Vaginal Ecology: What You Need to Know to Keep Things Healthy Down There

I’m a vaginal ecologist.

Say what?

Yes, you heard that correctly, a vaginal ecologist.

You see, like your gut, skin, and many other parts of your body, your vagina has its own unique microbial environment – the vaginal microbiome. As with any ecosystem, ecology is the branch of science that deals with the relationship of organisms to one another and to their environment – their ecosystem. Your overall health affects the health of your vaginal ecology, and your vaginal ecology in turn, affects your overall health – you and your microbiome create your internal ecosystem, and your external, day to day world, influences this.

As an important aside, I want to get semantic here for a minute. I don’t like the word vagina. Not because I’m uncomfortable saying it – I say it a lot for my work. It’s because I don’t like what it means – a sheath – because that just relegates a part of my body for one purpose only and the purpose of my vagina is not a place for someone to park his sword. I’m guessing you might feel the same. So going forward, I’m going to use a word that might be new to you – it’s yoni – which is the Sanskrit word which reflects a sacred view of women’s genitalia, and is symbolized by an inverted triangle. I like to think of the yoni as a sacred place, because I believe that how we think about our bodies influences the care we take of ourselves. You might say I’m a Yonicologist!

Hasn't Big Pharma Learned that Women Aren't Guinea Pigs?

This week I got prompted to hold the presses and write this article when a medical press release popped into my inbox. It was announcing the FDA’s approval of a new pharmaceutical for the treatment of Bacterial vaginosis – or BV. The drug, Seconazole (Solosec), is meant to ‘increase compliance’ – meaning that a woman will follow through on taking it, because it’s a one-dose treatment. Call me old-fashioned, but here’s why I will not be prescribing this drug:

  1. It was approved based on a total of only 333 women studied for use.
  2. It can result in vaginal yeast infections that might then also require medication treatment.
  3. It is admittedly, as stated by the FDA, a carcinogen that caused tumors in study mice – and it is unclear, they state, whether this risk in humans would result from chronic use or even just a single dose!!!

The “Chase Rule of 3”

When I attended Yale School of Medicine we had “the Chase Rule of 3” – named after then Dean, Herbert Chase, MD. The Rule states simply: Never use a medication until it's on the market for at least 3 years because it's in post-market surveillance that we often start to see the ugly truths about safety. It's a good rule. Because who wants to be the guinea pig for Big Pharma and find out in a few years that in fact, a single dose does cause tumors, or in the next generation, that it causes tumors and worse. We’re not that far from the DES nightmare that caused cervical abnormalities and cancers in the daughters of women who took this drug, and cancers in the sons. One would think the FDA would be more careful. Unfortunately, like so many government agencies, the Pharma lobby influences the FDA’s policies and decisions. And then when new pharmaceuticals hit the market, paid-for medical journal articles masquerading as science make sure that your doctors are prescribing them. Add to this paid-for television advertising and you are turned into a consumer before you know it. And to be sure, the risks are minimized. After all, with this drug, 333 women took it safely. Isn’t that reassuring? It shouldn’t be… it’s terrifying to me.

The companies behind these pharmaceuticals, as well as the hundreds of products that line the feminine hygiene aisles of grocery and drug stores, know that millions of women are looking for ways to get rid of symptoms that range from embarrassing to debilitating, particularly vaginal odor, along with its common companion, vaginal discharge. To Pharma, we are sitting ducks – representing big bucks.

There are quite a few common infections that can get our panties in a bunch, so to speak – vaginal yeast infections the one we’re all probably most familiar with, and perhaps comfortable talking about. But there’s another vaginal infection that’s actually the culprit behind most of the odor that women are trying to cover up with douches, sprays, and scented products. It’s called Bacterial vaginosis, and it affects nearly a third of women in the U.S. It leads to an unpleasant fishy odor, and irritation, itching, and burning. And here’s the thing – all of those over-the-counter treatments can actually just make it worse. Pharmaceuticals don’t get to the root cause, which is disturbance of the natural balance of bacteria that live inside the vagina.

