Vaginal douching: evidence for risks or benefits to women's health

'Basically, it's sorcery for your vagina': unpacking Western representations of vaginal steaming

Vaginal steaming made global headlines in 2015 after its promotion by celebrity Gwyneth Paltrow. One of many female genital modification practices currently on offer in Anglo-Western nations - practices both heavily promoted and critiqued - vaginal steaming is claimed to offer benefits for fertility and overall reproductive, sexual or even general health and wellbeing. We analysed a selection of online accounts of vaginal steaming to determine the sociocultural assumptions and logics within such discourse, including ideas about women, women's bodies and women's engagement with such 'modificatory' practices. Ninety items were carefully selected from the main types of website discussing vaginal steaming: news/magazines; health/lifestyle; spa/service providers; and personal blogs. Data were analysed using thematic analysis, within a constructionist framework that saw us focus on the constructions and rationalities that underpin the explicit content of the texts. Within an overarching theme of 'the self-improving woman' we identified four themes: (1) the naturally deteriorating, dirty female body; (2) contemporary life as harmful; (3) physical optimisation and the enhancement of health; and (4) vaginal steaming for life optimisation. Online accounts of vaginal steaming appear both to fit within historico-contemporary constructions of women's bodies as deficient and disgusting, and contemporary neoliberal and healthist discourse around the constantly improving subject.

High Levels of Inflammatory Cytokines in the Reproductive Tract of Women with BV and Engaging in Intravaginal Douching: A Cross-Sectional Study of Participants in the Women Interagency HIV Study

High levels of inflammatory cytokines in the genital tract suggest mucosal vulnerability and increased risk of HIV and sexually transmitted infection (STI) acquisition. Intravaginal douching is associated with bacterial vaginosis (BV) in women in the United States, and both douching and BV are linked to HIV and STI acquisition. This study evaluates inflammatory cytokines in the genital tract to increase understanding of the effects of both BV and intravaginal douching to the vaginal mucosa. A cross-sectional study of participants in the Miami WIHS investigated 72 reproductive age women (45 HIV⁺ and 27 high-risk HIV^-) who completed intravaginal douching questionnaires and underwent collection of vaginal swabs and cervicovaginal lavages (CVLs). BV was assessed using the Nugent score. Inflammatory cytokines in the CVLs (interleukin [IL]-6, IL-8, IL-1α, IL-1β, soluble intracellular adhesion molecule-1 [sICAM-1], interferon [IFN]α2, chemokine C ligand 5 (CCL5), vascular endothelial growth factor (VEGF), monocyte chemotactic protein-1 (MCP1), tumor necrosis factor alpha (TNFα), and secretory leukocyte protease inhibitor [SLPI]) were measured. Fourteen (19%) women reported intravaginal douching; 24 (33%) had BV. BV, intravaginal douching, and HIV were associated with higher levels of inflammatory cytokines. After controlling for demographic and risk factors and HIV status, women who had BV and douched had higher levels of inflammatory cytokines than those without BV and who did not douche, or who only had BV or only douched. These findings suggest that BV and douching are associated with greater mucosal inflammation and may facilitate HIV acquisition and transmission. Although longitudinal studies are needed to determine temporal associations and causality, interventions to decrease rates of intravaginal douching and BV could significantly decrease women's risks of acquiring STIs and HIV and limit the spread of HIV.

Pubic hair and its removal: A practice beyond the personal

Pubic hair removal, now common among women in Anglo/western cultures, has been theorised as a disciplinary practice. As many other feminine bodily practices, it is characterised by removal or alteration of aspects of women's material body (i.e., pubic hair) considered unattractive but otherwise “natural.” Emerging against this theorisation is a discourse of personal agency and choice, wherein women assert autonomy and self-mastery of their own bodies and body practices. In this paper, we use a thematic analysis to examine the interview talk about pubic hair from 11 sexually and ethnically diverse young women in New Zealand. One overarching theme – pubic hair is undesirable; its removal is desirable – encapsulates four themes we discuss in depth, which illustrate the personal, interpersonal and sociocultural influences intersecting the practice: (a) pubic hair removal is a personal choice; (b) media promote pubic hair removal; (c) friends and family influence pubic hair removal; and (d) the (imagined) intimate influences pubic hair removal. Despite minor variations among queer women, a perceived norm of genital hairlessness was compelling among the participants. Despite the articulated freedom to practise pubic hair removal, any freedom from participating in this practice appeared limited, rendering the suggestion that it is just a “choice” problematic.

The vaginal microbiota, human papillomavirus infection and cervical intraepithelial neoplasia: what do we know and where are we going next?

The vaginal microbiota plays a significant role in health and disease of the female reproductive tract. Next-generation sequencing techniques based upon the analysis of bacterial 16S rRNA genes permit in-depth study of vaginal microbial community structure to a level of detail not possible with standard culture-based microbiological techniques. The human papillomavirus (HPV) causes both cervical intraepithelial neoplasia (CIN) and cervical cancer. Although the virus is highly prevalent, only a small number of women have a persistent HPV infection and subsequently develop clinically significant disease. There is emerging evidence which leads us to conclude that increased diversity of vaginal microbiota combined with reduced relative abundance of Lactobacillus spp. is involved in HPV acquisition and persistence and the development of cervical precancer and cancer. In this review, we summarise the current literature and discuss potential mechanisms for the involvement of vaginal microbiota in the evolution of CIN and cervical cancer. The concept of manipulation of vaginal bacterial communities using pre- and probiotics is also discussed as an exciting prospect for the field of cervical pathology.

