Other Genital Hygiene Practices

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Routine Perineal Cleansing

Perineal hygiene is part of routine bodily cleansing. In America, showers and baths are the norm, with showers being more common. Handheld showerheads are popular in Western Europe but are less popular in America: in a California study, they were used by a one-quarter to one-third of women (52). Sponge baths and the use of handheld showerheads become more prevalent with increasing age, when reduced mobility becomes a factor. The bidet, common in Europe, is used rarely in America (52).

Ethnic differences in genital hygiene may be related to cultural beliefs. For example, studies in the United Kingdom found that immigrants of the Afro-Caribbean descent were more likely than the Caucasian women to wash the vulva with bubble bath or antiseptic (134). This appears consistent with the traditional belief system that rigorous bodily cleanliness is essential to health and well-being (111). However, cleansing with harsh soaps, chemicals, and antiseptics may cause vulvar contact dermatitis (135,136). For example, such practices were reported by 68% of patients with persistent vulvar symptoms (137).

In some parts of the developing world, practices are adapted to the lack of running water. In rural China, for example, mothers teach their daughters to cleanse the genitalia using water from a basin. This is done everyday from an early age, in the evening before going to bed, or before sexual intercourse (122). Washing from a basin, sponge baths, and bathing in rivers and streams are practiced in other regions of the world lacking running water.

Wet Wipes

Wet wipes are gaining popularity in North America and Western Europe. In the California study cited previously, usage rose with age from 26% among women younger than age 41 to 40% among women older than age 48 (52). Such products are often used more than once a day. Baby wipes, premoistened toilet wipes, and feminine wipes are all common choices (Farage and Bramante, unpublished data, 2004). In the late 1980s, reports appeared of allergic contact dermatitis to preservatives in some European wipes (138). The preservative in question (methylchloroisothiazolinone) is now highly regulated. Moreover, quantitative sensitization risk assessments have progressed over the last 20 years, such that it is now possible to safely formulate consumer products containing such preservatives at levels so low that they pose no significant risk of inducing contact sensitization.

Feminine Hygiene Sprays

Scented feminine hygiene sprays were popular in the United States in the 1970s. They fell out of favor as anecdotal reports of inflammatory reactions ensued (139). Clinicians consider deodorant sprays unnecessary and generally recommend against their use (50). However, the sprays continue to appeal to women who have deep-rooted beliefs about the need to avoid odor.


Vaginal douching is the insertion of a device into the vagina for flushing liquid into the vaginal vault. A preponderance of evidence links the practice to serious adverse health effects, with limited evidence of benefits. Nevertheless, douching is a strongly held cultural norm and a difficult habit to change among those who practice it.

Douche preparations: Several types of douche preparations are used. Substances found in the home reportedly used as douches include vinegar and water, household bleach, Lysol® (Reckitt & Coleman, Wayne, NJ), baking soda, yogurt, and water (140). Commercial preparations include solutions of vinegar or other acidifying agents (e.g., sodium citrate, sodium lactate, diazolidi-nyl urea), antiseptics, antibacterial preparations, alcohol, surfactant solutions, and antimicrobials (povidone-iodine).

Prefilled disposable bottles, refillable hanging bags, or refillable expandable bags are employed to irrigate the vagina. Bag-type applicators deliver a significantly greater volume and an eight-fold higher exposure duration than do disposable bottles (141).

Prevalence: Twenty-seven percent of American women douche regularly (Table 5). Among ethnic groups, African American and Latino women are more likely to douche than Caucasians (142) and Afro-Caribbean immigrants to the United Kingdom are more likely to douche than Caucasian British women (134). Douching is also commonly practiced in Africa: 29% of South African women (143) and 97% of pregnant women in the Cote d'lvoire (144) reported douching. Douching with a variety of substances (soap and water, shampoos, toothpaste, and commercial antiseptics) is a routine practice among sex workers in developing countries (145,146).

In the United States, douching is more prevalent among women who are less educated, living in poverty, or who have a higher risk of sexually transmitted infections (141,142,147). One survey found douching to be least frequent among adolescents aged 15 to 19 (16%) and most common among women aged 20 to 24 (28%) (142). A California survey among middle class white women found a higher prevalence of douching by those older than age 41 (27% to 30%)

Table 5 Percentage of North American Women Who Douche Regularly by Age and Ethnicity (U.S. National Survey of Family Growth, 1995)

Age range











































Source: From Ref. 142.

