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Moira Bradfield

The Complexities of Vaginal Infections with Moira Bradfield Strydom

Moira Bradfield

The Complexities of Vaginal Infections

Joining us today is Moira Bradfield Strydom a naturopath and founder of Intimate Ecology. Today, Moira speaks about the considerations and complexities of vaginal health with a particular focus on vaginal infections.

About Moira Bradfield Strydom

Over the last 16 years, Moira has been involved in the education and development of many of Australia’s Naturopaths, Nutritionists and Acupuncturists through her role as an educator with leading educational institutions.

In the last year, she has focussed her educational and presenting skills on ensuring that vaginal and intimate health of all clientele is considered in clinical practice. Discarding taboos and investigating.

As an experienced educator and presenter, Moira:

  • Provides regular professionally recognised Intimate Ecology training on the vaginal and genitourinary microbiomes
  • Mentors individual practitioners on complex cases
  • Facilitates an educational, social media group of over 2000 members, which provides relevant, recent and research-based information to holistic and integrative practitioners. Join Intimate Ecology Group.
  • Presents at indépendant educational seminars, webinars and events discussing sexual health, vaginal microbes and holistic care strategies
  • Is a PhD candidate at Griffith University, Gold Coast Australia, focussing on clinical interventions for Recurrent Vulvovaginal Candidiasis (RVVC)/Recurrent thrush and their effect on the vaginal microbiome

Connect with Moira:

Website: intimateecology.com.au

Facebook Group: Join Intimate Ecology Group.

 

Transcript

Introduction

Andrew: This is “Wellness by Designs.” I’m your host, Andrew Whitfield-Cook. Joining us today is Moira Bradfield Strydom, who’s a naturopath. She’s also a PhD candidate, and her PhD is on vaginal health and disorders. That’s indeed what we’ll be talking about today. Welcome to “Wellness by Designs,” Moira. How are you going?

Moira: I’m going well. Thanks for having me.

Andrew: Our pleasure. Now, you are a very dear friend of mine. I’ve watched you blossom and indeed delve totally into this space, which is just incredible to see, but tell us about this evolution from when I first met you. You always impressed me with your clinical aptitude, but why specialize in vaginal health when you could have been anything?

Moira: It’s a really great question because it’s not an area that I sought out and certainly not one that I thought I would end up in, and it came about in a number of ways. It came about because I was seeing things clinically that weren’t responding to protocols that I was utilizing and those protocols were probably based on the brevity of information that we received in our training. So most people both in mainstream medicine and in holistic medicine don’t receive adequate training in genitourinary health. And when I realized things weren’t responding, I went finding answers and the answers I found were amazing in that, obviously, there’s a microbiome in this space, and modulation of that microbiome can improve health states. There’s a lot we don’t think about in terms of integrating this into the being because, you know, there’s a tendency to think about it as a piece of anatomy that you apply remedies to without thinking about how that integrates into the other systems in the body and how that may be influenced. And when I realized that I could start to address it in that way, then I started to see, obviously, the clinical response to that. And from there it blossomed. I’d never been that interested in anything clinically before, and as I started to work with people and, you know, people were responding clinically then the practice grew from there.

Andrew: Okay. So, there’s a word that you said there, which I got to say sparks my ire and that is the word protocol. It implies that things have been tested and have been shown to get results during that “protocol.” And we know that some protocols, even medical protocols fail, but we can have at least, you know, a good shot at getting success. How did you find these protocols and, you know, just how far off a mark do you think they were?

Moira: Gosh, it’s probably a good question because I don’t know actually whether at that point there was things written down specifically, but when we were looking at, you know, this is…you know, when I guess the internet wasn’t as prolific and when I did my training, we had big textbooks and there’d be a small chapter on these things. And a lot of the approach in those chapters was to use antimicrobial therapy to kill, you know, that everything was an infection and didn’t necessarily, as I said, speak to the integration into the whole at that point. And they’re off the mark because what we know in other microbiome sites is very true in this microbiome site as well that to kill is not always necessary and that when you kill you kill indiscriminately, and that there are…just like there are ones that are pathogenic, there are also, obviously, beneficial microbes and that we need to nurture those.

And so, you know, that was where we were heading at that point, lots of, you know, just antimicrobials in that space which doesn’t impact discharge in a lot of people and it doesn’t account for the fact that these things are often cycling, it can come back on a monthly basis when we are looking at recurrent issues. So, yeah, they were pretty far off the mark, you know, and, obviously, that was disappointing in terms of clinical results. And not that I’ve ever been protocol-driven but, at that point, because I was looking for things that would work that I went into those sort of more traditional areas where we would seek information and tried those things that also didn’t work.

