Sexually Transmitted Diseases:
Predictors of Bacterial Vaginosis in Adolescent Women Who Douche
Schwebke, Jane R. MD*; Desmond, Renee A. PhD*; Oh, M Kim MD†
From the Departments of *Medicine and †Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
This work was supported by STD Cooperative Research Center (NIH U19 AI38514-09). The authors thank Pernell Brown, RN, Marga Jones, MPH, and Jeanne Merchant, MPH, for their assistance with this study.
Correspondence: Jane R. Schwebke, MD, University of Alabama at Birmingham, 703 19th St. South, ZRB 239, Birmingham, AL 35294-0007. E-mail: firstname.lastname@example.org
Received for publication October 28, 2003, and accepted February 5, 2004.
Objective: Risk factors for bacterial vaginosis (BV) include douching and sexual activity, although the exact cause of BV is unknown.
Goal: The goal of this study was to determine the relative significance of douching as a risk factor for BV.
Study Design: Two hundred fifty adolescent women who regularly douched were enrolled into a randomized douching intervention trial. Behavioral questionnaires and testing for sexually transmitted diseases and BV were performed. Associations between baseline characteristics and behaviors were compared for teens who were BV-positive and BV-negative at baseline.
Results: Positive correlates of BV included multiple partners, recent sexual intercourse, douching after menses, recent douching, and gonorrhea. Of these, douching after menses showed the strongest association (odds ratio, 5.11; 95% confidence interval, 1.99–13.15) in a multivariate analysis.
Conclusions: Douching after menses was strongly correlated with BV; however, difficulty remains in trying to evaluate douching and sexual behavior independently.
BACTERIAL VAGINOSIS (BV) is the most prevalent form of vaginitis, yet the etiology is unknown.1,2 Microbiologic changes consistent with BV include a decrease in the lactobacillus population, particularly those that produce hydrogen peroxide, and an increase in anaerobic and facultative anaerobic bacteria such as Gardnerella vaginalis, mycoplasma, Mobiluncus spp., and black-pigmented anaerobic rods.3–5 The most common diagnostic methods for BV include the clinical criteria of Amsel et al. and the Gram stain criteria of Nugent et al.1,6 Both sexual behavior and vaginal douching have been shown to be associated with BV. For the latter, however, the cause-and-effect relationship is unknown. The purpose of this study was to determine correlates of BV among adolescent women who douche to help determine the relative significance of douching in the development of BV.
Materials and Methods
The baseline data of the first 250 participants in an ongoing randomized, controlled trial of a douching behavioral intervention was analyzed. Women were eligible for enrollment if they were 14 to 23 years of age, had douched at least once in the preceding 35 days, and had been douching for at least 6 months. Participants were enrolled at a general adolescent clinic and recruited from primary care clinics and local university campuses. The Institutional Review Board of the University of Alabama at Birmingham approved the study. Women were interviewed about their sexual practices, douching behavior, and sexually transmitted disease (STD) history. Women were screened for STDs, including gonorrhea, chlamydia, trichomonas, BV, and herpes simplex virus type 2 (HSV-2), at their initial visit.
Urine specimens were tested for Neisseria gonorrhoeae and Chlamydia trachomatis using the ligase chain reaction (Abbott Laboratories, Abbott Park, IL). The presence of Trichomonas vaginalis was detected using the InPouch TV culture technique (BioMed Diagnostics, Inc., San Jose, CA). BV was detected using the Nugent method to interpret Gram-stained vaginal fluid specimens.6 Scores of 0 to 3 were considered normal, 4 to 6 as evidence of intermediate flora, and 7 to 10 as BV. Vaginal swab specimens were also cultured for lactobacilli. Specimens were transported in anaerobic holding media and inoculated onto MRS agar.7 Plates were incubated anaerobically for 48 to 72 hours and lactobacilli were identified as Gram-positive catalase-negative rods, which produced predominantly lactic acid as detected by gas chromatography.8 Type-specific serology for HSV was performed using a type-specific enzyme-linked immunosorbent assay using recombinant gG2 for herpes simplex type 2 (HerpeSelect, Focus Technologies, Herndon, VA).
