Almost immediately after treating for ureaplasma, I began to experience vaginal odor that came and went erratically and was worse after sex. It sounds like a classic case of bacterial vaginosis (BV), right? Only, none of the words I read online about any kind of vaginal odor, healthy or not, seemed like the right one. I didn’t have the language to describe what I was experiencing. And so treatment after treatment, I found myself in a white, clinical emptiness between mystery and the feeling that we weren’t treating for what was wrong with me.
Vaginal pH
The first line of treatment for most women who experience vaginal odor is pH-D, a boric acid suppository that lowers the pH of your vagina by literally placing an acidic compound up there. A healthy vaginal pH is considered to fall between 3.8 and 4.5 on the pH scale. In that range, the bacteria you want to grow, lactobacilli, while a pH above 4.5 promotes growth of disruptive bacteria. The idea behind pH-D is that if you have odor, you have an overgrowth of disruptive bacteria, and returning your vagina to an acidic state will stop their growth, giving your lactobacilli a chance to take back over.
I tried boric acid many times, and sometimes it subdued the odor a little, but I can say with certainty now that boric acid DOES NOT work for my body. In the words of my former gynecologist, it “made her angry,” meaning that as I sat there in stirrups, my vagina was red and inflamed. She thought that boric acid swung the pH of my vagina too far in the acidic direction, so that as my body was naturally trying to heal itself, which it will do (it just needs time), introducing boric acid was making it go on a roller coaster that actually made normalizing the pH of the environment harder.
I’d try boric acid once many months later, after my body had healed considerably from all of the antibiotics that had damaged my collective microbiome, as a preventive measure around the time of my period. I experienced odor after taking it, along with abnormal discharge. You could say the effect was correlative, but even if it were, the correlation was enough for me to suspect that it messed with my hormones and caused my symptoms.
Antibiotics: A Conventional Approach
In September I saw another gynecologist in the same practice for an emergency visit because I thought I was developing some sort of infection. She prescribed a metronidazole gel that I used for only one night because I hated it — it made me feel inflamed — followed by a clindamycin cream for one week that felt cool when I inserted it using the applicator. She also prescribed a vaginal estrogen cream for one month, but after two weeks I stopped using it because it caused irregular bleeding.
In November I was referred to a gynecology specialist who was a World Health Organization consultant and saw a lot of complicated cases like mine. She prescribed a two-week, twice-daily dose of oral metronidazole (to which I noticed no response whatsoever) to follow with clindamycin cream again, because of its anti-inflammatory properties. The prescription was for three times per week for at least four months; I made the decision to again stop treatment two months early when I met with an Evvy health coach who planted seeds of doubt in my head that this was a good approach.
Vaginal Microbiome Testing
I’d discovered Evvy and taken my first test just in time to bring the results to my appointment. While Evvy claims that test results are to be considered informational rather than diagnostic, they did serve as an amazing source of information when I had no other leads. I, along with all of the naturopathic doctors I know, am an advocate for information in the form of labs and clinical research.
The results from my first test showed that I had an L. crispatus-dominant vaginal microbiome, which translates to a Type 1 Community State Type (CST). Surprisingly, given the number of infections I’d had, this is considered the healthiest type, the most protective against infections including UTIs as well as the lowest risk for infertility and highest success rates of assisted reproductive techniques.
Research on vaginal microbiome CSTs is budding, and every microbiome shows variation, but the CSTs offer a helpful framework for describing what’s going on with your vaginal microbiome holistically while also showing the composition of your vaginal microbiome in detail. (Evvy uses a kind of next-generation sequencing called shotgun metagenomics that sequences any and all microbial DNA present and then matches it to microorganisms via bioinformatics, so you learn everything that’s in your vaginal microbiome.)
Each of the five CSTs is characterized by the type and amount of Lactobacillus present, which exhibit different protective effects:
· Type 1: L. crispatus dominant
· Type 2: L. gasseri dominant
· Type 3: L. iners dominant
· Type 4: no Lactobacillus dominance
· Type 5: L. jensenii dominant
Evvy tests served as a decision-making tool for me. After the extended treatment with metronidazole and clindamycin, plus a round of cefuroxime for a UTI (I learned later that this is not a good antibiotic, and I would never take it again), my Type 1, 96.63% L. crispatus-dominant CST was reduced to a Type 4 CST with 90% disruptive bacteria.
