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24 Sep 2017


By Gracie Carroll

My Q&A with Dr. Marla Shapiro On Understanding Your Vaginal Ecosystem

By Gracie Carroll

Why are women so damn shy about talking about their vaginas? This is the first question that struck me, and the first question I asked Dr. Marla Shapiro when I had the opportunity to sit down and interview her one-on-one about vaginal health thanks to a product called RepHresh.

Does it have to do with age? Is today’s younger, ‘woke’ and hyper-feminist generation more comfortable talking about their vaginas? Or are they showing up in a Feminist tee they bought online and still whispering to their doctor about their most intimate questions and concerns? According to Dr. Shapiro, it’s, unfortunately, still very much a ‘taboo’ topic, in every age group.

It’s not just in older women — we think that they’re not willing to talk about vaginal dryness — (but) younger women are not necessarily able to talk about their vaginal health,” she says.

“(Women are) not only shy talking about (vaginas) in general but they’re even shy to bring it up to their physician, or asking where to go and get advice; women understanding and talking about their vagina’s natural odours and things that are concerning, or not concerning, is something that women often don’t have any education about. (They) have no concept about vaginal health and what the vagina is all about.”

You might be wondering what compelled me to take part in an interview all about vaginas, and the answer is quite simple. It bothers me that it’s considered ‘taboo’ for women to talk about their vaginas, even to each other. It feels like every week either my boyfriend or bro-iest friends are sharing the latest and most ridiculous story about the change room shenanigans that relate to a teammate or dude’s butt, balls or penis. Personally, I can’t recall even one change room encounter in my entire life where another woman has commented on, or even joked about, tits, ass or vaginas with me.

Joking aside, there is some merit to how much more comfortable men are when it comes to talking about their genitalia with each other. A few years ago an old friend of mine discovered he had cancer after he asked our mutual BFF if he ever felt pain or experienced swelling in one of his testicles. It was that frank and open conversation that helped get him in front of a doctor, and possibly even helped save his life.

So why are women afraid of speaking about their vaginas so candidly? I will admit that even in my circle of alpha-female friends, it’s not something that we talk openly about very often, but I would love to see that change.

Because I too know that speaking openly about your vagina can (still) be a little uncomfortable, and that turning to Dr. Google can be scary as hell (my advice: don’t do it), I wanted to ask Dr. Shapiro for tips on talking to each other more openly, about some of the nitty gritty questions we all have, what the heck is a probiotic for your vagina (and why do we need it), and everything we need to know about the ‘Ecosystem of the Vagina’ as she calls it. See below for the highlights from our Q&A!

GC: What are some of the ways that you would suggest to make talking about or bringing up vaginal health — even just among your friends — more open and more comfortable?

MS: I think that the concept of women being intimate with each other, and having a conversation with each other, has to do with their comfort level. So, it’s a very difficult topic to broach, even in the comfort of my office — which women will see as a safe place. Women will come in if they think they’ve got an infection, that will drive them in, but, if they’ve got an irritation, or if they got their own particular odour that they’re not necessarily sure if it’s something wrong — I don’t know if they’re turning to each other and have that comfort level (to talk about it). They may feel more comfortable talking about sex, about their menstrual cycles, about period cramps, but this still remains this issue of ‘Vagina Shaming”. We want to be sensitive to women to be able to make them feel comfortable to be able to have this conversation (with each other).

I’m always saying in the office, the only dumb question is the question you don’t ask, that’s the dumb question! The one that you’re too embarrassed to ask or the one that you feel uncomfortable asking, or the one that you think I’m going to laugh at. I’m not going to laugh at anything.

It has nothing to do with being a feminist or not being a feminist, it has to do with the fact that this is your body, and the best indicator of if something is not right, is you. So, if someone doesn’t ask you, it’s not that it’s not important, they’re just not asking you. We want women to be empowered when it comes to their breast health and when it comes to their vaginal health, this is part of your body that you need to be familiar and comfortable with.

GC: When it comes to vaginal odour, how do you know what’s a good smell vs a bad smell? At what point should you visit a doctor?

MS: Every woman has their own unique scent, and I think you get familiar with what your own scent is; women, first of all, are often surprised to know that they have a scent. (As an example) If you have a pool, and you watch your pool, you’re very conscious about what the pH is in your pool because if it’s too alkaline or too acid, things can happen in your pool. Well, your vagina is the same type of ecosystem that has a very narrow range of pH, of what keeps things in balance. So, if you think of your vagina as an ecosystem — which it is! — there’s healthy bacteria — there’s healthy Lactobacillaceae — and things are kept in balance.

