Here's how Prof. Graziottin answers this question from her patients:

First, be consistent in having healthy lifestyles: the vaginal “microflora”, the vaginal microbiome, is very connected to the gut microbiota. They have a close dialogue, so to speak. So, very key, the quality of our nutrition, with low sugar, low saturated fats, ideally please no junk food, more vegetables, grains, fish and olive oil, limited or no alcohol, I strongly recommend you that. This helps to have a healthy gut microbiota and microbiome and a healthier vaginal microbiota and microbiome.

Second, try to reduce life stressors. Why is that? Because in our gut microbiome, we have a huge parabolic antenna, so to speak, kind of “satellite dish” that captures all the stressing factors and the cortisol our adrenal glands produce in response to stress, either physical or emotional. What's the point? The healthier the gut, the healthier the vaginal microbiome. The healthier the gut, the healthier the vaginal microbiome. So, simple lifestyle choices, for example, protecting the quality and duration of your sleep, your biorhythm, I strongly recommend to every patient, and I practice myself, brisk walking half an hour in the morning to go to work, to accompany your children to school. Why is that? Because you resynchronize your biorhythms and this will translate in a better gut microbiome and better vaginal microbiome. And also, by walking for half an hour, you steam off your stress and recharge clean energy for your life, your family, your health.

Three, pursue simple intimate hygiene habits:

• First of all, ideally, we women should wash our perineum soon after bowel voiding with a caring attitude to move the hands from front to back
• Second, try to use a soap-free cleanser, gentle, which protects the vulva microbiome and it will indirectly protect the vaginal microflora. And another important thing, with this gentle cleansing, we will eliminate from the vulva and the perineum the contaminant germs coming from the feces, of course, if they are in limited quantity.

Four, and very important to me as a doctor who cares about women's health: use consistently in every intercourse condom, unless you are in a stable, trustworthy relationship or you are looking for a baby. Why is that? This is absolutely the most effective measure to protect you, your microbiome, your intimate health from sexually transmitted infections and protect « your secret garden”, so to speak.

And fifth, respect your vulvar hair, maintain the hair on the vulva. You can clean all the rest but maintain that on the vulva. Why is that? Because the healthier the vulvar and vaginal microflora, thanks to the protecting hair, the more pleasant the scent and the taste of your intimate secretion. In particular, the « scent of women”, this fascinating, charming, capturing, seducing scent, is due to the activation of the precursor of pheromones by the microbiome in the vulva that is protected by the hair. So, if you want to maintain not only the health of your secret garden, but the perfume of your secret garden, protect your hair because these pheromones are the most attractive signal in sexual intimacy for you and your partner.

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Here's how Prof. Graziottin answers this question from her patients:

Let’s clarify this first:

• “Microbiota” is the word that defines the population of microorganisms that live in our vagina, contributes to its functions, and protects the vaginal mucosa. A partially different microbiota lives in the vulva and in the vestibulum.
• The term “Microbiome”, with the “M”: refers to their genetic content. In the fertile age, most of the microorganisms living in our vagina are Lactobacilli. They are our best friends, and they’re the most reliable “ally troops” as I say, to help our health. 
• We talk about “Eubiosis” when we want to indicate a healthy vaginal microbiota and microbiome, with low bacterial diversity. Say a few families, 80% Lactobacilli.
• We talk about “Dysbiosis” when we want to indicate a disruption of the equilibrium that we have in healthy conditions and the emergence of pathogenic strains of bacteria that may come from the bowels, the perianal area, or from intercourse and lead to sexually transmitted infections. The point is that in dysbiosis we have a high bacterial diversity because our microbiome is assaulted by other strains of germs. So, to be healthy, low bacterial diversity, 80% Lactobacilli. Problems when you have many more families coming from the bowel or from sexually unprotected by condom. That's why I always recommend using condoms in intercourse.

These are close friends. Then we have the Lactobacillus Iners, which are much more vulnerable to the aggression of germs from the bowel or intercourse with a sexually transmitted infection. This means three things:

• First of all, the more there are bacterial species in the vagina, high bacterial diversity, the more we have severe dysbiosis and this will translate into symptoms and vaginal leakage of yellow or green color and other symptoms.
• Second, this means that when we have high bacterial diversity, dysbiosis, we have an increase of Gardnerella vaginalis. This germ is normally present in every vagina, but in a very, very small quantity. When it increases in percentage, it will cause a very bad smell, such as the smell of spoiled fish. This is very, very unpleasant for the woman.
• Third point, there is an increased vulnerability to infections by commensal germs from the bowels: This means Escherichia coli, Enterococcus faecalis and others, which increase the risk of vaginitis and cystitis, which are infections of the vagina and of the bladder.