Meet the Queen of Your Vaginal Ecology

One of the most important groups of bacteria that helps keep the natural balance in most women is Lactobacillus. Lactobacillus keeps the vaginal pH low by producing lactic acid, which in turn, prevents less-vagina friendly yeasts, bacteria, and other organisms from getting a foothold and causing problems. Members of the Lactobacillus family (there are quite a few species) also help to keep the vaginal wall healthy by promoting mucus production thus providing a protective barrier against other bacteria, yeasts, and viruses – include HIV. It appears that we established a symbiotic relationship with these friendly organisms about 12 centuries ago when we introduced yogurt and other fermented dairy products into our diets. Interestingly, though, women’s vaginal flora does vary by ethnicity – and some women have vaginal flora that doesn’t have Lactobacillus as the dominant species – or even much Lactobacillus at all – and they have fully healthy vaginal environments without infection. So there’s still a lot we’re learning and it means that we need to not have a one-size-fits-all treatment plan – whether medically or naturally – and we might have to try slightly different approaches with different women when it comes to using probiotics restoratively.

Your Vagina, Your Health

The ecosystem of organisms that live in your yoni keep it – and you – healthy. In fact, when the yoni microflora is healthy, the yoni is actually cleaner than your mouth, according to Sharon Hillier, professor of obstetrics-gynecology and reproductive services at the University of Pittsburgh, and an expert in the role of vaginal ecology in HIV prevention.

Here are just a few of the many problems that can arise from disruptions in your yoni ecology, and can results from Bacterial vaginosis and other vaginal infections:

  • Chronic antibiotic use
  • Chronic pelvic pain and pelvic infection
  • Painful sex
  • Urinary tract infections
  • Vaginal dryness
  • Vaginal itching and irritation
  • Yeast, Gardnerella, and Group B Strep infections
  • Infertility
  • Preterm labor
  • HIV (Trauma to the vaginal wall from irritation and inflammation, along with an overwhelming overall increase in vaginal bacteria makes the tissue more ‘receptive’ to the HIV virus which is then transmitted to your blood stream. Thus, vaginal infections are a major global public health problem increasing women’s risks of HIV.

Vaginal dysbiosis have now been found in women with PCOS and is particularly associated with elevated androgens (i.e., testosterone). It also appears that these changes make us more susceptible to the inflammatory effects of several environmental toxins and increases a woman’s risk of developing endometriosis.Vaginal dysbiosis may also play a role in chronic pelvic pain, due to chronic inflammation in the uterus and pelvis. Gut and vaginal dysbiosis have now been directly linked to implantation problems, as well as to recurrent miscarriage. The wrong kind of gut flora can prevent conception, have been shown to reduce or even prevent IVF and embryo transfer effectiveness, can increase miscarriage risk, and can lead to preterm birth when you do get pregnant.

When those good florae aren’t hanging around in enough numbers and variety, inflammatory signaling results, and also organisms like BV which interfere with fertility, and even IVF, can take over the neighborhood.

A Yoni Doctor, At Your Service

Helping women to have healthy vaginas figures prominently and frequently into my work as a women’s health doctor – and you can see from the above list how important a healthy yoni is for pleasure – and for your overall health. It's also a barometer of how our microbiome is doing – when your vaginal ecology is imbalanced on a regular or semi-frequent basis, it's likely that you overall gut microflora is as well.

It’s actually super important that we get comfortable with our down-there’s because there’s a whole lot going on that we’re not talking about – and just living with – like discharge, vaginal odors, and itching or burning that we’re using products to treat, douches being a prime example – that aggravate the problem and keep us dependent on those products. And if you are going to the doctor because the symptoms are bothersome or worrisome enough – then you have found yourself dependent on one round of antifungal or antibiotic after another.

