Georgie Kovacs, founder of Fempower Health, interviews Suzanne Munson. She is the VP of Product Development and Compliance at Fairhaven Health.
Georgie: thanks for being here.
Suzanne: thanks for all the work you’re doing to promote women’s health!
Georgie: unfortunately, women aren’t taught much about their bodies. We often encounter pain and then just “suck it up.” I want to dispel some of those myths. Let’s talk about the basics of having a healthy vagina, so we can understand a normal (even a “personalized normal”) and what that should be like.
Suzanne: looking at medical textbooks and information about reproductive health, we know that a healthy vagina will be at pH 4 and have healthy bacteria present. These are hard to objectively measure at home. Not many of us have pH strips readily available. It’s often easier to identify an unhealthy vagina: painful intercourse, itchiness, odor, that can all indicate that your vagina is suboptimal. We’re more easily able to identify when things are not healthy.
Georgie: can you buy pH measuring strips to measure that in your vagina?
Suzanne: you can get them online, pretty much anywhere. They’re also pretty accurate. They become useful if you suspect there’s a problem. If you are working on improving your vaginal health you can see how it might improve over time.
Georgie: lubrication and healthy bacteria are also important for the vagina health. What should a properly lubricated vagina be like?
Suzanne: when vaginal health is compromised, women can experience pain or end up with recurrent yeast or bacterial infections. All of that can impact proper lubrication or how much lubrication is present. If we back up and look at how the vagina works to maintain equilibrium or overall state of health, you get a picture that it’s an intricate and beautifully designed system. The vagina has mechanisms for maintaining its own health. That involves a really close connection between vaginal pH and the vaginal microbiome. Microbiome being the collection of bacteria that are present in the vagina.
A healthy vagina has a pH of about 4 and plentiful bacteria. Friendly bacteria produce lactic acid, which keeps the pH low. Bacteria thrive when the pH is low. There is a sort of circle of good vaginal health. If there are any intervening circumstances that impacts the pH or bacteria, things get out of balance very quickly.
There are a few things that disrupt your vaginal health: semen has a pH of 7, during your fertile window your pH may raise temporarily, etc. Your body typically can lower it naturally. However, if the pH stays elevated it impacts the viability of that healthy bacteria.
In addition to keeping the pH low in the bacteria, they also function as a vaginal mucosal armor. You can see how it quickly becomes a vicious cycle if any important aspects are out of balance. This is why so many women “grin and bear it” all of the time. They’re dealing with odor that they don’t want, itching and irritation, not enough lubrication during sex which causes pain. As women age and vaginal dryness becomes more regular, these health issues impact your quality of life.
Georgie: there are probably things that you can do to help keep the system properly balanced and things that throw the system out of balance. Let’s talk first about the things we shouldn’t do: the things that negatively impact a woman’s vaginal health.
Suzanne: in survey research, we’ve found that women deal with these symptoms regularly. For instance, vaginal odor. These are odors that are not related to a specific diagnosable infection. The presence of these regular but unpleasant odors impact a woman’s quality of life. It changes the clothes a woman wears, the activity they participate in and the amount of sex that they have. They are embarrassing to women to the degree that they alter their lifestyle.
Women go to drastic measures to take control of these things. This is where the conversation about douching becomes important. This is advertised as a way to clean the vagina. When it’s working properly, the vagina maintains homeostasis without help. These products can end up doing more harm than good. Extensive washing washes out the good and the bad. You’re getting rid of the good bacteria and disrupting the vaginal mucosal armor that is there for the purpose of vaginal cleaning and protection. You’re leaving your body defenseless when you wash all of that out.
Georgie: so, it sounds like douching is not the best idea. So, what can someone do to solve for the unbalanced or improperly balanced vagina and help with odors and other symptoms?
Suzanne: sure. To drive the point home about douching: the National Institutes of Health warns women against douching because of an increased risk of cancer, infection and infertility. Women who douche have higher rates of STDs and things like cancer. It’s not a trivial matter. It’s a really big health consideration.
What women can do is support keeping your vagina in a healthy pH range and support the amount of healthy bacteria that is present. A couple of things I recommend: take a daily probiotic supplement that has lactobacillus and bifidobacteria. Fairhaven Health has a product called IsoFresh Vaginal Gel, which you insert and contains lactic acid. It’s bioadhesive so it stays put to help keep the vagina in a good range to support the health of flourishing bacteria.