Andrew: Yeah. you know, it smacks of a word that I learned from two practitioners who I have the utmost respect for, one was Mikash, and it was this word called terrain. And I can still remember in the early day’s everything as you say was kill, kill, right? The kill, kill mentality. And it never made sense that we’ve got this whole microbiota and we want to try and selectively kill stuff. Like, it’s a pretty niche sort of thing if there’s something wrong. But with regards to what you were talking about nourishing and nurturing and integrating, what was the flip there? Like, did it stop you from using antimicrobials, or did it just make you more judicial in how you use these things?

Moira: It’s made me more judicial. I think there is a time and a place for antimicrobials and the beauty of being able to test and sequence, obviously, gives us insight into when that’s more appropriate than at other times. And as my practice has evolved, I’ve also ended up in an area where I get the difficult cases, the ones that have been to other practitioners that have spent years on standard therapy. And so, I’m in a little bit of a different situation where I’m often trying to clean up that mess but also deal with perhaps more resistant microbes or conditions that are, you know, far worst spot than they would have been initially. So, I’ve come full circle in that I will still now use antimicrobials where there was a time when I was trying to avoid them completely. But I’m more selective in how and when and for how long I will be using those things. So, I’ll often pause things so it’s short courses on a monthly cyclic basis and always looking at the background in terms of that restorative aspect in a terrain and what can be going on there and integrating that into the whole as well.

So, you know, obviously working on the hormonal drivers, on the lifestyle, on the nervous system, addressing the gut if that’s appropriate for that person and going about it that way rather than only using an antimicrobial therapy because I think that was the issue in the past. It was, you know, here’s this specific tablet that will deal with candida, go for it, and/or only use that antimicrobial vaginally and, you know, that should fix everything. It doesn’t fix everything, you know. These people have…I’ve got patients that have had candida for 20 years, you know, or had recurrent candida, which is a whole diagnostic term, for 20 years. And so, they’re, you know, effectively new to a lot of those microbes already with interventions. So, you know, and if they haven’t worked why are they going to work now unless I take a different approach?

Andrew: Yeah. So I must apologize to our audience because I’m gonna say certain adjectives which, of course, would be quite humorous when we are talking about vaginal health. But before we dive into the main topic, I want to ask about how do your patients present? Do they present pre-diagnosed from a medico or do you get naturopaths that have just been through the mill, as you say, for…forgive me, do you get patients who have been through the mill for so long, they’re so fed up with the medical model that they’re now seeking other alternatives regardless of their diagnosis? Do you have to start with a diagnosis?

Moira: Yes and no. So I have a bit of a mix of clientele, but I also…because of the chronicity of a lot of these presentations and knowing what I know now about the diagnosis of these issues as we see with a lot of aspects in women’s health and female genitourinary health that I’m not necessarily trusting of a diagnosis even if I have that come to me as a label. So, I work through my process, which is a lot of questioning, obviously, an understanding and being aware of what tests are there and if people haven’t had the general, you know, microscopy and culture or a swab or a Pap screen or any of those things, STI screening. We start there because those are valid things to know about. But like in other areas of health, this sort of pushes past that that we can see functional disorders that aren’t necessarily a label as such, things that people are repeatedly told are normal as well when they’re very adamant that they’re not normal for them. And so, yeah, it’s a bit of both.

So, you know, the chronicity and people who’ve had these things for 20 years often come with pages and pages and pages of tests, and it gives me information because you can see microbes changing over time if you’ve got a big history of microscopy and culture and Gram stain because you can have a look at that in sort of a functional perspective. And, you know, obviously, it’s good to know that they don’t have STIs and things like that, but there’s a lot of sort of fringe diagnoses in this area that are not recognized standardly in many countries or are overlooked because of somebody’s age, you know, and people being told, oh, you can’t have that because you’re too young. You’re too young to have vaginal tearing because of estrogen deficiency or, you know, that aerobic vaginitis is not something we see until menopause. So these are the sort of things that come through as well that they have just been overlooked or being told there’s nothing they can do because they’ve stuck them in a box. So, yeah, it’s a bit of a mixed bag.

