Douching: Perceived Benefits But Real Hazards

W. Steven Pray; Joshua J. Prey

Disclosures

US Pharmacist. 2004;29(1) 

Introduction

The risks and benefits of vaginal douching have seldom been clearly explained to the American female. As a result, many women rely on folk wisdom or their mother's advice for douching. Although there are perceived benefits to douching, there is growing evidence that any potential health benefit may be outweighed by risks to the patient.[1,2]

The prevalence of douching varies depending on numerous factors, such as country surveyed, age group, and racial origin. Investigators surveyed 169 adolescent females attending a public family planning clinic in a small southern city in the United States. Their average age was 17 years; 53% were white, and 47% were black.[3] Sixty-nine percent reported douching. In another study of college students in the southern U.S., 40% reported douching.[4] Thus, a significant number of patients who visit the pharmacy douche.

Several surveys have explored the variables associated with douching. Numerous research studies confirm that women of African-American ancestry douche more than others.[4,5,6] Being sexually active is also positively correlated with douching.[3] Further, the age at which douching is initiated is positively correlated with the age of initiation of sexual activity.[3,4,6] Surveys of adolescents and adults who douche reveal that women are more likely to douche if they have a history of one or more sexually transmitted diseases (STDs), including HIV and herpes simplex type 2 infection.[3,6,7,8] The surveys also show that douching is more common in those who did not finish or completed only high school.[6,9] A survey of 125 white and 155 black university women found douching to be correlated with using oral contraceptives or spermicides and to encouragement from their mothers to douche.[4]

One overriding question is why women douche. Justifications vary by racial background. Among black women, the practice is most often encouraged by their mothers.[4] For white women, the primary motivators are television advertisements.[4]

When women who douche are surveyed specifically about their reasons for doing so, a persistent belief emerges. Respondents have the false perception that douching promotes cleanliness, perhaps through removal of harmful organisms. This belief may have been communicated by their mothers or the media, or they may have arrived at it independently. In a survey of adolescents, most who douched reported doing so for hygienic reasons.[3] A survey of black and white women revealed that 65% douched because they thought it was a good hygienic practice.[9] A survey of women attending primary care clinics demonstrated that 22% believed that douching kills germs that cause infections.[10] Some women also believe that douching postcoitally helps prevent STDs.[11] In one study, women who douche were found to harbor deeply rooted beliefs that douching promotes cleanliness.[12] Further, most started at a young age; family, friends, and various media sources reinforced its value. The investigators concluded that douching behavior would be very difficult to change; doing so would require changing women's basic beliefs and countering massive media marketing campaigns.

Surveys seldom ask respondents to identify those who recommend against douching. In one, however, women responded that the physician was the substantial source who discouraged douching.[9] Further, women who received advice from a health care advisor not to douche often discontinued the practice.

Older women and better-educated women are less likely to believe that douching prevents infections and pregnancies and are less likely to engage in the practice for those reasons.[9]

(Douching may actually confer health benefits in some instances. In a study of women with cervical cancer in Mali, investigators determined that never having douched increased the risk.[13] The study awaits replication to ensure that the association is not a statistical anomaly.

Vaginal Infection. For women of childbearing age, bacterial vaginosis is the primary etiology of vaginal infection.[14] In bacterial vaginosis, normal vaginal microflora is disrupted, facilitating overgrowth of anaerobes such as Gardnerella vaginalis, Prevotella species, or Mycoplasma hominis.[14] Fully 50% of patients are asymptomatic, although others notice a thin, white, homogeneous discharge that has a "fishy" odor.[14] Douching is a risk factor for bacterial vaginosis. In a study of 496 nonpregnant women, risk factors identified for bacterial vaginosis included vaginal douching within the last two months and hormone use within the past six months.[15] Any maternal infection, especially bacterial vaginosis, may impede successful pregnancy.[16] Investigators conducted a study of 454 pregnant women, discovering risk factors for bacterial vaginosis such as douching and number of lifetime sexual partners.[16] The risk of bacterial vaginosis is highest within the first seven days after douching.[17] Bacterial vaginosis also increases the risk of HIV infection, a possible reason for the association between douching and HIV infection.[18,19]

The potential for vaginal infection from douching is not limited to bacterial organisms. A study from Italy demonstrated that douching increases the risk of vulvovaginal candidiasis.[20]

Preterm Delivery. Douching is suspected to be a risk factor for preterm delivery (i.e., 20 to 36 weeks' gestation). In one study, investigators examined 262 women in a managed care organization who had experienced preterm delivery. Douching during pregnancy was found to have increased the overall risk of preterm delivery by a factor of 1.9.[21] Researchers have suggested that bacterial vaginosis induced by douching increases the risk of infection of the upper genital tract, which, in turn, increases the risk of preterm delivery.[14] Another hypothesizes that the patient had a preexisting vaginal infection, and douching simply facilitated entry of organisms into the upper genital tract. In this scenario, the result is chronic uterine bacterial colonization, with resultant triggering of the inflammatory response and subsequent stimulation of the environment to cause preterm delivery.

Pelvic Inflammatory Disease. Douching may also be a risk factor for pelvic inflammatory disease (PID). It may be through the propensity of douching to cause bacterial vaginosis, which increases the risk of PID.[22] Further, among women who douche and have PID, there is an increased risk of endometriosis and upper genital tract infection.[23] A recent study challenged the association between douching and PID. Investigators studied 1,827 women ages 18 to 34 who were regular users of a douche product; there was little to no association between PID and douching.[24]

False Beliefs Regarding Pregnancy Prevention. As many as 27% of women may be misled into believing that postcoital douching will help prevent pregnancy by washing sperm from the vagina.[10] This misperception may give the patient a false sense of security about the value of douching, as opposed to more effective birth control methods (e.g., oral contraceptives, condoms, the female intravaginal condom). Douching has never been found effective as a pregnancy preventive. In fact, the pressure of the douche may actually force ejaculate into the cervix, enhancing the risk of pregnancy.

Nonprescription Douche Products. At one time, there were three major lines of douche products in the typical pharmacy. The Betadine product line has been reduced with the elimination of Betadine concentrate. This leaves the Massengill and Summer's Eve disposable douche products. An examination of their ingredients allows the pharmacist to understand their intent. Some douche products (e.g., Summer's Eve Fresh Scent) contain mainly fragrance in water. Lacking a surfactant, they are intended only to leave a pleasant smell. Given the adverse effects of douching, their use is questionable. Other douches (e.g., Summer's Eve Island Splash, Intimate Whisper, or Evening Breeze) contain octoxynol-9, a surfactant that may cleanse by lowering the surface tension of the intravaginal vault. Some products (e.g., Country Flowers, Fresh Baby Powder) contain octoxynol-9 and cetyl pyridinium chloride, another surfactant. The user must be made aware of the potential risks in using these products so she can weigh their purported benefits with actual dangers. Another set of douche products contains vinegar (e.g., Summer's Eve Vinegar and Water, Massengill Extra Mild Vinegar and Water, Massengill Extra Cleaning Vinegar and Water). Vinegar/water douches have been used for decades to restore the vagina to its healthy acidic pH. However, their safety and efficacy are unknown. Further, if the woman has an actual vaginal infection, a vinegar/water douche will be ineffective in combating it. Instead, she should be urged to purchase a vaginal antifungal if the infection is thought to be due to Candida. Otherwise, a physician appointment is necessary.

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