Georgie: for the probiotic, I assume you mean taking it orally rather than vaginally?
Suzanne: there has been research about whether you can take a probiotic supplement and have it reach the vagina to make a difference. There are regulatory issues about recommending the use of a probiotic in the vagina. If you go on the internet, you’ll find any number of articles on how to insert your probiotic vaginally. I’m not in a position to recommend doing that. I’m also convinced that the research is sound enough in this area to suggest that taking an oral probiotic can have the benefit of replenishing the bacteria even in the vagina. Probiotics will be excreted through the feces which can make it into the vaginal canal.
Georgie: that’s helpful: I’ve heard it recommended to take vaginally but that makes sense as to why directions for that would not be present on a label.
Suzanne: if you see that, it could be a sign that the company isn't aware of the restrictions to make that recommendation. That claim may make me suspicious of the company’s motivations.
Georgie: as far as taking probiotics, I’ve done interviews with experts in gut health and we’re still better understanding the gut microbiome. Some say that taking the wrong probiotic or taking a probiotic when you don’t need it is not helpful. What are your thoughts on that and how would someone know “in my case, I should/shouldn’t take one daily?”
Suzanne: it’s an interesting conversation and there is much to learn. My reaction as a nutritionist is that most people are not to the point of having such a fine-tuned system that doing something healthy would hurt them.
Here’s a similar example: I see people say on the internet that they don’t like the “fad” around eating more kale. My response to that if someone is being criticized for eating kale, we've missed the point entirely. Encouraging people to eat more kale is not going to hurt anything.
From a big picture perspective, more people can benefit from more lactobacillus and bifidobacteria for vaginal health. For most people, we aren’t in the place where we need to be worried about an excess of those things.
Georgie: let’s talk about lubrication. I’ve read data that 20-25% may have painful intercourse and don’t seek help. I really want to spend time better understanding lubrication: what is normal? What isn’t normal? If it isn’t normal, what’s wrong?
What drives having a properly lubricated vagina?
Suzanne: a quick and easy way to describe how the body works when it comes to lubrication is that it is driven by the hormone estrogen. When estrogen surges, like when you’re about to ovulate, cervical fluid is produced. That’s why women see an increase in cervical fluid around ovulation. If they don’t, it could be a sign that something’s wrong with their estrogen levels. Anything that impacts estrogen could contribute to vaginal dryness: chemotherapy, having your ovaries removed, fertility treatments and menopause.
Estrogen also plays a key role in maintaining a healthy vaginal ecosystem as it promotes the production of glycogen in the vaginal cells. That’s a key source of fuel for healthy bacteria, which ties back into our previous conversation about the connection between pH and friendly bacteria. When estrogen is present, glycogen is being produced which serves as a source of fuel for the healthy bacteria. When estrogen declines, there’s less glycogen for the healthy bacteria to feed on and it starts an imbalanced cycle.
It all works together. If women are experiencing hormone imbalances, it sets the stage for poor vaginal health and poor lubrication. Anything we can do to ensure that women have the right amount of estrogen at the right time, the better this all works together.
Georgie: if someone is on fertility meds or has chemotherapy, those people would need lubrication. If someone is stressed, that could impact it. There are also so many women now tracking their cycles. 10 years ago, it was a piece of paper and I would estimate ovulation. For those who are just measuring cervical fluid, given that if your estrogen levels aren’t in the right place, you may not be producing it and that’s an important sign.
Let’s talk about monitoring, predicting ovulation: tools, signs, etc. What should women do?
Suzanne: there could be many reasons why a woman’s hormone levels aren’t where they need to be. I would definitely recommend that they see a doctor. But I also wish every woman had the synopsis of all of the working components of health. Like you mentioned, if they aren’t seeing cervical fluid when they’re ovulating that could be a sign of numerous health issues, including whether or not they can conceive. It protects the sperm as it makes its way through the reproductive tract to meet the egg. If you lack cervical fluid during your fertile window, you may have an issue with hormone levels, it can make intercourse painful, and can mean that the semen and sperm aren’t well-protected. That is the framework for the discussion I would want women to have with their doctors.
Georgie: there are many options for lubricants. If a woman is having challenges, what’s important to consider?
