Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage

The association between lifestyle factors and the composition of the vaginal microbiota: a review

PURPOSE

The vaginal microbiota offers valuable insights into women's sexual health and the risk of developing sexually transmitted infections (STIs) and bacterial vaginosis. Despite the public health implications of changes in the vaginal environment, existing data on this topic remain sparse.

METHODS

Following the PRISMA statement guidelines, we consulted five bibliographic databases, focusing on five main daily habits and behaviors. We included only studies published up to October 2023, investigating the influence of personal hygiene, sexual behaviors, hormonal contraception, smoking, alcohol consumption, and psychosocial stress on the vaginal microbiota using next-generation sequencing.

RESULTS

Based on our inclusion criteria, we incorporated 37 studies into this review. Hormonal contraception and personal hygiene were found to promote eubiosis of the vaginal microbiota. In contrast, sexual behaviors, smoking, alcohol consumption, and psychosocial stress were associated with an increased susceptibility to bacterial vaginosis, STIs, and severe pelvic inflammatory diseases due to a modified vaginal microbiota. Black ethnicity emerged as a confounding factor, with this population showing unstable vaginal microbiota. Oral contraception and a stable male sexual partner were found to favor Lactobacillus colonization, acting as a protective factor. Conversely, non-hormonal contraception and unprotected or non-penile/vaginal sexual activity increased the incidence of vaginal inflammation and bacterial vaginosis by disturbing the vaginal microbiota and reducing Lactobacillus abundance.

CONCLUSION

Daily habits and lifestyle can influence the composition of the vaginal microbiota, thereby affecting vaginal health. Disturbances in the vaginal microbiota could be associated factors for STIs and vaginosis. Therefore, prioritizing more appropriate management of the vaginal microbiota is crucial.

An updated study of the relationship between bacterial infections and women's immune system, focusing on bacterial compositions with successful pregnancy

Genital tract infections can cause a variety of harmful health outcomes, including endometritis, bacterial vaginosis, and pelvic inflammatory disease, in addition to infertility. Anaerobic bacteria, such as Gardnerella vaginalis, Megasphaera spp., and Atopobium vaginae, are more commonly identified in cases of bacterial vaginosis than lactobacilli. It is unknown how the microorganisms that cause pelvic inflammatory diseases and endometritis enter the uterus. Both prospective and retrospective research have connected pelvic inflammatory disorders, chronic endometritis, and bacterial vaginosis to infertility. Similar to bacterial vaginosis, endometritis-related infertility is probably caused by a variety of factors, such as inflammation, immune system recognition of sperm antigens, bacterial toxins, and a higher risk of STDs. Preconception care for symptomatic women may include diagnosing and treating pelvic inflammatory disease, chronic endometritis, and bacterial vaginosis before conception to optimize the results of both natural and assisted reproduction.

Navigating the Microbial Landscape: Understanding Dysbiosis in Human Genital Tracts and Its Impact on Fertility

Dysbiosis, an imbalance in microbial communities, significantly impacts the health and functionality of the human genital tract, with profound implications for fertility and reproductive health. This review explores the intricate relationship between genital tract microbiota and reproductive outcomes, highlighting the composition and dynamics of these microbial communities in both females and males. In females, the vaginal microbiota, primarily dominated by Lactobacillus species, is essential for maintaining a healthy vaginal environment, preventing infections, and supporting reproductive functions. In males, the genital microbiota influences sperm quality and reproductive health. Dysbiosis in the genital tract, manifesting as bacterial vaginosis, yeast infections, urethritis, or prostatitis, disrupts these microbial communities, leading to adverse reproductive outcomes such as infertility, pregnancy, and increased susceptibility to sexually transmitted infections. This review delves into the mechanisms through which dysbiosis affects fertility, including alterations in vaginal pH, mucosal immunity, inflammation, sperm viability, and motility. It also evaluates diagnostic methods, clinical implications, and management strategies, including probiotics, prebiotics, antibiotics, antifungal treatments, lifestyle interventions, and emerging therapeutic approaches. By understanding the microbial landscape of the genital tract and its impact on fertility, this review aims to inform targeted interventions that restore microbial balance and enhance reproductive health, ultimately improving fertility outcomes and the potential for healthy pregnancies.

