Knocked Up Podcast - BV, the Vaginal Microbiome and Fertility
Bacterial vaginosis, or BV, is one of the most common vaginal conditions in women of reproductive age, yet many women are unsure how it may affect fertility.
Bacterial vaginosis, or BV, is one of the most common vaginal conditions in women of reproductive age, yet many women are unsure how it may affect fertility. In this episode of Knocked Up, CREI fertility specialist Dr Raelia Lew explains what BV actually is, how it differs from thrush, and why the balance of healthy lactobacillus bacteria and vaginal pH matters when you are trying to conceive.
Choosing a pH balanced lubricant that supports healthy vaginal flora, like those from Ellechemy, can help maintain the natural environment lactobacilli need to thrive, which is especially important when you are trying to conceive.
TRANSCRIPT
Jordi Morrison: Hello and welcome to Knocked Up, the podcast about fertility and women's health. You were joined, as always, by me, Jordi Morrison and Dr. Raelia Lew, C-R-E-I fertility specialist. Welcome, Raelia.
Dr. Raelia Lew: Hi, Jordi. How are you?
Jordi Morrison: I'm really good. Today, we have a listener request about bacterial vaginosis and fertility. BV, as it is also known, has been in the news a little bit this year. From the very beginning, could you please explain to us what is bacterial vaginosis and why it's different to other infections that we think of, like thrush?
Dr. Raelia Lew: Sure. Well, BV or bacterial vaginosis is probably the most common genital tract disorder in women of reproductive age. And it's characterized as a shift from the healthy bacterial balance of the vagina, sometimes called the microbiome, which is or should be one that's dominated by lactobacillus, which is an acid-producing bacteria that keeps the pH of the vagina nice and negative.
Jordi Morrison: That's in yoghurt?
Dr. Raelia Lew: Yep. Another source of lactobacilli.
Jordi Morrison: I know that word. How do I know that word?
Dr. Raelia Lew: It makes lactic acid, and that's one of the acids of the vagina. But in bacterial vaginosis the balance tips and is dominated by unhealthy bacteria and quite commonly the sign and symptom that women notice is a kind of strong and you know in the medical literature described as a fishy vaginal odor. But women also experience increased discharge. Sometimes it's grey slash green in colour, which can be disconcerting. And that can be different from the discharge of something like thrush, which is a little bit more kind of described as cottage cheesy, white, yellow. And quite often bacterial vaginosis can also be accompanied by symptoms of discomfort, itching, burning in the vulvovaginal area and sometimes with pain during sex. So it's not a very pleasant condition.
Jordi Morrison: No, it doesn't sound it. And I think regarding the smell, there is a natural odour that the vagina has, isn't there? But this is quite distinct from what our natural smell would be.
Dr. Raelia Lew: Yeah, so the vagina is kind of not an area of the body that should have no odour, but the smell of bacterial vaginosis is strong and unpleasant. So you would notice it.
Jordi Morrison: You would notice it. And what causes this bacterial imbalance that leads to BV?
Dr. Raelia Lew: Well, it's one of those conditions that has different causes, and there can be different triggers and sometimes a bit of a vicious cycle. It can be after a course of antibiotics. It can be after sex with a new partner and it can be sexually transmitted. It can be associated with diet and with overuse of actually hygiene products. So washing away the normal healthy bacteria is not a good thing. And it's one of those things that once you lose the balance, it can be, the reason I say it's a vicious cycle is it can be very hard to re-establish the balance. And it is actually the good bacteria that need to be in the vagina that fight off the bad bacteria.
Jordi Morrison: And are some women more prone to BV than others? I know with thrush, it affects a percentage of the population, is BV similar in that sense?
Dr. Raelia Lew: Well, it's common in sexually active women, so it is more common in sexually active women, and it would be more common in women who have non-monogamous relationships because they have the opportunity to encounter these bacteria from a different partner. But it is super common, and it can affect anybody, and it doesn't really, you know, pick and choose. And when a woman has BV, it can be very upsetting for her. So like all STIs, it's not something to be ashamed of. It's something to speak openly with your doctor about and seek treatment.
Jordi Morrison: Oh, definitely. And one of the studies that came out this year that a lot of people have been talking about is a really important finding that if a woman has a diagnosis of BV and her partner is not treated, then she'll be at a higher risk of having a failure of treatment or a recontamination. And so sexual partners can pass BV back and forward like a ping pong match. So one of the ways we help women overcome BV is in fact to treat their partner as well as treating them. Would the partner have any symptoms or is there anything to watch out for?
