0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Article |

Douching:  A Problem for Adolescent Girls and Young Women FREE

Jeanne S. Merchant, MPH; M. Kim Oh, MD; Lorraine V. Klerman, DRPH
[+] Author Affiliations

From the School of Public Health (Ms Merchant and Dr Klerman) and School of Medicine (Dr Oh), University of Alabama at Birmingham.


Arch Pediatr Adolesc Med. 1999;153(8):834-837. doi:10.1001/archpedi.153.8.834.
Text Size: A A A
Published online

Objective  To compile available published data on the prevalence of douching practices in adolescent girls and young women and the effects of douching on gynecologic health, including studies of gynecologic changes due to douching in adolescent girls and young women, surveys that demonstrated the prevalence of douching in the populations, and policy statements or lack thereof from professional and medical organizations with regard to the practice of douching.

Data Sources  We did Internet searches, including a MEDLINE search, a literature review, and used the telephone, mail, and e-mail to contact professional organizations.

Results  Douching has been found to be strongly associated with increased risk for pelvic inflammatory disease, bacterial vaginosis, and ectopic pregnancy, the former of which is especially prevalent in adolescent girls and young women. Douching is practiced by 15.5% of adolescent girls and young women in the United States, with significantly higher prevalences in certain groups in the population. We have not found any official position of professional and medical organizations on the practice of douching.

Conclusions  Because vaginal douching has been shown to be associated with bacterial vaginosis, pelvic inflammatory disease, and ectopic pregnancy, and because no benefits are conferred on those who practice it, douching should be discouraged among adolescent girls and young women. There is a great need for further studies, particularly prospective ones, to determine if there is evidence of a direct causative influence of douching on pelvic inflammatory disease, ectopic pregnancy, and/or bacterial vaginosis, and to determine why adolescent girls and young women douche.

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.510 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 al10,12 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,6,19,2325 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,3133 endometritis,3437 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.

Advertising

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.