When a patient tells me that she’s experiencing any of the above symptoms or conditions, or develops a vaginal infection, in addition to helping her in real time to naturally relieve uncomfortable symptoms, my job is to help her restore the health of her vaginal ecology. In this article I’m going to share the steps you can take to keep your vaginal ecology healthy or restore it if you struggle with recurrent vaginal infections, and in the next installment, I’m going to give you specific herbal recipes from my 30+ years of clinical practice as a medical herbalist, straight from my award-winning women’s health textbook, Botanical Medicine for Women’s Health, for treating BV and yeast infections.

I want you to have the knowledge you need to take back your health without relying on commercial products that strip your vaginal health and make you dependent on more products, and without relying on pharmaceuticals – some of which are not as safe or well-tested as we might like to believe, and which also do not restore vaginal ecology health and therefore are just a temporary Band-Aid which may be okay once in a blue moon for some of the safer known tried and true medications, but not for recurrent use. And when it comes to pregnancy – while it’s important to get appropriate treatment for vaginal infections because untreated, certain ones can lead to preterm labor and other problems, even medications previously considered safe for oral and vaginal use have now come into question. We’ll talk more about that in the treatment article where I’ll also give you the symptoms of different infections and how to get an accurate diagnosis.

Vaginal Ecology – What You Need to Know

Natural MD Radio: Episode 64


Getting to the Root Causes of Vaginal Infections

Anything that leads to disruption in the vaginal flora, which also includes disruptions in gut flora, because the health of the gut flora plays a direct role, can upset your vaginal ecology enough to lead to infection. Ongoing disruption is a sign of ongoing imbalance in yoni-ecology.

Use of medications and products that disrupt your microbiome (gut or vaginal)

Antibiotics, oral contraceptives (birth control pills), steroids, and antifungal medications whether used orally or topically, can disrupt your vaginal ecology and lead to infection. Even just one round of antibiotics for a urinary tract infection, for example, has led many women into my office for the treatment of ensuing recurrent vaginal yeast infections. Spermicides, which are used independently and also found on many condoms, negatively alter vaginal pH, as do most vaginal lubricants on the market, and these can dramatically increase risk of infection. Additionally, most sanitary products on the market contain residues of bleaches and other chemicals used in their manufacture, and any perfumed products also contain irritants that can increase risk of infection.

What you can do for prevention:

Avoid unnecessary antibiotic use, choosing natural remedies whenever possible instead; avoid pharmaceutical treatment of vaginal infections in favor of natural therapies whenever possible (see this article here and also the next installment of this article; choose a natural condom and lube – Sustain is the best company on the market for these and the one I recommend in my practice.  If you do have to use an antibiotic, take a probiotic that contains Lactobacillus, Bifidobacterium, and Saccharomyces species along with it, and continue daily for up to 3 months after completing the antibiotic to protect and restore gut and vaginal flora. For your sanitary products, use only organic or natural cotton pads and tampons (yes, this is possible!), and avoid all perfumed products – even natural ones, for use in your sensitive lady parts! And don't douche – ever!

 Gut dysiobis

The health of the vaginal flora – or vaginal ecology – is not only dependent on your hormone levels and what you put in your vagina (tampons, douche, who you have with), but it’s also highly dependent on the health of your gut flora.

Imbalances in your gut flora, called intestinal dysbiosis, can be a Root Cause of chronic or recurrent vaginal infections, and clearing up dysbiois and rebalancing your gut flora can go a long way to preventing vaginal infections, and is almost always a part of the treatment plan in my practice.

 What you can do for prevention: To keep your gut flora healthy, make sure to include 6-8 servings of fruits and especially leafy green vegetables in your diet daily for fiber, regularly eat sweet potatoes and legumes, which have special (resistant) starches that feed health gut flora, and include lactofermented vegetables in your diet each day. If you tolerate fermented dairy products, they can be part of a yoni-healthy diet – and in fact, one of the leading gut flora researchers, in personal conversation, recently shared with me that his studies have shown that women who eat some good quality dairy products in small amounts in their diet may have more favorable species present. If you do experience recurrent infections, it’s also advisable to get extra support by taking a probiotic daily. Look for one that contains at least Lactobacillus reuteri and Lactobacillus rhamnosus, as these are very friendly for vaginal health. Emerging research is also highlighting the potential significance of Lactobacillus crispatus for promoting healthy vaginal flora. If you have significant symptoms of gut dysbiosis, check out my 28-Day Gut Reset, and read my book The Adrenal Thyroid Revolution which has an entire section on The 4R Program for Healing the Gut.

