Vaginal Health – What is Really Going on Down There?

The vagina is a resilient part of the human body that generally does a great job of maintaining its own health. According to the Department of Health and Human Services, it is best to let the vagina clean itself through the mucous it produces. This naturally occurring mucous washes away vaginal discharge, semen, and blood. Bacteria, primarily those from the Lactobacillus family, normally inhabit the vagina. This probiotic biome makes the vaginal canal slightly acidic, and this acidity acts as a natural protection against harmful bacteria and infections. However, even when left undisturbed, certain situations can still disrupt the vagina’s natural balance, and knowing what is normal and what is not can help us keep healthy down there.

The vagina is the elastic muscular canal leading from the cervix (the opening of the uterus) to the external genitalia (vulva). It is generally between 2.5 and 4 inches deep, and during sexual arousal, it relaxes and elongates even further. Childbirth and menopause can also change the depth of a vagina. The opening of the vagina is usually partially covered by a membrane known as a hymen. Contrary to popular belief, the hymen does not break when women have penetrative vaginal sex for the first time; instead, the hymen is already perforated to allow blood to pass through or tampons to pass into the vaginal canal. With initial penetrative sex, the hymen simply stretches. A hymen can also be initially stretched by engaging in everyday activities like riding a bike, vigorous exercise, inserting a tampon, getting a pelvic exam or pap smear, or riding a horse. The hymen varies in size and not every woman is born with one.

 The vagina is the route via which menstrual by-products exit the body. The vagina also serves as a tool for sexual intercourse and childbirth. The vagina is where penetrative sexual intercourse occurs and also a place where semen is deposited before it moves into the uterus to try to fertilize an egg. When babies travel down the vagina (birth canal) on their journey into the world, the vagina miraculously stretches from a couple of centimeters in diameter to about 10 centimeters (almost 4 inches) to accommodate the head of a newborn.

A healthy vagina has a slightly acidic pH between 3.8 to 5.0. The pH tends to increase with age, and people on the higher end of the normal range are often in perimenopause or menopause. The vagina does not contain glands; a well-balanced vagina will have a small amount of clear or milky discharge and a mild sour aroma or no smell at all. And just for fun, the vagina might have a slightly metallic scent just before or after menstruation. A healthy vagina is typically free of bumps, rashes, and itching, and healthy vaginal tissue often tends to be moist, pink, and pliable. Penetrative sex will not usually cause pain or discomfort to a healthy vagina.

So, how can we tell when something is off with the vagina? Some common signs and symptoms that occur when the vaginal pH is off or when there is some type of irritant or illness that we should get treatment for include:

• itching
• redness
• significant changes in vaginal odor
• changes in the color and amount of vaginal discharge
• pain during or after penetrative sex
• vaginal bleeding between periods, after sex, or after menopause
• bumps or lumps in or around the vaginal canal

Although the vagina is normally a healthy, self-cleaning organ, certain conditions such as yeast infections, bacterial infections, STDs, menopause, and certain cancers can disrupt the natural equilibrium in the vagina. Recognizing a few things that can go wrong down there and knowing how to manage these conditions can improve our overall vaginal health.

1.    Yeast Infections

About three out of four women will experience a yeast infection at some point in their lives. Yeast infections happen when the normal biome in the vagina is disrupted, and a yeast called Candida albicans can grow unchecked. Yeast infections can cause itching, chunky, foul-smelling vaginal discharge, redness, and a burning sensation. Several common culprits associated with developing a yeast infection include:

• Douching – your vagina is not meant to smell like fresh spring rain, and vaginas are perfectly capable of keeping themselves clean. Douching increases the risk of vaginal yeast overgrowth and could even lead to bacterial infections. Also, heavily perfumed soap and antibacterial soap can throw things off, leading to infections. 
• Antibiotics – many people who have recently completed a round of broad-spectrum antibiotics for a bacterial illness find that they develop a yeast infection soon afterward or even while still taking the antibiotics. Broad-spectrum antibiotics do not just eliminate specific illness-causing bacteria you may have been infected with from other illnesses; they also tend to interrupt the natural bacterial environment in the vagina, allowing yeast to grow. 
• Tight, wet, and synthetic clothes – tight-fitting pants or tights, nylon synthetic underwear, and staying in wet swimsuits or gym clothes for too long can all contribute to developing bacterial and yeast infections. Yeast loves to grow in damp, dark, warm places and nylon. To reduce the chance of yeast infection, change out of your wet clothes as soon as possible and wear breathable cotton underwear.

