Despite of vaginal douching has been strongly condemned by most of health care professionals; this practice remains a very common habit among women for several reasons.
To assess if there is any association between vaginal douching and bacterial vaginoses, STD and HIV
We conducted a systematic review and metanalysis to evaluate the relationship between vaginal douching and bacterial vaginosis, sexually transmitted diseases and HIV infection. The following databases were searched using Mesh terms: PubMed, Embase, Scielo and Google Scholar. Selection criteria: (1) prospective cohort studies of women using vaginal douching; (2) women 12 years or older and (3) studies published from 2000 to October 2011. Studies involving pregnant women were excluded. Methodological quality was assessed using Newcastle-Ottawa scale. Data collection and analysis: Review Manager 5.1 was used for statistical analysis.
Seven studies (2 STD, 3 Bacterial Vaginosis and 2 HIV) were included based on the chosen criteria: 9.796 women were enrolled. The global Risk Ratios for Bacterial Vaginosis, STD and HIV acquisition were, 1.24 (95%CI 1.12-1.43), 1.12 (95%CI 0.94-1.32), and 1.36 (95%CI 0.92-2.01) respectively.
There are few studies checking the association between vaginal douching and STD, BV and HIV infection. A weak positive correlation was found between vaginal douching and bacterial vaginosis, but not to STD and HIV infection.
Apesar de ducha vaginal estar fortemente condenada pela maioria dos profissionais de saúde; esta prática continua a ser um hábito muito comum entre as mulheres, por diversas razões.
Avaliar se há relação entre a prática de duchas vaginais e vaginose bacteriana, DST e HIV.
Foi realizada uma revisão sistemática e meta-análise para avaliar a relação entre a ducha vaginal e vaginose bacteriana, doenças sexualmente transmissíveis e infecção pelo HIV. Os seguintes bancos de dados foram pesquisados utilizando descritores: PubMed, Embase, Scielo e Google Scholar. Os critérios de seleção: (1) estudos prospectivos de mulheres que usam ducha vaginal; (2) mulheres com 12 anos ou mais e (3) estudos publicados de 2000 a outubro de 2011. Estudos envolvendo mulheres grávidas foram excluídos. A qualidade metodológica foi avaliada usando a escala de Newcastle-Ottawa. Coleta de dados e análise: Review Manager 5.1 foi utilizado para análise estatística.
Sete estudos (2 STD, 3 vaginose bacteriana e 2 HIV) foram incluídos com base nos critérios escolhidos: 9,796 mulheres foram incluídos. A razão de risco global para a vaginose bacteriana, DST e aquisição do HIV foram, (IC95% 1,12-1,43) 1,24 (IC95% 0,94-1,32) 1,12 e (IC95% 0,92-2,01) 1,36, respectivamente.
Há poucos estudos para verificar a associação entre a ducha vaginal e STD, VB e infecção pelo HIV. Foi encontrada uma correlação positiva entre a ducha vaginal e vaginose bacteriana, mas não para DST e infecção pelo HIV.
Vaginal micro flora (VMF) is the most efficient natural barrier against genital infections. The literature has recently accepted the fact that several factors can influence VMF, allowing science to see the delicate balance of this ecosystem as a result of several variables in a woman's life. These factors include age, pregnancy, menstrual cycle phase, sexual activity, vaginal practices and even diet1,2,3,4,5. One of the most important factor which leads to abnormal VMF is vaginal douching6.
It is known that abnormal VMF raises the risk of acquisition of HIV and other sexually transmitted diseases (STD)6,7,8,9,10,11,12,13
14 such as
Vaginal douching (VD) is wide spread around the world, and is more common than it is to be expected15. VD is defined as the practice of cleaning not only the vulvar introitus, but the entire the vaginal cavity, with a liquid solution for perceived hygienic, therapeutic and/or religious purposes1,16,17,18. VD can also be defined as wiping the internal genitalia with fingers and other substances (cotton, cloth, paper) such to remove fluids. This includes douching, which is the pressurized shooting or pumping of water or any other solution (including douching gel) into the vaginal cavity19.
The medical community frowns on VD, considered a homemade, self-prescribed household remedy. The majority of women disregards these admonitions, and continues douching regardless. The different reasons listed in recent studies include cleanliness after menses and before or after sexual intercourse, alleviating vaginal symptoms, as well as avoiding pregnancy, genital infections and HIV17,19,20.
The douching frequency is affected by such factors as culture and education17. Simpson
Numerous studies involving douching and genital infections point to the dilemma of establishing a cause and effect relationship. The difficulty lies in knowing whether pre-existing STD induced VD or if VD caused STD. Researchers also question whether VD is only a marker of sexual activity.
The purpose of this study is to evaluate the relationship between VD and BV, STDs and HIV infection.
This study used the MOOSE guidelines22.
The criteria for studies inclusion were:
• prospective cohort studies of women using VD; • women aged 12 years old or older; and • studies published after January 2000 up to October 2011.
• prospective cohort studies of women using VD;
• women aged 12 years old or older; and
• studies published after January 2000 up to October 2011.
Studies in which women were asked to stop using intravaginal practices and those involving vaginal microbicides, placebo products, tampons or other devices to deliver medication, and the ones involving pregnant women, were excluded.
