What IS “stinky” when it comes to vaginas?

A lot of women show up to my office saying there is a strong odor when they pull their pants down to go pee, or that their partners noticed that it smells different. But what people don’t realize is, that despite what the latest douching ads say, your vagina is supposed to have a bit of an odor.  Our vaginas are home to billions of bacteria and the balance of this bacteria changes constantly, creating different aromas varying from musty and fermented to coppery or sweet smelling. These smell variations are likely a result of your menstrual cycle, your hygiene habits, or just you.

The feminine hygiene industry has convinced us that vaginas should smell breezy fresh and flowery; anything else is unclean.  I’m sure you have seen lots of ads for feminine washes, refreshers and douches. Or you can find hundreds of videos on YouTube about vaginal hygiene routines and see things like steaming or inserting different foods and essential oils. This is nothing new.  Lysol is known today for making cleaning products, but their advertisements from the early 1900s told women that their husbands would leave them unless they washed out their vaginas with it —anything less would be “intimate neglect.”  Women suffered poisoning because of the insecurity the company pushed. Women actually died from poisoning by doing this.

So what smells ARE normal?

One if the most common smells is tangy or yeasty like sourdough bread or Greek yogurt.  This is typically a sign of the good bacteria that dominates the vagina, lactobacilli.  Sometimes this can produce a thin white discharge as well.

Another common smell is a coppery or metallic smell.  This is usually from some blood in the vagina and typically nothing to worry about.  Either menstrual bleeding, some spotting or a little bleeding after sex may be the culprit.  You do not need to see the blood for it to cause a change in the odor.

A third common description is a musty or skunky odor.  Unfortunately, the groin has lots of sweat glands and thanks to that, can smell like body odor.  Your body contains two types of sweat glands, apocrine and eccrine. The eccrine glands produce sweat to cool your body down and the apocrine glands respond to your emotions. These apocrine glands populate your armpits and, you guessed it, your groin. So, stress and emotional turmoil may cause a stronger odor than at other times.

So when should you call the doctor?

Bad vaginal odors are not subtle.  It definitely should not smell like fish or rotting food.  Likewise, some discharge is normal and varies through the month, but you should not have pain or irritation from it.  Those things should be checked out to see what is going on.

For the most part, the vagina is self-regulating.  If someone told you to wash your wool sweater in hot water, you would think they’re crazy.  You should have the same response if someone tells you to put something in your vagina! Though it may be tempting to douche or use a vaginal deodorant to decrease vaginal odor, these products may actually increase irritation and other vaginal symptoms. Vaginas have an odor that is healthy and normal. We need to accept that and not be self-conscious about it with others.

As a final note, I recently read an article and this line resonated with me: “If someone speaks to you about your body with anything but kindness and concern, it is he who has a problem.”

After practicing gynecology for more than 15 years, I know that if you can treat a vaginal infection without having to call your friendly gynecologist, you’ll do that 10 out of 10 times.

With all of the over the counter (OTC) products available, it is tempting to head to your pharmacy.  However, more often than not, you’re treating the wrong thing.

Often women presume all vaginal itching, irritation, and/or discharge is caused by a yeast infection.  This presumption is FALSE.  Yeast is not the most frequent cause of vaginitis — bacterial vaginosis (BV) is.

Yeast infections

Most patients who have any type of vaginal discharge immediately think that they have a yeast infection.  Yeast infections are more common in women prior to menopause.  The most common symptoms are vaginal itching (sometimes on the external skin and sometimes inside the vagina) and a white, cottage-cheese like discharge.  Many of my patients think that having a white discharge means that they have a yeast infection.  This is NOT true.  White discharge, even if it appears cottage-cheese like, is common and does not mean that you have a yeast infection.  If you have itching along with the discharge, it is more likely to be a yeast infection.

So, you’re hanging out in the feminine hygiene aisle, looking at all of the different options for your presumed yeast infection.  There are 1-day, 3-day and 7-day treatment options.  Which one should you pick?

Effectiveness:

For a true yeast infection, effectiveness is reported to be in the 70% range.  Effectiveness is lower for the one day, a little higher for the three day and highest for the 7 day dosing.   I know it’s tempting just to get it over with in one day but I find that patients who use the 1-day OTC treatment often end up in our office 3-4 days later with persistent symptoms.

Safety:

These medications are considered safe.  As with any medication, side effects can occur.  The most common side effects are burning and irritation and sometimes abdominal cramping.

However, with self-diagnosed “yeast”, the OTC treatments are less effective because many of these infections not actually caused by yeast and therefore the OTC treatments won’t work.

