1. Zuzelo, Patti Rager EdD, RN, ACNS-BC, ANP-BC, FAAN

Article Content

There is a lack of attentiveness to vaginal health during health care encounters with women. Rarely are women asked to describe the condition of their vaginas and to share signs and symptoms of what may be abnormal findings. Routine questions asked during a woman's examination typically address menses, birth control, and, possibly, sexual activity. These particular questions may feel more comfortable and less sexually charged than asking, "How is your vaginal health?" "Any issues with drainage or odor?" "What is the condition of your skin around your vulva, perianal region, and vaginal opening?" "Is intercourse or other sorts of sexual activity comfortable for you?" This is a concerning care gap, given the importance of a healthy vagina. A vignette based on actual experiences demonstrates the impact of failing to consider vaginal health.


This exemplar experience is informed by assessment data gathered by an adult nurse practitioner (ANP) during home visits with women older than 65 years. Visits are intended to identify educational needs, address gaps in care, discuss resource needs, and refer unmet physical or mental health care needs to the primary care provider (PCP). This particular encounter was with a woman who used incontinence pads "just in case" and who had recently been hospitalized for urosepsis requiring antibiotic therapy. She had required antibiotics several times during the previous 6 months or so for a variety of infections. After hearing about these experiences, the ANP asked the client about her vaginal health and encouraged her by sharing that it is not uncommon for women to experience itching, discharge, and discomfort in response to changes in the vagina caused by antibiotic therapy. The client and her daughter immediately began to describe vaginal and perianal issues that had been ongoing for several months. During this period of time, they had visited several physicians, including the PCP. No one had reportedly asked about her vaginal health. She was uncomfortable raising concerns because "if it was important or had something to do with my care, I figured that they would have mentioned it."


The daughter had been assisting her mother by applying diaper rash ointment and over-the-counter scented powders, but the mother's discomfort waxed and waned with occasions of scratching her vulvar region, commenting on the unpleasant drainage, and aggressively rubbing her skin with toilet paper and a wash rag during any opportunity to do so. A quick external examination revealed macerated pink skin, powder in reddened skin creases, and no visible drainage or notable odor at the time. The end result after a phone call to the PCP was a prescription for bacterial vaginosis and a follow-up appointment. The education provided during this encounter focused on vaginal health and the important need to speak up if worrisome signs and symptoms developed. Discussion ensued about medical therapies that increased the likelihood of vaginal flora disruption. Probiotic therapy, including supplements and foods, and skin care were also discussed.


Discomfort with or avoidance of vagina-specific health discussions does seem to be pervasive during nongynecologic health encounters. Vaginal health should be routinely and consistently addressed by care providers, and discussions should be culturally sensitive, polite, and age-appropriate. Education should include, in no particular order and not limited to, (1) the damaging effects of certain chemicals on vaginal integrity; (2) douching; (3) recognizing risks for bacterial vaginosis and vaginal yeast infections as well as associated signs and symptoms; (4) vaginal atrophy; and (5) vaginal health promotion.



Research findings demonstrate that popular chemicals can harm the vagina's epithelial lining and thereby enhance transmission of sexually transmitted infections, including herpes and human papillomavirus and human immunodeficiency virus (HIV) infection.1,2 There are a variety of marketed feminine hygiene products as well as personal lubricants that may be endocrine-disrupting chemicals, carcinogens, or allergans.1,3 Those women who practice douching and deodorizing at comparatively higher rates than other women, place themselves at greater risk from these products.1Women's Voices for the Earth, an organization devoted to amplifying women's voices to eliminate the toxic chemicals that harm our health and communities, calls for eliminating toxic chemicals from women's hygiene products.3 The organization notes that tampons are associated with hazardous chemicals that are used for bleaching and fragrance. Tampons may also have pesticide residue. Sanitary pads are similarly hazardous.3