Suzanne: there are three reasons a woman would want to use lubricants. One is pleasure during intercourse. Intimate lubricants may make the experience more pleasurable for some couples. Other times, couples are trying to conceive and want to use a fertility-friendly lubricant. The third is daily moisturization. Most pre-menopausal women (unless they’ve experienced chemotherapy or are taking a fertility med) won’t need this.
There are two big categories of lubricants: water-based and silicone lubricants. Each has their advantages. Water-based tend to be more gentle and produce less irritation. They dry up more quickly, so you may have to apply it more frequently during intercourse. For fertility specifically and as we age, I would almost always recommend a water-based lubricant. I’ve never seen a silicone fertility-friendly lubricant.
Then you will want to consider: what is being used to preserve the lubricant? Parabens are often used. These have been linked to reproductive health problems in both men and women. Paraben-free lubricants are key to supporting your reproductive health.
Another item is glycerol or glycerine. Glycerol is often used in lubricants and is suspected of harming the friendly bacteria. My recommendation is to choose one that doesn’t contain this.
Related to that is natural oils. It’s tempting to use a natural oil as an intimate lubricant or for daily moisturization. I mean coconut oil, olive oil, any natural oil. We have these around and think they’re natural. I get concerned when women use these repeatedly is that they are heavy and coat the vaginal lining. They are not easy to wash out. That has a way of impacting the vaginal armor and impacting the friendly bacteria. Then we start a cycle again of not having enough lubrication. With natural oils, there can also be some rancidity issues if they’ve been sitting out or exposed to air or light. You may end up introducing an oil into the vagina that has toxic chemicals present.
Georgie: I do know that some folks have tried oils. Even on TV you see things like that happen.
Suzanne: sure, once in a while but not an everytime lubricant.
Georgie: we spoke earlier around the cervical fluid having an egg white quality to protect the sperm. Do you find that an additional lubricant, especially one that is fertility-friendly, is helpful to have regardless of how great your cervical fluid is?
Suzanne: no product will claim to improve your chances of conceiving. The purpose of this product is to do no harm. Our Baby Dance lubricant is recommended to couples who are trying to conceive. Whether the lack or quality of cervical fluid is an issue, we want to be sure that they use a lubricant that has been verified to not harm sperm or eggs. So, we frame the conversation around not choosing one that will negatively impact pH, harm sperm or eggs or have other poor implications for your reproductive health.
Georgie: in regards to choosing a lubricant, we know that the front of the package is the marketing and the back of the package is the information. Can you help us understand how we pick ones that are in compliance with regulations and approvals? How do we cut through the clutter of the claims to understand the truth?
Suzanne: this is an important thing to understand. Any intimate lubricant that’s sold in the U.S. is considered a medical device, which makes it a Class 2 Medical Device. This is one step up from Class 1, which is considered to be the lowest risk. The FDA pays very close attention to products that are marketed as lubricants.
Fertility lubricants fall into a special class.
The problem is that manufacturers of lubricants are not allowed to say (per FDA regulations) anything on the package that says “FDA cleared.” Even though there’s an involved process about developing products that make fertility claims, including submissions of testing to the FDA, making the actual claims is also subject to strict standards. Because of the world we live in, people will sometimes say that their product can be used for fertility, even though there are only four products total in the U.S. that have been cleared for that purpose. It’s a little frustrating, being from a company that’s doing it the right way, what happens in the market. It’s confusing to customers and it’s not their fault.
The challenge I give to customers is to use what you know about your health and what you know about fertility and pull things together.
A lubricant that’s pH 7 is probably the healthiest for fertility because it’s pH matched to the fluids that are happening when you’re fertile. At most times in your cycle, you want your vaginal pH to be around 4, except when you’re ovulating. At the time of ovulation, you want the fluids in your body to be at pH 7 because that is matched to semen and sperm. If you have too low of a pH when sperm is trying to make its way to the egg, that sperm won’t do well.
Look for a water-based lubricant. That is easy to tell from the packaging.
Another marker of a healthy lubricant is the word “isotonic.” That describes that the product itself matches the salt concentration of your body fluid. This means there will be no pulling of water or pushing of water from or into your tissues. It will maintain the water equilibrium inside and outside the cells. Products that are hypertonic will pull water from the cells and dehydrate them.