Baseline descriptive continuous variables were compared using the t test and categorical variables were compared across vaginosis categories by chi-squared test or Fisher exact test. Factors that were significant in the univariate analysis at a P value of ≤0.10 were examined as risk factors in the multivariate analysis. Logistic regression was performed with backward and forward selection procedures to determine the significant predictors of vaginosis. Model fit was compared by using Akaike’s Information Criteria and the model with the smallest AIC was selected as the best model. For all final analyses, a P value of <0.05 was deemed statistically significant.
The analyses presented are based on the first 250 women enrolled into the study. The mean age of participants was 18.7 years, whereas the mean age of sexual debut was 15 years. Ninety percent of the participants were black. BV was present in 44.8% (112 of 250) of women, whereas 32.8% (82 of 250) had a lactobacillus-predominant vaginal flora. The remaining 22.4% (56 of 250) had intermediate vaginal flora.
Table 1 shows the comparisons of demographic, sexual history, behavioral and clinical variables for women stratified by the presence or absence of BV. Women with more than 1 sexual partner in the prior 3 months were significantly more likely to have BV than women without BV (29.3% vs. 17.8%, respectively, P = 0.04). Sexual activity within the week before study visit was also associated with BV but not significantly (P = 0.08). Otherwise, there were no significant differences in terms of STD/BV history or sexual behavior, including condom use between the groups.
The mean age at which douching was initiated was 16 years. Approximately 50% of women douched more than once per month with nearly all using a commercial product. Douching after menses was significantly associated with BV (P = 0.001). Furthermore, last douching within the previous week before the study visit was positively associated with BV (P = 0.04). Frequency of douching, duration of douching in terms of years, and douching for symptoms were not associated with BV.
Prevalence of Sexually Transmitted Diseases
On entry to the study, the prevalence of chlamydia, gonorrhea, and trichomoniasis in this group of teenagers was 16.4% (41 of 250), 4% (10 of 250), and 8% (20 of 250), respectively. Gonorrhea was significantly less frequent among women without BV. Although not statistically significant, more women in the BV group had trichomoniasis, chlamydia, and HSV-2 than did women without BV. Lactobacilli were isolated significantly more often from women without evidence of BV than from women with BV (61.5% vs. 27.2%, P <0.001). Prevalence of STD was not associated with frequency of or last episode of douching (data not shown)
Data from the multivariate analysis are presented in Table 2. At baseline, women who reported douching after menses were over 5 times more likely to have BV compared with those without BV (odds ratio [OR], 5.11; 95% confidence interval [CI], 1.99–13.15). Women who douched within the last week were significantly more likely to have BV (OR, 1.84; 95% CI, 1.07–3.18) controlling for sexual activity within the last 7 days.
Bacterial vaginosis is an extremely common vaginal infection characterized by prominent changes in the type and quantity of vaginal bacteria.9 The etiology remains unknown, hampering adequate treatment and prevention efforts. Several behaviors have been associated with BV, most notably sexual behavior and douching.1,10–18 Although douching has been frequently associated with BV, the cause-and-effect relationships are less clear. It is possible that douching has a direct effect on the vaginal flora leading to a decrease in lactobacilli and an increase in BV-associated bacteria. It is also possible that women could douche as a result of experiencing vaginal symptoms associated with BV. Data on the relationship between douching and BV are limited to cross-sectional studies with prospective data lacking and differing results have been reported. In a study of women attending clinics in Michigan, vaginal douching in the past 2 months was significantly associated with BV (OR, 2.9; 95% CI, 1.5–5.6). Unprotected sexual activity as well as greater than 15 lifetime male partners was also associated with BV but did not reach statistical significance. Use of hormonal contraception within the past 6 months appeared protective (OR, 0.4; 95% CI, 0.3–0.7).18 In a study of female sex workers in Nairobi, Kenya, douching was significantly associated with BV (P = 0.05) after controlling for the association of BV and STDs; however, sexual activity was not associated with BV in this cohort of highly sexually active women.16
Ness et al. reported on the results of a large multicenter study of the health consequences of douching and found that douching once or more per month was associated with abnormal vaginal flora (BV or intermediate flora) after controlling for other variables (OR, 1.4; 95% CI, 1.1–1.9). Douching within 0 to 7 days of the study visit was also associated with abnormal vaginal flora (OR, 2.1; 95% CI, 1.3–3.1). However, the majority of women reported douching because of vaginal symptoms.19 A longitudinal study of women attending an STD clinic in Seattle found acquisition of BV to be associated with both douching for hygiene (hazard ratio [HR], 2.1; P = 0.05) and with a new sexual partner (HR, 2.5; P = 0.004).20 Finally, in a study of women who have sex with women, Marrazzo et al. failed to find an association between BV and douching but did find an association with greater number of lifetime female partners, oral-anal sex, and failure to clean insertive sex toys.21 Our results are consistent with findings from previous studies in that both sexual activity and the timing of douching are associated with abnormal vaginal flora. In our study, multiple partners in the past 3 months, sexual intercourse within 1 week before the study visit, infection with gonorrhea, douching after menses, and douching within 1 week of the study visit were all associated with BV or intermediate vaginal flora. However, BV was not associated with frequency of douching, types of solutions used, or reasons for douching.