Knowing which woman’s prominent CST your patient belongs to is key to addressing recurrent vaginitis and bothering vaginal and sexual symptoms.

5 major groups of Lactobacilli, called “Community State Types, CST, live in the human vagina in the fertile age, with a few subtypes. 

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Here's how Prof. Graziottin answers this question from her patients:

When the muscles are very contracted, they squeeze the vaginal entrance and contribute to sexual pain.

So, your tightened pelvic floor is responsible for at least 50% of the pain you have in your vulva and during intercourse.

In this clinical situation it is key to teach the woman how the relax the pelvic floor muscles with:

• First, appropriate diaphragmatic breathing, which I teach her simply in the office during the gynecological examination;
• Second, “hands-on” relaxing physiotherapy;
• Third vaginal diazepam (2,5-5 mg), to be inserted in the vagina before dinner, for a short period of treating time, to ease the muscle’s relaxation (off-label, but with good scientific evidence).

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Here's how Prof. Graziottin answers this question from her patients:

To understand vulvar and sexual pain we must consider the importance of pelvic floor muscles. Look at me, imagine that my arms are the pelvic floor muscles like a double-edged door. If they are very tightened, they’re contracted and retracted, and they squeeze the entrance of the vagina (imagine my body is the vagina) and this will make penetration impossible. 

This is what happens in the serious severe vaginismus.

If the muscles are tightened but not that tightened, they allow penetration but this will cause “microabrasions” at the entrance of the vagina with key changes in the microbiome in the area (dysbiosis) and this will facilitate candida attack and an aberrant immunitary reaction to the candida. So you have all the symptoms of the candida infection, yet you cannot detect it with a sample in the vagina.

And more importantly, we have a change in the anatomy of pain fibers, and this is responsible for the burning pain you have at intercourse, during intercourse, and after intercourse. And this is the key symptom we define as “provoked vestibulodynia”, which is part of the vulvodynia.

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Here's how Prof. Graziottin answers this question from her patients:

It is very useful to initiate a focused conversation with very accurate wording (and visual aids):

• The perineum: personal hygiene is key to reducing the risk that microorganisms coming from the bowel may attack the vulva, the vagina and the bladder.
• The vulva, with its very useful hair, host and protector of the vulvar microbiome. The name includes key microorganisms important to protect the vulvar skin, but also for creating our exquisite “scent of woman”, based on pheromones.
• The clitoris, with its kingdom of pleasure.
• The vestibule, so sensitive and sensually welcoming and yet so vulnerable.
• The entrance of the urethra.
• The entrance of the vagina.

It is also better to clarify the level of the hymen and of the vulvar vestibule, and again the pelvic floor muscles. I show my arms and explain how they can be tightened, gently relaxed or very relaxed to allow intercourse. This will help in clarifying specific symptoms' sites, in case of vulvar pain or sexual pain, their key pathophysiology and key points of the therapy.

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Here's a quick look at Prof. Graziottin's best tips for a successful medical consultation:

For a successful consultation

• Listen carefully to the patient’s symptoms and complaints, whilst you’re taking the written medical history.
• Look at the patient’s eyes, with a gentle, welcoming, truth-worthy attitude.
• Focus on verbal and nonverbal messages with a caring attitude. This is key for a comprehensive medical perception of both the ongoing pathophysiology contributing to the current complaints and the emotional impact it has on the patient. 
• Don’t interrupt her after 45 seconds.
• Use simple words and pertinent, bright, easy-to-understand examples.
• Never say “impossible” whatever the symptom the woman is complaining about. A far better comment is: “I well understand how difficult it is to live with these symptoms ...” or “I well understand you” or “I feel how painful it is”: this empathic overture is useful and precious to create a trusting and collaborative atmosphere.
• Do not stare at the computer screen while you’re asking or answering sensitive questions.
• In my practice, a key part of the consultation is a very accurate physical examination (“reading carefully the body signs”); that is currently one of the most serious omissions in the medical practice, also in gynecology.