When you’re in balance, it’s within a pH range of about 3.5 to 4.5 and that has a scent associated with it, and that’s normal. That’s your scent, and there’s nothing to be done about that at all. But, if a woman notices a change in her scent, or a change in symptoms — there may be a change in discharge or itching — often there’s the assumption that there must be a disease process that’s going along with it. Often there’s no disease process per say (meaning an infection) but the pH can be out of balance, and it’s that pH that balances that ecosystem.

So if you take it to extremes, if things get too alkaline, for example, and yeast overtakes — which normally live in your vagina — then you can get a yeast infection. If the bacteria overtake, you can get bacterial vaginosis, which means there’s an overgrowth of the bad bacteria, and that gives a particular ‘fish odour’. Those are things that generally require treatment and women become quite symptomatic, but, often don’t even necessarily require medication.

GC: Can you tell me more about what it means to balance the pH of your vagina?

MS: You can balance the pH in your ecosystem — meaning your ‘vaginal vault’ — by giving it the appropriate Lactobacillaceae, and making sure the Lactobacillaceae keep things in check. There’s a very narrow balance; women will come in and see me because they think they have an infection, but in fact it may be because (their) pH is changing. pH can change because of hormones, the use of spermicides, sex, and diet. By balancing your pH, it may make a big difference in terms of what you notice. The whole concept of balancing your pH is by using something that will keep you in the 3.5 to 4.5 range — that’s what keeps things in check, and that’s what keeps things in balance.

It’s interesting, that if you look at the science and the medical literature, that even if you do have Bacterial Vaginosis, by balancing the pH (as opposed to using a medication,) often that will treat the Bacterial Vaginosis itself. For many of my women who notice that this is a recurring problem, we’ll talk about balancing their pH, and one of the ways you can do it is by using something that will balance the pH locally.

GC: What’s the role of a pH Balancing Gel and Probiotic for your vagina?

MS: The concept of a balancing gel (such as the RepHresh pH Balancing Gel), is that it adheres to the wall, and therefore keeps the pH in range, and will do it for up to 80 hours. So, for many women who notice that things are changing, by using something that maintains their pH, they in fact can maintain their “ecosystem” and often it just resolves the issue.

Probiotics are important not only in your intestinal health, but probiotics (like the RepHresh Pro-B Probiotic) are important in your vaginal health as well. We know that when you look at the Lactobacillaceae, they’re the moderators and they’re what keep the good bacteria and the bad bacteria in check, making sure that there’s not an overgrowth of yeast. I tell my patients to think of a probiotic for balancing and preventing recurrence. So for patients who have reoccurring issues, it may not be enough to just keep the pH in check locally, but to take an oral probiotic that will specifically work on the Lactobacillaceae in the vagina.


GC: What should women know about the “Ecosystem of the Vagina”, as you call it?

We’re so ecologically oriented, we think about the rain forest and the ecosystem, and how important it is, well, we have an ecosystem too. Our entire body is an ecosystem, and understanding how to balance your ecosystem, particularly if it’s a vaginal issue — and not even just if it’s a vaginal issue, just if there’s an odour or an itch that’s not abnormal — you can alter that by making sure that your pH is in check. It’s so interesting that everybody knows about their pool pH, but ask a woman about her own personal vaginal pH and they look at you like, ‘what are you talking about?’. pH is a really important concept and very important for women to understand in terms of your body.

There’s such a wealth of information that’s out there in terms of, what I call the “ecosystem of the vagina” and how to maintain the ecosystem of your vagina. Women are often wanting to do something that’s natural, or wanting to do something that doesn’t necessarily require medication, and then you’ll have an extreme where it’s not enough and someone has something that absolutely needs to be treated. But in women who often need to be treated because they have Bacterial Vaginosis, I’ll speak to them about what they can do about preventing this in the future.

I tend to think of maintaining your pH as a preventive strategy and looking at a probiotic if someone has a recurrent issue. We don’t all need probiotics, some of us have guts that work perfectly and we don’t use probiotics, other people do. For example, if you’re taking an anti-biotic, how many people complain about getting yeast infections after an anti-biotic? So by being pro-active at the same time in using a probiotic or using something that’s going to maintain the pH in your vagina, that often can prevent the secondary issues. So, you’re taking an antibiotic because you’ve got a chest infection, but you end up with a vaginal itch, that’s not fun. So, it’s about understanding how to maintain your vaginal ecosystem — which I think is a great word for women to understand.

