The Vagina Bible

The Vulva and the Vagina: Separating the Myth from the Medicine

Dr. Jen Gunter

• Publisher: Citadel Press
• Year: 2019
• ISBN:
  9780806539355
• Topic: Medicine
• Subtopic: General Health

Instant New York Times, USA Today, and Publishers Weekly bestseller!
Boston Globe bestseller
#1 Canadian Bestseller OB/GYN, The New York Times columnist, host of the show Jensplaining, and internationally bestselling author Dr. Jen Gunter now delivers the definitive book on vaginal health, answering the questions you've always had but were afraid to ask—or couldn't find the right answers to. She has been called Twitter's resident gynecologist, the Internet's OB/GYN, and one of the fiercest advocates for women's health…and she's here to give you the straight talk on the topics she knows best. Does eating sugar cause yeast infections? Does pubic hair have a function? Should you have a vulvovaginal care regimen? Will your vagina shrivel up if you go without sex? What's the truth about the HPV vaccine? So many important questions, so much convincing, confusing, contradictory mis information! In this age of click bait, pseudoscience, and celebrity-endorsed products, it's easy to be overwhelmed—whether it's websites, advice from well-meaning friends, uneducated partners, and even healthcare providers. So how do you separate facts from fiction? OB-GYN Jen Gunter, an expert on women's health—and the internet's most popular go-to doc — comes to the rescue with a book that debunks the myths and educates and empowers women. From reproductive health to the impact of antibiotics and probiotics, and the latest trends, including vaginal steaming, vaginal marijuana products, and jade eggs, Gunter takes us on a factual, fun-filled journey. Discover the truth about: •The vaginal microbiome
•Genital hygiene, lubricants, and hormone myths and fallacies
•How diet impacts vaginal health
•Stem cells and the vagina
•Cosmetic vaginal surgery
•What changes to expect during pregnancy and after childbirth
•What changes to expect through menopause
•How medicine fails women by dismissing symptoms Plus: •Thongs vs. lace: the best underwear for vaginal health
•How to select a tampon
•The full glory of the clitoris and the myth of the G Spot ... And so much more. Whether you're a twenty-six-year-old worried that her labia are "uncool" or a sixty-six-year-old dealing with painful sex, this comprehensive guide is sure to become a lifelong trusted resource.

Conditions

CHAPTER 31

Yeast

YEAST IS PROBABLY ONE OF THE MOST misunderstood conditions of the vagina and vulva. It is often overdiagnosed, meaning women are told they have yeast when they do not. Many women are plagued for years with a seemingly untreatable yeast infection, when they really are suffering from something else. And paradoxically, it is also underdiagnosed, as providers can miss it during testing.

The yeast-industrial complex, in both Big Pharma and Big Natural, is big business, complicating the information factor even further. Over-the-counter (OTC) yeast medication is heavily advertised, and there are more “natural” remedies for yeast than any other gynecological condition, from anti-yeast diets and detoxes to supplements and suppositories. The misinformation online is astounding, and while some may be well intentioned, most of the bad information is to move product.

The antidote? Yes, facts.

The Yeast-Vagina Connection

Yeast is a single-cell, microscopic organism, and there are many species of yeast that live normally on our body without typically causing harm. If I checked one hundred random women on the street who had no vaginal symptoms and they gave me a vaginal culture, about 20 percent would have yeast at that single point in time. If I used nucleic acid technology that can identify smaller quantities of yeast and sampled these same women, 65 percent would have yeast.

Colonization by yeast (so yeast is present, but there are no symptoms) drops with menopause for women who do not use estrogen. At first this seems counterintuitive, as one would think the loss of lactobacilli (gatekeeper bacteria) typical of menopause would favor overgrowth of yeast. This is a good example of the complexity of the vaginal ecosystem. A reason why GSM may protect against yeast is that the elevated pH makes it harder for yeast to cause infections. The lower glycogen stores may starve the yeast (glycogen is an energy source for yeast as well as lactobacilli). Low estrogen levels in the vagina may be one reason why infants do not get vaginal yeast infections despite having diaper rash, which is a skin infection with yeast.

It is normal for a premenopausal woman to have yeast. It is not whether you have yeast, it is whether that yeast is causing your symptoms. Any test that is positive for yeast must be put in context. Some women can have symptoms with low levels, and other have no symptoms with high levels.

Women who develop yeast infections are more likely to be colonized, and the reasons some women are colonized and others are not is not well understood. We also do not understand why some women transition between normal yeast not causing any mischief to raging inflammation and itch. Some theories include:

• AGGRESSIVE YEAST THAT IS ABLE TO EVADE THE VAGINA’S DEFENSE MECHANISMS.