Impact of targeted counseling on reported vaginal hygiene practices and bacterial vaginosis: the HIV Prevention Trials Network 035 study

The objective of this study was to describe the impact of intense counseling to reduce vaginal hygiene practices and its effect on bacterial vaginosis. A secondary data analysis of the HIV Prevention Trials Network 035 study was undertaken, focusing on HIV-negative, nonpregnant women who were at least 18 years old, in seven African sites and one US site. At enrollment and during follow-up quarterly visits, vaginal hygiene practices were determined by face-to-face administration of a behavioral assessment questionnaire. Vaginal hygiene practices were categorized as insertion into the vagina of (1) nothing, (2) water only, and (3) other substances with or without water. Each practice was quantified by frequency and type/combination of inserted substances. At quarterly visits, diagnosis of bacterial vaginosis was made using the Nugent score. Trends for vaginal hygiene practices and bacterial vaginosis were evaluated using generalized estimating equation models. A total of 3087 participants from the HIV Prevention Trials Network 035 study were eligible for this analysis. At enrollment, 1859 (60%) reported recent vaginal hygiene practices. By one year, this figure had decreased to 1019 (33%) with counseling. However, bacterial vaginosis prevalence remained consistent across the study observation period, with 36%-38% of women testing positive for the condition ( p for trend = 0.27). Overall, those who reported douching with water only (AOR = 1.03, 95%CI: 0.94-1.13) and those who reported inserting other substances (AOR= 0.98, 95%CI: 0.88-1.09) in the past quarter were not more likely to have bacterial vaginosis compared to those who reported no insertions. However, in South Africa, an increase in bacterial vaginosis was seen among those who reported inserting other substances (AOR: 1.48, 95%CI: 1.17, 1.88). In conclusion, targeted counseling against vaginal hygiene practices resulted in change in self-reported behavior but did not have an impact on bacterial vaginosis diagnosis in all but one site.

Does vaginal douching affect the type of candidal vulvovaginal infection?

The normal vaginal microbiota is a dynamic system that continually fluctuates under the environmental changes and different physiological conditions. Yeast infections of the vagina are caused by one of the species of fungus called Candida (C.). The study aimed to evaluate the types of mycobiota in women with vulvovaginal candidiasis (VVC) who were performing vaginal douching (VD) or not. Furthermore, it studied the antifungal sensitivity toward different fungi isolated from the vagina. In a cross-sectional study conducted in Assiut University Hospital, Egypt, women with VVC were interviewed regarding relevant history including the habit of VD. Vaginal swabs were obtained and processed by direct microscope and by culture on CHROMagar Candida and other differential media. The types of Candida in women with the habit of VD were compared with those not having this habit. We found that VD habit was practiced by 67.4% of women with VVC, and Candida albicans was the commonest (78.3%) type observed. There was no significant difference in the percentage of non-albicans types between women performing VD (23.6%) and those not reporting this habit (18.9%). Harboring non-albicans types were significantly increased in regular performers of VD compared with those who had this procedure only after sexual intercourse or after the end of menstruation (36.8%,12.5%, and 16.7%, respectively) (P = .048). Thus, vaginal douching does not influence the type of Candida infection involved in VVC. Frequent performance of VD increases the likelihood of having non-albicans types and the resistance to the common antifungal agents.

Glacial Acetic Acid Adverse Events: Case Reports and Review of the Literature

Glacial acetic acid is a dangerous chemical that has been associated with several adverse drug events involving patients over recent years. When diluted to the proper concentration, acetic acid solutions have a variety of medicinal uses. Unfortunately, despite warnings, the improper dilution of concentrated glacial acetic acid has resulted in severe burns and other related morbidities. We report on 2 additional case reports of adverse drug events involving glacial acetic acid as well as a review of the literature. A summary of published case reports is provided, including the intended and actual concentration of glacial acetic acid involved, the indication for use, degree of exposure, and resultant outcome. Strategies that have been recommended to improve patient safety are summarized within the context of the key elements of the medication use process.

Candidiasis (vulvovaginal)

INTRODUCTION

Vulvovaginal candidiasis is estimated to be the second most common cause of vaginitis after bacterial vaginosis. Candida albicans accounts for 85% to 90% of cases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of alternative or complementary treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of treating asymptomatic non-pregnant women with a positive swab for candidiasis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 23 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: alternative or complementary treatments; douching; drug treatments; garlic; intravaginal preparations (nystatin, imidazoles, tea tree oil); oral fluconazole; oral itraconazole; and yoghurt containing Lactobacillus acidophilus (oral or intravaginal).

Prevalence of vulvovaginal candidiasis, trichomoniasis and bacterial vaginosis among pregnant women receiving antenatal care in Southwestern Nigeria

Vaginal infections in pregnancy are associated with considerable discomfort and adverse pregnancy outcomes including preterm delivery, low birth weight and increased infant mortality and also predisposition to HIV/AIDS. This study evaluated the prevalence and factors associated with vulvovaginal candidiasis, trichomoniasis and bacterial vaginosis among women attending antenatal clinic at a hospital in Nigeria. A semi-structured questionnaire was administered and high vaginal swab samples were obtained from consenting pregnant women. The samples were processed following standard protocols. The prevalence of vulvovaginal candidiasis was 36%, while those of trichomoniasis and bacterial vaginosis were 2% and 38%, respectively. Infections were higher in the third trimester and many women admitted to practices that increase risk of these infections. Significant association was found between recent intake of antibiotics and vaginal candidiasis, same association was also found with bacterial vaginosis. Adequate investigation and prompt treatment will reduce the morbidity and attendant effects of these prevalent infections on mother and fetus.

ACIDFORM: a review of the evidence

OBJECTIVE

ACIDFORM is a candidate microbicide with spermicidal properties. A large Phase 3 trial is underway, and it is anticipated that this product will be approved for contraceptive use and marketed soon in the United States. The goal of this article is to critically review the evidence supporting the properties, safety profile and different uses of ACIDFORM gel.

STUDY DESIGN

We searched PubMed and Medline for any published literature on ACIDFORM.

RESULTS

ACIDFORM is an acidifying agent that works by lowering the vaginal pH to enhance the normal vaginal defenses. In addition to strong acid-buffering properties, ACIDFORM has high bioadhesive and viscosity-retaining properties. Several Phase 1 clinical trials have demonstrated the vaginal safety of ACIDFORM used alone or in combination with a diaphragm, although dose-dependent side effects appear to be present. Studies investigating the efficacy of ACIDFORM against sexually transmitted infections (STIs) are promising, but further trials are needed.

