This month we talk with Christina Enzmann, MD, about the disruptive impact of bar soap on the vaginal microbiome. She shares expertise on the link between hygiene practices and symptoms like itching, irritation, and odor, as well as the role of lactobacilli in biome health, hygiene tips, and more.
Christina C. Enzmann, MD, PhD, NMCP, FACOG is a board-certified OB/GYN, originally trained in Germany at the well-known University-Clinic-Hamburg-Eppendorf. During her first years as a young physician, she had the rare opportunity to be trained in gyneco-pathology and cytology, serving as a liaison between the department of OB/GYN and Pathology, taking part in the cervical dysplasia clinic. While she specializes in vulvovaginal disease, her other special interests include menopause, minimally invasive surgical procedures, and in-office hysteroscopies. She strives to improve women’s lives every day by educating those with heavy menstrual bleeding, fibroids, and endometriosis about their treatment options.
SHWI: What are the most commonly referred conditions that patients bring to your clinic and why do you believe they are increasing in numbers?
Christina Enzmann: The most common reasons I get patients referred to my practice at MedStar Good Samaritans Hospital in Baltimore are recalcitrant dysbacteriosis, which is most of the time recurrent bacterial vaginosis (BV) or yeast. But sometimes it can be other vaginal irritations or dyspareunia. Other patients are referred for unbearable menopausal symptoms like hot flashes, insomnia, mood changes, and sexual concerns. Often the menopause goes hand-in-hand with vaginal complaints. For example, patients may present with vasomotor symptoms as well as genitourinary symptoms of estrogen deficiency. This can be a combination of symptoms of vaginal atrophy (like dyspareunia, vaginal dryness and irritation), or more urinary problems (like recurrent UTIs, or urinary frequency or urge incontinence). It is thought that the gradual decrease of estrogen in the progressing post-menopause phase causes a change in the vaginal microbiome, away from a lactobacilli-heavy biome towards a more multi-microbial colonization. With the missing lactic acid production from the lactobacilli, the pH of the vagina rises significantly. And the lactobacilli-lacking postmenopausal microbiome can look under the microscope very similar to BV and also behave clinically very similar. But the postmenopausal microbiome changes are considered “normal”. If a woman becomes symptomatic, for example, and she has a burning discharge that has an odor, then topical estrogen or DHEA is actually the correct treatment – not Flagyl or other antibiotics. Estrogen is also widely known to help with dyspareunia due to the estrogen deficient state that is commonly referred to as vaginal atrophy. But, we also have good data that it helps with recurrent UTIs, urinary urge incontinence, and frequency in postmenopausal woman, because areas of the bladder have estrogen receptors. For that reason, the term vaginal atrophy was abandoned by the North American Menopause Society for the more encompassing term: genitourinary syndrome of menopause (GSM). The number of patients we see with vaginal irritations and concerns seems to be increasing and in my mind there are three contributing factors: 1. One part is due to a cultural change that has made more women feel comfortable to address their intimate issues with their gynecologist, and medical society now encourages physicians to screen for sexual function concerns. So the old Well Woman exam that used to focus on the very straightforward things like breast exam and cervical cancer screening, has become much more complex once we evaluate for, let’s call it “intimate wellness.” And these are good changes in my opinion. 2. Another cultural factor adding to the increasing numbers that is less helpful, is that female sexual intimate issues have gained their own dynamic following on social media, and women are peer pressured to conform to unrealistic standards of intimate appearance, performance, odor, etc. As a consequence of that, there are plenty of products with unsubstantiated claims advertised and marketed via online platforms. Women end up using products that are causing contact allergies or infections, or are worsening the same condition they were trying to treat and disrupting the vaginal microbiome.
Overall, I feel there is an unrealistic expectation of what a vagina should look or smell like and how it’s supposed to function. I had a 17-year-old girl come to see me quite distraught because she did not have an orgasm the first time she had sex and felt that her vagina had much less sensation during penetrative sex than she had been made to believe was normal. 3. And the third reason adding to increasing numbers of vaginal biome disruptions are our exaggerated hygiene habits: using products that are marketed to us by historically trusted brands who have, however, not adjusted their products to the gained knowledge about the importance of microbiome conservation and not testing their products for that purpose.
Products that are masking odor or relieving itch or disinfecting are waiting on the supermarket shelves for us, many with ingredients that we already know will disrupt the microbiome or cause contact allergies. Unless we as consumers call them out for that, nothing will change for a long time. Instead, women buy into the belief that a vagina should smell like roses all day long and feel that thoroughly soaping up in their favorite bar soap three times a day is a good thing.
SHWI: As a long-practicing gynecologist in vaginal and vulva health, we know you have been engaged in studies on the impact of bar soap on vaginal health. Can you share some of this research with us?
CE: I have not had the chance to perform a study yet where I can finally prove the detrimental impact of bar soaps on vaginal health. The effects of bar soaps on healthy skin in regards to microbiota disruption and disruption of the cell-to-cell adhesion barrier has been described in several dermatological studies from the late 1970s. I am familiar with these because of my dissertation in pediatric dermatology. I wrote back then about the change of measurable skin parameters in newborn children and how environmental influences can increase the risk for atopic dermatitis.
