S10 EP2_SEXUAL HEALTH_STIs and Vulvovaginal Health: Audio automatically transcribed by Sonix

S10 EP2_SEXUAL HEALTH_STIs and Vulvovaginal Health: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Intro/Outro:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome back to From First Period to Last Period. I'm your host, Kristyn, and I'm here today with Dr. Jessica Zolton. Hi, Dr. Zolton.

Dr. Jessica Zolton:
Hello! Thanks for having me.

Kristyn Hodgdon:
Of course! So, Dr. Jessica Zolton is a double board-certified OB/GYN, reproductive endocrinologist, and infertility specialist at RGI Fertility in Ohio. Welcome, I'm so excited to talk about all things STIs and vulvovaginal health, and everything that is considered taboo, but we say nothing is off limits here at Rescripted. And we talk about this every day, but I think a lot of times, people don't really think about how important it is for not only their gynecologic health but also their reproductive health. Yeah, absolutely; I definitely want to dive more into that. And this statistic was staggering to me. According to the CDC, more than 1 million STIs are acquired every day. So, I guess what are some of the common ones that people should know about, especially as they're thinking of trying to start a family?

Dr. Jessica Zolton:
Yeah, I think a lot of times people know it's routine care to come into an annual visit and have gonorrhea and chlamydia tests. This can be done with a vaginal swab or a urinalysis. We also check for trichomonas and then syphilis, which actually has a resurgence in the last few years. HPV and Herpes are very common, and we'll also check patients for hepatitis B and HIV.

Kristyn Hodgdon:
Okay. And that's at the initial consultation, or is that the OB/GYN visit?

Dr. Jessica Zolton:
Those are all common. Typically, when you're screening, either at your OB/GYN or at their infertility, the doctor will do gonorrhea and chlamydia tests, syphilis, hepatitis, and HIV, and that's usually standard for everybody.

Kristyn Hodgdon:
Okay, and if any of those come up positive, what's the protocol there?

Dr. Jessica Zolton:
Yeah, most of the time, we can treat with antivirals or antibiotics, and we'll treat both the patient and the partner and then check. And some of the things may require more extensive evaluation, such as obviously HIV and syphilis. But many times patients may unexpectedly screen positive, and so it requires surveillance for both partners.

Kristyn Hodgdon:
Okay, and do people often come with you with symptoms, or is it mostly after the fact when they're trying to get pregnant?

Dr. Jessica Zolton:
Yeah. So, most of the time, when somebody has an STD, they may not actually have any symptoms. So, for chlamydia, about 70% of patients do not have any symptoms. Some of the things that patients complain of are original discharge or irritation. HSV, so herpes, for a first infection, is usually very painful. And so sometimes, patients may even show up in the ER. The pain with urination or swelling and other types of infections in chlamydia may have a vaginal discharge. Very significant infections inside the pelvis are caused by things like chlamydia. You can actually have fever, chills, severe pain, nausea, and vomiting, and that is a concern then for pelvic inflammatory disease or PID.

Kristyn Hodgdon:
Yes, if it's left untreated and it turns into PID, is that when it gets into the territory of possibly affecting fertility?

Dr. Jessica Zolton:
And patients, if they're admitted with severe symptoms, might have imaging or sometimes even require surgery, and we can see a pelvic abscess, so this is a collection of infections admitted for things like IV antibiotics and sometimes have drainage of that infection. But it's not uncommon for patients that have had chlamydia; maybe it was treated, and they didn't even have any symptoms, they may still affect their fertility. So they can still have inflammation and scarring of the fallopian tube, and then that can block the fallopian tube and also increase the risk of things like an ectopic pregnancy.

Kristyn Hodgdon:
Wow, okay. So, if you do know that you've had an STD in the past, how can you advocate for yourself at either your OB/GYN or fertility specialist?

Dr. Jessica Zolton:
Yeah. So, usually, when we talk to patients at their first appointment, we'll ask some of these questions. If they have a history, we'll do an X-ray to look at their fallopian tubes. It's called an HSG or hysterosalpingogram. And if somebody has a history of an infection, we usually give them antibiotics when they have the procedure done. But this is a really good test. We're able to watch contrast flow inside the uterus out of the fallopian tubes. And we can see if there's a tubal blockage or if there's a dilated fallopian tube, which is called a hydrosalpinx. Sometimes, that then leads us either to go down a surgery path or, if both tubes are blocked, then usually the preceding to things like IVF.

