Women's health is a team sport. That's something we've all learned the hard way—not in residency, but years later when we realized how much we weren't taught about vulvovaginal health.

In this episode, I sit down with Dr. Meredith McClure from Dallas and Dr. Ashley Fuller from Seattle. They co-host the Labialogic podcast and both specialize in treating the conditions that most doctors either miss or dismiss—lichen sclerosus, desquamative inflammatory vaginitis, recurrent BV and yeast infections that won't go away.

All three of us left obstetrics years ago and now run gynecology-only practices. And we've all come to the same conclusion: what we learned in training wasn't enough. We were taught not to examine the clitoris. We weren't taught proper vulvar anatomy. We weren't taught how to diagnose or treat the complex cases that show up in our offices every single day.

We talk about why there's no one-size-fits-all approach to recurrent infections. We discuss the tests that doctors over-rely on for BV diagnosis that aren't actually accurate. And we share some of the worst medical gaslighting stories we've heard—like telling a PGAD patient "you've been through childbirth, how bad could this be?"

We also discuss AI in medicine, why private equity is a problem, and how teaching women proper anatomical language changes outcomes.

Highlights:

• We were all trained in residency not to examine the clitoris, which means many vulvar conditions get missed.
• Recurrent BV has no one-size-fits-all approach. Some DNA tests only check for Gardnerella and lead to false positives and overtreatment when what works depends on each person's unique microbiome.
• Don't use one-dose Monistat. It can cause severe inflammatory reactions in the vulva.
• Some vaginal inflammation doesn't show up on swabs and requires a microscope exam to diagnose properly.
• Teaching women proper anatomical language (knowing vulva vs. vagina, labia minora vs. majora) actually improves treatment outcomes.
• Lichen sclerosus is one of the most commonly missed diagnoses because doctors aren't examining the vulva properly.

We hope that this episode gave you information that can help you understand that there are clinicians out there that want to help and find answers to your vulvovaginal health concerns.

I appreciate everyone who is part of this community, and if you haven't already done so, I would appreciate you subscribing as it helps more women find the show so that they can get the information that they are looking for.

Connect with Dr. Fuller:

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Get in Touch with Me:

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hey, y'all, it's me, Dr. Smeena Arman, Gyno Girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Smeena Arman, sex, men, gynecologists, and menopause specialist in Chicago. Today, I am so excited to have two of my favorites on today. We're going to have this, I don't know, threesome going on today.

Hahaha

We're going to talk about something that, you know, over half of the population is affected by. I actually had to finish a podcast and I had to go get my vulva. So this is perfect. On demand. Well, you guys are on YouTube vulva on demand here. We're going to talk about vulva vaginal health and we're going to talk about all the things that you're burning, itching and anything else that comes up AI and all the things. But first of all, I to introduce Dr. Meredith McClure, who's a board certified OB-GYN.

Yes!

in North Dallas and has been there since 2007. She does bone vaginal diseases, sexual medicine, menopause, as well as Dr. Ashley Fuller. I'm gonna let them introduce themselves a little bit further on and tell us everything we need to know about them in 60 seconds or less. Go. I'm just kidding. Why don't you start, Meredith?

you

And go. Okay, I'm Meredith McClure. an OB-GYN in my training and I practice in Dallas, grew up in Dallas, so this is home for me. And I love everything, menopause, hormones, vulvas, and sex. And I love helping people to optimize their lives and sexual health. So it's a blast.

Yeah.

And they're part of the Labialogic crew. you guys probably know them from Labialogic. That's the other thing I forgot to say. Go ahead, Ashley.

Yeah

I'm Ashley Fuller and I am also a board certified OBGYN. I'm in Seattle, Washington. So we're getting multiple parts of the country covered between the three of us, which is awesome. And I work in the same space. Sexual health is my overarching kind of focus, but definitely menopause, perimenopause, complex vaginal disease and sexual health, because they all go together. You can't really do well without the others.

Yeah, we're the whole

Okay.

Exactly.

and love working in this space and super excited to talk to you guys today. I love talking about this stuff, obviously.

Yeah, so, Pride will be no surprise to the people that listen. We all met at Ishwish. So, that's where, you know, all the rock stars go. And so we actually have all the fun, but I know seriously, so Meredith and Ashley and I met at Ishwish and, know, we always see each other once or twice a year, depending on which conference we're at. And then sometimes just randomly otherwise, but it's always fun to catch up and

Yeah.

Hahaha

You know, we're all so passionate about the same topic. That's why it makes it so much funner, I think. And you guys have your own love story, how you guys met. Love it. It just fills my heart.

We do.

Yeah, we met in residency. all three of us are OB-GYN. So as you know, OB-GYN is a four year program. And I was a fourth year resident here in Dallas at Parkland Hospital or County Hospital. And I had this wonderful intern, which is the first year. And she was amazing. And I loved her then. And time goes on. And you hate to admit it, but almost 20 years later, here we are again and just having a blast.

I'm sorry.

you guys keep up.

Yeah, I mean, yeah, and I was like, Oh, that's good. You guys probably graduated around, you know, the same time that I did in terms of like, you know, maybe the 80 hour work week was just starting to kind of like, they're like, not everyone was paying attention. Well, we'll just let we'll slip between the cracks. You can work 100 hours this week. We're not going to really, you know,

Meredith was a nice upper level. She let me go to the bathroom.

Just, yeah. But not perfecting.

Yeah. Yeah, yeah. Shh, don't say anything.

So I feel like, don't say anything. They can't do anything to us yet. They just started this. So we sort of were in that era and it was hard. I think that's why so many of us will stay in touch with the friends that we made from residency because it's a difficult residency. It's a difficult time in life where you're working all these crazy hours.

Hahaha

Yeah.

And now we're on the other side and none of us to go be anymore. Wait, when did you guys stop?

Hahaha

Exactly!

Thankfully.

I'm kind of starting to tell my husband last night, was like, God, we're coming up on seven years since I stopped. Yeah.

Okay, wow. Yes.

Yeah, 2019 I think was last time I delivered a baby. Yeah.

Yeah.

okay. think I'm beat all of you. I think I was 2016 when I stopped opening. I love it.

Nice, yeah. It's a wonderful profession and it is so rewarding. It's extremely stressful, but it is so rewarding.