Role of Medical and Public Health Organizations

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

Aral  SMosher  WCates  W Vaginal douching among women of reproductive age in the United States: 1988. Am J Public Health. 1992;82210- 214
Link to Article
Zhang  JThomas  ALeybovich  E Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health. 1997;871207- 1211
Link to Article
Buckley  TGottlieb  A Blood Magic: the Anthropology of Menstruation.  Berkeley University of California Press1988;
Blumberg  J The Body Project: an Intimate History of American Girls.  New York, NY Random House Inc1997;
Forrest  KWashington  ADaling  JSweet  R Vaginal douching as a possible risk factor for pelvic inflammatory disease. J Natl Med Assoc. 1989;81159- 165
Wolner-Hanssen  PEschenbach  DAPaavonen  J  et al.  Association between vaginal douching and acute pelvic inflammatory disease. JAMA. 1990;2631936- 1941
Link to Article
Neuman  HHDeCherney  A Douching and pelvic inflammatory diseases. N Engl J Med. 1976;295789
Scholes  DDaling  JRStergachis  AWeiss  NSWang  SPGrayston  JT Vaginal douching as a risk factor for acute pelvic inflammatory disease. Obstet Gynecol. 1993;81601- 606
Joesoef  MRSumampouw  HLinnan  MSchmid  SIdajadi  ASt Louis  ME Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia. Am J Obstet Gynecol. 1996;174(pt 1)115- 119
Link to Article
Chacko  MRKozinetz  CARegard  MSmith  PB The relationship between vaginal douching and lower genital tract infection in young women. Adolesc Pediatr Gynecol. 1992;5171- 176
Link to Article
Abma  JedChandra  AedMosher  WedPeterson  LedPiccinino  Led Fertility, Family Planning and Women′s Health: New Data From the 1995 National Survey of Family Growth.  Hyattsville, Md National Center for Health Statistics1997;Vital Health and Statistics No. 23.
Chacko  MMcGill  LJohnson  TSmith  PNenney  S Vaginal douching in teenagers attending a family planning clinic. J Adolesc Health Care. 1989;10217- 219
Link to Article
Baird  DDWeinberg  CRVoigt  LFDaling  JR Vaginal douching and reduced fertility. Am J Public Health. 1996;86844- 850
Link to Article
Critchlow  CWWolner-Hanssen  PEschenbach  DA  et al.  Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching. Am J Obstet Gynecol. 1995;173534- 543
Link to Article
Rosenberg  MJPhillips  RSHolmes  MD Vaginal douching: who and why? J Reprod Med. 1991;36753- 758
Kendrick  JSAtrash  HKStrauss  LTGargiullo  PMAhn  YW Vaginal douching and the risk of ectopic pregnancy among black women. Am J Obstet Gynecol. 1997;176991- 997
Link to Article
Brown  RL Fatal air embolism after insufflation of vagina. Lancet. 1943;1616
Link to Article
Nathenshon  AL Extreme shock and near death resulting from a douche. West J Surg Obstet Gynecol. 1947;55187
Chow  WDaling  JWeiss  NMoore  DSoderstrom  R Vaginal douching as a potential risk factor for tubal ectopic pregnancy. Am J Obstet Gynecol. 1985;153727- 729
Link to Article
Gresenguet  GKreiss  JKChacko  MKHillier  SLWeiss  NS HIV infection and vaginal douching in central Africa. AIDS. 1997;11101- 106
Link to Article
Rosenberg  MJPhillips  RS Does douching promote ascending infection? J Reprod Med. 1992;37930- 938
Onderdonk  ABDelaney  MLHinkson  PLDuBois  AM Quantitative and qualitative effects of douche preparations on vaginal microflora. Obstet Gynecol. 1992;80333- 338
Chow  JMYonekura  MLRichwald  GAGreenland  SSweet  RLSchachter  J The association between Chlamydia trachomatis and ectopic pregnancy: a matched-pair, case-control study. JAMA. 1990;2633164- 3167
Link to Article
Daling  JRWeiss  NSSchwartz  SM  et al.  Vaginal douching and the risk of tubal pregnancy. Epidemiology. 1991;240- 48
Link to Article
Phillips  RSTuomala  REFeldblum  PJSchachter  JRosenberg  MJAronson  MD The effect of cigarette smoking, Chlamydia trachomatis infection, and vaginal douching on ectopic pregancy. Obstet Gynecol. 1992;7985- 90
Centers for Disease Control and Prevention, 1998 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1)1- 111
Pybus  VOnderdonk  AB Evidence for commensal, symbiotic relationship between Gardnerella vaginalis and Prevotella bivia involving ammonia: potential significance for bacterial vaginosis. J Infect Dis. 1997;175406- 413
Link to Article
Amsel  RTotten  PASpiegel  CAChen  KCSEschenbach  DHolmes  KK Nonspecific vaginitis: diagnostic criteria and microbial and epidmilogic associations. Am J Med. 1983;7414- 22
Link to Article
Nugent  RPKrohn  MAHillier  SL Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991;29297- 301
Bump  RCBuesching  WJ Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive sexual transmission. Am J Obstet Gynecol. 1988;158935- 939
Link to Article
Hillier  SLNugent  RPEschenbach  DA  et al.  Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. N Engl J Med. 1995;3331737- 1742
Link to Article
Meis  PJGoldenberg  RLMercer  B  et al.  The preterm prediction study: significance of vaginal infections. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Am J Obstet Gynecol 1995;1731231- 1235
Link to Article
Houth  JCGoldenberg  RLAndrews  WW  et al.  Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacteria vaginosis. N Engl J Med. 1995;3331732- 1736
Link to Article
Faro  SMartens  MMaccato  MHammill  HPearlman  M Vaginal flora and pelvic inflammatory disease. Am J Obstet Gynecol. 1993;169(pt 2)470- 474
Link to Article
Soper  DEBrockwell  NJDalton  HPJohnson  DJ Observations concerning the microbial etiology of acute salpingitis. Am J Obstet Gynecol. 1994;1701008- 1017
Link to Article
Hillier  SLKiviat  NBHawes  SE  et al.  Role of bacterial vaginosis–associated microorganisms in endometritis. Am J Obstet Gynecol. 1996;175435- 441
Link to Article
Sweet  RL Role of bacterial vaginosis in pelvic inflammatory disease. Clin Infect Dis. 1995;20(suppl 2)S271- S275
Link to Article
Sewankambo  NGray  RHWawer  MJ  et al.  HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis. Lancet. 1997;350546- 550
Link to Article
Cohen  CRDuerr  APruithithada  N  et al.  Bacterial vaginosis and HIV seroprevalence among female commercial sex workers in Chiang Mai, Thailand. AIDS. 1995;91093- 1097
Link to Article
Klebanoff  SJCoombs  RW Viricidal effects of Lactobacillus acidophilus on human immunodeficiency virus type-1. J Exp Med. 1991;174289- 292
Link to Article
Stevens-Simon  CJamison  JMcGregor  JADouglas  JM Racial variation in vaginal pH among healthy sexually active adolescents. Sex Transm Dis. 1994;21168- 172
Link to Article
Ivey  JB The adolescent with pelvic inflammatory disease: assessment and management. Nurse Pract. 1997;2278- 91
Link to Article
Rome  ES Pelvic inflammatory disease: the importance of aggressive treatment in adolescents. Cleve Clin J Med. 1998;65369- 376
Link to Article
Not Available, Feminine therapeutic care can be productive. Drug Topics 1994;13864- 65
Jossens  MOEskenazi  BSchachter  JSweet  RL Risk factors for pelvic inflammatory disease: a case control study. Sex Transm Dis. 1996;23239- 247
Link to Article
Jossens  MOSchachter  JSweet  RL Risk factors associated with pelvic inflammatory disease of differing microbial etiologies. Obstet Gynecol. 1994;83989- 997
Link to Article
Aral  SWasserheit  J Social and behavioral correlates of pelvic inflammatory disease. Sex Transm Dis. 1998;25378- 385
Link to Article