GC: If a woman wants to know more about her vaginal pH, and if her overall vaginal health is in check, would you suggest going to see a doctor first?

MS: I often tell my patients that if you’re not feeling that there is an issue, then there is no issue! If you feel that things are a little bit off, there’s no harm in trying a product that will balance your pH between 3.5 to 4.5, and see how you feel. There’s no downside (to using the product); if your pH is in range and you use something to maintain the pH it’s going to maintain the pH, if your pH is not in range and you use something that’s going to keep it in that pH range, then it’s going to get it in that pH range.

I think that women will sometimes feel a little uncomfortable reaching for an over-the-counter product without having the conversation with a health care provider first, but, understanding what it is that you’re doing empowers you to feel not so uncomfortable. Or, have the conversation with your health care provider and then understand what it is that we’re talking about

GC: How long should someone wait before seeing a doctor about an itch, a smell or anything else of concern?

MS: You’ve gotta know your own comfort level; I think a lot of women will know when something feels off, and will want to have it checked. Some women need the reassurance to know that maybe self medicating is the wrong thing for them to do. I think you’ve gotta rely on what it is that you’re feeling and seeing, and understanding that there’s a range between your own scent and what is considered normal, as well as scents associated with diseases, or just the uncertainties.

If you’re uncertain, check it out and get the advice. But I often think that what often ends up happening in a health provider’s office is that you get checked out, you know it’s not a sexually transmitted disease, and you walk out and you still have the same problem. Right? And that’s sort of the issue, the void that we’re trying to fill. That you need to be frank about, ‘Okay, that’s great that there’s nothing going on (in terms of disease), but I still have this discomfort’. This is because your ecosystem is not in check, and rather than repetitive antibiotics, there are some of the other things you can do. You can balance your pH, you can take a Probiotic, you can do things that support your vaginal health, that don’t require a subscription or don’t require medication.

So I think that it’s your comfort level; it’s hard to say wait 3 days, wait 5 days, wait 7 days. There’s no sort of magic test, if you will, I always say err on the side knowing, err on the side of information, rather than not.

GC: How do you know if a product is safe for you?

MS: You have to read, and you have to read and know what’s in what you’re using. You’re right to be cautious, and that merits a conversation with the pharmacist or with your health care provider, because products get licensed to use based on safety. Prescriptives are a completely different process in terms of regulations than over the counters, which is why I think it’s so important to recognize that when you have an over the counter product, you need to ask ‘what’s in the product?’ What is it doing? What does it claim to do? Is it going to do something that you don’t want it to do?’ I think that understanding that in the sense of probiotics where you’re using an oral medication, you want to use the probiotic that has science and evidence behind it (like the PreHresh Pro-B Probiotic).

GC: I feel like women are afraid to talk about their vagina, or think about it, and that a lot of women are afraid of their own smell, or even having a vagina that smells like a vagina. Do you ever find that women are making the choice to buy an intimate wash when really they would be needing something more like a balancing gel?

MS: There’s no question that women sometimes make the wrong decision, in terms of what it is that they’ve been doing, and you know, I always say ask first, and that doesn’t necessarily need to be someone like me, it could be someone like a pharmacist, but ask before if you’re not sure. And that’s the reason for this topic, you may  be making an assumption and doing something that has nothing to do with the underlying issue at hand.

GC: What are your thoughts on intimate washes? Are they something that’s necessary for women to be using?

MS: No, not from my point of view. In terms of science and evidence to support it, it’s not there at all, as opposed to the science and evidence of keeping your pH within that 3.5 to 4.5 range. And we talk about this throughout the entire lifespan, so if we were looking at women in menopause and later, one of the things that happens in the absence of estrogen is exactly that, your pH becomes way to alkaline, and that promotes vaginal dryness. So pH is important across the lifespan, its not that it’s just important for young women or middle aged women, it’s across the lifespan that it’s important to maintain that pH.

GC: Could you incorporate taking a probiotic for you vagina every day for an ongoing amount of time, like taking a probiotic for gut health? Could anyone take them to see if their vagina health improved?

MS: We certainly have the safety data associated with it so it becomes a personal choice. It’s the same thing as asking me, like, should I eat a yoghurt that’s got a probiotic or should I eat just plain yoghurt? There’s no downside in terms of safety at all. So, by all means, it’s a personal decision.

For more information on products by RepHresh recommended by Dr. Marla Shapiro, please visit RepHresh.com



Images of paintings by Georgia O’Keeffe courtesy of the AGO; the Georgia O’Keeffe exhibit at the AGO is on now until July 30th, 2017.

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