2. Bacterial Infections

One of the most common vaginal bacterial infections is Bacterial vaginosis (BV). BV, also known as Gardnerella vaginitis, has an infamous unpleasant smell, causes itching, can be painful, and can sometimes produce a greenish or yellow discharge. On the other hand, bacterial vaginosis can also be asymptomatic, with some infected women showing no signs or symptoms of the disease. BV is common among pregnant women; however, it can affect women of any age, although women between the ages of 15-41 have a higher chance of getting infected.

 It is important to know that BV is not a sexually transmitted disease (STD), although it is linked to sexual activity. According to the CDC, bacterial vaginosis can increase the chances of getting an STD. Typically, the vagina has a balanced flora of organisms, including Gardnerella vaginalis, a bacterium. An overgrowth of this bacterium can lead to BV, which is the most common cause of bacterial discharge. Certain situations can cause an overgrowth of Gardnerella vaginalis, upsetting the acidic balance of the vagina, thus leading to bacterial vaginosis.

 Some risk factors that can upset the bacterial environment of the vagina and thus, predispose the vagina to developing BV include:

• Douching
• Overuse of vaginal lotions
• Overuse of medications like antibiotics
• Previous sexually transmitted disease (STD)
• Hormonal changes associated with puberty, pregnancy, and menopause
• Having a new or multiple sex partners

 3.    Sexually Transmitted Diseases

If you need more motivation to practice safe sex consistently, keep in mind that STDs can bring many unpleasant vaginal symptoms into your life, most of which are treatable, although some are not. Proper use of a condom will not totally eliminate your risk of contracting an STD, but it dramatically reduces the probability. Some of the most common STDs, along with their symptoms, include:

• Chlamydia which can cause bleeding, pain, and vaginal discharge.
• Gonorrhea, which may lead to a thick, bloody discharge, heavy vaginal bleeding, and pain. 
• Genital herpes which can lead to blisters and sores in and around the vagina, pain, and itching. 
• Human papillomavirus (HPV), which often causes warts in and around the vagina and can lead to itching and bleeding with intercourse.

4.    Menopause

In perimenopause and menopause, vaginal conditions change as estrogen levels drop. A condition known as genitourinary syndrome of menopause (GSM), previously known as atrophic vaginitis, urogenital atrophy, or vulvovaginal atrophy, can occur due to the lack of estrogen during this period. GSM is marked by a thinning of the vaginal tissues, a decrease in vaginal elasticity, loss of hymenal remnants, and reduced libido. GSM is also characterized by a decrease in vaginal lubrication, which can lead to many unpleasant vaginal symptoms, including: 

• vaginal burning
• vaginal itching
• vagina irritation
• pain with sex
• vaginal bleeding, especially after sex

5.    Cancer 

Like most other parts of the body, the vagina and surrounding areas are also prone to cancer. Cervical and vaginal cancers are a few cancers that affect our vaginal health.

 Cervical cancer, which is cancer of the small canal between the top of the vagina and the uterus, is the fourth most common type of cancer in women, with over 600,000 women diagnosed annually worldwide. According to the World Health Organization (WHO), infection with human papillomavirus, a virus commonly transmitted through sexual contact, is the cause of cervical cancer in 99% of all cases. Although most cases of HPV infection resolve on their own, persistent infection can lead to cervical cancer in women. Symptoms to look out for include abnormal bleeding, watery, foul-smelling discharge, and pain during sex. Early diagnosis of cervical cancer can lead to successful treatment and management and a five-year relative survival rate of 91% if still at the early stage and localized within a specific part of the cervix.

 Vaginal cancer is a rare cancer that occurs in less than 9000 people in the United States every year. It is a disease where cancerous cells form in the vagina. Older people and people with HPV infections are at a higher risk of developing vaginal cancer. When caught early, the five-year relative survival rates are close to 70%. Symptoms of vaginal cancer can include abnormal bleeding and discharge, pain in the pelvis during sex, pain while urinating, constipation, and lumps in the vaginal canal. Like cervical cancer, HPV infection increases the risk of vaginal cancer, and about 75% of vaginal cancers are caused by HPV.

 So, how do you keep things healthy down there?

• Don’t douche
• Only take antibiotics when necessary
• Wear loose, natural fiber clothing as often as possible
• Practice safe sex
• Use only water-based lubricant with latex condoms to ensure their proper function
• Get the HPV vaccine if you are eligible
• Consider hormone therapy to manage vaginal symptoms if you are menopausal
• Get familiar with your vagina and do periodic vaginal self-exams
• When you become sexually active or after the age of 18, whichever comes first, get an annual exam with your gynecologist
• See your doctor if you have any new and concerning symptoms

 The vagina can usually take good care of itself, but when an imbalance or illness happens, some symptoms can be uncomfortable and unpleasant. The more familiar you are with your vagina and its normal baseline function, the better you can respond to any unpleasant changes down there to keep things healthy.