Douching linked to vaginal infection
Your next patient, a 19-year-old woman who is sexually active, says she douches on a weekly basis for hygiene purposes. She has been previously treated for a sexually transmitted disease (STD). What should you tell her?
Share the results of a just-released study: Women who douche at least once a month have higher rates of bacterial vaginosis (BV) infections than do women who don’t douche.1
Bacterial vaginosis is the most common vaginal infection in women of childbearing age, according to the Atlanta-based Centers for Disease Control and Prevention. About half of women with BV may be asymptomatic; those who do have symptoms may notice a fish-like odor or a thin white or gray vaginal discharge.2 Since bacterial vaginosis has been linked to acquisition of HIV, preterm birth, and pelvic inflammatory disease (PID),3-7 the new research adds to growing concerns about the adverse health effects from douching. (Review BV screening and treatment information in the Contraceptive Technology Update March 2002 article, "New guidelines are up for bacterial vaginosis," p. 31.)
To date, there has been no prospective data linking BV to douching, notes Roberta Ness, MD, MPH, associate professor of epidemiology, medicine and OB/GYN at the University of Pittsburgh, lead author of the new paper. The just-published information, however, is baseline data from a prospective cohort study on douching, BV, and incident PID; researchers will be publishing the prospective data in about a year, she reports.
Douching may disrupt the normal vaginal microbiology and lead to vulnerability to BV, concludes the new report.
Researchers studied 1,200 women at high risk for STDs at five clinical sites around the United States. They found that of the approximately 40% of women who reported douching regularly for hygiene reasons or to treat bothersome vaginal symptoms, two out of every five women had BV. The women with BV were much more likely to lack hydrogen peroxide (H2O2)+ lactobacilli, a specific kind of naturally occurring bacteria necessary to fight off BV-causing bacteria.
In the 1995 National Survey of Family Growth, regular douching was reported by 15.5% of adolescent girls and young women ages 15-19, and by 28% of those ages 20 to 24 years.8 In the 1995 report, regular douching was reported by 37% of African-American and 11% of white 15- to 19-year-old females; for those ages 20-24, 60% of African-Americans reported regular douching, while 20% of whites noted similar practices.
Women may believe that douching is good hygiene, similar to brushing their teeth, suggests David Soper, MD, vice chairman of business and clinical affairs and director of the division of gynecology at the Charleston-based Medical University of South Carolina. Some women may practice douching as a response to vaginal odor, and some are taught to douche by their mother or grandmother.
Douching is a cultural hygiene habit passed down through the generations, agrees Ness.
"It is not clear how hard it will be to get women to stop," she observes. "However, we have another publication coming out soon which suggests that health provider advice to stop may be important."
What can you do?
Here are some counseling tips you can use in talking with women about douching:
Emphasize the need to maintain normal vaginal flora as a way of maintaining vaginal health, says Soper. Because routine douching changes the delicate chemical balance in the vagina, it can make a woman more susceptible to bacterial infections and introduce new bacteria into the vagina and cervix.
Soper suggests contrasting the vagina with the mouth: The mouth with its teeth needs brushing, while the vagina is cleaner and doesn’t need similar hygiene techniques.
Some women believe that menstrual blood is "dirty," says Soper. Explain to them that menstruation is a normal process, and they do not need to be "cleansed" by douching.
Because the chemical balance of the vagina is very sensitive, direct women to let the vagina clean itself, according to information from the Washington, DC-based National Women’s Health Information Center (NWHIC).9 Warm water and gentle, unscented soap during the bath or shower is the best way to clean the sensitive outside areas of the vagina; products such as feminine hygiene soaps, powders, and sprays are not necessary, according to the NWHIC.
Remind women to return to your office if they experience symptoms such as vaginal pain, itching, burning, pain when urinating, or a vaginal discharge that is different from normal. Such symptoms may indicate a yeast infection, urinary tract infection, or bacterial infection that can be treated with medication.9
References
1. Ness RB, Hillier SL, Richter HE, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002; 100:765-772.
2. Secor RM. Bacterial vaginosis: Common, subtle, and more serious than ever. Clinician Reviews 2001; 11:59-68.
3. LaRuche G, Messou N, Ali-Napo L, et al. Vaginal douching: Association with lower-genital tract infections in African pregnant women. Sex Transm Dis 1999; 26:191-196.
4. Zhang J, Thomas G, Leybovich E. Vaginal douching and adverse health effects: A meta-analysis. Am J Public Health 1997; 87:1,207-1,211.
5. Stergachis A, Scholes D, Heidrich FE, et al. Selective screening for Chlamydia trachomatis infection in a primary care population of women. Am J Epidemiol 1993; 138:143-153.
6. Ness RB, Soper DE, Holley RL, et al. Douching and endometritis: Results from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis 2001; 28:240-245.
7. Gresenguet G, Kreiss JK, Chapko MK, et al. HIV infection and vaginal douching in central Africa. AIDS 1997; 11:101-106.
8. Abma J, Chandra A, Mosher W, et al. Fertility, Family Planning and Women’s Health: New Data From the 1995 National Survey of Family Growth. Hyattsville, MD: National Center for Health Statistics; 1997. Vital Health and Statistics No. 23.
9. National Women’s Health Information Center. Douching. Accessed at: www.4woman.gov/faq/douching.htm.
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For information on the Access and Resources in Contraceptive Health (ARCH) Foundation, contact ARCH Foundation, P.O. Box 220908, Charlotte, NC 28222-0908. Telephone: (877) 393-9071. Fax: (704) 357-0036. Web: www.archfoundation.com.
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