Figures

Tables

References

Aral  SMosher  WCates  W Vaginal douching among women of reproductive age in the United States: 1988. Am J Public Health. 1992;82210- 214
Link to Article
Zhang  JThomas  ALeybovich  E Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health. 1997;871207- 1211
Link to Article
Buckley  TGottlieb  A Blood Magic: the Anthropology of Menstruation.  Berkeley University of California Press1988;
Blumberg  J The Body Project: an Intimate History of American Girls.  New York, NY Random House Inc1997;
Forrest  KWashington  ADaling  JSweet  R Vaginal douching as a possible risk factor for pelvic inflammatory disease. J Natl Med Assoc. 1989;81159- 165
Wolner-Hanssen  PEschenbach  DAPaavonen  J  et al.  Association between vaginal douching and acute pelvic inflammatory disease. JAMA. 1990;2631936- 1941
Link to Article
Neuman  HHDeCherney  A Douching and pelvic inflammatory diseases. N Engl J Med. 1976;295789
Scholes  DDaling  JRStergachis  AWeiss  NSWang  SPGrayston  JT Vaginal douching as a risk factor for acute pelvic inflammatory disease. Obstet Gynecol. 1993;81601- 606
Joesoef  MRSumampouw  HLinnan  MSchmid  SIdajadi  ASt Louis  ME Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia. Am J Obstet Gynecol. 1996;174(pt 1)115- 119
Link to Article
Chacko  MRKozinetz  CARegard  MSmith  PB The relationship between vaginal douching and lower genital tract infection in young women. Adolesc Pediatr Gynecol. 1992;5171- 176
Link to Article
Abma  JedChandra  AedMosher  WedPeterson  LedPiccinino  Led Fertility, Family Planning and Women′s Health: New Data From the 1995 National Survey of Family Growth.  Hyattsville, Md National Center for Health Statistics1997;Vital Health and Statistics No. 23.
Chacko  MMcGill  LJohnson  TSmith  PNenney  S Vaginal douching in teenagers attending a family planning clinic. J Adolesc Health Care. 1989;10217- 219
Link to Article
Baird  DDWeinberg  CRVoigt  LFDaling  JR Vaginal douching and reduced fertility. Am J Public Health. 1996;86844- 850
Link to Article
Critchlow  CWWolner-Hanssen  PEschenbach  DA  et al.  Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching. Am J Obstet Gynecol. 1995;173534- 543
Link to Article
Rosenberg  MJPhillips  RSHolmes  MD Vaginal douching: who and why? J Reprod Med. 1991;36753- 758
Kendrick  JSAtrash  HKStrauss  LTGargiullo  PMAhn  YW Vaginal douching and the risk of ectopic pregnancy among black women. Am J Obstet Gynecol. 1997;176991- 997
Link to Article
Brown  RL Fatal air embolism after insufflation of vagina. Lancet. 1943;1616
Link to Article
Nathenshon  AL Extreme shock and near death resulting from a douche. West J Surg Obstet Gynecol. 1947;55187
Chow  WDaling  JWeiss  NMoore  DSoderstrom  R Vaginal douching as a potential risk factor for tubal ectopic pregnancy. Am J Obstet Gynecol. 1985;153727- 729
Link to Article
Gresenguet  GKreiss  JKChacko  MKHillier  SLWeiss  NS HIV infection and vaginal douching in central Africa. AIDS. 1997;11101- 106
Link to Article
Rosenberg  MJPhillips  RS Does douching promote ascending infection? J Reprod Med. 1992;37930- 938
Onderdonk  ABDelaney  MLHinkson  PLDuBois  AM Quantitative and qualitative effects of douche preparations on vaginal microflora. Obstet Gynecol. 1992;80333- 338
Chow  JMYonekura  MLRichwald  GAGreenland  SSweet  RLSchachter  J The association between Chlamydia trachomatis and ectopic pregnancy: a matched-pair, case-control study. JAMA. 1990;2633164- 3167
Link to Article
Daling  JRWeiss  NSSchwartz  SM  et al.  Vaginal douching and the risk of tubal pregnancy. Epidemiology. 1991;240- 48
Link to Article
