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Purpose: Although vaginal douching is associated with several adverse outcomes, the reasons why women douche have not been studied prospectively., Methods: Non-pregnant (N = 3620) women aged 15 to 44 years presenting for routine care at 12 clinics in Birmingham, Alabama, participated in a longitudinal study of vaginal flora (1999-2003). Participants were assessed quarterly for 1 year. The authors applied conditional logistic regression in a case-crossover analysis to determine the individual-level factors that vary between a woman's douching and non-douching intervals. Findings were compared to a population-level analysis utilizing generalized estimating equations., Results: Thirty percent of participants douched in every interval; 28% douched in some but not all intervals. The case-crossover analysis indicated a woman was more likely to douche when reporting "fishy" vaginal odor (odds ratio [OR]:2.74; 95% confidence interval [CI]: 1.55, 1.84), vaginal irritation (OR: 1.52; 95% CI: 1.10, 2.11), summer month (OR: 1.37, 95% CI: 1.13, 1.67), or increase in number of sex partners (> or = 3, OR: 2.42, 95% CI: 1.11, 5.26). Bacterial vaginosis/trichomoniasis treatment (OR: 0.72, 95% CL: 0.59, 0.89) and absent menses (OR: 0.37, 95% CI: 0.28, 0.50) were negatively associated with douching. These ORs were farther from the null than comparable population-level estimates., Conclusions: Programs targeting these predictors may decrease the untoward sequelae associated with douching. Furthermore, a case-crossover analysis applied to prospective studies can provide insights into time-varying factors.

Objective: The authors assessed the knowledge, beliefs about, and practices of vaginal douching among women attending 2 universities in the southeastern United States., Participants: There were 416 participants in this study; 46.9% were black and 44.5% were white., Methods: The authors administered a 30-item questionnaire to women enrolled in health-related and social science courses at 2 southeastern universities., Results: Approximately 38% of participants reported vaginal douching, mostly for hygienic reasons (70.7%). Most women first learned about douching from their mother. Douching was more common and more frequent among black women (48%) than among white women (27%). Age of first douche correlated positively with age of first sexual intercourse and age of first period., Conclusion: Women who had been informed not to douche by a healthcare professional were less likely to have douched within the past 6 months than were women who were not given this information. Misconceptions about douching are common and should be addressed by healthcare professionals.

Objective: To determine the prevalence of douching among a cohort of HIV-infected women and to examine clinical outcomes associated with frequent douching-namely bacterial vaginosis, presence of a sexually-transmitted infections, and genital tract HIV-1 RNA shedding., Study Design: Participants included a concurrent cohort of 187 women attending an HIV outpatient clinic in New Orleans, LA. Subjects underwent clinical examinations and answered questions in a computer-assisted survey at each visit., Results: At baseline, 1-, and 3-month follow-ups, 64.2%, 56.5%, and 54.7% of women, respectively, indicated that they douched. In multivariable analyses, douching >1 time a month was independently associated with the outcomes of bacterial vaginosis and presence of a selected sexually transmitted infection (Trichomonas vaginalis, Neisseria gonorrhea, or Chlamydia trachomatis). Although not significant, women who douched >1 time a month were also twice as likely to have genital tract HIV-1 RNA shedding as nondouchers., Conclusions: This is the first study performed in women infected with HIV to link a significant dose-response relationship between douching and the clinical outcomes of bacterial vaginosis and presence of a sexually transmitted infection, and to examine the association between douching and genital tract HIV-1 RNA shedding.

The aim of this study was to examine factors related to frequent douching among a predominantly black and Hispanic alternative school population. It was observed that although Hispanic females were more likely to douche weekly compared with black females (30% vs. 13%), monthly douching was associated with black ethnicity, beliefs related to the therapeutic value of douching, perceived partner expectations, having female relatives who douched, and pregnancy history.