That is.

extremely.

Yeah, I was telling a story because when I first stopped OB, because I had been a hospitalist and I started my own insurance-based practice where I was going to do only GYN and then I was like, wait, am I giving up OB too soon? And so there was a doctor at the Northwestern community that wanted help with call coverage and he was like, oh, I'll bring you into my practice once a week. And I was like, oh, maybe I shouldn't give up OB yet. So then

I went back and did OB for like one or two years. But I did it as a private practice doc, because I had previously worked in academics, right? So I went back and did it. And I did it as a private practice doctor working basically on call. Like it was me, him, and one other person. And we shared call. We had three independent practices. So it's kind of cool to have your own patient that you can follow through. it became very difficult, even just having the small practices that we did, because there was only three of us.

Mm-hmm.

My youngest was like four years old at times. So every time my paycheck would go off and I'd go, like she'd wake up at 3 a.m. and just sit there waiting for me until, yeah. And I would bring her donuts from Duck and Donuts. And so, and so as a result, ended up then like, okay, I think I'm really done with OB, but you know, I'd worked in academics and then I started OB in private practice. So it came with a tail that I didn't anticipate. I was like, now I have to do my tail.

Aww.

Yeah, always bring the donuts home when you're coming in.

Yep.

yeah.

yeah. Yeah. Yeah. Yeah.

So that was a bummer because in academics, you know, it's not a current space. It's no, it's a current space, not the other way. But anyway, that was my story. All right. So let's get into it, guys. Let's talk all things vulva vagina. mean, unless you guys have anything that you want to bring up, you know, that's been a burning, a burning issue with a patient or a burning vagina you treated this week or anything like that.

Yeah.

There's always a burning vulva and vagina. And I think what I was telling a patient actually this morning, I think it's hard and you all would agree, like, we are honestly like the last line of defense, I feel sometimes, because people, by the time they see us, they've seen five people or they've been dealing with this for so many years. like, but what they don't know behind the scenes is that there's sometimes where we're like, I'm having to like phone friends and like, but you have to, I you just have to, because we all work together. So I mean.

There's... that's always...

That's a weird joke.

soon.

Yeah. Yes. Yeah. Yeah.

And I know when we go to our meetings, like our last meeting, we were all sitting at dinner, like, we should start ordering this test for this condition and doing things like that.

Yeah, that's how it starts, right? Like that's how, even if you think, if I think back to like even understanding, you know, we now know between connective tissue disorders and inflammatory responses and endometriosis and all the things like, remember having these conversations with people at Ishwish, like, have you ever noticed that all your patients that have endo have POTS and you know, like, and then you put the pieces together and then all of a sudden people start like, yeah, let's look at this even closer and then you meet other people.

Yeah.

Yeah. It's the best. It's the best. I know you've had Alexis Kutchins on, listened to that podcast and I low key obsessed with her. But yeah, but like I heard her say something and she said that, she said, I think doctors should.

But I think that's how science changes too. It just takes much more time. Yeah.

Yeah.

obsessed with door shoes.

go, like as part of continuing education, to be required to go to other specialties meetings. And I think that's so spot on because you learn so much by collaborating and working with other specialties because we have siloed ourselves off in medicine so much into I just do this and this is my box and I'm a gynecologist and I just do.

I'm %

Yes.

Right

uterus and vagina and what gets neglected and all that, the vulva. We didn't get trained in vulva. And then you start talking to other specialists and a cardiologist, you see people with pain in their genitals? I see that all the time, but it's interesting. It's so fun.

Yeah.

Yeah. Yeah.

Yeah. Right. And that's how you put the connections together, right?

And that's what Ishwish does so well. I mean, we all could talk about how much we love Ishwish, but I mean, unlike any other conference I've been to, it's so multidisciplinary. And I learned so much about the spine and nerves and like the brain and things that like we weren't trained in. I'm a gynecologist, right? So I just love that. And then also kind of going back to what you saying about, you know, we always say evolve as a team sport. So I also love how we, you know, can always talk to each other about, we at Ishwish, meet each other. We know who's working in this space. And when we have these hard things, we can be like, Hey, what do you,

Yeah, yeah.

Yeah.

What do think about that? Yeah, totally. And I think that, you know, whether I don't know if you guys were at the lunch and learn by what's Cecilia, I can't remember her last name, but she discussed sort of some of the issues from like a patient perspective, but also from like a law and sociology perspective. But one of the things she said is one of the issues that patients notice is when we're so siloed that we start seeing people as just their parts. And so patients like start to think that too.

What do you think about this, ma'am? And I love that we have that collaboration.

Yeah. Yeah.

And so some of the patients with really bad vulvulaginal disease, like there's even this whole idea of like, they're thought of as the heart sync patients that when a clinician sees them in the waiting room and they know who they are, their heart syncs because they can't, like they either don't have the time to help them or they don't know what to do. But the patients are aware of that too. And I feel like that is the subspecialization of medicine that almost has to happen

Yeah? Absolutely.

should not leave out all the other things. And I think one of things that we do in our private practices is really talk about other systems because we have time to kind of explore it. But I think, yeah, I totally agree with you. I think that that's one of the things that makes Ishwish special, but also helps us understand that really women's health is a team sport. Like we can't do it without anyone else.

Hmm.

Yeah. Yeah.

Absolutely.

Well, what do you guys think about, so hold on, I'm to bring up some questions. Okay, so let's just start with sort of missed opportunities in vulvovaginal health, right? How often are people coming to you guys and I know you're in different parts of the country, but we all see it multiple times, yeast infection, yeast infection, untreated, it's not yeast at all, right?

Mm-hmm.

How often are you seeing that and what is it usually when you guys see it?

I mean, like, esclerosis is probably the thing that always comes to mind, you know, that, and you hear that in so many different scenarios. And even in passing, I'll hear people like, well, you know, I had, like, my daughter, you she had a baby and she has all these yeast infections. And I'm like, it's not really that, like, it's not easy to find that, that's like, it's sclerosis. Yeah. But that's probably the most common thing. But I think even just...

Right.