Andrew: You know, you said something really interesting there, and that is, you know, we can’t see this until such and such an age, and it smacks of the one in a million thing. I think as practitioners, don’t we always have to be mindful? There is always that one. You might have that one. And so, we’ve always got to be on our game to be aware of the anomalies, the people that are outside, as you say, that box of normal but who are still presenting with a real issue.

Moira: Yeah, definitely. And, you know, sometimes even just being aware of what the diagnostic criterion of these more chronic issues are. So if you take, for example, recurrent and chronic forms for vagina candidiasis or thrush. In their diagnostic criterion, there is culture negatives that are allowed, you know, to be able to say that that’s what it is, and so if someone is seeing, you know, a medical professional episodically when these things come up but they’re getting a negative culture even though it looks like thrush, then they’re often told that it’s not thrush and that there’s something else, you know, unknown or perhaps nothing going on when if you step back and look at that in what we now know about these issues then that totally fits that picture. And we also…you know, I think there’s an issue in labelling some of these recurrent and chronic issues as infections because they’re more like syndromes than anything, you know, that they are a cluster of a presentation that comes through for people and so you’re not gonna be able to pick up a microbe or an infection because it’s part of this bigger picture of immune complexity and recognition and hypersensitivity that goes on.

So it’s something that I hope to change going forward in my what hopefully will be a long research career, but it’s because I see people being overlooked and mismanaged at a primary level because someone is not stepping back and looking at their whole case or looking at the fact that they’ve had this occurring every month for the last year or the last, you know, five years or whatever but because they’re doing all of the standard testing and it’s not showing anything, then it must just be part of being who you are, you know, which is, obviously, frustrating when there’s inflammation or excoriation or, you know, discharge, which isn’t always present going on and that’s having quite severe life-impacting repercussions for that individual.

Andrew: Right. Let’s take a step back and let’s talk a little bit first about the classic symptoms of various vaginal infections and some of the differential diagnoses. Can we do that with you first? Because, obviously, as you are aware, there are anomalies and nuances to these but we need to start off with a base.

Moira: Yeah. So the base is…I mean, there are various ways to do this, I guess, and I can speak for a very long time on it. So I will try and reign it in is to start off with the symptoms. So things like discharge is a very telling characteristic to start with, and the discharge, the colour, the consistency, the odour give us some indication about whether something could be bacterial-driven if it is an infectious issue or whether it’s fungally driven. So, for example, when we look at something like bacterial vaginosis the discharge, typically, and there are always exceptions, but the discharge is typically watery or milky, quite gushy of homogenous and voluminous, and can also have an odour that is described as being fishy. And the odour is something that’s very interesting as well because there are other issues that can have an odour but you have to know the characteristics of the odour and this is something sometimes it’s very hard for people to describe, you know, to recall an odour because we can go into a slightly different type of odour which is rotten or foul, or, you know, slightly meaty as well.

I’ve had it described to me and the discharge that sometimes accompanies that can be variable and coloured, so it can be more green or slightly yellow. And this is a condition called aerobic vaginitis, which is generally more inflammatory than bacterial vaginosis, and bacterial vaginosis encompasses anaerobic microbes. And so, they’re two slightly different presentations. And aerobic vaginitis frustrated me. It’s the one that’s, you know, deemed to be only more of an issue in older people but it is an issue in younger people as well. So, you know, this odour often leads that people will get treatment for bacterial vaginosis but they won’t have the aerobic vaginitis recognized. And some treatments for bacterial vaginitis will push you into aerobic vaginitis as well. But the odour in that one is sort of the telling. And then the colour of the discharge is the telling thing as well because aerobic presentations tend to have a colour, you know, the yellows and the greens coming through for them in the discharge. Yeah. So…

Andrew: Okay. What about the symptom of itching, though? Because, like, I was involved in helping to diagnose a poor young lady who saw a naturopath. This naturopath consulted me and said, “What do you think sort of thing, you know, about candida?” And I was highly suspicious. I said, “There’s no other discharge going on, just the itch.” And I said, “Look, I’m really sorry. This patient needs to see a GP immediately,” which we did. And this poor woman who’d been seeing a partner who she thought was faithful, probably had not been because she now had developed herpes. So regarding itch, how do you link these other symptoms with discharge? Yeah. Can you go through that, for instance, the colour discharge, cottage cheese, no discharge, or just watery?

