see also:

• gynaecology
• sexually transmitted infections (STDs/STIs)

• see https://jeanhailes.org.au/contents/documents/Resources/Booklets/The_vulva.pdf - Jean Hailes Women's Health - patient information booklet on vulval health care for women (pdf) for more details
• Don’t use any soap or perfumed bath products to wash your vulva – only use water or soap substitute
• Never use talcum powder on your vulva (seems it may increase risk of ovarian cancer)
• Avoid swimming in chlorinated water if you can
  • After swimming, change out of swimwear immediately, shower to remove chlorine or salt and avoid wet clothing
• Wear cotton underpants rather than synthetic
• Wash underwear in pure, unscented soap and rinse them well
• Wear loose-fitting pants, avoid G-strings (may increase transport of rectal bacteria to vulva), pantyhose and tight jeans
• When urinating, lean forward to avoid a burning sensation
• After urination and/or bowel movements, always wipe or pat from front to back, using white unscented toilet paper
• It may help to bathe with a salt wash after you have been to the toilet or had sex
• Use 100% cotton sanitary pads and tampons. Menstrual blood may irritate your vulva, so consider using tampons
• Avoid using commercial lubricants with intercourse; natural oils such as olive or almond oil may be more suitable.

• the vagina harbors a huge microecosystem containing 10¹⁰–10¹¹ bacteria as well as fungi, etc ¹⁾
• the vagina is a self-cleansing organ
• vaginal discharge consists of desquamated vaginal epithelial cells, bacteria, and glandular secretions and helps to protect against vulvovaginal infections
  • discharge is normally white or clear in colour and possesses a slight, non-offensive odour
  • discharge is thick, sticky, and hostile to sperm early in the cycle
  • becomes thin and watery during ovulation due to rising oestrogen levels
  • in thrush, it has thick white cheesy discharge
• much of the normal genital odours arise from the apocrine skin glands associated with pubic hair regions and not from the vagina itself
• the microbiome constantly undergoes fluctuations during the female menstrual cycle and a woman’s entire life and varies with ethnicity and diet
  • vaginal pH is neutral or alkaline during childhood, dominated by anaerobic bacteria, Diphtheroids, coagulase-negative Staphylococci, E. coli and Mycoplasma species²⁾
  • rise in oestrogen that occurs during puberty promotes hyperplasia of the vaginal mucosal epithelium and increases the cellular glycogen content³⁾
  • oestrogen levels drive the production of glycogen in the vaginal tissue, which feeds the protective Lactobacillus bacteria during reproductive years
  • during pregnancy, the vaginal microbiome stabilises and reduces in diversity, generally being dominated by one or two species of Lactobacillus spp⁴⁾
  • menopause features lower estrogen, higher pH, and greater bacterial diversity rather than strict Lactobacillus dominance
    • the vaginal microbiomes of women with mild or moderate vulvovaginal atrophy (VVA), a condition that causes vaginal dryness and soreness in postmenopausal women due to estrogen decline, had 25-fold greater odds of being classified as CST IV-A compared to women with no VVA ⁵⁾
  • it can be altered in pregnancy
  • menstruation, sexual activity, antibiotics, hygiene practices (like douching or scented washes) can temporarily or permanently deplete lactobacilli, leading to imbalances such as bacterial vaginosis (BV) or yeast infections
• a healthy vaginal microbiome is usually dominated by Lactobacillus (usually make up 90-95% of bacterial microbiome in healthy pre-menopausal women) which produce various antimicrobial compounds such as bacteriocins, lactic acid and hydrogen peroxide
  • lactic acid produced by the vaginal microbiota helps maintain a low pH of 3.5–4.5, a major factor in limiting the growth of potentially harmful bacteria
  • Community State Types (CSTs) of vaginal microbiome:
    • CST I: Dominated by Lactobacillus crispatus (often considered the most stable and protective)
    • CST II: Dominated by Lactobacillus gasseri
    • CST III: Dominated by Lactobacillus iners
    • CST IV: Has lower levels of lactobacilli and higher microbial diversity (can be normal for some healthy women, particularly across different ethnicities, but may carry a higher risk of imbalance)
      • CST IV-A dominated by anaerobes of the genera Anaerococcus sp., Prevotella sp. and Streptococcus sp
      • CST IV-B by higher proportions of the genera Atopobium sp. and Megasphaera sp., amongst others
    • CST V: Dominated by Lactobacillus jensenii
  • a healthy vaginal microbiome can also be dominated by Bifidobacterium sp which also can produce lactic acid and bacteriocidins ⁶⁾
• the vaginal microbiome is important for vaginal health and can have a significant role in pregnancy outcomes, risk of various conditions, as well as clinical symptoms if dysbiotic
  • there are distinct microbial communities in cervical canal, uterus, fallopian tubes and peritoneal fluid, differing from that of the vagina⁷⁾
  • a healthy uterine microbiota likely also depends on the nutrients and hormones available to the uterus, as well as the microbiota in the vagina and the peritoneal cavity ⁸⁾
• clothing, sedentary lifestyle, contraception and delayed pregnancies common in modern life may modulate the vagino-uterine microbiota ⁹⁾
• a loss of protective Lactobacillus spp. in the vagina, especially in post-menopausal women, can allow colonisation of opportunistic UTI-associated organisms such as E. coli, Proteus, Klebsiella, and Enterococcus spp.¹⁰⁾
• vaginal dysbiosis is consistently associated with STIs including Human Immunodeficiency Virus (HIV), herpes simplex virus type-2 (HSV-2), Human Papilloma Virus (HPV), and Trichomonas vaginalis¹¹⁾

