With STDs continuing to rise in the United States, it’s important to know the facts. April is STD Awareness Month, a perfect time to get informed on what can be a silent health risk, even leading to death.  Here’s what you’ll want to know:

• The Centers for Disease Control and Prevention (CDC) estimate there are more than twenty million new STD (chlamydia, gonorrhea, and syphilis) infections in the U.S. each year.
• While curable with antibiotics, many cases go undiagnosed and untreated. Consequences of this can be severe, including infertility, ectopic pregnancy, stillbirth, increased HIV risk, even death.
• Certain groups are at increased risk, including sexually active women under 25.

The CDC currently sponsors four STD Awareness Campaigns:

• GYT: Get Yourself Treated is for young people to understand the myths and misconceptions surrounding STDs and to learn about appropriate testing and treatment.
• Test. Treat. Three simple actions by patients and healthcare providers can protect the health of the individual, their partner, and patients at large. First, have open and honest discussions with each other. Second, get tested or recommend appropriate testing. Finally, get or prescribe treatment.
• Syphilis Strikes Back focuses on the prevention, diagnosis, and treatment of this potentially deadly disease which can impact pregnant women and newborn babies, among others.
• Treat Me Right encourages patients to be proactive about taking care of their health and ask providers for what they need while equipping providers with critical communication and health information to treat their patients right.

Talk with your healthcare provider about your risk for STDs and any tests they might recommend. For more information from the CDC, go here.

If you are over 30, your pap smear is now being screened for HPV (Human Papillomavirus), and if you are under 26, you are being encouraged to get vaccinated for HPV.  If you have ever had an abnormal pap smear, you are tested for HPV automatically.  Why?  What is the fuss about?  Why is HPV so important?

What is HPV?

Well, we now know (and we didn’t know this in the past) that it is HPV (human papillomavirus) that is the cause of cervical cancer.  This virus is also responsible for other types of cancers, i.e. throat, vaginal, vulvar, anal, rectal, and penile cancers.  There are approximately 40 types of HPV strains that affect the genital region, but only 2 of these strains (named 6 & 11) have any symptoms.  These 2 strains cause venereal warts, also known as “condyloma” in medical speak.  Most people who have HPV do not have symptoms.  It is estimated that approximately 80% of all sexually active adults have been exposed to HPV at some time in their life.  It is the most common sexually transmitted disease.  Even having only one partner in life and using condoms still does not guarantee that you won’t be exposed to the virus.  So why might you catch this viral infection even if you are careful?  HPV is a skin virus.  This means it lives on skin cells on the outside of the genital area and not just on the penis or in the vagina.  Direct skin to skin contact, not just intercourse, can cause it to be transmitted.  Oral sex, vaginal sex, & anal sex all equally expose individuals to the disease, but so can intimate skin to skin contact.

How do I know if I have HPV?

We have a test for it.  All women over the age of 30 are routinely screened for high risk strains of HPV with the pap smear.  If the virus is active, you will test positive for the virus, even if the pap smear is normal.  If the virus is inactive, it will not be present on the pap smear.  Although there are approximately 40 strains of HPV, only a few are considered “high-risk”.  This means that if these strains are present, there is more potential for cervical cells to become abnormal and progress to precancerous changes.  For example, 2 strains (named 16 and 18) are responsible for two-thirds of all the cancers that I have mentioned.  You may also have been exposed to HPV, have it lying inactive in your body, have a history of normal pap smears, and you will test negative for the presence of the virus.  HPV only shows up when it is “active” or “infecting” the area tested.  This is why it is so important to have regular screening if you have ever been sexually active.  The good news is that most women will be able to suppress the virus through the normal immune system response within 2 years.  We also know that smoking will increase the risk of abnormal changes progressing to cancer, so another reason to consider quitting.

Does the HPV vaccine prevent infection?  Am I eligible to get vaccinated?

The vaccines (there are 2 different ones) prevent infection from the most dangerous HPV strains (#16, 18), and one of the vaccines (Gardisil) also prevents infection from the strains the cause venereal warts.  The vaccine is available for women and men younger than age 26.  It is actually recommended to start vaccinations prior to sexual intimacy for peak protection, therefore it is being offered anytime from age 11 forward.  If you have already been exposed to one of these HPV strains, the vaccine will not protect you against the one you have been exposed to, but will protect against the others.  If you are over age 26, the vaccines are not currently available to you.  Condom use is always recommended, but again is not 100% protective against HPV.  The more sexual partners you have, the greater the risk of exposure.

Happy Valentine’s Day to everyone! The holiday marked for hearts, flowers, and romance is a great day to talk about one of life’s greatest pleasures. Sex! Sex is one of those categories that, while not taboo, is not openly discussed, and leaves us wondering “Am I normal?” Based on surveys of married couples, 1-2 times per week is average. But remember- this is not a competitive sport! If the amount and type of sex you are having is good for you and your partner then it is “normal” too.

