Vaginal douches and other feminine hygiene products: women's practices and perceptions of product safety

A Syndemic Approach to Explore Factors Associated with Bacterial Vaginosis

Bacterial vaginosis (BV) is the most common genital infection in women and is associated with an increased risk of sexually transmitted infections and HIV. This study uses a syndemic approach to evaluate factors associated with BV. Non-pregnant, HIV-negative, sexually active, cis-gender women aged 18-45 years living in Miami, Florida were recruited from Nov.2018- Jun.2021. Participants completed a sociodemographic and behavioral questionnaire along with gynecological examinations. BV was diagnosed by Amsel criteria and confirmed by a Nugent score ≥ 4. A syndemic score was calculated as the sum of factors associated with BV. The association between syndemic score and BV was assessed using logistic regression. Of 166 women included, 60.2% had BV. Race, ethnicity, education, vaginal sex, recent cannabis use, and reasons for intravaginal practices were included in the syndemic score. Higher odds of BV were found in women with a score of ≥ 3 compared to women with a score of 0/1. A higher syndemic score was associated with increased odds of having BV. Multilevel interventions to decrease BV are needed to decrease women's risk of acquiring HIV.

Menstrual Products as a Source of Environmental Chemical Exposure: A Review from the Epidemiologic Perspective

PURPOSE OF REVIEW

Menstrual bleeding is a regular, common occurrence in a substantial portion of the population. Menstruators may use more than 10,000 menstrual products over the lifetime. Given the potential for environmental chemicals in menstrual products to be absorbed by the vulvar and vaginal epithelium into systemic circulation, we reviewed the available data on menstrual products as a source of environmental chemical exposure.

RECENT FINDINGS

Nearly two dozen studies have been conducted measuring environmental contaminants in menstrual products; all have detected environmental chemicals but had discrepant conclusions on exposure risks. Only three human studies have investigated menstrual product use and environmental chemical concentrations and all observed associations. Detection of environmental chemicals in menstrual products, in combination with challenges of exposure assessment, scarcity of human studies, and the exceedingly common occurrence of menstrual bleeding, motivates the need for further research. We provide recommendations to move this field forward.

Missed opportunities: misconceptions and lack of knowledge about vulval skin care in women attending a sexual health clinic

Vulval skin care is an important part of women's health, and this evaluation aimed to explore vulval care among women attending our sexual health clinic. A questionnaire was completed by 135 women over a five-week period. Forty-three women (32%) washed their vulva two to three times a day, with 93 (69%) using a detergent-containing product. Thirty-eight women (28%) used sanitary products when not menstruating. Ninety-five women (70%) reported at least one previous vulvo-vaginal condition. One hundred and two women (76%) reported being confident in vulval care; however, 60 women (44%) wished to receive more information. The mismatch between women's confidence and knowledge may reflect mixed sources of education used by women. We recommend that sexual health clinics review the information they provide to patients on vulval care.

Vulvar diseases: Approach to the patient

Patients with vulvar dermatoses often delay seeking medical treatment because of anxiety and embarrassment. Moreover, women frequently self-treat with various home remedies and see multiple clinicians before presenting to a dermatologist. Despite serving as the primary providers for patients with vulvovaginal symptoms, gynecologists typically receive limited training in the causes and management of these conditions. Dermatologists are experts in the evaluation and management of cutaneous disease and should be the caretakers of all skin, including the genitalia. Vulvar disorders are underrecognized by dermatologists for numerous reasons: inadequate training, lack of comfort with both interview and examination techniques, and unfamiliarity with normal anatomic variations. The first article in this continuing medical education series on vulvar dermatoses reviews the fundamentals, approach, and techniques that can be used to ensure a successful visit for both patient and provider.

