Vaginal discharge? Vaginal irritation? Odor? What to do? Vaginal infections are exceedingly common. In fact, they are so common that the majority of women will experience at least one in her lifetime. Vaginitis complaints are responsible for roughly 10% of doctor visits each year, amounting to nearly $10 million in annual costs.
Outlined below are the major causes of vaginal infections, associated complications, and how they are identified and treated.
The majority of vaginitis cases in women of childbearing age can be attributed to bacterial vaginosis (BV), yeast vaginitis, and trichomoniasis.
Bacterial vaginosis (BV) is the most common cause of infectious vaginitis, and is characterized by white, thin discharge with a fishy odor, and elevated vaginal pH that is often attributed to an imbalance of normal vaginal bacteria. Some women note symptoms are worse after intercourse or menses, while others experience no symptoms at all. It is important to treat symptomatic BV because this disruption in vaginal flora has been shown to increase risk for acquiring and transmitting sexually transmitted infections (STIs). Additionally, BV can lead to poor pregnancy outcomes. Your provider can diagnose this condition after doing a pelvic exam and collecting a sample of vaginal fluid. Conventional treatment primarily includes oral or vaginal antibiotics. Natural agents such as boric acid suppositories, vitamin C suppositories, and very specific species of probiotics may be sufficient in some cases or may augment conventional treatment in other cases. Unfortunately, BV recurs in as many as 58% of women who were previously treated and experienced resolution. For these cases we can look to other factors that may influence the existence of BV like biofilms that can harbor bacteria, preventing adequate exposure to antibiotics. Additionally, douching, low vitamin D status, smoking, diet, and stress may play a role in development and recurrence of BV.
Yeast vaginitis is also known as vulvovaginal candidiasis (VVC) and can cause symptoms of itching, burning, pain with intercourse, red and inflamed tissue, along with a yellow-white “cottage cheese” discharge. The most common culprits are Candida albicans (80–90 % of symptomatic cases), Candida glabrata (2–5 %), and Candida krusei (1-2 %). VVC is one of the most common vaginal infections – responsible for 40-50 % of all vaginal infections. About 75% of reproductive aged women will experience at least one episode of VVC. Unfortunately, up to 50% of these women will develop a second infection of VVC and up to 5% will become recurrent cases. Conventional treatment includes oral or local antifungal and restoration of the vaginal microbiota. In addition to conventional treatments, Naturopathic physicians may use botanical/nutraceutical antifungal agents to re-establish normal vaginal flora, as well as address gastrointestinal function and flora and many other risk factors for development and recurrence of VVC, namely, diet, lifestyle, and co-morbid conditions.
Trichamoniasis symptoms can range from none at all to including a thin, foamy, yellow-green discharge, vaginal itching, burning sensation or odor, pain with urination, lower abdominal pain, and irregular spotting especially after penetrative intercourse. Your doctor will do a pelvic exam and in addition to the discharge, may see red spots on your cervix, a presentation that is referred to as “strawberry cervix,” although this finding is rare. During the examination, your provider will likely take a sample of the discharge for testing and will likely note an elevated vaginal pH greater than 5. If trichamoniasis is confirmed, you will be prescribed an antibiotic to treat the infection. And since trichamoniasis is a sexually transmitted infection (STI), it warrants testing and treatment of your sexual partner as well.
Aerobic vaginitis (AV) is caused by aerobic bacteria, for example: Staphylococci, Streptococci, E. coli, E. faecalis, to name a few. Symptoms include vaginal redness, inflammation, and burning with a persistent green, yellow, gray discharge, and elevated vaginal pH. Your provider will test a sample of the discharge and if aerobic bacteria are confirmed, treat with antibiotics that are specific to the pathogenic bacteria and steroids for inflammation. A naturopathic approach can include the use of the antibiotics along with vaginal ecology restoration with select species of probiotics along with supporting overall immune health.
Mixed vaginitis can include a combination of the bacteria responsible for causing bacterial vaginosis and/or aerobic vaginitis and/or yeast vaginitis. Symptoms can include a yellow-green discharge, and a burning sensation, redness, and inflammation of the vulva/vagina. Examination and laboratory evaluation of vaginal discharge is very important so that targeted treatment may be used to eradicate the problematic bacteria. Restoration of healthy normal vaginal bacteria is also important as well as addressing any potential lifestyle factors that could have led to the infection.
