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the middle east and central Asia guidelines on female genital hygine

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Abstract

The following is a summary of The INTIMATE FEMININE HYGIENE Guidelines for the Middle East and Central Asia region: 1. All women at all ages are in need of a daily intimate feminine hygiene to keep their genital area clean and dry. 2. The vulva and vagina are common affected areas for contact dermatitis and should be kept away from environmental irritants or caused by certain hygienic products. 3. It is highly recommended to use hypoallergenic liquid cleansing agents with mild detergent effects and acidic pH ranging between 4.2 and 5.6. 4. Bar soaps and bubble baths are of abrasive nature and with high alkaline pH and should be avoided. Lactic acid based soaps with low pH have been shown to augment skin homeostasis and are helpful in cases of genital infections as adjuvant therapy. 5. Vaginal douching is not recommended due to its adverse obstetrical and gynecological effects 6. To avoid excessive moisture and allow reasonable ventilation of the genital area, wearing loose fitting cotton underwear and minimize wearing tight clothes is recommended. Undergarments should be changed frequently. 7. Talcum powder should not be used; perfumes and deodorants should be used sparingly, preferably after allergy testing. 8. Menstrual care should include using tampons and sanitary pads, as preferred, but frequent changing is essential. 9. Pre and post coital cleansing of the genital area especially the clitoris and the vulvar folds from front to back is recommended. Vigorous vulvar cleansing and vaginal douching are strongly discouraged. 10. Removal of pubic hair should be based on safe techniques and done with care to avoid sensitivity and scarring. 11. Postpartum care should include frequent cleansing, drying and using pads as necessary. Maintain dryness over the suture. Do not use creams on the suture. is prohibited. 12. Child genital care requires the caregiver to wash hands beforehand, the use of separate towels for children and not sharingto share the same bath tub with children.
The Middle East and Central Asia
Guidelines on Female Genital Hygiene
Prepared by an Advisory Committee representing this region:
Dr. Hisham Arab1, Saudi Arabia; Dr. Lamia Almadani, Saudi Arabia;
Dr. Muna Tahlak, United Arab Emirates; Dr. Monica Chawla, United Arab Emirates;
Dr. Monir Ashouri, Iran; Dr. Afsaneh Tehranian, Iran; Dr. Afsaneh Ghasemi, Iran;
Dr. Taheripanah, Iran; Dr. Mustafinah Gulyaf, Kazakhstan; Dr. Ali Khalil, Lebanon;
Dr. Edgar Haddad, Lebanon.
Reprint
REPRINTED FROM BMJ ME 2011;19:99106
99
LOCAL PRACTICE
BMJ Middle East | September 2011 | VOLUME 19
The Middle East and Central Asia
Guidelines on Female Genital Hygiene
Prepared by an Advisory Committee representing this region: Dr. Hisham Arab1, Saudi
Arabia; Dr. Lamia Almadani, Saudi Arabia; Dr. Muna Tahlak, United Arab Emirates;
Dr. Monica Chawla, United Arab Emirates; Dr. Monir Ashouri, Iran; Dr. Afsaneh Tehranian,
Iran; Dr. Afsaneh Ghasemi, Iran; Dr. Taheripanah, Iran; Dr. Mustafinah Gulyaf, Kazakhstan;
Dr. Ali Khalil, Lebanon; Dr. Edgar Haddad, Lebanon.
Introduction
e Middle East and Central Asia (MECA) region
is represented by more than 12 countries with an
approximate population of 200 million people. e
majority share the same religion and have similar
cultural background. Hence it would be feasible to
draw some kind of consensus for this population of
a practice that is very much inuenced by cultural
and behavioral believes, namely Intimate Feminine
Hygiene.
Feminine hygiene practices constitute health
behavior that is based on the physiological necessity
for the management of elimination products,
including urine, feces and, menstrual and vaginal
discharge. Specic references to feminine hygiene
practices have been lacking, despite the extensive
advancement in medical research and social and
health sciences. In addition, violation of feminine
intimacy in this region has always been dealt with
secrecy that sometimes might oend women, if they
were misinformed.
Accordingly, 11 scientists in the eld of Obstetrics
and Gynecology from the MECA region formed
this committee to establish guidelines on Intimate
Feminine Hygiene. Currently, the only available
guidelines are the Brazilian guidelines1. No other
medical society or college worldwide has established
a similar work. Despite the limited resources on this
subject, women these days deserve a clear, scientic,
and hopefully evidence-based advice on Intimate
feminine hygiene practice. Women have long working
hours, wearing tight clothes, and covered with local
dresses in a mostly hot weather, which make them
uncomfortable with sweat and unpleasant odor. In
addition, media advertisement increased women
awareness about “freshness”. Nonetheless, using the
wrong product can jeopardize women’s wellbeing.
ese guidelines are written aer extensive
literature review to provide the best up to date advice
on how to practice safe Intimate Feminine Hygiene.
Female genital anatomy
and physiology
e female genital tract consists of external and
internal compartments. e internal compartment
consists of the vagina, cervix, uterus, fallopian tubes
and ovaries. e external compartment can be divided
into outer and inner parts. e outer part includes
the mons pubis, the perineum and the outer surfaces
of both labia majora and minora. e inner part
(intermediate genital compartment) includes the inner
surfaces of both labia majora and minora, clitoris, and
the vestibule up to the hymeneal membrane.
Vulva
e structures of the vulva lie on the pubic bones and
extend caudally under its arch. e structures of the
vulva consist of the mons, labia, clitoris, vestibule, and
associated erectile structures and their muscles. e
1 Dr. Hisham Arab served as a
chairman and facilitator for this
committee.
These Guidelines have been
accepted and presented as oral
presentation at XXII Asian and
Oceanic Congress of Obstetrics
and Gynecology (AOCOG 2011)
in Taipei ; Taiwan
SAN 17528 Local edit BMJ2.indd 99 8/18/11 10:00 AM
99
LOCAL PRACTICE
BMJ Middle East | September 2011 | VOLUME 19
The Middle East and Central Asia
Guidelines on Female Genital Hygiene
Prepared by an Advisory Committee representing this region: Dr. Hisham Arab1, Saudi
Arabia; Dr. Lamia Almadani, Saudi Arabia; Dr. Muna Tahlak, United Arab Emirates;
Dr. Monica Chawla, United Arab Emirates; Dr. Monir Ashouri, Iran; Dr. Afsaneh Tehranian,
Iran; Dr. Afsaneh Ghasemi, Iran; Dr. Taheripanah, Iran; Dr. Mustafinah Gulyaf, Kazakhstan;
Dr. Ali Khalil, Lebanon; Dr. Edgar Haddad, Lebanon.
