Dearest:  My guest tonight is Elizabeth G. Stewart, M.D. Dr. Stewart is a gynecologist
and Director of the Stewart-Forbes Vulvovaginal Specialty Service at Harvard 
Vanguard Medical Associates. Dr. Stewart is also Assistant Professor of Obstetrics 
and Gynecology at Harvard Medical School and a member of Brigham and Women's
Hospital staff.

Dr. Stewart's perspectives as a full-time vulvovaginal practitioner, researcher, 
speaker and teacher shape her prominence as one of the leading voices advocating 
the importance of her specialty. Author of The V Book: A Doctor's Guide To
Complete Vulvovaginal Health, she's compiled complete coverage of the facts about 
the healthy vulva, vagina and vestibule. Dr. Stewart discusses "that part" of your 
body. "Vagina is hardly a household word," says Dr. Stewart.

"The V Book" was written because "so many women are unfamiliar with their bodies," 
the book contains information about everything: yeast infections, bacterial 
vaginosis, bladder inflammation, vaginitis and skin disorders, your genitalia, 
urinary and bladder infections, interstitial cystitis, vaginitis, trichomonas, 
atrophic vagnitis and strep vaginitis, vulvar pain, and vestibulodynia (pain in the 
vestibule) and painful intercourse. "The V Book" is not a gynecological sourcebook, 
but was written for the average woman who wants and needs to know more about 
vulvovaginal or V health. 

Dr. Stewart, it's a pleasure to welcome you to Power Surge. 


Dr. Elizabeth G. Stewart:  Happy to be with you! 


Dearest:  There must be hundreds of euphemisms for "vagina." Why is it so difficult 
for people to say vagina, yet so simple for the same people to say penis. What is 
the mystery surrounding this organ? 


Dr. Elizabeth G. Stewart:  I'm not so sure it is that simple for a lot of people 
to say penis, but I think that penis has come into popularity before the vagina. 
I tried hard to understand the veils and shrouds that cover the vagina and the 
best that I could come up with is veils and shrouds throughout history. 


Dearest:  Before we go to the queue, I have a question.. Power Surge, being mainly 
a menopause community, hears many complaints about vaginal dryness and
accompanying burning and itching. What are your recommendations for treating
the symptoms associated with vaginal dryness?


Dr. Elizabeth G. Stewart:  Depends on the reason for dryness. If it is menopause, 
normal sexual activity is a marvelous way to maintain function. If there is still 
dryness, a lubricant is the first step. Then one thinks of local estrogen products.


MaryAnneB2002:  I have vaginal discharged supposedly caused by irritation...Estrace 
prescribed but the ingredients burn. I suppose I need a compounded version. No 
other diagnosis; i.e., infection, etc. 


Dr. Elizabeth G. Stewart:  You need for your clinician to tell you what the 
irritation is infection, skin infection, skin problem, etc. If it's low estrogen 
and the cream burns, you are reacting to an ingredient in the cream base and 
compounding is the way to go. 


Ziggi:  I suffer from atrophy and chronic vulvar dermatosis (mostly itching and 
fissuring). Topical steroids and estrogen haven't helped. My gyno wants to "brush" 
my entire vulva with a CO2 laser so "new skin will replace old, damaged skin." 
Won't this cause burns and make things worse? 


Dr. Elizabeth G. Stewart:  You need a better answer for what is going on, and I 
would not recommend the laser for this. Suggest a skin biopsy to tell you what
is going on.


Ziggi:  Biopsy suggested lichen simplex chronicus 


Dr. Elizabeth G. Stewart:  For Ziggi - make sure you have been given the right 
strength steroid for this. 


Mer:  Yes, is LS (Lichen Sclerosus) something that can be on other parts of the 
body? 


Dr. Elizabeth G. Stewart:  Lichen sclerosus, LS, can affect the skin anywhere,
is often seen on the genitals. 


Dearest:  What is Lichen sclerosus? 


Dr. Elizabeth G. Stewart:  Lichen sclerosus is a chronic inflammatory skin disease 
of unknown cause that can affect the vulva. It causes itching and burning and can 
scar. We know how to manage it, but not how to make it disappear.


Lisa:  For chronic yeast,  how long can one safely use Diflucan? I also have LS.


Dr. Elizabeth G. Stewart:  Diflucan is often used as a single tablet to treat a 
simple yeast infection. But yeast can be recurrent and difficult. Then a single 
tablet of diflucan taken once weekly can be used safely without harm to the 
liver for months at a time. 