"It's not perfect but it's mine": Genital self-image among women living in Italy

The purpose of this article is to describe Italian women's attitudes toward their genitals, and the intersection of genital self-image (GSI) and reproductive and sexual health behaviors. Individual interviews were conducted with 46 reproductive-aged women. All interviews were transcribed verbatim with observer comments to identify emerging data patterns. Researchers completed coding between and within interviews for a constant comparative approach to data analysis to identify emergent themes. Participants expressed embarrassment discussing genitals and equated this with societal taboos; however, friends provided one opportunity to speak more openly. Odor discussions and hygiene practices were frequently occurring themes, especially during menstruation. GSI limited some daily activities and sexual experiences due to feelings of self-consciousness. Concerns stemmed from limited knowledge about how women's genitals should look, smell, and feel. In contrast, some women detailed positive GSI in terms of autonomy and self-care. Results illustrate practical recommendations for healthcare providers to address women's genital concerns and improve women's GSI and overall reproductive and sexual health experiences.

Effect of vaginal douching on vaginal flora and genital infection

Objective:

This study aimed at examining the effect of vaginal douching (VD), which is a traditional and cultural application, on the vaginal flora and genital infections.

Material and Methods:

This descriptive study included 190 women including those who did or did not perform VD. A questionnaire survey and vaginal sampling were employed. The collected samples were transported within 8 h for laboratory testing.

Results:

There was no significant difference between the two groups in terms of vaginal flora. In the VD group, only a few patients reported a history of Sexually Transmitted disease (STD), but none in the non-VD group had STDs (p<0.05). No significant difference in infections was noted. However, there was a significant relationship between the history of infections and VD (p<0.01).

Conclusion:

Women who performed VD are at risk for vaginal infections. Further studies are warranted in the future for clinical application.

Vaginal health and hygiene practices and product use in Canada: a national cross-sectional survey

Background

The vaginal microbiome influences quality of life and health. The composition of vaginal microbiota can be affected by various health behaviors, such as vaginal douching. The purpose of this study was to examine the types and prevalence of diverse vaginal/genital health and hygiene behaviors among participants living in Canada and to examine associations between behavioral practices and adverse gynecological health conditions.

Method

An anonymous online survey, available in English and French, was distributed across Canada. The sample consisted of 1435 respondents, 18 years or older, living in Canada.

Results

Respondents reported engaging in diverse vaginal/genital health and hygiene behavioral practices, including the use of commercially manufactured products and homemade and naturopathic products and practices. Over 95% of respondents reported using at least one product in or around the vaginal area. Common products and practices included vaginal/genital moisturizers, anti-itch creams, feminine wipes, washes, suppositories, sprays, powders, and waxing and shaving pubic hair. The majority of the sample (80%) reported experiencing one or more adverse vaginal/genital symptom in their lifetime. Participants who had used any vaginal/genital product(s) had approximately three times higher odds of reporting an adverse health condition. Several notable associations between specific vaginal/genital health and hygiene products and adverse health conditions were identified.

Conclusions

This study is the first of its kind to identify the range and prevalence of vaginal/genital health and hygiene behaviors in Canada. Despite a lack of credible information about the impact of these behaviors on women’s health, the use of commercially manufactured and homemade products for vaginal/genital health and hygiene is common. Future research can extend the current exploratory study by identifying causal relationships between vaginal/genital health and hygiene behaviors and changes to the vaginal microbiome.

Qualitative Analysis of Sexually Experienced Female Adolescents: Attitudes about Vaginal Health

STUDY OBJECTIVE

To explore adolescent's perceptions of vaginal health, practices, and vaginally-placed products.

DESIGN

Semistructured interviews were audio-recorded and transcribed until theoretical saturation was achieved.

SETTING

Adolescent medicine clinics in New York City.

PARTICIPANTS

Female adolescents (N = 22) who were sexually experienced, predominately Hispanic (73%, n = 16) with a mean age of 17.7 years (range, 15-20 years).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Interviews were used to assess perspectives on vaginal health, specific vaginal hygiene practices, and attitudes about vaginally-placed products (contraceptive rings, intrauterine devices), and proposed multipurpose technologies administered as ring or gel). The interviews were transcribed and coded for relevant themes.

