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Intimate hygiene practices and reproductive tract infections: A systematic review
  1. Alaa Dahera,1 (ad109{at}aub.edu.lb),
  2. Obey Albainib,1 (obeyalbaini{at}gmail.com),
  3. Lauren Siffc (lauren.siff{at}vcuhealth.org),
  4. Stephanie Farahb (stephanie.faresfarah{at}lau.edu) and
  5. Karl Jalladd,*
  1. aDepartment of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
  2. bDepartment of Clinical Research, Lebanese American University Medical Center, Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon
  3. cVirginia Commonwealth University School of Medicine, Virginia, USA
  4. dLebanese American University Medical Center, Gilbert and Rose-Marie Chagoury School of Medicine, Beirut, Lebanon
  1. ↵*Corresponding author. Lebanese American University Medical Center, Zahar Street, Achrafieh, Beirut, P.O. Box: 11-3288, Lebanon. karljallad{at}gmail.com

Abstract

Introduction Worldwide, women perform a variety of vaginal practices to enhance their intimate hygiene and sexual health.

Objective To conduct a systematic review to assess the different kinds of intimate hygiene practices and their association with reproductive tract infections and complications.

Methods PubMed, Medline and The Cochrane Library were used. Both observational and interventional studies targeting the urogenital infections and their association with hygiene practices were included. Exclusion criteria included studies that assessed the knowledge and attitudes towards intimate hygiene practices rather than their relation to infections. The design of this systematic review complied with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).

Results Fifteen articles were included. Intravaginal practices were found to be associated with reproductive tract infections. Reusable absorbent material used during menstruation increased the risk of Candida infection with an adjusted proportional reported ratio (aPRR) of 1.54 (95% CI 1.2–2.0), but no association with bacterial vaginosis or trichomonas vaginalis infection was noted. Bathing or vaginal washing during menstruation with water only showed a higher association with symptoms of urogenital infections when compared with washing with both soap and water during menstruation. Drying reusable pads inside the house and storing them inside the toilet was found to be associated with a higher candida infection prevalence. Moreover, bathing in sitting position during menstruation, not drying the genital area or using cloth for drying it, and not paying attention to hand washing, were all associated with a higher risk of genital infections. Finally, postpartum use of native homemade vaginal preparations might be a risk factor for ascending vaginal infections, and the use of inappropriate material for menstrual blood absorption was associated with secondary infertility.

Conclusion Several hygiene practices put women at higher risk for reproductive tract infections. We should continue to increase awareness to counter the misinformation resulting from marketing campaigns and common misconceptions.

  • Intimate hygiene practice
  • Reproductive tract infection
  • Sexually transmitted infection
  • Vaginal douching
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

https://doi.org/10.1016/j.gocm.2022.06.001

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    1 Introduction

    Worldwide, women perform a variety of vaginal practices to enhance their hygiene and sexual health.1 Some of the products commonly used include intravaginal cleaning (e.g., douching or washing with liquids), intravaginal and extra vaginal wiping (e.g., with a cloth or tissue), and intravaginal insertion of substances that dry or tighten the vagina and boost sexual pleasure.2,3

    However, the standard vaginal pH of 4.5, essential for maintaining a healthy vaginal immune barrier, can be disturbed by such feminine practice.4 Products used may affect the composition of the usual vaginal microbiome through alteration of pH or through direct bactericidal effects. Yet, the vaginal microbiome is important for a safe mucosal environment.3,4 While the presence of Lactobacilli in the vaginal environment indicates a healthy atmosphere and reduces the risk of inflammation, any disruption of this natural microbiome may be associated with major risk of inflammatory complications.4

    Several studies suggested that unintended and harmful side effects are often correlated with intravaginal practices, increasing the risk of reproductive tract infections. Those in turn can increase the incidence of other serious conditions, such as pelvic inflammatory disease, infertility, ectopic pregnancy, miscarriage and preterm birth.1,2,5–10

    Our review is the first of its kind, to our knowledge, that aims to assess the different kinds of intimate hygiene practices and their association with reproductive tract infections and complications.