Cytolytic vaginitis is a controversial condition where the abundant growth of lactobacilli results in the breakdown of vaginal epithelial cells. Symptoms mimic those of yeast vaginitis: vaginal/vulvar itching, burning, pain with intercourse and urination, and may be accompanied with a discharge. Treatment may include a sodium bicarbonate vaginal rinse as well as stress management and blood sugar control.
Chlamydia and gonorrhea are the most common bacterial causes of sexually transmitted infections. In women there are rarely symptoms indicating either infection, however, some women experience yellow vaginal discharge, urinary urgency or frequency, pain with urination, bleeding between periods, or pain with sex. Routine STI testing is highly recommended as once an infection is identified, targeted treatment can be administered to you and your partner. Left untreated, both gonorrheal and chlamydial infections can cause pelvic inflammatory disease (PID), ectopic pregnancy, chronic pelvic pain, and infertility and other severe complications. Other sexually transmitted infections like herpes simplex virus (HSV) and syphilis may also cause an abnormal vaginal discharge.
As you can see, there are numerous types of vaginal infections that can present similarly. As such, it is important that you see your provider so that proper assessment and possibly testing be performed in order to get you the most appropriate treatment. If you are experiencing any of these symptoms contact your provider for an office visit.
Constipation is a common complaint among pediatricians’ offices. Most children experience brief periods of constipation over time that usually resolve on their own. Symptoms that warrant medical attention include recurrent, prolonged constipation, bleeding, pain, excessive straining or fear of passing stool. Many children who have previously experienced painful bowel movements instinctively begin to withhold their stool, causing a vicious cycle of even harder-to-pass stool that may lead to impaction.
This article discusses common causes of constipation, prevention strategies and treatment. This article is not intended to diagnose, treat or replace the advice of a medical provider. Please share your concerns with your child’s doctor if he or she struggles with constipation. Routine well-child visits are important for ruling out metabolic, neurologic and endocrine causes for these symptoms.
Initiating solid foods or introducing cow’s milk to the diet may lead to constipation as it is easier to offset the correct ratio of fiber and water required to make soft, easy-to-pass stool. Cow’s milk slows intestinal movement and can satiate the child’s appetite, making it less likely they will drink water or eat fiber-rich foods.
Dysbiosis of our microflora can cause a multitude of symptoms, many of them gastrointestinal. Stool testing can help identify if the child is missing important probiotic bacteria in their gut- facilitating a more customized treatment plan. A different approach is to test for food allergies- another condition that can cause a wide variety of symptoms. Food allergy testing can be completed using a simple finger stick- no blood draw is needed.
Starting school can be a significant transition for children; they must learn to navigate new schedules, locations and classmates. A change in routine may interrupt a child’s natural bowel movement pattern- leading to withholding or a reluctance to use the restroom at school.
Stress is another common cause of disordered bowel habits. During times of stress, it is harder for a child to sense (and act) when their body is ready to have a bowel movement. Toilet training, travel and the arrival of a new sibling are all very common times when children may experience brief interruptions in their body’s natural routines.
Below are some general tips for avoiding constipation. Ultimately, evaluation and treatment by a medical professional is always recommended for a more personalized approach.
Routine: if a child is toilet trained, encourage they spend time on the toilet after every meal. If the child has struggles using an adult-sized toilet, start with a portable children’s toilet or use a stool to raise their feet so their knees are flexed. If the child is at school for a portion of the day, encourage time on the toilet before and after school.
Water: encourage 16-32 ounces of non-milk fluids per day. If the child is reluctant, you may add a small splash of juice or herbal tea to add natural flavor to the water. If the child drinks milk, lightly diluting the milk with a small amount of water can encourage adequate hydration while offsetting the constipating effects of dairy.
Fiber: a great starting point for calculating children’s optimal fiber intake is:
child’s age + 5-10 grams = total fiber intake per day.
For example: a 3-year old’s optimal intake is 8-13 grams of fiber per day (for a 6-year old child it’s 11-16 grams, etc.) Specific foods that can help treat constipation include prunes, pears, apples, chia seeds and flax seeds.