The strong association, which was noted in this study between douching after menses and BV, further strengthens the data linking douching to BV but does not resolve the question of cause and effect. Menses could exacerbate vaginal symptoms of discharge and/or odor either through a direct effect of blood in the vault or as a result of the instability of vaginal flora that has been shown to occur in many women around the time of menses.22,23 Thus, women could douche in an attempt to ameliorate these transient symptoms. It is also possible, however, that douching at a time of vaginal flora instability and vulnerability leads to BV.
Although the data associating BV with douching is compelling, it is still not possible to analyze douching and sexual activity as separate risk factors because the 2, as evidenced by this study, are interrelated activities. Although cross-sectional, our results for the prevalence of STDs at the initial study visit is of interest and compatible with previously published findings.24–26 Gonorrhea was significantly associated with BV as were chlamydia, trichomonas, and HSV-2, although these associations were not statistically significant.
In summary, douching after menses was strongly associated with BV; however, the findings from our study reconfirm the inherent difficulties in studying the independent effects of sexual activity and douching on the vaginal flora. Prospective studies are needed to determine if douching itself directly influences the composition of the vaginal flora.
1. Amsel R, Totten PA, Spiegel CA, Chen KCS, Eschenbach D, Holmes KK. Non-specific vaginitis: Diagnostic and microbial and epidemiological associations. Am J Med 1983; 74:14–22.
2. Rein MF, Holmes KK. ‘Non-specific vaginitis,’ vulvovaginal candidiasis, and trichomoniasis clinical features, diagnosis and management. Curr Clin Top Infect Dis 1983; 4:281–315.
3. Hill GB. The microbiology of bacterial vaginosis. Am J Obstet Gynecol 1993; 169:450–454.
4. Eschenbach DA, Davick PR, Williams BL, et al. Prevalence of hydrogen peroxide-producing Lactobacillus
species in normal women and women with bacterial vaginosis. J Clin Microbiol 1989; 27:251–256.
5. Spiegel CA, Amsel R, Eschenbach D, Schoenknecht F, Holmes KK. Anaerobic bacteria in non-specific vaginitis. N Engl J Med 1980; 303:601–607.
6. Nugent RP, Krohn MA, Hillier SL. Reliability of diagnosing bacterial vaginosis is improved by a standardized method of Gram stain interpretation. J Clin Microbiol 1991; 29:297–301.
7. DeMan JC, Rogosa M, Sharpe ME. A medium for the cultivation of lactobacilli. J Appl Bact 1960; 23:1305.
8. Hillier SL, Moncla BJ. Peptostreptococcus
, and other non-spore forming anaerobic gram-positive bacteria. In: Murray PR, Baron EJ, Pfaller MA, Tenover FC, Yoken RH, eds. Manual of Clinical Microbiology. Washington, DC: ASM Press, 1995:587–602.
9. Spiegel CA. Bacterial vaginosis. Clin Microbiol Rev 1991; 4:485–502.
10. Moi H. Prevalence of bacterial vaginosis and its association with genital infections, inflammation and contraceptive methods in women attending sexually transmitted disease and primary health clinics. Int J STD AIDS 1990; 1:86–94.
11. Barbone F, Austin H, Louv WC, Alexander WJ. A follow-up study of methods of contraception, sexual activity and rates of trichomoniasis, candidiasis and bacterial vaginosis. Am J Obstet Gynecol 1990; 163:510–514.
