What your vaginal pH should be—and why it matters
Any woman who has ever watched a celebrity flip her shiny hair in a TV commercial knows how vitally important it is to use a pH-balanced shampoo. No one knows why (I certainly don’t), and I would refer you to your hairdresser for more information. When it comes to the importance of vaginal pH, however, I’m an expert. To have a healthy sex life, a woman has to have a healthy vagina. Making sure your vaginal pH is normal is a key component of your “tool box,” since it is critical to almost every issue that will be discussed going forward—from vaginal dryness to vaginosis to pain in your pelvis.
What Is pH and Why Is It Important to My Vagina?
The term “pH” stands for “potential hydrogen” and is a measure of the acidity of the vaginal environment. (Yes, your vagina is an environment!) Your vaginal ecosystem is predominantly populated with beneficial bacteria called lactobacilli, the so-called good guys, which produce lactic acid and keep your pH in a healthy range. But like most neighborhoods, the vagina houses just enough of the pathogenic (bad) bacteria to potentially cause trouble if allowed to get out of hand.
A low, acidic pH keeps the vagina healthy for a number of reasons:
• Low pH increases antibacterial activity to keep good and bad bacteria in balance and decrease the opportunities for bad bacteria to grow.
• Low pH allows lactobacilli to colonize vaginal tissue, which in turn allows vaginal walls to function as a protective barrier to infection.
• Low pH prevents the growth of the pathogenic bacteria, such as Gardnerella, that cause odor, irritation, and discharge.
Unless something tips the balance, reproductive-age women (after puberty and before menopause) can normally maintain a healthy vaginal pH between 3.5 and 5 on a scale of 0 to 14. The healthy range between 3.5 and 5 indicates that there is an abundance of lactobacilli, a minimum of pathogenic bacteria, and a generally acidic environment. The problems occur when this balance is thrown off.
Triggers That Upset Your pH Balance
A number of triggers can upset the vaginal ecosystem and elevate pH, causing a funky odor, an increase or change in vaginal discharge, or a bacterial infection.
• Menstruation: Blood has a pH of 7.4, so when you menstruate, vaginal pH becomes elevated. Many women who suffer from recurrent infections find that their period is often the event that sets them in motion. This is particularly a problem for the perimenopausal woman, who has the double whammy of fluctuating estrogen levels upsetting her ecosystem along with her periods.
• Intercourse: The pH of semen is 7.1 to 8. That funky “day after intercourse” odor happens not because he has smelly sperm, but because the elevation in pH caused by his semen allowed the pathogenic bacteria to quickly multiply, crowding out the “good guys.”
• Douching and Cleansers: Any vaginal infusion of water or other fluids can affect pH. The pH of water is 7. Fragrances and perfumes can further tip the balance and be irritating to the vagina.
• Medication: Many medications, such as medicated douches, allergy and cold medications, and anti-estrogen chemotherapies, can dry out tissues and sometimes change vaginal pH.
• Antibiotics: Antibiotics are meant to kill pathogenic bacteria. Along the way, they can also kill off beneficial bacteria, allowing yeast and bad bacteria to predominate. Pretty much every woman is familiar with the frustrating cycle of treating a nongynecologic infection, such as a bladder infection or bronchitis, only to then deal with the inevitable vaginal infection.
• Perimenopause and Menopause: Anytime estrogen declines, vaginal pH rises. In fact, it is more useful for me to measure vaginal pH levels than to measure estrogen levels to determine the impact of hormonal fluctuations or decline. Vaginal atrophy is almost always associated with an elevation in pH. Vaginal pH may reach levels of 5.5 to 6.8 or higher in postmenopausal women.
An elevated pH is one indication that lactobacilli levels are low and “bad” bacteria are overpopulating the vagina. While some women with an alteration in the vaginal ecosystem have no symptoms, many have a funky odor and more discharge than usual. At its extreme, the result is bacterial vaginosis.
Bacterial Vaginosis
Bacterial vaginosis (BV), not yeast, is the most common cause of abnormal vaginal discharge, accounting for 40 to 50 percent of cases. While most women assume that any abnormal discharge is a yeast infection, it’s usually not. A number of studies have shown that even if a woman has had a yeast infection before, she is correct in her subsequent self-diagnosis of a yeast infection only 35 percent of the time. The first thing most women do when they get that uncomfortable “something’s happening down there that shouldn’t be” feeling is to run off to the drugstore and buy one of the dozens of anti-yeast medications available over the counter. More times than not, these over-the-counter products do not work—not because they are not good products, but because BV, not yeast, is the culprit. So how do you recognize the difference between yeast and bacterial vaginosis before you spend a month’s salary on the wrong medication?