Blood sugar imbalances and high sugar/high refined-carb diets

Pre-diabetes and diabetes are known risk factors for increased vaginal infections, particularly recurrent yeast infections, but even if you’re not diabetic, eating too much sugar on a regular basis, or foods that act as sugar in your body when they are digested, for example, alcohol and a diet high in refined carbohydrates, can be very problematic. For some women with recurrent yeast infections, even over-consumption of fruits and naturally occurring sweets like honey and dates, can contribute to the problem.

 What you can do for prevention: Eliminate added sugars and all refined carbohydrates from your diet until you’ve been infection-free for at least 6 months; if you don’t eat those but still get a lot of sugar in your diet in the form of fruits, honey, etc., reduce these. Emphasize keeping your blood sugar steady, which I teach how to do in detail The Adrenal Thyroid Revolution.

Take Your (V) Vitamins

Healthy mucosal tissue (that's the kind that lines your mouth, intestines, and yup, your yoni, too) requires not just good fiber and probiotics in your food, but certain nutrients – especially zinc, vitamin A, vitamin E, and vitamin C – which too many of us are not getting enough of in our diets. Eating good quality protein, nuts and seeds, and plenty of fresh veggies and fruits daily is indispensable for vaginal health, and deficiencies in these and other nutrients can set you up for trouble.

 What you can do for prevention: In addition to making sure you’re making the most of the foods you eat by including highly nutritious foods in your daily diet and not skipping meals, taking a multivitamin does provide some extra ‘health insurance,’ and if you are particularly susceptible to recurrent infections, is all the more important. To learn about some of the multi’s I use in my practice you can head over to this link ( it’s free to set up an account and you don’t have to purchase anything, but I do make those supplements available at a discount should you want to for your convenience – or choose any of the food-based multi’s at a natural foods store. The Whole Foods 365 brand, Innate, Rainbow Light, and many others are reliable).

 Sex and sexual partners

Multiple sexual partners, new sexual partners, frequent sex, chemically laden condoms, and unhealthy vaginal lubes can individually or collectively, disrupt the vaginal flora and pH and increase your susceptibility to vaginal infections, especially BV.

 What you can do for prevention: How many sexual partners one has is a personal preference – but whatever you choose – one or many – protection is critical – so condoms, condoms, condoms. As mentioned above, Sustain is the brand I recommend. Ditto for their lube which I’ve discussed in the link below this article as being vagina-friendly. If you get infections with sex, particularly BV, it could be something a partner is harboring, for example, men can carry bacteria in the penis that you pick up during sex – even though he may be asymptomatic. Oral sex can also change your vaginal pH dramatically and lead to infections. Keeping your vaginal flora otherwise health, and taking a probiotic either orally, inserted vaginally, or both can be helpful, and we’ll discuss this more in the treatment episode.

Hormonal changes

Menstruation, pregnancy, and changes that occur with menopause can all lead to changes in the vaginal pH which in turn, reduce Lactobacillus and allows for the overgrowth of yeast, BV, and other organisms. Yeast infections are thus especially common around our periods, and also during pregnancy, when the blood sugar is not only naturally higher, but because we’re more likely to want increased carbs, we’re feeding the yeast directly. During menopause, the drop in estrogen and progesterone appears to lead to vaginal pH changes that encourages the growth of BV particularly, and along with the increased tenderness and vulnerability of vaginal tissue, creates the perfect medium for infections to take hold.

