#5 Vulvar Health: Everything You’ve Been Itching to Know

Dealing with itchiness, discomfort, or unsure how to properly care for your vulva? Wondering if what you’re experiencing is normal? 

In this episode of The Vulvalution, we’re joined by Dr. Melanie Altas, Director of the BC Centre for Vulvar Health, for an honest, myth-busting conversation about vulvovaginal health. From everyday care and common misconceptions to chronic conditions, pain, and stigma, we unpack what’s normal, what’s not. This honest conversation offers practical guidance and reassurance for anyone who’s ever had questions about their vulva or vagina but didn’t know where to turn.

📚Episode resources: 

BC Centre for Vulvar Health: https://www.bcvulvarhealth.ca/ 

Patient handouts: https://www.bcvulvarhealth.ca/landing/vulvar-skin-conditions 

Vulvodynia Toolkit: https://www.vulvodyniatoolkit.com/ 

Book: The Vagina Bible by Dr. Jen Gunter

Transcript

Melanie 0:00

Many women will have been brushed off it's all in your head. Just have a glass of wine or just relax. itchiness is not normal. pain is not normal. It's definitely a signal from your body that something deserves attention. sexually transferred infections cannot be transmitted by sitting on a public toilet seat.

Sab + Mat 0:24

Why do I keep getting recurrent yeast infections? I noticed that in a lot of pharmacy, they're selling some soaps specifically for your vulva or specifically for your vagina. Would these be options that we could try there any way to reduce vaginal discharge if it's literally never stopping? Welcome back. Welcome back to the vul Volution. Another episode today. Very exciting one. Yes. We talked all about, guess what, the vulva again. That's right. We're gonna keep talking about vulvas until you feel comfortable talking about your vulva. Yeah. We didn't just talk about the vulva, we also talked about the vagina. Mm-hmm. And then our guests really mentioned what's normal, what's not normal. Yes. We talked a lot about how to properly care for your vagina and vulva, whether you should be using all of those products at the drug store like Vail or all those other mm-hmm. Scented products. If you need a specific pH, if it's really important to buy these products at the pharmacy if you are someone who has chronic itchiness, chronic yeast infections, chronic uncomfortableness mm-hmm. When it comes to your vulva or your vagina, this episode is for you. Yeah. If you're someone that doesn't know if they should sit on a public toilet seat because they could get an STI. Just like what I thought before this episode, then that's for you. She answered a lot of questions that I feel like for us it's maybe silly or like we just were shy to ask.'cause it's like, oh, we don't really wanna talk about it. What if like my vulvas itchy, or, you know? Yeah. So I hope you like this episode, and if you do, please give us a little subscribe and like our podcast. Yes. So, so without further ado, let's get into it. today we could not be joined by a better guest to walk us through it all Today we are joined by Dr. Melanie Altus, a gynecologist and clinical associate professor with the Department of Obstetrics and Gynecology at UBC. She's also the director of the BC Center for Vulva Health at Vancouver General Hospital and is a sexual medicine consultant at BC Cancer Agency. Dr. Altus clinical work focuses on vulvar and vaginal conditions, sexual pain disorders, and menopause. But what really stands out is her dedication to empowering patients with knowledge and tools to understand their bodies and advocate for their care. So, Dr. Altus, we're so excited to have you here. Welcome to the VUL Evolution.

Melanie 3:18

Thank you guys. I am very excited to be here today to talk about something that I'm, I'm really passionate about and, definitely something I think deserves to have increased awareness. So, so thank you for, um, for promoting this topic.

Sab + Mat 3:34

Absolutely. Okay. So we'll start with a few little questions, just to get to know you a little bit more. So our first question is, what does a typical day look like in your life? Just because as we mentioned, you have so many different hats as a clinician, professor, and director. So what does a typical day in your life look like?

Melanie 3:53

Yeah, so no two days for me are ever the same, which is actually something that I really like about my work. So I split my time between, clinical care, so looking after, after patients in the clinic. Um, we also do a lot of teaching with obstetrics and gynecology, residents as well as research. But typically I spend the majority of my time, directly exploring healing with patients. So through my vulvar disease clinic, through the v. Pain clinic through my sexual medicine clinics.

Sab + Mat 4:29

Fantastic. So could you tell us what led you to a career in vulva and vaginal health? It's kind of like a niche topic. I'm curious what led you here and how you ended up here.