Objective: This study tests the hypothesis that vaginal douching among women of reproductive age is associated with exposure to intimate partner violence (IPV)., Methods: The data source is a cross-sectional population-based sample of 2,002 women ages 18-45 in the Central Pennsylvania Women's Health Study. The survey included measures of IPV, douching behavior, and relevant sociodemographic and health-related covariates., Findings: Six percent of the sample reported experiencing any type of IPV in the past year, and 23% reported douching in the past year. IPV is significantly associated with douching after controlling for sociodemographic and health-related covariates. This finding holds for women with and without current reproductive capacity., Conclusions: This is the first study to identify an association between vaginal douching and IPV. Because vaginal douching is a risk factor for sexually transmitted infections, bacterial vaginosis, and adverse pregnancy outcomes, the findings could have important implications for prevention. Further research is needed to identify the reasons why women who have been exposed to IPV are more likely to douche.

Objectives: To evaluate the relationship between douching and bacterial vaginosis (BV) among women with and without prior abnormal vaginal flora., Study Designs: 1193 women had vaginal swabs obtained for Gram stain for BV, culture for vaginal microflora, and DNA amplification for Neisseria gonorrhoeae and Chlamydia trachomatis at baseline and 6, 12, 24, and 36 months. Self-reported douching was queried every 6 months., Results: In cross-sectional analyses, douching at least once per month was associated with BV among women who had BV at the immediately preceding visit but not among women with normal or intermediate flora. In prospective analyses, douching increased the risk of acquisition for BV among women with intermediate flora (adj. HR 1.5, 95% CI 1.1-2.4) but not among women with normal flora., Conclusions: Douching appeared to be associated with BV among women with already imbalanced flora but not among women with normal flora.

Aim: Vaginal douching is a common hygiene practice for many women all over the world, but it is associated with several health risks. Little is known about the beliefs and attitudes that promote and maintain douching practices. Therefore, the objective of the present study was to evaluate the status of vaginal douching practices of women in the Malatya province of eastern Turkey., Methods: This was a cross-sectional study. A sample of 465 Muslim women was interviewed to ascertain the status of vaginal douching practices. All participants were between 15 and 49 years of age and all were married. Data were collected by using a questionnaire in the process of conducting face-to-face interviews in June 2004. Data analysis included descriptive statistics and logistic regression modeling., Results: The present study revealed that the frequency of douching was 61.5% among women. The participants were frequently douching for feminine hygiene (47.6%). Vaginal douching practices were associated with several factors including education level (odds ratio [OR] = 1.991, 95% confidence interval [CI] = 1.154-3.434), family income (OR = 0.996, 95% CI = 0.994-0.998), marital age (OR = 0.402, 95% CI = 0.223-0.715), frequency of sexual intercourse (OR = 2.335, 95% CI = 1.532-3.554), and presence of genital syndromes/infections (OR = 1.813, 95% CI = 1.215-2.739)., Conclusion: This study provides preliminary information about women's douching practices and attitudes in the Malatya region of Turkey. It may also provide information to health-care practitioners in their efforts to educate women on the adverse effects of vaginal douching.

Objective: The purpose of this study was to examine how vaginal douching may influence risk of preterm birth., Study Design: We conducted a hybrid cohort study on risk factors for preterm birth. African American women who resided in Baltimore City, Maryland, were enrolled prenatally if they received prenatal care at 1 of 4 Johns Hopkins Medical Institution prenatal clinics or were enrolled after delivery if they delivered at the Johns Hopkins Medical Institution with late, none, or intermittent prenatal care. Interview data were collected on 832 women delivering singleton infants between March 2001 and July 2004., Results: The preterm birth rate was 16.4%. After adjustment for several potential confounders, those covariates that were associated with either vaginal douching or preterm birth in our sample or that were identified as confounders in the literature, vaginal douching 6 months before pregnancy, and < 3 times per month (prevalence ratio, 0.63; 95% CI, 0.42-0.95) were associated with a reduced risk of preterm delivery. Douching during pregnancy was associated with a trend toward increased risk of preterm birth (prevalence ratio, 1.64; 95% CI, 0.97-2.76)., Conclusion: Vaginal douching effects on the risk of preterm birth depend on the timing of the exposure. Douching in the 6 months before pregnancy, but not during pregnancy, appears to protect against preterm birth.

