Microbiotalk: "Break barriers and address taboos in women’s health"

Renowned for her dedication to advancing women's health, breaking taboos, and improving patient care. She is specialised in Obstetrics, Gynaecology, and Oncology. She is Director of the Center for Gynecology and Medical Sexology at H. San Raffaele Resnati in Milan and a Consultant Professor at the Department of Gynecology and Obstetrics, at the  University of Verona.

Founder of the Alessandra Graziottin Foundation, she is dedicated to improving women’s health and addressing pain.

A prolific author, co-author and/or editor with over 28 books and 135 papers, she has delivered more than 1,900 international lectures and frequently contributes to media on women’s health topics.

Liberating dialogue in gynecological consultations

The dark side of the gynecological consultation between challenges to be faced and dreams to be fulfilled.

So:

1. Three key questions to set the scenes
2. Methodological issues
3. and the betrayal of pain that is the first body “cry for help”. This is pain. The body saying, listen to me. Help me. I need something to change my suffering.

The questions to set the scene

• Who is the first and last protagonist of every medical consultation? 
• What do symptoms mean?
• What are the signs?
• -And what does diagnosis mean?

First point. The human body, our body, is the first and last protagonist of every medical conversation, but currently, it is more and more neglected and betrayed.
Symptoms are urgent to request for attention. They are a cry for help, particularly when there is pain as a leading symptom.
Signs are the objective findings we can find with a very careful physical examination. We must read the body, and this is totally neglected today. And then diagnosis from the Greek means to recognize the disease through two leading information, symptoms and signs, and then targeted exams. No. Tons of exams, and then I hope to find something.

Who listens to the pain syndromes?

Pain is the most neglected and normalized syndrome. This is the betrayal.
Psychological explanation, "you are distressed, you are stressed, you are depressed, you are too anxious, you don't like your body? Change partner.
What's the point? Pain has a solid biological etiology, and sexual pain is in absolute the most neglected.

What are the enemies?

• Inadequate physician training: zero in sexual medicine. 
• Time restrictions: fifteen minutes from today, sometimes five minutes. I cannot even ask how do you do and not examine
• Economic and financial priorities.

So my point, in the darkness of the diagnostic omission, there must be a change.

Proactive investigation of early pain symptoms, say, the predisposing factors, for example, to endometriosis, chronic pelvic pain, bladder pain syndrome, vulvodynia, irritable bowel syndrome and so on.
So the body is neglected, it is progressively marginalized in the medical consultation.

Telemedicine is the betrayal, final. The patient, listen to that, is the spokesperson for that body. Every patient, a child, young, is a spokesperson. The voice should improve the dialogue between the body and the physician, yet she's usually interrupted in the first minute.

Imaging today is the preferred diagnosis, because we have the St.Thomas syndrome. We “believe only what we see”. But there is a major point here, that every disease has a long phase below the visibility, and yet the damage is already there.

So: “you'll give birth with pain”. “It's normal to have pain when you have periods.”

Pain has been normalized for millennia, but still it is.

Particularly, we see three major clusters of normalization:

• Menstrual pain and premenstrual syndrome,
• Menstrual worsening of inflammatory diseases and autoimmune diseases during periods could be endometriosis, blood dependent syndrome, vulvodynia, asthma, epilepsy,
• and also, the menopause driven pain symptoms, arthralgias, all the symptoms of a gentle urinary syndrome at the menopause, arthralgias, as I said, cystitis and sexual pain.

What is the truth about pain?

And this is a major universal truth in every human and animal. Pain is almost always caused by a microscopic biological damage causing a biological stress. And the microbiome in the gut is the first target of every stress, physical and psychological. This will cause a response in our immunitary system, that is our army, and this causes inflammation, that is a micro fire inside our body. So we have a war inside the body. And a longer war means that you will exhaust your energy, your living energy.

We have two opportunity when we have this war.

• One, to remove the etiological factor, limit the damage, and restore the anatomical and functional tissue integrity with what we call acute “resolving” inflammation.
• But when we do not recognize the etiology of pain, when we do not remove this cause or when the damage is too serious, then the persisting damaging factor will create a chronic, non-resolving, very destructive inflammation, leaving just scars at the end.

So my metaphor, that is true for every disease in every part of our body. Let's look at every natural history of a disease like a movie, with two times.

• In the first time, we just have symptoms. The first photograms of the movie, and it's there that I can change the plot.
• If I wait until I see the lesion after eight to twelve years, like in endometriosis or think about breast cancer. One centimeter of breast cancer, stage one, has 1,000,000,000 cells and started ten, fifteen years before. So you understand that we arrived too late, and my challenge is to go there.

That's why I'm so grateful to work with this fantastic group.

So if I look at this girl, she has to face 450/480 cycles. Just one hundred years ago, we had 140/150. So we tripled periods. And this means it tripled the inflammation associated with periods.

How much pain can and should be prevented in this girl?

Look at data. In Italy, we have the same data. This is just one data from UK: 76% of gynecologists normalize pain. So the vast majority say having pain at periods is normal. And the younger the adolescent, the worse the neglect of the biological truth and intensity of pain.