Tampons
Since menstrual blood is known to increase pH, it makes sense that since tampons are designed to keep menstrual fluids in the vagina, they can further contribute to the problem, if there is a problem.
There’s a Fungus Among Us: The Difference Between Yeast Infections and Bacterial Vaginosis
A vaginal yeast infection is caused by a fungus, usually by Candida albicans. This is a very common fungus, found on the skin or in the gastrointestinal tract. A small amount of the fungus can live in the vagina without causing a problem, but an overgrowth of yeast results in the all-too-familiar cottage-cheese-like discharge and extreme itching. Antibiotics that kill surrounding bacteria frequently allow yeast to flourish, which is why yeast infections often occur after treating another illness.
BV, unlike yeast, does not result from a predominance of a single abnormal fungus but is a result of an overall change in the vaginal environment that eliminates the lactobacilli and allows an overgrowth of many types of less desirable bacteria, the most common being Gardnerella vaginalis. These unwelcome bacteria produce enzymes, which in turn break down vaginal protein, causing an unpleasant discharge and odor.
Unlike yeast infections, which have a thick white appearance, the discharge associated with BV is thin, grayish, and watery. Yeast has no odor, or possibly a slightly yeasty odor. BV has a characteristic fishy odor that gets even more pungent after intercourse, since semen increases pH levels and therefore exacerbates the situation. Condoms minimize BV-related effects, so if you are prone to BV, you may want to use a condom.
Vaginal Discharge: The Perils of Self Diagnosis
For most women, the process of diagnosing BV goes like this:
Step 1: You notice a pungent smell, irritation, and a discharge that wasn’t there before.
Step 2: You then make a midnight run to the corner pharmacy and after a humiliating conversation with the (male) pharmacist, you buy at least three products, usually spending your entire Starbucks budget for the month in the process.
Step 3: You get home and put disgusting cream into your vagina. You repeat for three nights, per directions. For the next few days you wear a panty shield in order to protect your underwear from the yucky medicine constantly coming out of your vagina, including the huge glop that plops out during the important presentation at work the next day. You make multiple excuses to your partner about why you don’t want to have sex.
Step 4: You finally finish the round of medication only to discover that the disgusting odor and irritation haven’t gone away.
Step 5: You call your gynecologist’s office and beg for an appointment. You’re told that the next available appointment is in two weeks.
Step 6: You send the receptionist flowers and beg for an earlier appointment, then get in on a cancellation, which happens to coincide with your weekly meeting with your boss. You tell your boss that you have an infection “down there” and you need to get to the doctor. Horrified, your boss asks for no further information.
Step 7: You take the afternoon off work to get to the doctor’s office, sit in the waiting room, and then finally get in to see the doctor, who tells you that you don’t have a yeast infection—you have BV, and you need to take an entirely different medication to make it go away.
Step 8: Relieved but frustrated, you go to the pharmacy, where you spend next month’s Starbucks budget on a new medication. You get to choose between another disgusting vaginal cream that will plop out of your vagina or an oral medication that will require canceling all your social plans for the next week since you can’t drink alcohol and you don’t want everyone to think you’re pregnant when you abstain. But finally, finally, in a few days you feel some relief.
What is the average time spent before getting a correct diagnosis of BV? At least two weeks. Average cost in time, money, and frustration? Way too high.
Vaginal Discharge: How Your Doc Checks It Out
As maddening as this process is, you really need to get an accurate diagnosis, especially if you have never had BV before. So how does your doctor make the diagnosis when you finally get your appointment?
He or she will put a speculum in, just like for a Pap test, and then use a swab to collect a sample of the discharge. If there is a suspicion of BV based on appearance and odor, some doctors simply check pH and look at the discharge under the microscope.
While this is not the most accurate way to make the diagnosis (other things can alter pH, and sometimes someone has more than one kind of infection), it is the least expensive and also generally the quickest way to figure out what is going on. Many doctors do not keep a microscope in the office and therefore rely on other tests that are more accurate but also more expensive. The most thorough way to determine if the culprit is indeed BV is to test the discharge for the presence of the DNA of Gardnerella vaginalis. While 95 percent accurate, (especially if combined with a measure of pH), these DNA probes are expensive and take anywhere from 12 to 72 hours to get a result.
Another approach your doctor may use is to test pH and the by-products of Gardnerella with one of the rapid-test office kits. These tests, while quick and less expensive, are not as accurate as the DNA tests—usually they have an 85 percent accuracy rate. If one of these tests comes back negative, you might want to go for another test if you are very concerned that you have BV.
What About Home Tests?
