00:07 – If you have a healthy and protective gut and a protective vaginal microbiome, then you just decreased the risk
00:14 – of the pathogens passing those two barriers in order to get to the bladder. Hi. Welcome back to the Live UTI Free channel. My name
00:19 – is Melissa and this is a follow up interview with doctor Krystal Thomas-White. If you haven’t seen our first interview with Doctor
00:25 – Thomas-White, check it out. The link is in the video description below. If you enjoy these videos, think they’re important, and
00:31 – want to support what we do, be sure to hit subscribe and tick the bell so you’ll be notified of our future content. Thanks again
00:45 – for joining us on this journey to making change in women’s health. Today I’m chatting with doctor Krystal Thomas-White, who is our scientific advisor here at Live UTI Free. She’s also the senior
00:51 – scientist at Evvy. Doctor Thomas-White is a microbiologist specializing in the female urogenital microbiome and how it relates to disease.
00:58 – Thank you for joining us for this follow up interview so you can answer more of our community’s questions. I’m so excited to be here. I always love talking
01:05 – with you, talking with the Live UTI Free community. Yeah. And we love having you as well. And I think a lot
01:10 – of people watching this probably aren’t aware of who you are. So, if you could provide some background on your work and your research, that would be really helpful.
01:17 – Yeah, be happy to. I did my PhD in the Wolflab, which was the lab that really was able to show that urine is not
01:24 – sterile. And I was able to be a part of discovering for the first
01:31 – time, actually first time in the modern day that there is a urinary microbiome. And we looked at a lot of how the microbiome was associated
01:40 – with health and disease. I did my dissertation on the connection between the vaginal and the bladder microbiome. So, we’re actually
01:48 – able to see that the exact same species and strain of bacteria are present in both the bladder and the vagina in individual women,
01:56 – which says that it’s a whole interconnected microbiome, not two
02:02 – disparate locations. After that I went and studied host microbe
02:07 – interactions at Stanford, and I’m now at Evvy, as you mentioned, we’re a at-home vaginal microbiome sequencing company. So, my
02:17 – job is to do a lot of – you know, we’re a startup so, I’m wearing a lot of hats – but I do everything from making sure that all of our content is
02:27 – scientifically accurate, as well as working with academic collaborators and actually doing science on our samples.
02:34 – And so, what has the research said in terms of what a healthy vaginal microbiome looks like?
02:40 – Yeah, the vaginal microbiome and the bladder microbiome, they’re actually very similar. As I said, they are connected. Tends to be Lactobacillus dominant is considered healthy
02:51 – and by Lactobacillus dominant, there’s four main ones. And I’ll say in order of what’s considered best to worst. Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus jensenii and then Lactobacillus iners.
03:05 – And what we know is that crispatus and gasseri can actually
03:11 – kill off pathogens, push out other pathogens. So, they just take up all the space
03:16 – so pathogens can’t colonize. They’re also producing chemicals
03:22 – that can kill or inhibit those different bacteria. So they’re considered very, very good. However, lactobacillus iners
03:33 – is kind of a tricky one. It’s just a bystander. It doesn’t produce a lot of those chemicals. Sometimes it’s healthy, sometimes it’s
03:40 – not. Sometimes you only see it in moments of transition, that type of thing? So, that’s healthy. Do you want me to also talk
03:46 – about disease? Yeah. Of course, it’s very important for this community.
03:51 – So, that is what is considered healthy is, Lactobacillus-dominant. What is considered unhealthy is a more
03:58 – diverse microbiome with lots of different bacteria present. So,
04:03 – Gardnerella, Prevotella, Mobiluncus, a whole bunch of anaerobes. Those are considered the pathogenic bacteria in the vagina that can
04:12 – cause a lot of symptoms like itchiness and smelly discharge and that type of thing. It’s also the profile of microbiome that’s
04:22 – been associated with a whole bunch of adverse outcomes. So, things like STI acquisition or cervical cancer progression, those types
04:30 – of things. So, that’s the dogma in the field. That’s like the dichotomy that
04:38 – all the literature is kind of based off of. But I do wanna mention that that is an imperfect model because what we see in our data
04:46 – is that no matter what profile you have, we find people that are symptomatic and lactobacillus dominant or asymptomatic and diverse.