RESULTS

Overlapping themes included young women's view of their vagina as a space that needed to be healthy for sexual partners and future fertility. The vagina could not be presumed to be healthy and conversations about vaginal health were limited to include only specific individuals. All reported a variety of practices to maintain their vaginal health, including showering 1-5 times a day and using soaps specifically for the vagina. Attitudes about vaginally-placed products revealed concerns about the sensory experience of having a product in the vagina, safety concerns and interest in the product's objective (prevention of pregnancy or infection).

CONCLUSION

Adolescents have very specific views and practices about their vaginas. Clinicians should initiate conversations about vaginal health and hygiene with adolescents and focus on the normalcy of the vagina. Development of vaginally-placed products should focus on the sensory experience, safety, and purpose of the product.

Feminine hygiene practices among female patients and nurses in Lebanon

BACKGROUND

Inappropriate feminine hygiene practices are related to vulvovaginitis. We investigated the prevalence of personal hygiene habits among Lebanese women as well as their awareness of adequate practices.

METHODS

Consists of a cross-sectional observational study. Female patients and nurses at Hotel-Dieu de France University Hospital in Beirut- Lebanon filled a questionnaire about their intimate hygiene habits and knowledge of proper practices.

RESULTS

The study included 249 women. 21.3 % of the 136 nurses and 38.9 % of the 113 patients reported a history of vulvovaginitis. The majority of women took an intimate bath at least twice daily. 14 % of nurses and 17 % of patients douched.20. Seven percent of the nurses and 43.4 % of the patients used wet wipes. 1.5 % of nurses and 4.4 % of patients used feminine deodorant sprays. There was a significant lack of awareness mainly among patients about suitable hygiene practices as well for their adverse effects.

CONCLUSION

Education provided by nurses, and other healthcare providers is essential to promote reproductive health among Lebanese women.

Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004

BACKGROUND

Diethyl phthalate (DEP) and di-n-butyl phthalate (DnBP) are industrial chemicals found in consumer products that may increase risk of adverse health effects. Although use of personal care/beauty products is known to contribute to phthalate exposure, no prior study has examined feminine hygiene products as a potential phthalate source. In this study, we evaluate whether vaginal douching and other feminine hygiene products increase exposure to phthalates among US reproductive-aged women.

METHODS

We conducted a cross-sectional study on 739 women (aged 20-49) from the National Health and Nutrition Examination Survey 2001-2004 to examine the association between self-reported use of feminine hygiene products (tampons, sanitary napkins, vaginal douches, feminine spray, feminine powder, and feminine wipes/towelettes) with urinary concentrations of monoethyl phthalate (MEP) and mono-n-butyl phthalate (MnBP), metabolites of DEP and DnBP, respectively.

RESULTS

A greater proportion of black women than white and Mexican American women reported use of vaginal douches, feminine spray, feminine powder, and wipes/towelettes in the past month whereas white women were more likely than other racial/ethnic groups to report use of tampons (p < 0.05). Douching in the past month was associated with higher concentrations of MEP but not MnBP. No other feminine hygiene product was significantly associated with either MEP or MnBP. We observed a dose-response relationship between douching frequency and MEP concentrations (p(trend) < 0.0001); frequent users (≥2 times/month) had 152.2% (95% confidence intervals (CI): (68.2%, 278.3%)) higher MEP concentrations than non-users. We also examined whether vaginal douching mediates the relationship between race/ethnicity and phthalates exposures. Black women had 48.4% (95% CI: 16.8%, 88.6%; p = 0.0002) higher MEP levels than white women. Adjustment for douching attenuated this difference to 26.4% (95% CI:-0.9%, 61.2%; p = 0.06). Mediation effects of douching were statistically significant for black-white differences (z = 3.71, p < 0.001) but not for differences between Mexican Americans and whites (z = 1.80, p = 0.07).