Melanie 4:39

Yeah, it definitely is a niche topic and, and it was a, a long journey to get to where I am right now. So I've been in practice for almost 20 years and I started ODE as a general O-B-G-Y-N. So that means I worked in the community and I delivered babies, I did operations, I covered the emergency room in addition to clinic. And after a few years in practice, I really. Realized I was connecting with my patients who experienced chronic vulva conditions. And I realized that this was an underserviced area and also an area that I felt it was really easy to have an impact. So this wasn't something that we were taught a lot in residency, which unfortunately in North America it's still not taught very well, but I think there's a lot of ways for physicians to explore and increase their own knowledge. And so I did that through conferences, through mentorship, through asking questions of experts and I really learned how to manage these conditions well, and then once I started in my practice, it just kind of ex. Expanded and expanded. And then, um, then came this opportunity to move entirely to Vancouver General Hospital and just work in these clinics. So that means I've given up overnight shifts. I don't work weekends anymore, and that's been really nice.

Sab + Mat 6:09

That that is a nice perk and you're doing the stuff you love. So it sounds like you did a beautiful transition.

Melanie 6:15

Yeah, absolutely. And, I really like working with with patients who have, who've usually suffered for a while. So having that opportunity to really connect with someone at the point that they begin healing and then following them along that journey is really rewarding.

Sab + Mat 6:33

Yeah. No, I can. It must be really nice for the patient to be able to open up to someone that actually understands or knows how to treat their problems or wants to treat their problems. Especially probably after seeing so many clinicians or physicians that maybe don't have the specialty you do and really being heard.

Melanie 6:51

Yeah. Yeah. I agree with you. Um, that is something we're trying to change and I do see a shift with, podcasts like this, where it's definitely increasing awareness amongst the general public, but also healthcare providers as well. So hopefully we'll see that under serviced area shift a little bit.

Sab + Mat 7:08

Yes. Mm-hmm. So you mentioned briefly there that this is definitely an under-researched or under-explored area. Do you have any specific memories of before you got into it, realizing how under-researched or how under looked into this area was?

Melanie 7:24

Yeah. So I think there are so many different layers to answer that question, but it was quite early on in my, career that I realized that my, my knowledge foundation that I had learned through medical school and residency. In this area was, was quite shaky. So it wasn't something that was taught very well. And, and keep in mind that as a gynecologist, I was a specialist in women's health. And, and this wasn't something that, we learned to the point where I'd be very, very confident. So I think when I started seeing people coming to me who were distressed about chronic symptoms that people tried to manage and they couldn't, and particularly in the area of vulva pain, so people who experience pain with sex or pain with tampons, that was something that I initially wasn't comfortable managing. But, learning how to manage it, so being curious, trying to seek answers and working with my patients as a team that, you know, we're gonna, we're gonna try to find answers to this and kind of connecting with that. That relief that people felt when they heard, heard those, those words.

Sab + Mat 8:36

Yeah. The work you do is very

Melanie 8:39

Mm-hmm.

Sab + Mat 8:39

I think. Yeah. Yeah. I absolutely agree. Okay. How do people usually react when you tell them that you do vulva and vaginal health? Do you have any stories of when you told someone how they reacted?

Melanie 8:53

Oh, that's a funny question. It's a great question though. But, one time that comes to mind, or several times along the same theme was going to conferences, particularly international conferences where you had to go through border control, passport control, and it was really, easy to get through passport control with minimal questions because as soon as people would ask, let's say I'm going to the states, someone would ask, you know, you're, you're coming here, you're going to a conference, and what's your conference on? And I would just say it's on vulva conditions. And they'd be like, alright, just go through

Sab + Mat 9:29

No follow up questions.

Melanie 9:30

follow up questions. Yeah,

Sab + Mat 9:33

That's hilarious. They're like, I don't know what that means.

Melanie 9:36

yeah, yeah. And I don't want to know what that means. So just, just go through, enjoy.

Sab + Mat 9:42

Yeah. That's a great example. I like that story a lot. Yeah.

Melanie 9:45

Yeah.

Sab + Mat 9:47

Okay, so we wanna talk a little bit about stigma before we get into more vulva vaginal care. And that's really just,'cause the point of this podcast is to get people talking, try to break down some of those barriers around talking about our vulvas vaginas or anatomy in general. So why do you think there's so much shame or silence around talking about our bodies and our reproductive anatomy in general?

Melanie 10:12

And, you know, I think that's a really good foundation to explore vulva health from. And definitely there's a mix of cultural, historic, and even knowledge barriers around, around the vulva and the vaginas. So for, for so many years, for even centuries women's health and particularly women's sexual health has kind of been wrapped in this silence or this embarrassment. So even words like. The vulva or vagina kind of makes people feel, feel really uncomfortable or, or kind of squirm and you can tell how really deep that stigma runs. And even in our clinics where we have the ability to take photos of conditions that we're seeing so that we can follow people over time. Um, and the photos appear on a TV screen. So the patients have the option if they want to, look and we can point out things, we can educate around anatomy and where to apply, like different treatments that we give them. And, it's not uncommon for us to hear someone voice words of disgust or shame or, that's so gross. I don't know how you can look at that all day, people want us to turn the screen off and that to me really emphasizes this deep shame and this deep stigma that women and, our society has around, around the vulva and I, that's not something we see around the penis for sure. Or the male, male anatomy.

