Tuesday, March 12, 2019

The Curious Phenomenon of “Keto Crotch”

I have a confession to make: I, Mark Sisson, suffer from keto crotch.

It’s embarrassing, really. I thought maybe it was just the change in climate moving from Malibu to Miami—the humidity, the heat, the fact that I’m paddling and swimming more often now. There’s a whole lot of moisture down there. Perpetual steaminess.

But then I met up with my writing partner and good pal Brad Kearns, who’s been working with me on my upcoming book. Brad lives in Northern California, which is far from hot or humid right now. He’s also a staunch keto guy most of the time, and, well, let’s just say I could smell him before I could see him. We met up at a coffee shop and cleared out everyone in a fifteen foot radius. We sampled a new exogenous ketone product he’s been trying and not one, not two, but three separate individuals approached to inquire if we were salmon fishermen.

Okay, let’s get serious. Does “keto crotch” really exist? And, if it does, what can you do to prevent it?

I’m writing this not because of overwhelming demand from loyal followers of the Keto Reset plan. In fact, I hadn’t ever heard of “keto crotch” before last week. There’s a good chance almost no one heard of it before March 2019, if Google Trend data for “keto crotch” searches is any indication. I’m writing this post because the barrage of news articles, Twitter hashtag campaigns, and extremely serious warnings from people with lots of acronyms after their name has led people to ask me if it’s a legitimate phenomenon. A few acquaintances have brought it up in social situations. Our marketing director found herself fielding keto crotch questions at a dinner for Expo West last week.

So, are women following a ketogenic diet experiencing an epidemic of stinky vaginas?

Probably not.

Is Keto Crotch Even Physiologically Plausible?

Vaginal odor does change. It fluctuates naturally, and sometimes it can get worse. The most common cause of unpleasant changes to vaginal odor is bacterial vaginosis, which occurs when something upsets the balance between the beneficial lactobacilli bacteria that normally live in the vagina and pathogenic bacteria. What can upset the balance?

The vagina is supposed to be an acidic environment; that’s how the healthy lactobacilli thrive. If something upsets that pH balance, tilting it toward alkalinity, unhealthy bacteria gain a foothold and become predominant, and begin producing unpleasant-smelling amines like putrescine, tyramine, and cadaverine. This is bacterial vaginosis. As it turns out, the lactobacilli bacteria normally present in the vagina are instrumental in maintaining an acidic pH. They consume glycogen, spit out lactic acid, and exert antimicrobial and antifungal effects that block common vaginal pathogens like candida, e. coli, and gardnerella from taking hold and causing trouble.

The interaction between diet and vaginal biome is understudied. To my knowledge, there exist no direct controlled trials that address the issue. It’d be great to have a study take a cohort of women, split them up into different dietary groups, and follow them for a year,  tracking their vaginal pH and bacterial levels. Alas, we do not.

We do have a study that provides a hint. In 2011, researchers looked for correlations between dietary patterns and bacterial vaginosis in a cohort of nearly 2000 non-pregnant mostly African-American women aged 15-44. While there probably weren’t many keto dieters, and the diets as a whole were of the standard American variety, glycemic load—which basically boils down to carb load—was the strongest predictor of bacterial vaginosis. Other markers of food quality, like a person’s adherence to “healthy eating guidelines,” initially seemed to reduce the chance of bacterial vaginosis, but those relationships were almost abolished after controlling for other factors. Only glycemic load remained highly significant.

This connection between dietary glycemic load and bacterial vaginosis starts looking more causal when you realize that diabetes—a disease where one’s “glycemic load” is perpetually elevated and exaggerated—is another risk factor for bacterial vaginosis.

There’s also a 2007 study that found “high” intakes of dietary fat, particularly saturated and monounsaturated fat, were a significant predictor of bacterial vaginosis. In this study, “high fat” meant around 39% of energy from fat. That leaves 61% of energy from carbohydrate and protein, the kind of “high-fat, high-carb” Standard American No-Man’s-Land that’s landed the country in the current metabolic predicament. High-fat intakes in the presence of high-carb intakes may very well be bad for your vagina, but it says nothing about the likelihood of keto crotch.

