Tuesday, July 9, 2013

How To Clean Your Vag

This post is going to be exactly what it sounds like. If that grosses you out, click to somewhere else.

In the office, I get a lot of questions about how to clean "down there." There are a lot of cultural influences that lead us to think of vaginas as unclean. Feminine hygiene products are marketed to women in a way that lead us to assume that we are inherently unclean. So many religions and cultures have mythology surrounding menstruation and women's bodies that imply a contamination or lack of cleanliness. Meanwhile, where are the testicular hygiene products?

Many of my patients come in thinking that any discharge means they have bacterial vaginosis (BV), a bacterial overgrowth that can lead to odor. While BV does exist, in my opinion* it is wildly overdiagnosed and overtreated, especially given that its presence has almost no spontaneous adverse consquences**. It can be very annoying, but it's not dangerous. It's not like Chlamydia, or HIV. It's not even as painful as a yeast infection. If you have BV or think you do, it's important to confirm it with a doctor, and not just assume you need antibiotics over and over. Those antibiotics can actually lead to a yeast infection, so be cautious.

First, a terminology clarification:
The outside female genitalia is called the vulva. The inside female genitalia is called the vagina. So even though we use vagina as a general term to refer to the entire female genitalia, the medical term only refers to the inside.

So what is the truth about the cleanliness of vaginas? 
First of all, yes, the vagina is full of bacteria. It needs to have that bacteria in order to stay healthy - they are the "good" bacteria. When you eliminate the bacteria (by taking antibiotics, for example), that allows overgrowth of other things, like yeast. Yeast can exist in the vagina, but when they grow too much, they can cause itching, burning, pain with sex, redness, or odor. There are certain bacteria that shouldn't be in the vagina - like Chlamydia (a sexually transmitted infection), or E. coli (a bacteria found in stool). Another bacteria that can exist in the vagina, Group B Strep (GBS), does nothing to the woman, but can cause a serious infection in infants, so if a pregnant woman has it, we give her Penicillin in labor to get rid of it before the baby comes out.

Should you clean your vagina?
Bottom line: not really. Most women have a small amount of daily mucous discharge. That discharge is produced by glands in the vagina. That mucous traps any untoward elements, and pushes them out. That's why the vagina is "self-cleaning." An increase in the amount of discharge isn't very concerning - usually it is related to the hormonal cycle, or random chance. A change in the color of the discharge can sometimes come with an infection, so you should see your doctor in that case. But using a douche doesn't really help. It pushes things up when you really want things to come down. And what is up? Your uterus and cervix. If there is anything dangerous in the vagina, you would be pushing it up toward your uterus, and potentially your fallopian tubes. That means that if there is "bad" bacteria in there, like Chlamydia or Gonorrhea, that bacteria would then be pushed upward into a sterile area, and cause Pelvic Inflammatory Disease, which can cause tubal scarring and infertility.

Should you clean your vulva?
Yes, this is OK. The vulva are on the outside, and so have the tougher external skin that covers most of our bodies. However, I have found that the vulvar skin, being hidden from the outside world most of the time, is more sensitive than the skin on your arms or legs. It can often become very irritated by shaving/waxing, or the detergent in soap, which strips off the natural oils. This can cause a vulvar dermatitis, which can be extremely itchy, and looks like dry patches of a lighter color than the rest of the skin. When this happens, I advise women to stop using soap or removing hair at least temporarily, and I usually prescribe a cream to help with inflammation. If you think you have vulvar dermatitis,  see your gynecologist. If you want to stop using soap on the vulva, I recommend washing with water and a washcloth. This can remove the dirt/discharge without irritating the sensitive vulvar skin.

Should you shave your vulva?
Meh. You can, if you want to, but stop if it causes problems. Hair removal pulls the hair from the shaft, and can introduce bacteria into the hair follicle. When this happens, a woman can get folliculitis, which looks like a small pimple, and is painful. If this happens, I advise women to stop hair removal at least in that area. It's important to remember that hair removal is entirely cosmetic, and has no medical benefits, so if it's causing irritation, it's time to stop, at least temporarily. Not every culture thinks women should be hairless.
One potential alternative is trimming the hair instead. This can avoid the folliculitis complication while still feeling neat/clean.

What should you do for the occasional itch?
If you are having persistent itch or pain, you can try an over-the-counter yeast cream, or see a gynecologist. But if you get the occasional itch down there, and you are pretty sure it's nothing, I recommend a cream like Vagisil (or its generic alternative "Vaginal Anti-Itch Cream"). It has a pain reliever and a soothing ointment, and can take care of the occasional itch, or pain from folliculitis. If it doesn't help, see a doctor.

How do you know if you need to see a doctor?
Occasional mild symptoms, like itching or odor, can arise with changes in cycle, especially around the time of menses. Something that does away quickly on its own, especially once your period is over, is usually no big deal. Symptoms that are severe, or that are constant and persistent, mean that you should be evaluated by a doctor.

These recommendations are not hard and fast rules. They're just my attempt to answer questions that it seems like all women have. Feel free to leave questions in the comments section, and I'll try to address them.

*This is my opinion, based on my professional experience, not a scientific statement. Others would disagree with me, but they can write their own damn blog.

**BV has been associated with some negative outcomes, like preterm birth or infection after surgery, but attempts at prevention and treatment have been mixed or have often failed, and it's unclear whether it's a cause or an association.