So another metaphor when I talk about endometriosis. Endometriosis is a biological civil war. It is our army against our tissues. Within the body, it is an immunity battle with genetic, endocrine, and microbiome driven fights. I presented about that at the International Congress in Dubai just ten days ago. With huge physical and emotional losses. This is the point.

And what happens when we deny the biological evidence of pain?

Pain changes its nature. At the beginning, it is nociceptive, we say. Send a friend that says: “beware, there's something wrong”. “Do something.” But if we deny that there is something wrong, biologically speaking, and there is a battle within the body, then it becomes a disease per se. Becomes neuropathic and nociplastic. So this huge inflammation will spread up to the brain and is the first cause of depression. Neuroinflammation causes depression associated to chronic pain.

So when sex hurts, for example, sexual pain disorders, vestibulodynia, pain and the entrance of the vagina, recurrent cystitis, what should I do? This is a paper of mine, very well commented by the reviewer. 

• I should have this picture on my desk, as I have, even at university, because we must share the language, the image of the genitals. This is one of my resident.
• The words
• Symptoms, etiology and meaning. Every symptom has a meaning. We must communicate it with the patient and the other colleagues.
• The pelvic floor role in pain. The biomechanics of pain in the genitals, 50% of the etiology is the muscle. Nobody pays attention to that.
• And then the strategy to cure pain and improve sexuality.

So looking at the pelvic floor muscle, I explained to my patient like a double edged door. If it is tightened like this, and I see it immediately from this point between the vagina and the anus, if it is retracting like this, this means that they have a very tight upper floor, and she will have for sure pain at intercourse, constipation, and recurrent cystitis, just looking at the genitals.
And if I see this tightened pelvic floor, I know the comorbidity: Vulvar pain, lower urinary tract symptoms, cystitis, and also the urge incontinence, constipation.

How can I evaluate pain?

The visual pain scale. But also I do that, very simple. Use three colors along the, month to see the intensity of pain you have during periods or in other moments. This will help me to find the worsening of pain during periods or at ovulation and help my patient with selective treatment.

• So key points, better treatment from health care professional because pain is key, is the leading witness of our work.
• Second, the role of microbiome in women's cells, fantastic, in the shadow of clinical awareness.
• Improving patient-doctor collaboration and the communication.

So our health care professionals, nurses, physiotherapist, doctor, of course, should be better trained in diagnosing and treating pain and related health issues and follow “how to talk about”, because it is really useful for the telepractice.

In conclusion, women's pain should be recognized as a biological warning, not ignore or normalize. This is my main take home message.
Doctors need better tool, train and believe and listen to women. Activate the brain. If you have pain, something is wrong. Nothing mysterious and nothing difficult.
The microbiome plays a crucial role, fantastic, another conversation.
Better communication, “how to talk about”, and thanks a lot for listening to me.

A consultant specializing in cultural and creative industries. She won Pioneer of the Year from the Sexual Freedom Awards (2019), was nominated for Rising Star of the Year in the DIVA Awards (2020), and received a Highly Commended distinction for Young Entrepreneur of the Year at the DIVA Awards (2023). Her debut book, "V: An Empowering Celebration of the Vulva and Vagina," was published by Penguin Random House in 2023. She is also an accomplished speaker, having appeared on stage, TV, radio, and podcasts.

I am Florence. I am the founder of the Vagina Museum in London, and like Emily said, it is the world's first bricks and mortar museum dedicated to gynecological anatomy.

This is one of our exhibits, the Glittery Tampon, or as we like to call it, our “Glampon”. It all started in 2017 with a tweet. This is the real tweet when I founded The Vagina Museum.

I was researching for a video where I had done top 10 animal penises, and I wanted to do a follow-up, top 10 animal vaginas, and I couldn't find information anywhere about animal vaginas. And it turns out there is a scientific bias against research into even female animal genitalia, not just human. And a friend of mine had just been in Iceland and said that she'd gone to the Penis Museum. She said, Maybe there's a vagina museum you can go to and ask their curator. So I went online, and there was no vagina museum.

So I tweeted: “People, there's a penis museum in Iceland, but no vagina museum anywhere. Who wants to start one with me?” And then as soon as I tweeted it, I thought, “Oh no, I want to actually start one. That's not just a joke.” So I started off by doing pop ups.

This is one of our volunteers, Alex, and this is us at a music festival in Wales. We did pop ups for people all around the country, and we also came to Paris once for a conference for sexuality in the disabled community. And then we moved homes a few times, and then we found our long term home here in East London. This is one of our exhibitions “All about endometriosis”.

You might be asking, why are you doing all this?

I mean, a tweet is funny, but it can't be the basis for a whole museum. And so this is our official values and charitable objectives and our mission. But if I could sum all of this up, it's about destigmatizing the gynecological anatomy, because as is the point of this whole conference, the gynecological anatomy is so stigmatized.

