Douching:  A Problem for Adolescent Girls and Young Women FREE

VAGINAL DOUCHING is an ancient and traditional practice done to cleanse the vagina.^1- 2 The belief that the vagina is unclean, particularly during and after menses, has been common around the world.³ In the United States, this belief was reinforced in the 1880s by public health concerns about the unsanitary nature of menstrual blood. In a guide about female hygiene published in 1902, Joseph Greer espouses that "every part of the body [should be] as clean as the face" and that menstrual blood "generates unpleasant odors, a sure sign of noxious effluvia and breeding bacteria."⁴ In the early 1900s, companies such as Lysol Incorporated began advertising campaigns encouraging young women to buy their commercial douche products to keep themselves clean.⁴ Even today, SmithKline Beecham, Phildadelphia, Pa, the manufacturer of Massengill douche products, describes douching as "a gentle shower for your vagina [that] gently cleanses to leave you feeling clean, fresh, and confident." While being "clean, fresh, and confident" may be highly desirable, douching is associated with pathogenic changes in the vaginal flora and an increased risk of pelvic inflammatory disease (PID) and ectopic pregnancy.^5- 10 Because many adolescent girls and young women douche, they increase their risk for these conditions.

In the 1995 National Survey of Family Growth, regular douching was reported by 15.5% of adolescent girls and young women aged 15 to 19 years and by 28% of those aged 20 to 24 years.¹¹ Chacko et al^10,12 conducted 2 cross-sectional studies of adolescent girls and young women attending family planning clinics in Texas and found that almost 70% of the subjects reported using vaginal douches, with about one quarter reporting douching within 48 hours of the clinic visit. Fifty-one percent douched at least once a week.¹⁰

Adolescent girls and young women who douche differ markedly from those who do not. In the 1995 National Survey of Family Growth, regular douching was reported by 37% of African American and 11% of white 15- to 19-year-old females. For those aged 20 to 24 years, 60% of African Americans, as opposed to 20% of whites, reported regular douching.¹¹ In the study by Chacko et al,¹² douching was practiced by 80% of African American teenagers, as compared with 46% of whites and 49% of Hispanics. Adolescent girls and young women who douche are less educated than those who do not. Most start douching when they are young for nonmedical reasons.^1,11,13 Douching behavior is more common among the patients of sexually transmitted disease clinics than college students.¹⁴ Thus, those who douche are those who are at highest risk for sexually transmitted diseases.

The reasons why adolescent girls and young women douche are poorly understood.^12,15 While most report that cleanliness is their ultimate goal,¹⁶ other sexual self-image issues and the influence of advertisements by commercial douche companies may underlie their motivation.

Studies showing adverse effects of "improper douching" were published as early as the 1940s.^17- 18 By the early 1990s, numerous studies had found correlations between douching and adverse gynecologic effects. Kendrick et al¹⁶ found no benefit of douching and no safe douching behavior. Joesoef et al⁹ concluded that douching should be avoided, particularly after menses and before sex. Published clinical studies suggest that the effect of douching is modulated by the products used for douching,^{9,13,16,19- 20} the reason for douching,⁸ frequency of douching,^6,8,19 timing in relation to sexual activity and menses,^9,13,21 and the duration of douching practices.¹⁶

In an experimental study of 10 healthy volunteers, Onderdonk et al²² demonstrated that douching resulted in microfloral changes 10 minutes after douching. After a normal saline or acetic acid douche, the microflora returned to the predouching level within 72 hours. However, repetitive douching with a solution containing the bactericidal agent providone-iodine caused more dramatic short-term and prolonged changes in microflora, allowing an overgrowth of pathogenic organisms that have faster growth rates than Lactobacillus species, the predominant normal vaginal flora.²² More than half of the adolescent girls and young women who douche use commercial preparations,^6,19,23- 25 which contain differing combinations of acidifiers, bacteriostatic or antimicrobial agents, and weak surfactants.

These vaginal microfloral changes associated with douching favor the development of bacterial vaginosis (BV).²² While the exact mechanism is not yet clear, the overgrowth of pathogenic organisms in the lower genital tract may increase the risk of ascending infection. Bacterial vaginosis is a clinical syndrome resulting from the replacement of the normal H₂O₂-producing Lactobacillus species in the vagina with high concentrations of facultative anaerobic and aerobic bacteria.^26- 27 Bacterial vaginosis is the most prevalent cause of vaginal discharge or malodor²⁶ and is the most common vaginal infection seen in women of reproductive age by primary health care personnel.²⁸ Bacterial vaginosis is diagnosed by the use of the clinical²⁸ or Gram stain²⁹ criteria. However, half of the women who meet the clinical criteria for BV (pH>4.5, positive Whiff test, clue cells, thin homogeneous vaginal discharge) have no symptoms. The epidemiology of BV suggests sexual transmission, but this has never been proven, although BV is rarely found in the sexually inexperienced.³⁰