Kristyn Hodgdon:
I didn't connect the dots between PID and Hydrosalpinx. I didn't realize that was like a cause and effect.

Dr. Jessica Zolton:
And 50% of patients with tubal factor infertility, the cause is chlamydia. It's not uncommon for patients to report chlamydia in the past. And most of the time, patients say, oh, it doesn't matter, like I had chlamydia when I was in my 20s, but that was ten years ago. Once it causes tubal scarring, it's permanent.

Kristyn Hodgdon:
Wow, okay, yeah. And then, and you can try with one too, but if both are blocked, is there an option to clear them with surgery, or is it usually just IVF?

Dr. Jessica Zolton:
It's usually IVF because the tube is such a delicate structure that if you have scarring inside the tube and the scar tissue is removed, it usually heals with scarring. It's really hard to repair a fallopian tube that's anatomically just abnormal.

Kristyn Hodgdon:
Got it, got it. And this is obviously in females. How can STIs affect fertility in males?

Dr. Jessica Zolton:
Yeah, I think because women are the ones who are early on to go to the gynecologist. We do a better job of keeping up with our wellness visits. And men don't even realize that the STIs can affect their fertility. Chlamydia can cause the blockage of tubes that transports sperm out of the penis, where you store the sperm is stored, and then the vas deferens and the urethra. These are all structures that can be blocked. And if you do a semen analysis and you that there's no sperm, sometimes it's just that the sperm is stuck, it can't come out. Then syphilis, gonorrhea, and chlamydia can also cause orchitis, which is swelling in the testicle. And if that happens, the concern is going to be that it actually damages the testicle. Once the testicular tissue is injured or damaged, sometimes it impairs sperm production, and so that might be a reason why somebody has infertility.

Kristyn Hodgdon:
Okay, and how is that treated?

Dr. Jessica Zolton:
If there's damage to the testicular tissue, there might not be a way to repair it. It may be things like the first step would be to send someone to a reproductive urologist, and they may talk about actually going into the testicle and removing sperm and then freezing that sperm for IVF, and that sometimes is the process for patients that have a blockage as well. If they have a blockage of the vas deferens, for example, then they can go into the testicle and remove sperm, but that sperm is going to be really used just for IVF. There's not enough sperm for insemination.

Kristyn Hodgdon:
Oh, interesting, okay. So, you don't need as much sperm for IVF fertilization. I didn't realize that.

Dr. Jessica Zolton:
Yeah, because if you're going through IVF, a lot of times, if it's male factor infertility, we have low sperm counts. We're concentrating on okay. There are less than let's say a million sperm, but it's really all about how many eggs we'll get an egg retrieval because we're not going to get a million eggs. So if you get 15 eggs, you have to find 15 good-looking sperm that are moving, and then you can inject that sperm into each egg. ICSI is intracytoplasmic sperm injection.

Kristyn Hodgdon:
Yeah, awesome. How often should individuals get tested for STI? Should they get tested before they start to try to conceive?

Dr. Jessica Zolton:
Yeah, most definitely. If everybody would present to their OB/GYN before they're trying to conceive. That way, we can identify as they're going to be an issue with conceiving. Still, we can also talk to patients than about starting a prenatal vitamin and doing some of the testing, the STI testing, and carrier screening. But with patients who are sexually active, and if they're less than 25, then they should be screened every single year. And then after 25, really, it's based on risk if you have a new partner, if there's a concern about inconsistent condom use, if their partner has a history of any, it would be great. Before intercourse with a new partner, you sit down and say like, how many partners have you had? Have you ever had any STI? And make sure that both partners are actually screened before their first interaction so that they lower that risk that they pass STI along.

Kristyn Hodgdon:
Okay, that's great advice. I wanted to talk briefly about HPV because I know that. Is that categorized as an STI?

