Why does vulvovaginal pain sometimes continue long after a yeast infection or bacterial vaginosis has been treated and the tests come back clear?
In this episode, Mathilde speaks with Dr Christina Enzmann, a board-certified OB-GYN and functional medicine practitioner who focuses on vulvovaginal disorders and menopause. Dr Enzmann is also medical director at Good Clean Love, a vaginal care company. She explains how the gut and vaginal microbiome connect, what damages the vaginal barrier, why pain can persist after an infection, and which tests are actually worth doing.
The gut and vagina connection: how gut health and inflammation shape vulvodynia and pelvic pain
Dr Enzmann started asking a simple question. Functional medicine has learned a great deal about gut barrier permeability, or leaky gut, so why would the same idea not apply to the vaginal mucosa? The gut helps set the body's inflammatory tone, hormone balance and stress response, and the gut and vaginal microbiome exchange with each other. She also points to the anatomy. The bowel, bladder and vagina sit close together in the pelvis, and women with endometriosis often have IBS and painful bladder syndrome too. When one of them is irritated, the others tend to react.
This also helps explain why people with vulvodynia, endometriosis and PCOS often have overlapping symptoms. Dr Enzmann notes that the amount of endometriosis seen at surgery does not match the amount of pain, so something must turn the volume up or down. She looks at inflammation, blood sugar and gut function. She also describes how oestrogen is broken down in the liver and then leaves through the gut, where an overactive enzyme called beta-glucuronidase can unpack it and send it back into circulation, feeding endometriosis. This is her clinical view, and she is open that parts of the science are still emerging.
The organs don't function in isolation. They really hang together.
Vaginal microbiome explained: lactobacilli, bacterial vaginosis, yeast infections and menopause
The gut microbiome thrives on diversity. The reproductive-age vagina is different. Dr Enzmann explains that it wants a near monoculture of lactobacilli, which make lactic acid and keep the vagina slightly acidic. That suppresses other bacteria and yeast, which matters because there is a direct route from the vagina to the uterus and abdominal cavity. Lactobacilli feed on glycogen stored in mature vaginal cells, and those cells depend on oestrogen.
After menopause, lactobacilli largely disappear and the microbiome becomes more diverse. That is not necessarily a problem, but it can look like bacterial vaginosis (BV) on a test. If a postmenopausal woman has symptoms, vaginal oestrogen may help more than an antibiotic. In younger women, BV means an overgrowth of mainly anaerobic bacteria, often with a fishy smell after sex, while a yeast infection brings clumpy white discharge and itching. BV also raises the risk of catching STIs and of preterm labour in pregnancy, so it is worth taking seriously.
Here we really want this monoculture of lactobacilli.
Why vulvodynia can persist after infection: vaginal barrier damage, over-treatment and sensitisation
Dr Enzmann sees several things that disrupt the vaginal barrier: antibiotics, unstable blood sugar, a high inflammatory tone, and above all the products used on and in the vulva and vagina. She names bar soap, loofahs and washcloths, panty liners, sprays and perfumed products. Many water-based lubricants also have an osmolality that is too high, which can draw water out of vaginal cells. Even treatments themselves can irritate. She describes people who use an over-the-counter antifungal, find the yeast gone but the pain still there, and end up with an inflamed mucosa.
A common story is repeated rounds of yeast treatment, then BV treatment, then yeast again, and then pain that will not go away. Dr Enzmann links this to barrier breakdown, an immune reaction, and sensitisation of the nerves. Central sensitisation is the term she uses, though she thinks peripheral and chemical sensitisation can occur at the same time, so that everything put in the vagina burns. In that case adding more creams is not the answer. Medications that calm nerve signalling, such as gabapentin (which can be compounded for topical use), may help, and she often starts by removing products rather than adding them.
Many things we see that are really vexing are often self-made. Like really just too much intervention.
Microbiome testing and what to do next: practical steps for vulvovaginal pain
Dr Enzmann only orders tests that will change what she does. In her office that means a nucleic acid amplification test for the vaginal microbiome and for STIs, and sometimes an old-fashioned culture, because it allows antifungal sensitivity testing and she has seen antifungal resistance. For complex cases she may use a more comprehensive vaginal microbiome kit, a gut health test and food sensitivity testing. She advises working with a practitioner who can interpret results, because microbiome tests are only a snapshot and a result that is normal for a 65-year-old can look abnormal to a layperson. She is also cautious about probiotics, since some strains can worsen histamine reactions or bloating.
If you cannot access this kind of care, she suggests starting with the basics. Stop using vaginal care products, and wash the vulva with clean water or a gentle organic gel on your bare hand, with no bar soap and no scrubbing. A zinc-based barrier cream can help irritated skin. If you use a water-based lubricant, look for one that reports its osmolality, or consider a clean silicone-based one. Dr Enzmann estimates that simply changing washing habits has resolved around 70 percent of her patients' problems. Then see a specialist who will examine you properly. You can reach Dr Enzmann through the contact form on her website or by email, and she is on Instagram.