CONCLUSIONS

The properties of ACIDFORM offer many advantages for use, either alone or in combination with another active ingredient, such as Tenofovir. Potential applications for ACIDFORM include use as a personal lubricant, a vaginal contraceptive (alone or with a barrier method) and a microbicidal product or as a formulation vehicle for an active ingredient.

IMPLICATIONS

ACIDFORM is a candidate female-controlled vaginal preparation with microbicidal and spermicidal properties. A dual protection method could prevent unwanted pregnancies and reduce the risk of STI acquisition.

Risk factors associated with human papillomavirus infection status in a Korean cohort

By surveying extensive epidemiological behavioural and sexual risk factors in a Korean twin cohort, risk factors for human papillomavirus (HPV) infection were investigated in South Korea. A total of 912 vaginal specimens were collected from the Healthy Twin Study, consisting of twins and their families. A range of epidemiological, behavioural, and sexual activity characteristics were evaluated using multivariate logistic regression analyses of family and twin relationships, adjusted to elucidate the risk factors for HPV infection. Of the various epidemiological characteristics, the possibility of extramarital affairs [odds ratio (OR) 2·48, 95% confidence interval (CI) 1·02-6·02] significantly increased the prevalence of HPV infection. Our multivariate regression analysis indicated that oral contraceptive use (OR 40·64, 95% CI 0·99-1670·7) and history of sexually transmitted disease (OR 2·56, 95% CI 0·93-7·10) were strongly associated with an increase in HPV infection. On the other hand, more frequent vaginal douching (OR 0·32, 95% CI 0·13-0·77) significantly decreased the prevalence of HPV infection. Our results suggested that HPV infection is associated with both biological and behavioural factors.

Human papillomavirus infections among Hungarian female sex workers

The purpose of this study was to assess the human papillomavirus (HPV) prevalence in cervical, oropharyngeal and anal samples of the high-risk population of Hungarian female sex workers (FSWs). HPV testing of swab specimens from FSWs (n = 34) using polymerase chain reaction (PCR) methodology was performed. Results were compared with control group (n = 52) matched for age. Questionnaires were used to obtain data regarding participants' sexual behaviour. Data were analysed using SPSS. HPV DNA was detected in at least one location in a great majority of FSWs (82.4%), compared with 46.2% of the general female population (P < 0.05). Both the cervical and the anal samples of sex workers showed higher infection rates than those of controls (64.7% vs. 34.6% and 50.0% vs. 15.4%, respectively, P < 0.05). High-risk HPV prevalence was also significantly higher in sex workers (55.9% vs. 25.0%, P < 0.05). A significantly higher proportion of FSWs had a history of genital warts (26.5% vs. 3.8%, P < 0.05). The results suggest that condom use may not result in adequate protection from HPV infection. The high infection rates among FSWs should be viewed as a priority group for HPV and cervical cancer prevention programmes since they are sources of HPV infection for the general population.

Vaginal douching by women with vulvovaginitis and relation to reproductive health hazards

Background

Vaginal douching (VD) is a common practice among married women all over the world specially those in the Middle East. It is used for personal hygiene or for other aesthetic reasons in many countries. The current study investigates the prevalence of VD among patients with vulvovaginitis in Egypt. It also compares the reproductive health hazards among women performing routine VD with those using external hygiene. It also investigates why, and how women practice this douching.

Methods

A cross sectional observational study was conducted in a tertiary university affiliated hospital in Assiut, Egypt. An interview administered questionnaire was administered to 620 women by two trained clinic nurses. Women presented to the outpatient clinic and diagnosed to have any type of vaginal infections were approached for participation. The principle outcome was the history of preterm labor in women who routinely performed VD versus those who did not (upon which sample size was estimated). Other outcome measures were the types of vaginal infections, and reproductive implications comprising, ectopic pregnancy, abortion and pelvic inflammatory disease (PID).

Results

The participants were predominantly multiparas from semi-urban background and middle socioeconomic level. Considering VD as a religious duty and a kind of personal cleanliness were the most common reasons for performing VD in 88.9% and 80.6% of the studied population, respectively. History of preterm labor was reported in 19.2% versus 11.9% (p=0.048), while history of PID in 13.2% versus 6.0% (p=0.008) in women performing VD compared to those not performing this habit, respectively. There were no significant differences between the two groups as regard the history of ectopic pregnancy or the number of previous abortions.

Conclusion

Vaginal douching is a prevalent practice in Egypt and has traditional and religious roots within the community. There are many misbeliefs around this habit in Egypt. Vaginal douching increases certain reproductive health hazards especially preterm labor and PID. Much effort and awareness campaigns are needed to increase women awareness about health hazards of this incorrect practice and to limit its use.

Acceptability of potential rectal microbicide delivery systems for HIV prevention: a randomized crossover trial

We assessed the acceptability of three of over-the-counter products representative of potential rectal microbicide (RM) delivery systems. From 2009 to 2010, 117 HIV-uninfected males (79 %) and females (21 %) who engage in receptive anal intercourse participated in a 6-week randomized crossover acceptability trial. Participants received each of three products (enema, lubricant-filled applicator, suppository) every 2 weeks in a randomized sequence. CASI and T-ACASI scales assessed product acceptability via Likert responses. Factor analysis was used to identify underlying factors measured by each scale. Random effects models were fit to examine age and gender effects on product acceptability. Three underlying factors were identified: Satisfaction with Product Use, Sexual Pleasure, and Ease of Product Use. For acceptability, the applicator ranked highest; however, differences between product acceptability scores were greatest among females and younger participants. These findings indicate that RM delivery systems impact their acceptability and should be considered early in RM development to enhance potential use.

Ethnicity, family socioeconomic inequalities, and prevalence of vaginal douching among college students: the implication for health

OBJECTIVE

This study assessed the association between ethnicity and family socioeconomic status (SES) as it relates to the prevalence of vaginal douching among female undergraduates in a university community.

PARTICIPANTS AND METHODS

This was a cross-sectional survey conducted between September 2011 and February 2012 among 1,535 female undergraduates using a semistructured behavioral questionnaire adapted by the authors from previous research related to vaginal douching practice.

RESULTS

The overall prevalence of vaginal douching was 79.35% and the practice was significantly associated with the mother's age, ethnicity, low SES (educational level, occupation, and monthly income), and area of residence. The father's age and SES were statistically nonsignificant.