Yeah.

complex genital pain can even be presented as itching in the vulva and burning and people think it's a yeast infection and then you have to, you get these patients and they come, we know they show up with a binder about this big of so many tests and you kind of have to take a minute and go, like validate it and go, yeah, I understand but you have to realize you're still not better. We need to look more outside of this cotton swab.

Alright. Mm-hmm. That's not a path of healing.

Mm-hmm.

Yeah.

You

Yeah, Yeah. Yeah, and.

No, of course.

that's going in your vagina when your problem's on your vulva.

Yeah, no, for sure.

Yeah. I think about like in simplex chronicus, so just like just kind of chronic inflammation from scratching, things like that. And then contact dermatitis too. I mean, definitely like I some patients recently that are really into that vagicill, you know, things like that, that like they think are helping them. It's helping their pain, but like ultimately, like I think it's actually causing their pain because it's like they're reacting to it. And so that kind of thing.

it.

enough

Yes. Yeah. And I do think some people don't recognize that itching is a neuropathic pain symptom too, right? and so I think those of us in this space have come to realize it's not something that's, I think, wholeheartedly ever taught to us. You know, like, I think that it's only like, oh yeah, but you know, the itching was actually a result of, you know, an inflamed nerve or peripheral nerve or a nerve ending.

Mm-hmm.

Yeah, and I don't know why women particularly, I don't know why it's so, is it more PC to say it's a yeast infection? Automatically they just go to yeast. That something's wrong down here and it must be a yeast infection.

Mm-hmm.

Right. And probably like because they can self treat it to right in this age of us direct to consumer stuff and how, you know, I mean, we can talk about this to have the whole idea of us as clinicians and doctors is going to get like weeded out in the future. Like, you know, all these tech companies are saying all this stuff about AI is going to replace doctors. I know if you saw that when they had the big chase healthcare.

Yeah.

conference where all the venture capitalists can come and they try to see who they want to fund. This one guy, can't remember his name. I'll have to put it in the notes. But he said, you know, we tell doctors that AI is not going to replace doctors, but we only do that so they can give us all their information because AI is going to replace doctors. I mean, he said it blatantly, right? And you're just like, this is what's this private equity concept is really screwing up.

Wow.

Yeah.

it's screwing up medicine because their bottom line is always going to be money, right? Like, you know, the bottom line is money. And so I think that is I mean, and I think there's probably a role for AI and everything that we have to accept it to some degree. Right. Like, I don't know. But I mean, how are you guys seeing it in your in your practices? You see people using AI a lot. Chat, GPT, these chat boxes.

Yeah.

I have patients that'll chat, know, oh, chat said this, you know, I had one, it was a while back, but she said that the progesterone IUD was FDA approved for uterus lining protection with menopause hormone therapy. And I said, well, chat's got that one wrong. That actually is not the case. It's not, good try chat, but that is actually not true. So, I mean, it's not perfect for sure.

Yeah.

Mm-hmm.

Yes. That's a lot.

Yeah. Yeah. No. No, it lies along.

Yeah, I've had a patient find me by chat GPT. I mean, and I was like, it's so interesting. But, I think if you are, you know, a lot of these patients are like Googling where they can find help, how they can find, you know, like what they can do. And then I think people like the three of us sometimes will appear just because we have blogs or podcasts and things like that. And I think that's actually really helpful. I was like really surprised, but she was like, I have this pain for 10 years and no one's been able to help me.

Yes. Yeah. Yeah.

And like, I found you and I was so glad she did because I did an exam and I identified what the problem was. And so, yeah, it was, you know, just some like and plainness that no one had ever looked very closely at. So I was happy that that chat GBT had sent her my way. So I think for those kinds of things will be good. I think it'll be interesting how AI changes things. I think it can be helpful. But, you know, so many of our patients, what they really need is someone to listen to them.

Yeah.

Yeah, yeah.

Yeah.

Yeah.

and validate their experience and not feel dismissed. And I just don't think that AI is going to be a good hand holder and really like have the empathy that I think patients that I think all three of us probably are really good at providing the patients, right?

Yeah. Yeah.

Yeah.

Yeah, right,

I mean, plus it's algorithmic automated care, right? And so we're all about nuance. We're all about looking at the person in front of us. And so you're telling us now that like, we're gonna automate care that is written probably by a white male, you know, who is not gonna take into anything else into consideration, which will just layer more bias and medicine as we speak, I think, you So think that's what's the, that's where I have trouble with it.

Yeah.

Yeah.

Mm-hmm.

Yeah. Yeah.

But the one interesting thing that I've found is I just telling guys offline that my son turned 16 and he had the flu. And so these kids are using chat GPT, right? So he comes to me asking if he should be on X, Y, and Z. And I'm like, okay, you know, like I'm an actual doctor, right? Like, you my husband. And so then I take him to the pediatrician because he needs to get swabbed. And I was so surprised at how he could communicate with the pediatrician.

Yeah, I think.

because he had used chat GPT to help. And I think that is where we'll see the tool as a benefit because I never thought of it in this capacity. usually I have to interject with him every few minutes when I'm with the pediatrician. I said nothing because he hit all the things that the pediatrician needed to hear. And I was like, well, how did you know to say all that? And he goes, well, when I chat when I was chatting GPT. So I think in that capacity as like an advocacy tool, it might be beneficial.

Mm-hmm.

Hmm.

and, and so that was when I said, okay, well, maybe there's something.

Yeah.

Well, I'd be curious, the, like, just even how are you using it in diagnostic tools, you know, like, with imaging and things like that. Like, I know at the menopause meeting a couple years ago, they had a GYN oncologist, and they're talking about how using it with, a colposcopy, where you're looking at a cervix, and, it can, like, detect where to biopsy and how it was probably better than human detection. And then there's a recent Ms. Medicine lecture with the breast radiologist, and was great. And she was saying how, with breast

Yeah.

Yeah. Yeah.

density, which is determined just by the radiologist's interpretation and visually. And they have an AI tool that they can kind of turn on, which actually is pretty good at kind of maybe even swing them more one direction or the other to really decipher, is it more dense? it less dense? You might be a C.

vision.

or a C minus, kind of something along those lines. It was really interesting to see it. She's like, when you're kind of in that gray zone and you don't know what to call it, you can turn on this AI tool for the mammogram. So yeah. So I don't know.

Yeah.