04:56 – So, it is a lot more complex than that dichotomy. And for anyone who falls in the diverse category, I definitely wanna tell you,
05:03 – if you don’t have symptoms, there’s not as much to worry about, right? Right. And we’re trying to figure out what is a protective
05:14 – microbiome that isn’t Lactobacillus dominant. What might that look like? Right. I mean, that’s important information and it
05:21 – covers some of the questions that we have in the list for today. And one of the other questions was, do biofilms and intracellular
05:28 – bacterial communities exist in a healthy body? Great question. I’ll start with biofilms because
05:35 – I think that’s a little bit more known. I think of a biofilm, like a apartment building where bacteria
05:44 – have built up this kind of hard wall that protects them from the outside environment, protects them from hormones or antibiotics
05:55 – or, in our case, if you’re thinking of the analogy, it protects
06:01 – you from the elements, right. But that is just the structure. And there’s a lot of different
06:07 – things that can live in that structure. So in a bacterial vaginosis
06:13 – or diverse vaginal microbiome state, there’s not just one bacteria in the bathroom, there’s Gardnerella, Prevotella. There’s all
06:20 – sorts of different – it’s called a polymicrobial biome. And it has a very particular type of structure. So, Gardnerella
06:29 – produces one type of biofilm whereas other bacteria produce others. But biofilms are also present with Lactobacillus dominant profiles.
06:39 – So, lactobacilli can produce their own matrix that can create
06:45 – its own biofilm. And there’s really cool research happening that shows like certain molecules that different lactobacilli make
06:54 – will promote other lactose to produce a biofilm. So, again, it’s
06:59 – this community-based colonization of a particular niche. So yes, they can be good and
07:09 – they can be bad, but from a bacterial perspective and that’s kind of – I’m a microbiologist, so I think from the bacteria perspective,
07:17 – you’re building yourself a nice protective structure that helps you survive. So, of course there’s gonna be lots of different
07:24 – bacteria that can do that. So, it’s more about what’s in the structure then the structure itself.
07:30 – Potentially, although there is some work looking into the components of the structure and that might be either
07:38 – like pro-inflammatory or maybe more resistant to antibiotics or something along those lines.
07:46 – But we’re starting – that’s very, very early research. Okay. And in your research at Evvy, have you found anything
07:53 – unusual in the vaginal microbiome that wasn’t known about before?
07:58 – Wasn’t known about before. I guess it depends on what your definition of known about before, so.
08:05 – I guess common knowledge in association with the vaginal microbiome.
08:11 – Let’s see. So, there’s not particularly new species or anything like that that
08:22 – we found. Right. I think that they’re there, but we just haven’t had the time to really dig into naming new bugs and getting that
08:30 – out in the literature. It actually takes a lot of work to do. Yeah, I guess.
08:36 – We’ve been more interested in understanding how the composition might interact with or is associated with
08:43 – different symptom profiles and treatment responses. And I think
08:49 – the most surprising thing was kind of what I was describing earlier
08:54 – is that we have people that are symptomatic that look like the canonical healthy, and people who are asymptomatically the canonical
09:03 – unhealthy. And really teasing that apart is part of the challenge.
09:10 – There’s a – I don’t know, this might be a tangent, but
09:16 – in Winnie the Pooh, there is a story. Yeah. That, Winnie the Pooh was walking around a group of trees
09:24 – in the snow, and he’s following footsteps, and he’s wondering who’s making those footsteps. And then he realizes there’s more
09:32 – footsteps that are coming and more footsteps that are coming. And it’s not until the end of the story you realize he’s just
09:38 – following his own footsteps he made last time he circled the trees.
09:44 – And that kind of happens in science too, right. Everything that we do is informed by the things that happened before. But sometimes
09:51 – you have to question what were the biases in intentional, unintentional,
09:58 – inherent in the data, whatever it might be. But what are the biases that that foundation might have been built on? And how do we get
10:06 – past those as we move forward? Yeah. And I imagine there’s quite a lot in women’s health.
10:12 – Yes, very much so. Particularly with the gender health gap. Right. We just haven’t had that much time to study
10:19 – women and women’s health. We haven’t said it yet in this interview, but we always do. More research is needed.
