How to care for your downstairs
It may seem surprising, but there are actually recommended do's and don'ts when it comes to daily care for your nether regions. And these are likely to be entirely different than what you have previously read in Cosmo or heard from social media influencers. Why, you ask? There is big money in development and marketing of beauty products, and companies with ‘essential’ products or services want a piece of that pie! According to a 2017 poll by Groupon, women spend an average of $313 per month on their image. This includes hair care, beauty products, and gym memberships. And that's some serious pie!
But what do you actually need to keep your vagina, vulva, and pelvic floor healthy? And why is a physical therapist writing this article? First things first: definitions. Before reading on know that the vagina is the canal extending from the external genitals to the cervix, and the vulva is the external female genitalia (labia, mons pubis or fatty area over the pubic bone, clitoris) and opening. And this article is being written because prevention is the best medicine. With a significant reduction in risk for inflammation and/or disease of the pelvic tissue, we eliminate some contributors to pelvic pain. And without pelvic pain, the resulting sequelae of things that can go wrong in the pelvic floor can be prevented before they start. Read on to discover how to best care for your downstairs!
Grooming
PC: Daniel Watson @danielwatsondesign
Let’s start with grooming. There are all sorts of ways to groom, just ask your local estetician what his or her specialties are. Just to name a few: a Brazilian is waxing to remove all pubic hair; a runway entails keeping a narrow, rectangular patch of hair over the vulva and removing the rest; a bikini-style wax or shave removes everything outside the lines of bikini underwear; and the variations are limitless. Per population studies, the majority of women groom with a razor, while waxing, sugaring, and hair removal creams make up the remainder. In a study that examined different levels of grooming (from none to complete removal of pubic hair) in correlation to sexually transmitted infections (STIs), complete removal of hair was associated with an increase in reported HPV, herpes, and syphilis, as well as other infections. Any history of grooming at all was associated with an increase in reported STIs. These findings support the theory that pubic hair functions to protect you from unwanted pathogens. It may also help to avoid skin discomforts from the friction of intercourse! But if STIs are not a concern for you (i.e.: you are in a monogamous relationship, no relationship, or other scenario) you should still be cautious. Hair removal has been found to cause minor complications, including itching (this is an actual studied side effect) and ingrown hair follicles.
As mentioned, it is thought that pubic hair does likely function as part of your immune system. If you typically have no issues with your urogenital tissues (no UTIs, no STIs, no bacterial vaginosis, etc.) then you have not walked in to the world of how hard these infections can be to deal with. Recurrent infections are not uncommon with UTIs and bacterial vaginosis (BV). While research is limited at this time regarding the potential of urogential infections from these sources, data has been collected and will hopefully be published shortly regarding the effects of grooming on the vaginal microbiome! In short, any introduction of foreign pathogens-from a razor or waxing products-in combination with the abrasion of shaving or waxing (any damage to skin removes a component of your immune barrier)-allows for a change in the vaginal microbiome. The vaginal microbiome is made up of a combination of bacteria, yeast, and other cells that colonize the vaginal and vaginal canal, and also function as part of the immune system. It is an area being very highly studied at this time because so much is being learned about its role in the host’s health, and there are very positive benefits for the host with a healthy microbiome . This study will have huge implications (I hope) in guiding women who struggle with a variety of infections to let them know for sure that pubic hair is either important to help combat them, or does not play a significant role and we do not need to worry about its presence or lack thereof. More on the microbiome later, though.
What to do about it
Ultimately, research is conclusive that pubic hair functions to protect a person from STIs. This is a very important, especially in the case of STIs that are life-long. As far as the unknown answers, including UTIs, BV, and yeast infections, my professional recommendation is the err on the side of caution. But that does not mean you can never wear a bathing suit again. Until more specific guidelines are studied and firmly supported, consider leaving the hair around the labia and mons pubis (the fatty tissue over the pubic bone). There has been a correlation between hair removal via non-electric razor from these areas specifically and vaginal dysplasia or cancer (I can only find one study on this, so please do not stress out reading this, but know that there may be some risk).