Introduction
e Middle East and Central Asia (MECA) region
is represented by more than 12 countries with an
approximate population of 200 million people. e
majority share the same religion and have similar
cultural background. Hence it would be feasible to
draw some kind of consensus for this population of
a practice that is very much inuenced by cultural
and behavioral believes, namely Intimate Feminine
Hygiene.
Feminine hygiene practices constitute health
behavior that is based on the physiological necessity
for the management of elimination products,
including urine, feces and, menstrual and vaginal
discharge. Specic references to feminine hygiene
practices have been lacking, despite the extensive
advancement in medical research and social and
health sciences. In addition, violation of feminine
intimacy in this region has always been dealt with
secrecy that sometimes might oend women, if they
were misinformed.
Accordingly, 11 scientists in the eld of Obstetrics
and Gynecology from the MECA region formed
this committee to establish guidelines on Intimate
Feminine Hygiene. Currently, the only available
guidelines are the Brazilian guidelines1. No other
medical society or college worldwide has established
a similar work. Despite the limited resources on this
subject, women these days deserve a clear, scientic,
and hopefully evidence-based advice on Intimate
feminine hygiene practice. Women have long working
hours, wearing tight clothes, and covered with local
dresses in a mostly hot weather, which make them
uncomfortable with sweat and unpleasant odor. In
addition, media advertisement increased women
awareness about “freshness”. Nonetheless, using the
wrong product can jeopardize women’s wellbeing.
ese guidelines are written aer extensive
literature review to provide the best up to date advice
on how to practice safe Intimate Feminine Hygiene.
Female genital anatomy
and physiology
e female genital tract consists of external and
internal compartments. e internal compartment
consists of the vagina, cervix, uterus, fallopian tubes
and ovaries. e external compartment can be divided
into outer and inner parts. e outer part includes
the mons pubis, the perineum and the outer surfaces
of both labia majora and minora. e inner part
(intermediate genital compartment) includes the inner
surfaces of both labia majora and minora, clitoris, and
the vestibule up to the hymeneal membrane.
Vulva
e structures of the vulva lie on the pubic bones and
extend caudally under its arch. e structures of the
vulva consist of the mons, labia, clitoris, vestibule, and
associated erectile structures and their muscles. e
1 Dr. Hisham Arab served as a
chairman and facilitator for this
committee.
These Guidelines have been
accepted and presented as oral
presentation at XXII Asian and
Oceanic Congress of Obstetrics
and Gynecology (AOCOG 2011)
in Taipei ; Taiwan
SAN 17528 Local edit BMJ2.indd 99 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
100
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
mons comprises of hair-bearing skin over a cushion of
adipose tissue that lies on the pubic bones.
Extending
posteriorly from the mons, the labia majora are composed of
similar hair-bearing skin and adipose tissue, which contain
the termination of the round ligaments of the uterus and the
obliterated processus vaginalis (canal of Nuck).
e labia minora, vestibule, and glans clitoris can be seen
between the two labia majora. e labia minora are hairless
skin folds, each of which splits anteriorly to run over, and
under, the glans of the clitoris. e more anterior folds unite
to form the hood-shaped prepuce of the clitoris, whereas the
posterior folds insert into the underside of the glans as the
frenulum.
Unlike the skin of the labia majora, the cutaneous
structures of the labia minora and vestibule do not lie on
an adipose layer but on a connective-tissue stratum that is
loosely organized and permits mobility of the skin during
intercourse.
In the posterior lateral aspect of the vestibule, the duct of
the major vestibular gland can be seen 3 to 4 mm outside the
hymenal ring. e minor vestibular gland openings are found
along a line extending anteriorly from this point, parallel to
the hymenal ring and extending toward the urethral orice.
e urethra bulges slightly around the surrounding vestibular
skin anterior to the vagina and posterior to the clitoris. e
urethras orice is anked on either side by two small labia.
Skene’s ducts open into the inner surface of the small labia
and can be seen as small, punctate openings when the
urethral labia are separated.
e holocrine sebaceous glands in the labia majora are
associated with hair shas, while in the labia minora these
sebaceous glands are freestanding. e holocrine sebaceous
glands lie close to the surface, and are easily recognized with
minimal enlargement. In addition, lateral to the introitus and
anus, there are numerous apocrine sweat glands, along with
the normal eccrine sweat glands. e holocrine sebaceous
glandse former structures undergo change with the
menstrual cycle, with increased secretory activity in the
premenstrual period.
Vagina
e vagina is a hollow bromuscular tube extending from the vulvar
vestibule to the uterus. In the dorsal lithotomy position, the vagina
is directed posteriorly toward the sacrum, but its axis is almost
horizontal in the upright position. It is attached at its upper end to the
uterus just above the cervix. e spaces between the cervix and vagina
are known as the anterior, posterior, and lateral vaginal fornices.
e opening of the vagina may be covered by a membrane or
surrounded by a fold of connective tissue called the hymen. is
tissue is usually replaced by irregular tissue tags later in life
as sexual activity and childbirth occur. e lower vagina is
somewhat constricted as it passes through the urogenital
hiatus in the pelvic diaphragm; the upper vagina is more
spacious. However, the entire vagina is characterized by
its dispensability, which is most evident during childbirth.
e vagina is closely applied anteriorly to the urethra,
bladder neck and trigonal region and, posterior bladder;
posteriorly, the vagina lies in association with the perineal
body, anal canal, lower rectum, and posterior cul-de-sac.
e vagina is composed of three layers, mucosa, muscularis and
adventitia.
e mucosa layer is formed by non-keratinized stratied
squamous epithelium, without glands. Vaginal lubrication
occurs primarily by transudation, with contributions from
cervical and Bartholin gland secretions. e mucosa has a
characteristic pattern of transverse ridges and furrows, known
as rugae. It is hormonally sensitive, responding to stimulation
by estrogen with proliferation and maturation2. e mucosa
is colonized by mixed bacterial ora predominantly with
lactobacillus. Normal pH is 3.5 to 4.5.
e muscularis layer is formed by connective tissue and
smooth muscle, loosely arranged in inner circular and outer
longitudinal layers.
e adventitia layer is comprised by the endopelvic fascia
adherent to the underlying muscularis.