10:26 – Yes, more research is needed. I’m sure we’ll get there. I’ll say that a little more. Plenty of times. Yeah. So, you’ve spoken a little bit about
10:33 – bacteria, but what about fungi? Are there things that show up in the vaginal and urine microbiomes that are connected?
10:42 – Particularly with fungi? Mm-hmm.
10:47 – I didn’t look in the bladder microbiome at fungi too much, although there is a couple of labs looking into that. And really, the main fungi that
10:56 – we’re concerned with at Evvy is, of course, Candida, which causes the majority of yeast infections. So, I can’t really speak to that as much. I don’t know how the two
11:06 – are connected. Yeah, it’s an area like we hear from people in the community who sometimes think that fungi could be causing their bladder
11:13 – symptoms. And it’s interesting because there’s not that much research in that area to know if it is in the bladder or if it’s coming
11:18 – from the vagina and causing irritation. So, it’s a big question for a lot of patients about whether – this is what this whole
11:24 – interview is about, the interconnection, how you can even tell whether symptoms are coming from. And it’s a huge question that
11:30 – requires more research. Yeah. And I can definitely say Candida can cause UTIs 100%.
11:39 – And the way I think about it is, there’s of course a lot of different
11:44 – sources of pathogens. You can be a sexual partner or
11:52 – like douching practice is not good for your microbiome, for example, but
11:58 – if some of the organisms are coming, say, from the gut, those bacteria will have to travel through your gut, get past the vagina
12:07 – to get into the bladder. So, if you have a healthy and protective gut and a protective vaginal microbiome, then you’ve
12:17 – just decreased the risk of the pathogens passing those two barriers in order to get to the bladder. Right. So, there’s definitely
12:25 – a connection. It is understudied 100%, but it is definitely there. So, yeah, if you have a healthy vagina,
12:36 – you’ll have a healthy bladder. You mentioned that some people have symptoms, but what
12:42 – looks like a healthy microbiome, are there symptoms that you’ve been able to link to specific organisms?
12:49 – Yes, we actually just submitted an abstract, which is really exciting. Oh, cool.
12:54 – Yeah. For the first time, we’ve been able to show specific species are associated with vaginal odor. So,
13:04 – a lot has been hypothesized that certain bacteria can produce certain compounds. They’re called biogenic means that cause bad
13:13 – smells. One of them is putrescine, which you can imagine what that smells like, it’s horrible. Cadaverine is another one. And we were able to show that certain – I think we had four different
13:27 – Prevotella species and three other particular species increase
13:35 – in abundance as people report an increase in bothersome odor.
13:41 – And then we’re also able to look for specific biogenic amine genes
13:48 – and saw that those also increase as people report an increase of odor. So, this is the first time that it’s actually been past
13:57 – the hypothesis section and shown to be actually correlated with what women are experiencing.
14:03 – Well, that’s great. Do you have other organisms and symptoms in mind for future research like this? Oh, yes. Everything. We wanna look at itching. We wanna look at burning. We wanna look
14:17 – at different types of discharge. One other thing that- this was a an abstract we published, I think, last year. I talked a little
14:28 – bit about how bacterial vaginosis is dominated by an anaerobic
14:33 – organisms. So that basically means anaerobic means it doesn’t like oxygen. There’s also a group of bacteria that are called
14:41 – aerobic organisms that do like oxygen. And those are the ones
14:48 – that you probably think of more in the bladder, like E.coli, for example, is one of them, Group B strep, that type of thing. And
14:58 – we did an analysis that if you had any aerobic organisms present
15:05 – in your vagina, you’ve had more severe symptoms and more symptoms in general than if you had only anaerobic organisms.
15:15 – Okay. So, there is a correlation there we haven’t been able to tease apart like E.coli specifically is associated
15:21 – with burning, but we do know that having that present causes an increase in severity and just more problems in general.
15:30 – Yeah. I’m sure we could find some volunteers if you wanna pursue that research.
15:37 – But there’s also a lot of questions about how the microbiomes change. And one of the things that comes up, a lot of sexual activity,
15:44 – people experience symptoms often after sex. But can you see changes in the microbiome because of vaginal sex?