I'll give you one example. There's a thousand examples I could give. In fact, I have an entire one hour talk where I have just about this:
-    This is an advert for an intimate soap from the 1970s, and as you can see, it says, “The odor problem that men don't have”. So they are specifically targeting women, saying, your genitals smell bad, and you must use our soap so that your husband doesn't hate you. And do you think that's a joke? I have real archive adverts.
-    There's one where a woman is knocking on her husband's bedroom door because he's literally locked her out from the bedroom saying, I don't want to have sex with you, and they say, “Do you have this problem? Use our soap.” And you think, well, this is from fifty years ago. Is this sort of thing still happening today? Well, of course it is.
-    This is a bus stop, an advert, that is literally two minutes from my house. This advert is for a company called Daye, where they've made a tampon that you use, you send it in the post, and they test it, and you can be diagnosed for STIs and other diseases. And so in the advert, you see the speculum from Roman times and then a speculum from the 1800s, and then it says, “The future is here”, and what you would be able to see if it weren't for the tape would be a model of a uterus with a tampon inside of the vagina demonstrating their product. But somebody in my local area, probably living only a few minutes away, has decided that seeing a uterus and a vagina with a tampon inside was so horrendous, they covered it up with tape, and they even covered up all mentions of the word tampon and vagina as well in the text. And this happened, I mean, a few months ago.

And why is stigma bad, anyway?

It's because stigma leads to things like misinformation. For example, this is a real tweet from a teenage boy saying, “Tampons should not be free. Why does everyone keep saying they should be? If you can't control your bladder, then that's not the taxpayer's problem.” And I'm sure everyone here understands that menstrual blood, of course, comes from the uterus and not the bladder. And this was in 2016. It may, hasten you to know that after he sent this tweet out and it went viral, his girlfriend dumped him. And you might think, well, what does it matter some teenage boy on Twitter thinks these things and he's got the facts wrong?
The thing is, random boys on Twitter eventually become random men with influence and power.

For example, in Michigan in 2012, in the the House floor, a politician was banned from debating on abortion debate by saying the word “vagina”. Now, of course, it wasn't really the word vagina that, of course, the Republicans were upset about. It was because she was discussing abortion, and they wanted to find a reason to get her to stop talking about abortion, but they used vagina shame to do that.

So how do we fight this stigma, this misinformation, and these bad policies in politics?

Well, first thing to do is we must start young.
For example, "Sex Education". This is a show that asks this very question, “How can we teach young people about sex and vaginas and all of these sort of things?” This is a screen grab from an episode where a vulva photo has been spread amongst the students, and it's a whole thing, and they all sort of do this Spartacus moment. It's my vagina. No, it's my vagina. And it's very powerful because the girl in the top right, she has her own story line about how she's been very embarrassed about the way her vulva looks. And so for her to stand up and say, it's no, it's my vagina, was very powerful. And actually, the Vagina Museum advised on this episode, and we helped them build some of the resources that you see in there.

And of course, so in the Vagina Museum, we do many initiatives to help fight this stigma and misinformation.

For example, we have many exhibits.

You can see here, in this corner, we this is an exhibit. It is real pairs of knickers that me and my curator took out of our own drawers. One of those pairs of knickers is mine. I won't tell you which. You can guess. And the reason for this is that we learned that many people didn't know that the bleaching you get in the gusset of the knickers is a very normal thing. Between puberty and menopause, our vaginas are about pH 3.8. They're acidic. And so they bleach our underwear. A lot of people don't know that's a normal thing and think that they are diseased in some way, and, you know, they never ask their friends, they don't want to waste their doctor's time, so they just live their whole life feeling bad about this. So we put these knickers on display to show, look, it's a completely normal thing. And then when we put it on social media, you can see here we had 1,000,000 engagements, 5,000,000 people saw this because there were so many people around the world who didn't know this information. And as you can see, it was reported on all over the news.

We also do community events where we engage people in another way.

This is from an art workshop where a child drew his mother pregnant. So that little baby is his future sibling.
We also do campaigns, marketing campaigns, awareness campaigns.

This is from our campaign when we first opened after the lockdowns, the COVID lockdowns, called Open Soon. And we had 52 artists create art for us, and that was on display all over London. We received three complaints, which I think was too low, actually.

And then I also wrote a book as well with Penguin Books. This is called "V, an empowering celebration of the vulva and vagina", which is all about these things, about how to destigmatize. And it's a book about health and anatomy, but also culture and religion and language.

And you might ask, are these initiatives working?

I think the answer is yes.

These are two examples of feedback cards we got in the museum. You can see here, someone says:

• “what the fuck? I studied, soon to graduate. This never gets taught in a Russell Group University anatomy class.” And I mean, the the stuff in the Vagina Museum is very basic, so if they're not learning that, then I'm worried what they are learning, and it's probably nothing.
• And on the right here, you can see someone who wrote, “I'm 11, and I came here today with my auntie. I feel like you never really get taught these things about things like this at school or anywhere, really. Girl, power.”

And so, I'm so proud that we could make a positive influence on her life, but I think it's so interesting that even at 11 years old, she is understanding that there is so much stigma already, and that's why we have to start this education so young.