Sab + Mat 11:44

Yeah, that's so true. I actually remember the first time I saw a picture of a vagina at a conference or a vulva actually at a conference, and I was taken aback and I had to kind of stop myself and be like, why am I, why am I taken aback by this? This is just another part of our anatomy. And it, yeah. Couldn't be that way. But even like myself, I, I totally understand that. So that's such an interesting example to bring up. Well some people don't like it organs, but yeah. I think that when I saw like a, an intestine or like your stomach open, I'm like, oh, okay. And then I see a vulva or a vagina open. I'm like, Ugh. Yeah. Yeah. Which doesn't make sense. I love that you're showing photos. I feel like that's so nice.'cause you can't really Google like, what is this specific vulva condition that I have? it's nice that you have that for your patients.

Melanie 12:31

yeah. And, and certainly when you get into vulvar conditions, there's a huge spectrum and it's very individualized. And if people do Google their conditions, sometimes the worst scenarios will be what they find, which may not be their own experience. But just going back to what you were saying about your your own personal reactions to things like the vulva and photos, I, I think in our society now that would be expected to have that reaction. And I think rather than kind of avoiding that, feeling more resisting or trying to. Push it aside. I think recognizing those, feelings that come up and maybe those biases and, kind of sitting with them and even questioning, like questioning those. And, and that's something I try to do in my clinic. Like, just be really curious about someone's reaction. So why, you know, why does that disgust you or, why do you feel like shame about that? I think, I think being curious yourself about your own feelings that come up can kind of just lead to expansion and growth, I think for sure.

Sab + Mat 13:34

I think it's very interesting.'cause if someone asked me like five years ago, why did I feel that way when I saw a photo of a vulva or vagina, I don't think I would know why. I think it's just an internal sensation that I feel, but I don't really know why, which is probably societal, the society that put it on us, I don't know. Yeah. No, and I think you're right. I think conversations like this are important. Mm-hmm. To make people start questioning why they might feel that way and then mm-hmm. Start breaking down some of that stigma within themselves. Yeah.

Melanie 14:06

definitely.

Sab + Mat 14:08

I wonder if stigmas around vulva or vaginal health, do they affect care of people that have issues?

Melanie 14:16

Yeah, I definitely think so. So I do see people who have waited long periods of time before seeking access to care because they felt embarrassed or maybe someone, a previous provider had brushed them off. Or also people don't have the language or the knowledge or the words to, you know, to describe what they're feeling, what they're experiencing where their symptoms are. So I definitely do see delays. Delays in care.

Sab + Mat 14:47

Are there any ways that you, in your own practice, try to make sure people feel not stigmatized by their issues or feel very welcome to share their issues in your own office?

Melanie 14:59

Yeah, I think there are multiple things that people can do and I think the most important is to use really clear and nonjudgmental language. So calling body parts by their correct names, and creating space for any type of question whether. Any big or small type questions. And, and we're really also mindful of a lot of the words that we use in practice. Even just doing exams. Like just when we, like for instance, say, we're touching a part of the body or we're palpating, we'll try to say that rather than we're feeling. So that just has a little bit more, more emotion tied to it. Or we'll say things like, let your knees fall off to the side rather than like, spread your legs. Um, so we're really mindful about language like that. And that's something our clinic has spent a lot of time together navigating and deciding how we're going to explain things. The other thing that I think is really helpful with our clinic that I would encourage other, providers to do is to have posters or books kind of scattered around the clinic or the office where you, see people just around things like the, you know, the, vulva or sexual health or, women's health. And, and I think that helps for people to feel that they can ask questions o without kind of feeling embarrassed.

Sab + Mat 16:26

Yeah. That's nice. Right? When they walk in the door, they feel like a. It's a welcoming environment where there are no silly questions.

Melanie 16:32

Yeah, exactly. Exactly.

Sab + Mat 16:35

Those are great concrete examples that you guys are implementing. I feel like I wanna go to your clinic. I don't have anything wrong right now, but if I do, I'll be there.

Melanie 16:44

Excellent.

Sab + Mat 16:44

Yeah. And it just reminds me of her logo, which is a big vulva in a revolution. So I think it's good to show the vulva a little bit more. My mom actually said when she saw the logo, she was like, I love that you guys are putting the vulva out there.'cause I feel like little kids, they always draw penises everywhere. Yep. And we were like, should we just start drawing vulvas everywhere, like in our notebooks and stuff like that? Maybe start that trend going instead. Mm-hmm.