Bacterial vaginosis is associated with adverse pregnancy outcomes,^31- 33 endometritis,^34- 37 and complications after invasive gynecologic procedures.²⁶ An association between BV and increased human immunodeficiency virus 1 infection in young women was found in cross-sectional studies in Ugandan and Thai women.^38- 39 In vitro research has suggested that BV may increase the survival of human immunodeficiency virus 1 in the genital tract.⁴⁰ A study of racial variation in vaginal pH found that normal African American adolescent girls and young women, compared with their white counterparts, tended to have a higher vaginal pH, a condition associated with BV.⁴¹ In a study of 175 adolescent girls and young women aged 14 to 21 years attending a family planning clinic, 25% of those who douched and 15% of those who did not had BV.¹⁰

Pelvic inflammatory disease is the condition most strongly associated with douching. In PID, microorganisms ascend from the vagina to the endometrium, fallopian tubes, or contiguous structures.⁴² The incidence of PID is highest in the adolescent population and the disease is the leading cause of infertility in the United States.⁴² The 1995 National Survey of Family Growth reports that approximately 6.1% of females in the United States aged 15 to 24 years have impaired fecundity,¹¹ with 2.7% aged 15 to 19 years and 6.1% aged 20 to 24 years having been treated for PID in the past.¹¹ Another report estimates that 1 in 8 sexually active 15-year-old girls and 1 in 10 sexually active 16-year-old girls have PID.⁴³ Only 1 in 80 women aged 24 years have PID. Of the 1 million females who are diagnosed with PID each year, 70% are younger than 25 years. Although the incidence of PID is decreasing among women in the United States, the incidence of PID is increasing in the adolescent population.⁴²

Pelvic inflammatory disease can remain asymptomatic for many years, with adolescent girls being least likely to experience or report symptoms.⁴² Scholes et al⁸ found that young women and adolescent girls who douched because of symptoms of infection were 8 times more likely to have PID than those who douched for other reasons, and this risk was elevated 3-fold for those who douched at least once a week.

A case-control study revealed that every type of douching behavior (eg, the apparatus usually used or the reason for douching) was associated with an increased risk for ectopic pregnancy in African American adolescent girls and young women.¹⁶ Even women who douched for routine cleanliness were at an increased risk for the condition. The risk of ectopic pregnancy increased with increased frequency of douching and the number of years that an adolescent girl or young woman had douched at least once a month, although the effect was modulated by the type of apparatus used. The authors were not able to identify any particular douching behavior that seemed safe.¹⁶

The persistence of douching despite its potential adverse effects is probably due to aggressive advertising by manufacturers of douching products and to the absence of cautionary statements by authoritative medical and public health organizations.

In 1994, the last year for which sales figures were available, douching products grossed $144 million, making up the second largest sector of the feminine care market.⁴⁴ In a guide published to help drugstores identify crucial items of which they should never run out, commercial douches represented 3 of the 5 feminine care products included.⁴⁴ Companies advertise their douching products extensively and will probably resist attempts to curtail their sales.

None of the organizations that might be expected to urge that douching be avoided have published such statements. These include the federal Food and Drug Administration and professional societies such as the American Academy of Pediatrics, the Society for Adolescent Medicine, and the American College of Obstetricians and Gynecologists. We investigated the stance of each organization by telephone, literature review, and the Internet but could find no statement about the practice addressed to physicians or to the general public.

The absence of such statements may be owing to the lack of definitive studies. Most clinical studies are cross-sectional and retrospective in nature, and thus are unable to determine causative relationships between douching and adverse outcomes. Some studies failed to show a conclusive correlation between PID and douching.^25,45- 46 Conflicting findings with regard to the incidence of lower genital tract infections and the use of a medicated douche were found in earlier studies.^6,21 Limited experimental studies suggest that douching solution does not easily ascend above the cervical os, even in menstruating women. Rosenberg and Phillips²¹ concluded that further information is needed to determine whether douching is a causal factor or an indicator for behaviors that increase the risk of sexually transmitted diseases and their complications. Recent literature has not changed this situation. Nevertheless, no study has found favorable outcomes of douching.

Because vaginal douching has been shown to be associated with BV, PID, and ectopic pregnancy, and because no benefits are conferred on those who practice it, douching should be discouraged among teenagers. As addressed by Aral and Wasserheit,⁴⁷ additional prospective studies should be conducted to answer some of the remaining questions about the relationship between douching and adverse outcomes, particularly in adolescent girls and young women. Studies of the reasons why adolescent girls and young women begin and continue to douche are also needed so that successful programs can be developed to reduce this practice. However, federal agencies and professional societies should not wait for the results of these studies. They should issue cautionary statements on the basis of research findings that are currently available. Because of the high rates of health problems linked to douching, it is urgent that health professionals discourage this practice, particularly among adolescent girls and young women.

Accepted for publication December 18, 1998.

The preparation of this paper was made possible in part by grants MCJ9040 from the Federal Bureau of Maternal and Child Health, Washington, DC; C60117041 from the Centers for Disease Control and Prevention, Atlanta, Ga; and 5U19A138514 from the National Institute of Allergy and Infectious Diseases, Rockville, Md.

Corresponding author: Jeanne S. Merchant, MPH, University of Alabama at Birmingham, Suite 201, Children's Midtown Center, 1616 Sixth Ave S, Birmingham, AL 35233.

Editor's Note: I wonder how many clinicians ask their patients about douching. In my random convenience sample I've found none, including myself. Time to change that.—Catherine D. DeAngelis, MD