Resistant C. albicans implicated in recurrent vulvovaginal candidiasis (RVVC) among women in a tertiary healthcare facility in Kumasi, Ghana

BACKGROUND

Vulvovaginal candidiasis is a common fungal infection that affects the female lower genital tract. This study determined the major risk factors associated with vulvovaginal infection (VVI) in the Ashanti region of Ghana and also determined the antifungal resistance patterns of Candida albicans isolates to some antifungals.

METHODS

Three hundred and fifty (350) high vaginal swab (HVS) samples were collected from women who presented with signs and symptoms of VVI. A structured questionnaire was administered to one hundred and seventy-two (172) of the women. HVS samples were cultured on Sabouraud dextrose agar with 2% chloramphenicol. The polymerase chain reaction was employed to confirm C. albicans. Antifungal susceptibility testing was performed and the susceptibility of C. albicans isolates to fluconazole, clotrimazole, amphotericin B, nystatin, miconazole and 5-flurocytosine were assessed.

RESULTS

Vaginal infection was most prevalent amongst females in their reproductive age (21 to 30 years; 63.0%). The study found a significant association between vaginal infections and some risk factors such as sexual practices (p < 0.001), antibiotic misuse (p < 0.05), poor personal hygiene (p < 0.005) and birth control methods (p < 0.049). Out of the 350 HVS samples collected, 112 yielded yeast cells with 65 (58%) identified as C. albicans. The C. albicans isolates were resistant to 5' flucytosine (100%), fluconazole (70%), voriconazole (69.2%), miconazole (58.5%) and nystatin (49.2%). C. albicans isolates were more susceptible to amphotericin B (53.8%) and clotrimazole (45.1%), although an appreciable number of isolates showed resistance (46.1% and 52.3%, respectively).

CONCLUSION

There should be nationwide education on all associated risk factors of VVI. Also, use of the various antifungal agents in vaginal candidiasis should proceed after antifungal susceptibility testing to ensure efficacious use of these agents.

Candida albicans skin infection in diabetic patients: An updated review of pathogenesis and management

Candida species, commensal residents of human skin, are recognized as the cause of cutaneous candidiasis across various body surfaces. Individuals with weakened immune systems, particularly those with immunosuppressive conditions, are significantly more susceptible to this infection. Diabetes mellitus, a major metabolic disorder, has emerged as a critical factor inducing immunosuppression, thereby facilitating Candida colonization and subsequent skin infections. This comprehensive review examines the prevalence of different types of Candida albicans-induced cutaneous candidiasis in diabetic patients. It explores the underlying mechanisms of pathogenicity and offers insights into recommended preventive measures and treatment strategies. Diabetes notably increases vulnerability to oral and oesophageal candidiasis. Additionally, it can precipitate vulvovaginal candidiasis in females, Candida balanitis in males, and diaper candidiasis in young children with diabetes. Diabetic individuals may also experience candidal infections on their nails, hands and feet. Notably, diabetes appears to be a risk factor for intertrigo syndrome in obese individuals and periodontal disorders in denture wearers. In conclusion, the intricate relationship between diabetes and cutaneous candidiasis necessitates a comprehensive understanding to strategize effective management planning. Further investigation and interdisciplinary collaborative efforts are crucial to address this multifaceted challenge and uncover novel approaches for the treatment, management and prevention of both health conditions, including the development of safer and more effective antifungal agents.

Postpartum care: Clinical considerations for improving genital and sexual health

The postpartum period encompasses the biological and psychoaffective transition to motherhood. However, it remains a most neglected phase in a woman's life. Furthermore, the transition to parenthood is a critical and potentially disrupting factor in a couple's relationship, which can be complicated by undiagnosed biological and psychosexual difficulties. Lack of recognition of the many biological and medical factors that can affect women's health and sexuality in the postpartum period is a common and persistent clinical omission worldwide. Communication difficulties exist between healthcare professionals and women and there are wording biases in describing female genitalia. This can further contribute to the diagnostic lack of attention and timely diagnosis and treatment of even very bothersome symptoms. Early diagnosis and treatment of common postpartum conditions is vital and quality care for new mothers should include psychological and emotional support, lactation assistance, early diagnosis and treatment of genital and sexual pain symptoms, pelvic floor rehabilitation and sexual health guidance. The inclusion of correct genital hygiene practices is a critical element of postpartum gynaecological counselling and can help improve overall genital and sexual health. In this review, we summarise the variability in global professional guidelines for postpartum care, identify common health problems faced by postpartum women and discuss appropriate postpartum care. We pay specific attention to prominent biological or medical factors that can impact the emotional and psychosexual wellbeing of women and couples. The aetiology, diagnosis and treatment of sexual dysfunction, in particular sexual pain disorders, is therefore discussed with a pragmatic approach. Finally, the role of intimate hygiene care is discussed with special attention given to cleanser ingredients with solid scientific evidence to help clinicians adopt a more tailored approach with their clinical recommendations.