Dr. Raelia Lew: Interestingly, they don't necessarily cause symptoms or bother them. So they can be in some ways a vector, I guess we would call it in medical terms, someone who passes on a condition without necessarily suffering from that condition.
Jordi Morrison: Okay. Bacterial vaginosis is three times more common in infertile women than fertile women. How does BV contribute to infertility?
Dr. Raelia Lew: So BV as well as other STIs in general can decrease fertility in a number of different ways. One of the ways is through causing inflammation and inflammation and immune system overactivity can make the reproductive tract a more toxic environment for egg, sperm and embryo. It can also cause damage to sperm, to vaginal cells. It can interfere with the production of healthy cervical mucus, which is physiologically important during ovulation to help sperm ascend into the female reproductive tract. So having that discharge and inflammatory mucus can reduce the physiological important functions of fertile mucus. You can also have, in extreme cases of STIs, damage to the reproductive tract that is permanent, so things like scarring from infections so that sperm and egg can't meet together and blockage of the fallopian tubes. But that's much more common in infections like chlamydia and gonorrhea than it is with BV.
Jordi Morrison: And how does BV influence the vaginal pH? And does this matter when it comes to conception?
Dr. Raelia Lew: Look, it does. So women who are diagnosed with BV tend to have a loss of dominance of lactobacilli and it's more that the lactobacillae are really important in maintaining the ideal pH of the vagina which is about 4.5 a little bit negative and the lactobacilli are what we call symbiotic bacteria we've evolved to have them in our vagina and they help us and they are important in maintaining that pH. It's an important protection for women to stave off infection and irritation and maintain vaginal health. And the ecosystem of healthy bacteria in the vagina are symbiotically associated with improved fertility. So we see that women who have a higher lactobacillus profile actually are overrepresented in fertile populations. And women with a microbiome disturbance and an absence of lactobacillia overrepresented in infertile populations. So finding that equilibrium, again, is really important to have the ideal pH in the vagina. And there's lots of things that can disturb pH in the vagina as well and products that we sometimes use in the modern world that previous generations wouldn't have necessarily used. If we choose inappropriate products such as lubricants, then that in itself can disturb the pH of the vagina and increase someone's susceptibility to contracting BV because it can disturb their normal flora. So one shout out to our alchemy products is that they are designed to be pH perfect for the vagina and our Ellechemy Protectility lubricant is, in my opinion, the ideal lubricant for women and couples who are trying to conceive for this reason and that was why it was designed.
Jordi Morrison: Are there any risks of untreated BV during pregnancy?
Dr. Raelia Lew: So yes, BV also has been associated with an increased risk of pregnancy loss, an increased risk of biochemical pregnancy following IVF and natural conception. And when women do have BV present during pregnancy, there may be an increased risk of miscarriages, preterm birth and low birth weight babies born, as well as an increase in postpartum infection. So it is good to treat BV when we find it rather than ignore it.
Jordi Morrison: And can it lead to any long-term issues with fertility?
Dr. Raelia Lew: Well, as we mentioned before, if it was extreme and if it caused scarring in the female reproductive tract, then potentially it could. But I would reassure women who've had BV that is highly unlikely that if their BV is treated, that it will have any long-term consequences for the future fertility. So it may cause infertility and be a contributing factor, but once it's treated, unless you've had an extreme example, it would be highly unlikely to have impacts on long-term fertility for women. One thing that I will say about BV is that there is an association that when women have a bacterial imbalance, they are more susceptible to other STIs. So women of reproductive age who may be sexually active and who contract BV may, due to their vaginal susceptibility and vulnerability in the presence of BV, also be more susceptible to contracting other infections. And that includes things like HPV, human papillomavirus, which is the virus that causes genital warts and cervical abnormalities that can lead to cervical cancer. And also HIV. So women who have BV are more likely if exposed to contract HIV. Now hopefully women who are not in a monogamous trusted relationship will not be having unprotected sex. And we would always say for women who are not trying to conceive in a new or non-monogamous relationship we do recommend barrier contraception with condoms to prevent STIs. And if you are starting to try to conceive or you are in a trusted relationship and you want to have unprotected sex, it's really important to pop in, see a specialist or even your GP and have an STI screen and your partner must also and then once you've got the all clear that would be protective for you should you plan to have unprotected sex.
Jordi Morrison: We have a note here about douching and I almost can't believe that I'm still hearing this word but that some people do believe that douching can help prevent or cure BV. Surely this is false.