You can buy a kit (which is very expensive) at the drugstore that is supposed to determine if you have a yeast infection or a bacterial infection. This kit is nothing more than a pH test. They are most useful if your pH tests in the normal range, as this is a reasonable indication that your itching and discharge is the result of a yeast infection. An elevation in pH could mean BV, but it could also be atrophic vaginitis, the presence of menstrual blood, another infection like trichomonas, or semen. Save your money and go to your doctor instead.
Make It Go Away!
Once you have a diagnosis, the goal is to get rid of the discharge and odor ASAP.
In the United States, BV is treated with oral or vaginal metronidazole, clindamycin, or tinidazole. Each of these antibiotic products requires a prescription.
Being Proactive and Taking Care of Your Vaginal Health
The good news is that BV is treatable and pretty much any of the previously mentioned medications will make it go away. The bad news is that it comes back 30 to 50 percent of the time and most women who have had BV don’t need a trip to the doctor to know they have it again. With such a high recurrence rate, it makes sense for women to be proactive and take steps (described below) to maintain a normal pH and let the lactobacilli do the work to prevent the overgrowth of bacteria instead of relying on recurrent courses of antibiotics to kill the offending bacteria once they have established residency.
Some women, in spite of doing everything right, still have a high recurrence rate. It’s crucial to make sure there is nothing else going on. I had one patient who was treating her “BV” for months and finally at my insistence reluctantly came to the office to see what was causing her persistent vaginal odor and discharge. She was mortified when I pulled out a tampon she had forgotten from her last period—seven months earlier.
If you continue to have recurrent BV despite maintaining a normal pH and avoiding triggers, a more intense antibiotic regimen is in order, such as a prolonged course of oral metronidazole or tinidazole followed by twice-weekly applications of metronidazole gel for three to six months.
Not surprisingly, this long-term antibiotic approach can result in increased yeast infections. So unfair.
When women complain about a smell down there, I ask whether it smells like fish or smells like the zoo. If it smells like fish, more often than not it is bacterial vaginosis; if it smells like a zoo, the cause is usually a tampon that they forgot to remove.
Do You Even Need to Treat It?
Bacterial vaginosis will spontaneously resolve in up to one-third of women if the lactobacilli are able to charge in, take control, and give off lots of lactic acid so that the pH corrects itself. This is less likely to occur in a menopausal woman, however, because her baseline pH is well above the normal range.
The Consequences of BV Go Way Beyond a Smelly Discharge
It’s not just about an irritating discharge. Women with BV are at risk for many more serious medical conditions, including preterm delivery, post-hysterectomy infection, and an increased tendency to acquire sexually transmitted infections such as gonorrhea and chlamydia. They also have an increased risk of pelvic inflammatory disease and subsequent infertility.
When BV-Like Symptoms Are Not BV
Occasionally a patient will complain of odor and irritating discharge but the tests for BV are negative. Sometimes the unpleasant smell and “discharge” are not even coming from the vagina. Incontinence (involuntary loss of urine) affects up to 30 percent of women. Urine on the outside of the vagina is extremely irritating. Urine on underwear is eventually going to smell. Sometimes it’s hard to tell the difference.
In some cases the pH is “off” just enough to cause an odor without having full-blown BV. A course of Rephresh, an over-the-counter pH-regulating vaginal gel, often will correct the problem. In other situations, however, women are suffering from a more complicated condition known as atrophic vaginitis.
At first glance, atrophic vaginitis and BV seem to be the same thing. Both are associated with an elevation in pH. Both have an irritating discharge. The difference is that you can develop BV if you have normal estrogen levels. In fact, most BV is in young women, not menopausal women. Vaginal atrophy, on the other hand, is a direct result of low estrogen levels, which most typically is a result of the ovaries winding down during perimenopause or after menopause.
Atrophic vaginitis refers to a condition of low vaginal estrogen levels along with symptoms such as vaginal dryness, burning, itching, discharge, and bleeding. In addition, women with atrophic vaginitis have thin and inflamed vaginal tissue that not only bleeds easily but, yes, tears easily. Even a Pap test can cause bleeding and pain. It is no surprise, then, that intercourse for these women can truly be a nightmare. If that wasn’t bad enough, women with vaginal atrophy are also at increased risk for recurrent urinary tract infections, urinary frequency and/or discomfort urinating even in the absence of an infection, yeast infections, and bacterial vaginosis. The treatment for atrophic vaginitis is vaginal estrogen (see chapter 13), which decreases the pH, thickens the vaginal tissues, and eliminates these symptoms. The vaginal moisturizer Replens is an option for women who prefer not to take estrogen.
