Episode 19 Vaginal Dermatitis and Allergic Triggers in Women’s Intimate Health
===



Introduction to vaginal dermatitis and allergic reactions
---

Dr. Meagan: If you've ever dealt with itching, burning, or irritation in the most sensitive part of your body and been told over and over that it must be yeast or BV, you are not alone. For many women, the real culprit isn't an infection at all; it's an allergic reaction. And the same way that you might get a rash from something like nickel and jewelry or a lotion that's scented, you can also react to toilet paper, wipes, soaps, even the elastic and clothing. So today we're gonna talk about vaginal dermatitis and allergic triggers in intimate health and what you can do about it. So welcome everybody. This has been a topic that we have sort of chatted about adding for a long time.

And finally decided today is the day. So today's just, we're just gonna jive right in. We also talked about perimenopause and all of that earlier. So if you wanna hear that, that will be on an episode as well. So we're literally talking about vaginal health and then things that can go wrong and some honestly outside the box ways of thinking about it.


Allergist perspective on treating vaginal issues
---

Dr. Meagan: So throughout my career, I have oddly enough actually had multiple patients referred to me for vaginal issues and I don't recall that from fellowship and that certainly wasn't something on my boards that came up. And I was really surprised when this started coming and 

Dr. Kara: It wasn't your bingo card, Meagan?

Dr. Meagan: It wasn't in my allergist bingo card and I have done more pelvic exams than I ever thought I would as an allergist. That was very shocking to me, that people are coming in with this complaint. And the complaint, it could be different things. I've had people who have issues with discharge, recurrent feelings of itchiness or discomfort. Sometimes they may have exam findings that you can see as far as like mucosal changes but not always.

And so, this is something that is, I think, hard for people to talk about too. And a lot of people would never know to go to an allergist. Luckily, when I was working in the academic setting, I had a colleague who does adolescent gynecology. And she sent a patient to me and we ended up figuring out that her symptoms in the vaginal area were actually a dermatitis.


Case study: Metal allergy from braces causing symptoms
---

Dr. Meagan: And after patch testing, which is the type of testing that we can do that looks at not anaphylactic type of reactions, but those reactions that occur sort of more slowly with a different set of immune cells. We were able to figure out that this all started when she got her braces. And so on patch testing, she was actually positive to nickel and cobalt, which we later realized were both metals in her braces. And when they were removed, it all went away, and so we actually published a.

Dr. Amber: I'm sorry to interrupt you, Meagan, but just to connect the dots for people. Her exposure to the metal was on her teeth and gums and mucosal surface of the mouth, but her symptoms were not showing up there. They were showing up in her genital area.

Dr. Meagan: Exactly. And that's one of the things about contact dermatitis in particular that I tell people is that contact dermatitis is such a weird thing because the T cells that are really in your skin don't always have the same memory in different places. The way if you're allergic to a peanut, you eat it, sort of all the cells in your body could potentially, react exactly. But for contact dermatitis, those cells don't have great memory. So it's very possible for you to have an allergy to something and you have a rash, for instance, in one specific part of your body. From something like a body wash that you use all over, but it just being the rash in one spot. And so I always tell people to keep that in mind because it's hard to, I think, accept that. I wash all over with this wash, isn't this rash all over? I mean that's it's a very real thing.


Understanding skin sensitivity and contact dermatitis
---

Dr. Meagan: And the other thing is that different skin has different sensitivity all over your body in the sense of skin thickness. So there are different portions of your body that are just more likely to show rash and symptoms of being irritated than others. So it's also possible that you, again, for instance, have a reaction with shampoo, but it might not bother your scalp all that much, but it really bothers the skin around your face, you know, around your eyes. 

Dr. Amber: Particularly eyes tend to be the thing, like when somebody has a contact dermatitis problem that they may come into our office with an eyelid rash, but really it ends up being, oh, it's your hair shampoo or your nail polish or something.

Dr. Meagan: Exactly. So I have sort of, I suppose maybe developed a reputation in the area where people send me people now that have sort of these vaginal complaints that don't appear to be some type of infectious cause. And so I work with these patients a lot and we have found patch testing to be so helpful in that regard. I'm just trying to think of the different things that we've discovered over the years. Toilet paper seems to be killer. Trying to find a natural toilet paper without dyes.

Dr. Amber: The white toilet papers have dyes? I never knew that.

Dr. Meagan: And there are different chemicals, of course, in wipes. I always try to get my patients to get natural cotton, like feminine care products and to try, if they're not allergic to any sort of rubber accelerators, on patch testing. Which is one of the things that we see that comes from latex that can be found in like elastic and things like that, using the period underwear and completely skipping products. So that is, I feel like I spent an inordinate amount of time talking about that. But for those things, what sucks is that for patch testing, depending on what you are a member of as a physician, you can sometimes access these databases where you input, the patient's allergic to this, and this, and it will spit out safe products. But the products that are things like toilet paper and panty liners, tampons, that kind of stuff doesn't list ingredients. So it's not something that it can necessarily spit out back for you that this is a safe one. So it takes a lot of trial and error.