Uterus
e uterus is a bromuscular organ usually divided into
lower cervix and upper corpus or uterine body
Cervix
e portion of cervix exposed to the vagina is the exocervix
or portio vaginalis. e exocervix has a convex round surface
with a circular or slit like opening (the external os) into the
endocervical canal. e endocervical canal is about 2 to 3 cm
in length and opens proximally into the endometrial cavity at
the internal os.
e cervical mucosa generally contains both stratied
squamous epithelium, characteristic of the exocervix, and
mucus-secreting columnar epithelium, characteristic of
the endocervical canal. However, the intersection where
these two epithelia meet “the squamocolumnar junction”
is geographically variable and dependent on hormonal
stimulation. It is this dynamic interface, the transformation
zone constituted by the squamocolumnar junction that is
most vulnerable to the development of squamous neoplasia.
In early childhood, during pregnancy, or with oral
contraceptive use, columnar epithelium may extend from the
endocervical canal onto the exocervix, a condition known
as eversion or ectopy. Aer menopause, the transformation
zone usually recedes entirely into the endocervical canal.
Production of cervical mucus is under hormonal inuence.
SAN 17528 Local edit BMJ2.indd 100 8/18/11 10:00 AM
101
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
It varies from profuse, clear, and thin mucus around the time
of ovulation to scant and thick mucus in the postovulatory
phase of the cycle.
Corpus
e body of the uterus varies in size and shape, depending
on hormonal and childbearing status. At birth, the cervix and
corpus are about equal in size; in adult women, the corpus has
grown 2 to 3 times the size of the cervix.
Fallopian Tubes
e fallopian tubes and ovaries collectively are referred to as
the adnexa. e Fallopian tubes are paired hollow structures
representing the proximal unfused ends of the Müllerian
duct. e Fallopian tubes vary in length from 7 to 12 cm, and
their function includes ovum pickup, provision of physical
environment for conception, and transport and nourishment
of the fertilized ovum.
Ovaries
e ovaries are paired gonadal structures that lie suspended
between the pelvic wall and the uterus by the infundibulopelvic
ligament laterally and the uteroovarian ligament medially.
Age related changes in female genitalia
During the course of intrauterine development, the uterus
is formed at weeks 13-14 as a result of fusion of the distal
portions of the paramesonephric ducts. At weeks 16-20, a
vesicle cervix and upper one third of vagina is dierentiated.
Vulvar lips are developed at the beginning of the 17th week. A
well-marked hymen is evident by week 24-25.
During childhood (up to age 10 years), a gradual growth
of genital system organs is observed. However, there are some
features that are maintained as typical for the age, namely: size
and position of the cervix being superior to the uterine body,
convoluted uterine tubes, absence of mature follicles in the
ovaries, and absence of secondary sexual characteristics.
Girls’ vaginas during this period are characterized by
attened fornices having almost vertical direction due to
uterus and appendages located beyond the small pelvis.
Vaginal walls are closely adjacent to each other forming a slit-
like vaginal lumen. Mucosal lining of the vagina is coated with
stratied squamous epithelium. In the newborn it consists
of 30 and more strata of epithelial cells rich in glycogen. At
birth the vagina is completely sterile but become populated
with microorganisms within the rst day of life. In 3-4 days,
self-cleaning of the vagina will begin under the inuence of
Döderlein rods. Later on, cocci appear in the vagina3.
During the period of puberty and reproductive age, not
only maturation of reproductive system, but also completion
of physical development of female organism should occur,
including: lengthening of the body, ossication of tubular
bone growth zones, body build formation and distribution
of adipose and muscular tissues according to female type.
Maturation of the hypothalamo-pituitary-ovarian system will
result in estrogen production and is associated with increasing
size of breasts, appearance of pubic hair and changes in the
vaginalora due to appearance of lactobacilli. Increased levels
of estrogen are also responsible for the increased amount of
clear, stretchy cervical secretions seen around ovulation. Aer
ovulation, discharge tends to become less watery and
may
look more like library paste in its consistency.
e most salient changes are linked to puberty, the
menstrual cycle, pregnancy, and menopause. e cutaneous
epithelia of the mons pubis, labia, and clitoris originate from
the embryonic ectoderm and exhibit a keratinized, stratied
structure similar to the skin at other sites. e mucosa of
the vulvar vestibule, which originates from the embryonic
endoderm, is non-keratinized.
e vagina, derived from the embryonic mesoderm, is
responsive to estrogen cycling. In women of reproductive
age, the vaginal mucosa responds to steroid hormone
cycling, exhibiting maximal thickness and intracellular
glycogen content at mid-cycle. Vulvar skin thickness remains
unchanged but menstrual cycle-associated changes occur at a
cytological level.
e vulva and vagina further adapt to the needs of
pregnancy and delivery.
Aer menopause, tissue atrophy ensues. Low estrogen
causes the normal cells lining the vagina to be replaced by
dierent ones that create a much thinner lining. is leaves
nerve ber endings close to the surface of the vagina and
vulnerable to stimulation from friction during penetrative
sex. Normal bacteria that live in a healthy vagina disappear
as it becomes less acid so that infections become more
common4.
Postmenopausal changes in skin barrier function, skin
hydration, and irritant susceptibility have been observed
SAN 17528 Local edit BMJ2.indd 101 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
100
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
mons comprises of hair-bearing skin over a cushion of
adipose tissue that lies on the pubic bones.