Other concerning products that contain risky chemicals include genital wipes, douching products, anti-itch creams, and deodorant sprays.3 Of note, holistic providers need to keep in mind that the Federal Drug Administration does not require ingredient labeling on tampons and sanitary pads, nor is testing required to check for harmful chemicals.3 Providers need to consider that black and Latina women are at potentially greater risk of exposure to harmful chemicals used in feminine hygiene products because of their higher rate of product use.3



Douching practices vary worldwide, and douching facts and risks are misunderstood. Vaginal douching is the act of introducing a selected liquid, commercial or homemade, into the vaginal canal with the intent to clean or intervene with some sort of therapeutic goal. In the United States, approximately one-third of women utilize douching. Black women practice douching with greater frequency than white women.2


Female sex workers may include disinfectant in douching fluid following sex.4 Women may also administer vaginal douches for perceived hygienic purposes, religious beliefs, pregnancy prevention, or postmenses rinsing.5 Research findings support that douching is associated with adverse health effects and has few benefits.4-6 Douching consequences include increased risk of sexually transmitted infections, bacterial vaginosis, HIV infection, genital human papillomavirus infection, pelvic inflammatory disease, cervical cancer, and ovarian cancer risk.2,4-7 Vaginal douching increases exposure to phthalates (industrial chemicals), associated with negative influences on the reproductive, endocrine, and developmental systems.8


Research findings support an association between negative health outcomes and douching practices.4,9 Health care providers should regularly ask women about douching practices as part of the vaginal health assessment. Women who douche should be educated about the adverse effects and serious risks associated with this activity. Providers need to actively discourage women from vaginal douching.



Holistic health care providers need to teach women about risk factors for vaginal infection and associated signs and symptoms. As providers become more consistent with proactively raising the topic of vaginal health, women may become more comfortable raising concerns and sharing symptoms. For the approximately 50% of women with signs and symptoms of bacterial vaginosis, a grayish, malodorous discharge (fishy) is common.10 Vaginal yeast infections typically present with symptoms that include burning, itching, and thick, white discharge (cottage cheese).11 Women who have been educated to detect these signs and symptoms may be more likely to seek intervention in a timely fashion. Many women are unaware of the disruption to normal flora that is caused by antibiotic therapy. Those who are informed before beginning antibiotic therapy may be better able to ward off secondary vaginal infections by using probiotic therapy and avoiding douching and chemical exposures that harm the epithelial lining and vaginal alkaline state. Although there is no conclusive evidence to support probiotic therapy as a treatment option for vaginal health maintenance and restoration, the possibilities are promising and there are no adverse effects.10,12,13



Approximately 25% of postmenopausal women will experience signs and symptoms associated with vaginal atrophy. Despite the frequency of this condition, the topic is often inadequately explored by health care professionals. As a result, women may needlessly suffer with itching, burning, urinary frequency, painful sexual intercourse, vaginal canal tightening, vaginal discharge, and an increased likelihood of urinary tract infections.14 Vaginal atrophy symptoms may be self-limiting, but evaluation is important to ensure a correct differential diagnosis. There are treatment options, and it is important for women to have the information necessary for informed decision making. A relaxed, comfortable conversation should include content about avoiding anti-itch remedies and lubricants that contain unknown chemicals, parabens, methylisothiazolinone, and others. Women may find helpful the Women's Voices for the Earth Web site and its review of hazardous chemicals often found in women's hygiene products.3



A healthy vaginal state may be supported by probiotic therapy, defined as consisting "of bacteria or yeasts and can be considered functional foods that can re-colonize and restore the microflora symbiosis of the intestinal tract."15(p703) Lactobacilli are the most plentiful and dominant microbes found in the healthy vagina. These organisms produce composites that have antimicrobial properties, or protection against pathogens. These compounds include hydrogen peroxide, lactic acid, and antibacterial substances.15 There is insufficient evidence at this time to support definitive administration of probiotic therapy as treatment of bacterial vaginosis or as an intervention to prevent infection before or after antibiotic therapy.10,12 More research is needed, including randomized control trials. Probiotics may be administered intravaginally or orally. When probiotics are administered orally, the microbes passively migrate from the rectum to the vagina.12,13,15,16


Nurses and other health care providers need to incorporate vaginal assessments and teaching into regular health routines. Providing women with opportunities to learn about their vaginas, including strategies to maintain and promote a healthy state, is important. Holistic health care providers should assure women that it is appropriate and desirable to candidly share health information about their vaginas.