• A WEAKENED VAGINAL MICROBIOME THAT ALLOWS NORMAL YEAST TO OVERGROW: This may be lactobacilli that are unable to control yeast or another mechanism.

• CONDITIONS THAT FAVOR THE GROWTH OF YEAST: For example, high sugar levels in the urine or high estrogen levels favor yeast.

• IMMUNE SYSTEM ISSUES: Women who are on medications that suppress the immune system or have AIDS are at higher risk for yeast infections.

• MICROTRAUMA: Causes include scratching or from sex. For yeast to cause symptoms, it has to avoid the defense mechanisms and stick to cells. Microtrauma damages surface defense mechanisms that prevent yeast from attaching.

• ATYPICAL RESPONSES TO NORMAL LEVELS OF YEAST: A good analogy is the variation in responses to seasonal allergies. Some people can tolerate any amount of pollen and never get a runny nose, some people are only bothered occasionally, while others are very symptomatic with the smallest exposure.

• LOW IRON: Studies have linked this with yeast infections. Two possibilities include scratching (trauma), as low iron can cause an itch, and a direct impact of low iron on some part of the immune system.

With recurrent infections, some additional factors may be involved:

• RESISTANCE: Some yeast cannot be treated by the commonly available prescription and over-the-counter medications.

• BIOFILMS: These are complex structures that allow yeast or bacteria to form protective coatings and adhere to tissues and even to devices, such as IUDs and the contraceptive ring. This allows the yeast to avoid detection and capture by the immune system and medications and may thus be a source of reinfection.

Other cofactors for yeast colonization are cigarette smoking and the use of cannabis. For more information on the role of underwear (or lack thereof) see chapter 8.

How Common Is Yeast?

Approximately 70 percent of women have at least one lifetime yeast infection, and 5–8 percent experience recurrent infections, meaning four or more a year. The most common yeast species is Candida albicans (about 90 percent of infections). Other species that can cause symptoms are collectively called non-albicans and include Candida glabrata (second most common), Candida parapsilosis, Candida tropicalis, and Candida krusei. They are less likely to produce vaginal and vulvar symptoms—approximately 50 percent of the time when they are identified, they will not be the cause of the symptoms.

Non-albicans species are, however, increasing. Many are resistant to the regular medications used for yeast, and the widespread use of yeast medications has changed patterns of colonization, favoring the growth of yeast that is inherently resistant to the medications.

What Is a Yeast Infection?

When yeast overgrows, it causes an inflammatory reaction, which causes swelling, redness, itching, burning, and pain. A feeling of vaginal dryness and pain with sex are other common symptoms. Some women describe a thick, white, curdy discharge, but that is an unreliable sign of infection. One study tells us that women who do not have a yeast infection are just as likely to have a thick, white, curdy discharge.

The itching caused by yeast can be intense. If you feel as if you need to scratch or that you are scratching in your sleep, then yeast has to be considered. For other women, the itch is less intense and burning is the predominant symptom.

Self-diagnosis with yeast is notoriously inaccurate. The classic symptoms are also the classic symptoms of irritant reactions, allergic reactions, and some skin conditions (see chapter 35). Some women with bacterial vaginosis (BV) do not perceive any odor and may mistake their vaginal irritation and burning for yeast.

In one study, women who were planning on buying an OTC medication for yeast were tested, and it turned out only 40 percent of them would have been treating themselves correctly had they bought the medication. Besides the expense, repeated exposure to yeast medication that you do not need can lead to resistance and the emergence of yeast that cannot be killed by these medications. There is also the aggravation of treating yourself, often repeatedly, without success. Many women who have tried these medications, often for years, tell me it makes them feel broken when a therapy that is supposed to work does not.

How to Diagnose Yeast

Yeast on the skin causes a red rash that may be itchy or tender to the touch. The rash classically has what we call satellite lesions—small islands of rash next to the larger area. This is diagnosed by looking at the skin. Unless the rash is atypical, a biopsy (a small sample of cells cut from the skin) is rarely required.

Your provider might see vaginal swelling and redness, but as women can have different responses, it is possible to be very uncomfortable with very little objective evidence of inflammation on exam. Your provider should test your vaginal pH, which should be less than 4.5.

Tests for yeast include the following:

• LOOKING AT A SWAB UNDER THE MICROSCOPE: A test that’s very inexpensive and has immediate results. C. albicans can be identified this way, but the non-albicans species are too similar to distinguish from each other. The disadvantage is that even experienced providers can miss yeast 30–50 percent of the time.