15:52 – Definitely. There are studies that have looked at that. Sex just messes with the microbiome in general, right. Things get
16:02 – moved around, there’s new microbiomes getting introduced. So, the penis, semen, they all have their own microbiome. And semen
16:11 – can cause a change in pH. We know that if you use condoms, your risk of bacterial vaginosis goes down for people who have recurrent
16:19 – BV, so 100%, sex is one of the most significant triggers for
16:27 – vaginal issues. Right. And what about things like a pap smear or transvaginal
16:32 – scan? A lot of people report symptoms after something like that. Oh, that’s really interesting. I haven’t actually
16:38 – heard that before. And yeah, there’s no research on that that I’ve seen. That’s what I figured. So, there’s a lot of speculation
16:45 – about whether something new is being introduced or if it’s a mechanical problem that’s just causing a disruption or friction or damage.
16:51 – And but we do hear that a lot, and it would be great to have some research into that area of things too.
16:57 – That’s fascinating. Yeah, I’ll put it on the list. I have a long list of studies that need to be done. And it’s the same question for people who use pessaries
17:05 – for a pelvic organ prolapse that often is associated with an increase in UTIs, and I’m not sure if research has been done
17:11 – around that either. It’s been a while since I looked into the research around pessaries. I remember from a few years ago that
17:20 – it can definitely change the microbiome,
17:28 – part of the issue is that pessaries are used for fairly long-term use, right. And they can cause sores just where they’re rubbing
17:35 – up against the side of the vaginal wall, but I haven’t looked into that recently.
17:42 – Okay. Yeah, but I haven’t either, so I guess we’ll both have to look into it now. Do some more studying there.
17:48 – Yeah. And so, we’ve been talking about dysbiosis. But we’re always told that vagina is self-cleaning. So, how does it clean
17:56 – itself. And then why can a dysbiosis happen? That is a great question. And
18:04 – I’ll start with how does it clean itself. It cleans itself by
18:09 – creating mucus. Right. That’s what discharge is is it’s the cervix creating mucus that is then pushing everything out through the
18:17 – vagina so that it gets foreign objects and potentially microbes
18:25 – out of the system, but anyone who has tracked their vaginal mucus, say for like fertility or anything. We know that it changes
18:33 – in consistency throughout the menstrual cycle. And it’s not coming out like with any force. Right. So, if there’s bacteria that have
18:43 – created a biofilm, remember, that’s a pretty thick, strong structure and something like mucus isn’t gonna have the capabilities of
18:51 – pushing it out. Think about it like if you have sex and your microbiome
18:58 – changes like that is your trigger, and Lactobacilli aren’t able to recolonize fast enough. Instead, another bacteria comes in
19:06 – and is able to colonize, your vagina self-cleaning capabilities
19:11 – aren’t going to be happening at a fast enough rate to prevent that. Right. Another time that people experience symptoms is
19:19 – just with their menstrual cycle as it changes throughout the month. Have you seen the microbiome change in your research in accordance
19:25 – with the cycle? Yes. We haven’t done any in-depth studies
19:32 – around cycles, but there’s definitely literature on that. What
19:37 – we do know is that the microbiome fluctuates in response to estrogen.
19:42 – And actually the bladder microbiome does as well, maybe not by
19:47 – rates of cycles, but the bladder microbiome becomes more diverse following menopause, for example. Let’s talk a little bit about estrogen first. So, estrogen, when it’s
20:00 – in the vaginal tissue, it allows the tissue to be thicker, it creates better tight junctions. So, it’s just healthier in general.
20:08 – But it also produces glycogen which is a food source for Lactobacillus.
20:14 – And Lactobacillus can eat that food source. It can grow very rapidly and take up more of the space, again preventing pathogens from
20:22 – entering. If you lose that estrogen for whatever reason, whether it’s menopause, postpartum fluctuations, just normal fluctuations
20:31 – in your hormone cycle, then the Lactobacillus just loses its food source so it can’t grow as well. And that’s part of the reason
20:39 – why we think we see those fluctuations throughout the menstrual cycle.
20:45 – Yeah. It’s interesting. That’s one of the reasons that things seem to change for some people. A lot of people ask whether
20:50 – there’s any research into diet and how it might impact the vaginal microbiome.
