Vaginal pH wash products effectively maintain or alter vaginal pH balance.
the verdict
CONTESTED
contested - the weight sits with the supporting side
refutedsupported
the weight of evidence
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Published literature reports conflicting findings and a general paucity of medical data regarding whether personal hygiene and feminine wash products effectively maintain or alter vaginal health and pH balance.
Knowledge of female genital anatomy and physiology is often inadequate or incorrect among women. Precise patient-physician conversations can be inhibited by a reluctance or inability to speak accurately about the vulva and vagina, with the terms often being used interchangeably. There is a paucity of scientific evidence and clinical guidelines to support women and physicians in ensuring best practices in feminine hygiene. In this review, the unmet needs in the field are highlighted. Evidence is provided for the complex array of physiological and pathological systems, mechanisms and behaviours that either protect or, if inappropriate, predispose the vulva and vagina to infections, irritation or other conditions. The need for attention to perineal health is recommended, given the interdependence of perineal and vulvar microbiota and the risk of colonic pathogens reaching the vulva and the vagina. Differences in feminine hygiene practices can vary widely across the world and among varying age groups, and suboptimal habits (such as vaginal douching or the use of certain cleansers) can be associated with increased risks of vulvar and vaginal conditions. Critical areas for discussion when advising women on their intimate health include: advice surrounding aesthetic vulvar cosmetic trends (such as depilation and genital cosmetic surgery), bowel health and habits, and protection against sexually transmitted infections. Routine, once-daily (maximum twice-daily) washing of the vulva with a pH-balanced, mild cleanser is optimal, ideally soon after bowel voiding, when feasible. Due to the finely balanced ecosystems of the vulva, the vagina and the perineal area, a scientific and clinical perspective is essential when determining the most appropriate vulvar cleansers based on their components. Correct intimate care may contribute to improved genital and sexual health and overall well-being. An increased awareness of correct practices will empower women to be the advocates of the
60 Incontinence can cause embarrassment, especially for women, because it can interfere with self-image and consequently self-esteem and sense of attractiveness. 60 , 61 Meanwhile, 60% of menopausal women experience vaginal discomfort and 87% experience sexual dysfunction, with a significant negative impact on QoL. 62 Following menopause, various genital symptoms, sexual and urinary symptoms and signs, termed as ‘genitourinary syndrome of menopause’ (GSM), can have a profound impact on the QoL of post-menopausal women. 63 , 64 These symptoms may cause women to seek further information or products to maintain their intimate health.
The impact of hygienic behaviours on intimate health Many myths or ‘fake news’ circulate around feminine hygiene and intimate care: for example, the need to wash excessively, perform vaginal douching, and use soaps, shower gels, scrubs, deodorants and over-the-counter preparations. However, washing too frequently can impair the vulvar and perineal skin microenvironments, causing irritation and exacerbating existing conditions.
Images courtesy of Professor Franco Anglana, MD, and used with permission. Vaginal douching may alter the normal vaginal microbiome, predisposing women to dysbiosis, including bacterial vaginosis, infections from colonic pathogens and STIs. 3 , 119 , 150 Vaginal douching has also been associated with an increased risk of pelvic inflammatory disease, endometriosis, cervical cancer and adverse pregnancy outcomes.
157 Given these potential adverse effects and the widespread use of over-the-counter feminine hygiene products, 65 such products should be more adequately tested by the suppliers to ensure that they do not cause vulvar skin irritation, sensitisation or pH or microbiota imbalances. Evidence base for specific feminine wash components Feminine washes must respect the individual needs of the vulva and avoid disrupting its natural balance. As noted above, feminine washing should ideally be limited to once per day, but for women required to wash more regularly (e.g.
those with IBS with frequent diarrhoea), a product that respects the unique vulvar microenvironment is necessary to maintain the microbiome balance and avoid dryness and exacerbation of any existing issues. 3 Of the feminine wash products available, many claim to have efficacy in odour-neutralizing, moisturizing or antibacterial activity. 3 Common ingredients include lactic acid, glycerine, and a variety of natural extracts. 3 One such natural extract is thymol, a major component of thyme oil.
Reprinted from Int J Antimicrob Agents, Vol 31(5), Braga PC, Culici M, Alfieri M, et al., Thymol inhibits Candida albicans biofilm formation and mature biofilm, p472–477, Copyright (2008), with permission from Elsevier. 158 The inclusion of lactic acid in feminine hygiene products has been shown to promote vulvar and vaginal health through maintaining an acidic pH, 78 , 163 while glycerine is used widely in dermatological interventions as a skin conditioning agent. 164 , 165 Working as a humectant, glycerine attracts water from the atmosphere or deeper in the dermis to maintain hydration levels in the upper epidermis layers.
The thymol-containing cleansing wash described above (also containing glycerine, ketoglutaric acid and lactic acid) has the capability to satisfy many of these emerging needs, by reducing pH, maintaining skin hydration, relieving vulvar and vaginal discomfort and improving sexual disturbances. 166 , 171 The thymol-containing cleansing wash therefore represents an appropriate cleansing option for maintaining the delicate and complex equilibrium of the vulva. Given our evolving knowledge of feminine hygiene and intimate care, there is a need for rigorous evidence-based scientific and clinical studies to determine further appropriate components for feminine wash products.
