Vaginal washing is a common practice worldwide, and is motivated by perceptions that the vagina by nature is “unhygienic” (1). Methods of vaginal washing vary greatly across different regions. In the united states, women are more likely to douche (using a jet or stream of water) a few times a month using commercial products (1). In Africa, women are more likely to use a hand or piece of cloth to wash inside the vagina using water, household remedies, or soaps (1). Unfortunately, vaginal washing has been associated with increased risk of bacterial vaginosis (BV) and HIV acquisition (1) .
The Importance of the vulvovaginal area
Before we discuss PH balanced washes, we need to understand the importance of hygiene in external female genital area ( the vulvovaginal area) (4). The vulva is the first line of defense to protect the genital tract from infection (4). Contaminants often collect in the vulvar folds, and increased moisture, sweating, menses, and hormonal fluctuations influence vulvar microbial growth and species balance, potentially resulting in odor and vulvovaginal infections (4).
The Vaginal Microbiome
The vaginal microbiome (the balance of good and bad bacteria) plays a key role in overall vulvovaginal health, including your risk in developing infections (5). The vaginal microbiome in its “optimal” state, contains high concentrations of Lactobacillus species, and in “sub-optimal” states is characterized by increased bacterial species diversity and high concentrations of other bacterial species (6).
The vaginal microflora can fluctuate dependent on many factors including: age, hormonal shifts (ie. menopause, pregnancy and menses), infections, use of antibiotics, sexual intercourse, hormonal contraception and hygiene practices (5,6). Several studies suggest that the normal vaginal microbiome can also differentiate with ethnicity, with white and asian women having a higher percentage of lactobacillus species compared to hispanic and black women (5).
One study assessed the vaginal microbiome throughout full-term, uncomplicated pregnancies and found low diversity and high stability throughout pregnancy (5). This means that a full term healthy pregnancy is likely to have the same 1-2 strains of beneficial bacteria dominating with low changeability (5).
If the vaginal microbiome is disturbed, besides causing vaginal infections, another negative effect is that bacteria can alter the immune response and healthy barrier of the human vaginal cells, leading to the development and progression of reproductive disease (5).
Healthy pH Levels
So when we choose an “intimate wash” , we are hoping to impact our vulvar pH, moving it towards a “healthy pH” (5). A healthy vulvar pH is around 4.7 and the vagina is an average of 3.5 with reports ranging from 3.8 to 4.2 during the menstrual cycle (5).
Factors Impacting The Vulvar and Vaginal pH
Various factors may affect vulvar pH, including humidity, sweat, vaginal discharge, menstruation, urine and fecal contamination, genetics, age, soap, detergents, cosmetic products, lubricants and spermicides, wearing tight clothing or sanitary pads, shaving, and depilation products (5). Prolonged drying of the vulvar skin has been shown to significantly reduce its pH (5).
Vaginal pH, much like the microbiome, varies with ethnicity (5). A study found that the vaginal pH of healthy reproductive-age Hispanic and Black women was much less acidic than that of White and Asian women, reflecting the lower prevalence of lactobacillus species in these two ethnic groups (5).
The Impacts of pH & Microbiome on Human Health.
Vulvovaginal disease is often caused by multiple factors such as immune deficiency, hormonal changes, stress, or use of a vaginal douche or soap to clean the vagina (8). These factors may upset the normal microbiome leading to various infections (8).
The normal vaginal flora, vaginal pH, and vaginal discharge are all components of the defense mechanisms that protect against vulvovaginal infections (5). Beneficial bacteria help maintain an acidic pH, produce antimicrobial compounds and compete with harmful bacteria, so that they are unable to attach to the vaginal mucosa (5). Protection against a speficic bacteria known as Group B Streptococcus is particularly important for pregnant women, as it often colonizes the vagina through the gastrointestinal tract and increases the risk of preterm delivery, neonatal meningitis, and even fetal death (5). It may also cause asymptomatic urinary tract infections, upper genital tract infections, and postpartum endometritis (5).