Melanie 17:14

Sounds great.

Sab + Mat 17:16

Okay. Now we're gonna move on to more general questions about vulva and vaginal care before going more into some specific vulva or vaginal conditions. Um, and for that we're gonna play a little game. So I don't know if our audience, remember from last episode we talked about Belinda. So Belinda had a lot of questions about menstrual cycle, but now we're gonna do the same game. So, Belinda's brilliance or baloney, which brilliance means that she's right and baloney would mean that she's, um, maybe not right. So we're gonna start with our first treatment, which is, what Belinda thinks you should wash inside the vagina regularly with soap.

Melanie 17:57

So I would say bologna for sure. So the vagina and the vulva for the most part are self-cleaning. So using, um, particularly fragmented soap soaps with lots of preservatives can actually upset the natural flora of the vagina and vulva and can cause irritation and inflammation. So best to avoid.

Sab + Mat 18:22

Okay. And I just have a follow up personal questions. I noticed that in a lot of pharmacy, they're selling some soaps specifically for your vulva or specifically for your vagina. Are these, would these be options that we could try or would you not recommend them?

Melanie 18:39

So I would not recommend them. I think there are a lot of companies that are taking advantage of the shame and the embarrassment that women feel about the vulva and vagina and are trying to leverage that to sell all of these scented expensive products that balance the pH, et cetera. And truly the vulva vagina are really self-cleaning. So actually just using water is fine and that kind of bothers some people. They can't imagine just using water. So we'd recommend just using really unscented, hypoallergenic products, or cleansers. So some really good brands are just the ones who, that have been around for a long time, like CeraVe, Aveeno, um, are really good brands to, to start with.

Sab + Mat 19:27

Okay. Okay. How about this one? Cotton underwear is better for vulva health than synthetic materials.

Melanie 19:34

Uh, that is correct. So I'd say brilliance. Um, so we definitely recommend cotton underwear when people have vulva conditions. So, if the skin is sensitive or if it's irritated, then that would be one of the first things I would talk to someone about is switching to cotton underwear.

Sab + Mat 19:55

Okay, great. Another statement that Belinda has is Douching helps you feel cleaner and prevents infections.

Melanie 20:04

That is baloney for sure. Belinda. Um, so I would say should never do any cleaning inside the vagina, which is what douching is, is kind of inserting a product into the vagina and that can really disrupt the vaginal microbiome, so the flora, the back normal bacteria, and it can also directly cause inflammation and irritation. So not something we'd recommend.

Sab + Mat 20:29

Okay. Changes in the vulva or vaginal odor can signal infection or imbalance.

Melanie 20:36

That is brilliance. So, definitely if you start experiencing a really strong odor a sudden onset or an odor that kind of has a fish like odor, then that can definitely suggest an infection. So something called bacterial vaginosis. So, if there are any changes like that we'd recommend getting checked out by a provider. And not self-treating either.

Sab + Mat 21:02

Okay. Um, healthy vaginas are supposed to have no discharge at all.

Melanie 21:08

And that is not true. So baloney, so normal discharge is very healthy. So it is something that will actually fluctuate throughout the menstrual cycle in premenopausal women. And it can have a protective effect. So, in premenopausal women discharge is very healthy.

Sab + Mat 21:29

Okay. Another one about discharge changes in discharge can sometimes be an early sign of infection or an STI.

Melanie 21:38

Definitely. So, it can be sort of an early warning sign. So if it changes color consistency that is persistent then that it can signal an infection or a bacterial vaginosis or an S-T-S-T-I, but also keep in mind what I just said, that the discharge can actually cycle throughout a normal menstrual cycle.

Sab + Mat 22:03

Okay. Is there anything that Belinda hasn't covered regarding care and hygiene that you would like to mention?

Melanie 22:11

Yeah. So you know, with this question, I would really like to emphasize that less is best. So one of the biggest mistakes that we see in our clinic is people who kind of buy into what's being marketed to them. That they need to over unclean, they need to over treat, where they should actually be. Avoiding scented products, definitely avoiding, wipes. Definitely avoiding wearing daily liners. So less is bath, so just water or one of those, really mild cleansers if need be.

Sab + Mat 22:43

Fantastic. Thank you so much for playing along with Belinda's game. That was lovely. Super informative for lots of people on their day-to-day care. Mm-hmm. We wanna move on now to some vulva vaginal conditions, so people who. Not just day-to-day care of their vulvas, but might have something else going on. So when patients come to the center for VOR Health, what are the most common symptoms they're complaining of?