Extending
posteriorly from the mons, the labia majora are composed of
similar hair-bearing skin and adipose tissue, which contain
the termination of the round ligaments of the uterus and the
obliterated processus vaginalis (canal of Nuck).
e labia minora, vestibule, and glans clitoris can be seen
between the two labia majora. e labia minora are hairless
skin folds, each of which splits anteriorly to run over, and
under, the glans of the clitoris. e more anterior folds unite
to form the hood-shaped prepuce of the clitoris, whereas the
posterior folds insert into the underside of the glans as the
frenulum.
Unlike the skin of the labia majora, the cutaneous
structures of the labia minora and vestibule do not lie on
an adipose layer but on a connective-tissue stratum that is
loosely organized and permits mobility of the skin during
intercourse.
In the posterior lateral aspect of the vestibule, the duct of
the major vestibular gland can be seen 3 to 4 mm outside the
hymenal ring. e minor vestibular gland openings are found
along a line extending anteriorly from this point, parallel to
the hymenal ring and extending toward the urethral orice.
e urethra bulges slightly around the surrounding vestibular
skin anterior to the vagina and posterior to the clitoris. e
urethras orice is anked on either side by two small labia.
Skene’s ducts open into the inner surface of the small labia
and can be seen as small, punctate openings when the
urethral labia are separated.
e holocrine sebaceous glands in the labia majora are
associated with hair shas, while in the labia minora these
sebaceous glands are freestanding. e holocrine sebaceous
glands lie close to the surface, and are easily recognized with
minimal enlargement. In addition, lateral to the introitus and
anus, there are numerous apocrine sweat glands, along with
the normal eccrine sweat glands. e holocrine sebaceous
glandse former structures undergo change with the
menstrual cycle, with increased secretory activity in the
premenstrual period.
Vagina
e vagina is a hollow bromuscular tube extending from the vulvar
vestibule to the uterus. In the dorsal lithotomy position, the vagina
is directed posteriorly toward the sacrum, but its axis is almost
horizontal in the upright position. It is attached at its upper end to the
uterus just above the cervix. e spaces between the cervix and vagina
are known as the anterior, posterior, and lateral vaginal fornices.
e opening of the vagina may be covered by a membrane or
surrounded by a fold of connective tissue called the hymen. is
tissue is usually replaced by irregular tissue tags later in life
as sexual activity and childbirth occur. e lower vagina is
somewhat constricted as it passes through the urogenital
hiatus in the pelvic diaphragm; the upper vagina is more
spacious. However, the entire vagina is characterized by
its dispensability, which is most evident during childbirth.
e vagina is closely applied anteriorly to the urethra,
bladder neck and trigonal region and, posterior bladder;
posteriorly, the vagina lies in association with the perineal
body, anal canal, lower rectum, and posterior cul-de-sac.
e vagina is composed of three layers, mucosa, muscularis and
adventitia.
e mucosa layer is formed by non-keratinized stratied
squamous epithelium, without glands. Vaginal lubrication
occurs primarily by transudation, with contributions from
cervical and Bartholin gland secretions. e mucosa has a
characteristic pattern of transverse ridges and furrows, known
as rugae. It is hormonally sensitive, responding to stimulation
by estrogen with proliferation and maturation2. e mucosa
is colonized by mixed bacterial ora predominantly with
lactobacillus. Normal pH is 3.5 to 4.5.
e muscularis layer is formed by connective tissue and
smooth muscle, loosely arranged in inner circular and outer
longitudinal layers.
e adventitia layer is comprised by the endopelvic fascia
adherent to the underlying muscularis.
Uterus
e uterus is a bromuscular organ usually divided into
lower cervix and upper corpus or uterine body
Cervix
e portion of cervix exposed to the vagina is the exocervix
or portio vaginalis. e exocervix has a convex round surface
with a circular or slit like opening (the external os) into the
endocervical canal. e endocervical canal is about 2 to 3 cm
in length and opens proximally into the endometrial cavity at
the internal os.
e cervical mucosa generally contains both stratied
squamous epithelium, characteristic of the exocervix, and
mucus-secreting columnar epithelium, characteristic of
the endocervical canal. However, the intersection where
these two epithelia meet “the squamocolumnar junction”
is geographically variable and dependent on hormonal
stimulation. It is this dynamic interface, the transformation
zone constituted by the squamocolumnar junction that is
most vulnerable to the development of squamous neoplasia.
In early childhood, during pregnancy, or with oral
contraceptive use, columnar epithelium may extend from the
endocervical canal onto the exocervix, a condition known
as eversion or ectopy. Aer menopause, the transformation
zone usually recedes entirely into the endocervical canal.
Production of cervical mucus is under hormonal inuence.
SAN 17528 Local edit BMJ2.indd 100 8/18/11 10:00 AM
101
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
It varies from profuse, clear, and thin mucus around the time
of ovulation to scant and thick mucus in the postovulatory
phase of the cycle.
Corpus
e body of the uterus varies in size and shape, depending
on hormonal and childbearing status. At birth, the cervix and
corpus are about equal in size; in adult women, the corpus has
grown 2 to 3 times the size of the cervix.
Fallopian Tubes
e fallopian tubes and ovaries collectively are referred to as
the adnexa. e Fallopian tubes are paired hollow structures
representing the proximal unfused ends of the Müllerian
duct. e Fallopian tubes vary in length from 7 to 12 cm, and
their function includes ovum pickup, provision of physical
environment for conception, and transport and nourishment
of the fertilized ovum.
Ovaries
e ovaries are paired gonadal structures that lie suspended
between the pelvic wall and the uterus by the infundibulopelvic
ligament laterally and the uteroovarian ligament medially.
Age related changes in female genitalia
During the course of intrauterine development, the uterus
is formed at weeks 13-14 as a result of fusion of the distal
portions of the paramesonephric ducts. At weeks 16-20, a
vesicle cervix and upper one third of vagina is dierentiated.
Vulvar lips are developed at the beginning of the 17th week. A
well-marked hymen is evident by week 24-25.
During childhood (up to age 10 years), a gradual growth
of genital system organs is observed. However, there are some
features that are maintained as typical for the age, namely: size
and position of the cervix being superior to the uterine body,
convoluted uterine tubes, absence of mature follicles in the
ovaries, and absence of secondary sexual characteristics.
