The care of ‘down there’

Let face it, it’s hard enough to get a teen girl to look up long enough to answer basic questions during an exam, let alone start a completely uncomfortable conversation about vaginal hygiene. Realistically, though, if we don’t have the conversation, who will? Sure, moms give some instructions on how to wipe properly and remind teens to change their pads frequently, but are they giving the correct advice? Are many women just suffering in silence, assuming it’s just something women deal with? Or are they continuing harmful practices that have been passed down through the generations?

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Bacterial vaginosis

Bacterial vaginosis (BV) is a polymicrobial syndrome characterized by an imbalance of resident bacteria flora in the vagina.¹ The normal flora is predominantly lactobacilli and produces hydrogen peroxide, which keeps the vaginal pH around 4.5. When normal flora is disrupted, other bacteria such as Gardnerella vaginalis, Mycoplasma hominis, and Prevotella bacteroides, to name just a few, can take over, resulting in an unpleasant odor, a watery discharge, and a lower pH. Although originally thought to be sexually transmitted, BV can occur at any age and without having intercourse.²

The incidence of BV varies among races, among socioeconomic classes, and with age. Cultural practices and resources play more of a role than physiologic differences.² For example, African American women, particularly Caribbean blacks, have higher rates than white women, but douching also is more common among African American and Caribbean blacks than whites. Washing with harsh antiseptics or perfumed soaps also can increase risk, and BV can be sexually transmitted, so the number of partners a woman has can increase that risk.

The presence of BV also has significant social, interpersonal, and work effects and, for some women, is the source of extreme anxiety and distress, which is why many women turn to extreme measures such as douching to control it.^3,5

Furthermore, BV is associated with preterm labor and low birth weight infants. Studies have shown that women who are culture positive in their second trimester are at greater risk for adverse outcomes.⁶

Douching

Douching began in the mid-1800s with the advent of the Eguisier irrigator, which was sold in French pharmacies and consisted of a plunger and a nozzle and was used to prevent pregnancy. Then, in the 1920’s, Lysol was used as the antiseptic, with claims that it acted as a spermicide. Rinsing out the vagina after coitus was believed to kill any sperm in the body and prevent pregnancy. It wasn’t until the 1980’s that the ill effects of Lysol on the vagina were acknowledged and the practice was discontinued.⁴

Although, generally, douching has fallen out of favor and most authorities advise against it,studies have shown that there can be a benefit when used for vaginosis or vaginitis in relieving symptoms.^5,2 Those benefits do not outweigh the possible adverse effects. The process of douching allows for a pressurized solution to be injected into the vagina, thereby flushing bacteria throughout the vagina and into the uterus. In adolescence, the endothelial lining is more prone to adherence of the bacteria, so contracting a sexually transmitted infection is more likely and can increase the risk for ectopic pregnancy.² The mucus lining of the vagina also tends to be thick; using harsh soaps thins the mucosa, again increasing the likelihood of infections. Furthermore, studies have confirmed that there also is a higher transmission rate of HIV and chlamydia when BV is present.²

Treating and preventing BV

The treatment of choice for BV is metronidazole taken orally or introduced vaginally. Studies have shown that recolonization of the lactobacilli can be slow, so the addition of lactic acid can be helpful. Clindamycin orally or vaginally also is a reasonable choice. Given that most of the bacteria causing BV have beta-lactamase, penicillin is not effective.⁷

Probiotics taken orally have a natural migration to the vaginal area and promote recolonization.⁷ Taking 250 mg of vitamin C 6 days/month for 6 months also has been shown to be helpful in recolonization and prevention of recurrence.⁸

A discussion of proper vaginal hygiene is important for adolescents and teens. Poor hygiene can significantly affect their social and interpersonal relationships, as well as their self-esteem. It puts them at greater risk for contracting sexually transmitted infections, and if they become pregnant, of having an adverse outcome.

Make teens aware that any vaginal odor is abnormal, and explain the different types of discharge and which require a doctor visit. In addition, inform them that douching with harsh or perfumed soaps changes the pH of the vagina, which can lead to bacterial overgrowth, so douching should be avoided. Advise them to change pads used during the menstrual cycle every 4-6 hours, and that cotton underwear and loose-fitting clothes also can reduce vaginal irritation. Lastly, advise teens to drink lots of fluids, eat yogurt, and take vitamin C and probiotics to reduce the risk of recurrence.

Dr. Francine Pearce