(Very) Intimate Matters

Worldwide, women use a variety of intimate hygiene products as part of their daily cleansing routine. These practices are impacted by many factors, including personal preference, cultural norms, religious practices, and guidance from health care professionals. Although there is abundant literature on the vaginal environment, little is known about the vulvar area and how personal hygiene practices can affect its biological and physiological stability. More specifically, there is little published in the medical literature about intimate feminine hygiene as it relates to external topical washes and the role intimate feminine hygiene plays in managing unpleasant symptoms and supporting overall intimate health.

The vulva is the first line of defence to protect the genital tract from infection. 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 odour and vulvovaginal infection.

Vulvar skin differs from other skin sites in hydration, friction, permeability, and visually discernible irritation and is more susceptible to topical agents than forearm skin because of its increased hydration, occlusion, and frictional properties. The non-keratinized vulvar vestibule is likely to be more permeable than keratinized skin. Genital skin is unique in that it is covered by a thin stratum corneum containing large hair follicles, making it easier for microbial and other substances to permeate the skin.

Although knowledge about the microbial composition of the external vulvar area is in its infancy, maintenance of the microbiota ratio is anticipated to play a key role in overall vulvovaginal health. Data have shown that the normal vulvar flora includes vaginal, urethral, and colonic microbes as well as microbes characteristic of intertriginous skin.

The normal vaginal flora, acidic vaginal pH, and vaginal discharge are all components of the innate defence mechanisms that protect against vulvovaginal infections. Resident bacteria help maintain an acidic pH and compete with exogenous pathogens to adhere to the vaginal mucosa. They also fend off pathogens by producing antimicrobial compounds, such as bacteriocin.

Following menopause, and as estrogen levels fall, vaginal pH increases, and this alkaline pH is associated with increased colonization with pathogenic microbes. Vulvar skin disorders are also more prevalent after the menopause.

Many factors contribute to feminine hygiene practices, including personal preference and cultural and societal influences. Although vaginal douching is common for many women, there are no known confirmed health benefits, and this may undermine the innate immune defences by altering the normal vaginal flora and predisposing women to infections.

Vaginal douching has also been associated with an increased risk of pelvic inflammatory disease, endometriosis, and sexually transmitted infections. In contrast, routine washing of the vulva is desirable to prevent accumulation of vaginal discharge, sweat, urine, and fecal contamination to prevent offensive body odour. Although vulvar cleansing may be a useful adjunct to medical treatment, vulvar cleansing products are not designed to treat infections. There has, however, been a surge in intimate hygiene products for cleanliness and odour control, but some may upset pH in the vulvovaginal area, which will affect the composition of the normal vulvovaginal microbiota needed for protection against infection.

In 2011, the Royal College of Obstetricians and Gynaecologists (RCOG) performed extensive literature searches to develop evidence-based guidelines intended for the general gynecologist for improving initial assessment and care of vulvar skin disorders: (1)

• Most women with a vulvar disorder (e.g. contact dermatitis, vulvovaginitis) need advice about vulvar skin care and how to avoid contact irritants.

• Washing with water can cause dry skin and make itching worse. Use a small amount of soap substitute and water to clean the vulva.

• Shower rather than bathe and clean the vulva only once a day. Overcleaning can aggravate vulvar symptoms (e.g. symptoms of contact dermatitis). An emollient may be helpful.

• Avoid using sponges or flannels. Just use your hand. Gently pat dry with a soft towel.

• Wear loose-fitting silk or cotton underwear. Avoid close-fitting clothes. Wear loose-fitting trousers or skirts and replace tights with stockings. You may prefer to wear long skirts without underwear.

• Sleep without underwear.

• Avoid fabric conditioners and biological washing powders. Consider washing underwear separately in a non-biological laundry detergent.

• Avoid using soap, shower gel, scrubs, bubble bath, deodorant, baby wipes, or douches on the vulva.

• Some over-the-counter creams, including baby or nappy creams, herbal creams (e.g. tea tree oil, aloe vera), and “thrush” treatments, may include irritants.

• Avoid using panty liners or sanitary towels on a regular basis.

• Avoid antiseptic (as a cream or added to bath water) in the vulvar area.

• Wear white or light coloured underwear. Dark textile dyes (black, navy) may cause an allergy, but if new underwear is laundered before use, it will be less likely to cause a problem.

• Avoid using coloured toilet paper.

• Avoid wearing nail varnish on fingernails if you tend to scratch your skin.

The use of conventional panty liners (i.e. with a non-breathable back sheet) is a widespread practice but can increase the temperature, skin surface moisture, and pH of the vulvar skin, thereby significantly changing the microclimate of the vulva.

Extensive pubic hair removal, which was typically only done for cultural and religious reasons, has become more common for aesthetic reasons (2) Hair removal may cause skin microtrauma and subsequent spread of infectious agents throughout the pubic area. Severe consequences may include vulvovaginal irritation and infection and spread of sexually transmitted infections (e.g. molluscum contagiosum and HSV). (3) In a recent study of pubic hair removal practices, over half of women reported removing all pubic hair and the majority experienced one or more complications due to removal. (3) Pubic hair serves as a physical barrier for the vulvovaginal area and complete removal could lead to increased susceptibility to infections, although more data are needed to establish this link.

Gentle vulvar cleansing is desirable, and evidence suggests that it is an important aspect of female intimate hygiene and overall vulvovaginal health. Because of the risks associated with internal washing/douching, external feminine washes are considered more appropriate for intimate health, particularly those containing lactic acid, with an acidic pH that augments skin homeostasis and may serve as a helpful adjunct therapy in women with vaginal infections or taking antibiotics. Vulvar cleansing may be a useful adjunct for women with odorous vaginal discharge, and daily use of a feminine wash may reduce the risk of recurrence of bacterial vaginosis.

In addition, clinical practice guidelines recommend women to use a pH-balanced hypoallergenic cleansing agent for daily vulvar cleansing. These external washes need to be carefully formulated for mild, gentle cleansing without impacting the natural flora, particularly in cultures where women may use these products frequently. It is also important for intimate feminine hygiene products to be assessed clinically to ensure that they are well tolerated and provide targeted antimicrobial and other health benefits without negatively impacting the natural vulvovaginal microbiota.

NOT MY OWN WORK. Taken from:

Chen Y, Bruning E, Rubino J, Eder SE. Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Womens Health (Lond). 2017 Dec;13(3):58-67. doi: 10.1177/1745505717731011. Epub 2017 Sep 22. PMID: 28934912; PMCID: PMC7789027.

References:

(1) Royal College of General Practitioners. The management of vulval skin disorders, http://www.snhcic.org.uk/assets/cms_page_media/211/RCOG%20-%20Vulval%20Skin%20Disorders.pdf

(2) Farage MA, Bramante M. Genital hygiene: culture, practices, and health impact. In: Farage MA, Maibach HI. (eds) The vulva: anatomy, physiology and pathology. New York: Informa Healthcare, 2006, pp. 183–216

(3) DeMaria AL, Flores M, Hirth JM, et al. Complications related to pubic hair removal. Am J Obstet Gynecol 2014; 210(6): 528.e1–5.

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