Objectives of this secondary analysis were to describe the prevalence of vaginal douching among 1,432 women on active duty in the military and to examine demographic and behavioral factors associated with douching. More than one-half (54.5%) of the respondents reported douching at least once in their lifetimes; 63.5% of those douched during the previous year, and 45.8% of those douched in > or = 6 of the past 12 months. Multiple regression analysis showed that being African American, using tampons, having sexual intercourse, having more than one sexual partner in a month, using spermicides, and being in the enlisted and noncommissioned officer ranks were associated with more frequent douching (20.1% of the variance in douching behavior was explained). Despite access to regular gynecological examinations and related health counseling, a significant number of military women continue to douche. These women may benefit from specific intensive information on normal vaginal self-cleansing mechanisms and the health hazards of douching. Military efforts to diminish this self-care behavior and to enhance providers' knowledge about the scope of the problem may improve women's health and military readiness by decreasing the incidence of negative consequences of douching.

Introduction: Vaginal douching is a widespread practice among American women. Little research has been done examining variation in the practice or identifying risk factors., Methods: We collected data on douching, as well as hypothesized predictors of vaginal douching, as part of a cohort study on preterm birth. African-American women residing in Baltimore City, Maryland, were enrolled if they received prenatal care or delivered at The Johns Hopkins Medical Institution. Interview data were collected on 872 women between March 2001 and July 2004, with a response rate of 68%. Logistic regression analysis was selected to identify factors associated with douching in the 6 months prior to pregnancy., Results: Almost two thirds of women reported ever douching and more than two thirds of those women reported douching in the 6 months prior to pregnancy. Variation was seen in the practice of douching with regard to frequency as well as technique. After adjusting for several confounders, prenatal enrollment (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.29, 2.53), more unmet needs for time for "non-essentials" (OR, 1.83; 95% CI, 1.27, 2.63), smoking in the year prior to the birth (OR, 1.78; 95% CI, 1.22, 2.60), and age >19 years (OR, 2.60; 95% CI, 1.36, 4.97) were significant predictors of douching in the 6 months prior to pregnancy., Discussion: We identified considerable heterogeneity in the practice of vaginal douching in a cohort of low income African-American women., Conclusions: Future studies should incorporate measures of the predictors of douching and detailed exposure information to determine the independent contribution of vaginal douching to health outcomes.

Objective: The aim of this study was to determine the vaginal douching habits and associated factors of women attending two different healthcare clinics., Study Design: This cross-sectional study was conducted between 1 and 31 May 2004. All participants were women (n=635) who attended either a university hospital gynecology clinic or a primary health care center family planning unit. One-way ANOVA, chi-squared test, and binary and multiple logistic regression analyses were used for the statistical evaluation of data., Results: The mean age of the participants was 36.90+/-10.72 years (range: 18-75). Half of the participants believed vaginal douching had a positive effect on health. They believed vaginal douching demonstrates cleanliness, prevents infections and pregnancy, removes sperm following intercourse, a necessity of Islamic doctrine, and reduces symptoms like discharge, unpleasant odor, etc. Of the women, 50.2% performed vaginal douching. Vaginal douching was associated with age, education level, type of dwelling, working outside of the home, age at marriage, age at birth of first child, parity, spontaneous abortion, history of pelvic inflammatory disease, use of contraceptives, and attending a healthcare clinic., Conclusion: Douching is a common habit among Turkish women. Many women are not aware of the harmful effects of douching. Public health and health professionals should monitor more closely this traditional habit in Turkey.