To the specialist’s credit, she was knowledgeable — we had an in-depth conversation about L. crispatus — and I think she at least suspected a hormonal component to the problem, rather than assuming it was all microbial. She put me on the Nuvaring, which contains mostly localized estrogen that she thought could help to increase my lactobacilli count; she didn’t see many under the microscope. (I say mostly because nothing in your body is entirely separate from the rest of your body; at least some amount of estrogen will circulate in your bloodstream, as naturopathic doctors would educate me.)
My Evvy results, however, solidified my commitment to exploring a naturopathic approach to treatment. After working with a naturopathic doctor (ND) for two months, my microbiome was at least restored to a Type 2 state dominated by L. gasseri, but I had only 0.34% L. crispatus. I mourn the loss of my L. crispatus. Sometimes I wonder if I’ve gotten it back and think about testing with Evvy again — after learning so much about my body, I didn’t feel the need to anymore — but maybe I will, someday soon.
Naturopathic Medicine for Vaginal Infections
Everyone was trying to treat BV, an imbalance of vaginal bacteria favoring pathogenic anaerobes such as Gardnerella (the most common culprit), Atopobium vaginae (which one doctor told me grows on the scaffold created by Gardnerella biofilms), Mobiluncus, Prevotella, Streptococcus, Mycoplasma, Ureaplasma, Dialister, and Bacteroides. BV isn’t the only condition associated with vaginal dysbiosis; aerobic vaginitis (AV) is another, characterized by an overgrowth of aerobic, rather than anaerobic, disruptive bacteria. One gynecologist at one point in time did wonder if this is what I had. I never got an answer.
The problem with this type of thinking is that what I was experiencing wasn’t only microbial; it was microbial and hormonal. Naturopathic doctors, who have a deeper respect for relationships within the body, understood that.
When it comes to naturopathic medicine, I can’t emphasize enough that you have to have confidence in who you’re working with. Always consult your gut as your source of truth, or, in a way that is all too real for the context of this article, use the sniff test.
Hormone Imbalance Can Cause Vaginal Infections
My first assignment from my first ND was to take the DUTCH Complete test, which measures sex and adrenal hormones and their metabolites, along with six organic acids. This test was another beginning. Every gynecologist I have ever asked has told me that hormone tests aren’t meaningful, because they capture your levels at a single point in time, while your hormones fluctuate over your cycle — but the DUTCH test took note of where I was in my cycle and compared my levels to the normal range for that period of time.
The results showed that my levels of all three primary estrogens — estrone, estradiol, and estriol — were low, and in the case of estriol, nearing the postmenopausal range. My ND explained that in some women, use of birth control over many years can do this, because what birth control does is essentially tell your brain it doesn’t need to produce the hormones it’s replacing. With time, however, hormone balance (and fertility) can be restored.
Estrogen promotes the growth of lactobacilli by producing glycogen, which helps lactobacilli to grow. Not only does this in and of itself help to maintain a healthy vaginal microbiome, but lactobacilli produce lactic acid, which facilitates local immune response by increasing the release of interleukin (IL)-1β and IL-8 from vaginal epithelial cells. Vaginal epithelial cells only produce L-lactic acid, whereas certain types of lactobacilli (including L. crispatus, L. gasseri, and L. jensenii) produce D-lactic acid, so having those types of dominant strains can further increase the amount of lactic acid present.
The test also showed that my cortisol levels upon waking and in the morning were low, which explained why I felt so tired in the mornings. For this, my ND gave me supplements with high doses of vitamins B5, B6, and B12, which support the adrenals and energy levels and can be depleted by birth control, as well as adrenal-supportive herbs, such as rhodiola and eleuthero.
The adrenals are a part of the hypothalamic pituitary adrenal (HPA) axis (there is also a hypothalamic pituitary ovarian axis). In this way they facilitate communication between the nervous system and endocrine system, producing hormones such as cortisol and the “fight or flight” hormones adrenaline and noradrenaline. Prolonged periods of stress, such as those caused by chronic infections, can cause your adrenals to go into overdrive, or survival mode.
While the adrenals don’t make estrogen, there is a connection between stress, the reproductive axis, and fertility. And while scientists don’t seem to know why stress affects fertility, I wonder if the HPO axis has something to do with it.