Girls’ vaginas during this period are characterized by
attened fornices having almost vertical direction due to
uterus and appendages located beyond the small pelvis.
Vaginal walls are closely adjacent to each other forming a slit-
like vaginal lumen. Mucosal lining of the vagina is coated with
stratied squamous epithelium. In the newborn it consists
of 30 and more strata of epithelial cells rich in glycogen. At
birth the vagina is completely sterile but become populated
with microorganisms within the rst day of life. In 3-4 days,
self-cleaning of the vagina will begin under the inuence of
Döderlein rods. Later on, cocci appear in the vagina3.
During the period of puberty and reproductive age, not
only maturation of reproductive system, but also completion
of physical development of female organism should occur,
including: lengthening of the body, ossication of tubular
bone growth zones, body build formation and distribution
of adipose and muscular tissues according to female type.
Maturation of the hypothalamo-pituitary-ovarian system will
result in estrogen production and is associated with increasing
size of breasts, appearance of pubic hair and changes in the
vaginalora due to appearance of lactobacilli. Increased levels
of estrogen are also responsible for the increased amount of
clear, stretchy cervical secretions seen around ovulation. Aer
ovulation, discharge tends to become less watery and
may
look more like library paste in its consistency.
e most salient changes are linked to puberty, the
menstrual cycle, pregnancy, and menopause. e cutaneous
epithelia of the mons pubis, labia, and clitoris originate from
the embryonic ectoderm and exhibit a keratinized, stratied
structure similar to the skin at other sites. e mucosa of
the vulvar vestibule, which originates from the embryonic
endoderm, is non-keratinized.
e vagina, derived from the embryonic mesoderm, is
responsive to estrogen cycling. In women of reproductive
age, the vaginal mucosa responds to steroid hormone
cycling, exhibiting maximal thickness and intracellular
glycogen content at mid-cycle. Vulvar skin thickness remains
unchanged but menstrual cycle-associated changes occur at a
cytological level.
e vulva and vagina further adapt to the needs of
pregnancy and delivery.
Aer menopause, tissue atrophy ensues. Low estrogen
causes the normal cells lining the vagina to be replaced by
dierent ones that create a much thinner lining. is leaves
nerve ber endings close to the surface of the vagina and
vulnerable to stimulation from friction during penetrative
sex. Normal bacteria that live in a healthy vagina disappear
as it becomes less acid so that infections become more
common4.
Postmenopausal changes in skin barrier function, skin
hydration, and irritant susceptibility have been observed
SAN 17528 Local edit BMJ2.indd 101 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
102
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
on exposed skin but not on the vulva. Nevertheless, older
women with incontinence are at increased risk for developing
incontinence dermatitis. A combination of factors, such as
tissue atrophy, slower dissipation of excess skin hydration,
shear forces associated with limited mobility, and lower tissue
regeneration capacity increase the risk of morbidity from
incontinence dermatitis in older women.
Age related changes of vaginal pH
e normal postmenarchal and premenopausal vaginal pH
is 3.8-4.2.
•
At birth lactobacilli is predominant in the vagina since the
vaginal lining is still under the inuence of the mother’s
estrogen. e vaginal pH at this stage is low. Once the
maternal hormonal eect disappears the vaginal pH rises
and remains close to 7 during childhood until puberty.
•
At menarche, lactobacilli is once again predominant
due to rise of estrogen level which converts vaginal cells
glycogen into lactic acid. Lactic acid is responsible for
the acidication of the vaginal environment allowing the
lactobacilli to form a protective layer that guards against
infection of the vagina5. e normal pH at this stage is
3.8 to 4.2.
•
During menstruation or pregnancy, the female hormone
levels uctuate, which in turn disrupts the pH balance
of the vagina. is interference with the natural acidic
environment of the vagina allows bacterial invasion6.
•
During menopause, lack of estrogen causes vaginal
dryness, and for the same reason lactobacilli and lactic
acid are also reduced, causing the vaginal pH to rise up to
6-7, making the vagina more prone to harmful infections.
Vulvitis and Vaginal Discharge
e vulvar skin, especially the intertriginous areas, is a
frequent site of contact dermatitis. e vulvar skin is more
reactive to exposure by irritants than other skin areas such
as the extremities. Contact dermatitis may be one of two
basic pathophysiologic processes: a primary irritant (non
immunologic) or a denite allergic (immunologic) etiology.
Substances that are irritants produce immediate symptoms
such as a stinging and burning sensation when applied to the
vulvar skin. e symptoms and signs secondary to an irritant
disappear within 12 hours of discontinuing the oending
substance.
In contrast, allergic contact dermatitis requires 36 to 48
hours to manifest its symptoms and signs. Oen the signs
of allergic contact dermatitis persist for several days despite
removal of the allergen.
Biological Irritants
Commonly, biologic uids such as urine and feces cause
irritation of the vulvar skin. Rarely, some women will be
allergic to latex or semen.
Chemical Irritants
e majority of chemicals that produce hypersensitivity of
the vulvar skin are cosmetic or therapeutic agents, including
vaginal contraceptives, lubricants, sprays, perfumes, douches,
fabric dyes, fabric soeners, synthetic bers, bleaches, soaps,
chlorine, dyes in toilet tissues, and local anesthetic creams.
External chemicals that trigger the irritation process must be
avoided.
Signs & Symptoms
Acute contact dermatitis results in red, edematous, inamed
skin. e skin may become weeping and eczematous. e
most severe skin reactions form vesicles, and any stage may
become secondarily infected. e common symptoms of
contact dermatitis include supercial vulvar tenderness,
burning and pruritis.
Treatment
e foundation of treatment of contact dermatitis is
to withdraw the oending substance. Sometimes the
distribution of the vulvar erythema helps to delineate the
irritant. For example, localized erythema of the introitus
oen results from vaginal medication, while generalized
erythema of the vulva is secondary to an allergen in clothing.
It is possible to use a vulvar chemical innocuously for many
months or years before the topical vulvar “allergy” develops.
