“The Superhero in Your Vagina”
by Kendall Powell
Mosaic, October 11, 2016
[Powell notes: This is a long pitch, but that’s because it was a follow-up to an in-person pitch and the editor also asked for a list of possible travel sites and sidebars.]
The superhero in your vagina
When a girl enters puberty, her vagina does something unique in the animal world. It attracts a single bacterial species, which takes up long-term residence and uses acid to keep disease at bay.
If she’s lucky, Lactobacillus crispatus or a close relative might live there happily through her reproductive years, as a protector of that sacred space that ushers new life into the world. You might expect this warm, moist exposed cavity to be teeming with a diverse set of microbes, but researchers are learning that a healthy vaginal microbiome is dominated almost solely by a sort of one-hit wonder.
These Lactobacillus residents pump out an unusually high level of lactic acid, which acidifies the vagina and may keep other bacteria from thriving. In fact, women who harbor L. crispatus have vaginal mucus with the superpowers to trap and kill HIV, helping to reduce the risk of infection.
But for one-third of women on the planet, L. crispatus is unceremoniously pushed out of its vaginal abode by a condition called bacterial vaginosis (BV). An unwelcome souvenir from unprotected sex or another disruption to the vaginal environment, a mixed cocktail of good and bad bacteria takes over the vagina. This microbial coup can expose women and their children to devastating health consequences, including a higher risk of stillbirth, preterm birth, perinatal infections, and of acquiring and transmitting HIV, herpes and other STDs.
The sheer magnitude of the problem is stunning: although at any given time an estimated 1.1 billion women have lost the microbial battle, most have no idea they were even fighting one. The mild symptom of a fishy-smelling discharge shows up in less than half of women with BV and few bother to seek treatment. For those who do, doctors can’t offer a long-term cure and instead often prescribe a broad-spectrum antibiotic that may make the problem worse by further disrupting the microbiome.
It is a massive, silent and only partially understood public health crisis.
Richard Cone and other researchers are hoping to thwart the vaginal villains by finding ways to return the Lactobacillus guardian to its rightful place. “Anything we can do to help more women, more of the time have L. crispatus in their vaginas, then the world will be a better place,” says Cone, a biophysicist at Johns Hopkins University.
Easier said than done, of course. As epidemiologist Jenifer Allsworth says, we are at “the more we learn, the less we understand” stage, with studies just beginning to illuminate what a “healthy” vaginal microbiome looks like, and to define and track how vaginal microbe communities may shift with race, age, and different phases of the menstrual cycle.
Researchers are also trying to pin down why some women have healthy vaginas all their lives, others suffer transient BV and recover, and some succumb to recurrent bouts. African American and Hispanic women have a higher prevalence of BV, for example, though the reasons are unclear. The condition also appears to track with poverty. And while BV often occurs after recent unprotected sex, a small but significant proportion of virgins have BV too.
Finally, there are more philosophical questions: who’s to say what a healthy vagina actually looks like, for instance? Many of the most passionate researchers rail against the past patriarchy of “old, white men” who have so poorly defined vaginal health to date—though several of these advocates are also old, white men. Also, should we be treating a condition that does not cause direct disease? Probiotics expert Gregor Reid likens BV to dental plaque—a bacterial dysfunction that can cause major health problems if left unchecked: “Do you treat that? Yes, if you go to the dentist, by scaling the teeth, knowing damn fine well that, within days, it will all be back.”
Reid and others complain that methods for diagnosing and treating BV haven’t changed in two decades. Now, however, the genetic sequencing revolution is giving researchers potent new tools for discovering when the vaginal microbiome is truly disrupted and how it might be restored. It’s a crucial puzzle to solve. After all, as geneticist Larry Forney argues, this is the most critical microbiome for successful reproduction and the continuation of our species. It’s a moment reminiscent of the 1970s when women broke out hand mirrors to get a better look at their own anatomy and realized how little they (and the medical experts) knew about the organ that defines womanhood.
For Mosaic, I would love to explore the new frontiers of vaginal microbiome health. I would report on efforts by Cone, Forney, Allsworth and Rebecca Brotman at the University of Maryland to better define and diagnose BV and raise awareness of this often-unnoticed but potentially devastating condition. I would contact researchers such as microbiologist Amanda Lewis at Washington University in St. Louis who investigates how Lactobacillus protects the vagina at the cell and molecular level. I would also speak to experts on the adverse health outcomes associated with BV, such as STD expert Jane Schwebke at the University of Alabama and Sharon Hillier at the University of Pittsburgh, who studies preterm birth. I would also explore the latest attempts by Cone, Reid and the company Osel to develop and test treatments designed to reintroduce Lactobacillus and encourage it to thrive—through gels, vaginal rings, sex lubes, or oral probiotics. I would explore why a women’s health issue affecting hundreds of millions has no large pharmaceutical companies clamoring to produce the next BV drug (and the matching TV commercials of women frolicking at the beach).
Places that I might visit to see vaginal microbiome research in action:
- Allsworth’s clinics in St. Louis or Kansas City where she has successfully recruited African American women for studies on BV. She reports an unexpectedly high level of participation in this community because they all know someone whose quality of life has been affected by BV.
- Samual Lai’s laboratory at Duke University where he has studied the ability of women’s cervicovaginal mucus to trap HIV particles in the lab.
- OR: Multiple labs could be visited in the Baltimore area as geneticist Jacques Ravel and epidemiologist Rebecca Brotman are both at University of Maryland and biophysicist Richard Cone is at Johns Hopkins University. Also, there is a group of three PI’s studying the vaginal microbiome in relation to pregnancy and preterm labor and birth at nearby Virginia Commonwealth University in Richmond, VA.
- A more detailed look at what is behind the passionate ‘feminism’ driving three old white guys, Richard Cone, Gregor Reid, and Larry Forney, who strive to get vaginal health on the radar of women, their doctors, and the pharmaceutical companies.
- The vaginal microbiome is also thought to be the ‘mother’ of all microbiomes, at least for babies born vaginally. The genesis of our skin, mouth, and gut microbiomes starts here.
- BV and sex—a complicated relationship. This sidebar would look at whether BV is truly associated with unprotected sex or not. Although history has called it a ‘sex-associated’ condition, BV shows up in about 15-20% of women who self-report being sexually inexperienced. In addition, some studies have found an increased prevalence of BV in women with uncircumcised male partners. If true, this would create a potentially dangerous feedback loop in certain African countries where HIV rates are high and rates of circumcision are low—putting women at higher risk of both acquiring and transmitting HIV. Others say the connection to circumcision is inconclusive.
- The ‘My Vagina’ Project. I’d be willing to submit a sample to the American Gut Project (or Ravel’s lab) to have my own vaginal microbiome sequenced to find out what microbes are living in there. Given the sensitivities about race, socioeconomic status, and recent sexual history, it might be more interesting (and less nerve-wracking for me!) to see if any other women at Mosaic would be willing to participate as well so that we could report results in the ‘aggregate’.