CONCLUSION

Ethnicity and low SES of mothers were significantly associated with a higher prevalence of douching in daughters. These factors should be considered among others in any intervention to discourage vaginal douching among college women.

Induced abortion, contraceptive use, and dual protection among female sex workers in Moscow, Russia

OBJECTIVE

To describe abortion history and current contraceptive use among female sex workers (FSWs) in Moscow, Russia.

METHODS

A clinic-based survey was conducted among 147 FSWs in Moscow during an 8-month period in 2005.

RESULTS

In total, 83 of 143 (58.0%) FSWs reported a history of abortion, with 45 of 143 (31.5%) indicating multiple abortions. Condoms were the primary form of contraception (145/146 [99.3%]); just 17 of 142 (12.0%) FSWs reported using non-barrier modern contraception. All women who reported using a non-barrier modern method also indicated condom use (i.e. dual protection). Non-barrier contraceptive use was associated with inconsistent condom use (odds ratio [OR] 3.10; 95% confidence interval [CI], 1.07-9.02) and multiple abortions (OR 4.71; 95% CI, 1.19-18.62).

CONCLUSION

The results illustrate substantial risk for unintended pregnancy among FSWs. Further research is needed regarding the dynamics of non-barrier contraception and condom use. Efforts to improve the health and wellbeing of FSWs should include access to safe and effective contraception, in addition to HIV prevention.

Reproductive factors in relation to ovarian cancer: a case-control study in Northern Vietnam

BACKGROUND

Ovarian cancer, one of the most common cancers in women and the most serious gynecologic cancer, is known to be influenced by reproductive factors, but these factors have not previously been examined in Vietnamese women.

STUDY DESIGN

We analyzed 262 ovarian cancer patients recruited from 27 hospitals in 12 provinces and Ha Noi City from April 2001 to May 2006, plus 755 controls matched by age and residential address.

RESULTS

The risk of ovarian cancer was significantly lower in parous women than nulliparous women. Use of an intrauterine contraceptive device was also associated with a reduced risk. In contrast, induced abortion, late menopause and years of ovulation were significantly associated with an increased risk of cancer.

CONCLUSIONS

Parity and intrauterine device use were associated with a reduced risk of ovarian cancer in Vietnamese women, whereas induced abortion, late menopause and years of ovulation were associated with an increased risk.

HIV prevention and transmission myths among heterosexually active adults in low-income areas of South Florida

Misconceptions about HIV transmission and prevention may inhibit individuals' accurate assessment of their level of risk. We used venue-based sampling to conduct a cross-sectional study of heterosexually active adults (N = 1,221) within areas exhibiting high poverty and HIV/AIDS rates in Miami-Dade and Broward counties in 2007. Two logistic regression analyses identified correlates of holding inaccurate beliefs about HIV transmission and prevention. Belief in incorrect HIV prevention methods (27.2%) and modes of transmission (38.5%) was common. Having at least one incorrect prevention belief was associated with being Hispanic compared to white (non-Hispanic), being depressed, and not knowing one's HIV status. Having at least one incorrect transmission belief was associated with being younger, heavy alcohol use, being depressed, not having seen a physician in the past 12 months, and not knowing one's HIV status. Among low-income heterosexuals, HIV prevention and transmission myths are widespread. Debunking them could have HIV prevention value.

Preventive measures against sexually transmitted infections among female sex workers in Lanzhou, China

BACKGROUND

We assessed the effects of preventive practices on sexually transmitted infections (STIs) and reproductive tract infections (RTIs) among female sex workers (FSWs) in Lanzhou, China.

METHODS

A cross-sectional survey was conducted among 350 FSWs from November 2008 to January 2009. Demographic information and behavioural factors associated with STIs were collected from all the participants. Blood samples and cervical swabs were obtained, and genital and cervical examinations were done at the collection site. A multivariate logistic regression model was used to analyze the relationships between preventive measures and the incidences of STIs and RTIs.

RESULTS

The utilization rates of vaginal douching (VD), regular intravenous infusion (RII), and prophylactic oral antibiotics (POA) among FSWs were 72.9%, 35.7%, and 36.3%, respectively. The preventive measures had no impact on diagnosed STIs. On the contrary, the use of VD + POA could increase the risk of vaginal infection by 2-fold (odds ratio (OR) 2.9, 95% credible interval (95% CI) 1.3-6.7). Moreover, the risk for cervical infection increased with the use of POA alone (OR 4.0, 95% CI 1.1-15.4), VD + POA (OR 4.2, 95% CI 1.7-10.3), and VD + RII (OR 2.5, 95% CI 1.1-5.7).

CONCLUSIONS

VD, RII, and POA, which were used widely by FSWs to prevent STIs after sex with their clients, were assumed to prevent STIs. Instead, our study indicates that they could increase the risk of vaginal or cervical infections. Therefore, FSWs should be informed of proper preventive strategies to reduce the incidence.

Vaginal douching practices among Turkish married women

AIM

This study was conducted to investigate the prevalence of the practice of vaginal douching among Turkish married women and associations between their douching status, predisposing factors, and effects on their health.

METHODS

This cross-sectional survey of women between 17 and 61 years of age was conducted between February 1, 2007, and May 18, 2007, in the Maternity-Gynecology and Children's Hospital in Ordu, Turkey. The sample of this study included 427 women. A confidential and anonymous self-reported questionnaire was collected in a convenient sample of the women.

RESULTS

Of the 427 women in the study, 165 women (38.6%) had douched at some time. Housewives [odds ratio (OR) 2.660, 95% confidence interval (CI) 1.162-6.090], women who had experienced a spontaneous abortion (OR 4.676, 95% CI 1.606-13.618), or had beliefs about positive health effects of vaginal douching (OR 29.603, 95% CI 14.090-62.192) also had risk factors associated with vaginal douching practices.

CONCLUSION

In conclusion, this study found that vaginal douching is a common practice among women. Many of the women who practiced vaginal douching believed in its health benefits. The results may enhance healthcare practitioners' knowledge and efforts to educate their patients.