This type of consultation may take more than 15 minutes, but the reward is:

• A solid trust alliance with the patient
• A comprehensive clinical evaluation and a higher probability of a very accurate diagnosis
• A more precise reading of predisposing, precipitating and maintaining factors contributing to current symptoms or pathology.
• A timely reading of comorbidities
• Stronger adherence to the treatment plan
• More effective therapies, also in complex cases of persistent sexual dysfunctions, chronic vulvar pain, chronic pelvic pain, or pain after cancer treatments.

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In the vast landscape of our bodies, there lies an unseen world of astonishing complexity: the gut microbiome. It's a bustling community of microbes, a hidden rainforest within each of us, profoundly influencing our health. For years, scientists believed a diverse mix of these tiny organisms was the key to a healthy gut. But like any complex ecosystem, it's not just about the number of species, but also about what they do. The focus is now shifting to functional diversity (sidenote: Functional Diversity This describes the range of metabolic activities performed by the gut microbiota. It is a more important indicator of gut health than simple taxonomic diversity because different microbial compositions can perform similar metabolic functions. Assessing functional diversity can provide a more accurate prediction of physiological states than compositional diversity alone. ) – the range of jobs these microbes perform. It’s not enough to have a variety; these microbes need to be working in harmony. ¹

The unseen workforce

Just as a rainforest supports diverse life, so too does our gut. These microbial inhabitants are not idle passengers, they're essential workers. They produce vital substances called short-chain fatty acids (sidenote: Short chain fatty acids (SCFA) Short chain fatty acids (SCFA) are a source of energy (fuel) for an individual’s cells. They interact with the immune system and are involved in communication between the intestine and the brain. Silva YP, Bernardi A, Frozza RL. The Role of Short-Chain Fatty Acids From Gut Microbiota in Gut-Brain Communication. Front Endocrinol (Lausanne). 2020;11:25. ) (SCFAs), which are like fuel for our gut lining and keep our immune system in check. One of these SCFAs, called butyrate, is like a superhero, providing energy to cells in our colon.

Then there are the bile acids, initially made by the liver and then transformed by gut bacteria, which are crucial for digesting fats, working like the digestive system's own little detergent. The liver and gut are in constant conversation – a two-way street influencing each other. The gut produces molecules that act like messengers to the liver, and the liver sends back bile acids.

A protective barrier

Our gut is not just a place for microbes; it is an important barrier. The mucus layer (sidenote: Mucus Layer This is a complex, dynamic barrier lining the gut, primarily composed of water, electrolytes, lipids, and mucins. It physically separates bacteria from the intestinal epithelium, preventing direct contact and maintaining gut barrier integrity. The thickness and turnover of the mucus layer are crucial for a healthy gut. ) , a glistening, jelly-like substance, acts like a bodyguard, preventing bacteria from directly touching the delicate lining of our intestines. This layer is constantly renewed – a meticulously managed process like a city’s sanitation system – maintaining protection. It’s also surprisingly affected by what we eat.

Certain fibres and prebiotics can help to support the mucus layer, ensuring it remains robust. But some processed food with emulsifiers can disrupt this layer and cause the gut barrier to become more permeable – like a city whose wall has been breached.

Resilience is key

Like a rainforest that withstands storms, a healthy microbiome needs to be resilient (sidenote: Resilience This refers to the ability of the gut microbiota to maintain a stable composition over time and resist disturbances such as antibiotics or dietary changes. A resilient microbiota can recover quickly from disruptions, reducing the risk of long-term health issues. ) . It should be able to bounce back quickly after disturbances, like illness or antibiotics, that upset its delicate balance. We are beginning to understand that a healthy gut is not a fixed entity; it’s dynamic and unique to each person. It is influenced by birth, our environment, lifestyle and diet. This makes defining a ‘healthy’ gut complex, and it requires much more scientific exploration.

Depression, which is thought to affect more than 280 million people worldwide, remains difficult to treat: 70% of patients do not respond to antidepressants and/or develop side effects. Hence the urgent need to identify modifiable risk factors and develop new therapies.

As the Mediterranean diet has shown beneficial effects on depression, researchers have turned their attention to the gut-brain axis. And more specifically to the interaction between citrus consumption, the gut microbiota and the risk of depression in 32,427 women from a cohort of British nurses, Nurses' Health Study II (NHSII) ¹. 