20:57 – Not very much, unfortunately. All of the diet
21:02 – microbiome work is in the gut, and I know it’s very frustrating, again, to say more research is needed, but probably the only connection
21:11 – there is what I was saying, healthy gut, healthy vagina, healthy bladder. So, if you can decrease the amount of pathogens, whether
21:21 – that’s Candida or E.coli in the gut by diet, then that potentially
21:27 – has the downstream effect of preventing pathogens in the bladder,
21:33 – but yeah, the research is very, very sparse. Yeah. And it’s a huge area of interest for patients because
21:39 – a lot of people do find that changing their diet impacts their symptoms. So, it would be really great to see more work done in
21:44 – that space. And there’s been some work, looking at bladder irritants potentially. So, like some people can’t drink coffee
21:53 – because it causes them bladder pain, for example, but that hasn’t
21:59 – been correlated to the microbiome in any way. Okay. Yeah, it’d be interesting to see. You mentioned that
22:06 – douching is a bad practice. It can disrupt the microbiome. But what about using a bidet after using the bathroom? Do you think
22:13 – that could be positive or negative in the same way that douching is? That’s also a great question that has not
22:19 – been studied, but I have wondered about it myself. Yeah. A lot of people have sent this question over the years.
22:27 – Yeah, well, maybe we need a bidet study as well.
22:32 – It would be beneficial. Yeah. So, I, unfortunately can’t answer that because we just don’t know.
22:38 – We’ll just keep that one on the list then. Yes. And a couple of people asked if steroid creams impact the
22:44 – vaginal or bladder microbiome, and if that’s even known yet. It’s not known, but I know certain steroids
22:53 – help with certain types of conditions. Its effect on the microbiome is unknown.
23:00 – Have there been any studies into whether the microbiome impacts the ability to conceive?
23:06 – Yeah, that’s a super interesting area of research. There’s actually a lot of interest in that right now. And
23:14 – it looks very promising. I’ll say that for sure. What we’ve seen in a lot of observational studies of people who have something
23:24 – like recurrent implantation failure of IVF. So, the embryo is put in, but it just doesn’t create a viable pregnancy.
23:35 – We see that the people who have that problem tend to have a more
23:43 – diverse microbiome, Non-Lactobacillus dominant. And it’s unclear,
23:49 – the mechanism behind that. We don’t know why. The theory is that the diverse microbiome is somehow causing like low-level, low
23:58 – grade inflammation somehow that is making it unlikely for the
24:05 – pregnancy to succeed. Okay. That there’s a couple really cool studies
24:12 – that we’re looking at. Can you change the vaginal microbiome to then increase rates of conception?
24:18 – That was gonna be my next question. Yeah, it looks like maybe. So, there’s only
24:24 – really one study that has done it fairly thoroughly. And this was done in Japan. And what they did was a type of vaginal microbiome sequencing before
24:36 – they did antibiotics and probiotic or combinations thereof and then check the vaginal microbiome again. So, kind of, they wouldn’t
24:44 – do the embryo transfer until the microbiome was in a Lactobacillus-dominant state.
24:51 – Okay. And they compared that cohort that went through this really intensive microbiome treatment to a cohort that didn’t
24:59 – do anything. They just did sequencing, but they didn’t follow up on that. And what they found is that the microbiome shifting
25:06 – actually did help and did improve outcomes for that cohort, which is very new. Wow, that sounds really promising.
25:12 – Very promising. But it was only done once. Yeah. It needs to be redone on a more diverse population of people and a larger study, that type of thing, but it is very promising.
25:21 – Has that research with the microbiome being carried through into pregnancy itself to see whether there’s an impact there too?
25:29 – We do know that the vaginal microbiome has
25:35 – some signals for predicting things like pre-term birth. And we’ve also looked or not, but lots of research has been done looking
25:45 – at the microbiome over pregnancy. So, we’ve talked about hormones. There’s so much going on with hormones when you’re pregnant.
