The microbiota of the vulva and vagina: Ways of washing to optimise the protective function of the vulvo-vaginal microbiota during pregnancy

Background: The microbiota of the vulva and vagina has a crucial protective function, which is important for all women and has particular significance in pregnancy. Yet this microbiota is part of a delicately balanced ecosystem, susceptible to extrinsic factors which include the simple matter of how women wash themselves. Clinical observation and anecdotal evidence indicate that women in Aotearoa New Zealand have washing practices that may compromise the naturally acidic vulvo-vaginal environment crucial to optimising the protective function of the microbiota. Aims: The aims of this review are: to determine if there is dissonance between how women are washing their vulva and vagina and recommended washing practices; and to raise awareness of the emerging significance of the vulvo-vaginal microbiota to women’s health, particularly in pregnancy. Method: A literature review was undertaken to discover what is reported (in the published literature) about the ways women wash themselves, products used, and their effect on the vulvo-vaginal microbiota. The evidence behind the “wash with water” recommendation was investigated. Findings: There is a lack of primary research on ways of vaginal washing used by women in Aotearoa New Zealand. Globally, women are routinely using a variety of products that include soap, anti-bacterial wipes, gels and baby wipes, and invasive vaginal washing practices such as douching, flannel scrubs and internal soap cleansing. All washing products, including gentle soap but excluding lactic-acid based gels, alter pH levels when used on either the vulva or the vagina. Washing practices that alter vaginal pH levels can cause a microbial shift into a sub-optimal state that compromises the protective function of the vulvo-vaginal microbiota and is more susceptible to bacterial vaginosis and group B streptococcus vaginal colonisation. The frequency and duration within suboptimal states may be predictors of risk. Conclusion: There is dissonance between the ways women wash their vulva and vagina, and evidence-based advice to just wash with water. The back-to-basics message “just wash with water” promotes a way of washing that optimises the protective function of the vulvo-vaginal microbiota, while also protecting the integrity of vulval skin, and supporting physiological self-cleaning of the vagina.

Association between vaginal washing and detection of Lactobacillus by culture and quantitative PCR in HIV-seronegative Kenyan women: a cross-sectional analysis

ObjectivesVaginal washing has been associated with reductions in cultivable Lactobacillus and an increased risk of both bacterial vaginosis (BV) and HIV infection. The effect of vaginal washing on the quantity of individual Lactobacillus species is not well characterised. This analysis tested the hypothesis that vaginal washing would be associated with a lower likelihood of Lactobacillus spp. detected by both culture and quantitative PCR (qPCR).MethodsWe conducted a cross-sectional study of 272 HIV-seronegative women enrolled in an open-cohort study in Mombasa, Kenya. Vaginal washing and sexual risk behaviours were assessed using face-to-face interviews. Vaginal Lactobacillus spp. were detected using cultivation and PCR methods, with L. crispatus, L. jensenii and L. iners concentrations measured using qPCR assays targeting the 16S rRNA gene. Poisson regression with robust SEs was used to assess associations between vaginal washing and Lactobacillus detection by culture and qPCR.ResultsEighty percent (n=217) of participants reported vaginal washing in the prior week. One-fifth (n=58) of participants had BV by Nugent score. In unadjusted analysis, vaginal washing was associated with a 45% decreased likelihood of Lactobacillus spp. detection by culture (prevalence ratio (PR): 0.55, 95% CI 0.37 to 0.82). Adjusting for age and condomless sex in the prior week did not change the magnitude of the association (adjusted PR (aPR): 0.56, 95% CI (0.37 to 0.85). Vaginal washing was associated with approximately a 40% reduction in L. crispatus detection (aPR: 0.57, 95% CI 0.36 to 0.92), but was not significantly associated with L. jensenii (aPR: 0.68, 95% CI 0.42 to 1.09) or L. iners detection (aPR: 1.03, 95% CI 0.92 to 1.15).ConclusionsVaginal washing in the prior week was associated with a significantly reduced likelihood of detecting cultivable Lactobacillus and L. crispatus by qPCR. Given associations between Lactobacillus detection and improved reproductive health outcomes, these results provide motivation for additional study of vaginal washing cessation interventions to improve vaginal health.