That's so interesting. Yeah. so, and so it might, I think, in some capacity for our patients who, you know, because I think we deal with people who are already have become depressed and anxious because they're chronic or vaginal conditions. And so maybe in some capacity, it might help them to better.

you know, because it takes a lot of, I think, intestinal fortitude to keep going to a clinician doctor over and over again, right? Like, and so I give our patients so much credit because, you know, then they have to go and relive the story again in hopes that you're rating that, you you heard about that this doctor might actually listen and have some different response. Like, I think that's what I see is like very interesting that, you know, maybe this will help, you know, them to collect their information better or something. You know, I'm just thinking how it might help the full vaginal world.

Yeah. Yeah. mean, it gives them, like your son, just more tools and information to just communicate. And yeah. And it might even just shed more light on situations for them to be more vocal and comfortable even with this, to validate, like, hey, this is a real thing.

I was like

Yeah?

Yeah. Yeah.

Yeah.

Because it is, like you said, so isolating, because this is such a shameful part of the body. And if this is something that's wrong with me, I'm the only person that has this. But really, this stuff is so common. We see it all the time. It's just people talk about it. They don't want to talk about it. It's a silent thing.

Yeah. And it may help give them the language to talk about it too. Like the anatomy, the part, you know, like we talk a lot about in our podcast, like, you women aren't taught these, these, like their vulva anatomy, like the Libya and the Libya menorah and the Libya majora. So, so often I'll ask people, where does it hurt? And like, you know, is it the inside or the outside? And if it's on the outside, where on the outside, I'll pull out my little vulva puppet, like what you have and say like, where, show me where. Yeah, exactly.

Right.

Yeah.

Yeah, yeah.

Thank

Yeah. I literally, I literally, this is about, I have this sitting on my desk and I always think, I'm like, this vulva is staring right at the patient sitting across from me. But they're like, it hurts. I'm like, show me where it hurts. Like, where on this part? You know, it's, because they know, but they just may not know the nerve. Right.

Yeah.

Yeah, yeah, yeah, they just don't know the words. But I think that's why I think our education is important for helping them to kind of delineate because you can't really get help if you don't know how to communicate that help.

Yeah, definitely.

And I think that's like a, I think they call it like a cultural health capital almost where like you have the right language tools and vocabulary to get forward when it comes to your healthcare. And that would make you have like a more successful outcome potentially. Let's talk a little bit about sort of vulval vaginal infections and the most common things like.

I feel like BV is the infection that keeps coming back. The X that won't go away. Let's talk about your approach to recurrent BV, for instance, and you guys can both chime in. If one of you can just review for who is listening what we described as BV and then go from there. And the new research, maybe tell me how you want to use it.

Yes.

Ashley's the microbiology nerd, so I'll let her take this away. She loves microbiology.

Okay, let's go, Ashley.

I do. I love microbiology and microbiome stuff. And I think that's one of the biggest things I always tell patients. know, BV is, you know, it's a microbiological state. It's a microbiome shift. So it's not just one bacteria. It's a conglomeration of not good bacteria and less good bacteria, right? And usually the symptoms are like that kind of thin watery discharge and the fishy odor. Although sometimes some patients will say they feel itchy or

I'm good. Yes.

Mm-hmm.

Right, Yeah. Yeah.

but it's generally not because it's an osis, not an itis, right? So it's not inflammatory. Although I definitely have some patients that do feel those things. But I guess one of my big frustrations in the BV space is just that I don't know if this happens in Chicago as much as it happens in Seattle. People use these affirmed DNA tests that test just for Gardnerella and it comes back positive and they end up getting treated over and over again for a false positive.

Yeah.

BV tests when they don't really have BV, I really like either the PCR that's like a multispectrum PCR that will look for the good bacteria and the bad bacteria and give you kind of a bigger, like we call them new swabs or aptoma swabs. I think that's a much more accurate diagnosis. And I always look under the microscope because I just like sometimes that is the... People still tell me their story of like, when did it all start? Well, I had BV over and over and over again. I took metronidazole over and over again and then I got a bad yeast infection. And now I have this...

Yes.

Yeah.

Yeah. Yeah. Yeah. Yeah. Or just start like an inflammatory cascade of stuff. Yeah. so and then we have that. But we do know that their recurrences do happen, you know, at least a third of the time or something like that.

chronic vulvar pain. I'm like, but it kind of all started from like was did you really have baby or not? I don't know.

Yeah. Yeah.

Yeah.

Yes, yes.

Yeah, I mean, there's some people I think that in the microbiome, I don't think we're totally there yet for vagina, but there's something there. And some people, there's different types of microbiomes and some people that's just, that's more prone to shift that direction.

Yeah.

Yeah. Yeah.

And so now, and although we never used to classify it as an STD, I think we all had the patients in the past that were just with one, this one partner would start getting the VV. And then I remember, I still remember this patient and she was like, I'm just, she finally like ended the relationship and like.

She never got BV for like another year or something after that. so I'm just posing somewhere. And so do you guys want to talk about that paper? I talked about it at one point on this podcast, but the paper that came out was JAMA last year, I think, right? About recurrent BV in treatment reporters. And are you using it? Are you using it in your office? Totally.

Mm-hmm.

Yeah. Yeah, definitely. think it's exciting. I agree. It's not necessarily that it's an STI, but just that we know that this bacteria can be passed back and forth, right? And so in that study, treated men with a male partner with oral metronidazole and topical clindamycin. And they saw like a 50 % reduction in recurrence. But I think the thing to take away from it is they went from like a 60 % recurrence rate in that 12 weeks to like a 30 % recurrence rate. So it did definitely help it, but it's still really high.

It's still really hot.

I think it kind of like reminds us that we don't totally understand exactly why people have these recurrences. And like Marissa was saying, we know some people have a microbiome that's more likely to send them down this path. That's just their baseline. so how do we, what can we do? And I think that there's definitely different regimens out there of metronidazole once or twice a week, like methamethamethanol metronidazole after a longer course of oral flagel, or sometimes triboric acid.

you

Mm-hmm.

patients. not always a huge boric acid fan, but sometimes if they feel like sex is one of the triggers and the partner's already been treated, then sometimes boric acid after sex, that kind of thing. Meredith, do you have other things that you try for recurrence?

Yeah. Yeah. I mean, you know, I always, I ask every single person like about their period and, you know, because some people here are people like, it's every time I get my period, you know, and like, well, that's blood and blood is a higher pH and part of the diagnosis of BV is a pH above 4.5 because your normal vaginal pH is 4, 4.5 and so there's probably something in women who think these, their microbiome that just lives at a higher pH, they have less, you know, good lactobacillus and...

Yeah.

Mm-hmm.

And so it doesn't take much for them to flip to symptomatic. so you'll hear, what's worse is my period, so could you maybe work on their menstrual bleeding? And then of course semen is also basic. And if they're having sex without a condom and with a penis, and like I just really one recently, and she had baby, and had odor and all the things. then ever since she's been using a condom and has not had baby. So you kind of like even just like just what's happening and creating disruptions in their.

Yeah.

I mean, so.

Microbiome.

Yeah. And I think the key is here, like, you know, we have guidelines and we have algorithms, but there's like no one size fits all when it comes to some of these more complex patients, right? Like, it's not like you're throwing the same thing at every single patient and one microbiome isn't identical to another. Do you guys like those direct to consumer sort of, you know, kits that people bring?

Yeah.

Yeah.

Yeah.

Yeah, think they're I mean, I think they're promising I think they're great in data collection You know, I think we'll get a lot of information from it But you know again like you have people with certain symptoms that that reach out to these things and it might be a vulva itchin burning pain that they and they come back and they're like well it must be this because this Q-tip in my vagina that I sent off has yeast on it and Like really it or it's like an sclerosis So it's

Yes, exactly.

I

Yeah.

Yeah. Does someone look at your vulva? Has anyone ever looked at your vulva?

Yeah, yeah. I I ask women all the time, like, I went to the emergency room and I had a pap smear. I'm like, well, don't really get pap smear in the emergency room. And then I'm like, did anyone even look down there? And they often don't. They just empirically treat them for things. And they say, well, it has to be a UTI or a BV. It actually requires an exam. AI isn't going to do that.

Yeah.

Yeah.

Right.

Right, Let me be honest, most of us probably, I I feel like lichen squirrels, some of these conditions, you can't unsee once you've seen it enough, right? Like you can't unsee the loss of the labia minora. You can't unsee.

Mm-hmm.

these patches of, you know, like, kind of vacation and all the things. So, but what I, what I think happens and tell me if you guys agree is that because we in gynecology really, mean, I'm sure it's changing now, but at least when we were getting trained, didn't have this great sort of, understanding of all our anatomical changes that happened. Nobody told you the first exam should start by, you know, let's retract the clitoral hood. Let's look at the labia minora. Let's look at the labia major. Let's, you know,

Yeah, I've seen it.

Mm-hmm.

not just swab for SPIs or that lesion that might be herpes, right? And so.

Yeah.

Yeah, I mean, Ashley and I trained at the same place. I don't know if you guys I mean, like, you mean, I like it, the clitoris was a no go zone. Yeah, don't you dare even consider it. Yes.

No go, no go. mean, you do not get, don't make things uncomfortable. And it's like, okay, I mean, and you know, there is obviously new, I mean, you can't just, you know, examine a clitoris without explaining it to, you know, you can't, there's bodily issues we have to address, right? Like.

Mm-hmm.

we in this space do have to be cognizant of the fact that like we have to talk, we have to talk to our patients while they're dressed and tell them exactly what we're going to be doing. Right. And because I know that people have gotten, you know, there, I remember hearing at Ishwish maybe five, five, six years ago, there was somebody who started examining clitoris after, maybe didn't explain it. And so I think got like written, you know, some sort of something happened from a legal perspective to him. And it happened to be a male too. So I don't know, you know.

Mm-hmm.

to what extent you weren't communicating why you're doing it, right? And so there's always that issue. But I think for sure we were told never to examine the clitters, is like, urologists are never taught not to examine the I guess the go-to. I think, again, it goes to the fact that we don't value women's pleasure, I think. We're just trying to take the fires down and make sure that things are not like...

Right?

inflame red on fire kind of things, but not trying to make life better without thinking about it.

If you don't acknowledge it, it's still just this shameful we don't talk about organ, which is, yeah.

Morgan, right? The only organ made for your own pleasure. Yeah. Problems, big problems.

Right, right.

which can actually cause, and it can actually cause people problems. You know, if I have pain and it's in my clitoris, how terrified are you to reach out to a doctor about that?

Yes?

Totally, totally, right? And so that's why I loved when that New York Times article came out with Rachel. It's a couple years ago. Half the world has the clitoris. Why are doctors not examining it? It's because we were told not to examine it. I do think that things are changing now. People are a little more aware. But I still see it all the time. I'm sure you guys do too. How did they not see this on your vulva?

Mm-hmm.

Yeah.

Yeah.

Don't touch that. Yeah.

Yeah.

You know.

Yeah, think people, mean, I often think you just put the speculum in and do the PEP smear. That's what you're down there for, right? So it just gets, it's a fly-by zone, flyover zone. You just don't even notice it. So it's just terrible.

Right in there. Yeah. And right. And nor do you really have time to notice it in a 10 minute visit, right? Or 15 minutes. So I mean, you we all work outside of the health insurance system, but I can tell you, like having done it in an insurance based model, was challenging to try to see the number of patients that you need to to keep your roof open.

Absolutely.

Yeah? Yeah?

you know, or dictated by your medical institution that you work for. You have to 30 patients a day to keep, you know, whatever. And so, you know, we all know the healthcare system wasn't built for women in mind. I mean, really no patients, but especially not women. So what about like when it comes to recurrent yeast? Are there any go-to things that you guys, have you guys tried like, you know,

Yeah.

Yeah, keep the lights on.

Yep.

No.

Don't you see when you start women on menopausal hormone therapy and then they, know, yeast love estrogen. So, they're always like, wait, what? I thought like this was supposed to help my natural microloin. So, you know, the people that have tendencies to it, what do you guys do for recurrent yeast infections when you know it's yeast? And how do you distinguish between, you know, what's the different, do you guys do testing for the different types of yeast and everything?