Melanie 23:09

Yeah, definitely by far is itchiness is the most common. So that can be a sign of infection, so like a yeast infection. Um, if people get yeast on the vulvar skin, it can cause itchiness. So it's not necessarily always associated with discharge with different types of skin conditions. So things like eczema, psoriasis, itchiness can be, an early sign. So that's definitely by far the most common.

Sab + Mat 23:39

Are there certain symptoms that people tend to ignore or dismiss for too long that might be a problem,, in their health later on?

Melanie 23:47

Yeah, I would say the same thing. Itchiness. And what we commonly see is that people will experience itchiness. They may think it's a yeast infection, they may, self-treat, so use over the counter products or will see sometimes people experience itchiness where they think that it's due to a lack of hygiene, which is not true, and they may kind of buy into that or explore a lot of those over the counter products, which can actually make things worse. So we will commonly see people been experiencing itchiness for a very long period of time before they've decided to seek out seeing a physician.

Sab + Mat 24:29

So would you say that itchiness is not normal or is there like if you a little itchy, it could be normal, but if it's too much, what's the, when should we go and see a specialist or a doctor?

Melanie 24:43

Yeah, so I would say itchiness is not normal. Um, so let's say if you start experiencing mild itchiness, is it due to yeast? And I think trying an over the counter medication would be reasonable, like estin or if you're someone who's using a lot of those scented products maybe the itchiness is due to irritation from some of the components of that product. You could explore stopping those. But if the itchiness doesn't respond to either one of those methods, then I think it deserves checking in with your, with your physician. Definitely. So I would say itchiness is not normal.

Sab + Mat 25:25

Okay. That's important. I think a lot of people are just living with the itchiness. Mm-hmm. Unfortunately.

Melanie 25:30

yeah, I agree. I agree. And um, you know, I know we're covering a lot in this podcast, but a really good resource for people is to check out a handout on our website. So it's bc vulvar health.ca, and we have a skincare handout that people can look at for our recommendations on what to do,

Sab + Mat 25:48

Hmm. We'll put it in the description of the, the episode.

Melanie 25:51

Perfect. But yeah, if something doesn't respond to your initial steps, then, then seek out care early. For sure.

Sab + Mat 25:58

Okay. And is there any indication with common symptoms of something that might be a simple infection versus something more complex?

Melanie 26:07

So I think that would be something that would be really difficult for someone to figure out on their own. I would say if you're experiencing itchiness and you have that kind of classic yeast like discharge, like that thick clumpy, um, kind of like curdled milk discharge, that kind of goes along with, with it being a yeast infection, I think you could be pretty confident with that initially. But, for the most part it's really hard for people on their own to tease those things out. And I always advocate for people checking in with their physician as early, as early as possible. And it's not something that's urgent. But what I mean is not to try self-treating for months and months and months on end, which is unfortunately something that we do see often.

Sab + Mat 26:54

I have a follow up question to what you just mentioned about the typical like cottage cheesy thing that I think people hear with yeast infections. How common is it that people have that symptom versus. Just having the itchiness or other symptoms,

Melanie 27:09

Yeah. So what's really important is the, the vulva and the vagina are different. So it's possible to have itchiness within the vagina associated with that discharge. Um, that goes along with a vaginal yeast infection, but it's also possible to have no discharge and your skin is on the outside, so on the vulva is really itchy and inflamed. So it doesn't like those two, can be very separate. And why I would mention that is because we do sometimes see people who go and get swabs done, either on their own or with their family doctor. And the vaginal swab is negative for yeast, but they actually have yeast in the skin. So the swab wasn't actually done where the yeast where the yeast was, which was in the skin.

Sab + Mat 27:59

Oh, and is that why? Some certain treatment, they're gonna have a cream and something to put inside so that they can treat both in case. Okay.

Melanie 28:08

Exactly. Yeah.

Sab + Mat 28:09

this is good context. I don't think I knew this. Yeah, I didn't know either.

Melanie 28:14

yeah, yeah,

Sab + Mat 28:15

So you could self-treat, let's say you have itchiness, but it's not inside. You could just use the cream and not necessarily have to put in the medication inside?

Melanie 28:25

You could. Yeah, you could. And I would say, so those over the counter yeast treatments are very short term. So if you don't respond within a few days, then I would say that you probably have made the wrong diagnosis for yourself, and then you can go to your, your family doctor.

Sab + Mat 28:43

Good to know.'cause I feel like some people would buy it again and again. Yeah. Yeah. And just think that they have the same problem coming up over and over again.

Melanie 28:54

yeah,

Sab + Mat 28:56

Okay. So what are some of the most common conditions that you treat?

Melanie 29:01

yeah. So we see a lot of a skin condition called lichen sclerosis. Have you heard of that before? You have.