Initial treatment of severe lesions is by using water
compresses for 30 minutes several times a day, followed by
drying the vulva with cool air from a hair dryer. e vulvar
skin should be kept clean and dry. Cotton undergarments
that allow the vulvar skin to aerate should be worn, and
constrictive, occlusive, or tight-tting clothing such as
pantyhose should be avoided. Hydrocortisone (0.5% to 1%)
as lotions or creams may be rubbed into the skin two to three
times a day for a few days to control symptoms.
Inammation of the vulva can, with time and intensity,
spread to the vagina. Conversely, an inammation that
originates in the vagina can ultimately cause inammation in
the vulva. Vaginitis is the reason most oen cited for visits to
Obstetricians and Gynecologists7,8.
Vaginal Discharge
Physiologic Vaginal Discharge can be white, transparent,
thick and odorless. It is formed by mucoid endocervical
secretions in combination with sloughing epithelial cells,
normal bacteria and vaginal transudate. e amount is 1 to
Cause Physical Examination Gold standard test pH Leukocytes Wet mount
Findings
Bacterial vaginosis Variable Gram stain 4.5 No Clue cells
Trichomoniasis Variable, Strawberry spots Culture 4.5 ± Motile
on cervix trichomonads
Candidiasis Adherent white discharge Culture 3.8-4.5 ± Pseudohyphae
or budding
Table 1 | Comparative findings among common causes of vaginitis
SAN 17528 Local edit BMJ2.indd 102 8/18/11 10:00 AM
103
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
4 ml but increases in pregnancy, use of contraceptives, or at
mid-menstrual cycle close to the time of ovulation.
Vaginal discharge due to infection is commonly seen with
one of the following conditions:
-
Bacterial vaginosis (40 – 50%)
-
Candidiasis (20 – 25%)
-
Trichomoniasis (15 – 20%)9.
Special Categories
1.
Diabetic Woman are more susceptible to develop
resistant Candida vulvo-vaginitis. Uncontrolled long
standing diabetic neuropathy can be linked to urinary and
fetal incontinence with secondary vulvar irritation and
excoriation. Moreover, diabetic women are more prone to
develop serious vulvar disease. Post traumatic necrotizing
fasciitis in the diabetic patients may have an insidious
onset but requires early diagnosis and aggressive surgical
management.
2.
Immuno-compromised women are at higher risk of
developing pre-invasive and invasive cervical and vulvo-
vaginal cancers as well as genital warts and herpes.
Intimate Feminine Hygiene
I. External Wash
e external compartment of female genitalia is under
constant exposure to insulting factors that aect its
homeostasis and in particular the skin pH. ese insulting
factors include endogenous or physiological factors and
exogenous or iatrogenic ones. Endogenous factors are
humidity, transpiration (sweat), sebum secretions, anatomical
folding, genetic predisposition and age. Exogenous factors
include detergents, cosmetic products, tight clothing, shaving,
as well as topical cream or powder application. Hence the
mainstay of cleaning this area is to chose a mild detergent that
has a physiological pH of 4.2-5.6 and is capable of enhancing
skin homeostasis10.
1. Soaps
Bar soap is the mostly used female hygiene product in many
countries. Bar soap is usually alkaline or neutral, with a
pH between 7 and 10, dierent from vulvar skin which is
somehow of acidic pH.
Alkaline pH may promote dryness, decreased acidity of
the vulvar skin and can contribute to vulvitis. Whether a fatty
acid soap or a synthetic detergent, the soap function is to
reduce the surface tension of water and to dissolve materials
such as grease and oils that cannot be removed easily by water
alone. Materials used for personal cleansing, such as bar
soaps, body washes, bubble bath, and feminine washes consist
of mixtures of surfactants. Consumers who experience mild
irritant reactions that they perceive to be related to the use of
a specic product should simply switch products.
2. Liquid soaps & Cleansing Solutions
Several intimate liquid soaps are products based on lactic
acid, because lactic acid is a natural component of the skin.
However, intimate liquid soaps dier in many associated
excipients11.
ere are many compounds present in liquid soaps. e
most important are lactic acid, glycerin, fatty acid salts that
remove dirt from skin, pH controllers and EDTA that prevent
precipitation (calcium and magnesium combination when
used with hard water).
e main attribute of liquid soaps is to be able to maintain
the pH closer to the ideal pH, for the development and
maintenance of skin cells.
Lactic acid based cleansing solutions for female genitalia
are only recommended for external use and not for vaginal
douching. ey can be used as adjuvant therapy for genital
infection or inammation but not as treatment
.
In a multicenter based clinical trial in Vietnam, adding
lactic acid lactoserum as external wash to a standard
regimen for treating bacterial vaginosis was found to be
useful in relieving women vaginal complaints12Abased
liquid soap.
It is highly recommended to use hypoallergenic
products and products that provide mild detergent eect.
3. Tissues & Wipes
Tissues and wipes products are relatively recent additions
to the consumer market. Baby wipes were the rst
premoistened wipes to penetrate the market signicantly.
Now, this range of products includes ushable personal
cleansing cloths and products targeted specically for
women. e formulations of these products vary, but
consist mainly of water with mild surfactant, preservatives,
antimicrobials, and fragrance. Some brands include skin
treatment agents, such as lotions with vitamin E or aloe.
ere are very few reports in the literature of adverse
reactions to these products.
4. Odor Control Products
A variety of products are available for use by women
to control odor. ese odor control products include
feminine deodorant sprays, body splashes, fragrances and,
feminine suppositories. Typically, odor control products
are packaged in aerosol or pump spray for external use,
primarily to be applied on or adjacent to the female
genitalia to absorb moisture, deodorize, neutralize or
otherwise control odor. ese products may contain
antimicrobial agents, astringents, and perfumes.
e aerosol products also contain propellants. ere are
few reports in the scientic literature of adverse reactions
of modern feminine deodorant sprays. A careful choice of
ingredients and safety testing prior to marketing minimize
risks of irritation or sensitization.
Other products available for odor control are feminine
suppositories containing antimicrobials, such as benzalkonium
chloride. Such products are oen used aer small surgical
procedures. However, some brands are advertised as
deodorants and sold for routine use, which is wrong.
Talcum Powder
In their early days, some odor control products contained
talcum powder to absorb moisture. Some women apply
talcum powder either directly to the vulva or indirectly
through application to menstrual pads, diaphragms or
condoms for odor control. Modern products marketed
specically for feminine hygiene use have replaced talcum
powder with cornstarch or baking soda.