Due to that background, asking patients about the exact kinds of products and the way in which these personal hygiene products are being used has always been very natural to my practice. It’s one of the first questions I ask any patient who presents with vulvovaginal complaints. It very soon became evident to me that there is a tight connection between bar soap use and dysbacteriosis, at least in the regional area where I have been practicing. I also learned that it seems to be common practice and ritual to work up a thick lather of that soap on a washcloth or sponge, and rub every corner of your body, including the vulva, and often in between the vulva.
Once an unpleasant odor or irritation develops, many desperate women push the wash rag up inside their vaginas or push their soapy fingers up there – all with that historic thinking that the vagina is that dark and potentially dirty place, where we have to irrigate and disinfect and cleanse properly.
Even if women use their bar soaps or any other products only outside of their genitals, our perineal microbiome is a continuum, and what we do outside will affect the inside. So if we don’t ask these questions about these intimate practices, we will of course never know and be able to make a connection. I was fortunate to have been invited to do some teaching in Goma, Congo, at the Heal Africa Hospital. There I learned that a common practice is to place a combination of herbs inside your vagina in order to make the vagina feel tighter for intercourse. Again, women are not necessarily forthcoming with sharing that type of information, unless you are actually asking for it. At my new practice facility with Medstar in Baltimore I will build a clinic with focus on vulvovaginal disease and I hope that will allow me to reinvestigate the long term tissue effects and microbiome alterations of bar soaps and other hygiene practices.
SHWI: What other primary irritants do you recommend your patients to avoid to maintain their vaginal biome?
CE: The number one irritant is bar soap, because the soap scum deposits into vaginal mucosa and disrupts the cell-to-cell adhesion barrier, which strips it of its defense mechanism and makes it vulnerable for yeast infection. Even worse are the very popular soaps that claims to deposit lotion back on your skin – these are some types of mineral fatty acids that are deposited back on your skin after your natural skin oils have been striped. Unfortunately, these mineral acids seem to be food for BV bacteria. Ninety-nine percent of recalcitrant BV patients I see are using that type of soap, and I am telling them right away that if they don’t stop using that they will never get rid of their BV. What annoys me the most is that even dermatologists seem to have fallen for the century-long marketing and continue to recommend those types of soaps to patients with delicate skin – completely unaware of how it changes the microbiome of the skin and severely disrupts the vaginal and perineal microbiome. I could rumble on forever on the history of bar soap use in the U.S. and why it has been ingrained in our society that the “more is better,” but I will move on. The next infamous irritant is benzocaine, an ingredient in the popular Vagisil cream and most products that claim itch relief. It’s the known primary cause for terrible vulvar contact dermatitis. And very common. The worst is that women don’t realize the connection of their dermatitis to that product, because whenever they apply it, the itch feels better for a short time. So they come and tell me that this is the only product that gives them relief, only for me to grab it (in the case of which they’ve brought it into the office),and throw it in the trash in front of their eyes. Because, unfortunately personal and folklore beliefs are often much stronger than any information I am able to provide during a first visit. I often find that several visits and conversations are needed to finally convince women to abandon their old habits. The last on my most common list of irritants are in general moist wipes. I am not sure which ingredient causes all that irritation – if it’s the parabens that are used as preservatives or maybe some have benzocaine too – but, I have not found one wipe that is not prone to cause irritation. One brand is called Water Wipes and it’s a baby wipe that's often mentioned in the vulvar disease conferences as being an acceptable option because it only contains 99% or so water and some grapefruit extract. But I wonder, why do we need grapefruit extract on our vulvas? Have we ever tested how grapefruit extract affects the biome of our delicate area if we use it daily? Or do we assume it must be good because it sounds like something natural? We have to stop assuming things and instead request that all intimate product ingredients be tested for their long-term effect on the vaginal microbiome and sensitive perineal mucosa and skin.
SHWI: An increasing amount of research supports the importance of maintaining the vaginal microbiome. What do you recommend for your patients?
CE: For the delicate feminine tissue, I think you can use most organic shower gels, which are sulfate and paraben free. An excellent product that is formulated for the delicate vulvar tissue is the moisturizing Balance wash from Good Clean Love. However, I always instruct my patients that even these products are only to be applied very sparingly to the outside vulva, and should not be worked up in a lather and applied with a washcloth in order to reach every delicate fold, which is a common practice and thought to help with cleanliness. This practice is prone to cause microbiome disruption, particularly if women shower three times a day and follow the same ritual every time. In women who are prone to occasional irritation or odor, they can use the Restore Moisturizing Vaginal Gel from Good Clean Love, which is Bio-Matched® to the vaginal environment and also contains lactic acid which balances the pH and helps the good bacteria thrive. I use this as a part of my BV eradication protocol. A new product by Good Clean Love that I am excited about and I just started to use in my armamentarium is the vaginal probiotic, BiopHresh Vaginal Homeopathic Suppository. The reason I am so excited about it is because there has never been any evidence that the oral probiotics available on the market ever reach the vagina or cause any lasting change. So I could not really bring myself to recommend my patients to spend the money. However, with a vaginal probiotic that provides several strains of lactobacilli we would find in a healthy vagina, and I think that is a very promising approach.
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