Sab + Mat 29:12

Yes. Only'cause somebody was doing a presentation on one of our classes. Yeah. But I don't think I could explain what it is.

Melanie 29:19

Yeah, so it's a skin condition that can affect the genitals. So it can affect the vulva. And it is, we don't know exactly what causes it. There's some people think it's genetics, some people may think it's autoimmune, but we don't truly know the exact etiology. But it's very common and it can affect, children, it can affect people who are of reproductive age and postmenopausal women. And it presents with itchiness. It presents with a. Thinning of the skin, or it can present with a thickening of the skin, which we call lichenification. Um, the skin can sometimes become thin, like looks like that cigarette paper. You can also start to see changes in the vulvar anatomy. So one of the common changes we'd see is kind of flattening of the folds of the skin. So that's a common skin condition. I would say it's probably the most common one that we see. So we'd consider it an inflammatory condition. So it's the inflammation that's causing the itchiness and causing the physical exam findings. It's something that is quite easy to diagnose either by just having a doctor look at it, or some people need a biopsy and we treat it with um, topical steroids. So steroid creams and it responds very well. So that's one condition we see a lot of. The second condition that, I always like to mention is a condition called vulvodynia. So vulvodynia is a chronic pain condition where people get pain on the vulva, usually around the vaginal opening, and it can cause pain with any type of insertion. So sexual insertion, tampons with, um, with pelvic exams, and that can be related to a lot of different things. So a lot of different potential causes like hormones, it can be due to nerve sensitization, pelvic floor tension, so tightening or contraction of the muscles in the pelvic floor. So those are the two most common ones that we see.

Sab + Mat 31:28

Interesting. Are these two conditions treatable or are they like chronic?

Melanie 31:33

Yeah, so Lichen Sclerosis is a chronic condition, so it's something that people have, for a lifetime. But what I tell people is that we can usually put it into kind of a remission or so we can manage it. So once we get the acute inflammation stabilized with a regular steroid use, like maybe daily, then we can taper them down to once or twice a week of applying the steroid. So the steroid in that case is to keep them in remission, to prevent inflammation or flareups and to prevent further changes to the vulva anatomy. So, it's rare for us to see someone who's refractory to treatment, but we do have some second and third line treatments for that. With the nia, that is a condition that is treatable. So the treatment is very individualized, depending on the contributing factors or the etiology, but that is a condition where we do see, we do see improvement with the treatments we have available and, um, like other chronic pain conditions. So there are some people where they don't have complete resolution of symptoms, and our goal is to optimize their pain and their functioning as best as possible.

Sab + Mat 32:49

Okay. I think I fear that there's so many people that maybe struggle with leg and sclerosis and are like. It on on other things or are concerned about getting treatment, what would you say to those people who might be hearing this and thinking, oh wait, is that for me? Is that about me?

Melanie 33:05

Yeah. So these would be, um, people who are maybe accepting that their skin is just itchy. They may think that their skin is just dry and itchiness is something that they need to put up with. And for those people, I would certainly encourage them to see a physician and to maybe get a referral to see a gynecologist or to see someone who has an interest in vulvar skin conditions. So that may also be a dermatologist as well.

Sab + Mat 33:33

And just out of curiosity, how common is this condition?

Melanie 33:37

So it's definitely not rare to me, because I see many people every single day. To me it seems like everyone has it. So, um, but that's actually not true. And we think that it's probably underdiagnosed. In the past, historically, I would say lichen sclerosis has mainly been thought to be a condition of post-menopausal women. But we know now that that's not true. And what's likely the case is that people who are pre-menopausal, it's just not as obvious and it's not obvious until they get, um, into the postmenopausal years. So people who have been putting up with maybe some subtle symptoms, so maybe that mild itchiness, maybe there have been some very subtle changes to the skin that the physician hasn't picked up on when doing their pelvic exams. But yeah, it's definitely, it's more common than we, we think, for sure.

Sab + Mat 34:35

And what about v?

Melanie 34:37

Yeah, so vini is also very common, so, the numbers that we usually would say for vulvodynia is probably conservatively 8% of women at some point have had vulva vaginal pain related to insertions. So sexual activity tampons. Um, for some people they may have been there right from the beginning. There are some people who develop what we call secondary vulvodynia, so where it's later, later in life, but population-based studies have said it's about 8% and maybe even up to 16%. So you definitely know with someone who has vulvodynia and they may not be talking about it. They may be kind of suffering in silence with that,

Sab + Mat 35:23

Yeah. Are there any misconception that you often hear about these two conditions that you mentioned?