SAN 17528 Local edit BMJ2.indd 103 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
102
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
on exposed skin but not on the vulva. Nevertheless, older
women with incontinence are at increased risk for developing
incontinence dermatitis. A combination of factors, such as
tissue atrophy, slower dissipation of excess skin hydration,
shear forces associated with limited mobility, and lower tissue
regeneration capacity increase the risk of morbidity from
incontinence dermatitis in older women.
Age related changes of vaginal pH
e normal postmenarchal and premenopausal vaginal pH
is 3.8-4.2.
•
At birth lactobacilli is predominant in the vagina since the
vaginal lining is still under the inuence of the mother’s
estrogen. e vaginal pH at this stage is low. Once the
maternal hormonal eect disappears the vaginal pH rises
and remains close to 7 during childhood until puberty.
•
At menarche, lactobacilli is once again predominant
due to rise of estrogen level which converts vaginal cells
glycogen into lactic acid. Lactic acid is responsible for
the acidication of the vaginal environment allowing the
lactobacilli to form a protective layer that guards against
infection of the vagina5. e normal pH at this stage is
3.8 to 4.2.
•
During menstruation or pregnancy, the female hormone
levels uctuate, which in turn disrupts the pH balance
of the vagina. is interference with the natural acidic
environment of the vagina allows bacterial invasion6.
•
During menopause, lack of estrogen causes vaginal
dryness, and for the same reason lactobacilli and lactic
acid are also reduced, causing the vaginal pH to rise up to
6-7, making the vagina more prone to harmful infections.
Vulvitis and Vaginal Discharge
e vulvar skin, especially the intertriginous areas, is a
frequent site of contact dermatitis. e vulvar skin is more
reactive to exposure by irritants than other skin areas such
as the extremities. Contact dermatitis may be one of two
basic pathophysiologic processes: a primary irritant (non
immunologic) or a denite allergic (immunologic) etiology.
Substances that are irritants produce immediate symptoms
such as a stinging and burning sensation when applied to the
vulvar skin. e symptoms and signs secondary to an irritant
disappear within 12 hours of discontinuing the oending
substance.
In contrast, allergic contact dermatitis requires 36 to 48
hours to manifest its symptoms and signs. Oen the signs
of allergic contact dermatitis persist for several days despite
removal of the allergen.
Biological Irritants
Commonly, biologic uids such as urine and feces cause
irritation of the vulvar skin. Rarely, some women will be
allergic to latex or semen.
Chemical Irritants
e majority of chemicals that produce hypersensitivity of
the vulvar skin are cosmetic or therapeutic agents, including
vaginal contraceptives, lubricants, sprays, perfumes, douches,
fabric dyes, fabric soeners, synthetic bers, bleaches, soaps,
chlorine, dyes in toilet tissues, and local anesthetic creams.
External chemicals that trigger the irritation process must be
avoided.
Signs & Symptoms
Acute contact dermatitis results in red, edematous, inamed
skin. e skin may become weeping and eczematous. e
most severe skin reactions form vesicles, and any stage may
become secondarily infected. e common symptoms of
contact dermatitis include supercial vulvar tenderness,
burning and pruritis.
Treatment
e foundation of treatment of contact dermatitis is
to withdraw the oending substance. Sometimes the
distribution of the vulvar erythema helps to delineate the
irritant. For example, localized erythema of the introitus
oen results from vaginal medication, while generalized
erythema of the vulva is secondary to an allergen in clothing.
It is possible to use a vulvar chemical innocuously for many
months or years before the topical vulvar “allergy” develops.
Initial treatment of severe lesions is by using water
compresses for 30 minutes several times a day, followed by
drying the vulva with cool air from a hair dryer. e vulvar
skin should be kept clean and dry. Cotton undergarments
that allow the vulvar skin to aerate should be worn, and
constrictive, occlusive, or tight-tting clothing such as
pantyhose should be avoided. Hydrocortisone (0.5% to 1%)
as lotions or creams may be rubbed into the skin two to three
times a day for a few days to control symptoms.
Inammation of the vulva can, with time and intensity,
spread to the vagina. Conversely, an inammation that
originates in the vagina can ultimately cause inammation in
the vulva. Vaginitis is the reason most oen cited for visits to
Obstetricians and Gynecologists7,8.
Vaginal Discharge
Physiologic Vaginal Discharge can be white, transparent,
thick and odorless. It is formed by mucoid endocervical
secretions in combination with sloughing epithelial cells,
normal bacteria and vaginal transudate. e amount is 1 to
Cause Physical Examination Gold standard test pH Leukocytes Wet mount
Findings
Bacterial vaginosis Variable Gram stain 4.5 No Clue cells
Trichomoniasis Variable, Strawberry spots Culture 4.5 ± Motile
on cervix trichomonads
Candidiasis Adherent white discharge Culture 3.8-4.5 ± Pseudohyphae
or budding
Table 1 | Comparative findings among common causes of vaginitis
SAN 17528 Local edit BMJ2.indd 102 8/18/11 10:00 AM
103
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
4 ml but increases in pregnancy, use of contraceptives, or at
mid-menstrual cycle close to the time of ovulation.
Vaginal discharge due to infection is commonly seen with
one of the following conditions:
-
Bacterial vaginosis (40 – 50%)
-
Candidiasis (20 – 25%)
-
Trichomoniasis (15 – 20%)9.
Special Categories
1.
Diabetic Woman are more susceptible to develop
resistant Candida vulvo-vaginitis. Uncontrolled long
standing diabetic neuropathy can be linked to urinary and
fetal incontinence with secondary vulvar irritation and
excoriation. Moreover, diabetic women are more prone to
develop serious vulvar disease. Post traumatic necrotizing
fasciitis in the diabetic patients may have an insidious
onset but requires early diagnosis and aggressive surgical
management.
2.
Immuno-compromised women are at higher risk of
developing pre-invasive and invasive cervical and vulvo-
vaginal cancers as well as genital warts and herpes.