Correct intimate care may contribute to improved genital and sexual health; however, a lack of knowledge of the correct
Women use various feminine hygiene products, often as part of their daily cleansing routine; however, there is a paucity of published medical literature related to the external vulva and how personal hygiene practices can affect it. This review article provides background information on the physiological changes that occur during women's lives and reviews the relevance of transient and resident microbiota as they relate to common vaginal and vulvar disorders. It also discusses the need for female intimate hygiene, common practices of feminine hygiene from a global perspective, and the potential benefits of using suitable external, topical feminine vulvar washes to minimize the risk of vulvovaginal disorders and to improve overall intimate health in women around the world. Supported by international guidelines, daily gentle cleansing of the vulva is an important aspect of feminine hygiene and overall intimate health. Women should be encouraged to choose a carefully formulated and clinically tested external wash that provides targeted antimicrobial and other health benefits without negatively impacting on the natural vulvovaginal microbiota.
Abstract Women use various feminine hygiene products, often as part of their daily cleansing routine; however, there is a paucity of published medical literature related to the external vulva and how personal hygiene practices can affect it. This review article provides background information on the physiological changes that occur during women’s lives and reviews the relevance of transient and resident microbiota as they relate to common vaginal and vulvar disorders.
It also reviews global feminine hygiene practices and the potential benefits and risks of external feminine vulvar washes in overall feminine intimate health. There has been a recent increase in female intimate wash products on the
70 Vaginal products Vulvar products Product formats Lubricant Liquid wash (gel) Moisturizer Wipes Tablet Bar soap Estrogen product Spray Self-diagnostic kits for pH or hydration Foam Others: topical prebiotics/probiotics Others: talcum powder, cream, and deodorant Key actives Lactic acid Lactic acid Glycerin Glycerin Vitamin Vitamin Naturals: lavender, chamomile, aloe, etc Naturals: green tea Characteristics Botanical/herbal Antibacterial Gentle pH neutral pH balance Hypoallergenic Dermatologically tested Odor-neutralizing Odor-neutralizing Moisturizing Hypoallergenic Respect microflora Soap-free, paraben-free, fragrance-free Suitable for everyday use Avoid Douching Soap or harsh surfactant Oil-based lubricant Disruption of pH or natural flora Scientific support for a properly designed feminine wash Although common sense dictates that good feminine hygiene is desirable and healthy, no systematic trials have evaluated the health impact of vulvar hygiene.
In another study, women with vulvar use of bubble bath were twice as likely to have bacterial vaginosis than women who did not use this product, and bacterial vaginosis was three times more common in women using antiseptic solutions on the vulva or in the vagina and six times more common in women using a douching agent. 17 Washing with water alone or with harsh surfactants can be abrasive, may impact the local flora, and could lead to dry skin and vulvar itching, thereby increasing the risk of infection. A recent in vitro study suggested that some vaginal products may be harmful to Lactobacillus bacteria and alter the vaginal immune environment and therefore should be used with caution.
56 Since harsh soaps may irritate the vulvar skin and mucous membranes and provoke or exacerbate vulvar dermatitis, feminine wash products should be formulated and tested specifically for the vulvar area to ensure that they do not cause skin irritation or sensitization. Bahamondes and colleagues 73 demonstrated that using a lactic acid plus lactoserum liquid soap (~pH 4) for vulvar cleansing may help prevent bacterial vaginosis recurrence after oral metronidazole.
In a large study during which women were asked to use feminine wash products containing natural plant extracts for 4 weeks, a positive clinical effect was shown favoring reduction of vaginal pH and improvement of symptoms and quality of sexual activity compared with pretreatment. 74 , 75 Another study demonstrated that a feminine intimate hygiene deodorant spray with or without antibacterial components (0.01% or 0.02% chlorhexidine) did not significantly affect perivaginal microflora 11 ; however, the study was done before molecular identification techniques such as 16s ribosomal RNA (rRNA) microbiome sequencing and shotgun metagenomics became readily available.
Currently, there are many different intimate feminine hygiene products that may be used for cleanliness and/or odor control, but some can alter the normal pH level/microbiota needed for protection against infection. Although there is much published literature on the internal vaginal environment, there is relatively limited information related to the external vulva and how intimate personal hygiene practices can affect it. Thus, education about the importance of, and potential risks associated with, female intimate hygiene is an important priority for both health care professionals and women to advance overall intimate health and hygiene.
It will be interesting to observe whether start-up companies will find a better alternative to vaginal seeding using defined combinations of customized vaginal bacteria. Considering the increasing amount of research and data in the vulvovaginal microbiome field, should the future MECA and RCOG guidelines evolve to incorporate this very important aspect of vulvovaginal health? With the rapidly developing field of microbiome research, therapeutics, and diagnostics, we can expect to see more product offerings that will not only maintain the innate vulvovaginal microflora but also selectively boost the beneficial strains to enhance immunity against pathogenic infections.
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