Objective: Use of vaginal douche products has been linked with a variety of reproductive health problems; nonetheless, the practice of douching persists. The goals of this study were to 1) determine the use of vaginal douches and other feminine hygiene products, 2) ascertain how safe women think vaginal douche products are, and 3) evaluate women's readiness to stop douching., Methods: A random-digit-dial computer-assisted telephone survey was conducted among US women between the ages of 18 and 44., Results: Of the 2,602 women interviewed, 11.8% (n = 307) engaged in regular douching (White: 9.1%; African American: 27.7%; Hispanic: 15.0%). Women who douched, compared to women who did not douche, used other feminine hygiene products significantly more often (vaginal sprays [ p < .0001], wipes/towelettes [ p < 0.01], vaginal powder [ p < 0.0001] and bubble bath for feminine cleansing [ p < 0.001]). Women who douched also were more likely than nondouchers to agree with the statement, "Douche products are safe to use; otherwise they wouldn't be on the market" (70.3% vs. 33.4%, respectively; p < 0.0001). Nearly all women (90.0%) who douched had no intention to discontinue the practice., Conclusion: Compared with women who do not douche, women who douche use other feminine hygiene products at a much higher rate and also believe that douche products are safe. Women who douche will remain resistant to stopping the practice without innovative interventions. Given that most women start douching in adolescence, teens should be targeted for prevention efforts.

Objective: The objective of this study was to identify douching patterns and their relation to sexually transmitted disease (STD) among black women seeking an STD evaluation., Study Design: This study was a cross-sectional survey with biologic testing for chlamydia and gonorrhea infection., Results: Of 891 participants, 46.1% were current douchers. Commonly identified reasons for douching were to cleanse after menses (65.4%) and to feel fresh (42.2%). Frequent douching was associated with douching after sex (P<0.001), to alleviate an itch (P<0.001), and to feel fresh (P<0.001). Women who douched during menses (adjusted odds ratio [AOR]=4.78; 95% confidence interval [CI]=1.13-20.13) and to alleviate an itch (AOR=3.66; 95% CI=1.00-13.41) were more likely to have a current chlamydial infection., Conclusions: Douching was common among this high-risk population of black women. Prospective studies are needed to determine the consequences of douching and any mediating effects of women's motivation for the behavior on reproductive health.

Study Objective: To characterize the discussions on douching that female parents/guardians have with daughters., Design: A questionnaire assessing personal douching history, beliefs on the practice of douching, and what they had discussed or intended to discuss about douching with their daughters was administered to women who were parenting females 11-21 years of age., Participants: Fifty-seven women who had douched or currently douche completed the questionnaire., Results: Fifty-six of the women had discussed or planned to discuss the subject with their daughters. The girls with whom they had had a discussion were significantly older (16.2 years) than those with whom they planned to have a discussion (14.1 years). Most (73%) of the women had encouraged or planned to encourage douching, while only 18% had or planned to discourage it. Mothers had or planned to have the conversation in the context of menses (76%), sexual activity (40%), or when their daughter instigated the conversation (44%). Over 40% of the mothers had not or did not intend to discuss any negatives about douching. Only ten of the women stated that a health care provider had spoken to them or their daughter about the subject., Conclusion: Female parents/guardians are an important source of information about douching for their daughters. Health care providers need to educate girls as well as the women who parent them on the health risks associated with douching. Public campaigns aimed at decreasing douching should target this intergenerational transfer of information.

Objective: To determine if douching with Water Works device for 1 month can (1) lower or eliminate perceived vaginal odor by subject; (2) have any effects on vaginal ecosystem., Methods: Ten women with perceived vaginal odor with or without discharge, douched every day for 4 weeks in an open-label, nonrandomized pilot study. Primary outcome measures included perceived vaginal odor by subject, lactobacilli score from Nugent slide, and acceptance of the Water Works douching system. Secondary outcome included the safety of using this douching device., Results: At week 4, there was improvement in vaginal odor (P=.0006) and there was no significant change in lactobacilli score., Conclusion: Douching with Water Works device is associated with reduction or elimination of vaginal odor without adversely affecting the vaginal ecosystem.