Maintaining the Balance
Preventing recurring infections is always better than treating recurrent infections, and many women who suffer from recurrent BV infections find that their period or intercourse is the event that sets them in motion time after time. Some women ask how something as natural and normal as menstruation or intercourse can cause such a problem. Aren’t women intended to have periods and sex? The answer is that, while most women’s bodies can tolerate periods of pH elevation, in some women even a slight imbalance can tip the scales. In addition, women were never meant to have so many menstrual periods.
Biologically, women are supposed to be pregnant and/or nursing during their reproductive years. Today the average woman has two or three pregnancies, may start menstruating as young as eight or nine, and keeps on going until the early fifties. Modern women have on average 450 to 500 periods in a lifetime, as opposed to the 50 periods that our prehistoric ancestors experienced. No wonder our vaginas are exhausted! So no, I am not going to suggest that you stop having sex. I’m not going to suggest that menstruating women stop using tampons. (I consider tampons to be one of the top ten most important inventions of the twentieth century, right up there with sliced bread.) Luckily, there are a number of more practical strategies to maintain normal pH.
Don’t Douche!
While douching is an incredibly tempting “quick fix,” it will only freshen things up for about ten seconds and then inevitably make things worse. Not only does douching elevate the pH, it also dries out the tissues and washes away whatever lactobacilli you have. Scented douches can irritate things even more. In addition, douching is associated with an increase in pelvic inflammatory disease and subsequent infertility.
Consider Using Estrogen Therapy
In post-menopausal women, persistent odor and irritation, more often than not, is from vaginal atrophy, pH imbalance, or vaginal infections that will be corrected with systemic or local estrogen therapy. (See chapters 13 and 14 for more information.)
Avoid Menstruating
If, you are using hormonal contraception, such as a low-dose birth control pill, you can avoid the whole change in pH caused by menstrual blood by avoiding menstruation. That’s right! Take your pill straight through the placebo days and skip having your period. And yes, this is safe. As discussed in chapter 9, skipping menstruation is a common treatment for endometriosis.
Vaginal Products for Normal pH
In addition to behavioral choices, there are a number of products available to restore and maintain normal pH.
• RePhresh is the over-the-counter vaginal gel that restores normal pH. It can be used every three or four days. In Europe it is actually approved to treat BV.
• RePlens is intended to be used as a long-acting vaginal moisturizer (see chapter 5), but like its sister product Rephresh, it also maintains a normal pH. Replens is a good alternative for women who are reluctant to use estrogen.
• A daily oral probiotic containing lactobacillus has been clinically shown to help maintain the normal amount of vaginal lactobacilli. Pro B, for example, contains two probiotic lactobacilli strains called Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14. These unique strains can naturally balance yeast and bacteria to maintain good vaginal health.
How Is Your Healthy pH Balance Relevant to Sex?
At the risk of stating the obvious, an imbalance in pH—whether it is due to vaginal atrophy, BV, or both—is pretty much going to sabotage your sex life. Here’s why:
• Vaginal walls that are inflamed are not going to lubricate properly, making intercourse extremely uncomfortable.
• Unpleasant odor and discharge are not particularly conducive to feeling sexy or encouraging intimacy.
• Intercourse will generally result in even more discharge, inflammation, and odor.
Dr. Streicher’s SexAbility Survey
When asked if they avoided receiving oral sex because they thought their vagina might smell or taste bad,
27.0 percent of women said yes
73.0 percent said no
Interestingly, nearly the same percentage of men avoided giving oral sex because of their partner’s unpleasant vaginal odor or taste.
29.9 percent of men said yes
70.1 percent said no
The one thing that yeast infection, BV, and atrophic vaginitis all have in common is an alteration in the normal vaginal environment. Keep your pH normal and your vagina will thank you.
Myths
Myth: Wearing tight, wet bathing suits increases the risk of vaginal infections.
Truth: Wearing tight, wet bathing suits does not cause vaginal infections.
Myth: A probiotic intended for colon health also works for the vagina.
Truth: A probiotic can help keep healthy balance of good and bad bacteria in your vagina, but you need to take a vaginal, not a colon, probiotic, such as Pro B.
Myth: Putting yogurt in your vagina is a good way to treat a yeast infection.
Truth: I happen to be a big fan of yogurt and eat it almost every day for breakfast. It is a great way to keep your weight in balance, but not your vagina. Eat it if you like it. Do not put it in your vagina.
Myth: Thong underwear increases vaginal infections.
Truth: Never!
Myth: BV and yeast infections are sexually transmitted infections.
Truth: While not sexually transmitted, they are sexually associated since intercourse can alter pH and increase susceptibility.
Myth: You can’t have both BV and a yeast infection at the same time.
Truth: It’s actually not uncommon to have both, since some of the same triggers that cause the lactobacilli to diminish also cause yeast to flourish. If you have both, you need to treat both.