Melanie 35:30

So, um, I would say mostly around the vulvodynia or the, the, let's say sexual pain. So, because when people look at the skin of someone who has vulvodynia, the skin looks normal, it looks healthy for the most part, unless there's a hormonal component. But, what's actually going on is underneath the skin. So the nerves underneath the skin are sensitized. The pelvic floor muscles underneath the skin are contracted and, kind of dysfunctional. So. Many women will have been brushed off by their partner by their close female family members who they've confided in or their physicians just saying, you know, the skin looks normal. It's all in your head. Just have a glass of wine or just relax. Or, you know, particularly trusted family members have told people the first time you have sex is supposed to be painful. And I've many women who have seen me after many years who've said, I just, I just thought sex was supposed to be painful. So those, I would say are the top misconceptions that I hear.

Sab + Mat 36:42

So if it's painful, it's not normal. Yeah.

Melanie 36:44

not normal. It's not normal. No.

Sab + Mat 36:48

On the mention of pain, I think pain often comes up in V conversations for some people. What are the most common causes of pain, generally outside of vulvodynia, and how do you approach helping patients?

Melanie 37:02

Yeah, so when someone is presenting with vulvar pain, it's really important to do an exam because you need to rule out all of those conditions, some of which we've talked about already. So rule out all of the inflammation, rule out all of the infections, rule out, um, cancer and precancerous cells because people with lichen sclerosis and eczema may have pain with sex. So, so all of those things are important to reload. Then when we look at someone who is experiencing vul sexual pain, when the skin looks healthy, some of the things that can be contributing to it are hormones. So there's a small subset of women on the birth control pill or hormonal contraception who experience nerve sensitization and atrophy or thinning of the skin around the vaginal opening that can lead to pain. There are people who have maybe had a history of recurrent yeast infections and the yeast infections stopped, but they still had pain with sex. And we think in that case that the yeast infections have led to nerve sensitization. And there's some people who just have nerve sensitization where, um, we don't know what causes it. So, when nerves are sensitized, they cause a burning pain with touch. There's also people with pelvic floor dysfunction, so where their pelvic muscles are really tight, and that may be secondary to pain, but it also may be due to things like anxiety. Fear, chronic stress, past traumas, um, can lead to pelvic floor dysfunction. So those, muscles in the pelvic floor are very, very, very strong. And then there can also be psychological component as well. So, one of the things that we talk about is something called central sensitization. So this is where the nervous system, so the brain, the spinal cord, are sensitized or upregulated, and they, um, they start putting a spotlight on the pain that you're experiencing in the body. And when the pain is spotlighted, it can kind of exaggerate the pain. And for some people, all of those things can be contributing. For some people, maybe there's one more than the other. But it's really important when you're assessing someone who has vulvodynia or vulvar sexual pain, what, for that person, what are the contributing factors? And then designing a treatment plan that addresses those contributing factors.

Sab + Mat 39:27

Interesting. Okay. Now let's move on to our section, what women really wanna know. So our audience before this podcast, they asked some questions, anonymously, and then we're gonna ask them to you

Melanie 39:40

sounds good.

Sab + Mat 39:41

So the first one is, why do I keep getting recurrent yeast infections?

Melanie 39:45

Yeah. So, if yeast keeps coming back, so definitely what I would make sure is that you have confirmed the diagnosis so that you've seen your family doctor and you've actually had a swab that has confirmed yeast.'cause there are a lot of conditions that can mimic it. Then what is also really important for people where it's documented. And they keep getting yeast infections. It's also important to continue confirming those with a swab because sometimes there can be a strain of yeast that is more resistant to the common medications we use to treat yeast, so like the Estin or a pill called Diflucan. And you would need to confirm that with a vaginal swab through your doctor. Then there, there are also people who have what I would say are risk factors for recurrent yeast. So that would be like someone who has poorly controlled diabetes. So yeast loves sugar and um, if the diabetes is not well controlled, it can feed on that sugar. People who maybe take recurrent courses of antibiotics that puts them at higher risk of yeast. There's some people when they're on hormonal contraception, particularly the birth control pill, it may increase, their yeast infections. However, there is a small percentage of people where all of those things are negative and they just keep getting recurrent yeast infections that require recurrent courses of anti-yeast medication. Or there's some people who even need to be on what we call maintenance or suppression. So where they take it, take something maybe once, once a week, once a month, whatever works for them. And we don't quite know why that small percentage of people continue to get, um, recurrent yeast infections,

Sab + Mat 41:44

okay. Another question that some of our audience had, but also I had personally was, can I get an STI If I sit on a public toilet, I've been told by my mom, my grandma, every woman in my family that I should never sit on a public toilet. So I have to squat. And when I told you, Sabrina and others of my friends here, they said that they always sit

Melanie 42:09

sexually transferred infections cannot be transmitted by sitting on a public toilet seat. So those type of infections need actually direct contact between mucus membranes or contact through almost immediately through body fluid exchange. So, bacteria, viruses, they don't survive for long periods of time on surfaces like, uh, like a toilet, like a toilet seat. You're probably much more likely to get a cold or a flu by touching a, a doorknob or something like that,

Sab + Mat 42:39

Okay.