Moira: Yeah. So let’s pick up here where we were at bacterial presentations, I guess, between those two things, aerobic and anaerobic, so aerobic vaginitis and bacterial vaginosis. The osis and the itis give us some information there as well because, typically, bacterial vaginosis will not have the itch and if it does it’s very low level with the exception of one or two particular microbes like prevotella which tend to drive a little bit more inflammation in that area. So in bacterial presentations then itch is more characteristic in aerobic vaginitis. And then itch is one of those very general symptoms that I tend not to diagnose just on itch, obviously, because everybody seems to have this tendency to go, “Oh, this is candida,” and candida is, obviously, something to consider but it’s not one of the most common presentations we would be seeing clinically because that is actually bacterial vaginosis which is the most common presentation.

So we need to sort of dig down onto things like is there a discharge? You know. What does that discharge look like? Because in an acute episode of thrush or candida there typically is that cottage cheese discharge, so you’re looking for that and quite extremes of itch and irritation as well. When thrush becomes chronic or recurrent, sometimes the discharge dissipates or decreases quite significantly and the itch and the irritation is something that’s ongoing, but it also…you know, if we see long histories and there hasn’t been adequate diagnosis, sometimes we need to consider that itch can also be dermatological because there are things lichen sclerosis which sometimes people will have 20 years of thinking they have thrush and then somebody finally does a biopsy and it’s actually a dermatological condition.

And in that, you know, things like herpes, for example, which is incredibly common, does have an itch as well. And you can obviously have all of these things going on as well. People do flick between different presentations because the disorder allows another microbe to grow, you know, or to take advantage of the environment as well. So, you know, you very well may have candida occurring at the same time as a herpes outbreak, or bacterial vaginosis can mean that you are more at risk of contracting something like that or having an acute presentation flare up as well. So, it speaks to the importance, obviously, of if somebody is self-diagnosed or actually getting these standard STI screens done and getting a swab done at the very beginning. And the issue with herpes, obviously, is that people will assume because they’ve had STI screens that they’ve been tested for that when it’s not part of a standard STI panel. They actually need to swab a lesion, you know, or swab the vulva when there are symptoms present because that’s going to give you the most adequate testing for that and definitive, and that’s not always something that goes on as well and people can pass these issues without, you know, visual lesions, etc. as well. So it becomes very interesting when we step back and look at that and what that means for people as well, in terms of shame, etc.

But yes, it’s really important that we differentiate, and itch is very nonspecific until you start asking the questions to find the specific things that are going on for that person. And the thing that I often hear myself saying is not everything is thrush, you know. That’s just one thing that people are quite aware of, I guess. But the other things are actually more common than thrush can be, and if we’re going into symptoms that are recurring quite frequently, we need to understand the patterns and the frequency of that so that we can understand what it could be as well.

Andrew: Okay. So one thing really irked me then, and you said a woman had been having this issue for 20 years and finally got a biopsy. How common is this?

Moira: Unfortunately, for lichen sclerosis, for example, it’s a very common story that we hear for both males and females, and understandably, you know, biopsies become a very specialized thing, and usually you have to move through to in terms of a referral pathway to see a dermatologist or to see, you know, somebody that specializes in vulval issue issues like, you know, not all gynecologists do, for example, and not all dermatologists do. So it’s not an uncommon thing for me to hear that people have never had a biopsy. And it’s frustrating. And I understand the hesitancy around it. It’s obviously quite an invasive procedure, but it’s frustrating when people have had quite chronic symptoms and are not necessarily finding relief to be hearing that that’s what hasn’t gone on. And it’s certainly something now I’ve started to, in my treatment planning, when I, you know, send somebody off a document, it will have a thing that says future considerations, you know, there is a possibility that this could be something else and we need to consider and reassess if this hasn’t, you know, changed in a certain timeline.

Because, you know, the more I learn about presentations like lichen sclerosis and lichen planus, which I thought to be quite rare, is that they’re perhaps not as rare as we think they are. They’re just not as diagnosed frequently as they should be, and that there are a lot of people suffering, obviously. And, again, you can have multiple things going on, so you may very well have thrush but you’ve also got this other thing in the background and it does come down to adequate physical exam, people understanding their own anatomy and what may have changed over time because there are some questions you can ask around, you know, white plaques or anatomical changes because, with lichen sclerosis, there is architectural changes in that they can lose part of the labia or, you know, things can become adhered, and those sort of things can be telling as well as the other things like fissuring or ulceration which, obviously, crosses over into that herpes diagnosis as well. So it’s about making sure that those things are tested when they’re present.

