Vaginal Douching Barbara Hansen Cottrell

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1 IN REVIEW Vaginal Douching Barbara Hansen Cottrell Objective: To review current literature on vaginal douching. Data Sources: MEDLINE, CINAHL, and Cochrane databases from 1997 to 2001, using keywords douche or douching; 2001 Web sites of the Centers for Disease Control and Prevention; and Internet search engines for information about current retail sales of douches. Study Selection: MEDLINE included 67 records, CINAHL 18, and Cochrane 2. Abstracts of articles in English were reviewed, and those pertaining to vaginal douching practices were included. MEDLINE had 44 pertinent articles, CINAHL 11, and Cochrane 1. References from these articles were reviewed and included when appropriate. Data Extraction: Articles were reviewed and summarized. Data Synthesis: Vaginal douching is a common practice for women in the United States. Douching is associated with adverse reproductive and gynecologic outcomes including bacterial vaginosis, preterm birth, low-birth-weight infants, pelvic inflammatory disease, chlamydial infection, tubal pregnancy, higher rates of HIV transmission, and cervical cancer. Cultural beliefs and educational factors strongly influence douching practices. Conclusions: Nursing assessment of women should include information on vaginal douching practices and beliefs. Nurses should use culturally appropriate educational strategies to discourage women of all ages from using vaginal douches as part of routine feminine hygiene because of the associated risks. Further research is needed on factors that influence women s beliefs and douching practices. JOGNN, 32, 12 18; DOI: / Keywords: Bacterial vaginosis Douche Douching Accepted: July 2002 Many women believe douching is a normal and expected part of feminine hygiene. Approximately 29% of American women purchase nonprescription douches, spending about $500 million per year (Columbia Laboratories, 2000). Vaginal douches are over-the-counter products used by women after menstruation or sexual intercourse for cleanliness, odor control, and relief of vaginal itching and irritation. Social, cultural, and educational factors influence douching practices. The purpose of this article is to review the literature on vaginal douching. Recent research suggests that vaginal douching is associated with adverse gynecologic and reproductive outcomes. Women continue douching even though this practice is associated with pelvic inflammatory disease, ectopic pregnancy, Chlamydia, infertility, bacterial vaginosis, low-birth-weight infants, preterm labor, and possibly cervical cancer. Recent literature documents reasons physicians and nurses should assess their clients douching practices and discourage routine douching. Adverse Health Effects Associated With Douching Vaginal douching has been associated with many health risks in women (see Table 1). Douching washes out the normal balance of bacteria in the vagina and puts women at risk for developing bacterial vaginosis (BV). Douching with saline or acetic acid has been found to result in microfloral changes in the vagina within 10 minutes; flora took up to 72 hours to return to the predouching levels (Onderdonk, Delaney, Hinkson, & DuBois, 1992). When bactericidal compounds were used in douches, short- and long-term changes occurred that allowed overgrowth of pathogenic organisms that suppress lactobacillus. 12 JOGNN Volume 32, Number 1

2 TABLE 1 Complications Associated With Douching Gynecologic Obstetric Bacterial vaginosis Preterm labor Increased risk of HIV Low-birth-weight infants Increased risk of Reduced fertility Chlamydia Ectopic pregnancy Pelvic inflammatory disease These changes in flora after douching favor the development of BV. There is an increase in the prevalence of BV in women who douche (Holzman et al., 2001). BV increases the risk for preterm labor and birth (Fiscella, 1996) and is associated with preterm birth of low-birthweight infants independent of other recognized risk factors (Hillier et al., 1995). In the United States, BV is one of the most common vaginal infections in women of childbearing age, and about 16% of pregnant women have this infection (Centers for Disease Control and Prevention, 2001). Using the 1995 National Survey of Family Growth, Fiscella, Franks, Kendrick, and Bruce (1998) compared the risk of giving birth to low-birth-weight infants among women who reported they douched regularly with the risk among women who did not douche. Regular douching was associated with an increased risk of low birth weight. The higher the frequency of douching, the higher was the woman s risk for giving birth to a low-birth-weight