Diagnostic approach and treatment options
---

Dr. Amber: I guess just to kind of think back, if there's somebody listening to this who says, "My vaginal area is really itchy," a first step would be talk to primary care or your primary gynecologist, would you say to rule out infectious causes of things that can cause itching in that area 'cause that's probably the most common. But if they don't find anything that good.

Dr. Kara: Or if the treatments aren't helpful, if you're using, Monistat or getting even Fluconazole tablets to treat yeast or you're being treated for bacterial vaginosis with metronidazole and that treatment doesn't work as you would expect it to, then that's really important to know and to gives you some information to say, Hey, it probably wasn't yeast. It probably wasn't BV to begin with.

Dr. Amber: So then seek out your allergist and that's where we can do patch testing and help identify this. One other cool invention I recently became aware of that's great for patients like this while you're in that period of trying to sort things out and just to give a little symptom relief, have you guys heard about the VPod? Last year, I went to VC Fest in Cleveland and I met this female inventor. She's a professor, she's also a social worker. But she, for whatever reason ended up meeting a lot of women that were suffering with vulva discomfort and probably just related to her field, they, were telling her about this. And so she came up with, I'm gonna show you guys. It's, this is probably an oversimplification, but it's an ice pack for the vulva. It fits perfectly down there. It's, something you would buy for yourself and not share with anyone else in your family, obviously. But everyone could have their own if they needed it.

But it's frozen and you just, when you sit down to watch your shows for the night or go into bed, just slide that down there and it gives a lot of comfort when you have itching or discomfort.

Dr. Kara: That is brilliant. It's like a reusable version of those disposable ones you get when you have a baby. 

Dr. Amber: Exactly. But this is like ergonomically formed to that area and it's smaller, so it's

Dr. Kara: That is, yeah, more discreet than the ginormous, 

Dr. Amber: Yeah. When you have a baby with a giant ice pack, you're like, yes. Give me that.


Important conversations about intimate health
---

Dr. Meagan: How interesting. One of the things that just struck me too that I think we have to remember when talking about vulva irritation and vaginal issues is you actually do get to the point where we as physicians have to have some uncomfortable conversations. And so, for instance, one of the things that we don't ask a lot of patients about are masturbation habits. Right? That's not something that we commonly say. Could you tell me about this? We'll sometimes ask about sex partners and things like that. But for some of the patients that I have had that have had significant vulvar irritation or what looks like contact dermatitis in that area, or even the mons pubis, like for non-medical people listening, it's the part sort of on the top where you grow pubic hair.

So, I have had to have some pretty uncomfortable conversations with patients. And I'll preface that and say, I know that this is awkward. This isn't something that you usually talk to your doctor about but we do need to know not only sexual partners, do you use condoms? That kind of thing. But you know, is there anything else that we're putting down there that may be causing irritation that we just may not realize it? And so, that's an important part of this for anybody listening, don't be afraid to even remind your allergist whenever you are talking about vulvar discomfort, of all the things that go and touch down there, because it's not always the normal things. It's not always necessarily gonna be a shampoo or something like that.

Dr. Amber: And one other thing that, this is rare, but there have been case reports, multiple case reports about semen allergy. So, that's another thing that if you feel like, gosh, we've checked all these boxes, we've thought about contact derm from my toilet paper and my pads, and any other care products, could it be something like that? I don't know that's something we can really test for.

Dr. Kara: I've heard of it discussed on rare occasion in some of the allergist specific social media groups, and I think it's not something that is routinely offered because there is a lot of certainly concern for CYA, like of like infection risk or other things. Right? Because you are dealing with bodily fluids and needing to use those for testing or so forth. But there are some practices that do specialize in that. 

Dr. Amber: We do skin prick testing and patch testing.

Dr. Kara: I think it was more related to skin prick, but I am not a hundred percent.

Dr. Amber: But we certainly, I mean, we do that with other things like foods. If somebody thinks they're allergic to, let's say banana, that's not a common food allergen. Most allergists don't keep banana extract, but you can bring fresh banana and we can prick the banana, prick the skin. It's a really great way to test. That same concept would be used for testing semen allergy. Someone would have to bring in the sample of the, suspect contributor to the potential rash or irritation, and that could be tested. But yeah, like you said, Kara, it's not a commonly offered service. So it would, if it got to where that was the consideration that, gosh, we really think it might be this, you just need to have an open conversation with your allergist and see is there a safe way that we could test this?


Autoimmune conditions and vaginal health
---

Dr. Kara: I think it's really important also and I'm gonna try to broach this without like oversharing too much. But prior to my Sjogren's diagnosis, I talked with my OB-GYN because I was having significant issues in that area. And I can't remember if we were engaged, if we were married, whatever at the time, I would've been in my late twenties, early thirties. And so, frankly I was embarrassed and didn't bring it up till the very end of the visit. And so when you have that, we call it the doorknob complaint, like you don't always get like the doc's full attention, right? And so it was brushed off as like, oh, it's probably dryness, or you need to use lubricant, or what have you. But in hindsight, I now realize that, the dryness that's associated with Sjogren's isn't contained just to eyes and mouth or nose or skin. It also can affect, vaginal dryness and so other conditions, so like lichen sclerosis is another autoimmune condition that you would want to be evaluated for kind of through that process because the treatment is different.