Qualitative Assessment of Vulvovaginal Health Information on Social Media

STUDY OBJECTIVE

Adolescents and young adults use vulvovaginal hygiene practices, products, and treatments. Access to social media platforms allows health information, including gynecologic care, to be easily disseminated and more accessible. Our objective was to characterize and assess vulvovaginal health information available on a popular video-sharing social media platform.

METHODS

In this cross-sectional analysis study, search terms related to vulvovaginal health were included to assess the top videos appearing on June 15, 2022. Descriptive statistics, uploader demographic characteristics, and content characteristics were recorded for each video. Information quality was evaluated using the DISCERN instrument.

RESULTS

One hundred and sixty-four videos met the study criteria with a combined total of over 500 million views, over 1.5 million shares, and nearly 60 million likes. Over 90% of videos consisted of educational content or product advertisements, and nearly 70% of videos provided information on general vulvovaginal hygiene and health. Seventy-five percent of videos were uploaded by private companies and nonmedical individuals. The mean DISCERN score was 1.6 out of 5. Medical providers scored significantly better than other uploaders on 12 of 16 DISCERN items, and mean overall publication quality scores were significantly higher for videos created by medical providers than nonmedical individuals and private companies (P < .0001).

CONCLUSION

Social media platforms are a popular medium for vulvovaginal health information, accumulating over half a billion views within a short timeframe. Although medical providers had fewer shortcomings in their videos, the overall quality of health information shared was low, with serious or extensive shortcomings.

Prophylactic application of vaginal lactic acid bacteria against urogenital pathogens and its prospective use in sanitary suppositories

Beneficial and pathogenic microbes coexist in the vaginal canal, where a diminishing population of lactic acid bacteria may cause recurring urogenital infections. Probiotic bacteria Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus vaginalis, and pathogenic microbes Enterococcus faecalis, Enterobacter cloacae, Shigella sp., Staphylococcus epidermidis, and Escherichia fergusonii were isolated from vaginal swabs. Lactobacillus sp. and their probiotic culture free supernatant (PCFS) inhibited the growth of the above-mentioned urogenital pathogens. L. crispatus produced both lactic acid and hydrogen peroxide, exhibiting the best antimicrobial potential against the studied pathogens. Lyophilized L. crispatus had a shelf life of 12 months and the lyophilized PCFS also retained its antibacterial property with a minimum inhibition concentration of 1 μg/μL. Carboxy-methyl cellulose-alginate, a green alternative to super-absorbent polymers, was encapsulated with L. crispatus cells. The probiotic in its encapsulated state retained its viability for 21 days, and the bead showed 30% solvent absorptive capacity. PCFS-laced non-woven fabric displayed antibacterial property with no change in its physicochemical properties. These probiotic and postbiotic formulations have excellent prophylactic potential for urogenital infections. Such formulations can be exploited as additives in sanitary suppositories to enhance vaginal health.

Maintaining vulvar, vaginal and perineal health: Clinical considerations

Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of their own intimate health.