infant. Douching may represent a major preventable risk factor for low birth weight. A meta-analysis of articles published in English from 1965 to 1995 indicated that douching increases the overall risk of pelvic inflammatory disease by 73% and the risk of ectopic pregnancy by 76% (Zhang, Thomas, & Leybovich, 1997). Frequent douching was highly associated with pelvic inflammatory disease and modestly associated with cervical cancer. In 1997, the U.S. Food and Drug Administration s Nonprescription Drugs Advisory Panel recommended changes in the labeling of vaginal douches to include warnings about the risk of pelvic inflammatory disease. The panel also advised that educational materials about risks of douching be made available to practicing clinicians. Among a predominantly African American group of 654 women with clinical pelvic inflammatory disease, frequent and recent douching was associated with endometritis and upper genital tract infection (Ness et al., 2001). In a study of nonpregnant women attending primary care clinics, women who douched had an increased likelihood of chlamydial infection compared with women who did not douche, and the likelihood was higher for women who reported douching more often (Scholes et al., 1998). Among African women who are pregnant, douching is a widespread practice. In this population, HIV infection was 2 times more frequent in women using antiseptics in douching, and chlamydial infection was associated with douching with antiseptics (La Ruche et al., 1999). Chlamydial infection can lead to fallopian tube scarring and contribute to the higher incidence of ectopic pregnancy and infertility associated with douching. In a study of more than 1,000 African American women, vaginal douching was associated with an increased risk of ectopic pregnancy, and the risk increased with more years of douching at least once per month (Kendrick, Atrash, Strauss, Garguillo, & Ahn, 1997). Even women who douched for routine cleanliness were at increased risk of ectopic pregnancy. In Surabaya, Indonesia, a significant association between sexually transmitted infections and douching habits was found among 599 pregnant women attending a prenatal clinic (Joesoef et al., 1996). Women douched with water (19%) or water and soap (63%). Douching with water alone after sexual intercourse was not associated with sexually transmitted disease, but douching with betel leaf, commercial agents, or water and soap was associated with sexually transmitted infections. Racial disparity in preterm labor rates may be related in part to douching practices (Bruce, Fiscella, & Kendrick, 2000). Rauh, Culhane, and Hogan (2000) documented concerns about the high prevalence of BV among African American women, who are also at high risk for preterm birth. The rate of preterm birth is twice as high among African American women as among White women (Savitz et al., 1999). Fiscella (1996) found higher rates of BV among African American women, which account for almost 30% of the racial gap in preterm births. Reasons for the racial disparity in preterm deliveries are not clearly understood. Bruce et al. (2000) hypothesized that vaginal douching plays a key role in the risk of infection-related spontaneous preterm birth. Douching during pregnancy increased the risk of preterm delivery for women in a managed care organization in Atlanta, Georgia (Bruce et al., 2002).Vaginal douching is 2 to 3 times more prevalent among African American women than among White women (Zhang et al., 1997) and is associated with higher rates of BV. Douching may facilitate the ascent of microorganisms into the upper genital tract, resulting in a chronic bacterial colonization inside the uterus. During pregnancy, the host inflammatory response is initiated in response to the uterine chronic bacterial colonization, which stimulates preterm labor and birth. Thus, the practice of douching may explain a substantial proportion of the racial disparity in preterm birth and is potentially preventable with education (Bruce et al., 2000). Researchers in England found BV twice as common among Black Caribbean women as among White women January/February 2003 JOGNN 13

