Post-coital vaginal douching is risky for non-regression of low-grade squamous intraepithelial lesion of the cervix

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 association between douching, genital talc use, and the risk of prevalent and incident cervical cancer

While human papillomavirus is the primary cause of cervical cancer, other factors may influence susceptibility and response to the virus. Candidates include douching and talcum powder applied in the genital area. We used Cox proportional hazards models to estimate confounder-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) in the Sister Study (2003-2009), a US cohort of women aged 35-74. We considered pre-baseline (n = 523) and incident (n = 31) cervical cancers. Douching at ages 10-13 was positively associated with pre-baseline cervical cancer (HR 1.32, 95% CI 0.86-2.03), though the association was not statistically significant. We did not observe an association between adolescent talc use and pre-baseline cervical cancer (HR 0.95, 95% CI 0.76-1.19). Douching in the year before enrollment was positively associated with incident cervical cancer (HR 2.56, 95% CI 1.10-5.99). The association between recent genital talc use and incident cervical cancer was positive, but not statistically significant (HR 1.79, 95% CI 0.78-4.11). The observed positive association between douching and incident cervical cancer is consistent with previous retrospective case-control studies. In the first study to examine genital talc use and cervical cancer, we did not see evidence of an association.

Vaginal douching in Zambia: a risk or benefit to women in the fight against cervical cancer: a retrospective cohort study

Background

Cervical cancer was the most commonly diagnosed cancer and the leading cause of cancer related deaths in 2013 among women in Zambia. We determined factors associated with vaginal douching with any solution other than water and examined its role as a risk factor for abnormal cervical lesions among Zambian women.

Methods

We conducted a retrospective cohort study using data from the Cervical Cancer Prevention Program in Zambia among 11,853 women (15 years or older) who had screened for cervical cancer from 6 provinces of Zambia. Stata version 15 was used to analyze the data. Investigator led stepwise logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals for various characteristics, with vaginal douching with any solution as primary outcome and abnormal cervical lesions as secondary outcome.

Results

Douching with any solution other than water was practiced by 8.1% (n = 960) of the study participants. Older women (35–44 and 45 years or older) vs young women (15–24 years old) were less likely to douche with a solution (AOR 0.74; 95% CI: 0.57–0.97, p = 0.027 and AOR 0.65; 95% CI: 0.49–0.87, P = 0.004), respectively, and so were women in informal employment compared to housewives (AOR 0.72; 95% CI: 0.58–0.89, p = 0.002). Odds of douching were higher among women with secondary vs. no formal education (AOR 1.64; 95% CI: 1.15–2.35, P = 0.007), and among women who used condoms sometimes compared to those who never with their regular sexual partners (AOR 1.19; 95% CI: 1.01–1.40, PP = 0.037). About 12.2% of study participants had abnormal cervical lesions. The use of either vinegar, ginger, lemon, salt or sugar solution was associated with increased risk of abnormal cervical lesions (AOR 7.37; 95% CI: 1.43–38.00, p = 0.017) compared to using water.

Conclusion

We find an association between douching with a solution and a woman’s age, educational attainment, occupation and condom use. Vaginal douching with either vinegar, ginger, lemon, salt or sugar solution was associated with increased risk for abnormal cervical lesions. We recommend further research on ever vs never douching and the risk for abnormal cervical lesions.

Intravaginal practices and genital human papillomavirus infection among female sex workers in Cambodia

OBJECTIVES

Intravaginal practices (IVPs) include washing, wiping, or inserting something inside the vagina. This study investigates the associations between IVPs and genital human papillomavirus (HPV) infection.

METHODS

We conducted a cross-sectional study of 200 female sex workers aged 18 to 35 years in Phnom Penh, Cambodia. From August to September 2014. Data on sociodemographic characteristics, IVPs, and other behaviors were collected through face-to-face interviews. Self-collected cervicovaginal specimens were tested for 37 HPV genotypes.

RESULTS

Multivariable Poisson regression models showed that a lower number of infecting HPV genotypes were associated with intravaginal washing in the past 3 months (incident rate ratios [IRR] = 0.65, 95% confidence interval [CI]: 0.46-0.94) and often performing intravaginal washing shortly after sex (IRR = 0.89, 95% CI: 0.81-0.99). Intravaginal washing before vaginal sex, intravaginal wiping, and intravaginal insertion were not associated with HPV infection.

CONCLUSION

These findings challenge the existing view that all types of vaginal cleansing are harmful. Specifically, intravaginal washing shortly after sex (mainly with water) may help prevent HPV infection in female sex workers, who have several partners and thus frequently expose to sources of HPV infection with different genotypes.