MillieCook:  Do you have any recommendations for Vulvar Vestibulitis and are there 
any new medications for it?  I know there is no cure at this time. 


Dr. Elizabeth G. Stewart:  If you know any trigger that seems to have set it off 
such as repeated yeasts infections get rid of the trigger. Then I use topical 
xylocaine anesthetic 5 times a day, with an antidepressant such as Nortriptyline 
working up to a dose of 100- 150 mg. Physical therapy with biofeedback is also 
helpful.


MillieCook:  There have been no yeast infections or anything determined.


Dr. Elizabeth G. Stewart:  All these things are addressing nerve endings that are 
not working well and are causing pain on touch in the vestibule. 


Dearest:  And an antidepressant can be a solution? 


Dr. Elizabeth G. Stewart:  Yes- it has nothing to do with depression or in your 
head. The medicine builds up chemicals that the nerves need to work right again 
after their insult, and the medicine also works on crazy circuits that have been 
set up in the central nervous system. 


Dearest:  Fascinating. I'd never have thought of an antidepressant as treatment. 
Thank you. 


Sunshine1104:  I have had what seems like UTI's but come back negative. What
else can it be?  Every few months or so. No discharge or anything. It feels
just like UTI.


Dr. Elizabeth G. Stewart:  The urinary opening (urethra) is right in the middle of 
the vestibule, the special tissue that surrounds the vagina. If there is something 
that irritates this area it can feel like a urinary infection. Low estrogen is 
famous for this, but yeast infections or skin diseases can also cause irritation. 
The big one though is vestibulitis, an inflammatory insult to the nerve endings in 
that area that feels sometimes just like a urinary infection. 


Sunshine1104:  So it may be low estrogen. Thanks. 


Ladyblue:  Have you used Estrace or estrogens to rebuild tissue to give it back 
it's elasticity once a disease like LS has been controlled with steroids? 


Dr. Elizabeth G. Stewart:  All the time. Estrogen is not a treatment for lichen 
sclerosus, but once the inflammation is in control estrogen is a big help to keep 
the skin in this area that loves estrogen happy.


Ladyblue:  Thank you so much! It worked for me. 


EllieKatz:  What causes Bartholin cysts and boils/cysts in the groin area --
hormones or bacteria? My mom had them (boil-type things), so does my sister 
and so do I. I had a Bartholin cyst on exterior labia and also am prone to 
cysts/boils. I don't know exactly what they are, but are extremely painful and 
swollen until they drain. It's so embarrassing and don't know what to do. Please,
any suggestions on how to treat?  


Dr. Elizabeth G. Stewart:  Bartholin cysts form when the opening to the gland 
buried under the labia gets blocked. Infection can set in and then drainage of
the infection is necessary.  Bartholin cysts and abscesses can keep coming back,
but they are always in the same area- at the base of the large outer lips, the 
labia. Other cysts or infections can occur when the hair follicles get blocked - 
this is called hidradenitis suppurativa. It can be helped with antibiotics, 
avoiding any hormones that are less estrogen and more androgen- like
depo-provera. Sometimes the areas have to be cleaned out surgically. 


Marlo:  I heard there's a new estrogen cream that doesn't enter your bloodstream 
through the vagina. Do you know the name of it?


Dr. Elizabeth G. Stewart:  There are two estrogen products that are limited to
the vagina. The Estring is a ring worn in the vagina. It releases teeny amounts
of estrogen that remain in the vagina and do not get into the blood. It is so safe 
that breast cancer patients are allowed to use it. Vagifem tablets are also put 
into the vagina and have little absorption into the blood, but there is some.
These are great products for women! 


Marlo:  Thanks! 


Dearest:  Dr. Stewart, what about all these OTC Products women use to treat vaginal 
inflammations when they're "self medicating?" Can't they often cause more problems 
than they cure? 


Dr. Elizabeth G. Stewart:  I think you're referring to OTC antifungal or yeast 
creams. We now know that two thirds of women who purchase these do not have yeast 
infections.  And yes- they can cause irritation- but above all they keep you from 
getting the right answer to what the problem is. Remember- all V problems itch and 
feel like a yeast infection!


Dearest:  Thank you, Dr. Stewart. 