Thank you so much, and I hope that you will come to visit the Vagina Museum.
 

A postdoctoral researcher at the University of Antwerp, she is specializing in the intricate relationship between women and their microbiomes. Passionate about bridging gender health gaps, she plays a key role in Isala, the world's first citizen science project empowering women to explore their vaginal microbiome in a groundbreaking and taboo-breaking way. Their research map microbiota, examines lifestyle influences, and develops microbiome-based diagnostics. Through research, advocacy, and education, Dr. Ahannach strives to equip women with knowledge to take control of their health and contribute to lasting change in the field of women’s health research.

I'm Sarah, and I'm a senior researcher at the University of Antwerp. And today, I'll tell you about the vaginal microbiome. I had lovely introductions about women's health, about the microbiome, about all kinds of topics that are taboo. I'm gonna go a little bit deeper on one of them. So I don't have to tell you that we're here today to talk about something that hasn't been researched enough and barely. But it's also really important in the fact that up to almost eighty percent of women have issues regarding to recurrent infections, but also fertility, pregnant complications, and so on. And it hasn't been researched enough, and we don't know why.

But I also don't want to make this like a pink revolution, like women for women. No. It really has an impact also on children.If the vaginal microbiome is, not balanced, you have it can be related to preterm birth, neonatal infections, and even further, not just women and children, but also men. Men are also impacted by this. So this is a non pink revolution. It impacts everyone. And we like to call it our third genome, but then the gut the second genome, because, you know, it's still a hundred percent of people that have a gut.

But nevertheless, what we have, realized is a lot of research has been happening together with hospitals, which is very relevant. But then we don't know what just a general healthy vaginal microbiome is if we always study women that have a complication. And if you don't know what health is, then how can you better understand what disease is? So besides just knowing what the microbiome is, we study also the mechanisms of what they do and how they function. We also don't know we also know that there is no animal model actually for the for the vagina.

There is no anatomical vagina that looks the same as humans, but also there is no animal that has a similar microbiome as a vagina that humans have. We are, by the way, studying the vaginal microbiome of bonobos with our close relatives, and they don't have the same vaginal microbiome. Paper to be published. So we've decided to go over the citizen science approach to reach a broad range of women and help them contribute to our science. So they don't just ask questions, but they also help with data collections, they give input, and we published on this, on why citizen science is very relevant.

But I'm gonna go immediately to our example, which is the Isala project. The Isala project is named after Isala van Dies, the first female physician in Belgium. She was not allowed to study medicine, so she had to go to Switzerland. She studied medicine there, came back to Belgium, and then they told her, ah, you're not allowed to be a medical professional. So then she went to The UK, and then she came back, and then she changed the law.So she's a role model, and we named a project after her. So what is unique about our Isala project is we have lots of scientific goals. So our general goal is we want to map the vaginal microbiome of women and healthy women, just general, all over the world. But we also want to study the impact of lifestyle and environmental factors on the microbiome. We also want to study the beneficial capacities of lactobacilli.

So we have a large database with all kinds of live back, bacteria we study in our labs. What is unique about our project is that we also have societal goals. We wanna break the taboo on women's health. We wanna, talk about intimate topics. We wanna also join a multidisciplinary research on this topic.It's not just the microbiome like we've been taught before. It's also pain. It's also taboo. It's also culture. And we wanna also bring women in science more into the picture.

So we do this with all kinds of science communication tools. We try to, use a lot of infographics, social media, all kinds of blogs, not just a boring white paper informed consent. So in we launched in March 2020, and we were looking for 200 participants. And people told us, like, oh, no one's really wanna gonna take a vaginal swab. It's kind of gross. And we thought, oh, maybe we as researchers just think this is cool and nobody else thinks this is cool. And then actually within ten days, more than 6,000 women registered. Sending us messages like, oh, finally a project about us, finally about us. It was really nice to hear, and then they kind of give us the the the groove to continue, even though we didn't have the funding because so we published on this. And if for those who know Belgium, it's, it's, it's it's close to France, obviously. But we we started with, the the top part of Belgium, which is the Flemish speaking part. And as you can see, we got women all over Belgium from those large cities and to the smallest towns to participate and take a vaginal swab at home and send it to the lab. What I just wanna say about this slide is that our oldest participant was 98 years old. She was in a retirement home, and her granddaughters participated, and then we helped a lot and had to call with her to help her fill out the survey.

But the first question is, what are these bacteria living in in the vagina?

And we know about lactobacilli, but we didn't know how prevalent they were in the general women. So these are two graphs that kind of shows the same. The first one shows actually each line is a participant. And if you think you're like, oh, like, it's kind of screwed up this, this graph because you saw you see so many colors of the same. But actually, that means that a lot of women are just dominated fully by one type of bacteria. If you look at the pie chart, that just kind of gives an overview of what kind of how many women were dominated by bacteria. And you see, like, the blue part is Lactobacillus crispatus, which is associated to health mostly, and most women are dominated by it. But you also have Lactobacillus iners, which we don't know yet. Sometimes it can be good, sometimes it can be less. And there are all kinds of other bacteria.