Phillips  RSTuomala  REFeldblum  PJSchachter  JRosenberg  MJAronson  MD The effect of cigarette smoking, Chlamydia trachomatis infection, and vaginal douching on ectopic pregancy. Obstet Gynecol. 1992;7985- 90
Centers for Disease Control and Prevention, 1998 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep. 1998;47(RR-1)1- 111
Pybus  VOnderdonk  AB Evidence for commensal, symbiotic relationship between Gardnerella vaginalis and Prevotella bivia involving ammonia: potential significance for bacterial vaginosis. J Infect Dis. 1997;175406- 413
Link to Article
Amsel  RTotten  PASpiegel  CAChen  KCSEschenbach  DHolmes  KK Nonspecific vaginitis: diagnostic criteria and microbial and epidmilogic associations. Am J Med. 1983;7414- 22
Link to Article
Nugent  RPKrohn  MAHillier  SL Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol. 1991;29297- 301
Bump  RCBuesching  WJ Bacterial vaginosis in virginal and sexually active adolescent females: evidence against exclusive sexual transmission. Am J Obstet Gynecol. 1988;158935- 939
Link to Article
Hillier  SLNugent  RPEschenbach  DA  et al.  Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. N Engl J Med. 1995;3331737- 1742
Link to Article
Meis  PJGoldenberg  RLMercer  B  et al.  The preterm prediction study: significance of vaginal infections. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network Am J Obstet Gynecol 1995;1731231- 1235
Link to Article
Houth  JCGoldenberg  RLAndrews  WW  et al.  Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacteria vaginosis. N Engl J Med. 1995;3331732- 1736
Link to Article
Faro  SMartens  MMaccato  MHammill  HPearlman  M Vaginal flora and pelvic inflammatory disease. Am J Obstet Gynecol. 1993;169(pt 2)470- 474
Link to Article
Soper  DEBrockwell  NJDalton  HPJohnson  DJ Observations concerning the microbial etiology of acute salpingitis. Am J Obstet Gynecol. 1994;1701008- 1017
Link to Article
Hillier  SLKiviat  NBHawes  SE  et al.  Role of bacterial vaginosis–associated microorganisms in endometritis. Am J Obstet Gynecol. 1996;175435- 441
Link to Article
Sweet  RL Role of bacterial vaginosis in pelvic inflammatory disease. Clin Infect Dis. 1995;20(suppl 2)S271- S275
Link to Article
Sewankambo  NGray  RHWawer  MJ  et al.  HIV-1 infection associated with abnormal vaginal flora morphology and bacterial vaginosis. Lancet. 1997;350546- 550
Link to Article
Cohen  CRDuerr  APruithithada  N  et al.  Bacterial vaginosis and HIV seroprevalence among female commercial sex workers in Chiang Mai, Thailand. AIDS. 1995;91093- 1097
Link to Article
Klebanoff  SJCoombs  RW Viricidal effects of Lactobacillus acidophilus on human immunodeficiency virus type-1. J Exp Med. 1991;174289- 292
Link to Article
Stevens-Simon  CJamison  JMcGregor  JADouglas  JM Racial variation in vaginal pH among healthy sexually active adolescents. Sex Transm Dis. 1994;21168- 172
Link to Article
Ivey  JB The adolescent with pelvic inflammatory disease: assessment and management. Nurse Pract. 1997;2278- 91
Link to Article
Rome  ES Pelvic inflammatory disease: the importance of aggressive treatment in adolescents. Cleve Clin J Med. 1998;65369- 376
Link to Article
Not Available, Feminine therapeutic care can be productive. Drug Topics 1994;13864- 65
Jossens  MOEskenazi  BSchachter  JSweet  RL Risk factors for pelvic inflammatory disease: a case control study. Sex Transm Dis. 1996;23239- 247
Link to Article
Jossens  MOSchachter  JSweet  RL Risk factors associated with pelvic inflammatory disease of differing microbial etiologies. Obstet Gynecol. 1994;83989- 997
Link to Article
Aral  SWasserheit  J Social and behavioral correlates of pelvic inflammatory disease. Sex Transm Dis. 1998;25378- 385
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles