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

Listen to the TIMING of the itching. If itching peaks at night, we have two major causes:

• First, bowel parasites, they could be in play because they migrate through the anus in the perineum at night to deposit their eggs. They are more frequent in children and adolescents, with rare cases in adult and elderly women. But the search of parasites is key in the feces to confirm the diagnosis. The search of the parasites in the feces will confirm the diagnosis. Clinical examination, a vaginal swab with the exam of the secretion at the microscope in the office or a culture test can confirm the diagnosis.
• The most frequent etiology of itching at night with increasing age is the so-called vulvar lichen sclerosus. It is present also in children and adolescents, but it increases in prevalence with increasing age. 
• It is an autoimmune disease, what does it mean? Our immune system attacks the vulvar tissues in all their components, with progressive thinning and whitening of the vulvar skin, fusion of the labia, destruction of the tissue, and damage to the nerve terminals, the nerve endings. This is responsible for the itching feelings.

When the itching is also frequent during the day, think about the Candida infection and important to an aberrant response of our immune system, abnormal response, to the candida antigens. Because this causes itching, and again, we need a clinical examination of the vaginal swab with the exam of the suppression at the microscope of the office and a culture that can confirm if really a candida infection is in play in causing this itching day and also at night.

The predisposing factors include:

• First, an inappropriate diet rich in sugar: That's why we strongly recommend a sugar-free or almost-free diet. Why that? Because sugar gives a lot of energy to the candida and she will aggress us with much more intensity. But also because sugar causes gut, vaginal and vulvar dysbiosis.
• Second, we may have hyperactivity of the pelvic floor, too tight on the pelvic floor, and this predisposes to microabrasion that increases the probability of the aberrant immune reaction to candida antigen.
• And then, vulvar and vaginal dysbiosis worsens the infection and predisposes to recurrences, in spite, very important, of both oral and topical antimycotic treatment.

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

First of all, every woman should know that Uropathogenic Escherichia Coli (UPEC) is a true “terrorist inside the bladder wall”. Why? Because they are there even when the urine exam is negative. So you have the enemy inside the bladder wall. This will also cause a progressive inflammation of the bladder wall. So first you have the cystitis and then you have persistent pain in the bladder. And then this may lead to interstitial cystitis. So it's a very serious condition to block the Escherichia coli, so to say, in the first episodes of cystitis.

There are three major “triggering conditions” for the cystitis and urinary tract infection: 

First of all, and women know that very well, intercourse may “traumatize” the urethra, more so when the woman has very tightened pelvic floor muscles. Cystitis appears 24 to 72 hours after intercourse. 
When cystitis is the first symptom women complain of, 60% of women complain also of pain at intercourse at the entrance of the vagina, squeezed, so to say, by the tightened pelvic floor muscles.

• Second, the second etiology of recurrent cystitis is acute diarrhea or constipation because this increases the possibility that contingent plotons, so to say, of Escherichia coli, your pathogenic, cross the bowel wall and through the lymphatics or the blood, aggress the bladder.
• The third and very, very important is the environmental cold. Environmental cold increases the aggressiveness of Intracellular bacterial communities. Why? when a rapid and marked difference of temperature – between, for example, the beach in hot summer, and the bar when you go to take a beer or a water. The sudden difference causes rapid dysbiosis in the gut and this increases the likelihood that your pathogenic bacteria cross the bladder wall and aggress via the lymphatics of the blood the bladder.

And at the same time, this increases the aggressiveness of the intracellular bacterial communities. So this double attack increases the likelihood of a “cystitis a frigore”, said caused by the cold, as the old physicians, Latin physicians, used to say 2,000 years ago.

To prevent recurrent bladder infections the winning strategy is to avoid antibiotics, except in severe cases of hemorrhagic cystitis, as they worsen gut dysbiosis, increase antibiotic resistances, worsen irritable bowel syndrome and the vulnerability to Escherichia coli attack. 

A preventive approach with phytotherapy can be made including D-mannose and red-current at nighttime, may help. 

Oral and vaginal probiotics may contribute to protecting the bowel, the vagina and the bladder!

And don't forget to recommend the relaxation of the physiotherapy for the pelvic floor.

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

First of all, Urinary Tract Infections (UTI) are caused mostly by Uropathogenic Escherichia Coli (UPEC). What does it mean? The name is clear, this germ can attack the bladder, the urethra and also the kidney, causing very very serious infections of increasing severity 

This UPEC, Uropathogenic Escherichia Coli, is a member of a big family, more than 100 brothers, so to speak. They live very happily. They live happily in our gut without causing any harm. However, when the UPEC reaches the urinary tract, it can attack the urinary cells (say the urothelium and later the bladder and the urethral wall) with a very specific damaging strategy.

What we know now is that the UPEC can attack the bladder via three major pathways:

• The first is via the perineal area, attacking the vagina first, and the bladder second. This pathway is more frequent in situations when the woman has low or no estrogens, for example, when she has no periods because she has psychological emotional problems or eating disorders, or when she is lactating, or after the menopause. In all these three conditions, where the level of estrogens is very low in the tissue, we have a major change in the microbiota in the vulva, in the vagina, and in the bladder, and this microbiome becomes more vulnerable to the attack from the Escherichia coli uropathogenic.

• Second, the Uropathogenic Escherichia coli, which is specialized in attacking the bladder may attack via the reactivation of the so-called “intracellular bacterial communities” (IBCs). What does it mean? During the first or second or third attack of cystitis, Escherichia coli takes away the coat, attacks the cells that line the inner part of the bladder and the urethra, enter into the cell, and become resident. These become resident intracellular bacterial communities that are almost dormant, but become very aggressive, for example, 24-72 hours after intercourse, causing post-coital cystitis. 
• They can also attack the bladder through the bowel wall, They can attack through the bowel wall when the woman complains of irritable bowel syndrome, diarrhea, constipation, food intolerance to lactose or gluten, or after antibiotics. In all these cases, we have gut dysbiosis, and because we said this will damage also the wall of the bowel and cause the so-called leaky gut syndrome, say, we have a passage of germs through the bowel wall, and this via the lymphatics or the blood can attack the bladder and the urethra.

So, three major pathways, the first through the perineal area, attacking first the vagina and then the bladder, this is particularly relevant when estrogens are low. Second, through the reactivation of Escherichia coli already inside the bladder wall, and third, through the bowel when we have gut symptoms.

A good collaboration with a competent gastroenterologist is, therefore, key to addressing this component of the infection of the bladder stemming from the bowel.

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

The healthy vulva and vagina have a very delicate scent and taste, thanks to their natural microbiota in eubiosis, say, in a very good dynamic equilibrium and health.

In this condition, the vagina has a prominent family of lactobacilli, say, 80% Crispatus, Gasseri or Jensenii, and a natural perfect acidity with a pH around 4.

If the vagina secretions smell bad, like the smell of a spoiled fish, the cause is an increased proliferation of a microorganism called Gardnerella vaginalis, which is normally present in the vagina but in very small percentages. What's the point? The percentage increases with the increase of the vaginal pH.

This means that the normal acidity of vaginal secretions, which in the fertile age is perfect at around 4, increases to 5 or more for a number of reasons:

• First of all, gut dysbiosis, because they communicate with each other.
• loss of sexual hormones, particularly after menopause,
• or unprotected sex, just to mention a few, and the most frequent.

When the pH becomes 5 or more, the likelihood of bad scent increases. To maintain the low percentage of Gardnerella, typical of a dynamic eubiosis, we should guarantee the normal level of estrogens in the vaginal, maintain the menstrual cycle very regularly, and have a very healthy gut and vaginal microbiome.

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

The cleaning should be done daily, ideally after bowel voiding, using the hand from front to back. Prefer a gentle, soap-free cleanser able to protect selectively the intimate vulvar flora and protect indirectly the vaginal microbiota and microbiome. 

In couples that are loyal to each other, and with appropriate personal hygiene, washing the genitals after sex is not recommended. It is recommended when the couple likes anal intercourse (that should always be done with a condom!) for two main reasons :

• To protect the spreading of the colonic bacteria into the perineal area and spreading them to the vulva, changing aggressively the vulvar microbiome
• and also to prevent sexually transmitted infections.

If you change partners often, use condoms consistently, from the beginning of the intercourse and in every type of intercourse. Because this is the safest defense line for keeping your secret garden clean and happy, i.e. to protect your vulvar and vaginal microbiota at your best.

In short, what I say is that to prevent the invasion of pathogens and germs is the first logical act of self-protection because you value. Opposite to that and beware this point, washing the genitals, the vulva, the vaginal, doing the vaginal douching after intercourse, beware, after unprotected sex, it is a dangerous illusion of self-protection. Why is that? 

In too many cases, the damage is secretly done, particularly when the partner is a “healthy carrier”,  What does this mean? It has no symptoms nor signs of infection and yet it has, for example, the papillomavirus inside the sperm and this will be transmitted to you. Washing means nothing. So, the first line to protect yourself consistently is to use condoms in every intercourse with every partner and in every type of intercourse. This will promote and protect yourself, your whole health and the vulva and vagina microbiome effectively and consistently. You value. Do it.

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

• Periods should not hurt much. Usually, in most women, they cause a mild discomfort that does NOT interfere with daily life and personal activities (school, sports, friends, work, leisure). Important! We do have friends microorganisms also within the uterus. Today we talk about the endometrial microbiome and now we understand that the health of this microbiome contributes to painless, so to say, periods, whilst a dysbiotic microbiome may be a contributor also to painful periods and the progression to endometriosis.
• First sexual intercourse can be painless in some women, when the hymen is naturally very thin and elastic we talk about a “complacent hymen” or it has been gradually dilated with the finger during foreplay. In the majority of women, the first intercourse causes a mild pain, that usually fades away after two or three intercourses.

In less frequent situations, the first intercourse is extremely painful and some women cannot accept the penetration at all. In this case, we have a very tight and tightened pelvic floor contraction and this is responsible for the sexual problem called vaginismus, causing sexual pain. In this case, if the woman keeps on, and a couple, keeps on trying to have intercourse, this will damage the mucosa, cause dysbiosis of the local microbiome and this is another cause of vestibulodynia, say, this burning pain that women will have not only during the attempt of penetration but also afterwards.

This requires a very rigorous medical treatment with a competent sexual medicine approach.

So, sexual pain is never in women's head, it has a very solid biological basis, more solid when pain is excruciating.

When pain during periods, dysmenorrhea, interferes with daily activities, it is worth medical attention the sooner the better. It may be the first sign of endometriosis that is still below the visibility threshold of the current imaging diagnostic techniques. 

Vaginismus, a sexual disorder characterized by the phobia of penetration, must be considered when pain is excruciating, up to prevent penetration. The phobia is associated with a variable degree of defensive tightened contraction of pelvic floor muscles. The repeated attempts of penetration may damage the vestibular mucosa contributing to vestibular pain up to vestibulodynia.

Key point: sexual pain is NOT normal. It should be competently diagnosed and treated, the sooner the better.

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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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