Below this article you’ll find some charts with the average fiber content of various fruits, vegetables and cereals. A nutritionist or dietician familiar with children’s nutrition is also a fantastic resource and can teach you and your family how to eat for all stages of life.
Below are general treatment guidelines for mild-moderate constipation. For severe or chronic constipation, more aggressive treatment is warranted and must be supervised by a physician.
For mild constipation, a conventional doctor may prescribe laxatives like Miralax or lactulose in weight-specific doses. As a naturopathic physician, I may consider starting with magnesium that helps draw more water into the stool and thus make them easier to pass.
Severe constipation and/or stool impaction involve both oral as well as rectal medications. This treatment usually involves a bowel “clean out” to start, then is followed by supplementation of stool softeners to prevent recurrence. A clinician may recommend daily laxative use for several weeks, then taper down the dose very slowly once the child returns to normal bowel tone.
Water, diet and fiber will also be a part of a holistic treatment strategy.
The Bottom Line (get it?): Prevention is the best cure for constipation. Fiber, fruits, vegetables, water and regular physical activity create a recipe for lifelong healthy bowel function. Intervene at the first sight of constipation- prolonged pain with bowel movements will cause the child to withhold stool and can trigger fear of going to the bathroom. Stool withholding leads to even worse constipation and often will require a “bowel clean-out” if the constipation becomes severe or prolonged.
Oh, and lastly….. have you heard of that movie called Constipation?
You haven’t?? That’s probably because it hasn’t come out yet!
Table 1: Fiber content of fruits, vegetables and cereals.
References and Resources:
UpToDate: Prevention and treatment of acute constipation in infants and children
Dr. Val Manning sees patients from infancy into adulthood, focusing on preventive strategies when possible and creating sustainable, integrative treatment plans that fit the whole family. She is credentialed with various insurance companies and is currently accepting new patients.
If you want to find out more about nutrition and how it affects the topic discussed in this blog you might be interested in seeing our Registered Dietitian Nutritionist. Call the clinic to learn more or schedule an appointment.
Carly Kellogg Knowles, MS, RDN, LD
Carly has a Master of Science degree in Nutrition and is a certified Registered Dietitian Nutritionist. She is the owner of Vibrant Nutrition & Health – An Integrative and Functional Nutrition Practice in NW Portland, OR.
She specializes in medical nutrition therapy for:
-Chronic disease (anemia, autoimmune disease, cancer, pre-diabetes/diabetes, gallbladder disease, heart disease, high blood pressure, inflammation, osteoarthritis, weight management)
-Eating disorder recovery
-Fertility, pregnancy, postpartum, and breastfeeding
-Intuitive eating and wellness
She is credentialed with various insurance companies and is currently accepting new patients.
The previous posts outlined lifestyle modifications for improving sleep, as well as various nutraceutical and botanical treatments for attaining better sleep.
However, what if it’s been several weeks and none of these treatments seem to be helping? This is where the investigation begins. You doctor will perform a more detailed evaluation- often including lab testing and referrals- to help discern the cause of this hard-to-treat insomnia.
Lab workup may start by analyzing your thyroid function, ruling out hyperthyroidism as a cause and/or blood sugar testing to determine if highs or lows are involved. Another test, unique to alternative medicine, provides a salivary 4-part cortisol measurement. This will help to identify if the insomnia occurs because of abnormal cortisol secretion. Another valuable test measures neurotransmitter levels (including serotonin, histamine, GABA and others) to identify and treat deficiencies or excesses.
It is likely your doctor has already performed a full physical exam; however, they may choose to repeat it and pay special attention to heart function, neurological function, as well as oral and throat anatomy.
Other conditions that are important to rule out include restless leg syndrome and musculoskeletal pain or spasm.
If needed, your doctor may refer you to a sleep specialist to rule out sleep apnea. Physical therapy or orthopedic referrals can be useful to help treat chronic pain. Lastly, your doctor may choose to refer to a mental health practitioner for further evaluation; it is important to identify if sleep difficulties originate from mental or emotional causes.
Contact your doctor today if you suffer from sleep difficulties that do not respond to treatment. It is an important issue to address as poor sleep has negative health effects, both short and long term.
To a good night’s rest!