Now the question was, how healthy are our vaginas? Well, fairly healthy based if we compare it to studies that were only done with hospitals and just women that just went to the gynecologist in the hospital, but if everybody here in the room knows, who goes to the hospital for just the checkup? So we found that around eighty, the women were, dominated by around eighty percent with lactobacilli. And we found that these bacteria work together. It's not just one bacterium. They work together. They help each other. It's like, if you look at the forest, it's not just all the species work together to keep a healthy forest.

We communicate our results not just in boring papers, so on our websites. We give more context on the microbiome. Everybody gets their profile, but we explain, we bring nuance. So these are, for example, the bacteria. This is an example of what is Lactobacillus crispatus, where can you find it, what does it do, and so on. So we try to also have a web page for medical professionals because as we've heard before from professor that indeed not a lot of gynecologists know so much about the microbiome. I've even heard one tell me that they don't believe in the microbiome.

But what I think is really nice is we started in 2020, and we're now in almost 15 countries, over five continents. And how it happened? It was just us giving a talk, and then researchers came up to us and they were like, oh, we also want to study the vaginal microbiome in my country. And we're like, okay, cool. So cool. So let's share, we wanted to share our protocols. We wanted to help them as much as possible. And, now we're also in Cameroon, in Nigeria, in Singapore, and some are setting up and some are just collaborating with each other. So it's really exciting.

• If you can see here in the picture, I think one example is here on top, Lekki. So they're also named after their own role model. So Lekki is in Cameroon, and Josiane had to talk with the chief of the tribe to get permission to talk with the women there and take samples.
• We have Dora in Nigeria, Laura in Peru.
• In Peru, we study, in the Amazon, in the coast, and the highlands. And for the Amazon, you really have to take a boat to get there. So the women have never been tested so it's really nice. And it's always done by researchers there, just not Eurocentric researchers going there white and say, I'm gonna study you, take all your microbes.

So we published on this, and we found also, and we're still studying that the microbiome is different in different countries because it's influenced by different aspects. So our question is, what are the things that have an impact on the microbiome?

So this is a a boring chart that we published, but I'm gonna go go into a bit in detail. For Isala, women filled out a survey. It took forty five minutes, but thousands of women filled it out. So that says a lot about excitement because who fills out an hour long survey about their mental health, their physical health, and so on? We saw that being pregnant has an impact on your microbiome even if it doesn't end in a birth. So just having been pregnant, called so we really saw a difference between women who have never been pregnant and those who have been.

Also, if you look at age, as a woman ages, especially after menopause, the hormonal fluctuations also change, but the microbiome becomes more diverse, making them more prone for infections. We also saw an impact for hormones. So throughout the menstrual cycle, the microbiome also follows a little bit the hormonal fluctuations. Also, the contraceptive pill, people were really interested in that. It was really a topic in Belgium. Women were asking us, what is the impact of diet? And we're like, diet? But, yeah, what's the link with diet? We never really thought of it because we were always learning to be gastrointestinal system, reproductive system, all different, but actually they're linked. So we saw that some foods had an impact, but that's association. So we're doing more studies into causation. So maybe there is a gut vagina axis. Where is it maybe? There are all kinds of theories, the perineum outside or absorption into the gut that maybe kind of links your immune system and your vaginal microbiome, all kinds of theories because it's haven't been done before. So it's all kind of new.

And we also communicate these results to the public. But it's important to know that we found, actually, we can only explain 10% of the vagina. But for the gut, we can only explain 7%, so that's more. Now it's always important to realize how can we be more inclusive and not just do research on the rich white, but on everyone. So we wanted to study and we do focus groups with all kinds of people like, why would you participate in studies? What is important to you? We realized that:

• awareness is important,
• but also the language, the type of language that you use, what you say, what your message is,
• Trust. Who do I trust? Not everybody trusts scientists. Sometimes we trust our GP, or gynecologist, or pharmacist.
• Taboo. Not sometimes we think a group is full of taboo, but they're so open. Like, it's, we were so, surprised by it and
• to be subtle.

So we are having all kinds of new phases of projects, and the one that also is running right now during Ramadan is a Rufaida project, where we're studying the impact of fasting and food on the vaginal and gut microbiome. Because 1,000,000,000, women in the world are Muslim, and they're fasting one month a year and hasn't been studied before.

So So that's kind of crazy if you think about it. And there are kind of all kind of theories there because in the gut we have all kinds of bacterial fermentations, and there are also all kinds of diets coming out. Who has a friend that friend that is doing intermittent fasting or starting intermittent fasting or thinking of key to diet. I see a lot of people nodding. So it's not just what we eat, when we eat it, and how does it impact our gut and vagina, and we're studying it right now.

So women are taking samples before Ramadan, during Ramadan, after Ramadan. So it's right now Ramadan, and I'm also participating in my own study. And last year we studied it just by taking surveys, and we already found that the women experienced less stress during Ramadan and more community. So I'm curious to see this impact also on the microbiota.