Dr. Raelia Lew: Yeah, it's definitely false. You shouldn't be cleansing the vagina with chemicals. That's really important. A lot of soaps are, in fact, alkaline, which is the opposite of what the vagina needs. And even when we use more neutral or even pH adjusted water, it's unnecessary. The vagina sometimes has been described as a self-cleaning organ and it is true that the natural protection of the lactobacillia is what the vagina needs to be healthy and washing our natural flora away only creates a niche for bacteria that we don't want in the vagina.
Jordi Morrison: You've given us, at the top of the episode you gave us a really good indicator of what the symptoms are and it sounds like you would notice them and it sort of wouldn't be hard to self-diagnose in a way. But it's important to avoid self-diagnosis, isn't it? And to see real healthcare, in all cases, but with BV as well.
Dr. Raelia Lew: Definitely because, especially because STI symptoms and signs can be overlapping and it's important to get an actual diagnosis because if you have the wrong diagnosis, then you may apply a treatment that is not effective. The gold standard test for diagnosis is a what's called a gram stain of the vaginal swab and we see clue cells which are cells of the vagina that are infected with bacteria and we also culture bacteria to see if particular bacteria are dominant and whether they have different antibiotic susceptibilities and we look at the pH and that's how we diagnose BV but we also can exclude other infections. So we tend to do a test for things like chlamydia and gonorrhea and mycoplasma and ureaplasma and other pathogens that can cause vaginal concerns like candida. And we want to know specifically what we're treating. We can isolate the bacteria Gardnerella vaginalis, but BV can be complex. It's not always one particular bacteria that causes it. And especially if it's linked to other STIs, you want to get checked for everything.
Jordi Morrison: That's right. And the reason that BV is called BV bacterial vaginosis, it does sound like a bit of a general term in itself because it doesn't specify a particular bacteria. Is there a range of bacteria that can be involved? And how is it treated?
Dr. Raelia Lew: So BV is generally treated with antibiotics and we're lucky that most of the antibiotic susceptibilities are retained for the kind of bacteria that do infect the vagina. We are in medicine entering an era where through the longer duration of antibiotics being available and probably the overuse of antibiotics in some settings, we have bacterial resistance to certain antibiotics in different areas of medicine. So we certainly don't want to be using antibiotics if they are not truly indicated because if you use antibiotics too much, it gives the opportunity for bacteria to become resistant to antibiotics, which are the tools we have. With BV, we tend to use an antibiotic called metronidazole and that covers a lot of anaerobic bacteria or bacteria that don't thrive in an oxygen-rich environment and we tend to use it vaginally rather than systemically so treat the problem where the problem is and more and more when I'm treating patients with BV in my clinical practice I'm following it up with a lactobacillus vaginal probiotic to try and after we get rid of the bad bacteria recolonize or support the recolonization of the vagina with a good bacteria because they're our best asset in preventing recurrence. With men we tend to treat with more systemic antibiotics or oral antibiotics rather than topical antibiotics. And that's because of their anatomy being different.
Jordi Morrison: If a woman is having struggles with fertility and she knows she has recurrent BV, when should she seek specialist fertility advice?
Dr. Raelia Lew: So the advice is going to be the same for anyone who is suffering infertility that if you're not getting pregnant and it's been six to 12 months of trying, you should reach out for advice, regardless of the underlying cause. And if you are older, so aged over 35, definitely at the six month mark, reach out to your GP and seek a specialist referral for some advice. Infertility is in general multifactorial most of the time and it's really important for couples in a heterosexual context to have a full assessment of both partners. If anybody, whether they're trying to get pregnant or not, has symptoms of BV, they should reach out for help and I think women suffer in silence a lot and unnecessarily so and breaking that cycle of BV can have really positive impacts on their comfort, on their sexual life, and on their vaginal health. And I think especially in the case of BV, the partner probably needs to be treated as well.
Jordi Morrison: Definitely. I think the evidence now is clear that BV is not just an imbalance of the vagina for the woman. It's actually classified now as an STI and both partners do need to be treated in order to eradicate the imbalance. You've mentioned antibiotics, topical antibiotics for treating the partner with a vagina. In terms of the partner with a penis, how are they treated?
Dr. Raelia Lew: With oral antibiotics. And we would treat them with a spectrum of antibiotics that would cover the bacteria of the infection that we found.
Jordi Morrison: Thank you, Raelia.
Hosted by Dr Raelia Lew and Jordi Morrison
Dr Raelia Lew is a RANZCOG Board Certified CREI Fertility specialist, Gynaecologist and the Director of Women’s Health Melbourne.
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