Dr. Jessica Zolton:
It is, yeah, and HPV, it's wonderful now we have a vaccine, and I'm older than patients in the vaccine. I wasn't around when I was in my adolescence, but now it's offered to all kids aged 11 and 13, 11 to 13, but now we've extended it to all age groups. The reason is that 8 in 10 people are going to be infected with HPV throughout their lives. So this vaccine is going to help decrease the risk of getting cancers of the vagina, the vulva, anus, and rectum and then also decrease the risk of genital warts. And if everybody would get this vaccine as kids, we're going to have a big, drastic decline in people who have those cancers. And when women are going to their OB/GYN for their pap smear, we're usually checking for HPV at the same time. A lot of times, our body may clear the infection, but it's when the body doesn't that we're more concerned about then increasing our risk of having things like cervical cancer. And this is a huge plug for vaccines. It can be a series of 2 or 3 shots. Millions of people have had the vaccine, it's safe. So if you think that you haven't asked your doctor about it, and it can be your general practitioner or your OB/GYN to actually administer the vaccine, it's not something that we give in pregnancy, though, would be between pregnancies, or especially if you're in your teenage years or your 20s.

Kristyn Hodgdon:
So, you talked about diagnostic tests. Are there any other diagnostic tests aside from the HSG that can help rule out fertility issues related to STIs?

Dr. Jessica Zolton:
If you're thinking about a hydrosalpinx or tubal abnormality, sometimes we can catch those on ultrasound. Sometimes, you might see this big fluid-filled structure close to the ovary, but we know it's not part of the ovary. So sometimes that lets us know that we think that there could be a hydrosalpinx. The true test really is always looking at the HSG, and then, for men, a semen analysis. A lot of times, partners are sometimes the females who take this on themselves and say, I'm just going to do all the testing first. I want to see what's going on with myself. But a lot of times, men also have semen analysis kind of abnormalities, and you wouldn't want to get started with a treatment unless we have the semen analysis back.

Kristyn Hodgdon:
Yeah, I saw, I think it was a fertility doctor that I follow who said, semen analysis is the cheapest and low-risk way to get to the bottom of literally 50% of the fertility equation, and then so many men are reluctant to do it.

Dr. Jessica Zolton:
And they can do it at home. They don't even need to be the ones that bring in the semen analysis. Their partner can bring it in. It's not uncomfortable. So, it's an easy test to check off the list, but I think it's a team effort. Sometimes, I ask the female partner, hey, just continue to push them to get that scheduled.

Kristyn Hodgdon:
Yeah, absolutely. So moving on to vaginal infections. Vaginal infections are one of the top reasons that women go to the doctor. And so, what are some common types of vaginal infections to look out for? I think some of the ones off the top of my head are UTIs and yeast infections, but I recently learned about BV and how prevalent that is, and it was mind-blowing.

Dr. Jessica Zolton:
Vaginosis is probably what causes most infections.

Kristyn Hodgdon:
Really? Okay.

Dr. Jessica Zolton:
Yeah. It is really, I think, most of us will say, oh, it's when we get calls from patients. I think I have a yeast infection, and they've already taken a lot of things over-the-counter to treat it. And then we bring them in, and we can do a speculum exam and get some the vaginal discharge and look under the microscope and actually be able to say, is this yeast? Is it bacterial vaginosis? Both can be treated with oral antibiotics. And I always encourage people if they're having trouble, to stop using all the things over the counter and see their doctor because usually they can get right down to the treatment.

Kristyn Hodgdon:
Right, so you can kill two birds with one stone. Yeah, and those over-the-counter treatments are not fun anyway.

Dr. Jessica Zolton:
No, and sometimes it's very common that patients will say a yeast infection. You'll have a little bit of itchiness and probably like a cottage cheese discharge. That's always very easy, but the bacterial vaginosis is the one that has more of an odor to it, and it can be like this grayish-white discharge. And it's probably the most common thing that we would see when I used to deliver babies that patients would complain about in the first trimester, too. The reason is that our estrogens change in pregnancy and throughout our life; sometimes, our kind of natural pH just changes and then allows one type of bacteria to overgrow all these bacteria. There are lots of different types of bacteria that cause bacterial vaginosis. Still, they're all kind of part of our normal microbiome, which is that when one is given the opportunity to overgrow, that's when we see symptoms.

Kristyn Hodgdon:
Yeah, I'm sure every woman has had at least one of these in their lifetime. So, when it comes to fertility, how can any of these impact fertility? Or if you're trying to conceive and you have this, should you, like, hold off? How does that all work?