And then to end with last year, we also, asked we went to send a picture of the iftar table. It was actually a contest. And then these three tables, one of the 30. So it's also really a community based research. It's not just about send us your samples, it's about more than that. So maybe next year, I can I can tell you more about the results? But for now, I wanna thank the entire team working on this, just in Belgium, but also international collaboration collaborators, and thank everyone for your attention.

So we had many, many questions. I will take some. So so the first one is for Florence.

Since you started, do you feel a progress or a backlash towards vagina or female genital topics?

Oh, that's an interesting question. I think through my work in the vagina museum, we've seen a real positive change in the way that people have been talking about the gynecological anatomy, and I can give you lots of examples about how I've changed people's minds and improved people's lives. I think in the wider perspective though, there is an interesting thing happening that the whole world, I feel like, is becoming more and more polarized, and there's data to show this. And of course, women's rights come into that, it's not just politics, but, you know, there's a lot more shame, and you go on the Internet and you see even, like, you know, people are criticizing women if they dress like the way they dress, the way they look and everything. So But on the other hand, then there are a lot of people who are becoming a lot more, supportive. So it's hard to say. In some in some areas, yes. In some areas, no. Okay. Thank you, Florence.

I have one question for Sarah. So you mentioned the Isala sisterhood, the daughter project such as the “Nuna project”? Can you tell us a bit more about it?

Yeah. Definitely. So, another question we just received questions via Instagram and social media, and women were like, yeah. “I'm I'm wearing this type of underwear, and what's the best fabric?” And then we were like, oh, we don't know if there is a best fabric. And we also don't wanna move towards a society where women get the whole list from their gynecologist, like you have to do this and this and this and this, and then they still have an infection because it's maybe just genetics and immune system.
So we started to to set up a study, and then we actually were thinking, it's not just underwear, it's also our menstrual hygiene products. Every month we have, we use them and, and they're they haven't been studied before and they impact on the microbiome. Recently, there was a report about chemicals being found and toxins in the product, but not their impact on our health. But, okay, if they're found, then they must be doing something.
So now we have the Luna project where, they're actually almost finishing the women. So it's a hundred women, those that take the pill and those that don't. And every month they wear another type of menstrual product. So we have the tampon, we have the pads, we have the menstrual cup, and then we have two types of menstrual underwear. So we have the cotton and synthetic, and then they're sending it samples to our lab, so we're analyzing them.
And we're doing actually, similarly in Peru and in Cameroon where women wear the pads and the and the tampon. So, we hope to compare the data. But from the so this is an intervention study from the Isala study that I talked about.
We do already saw that wearing, the menstrual pad was some kind of indicated for a more diverse microbiome. But this this is something that sparked our interest, and we wanted to see if it's necessarily that or it's different or the way people wear it.

So it's it's more than that. It's always better to understand what's the cause, so we're doing it right now. Thank you. Same to Sarah.

A question for Alessandra: How to open women's words during a consultation?

• If you don't have receptors, there is no way. Mhmm. I mean, if we are not trained first Okay. To clinical history.
• Second, to listen carefully to pain as a leading symptom of every consultation.
• Third, if we do not update our knowledge in pathophysiology, what's behind I mean, pain is the tip of the iceberg.

But as a doctor, I must know the pathophysiology that maintain this pain. So if I have not of this, there is no conversation. Not at all. So that's why I'm so critical about the level of training today, because we are all evidence reading papers. Imagine that is a study, a report in US. A resident spend one hour and a half in the ward with patient and the five hours and a half with a computer on the computer. So are we curing papers or are we curing human being? Mhmm.

If we do not change and re put the priority of the body, as I say, as the first protagonist, I don't see a bright future, honestly. So a lot of ideology and a loss in the heart of medicine. A lot of things to change. A lot. Yes, but we are committed. And together, maybe we can change with different perspective, but with one goal, to improve. Thank you so much, Alessandra.

Question for Florence. How could we educate young population regarding specificity of intimate health?

That's a very big question. There there's a lot of ways we can educate young people.

• I think schools is one, but I think sometimes there's too much focus on only schools.
• It also needs to be in the home and parents need to be confident and comfortable to teach their children. We have a lot of people come into the vagina museum saying, you know, I have a toddler and I need to start really teaching them about their bodies. What should I call their parts? I don't know what to say. It feels so inappropriate to just say the words. And I say, no. They may be three years old. Call it a vulva. It's like, it might feel a bit strange to hear a three year old say the word vulva, but it's much better than, you know, fufu and fanny and mini and front bottom and all of these things. Because when you use those euphemisms, what you're saying is that this is a part of the body that should be kept away and you should be ashamed of.
• But then also we need to teach young people in our culture as well, and make it more normalized. For example, in Sweden, there is a really cute cartoon, I can't pronounce Swedish, so bear with me, but it's called Snopon and Snippen, and it's a little cartoon and it's like a little speaking penis and a little speaking vulva to teach young children.

And also, there's a Yeah. Well, so and it Sorry. I I could talk for hours about all the different great educational initiatives. But, the point is that it must be in every single axis of our society, not just in one. Thank you, Florence.