CONCLUSIONS

Vaginal douching may increase exposure to DEP and contribute to racial/ethnic disparities in DEP exposure. The presence of environmental chemicals in vaginal douches warrants further examination.

Feminine Hygiene and Vaginal Douche Practices in Middle-aged Women

PURPOSE

The study was done to survey feminine hygiene and vaginal douche practices in middle-aged women to obtain basic information for public health education.

METHODS

With a descriptive survey design, 134 middle-aged women who have menstrual period were recruited via convenience sampling. Survey contents were from the study by Czerwinski (2000) regarding feminine hygiene and vaginal douching practices. After obtaining IRB approval, a self-administered structured questionnaire was distributed to study participants.

RESULTS

Mean age of middle-aged women was 46.88 years old. Fifty-six percent of the women practiced vaginal douching. Women performed douching with water (68%), commercial products (13%), soap (12%), and vinegar-mixed water (6%) for clean and fresh feeling, removal of unpleasant odor, and removal of vaginal discharge. Vaginal douche practice was significantly related to a history of vaginitis.

CONCLUSION

The study results indicate that most of the women practiced inadequate feminine hygiene especially in douching, suggesting that is important to develop education programs on feminine hygiene practices for women of all ages, especially regarding douching and hand washing before and after changing pads or tampons.

Prevalence and correlates of recent vaginal douching among African American adolescent females

STUDY OBJECTIVE

To describe the prevalence and correlates of vaginal douching among urban African American adolescents and to examine the association between douching and sexually transmitted infection (STI) status.

DESIGN

Demographic, psychosocial, and behavioral data were collected through cross-sectional, self-administered surveys. Self-collected vaginal swabs were assayed using nucleic acid amplification tests for trichomoniasis, chlamydia, and gonorrhea.

SETTING

Sexual health clinic in a large metropolitan area of the southeastern United States.

PARTICIPANTS

African American females (N = 701), ages 14-20, participating in a human immunodeficiency virus prevention intervention.

MAIN OUTCOME MEASURE

The outcome of interest was the association between vaginal douching (lifetime, past 90 days, and past 7 days) with demographic characteristics (eg, age, education, and socioeconomic status), physical and mental health status, STI status, sexual behavior (eg, number of vaginal sexual partners, age of sex partners, consistent condom use in the past 90 days, sex while self/partner was high on drugs or alcohol), and psychosocial characteristics (eg, sexual adventurism, social support, peer norms, sexual satisfaction, self-efficacy for sex refusal, self-esteem, relationship power, risk avoidance).

RESULTS

Forty-three percent reported ever douching, and 29% reported douching in the past 90 days. In bivariate analyses, recent douching was associated with demographic, behavioral, and psychosocial variables, but not current STI status. In multivariate analyses, recent douching was associated with age (odds ratio [AOR] = 1.13, confidence interval [CI] = 1.02-1.25), lower socioeconomic status (AOR = 1.25, CI = 1.05-1.47), and having sex with much older partners (AOR = 1.87, CI = 1.22-2.86).

CONCLUSION

Increased age, lower socioeconomic status, and older partners may be salient risk factors for douching behavior among African American young women.

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.

Genital malodor in women: a modern reappraisal

Genital malodor is a common distressing complaint that brings a woman to her physician's office. Vaginal infections, primarily bacterial vaginosis and trichomoniasis, still remain the commonest causes and are relatively easy to diagnose and treat. However, in approximately one third of women who present with malodor, no cause is identified. Although data on the management of vaginal discharge are extensive, the management of genital odor beyond common vaginal infections remains poorly studied. This presents a frustrating situation for both the patient and her physician. Often, patients resort to home remedies and over-the-counter preparations, which, while providing short-term relief for some women, almost never address the cause and, in some cases, can exacerbate symptoms. In this review, we have attempted to consolidate the known and documented causes of genital malodor including the nonvaginal causes and provide case studies that will help clinicians understand the possible settings for the various causes. We also provide an algorithm for the management of this symptom beyond vaginal infections.