The Importance of Immunological Disorders in the Pathogenesis of Lichen Sclerosus in Pediatric Patients: A Systematic Review

Lichen sclerosus (LS) is defined as a chronic mucocutaneous inflammatory disease with a localization predominantly to the anus and genitals (vulvar sclerosus (VLS)). Pediatric lichen sclerosus (LS) is a chronic inflammatory skin condition with predilection for the anogenital area that if untreated can lead to scarring. Vulvar LS is characterized by two peaks in incidence: it occurs in prepubertal girls and in postmenopausal women. To date, several mechanisms and risk factors have been proposed in the pathogenesis of pediatric vulvar LS; however, the etiology of this condition is still not fully understood and constitutes a challenge for scientists and clinicians. The presented research aimed to systematically review the existing literature on the pathogenesis of pediatric LS and to identify possible underlying autoimmune mechanisms and molecular networks. The clinical presentation of pediatric lichen sclerosus and available treatment modalities are also presented to acquaint a broader audience with this underdiagnosed and undertreated condition. As a result of our review, we discuss several potential mechanisms, molecules, and pathways that have been recognized in this disease. The purpose of our review was also to summarize what we can induce in further studies, which will ultimately help to identify the mechanism responsible for the disease and aid in the development of new, more effective treatment strategies for diagnosis and treatment by clinicians and researchers.

The role of female intimate hygiene practices in the management of vulvovaginal candidiasis: A randomized, controlled open-label trial

In this multicenter, observational, controlled open-label trial, researchers randomized 200 women with vulvovaginal candidiasis (VVC) to: Group 1, 6-days clotrimazole 2% vaginal cream once-daily plus 15-days concomitant acid pH thymol and zinc-containing cleansing wash (SaugellaActi3) twice-daily; Group 2, 6-days clotrimazole treatment alone. In both groups, pruritus and burning VAS scores improved from baseline at Days 6, 10 and 15. On Day 10 and Day 15, the pruritus score was significantly lower in Group 1 versus Group 2 (P <0.005 at both timepoints), suggesting acid pH thymol and zinc-containing cleansing wash ameliorates VVC-associated pruritus as part of a female hygiene regimen.

Factors Associated with Vaginal Lactobacillus Predominance Among African American Women Early in Pregnancy

Background: Vaginal Lactobacillus is considered protective of some adverse reproductive health outcomes, including preterm birth. However, factors that increase or decrease the likelihood of harboring Lactobacillus in the vaginal microbiome remain largely unknown. In this study, we sought to identify risk and protective factors associated with vaginal Lactobacillus predominance within a cohort of pregnant African American women. Materials and Methods: Vaginal microbiome samples were self-collected by African American women (N = 436) during their 8-14th week of pregnancy. Sociodemographic information and measures of health behaviors, including substance use, antibiotic exposure, sexual practices, frequency of vaginal intercourse, and the use of vaginal products, were collected through participant self-report. The V3-V4 region of the 16S rRNA gene was targeted for amplification and sequencing using Illumina HiSeq, with bacterial taxonomy assigned using the PECAN classifier. Univariate and a series of multivariate logistic regression models identified factors predictive of diverse vaginal microbiota or Lactobacillus predominance. Results: Participants who used marijuana in the past 30 days (aOR 1.80, 95% CI 1.08-2.98) were more likely to have diverse non-Lactobacillus-predominant vaginal microbiota, as were women not living with their partners (aOR 1.90, 95% CI 1.20-3.01). Cohabitating or marijuana usage were not associated with type of Lactobacillus (non-iners Lactobacillus vs. Lactobacillus iners) predominance (aOR 1.11, 95% CI 0.52-2.38 and aOR 0.56, 95% CI 0.21-1.47, respectively). Conclusions: Living with a partner is conducive to vaginal Lactobacillus predominance. As such, cohabitation may be in important covariate to consider in vaginal microbiome studies.

Analysis of the Vulvar Skin Microbiota in Asymptomatic Women and Patients With Vulvar Lichen Sclerosus Based on 16S rRNA Sequencing