Andrew: Very interesting that you said dermatologist rather than an OBGYN. So a dermatologist would be the person to do the biopsy here. It’s a funny sort of thing that…you know. Obviously, it’s dermal, but it’s intravaginal. It’s not on the surface of the skin. Interesting.

Moira: It’s a bit of a mixed bag. So lichen sclerosis is a vulva pathology, not an intravaginal one. Lichen planus occurs intravaginally. And so, ideally, people end up somewhere with somebody that has specific knowledge and specialization. And GYNs…Definitely, I have seen this done at a GYN. I’ve seen this done at a general practice level as well but with people that have quite specialized knowledge, and then there are a specific set of people that are vulval dermatologists that deal with vulval presentations because there’s quite an array of them that occur. There are either lichens, there are eczemas, there’s psoriasis of the vulva. There’s obviously enteropathy or neoplasias that can occur with these issues as well.

So it’s a very specialized area but they tend to be very good, you know, if you can…because I do find sometimes just because, obviously, the differences between gynecological practice, you know, private and public and all of those things, moving towards somebody that deals with these things all the time, obviously, gives you more confidence, I think, that things are being differentiated appropriately and that perhaps a biopsy has been considered if it is appropriate or not based as well on their understanding and what they see, which is, hopefully, a lot of this as well to be able to make those judgment calls. So I tend to prefer that they either go to a specialist gynecologist, you know, that has experience in this because there are, obviously, people that deal more with obstetrics and other people that…right? Like, there isn’t any sort of medical profession, or they go down the vulval dermatologist route. So either of those tends to be a good option.

Andrew: There’s also the issue, of course, with various pathogens invading a certain or specific type of cell, for instance, chlamydia particularly attaches to and invades columnar epithelium, not squamous. So if you did a swab of the vagina, which is squamous, your test will be negative because you haven’t looked at the right tissue to be tested. So how often do you find this sort of issue, the wrong tissue has been tested hence a negative result when you are seeing an obvious issue with this pathogen?

Moira: Yeah, it doesn’t…well, to my knowledge, it doesn’t seem to occur that often. There is…you know, swab quality, obviously, is something to consider with any sort of diagnostic and particularly if we’ve seen things that have fluctuated between positives and negatives as well. But there’s quite a lot of work done on the adequacy of self-swabbing, for example, in vaginal health to test for both STIs but also microbiome, and there’s not a huge amount of variance in terms of…you know. It’s good enough in the research that we can confidently say people should be able to self-test, which, obviously, takes away a lot of the access issues that people may have or the hesitancy that people may have of going to a health professional and having a swab done. So I think that it’s something to consider, you know if it looks and sounds and feels like something but we’re getting negatives and perhaps, you know, swab quality is something to consider. But in my experience most of the time, if we are thinking that that’s what it is, generally, we will find it. And this can be true, you know, because STI screen is coming a long way as well and, obviously, there is now, you know. They’ve piloted in Australia home screen tests for things like chlamydia and even, you know, pushing now into things like HPV as well and finding that that’s quite appropriate and successful as a testing scheme.

Andrew: Okay. All right. Well, that’s cool. That’s good news. Certainly better than what I thought. The other thing you mentioned is temporal changes, you know, women who, you know, commonly get like, for instance, a cyclical issue around the time of their period or at some other time in their menstrual cycle. So you’ve got temporal changes due to hormones in the woman, but there’s also the issue of chronic reinfection from the male as well. And I remember this was a thing back in my day about what’s called ping pong infection. It fell out of favour. What’s going on here? What do you find the real issue is and how effective or important do you find it is to look at the male partner?

Moira: Yeah, it’s a really great question because I think medically we’re still in a place where, you know, they’re only dealing with the individual that has the symptoms and not often looking into partners or even partner interaction because that’s a whole nother subset of microbiome change. And, you know, with STIs, you know, reinfection is certainly something we need to consider. And there’s still microbes. We’re dealing always with microbes. It’s about microbes and their ability to obviously be pathogenic and cause cellular change and damage. And the virulence of that obviously determines whether something is a sexually transmitted infection and requires immediate attention versus what we’re now calling sexually enhanced disorders.

And so, in answer to that question, I think that partner interaction is something we need to be considering, but like we see in any microbiome site, there are lots of variances of normal. And, you know, if we take something like a heterosexual interaction, for example, because it’s probably an easy way to give an explanation when we look at the penile microbiome, this is an external skin site and so it’s a very different makeup to what we would see inside the vaginal canal. It tends to be more aerobically, you know, skin-based microbe staph and strep and all of those sort of things. And so, that interaction is a very common interaction that many, many people have on a daily basis but not everyone ends up with an issue. And this talks to then the terrain or the robustness of the microbiomes as they interact. Like, it is a microbiome site that’s, by design, meant to interact with others. And we need to be aware that, you know, if it’s being challenged and not recovering then that’s the issue more so than perhaps what microbes are being introduced.