And so that might be something else that is on what we call that differential diagnosis or all the different possibilities of what might be causing your symptoms. And depending on the nuance of those symptoms, that may be something that comes up. So I wanted to at least make mention of, those other, perimenopause, menopause, right? Having lack of estrogen to those tissues changes the tissues, makes them more dry, more sensitive. Other autoimmune conditions like Sjogren's and lichen sclerosis can do the same and can also maybe set you up for being more sensitive to detergents, panty liner, all those sorts of things.

Dr. Meagan: That's a really good point. One of the other things I thought about earlier that I think it's okay to talk about now is a lot of people, if they have recurrent candidiasis in the vaginal area, so having recurrent yeast infections. I have had some people refer patients to me for that, but I just wanna say that I think that in particular is important to think about discussing with an allergist immunologist, because of course, we don't just do allergies. We work with the immune system whenever it's not working very well, and we have to sometimes work with it when it goes haywire as well, like autoimmune disease. So, I say all of that to say that I have had several patients who felt like they weren't really being taken seriously about getting recurrent yeast infections, or their physicians didn't believe them when they say, I need more than just one fluconazole to treat this. And there is a disease called chronic mucocutaneous candidiasis that is an immuno deficiency that lives out there, and I'm sure that there are more people who have it than we know of because it's not actually currently something that's testable, possibly outside of a research setting, it's diagnosed by history.


Chronic infections and immune system involvement
---

Dr. Meagan: And so I have had quite a few patients that I have ended up diagnosing with that. And I think giving them that diagnosis at least helps when they see other providers. So it can, I think, reinforce that, yes, this isn't your normal yeast infection that you're dealing with.

You're, this will come back and back. And so I deal with that all the time. For instance, with my CVID patients who get a lot of antibiotics, whether or not they have any sort of CMC, the chronic mucocutaneous candidiasis, sort of genetically at all, they're getting antibiotics all the time.

And so I go ahead and I give quite a bit of fluconazole and go ahead and prescribe it early. But if you don't have a known immune system problem, but you get this recurrent yeast infection all the time, it's worth looking at. About whether or not you have CMC and then having that diagnosed by an immunologist can give you, I guess, a little bit more power whenever you're trying to argue, yes, I actually need three fluconazole instead of just one.

Dr. Kara: I have one other thing that I think kind of blew my mind when I learned about this and I don't routinely ask patients about this 'cause I do think that they would probably look at me like, what? But, if we think about I'm gonna take the three of us back to histology class, like our first year of medical school when we were learning what tissues look like under the microscope.

When you look at tissue that lines your nasal passage, waste and sinuses, it looks remarkably similar and virtually hard to tell the difference between that tissue and our vaginal mucosal tissue. Both are very similar in their structure. So there have been not a lot of studies, but there have been a few studies that have shown that some women will have increase in vaginal discharge when their seasonal allergies are less well controlled and that inhalant allergies may compound kind of this chronic vaginitis syndrome. Some of these papers are back from 10, even 25 years ago. There were even a few studies looking at using allergy shots to potentially help a subset of patients with recurrent yeast infections if they had positive allergy testing. So, it would be interesting to eventually kind of re-look at that from a science standpoint of like, Hey, did your symptoms get better when you went through allergy shots or ILIT for instance? But it is kind of this interesting, like, oh gosh, things that we don't always connect those dots because frankly, we don't always time have time in the visit. It doesn't always seem appropriate to bring up, but it does kind of have you stroking your imaginary beard.


Connection between allergies and vaginal symptoms
---

Dr. Meagan: It does. And that kind of goes along with just what um, Amber, you talked about earlier on another session about picking away at the layers of all the different things that contribute to what ails us, right? And so if allergic inflammation is indeed either more systemic, like full body than what we realize, or at minimum contributing to issues in all of the tissues that are sort of the same as the nasal and respiratory epithelium that we are more familiar with and more commonly associate with environmental aeroallergens. Is it, it may be worth looking at that kind of thing, that controlling that overall makes other things better because it takes away a layer of, yep, the stack of things that cause problems.

Alright. Well thank you guys for listening to us today and listening to some of our weird stories and weird questions and things that you should share with your doctor. Please, if you do have other people you think that would benefit from this, because again, this is a topic that is becoming less taboo, but something that also is still not spoken of very freely and people don't always feel, I think personally, it's just an embarrassing topic if you wanna just bring up amongst friends, like, "Hey, my, my vagina's itching, what do I do?" Nobody wants to do that. So anyway, so I hope that this helps to make the conversation about that more easy to have and more sort of in the backs of people's minds. So, if you would like to share stories that you may have personally, or if you have questions that we didn't answer but you'd like to elaborate on more, or if you found something in particular that really irritated you and the vulva area, you can post even under an anonymous profile, no judgment. It would just be nice for us to see and be able to learn from that. So, give us likes and reach out to us because we would love to communicate more about this and hopefully you'll listen next time. 

​



​