Melanie 42:40

just because of the frequency that people, people do that. But definitely not, not a toilet seat at all.

Sab + Mat 42:45

Okay. So there's no risk sitting directly on a toilet seat,

Melanie 42:49

No,

Sab + Mat 42:50

Okay. You can sit to know, it's like a chair. Get comfortable. Yeah. Less squatting for me, for sure. Okay. You're gonna lose some leg muscles. Maybe. Maybe it'll be comfortable. Mm-hmm. Um, last one from our audience is, is there any way to reduce vaginal discharge if it's literally never stopping? My doctor says it's normal, but it's quite annoying for me.

Melanie 43:13

Yeah. So this, this is a hard question that we get every once in a while. So the, the kind of, the short answer is no. Once, let's say once an infection is ruled out or inflammation or, if everything, everything is, is kind of healthy we definitely do see some people who are just really bothered by a heavy, normal discharge. And unfortunately right now, within medicine we don't have answers for that. So we don't have a anything to improve that or to change that. And I would. Just kind of also put a caveat there that there's also a lot about vulva and vaginal health that we, we don't know. And there's a lot about something called the microbiome, which people are starting to hear that, on social media and in magazines and newspapers. So that may be a familiar word to your, um, to your public. But there's a lot that we don't know about the microbiome and so there, there may be contributing factors of diet or environment, but right now we just don't know the answer to that and we don't have a fix for that.

Sab + Mat 44:27

Okay. Well that's good information to know. Mm-hmm. Okay. Now let's just wrap up so what's one small way that people can start caring more about their vulva or vagina health today? Like what is something that it can start changing now?

Melanie 44:44

Yeah. Yeah. So I think you guys have covered a lot of stuff, so I think just listening to your podcast will be helpful for most people. But just kind of keeping things really simple, I would just start by getting comfortable using the word vulva. And, um, and kind of getting comfortable with, you know, with your own body, um, with your own body around that. And also I would definitely say keeping things really simple. So gentle care, warm water, cotton fabrics, are a really good place to, to start. Just keep it, keep it simple.

Sab + Mat 45:19

Fantastic. And are there any websites or resources, books that you wanna recommend for anyone who has further questions at all?

Melanie 45:28

Yeah, so on our website we have a lot of handouts. So our website is bc vulvar health.ca. And we have a lot of patient handouts on all the conditions that we've talked about today, including skincare. And we also have translated our most popular ones into French, Punjabi and Chinese. So, I would definitely start by. Exploring that Explor for people who are interested in learning more about, um, Vidia. We've also created a, a toolkit for family doctors. It's called Vidia, toolkit.ca, um, or.com. I can.com actually. So people can also explore that as well. The other, when I'm recommending books to people. Um, a really good book to start with around vulvar and vaginal health is by a, gynecologist. She's Canadian originally, but she works in the states right now. And her name is Dr. Jennifer Gunter, and she wrote a book called The Vagina Bible. So that's a, a common book that I'd recommend.

Sab + Mat 46:32

I love the name. Thank you for sharing those resources. Mm-hmm. Now the final question that we ask all of our guests. If you could bust one myth about women's health today, what would it be?

Melanie 46:45

Uh, so I would say, oh, there's so many. But I would say that, um, pain is not normal. It's definitely a signal from your body that something deserves attention. And also talking about it isn't embarrassing. It's actually empowering, I think.

Sab + Mat 47:05

That's what we're trying to do with the podcast. Make it empowering and not scary and normal. Mm-hmm. Woo. I'm, I'm getting excited.

Melanie 47:14

Yeah. I agree.

Sab + Mat 47:15

Okay, and last question, another big one. What is one change you hope to see in women's health in the next 10 years?

Melanie 47:24

Okay, just one. Oh, there's okay. There's so many. I would say that definitely I. Universal access to multidisciplinary care. So I would hope that, people could have access to equal access to a gynecologist, a physiotherapist, psychologist.'cause all of these things that I have mentioned to you do require multidisciplinary care. And right now we are, um, limited by financial barriers because physio psychology is not, readily available to everyone. I would also want more research and more education in med school and residency on buffer conditions and on women's sexual health.

Sab + Mat 48:08

Fantastic. Great answer. Okay. Well thank you so much for joining us today. I think our audience is gonna love this episode. Yes,

Melanie 48:17

Thank you for having me guys.