So, that’s one component of it, but there are specific areas like, for example, the workaround bacterial vaginosis, which is now known to be a sexually enhanced disorder in that they can see that the interactions that occur with sex will be predictive, for example, of bacterial vaginosis and then will also drive or influence that presentation, so by the nature of pH disruption or then the translocation of microbes. So there were some studies that came out late last year that we’re looking at partner interactions and from the starter essential penile and seminal microbiome of a male partner, they were able to predict which females would end up with BV. So, that is I think a very important thing, and that’s happening in lots of different aspects of infectious disease in this space. But we’re not at a point medically, anyway, where the recommendations are to treat male partners. I see it come through from some quite specialized people in this area, and I think it’s important when things are quite recalcitrant or when it’s a very obvious reinfection cycle, but you do need to control for those other things first.

So clinically, I don’t insist that we always treat partners. I do talk to people about what behaviours may, you know, mean that we’re challenging this microbiome when we should be actually focusing on restoration, and then we’ll go and challenge it later. So, you know, making people modify how they sexually interact via, you know, using a barrier method, you know, minimizing oral contact, if we can, for a period of time, and then restoring because sometimes that’s enough to mean that they can interact with an individual without actually going into a flare or an infectious episode. So it’s quite complex and, obviously, with pathogens and microbes, there are…like with Gardnerella, which was one of the main bacterial vaginosis microbes, is more than 14 different types of strains that they’ve identified, and not all of those are pathogenic. And so, only some of them are more destructive in an environment or are able to gain the upper hand as well. And so, you know, you need to look at those sort of factors in it. And yeah, it’s a tricky area, I guess, to navigate at this point.

Andrew: I want to go on to treatments before we run out of time, but I could talk to you about this for so long because you are so interesting. But I want to catch myself there, and that your sister, Kerrin Bradfield, who helps people with gender issues and does a lot of sex therapy and things like that would beat me around the head with a piece of  for me restricting that cross-infection to male to female where, of course, there are female partners, there are sharing of sex toys and things like that. So you, obviously, as a practitioner, all practitioners must be aware of that personal relationship issue, whether that’s male to male, male to female, or female to female, or whatever. So I just caught myself. Sorry, I berate myself for doing that. Kerrin, it didn’t work. I’m still waking up. But can we move on to safe therapies and effective therapies? You know, the traditional thing is just use some probiotics. Your research has shown otherwise, and indeed that’s part of your PhD, but can we go into a little bit of what you do for terrain even down to nutritional efficiencies, for instance? And also what probiotics you find useful for various conditions, if not all, but…

Moira: Yeah. Gosh. Where do I start with that?

Andrew: I should warn people that Moira has Intimate Ecology as a Facebook group and the lessons in there are legion and many. So we are only really sniffing the tip off the iceberg. So Moira, over to you, forgive me.

Moira: Okay. So if we’re thinking about terrain then we need to look at the influences on that. And hormones are a really great place to start if you’re dealing with female anatomy. So the microbes themselves fluctuate over the course of the menstrual cycle if there is one and estrogen is the driver that generally supports a healthier microbiome site in this space. So you need to be looking at what’s going on with that particular hormone and addressing that if there are inconsistencies and issues if you can. Then we step back and look at this like any other mucus membrane in the body and microbiome site in the body and think about what it needs to have, obviously, healthy cells and hormones are part of that. Estrogen is a big part of tissue integrity in this space, but what else could be going on that we could influence? And that does come down to nutrition. A lot of the time we import nutrients like vitamin D, for example, has quite a big influence on the microbiome in this space, and obviously has other repercussions when we pull it out into a systemic level. So often I will be testing vitamin D and seeing if it’s optimal and if it’s not optimizing it.