A bio-behavioral intervention to decrease intravaginal practices and bacterial vaginosis among HIV infected Zambian women, a randomized pilot study

BACKGROUND

Intravaginal practices (IVP) (cleansing or introducing products inside the vagina for hygiene, health or to please sexual partners) are common among women with HIV. IVP increase the risk of developing bacterial Vaginosis (BV), the most common genital infection associated with transmission of sexually transmitted infections and HIV. This study tested a pilot intervention to reduce IVP and BV in HIV infected women in Zambia.

METHODS

One hundred twenty-eight HIV infected women engaging in IVP were randomized to two conditions: enhanced standard of care (n = 70) and experimental (n = 58) from May 1, 2013 to February 28, 2014. All participants received a brief educational counseling session on discontinuation of IVP, and those with BV, were provided with medical treatment for BV. Women in the experimental condition received an additional group-based, culturally tailored intervention. Participants completed questionnaires assessing sexual risk factors and IVP and were assessed for BV using Nugent criteria at baseline, 6 months and 12 months.

RESULTS

At 12-month, the proportion of self-reported use of IVPs decreased in the experimental condition: soap (28% vs. 47%); cloth or a rag (19% vs. 38%); and traditional medicines (22% vs. 42%) (all p < 0.05)) compared with the enhanced standard of care condition. The prevalence of BV at 6 and 12 months did not differ by study condition but averaging over study condition, prevalence of BV decreased from 64.2% at baseline to 15.6% at 6 months (p < 0.01) and to 23.6% at 12 months (p = 0.15). Using an enhanced standard of care approach and an enhanced standard of care + a group intervention, IVP and BV decreased over time, but the experimental condition had greater reduction in self-reported use of IVP.

CONCLUSIONS

Future studies should address interventions in communities with high burden of IVP, BV and HIV. Interventions that could be administered during routine medical care and decrease IVP and BV are needed, and should be considered part of women's health programs.

TRIAL REGISTRATION NUMBER

NCT03134924 (retrospectively registered 21st April 2017).

Intravaginal Practices in Female Sex Workers in Cambodia: A Qualitative Study

Intravaginal practices (IVPs) are associated with several adverse health outcomes, including HIV infection. However, few studies have examined this topic in Asian cultures, particularly in female sex workers (FSWs). This theory-based qualitative study aimed to describe the IVPs and to identify salient determinants of these practices in FSWs in Phnom Penh, Cambodia. We conducted in-depth interviews using open-ended questions with 30 FSWs in July-August 2014. We analyzed data using thematic content analysis, with thematic codes based on the constructs of the theory of planned behavior. The results showed that the most common IVP was a combination of intravaginal washing and wiping, to which we refer as intravaginal cleansing. There was a clear and close connection between IVP and sex work. Perceived benefits of intravaginal cleansing were numerous, while the perceived risks were few. As a result, the attitude toward intravaginal cleansing was favorable. A common misperception of benefit was that intravaginal cleansing could prevent sexually transmitted infections. Local physicians considerably influenced the subjective norm related to IVP. Intention to quit IVPs was suboptimal. In conclusion, the psychological factors associated with IVPs in FSWs were somewhat different from those in the general population of Cambodian women and women in other countries. Behavioral beliefs, attitude, and subjective norms appeared salient and important factors in IVPs. Interventions aimed at reducing IVPs should target these constructs as well as the sex-work-associated economic motives. Local physicians may be an agent to change IVP and an effective channel to deliver interventions.

Douching practices among female sex workers in Phnom Penh, Cambodia

Several studies indicate that douching has few benefits but numerous adverse health outcomes, including increased risk for sexually transmitted infections and HIV. No published study explores douching practices among Cambodian female sex workers. This report provides preliminary data about the prevalence and frequency of douching among female sex workers in Phnom Penh, Cambodia. Survey data were obtained from 81 female sex workers who were taken into custody due to engagement in commercial sex from March to June 2011. Results showed that 91% of participants douched. The mean numbers of times douched before sex and after sex per 10 sex episodes were 4.43 (SD = 3.87) and 4.63 (SD = 3.94), respectively. Half of the participants thought that douching could help to prevent sexually transmitted infections including HIV; 24% were unsure about this. Usually, douching after sex was associated with ever obtaining an HIV test (p = .012) and was marginally associated (although not statistically significant) with a higher average number of clients per week (p =. 063) and consistent condom use with clients (p = .053). This suggests that these practices may be related to individual perceptions of sexually transmitted infections/HIV risk or susceptibility. Given the commonness of douching and related misperceptions among Cambodian female sex workers, future studies and interventions are needed to prevent adverse health problems.