Vulvar lichen sclerosus (VLS) is a chronic inflammatory skin disease that brings life-long and psychological distress to patients. It remains unclear whether this condition is related to changes in the skin microbial community. The aim of this study was to evaluate the compositional characteristics of the vulvar skin microbiota between VLS patients and asymptomatic postmenopausal women. We included 60 cases of postmenopausal patients in the outpatient vulvar clinic of Peking University First Hospital from August 2020 to October 2020. Thirty-one patients were diagnosed with VLS by vulvar skin biopsy (VLS group), while 29 women were asymptomatic volunteers (control group). DNA was extracted from vulvar skin swabs of the VLS and control groups. The V3-V4 fragments of 16S rRNA were targeted for high-throughput sequencing and gene sequence analysis. The sequencing results were analysed by α diversity, β diversity, species composition, LEfSe analysis to compare the compositional differences of the vulvar skin microbiota between the two groups. Our study revealed that at the phylum level, patients with VLS had a lower relative abundance of Firmicutes (p < 0.0001) and a higher relative abundance of Proteobacteria than the control group (p < 0.0001). At the genus level, Lactobacillus spp. accounted for the largest proportion of the microflora in the asymptomatic controls, while the proportion of Prevotella spp. in the VLS group was the highest. In the VLS group, the relative abundance of Finegoldia spp., Ralstonia spp., Peptoniphilus spp., Anaerococcus spp., Campylobacter spp., Providencia spp. Kelbsiella spp., Ezakiella spp., and Escherichia-Shigella spp. was significantly increased compared with the control group. Although there was no significant difference in the α diversity of the vulvar skin microbiota, the β diversity differed significantly between the two groups.

The Human Vulvar Microbiome: A Systematic Review

The link between cancer and the microbiome is a fast-moving field in research. There is little knowledge on the microbiome in ((pre)malignant) conditions of the vulvar skin. This systematic review aims to provide an overview of the literature regarding the microbiome composition of the healthy vulvar skin and in (pre)malignant vulvar disease. This study was performed according to the PRISMA guidelines. A comprehensive, electronic search strategy was used to identify original research articles (updated September 2021). The inclusion criteria were articles using culture-independent methods for microbiome profiling of the vulvar region. Ten articles were included. The bacterial composition of the vulva consists of several genera including Lactobacillus, Corynebacterium, Staphylococcus and Prevotella, suggesting that the vulvar microbiome composition shows similarities with the corresponding vaginal milieu. However, the vulvar microbiome generally displayed higher diversity with commensals of cutaneous and fecal origin. This is the first systematic review that investigates the relationship between microbiome and vulvar (pre)malignant disease. There are limited data and the level of evidence is low with limitations in study size, population diversity and methodology. Nevertheless, the vulvar microbiome represents a promising field for exploring potential links for disease etiology and targets for therapy.

Insights into the role of vaginal microbiome in women's health

The vaginal microbiome is a complex and dynamic microecosystem that fluctuates continually throughout a woman's life. Lactobacillus, a bacterium that possesses antibacterial properties dominates a healthy vaginal microbiome. Bacterial vaginosis is the most common vaginal disorder that has been linked with the dysbiosis of normal vaginal microbiota. Despite the importance of vaginal microbiome, little is known about functions it performs especially, how it helps in protecting the female reproductive tract. This knowledge gap is a significant impediment to the development of effective and feasible clinical treatments that might be required to improve women's health. Thus, a deeper understanding of the functional aspects and not just the composition of vaginal microbiome may aid in improving the diagnostics and treatment strategies. Recent advancement in molecular methods and computational biology have allowed researchers to acquire more knowledge about the vaginal microbiome. The use of metagenomics (culture-independent high-throughput technology) and bioinformatics tools have improved our understanding of the vaginal microbiome. In this review, we have attempted to explore the factors that may alter normal vaginal microbiota homeostasis such as age, sexual behavior, ethnicity, and hygiene, and so forth. We also discuss the role of probiotics in restoring healthy vaginal microbiome.

Understanding Women's Vaginal Douching Behaviors and Practices for Consideration in the Development of a Potential Future Vaginal Microbicide Douche for HIV Prevention: A Systematic Review of the Literature