Yeah, I mean, me being the big microbiology nerd I am, I just love the yeast and I've had some really interesting patients lately with like, I had a Candida lucetain the other day and I had a patient with recurrent Saccharomyces cerevisiae, like could not get rid of it. I think we just did though. And I think we finally persevered and got it. Anyway, but it's just been fascinating. So, I mean, I, for like, you know,

It's just tough.

for regular recurrent yeast, Canada Albicans, which is kind of our run in the mill yeast, will put them, if they've had it, by the time they've gotten to me, like this has been going on for long enough, but usually I'll do a couple of doses of oral fluconazole and then I'll put them on a suppression once a week for a couple of like three months and see if we can come off of it. I definitely have some patients that like I'll leave on for longer. Definitely have this lecture from Jack Sobel.

Yeah. Yeah.

you

seared in my head of like him saying that this is a genetic thing. So people are genetically predisposed to getting more recurrent yeast and some people need long-term like azole suppression. So I was always kind of scared of giving people for too long, but I think people just need it. When you stop it, it comes back. There's more more azole resistance though in some of the in Canada Albicans and then Canada Globalta is the other one that's more most common and that one has a lot of resistance. So

Yes.

you

I think when we get into these more rare yeasts, we get into these places that we don't have as many options. There was this great medication called Brexifem on the market for a while, and now it's not for unclear reasons. I don't even know if it's ever going to come back. yeah, so it's.

I don't know. Have you guys used Bepzoha at all for the postmenopausal woman? have you kind of like...

think I've used it like once or twice, I know like Jack Sobel was giving that lecture and you know, he was saying that they've compared the Joa to the weekly Fuconazole and it's pretty much the same, you know. So I tend to use just the weekly Fuconazole.

I think for Canada, Galbraata, that it might be a little bit better. I guess it's supposed to be like fungocidal versus like fungostatic, meaning that it's trying to really, for those listening, eliminate all the fungus as opposed to reducing it. And so, you know, is there, I have used it a couple of times when it's gotten approved by insurances, because that's the other hurdle, right? Trying to get the right insurance.

Yeah.

Yeah, exactly.

And so, yeah, we'll see. mean, it'd be nice if more options were available.

Yeah, they're tough. Those are really tough cases.

Yeah.

And then, course, it's like a really, I mean, you've probably all seen these really bad vulva vaginitis, where it's really like the vulva is so, I mean, I just remember seeing the most enlarged vulva ever. And I was like, this is yeast. And people were like totally blown by it because the labia can really get endemic when it's really on the vulva. So I think that's something people consider enough either. And what's your take on that?

Yeah. Ash.

the over-the-counter one-and-done doses that'll like blow it to that level.

Yeah, monistat. Don't do it. It's so bad. It's so bad. And there's no going back if your vagina is not a fan. It's over. It's so bad. It's like that and Vagisil. Why are they over the counter? It's awful.

Don't do it. Don't do it.

Don't do it, I you're going to agree. Do not do the one I'm done.

Yeah. my God. Like just thinking about, I didn't mess, right? It's like, why are they over the counter? I wish I'd do that one day. The next time we're together, we'll go through that. You know how some people do that? They'll go through the computers and say, what did, how many, two out of three OBGYNs recommend this? Like, let's go and see. Two out of three global imaginal specialists. What do we recommend? Are we three? Yeah. So you're out of three recommend this.

The drugstore, yeah.

Yeah.

We should do it.

Yeah. Yeah. Yeah.

Three out of three, do not recommend.

No, it's so true actually. And I think that's sort of one of the things that I see sometimes like start precipitating some of the worst inflammatory infections, right?

Yeah. Yeah. Yeah, that and the dreaded medicine that makes you urinate sugar for diabetes. It's some of the worst yeast infections I've ever seen in my life.

Yeah, for sure.

Yeah, no, you're right.

It's like, I actually had a patient the other day and I saw it on her med list. thought, oh God, I'm like, are you okay? She's like, I'm fine, I don't know what you're talking about. You're like the one person I think that I've ever met. But I don't know because they come to us because they have problems from it. But she was doing fine with it.

Right. Yeah, that's totally true. And then I wanted to ask you guys about how you treat sort of when it's in between inflammatory, infectious, and hormonal. Like what's happening with something like a disquemative inflammatory vaginitis, right? Like that's one of the things that I think we see a lot of because of what we do, but probably a lot of

I have a lot of clinicians that listen, so there might be people that have never seen it or heard of it in practice. So walk us through the type of patient you see with that kind of condition.

Yeah, DIV is what led me to the vulva conference, actually. Because I was so, yeah, I was so frustrated and I just felt like I wasn't helping this one particular patient. And I literally looked at her and I said, I feel like your vagina skin is falling out. Like I couldn't figure it out. And you know, because it's just so much copious discharge that they have. mean, it's, it's, and it hurts and it's pain. Like it's just the worst.

But which size is he?

you

Yeah.

night.

painful sex and everything.

It is the worst. And then recognizing, god, that's what that was. And at the time, I just gave her estrogen cream, and it kind of got a little better. But those are really tough. I think, no, it's kind of almost a diagnosis of exclusion sometimes. But it's using the microscope and the pH and the story. And so many of them are in that perimenopausal.

Bye.

Yeah.

It's not an easy diagnosis either, right?

time when it comes, but I've seen it in younger women too. So yeah, it's a challenge.

too.

I think it's hard sometimes to patients who come to me, I'm sure we all have this, well I don't have the symptoms today. I'm like, oh, I'm like, well thing is your discharge is normal, but then they send me pictures of like, like discharge that looks just like DIV and I'm like, but I need you to come back a different day. So I always think it's, I'm sure some clinicians are like, ooh, pictures. I personally am like, oh, pictures awesome. Like I want to see what it looks like when it's really bad.

Yeah.

Yeah.

Yeah.

Yes, yeah. So can you explain to other people listening like how would you define it and how would you diagnose it?

Yeah.

Yeah, mean, DIV is a high pH, usually higher than five. mean, bright blue on my paper, my pH paper. And then tons of white blood cells. It's super inflammatory under the microscope. then lots of what we call parabasal cells, which are cells that are like that first layer of mucosa in the vaginal mucosa. I think of them as low estrogen cells, but they're not necessarily that. But just like that first layer, but they're sluffy. I mean, it's kind of like the skin inside the vagina is

Yeah, course.