In a study of pregnant women, elevated vaginal pH without current vaginal infection was significantly associated with preterm birth, and a 30% greater risk of infection with multiple human papillomavirus (HPV) (5).
Following menopause, as estrogen levels fall, the vaginal pH increases, and this alkaline pH is associated with increased harmful bacteria colonization (5). This is one of the main reasons why vulvar skin disorders are more prevalent after the menopause (5).
Over the counter vaginal care products
While vaginal douching may not be as popular as it once was, women are frequently using many over the counter products to help reduce their vaginal symptoms. Research examining American women’s vaginal practices beyond douching found that those who douched were more likely to use other commercially available vaginal products such as sprays, wipes, powders, and bubble bath for feminine cleaning (2) .
Reserach has found:
- 42- 53% of women had used vaginal sprays (2)
- Up to 50% used feminine wipes (2)
- Up to 46% used anti-itch products (2)
- 2% used deodorant suppositories (2)
Prevalence of vaginal infections
Eighty percent of women are said to have experienced at least one of the following vaginal symptoms in their lifetime (3).
- Itching (74.5%)
- Burning (50.2%)
- Unusual discharge (45.2%)
- Redness (34.9%)
- Irritation/rash (21.3%)
- Swelling (17.9%)
- Sores (10.7%)
In addition, over 50% reported having been clinically diagnosed at least once in their lifetime with a yeast infection/candida and a urinary tract infection (UTI) (3). Approximately 12% reported a bacterial vaginosis (BV) diagnosis at least once in their lifetime. Diagnosis of a sexually transmitted infection (STI) was reported by up to 6% of the sample, and approximately 6% of the sample had been diagnosed with cervical cancer (3).
A Canadian study found:
- Participants who had used any vaginal/genital health and hygiene product(s) in the 3 months prior had approximately three times higher odds of reporting any adverse health condition (2)
- The use of gel sanitizers was associated with higher odds of having a yeast infection and BV (2)
- The use of both feminine and baby wipes was associated with higher odds of UTI, and vaginal moisturizers/lubricants was associated with higher odds of both yeast infection and UTI. (2)
- Vaginal douching was associated with higher odds of yeast infection, BV, and UTI (2)
Over the past decade, there has been a surge in intimate hygiene products for cleanliness and odor control, but some may actually upset pH in the vulvovaginal area, impacting the composition of the normal vulvovaginal microbiota needed for protection against infection. One study found that women with vulvar use of bubble bath were twice as likely to have bacterial vaginosis, and bacterial vaginosis was three times more common in women using antiseptic solutions on the vulva or in the vagina. Furthermore, bacterial vaginosis was six times more common in women using a douching agent.
Cleaning your lady parts the proper way
Routine washing of the vulva (external female genitalia) is necessary to prevent the accumulation of vaginal discharge, sweat, urine, and fecal contamination and to prevent offensive body odor. Although vulvar cleansing may be a useful adjunct to medical treatment, over the counter vulvar cleansing products are not designed to treat infections.
Washing with water alone or with harsh surfactants can also 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 .
Since harsh soaps may irritate the vulvar skin and mucous membranes and worsen 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.
Take home points..
- Cleansing your vulva is an incredible part of proper hygiene and can help to maintain and balance a healthy microbiome
- Over the counter products may do more harm than good when they are used in the vulvovaginal area
- It is important to ensure you are being properly evaluated for any odors, redness or discharge that causes you to seek over the counter products in the first place
- If you are concerned about getting the optimal vaginal microbiome to prevent infection and promote a healthy pregnancy, speak to your naturopathic doctor to ensure you are being recommended quality products
- Speak to a professional if you are concerned about your vaginal care products
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References
- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210825
- https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0543-y
- https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0543-y
- https://journals.sagepub.com/doi/full/10.1177/1745505717731011
- https://journals.sagepub.com/doi/full/10.1177/1745505717731011
- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0210825
- https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0543-y
- https://journals.sagepub.com/doi/full/10.1177/1745505717731011