• A CULTURE: A swab is sent to the lab, and any yeast is grown and identified. This is the gold standard. A culture identifies the species of yeast, which can be helpful for women who do not respond to therapy or who have recurrent infections. A culture is more expensive than microscopy; however, microscope skills are not needed. Results take 3–5 days.

• A NUCLEIC ACID TEST: There are at least two on the market: BD MAX and NuSwab. They can identify several species of yeast. The advantage is these swabs can test for other infections if needed, such as trichomoniasis or BV. They also take microscope skills out of the picture. Their disadvantages are that they are typically more expensive than cultures and not all insurance covers them—they can be as much as $75–100. Results may take several days.

You do not need to be screened for yeast

Many women want to get checked for yeast, but you should only be tested if you have symptoms.

When an Exam Is Just Not Possible

In an ideal world, every women would get an accurate diagnosis from their provider before starting therapy. That reality does not exist for every woman. It may be reasonable to consider buying an over-the-counter (OTC) yeast medication or calling in for a prescription if you meet these criteria:

• Not menopausal or menopausal and using estrogen: women who are menopausal and are not on estrogen have a very low chance of having yeast.

• Intense vaginal itching: you want to scratch high inside.

• No odor.

• No blood in discharge.

• No need to be seen for STI testing.

• No history of recurrent infections, meaning three or fewer infections a year.

• When you have treated identical symptoms before, they have resolved within a week and did not return sooner than two months.

Treatment for C. albicans

The class of drugs is called the azoles. This is the medication in the OTC creams and ovules, and they come in one-day, three-day, and seven-day regimens. They are all equally effective. Many women find the creams very soothing, but if you are very inflamed, any product may burn on application. Some lower-quality data suggests that clotrimazole might be the best tolerated with the least irritation.

The oral medication that is widely used is fluconazole (trade name Diflucan, but a generic is available). A single 150 g dose is fine for mild to moderate infections. Two doses spaced seventy-two hours apart may be more effective for severe infection when there is a lot of redness and swelling. The medication works for seventy-two hours, so giving a second dose sooner is not necessary.

The oral and topical medications are equally as effective—they both cure a yeast infection due to C. albicans 90 percent of the time. I know many women and even many providers have a hard time believing this, but no study has demonstrated superiority. The Centers for Disease Control and Prevention (CDC) suggests that either the topical or oral is appropriate; however, the Infectious Diseases Society of North America (IDSA) recommends the topical therapies first, as they will not affect the yeast in your bowel. I favor this approach, and where possible and practical it is best to treat with the medication that will cause the least collateral damage to other tissues.

Oral fluconazole has a lot of drug interactions, so that is a consideration when choosing a therapy. Fluconazole can affect some blood thinners, and there is a possibility of serious drug interactions with some cholesterol medications as well as trazodone, a medication often used for sleep. Always tell your provider and your pharmacist about your medications. The vaginal medication is absorbed in a very minor degree and is not believed to have the potential for serious drug interactions.

I tell women about the IDSA recommendations, but ultimately if there is no concern about drug interactions, I let them choose. Many cannot stand the creams, and others find the pill makes them nauseous.

Some other treatment tricks:

• START AN ORAL ANTIHISTAMINE: Such as cetirizine (Zyrtec) or loratadine (Claritin), the generic version is just fine. This helps to reduce the itch and you will feel better faster.

• A TOPICAL STEROID ON YOUR VULVA: Will help reduce inflammation and itch.

Be realistic about how long it will take to feel better. You should start to feel better by seventy-two hours, but it may take a week for all of the inflammation to subside.

Recurrent C. albicans

This is generally well treated with 150 mg of fluconazole once a week for six months. The idea is to suppress the yeast, giving time for whatever mechanism that allowed the yeast to occur to resolve. While on the therapy, most women do well and have no symptoms. Once it is stopped, the yeast returns for 30–50 percent of women. If this is you, it is time to see a specialist.

I Used a Yeast Medication, and My Symptoms Did Not Go Away

This is a common scenario, as 50–70 percent of women who self-diagnose with a yeast infection actually have a different diagnosis.

Let’s break this down because it is important. We will be generous (also the math is easier) and say that 50 percent of women who self-diagnose with yeast are correct. We know both the OTC medications and prescription fluconazole work 90 percent of the time.

We will start with one hundred women who think they have a yeast infection and used either an OTC medication or fluconazole that was prescribed over the phone or that they had at home—fifty will have yeast and fifty will not. Of the fifty who have yeast, forty-five will get better and five will be medication failures. The fifty who never had yeast to begin with will not get better. Of the original one hundred, fifty-five women will still have symptoms, and only five (or 9 percent) have yeast. If you are in that 9 percent you need to be seen, because there is a chance you could have the type of yeast not treated by the medi...