    2 Materials and methods

    2.1 Sources

    The design of this systematic review complied with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA), while the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) guidelines offered a systematic strategy for searching for qualitative and mixed-methods research studies. No review protocol was published. This study was institutional review board (IRB) exempt.

    We used electronic databases including PubMed, Medline and The Cochrane Library to search for our targeted articles (Table .1) We narrowed our key terms to “menstrual hygiene products”, “vaginal douching”, “reproductive tract infections” and “sexually transmitted diseases”. All our research was done in English language, and each database was searched until January 2021.

    View this table:
    Table 1

    Search strategy of the electronic databases used.

    2.2 Study selection

    Non pregnant women of menstruating age (10–49 years) were eligible for enrollment. We excluded women who were currently menstruating, underwent previous hysterectomy, were using antibiotics or oral contraceptive pills during the past three weeks, women with history of diabetes mellitus, human immunodeficiency virus (HIV) or other severe medical disorders. Types of intimate hygiene practices included intravaginal douching, that identifies as the practice of cleaning the vagina with liquid agents for hygienic and/or therapeutic purposes; insertion of certain cleansing products that include powders, creams, herbs, tablets, sticks, stones, leaves, and traditional products inside the vagina to dry or tighten it; sanitary napkins; pads; cloths; menstrual cups; cleansing and washing, alongside household environment, homemade vaginal preparations. Urogenital infections included Bacterial Vaginosis and those caused by Candida, Staphylococcus aureus, Chlamydia, Gonorrhea, Trichomonas, syphilis, HIV, Herpes simplex virus (HSV), Human papilloma virus (HPV), Escherichia coli as well as pelvic examination and self-reported symptoms of itching, pain, irritation or discharge. The included studies assessed the rate of urogenital infections and its association with the type of intimate hygiene practices. We included observational (cohort, cross sectional, case control) and interventional studies (randomized controlled trials). We looked for qualitative, quantitative and mixed-methods research. The authors hand searched reference lists of the identified articles as well.

    2.3 Data analysis

    We carefully performed the following steps: data collection, cleaning, analysis, and interpretation. Two reviewers (AD and OA) independently searched information sources and screened the abstracts of the generated studies while records were managed through a specific software (Microsoft excel). Identified studies were assessed according to the inclusion and exclusion criteria by qualifying each article as eligible, not eligible or might be eligible. Articles that could not be directly excluded had their full texts reviewed by both reviewers. A study was included if both reviewers agreed that it satisfied the inclusion criteria.

    2.4 Data synthesis

    Data were extracted from individual research studies with similar objectives and outcomes and were carefully evaluated to assess relevance to this systematic review.

    Two reviewers (AD and OA) independently extracted data using a standardized form. A third reviewer (KJ) proofread the data for clarity and consistency. Data extracted included the following: study and author details, sample characteristics, sample size, interventions and results. The same reviewers (AD and OA) assessed the risk of bias for non-randomized studies independently using the Newcastle-Ottawa Scale (NOS).11 This scale is based on 3 factors: selection of the exposed participants, comparability to controls, and assessment of the outcome. Randomized controlled trials were assessed for quality appraisal using Critical Appraisal Skills Programme (CASP) for randomized controlled trials.12 It focuses on the results, their validity and importance. All tools were piloted prior to data collection. Reviewers (LS) and (SF) contributed in writing and reviewing the manuscript.

    It was decided that a meta-analysis of individual variables would be performed if there were data from three or more studies to combine. However, this was not performed due to the heterogeneity of data collected in the included observational studies.