Lots of things, I guess, along that line like we would with the gut looking at how we can support, you know, integrity in that space, so looking at prebiotic fibers. And these are more often than not using oral and ingested therapies. So there’s not necessarily a huge amount of research that shows that these things via oral ingestion influence the mucosa but there is certainly some there that we can take and definitely working with lots and lots of people, I’ve seen that what works and what doesn’t work. Usually in there is some form of fatty acid. And again, it’s about, you know, looking at the space integrity. The moisture in this area is a really important consideration as well because when we look at interactions that are friction-based like sex, the damage occurs because there’s perhaps not adequate lubrication which comes through with hormones and, obviously, arousal and things like that but also the mucus membrane in itself and the inflammatory state that it might be experiencing. So I’ll use fatty acids in that space for most people. Generally is sort of a background type of thing.

Then probiotics, which is a very big topic. And I think that there’s a tendency and it’s something that I try and change. There’s a tendency that, you know, one specific probiotic combination will fix everything. Anything that’s vaginal-related, just shove some of that up there and you’ll be good to go. And in my experience, that’s not the case at all. And there are some things that will support using a Lactobacillus-dominated probiotic, and there are now many different strains that come through in the research for different things. But in my experience, if you’re dealing with something that is perhaps more fungal-driven like recurrent thrush, or if we look at recurrent thrush also that’s more of a hypersensitivity disorder so it’s more immunoregulated than anything. A probiotic doesn’t fix it, or it does for only the people whose recurrent thrush is triggered by quite a significant pH shift or is more characteristic of positive cultures than negative ones. So for those people, you know, probiotics aren’t top of my list. I’ve got many other things that I would be thinking about and addressing and choosing from first because I don’t like to give people lots of supplements.

And so, most people also in these conditions have tried a probiotic and may not have already had success with it. So it’s about being judicial. I mean, you know, if it’s a bacterial-driven issue like bacterial vaginosis or even recurrent UTIs, then usually I will have some level of probiotic in the background that we are using orally. And then for some people, it’s appropriate to use it vaginally. But that’s not everyone because when we look at these complexities of vaginal health disorders, there are also other things. I mean, people can’t insert things or they may be reactive on that mucosa because it’s so inflamed. And so, intravaginal preparations for people that have inflammation sometimes are completely contraindicated until you actually bring that inflammation down and get some level of normalcy back in there as well. But they are important to consider.

And there is obviously…When we look at vaginal health, there’s a lot more research coming through on probiotics because everybody seems to be very interested in that, you know, and there are specific strains that come through as well, but it’s a very mixed bag. I mean, even the Cochrane Review, which is a few years old now, but does say, you know, it’s promising but there’s not enough, and obviously, the study design isn’t heterogeneous enough in that we can actually even make conclusions on whether this is working or not. But I certainly think that you know, when we look at the individual studies for individual circumstances for some conditions like bacterial vaginosis, they are worth employing in that space in the background as well. But there are other intravaginal remedies as well that have similar levels of evidence, you know, looking at the bacterial vaginosis, the vitamin C pessaries, or if we look at more, sort of, menopausal presentations, then using things like fennel pessaries or fennel creams and things like that. So there are some really interesting things that people have put in vaginas and have had some success in terms of addressing specific presentations.

Andrew: Fennel pessaries, I’ve never heard, vitamin C pessaries, never heard of them. I was thinking more along the lines of, you know, the vinegar douche. Obviously, you’ve got to be very careful of existing inflamed tissues, it’ll burn the hell out of you, but also things like calendula, colostrum. What’s the other one? Butyrate.

Moira: So, well, I haven’t used butyrate for…

Andrew: Can you comment on those?

Moira: Yeah. Gosh, there’s a lot in there, and those are all things that I would employ for different presentations. Like, I am a bit of a fan of apple cider vinegar, diluted apple cider vinegar because acetic acid has antifungal properties and some of the issues that we see with antifungal medications are that they’re fungistatic not fungicidal, whereas acetic acid promises to have some fungicidal action. But the evidence on that is brief. It’s something that, in part of my Ph.D., I’ve done a lit review on and there’s some really cool stuff happening in dentistry, obviously, with candida in dentures and things like that where they’ve used vinegar rinses. But it’s something that we need to consider. You’re right about the inflammatory aspect of people’s presentations. And again, if you are having to do something to control and you’re having to do it on a regular basis, if you’re having to use an irrigation of diluted vinegar quite regularly, then it’s not fixing the issue, you know. You still need to step back and go, “Why? Why? What’s going on here?”