3 (Rajamanoharan, Low, Jones, & Pozniak, 1999). Douching with commercial or homemade solutions was significantly more common among women with BV than among those without the infection. After controlling for hygiene practices and a history of bacterial vaginosis, the researchers found no ethnic difference in the incidence of BV. These researchers concluded that ethnic differences in genital hygiene practices explained the twofold increased risk of BV in Black Caribbean women. Types of Douches Several types of douches are available: pre-filled disposable bottles of various mixtures, refillable hanging bags, and refillable expandable bags. The type of douches used, the mixture used, the frequency of use, and who is most influential in a woman s douching decision are not well documented in various cultural and high-risk groups. Bag-type douches deliver significantly greater volume than do disposable bottles, and the bags produce fluid exposure times as much as 8 times longer than do the disposable bottles. The longer exposure time and larger fluid volume exposure may contribute to the higher rates of pelvic inflammatory disease and ectopic pregnancy seen with use of bag-type douches (U.S. Food and Drug Administration, 1997). Few studies report detailed information about the type and amount of fluid used for douching. Women use commercial and homemade douches, which usually contain vinegar and water. Rarely was information reported about homemade preparations. One study found that some women douched with bleach and terpene-containing cleaning solutions made from pine trees (Lichtenstein & Nansel, 2000). Prevalence of Douching The prevalence of douching varies among the population studied. Factors such as culture or ethnicity, educational level, and socioeconomic status are associated with the practice. According to the 1995 National Survey of Family Growth, approximately 27% of women in the United States douche regularly (Abma, Chandra, Mosher, Peterson, & Piccinino, 1997). Consistent with earlier national surveys, racial and socioeconomic differences were found in douching practices. Ethnicity/Culture Data from this national survey revealed that two thirds of African American women versus one third of White women reported douching (Abma et al., 1997). In a Michigan county health department clinic, women were asked to complete a questionnaire that included information about douching. Analysis revealed that 30% of African American women and 14% of White, non- Latina women used a vaginal douche at least once per month (Holzman et al., 2001). In London, England, vaginal douching was 2 times more common in Black Caribbean women than White women (Rajamanoharan et al., 1999). Among women in Africa, the practice of douching is much more prevalent than among women in the United States. In a study describing douching practices in 552 pregnant women in Abidjan, Cote d Ivoire, 97% of respondents reported douching and viewed douching as a common practice (La Ruche et al., 1999). Unlike other published studies, Foch, McDaniel, and Chacko (200l) found no racial difference in the prevalence of douching, possibly because of sample selection bias and the cultural practices in southwest Louisiana. In a family planning clinic where sexually active women were more likely to seek services than those who were not sexually active, these researchers found that White women were more likely to agree that most women never need to douche and that African American women were more likely to agree that vaginal douching clears up odor and discharge (Foch et al., 2001). Vaginal douching is associated with pelvic inflammatory disease, bacterial vaginosis, Chlamydia, infertility, preterm labor, low-birth-weight infants, ectopic pregnancy, and increased risk for HIV transmission. Educational Background Among both African American and White women, the prevalence of douching was higher in groups with lower educational levels. Among African American women, 70% of those who had not completed high school reported douching versus 40% of those with bachelor s degrees or higher. Among White women, 50% of those who had not completed high school reported douching compared with 9% of those with bachelor s degrees or higher (National Center for Health Statistics, 1997). Age Douching was least frequent among 15- to 19-yearolds (16%) and most frequent (28%) among 20- to 24- year-olds (Abma et al., 1997). In a 1999 study of adolescent females attending a public family planning clinic, 69% of 169 participants reported vaginal douching (Foch et al., 2001). In a California study of professional women, 19% of the women younger than age 41 years reported douching and 27% to 30% of women 41 years and older reported douching (Czerwinski, 2000). 14 JOGNN Volume 32, Number 1