KathyK2970:  I'm 32 and suffer from raw, vaginal irritation. Treated for 6 months 
for yeast and/or bacterial infections, and then given Temovate for possible LS
with little response. Recently had biopsy to rule out LS and it showed "severe 
inflammation" and "possible HPV changes" although I have no lesions. Aldara made
it much worse. I don't believe this is truly my problem. What is my next step? 


Dr. Elizabeth G. Stewart:  You need to find a clinician who can sort things out.
Be seen when your symptoms are at their worst at a time when you have not had any 
yeast medications and have a culture for yeast in a broth called Sabaroud's medium. 
Yeast can be hard to diagnose and does not always show up under the microscope. If 
studies for yeast are negative- or if you have been on a weekly Diflucan tablet for 
6-8 weeks and are still raw and irritated you may have vulvodynia. 


KathyK2970:  Thank you so much! 


HunterSu_98:  what kind of success rate is there if I have surgery for vestibulitis 
I'm 44 am had a total hysterectomy, what are inclusion cysts desparate? 


Dr. Elizabeth G. Stewart:  Surgery for vestibulitis has a good track record around 
60-80% in the hands of an experienced surgeon and for someone who has pain only
on touch around the vaginal opening. Inclusion cysts are common and painless pieces 
of the skin surface epithelium that have gotten buried and form a little bump. 


HunterSu_98:  They do hurt as they come to the surface. 


Minou:  Last year I had a bladder infection. It was treated, then came vaginal 
burning and throbbing pain for about three weeks. Same time had spotting. Then 
diagnosed with endo on ovary which culminated in ovary removal. No one could
give me an answer about the vaginal pain though. I was going nuts. What could
have caused the sharp throbbing pain?


Dr. Elizabeth G. Stewart:  Endometriosis is often seen with other pain problems 
such as vestibulitis that can cause urinary symptoms, or a bladder problem called 
interstitial cystitis. 


Trish:  What is the most aggressive way to treat yeast and BV? I have had this 
condition for a year now on and off.. Tired of the office visits and treatments 
that don't work. Have been on Metrogel, terazol, flagyl, over the counter yeast.. 
You name it, I've taken it. Will Acidophilus help? Could it be a pH problem? Was 
first cultured and told I had both yeast and BV (Bacterial vaginosis). 


Dr. Elizabeth G. Stewart:  Are you sure you have yeast? Need a culture on 
Sabaroud's medium or a good clinician who sees yeast under the microscope. If you 
have had more than 4 yeast infections in a year you need suppression with weekly 
Diflucan for 12 weeks. Recurrent BV is treated now with weekly metrogel. But 
vestibulitis masquerades as repeated yeast and bacterial infections! 


Ladyblue:  Do you feel that LS has an autoimmune connection? 


Dr. Elizabeth G. Stewart:  I do indeed and keep waiting for further info. I see a 
lot of LS with other auto-immune problems- early menopause, thyroiditis, diabetes, 
etc. 


Ali:  Back to the discussion of Estrace treating tissue damaged by LS. Have you 
ever seen it "unfuse" skin that has scarred, or help bring back the clitoris after 
it has been buried, so to speak? Any other suggestions to help with damage that has 
occurred, other than surgery? Finally, in your opinion, what are the risks with 
surgery? Do they outweigh the potential benefits?  


Dr. Elizabeth G. Stewart:  Undoing the scarring from LS is unlikely to happen
if it's been around for a time.  So neither estrogen nor steroids can do that. 
Scarring often recurs after surgery so it's something to consider carefully. 
Usually women do okay sexually even if there is fusion over the clitoris. 


Tbonewitz:  for the last 6 years when me and my husband have intercourse I would 
have burning and irritation for a few days after, not every time. now I am 
definitely menopausal and it happens every time. I've never discussed it with my 
doc cause I always thought it had to do with what he was eating. I don't think it's 
yeast, cause it always goes away after a few days without treatment. 


Dr. Elizabeth G. Stewart:  If you are menopausal and not using estrogen, burning 
and irritation with intercourse are often helped by a little estrogen cream. 


Tbonewitz:  Can I get it over the counter? 


Dr. Elizabeth G. Stewart:  No, it's a prescription item. 


Tbonewitz:  Thanks so much 


Dearest:  Tbone, you can E.mail me and I'll let you know where you can get the 
cream. Dearest@aol.com 


Tbonewitz:  Thanks Dearest!!! 


RetreadMom:  I'm 42 in perimenopause (experiencing just about every one of it's 
symptoms) with 4 children ages 3, 5, 20,and 21. What alternatives are there when 
two or more medicines that you MUST have, conflict? 