Image courtesy of www.theinsomniaclinic.co.uk
A note about supplements and botanicals: herbs are powerful medicines that hardly ever have just one function. On the contrary, herbs and nutraceuticals have various actions that act synergistically. Please check with your clinician who is knowledgeable in these areas before initiating a new product as it carries the risk of interfering with other medications.
In the beautiful and vast world of botanical medicine, there are well-known, tried-and-true herbs for insomnia. The classic insomnia herbs, and some with published research include skullcap, valerian, lemon balm, kava, hops, passion flower and chamomile. Other great herbs that may help relax the body and brain for sleep include lavender, oatsraw, and even poppy. Ashwaghanda has been studied for its sleep-inducing effects over time and may help establish a healthy sleep cycle with regular use.
The herbs mentioned above come in a variety of forms- alcohol/water based tinctures, non-alcohol based tinctures, capsules, tablets, loose leaf teas or powdered root. They’re available as single-herb products or are combined with multiple herbs and/or nutrients for a stronger effect. At many naturopathic clinics, doctors can even create a customized combination of herbs that are specific to your unique needs; this is called an herbal formulation. Tea blends are also a great option, but could potentially interrupt sleep if it ultimately causes you to wake in the night to urinate!
Soothing scents like lavender, chamomile or rose can switch our brains into nighttime mode. These oils vaporize well in an essential oil diffuser. You can also take a warm Epsom salt bath with a few drops of oil sprinkled in… with a candle burning nearby. Some soothing, relaxing music playing softly in the bathroom won’t hurt either! Are you getting sleepy yet?
DIY- To make a lavender hydrosol spray at home, add 10 drops of lavender oil into a spray bottle full of water. Spray this mixture in the air, on your skin or even in your bedroom for maximum aromatherapy effect.
While browsing the aisles at our local health foods store, there is no shortage of products to help us sleep. The art of the medicine lies in selecting the correct one for the type of insomnia you have. Examples of products on the market for insomnia include 5-HTP, L-tryptophan, melatonin, magnesium, l-theanine, GABA, phenibut…. and there are many more. Each of these products boasts a different mechanism for shifting our body into sleep mode. The most effective way to know which one works for you is to have a comprehensive intake with your doctor who will take a careful and informed health history. There are also situations where underlying causes need testing such as thyroid, glucose, cortisol, melatonin, and neurotransmitters. Many times, we encourage our patients to use a product regularly for a few weeks before we determine its effectiveness .
Over the counter pharmaceutical and prescription-only drugs for sleep are our last resort as naturopathic physicians. These are necessary in some situations; however our goal is short term use while we work on other aspects of your overall health. There are various types of medications for insomnia- some have a risk for dependence and can cause unpleasant side effects. For these reasons, they are best discussed at your doctor’s office.
Up next: PART 3- Investigating Insomnia: when treatments aren’t helping
Image courtesy of www.theinsomniaclinic.co.uk
Although it may be an obvious fact, it must be said; sleep is an integral part of our lives. A good night’s sleep allows the body and brain to rest.
While we sleep, our immune system goes on high alert and scans the body for infection. Our brain converts short term memories into long term storage, a process called consolidation. And lastly, our conscious brain temporarily takes the back seat while our subconscious runs loose.
When sleep quality starts to diminish, consequences are felt immediately and their detrimental effects accumulate over time. Studies suggest that poor sleep (or less than 7 hours per night) increases one’s chances of heart disease, obesity, depression and even diabetes. Yikes!
“OK you’ve scared me enough Dr. Manning- what am I going to do to start sleeping better??”
While often a challenging chronic health issue, insomnia is one of the most responsive conditions to naturopathic treatment modalities. The solution for you could be an easy switch or it may require a comprehensive evaluation and plan- always check with your doctor before initiating any treatments listed in this article.
Below you will find an overview of naturopathic approaches to insomnia- split into three parts:
- Insomnia Basics: finding the root cause and lifestyle interventions
- Botanical and nutraceutical treatments for insomnia
- Investigating insomnia: when treatments aren’t helping
Insomnia Basics: finding the root cause and lifestyle interventions
Treatment for insomnia should never be “one size fits all.” As always in naturopathic medicine, identifying and addressing the root cause of why you can’t sleep is paramount to treatment success and long term cure.