Despite clinicians consistently advising against vaginal douching, 29-92% of women worldwide report douching. This review documents women's douching practices, motivations for douching, and specific associations (or absence of associations) between vaginal douche use and vaginal outcomes thought to be associated with douching. Understanding women's existing douching behaviors and vaginal health outcomes is critical for developing a safe vaginal microbicide douche that can be used as HIV pre-exposure prophylaxis (PrEP). A vaginal douche as PrEP could help prevent new HIV infections, since emerging evidence shows some women discontinue oral PrEP. We performed a systematic review of the literature using the guidelines for Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Articles included in the analysis (N = 48) were published 2009-2019 in English and focused on women's experiences with douching. Two trained independent reviewers assessed these articles for content on vaginal douching, including racial/ethnic focus of studies, study design, sampling, women's reasons for douching, contents of douche solutions, and associations between vaginal douching and vaginal health outcomes. Several studies focused on Black women (N = 12 studies) or had no racial/ethnic focus (N = 12). Just over half of all studies (N = 24) were cross-sectional and involved a self-reported questionnaire and lab samples. Studies sampled women from health clinics where they were (N = 13) or were not (N = 14) presenting for vaginal health complaints. Women's primary motivation for douching was for "general cleanliness" (N = 13), and most douche solutions contained water (N = 12). There was little empirical agreement between vaginal douche use and most vaginal health outcomes. Future studies of PrEP vaginal douches should be well controlled and prioritize safety to ensure positive vaginal health outcomes.

The Role of Fatty Acid Metabolites in Vaginal Health and Disease: Application to Candidiasis

Although the vast majority of women encounters at least one vaginal infection during their life, the amount of microbiome-related research performed in this area lags behind compared to alternative niches such as the intestinal tract. As a result, effective means of diagnosis and treatment, especially of recurrent infections, are limited. The role of the metabolome in vaginal health is largely elusive. It has been shown that lactate produced by the numerous lactobacilli present promotes health by limiting the chance of infection. Short chain fatty acids (SCFA) have been mainly linked to dysbiosis, although the causality of this relationship is still under debate. In this review, we aim to bring together information on the role of the vaginal metabolome and microbiome in infections caused by Candida. Vulvovaginal candidiasis affects near to 70% of all women at least once in their life with a significant proportion of women suffering from the recurrent variant. We assess the role of fatty acid metabolites, mainly SCFA and lactate, in onset of infection and virulence of the fungal pathogen. In addition, we pinpoint where lack of research limits our understanding of the molecular processes involved and restricts the possibility of developing novel treatment strategies.

Real-World Practices and Attitudes Towards Intimate Self- Care: Results From An International Women's Survey

OBJECTIVE

Vulvovaginal health is important to women's overall health, fertility, sexuality, self-perception, self-confidence and intimacy. It is important to identify the existing perceptions and levels of knowledge about intimate care practices from women in different countries, and with different cultures, religions, and perspectives to help women overcome barriers to optimal intimate care.

METHODS

An anonymous online survey about general and intimate hygiene routines/habits was distributed across 10 countries (England, France, Germany, Italy, Portugal, Russia, China, Philippines, Taiwan, Thailand). The sample consisted of around 10,000 women (aged 18 to 60 years) recruited through an online panel.

RESULTS

The survey indicates that for many women, cleaning the intimate area is not just about hygiene, but also about taking care of themselves. Intimate care practices, performed daily, varies widely among the countries (from 38% to 91%). Italy, Philippines Portugal, Russia and Thailand were the countries with higher percentage. Intimate care is mainly associated with hygiene and health benefit, but interestingly women engage in intimate care more often with age. Most women worldwide are comfortable talking about female genitalia but still consider it a taboo topic, particularly among younger generations. Asian countries continue to carry negative connotations.

CONCLUSIONS

This survey is the first of its kind for number of women involved in this research and for multi-cultural design. Women perceive that practicing intimate care positively impacts their health and wellbeing. However, intimate care is still not one of the most frequent daily routines for many women.

Healthy, safe and responsible: the modern female traveller

One-half of all travellers are women; yet, there is a distinct lack of detailed travel health knowledge on topics of unique relevance to women. While there is medical advice relating to stages in the female lifecycle, it neglects women-specific practical aspects despite their ability to harm travellers’ health and cause inconvenience. This paper discusses comprehensively three major aspects of travel as they relate to women. First, it suggests the management of personal hygiene, bodily functions, menstruation and sexual behaviour, and alerts to the limited knowledge on travel mental health issues.

Second, apart from travelling in a female body with its specific demands, being a woman requires special attention to safety and security. Within various travel contexts, women have many opportunities for minimising potential risks.

Finally, guided by travel medicine’s acknowledgment of its role in the concept of responsible travel, this article goes beyond the usual general statements and broad advice and offers detailed and practical suggestions on how the female traveller can contribute to the overall goal of minimising any potential harm to fellow humans and the natural environment. Recognising the scarcity of women-specific travel information, pathways to better education, and a range of suggestions for urgent research facilitate the provision of high-quality travel health care tailored specifically to women’s needs.