Bacterial vaginosis (BV)

As previously mentioned, BV is the most common cause of vaginal infections.  It is caused by an imbalance of bacteria in the vagina and causes and overgrowth of bacteria.  Bacteria is a normal, healthy, part of the vaginal flora.  However, if it overgrows, it can cause a gray, watery discharge that frequently has a fishy odor.  Some women note itching or burning in the vagina with BV (therefore it is often mistaken as yeast).  There is nothing over the counter to treat BV – DO NOT grab that douche – it will only make it worse!  A quick visit to the gynecologist can confirm the diagnosis and get you set up with a prescription to treat BV.

If you think you have a vaginal infection, do you absolutely need to see your gynecologist?  It’s usually a good idea to get to the root of the problem and get started on the most effective treatment.  However, if your symptoms are not recurrent, you do not have a new sexual partner, you have no vaginal odor and you don’t have diabetes or immunosuppression, you can give an OTC treatment a try.  If your symptoms are not straight forward or you’re just not sure, it is best to see your provider.

If any OTC product fails, then it would be recommended to be seen by a provider.

Pelvic organ prolapse (POP) occurs in as many as 40% of women, most commonly after age 40. One of the most common first symptoms is a bulge protruding from the vagina. Typically one’s first reaction to this is terror, but don’t worry, there is no need for panic.

POP is the result of a laxity of muscles, ligaments and connective tissues that support organs such as the uterus, bladder and rectum. POP, therefore, can be the result of one or several organs, all of which may or may not cause symptoms. The most common symptom is that of a bulge coming out of the vagina, which can rub against the underwear and cause irritation and bleeding. Other organ specific symptoms include:

1. The uterus: The uterus is normally supported by the utero-sacral ligaments as well as other connective tissues. A prolapsing uterus often can feel like one is sitting on a lump.
2. The bladder: Usually a soft bulge at the top of the vagina. It can be associated with incontinence, difficulty urinating or a pressure sensation.
3. The rectum: This is a bulge that comes from the backside of the vagina. It can be associated with difficulty getting a stool out. Commonly, women will describe “splinting” which is putting fingers in the vagina to push the stool out of the rectum.
4. The small bowel: This is the least common of the prolapses, and represents a “true hernia” or a fascial defect in the upper vagina. It is most commonly associated with a soft bulge and can happen after hysterectomy as well.

The cause of POP is usually a combination of factors. Genetic predisposition is common. Trauma (most commonly from childbirth, especially large babies) plays a role. Increased strain on pelvic organs is also a common factor. This includes jobs that require heavy lifting, obesity, or smokers, particularly with a chronic cough.

Treatment options range from behavioral modifications or exercises (for mild prolapse) to pessaries to surgery.

A pessary is a device that one places in the vagina and pushes the organs into their normal positions. (On a historical note, the original pessary was a potato, which rapidly fell out of favor as it tended to grow roots. The next rendition of pessaries was yarn dipped in wax and molded. This was the style used for thousands of years until the invention of rubber.) Pessaries come in numerous sizes and shapes. A good pessary is one that a woman doesn’t feel when it is in, stays in place and corrects all of her symptoms.

Surgical correction is specific to the prolapsing organ(s). Surgery is most commonly done entirely through the vagina and requires a one night’s stay in the hospital. Gynecologists are well versed in all treatments for POP and I would encourage anyone with prolapse to discuss it with their gynecologist.

The human papillomavirus or more commonly known as HPV is a virus that is spread by skin to skin contact.  There are over 200 types of HPV, some HPV strains are the cause of the common plantar wart and common flat warts.  Other strains of the HPV virus are associated with genital warts and precancerous/cancer on areas of the cervix, vagina, vulvar, anus, oral pharynx (back of throat), and penis.  Common HPV types which are associated with these anogenital conditions are HPV type 6, 11, 16, and 18.  Anogenital HPV is now considered the most common sexually transmitted infection (STD).  Approximately 80% of sexually active women and men have been exposed to HPV in their lifetime.  One can be exposed to the HPV virus anytime in their lifetime but the most common time for initial exposure is during the first decade of becoming first sexually active.  Often times HPV infections are transient and can come and go, it is when the virus remains for prolonged periods of time and the body does not clear the virus is when  one is put a risk for HPV related cancers of the cervix, vagina, vulvar, anus, oral pharynx, and penis. 

Anogenital HPV infection is primarily transmitted by genital to genital skin contact.  It can also be transmitted thru anal genital contact and oral genital contact.  Ways one can help reduce their risk of contracting HPV is limiting the number of sexual partners, and being in a monogamous relationship.  Condoms can lower your risk of getting HPV, but the condom does not cover all the areas of the genitals where the virus can be present, so they are not completely effective.   The HPV vaccine can help protect both male and females from the 9 most common strains of anogenital HPV, which will help prevent HPV related cancers.  This vaccine is recommended beginning at ages 11-12, but can be given up to age 45. 

So in conclusion to the question, Is HPV and STD?  The answer is the anogenital HPV strains are an STD and they are the most common STD there is.