Dr. Jessica Zolton:
I think if you're having any discomfort, then it's probably going to affect your sexual activity.

Kristyn Hodgdon:
Very true.

Dr. Jessica Zolton:
By that route.

Kristyn Hodgdon:
This is coming from someone who can't have sex to get pregnant, so disregard.

Dr. Jessica Zolton:
For women with BV, it's more, so there are not really great studies linking it to specifically fertility. They're not directly linked, but we know if somebody has BV, they're more likely to acquire other STIs. They probably somehow allow other bacteria to infect a little bit easier. But infections in pregnancies, so BV in pregnancy has been linked to pre-term birth, and then UTIs in pregnancy can get very serious. That's why we're constantly checking women's urine, making sure that they don't have an infection because sometimes there are no signs. But in pregnancy, the infection travels up to the kidney, it's called pyelonephritis, and that can be associated with preterm delivery and sepsis, and so we take that very seriously. If you've had a UTI during pregnancy, then we keep checking your urine throughout to make sure that you don't have an undiagnosed infection.

Kristyn Hodgdon:
Okay, wow. I did not realize that was why you give so many urine samples to pregnant.

Dr. Jessica Zolton:
We're also always checking for protein to see if there's a risk of preeclampsia, but we get a lot of information from that urine.

Kristyn Hodgdon:
Love it. So, I think that a lot of women experience this as well as like persistent, or you get a yeast infection, it clears up, and then you get it again in the next month, and it's just ongoing. Like how do you advise your patients to deal with that, especially if they're trying to conceive?

Dr. Jessica Zolton:
Oral medication is best than the over-the-counter kind of topical. Sometimes patients need to take a prophylaxis dose, and sometimes patients will call and say, I have a cold or I have a UTI and I'm taking an antibiotic, I always get an infection, a yeast infection afterward, so we'll pre-treat people to decrease the risk. But a lot of times, they might be doing things that increase the chances of them actually getting an infection. So sometimes it's in the summer, if you're in a wet bathing suit, you need to make sure you change it, you're not going to sit all day, And wearing tight-fitting clothes can also increase the risk. But anything that's over the counter, like any lotions or wipes we really shouldn't be using.

Kristyn Hodgdon:
Yes, that was going to be my next question. Because I think there's an entire market of products dedicated to vaginal hygiene. And it's not totally necessary because the vagina is a self-cleaning oven, right?

Dr. Jessica Zolton:
It's, and the skin's really sensitive. And I know a lot of times patients will say like they get fabric softener or like new detergent, anything scented can cause irritation. Unfortunately, at my house, everything is unscented. It's all free of all of any sex. I do have babies, too, so I'm worried about their skin.

Kristyn Hodgdon:
But once you go unscented, like with most things, scents just overpower everything when they are like bath and body works soap. So I'm like, oh my gosh, this is pungent.

Dr. Jessica Zolton:
You realize you don't really need that. That's all you can smell all day. I think if you think about kids and how sensitive their skin is, bubble baths sometimes are too much for an infant, and that's the same with your vaginal health. You don't realize some of the things that we do is just setting you up, especially if you're like on vacation, you're like, oh, I'm going to go in this hot tub at my hotel that is just setting you up for an infection, too.

Kristyn Hodgdon:
Oh, yeah.

Dr. Jessica Zolton:
A lot of medications that somebody might use, sometimes steroids can cause issues if they're taking them from maybe asthma exacerbation. But it's interesting, some of our patients I remember in residency would have recurrent yeast infections, and then we actually checked their sugar and found out that they're diabetic. And so uncontrolled diabetes, sometimes patients will know that other things in their life kind of impact their vaginal health, which is not unheard of. Our body is all kind of functioning together, but vaginal health might be another signal of our overall health.

Kristyn Hodgdon:
Yeah, absolutely. There's been some chatter about the vaginal microbiome and stuff like that, too. Do you have any insight there?

Dr. Jessica Zolton:
I think we're still trying to really figure it out. The microbiome in all types of medicine is really a hot topic. So, with our GI, some patients will try over-the-counter supplements, and that's what's hard is which one should you use. And we think that potentially anything with lactobacilli might be better, but you have to remember probiotics are not FDA-regulated. So we don't really know if whatever's in the bottle is really, truly there. They don't have to prove the quality or the content. If you take it and it improves your health, I think that's okay to continue, but if you're trying to conceive, I am a less is more type of person. I would say vitamin is the most important thing to take, and if you're not finding benefits from these other things like probiotics, then I don't think there's a reason to continue it.