Objective: To document knowledge, beliefs, douching practices, prevalence of bacterial vaginosis, and preterm births in women who douche., Design: Descriptive, cross-sectional nonexperimental design., Setting: Six private midwifery/nurse practitioner offices and eight county health departments in the Florida panhandle., Participants: Four hundred eighty-three English- or Spanish-speaking women aged 14 to 45 years., Methods: Self-administered questionnaire about douching; medical record review., Main Outcome Measures: Prevalence of douching, history of preterm labor, preterm births, and prevalence of bacterial vaginosis., Results: Of 483 women, 76% had douched, 43% douched at least once per month, and 36% were unaware they should not douche. As determined by odds ratio, women who douched monthly were 2.5 times more likely to have a history of bacterial vaginosis than women who did not douche (p < .001), and women who douched weekly were 2.75 times more likely to have bacterial vaginosis (p = .004). Of 409 clients with medical records available, 32 had preterm births of which 69% had a history of bacterial vaginosis (x2 = 4.5, df = 1, p = .034). Among women with preterm births who douched regularly prior to pregnancy (n = 14), 87% had a history of bacterial vaginosis (x2 = 7.14, df = 1, p = .008)., Conclusions: Associations of douching with bacterial vaginosis and bacterial vaginosis with preterm labor were significant. Health care professionals should initiate discussions to discourage douching.

Objective: The objective of this study was to evaluate an intervention to reduce vaginal douching among adolescent and young women who report douching., Study: This study consisted of a randomized, controlled trial of 275 primarily black adolescent and young adults aged 14 to 23 years. All women participated in 3 15-minute individualized counseling sessions. The experimental group received interventions based on their stage of readiness for ceasing vaginal douching. The comparison condition emphasized healthy eating and nutrition. The primary outcome measure was douching cessation (i.e., no douching in the preceding 3 months) at the 6-and 12-month assessment; a secondary outcome was progression through the stages of change toward douching cessation., Results: Based on an intention-to-treat model, participants assigned to the douching intervention group were significantly more likely to report having stopped douching at 6 months (relative risk [RR], 1.34; 95% confidence interval [CI], 1.03-1.73) and at 12 months (RR, 1.60; 95% CI, 1.28-2.00). At baseline, 89.9% of all women reported no intention to stop douching. Also based on an intention-to-treat model, there were no differences in stage across the 2 groups at 6 months (P = 0.29); however, at 12 months, the difference between the intervention and comparison group was statistically significant (P = 0.008)., Conclusion: Stage-matched interventions can reduce douching among adolescent and young adult women.

Objective: The purpose of this study is to characterize African-American women attending a community clinic who report frequent douching (douching > or = 2 times per week)., Methods: A consecutive sample of 115 black women attending a community clinic were interviewed face-to-face about their douching practices. Logistic regression was used to control for age and compute odds ratios and 95% confidence intervals., Results: Of the 115 women interviewed, 93% (107) had douched sometime during their lifetime; 16% (18) reported douching > or = 2 times per week. Frequent douchers compared with women who douche < 2 times per month were more likely to report douching after sex [89% (n=16) vs. 49% (n=32), odds ratio (OR): 5.35, 95% confidence interval (CI): 1.09, 26.2] or after discharge [89% (n=1 6) vs. 58% (n=38), OR: 8.11, 95% CI: 1.64, 40.1], and self-report a history of gonorrhea [28% (n=5) vs. 8% (n=5), OR: 4.87, 95% CI: 1.07, 22.2]., Conclusion: Further research should be done to understand the use of douching as an STD/HIV prevention method and the association between sexual risk behaviors and douching practices.