Source: From Ref. 142.

compared to those younger than age 41 (19%) (52). The frequency of douching among the U.S. women ranges from daily to monthly.

Motivating factors: Women who douche do so primarily to feel clean and they consider douching to be a sound hygienic practice (147-149). Among African American women, douching is often initiated on the advice of the mother, family, or friends; Caucasian American women are more influenced by the media (150). The majority of practitioners begin douching at menarche.

The importance of feminine cleanliness is paramount among women who douche. It is a principal motivating factor among African Americans who favor this practice (148,150). This may be related to traditional belief systems, which maintain that cleanliness contributes to health and that the body should be kept clean inside and out (111). Women also douche to avoid odor and to be clean after menstruation and sexual activity; hence in both Europe and North America, early onset of douching is more prevalent among those who initiate sexual activity at an earlier age (151,152).

Strongly held cultural beliefs and the perceived lack of suitable alternatives make it difficult for women to give up douching (150). Warnings that douching may be harmful are not highly persuasive; women reason that commercial douche preparations would not be widely available if they were unsafe. Among African American women who douche, health-care providers are not viewed as credible sources of information when their advice conflicts with trusted sources such as family members (111,150). Caucasian women who douche are somewhat more likely to consider douching unhealthy and may be more readily influenced by health-care providers to give up the practice (149).

Health implications: Epidemiologically, douching is associated with an increased risk of bacterial vaginosis (BV), pelvic inflammatory disease (PID), ectopic pregnancy, preterm births, STDs, and cervical cancer (140). Potential confounding factors cloud the epidemiologic assessment of the health risks, making it difficult to assess whether douching is a causative factor or simply a more common behavior among demographic groups at risk for such health conditions (Table 6). The strength of the association varies widely among case-control studies; few prospective studies are available.

In laboratory studies, douching preparations were antimicrobial to vaginal organisms (153). Depending on their composition and antimicrobial properties, these preparations caused either a transient washout effect in the vagina or a decrease in the density of vaginal microbes beyond the washout effect (154). Microbial counts eventually recovered (155).

BV is associated with an anaerobic shift in the vaginal microbial ecology that causes a fishy, malodorous discharge. Several studies have demonstrated an increased risk of BV among women who douche. For example, African American and Afro-Caribbean women, groups who douche more often than Caucasians, also have a higher risk for BV (134,156). It is unclear whether the statistical link to douching reflects the fact that women with malodorous

Table 6 Health Conditions Epidemiological^ Associated with Douching

Health condition

Hypotheses supporting a causative role for douching

Potential confounding factors


Ectopic pregnancy

Preterm births

Douching temporarily alters the microbial ecology of the vagina, which may facilitate disease acquisition

Douching temporarily alters the microbial ecology of the vagina, which may facilitate disease acquisition Douching with irritating substances may make the vaginal mucosa and cervix more susceptible to colonization by invading pathogens The physical pressure of douching may facilitate uterine colonization by ascending pathogens The risk of PID is linked to douching frequency Douching may promote upper and lower genital tract infections that increase the risk of ectopic pregnancy

Douching may play a role in infection-related preterm births

Cervical cancer Sexually transmitted infection with HPV is a risk factor for cervical cancer Cancer risk rises with douching frequency

Women may douche in response to BV symptoms Women who douche share risk factors with women at risk for BV and sexually transmitted diseases Women douche to feel clean after sexual intercourse Douching is more prevalent among sexually active women Women who douche share demographic characteristics with women at risk for STDs Women may douche in response to symptoms of infection Early sexual debut, having multiple sex partners, exposure to STDs, and other demographic risk factors for PID are also common to women who douche Ectopic pregnancy is more common in women with a history of PID. Such women share common risk factors with women who douche Preterm birth and douching are more prevalent among certain demographic groups Risk factors for STDs are shared by women who douche

Abbreviations'. BV, bacterial vaginosis; HPV, human papilloma virus; PID, pelvic inflammatory disease; STDs, sexually transmitted diseases.

discharge are more likely to douche, or whether alterations in the vaginal flora caused by douching predispose women to acquiring BV. Douching is more common during menstruation and after intercourse, a time of instability in some vaginal microbial populations (157,158). In one study, douching after menstruation was the strongest predictor of BV (158). Others found that douching with commercial antiseptics was strongly associated with BV risk (134) and that the acquisition of BV was linked having a new sexual partner and douching for hygiene (159). Such findings support the theory that douching may alter the protective balance of vaginal flora and contribute to the acquisition of BV.