Cervicovaginal secretions protect from human papillomavirus infection: effects of vaginal douching

OBJECTIVE

Cervicovaginal secretions (CVSs) are reported to protect against human papillomavirus (HPV) infection. Although vaginal douching is known to clear both viral inoculants and CVSs, its effect on CVSs in women with HPV infection is unknown.

MATERIALS AND METHODS

The in vitro HPV pseudovirus infection system was used to test the protective activity of CVSs against HPV infection in samples collected before and after vaginal douching. To simulate different time points of vaginal douching in relation to viral exposure, the cell CVS reconstitute was washed after different viral exposure durations.

RESULTS

In the CVSs of premenopausal and postmenopausal women who did not perform douching, the CVSs inhibited HPV infection by 56.7 ± 1.8% and 53.6 ± 2.5%, respectively; in women who had performed douching, the CVSs inhibited HPV infection by only 31.2 ± 7.1%, which was significantly lower (p < 0.01). Cell washing effectively cleared 60-90% of the infectious load with the greatest activity occurring within 30 minutes after inoculation. In the presence of CVSs, a sustained inhibition of HPV infection existed for up to 8 hours after HPV exposure, and cell washing increased the clearance to up to 82-93% of the infectious load.

CONCLUSION

This study confirms the protective activity of CVSs against HPV infection regardless of age. In this in vitro study, the net effect of douching was found to be beneficial.

Examining targets for HIV prevention: intravaginal practices in Urban Lusaka, Zambia

Intravaginal practices (IVP) are the introduction of products inside the vagina for hygienic, health, or sexuality reasons. The influence of men and Alengizis, traditional marriage counselors for girls, in promoting IVP has not been explored. We conducted gender-concordant focus groups and key informant interviews with Alengizis. The responses were conducted grouped into three themes: (1) cultural norms, (2) types and reasons for IVP, and (3) health consequences. We found that IVP were used by all participants in our sample and were taught from generation to generation by friends, relatives, or Alengizis. The reasons for women to engage in IVP were hygienic, though men expect women to engage in IVP to enhance sexual pleasure. Approximately 40% of women are aware that IVP can facilitate genital infections, but felt they would not feel clean discontinuing IVP. All men were unaware of the vaginal damage caused by IVP, and were concerned about the loss of sexual pleasure if women discontinued IVP. Despite the health risks of IVP, IVP continue to be widespread in Zambia and an integral component of hygiene and sexuality. The frequency of IVP mandates exploration into methods to decrease or ameliorate their use as an essential component of HIV prevention.

Effects of feminine hygiene products on the vaginal mucosal biome

Background

Over-the-counter (OTC) feminine hygiene products come with little warning about possible side effects. This study evaluates in-vitro their effects on Lactobacillus crispatus, which is dominant in the normal vaginal microbiota and helps maintain a healthy mucosal barrier essential for normal reproductive function and prevention of sexually transmitted infections and gynecologic cancer.

Methods

A feminine moisturizer (Vagisil), personal lubricant, and douche were purchased OTC. A topical spermicide (nonoxynol-9) known to alter the vaginal immune barrier was used as a control. L. crispatus was incubated with each product for 2 and 24h and then seeded on agar for colony forming units (CFU). Human vaginal epithelial cells were exposed to products in the presence or absence of L. crispatus for 24h, followed by epithelium-associated CFU enumeration. Interleukin-8 was immunoassayed and ANOVA was used for statistical evaluation.

Results

Nonoxynol-9 and Vagisil suppressed Lactobacillus growth at 2h and killed all bacteria at 24h. The lubricant decreased bacterial growth insignificantly at 2h but killed all at 24h. The douche did not have a significant effect. At full strength, all products suppressed epithelial viability and all, except the douche, suppressed epithelial-associated CFU. When applied at non-toxic dose in the absence of bacteria, the douche and moisturizer induced an increase of IL-8, suggesting a potential to initiate inflammatory reaction. In the presence of L. crispatus, the proinflammatory effects of the douche and moisturizer were countered, and IL-8 production was inhibited in the presence of the other products.

Conclusion

Some OTC vaginal products may be harmful to L. crispatus and alter the vaginal immune environment. Illustrated through these results, L. crispatus is essential in the preservation of the function of vaginal epithelial cells in the presence of some feminine hygiene products. More research should be invested toward these products before they are placed on the market.