At any rate, neither study was a controlled trial, so we can’t say anything about causality.

What about a yeast infection? The most common offender is candida, which usually favors sugar for fuel, but there’s also evidence that it can metabolize ketones. Could keto make a latent yeast infection worse and lead to smelly “keto crotch”?

Perhaps keto can make candida worse (that’s for another day), but that’s not the cause of “keto crotch.” Candida vagina infections don’t smell very much, if at all, and they certainly don’t smell “fishy.” That’s only caused by bacteria and the aforementioned amines they can produce.

Free glycogen levels in vaginal fluid are a strong predictor of bacterial vaginosis. If ample glycogen is available, the good lactic acid bacteria have plenty of food and produce plenty of lactic acid to maintain the acidic pH conducive to vaginal health. If inadequate glycogen is present, the lactic acid bacteria have less food and produce less lactic acid, increasing the chances of the pH tilting toward alkalinity. An alkaline vagina is a vagina where pathogenic bacteria—the ones that produce stinky amines—can establish themselves.

The question then is if ketogenic diets lower free glycogen in the vaginal fluid. That’s a fair question. I wasn’t able to find any solid answers. I guess “ketosis effect on vaginal glycogen” isn’t the most lucrative avenue of scientific inquiry.

Should I Worry?

Even assuming this is a real phenomenon, it’s a rare one. The vast, vast majority of people following a ketogenic diet aren’t coming down with keto crotch. Other than a few Reddit posts from the past 5 years, I haven’t seen anyone at all in our neck of the woods complain.

Maybe people doing Primal keto are eating more nutrient-dense ketogenic diets than people doing conventional (or caricature) keto. Salads, steaks, eggs, and lots of non-starchy veggies are a great way to stay keto and obtain micronutrients. And there are links between micronutrient status and bacterial vaginosis. The most common relevant deficiencies include vitamin D (correcting the deficiency can cure the vaginosis) and folate. Hard to get adequate folate if your diet is based on salami and cream cheese.

We also know that the health of your skin biome tracks closely with that of your gut, and that eating plenty of non-starchy veggies, fermented foods (yogurt, kefir, sauerkraut, kimchi, etc), and colorful produce can provide prebiotic fiber, prebiotic polyphenols, and probiotic bacteria that nourish your gut biome. If the vaginal biome is also connected to the gut biome (and it is), tending to the latter should also have positive effects on the former.

The Primal brand of keto tends to emphasize micronutrients and gut health a bit more than some other types of keto I see floating around. If—and it’s a very big “if”—keto crotch is legit, that may explain some of the discrepancy.

Finally, be sure to check out this very interesting Twitter thread where the author lays out his suspicions that the whole “keto crotch” phenomenon might be a manufactured stunt designed to vilify the ascendant ketogenic diet. Nothing definitive, but it’s certainly food for thought.

If You’re Concerned…

Okay. Say you’ve recently gone keto and your vagina is smellier than usual. (And you’ve ruled out other, more obvious potential causes like changes in soaps, etc.) It’s hard to ignore, and I wouldn’t want you to. What can you do?

  • Confirm that you have bacterial vaginosis. Seriously, get it checked out.
  • Make sure you’re getting enough folate and vitamin D. Supplement if need be.
  • Eat prebiotics and probiotics. Fermented food and/or a good probiotic supplement.
  • Try a carb refeed. If ketosis depletes vaginal glycogen and increases pH, the occasional carb refeed could restore glycogen by 30-50 grams and should do the trick. Note that this is entirely theoretical; I’m not saying it’s a “problem” on keto.
  • Hang out in the keto zone. I’ve written about the keto zone—that metabolic state where you’ve reached full keto and fat-adaptation and find yourself shifting in and out of ketosis as you please due to increased metabolic flexibility. A few carbs here, a fasting day there, a few more days of keto. Again, if full keto is theoretically depleting vaginal glycogen, maybe relaxing your restrictions will solve the issue while maintaining your fat adaptation. This is actually where I hang out most of the time.