More citrus, less depression

Between 2003 and 2017, 2,173 cases of depression were observed in the 32,427 women in the NHSII. Looking at their dietary intake, the researchers ² showed that those who consumed the most citrus fruits (vs. the quintile of those who consumed the least) had a 22% lower risk of depression, after adjustment.

This link is thought to be specific to citrus fruit: no significant association was found between depression and total consumption of fruit, vegetables, apples or bananas.

What components in citrus fruits could explain their antidepressant effect? It would seem that only naringenin and formononetin, two flavonoids especially found in citrus fruit juice and peel, are involved. Vitamin C, though beneficial and much vaunted, is thought to be irrelevant here.

The mechanisms involved

Analysis of the microbiota of 207 women in NHSII who participated in the sub-study Mind-Body Study ⁴ dedicated to mental health enabled the researchers to show that citrus consumption promotes the presence of beneficial bacteria, including Faecalibacterium prausnitzii, a bacterium that is under-represented in people with depression, and reduces the presence of some pro-inflammatory bacteria.

This correlation was confirmed by researchers in a cohort of men (Men's Lifestyle Validation Study). All that remained was to understand the link between this bacterium and the brain.

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Functional dyspepsia is a chronic and remitting disorder originating from the upper gastroduodenal region, characterized by one or more of the following symptoms²: 

Functional dyspepsia is a highly prevalent DGBI based on strict Rome IV criteria:

However, prevalence estimates vary depending on diagnostic criteria and geographic regions.

Functional dyspepsia is slightly more common in women than in men and can affect individuals of all ages. The condition is often underdiagnosed, as symptoms may overlap with other gastrointestinal disorders such as gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). Despite its high prevalence, functional dyspepsia remains a challenging condition to manage due to its complex and multifactorial pathophysiology.

There are two subtypes of Functional Dyspepsia:

• EPS: Epigastric Pain Syndrome
• PDS: Postprandial Distress Syndrome which is the most common form

These two subtypes of dyspepsia sometimes overlap

Although the precise pathophysiological mechanisms underlying functional dyspepsia are not yet fully understood and the precise etiology of the disorder remains elusive, recent evidence identified the following pathophysiological mechanisms¹:

• Psycological factors: Altered gut-brain interaction: including stress and anxiety, influence gut function and may exacerbate symptoms
• Stomach hypersensitivity and dysmotility: Increased sensitivity of gastric and duodenal sensory neurons leads to exaggerated pain and discomfort in response to normal stimuli; disruptions in gastric motility, such as delayed gastric emptying, and impaired fundic accommodation 
• Intestinal immune activation: Low-grade inflammation, particularly increased mast cells and eosinophils in the duodenum, contributes to symptoms
• Gut barrier alteration: A disrupted intestinal barrier allows food antigens and microbial products to penetrate the mucosa, potentially triggering immune activation
• Altered duodenal microbiota: Changes in the gut microbiota may contribute to immune activation, visceral hypersensitivity, and altered motility

These mechanisms interact in a complex manner, making functional dyspepsia a multifaceted disorder requiring a personalized approach to treatment.

What to tell the patient ?

The diagnosis is based on symptoms according to Rome criteria²:

• Presence of at least one symptom severe enough to impact usual activities in the last past 3 months and at least for 6 months prior to diagnosis.
• and no evidence of structural disease (including on upper endoscopy) that is likely to explain the symptoms.

Recommended as routine tests:

• H. pylori test is recommended as the first one to be carried out: stool antigen, urea breath test
• Evaluation of the lower GI symptoms as IBS frequently overlaps with FD; essential to assess for celiac disease
• Assessment of the drug history (particularly about opioids, cannabis and NSAIDs)

Consider in specific case:

• Endoscopy for patients with recent onset symptoms and weight loss, and more than 55 years old; biopsy should be done if H. pylori status is unknown at endoscopy
• Gastric emptying (preferable scintigraphy) in case of nausea/ vomiting

Not useful as routine test: 

• Blood testing

General management

The management of functional dyspepsia follows a multifaceted approach aimed at symptom relief and improving quality of life^3,6,7

What to tell the patient ?

Most frenquently asked questions on Functional Dyspepsia: 

Follow-up approach depends on response to treatment (many non-responders)

2-3 months is a good interval for follow-up, with increasing intervals in case of treatment response Depending on the patient’s initiative

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