This modification to grooming allows you to have some protection of the pubic hair without worrying about how your bathing suit will be affected, or worrying about the more extreme but rare possibility of vaginal cancer. It will also help to avoid pathogen introduction to the vaginal area by keeping the razor and any other products away from the vulva. If you really must do complete grooming to no pubic hair, consider that the abrasion of shaving can be especially aggravating for sensitive skin. If you notice your skin becoming irritated try switching to waxing or sugaring. There are washable waxing products that allow you to wash out any area of accidental application if you are doing it DIY-style and mess up placement. I highly recommend this honey-based kit.
Cleaning
PC: JESHOOTS.COM @jeshoots
The microbiome of the vaginal area was briefly mentioned above. Specific microbes are very important for maintaining the health of the vaginal and vulvar areas, and a healthy vagina tends to be dominated by Lactobacillus bacteria. A person’s microbiome is completely individual, and a fingerprint of sorts that changes with time, environment, habits, contraception type, and many other factors, but is always individual in proportions of the various genus and species present. Ethnicity, socioeconomics, and birth method interestingly also have a role.
Lactobacillus bacteria are important because of their role in producing lactic acid, which keeps the vaginal pH in the acidic range (pH 3.4-4.4 for White and Asian women, and slightly more basic for Hispanic and Black women). Maintenance of this acidic environment is essential to maintaining a healthy pelvis. An unhealthy vaginal microbiome is an important risk factor for acquisition of STIs and adverse reproductive and obstetric outcomes. It also plays a role in the development of bacterial vaginosis (an infection not classified as a STI), which affects approximately 24-30% of the female population. Bacterial vaginosis, or BV, is a risk factor in development of a plethora of pelvic issues.
But if bacterial vaginosis causes the vaginal pH to become more basic, but it is not a STI, how do you get it? Any disruption to the vaginal microbiome can contribute to an alteration in the bacteria that colonize the vagina. This includes antibiotic use, contraceptives that alter the hormone cycle, and hygiene habits. There are so many studies that support douching as a primary contributor. But a very common side effect of BV infection is vaginal odor, with the possibility of zero other symptoms. This can set women up to think they need a product to address odor, when the issue is actually related to a bacterial imbalance. Using products to cover or temporarily remove the odor may actually worsen the infection.
What to do about it
First, it is important to understand that your vulvovaginal area is not supposed to smell like a field of flowers. It is also not supposed to be sparkly or flavored, unless this is for very brief amounts of time. Second, do not douche. While the practice seems to be much less common than previously, there are very few instances that it is actually appropriate. For most women it is unnecessary and has been repeatedly shown to contribute to an unhealthy vulvovaginal area. Anecdotally, douching with vinegar may potentially be helpful if you have an in situ pessary. But please discuss that particular case with your urogynecologist or naturopath to avoid tissue harm. For every woman: wash only the vulva. For most women, rinsing solely with warm water in the shower should be enough, or a gentle product may be used in the case of very sensitive skin. The Royal College of Gynecology (RCOG) and a committee from the Middle East and Central Asia (MECA) released guidelines in 2011 (the most recent I could find) on vulvovaginal care. MECA guidelines are slightly more clear, and recommend products that are hypoallergenic with slight detergency and a pH between 4.2 to 5.6. They recommend avoiding bar soaps and bubble baths as they tend to have a higher (more basic) pH, which may negatively impact your tissue and biome. They also suggest that a lactic-acid based liquid with an acidic pH may help maintain vulvar health and provide some symptom relief in the time of infection (with the caveat that these products are not designed to treat infections).
These recommendations are pretty specific without giving actual product recommendations, and because the market changes so frequently it would be impossible to keep up on what is ‘good.’ So here are my step-by-step instructions:
Order pH strips. I have mentioned the importance of pH about 8 times in this article now, so I hope you are gleaning its importance. If you want to order something other than what I have linked, please purchase a product with a range of 0-14. This is the most efficient way to check yourself, especially through the changes of pregnancy, postpartum, and menopause, which are all points in time that a woman is more susceptible to potentially negative changes in her biome.