12. Paavonen J, Miettinen A, Stevens CE, Chen KCS, Holmes KK. Mycoplasma hominis
in non-specific vaginitis. Sex Transm Dis 1983; 45:271–275.
13. Wølner-Hanssen P, Eschenbach DA, Paavonen J, et al. Association between vaginal douching and acute pelvic inflammatory disease. JAMA 1990; 263:1936–1941.
14. Onderdonk A, Delaney M, Hinkson P, DuBois A. Quantitative and qualitative effects of douche preparations on vaginal microflora. Obstet Gynecol 1992; 80:333–338.
15. Rajamanoharan S, Low N, Jones S, Pozniak A. Bacterial vaginosis, ethnicity, and use of genital cleaning agents: A case control study. Sex Transm Dis 1999; 26:404–409.
16. Fonck K, Kaul R, Keli F, et al. Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya. Sex Transm Dis 2001; 77:271–275.
17. Newton E, Piper J, Shain R, Perdue S, Peairs W. Predictors of the vaginal microflora. Am J Obstet Gynecol 2001; 184:845–855.
18. Holzman C, Leventhal J, Qiu H, Jones N, Wang J, Group BS. Factors linked to bacterial vaginosis in nonpregnant women. Am J Public Health 2001; 91:1664–1670.
19. Ness R, Hillier S, Richter H, et al. Douching in relation to bacterial vaginosis, lactobacilli, and facultative bacteria in the vagina. Obstet Gynecol 2002; 100:765–772.
20. Hawes S, Hillier S, Benedetti J, Stevens C, et al. Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996; 174:1058–1063.
21. Marrazzo J, Koutsky L, Eschenbach D, Agnew K, Stine K, Hillier S. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002; 185:1307–1313.
22. Priestley CJF, Jones BM, Dhar J, Goodwin L. What is normal vaginal flora? Genitourin Med 1997; 73:23–28.
23. Schwebke J, Richey C, Weiss H. Correlation of behaviors with microbiological changes in vaginal flora. J Infect Dis 1999; 180:1632–1636.
24. Cherpes T, Meyn L, Krohn M, Lurie J, Hillier S. Association between acquisition of herpes simplex virus type 2 in women with bacterial vaginosis. Clin Infect Dis 2003; 37:319–325.
25. Wiesenfeld H, Hillier S, Krohn MA, Landers D, Sweet R. Bacterial vaginosis is a strong predictor of Neisseria gonorrhoeae
and Chlamydia trachomatis
infection. Clin Infect Dis 2003; 36:663–668.
26. Thomason JL, Gelbart SM, Sobun JF, Schulien MB, Hamilton PR. Comparison of four methods to detect Trichomonas vaginalis
. J Clin Microbiol 1988; 26:1869–1870.
This article has been cited 39 time(s).
Sexually Transmitted DiseasesRisk factors for bacterial vaginosis in women at high risk for sexually transmitted diseasesSexually Transmitted Diseases
Journal of Infectious Diseases
High recurrence rates of bacterial vaginosis over the course of 12 months after oral metronidazole therapy and factors associated with recurrence
Journal of Infectious Diseases, 193():
American Journal of Obstetrics and GynecologyRisk factors for bacterial vaginosis during pregnancy among African American womenAmerican Journal of Obstetrics and Gynecology
Sexually Transmitted InfectionsLife in the littoral zone: lactobacilli losing the plotSexually Transmitted Infections
Bjog-An International Journal of Obstetrics and GynaecologyPsychological and biological markers of stress and bacterial vaginosis in pregnant womenBjog-An International Journal of Obstetrics and Gynaecology
Maternal and Child Health JournalVaginal Douching Among Latinas: Practices and MeaningMaternal and Child Health Journal
Journal of Womens Health
Perceived life stress and bacterial vaginosis
Journal of Womens Health, 14(7):
International Journal of Std & AIDSThe polymicrobial hypothesis of bacterial vaginosis causation: a reassessmentInternational Journal of Std & AIDS
Maternal and Child Health JournalVaginal Douching Among Latina ImmigrantsMaternal and Child Health Journal
Pediatric Clinics of North America"What's really going on down there?" A practical approach to the adolescent who has gynecologic complaintsPediatric Clinics of North America
Paediatric and Perinatal EpidemiologyAlteration in vaginal microflora, douching prior to pregnancy, and preterm birthPaediatric and Perinatal Epidemiology
Journal of Reproductive Medicine
Factors Associated with Recurrent Bacterial Vaginosis