Prescribing contraceptives for women with schizophrenia

Although women with serious mental illness have high rates of lifetime sexual partners, they infrequently use contraception. Consequently, the prevalence of sexually transmitted infections is high in this population. In addition, while the overall rate of pregnancy in women with schizophrenia of child-bearing age is lower than in the general population, the percentage of pregnancies that are unwanted is higher than that in the general population. The objective of this paper is to help clinicians explore knowledge of appropriate methods of contraception for women who suffer from schizophrenia. The authors reviewed recent literature on the use of contraceptive methods by women with schizophrenia treated with antipsychotic and adjunctive medications. Contraceptive counseling to women and their partners is an important part of comprehensive care for women with serious and persistent mental illness. Women with schizophrenia who smoke, are overweight, or have diabetes, migraine, cardiovascular disease, or a family history of breast cancer should be offered non-hormonal contraception. Women with more than one sexual partner should be advised on barrier methods in addition to any other contraceptive measures they are using. Clinicians should be alert for potential interactions among oral hormonal contraceptives, smoking, and therapeutic drugs. Long-lasting contraceptive methods, such as intrauterine devices, progesterone depot injections, or tubal ligation are reasonable options for women having no wish to further expand their families.

Effect of treatment assignment on intravaginal cleansing in a randomized study of the diaphragm with candidate microbicide

BACKGROUND

Intravaginal cleansing may predispose women to adverse health outcomes and may interfere with the effectiveness and safety of female-initiated methods for preventing sexually transmitted infections (STIs). In a 4-week randomized study of 192 Malagasy sex workers, we evaluated associations between self-reported intravaginal cleansing and randomization assignment: diaphragm with viscous candidate microbicide gel (Acidform™, TOPCAD, Chicago, IL, licensed to Instead, Coppell, TX), diaphragm with placebo hydroxyethylcellulose gel (HEC, ReProtect LLC, Baltimore, MD), Acidform alone, or HEC alone.

METHODS

Women were counseled to avoid intravaginal cleansing and were blinded to gel assignment. We evaluated changes in self-reported intravaginal cleansing across the study and assessed the effects of treatment assignment and covariates on frequent (more than once daily) intravaginal cleansing. Significant predictors in domain-specific models were evaluated in an all-domain multiple regression model.

RESULTS

The proportion of women reporting intravaginal cleansing decreased from baseline (97%) to week 1 (82%) (p < 0.001). Self-reported frequent intravaginal cleansing decreased from baseline (87% to 56%) during the same time period (p < 0.001). In adjusted analyses, the Acidform-diaphragm group had 60% lower odds of frequent intravaginal cleansing during the study (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.8) compared to the control group (HEC only). HEC-diaphragm and Acidform only users did not differ from controls. Living on the coast of Madagascar, not cohabiting, frequent intravaginal cleansing at enrollment, and high coital frequency predicted frequent intravaginal cleansing during follow-up.

CONCLUSIONS

Gel characteristics and the diaphragm's presence likely influenced women's cleansing. Viscous gel delivered by a cervical barrier (such as a diaphragm) may minimize the likelihood of frequent intravaginal cleansing.

Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: findings from a multicountry household survey

BACKGROUND

Women worldwide use various vaginal practices to clean or modify their vulva and vagina. Additional population-level information is needed on prevalence and motivations for these practices, characteristics of users, and their adverse effects.

METHODS

This was a household survey using multistage cluster sampling in Tete, Mozambique; KwaZulu-Natal, South Africa; Yogyakarta, Indonesia; and Chonburi, Thailand. In 2006-2007, vaginal practices and their motivations were examined using structured interviews with women 18-60 years of age (n=3610).

RESULTS

Prevalence, frequency, and motivations varied markedly. Two thirds of women in Yogyakarta and Chonburi reported one or more practices. In Yogyakarta, nearly half ingest substances with vaginal effects, and in Chonburi, external washing and application predominate. In Tete, half reported three or four current practices, and a quarter reported five or more practices. Labial elongation was near universal, and 92% of those surveyed cleanse internally. Two third's in KwaZulu-Natal practiced internal cleansing. Insertion of traditional solid products was rare in Chonburi and Yogyakarta, but one tenth of women in KwaZulu-Natal and nearly two thirds of women in Tete do so. Multivariate analysis of the most common practice in each site showed these were more common among less educated women in Africa and young urban women in Asia. Explicit sexual motivations were frequent in KwaZulu-Natal and Tete, intended for pleasure and maintaining partner commitment. Practices in Chonburi and Yogyakarta were largely motivated by femininity and health. Genital irritation was common at African sites.

CONCLUSIONS

Vaginal practices are not as rare, exotic, or benign as sometimes assumed. Limited evidence of their biomedical consequences remains a concern; further investigation of their safety and sexual health implications is warranted.

Women's perception of cervical cancer and its prevention in rural Laos

BACKGROUND

Cervical cancer is the second most common cancer of women in the world, and it becomes a major cause of cancer mortality in low-income countries. Currently, little is known regarding cervical cancer incidence in Laos, although it is anticipated to be high like in neighboring countries. To be able to develop a screening program in the country, it is essential to explore women's perception of the disease. The purpose of this study was therefore to describe knowledge, awareness, and attitudes regarding cervical cancer among rural women of Laos.

METHODS

In a descriptive cross-sectional study, women were interviewed using a structured questionnaire covering sociodemographic factors, knowledge of the disease and its risk factors, awareness, and attitudes toward cervical cancer and its prevention.

RESULTS

Eight hundred women were included in the study, and 58% claimed to know about cervical cancer. Approximately one third (38%) considered themselves to be at risk, but less than 5% had ever had a Papanicolau test. Sixty-two percent believed it was possible to prevent cervical cancer and that vaccination may be a suitable method, but only 14% know about risk factors. Another method for prevention was frequent vaginal douching, which was suggested by 70% of the women. Symptoms like bleeding and discharge were correctly identified as possible indicators of cervical cancer, but only 57 women (7%) knew that an early stage of the disease could be symptom-free. Lack of subjective symptoms was the main reason for women to refrain from gynecological examinations.