Vaginal Suppositories
The findings revealed a root cause of my infections: my body didn’t have enough estrogen, and it was too stressed out to make more of it. To increase the amount of local estrogen in my vagina, I used Bezwecken ovals, the 2x strength kind, which contain estrogen and helped a lot. (Months later, to help with vaginal dryness, I would self-prescribe the 1x kind, and they gave me a yeast infection! This just goes to show that the vaginal microbiome is always changing, as is what the body needs.)
By February, I was opening capsules of the probiotic Femdophilus to mix into solid coconut oil and insert as a makeshift vaginal suppository for when the itching got bad, which is typically associated with yeast but I always attributed to dysbiosis. It was a wild approach, thinking about it now, but it was a tip from my ND and it worked when I needed it to.
Healing from Vaginal Dysbiosis
By late spring, when that ND had helped to stabilize me but didn’t know how to fully resolve my symptoms, she referred me to another ND, whom I saw four times between May and September. (To anyone who has been motivated enough to pay out of pocket for the help of a specialist who doesn’t have to contract with provider networks because their knowledge is so sought after, my heart goes out to you.)
What Is the Mycobiome?
In our first 15 minutes together, this specialist identified an important factor in what was causing my symptoms, one about which I think her instinct was right: something fungal was going on. After taking the number of courses of antibiotics I had, she said, there had to be.
While infinitely smaller than the bacteriome (so much so that it is sometimes called the “rare biosphere”), the mycobiome interacts with it closely. The vaginal microbiome cannot be comprehensively studied without considering the role of the vaginal mycobiome or hormone health!
While the vaginal mycobiome has not been fully characterized, meaning some of the sequences haven’t been identified, we do know that it contains at least 11–20 different genera, most of which are Candida. Candida lives in the gut as well as in the vagina (you have a gut mycobiome too), and research shows that a decrease in anaerobic bacteria or a shift in your Firmicutes to Bacteriodetes ratio (too far in either direction can lead to issues) can promote Candida overgrowth. As with many kinds of bacteria, Candida, among other fungi, is not inherently bad — you want some of it — but too much can be.
Can the Mycobiome Cause Vaginal Infections?
After giving my kidneys and adrenals some love and using nutrients and herbs to promote healthy microbial balance in my gut, the fact that I was still experiencing some UTI and vaginal symptoms led the ND to take a more aggressive approach. She prescribed fluconazole, 200mg every three days.
In mid-September, I took the first seven of 15 capsules before pausing, when my gynecologist advised that taking that much fluconazole could pose a danger to your liver enzymes; when I raised my concern with the ND, she said once every three days wasn’t dangerous. I don’t know who was right. I will say that, not long after taking seven more of the fluconazole (I saved one), I did begin to experience GI symptoms that continued to worsen for two months until I started taking Seed’s DS-01® Daily Synbiotic (a synbiotic is a combination probiotic and prebiotic). My theory, which research supports, is that the fluconazole wiped out my intestinal Candida (I have the GI Map results to prove it), causing dysbiosis there.
After taking the fluconazole, though, something else happened that was magical. For the first time in two years, I finally started to feel better. For one perfect early October weekend, nothing was vaginally wrong with me.
Of course, pharmacies stopped stocking the generic of Nuvaring that I liked, so I had to switch to the other generic, which I knew my body didn’t like as much and it put up a fight about when I switched back. It took three months for my cycle to normalize, even though the rings contain the same hormones in the same amounts and are made of the same materials. (The ND told me there are differences between manufacturers, but I scoured the packaging of one, searched the manufacturer website of the other, and cannot for the life of me figure out what my body was reacting to.)
Over the past several months, I’ve had odor on occasion maybe twice for one day, and not at all recently. I can have sex without noticing odor afterwards, or worse, during. My pH is consistently normal (you can order test strips) and my gynecologist consistently says my estrogen levels look normal or a little low but okay (a gynecologist can tell this from an examination). I’m not itching in the middle of the workday, waiting for that unknown vaginal infection to turn into a UTI too. (Once, I am almost certain that either I had a Candida UTI or my treatment with many, many doses of herbs suppressed bacteria so much that it gave way to a yeast infection — who knows?)
I think there was truth to the ND’s instinct, and yet she never described specifically what fungi might have been contributing to my symptoms. While I am not a scientist, all of those close reading papers I wrote at university taught me to make connections among disparate topics, and as I am someone who lights up when going down scientific rabbit holes, I often emerge with ideas for research directions. Research on the role of the vaginal mycobiome in microbiome eubiosis is one of them.