Check your own acidity. Once you’ve received your mini science kit in the mail (pH strips), it’s time to find out about yourself. After a shower and pat dry, grip the end of the strip with one hand and separate your labia with the other. Gently move the test strip around the vulva and you can sample a bit of the lower vagina if you are comfortable. Find your corresponding reading. IF you are not in the recommended range of about 3.4 to 4.8, it is time for you to schedule an appointment with your gynecologist to get to the root of the problem.
Check your products. Anything that is not labeled as hypoallergenic should not be used on your vulva. All those products that remain need to be checked for pH, keeping only those in the recommended range of 4.2 to 5.6 to be used on your vulva.
Cleanse the vulvar area gently with your chosen product (or warm water alone), separating the labia to clean between the minora (more toward your center, or medial) and majora (more toward the thigh, or lateral) on each side, and then cleansing the vulva from the clitoris to the perineum (the skin between the vagina and the anus). Do this only once per day, avoiding use of sponges and cloths to eliminate potential bacterial introduction from these sources. Avoid placing any of the cleanser internally to protect your microbiome! And assess your tolerance to your product. Getting itchy? Noticing a non-preferable odor? Try something else.
Take a look-see. Get out a mirror and truly look at your vulva (spreading the labia open gently to see). Does the skin appear irritated and red, white-ish, or a nice pinkish skin tone (keeping your ethnicity in mind, the skin should appear plump with good blood flow somewhat similar to the skin inside your lower lip)?
Wear cotton underwear. They help to regulate heat and moisture better than other fabrics, especially polyester. You can also try bamboo fabric, which is a breathable fabric and supposedly good for odor reduction if that’s a concern.
}at your vagina does not function in isolation. Changes in your GI tract, use of antibiotics, and a plethora of other factors can affect your vulvovaginal area. Enlist the help of your physician if you feel like anything is 'off’ or may not be optimal.
What about probiotics?
PC: CDC @cdc
This is an area needing further investigation, and more outside my scope of practice. But it is an important consideration as no part of a body functions in isolation of other parts, and antibiotic use can have significant effects outside of their target. There is a beautiful resource called The Clinical Guide to Probiotic Products based on what is available in the US. If you are in Canada, see here, and European guidelines are here. This resource is great because it lists actual products and their studied uses, taking the guesswork out of finding a specific bacteria strain randomly listed in the literature. For anyone experiencing BV or yeast infections, there is level one (based on at least one randomized controlled trial) evidence to support three different products (see the list for specifics). At this time, these are the only pathologies showing improvement with the use of probiotics in this resource. Side note: this list has products recommended for a huge variety of digestive issues, including a section for kids, its very worth your time!
Other tips for a healthy vulva and vagina
Urinate after sex. Semen is basic! Plus better to flush out the urinary tract after introduction to foreign material.
Stay hydrated. Keeping good blood flow to these tissues keeps them healthy.
If you are early postpartum, breastfeeding, or in menopause and affected by vulvovaginal dryness, talk to your physician about topical estrogen. This can make a significant difference in many symptoms for women, and research shows it can be considered even with a history of breast cancer.
Consider an over the counter moisturizer if dryness is a problem day to day (this could be coxonut oil, V Magic, etc.). It's like chapstick for your labia. This is also an excellent option for menopause without worrying about any estrogen input from topical cream if that is a concern for you and your history.
In Summary
All recommendations in this article are based on the research available at this time. In summary, be careful with the level of grooming you regularly participate in. If you feel you need to completely remove all hair from the pubic area, consider that shaving appears to show more risks than other methods of hair removal (but also it is a more common practice so has a higher number of studied subjects). Also, consider all of your cleansing products and habits. Stick to cleansers that are gentle and fall within the recommended pH range. A healthy vagina is a happy vagina! And prevention is the best form of medicine. Please don’t hesitate to PM or DM me if you have any questions through The PT-Mom social media accounts, and I will do my best to offer guidance!
Thank you for reading! Please follow The PT-Mom on Instagram and Facebook to stay updated with all things pelvic health!
Cover photo credit: Yusuf Evli @yusufevli
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