4 Socioeconomic Factors Douching was found to be more common among women who live in poverty (50%) than among those who do not (28%). Seventy percent of African American women living in poverty reported douching (Abma et al., 1997). The reasons for increased douching in this population are unknown. In the southern United States, low-income women were more likely to douche than were middleincome women (Lichtenstein & Nansel, 2000). In a nonexperimental descriptive study of 173 professional women in California, 20% to 30% reported douching even though they knew the dangers associated with this practice (Czerwinski, 2000). Vaginal douching during pregnancy was reported in 5% of African American women and 4% of White women in a North Carolina study of vaginal ecology during pregnancy, but information about douching practices before pregnancy was not available (Royce et al., 1999). Many women believe douching is an expected and necessary feminine hygiene practice and are unaware of its health risks. Frequency of Douching Although few studies have documented the frequency of douching, those that have done so reported a wide range. Using the cross-sectional interview data of a United States national survey, Fiscella et al. (1998) documented a range in the frequency of douching from daily to monthly. After intercourse, some women always douched, whereas others douched when they had different or multiple partners (Litchtenstein & Nansel, 2000). In a community health department clinic in Michigan, women completed a self-administered questionnaire about vaginal symptoms and reasons for douching. Among nonpregnant women, 18% reported douching at least once a month. Twenty-four percent had used a douche within the last 2 months (Holzman et al., 2001). Beliefs and Misconceptions About Douching Most women report douching to feel clean (Holzman et al., 2001). This finding was confirmed by Gazmararian, Bruce, Kendrick, Grace, and Winn (2001) in their exploration of women s attitudes and practices related to douching. Through focus groups in Tennessee, these researchers found that women have a deeply rooted belief that douching makes them feel clean. This belief is reinforced by family, friends, and the media. Many women believe douching is an expected and necessary feminine hygiene practice. Lichtenstein and Nansel (2000) documented that women douche after menstruation to eliminate residual menstrual odor and to create a feeling of cleanliness. Women also douche after sexual intercourse for cleanliness and odor control and douche other times of the month for the same reasons. African American women place more emphasis on douching after sexual intercourse than do White women. Women also douche to prevent or treat vaginal infections and unpleasant fishy odors (Lichtenstein & Nansel, 2000). Adolescent females attending a public family planning clinic in Louisiana douched mostly for hygienic reasons, and the age of first douche correlated positively with age of first intercourse (Foch et al., 2001). Many women have alarming misconceptions about douching. In a cross-sectional survey of approximately 4,000 women receiving benefits from the Women, Infants, and Children program, 11.8% of women reported douching to prevent infection with the human immunodeficiency virus (HIV) (Crosby, Yarber, & Meyerson, 2000). Research has documented, however, that douching is associated with the acquisition of HIV (Taha et al., 1998). Misconceptions about the prevention of sexually transmitted infections (STI) among STI clinic attendees (N = 3,498) were studied in five large American cities through interviews. Forty-five percent of those interviewed believed that douching helped prevent sexually transmitted infections (Crosby, Newman, et al., 2000). Douching is a clear risk factor, however, for cervical Chlamydia trachomatis infection (Scholes et al., 1998). Many women are not aware that vaginal odors and discharge occur and fluctuate normally during the menstrual cycle. Some women douche to reduce vaginal odors that are normal. Most women in the Lichtenstein and Nansel study (2000) were not aware that a fishy odor was a symptom of bacterial vaginosis. These women douched to eliminate fishy odors after sexual intercourse. These researchers pointed out that women may be douching in response to odors associated with infection-related discharge that requires medical treatment. Facts About Feminine Hygiene Douches are advertised as cleansing products for women to use after their menstrual period. Douching starts at a young age and is reinforced by family, friends, and media marketing efforts (Gazmararian et al., 2001). This marketing perpetuates the myth that douches clean the vaginal area, when, in fact, douches alter the natural vaginal flora and predispose women to bacterial infection (Onderdonk et al., 1992). The vagina is self-cleaning with its own natural flora. Clear vaginal discharge is both normal and healthy. A normal vaginal discharge has no unpleasant or fishy odor. January/February 2003 JOGNN 15