Inflammation, HIV, and Immune Quiescence: Leveraging on Immunomodulatory Products to Reduce HIV Susceptibility

The relationship between inflammation and HIV has been a focus of research over the last decade. In HIV-infected individuals, increased HIV-associated immune activation significantly correlated to disease progression. While genital inflammation (GI) has been shown to significantly increase the risk of HIV acquisition and transmission, immune correlates for reduced risk remain limited. In certain HIV-exposed seronegative individuals, an immune quiescent phenotype characterized reduced risk. Immune quiescence is defined by specific, targeted, highly regulated immune responses that hinder overt inflammation or immune activation. Targeted management of inflammation, therefore, is a plausible strategy to mitigate HIV risk and slow disease progression. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as hydroxychloroquine and aspirin have shown encouraging preliminary results in low-risk women by reducing systemic and genital immune activation. A topical NSAID, containing ibuprofen, is effective in treating vulvovaginal inflammation. Additionally, the glucocorticoids (GCs), prednisolone, and dexamethasone are used to treat HIV-associated immune activation. Collectively, these data inform on immune-modulating drugs to reduce HIV risk. However, the prolonged use of these pharmaceutical drugs is associated with adverse effects, both systemically and to a lesser extent topically. Natural products with their reduced side effects coupled with anti-inflammatory properties render them viable options. Lactic acid (LA) has immunomodulatory properties. LA regulates the genital microbiome by facilitating the growth of Lactobacillus species, while simultaneously limiting bacterial species that cause microbial dysbiosis and GI. Glycerol monolaurate, besides being anti-inflammatory, also inhibited SIV infections in rhesus macaques. The proposed pharmaceutical and natural products could be used in combination with either antiretrovirals for treatment or preexposure prophylaxis for HIV prevention. This review provides a summary on the associations between inflammation, HIV risk, and disease progression. Furthermore, we use the knowledge from immune quiescence to exploit the use of pharmaceutical and natural products as strategic interventions to manage inflammation, toward mitigating HIV infections.

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.

A 28 Day Clinical Assessment of a Lactic Acid-containing Antimicrobial Intimate Gel Wash Formulation on Skin Tolerance and Impact on the Vulvar Microbiome

While intimate feminine hygiene products are widely used as part of daily cleansing routines, little is known about how these products impact the vulvovaginal area and its microbiome stability. This 4 week clinical study assessed tolerance of a novel gel wash containing lactic acid (pH 4.2) for external daily use when used on the external genital area and its effects on skin moisturization, vulvar skin pH, and the vulvar microbiome. After a 7 day pre-study conditioning period, 36 healthy females in three balanced age groups (18–29, 30–44, and 45–55 years) used the gel wash to cleanse their external genital area (mons pubis and vulva) and entire body at least once per day for 28 days. Skin tolerance of the gel wash was assessed by the gynecologist. Effects of the gel wash on vulvar skin microbiota were studied by performing bacterial 16S rRNA and fungal internal transcribed spacer (ITS) microbial richness and diversity analysis. Based on gynecologic assessment after 28 days of use, the gel wash showed acceptable tolerance, with no signs of increased dryness, redness, edema, itching, stinging, or burning. Use of the gel wash was associated with a significant increase in both short-term (single application) and longer-term (daily use for 28 days) skin moisturization. There was no significant change in vulvar skin pH over time with daily product use, and the gel wash did not significantly affect the natural vulvar microbiome species richness or diversity for bacteria or fungi. Results showed that this gel wash is a mild, moisturizing cleanser that maintains the natural pH and microbial diversity of vulvar skin. To our knowledge, this was the first study to assess the effect of an antimicrobial feminine gel wash on the natural pH and vulvar microbiome habitat of the skin using bacterial 16S rRNA and fungal ITS genetic sequencing techniques.

Evaluation of Vulvovaginitis and Hygiene Habits of Women Attended in Primary Health Care Units of the Family

Background

This study aims to investigate the occurrence of vulvovaginal infections, to describe and to relate the hygiene habits of women who were treated at the Units of Primary Attention to Family Health in a municipality in the interior of Brazil.