Yeah, exfoliating always.

And then they usually have like, like you see inflammation inside either at the opening or on the cervix and they just have copious, copious discharge. And so those are kind of the ways that we define it. It's something that will never show up on a swab. So these women often will come in have been tested a billion times and everything's negative. But it's in a lot of times they will, you know,

Yeah.

It is kind of on the spectrum of this, know, aerobic vaginitis, right? But it's like, it's hard to say if there's a particular bacteria that causes it. It's not really an infection. It's like a, it's like a, I kind of like a non-infectious like inflammation, basically.

Thank

Yes.

It's like, yeah, I kind of look at it as like a skin disorder, you know? And there's some thoughts of like, is it kind of like, I'm like in plantis associated, like we just don't totally know all the things we need to know about it yet, but you can kind of see it even along with a like in plantis patient, like they'll have it in the vagina and it creates a DIV picture.

Great.

Yeah.

Right? We don't know.

Yeah, no, for sure. And so I think most of us have to like compound something for them to use. Like I use a steroid, clindamycin, estrogen compote. That's what we've all learned. I'll learn this. Maybe a little bit hormonal, maybe.

Mm-hmm. Yep. Just hit it. Just... Yeah. And a lot of them... go ahead.

Well, think like the most of lot of the recommendations are like, well, use Klinda and use Klinda, you know, every night for four weeks and then drop down. And then if that doesn't work, add estrogen. And if that doesn't work, hydrocortisone. I'm like, why are we doing this? Like, at least by the time it gets us, they've been messing with this for a long time. Like all three, you take all three.

Yeah.

Yeah, just.

All three. All three. Exactly.

Yeah. Yeah. And a lot of them need a maintenance after even like it's they might even need to use something once a week, I find. And then of course they all need vaginal estrogen after. Just keep that, keep that pH normal.

Right. After it's one minute. Better. Yeah. And I think those are the, cause it is true. Cause then they always didn't have like the stickiest sort of discharge and it's like stuck. Their vulva can be stuck to each other. And so I think those are some of the cues that we see, but and unfortunately I feel like we deal with the patients. We were talking about sort of like the patients that get gaslit, but you know.

Yep.

Let's talk a little bit about medical gas lighting. What are the most common stories you hear from patients who have seen multiple polvoiders? what's the most, like, someone actually said that to you? Like, have you, did you guys have, like, some good ones? We all have some.

Yeah, I had one this week. was like, I was so mad. And this is just a high-risk breast cancer patient and was doing really well on Do-A-V, which is a great option for her. Two medicines and one pill, both negative at the brass, treating her off-lashes and protecting her uterus and all the things. And she met with an oncologist who told her that they couldn't condone her taking hormones.

Yeah.

Cool.

and she's getting screenings every six months. She doesn't have a gene. She's doing all the right things and she's miserable. And then with her vaginal symptoms, they wouldn't let her do vaginal hormones. And they said, you're just gonna have to figure something out. I was...

Yeah.

She says, here's my list of

You're just going to have to figure something out. Well, that's why I'm here.

That's why I asked you for help.

I was floored. I was so mad for her.

Great.

Oh my God. I had a patient tell me that like her doctor said, well, you've been through childbirth. Like how bad could PGAB be? Like your body was made for this. You've had babies. Like, so what? You have a little arousal. Like what? Like these women are so straight up.

my God.

my gosh, it's so bad.

Yeah, and the condition that this has a known suicide rate. It's awful.

Yeah, yeah. It's crazy. What about you Ashley?

Yeah, that's crazy.

I mean, think women are dismissed so much, especially in these spaces of hormones and pain. And I think a lot of it, because we know so many clinicians actually are pretty well intended, I think a lot of it has to do with lack of education. Like they don't really know how to help them because no one's taught them. Like no one taught us. I'm not defending what they're saying. I don't agree with what they're saying. But I think a lot of it comes from lack of time in our health care system and then lack of education on these issues because I think if people

Right.

knew how to help these issues, they would want to help them. don't think, I think, or they've been like, they've been told like hormones cause cancer or they haven't, they haven't gone past that point of education or 2002 WHI data and haven't realized, oh wait, it doesn't. and so that's how this all happens. But we mean, the stories are ridiculous. Like you don't have enough hot flashes to take HRT. you know,

Yeah.

Yeah.

Yeah.

Yeah.

Yeah, right. just like things like that or you for all the sexual health stuff. Well, I mean, you should just have a glass of wine. You should, know, whatever it is, relax more, you know.

The glass of wine thing is so common. It's crazy. mean, it was even in that paper by Kaylee Moss on Get Medical Gaslighting. Yeah, just relax. Thank yourself on Bubble Bath at all.

I, yes. Yeah. Just, just relax. Yeah.

Yeah.

Yeah.

Yeah. Go on vacation. Go on vacation sex.

Yeah, that'll make you want to have sex with that'll make you want to have sex more.

Yeah. No kidding. Oh my God. I mean, you know, the truth is we know, we all know it's biopsychosocial. It's much more complicated than, you know, one thing or another, but you can't just always tell people everything is super tentoral. Like it's not, because then it really does become that way, right? Like how many of our patients become anxious and become depressed because at the end of the day, they're dealing with chronic pain. Like it's really hard.

Yeah, absolutely.

Let's do little lightning round for just for some fun because I know we're about to get, you know, let's start. Okay, what do you guys think about, do have patients ask you, should I sleep naked for better about mobile vaginal health? Yes or no?

me that a lot but if I were asked that I'd be like you do you do you whatever works.

Yeah, I had a patient ask me, and I was like, you to repeat what I taught.

Yeah, I mean, I've heard that that's better. You know, like, I definitely have heard people say that that you should do that. And you share things out. I tell people like, if that feels awesome, then they should do it. If not, then don't like, so I don't feel strongly about it.

Hear it out.

Yeah, yeah, yeah, I guess. What about cotton underwear? A must or must have or no?

I think it's a good idea.

Yeah.

good idea but again like if you're wearing something else and it's not bothering you it's fine.

Right. I think we all give guidelines for a mobile vaginal health. And I feel like these are guidelines given to the majority of women who suffer from one of the conditions. Most people can probably wear songs and they're OK. But it's never like never wear a phone. But the people that we tend to see, songs are the worst thing for them, right?