5 Women who have excessive, foul-smelling, or fishy odor of their vaginal discharge should be encouraged to see their health care provider to determine if they have an infection that needs treatment. Douches and herbal therapies should not be used to self-treat sexually transmitted diseases or vaginal infections. Women should be instructed not to douche prior to having a gynecologic examination. Although a douche is not a contraceptive and should not be used to prevent pregnancy, douching can reduce fertility by 30% (Baird, Weinberg, Voigt, & Daling, 1996). What Constitutes Appropriate Feminine Hygiene Practices? A variety of steps can be taken to address women s concerns about cleanliness. Women should be encouraged to wash their hands before and after genitourinary contact, especially when using tampons or pads. The perineal area should be wiped from front to back after urination/ defecation to decrease the chance of rectal contamination to the vaginal area. Pads should be placed from front to back as well. Unscented soap and water can be used for cleansing the perineal area. If unscented wet wipes are used, each should be used only once, wiping from front to back, and then discarded. Vaginal deodorants, sprays, gels, suppositories, powders, or tablets are not recommended for routine hygiene. Instead, sponge baths, tub baths, showers, and use of a handheld shower head are alternative perineal cleansing practices. Cotton underpants are recommended. Women should be encouraged to examine their external genitalia once a month. A mirror can be used in a sitting or squatting position, so the genitalia are exposed and can be better viewed. Women should inspect the genital area for symmetry, mole growth, lumps, skin discoloration, lesions, tenderness, and discharge. Unusual findings should be evaluated by a health care provider. Innovations Designed to Prevent Douching Interestingly, Merchant, Oh, and Klerman (1999) were unable to find that any official positions were taken by professional and medical organizations on the practice of douching. The Capital Area Healthy Start Racial Disparity Task Force for Infant Health in Florida (2001) is one of the first organizations to initiate a campaign to stop the practice of douching. In August 2000, the taskforce began a public awareness campaign (PRIDE: Prevent Infant Deaths) directed at the African American community. This community was chosen because African American infants born in the United States in 1998 were twice as likely to die as were White infants and because Florida s infant mortality rate was higher than the national average (13.4 for African Americans compared with 5.6 for Whites, whereas the nationwide mortality rate was 7.2 [Department of Health, State of Florida Office of Vital Statistics, 1999]). One aspect of the campaign addressed self-care practices, such as vaginal douching, that can cause infection (BV) and increase the risk of preterm birth and low birth weight. Among the many recommendations of the campaign is that women stop douching because the practice is associated with infections that lead to preterm labor and delivery. Scientists at the Centers for Disease Control and Prevention (2001) recognized that douching can upset the normal balance of bacteria in the vagina and put women at increased risk for BV. On the center s Web site, four prevention steps are identified to reduce the risk of upsetting the natural balance in the vagina and developing BV. The CDC recommends using condoms during sex, limiting the number of sex partners, using all of the medicine prescribed for treatment of BV (even if the signs and symptoms go away), and do not douche. Implications for Nurses It is critical that nurses understand the reasons women douche, the facts about douching, and what constitutes healthy feminine hygiene practices. In addition, nurses should examine their own attitudes and beliefs about feminine hygiene practices. By updating knowledge with evidence-based research, nurses will be able to address women s beliefs and concerns about feminine hygiene with confidence. The role of douching and its relationship to BV and other adverse health outcomes in women and their children should not be ignored. Kendrick et al. (1997) found that there is no benefit derived from douching and no safe douching behavior. Issues of social context, including personal and culturally based motivations for douching, require further study. The conditions that underlie racial and ethnic disparities in health care also need further study (Rauh et al., 2000). Community-based interventions must be developed to reduce the persistent disparities in douching practices that affect maternal and infant health, especially among minority racial and ethnic groups (Henry, 2001). Douching is