Dr. Elizabeth G. Stewart:  Retread- I don't understand your question. 


RetreadMom:  Certain medicines that my doctor has prescribed do conflict, but they 
are working well for me. 


Dearest:  I think that's difficult for the doctor to answer unless she knows your 
condition, what the medications and contraindications are. 


Dr. Elizabeth G. Stewart:  If you mean that your meds are giving you some unwanted 
side effects but are helping, seems that going with the help part is important.


RetreadMom:  An example: I'm on Sarafem for the mood swings and Flexeril for the 
fibro. Pharmacist said there's a conflict. 


Dr. Elizabeth G. Stewart:  You need to report the pharmacist's conflict to your 
clinician and get him/her to decide if it's legitimate. 


Dearest:  Besides, although you may not be "experiencing" overt difficulties from
mixing medications, you don't know how your body is reacting inside. 


Lisa:  I'm 37 and have LS. I will have to treat myself for life with steroids. What 
is your protocol? Should a potent steroid always be used or once in maintenance 
lower to a less potent steroid? Is long term steroid use dangerous? What about 
protopic?  Is long term steroids safe for LS? 


Dr. Elizabeth G. Stewart:  I ask my patients with LS to use ultrapotent steroids 
once or twice weekly and I have not had any problems in 12 years of doing this.
I see the disease come back all the time when people go off the medication. 
Protopic has been disappointing to date for LS.


KathyK2970:  Do you think changing your diet (i.e., low oxalate diet) can improve 
some of the irritation and other symptoms? 


Dr. Elizabeth G. Stewart:  Women often have improvement of vulvar burning right 
after they eat something like chocolate or citrus or coffee. It is well worth 
checking into. 


KathyK2970:  Thank you again for your information! 


Kalanie:  I am just wondering, what is the "BV" that was discussed earlier? 


Dr. Elizabeth G. Stewart:  Bacterial vaginosis is the commonest vaginal complaint. 
It means that the good bacteria the lactobacilli, are overwhelmed by other normal 
bacterial inhabitants of the vagina, causing discharge and odor. No one knows
the cause.  


Kimmie:  I was diagnosed with LS after having Implanon implant put in. I am 
positive this is the cause, and have only some fusing, no itching or pain. Had 
some bleeding with i/c but oestrogen cream helped. Do not want to have implant 
taken out due to benefits. Is there anyway I can counteract the progestin 
without having implant removed? I am 41 and pre-menopausal. 


Dr. Elizabeth G. Stewart:  Your LS may have become obvious right after the implant 
so that the latter seems like the cause - but it is really unlikely. Encourage you 
to treat the LS as recommended with a steroid and continue your implant if you are 
happy with it. 


Ladyblue:  Just to say that I was 'solidly' fused with my smaller labial lips and 
clitoral hood for 3 years and the Estrace DID unfuse me 99% *smile* 


Fejdoc:  I'm in a pre menopausal age, had vaginal dryness, now I've used evening 
primrose oil caps and it's improved a lot. Am I doing right or not?  


Dr. Elizabeth G. Stewart:  That's a fine lubricant and it sounds like it's working.


BHB023:  I also have LSA and am 20, have you used Protopic or Elidel to treat 
patients, and if so do you suggest staying at a consistent dosage (2 times a day or 
as needed) or do you suggest tapering down and using a maintenance dosage? I am 
using Protopic .1% 2 times a day or as needed now but my dermatologist never said 
anything about reducing the dosage and wanted to know your thoughts. 


Dr. Elizabeth G. Stewart:  Protopic is the new kid on the block.  To date I haven't 
had much success with it and LS. I use what the British dermatologists who have 
worked extensively with LS recommend - an ultrapotent steroid, intensively at 
first, then once or twice weekly indefinitely. 


Dearest:  Dr. Stewart, I apologize for keeping you so late, but thank you for a 
wonderfully informative and stimulating chat about vulvovaginal health and 
diseases. I have "The V Book: A Doctor's Guide To Complete Vulvovaginal Health" 
beside me and, as a lay person, I can tell you it's written in a style 
that's perfect for the average woman while providing comprehensive 
information about everything related to vulvovaginal health. 

Every woman has vaginal issues and you'll find answers to all your questions in 
"The V Book." Also, surf over to Dr. Stewart's site, www.thevbook.com, to
read more about her work.      



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aka Alice Stamm
Power Surge
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