STATEMENT OF THE PROBLEM
Studies have shown links between the practice of vaginal douching (intravaginal cleansing with a liquid solution) and several adverse health outcomes. Some of these adverse health outcomes include pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low-birth weight, preterm birth, HIV transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.1 Douching alters the normal vaginal pH and vaginal flora, weakening the vagina’s natural defenses and creating an environment more susceptible to the overgrowth of pathogens. In addition, the process of inserting fluid intravaginally can help to push harmful bacteria further up into the reproductive tract.
There is some conflict, however, among studies with respect to those adverse health outcomes that have a causal link or an observed association. For example, those women with certain risk factors (i.e., multiple sexual partners, poverty, certain races, and lower educational level) are also at a greater risk of sexually transmitted infection, bacterial vaginosis, and pelvic inflammatory disease. This situation makes it difficult to determine causality, because women may douche as a result of infection-related symptoms rather than as a part of their normal hygienic practice.1 There is a need for more studies of the causal relationship between douching and sexually transmitted infections and various vaginal and reproductive tract infections to determine whether the infection is, in fact, directly connected to douching or whether women are douching to alleviate symptoms of the infection. The 2002 National Survey of Family Growth reports that women who douched in the 12 months prior to the survey had a higher prevalence of pelvic inflammatory disease than those who did not douche.2 A study of douching and endometriosis found that recent and frequent douching in a group of women with clinical pelvic inflammatory disease was associated with endometritis and upper genital tract infections in those women with normal or intermediate vaginal flora.3
Although some studies report that bacterial vaginosis is sometimes sexually transmitted, it can also occur in women who have never had sexual intercourse.4 Douching prevalence is higher among women with lower educational levels; a racial difference persists as well. Approximately 52% of African American college graduates reported that they douched compared with their White (12%) and Hispanic (30%) counterparts.2
Beyond the immediate connection between douching and reproductive tract infections, the sanitization of women’s bodies by the feminine hygiene industry brings forth concerns about toxins or antimicrobial agents in antiseptic douching products that are inhibitory to lactobacilli. The major bacteria in a normal, healthy vagina are lactobacilli.5 Women with bacterial vaginosis, for example, have been found to have decreased hydrogen peroxide (H2O2) producing lactobacilli.6 Douching can upset the normal vaginal flora, creating a greater susceptibility to certain sexually transmitted diseases. Women who douche are at greater risk of contracting bacterial vaginosis. In their efforts to treat the symptoms of bacterial vaginosis through douching, the healthy bacteria are killed, and unhealthy bacteria are allowed to grow. If a pregnant woman has bacterial vaginosis and douches, chronic bacterial colonization of the endometrium may cause premature rupture of the uterine membranes or early labor.1
A key reason why women continue to douche is the aggressive advertising by manufacturers of douching products. Major pharmacies and grocery stores have entire aisles dedicated to feminine hygiene products. Positioned directly next to the tampons and sanitary napkins, one can find a broad selection of “medicated” solutions, disposable douche products, and feminine sprays in a number of different scents.
Over the years, messages about vaginal odors, postmenstrual bleeding, and maintaining a “clean, crisp” feeling have been passed on to women by douche manufacturers. Douche manufacturers have, in turn, profited to the tune of approximately $144 million annually,9 as women add to their annual health care cost by spending as much as $500 per year for over-the-counter vaginal products that are not medically necessary.10 There are at least three major manufacturers of douche products. In addition, most of the major pharmacies have their own brand of disposable douches.
Despite the research pointing to various associated health risks and adverse effects, the sanitization by women of their bodies is still a regular practice. It was reported in the 1995 National Survey for Family Growth that approximately 27% (an estimated 16 million) of US women ages 15 to 44 douche regularly (African American 55%; Hispanic 33%, and White 21%).11 The 2002 National Survey of Family Growth shows that douching continues to be a more common practice among African American women, as 59% of the respondents douched in the 12 months prior to the interview. A random telephone survey of 535 adult women living in the southeastern United States found that 65% of the women believed that douching was a good hygienic practice.12 Half of the 65% reported that douching was necessary for good hygiene. More African American women believed this to be true than White women. Along age and class lines, older women and less-educated women were more likely to believe that douching prevented infections and pregnancies. Reasons given included washing away old blood after the menstrual cycle, washing away fluids after sexual intercourse, and self-treating abnormal discharge.