You wanted to add something?
Alessandra: Just to stress that every woman still call vagina the vulva. Mhmm. And they say my vagina is dry, but they mean the vulva. Mhmm. So that's why I was insisting having the picture on the desk of every doctor and say, having the vertical and the or the picture of the vulva. So that we say, where do you have pain? Where do you feel itching? Where do you feel that something is burning? In the map. And also, so in, for example, that the hymen is the line of separation between the real vagina, that is up and the vulva. And this, vestibulum, is the richest in sensitive fibers. So that means a lot of pleasure if everything goes well, but a lot of pain if something goes wrong, and the microbiome has a huge say there. Right.
Even adult women should learn that the vagina is the one the channel up there Yes. And the vulva is the outside. And when they have symptoms, they should use the proper words. So the education is not, fundamentally agree a 100 % for children, but unless the adult use the appropriate language. Otherwise, we are really mismatching even the site of the symptom. And if you are not a very accurate doctor with the picture there saying, what are we talking about, You miss the point. Yeah. So educations about anatomy of women. Exactly.

Sarah, a question for you. How many people are involved in ISALA project as a whole?

Oh. I think in Belgium right now, we have about 10,000. And then worldwide, I don't have the exact number because it's everyday sampling. But, for example, tomorrow they'll be coming samples from Cameroon, and a researcher is coming with them. So, yeah, it's it's growing. So our goal is really to create, like, a global atlas of the vaginal microbiome.
Huge. Very huge. Thank you.

Alessandra: What can be put in place to prevent menstrual pain? 

Huge question. Why do women have menstrual pain? Why some have menstrual pain? What are the predictors? We have a huge study from UK on 5500 women with endometriosis and 22000+controls. What we found if what they found.
If women have heavy menstrual bleeding, the probability of having then endometriosis is 5 times the odds than women having normal bleeding.
But, important, if women have heavy menstrual bleeding, they are anemic, iron deficient anemia, and this doubles the risk of depression and doubles the risk of low sex drive. But none sexologists ask about periods and checks if there is anemia. So everybody spend ages with psychologists when you need iron.
Second, if you have pain at intercourse, you have 10 times nine 9.8 the odds of having endometriosis. And if you have pain during periods, 9.8  again. But if you put the three together, the risk is 22.9. This means that Amazing. Obviously, you have something serious. Yes. So what should I do? First, very accurate clinical histories. Check everything, your mono profile, blah blah blah. And then give a progesterone. Give a pill. Give a patch. Give a something to normalize the level of estrogen. Why that? When estrogens fluctuates, they are a trigger of inflammation. When they're stable, they reduce inflammation. This is a major point in infertility. It's still confusing because people don't different people, researchers, physician, don't differentiate fluctuation versus flat.

Remember, 100 years ago and from 200 000 years, women had maximum, as I was saying rapidly, 140-150 periods in their all fertile age. Very often less than 100. Because late puberty, a monarch, then many children, two years' lactation. So early death, by the way. So now we have tripled the menstruation. This means 13 periods per year. And if you have pain, this mean 13 peaks of immunitary fire.
This means if a heavy menstrual bleeding, that the blood goes inside the pelvis, disseminate, and creates endometriosis. So we cannot dismiss heavy menstrual bleeding. 20% of women have it. One in five. Yeah.
So just to give you numbers, because this is the evidence we need, but then go back to pathophysiology and change the destiny. Voila. Very good. Thank you. Thank you, Alessandra.

Now, I have a question for all speakers. We are talking about women's, but, yes, how to get men more involved in women's health?

Florence: Well, I mean, at the Vagina Museum, we some people sometimes ask, can men visit? Of course. I'm like, yes, obviously. And the only people that have ever said, oh, maybe I wouldn't visit are gay men. But even they love it and they come as well because they come with their friends, and they have sisters and mothers. Everyone understands they need to learn about it. We often have single fathers come in with their daughters especially because they think, Oh, I'm going to have to talk about puberty with them, and I don't know how to talk about that because I've never had a period. So maybe the gallery assistant or the person on the front desk can help. So we have a lot of that. But we have men of all different ages, and I think a big part of it is just saying, Yes, you are allowed to talk about this, you are allowed to ask me about this. And some of the ways in my personal life I do that is if I'm going to the toilet because I need to change my pad, rather than hiding it up my sleeve or something, I just take it up and I just walk. You know? And I say, I'm not gonna be ashamed. Are you embarrassed? I'm not embarrassed. Thank you. No problem.

Sarah?
I think it it starts very early in school already. If you talk very openly about the topic, about educating, and everybody if you sometimes even guys have to write, like, a a report on the vagina or the microbiome or whatever, then it it already starts like that. And then it's also exposure. Exposure does a lot. And, yeah, I think it's also up to us women to not just make it be for women by women. No. It's for everyone. It's relevant for everyone. But men also need to educate themselves. They were old enough, it's not just about discrimination or racism, but you need to educate yourself about, yeah, what's everybody knows a woman, even if you don't, then it's still relevant. So, I think it's about responsibility and education, in a way.
But I feel like there is a shift right now. I see even our research team is very diverse, and the guys are very ”I studied the vagina for eight years” already, so it's totally fine. So, it's openly talking about it, I guess.