    3 Results

    Our broad search identified 262 articles from the database and 15 more articles by hand-search of references. Of the 277 studies, 12 studies were duplicates. After abstract screening of the 265 remaining articles, 247 studies were excluded since they did not match our inclusion criteria. After full article review of the remaining 18 articles, a total of three studies were excluded for the following reasons (Supplementary Table 1): Two of them focused on the assessment of functional literacy regarding intimate hygiene practice rather than its relation to infections,13,14 and one was a laboratory-based experimental study.4

    3.1 Overview of the included studies

    Fifteen articles met the inclusion criteria (Fig. 1 and Table 2). Most of the studies were cross-sectional,1,2,7,8,10,15–17 three were case-control,6,18,19 one was a cohort,20 and three were randomized controlled trials (RCT).9,21,22 Four studies were conducted in India,6,8,10,20 four in China,7,15–17 two in Kenya,9,22 one in Pakistan,19 one in Cambodia,2 one in Turkey,18 one in Malawi,1 and one in Jamaica.21 Qualitative or mixed methods studies were not found. All studies were written and published in English. The eligible studies included a minimum of 200 participants1,2 and a maximum of 577,758 participants.20

    View this table:
    Table 2

    List of included articles.

    Fig. 1
    Fig. 1

    PRISMA 2009 flow diagram.

    Quality appraisal of all included studies was done according to New-Castle Ottawa Scale11 for non-randomized studies12 for randomized controlled trials. No low-quality studies were noted, and hence no studies were excluded for low quality appraisal.

    Most of the studies targeted sexually transmitted infections. Five studies focused on HIV infection5,7,15–17 and blood tests were taken to diagnose it. Two articles investigated the risk of HPV infection,1,2 diagnosed using cervico-vaginal specimens, four articles targeted trichomonas infection,9,10,16,17 detected by endocervical swabs. Chlamydia and Gonorrhea were mentioned in five studies7,9,15–17 and were diagnosed using endocervical swabs. HSV was mentioned in two studies1,16 and syphilis was targeted in four studies7,15–17; both were detected by blood tests. Vaginal swabs were used to detect bacterial vaginosis, targeted in five studies.1,5,6,9,10 Candida infection was mentioned in two studies9,10 where they used vaginal swabs for screening. Two studies screened menstrual cups for Escherichia coli growth and used vaginal swabs to detect S. aureu.9,22 It is important to note that three studies relied on pelvic examination and self-reported symptoms of itching, pain, irritation or discharge.8,20,21

    The majority of practices identified were intravaginal douching and insertion of certain cleansing products such as powders, creams, herbs, tablets, sticks, stones, leaves, and traditional products.1,2,15–17,21 Five articles targeted sanitary napkins, pads and cloths,6,9,10,16,18 while two publications studied menstrual cup effects.9,22 Four studies investigated cleansing and washing practices alongside household environment,6,8,10,18 and just one mentioned the use of self-prescribed prophylactic oral antibiotics and vaginal douching.7

    Out of the 15 studies that were included, only two showed no association whatsoever between the intimate hygiene practices and the risk of reproductive tract infections.1,22

    3.2 Urogenital infection risk and intravaginal practices

    Two studies found an association between vaginal douching and history of sexually transmitted diseases (STD) in the last 12 months, but not with current sexually transmitted diseases. The authors concluded that this was explained by the fact that douching was practiced in response to the symptoms of sexually transmitted infections rather than to prevent the infection itself.15,17

    Another study suggested that the use of vaginal douching with prophylactic oral antibiotics doubled the risk of developing vaginal infections odds ratio (OR) of 2.9, (95% CI 1.3–6.7). Similarly, the use of prophylactic oral antibiotics only, and prophylactic oral antibiotics with vaginal douching increased the risk of cervical infections with OR of 4.0 (95% CI 1.1–15.4), 4.2 (95% CI 1.7–10.3) and 2.5 (95% CI 1.1–5.7), respectively.7

    Though data showed that intravaginal practices are associated with reproductive tract infections, some studies7,15–17 were targeting female sex workers who are already at a higher risk of sexually transmitted infections.23