Kristyn Hodgdon:
And is vaginal pH intertwined with that at all, or is that something different? So many buzzwords.

Dr. Jessica Zolton:
Yeah, so our estrogen causes us to have a lot of kind of glycogen production. And then with that, we have all this lactobacillus, and that's going to decrease our pH. So our kind of vaginal tissues are in an acidic range, and then that actually protects our body from the overgrowth of other organisms. And so we have this very balanced system, and they're supposed to all these other bacteria will keep the other ones in check. You have things like group B strep, E. Coli, and the Gardnerella associated with BV, but all of these things are always there. So that's why if you take an antibiotic, if it wipes out, let's say, E. Coli, then it allows something else to start growing. And that's where you're figuring out what am I doing in my everyday life that's affecting potentially my microbiome and really common, like I said, like antibiotics. It may be something that you're not even aware of, but maybe a lubricant you're using, or it could be some soap that changes the environment of your pH. I'm like old school. If you're thinking about, okay, I want to have a natural probiotic, then it's the yogurt, cheese, and ingesting. And some studies have been done to say if you're on an antibiotic, should you start just having a yogurt with that? I would say that the results are a little bit mixed, but it's a pretty cheap and not invasive kind of way to see if that helps keep your microbiome in check. And you always check if you look like the live and active cultures. That's what tells you that it can replace your microbiome, if you will, in a good way.

Kristyn Hodgdon:
That's good advice. Yeah, I loved your analogy about if you wouldn't put it on your babies, if you wouldn't use it when you're pregnant, maybe don't use it when you're trying to conceive.

Dr. Jessica Zolton:
Yeah. I think it's simple sometimes, but a well-balanced diet, trying to stay away from high-glycemic foods, getting outside, and exercising are all probably good for our reproductive health. I tell a lot of my patients that if it's good for your heart, it's more than likely great for reproduction.

Kristyn Hodgdon:
Is there anything we miss? Any other taboo topics? Oh, when it comes to lubes, because that's something that a lot of people use, and they don't even think twice when they're trying to conceive naturally, what are your recommendations there?

Dr. Jessica Zolton:
Yeah. So again, avoid scented vaginal products and avoid douches. But when looking at lubrication, you should find something that has hydroxyethyl cellulose. I think if you're on any fertility websites, it always precedes or conceived plus. Those are the ones that are not going to kill the sperm. And then, likely, if it's friendly for the sperm and eggs, it's going to be friendly for you. FDA already now classifies things as fertility-friendly. So they're called like PEB, and it means that they're these supplements or these products are okay for like sperm and eggs and embryos. What's interesting is it's hard to find that list. And if you have a product at home, it may not actually have PBB on it. I think that's the next route. But things to avoid: anything with oils, anything silicone-based, and anything with glycerin. These are going to alter your glycerin, which is going to alter the lactobacillus. So you definitely want to find something good for both your vulva health and then also for reproduction.

Kristyn Hodgdon:
Lastly, what would you recommend about the way people think about STIs and down-there care in general?

Dr. Jessica Zolton:
I think if everybody is more open with their partners if you can have a conversation, hopefully, if you're going to be intimate with someone, you can talk about your prior partners and make sure that everybody gets tested before and use condoms with concerns for fertility. But, you know, overall health, there are a lot of patients who just are not aware that their past sexual infections can cause fertility issues. And I think bacteria, there's good and bad, and so don't think our bodies are void of all this bacteria we live in. Our skin has bacteria, and there's no reason to think that you have to have a harsh chemical applied at any time, at any place in your body, to help treat that. So be kind to your body and choose sensitive products.

Kristyn Hodgdon:
Awesome. Thank you so much, Dr. Zolton. This was wonderful, and it was so great meeting you.

Dr. Jessica Zolton:
Yeah, it was great to meet you, too. Hopefully, we'll meet again.

Kristyn Hodgdon:
Yeah, absolutely. Thank you again. Talk to you soon.

Intro/Outro:
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