Yeah.

Yes.

Yeah.

Right.

Yeah, most of our patients are not wearing underwear and wearing dresses because they have pain and then that just exacerbates their pain.

Right.

Yeah.

Right. Right.

Yeah, yeah. I remember I saw one of my patients recently and she was wearing tight leggings and my mouth dropped. I was like, my God, are you better? And she was like, well, yeah, how did you know? I was like, you're wearing leggings. I can't believe it. And she was like, yeah, no, it's true. But I think that that's what patients learn to kind of like.

It's a win, it's a win.

You

make their lifestyle fit their pain versus like, you know, if I fix the pain in the process. I think while you're doing it, while you're getting evaluated is something that has to get done. But what do you think, panty liners, are they villamists or do we think that like people, I mean, I think it's, again, it's like, what are you using it for, I guess, right? Like.

Yeah.

Yeah. mean, some those panel layers have a bunch of fragrances in them and can be irritating. I, you know, if people feel like they need it because they're leaking a little bit of urine or they've discharged, mean, yeah, it kind of depends. I think like I love the idea of underwear, like trying that instead and seeing if that's better. But I definitely think it can be irritating. But for some people, they wear them every day and they're fine. So.

Yeah.

Right.

Again, it depends on what you're susceptible to. I wear lot of incontinence underwear because I just haven't when I exercise.

I was a tampon wearer when I exercised for that and then I did public floor physical therapy and actually doing a lot better.

Yeah. good. Yeah. It helped me for a bit, but I probably need to sling at some point. I have to get myself to do it. Because doctors are the worst patients. What do you think about probiotics for vaginal?

Yeah.

in all that spare time we have, right?

Well, that's a good one.

I know, right? It's hard.

Are we there yet? Is it prime time?

Yeah. I mean, I think I like the idea of it, but I don't, I have a hard time understanding how the oral probiotics are really helping the vagina. Right? Like I don't, I mean, all these companies claim that it helps. So I think vaginally dose probiotics make way more sense to me.

We don't have a state.

I've been using, there's a couple of ones out there now that are just lactobacillus crispotis, which is one of the good lactobacillus I would really want. But I've actually had people overdo it and then had more burning because they had too much crispotis. I mean, I feel like, yeah, right? We could like almost.

Yeah.

that's what I imagine.

Yeah, you're treating one extreme and you go all the way by the other side.

Yeah. So I just think sometimes it's hard. think the idea of it is really good and practice. not sure we're exactly, we have enough data or understand exactly how this can help or what the perfect microbiome is, right? Like, and how do get people there? So I think that we still have some work to do on that. But I think for some patients, like for DIV, like when we're trying to kind of get them off that triple cream that we were talking about before,

Okay, bye.

like trying to regrow a nice lactobacillus like environment would actually be good, but it's just trying to, is there the perfect one out there? I don't know.

environment.

I think that's the hard part with supplements, There's like not enough standardization and not enough like to say that, so it's hard. It's hard to endorse stuff from my perspective. And I think you guys are the same way. Like it's hard to endorse something that we don't know is as evidence driven as we want.

Yeah, definitely.

But I have patients that come to me on this stuff and they're like, it's really helped. So I'm not going to like, you know, force them off. I know it helps you, but I don't like the Gerada though. if it's helping them, then I feel like it's, know, we'll do an assessment of their vaginal microbiome and go from there. So, well, it's been great. So what I always like to end with, so my husband jokes that like my listeners are vaginantes.

Absolutely.

Yeah. Yeah.

Yeah. Yeah.

So fun.

I like that.

I love that.

So what's your hot take or vagilante verdict for like the audience? Like what's the one thing you want people to remember or learn what to do or, know, what's your hot take?

Hmm.

My thing is know your anatomy. And if you have a problem, tell your provider where it is. Don't be afraid to say volva or just say outside. Really point and show them where you're having your problems.

Yes.

Yeah, totally.

Yeah. I mean, I was going to say that, you stole it from me. But it's a good one. I also think like, you know, if you're having, if you're having itching or an issue, you should, you should ask for an exam. And, you know, I think so often women say call and say, I'm itching. must, and then they're told you must have yeast and they're just given an over the counter or I'm not over the counter, an oral medication and it doesn't get better. I mean, they definitely need, you need an exam if things aren't improving. And if you're a clinician, like a lot of clinicians not

Yes.

to no fault of their own, was never taught about examining the vulva, you need to kind of find your way to someone who knows. And sadly, even not all gynecologists know, because I used to be one of them. you know, we just weren't taught this. So it doesn't feel like you should have to find like a vulva specialist for a lot of things, but for some things you do.

Yeah.

Yeah, for sure. I mean, to a point is like, know, medicine involves and you have to keep up with it. So I think a lot of people don't have the capacity to go to conferences or, you know, whatever based on where they work. Right. But I think, you know, even our understanding of vestibulidinia has changed over the last 15 years. So it's not even something if we were lucky enough to have someone to know about it in our residency, it's not even something we would have learned about back then. Right. Because it's like changed so much.

And so I do think that like that's why continuing medical education is so important and to keep your finger on the pulse of, know, vulva, vaginal health and metham hormones and everything. So, and it's hard to do when you're seeing 40 patients a day and you have to go home and chart for an hour and you get two weeks off a year and all the things. So like, I think we've all been in that situation where we were there. And so I always, I have always given.

Yep.

to all those doctors out there that are doing all the hard work because, you know, while it's hard to own your own practice, like everyone could agree it's another child in our life that we have to take care of. You know, we do have the autonomy to kind of do things on our terms in that capacity, to some extent at least. All right, awesome. Well, I'm going to put in the show notes, you know, where you guys can be found and everything. But I really appreciate you guys being on. This has been fun.

Absolutely.

Hmm

Yeah.

So thank you and we'll make sure that we have all your info on how people can get in touch with you and follow you and everything. But thanks for being on, was fun. Awesome, so thanks everyone for listening. I'm Dr. Spina Romano, Guido Girl. Remember, I'm here to educate so could advocate for yourself. Please join me next week.

Awesome. Thanks for having us. It was great.

Thanks for having us.