Eligible studies were identified by searching the following databases: PubMed, Embase, Scielo and Google scholar. The studies were identified by a wide literature search of databases following medical subject heading terms and/or text words: "vagina", "intravaginal", "vaginal douching", "cleansing", "washing", "intravaginal practices", "insertion", "genital lesions", "HIV", "STD", "bacterial vaginosis", "trichomoniasis", "candidiasis", "uterine cervicitis", "uterine cervicitides", "cervicitides", "cervicitis", "cervicit", "endocervicit", "vaginal discharge", "pelvic inflammatory disease", "cervicovaginal infections" and "cohort studies". Reference lists of the identified publications for additional pertinent studies were reviewed. No language restrictions were imposed.
Three researchers searched for articles published up to October 2011. After searching the databases, 248 potentially relevant papers were identified, 185 of which were excluded after the review of both title and abstract. Reviews were done and disagreements were resolved by consensual discussion. Thus, 63 papers met the criteria and were reviewed in full. There were no articles in languages other than English which, based on the abstract analysis, met the criteria. The approved studies had their references researched for potential studies to be added in this meta-analysis. After a full review, 11 papers were included, but four coincident articles were found (they were in more than one database at the same time), remaining, finally, seven studies (
Various study characteristics were extracted from the original reports and included in the meta-analysis. The extracted data included publication data (first authors' last names, year of publication and country of studied population), number of new cases of specific outcome and follow-up period (
STD: sexually transmitted disease; PID: pelvic inflammatory disease
Data were entered in the Review Manager (RevMan) 5.123. RevMan allows the user to enter protocols as well as complete reviews, including text, characteristics of studies, comparison table, and study data, and to perform analysis of the data entered. The total Risk Ratio was analyzed overall, using fixed and random effects models and was tested for heterogeneity of effects using the χ² test.
We defined STD, BV and HIV infection as the outcomes. Seven reports, involving 12,511 women, were included. The design features of cohort studies of vaginal issues incidence in women who use VD which were approved to the meta-analysis are shown in
Only one study24 made the relation between VD and Pelvic Inflammatory Disease (PID),
The data were classified according to the frequency of VD as none (n = 733), once per month (n = 272) and twice or more times per month (n = 194). The four-year incident rate of PID was 10.9% and of gonococcus and/or chlamydial cervicitis was 21.9%. After adjustment for confounding factors, douching two or more times per month at baseline was not associated with PID (HR = 0.76; 95%CI 0.42 - 1.38) or
The results demonstrated that, compared to females who never douched, the time to STD was shorter for those who always douched (HR = 2.1; 95%CI 1.2 - 3.4) and for those who intermittently douched (HR = 1.5; 95%CI 1.0 - 2.2). After adjusting for HIV status, race baseline sexual history, and age, the hazard of STI was 1.8 times larger for participants who always douched rather than for participants who never douched (95%CI 1.1 - 3.1), whereas the hazard of STI was 1.4 times larger for participants who intermittently douched than for participants who never douched (95%CI 0.9 - 2.0). Wong
Assessing 1193 women which 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, Hutchinson
Three studies were approved to meet the BV outcome. Brotman
In the context of the HIV outcome, two studies were approved. The first of them, McClelland
As stated earlier, it is unclear whether VD is a direct cause or a cofactor in the progression of vaginal and/or systemic infections. It may also simply be a risk marker; none of the studies published so far have managed to clarify these possibilities. Given this fact, more recent studies have put this dilemma into question21,33,34.
It is important to highlight that there are few studies fulfilling methodological queries to check the association between vaginal douching and vulvovaginal and systemic infections. No consensus could be reached regarding the cause-effect relationship between VD and BV acquisition, despite there being a weak positive correlation. Within the three selected studies, a significant positive correlation was observed in only two of them28,29, specifically in women who douched more than 15 times or up to 14 times a week29. The fact that VD could be a risk marker allows us to assume that the risk of acquiring BV could possibly increase with increased vaginal douching frequency. As a result of this train of thought, the studies were used to construct a forest plot graph (
On the other hand, no positive correlation was found between douching and STD and/or HIV infection. Two studies evaluated the correlation between VD and STD24,25 and one24 did not find a positive correlation. Tsai
The only study which did not confirm a positive correlation was the one by Ness24. After adjusting for confounding factors, this study found that vaginal douching two or more times per month at baseline was not associated with neither PID (aHR = 0.76, 95%CI 0.42 - 1.38) nor
Similarly to the vaginal douching-BV correlation, disagreement was also found between the two studies regarding the causal relationship between VD-HIV (
One of the greatest limitations in our meta-analysis was the scarcity of articles found in the literature considering the possible influence of vaginal douching on vulvovaginal and systemic infections. This gap in the research was also observed in studies specifically evaluating vaginal douching and cervicitis incidence. Only one study24 addressing the issue in accordance with the inclusion criteria for of this work was found.
More methodologically correct and diversified research is needed to reach conclusive results concerning vaginal douching.
. Cidade Universitária "Zeferino Vaz", Universidade Estadual de Campinas. Rua Alexander Fleming, 101. Campinas (SP), Brasil. CEP: 13083-881. Tel: +55 (19) 3521-9306. E-mail: firstname.lastname@example.org