Guess what, that biological clock that’s ticking is no myth, and it’s what sometimes causes the sex drive in females to increase. In your early 20’s, menstrual periods are typically regular. Pre-programmed into us for “propagation of the human race” is the increase of desire around ovulation (when we are most fertile). The hormones inducing ovulation increase both sexual interest and the ability to orgasm. If your sex drive isn’t as high as it usually is, it could be your method of pregnancy protection. Birth control pills decrease testosterone, which for some women can decrease desire. For others, however, the confidence of pregnancy protection gives them freedom and peace of mind which can increase desire.

As life transitions into marriage and stable relationships, a level of confidence is reached. Many women feel more knowledgeable about what they like and can ask for it. The increase in experience increases the orgasm potential. This is why you hear “women have their sexual peak in their 30s”. Many women notice a dramatic increase in sex drive during the second half of pregnancy (after the morning sickness a fatigue resolve!). The skyrocketing progesterone and estrogen levels, the increased blood flow and vulvar swelling, and the intimacy pregnancy brings with a partner can all contribute to an increased desire.

However, if you aren’t feeling particularly frisky post-baby…you are not alone! Immediately after delivery, the same hormones that got you riled up plummet. The baby is putting new demands on the household, adding exhaustion and stress to the mix. Breastfeeding relies on prolactin which further decrease the sex hormones. This leads to thinning of the vaginal tissue which may cause pain and decreased lubrication. So if you aren’t hitting records in the bedroom post-baby, it’s okay.

As ovulation reestablishes itself, the hormones stabilize and desire improves. That being said this is time of navigating parenting styles, partner work load discrepancies (both in and out of the home), self vs family time. Finding this balance is difficult but key in having a healthy relationship and sex drive.

Perimenopause hits on average mid 40’s. The hormonal changes may decrease spontaneous interest but should not decrease the ability to enjoy sex or orgasm. Menopause itself, as defined by 1 year without a period, brings a significant decrease in estrogen and testosterone. This leads to decreased lubrication and blood flow to the vagina. Over the counter lubricants are important during this time, to ensure that there is no pain involved. If these are not enough, then prescription local estrogen replacement can be help tremendously.

So you can see, your sex drive will change as you go through life. In general, women who have a stronger emotional connection with their partner will tend to have an increased desire for sex. As such, intangible aspects of life have a strong effect on your sex life. Relationship issues, stress, fatigue, exercise and self-image are all important contributors to how much you are turned on. As you age, you may be less the “initiator” and may become more “receptive”. And bottom line- if it is okay for you and your partner it’s normal- whether that is daily
or once a year!

One of the common misconceptions about women’s health is that yogurt cures yeast infections. How did this idea get started? And why isn’t it true? And if there is no benefit from using yogurt in the vagina or on the vulva, are there other food-related products that are useful?

First of all, what is a yeast infection?

Candida albicans is a fungal organism commonly found in nature and frequently found on humans. It is a yeast-type fungus, which has to do with the microscopic form it takes. That is why vaginal infections (vaginitis) caused by this fungus are called “yeast infections.” These infections cause itching, burning, often a vaginal discharge, and are common. It is a lucky woman who has never had a yeast infection!

Where does the yogurt idea come from?

In order to understand the mistaken connection between yogurt and yeast infections we need to review some microbiology. Lactobacillus is a Genus of bacteria that metabolizes sugars and produces lactic acid. There are many types that are found in animals (including humans) and in foods, and these types are specific as to where they “live.” Lactobacillus acidophilus is the type most commonly used to make yogurt (by fermenting the lactose sugar in milk). It is NOT the type found in the vagina, just its cousin.

Why doesn’t it work?

Lactobacillus is the most abundant bacteria in the vagina, and there are at least four to five types found there, but none are acidophilus . Due to the production of lactic acid by these bacteria, the pH of the vagina is kept acidic, which helps in the natural defense against infection. Therefore it is known as the “good bacteria.” But when something disrupts the natural vaginal defenses, such as a course of antibiotics, there can be an overgrowth of Candida albicans causing an infection. Putting yogurt, and thereby acidophilus bacteria in the vagina doesn’t produce any beneficial effect. It doesn’t kill off the yeast, and it certainly doesn’t grow and produce more of the “good bacteria” because it is a different type of lactobacillus!

How can so many websites be wrong?

The idea of self-treatment of yeast infections with yogurt started back in the 1980’s, before there were any over-the-counter yeast infection medications (antifungals) available. This seemed to go out of fashion for a while, but now with the growth of the internet it is even easier to spread and therefore perpetuate false information. One website author picks up misinformation from another website and republishes it, making it look like multiple sources agree. Even Wikipedia states that yogurt is a treatment for yeast infections! Yogurt is not, in fact, a treatment for anything; it is just a healthy food, a great source of calcium, and a tasty snack. And by the way, some websites also recommend other food remedies for vaginitis including sea salt, apple cider vinegar, and garlic. Applying these products to the vagina or vulva will be smelly, ineffective, and probably painful for inflamed skin, and can even make the inflammation worse, so don’t use them either.

So don’t believe everything you read, don’t believe everything you hear, and DON’T PUT FOOD IN YOUR VAGINA!

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.