The popularization of a way to remove semen from the vagina came from Charles Knowlton, a Massachusetts doctor in the 1800s. Knowlton published a description of douching in his 1832 publication, The Fruits of Philosophy; or the Private Companion of Young Married People.13 Knowlton suggested using a syringe filled with a solution of the astringent alum and infusions of white oak or hemlock bark, green tea, or raspberry leaf. Shortly thereafter, Frederick Hollick spoke of the douching in his publication, The Marriage Guide, which was printed in 300 editions between 1850 and 1875.14 Edward Bliss Foote also celebrated douching in his publication, Medical Common Sense.15 It is estimated that 250,000 copies of Foote’s publication were sold between 1858 and 1900.16 In the early 20th century, varying types of chemicals and detergents were advertised as feminine hygiene douches; Lysol and Fresca advertised their products for use as contraceptive “feminine hygiene” douches.17 For many African American women, cleansing the vaginal cavity is part and parcel of a monthly hygienic ritual associated with menstrual cycles. In the African American community, douching is a practice that has been handed down generationally.18
In the Gynecologic Infections Follow-Through (GIFT) Study of 532 douching women, 45% of the respondents cited their mothers as the person who first recommended douching.19 Approximately 28.6% of the respondents cited friends and other relatives as the first persons to recommend douching. In this same study, women gave the following reasons for douching: to cleanse after the menses, general hygiene, before or after sex, to reduce vaginal odor, “it’s normal to douche,” abnormal vaginal discharge, bleeding between menses, pregnancy prevention, and recommendation by a health professional. Pregnancy prevention and recommendation by a health professional were reported by 3% or less of the respondents. Few women in the study linked douching to health conditions such as pelvic inflammatory disease, HIV infection, or cervical cancer. A little more than half of the women (52%) did not think anything would happen it they stopped douching, or they thought they would experience some adverse effect, including feeling less clean, being less sexually attractive, or more likely to get an infection if they stopped douching. More than half of the respondents reported being advised by a health professional to stop douching. However, 85% reported that they would stop if they were told that douching might cause a sexually transmitted infection, infertility, or cancer.
Another area of grave concern is the way in which feminine hygiene products, specifically, douching products are regulated. The US Food and Drug Administration (FDA) classifies douche products as cosmetics. Cosmetics need not be sterile; however, they must not be contaminated with microorganisms that may be pathogenic, and the density of nonpathogenic microorganisms should be low. FDA requires tamper-resistant packaging of products used vaginally. However, FDA does not stringently review or regulate douche products. Nor does FDA require that cosmetic manufacturers or marketers test their products for safety. FDA merely “strongly urges” cosmetic manufacturers to conduct toxicological or other tests manufacturers deem appropriate to substantiate the safety of their products. Under the Federal Drug and Cosmetic Act,20 cosmetic manufacturers are not required to register manufacturing establishments or formulations with FDA or make safety data available or other information available before a product is marketed in the United States. Providing this information is on a voluntary basis. The growing bank of scientific research did prompt the FDA to reopen its records to review new data in 1997.21
The issue of douching among women has gone historically unaddressed by the public health community. Despite the wide body of research that points to various adverse reproductive and maternal outcomes and medical personnel’s knowledge of the harmful effects, scores of women still continue this harmful practice. Few groups, including the American Public Health Association (APHA), have formulated statements guiding women and health providers around this practice.22 Programs and information are available that warn women about the harmful effects of douching. For example, The National Women’s Health Information Center produced a douching fact sheet of “frequently asked questions” about douching, Blue Cross Blue Shield of Massachusetts has a fact sheet, and federally funded Title X family planning guidelines include counseling about avoiding douching in its counseling and education program guidelines.23–25 In some instances, a physician may advise a woman to douche for certain chronic vaginal infections.
Because of the evidence of negative reproductive health and other negative health effects related to douching, the following steps of action should be taken:
- Schools of public health, pharmacy, and medicine and nursing should include in their curriculum specific education about the impact of douching on reproductive and maternal outcomes.
- Public health efforts should be increased through federal and state public health departments, federal and state offices of women’s health, private and public medical institutions, local and state departments of public health, and physicians and other medical professionals to provide culturally competent education to women about the reproductive and maternal risks associated with douching.
- FDA should review existing data and require additional studies on the safety of douching and the prevalence of adverse health outcomes and then make public the findings of such studies. FDA should also require studies of the safety of douching and the prevalence of adverse health outcomes and then make public the findings of such studies.
- The US surgeon general should include a warning label with all associated risks on douching product labels.
- Public health promotion efforts should be increased through the use of population-specific media venues such as radio, television, and newspaper to provide culturally competent education to women about reproductive and maternal risks associated with douching.