So… Why can’t I sleep?
Looking deeply and with depth at your problem can help you identify the reason why sleep is not a satisfying, refreshing experience. Your doctor may ask the following questions:
- Do you have trouble falling asleep?
- Do you have trouble staying asleep?
- Do you wake often throughout the night?
- How much time do you spend in bed? Sleeping? Doing other activities in bed like reading, watching TV, eating?
- What is your work/school/home schedule like?
Some causes of insomnia are obvious while others may take a little digging (e.g .nutrition, pain, medications, anxiety) and maybe testing for a thyroid disorder, a blood sugar problem or cortisol dysregulation among others.
Food, News and Booze
Do you eat large meals shortly before bedtime? Do you watch headline news at night? Do you engage in a liquor, beer or wine night cap most evenings? These all have the potential to significantly interfere with your body’s “winding down” process, either by causing a spike in your blood sugar or even worse- a spike in your body’s stress hormone, cortisol.
Experiment this week by replacing your evening TV time with a relaxing book, a warm bath or gentle stretches before bed. Save the headline news for the following morning or afternoon.
Aim to eat your last meal for the day at least 60-90 minutes before you hit the hay, that way your body will be finished digesting food once it’s time to sleep. If you find yourself hungry before bedtime, eat a light protein-focused snack like veggie sticks, nut butter, hummus, hardboiled egg or a small piece of cheese.
Aim to limit your exposure to inflammatory or stimulating social media, television or music if you’re the sensitive type. Often, these images, words and/or articles linger in our subconscious mind long afterward and inhibit truly restful sleep.
Ready… Set… Sleep! Establishing a Bedtime Routine
The body responds surprisingly well to routine. If you regularly repeat a similar sequence events leading up to bedtime your body will begin to learn that these activities equal sleep- and over time it will become easier to fall asleep. There is a practice called sleep hygiene that outlines several practices for attaining satisfying sleep. More info regarding this can be found here.
Try brushing your teeth, changing into your PJ’s, dimming the lights, etc. in the exact same order every night for a week. Notice if your body begins to relax and prepare for sleep as soon as you start that routine. Often, preparing our bag, supplies, outfits, etc. for the following day can make us feel less stressed and more clear-minded as we drift off to sleep.
Other lifestyle tips for sleep
Meditation offers a multitude of benefits for sleep. Try mindfulness meditation, progressive muscle relaxation, loving kindness or mantra meditations. Meditation can be self-guided or guided by a podcast, audio recording or book. Stretching, yoga and tai chi are also great ways to enhance your sleep if you prefer movement meditation. Journaling our day, our thoughts or even our concerns can help free more of our mental space for rest, sleep and rejuvenation.
Napping is a great way to recover from a poor night’s sleep, however it can interfere with the following night’s sleep. If you must nap, limit to 30 minutes only and avoid napping too late in the evening.
Exercise is the one of the most underrated, untold secrets in medicine. The benefits of regular exercise (150 minutes per week, to be exact) are immense. Regular exercise not only helps us sleep better at night, it improves almost every aspect of our health. Start small: a few minutes per day or a few days per week. Increase your amount/intensity slowly and ask for guidance if you run into difficulties or develop pain in your joints.
Image courtesy of www.theinsomniaclinic.co.uk
Coming up next: Botanical and nutraceutical approaches to insomnia.
– “Sleep and Chronic Disease,” www.CDC.gov
By Erin Conlon, ND, MS
As we go through life we experience various and sundry joys of fluctuating hormones. For many women, teen years bring forth a roller coaster of emotions and physical changes as we experience new and evolving levels of hormones. The modification of hormones in pregnancy can further alter bodies and impact emotions. Finally, the culminating change in hormones, known as menopause, influences the body in entirely new ways, as hormone production declines.
The menopausal change in hormone levels may present with an assortment of symptoms that includes flushing with waves of internally generated heat, mood lability, vaginal dryness, and mental cloudiness. Symptoms of hot flashes, mood swings, and brain fog often bring a woman into her doctor’s office, as these are commonly discussed topics. But all too often, symptoms of vaginal dryness or pain with vaginal penetration are left untreated due to associated social stigmatization. It should be noted that roughly 50% of postmenopausal women experience vaginal dryness between the ages of 50 and 70, a number that increases to over 70% after age of 70. Unfortunately, only about 25% of affected women seek medical treatment for this condition.