a very difficult behavior to change because of women s deeply rooted beliefs about it. A woman s culture plays an important role in this belief system. Efforts to influence this behavior must consider women s beliefs and the media marketing efforts that promote douching. Simplistic interventions that only provide risk information about douching are not likely to result in behavior change (Gazmararian et al., 2001). Some health care providers used to encourage women to douche routinely as a matter of personal hygiene (Rooks, 1999). Now that epidemiologic studies have been conducted and the evidence suggests that serious conditions can result from douching, health care providers should discourage this outdated practice. Health care providers 16 JOGNN Volume 32, Number 1

6 should assess each client s hygiene practices and whether or not they douche. Nurses are in a position to provide women with accurate information on the complications associated with douching. In the African American culture, the mother s advice is highly regarded with respect to douching practices (Lichtenstein & Nansel, 2000). Foch et al. (2001) found that two thirds of both African American and White women learned about douching from their mothers. If possible, nurses should include the client s mother when information is presented about douching. Nurses should assess beliefs and practices related to vaginal douching and inform women of the associated risks. Beliefs, attitudes, and motivation for douching should be assessed because these are more important to women than the information offered by health care providers. Most of the women in the Lichtenstein and Nansel study (2000) knew that health care professionals did not recommend douching, but this knowledge did not appear to influence their behavior. Czerwinski (2000) suggested that the persistence of douching in a significant percentage of educated professional women may stem from not understanding that normal secretions are a natural selfcleaning process of the vaginal area and from a concern about cleanliness. Douching is associated with adverse health effects and has no documented health benefits. Professional organizations should be encouraged to take a position against vaginal douching (Foch et al., 2001; Merchant et al., 1999). Nurses can listen to women s concerns about feminine hygiene; try to understand how their family, culture, and the mass media have influenced this aspect of their lives; and provide up-to-date information about douching alternatives. The reasons women continue to douche while knowing about the harmful effects of this practice need further investigation. REFERENCES Abma, J. C., Chandra, A., Mosher, W. D., Peterson, L. S., & Piccinino, L. J. (1997). Fertility, family planning, and women s health: New data from the 1995 National Survey of Family Growth. Vital & Health Statistics Series 23, Data From the National Survey of Family Growth, 19, Baird, D. D., Weinberg, C. R., Voigt, L. F., & Daling, J. R. (1996). Vaginal douching and reduced fertility. American Journal of Public Health, 86(6), Bruce, F. C., Fiscella, K., & Kendrick, J. S. (2000). Vaginal douching and preterm birth: An intriguing hypothesis. Medical Hypotheses, 54(3), Bruce, F. C., Kendrick, J. S., Kieke, B. A., Jagielski, S., Joshi, R., & Tolsma, D. D. (2002). Is vaginal douching associated with preterm delivery? Epidemiology, 13(3), Capital Area Healthy Start Racial Disparity Task Force for Infant Health. (2001). Stop douching. Tallahassee, FL: Capital Area Healthy Start Coalition. Centers for Disease Control and Prevention. (2001). National Center for HIV, STD and TB prevention division of sexually transmitted diseases prevention. Bacterial vaginosis. Retrieved from FactsBV.htm Columbia Laboratories. (2000). Columbia laboratories announces the completion of a clinical trial demonstrating that mephil is superior to douches. Retrieved from Crosby, R. A., Newman, D., Kamb, M. L., Zenilman, J., Douglas, J. M., & Iatesta, M. (2000). Misconceptions about STD-protective behavior. Project RESPECT study group. American Journal of Preventive Medicine, 19(3), Crosby, R. A., Yarber, W. L., & Meyerson, B. (2000). Prevention strategies other than male condoms employed by lowincome women to prevent HIV infection. Public Health Nursing, 17(1), Czerwinski, B. S. (2000). Variation in feminine hygiene practices as a function of age. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 29, Department of Health, State of Florida Office of Vital Statistics. (1999). Florida Vital Statistics Annual Report, 1999 [Data file]. Retrieved April 8, 2002, from myflorida.com/planning_eval/vital_statistics/99vitals/99v SCOMP.pdf Fiscella, K. (1996). Racial disparities in preterm births. The role of urogenital infections. Public Health Reports, 111, Fiscella, K., Franks, P., Kendrick, J. S., & Bruce, F. C. (1998). The risk of low birth weight associated with vaginal douching. Obstetrics & Gynecology, 92(6), Foch, B. J., McDaniel, N. D., & Chacko, M. R. (2001). Racial differences in vaginal douching knowledge, attitude, and practices among sexually active adolescents. Journal of Pediatric and Adolescent Gynecology, 14(1), Gazmararian, J. A., Bruce, F. C., Kendrick, J. S., Grace, C. C., & Winn, S. (2001). Why do women douche? Results from a qualitative study. Maternal and Child Health Journal, 5(3), Henry, J. K. (2001). Eliminating health inequities: National goals and developing programs. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 30, Hillier, S. L., Nugent, R. P., Eschenbach, D. A., Krohn, M. A., Gibbs, R. S., Martin, D. H., et al. (1995). Association between bacterial vaginosis and preterm delivery of a lowbirth-weight infant. The Vaginal Infections and Prematurity Study Group. New England Journal of Medicine, 333(26), Holzman, C., Leventhal, J. M., Qui, H., Jones, N. M., Wang, J., & the BV Study Group. (2001). Factors linked to bacter- January/February 2003 JOGNN 17

7 ial vaginosis in nonpregnant women. American Journal of Public Health, 91(10), Joesoef, M. R., Sumampouw, H., Linnan, M., Schmid, S., Idajadi, A., & St. Louis, M. E. (1996). Douching and sexually transmitted diseases in pregnant women in Surabaya, Indonesia. American Journal of Obstetrics and Gynecology, 174(1), Kendrick, J. S., Atrash, H. K., Strauss, L. T., Garguillo, P. M., & Ahn, Y. W. (1997). Vaginal douching and the risk of ectopic pregnancy among Black women. American Journal of Obstetrics and Gynecology, 176(5), La Ruche, G., Messou, N., Ali-Napo, L., Noba, V., Faye-Kette, H., Combe, P., et al. (1999). Vaginal douching: Association with lower genital tract infections in African pregnant women. Sexually Transmitted Diseases, 26(4), Lichtenstein, B., & Nansel, T. R. (2000). Women s douching practices and related attitudes: Findings from four focus groups. Women and Health, 31(2-3), Merchant, J. S., Oh, K., & Klerman, L. V. (1999). Douching: A problem for adolescent girls and young women. Archives of Pediatrics and Adolescent Medicine, 153(8), Ness, R. B., Soper, D. E., Holley, R. L., Peipert, J., Randall, H., Sweet, R. L., et al. (2001). Douching and endometritis: Results from the PID evaluation and clinical health (PEACH) study. Sexually Transmitted Diseases, 28(4), Onderdonk, A. B., Delaney, M. L., Hinkson, P. L., & DuBois, A. M. (1992). Quantitative and qualitative effects of douche preparations on vaginal microflora. Obstetrics and Gynecology, 80, Rajamanoharan, S., Low, N., Jones, S. B., & Pozniak, A. (1999). Bacterial vaginosis, ethnicity, and the use of genital cleaning agents: A case control study. Sexually Transmitted Diseases, 26(7), Rauh, V. A., Culhane, J. F., & Hogan, V. K. (2000). Bacterial vaginosis: A public health problem for women. Journal of the American Medical Women s Association, 55(4), Rooks, J. P. (1999). Evidence-based practice and its application to childbirth care for low-risk women. Journal of Nurse- Midwifery, 44(4), Royce, R. A., Jackson, T. P., Thorp, J. M., Hillier, S. L., Rabe, L. K., Pastore, L. M., et al. (1999). Race/ethnicity, vaginal flora patterns, and ph during pregnancy. Sexually Transmitted Diseases, 26(2), Savitz, D. A., Dole, N., Williams, J., Thorp, J. M., McDonald, T., Carter, A. C., et al. (1999). Determinants of participation in an epidemiological study of preterm delivery. Paediatric and Perinatal Epidemiology, 13(1), Scholes, D., Stergachis, A., Ichikawa, L. E., Heidrich, F. E., Holmes, K. K., & Stamm, W. E. (1998). Vaginal douching as a risk factor for cervical Chlamidia trachomatis infection. Obstetrics and Gynecology, 91(6), Taha, T., Hoover, D., Dallabetta, G., Kumwenda, N. I., Mtimavalye, L. A., Yang, L. P., et al. (1998). Bacterial vaginosis and disturbances in vaginal flora: Association with increased acquisition of HIV. AIDS, 12, U.S. Food and Drug Administration. (1997). Pressure and flow measurements in vaginal douches [Technical Support]. Retrieved April 8, 2002, from ost/rpt97 Zhang, J., Thomas, A. G., & Leybovich, E. (1997). Vaginal douching and adverse health effects: A meta-analysis. American Journal of Public Health, 87(7), Barbara Hansen Cottrell, MSN, ARNP, is an associate professor, Florida State University School of Nursing, Tallahassee. Address for correspondence: Barbara Hansen Cottrell, MSN, ARNP, Florida State University School of Nursing, Tallahassee, FL bcottrel@garnet.acns.fsu.edu. 18 JOGNN Volume 32, Number 1