Then things like colostrum vaginally is interesting. I mean, a lot of those sort of things speak to improving like the bacillus levels in the area. So there’s some research around colostrum in vaginas that are menopausal as well about improving the microbiome in that space. So there are lots of different things that we can try. I mean, I think when I step back and think about the many different intravaginal things I use from lactulose to, you know, diluted hydrogen peroxide, those sort of things have specific spaces but I think that they require somebody to really understand what they’re trying to do in that area before you go and just pop it in there because you can also disrupt and you can burn and you can cause irritation. And certainly when we step back and think, “Gosh, first do no harm,” you shouldn’t be employing things without assessing the level of inflammation that somebody actually has and whether that is even going to be appropriate, as I said.

Often, I don’t do intravaginal things for people that have high levels of inflammation, or I’ve learned to pick somebody that would likely respond quite negatively to a vaginal intervention at the starting line, you know, and worked with that because there’s a whole lot of other stuff, you know. People have created…I’ve seen people that have developed allergic responses to tea tree or lavender oil because they’ve tried to use those intravaginally on a tampon. And, you know, we need to be really mindful. This is a really sensitive eco niche and, you know, it burns and it’s not a burn that settles quickly either, so, you know, those sort of things. But there are other quite available things as well on the market that people may like to try. Like, lactic acid seems like a very scary intervention but it’s actually quite appropriate for a really wide range of disorders both bacterial and fungal, and lactic acid often comes in more of sort of an oil-based pessary so it can be a little bit more soothing as well. So those sort of which shift pH can be I think more confidently used from the beginning for more people than some of these small things like the vinegar dishes or the hydrogen peroxide, lactulose irrigations, or the things that by nature you would think would burn if you put it on a wound. Those are the things you need to be cautious about.

Moira, there’s so much to cover, too much to cover in one podcast. Would you join us again to go through some of these treatments in-depth and the practicalities of how you, for instance, do a lactulose douche?

Moira: Mm-hmm.

Andrew: Never heard of it. And, you know, some of these things, they’re quite messy so they need some involvement of preparation for the woman before they embark on a treatment regime. Would you join us back on “Wellness by Designs” at another stage?

Moira: Yeah, definitely. I’d love to.

Andrew: Great.

Moira: Certainly some acrobats that need to be involved as well.

Andrew: Yeah. So just a brief last question because this is, as you said, you know, there are some issues with, for instance, tea tree oil. I won’t go into a story there about herbal preparation. But, you know, so even vinegar, that can burn. What general safety aspects do we have to be aware of with regards to safety for our patients so that we don’t indeed cause more harm?

Moira: Yeah. I guess there are a few. One is who is this person and what stage of life are they in? Because there’s a tendency when we look at people who have menopausal vaginas, for example, they tend to be more reactive because they’re more aerobic-dominated so there’s more inflammation from the offset. So those are the people I tend to be more hesitant around. And also stage of life in terms of pregnancy, for example. There is some ability to apply intravaginal remedies in pregnancy but you need to have some awareness around risk past pregnancy, cervical competency, you know, what’s going on for that individual because it’s not a one…You can’t apply the same thing to everybody. So there’s that level. And then just as a general assessment, I’m always asking about the level of inflammation. Past reactivity, you know, what have they tried and what happened? And if I assess that they’ve tried something that I would consider to be quite inert and they’ve reacted in a really pro-inflammatory state, then that’s also a bit of a hallmark for me. Allergy and atopy obviously need to come into this as well. And a lot of these more recurrent vaginal disorders are characterized by an allergic response, so that’s obviously something you need to be mindful of as well.

And then if we move into sort of the vulva dermatological issues, I always am assuming that less is more and that these people are highly reactive because things like lichen sclerosis, you know, are very reactive in terms of anything that they put on there. You really need to find the magical ingredient that’s the soother, and often that’s very simple, not complex, you know, single vegetable-based oils or plant-based oils versus things that have lots of herbs and essential oils and nutrients in it, and starting off and building up is a much better approach for those people. So really you have to ask the questions around, you know, what’s going on? What have you tried? What’s your past sensitivity? And what is the risk for this person at this point if I was to apply a vagina remedy because that’s a big part of whether it will be appropriate or not for them?

Andrew: There’s so much to learn. Moira, thank you so much for taking us through just a little bit of this today, and for everyone out there, if you’re interested in learning more about this, Moira has a course, Intimate Ecology. You can join. You can learn more. There are volumes of stuff to learn from that course and it’s growing every day. But thank you so much, Moira, for joining us today, and thank you, everybody, for joining us today on “Wellness by Designs.” Of course, all the show notes and all the other podcasts are up on the designsforhealth.com.au website. So thank you so much for joining us today on “Wellness by Designs.” I’m Andrew Whitfield-Cook.