- Martino JL, Vermund SH. Vaginal douching: evidence for risks or benefits to women’s health. Epidemiol Rev. 2002;24:109–124.
- Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Stat 23. 2005; No. 25: Page 32, Tables 106-108.
- Ness RR, 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.
- Bump RC, Buesching WJ 3rd. Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive transmission. Am J Obstet Gynecol. 1988;158:935–939.
- Horowitz BJ, Mardh PA, eds. Vaginitis and vaginosis. New York: Wiley-Liss; 1991.
- Hillier SL, Krohn MA, Rade LK, et al. The normal vaginal flora, H2O2-producing lactobacilli, and bacterial vaginosis in pregnant women. Clin Infect Dis. 1993;16(suppl 4); S273–S281.
- Goldenberg RL, Andrews WW. Intrauterine infection and why preterm prevention programs have failed (Editorial). Am J Public Health. 1996;86:781–783.
- Rogers B. Preventing preterm low birth weight. Covering kids and families home. Oklahoma Institute for Child Advocacy. Available at: http://220.127.116.11/search?q=cache:zoLTxEEQPEEJ:www.ohca.state.ok.us/WorkArea/downloadasset.aspx%3Fid%3D1640+preventing+preterm+low-birth+weight+%2B+oklahoma+institute+for+child+advocacy&hl=en&ct=clnk&cd=3&gl=us. Accessed December 20, 2007.
- InteliHealth, Health News. To douche or not to douche? Jury’s still out. Cox News Service. Available at: www.intelihealth.com/IH/ihtIH/WSIHW000/333/343/312827.html. Accessed Accessed December 20, 2007.
- Nyirjesy P, Weitz MV, Grody MH, Lorder B. Over-the-counter and alternative medicines in the treatment of chronic vaginal symptoms. Obstetrics & Gynecology. 1997;90:50–53. 11. Abma JC, Chandra A, Mosher WD, Peterson LS, Piccinino LJ, Fertility. Family planning, and women’s health: new data from the 1995 National Survey of Family Growth. Vital Health Stat 23. 1997; No. 19:1–114. 12. Funkhouser E, Pulley L, Lueschen G, Costello C, Hook E, Vermond SH. Douching beliefs and practices among black and white women. J Womens Health Gend Based Med. 2002;11(1):29–37.
- Knowlton C. The Fruits of Philosophy; or the Private Companion of Young Married People. Mount Vernon, NY: Peter Pauper Press; 1832.
- Hollick F. The Marriage Guide. New York, NY: T.W. Strong; 1850.
- Foote EB. Medical Common Sense. New York, NY: Murray Hill Publishing; 1858.
- Planned Parenthood. A History of Birth Control Methods. Available at: www.plannedparenthood.org/news-articles-press/politics-policy-issues/birth-control-access-prevention/bc-history-6547.htm. Accessed December 7, 2007.
- Rome LC. The perils of vaginal douching. Museum of Menstruation and Women’s Health. 1998. Available at: www.mum.org/vagdouch.htm. Accessed December 20, 2007.
- Funkhouser E, Hayes TD, Vermund SH. Vaginal douching practices among women attending a university in the southern United States. J Am Coll Health. 2002;50:177–182.
- Ness RB, Hillier SL, Richter HE, et al. Why women douche and why they may or may not stop. Sex Trans Dis. 2003;30(1):71–74.
- Federal Drug and Cosmetic Act. 21 CFR 710, 720 and 730.
- Antifungal Drug Products for Over-the-Counter Human Use; External Analgesic Drug Products for Over-the-Counter Human Use; Skin Protectant Drug Products for Over-the-Counter Human Use; and Topical Antimicrobial Drug Products for Over-the-Counter Human Use; Reopening of Administrative Records. Federal Register. November 19, 1997;62(223):61710–61712. Available at: http://www.fda.gov/cder/otcmonographs/Antifungal/antifungal_19971119.htm. Accessed January 13, 2008.
- Martino J, Pairoj SY, Vermund, SH. Vaginal douching: personal practices and public policies. J Womens Health. 2004;13:1048–1065.
- National Women’s Health Information Center, U.S. Department of Health and Human Services, Office on Women’s Health. Douching: frequently asked questions. Available at: www.4woman.gov/faq/douching.htm. Accessed December 21, 2007.
- Healthyme. Douching. Available at: www.ahealthyme.com/topic/douching. Accessed December 7, 2007.
- Title X Region X infertility prevention project manual, program guidelines for Title X services. Available at: www.centerforhealthtraining.org/download/R10_IPP_2005_complete.pdf, Section III, Page 9. Accessed December 21, 2007.
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