Methods

This was a cross-sectional study that was carried out in two Primary Health Care Units of the Family of Uberlândia, Minas Gerais, Brazil. The population sample consisted of 100 women who underwent gynecological consultation in the health units. Data were collected through interviews and by the analysis of medical records. Results were reported according to laboratory reports.

Results

The participants' ages ranged from 18 to 45 years, with a median of 36 years. Thirty women (30%) presented alterations in the microbiota from a Pap smear, where bacterial vaginosis (diagnosed with Amsel criteria) was the predominant microorganism (83.3%). More than half of the women in the study who had vulvovaginitis wore cotton panties (70%, p = 0.651) and tight jeans/pants (83.3%, p = 0.010). The habit of depilating the genital area was reported by all the women, with the razor blade being the most commonly used tool (68%; p = 0.196).

Conclusion

Bacterial vaginosis was the most commonly reported infection in the cytological exams. Care with genitalia and genital hygiene habits may be associated with the occurrence of vulvovaginitis.

High prevalence of cervical high-risk human papillomavirus infection mostly covered by Gardasil-9 prophylactic vaccine in adult women living in N'Djamena, Chad

Background

We conducted in 2018 a descriptive, quantitative, population-based, cross-sectional survey estimating the prevalence of cervical high-risk human papillomavirus (HR-HPV) infection and associated risk factors among adult women living in N’Djamena, Chad.

Methods

Five of the 10 districts of N’Djamena were randomly selected for inclusion. Peer educators contacted adult women in community-churches or women association networks to participate in the survey and come to the clinic for women’s sexual health “La Renaissance Plus”, N’Djamena. Medical, socio-demographical and behavioral informations were collected. HPV DNA was detected and genotyped in endocervical swab using Anyplex II HPV28 genotyping test (Seegene, Seoul, South Korea).

Results

253 women (mean age, 35.0 years; range, 25–65) including 3.5% of HIV-positive women were prospectively enrolled. The prevalence of HPV infection was 22.9%, including 68.9% of HR-HPV infection and 27.6% being infected with multiple genotypes, providing a total HR-HPV prevalence of 15.8% (95% CI%: 11.3–20.3). The most prevalent HR-HPV genotypes were HPV-58, HPV-35, HPV-56, HPV-31, HPV-16, HPV-45, HPV-52 and HPV-18. HPV types targeted by the prophylactic Gardasil-9 vaccine were detected in nearly 70% (67.5%) and HPV-58 was the most frequently detected. HIV infection was a risk factor strongly associated with cervical infection with any HPV [adjusted Odds ratio (aOR): 17.4], multiple types of HPV (aOR: 8.9), HR-HPV (aOR: 13.2) and cervical infection with multiple HR-HPV (aOR: 8.4).

Conclusion

These observations highlight the unsuspected high burden of cervical HR-HPV infection in Chadian women, and point the potential risk of further development of HPV-associated cervical precancerous and neoplastic lesions in a large proportion of women in Chad. The high rate of preventable Gardasil-9 vaccine genotypes constitutes the rationale for introducing primary vaccine prevention against cervical cancer in young female adolescents living in Chad.

Complement Activation During Early Pregnancy and Clinical Predictors of Preterm Birth in African American Women

Complement activation is essential for select physiologic processes during pregnancy; however, excess activation has been associated with an increased risk for preterm birth (PTB). African American (AA) women experience disproportionately higher rates of inflammation-associated PTB than other groups of women; thus, the purpose of this study was to explore the relationship between complement activation and perinatal outcomes among AA women. A plasma sample was collected between 8 and 14 weeks' gestation from a cohort of healthy AA women (N = 144) enrolled in a larger PTB cohort study. Medical record review was conducted to collect information on clinical factors (cervical length, health behaviors, gestational age at delivery). Multiple regression analysis was used to explore the relationships between complement marker (C3a/Bb) concentrations and the outcomes of interest after adjusting for baseline characteristics. C3a/Bb concentrations were not significant predictors of the gestational age at delivery, cervical length, or behavioral risk factors for PTB in this sample. Complement markers may not influence pregnancy outcomes among AA women in the same way as in predominantly white populations; however, more studies are needed to define complement dysregulation and the relationship with outcomes among AA women.