Alessandra: Well, a number of consideration.
First, imagine in the history, breast was a prominent sign, not the genitals. And today, we have a major problem. You can confirm that Because in anatomy books at school, labia are represented as two tiny lines. And today, we have a huge request of labiaplasty Mhmm. To make the labia thinner and smaller. That is absolutely a mediagenic and “book genic” disaster, first.
On the other hand and in positive, when I have husbands, fathers or sons, accompanying the woman in the medical consultation, I can say that I see the best of the male side of the world. Because I don't like this polarization, we women all the best and the other all the evil. No. Let's say that we are also we do have stupid women and we have smart men. And what is my privilege, having had so many men accompany their partner or daughter, is to see that when I explain to them why she has pain, why she has pain at intercourse, and I explain the biomechanics of pain, the face of the husband or the lover, whatever, changes, Because I'm speaking as a man would like to. Not everything psychological, she's refusing you, she doesn't want to have sex, blah blah blah. But there is a mechanical reason. She's the door is closed. Let's open the door. I can teach you if you want and she wants how to relax the pelvic floor as a foreplay. And they become the best assistant. So let's work together, not polarize all the good and all the evil. No. There are quality people, both gender, and if we collaborate, this is my main message. Otherwise, the fight is a waste of energy. 

Florence: Can I Yeah? Oh, sorry. Can I share a really quick story from the Vagina Museum that you reminded me of, where this is one of the best things that's ever happened. In the Vagina Museum, we have a wall of photographs of vulvas of all different shapes, hair, colors, everything. It's really diverse and you can spend hours looking at it. And one of our receptionists told me that one day two women came out of this exhibit and were talking right in front of them, and one of them said: “You know, I think my boyfriend just doesn't appreciate the way my vulva looks.” And having looked at the exhibit, they're like, “Oh, wow, everyone's so beautiful, I'm so beautiful, I'm so unique, and my boyfriend, he doesn't appreciate it.” And then she picked up her phone and she dumped him there and then. No. I was like, “changing lives”.

There's also a question for Sarah: How can we help in the development of ISALA project worldwide?

Oh, of course. You're very welcome to join. You can just follow, the project. We have a newsletter coming out. We'll every, every season where we update about the results, about everything that's going on. But you can also participate. Look if there is an Isala project in your country.
If there isn't one, you can check-in with us and start one. What's the name again for the the French one? Madeleine. Madeleine. So there is also one in France.
So, then if you're in France and you wanna participate, then, I can link you up. It's, it's together with Institut Pasteur. So, so we also have a French sister. So yeah.

And I just wanted to follow-up on the topic of before. I've one of the studies that we do with the sociology, we also noticed that doctors are ashamed to talk with their some of their especially male doctors. And even if it's a woman with a veil or if, if she's more diverse or if they're like, oh, she's for example, we had to study with breast cancer, patients, and they also can have a vaginal dryness, and it can hurt a lot. And even then, they don't. They discuss everything about the treatment with the women, but then if it comes about vaginal health, they're, like, a little bit ashamed. Like, oh, we don't wanna talk about sex with you. Maybe you don't have sex. Like, but everybody has sex. So that's kind of I think it's not just us, it's really all physicians to be able to be also open with your, with the women, and it doesn't depend which color they are. Everybody, has a life and they deserve actually the information. So I just wanted to put it out there that that's also still an issue. And we always think that the doctors tell everything and are not ashamed, but even they feel a little bit of shame.

So Thank you. Thank you so much. Just one minute because we are we are we are very, late. So you you wanted to to say something last word Alessandra:

I have a question for her because it was very interesting on the data you presented. So if I read correctly, you said that the Crispatus was 48%. Mhmm. But I was surprised to find that, Jensenii, Gasseri were  3 and 4%, whilst from the literature, it seems they are much more represented.
So my question is, did you find that this is is this a medium about the data you have? Or is it in Europe? So because it is really different from what we have in our evidence in the books.

Sarah: Yeah. I think it's it can be very centralized sometimes to countries. But, if you look at The US data, it's it's quite different. But they also kinda, strategize it. It like, stratifies it into race, which is kind of a social construct, and it doesn't make sense to make a distinction. And we have to more look at socioeconomic levels. And I think that's kind of where we're trying to improve is to also have women of all layers of society, women living in poverty, or have different access to preventive care. So that's also a different group to approach.
But I think generally, West Western Europe can be quite similar. Okay. Unless you go deep dive into groups and you have to more look at socioeconomic status. But if you go in the in the world, there is, for example, in Uganda, vaginal soaps are really hot topic. It's being advised everywhere. In the stores, you have all kinds of brands. So that's also, let's say, like, marketing culture. But we're also starting one in Italy, actually. So Good.

So thank you very much. I would like to thank you all of our incredible speakers, Sarah, Laurence, Alessandra. Thank you so much.