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.

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.

Vaginal douching among Latina immigrants

Little is known about vaginal douching among Latina immigrants in the U.S. Understanding factors associated with douching is important due to the negative reproductive outcomes associated with this practice. This study examined demographic and behavioral factors associated with vaginal douching among Latina immigrants. A cross-sectional anonymous survey was administered among a convenience sample of 206 Latina immigrants aged 19-44 years (mean = 28 years) living in the U.S. at least 6 months (mean = 4 years). Demographic and behavioral characteristics, history of regular douching (at least once a month for 6 months), and current regular douching (at least once a month for the last 6 months) were assessed. Adjusted odds ratios (adj. OR) were estimated using multiple logistic regression. Overall, 25% (n = 50) of women reported ever douching regularly and 15% (n = 31) reported current regular douching. Ever douching regularly was significantly associated with a woman's number of lifetime sex partners (adj. OR = 1.6 per additional partner over one, 95% CI: 1.1-2.5), hormonal contraceptive use (adj. OR = 0.3, 95% CI: 0.1-0.9), and healthcare seeking behavior (adj. OR = 2.3, 95% CI: 1.1-5.2). Regular vaginal douching is a common practice among Latina immigrants. Factors associated with douching in this population vary from those in other U.S. populations and, therefore, it needs to be addressed in a culturally appropriate manner.

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.

Lime Juice as a Candidate Microbicide? An Open-Label Safety Trial of 10% and 20% Lime Juice Used Vaginally

OBJECTIVE

Lime has a long history as a contraceptive and vaginal hygiene douche, and ongoing use in Africa is documented. We report on the first safety study on diluted lime juice to assess its potential as a candidate microbicide.

METHODS

Twenty-five sexually abstinent women were randomly assigned to apply a 10% or 20% concentration of lime juice or 0% (water-only) through a soaked tampon once daily for 14 consecutive days. Tests for genital infections, measurement of inflammatory biomarkers, and a colposcopy were performed before and after treatment.

RESULTS

No participant showed severe vaginal irritation. Two women developed a yeast infection after using lime juice. More than 70% of women in all groups reported side effects, most being singular, mild, and transient events. The users of 20% diluted lime juice experienced a significantly higher frequency of burning and dryness. Vaginal inflammatory biomarkers showed no significant change between preexposure and postexposure levels. The naturally low vaginal pH showed little change, and lactobacilli colonization did not decrease.

CONCLUSIONS

Lime juice up to 20% concentration has an acceptable safety profile for vaginal use. However, as new in vitro research shows that the effectiveness of lime juice to prevent HIV transmission in concentrations lower than >or=50% is unlikely and concentrations of 50% have been shown to be toxic, women should be discouraged from commencing or continuing the vaginal use of lime juice.

Vaginal douching and intimate partner violence: is there an association?

OBJECTIVE

This study tests the hypothesis that vaginal douching among women of reproductive age is associated with exposure to intimate partner violence (IPV).

METHODS

The data source is a cross-sectional population-based sample of 2,002 women ages 18-45 in the Central Pennsylvania Women's Health Study. The survey included measures of IPV, douching behavior, and relevant sociodemographic and health-related covariates.

FINDINGS

Six percent of the sample reported experiencing any type of IPV in the past year, and 23% reported douching in the past year. IPV is significantly associated with douching after controlling for sociodemographic and health-related covariates. This finding holds for women with and without current reproductive capacity.

CONCLUSIONS

This is the first study to identify an association between vaginal douching and IPV. Because vaginal douching is a risk factor for sexually transmitted infections, bacterial vaginosis, and adverse pregnancy outcomes, the findings could have important implications for prevention. Further research is needed to identify the reasons why women who have been exposed to IPV are more likely to douche.