CONCLUSIONS

This study indicates that rural women in Laos have limited knowledge about cervical cancer and even less about screening and prevention. There is a need to educate the general community about the disease and its prevention.

Vaginal douching practice and related symptoms in a rural area of Turkey

PURPOSE

To investigate vaginal douching habits and associated factors among women living in rural Turkey.

METHODS

This study was performed in the gynecology department of a government hospital in a rural area of Turkey, from February to March 2010. The study included 393 women admitted to the gynecology clinic. The age, marital status, education, socioeconomic status, reason for vaginal douching, douching frequency, symptoms, and previous treatments were investigated. All of the subjects were asked about the use of, frequency, and reason for vaginal douching. Significant risk factors in the vaginal douching group and odds coefficients were found using binary logistic regression.

RESULTS

The major symptoms of the subjects were itching and vaginal discharge. Of the 393 women, 317 (80.66%) performed vaginal douching and all of them had recurrent or treatment-resistant mixed agent vulvovaginitis. The majority of the women douched for ritual cleansing or washing before prayer (n = 278; 91.6%). The majority of the cases (n = 354; 90.1%) were of lower socioeconomic and educational status. The odds ratios and 95% confidence interval (CI) of the risk variables vaginal douching frequency, cervical motion tenderness, dyspareunia, and vaginal itching were 9.39 (2.07-42.48), 7.31 (2.08-25.64), 6.52 (2.26-18.78), and 1.46 (1.22-1.74), respectively.

CONCLUSIONS

In our region, vaginal douching is a common practice among women, especially those of lower socioeconomic and educational status. Clinicians should inform patients about the risks of vaginal douching to minimize the risks associated with this behavior.

Correlates of trichomonas prevalence among street-recruited, drug-using women enrolled in a randomized trial

OBJECTIVES

Substance-using women need prevention technologies and programs to reduce risk of HIV/sexually transmitted infection (STI). We examined STI prevalence and identified risk correlates for female drug users.

METHODS

We used interviewer-administered and computer-assisted surveys, and tested specimens for four, treatable STIs (trichomonas, early syphilis, gonorrhea, chlamydia) on 198 HIV-seronegative, street-recruited, substance-using women enrolled in a randomized trial to reduce HIV/STI risk.

RESULTS

Most women were crack users (88%), reported sex exchange (80%) and were not in drug user treatment (74%). Two-thirds were African-American and nearly all were unemployed. Protection during sex was infrequent. African-American women reported fewer unprotected sex acts and fewer sexual partners, but greater crack use and more sex-for exchange, than whites or Hispanics. Trichomonas prevalence (36.9%) exceeded that for chlamydia (3.5%), syphilis (1.5%), and gonorrhea (0%). In multivariate logistic regression, having a primary and casual partner more than doubled (AOR 2.86) the risk of having trichomonas and being African-American raised the risk by more than 8 times (AOR 8.45).

CONCLUSIONS

African-American, drug-using women, and women with multiple partner types, are in urgent need of effective STI/HIV prevention interventions.

An updated review of of evidence to discourage douching

PURPOSE

To review current studies on vaginal douching.

DATA SOURCES

MEDLINE PubMed, CINAHL, and Cochrane databases from 2002 to 2008 using MeSh terms "vaginal AND irrigation or vaginal and douching" from 2002 to 2003 and "vaginal douching" and "vaginal douching and adverse effects" from 2004 to 2008.

STUDY SELECTION

MEDLINE PubMed included 156 records, CINAHL 15, and Cochrane 10. Articles in English were reviewed, and those pertaining to vaginal douching and reproductive and gynecologic outcomes were included. References from these articles were reviewed and included when appropriate. 2008 Web sites of the Centers for Disease Control and Prevention were also included.

DATA EXTRACTION

Articles were reviewed and summarized.

RESULTS

Vaginal douching is a common practice for almost one-third of women in the United States. Douching is associated with adverse pregnancy outcomes including ectopic pregnancy, low birth weight, preterm labor, preterm birth, and chorioamnionitis. Douching is more prevalent among non-Hispanic black women than among white women or Hispanic women. Douching alters the vaginal flora and predisposes women to develop bacterial vaginosis (BV), which is also more prevalent among women who douche and among black women. Douching is also associated with serious gynecologic outcomes, including increased risk of cervical cancer, pelvic imflammatory disease, endometritis, and increased risk for sexually transmitted infections, including HIV. Many factors influence women's douching behaviors, including social, cultural, and educational factors. Healthcare providers can influence women to stop douching.

CLINICAL IMPLICATIONS

Healthcare providers may not be aware of the mounting evidence of negative health outcomes associated with the practice of douching. At every opportunity, healthcare providers should ask women whether they douche and inquire about vaginal douching practices and beliefs associated with the practice. Douching should be discouraged because it places women at risk for multiple health problems.

Race of male sex partners and occurrence of bacterial vaginosis

BACKGROUND

Whether bacterial vaginosis (BV) is sexually transmitted is uncertain. Also it is unknown why BV is approximately twice as prevalent among black as among white women. An association of BV with a characteristic of the male sex partner, such as race, might support sexual transmission as well as account for the observed ethnic disparity in BV.

METHODS

Three thousand six hundred twenty nonpregnant women 15 to 44 years of age were followed quarterly for 1 year. At each visit, extensive questionnaire data and vaginal swabs for Gram's staining were obtained. The outcome was transition from BV-negative to positive (Nugent's score > or =7) in an interval of 2 consecutive visits.

RESULTS

BV occurred in 12.8% of 906 sexually active intervals to white women-24.8% of intervals when the woman reported a black partner and 10.7% when all partners were white. Among white women, there was a 2-fold increased risk for BV incidence with a black, compared with a white partner (risk ratio [RR] 2.3, 95% confidence interval 1.6-3.4; adjusted RR 2.2, 95% confidence interval 1.5-3.4), but differed according to condom use. In the presence of consistent condom use, the adjusted RR was 0.7 (0.3-2.4); it was 2.4 (1.0-6.2) in the presence of inconsistent use; and 2.7 (1.7-4.2) in the absence of condom use. Black women could not be studied, as there were insufficient numbers who reported only white male sex partners.