That’s it for today, folks. Do you have “keto crotch”? Do you know anyone who does? Or did your vaginal health improve on keto? I’m curious to hear what everyone’s experiences have been, so don’t be shy.

Take care and be well.



Thoma ME, Klebanoff MA, Rovner AJ, et al. Bacterial vaginosis is associated with variation in dietary indices. J Nutr. 2011;141(9):1698-704.

Kalra B, Kalra S. Vulvovaginitis and diabetes. J Pak Med Assoc. 2017;67(1):143-145.

Taheri M, Baheiraei A, Foroushani AR, Nikmanesh B, Modarres M. Treatment of vitamin D deficiency is an effective method in the elimination of asymptomatic bacterial vaginosis: A placebo-controlled randomized clinical trial. Indian J Med Res. 2015;141(6):799-806.

Dunlop AL, Taylor RN, Tangpricha V, Fortunato S, Menon R. Maternal vitamin D, folate, and polyunsaturated fatty acid status and bacterial vaginosis during pregnancy. Infect Dis Obstet Gynecol. 2011;2011:216217.

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Best Advice to New Parents

Hi, guys!

Just popping in real quick with a (very) random post with some highlights from the weekend. I polled my followers on Instagram as well as the readers here, and I was surprised to see what so many still read the blog on the regular. I honestly love that, so I’m going to do my best to share more frequent “day in the life” posts here. If you’re coming to the blog, I want to keep you happy! 🙂 With that, here’s a recap from life lately!

Can we talk about my spine? Isn’t this x-ray insane?! No wonder I have back issues. My chiropractor is amazed that I can do some much physically with what I have going on. I’m actually a good candidate for surgery, which is crazy to think. I have no plans to go that route, but I’m happy I can do pretty much everything I want.

I actually visited my chiropractor to take some updated x-rays to see whether or not what I’m doing with Zen Den is working. Cliff’s Notes: It is! I’ll write a more in depth post soon. I’m also waiting for some more info from the chiropractor, but it’s all quite fascinating!

Here’s a random, but delicious dinner that I ate last night. I actually have loose “framework” for how I build my meals based on what I food prep over the weekend. If you guys want additional details, let me know. Maybe I’ll write a blog post about it. In the meantime, it’s very much like my “Build-Your-Own CAVA-Inspired Bowl” checklist, which, for the record, is NOT a sponsored post. I just really like CAVA and thought it would be helpful to have an infographic or sorts to plan out your bowls.

On Saturday night, Mal and I joined a bunch of friends for “Escape the Mystery Room” at the Kingston Collection, and it was a ton of fun! You basically get clues to “escape” the room, and there are different themes for each room. We did Sherlock’s Library.

Truthfully, I was a bit confused when we first started, but as we figured out clues, it made more sense. I definitely want to do another one sometime soon!

Our little fish is still loving and progressing with his swimming skills. Lessons are obviously super helpful, but Quinn really seems to connect the dots when he’s swimming on his own and trying new things. We also had a blast at family swim at Goldfish on Sunday afternoon. It’s the perfect activity for winter. The pool is 90 degrees F, so even I like going in! 🙂

On Saturday afternoon, I attended a friend’s baby shower. It was really cute, and the dessert selection was A+. It was also really nice to catch up with girlfriends and swap baby stories. Oooh, they grow up so fast!

At the shower, there was a little activity where you could offer your best advice to the new parents. My advice was actually given to me by a friend who had twin boys. Mal and I took note, and it definitely helped us in the middle of the night NOT to talk to one another (unless we really needed to). We’re both quite crabby with a lack of sleep!

Question of the Day

What’s your best advice to new parents?

Have you ever done an “Escape the Room”?