    3.3 Urogenital infection risk and sanitary napkins, pads, cloths and menstrual cups

    Reusable absorbent material used during menstruation were found to increase the risk of Candida infection with an adjusted proportional reported ratio (aPRR) of 1.54 (95% CI 1.2–2.0), but no association with bacterial vaginosis or trichomonas vaginalis infection after adjustment of confounding factors was noted10; however, an earlier study found that the adjusted odds ratio (aOR) of women applying reusable absorbent pads to have been diagnosed with at least one urogenital infection (bacterial vaginosis or urinary tract infection) was 2.8 (95% CI 1.7–4.5).6

    3.4 Urogenital infections risk and washing practices

    Only one study found that bathing or vaginal washing during menstruation with water compared to water and soap was associated with symptoms of urogenital infections.18 Similarly, Baker et al. showed that bathing daily with soap, washing hands after defecation with soap, and washing hands after defecation with mud/soil were associated with a higher risk of reproductive tract infections compared to washing with water only or no hand washing, with OR of 6.55 (95% CI ​= ​3.60, 11.94), 10.27 (95% CI ​= ​5.53, 19.08) and 6.02 (95% CI ​= ​3.07, 11.77), respectively.8

    3.5 Urogenital infections risk and household environment

    Drying reusable pads inside the house and storing them inside the toilet was found to be associated with a higher candida infection prevalence, compared to drying them in an open space (aPRR ​= ​1.78, 95%CI 1.34–2.38) or being stored within a cupboard in the changing room (aPRR ​= ​1.96, 95%CI 1.49–2.57).10 Similarly, bathing in sitting position during menstruation, not drying the genital area or using cloth for drying it, and not paying attention to hand washing were all associated with a higher risk of genital infections, while genital cleaning was found to decrease the risk of genital infections.18

    3.6 Urogenital infections risk and homemade vaginal preparations

    One study reported that postpartum use of native homemade vaginal preparations might be a risk factor for ascending vaginal infections causing adhesions and secondary infertility, with an aOR of 3.1 (95% CI: 1.6–5.7). Similarly, the use of inappropriate material for menstrual blood absorption such as cotton, unwashed rags or washed rags dried inside the room was associated with secondary infertility.19

    4 Discussion

    Our study is the first to assess a variety of female hygiene practices and their association with the prevalence of reproductive tract infections. This systematic review found a significant association between using unhygienic methods during menstruation and the risk of urogenital infections, as presented in four studies.6,10,18,20 Women who used daily pads were found to have a high frequency of genital infections.18 Unhygienic menstrual products6,10,18,20 and unsanitary washing practices8 create abnormal moist conditions in the genital area and alter vaginal pH. Similarly, some vaginal products sold over the counter affect the vaginal epithelium4 and might have a cytotoxic effect on the survival of beneficial Lactobacillus species24 in the vaginal environment. For example, soap or shampoo use for vaginal washing in particular might alter the vaginal microbiota,25 leading to a higher risk of vaginal symptoms compared to the use of water only for cleaning.8,18

    One study found no significant association between Staphylococcus aureus infection and use of cups, pads or the usual practices like clothes, paper and bedding. It also mentioned no detected harms in its small sample, even though Escherichia coli growth was found in 37.1% of the used cups.22 Another similar article demonstrated that menstrual cups used for at least 9 months were associated with a lower prevalence of bacterial vaginosis compared to pads and control arms when pooled. Menstrual cups and sanitary pads were also associated with a low prevalence of sexually transmitted diseases, particularly Chlamydia trachomatis and Trichomonas vaginalis but not Neisseria gonorrhea.9