CONCLUSION

The association of BV occurrence with partner's race, and its blunting by condom use, suggests that BV may have a core group component and may be sexually transmitted.

Human immunodeficiency virus infection in Alabama women: sociodemographic, behavioral, and reproductive health characteristics and factors associated with lack of human immunodeficiency virus-1 viral control

BACKGROUND

Human immunodeficiency virus (HIV) infection among women in the southern United States is on the rise. This study examined sociodemographic profile and behavioral risk factors for HIV and sexually transmitted infections and assessed factors associated with HIV-1 viral control in a cohort of 280 HIV-infected Alabama women aged 17 to 66 years.

METHODS

Women receiving care for HIV infection at a university outpatient HIV clinic were enrolled in the study. Women completed a self-administered questionnaire on demographics and behavioral risk factors at enrollment. They were followed up with appointments at least every 6 months with Papanicolaou smears, cervicovaginal lavages, cervical and vaginal swabs, and blood specimens collected at each visit.

RESULTS

Of the women in the study, 69% were black, had mean age of 36 years, and approximately three fourths were mothers with annual household income <$20,000. White women were likely to have been HIV infected for a longer period (50.2 versus 36.3 months; P = 0.02) and had significantly lower viral loads at enrollment (P = 0.04) than black women. Factors associated with lack of HIV-1 control (> or =10,000 RNA copies/mL) at enrollment included black race/ethnicity (odds ratio [OR]: 2.8; 95% confidence interval [CI]: 1.2-6.8), CD4+ T-cell count <200 cells/microL (OR: 20.1; CI: 8.6-47.0), being diagnosed with HIV <6 months (OR: 3.5; CI: 1.4-8.9) and not being on any antiretroviral therapy (OR: 2.5; CI: 1.1-5.7).

CONCLUSION

Poorer HIV-1 viral control in black women at enrollment may indicate suboptimal access to HIV testing, delays in receipt of medical care after HIV-1 diagnosis, and/or some underlying biologic or social race-related influence.

Candidiasis (vulvovaginal)

INTRODUCTION

Vulvovaginal candidiasis is estimated to be the second most common cause of vaginitis after bacterial vaginosis. Candida albicans accounts for 85% to 90% of cases.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of drug treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of alternative or complementary treatments for acute vulvovaginal candidiasis in non-pregnant symptomatic women? What are the effects of treating a male sexual partner to resolve symptoms and prevent recurrence in non-pregnant women with symptomatic acute vulvovaginal candidiasis? What are the effects of alternative or complementary treatments for symptomatic recurrent vulvovaginal candidiasis in non-pregnant women? What are the effects of treating a male sexual partner in non-pregnant women with symptomatic recurrent vulvovaginal candidiasis? What are the effects of treating asymptomatic non-pregnant women with a positive swab for candidiasis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 61 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: alternative or complementary treatments; douching; drug treatments; garlic; intravaginal preparations (boric acid, nystatin, imidazoles, tea tree oil); oral fluconazole; oral itraconazole; treating a male sexual partner; and yoghurt containing Lactobacillus acidophilus (oral or vaginal).

Vaginal douching in Cambodian women: its prevalence and association with vaginal candidiasis

BACKGROUND

We determined the prevalence of vaginal douching (cleansing of the vagina with liquid) in a sample of Cambodian women, and examined the associations of douching with genitourinary symptoms and infections, after controlling for potential confounding factors, including genitourinary symptoms and sociodemographic factors.

METHODS

A total of 451 adolescent and adult females aged 15 to 49 years who attended 17 maternal and child health (MCH) clinics in 7 provinces of Cambodia in 2001 were consecutively enrolled as a part of the Sexually Transmitted Infection Sentinel Survey. Sociodemographic factors, genitourinary symptoms, and frequency of douching were assessed by face-to-face interviews using a structured questionnaire. Vaginal infections were examined by using standard diagnostic procedures specific to each pathogen.

RESULTS

The proportion of participants who douched at least once a week was 76.7% (n = 346). Douching was significantly more prevalent in urban than in rural women (85.7%, n = 198 vs 67.3%, n = 148; P < 0.001). Frequency of douching was significantly associated with genitourinary symptoms, which were most prevalent in participants who douched from several times a week to once a day; genitourinary symptoms were less prevalent in those who douched more than once a day. Douching was significantly associated with vaginal candidiasis, but not with trichomoniasis or bacterial vaginosis, and this association persisted even after controlling for sociodemographic factors and genitourinary symptoms.

CONCLUSIONS

Vaginal douching was very common among Cambodian women visiting MCH clinics. Further investigations are warranted to elucidate the reasons for douching. In addition, women should be informed that douching may endanger their reproductive health.

A descriptive study of douching practices in Turkish women

Vaginal douching is a common hygiene practice for many women all over the world. Little is known about the beliefs and attitudes that promote and maintain douching practices. Therefore, the aim of this study is to evaluate the status of vaginal douching practices of women in the Erzurum province of Turkey. The present study was a descriptive and cross-sectional quality. All participants were 15-49 years of age and all were married. Data analysis included descriptive statistics and chi(2) test. The present study revealed that the frequency of douching was 51.4% among women and that the most common reason for their habit was feminine hygiene and the most popular material used was water. A statistically significant relationship was found between the habit of doing the vaginal douching and the educational level, age of marriage, number of births, case of genital infections within the last year and presence of complaints indicating vaginal infections for the last month. This study provides preliminary information about women's douching practices and attitudes. It might also provide information to health-care practitioners in their efforts to educate women on the adverse effects of vaginal douching.

Prevalence and predictors of HIV infection among female sex workers in Kaiyuan City, Yunnan Province, China

BACKGROUND

Sexual transmission is the fastest growing route of HIV transmission in China. We undertook this study to describe the risk factors for HIV infection in female sex workers (FSWs), and to determine the commercial sex venues where FSWs are most at risk of being infected with or infecting others with HIV.

METHODS

This was a cross-sectional study of 737 FSWs in Kaiyuan City, Yunnan Province in southern China, which took place from March to May 2006.