1. Wendee N. A question for women's health: chemicals in feminine hygiene products and personal lubricants. Environ Health Perspect. 2014;122(3):A70. [Context Link]


2. Bui TC, Thai TN, Tran LTH, Shete SS, Ramondetta LM, Basen-Enguist KM. Association between vaginal douching and genital human papillomavirus infection among women in the United States. J Infect Dis. 2016;214:1370-1375.doi:10.1093/infdis/jiw388. [Context Link]


3. Women's Voices for the Earth. Feminine care products and toxic chemicals. http:// Published 2016. Accessed December 13, 2016. [Context Link]


4. Li J, Jiang N, Yue X, Gong X. Vaginal douching and sexually transmitted infections among female sex workers: a cross-sectional study in three provinces in China. Int J STD AIDS. 2015;26(6):420-427. doi:10.1177/0956462414543937. [Context Link]


5. Bui TC, Tran LTH, Ross MW, Markham C. Douching practices among female sex workers in Phnom Penh, Cambodia. Int J STD AIDS. 2015;26(4):238-242. doi:10.1177/0956462414533098. [Context Link]


6. Mete S, Yenal K, Tokat M, Sercekus P. Effects of vaginal douching education on Turkish women's vaginal douching practice. Res Theory Nurs Pract. 2012;26(1):41-52. doi:10.1891/1541-6577.26.1.41. [Context Link]


7. Gonzalex NL, O'Brien KM, D'Aloisio AA, Sandler DP, Weinberg CR. Douching, talc use, and risk of ovarian cancer. Epidemiology. 2016;27(4):797-802. doi:10.1097/EDE.0000000000000528. [Context Link]


8. Branch R, Woodruff TJ, Mietro SD, Zota AR. Vaginal douching and racial/ethnic disparities in phthalates exposures among reproductive-aged women: National Health and Nutrition Examination Survey 2001-2004. Environ Health. 2015;14:57. doi:10.1186/s12940-015-0043-6. [Context Link]


9. Cottrell BH. An updated review of evidence to discourage douching. MCN Am J Matern Child Nurs. 2010;35:201-207. [Context Link]


10. Senok AC, Verstraelen H, Temmerman M, Botta GA. Probiotics for the treatment of bacterial vaginosis. Cochrane Database Syst Rev. 2009;(4):CD006289. doi:10.1002/14651858.CD006289.pub2. [Context Link]


11. Vaginal yeast infection. Office of Women's Health. US Department of Health and Human Services' Web site. https:// Accessed December 13, 2016. [Context Link]


12. Homayouni A, Bastani P, Ziyadi S, et al Effects of probiotics on the recurrence of bacterial vaginosis: a review. J Lower Genital Tract Dis. 2014;18(1):79-86. [Context Link]


13. Reid G. Probiotic and prebiotic applications for vaginal health. J AOAC Int. 2012;95(1):31-34. doi:10.5740/jaoacint.SGE_Reid. [Context Link]


14. Abnerathy K. Vaginal atrophy: secret symptoms? Prim Health Care. 2012;22(8):27-30. [Context Link]


15. Iannitti T, Palmieri B. Therapeutical use of probiotic formulations in clinical practice. Clin Nutr. 2010;29:701-725. [Context Link]


16. Borges S, Silva J, Teixeira P. The role of lactobacilli and probiotics in maintaining vaginal health. Arch Gynecol Obstet. 2014;289(3):479-489. doi:10.1007/s00404-013-3064-9. [Context Link]