25:54 – So, there is a shift like people tend to become more lactobacillus
26:02 – dominant by the end of pregnancy. And then once you have the pregnancy, there is a massive hormone drop,
26:09 – postpartum is kind of considered the mini menopause, and that’s kind of what you see is that the hormones are taking a while to
26:16 – bounce back. And that correlates with shifts in the microbiome. So, that’s in a healthy pregnancy. That’s what happens. What a
26:26 – lot of research is finding is that if you sequence the microbiome early, say, in the first trimester, there are certain signals
26:32 – that potentially can predict if pre-term labor will occur, preterm being less than 37 weeks
26:42 – gestation. There’s people who’ve looked at bacterial signals, metabolomic signals, there’s a ton of research in this area right
26:51 – now. But we don’t really know if we can shift the microbiome after
26:56 – you find that signal in the first trimester, right, because then the hormones are taking off. So, once we find that signal, what
27:05 – can we do about it is still a little bit unanswered question. Yeah, but it’s so important for so many people. So, it
27:11 – would be great to see that research done too. And there’s people working on it. It’s just that biotherapeutics are hard.
27:20 – Yeah, definitely. And we’ve talked a lot about the unhealthy state of the microbiome. What do you think about people testing
27:27 – when they don’t have symptoms? Is there any benefit to doing that? Yeah, because you need a baseline. You need
27:33 – to know what your microbiome looks like when you don’t have symptoms. So, you know that when you do have symptoms what is changed. Right.
27:42 – Like I said, there is a lot of people with a diverse microbiome that are asymptomatic. So, if you are only going to
27:53 – test when you’re symptomatic and you have diverse microbiome, you’d be like, oh my God, things are wrong. But if that was your
28:00 – baseline like before, maybe it’s not just Gardnerella, maybe it’s like we’re saying you got a low level of aerobe there. And that’s
28:09 – really the problem that you want to actually look at. And those types of shifts are really good to know for your own information about your body.
28:16 – It makes sense. I’m sure a lot of people test for the first time when they have symptoms though. So, how do you know what you’re looking
28:22 – at and what to recommend treatment for? We base everything off of the literature and
28:28 – medical recommendations. So,
28:34 – Evvy works with doctors that use our tests to help prescribe medications.
28:41 – And those doctors will decide based on the results and the symptoms if treatment is necessary. So, I am a PhD. I do not like to talk
28:51 – too much about medications, but it’s all evidence based.
28:59 – Well, we could talk about the research potentially into certain treatments for vaginal dysbiosis. So, is there a research
29:05 – around like oral probiotics or antibiotics or anything else, boric acid. The things that people often talk about when it comes to
29:13 – vaginal infection. Yeah. Let’s start with probiotics.
29:21 – There have been a lot of research on probiotics with a lot of very confusing results. One study will say one thing and another study will say another.
29:29 – And we recognize that that can be really challenging.
29:34 – But what we do know or I should say
29:39 – the reason for that, the reason that there’s all these different results, it comes down to the fact that
29:47 – the organisms, the study design and the outcome measures are all
29:52 – different across all of these different studies. And so, it’s really hard to say was it the organism? Was it the study design?
29:59 – Was it the outcome? Like what part of this didn’t work? We do know that if you take an oral probiotic, that can affect your
30:10 – gut microbiome. We don’t know if it has a corresponding effect to the vaginal microbiome in the majority of people. Some people,
30:17 – yes, but not necessarily enough to be statistically significant. People have tried to track like the strain that someone took as
30:26 – a probiotic. Could you find it in the gut? Could you find it in the vagina? Could you find it in the bladder? And the answer is yes for the gut. Sometimes for the vagina, but we don’t know if
30:36 – that’s a sampling time point issue, a transfer between those sites,
30:41 – it’s hard to say. Yeah. When we look at a vaginal or topically applied
30:47 – probiotic, we do see that the strain is there temporarily, but
30:54 – not long term. It’s called ingrafting, right. It doesn’t ingraft per se. And there’s a couple of reasons for that. The first is
31:03 – most of the strains that are approved for use in the US are not originally from the vagina. They’re from foods, yogurts and that
31:12 – kind of thing. So, these are not lactose that really wanna be there. But they do potentially help kind of hold the hand of the
31:21 – microbiome as it’s recovering. So, say you’ve taken an antibiotic
31:26 – and it’s just wiped out your vaginal microbiome. You want something to be in there temporarily so that bad bacteria don’t colonize
31:35 – to give your native Lactobacilli a chance to regrow. So, that’s probiotics. Was there anything else in there?