• antibiotic use
• hormonal changes
  • menstrual cycle, contraceptives, menopause, etc
  • there is Lactobacillus-depletion during menses when oestrogen levels are lowest, with a shift towards Lactobacillus-dominance just prior to ovulation when oestrogen levels are highest¹²⁾
• sexual intercourse
  • condom users have a higher prevalence of hydrogen peroxide-producing Lactobacilli, and are less likely to exhibit a non-optimal CST III (L. iners) microbiome¹³⁾
  • BV associated bacteria as well as sexually transmitted infections (STDs/STIs) may be transferred from sexual activity
• retained tampons
• feminine intimate hygiene practices
  • these are generally disruptive and should generally be avoided and may create a vicious cycle of increasing itchiness, odour and discharge ¹⁴⁾
  • vaginal douching
    • has been associated with increased risks of BV, preterm birth, and pelvic inflammatory disease (PID), which can lead to infertility
  • vaginal washes, wipes, and sprays
    • using feminine washes/gels had 3.5 and 2.5 times the odds of reporting BV and UTIs, respectively ¹⁵⁾
    • after two hours of use of nonoxynol-9 and Vagisil, Lactobacillus growth became suppressed and at 24 h they had a complete bactericidal effect¹⁶⁾
• chronic stress and high cortisol levels
  • stress-related vaginal dysbiosis is hypothesised to be caused by increased cortisol levels which suppress immune activity leading to the loss of Lactobacillus sp. dominance and psychosocial stress increases the risk of BV¹⁷⁾
• smoking
  • decreases oestrogen levels, increases probability of CST-IV microbiomes, increases vaginal pH and increases risk of BV¹⁸⁾
• diet
  • insufficient intake of micronutrients such as vitamins A, C, D, E, β-carotene, folate, and calcium may increase the risk of BV ¹⁹⁾
  • increased carbohydrate intake may fuel Lactobacillus spp. growth within the vagina by increasing the free glycogen levels however, carbohydrates with a high glycaemic index have also been demonstrated to increase the risk of BV in women²⁰⁾
• BMI
  • research currently gives conflicting data regarding BMI vs BV rates

• see also candida fungal infection / thrush
• most women colonised with C. albicans do not display any symptoms of infection, but changes in host and behavioural factors can lead to candidiasis
• vulvovaginal candidiasis is an opportunistic yeast infection causing vulvovaginitis and can present with symptoms such as itchiness, thick white discharge, and dysuria
  • affects ~70% of women in their lifetime
  • particularly common in diabetics, immunosuppressed, oestrogen use, pregnancy and in those in whom the normal microbiome has been disrupted such as by broad spectrum antibiotics
  • has also been recognised that the use of the COCP, hormonal IUD, and some sexual, hygiene and clothing habits can predispose women to infection

• bacterial vaginosis (BV) is characterized by the loss or sharp decline in the total number of Lactobacillus and a corresponding marked increase in the concentration of olbigate naerobic microbes
  • Gardnerella vaginalis is the most common microorganism identified from BV
  • microorganisms, such as Atopobium and Prevotella, also have a strong relationship with BV ²¹⁾
• globally, bacterial vaginosis remains the most common vaginal dysbiosis affecting women and people assigned female at birth, placing a substantial burden on health services and the economy
• bacterial vaginosis affects one third of reproductive-aged women
• bacterial vaginosis-associated bacteria have been detected in both the penile urethra and penile skin
• BV is confirmed to be associated with adverse gynecologic and obstetric outcomes, such as sexually transmitted infections, pelvic inflammatory disease, and preterm birth

• more than 50% of women treated for bacterial vaginosis have recurrence within 3–6 months after treatment - and re-infection from partner is a significant cause of this²²⁾
• recurrences are higher if:
  • male partners are not also treated concurrently with oral and topical antimicrobials²³⁾
    • Rx regime: concurrent female treatment and male-partner treatment (MPT; oral metronidazole and topical 2% clindamycin cream applied to the penile skin twice daily for 7 days) reduced bacterial vaginosis recurrence over 12 weeks
  • possibly if an IUCD is in situ ²⁴⁾
  • inadequate clearance before resuming sex ²⁵⁾
    • this may be partly due to inability of antibiotics to eliminate the biofilm-associated bacteria of BV in vagina²⁶⁾
      • G. vaginalis and other BV-associated bacteria are eradicated or are largely decreased in only 58% of the patients treated with metronidazole
    • post-treatment assessments of bacterial vaginosis before resumption of sex, particularly in women not readily attaining a cure, could help identify those at risk of persistence and in need of more intensive therapeutic approaches