Journal of Reproductive Medicine, 55():
Women & HealthVaginal Hygiene Practices and Perceptions Among Women in the Urban NortheastWomen & Health
Culture Health & SexualityVaginal hygiene and douching: perspectives of Hispanic menCulture Health & Sexuality
Clinical Microbiology and InfectionVaginal and endocervical microorganisms in symptomatic and asymptomatic non-pregnant females: risk factors and rates of occurrenceClinical Microbiology and Infection
Journal of Family Planning and Reproductive Health Care
The management of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge
Journal of Family Planning and Reproductive Health Care, 32(1):
Womens Health IssuesVaginal douching and intimate partner violence - Is there an association?Womens Health Issues
Jognn-Journal of Obstetric Gynecologic and Neonatal NursingDouching Patterns in Women Related to Socioeconomic and Racial/Ethnic CharacteristicsJognn-Journal of Obstetric Gynecologic and Neonatal Nursing
American Journal of EpidemiologyA longitudinal study of vaginal douching and bacterial vaginosis - A marginal structural modeling analysisAmerican Journal of Epidemiology
Clinical Infectious DiseasesSexual Risk Factors and Bacterial Vaginosis: A Systematic Review and Meta-AnalysisClinical Infectious Diseases
Journal of Microbiological MethodsFlow cytometric quantification of bacteria in vaginal swab samples self-collected by adolescents attending a gynecology clinicJournal of Microbiological Methods
American Journal of Obstetrics and GynecologyThe effect of vaginal douching cessation on bacterial vaginosis: a pilot studyAmerican Journal of Obstetrics and Gynecology
Journal of Infectious Diseases
Influence of sex hormones, HIV status, and concomitant sexually transmitted infection on cervicovaginal inflammation
Journal of Infectious Diseases, 191(3):
Journal of Midwifery & Womens HealthEtiology, diagnosis, and management of vaginitisJournal of Midwifery & Womens Health
Sexually Transmitted DiseasesAn intervention to reduce vaginal douching among adolescent and young adult women: A randomized, controlled trialSexually Transmitted Diseases
Journal of Infectious Diseases
The association of Atopobium vaginae and Gardnerella vaginalis with bacterial vaginosis and recurrence after oral metronidazole therapy
Journal of Infectious Diseases, 194(6):
Journal of Sexual MedicineBeyond Douching: Use of Feminine Hygiene Products and STI Risk among Young WomenJournal of Sexual Medicine
Tropical Medicine & International HealthEffect of consistent condom use on 6-month prevalence of bacterial vaginosis varies by baseline BV statusTropical Medicine & International Health
Current Medicinal Chemistry
Are Plant Extracts a Potential Therapeutic Approach for Genital Infections?
Current Medicinal Chemistry, 20():
Pharmacological ResearchMicrobiota of male genital tract: Impact on the health of man and his partnerPharmacological Research
Journal of Midwifery & Womens HealthVaginal Infections UpdateJournal of Midwifery & Womens Health
Plos OneHormonal Contraception Is Associated with a Reduced Risk of Bacterial Vaginosis: A Systematic Review and Meta-AnalysisPlos One
Current Opinion in PediatricsBacterial vaginosis: many questions - any answers?Current Opinion in Pediatrics
Sexually Transmitted DiseasesRisk Factors for Bacterial Vaginosis Incidence in Young Adult Thai WomenSexually Transmitted Diseases
© Copyright 2004 American Sexually Transmitted Diseases Association
What does "Remember me" mean?
By checking this box, you'll stay logged in until you logout. You'll get easier access to your articles, collections,
media, and all your other content, even if you close your browser or shut down your
To protect your most sensitive data and activities (like changing your password),
we'll ask you to re-enter your password when you access these services.
What if I'm on a computer that I share with others?
If you're using a public computer or you share this computer with others, we recommend
that you uncheck the "Remember me" box.
Data is temporarily unavailable. Please try again soon.
Readers Of this Article Also Read