 What you can do for prevention: Hormone balance is a more complicated conversation than we’ll get into here – my next book, The Hidden Hormone Epidemic coming out in January 2019 is all about it, and we’ll have other conversations in blogs and podcasts on this topic. But it is important to be especially mindful of vaginal health and all of the factors than can disrupt your vaginal ecology – during times of major hormonal shifts. So for example, a probiotic during our periods, pregnancy, and perimenopause can make a huge difference, as can avoiding high blood sugar, and common triggers, like using a condom during male-female sex in menopause when the pH of sperm and the reduced estrogen in the vagina can be a recipe for BV.

The “Thong Effect” 

Anything that causes migration of bacteria or other organisms from your rectum to your yoni can cause infection. This includes wiping from back to front after a BM (you’re only ever supposed to wipe front to back!), wearing a thong (yes, ditch the tightrope that microorganisms ‘walk’ across to cause infection), menstrual pads, and same part vaginal contact with vagina after or during anal sex.

 What you can do for prevention:

Always wipe front to back when you poop (and teach your girls to do this – you’d be amazed at how many women don’t know the right way to wipe); if you have anal sex, make sure there’s no same part vaginal contact (fingers, etc.), and ditch thongs – they are not our best friends. For a seamless look instead, try seamless underwear or boy shorts. Always make sure your undies have a breathable cotton crotch, too. During your period, change your pad often to keep down on irritation.

 Become Your Yoni’s Best Advocate!

As one researcher, Hilary Reno, is quoted as saying in an article in The Atlantic, The Superhero in Your Vagina, “There’s no advocacy group for keeping our vaginas healthy.” I hope this article helps you become an advocate for your own!

Falagas, M. E. Probiotics for Prevention of Recurrent Vulvovaginal Candidiasis: a Review. Journal of Antimicrobial Chemotherapy, vol. 58, no. 2, 2006, pp. 266–272.

Martin, D. H. The microbiota of the vagina and its influence on women’s health and disease. Am. J. Med. Sci. 343, 2–9, doi: 10.1097/MAJ.0b013e31823ea228 (2012).

Reid, Gregor, and Andrew W. Bruce. Selection Of Lactobacillus Strains for Urogenital Probiotic Applications. The Journal of Infectious Diseases, vol. 183, no. s1, 2001.

Reid, G. Oral Probiotics Can Resolve Urogenital Infections. FEMS Immunology and Medical Microbiology, vol. 30, no. 1, 2001, pp. 49–52.

Romm, A. Botanical Medicine for Women’s Health. St Louis. Elsevier. 2017.

Rönnqvist, Per Daniel Johannes, et al. Lactobacilli in the Female Genital Tract in Relation to Other Genital Microbes and Vaginal PH. Acta Obstetricia Et Gynecologica Scandinavica, vol. 85, no. 6, 2006, pp. 726–735.

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Read or leave comments 7 Comment

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Absolutely LOVED this article. Recentlybought your thyroid book and women's health book. Excited to have them both. I'm a Nurse Practitioner and alternative health provider. Hoping to have my own practice up and running at the first of the year. I think you are are an AWESOME WOMAN and professional. Considering taking your women's healthcare program. At one time I seriously thought about doing a Doula program. Thanks for your practical teaching'


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Enza Lilley

Excellent article! Sharing with my clients!


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Yet another excellent article. Aviva! I especially like the Chase Rule of 3---do NOT take any pharmaceutical that has been on the market less than 3 years! It is, as you suggest, unconscionable for meds to be marketed with minuscule test groups. At least the 333 persons who tested this med were [probably] women---yikes. Great suggestions, as always, for creating health!


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Instead of the 3 years rule I think it should be 10.


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Judy Kaplan

I love your clarity, Aviva! And thankful for your very special spark of genius that you so generously share.


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Ashish Paul

Dear Dr Aviva, I absolutely loved your take on not calling it vagina but Yoni. It made a lot more sense to me today reading your article. I am an Ayurveda Vaidya and a Medical herbalist in the UK. So from now on I will use Yoni too. Warm regards