31:45 – There is. But that makes sense what you said about the probiotics based on patient experience, which is that many people
31:50 – say they feel better while they’re using a vaginal probiotic, but then the benefit of it disappears when they stop using it.
31:56 – And so, is there a way to permanently improve the vaginal microbiome or is it a placeholder while your body does what it needs to
32:03 – do and rebuilds it. There’s a couple groups that are trying to do the research on vaginal specific organisms so like Lactobacillus
32:15 – crispatus, Lactobacillus gasseri. There’s a company called Lactam B that’s looking at a crispatus treatment. And there’s a couple of
32:24 – groups that are looking at consortia. So, like a combination of different bugs that would be given as a treatment. But all of
32:32 – that is fairly early stages. They’re still going through like the clinical trials process, which is really hard for like biotherapeutics
32:41 – because it’s a new frontier for the FDA.
32:47 – Yeah. That’s what one of the problems is for patients, too. Just accessing things and wanting to try things but not being
32:55 – able to, wanting to participate in clinical trials too. And so, there’s a lot of interest in the patient community for these types
33:01 – of therapies. Yeah. And that’s exciting. It is exciting. If only there were more trials so more
33:08 – people could join. And yeah, that’s the goal, right. But the other
33:13 – question was you mentioned just in passing that oral antibiotics can decimate the vaginal microbiome. Is that always the case
33:21 – when you take antibiotics or just with some types? Just with some types. The main treatments
33:29 – that have been studied on the vaginal microbiome are clindamycin and metronidazole, both of which preferably you would take topically,
33:38 – but not everyone can. I’m not as sure if you’re taking something like amoxicillin or penicillin, how big of an impact that might
33:47 – have on the vaginal microbiome, but I can imagine that it would to some extent, any antibiotic that you take orally is gonna affect
33:55 – almost every system of your body that has a microbiome. Right. And so, we’ve talked about good bacteria. But some
34:03 – people report having an overgrowth of good bacteria that causes symptoms. Are there known treatment methods for that?
34:11 – Great question. That is a condition called Cytolytic Vaginosis or CV. And it’s an overgrowth of bacteria,
34:19 – potentially a Lactobacillus. So it’s a very understudied condition,
34:25 – but the literature that’s out there shows that if you have too much of lactic acid, that can actually cause irritation to the
34:33 – vaginal lining, which is pain, itchiness, that type of thing. We don’t yet know exactly which organism causes that or what the
34:43 – threshold is for the level of lactic acid or bacteria that you need to have in order to be diagnosed with CV, because the literature
34:50 – just hasn’t been done yet. And it’s really not a common or even
34:55 – accepted diagnosis in the US, more so in the EU.
35:01 – Okay. In the US, it’s very challenging to have anyone even kind of admit that it’s a condition.
35:09 – The papers that have looked at it, there’s a really easy treatment. The first thing is stop any probiotics you’re taking. So, when
35:17 – we talk to doctors, they’re like if I diagnose someone with CV, they’re probably taking way too many probiotics. And if you stop
35:25 – the probiotics, sometimes that’s all you need. And your body will go back into balance and it all goes away. So, there can be too
35:32 – much of a good thing. So, that’s the first thing. If it still doesn’t go away, it’s
35:43 – called a sitz bath – S-I-T-Z. And it’s a sodium bicarbonate water solution
35:50 – that you sit in. And that is just changing your pH. So, it’s just killing off a little bit of your lactic acid bacteria so that
35:58 – the amount goes down and everything kind of goes back into balance. Okay. And are there other strains of probiotics you could
36:07 – use to balance the overgrowth of a good bacteria? No, just stop taking probiotics for a while
36:14 – and see how your symptoms respond. That would be the first step for sure. So, what are antimicrobial peptides and do you think they
36:20 – have a place in the treatment of UTI and bacterial vaginal infection?
36:26 – Great question. Antimicrobial peptides are or AMPs for short, I’ll probably use the acronym, are small compounds
36:34 – that are produced either by the host or by bacteria that you’ve evolved them as a host to kill off certain bacteria. So,
36:44 – it’s an immune function. So, immune function, either that the epithelial cells are producing or that other bacteria like bacteria
36:51 – to bacteria warfare, basically. And there is a ton of different kinds. I am not up to date in all the different varieties but
37:00 – they do show up both in the bladder and vagina very prominently.