RESULTS

The overall HIV prevalence was 10.3%, but prevalence varied with sex venue with 25.8% of FSWs working on the streets being HIV-positive and none of the FSWs working in nightclubs. Adjusted odds ratios (OR) of HIV infection were 9.1 (95% confidence interval (CI) 4.67-17.55) for injection drug use, 3.3 (95% CI 1.46-7.37) for non-injection illegal drug use, 2.7 (95% CI 1.25-5.93) for duration of sex work > or = 5 years, 2.2 (95% CI 1.05-4.70) for infection with herpes simplex virus type 2, and 2.0 (95% CI 1.12-3.47) for working at a higher risk entertainment venue. Although condom use was not a significant risk factor in the overall model, FSWs in lower risk venues who reported consistent use with clients had a 70% reduction in HIV infections (OR 0.30, 95% CI 0.12-0.90).

CONCLUSIONS

Illegal drug use, particularly with injection drugs, is the single greatest risk factor for HIV infection among FSWs in Kaiyuan City, China. FSWs working on the street or in temporary sub-lets, beauty salons, or saunas are at particularly high risk for transmitting and being infected with HIV. HIV prevention efforts among FSWs should target illegal drug users and these other subgroups.

Vaginal hygiene and douching: perspectives of Hispanic men

Vaginal douching is widely practised by women in the USA, particularly among minority ethnic groups, and is associated with increased risk of pelvic and vaginal infections. Douching practices are shaped by social and cultural norms regarding female hygiene, reproduction and sexuality. Little previous research has addressed the beliefs and practices of Latina women and none has included the perspective of men, though limited data suggests that women may douche to please male partners. The present study seeks to identify the socially and culturally shaped beliefs and attitudes that influence douching practices from the perspective of Latino men. We conducted in-depth qualitative interviews in English or Spanish with adult Latino men seeking primary care at a community health centre in New York City. Results indicate that these Latino men (mostly of Caribbean descent) are emphatic about the role of cleanliness in vaginal health, reporting that it substantially influences their choice of partner. Most are very supportive of douching, which they consider a necessary hygiene activity. Vaginal health is perceived as a state that must be attained and maintained through proactive hygiene measures that remove seminal residue, menstrual blood, sweat and bacteria that contaminate the vagina. The implications of these findings for interventions with Latina women are discussed.

Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents

OBJECTIVE

The objective of the study was to examine the association between douching and 4 sexually transmitted infections (STIs).

STUDY DESIGN

We followed up 411 high-risk human immunodeficiency virus-infected and uninfected female adolescents aged 12-19 years over a median 3-year period, both by time from study entry/first STI-free visit until an incident STI for participants who never, intermittently, and always douched and also by reported douching at a given STI-free visit and incidence of STI at the next visit, using adjusted Cox proportional hazards models to calculate hazard ratios (HR).

RESULTS

The time to STI was shorter for adolescents who always (HR, 2.1; 95% confidence interval [CI], 1.2-3.4) and intermittently (HR, 1.5; 95% CI, 1.0-2.2) douched, compared with never-douchers. An adjusted hazard for STI was 1.8 times larger for always-douchers (95% CI, 1.1-3.1) and 1.4 times larger for intermittent douchers (95% CI, 0.9-2.0), compared with never-douchers. When classifying by follow-up after an STI-free visit, always-douchers had a shorter STI-free time than never-douchers (HR(adj), 2.1; 95% CI, 1.5-3.1).

CONCLUSION

Counseling to discourage douching may reduce STI risk in adolescents.

The use of rectal douches among HIV-uninfected and infected men who have unprotected receptive anal intercourse: implications for rectal microbicides

Although some rectal douches result in surface epithelium loss and potential increase of HIV transmission, men who have sex with men (MSM) continue to use them. We describe the prevalence of this practice among MSM engaging in unprotected receptive anal intercourse (URAI) in risky circumstances. A multiethnic sample with overrepresentation of HIV-negative MSM who had URAI in the previous year was recruited exclusively through the Internet. Participants were 105 MSM (78 HIV-negative, 27 HIV-positive). A total of 53% of HIV-negative and 96% of HIV-positive men douched in preparation for sex, most of them frequently or always, mainly for hygienic purposes. 27% of HIV-negative and 44% of HIV-positive douched after sex, partly believing douching protected from infections. Douching practices started around age 25. Regression analyses found the association between HIV status and douching occasions persisted after controlling for demographic characteristics and number of URAI occasions. Rectal douching in preparation for sex is common among men who practice URAI. This population could benefit from alternatives to condoms, such as rectal microbicides. Given the popularity of pre-coital douching and its frequency, a harmless rectal douche that could deliver a rectal microbicide could have great acceptability.

Vaginal douching among Latinas: practices and meaning

OBJECTIVES

Vaginal douching is widely practiced by American women, particularly among minority groups, and is associated with increased risk of pelvic and vaginal infections. This research sought to investigate vaginal hygiene practices and meaning associated with them among Latina women and adolescents. Study results would guide development of an intervention to decrease douching among Latinas.

METHODS

In depth qualitative interviews conducted with English- and Spanish-speaking women aged 16-40, seeking care for any reason who reported douching within the last year (n = 34). Interviews were audiotaped, transcribed and analyzed using qualitative methods. One-third of interviews were conducted in Spanish.

RESULTS

Two explanatory models for douching motives emerged: one stressed cosmetic benefits; the other, infection prevention and control. Most women reported douching to eliminate menstrual residue; a small number reported douching in context of sexual intercourse or vaginal symptoms. Many were unaware of associated health risks. Respondents typically learned about douching from female family members and friends. Male partners were described as having little to no involvement in the decision to douche. Women varied in their willingness to stop douching. Two-thirds reported receiving harm reduction messages about "overdouching". About half indicated previous discussion about douching with health care providers; some had reduced frequency in response to counseling. A number of previously unreported vaginal hygiene practices and products were described, including use of a range of traditional hygiene practices, and products imported from outside the US.

CONCLUSIONS

Respondents expressed a range of commitment to douching. Counseling messages acknowledging benefits women perceive as well as health risks should be developed and delivered tailored to individual beliefs. Further research is needed to assess prevalence and safety of previously unreported practices.