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A Baller Stain Remover + More Cool Things

^^Note the open door! We are finally having some mild days here. The fresh air is SO nice!! Isn’t it crazy that Birch has never felt the sunshine on his body. His arms and legs have never felt fresh air. I can’t wait for our Florida trip coming up so he can experience the joy that is warm sun for the first time! I bought him this cute little swim suit for the trip : )

Baller Stain Remover

I gotta share this before and after! I first used Oxiclean (MAX FORCE!!) on this blow-out stain and washed it regularly with a Tide pod. As you can see, the stain did not come out. I’ve had this Amodex stain remover for a long time after some of you guys recommended it years ago. I don’t know why I have the Oxiclean because the Amodex works SO much better. Look at the stain 5 minutes later – all gone! I just squirt the Amodex on it and rinse with warm water while doing some scrubbing action. (Side note: many of you on Instagram said sunshine is the best stain remover.)

Magazine-a-Holic No More

I used to get a billion home magazines. They were my go-to entertainment at the gym. But simultaneously I have cut back on my cardio machine time and when I do use one, I listen to podcasts instead. These days I only get a few magazines – HGTV, Better Homes and Gardens, and Country Living. My favorite Coastal Living just morphed away from subscriptions. Do you guys still read magazines?

Lunch: pre-soccer sandwich and pretzels. 

Crawdads Are Singing

LOVING this book! I love that it’s set in North Carolina, it’s a little bit adventure, a little bit survivalist, a little bit romance, and a little big mystery. All of my favorites rolled into one and beautifully written too. I’m not even halfway through and really into it. If only I could read more than 5 pages per night before falling asleep! I want to keep reading, I really do, but my eyes just won’t have it! I did a little bit of morning coffee reading on Sunday to try to get ahead.

New Soccer Bag

My old soccer bag was a giant duffle with stuff spilling out of the pockets. It also had no water bottle holder, which is perhaps the most important pocket of them all. A friend had a similar bag to this one at our indoor games, and I bit the bullet to replace my old one with this one. SUCH a good choice. Not only are there two water bottle pockets (I have one with electrolytes and one with ice water), but I love that it stands upright on the field.

There are so many great pockets too. Its only drawback is not having a pouch for dirty shoes, so I just have a drawstring bag for my cleats. Problem solved!

Mazen’s Scrambled Eggs

Let me tell you a story about these eggs. I fed Mazen scrambled eggs nearly every day when he was one. I alternated between eggs, yogurt, and oatmeal – three foods I think are of superior nutrition. Poor Mazen woke up one day around age 2 and never ate an egg again.

Fast forward to age 6.5 and we were getting ready for bed the other night.

“What do you want for breakfast tomorrow?” I asked him.

“Scrambled eggs!” he said.

“Seriously? You want eggs?” I said incredulously.

“Yes, I saw a dude on You Tube eating them and they looked good.” he responded.

Well then! So as promised in the morning he was delivered a plate with one scrambled egg and buttered toast. I was up nursing Birch in bed holding my breath to see if he would eat them. Did he take even one bite? Nope. He said: “These don’t look like the You Tube eggs.”

MAZEN! I will have to look up this video and compare.

So needless to say, ate his eggs for breakfast. With leftover cornbread and grapes!

Smoked Not Smoked

Thomas made the best smokey salmon for our Sunday dinner. But it was not smoked salmon – it was just salmon with smoked flavor! He put brown sugar and a little Liquid Smoke on top and then grilled it inside aluminum foil so it stayed nice and moist. It was some of the best salmon we’ve made at home yet! I made a salad dressing (eyeballed) with yogurt, olive oil, lemon, lemon zest, salt, pepper, garlic powder, and fresh dill. Fresh dill is 100% my favorite herb!

Hope you guys are having a great week!

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Clean Eating Olive Pasta Recipe

This clean eating olive pasta is so crazy simple to make and totally hits the spot!

We all have those days where we go crazy trying to get it all done. Days where there is no way on earth we are… Read more →

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