Is the vaginal cleansing product industry causing harm to women?

KEYWORDS:

• Corporate interests
• douches
• microbiome
• vagina
• vaginal hygiene
• vaginal cleansing products
• vaginal microbiome
• women’s health

Over the counter vaginal cleansing products are part of a growing market. In the United States, for example, consumers spend over two billion dollars a year on douches, deodorant sprays, washes, personal wipes, and powders [1]. Advertising for these types of products tends to construct vaginal cleansing as both desirable and trendy for women [2]. Perhaps more concerning, the advertising of vaginal cleansing products often suggests to women that they are necessary for vaginal hygiene. This messaging is typically conveyed using terms like ‘clean’ and ‘fresh’ in product names and descriptions. For example, products like Vagisil Clean Scent Feminine Wash, RepHresh Clean Balance Douche, Summer’s Eve Fresh Scent Douche, and Femfresh Freshness Deodorant all demonstrate the use of this ‘clean and fresh’ marketing [3]. The implied association in this branding between product use and vaginal cleanliness/freshness capitalizes on cultural messages that women’s bodies are problematic, unclean, inadequate, and require intervention through the use of cosmetic products to improve their bodies [4–6]. These messages are not new and are linked to a long history of vaginal douches first being commercialized and marketed to women in the United States during the 20^th century as a form of vaginal deodorization, freshness, and cleanliness [7].

There has been accumulating evidence to suggest that many vaginal cleansing products have adverse health effects. The harms of douching, in particular, have been documented since the 1980’s [e.g. 8]. Some of these early medical studies connected adverse health outcomes to the added antibacterial ingredient hexachlorophene in douches which can cause nausea, vomiting, spasms, coma, and even death [7]. While the Food and Drug Administration (FDA) banned the use of hexachlorophene in cosmetics in the USA in 1971, over-the-counter douches today continue to be linked to adverse health effects; yet they are widely sold throughout Canada, the United States and internationally [7,9]. Adverse health effects include bacterial vaginosis, cervical cancer related to increased risks of contracting human papillomavirus infection (HPV), upper genital tract infections which can result in tubal factor infertility and ectopic pregnancy among others [10–14] As most research in this context has focused on douches, much less is known about the health effects of other vaginal cleansing products despite the fact that products like vaginal wipes and sprays are used very commonly by women. For example, cross-sectional studies conducted in the United States have reported that between 17 and 50% of women have used vaginal wipes and between 42 and 53% have used sprays [15,16]. Nevertheless, although there is much less research on vaginal cleansing products other than douches, the studies that have been conducted suggest that at least some of them are similarly associated with health risks. In particular, lubricants, deodorant sprays, and vaginal powders may increase women’s susceptibility to urinary tract infections, bacterial vaginosis, sexually transmitted infections, and an increased risk of ovarian cancer [17–20]. Other vaginal practices, such as vaginal steaming similarly pose harms to women’s health [21]. However, we do not know the full extent of the health risks associated with the wide range of vaginal cleansing products on the market and more research on these products is urgently needed.

The mechanism by which some vaginal cleansing products cause health problems is linked to disruptions in the vaginal microbiome. The vaginal microbiome is a vital part of a woman’s reproductive health and has a role in fertility and reproductive success, quality of life, and defending against potential pathogens [22–24]. When there is disruption of the vaginal microbiome this may predispose women to lower reproductive tract infections or even cause infertility [24,25]. Some studies suggest that intra-vaginal cleansing products can disrupt the microbiome by removing healthy mucous and bacteria from the vaginal cavity [18,26]. Douches and vaginal deodorants have both been shown to alter the vaginal microbiome over a period of time [25]. Again, due to the limited research that has been done on the vaginal microbiome in connection with vaginal cleansing products and practices, additional research is needed to determine if other products similarly have detrimental effects on the vaginal microbiome.

It should be acknowledged that some vaginal products may have benefits for women’s vaginal health. For example, while there is evidence to show that vaginal lubricants may disturb the vaginal microbiome, there are also some benefits including reducing discomfort and mucosal damage after vaginal intercourse and vaginal dryness after menopause [27]. Nevertheless, due to the dearth of research conducted on the topic, we do not know the extent of either the benefits or the harms and whether the benefits of some of these products outweigh the harms that have been reported especially for products that are specifically marketed for vaginal cleanliness and freshness. Ultimately, any product that has the chemical capability to alter the mucosa or pH of the vagina may cause more harm than good.

For the reasons outlined above, we believe that there is good reason to be concerned that the vaginal cleansing product industry is harmful to women. In particular, the industry uses marketing that promotes unattainable standards of vaginal hygiene to sell products, some of which are known to be associated with significant health risks. While one could argue that women have the ability to simply choose not to use these products, this ignores the broader societal pressures that some women experience in needing to be ‘clean’ [3]. We conducted a study to understand women’s motivations for using vaginal cleansing products using in-depth qualitative interviews [3,4]. One of the main reasons the women in our study gave was to attain vaginal cleanliness. For them, vaginal cleanliness meant an absence of vaginal odor and discharge. Other studies have been conducted that similarly show that attaining vaginal cleanliness is a commonly reported reason for why women use these products [14,28]. This is concerning, as the presence of vaginal secretions is often representative of women who are in good physiological health [29]. While it is important to recognize that some forms of vaginal odor and discharge may be indications of infections, such as bacterial vaginosis, vaginal emissions in a healthy vagina play important roles in protecting against irritation and infection. For this reason, vaginal cleansing products aimed to eliminate vaginal discharge are not only harmful but used under the wrong pretense as vaginal discharge, even fairly substantive discharge, is normal.

The notion that vaginal cleansing products may be harmful to women is also reflected in current medical recommendations in Canada and the United States. According to the Canadian Women’s Health Network, women are not advised to use douches or scented deodorants because they may cause irritation and are unnecessary for vaginal health and hygiene [30]. Guidelines on Screening and Management of Bacterial vaginosis from the Society of Gynecologists and Obstetricians of Canada note the association of douching and acquisition of bacterial vaginosis and advise against this practice [31]. Similarly, the United States Office of Women’s Health notes that vaginal cleansing products like douches are unnecessary for vaginal cleanliness and have been linked to problems during pregnancy as well as other health risks [32]. Furthermore, due to the self-cleaning capacities of a healthy vagina, the Canadian Women’s Health Network emphasizes that no substances aside from the application of water is recommended in and around the vulva area [30]. Given that the market for vaginal cleansing products is continuing to grow, at least within North America, we believe the vaginal cleansing product industry needs to be held accountable for the potential harms that their products pose to women [33,34]. Products that have been shown to cause harms should be taken off the market. Products that may be causing harms should ideally also be removed pending evidence for their safety, but at very least labeled transparently noting that they may be associated with health risks. And given that we know from decades of research in the tobacco, alcohol, and food industries, if it is unlikely for the feminine hygiene industry to self-regulate responsibly, we call upon regulators to take a firmer stance with regard to the sale and promotion of vaginal cleansing products [35].

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The research reported in this article was funded by the Canadian Institutes of Health Research.