To summarize, look for water-based, pH 7 and isotonic. Focus on paraben-free products. Choose a lubricant that doesn’t have glycerol or glycerine in it. Those are the five things I would challenge consumers to look for when they want a fertility supportive lubricant.
Georgie: let’s get to menopause. This is an interesting state in a woman’s life: we don’t know much about it and every woman presents differently. Talk a little bit about what happens to a woman’s body as she ages and how lubrication can help.
Suzanne: estrogen is the key. It’s almost as simple as that, although everything is more complex than one statement. As our estrogen levels decline over time, we see a decline in our natural lubrication. That leads to a huge majority of menopausal women complaining of vaginal dryness, not just during intercourse. This is a daily vaginal dryness. The lack of moisturization highlights other irritating symptoms like itching, odor, burning and other discharge. The decline in estrogen starts a cascade of vaginal health problems that are really impactful to menopausal women.
Georgie: what should women have in their toolkit to help them?
Suzanne: this is why hormone replacement therapy can be an important tool: it can help replenish those estrogen levels. There is some good research about phytoestrogens, which are more natural approaches to supporting women’s health. In the absence of hormone replacement therapy or being able to replenish estrogen in some other way, you can use products that alleviate symptoms.
Water-based lubricants with lactic acid can support healthy pH and allow friendly bacteria to grow.
Georgie: I know that Fairhaven Health developed a product specifically for menopausal women called Sage. With using something like Sage, do women mainly use it during intercourse? Is it a daily application?
Suzanne: our Sage product is both a lubricant for intercourse and a daily moisturizer for temporary relief of vaginal dryness. We know that at this age it’s not just lubrication during intercourse to make it less painful. Women want something every day to take away the burning, irritation and dryness. Our Sage lubricant is pH 5. One of the interesting things about menopause is that there is a belief that the healthy pH is not exactly 4 anymore. For some reason, as we age, the healthy pH range goes up a little bit. We’ve targeted our product to be higher than the pH 4.
This product also has no parabens, no glycerol and no hormones.
Georgie: is there anything else based on women’s experiences - is there anything specific in regulations for the products that support women during menopause?
Suzanne: there aren’t any specific regulations related to products for menopause. It’s grouped in with other lubricants. I think we will start talking more about specific needs for menopausal women and creating a framework that shows that this is a unique season of life and requires a special set of specifications and considerations.
Georgie: it really is great to see. I’ve been following women’s health extremely closely for 10 years. I’m starting to see now that menopause is considered much more part of the conversation. There is more research needed but I see the path leading in that direction.
Share a little bit about anything that women who are in menopause are talking about when it comes to using a product like Sage. We just don’t know a lot about menopause. Some people think that one day your body just clicks and you’re in menopause. From the lubrication perspective and general insights, what should women know?
Suzanne: I’d like to give a shout out to the baby boomers here. As they reached menopause and having uncomfortable symptoms, they started demanding solutions. This has caused a revolution in the conversation about vaginal health. Often, women’s complaints are discounted or trivialized (or even doubted). Over the last 10 years, because women have started demanding solutions, more solutions are being provided.
Last year I was at a meeting of OB/GYNs and when I looked around, almost every single exhibitor was showcasing products for menopause. This is something very new! We owe it a lot to the women who have been aging into menopause with a different attitude and expectations around their quality of life. We owe them a debt of gratitude in that it has pushed medical professionals and people in healthcare to look at this in a new way and help provide solutions.
Georgie: I was chuckling because, seeing a room full of companies who are now providing support and products for women who are facing menopause is great but there is also a lag in knowledge and understanding of those options. You did a good job today of educating us around how women’s bodies work and how lubrication helps. This empowers us to make decisions based on information and not just marketing.
What are the key takeaways for people who have listened in today?
Suzanne: it bothers me to hear that women make choices about how they live their lives based on suboptimal vaginal health. I’d love everyone to leave this feeling empowered: don’t ignore your symptoms. Don’t just grin and bear it. There are ways to address vaginal health and restore it to a place where you feel good. You don’t have to alter your lifestyle because of it.
Georgie: thank you for your time. I really appreciate the knowledge that you’re willing to share with a broader group. We're going to keep putting these messages out there and make sure that women are educated and do right by themselves. Thank you to all of the clinicians out there who are supporting women in these struggles.