Objective: To describe the use of lemon/lime juice for douching by female sex workers (FSWs) and family planning clients (FPCs) in Jos, Nigeria., Method: A total of 300 sexually active women comprising 200 FSWs and 100 FPCs were interviewed in June 2004 to determine the mode and rationale for the use of lemon/lime juice for sex., Result: Majority of the women 167/300 (55.7%, 95% CI = 50-61%) i.e. 163/200 (81.5%, 95% CI = 75-87%) FSWs, 4/100 (4%, 95% CI = 1-10%) FPCs used vaginal lemon/lime douches. Lime juice was used by 105/167 (62.8%, 95% CI = 55-70%), lemon juice by 30/167 (18%, 95% CI = 12-25%) or a mixture by 18/167 (10.8%, 95% CI = 7-25%). The juice was used either neat 44/167 (26%, 95% CI = 20-34%) or diluted in water 75/167 (45%, 95% CI = 37-53%) either before or after sex. Nineteen per cent (32/167) found the juice painful. Over half of the women believed that it protected them from pregnancy and/or sexually transmitted infections; they did not know their HIV status. Eighty-six per cent would recommend it to others, and 71% would be willing to take part in a study to evaluate its safety and efficacy., Conclusion: Lemon and lime juice are widely used for douches among women at high risk of HIV transmission. There is an urgent need to determine whether or not this practice promotes or prevents HIV infection.

Background: Vaginal douching is associated with adverse reproductive health outcomes, yet both health providers and women are often poorly informed about details of this practice., Methods: We searched the English language articles in the MEDLINE database (1965-March 2004) to describe vaginal douching products, policies of professional organizations, predictors of douching practice, douching methods used, timing of use, and motivation. A key report was obtained from the Food and Drug Administration (FDA) via the Freedom of Information Act. Additional product information was obtained from manufacturers. Primary key terms for the literature search included (vagina OR vaginal) and (douche OR douching). Health effects of douching are reviewed briefly; personal practices and public policies are highlighted., Results: From the literature search, we identified 432 papers, of which 150 were reviewed in detail. Contrary to the assumptions of many health professionals, douching products are only loosely regulated by the FDA. Few professional organizations have clearly stated policy statements regarding douching. In the United States, the prevalence of douching varies considerably by race (more common among African Americans) and age cohort (more common in women born earlier). Internationally, vaginal douching is common in some cultures and is rare in others. Opinions of mothers, peers, and health professionals, in addition to marketing of commercial products, affect douching behavior., Conclusions: Regulation of vaginal douching products and public education efforts on douching behavior need to be reassessed. Because of the preponderance of evidence that suggests an association between vaginal douching and adverse reproductive health outcomes, professional and public health associations should consider educational and policy activities to discourage women from douching.

The practice of vaginal douching dates back centuries. Numerous studies have shown that douching is quite prevalent and often begins during adolescence. Motivation for the initiation and maintenance of this practice appears complex, and presents challenges to the intervention efforts. The practice of douching remains controversial. Douching has been implicated in numerous adverse reproductive health outcomes such as increased risk for pelvic inflammatory disease, ectopic pregnancy, reduced fertility, and bacterial vaginosis. However, recent studies in developing countries have suggested that in certain circumstances, douching may actually be beneficial. We summarize key findings from the review of published literature and ongoing research, as well as highlight research challenges to our understanding of the role of vaginal douching in reproductive health.

HIV transmission through heterosexual contact remains the greatest risk factor for women globally. Topical microbicides applied intravaginally may offer a female-initiated HIV prevention option for many who are unable or unwilling to use male condoms or who would want additional protection. This article presents results of focus groups in Bridgeport, Connecticut, Providence, Rhode Island, and San Juan, Puerto Rico, with women who use crack or heroin or have male partners who inject illegal drugs. Participants revealed motivation for and openness to using microbicides effective against HIV should they become available. Additional lubrication during intercourse was one of several expected positive features of microbicides; women saw lubrication as a means of enhancing pleasure and reducing condom irritation and breakage while also protecting them from infection. Conversely, some women feared that their male partners would interpret excessive lubrication as an indication of infection, improper hygiene, or evidence of sex with another man. Focus groups also provided insight into how aspects of different women's sexual lives, including partner type, might influence the issues that would concern them if and when they tried out new microbicidal products in the future.