    Three studies showed that intravaginal practices were associated with a reduced rate of reproductive tract infections.2,16,21 Interestingly, one study found that intravaginal practices, particularly douching with toothpaste or disinfectant, increased the risk of HIV and HSV-2. However, it also reported that those same practices were associated with a lower prevalence of Neisseria gonorrhea and Chlamydia trachomatis infections.16 Bui et al. reported that the majority of the participants used water and added salt, soap or lemon in intravaginal washing and some used commercial products. It was noticed that intravaginal washing in the previous three months and performing this practice shortly after vaginal intercourse reduced the incidence of HPV infection.2 Though intravaginal washing before sex can remove the protective vaginal secretions and mucus barrier facilitating HPV acquisition, it may help clear HPV viral loads transmitted when practiced after sex. This was supported by an in vitro study reporting that 90% of HPV infections were prevented by washing 30 ​min after HPV exposure, which is the approximate timing needed for HPV to attach to cells.26 Nonetheless, one study reported no significant association between intravaginal practices and HPV, bacterial vaginosis or HSV-2.1

    Practicing frequent self-washing during menstruation was associated with a low risk of reproductive tract infections,18 particularly candidiasis and bacterial vaginosis.10 Menstrual dysregulations and prolonged accumulation of blood and discharge in the vagina may alter the vaginal ecosystem, thus self-washing and flushing can help prevent reproductive tract infections.27 Interestingly, Trichomonas vaginalis infection risk was not significantly increased with such practices,10 possibly because of its low prevalence,28 along with the fact that it is a sexually transmitted infection.29

    Studying water cycle facilities, two studies found that changing the absorbent material in a toilet facility was found to decrease the risk of bacterial vaginosis.6,10 Using a latrine without water for defecation and walking short distance to a bathing location were both associated with a lower incidence of reproductive tract infection symptoms compared to open defecation in a cross sectional study.8 Thus, our data suggested that having a safe, stress-free, and hygienic place with access to water can decrease reproductive tract infection risk.

    The higher frequency of HIV among women who are non-female sex workers practicing intravaginal cleaning and using intravaginal products for sex aiming to tighten and dry the vagina can be attributed to epithelial injuries.3,5 Those products were in fact a way to facilitate viral entry during intercourse by causing physical abrasions in the cervico-vaginal epithelium.30

    In summary, any intimate feminine practice that alters the vaginal pH, injures the vaginal epithelium, or the use of unhygienic menstrual products and unsanitary washing practices may increase the risk of reproductive tract infections.

    4.1 Strengths and weaknesses

    The main strength of this review is that it is the first of its kind, to our knowledge, to include several female hygiene practices and correlate their use with reproductive tract infections. Another strength is that recent studies were involved including randomized control trials, which enhanced the quality of evidence. There are potential limitations in our review. Most of the studies involved were observational, conducted mainly in South Asia and Africa. Access to intimate products and safe, clean and private hygiene spaces are often not uniform across countries with different socio-economic status and geography, which made it challenging to generalize the results. In addition, some studies were based on self-report, increasing the risk of bias.

    4.2 Clinical implications

    Medical practitioners should be aware of the diversity of intimate hygiene practices and their adverse outcomes on the gynecological health including changes in the vaginal microbiota. It is their role to advise women on the methods and frequency of hygiene practices.

    4.3 Conclusion

    Intimate hygiene practices may put women at a higher risk of several reproductive tract infections. Health care providers and public health experts should continue to increase awareness regarding intimate hygiene practices to counter the misinformation resulting from marketing campaigns particularly through social media and common misconceptions.

    Author contribution

    All authors participated in at least one of the following: designing the work; data collection; data analysis. They all contributed to drafting and revising the paper and approved of the final version, and are thus will be held accountable for all aspects of the work.

    Conflict of interest

    None.

    Financial Support

    None.

    Declaration of interests

    The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

    Acknowledgement

    None.

    Appendix

    Appendix A Supplementary data

    The following are the Supplementary data to this article:

    Multimedia component 1

    Multimedia component 2

    Multimedia component 3

    Appendix A Supplementary data

    Supplementary data to this article can be found online at https://doi.org/10.1016/j.gocm.2022.06.001.

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    Footnotes

    • ↵1 Co-authors who contributed equally to the manuscript