PID is a polymicrobial infection of the upper urogenital tract initiated by ascending pathogens. BV, non-Caucasian race, low socioeconomic status, multiple sexual partners, and exposure to sexually transmitted organisms, the major risk factors for PID, are also common in women who douche. A meta-analysis of research published between 1965 and 1995 concluded that douching increases the risk of PID by 73% and the risk of ectopic pregnancy by 76% (134). Although women who douche and women at risk for PID share many of the same characteristics, douching serves as a pressurized vehicle for ascending microbes, which may facilitate the acquisition of PID. PID is also a risk factor for ectopic pregnancy, which may explain the statistical link of the latter to douching.

Douching is more prevalent among women at risk for STDs and HIV. In a study of racial and ethnic differences in vaginal flora, douching more than once a month was associated with the vaginal colonization by sexually transmitted microbes, although the latter was associated more consistently with race than with behavioral factors (156). Most studies indicate a statistical association of douching with STDs and HIV infection; however, a few studies in developing countries among women at high risk for STDs suggest that the practice lowers the risk of HIV infection (160) and human papilloma virus (HPV) regression (161) in such populations.

Based on the weight of the evidence, the consensus remains that douching is unnecessary for genital hygiene and may have serious adverse consequences on reproductive health. Nevertheless, few professional organizations have explicit policies on the health consequences of douching. This may be due to the difficulty in drawing firm conclusions about causation from cross-sectional epidemiologic studies. A randomized controlled trial of douching intervention (B-WELL trial) will evaluate the efficacy of intervention in changing adolescent douching behavior (162). Successful intervention strategies may ultimately provide a tool for prospectively assessing the risks and benefits of vaginal douching.

Perineal Powders

In the United States, some women customarily apply talc powders to the perineum on a daily basis. Such women are more likely to be overweight and to douche, smoke, and drink alcohol (163). The average duration of exposure can exceed 20 years (164).

Since 1979, numerous retrospective epidemiological studies have linked perineal talc exposure to ovarian cancer. The increased risk is highest for invasive forms of the disease. Some studies among women who use perineal powders suggested that tubal ligation was protective (164,165).

The statistical link between perineal talc application and ovarian cancer is highly controversial because of weak odds ratios, the absence of a clear dose-response relationship, and the lack of a robust mechanistic hypothesis to explain how talc exposure may cause or promote ovarian cancer.

A 2003 meta-analysis of 16 studies with an aggregate of 11,933 subjects found a 33% increased risk of ovarian cancer in perineal talc users but no clear dose-response relationship (166). Conversely, analysis of a subset of hospital studies showed no relationship to talc use, suggesting that a spurious statistical association may account for population-based data.

These studies were all retrospective. By contrast, a long-term prospective study of 121,700 nurses found no overall association between perineal talc powder and ovarian cancer (167). There was a moderately increased association for invasive forms of the disease. The risk of epithelial ovarian cancer among talc users was no higher among women who had not had a tubal ligation.

Hence, the weight of the evidence among retrospective case-control studies, coupled with the results of the large, prospective study involving nurses, suggests that the statistical association between perineal talc exposure and ovarian cancer risk may be the result of selection bias or other confounding factors. Body mass index may be one such factor, as overweight women are more likely to use perineal powders and are at higher risk for ovarian cancer (168). Uncontrolled socioeconomic variables may also play a role in the observed association.

Hair Removal

In the West, pubic hair removal is practiced for esthetic reasons. Common methods include shaving, the use of chemical depilatories, wax epilation, electrolysis, and laser hair removal. All methods tend to cause occasional mild folliculitis. Rare instances of severe cases progressing to keloid scars have been reported on the legs (169). In the late 1990s, an epidemic of allergic contact dermatitis to colophonium in epilating wax occurred in Europe (170). Occupational allergy to colophonium was also reported in a beautician who handled epilating waxes (171).

Pubic hair removal is performed in some countries. In response to a survey of 635 Turkish women, 98% reported pubic hair removal on a regular basis (once a week, every few weeks, or once a month) (Farage, Unpublished data, 2000). Hair removal is performed before or after the menstrual period, either with a lemon-sugar paste or by shaving. Those who shaved reported a higher frequency of skin irritation than those who used a lemon-sugar paste.

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