Vaginal dryness is often accompanied by sensations of itching and burning, increased incidence of urinary tract and vaginal infections, and urinary leakage. Furthermore, vaginal dryness can contribute to pain with penetrative vaginal activity and an associated decreased libido. This constellation of symptoms may all be attributed to a condition call atrophic vaginitis. This atrophy/thinning, also affects a decline in pelvic floor/vaginal tone, urinary incontinence, and changes in the vaginal and bladder ecology such that vaginal and bladder infections can become more common.
Atrophic vaginitis is the change in vaginal tissue and lower urinary tract following the loss of estrogen, which may occur with natural, surgical, or chemical menopause. Current standard-of-care treatment for atrophic vaginitis is local vaginal estrogen. The hormone can be delivered to the vagina through a variety of methods, including creams, suppositories, vaginal tablets or ring. Creams, tablets and suppositories are generally used nightly for two weeks and then twice a week thereafter. Rings are used continuously. The purpose of this long-term therapy is to help preserve the ecology, pH, and tissue of the vagina. While the majority of the hormone is delivered directly to the vaginal tissue, some studies have shown that vaginal estrogen may contribute to elevations in systemic estrogen. The potential for vaginal estrogen therapy to alter body-wide hormone levels, albeit very minimally, makes the treatment less than ideal for some women.
Fortunately, there are other options to treat atrophic vaginitis! DHEA, also known as dehydroepiandrosterone, is a precursor hormone that when in the presence of necessary enzymes, can be converted to testosterone and eventually estrogen. In November 2016, the U.S. Food and Drug Administration approved DHEA to be used vaginally to treat atrophic vaginitis and associated symptoms. Research regarding DHEA has demonstrated the ability for the compound to improve symptoms of vaginal dryness and pain with sexual activity. In the future we may find that DHEA improves libido. Presently, however, data are limited and more research is needed to truly elucidate the impact of DHEA on libido. Additionally, daily use of DHEA appears to keep systemic hormones within the same ranges demonstrated in menopausal women not using hormone therapy. However, small increases in systemic estrogen have been noted with daily DHEA use, thereby potentially ruling it out as a treatment option in certain populations of women. Finally, it is of note that DHEA must be used daily in order to remain effective.
Discussed here are just two potential treatment options for atrophic vaginitis. Primary care doctors and women’s health providers have a variety of treatment options for this condition. Talk to your doctor about any menopause associated vaginal symptoms that you may be experiencing so you can get a tailored treatment that is best for you!
Building Your Winter Blues Toolbox
Valeria Manning, ND
Seasonal Affective Disorder, better known as S.A.D., affects approximately 3-6% of the general population. The incidence is higher in northern latitudes and among women of reproductive age. Typical presentations of S.A.D. overlap significantly with major depressive disorder, however S.A.D. occurs in a more cyclical nature during the autumn and winter months.
Fatigue is the most common complaint doctors see in their office. The causes of low energy are numerous, and often there isn’t a single culprit. However, in women of reproductive age, low iron can be a common cause of or contributing factor to low energy. Many of my patients have been told to supplement iron in the past, but they haven’t been told why or for how long. Let’s explore the subject.
When considering any nutrient in the body, we have to think about 3 factors: how much of it are we taking in (diet or supplement), how much of it is getting absorbed in our digestive system, and how much are we losing.
One of the major challenges in my practice is relaying information about single nucleotide polymorphisms (SNPs) in a way that’s accessible and empowering for my patients. The acronyms alone make it daunting to approach: MTHFR, COMT, MAO, VDR, UGH (okay, that last one was mine). Genomic medicine can be a powerful tool for improving and optimizing health, so with that in mind, let’s try to decode the alphabet soup.
In Chinese medicine, spring is an excellent time to cleanse and renew. Much like the buds sprouting on plants outside, the body is energized and ready to emerge from its winter dormancy. The buzzword “detox” can evoke thoughts of deprivation with a dash of lemon-cayenne water, but there are many avenues for resetting your health. Below are some gentle ideas. (more…)