopause have a
pH of 6 to 7.5. Vaginal dryness and painful intercourse are signs of hormonal shifting as estrogen levels drop off. Shunney said most women need to boost vaginal estrogen at some point, though the age varies immensely.
Infections—Pathogens create a more alkaline environment, which is why vaginal pH testing is a good way to gauge microbiome health. There are a variety of over-the-counter pH tests that help determine whether there’s an infection and offer a clue about what type of infection it is since they all typically have a specific pH range. A
2021 article in Diagnostics offers detailed information about testing.
PH testing may not be a perfect approach—women with Candida albicans overgrowth typically register normal vaginal pH—but it can be especially helpful monitoring for those who are asymptomatic, which includes 20 to 50 percent of women with trichomoniasis, the most common sexually transmitted infection. This disease
predisposes women to cervical cancer, PID, and infertility. Pregnant women infected with trichomonas are at risk of premature labor and placenta rupture and having babies with low birth weights.
Understanding the Vaginal Microbiome
While the vaginal microbiome can constantly change, it operates differently than the gut microbiome, which thrives with diverse species. A healthy vaginal microbiome ought to be dominated by Lactobacillus, a genus of antimicrobial bacteria. Vaginal microbe diversity is actually detrimental to feminine health.
Gardnerella vaginalis is suspected to be the culprit in most BV cases. Named after Hermann L. Garner in 1955, the bacteria was once implicated as an infection but is now largely believed to be part of a healthy vaginal microbiome. Its overgrowth as the dominant species contributes to BV. Yet
literature updated in 2022 still describes bacteria as infectious.
“This is not an infection of Gardnerella. This is an overgrowth that has resulted in way more Gardnerella and other bacteria than we would expect to be there in a healthy, symptom-free vagina,” Shunney said. “Gardnerella is one of many different bacteria that can overgrow in that kind of inflammatory dysfunction.”
There are many species of Lactobacillus, but a healthy vagina should be dominated by Lactobacillus crispatus microbiota.
Research shows, however, that Black and Mexican American women have lower levels of this species and higher rates of BV than white, non-Hispanic women. They tend to also have different vaginal pH levels and more inflammatory microbiomes.
While the reasons remain unclear, Black women are 20 times more likely to suffer from human immunodeficiency virus (HIV) than white women, and having BV raises HIV risk by 60 percent. A
2016 article in the American Journal of Reproductive Immunology describes the relationship as “discouraging,” pointing to poverty, dietary factors, smoking, vitamin D levels, and higher incarceration levels as possible reasons.
A Whole Body Approach
A plethora of BV risk factors offers many prevention options. The
connection between the gut and vaginal microbiome has been established, as well as the relationship with
stress, which disproportionately affects Black women. A
2022 study in Biological Psychology on discrimination reported that being treated unfairly based on race increased the risk of depression and anxiety and raised inflammatory markers, including changes in the gut microbiome.
In addition to lowering stress, Cabeca suggested a probiotic-friendly diet, rich in fiber and fermented foods, plus avoiding sugar, which creates more inflammation and is especially harsh in menopausal women.
Shunney has seen success with lactic-acid-based products with her patients, available even in washes and gels. Lactobacillus produces lactic acid, a chemical responsible for taking down unhealthy microbes. While it seems boosting lactic acid would be a logical solution, research appears inconclusive, according to a 2021
review of studies in Plos One.
For decades, naturally-minded women have used oregano oil, and garlic or grapefruit seed extracts. The problem, Shunney said, is that they do the same thing as antibiotics and their use doesn’t address the root cause of microbial imbalance.
Boric acid is another alternative to antibiotics that has antiseptic, antiviral, and antifungal properties. Administered vaginally only—oral use is unsafe—it can be obtained by a physician or online. A
2020 study in the Journal of the American Sexually Transmitted Diseases Association found it well tolerated, even long-term, and potentially useful for antibiotic-resistant cases of BV.
Other behavioral modifications women might try include sweat-inducing activities like sauna or exercise, as well as antimicrobial clothing and underwear, as some fabrics trap bacteria.
While vaginal issues are a top motivator for women to make doctor appointments, it may be because it’s the tipping point for a body that’s off-balance. Like many other health conditions, vaginitis is rarely fixed with a pill, which is something Shunney said can be frustrating for a lot of patients.
“I love this idea of giving you this pill and it will fix it. It’s just rarely the end of the story,” she said. “Multiple things are going on that cause a body to become out of balance. The things that are causing it to get out of balance may manifest with one type of symptom but may be impacting a vast amount of symptoms and therefore having a broader effect on health.”
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