37:07 – I am not up to date on how that is being used for treatments.
37:13 – I haven’t really seen as much literature on that, although I know that some people are working on it. I just don’t know the state
37:18 – of that literature. Okay, so what is considered normal for a vaginal pH and is it possible to change it?
37:26 – Yes, it’s very possible to change it. A normal pH is usually less than 4.5, I believe. So, it’s fairly acidic.
37:37 – Like I was mentioning before with CV, if it gets too acidic, you can make it more basic.
37:46 – There’s a whole bunch of different new treatments out there that are using lactic acid as a component
37:54 – of the treatment. So, like a vaginal gel or something like that, with lactic acid built in to try and automatically change the
38:02 – vaginal microbiome and the pH. And can that then change the microbiome or does it just
38:10 – help with symptom relief? Yeah. So the reason lactobacillus produce
38:16 – lactic acid in general in the vagina and why we think we kind of co-evolved together to do that, is that it’s toxic to some
38:25 – of those pathogens. Lactic acid actually kills different bacteria, Lactobacillus love it. But a lot of other bacteria don’t. So,
38:33 – it is that part of the protective effect that lactobacillus actually has. Overall, in your research, have you seen that it’s possible
38:41 – to permanently change the vaginal microbiome to a healthy state?
38:46 – Permanently, no. Yes, you can change it to a healthy state, but things are always going to happen, right?
38:52 – You have sex, during your menstruation, you go through menopause,
38:57 – you are having incredibly stressful time in your life, things are going to shift your microbiome. So, having a protective microbiome
39:05 – will help prevent episodes from happening more frequently. So, if you have recurrent BV and you have a healthy microbiome,
39:13 – maybe you’ll have fewer episodes in a year. But life happens, right? And things happen. We’re just not going to be able to say anything
39:23 – is permanent when it comes to microbiome. Yeah, I think that’s fair. It’s better just to understand that process
39:30 – and work towards a healthy state whenever you can. Exactly. Whenever you can. And then you have
39:37 – the knowledge when something else happened. You’re like, okay, this is my trigger. This is what happened. Now, I’m gonna go work
39:43 – on fixing it. And I think the testing can help with that for a lot of people. And we often get the question like how can a patient advocate
39:50 – for themselves if they are seeking to do a test like an Evvy test or a different kind of test for the urinary microbiome. How
39:57 – can they talk to a doctor about that and have that doctor take it seriously? For the Evvy test, you can just buy it on
40:04 – your own from like the comfort of your own home. You don’t need the doctor to approve it. So, that’s easy. When it comes to bladder
40:15 – test because I don’t know that many on the market right now that are direct-to-consumer. Going through a physician, I would say,
40:23 – Live UTI Free, has a great handout that you can print out and take to the doctor to help explain what the bladder microbiome
40:30 – is and how you’re thinking about recurrent infections and helping you advocate for your own care that way. And I always say this
40:39 – and I know it’s so hard in the US where your doctors are determined
40:44 – by your insurance, but if your doctor doesn’t believe you and you’re being gaslit, just go find another one. There are a lot
40:50 – of doctors out there, and if it doesn’t work for you, there’s
40:55 – no reason to stick with them. Yeah, yeah, it is tough. We can provide some information about clinicians too, if people wanna reach out for that, but
41:03 – yeah, you’re right, It can be hard to change because it can be out of network, or it can just be impossible to pay for someone else. So, it’s a struggle.
41:12 – That is, I 100% recognize that. Yeah. Well, that comes to the end of our list now, of questions.
41:19 – Thank you so much for joining us again to answer them. I’m sure there will be another opportunity in the future with more questions.
41:25 – My pleasure. This was lovely. Thank you so much and I look forward to next time.
41:31 – Thanks so much for watching. If you’d like to learn more about this or related topics, be sure to check out our other videos or head over to the liveutifree.com for articles related to this
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41:49 – Thanks so much for watching. And until next time, keep asking questions and pushing for better solutions.