Intimate Feminine Hygiene
I. External Wash
e external compartment of female genitalia is under
constant exposure to insulting factors that aect its
homeostasis and in particular the skin pH. ese insulting
factors include endogenous or physiological factors and
exogenous or iatrogenic ones. Endogenous factors are
humidity, transpiration (sweat), sebum secretions, anatomical
folding, genetic predisposition and age. Exogenous factors
include detergents, cosmetic products, tight clothing, shaving,
as well as topical cream or powder application. Hence the
mainstay of cleaning this area is to chose a mild detergent that
has a physiological pH of 4.2-5.6 and is capable of enhancing
skin homeostasis10.
1. Soaps
Bar soap is the mostly used female hygiene product in many
countries. Bar soap is usually alkaline or neutral, with a
pH between 7 and 10, dierent from vulvar skin which is
somehow of acidic pH.
Alkaline pH may promote dryness, decreased acidity of
the vulvar skin and can contribute to vulvitis. Whether a fatty
acid soap or a synthetic detergent, the soap function is to
reduce the surface tension of water and to dissolve materials
such as grease and oils that cannot be removed easily by water
alone. Materials used for personal cleansing, such as bar
soaps, body washes, bubble bath, and feminine washes consist
of mixtures of surfactants. Consumers who experience mild
irritant reactions that they perceive to be related to the use of
a specic product should simply switch products.
2. Liquid soaps & Cleansing Solutions
Several intimate liquid soaps are products based on lactic
acid, because lactic acid is a natural component of the skin.
However, intimate liquid soaps dier in many associated
excipients11.
ere are many compounds present in liquid soaps. e
most important are lactic acid, glycerin, fatty acid salts that
remove dirt from skin, pH controllers and EDTA that prevent
precipitation (calcium and magnesium combination when
used with hard water).
e main attribute of liquid soaps is to be able to maintain
the pH closer to the ideal pH, for the development and
maintenance of skin cells.
Lactic acid based cleansing solutions for female genitalia
are only recommended for external use and not for vaginal
douching. ey can be used as adjuvant therapy for genital
infection or inammation but not as treatment
.
In a multicenter based clinical trial in Vietnam, adding
lactic acid lactoserum as external wash to a standard
regimen for treating bacterial vaginosis was found to be
useful in relieving women vaginal complaints12Abased
liquid soap.
It is highly recommended to use hypoallergenic
products and products that provide mild detergent eect.
3. Tissues & Wipes
Tissues and wipes products are relatively recent additions
to the consumer market. Baby wipes were the rst
premoistened wipes to penetrate the market signicantly.
Now, this range of products includes ushable personal
cleansing cloths and products targeted specically for
women. e formulations of these products vary, but
consist mainly of water with mild surfactant, preservatives,
antimicrobials, and fragrance. Some brands include skin
treatment agents, such as lotions with vitamin E or aloe.
ere are very few reports in the literature of adverse
reactions to these products.
4. Odor Control Products
A variety of products are available for use by women
to control odor. ese odor control products include
feminine deodorant sprays, body splashes, fragrances and,
feminine suppositories. Typically, odor control products
are packaged in aerosol or pump spray for external use,
primarily to be applied on or adjacent to the female
genitalia to absorb moisture, deodorize, neutralize or
otherwise control odor. ese products may contain
antimicrobial agents, astringents, and perfumes.
e aerosol products also contain propellants. ere are
few reports in the scientic literature of adverse reactions
of modern feminine deodorant sprays. A careful choice of
ingredients and safety testing prior to marketing minimize
risks of irritation or sensitization.
Other products available for odor control are feminine
suppositories containing antimicrobials, such as benzalkonium
chloride. Such products are oen used aer small surgical
procedures. However, some brands are advertised as
deodorants and sold for routine use, which is wrong.
Talcum Powder
In their early days, some odor control products contained
talcum powder to absorb moisture. Some women apply
talcum powder either directly to the vulva or indirectly
through application to menstrual pads, diaphragms or
condoms for odor control. Modern products marketed
specically for feminine hygiene use have replaced talcum
powder with cornstarch or baking soda.
SAN 17528 Local edit BMJ2.indd 103 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
104
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
Several epidemiological studies have suggested a slight
increase in the risk of ovarian cancer with talcum powder
use. However, other studies showed no association.
II. Vaginal Douching
Vaginal douching is the process of inserting a device
into the vagina for the purpose of ushing liquids inside.
Vaginal douching has been subject to debate in scientic
journals for decades.
e composition of douches varies from purchased
douches to homemade solutions such as water and vinegar.
Regular douching may vary between women in
dierent countries.
Vaginal douching has been implicated in a number of
adverse reproductive health outcomes including increased
risk of pelvic inammatory disease (PID), ectopic
pregnancy, cervical carcinoma, reduced fertility, increased
susceptibility to sexually transmitted infections (STIs),
including HIV infection and bacterial vaginosis, preterm
delivery and, low birth weight infant13,14.
Prospective studies are needed to determine whether
douching is a causal factor for infection (or disease) or is
a rather common behavior among women who are at risk
for these conditions15.
Hence, vaginal douching is not advisable to use for the
purpose of feminine hygiene.
III. Clothing
Clothing is one of the important factors in prevention
of vulvovaginits. Bacteria and yeast thrive in moist or
damp places. erefore, clothing that increases local heat
and moisture such as nylon underwear and tight-tting
garments including leotards, tights, rubber pants, skintight
jeans, nylon underclothing and tight-tting diapers
can contribute to vaginal infections and prepubertal
vulvovaginitis 16.
Cotton underwear is preferable to synthetic materials
because cotton is very breathable, and allows air to
circulate around the external genitalia. Aeration helps to
keep microorganisms from building up and also helps
maintain sound skin around the vaginal area. In order to
prevent vaginal infections, it is important to change damp
clothes, specially for those women that sweat easily or
exercise oen.
For children, scented or colored toilet paper should not
be used.e child should switch from tight-tting clothing
and underwear made of wool or nylon to loose-tting
clothing, skirts, and cotton underclothing. e underwear
should be changed frequently. Aer bathing, vulvar tissue
should allow to air-dry or be dried very gently with a so
towel without rubbing17.
Female Genital Hygiene
I. Hygiene in childhood
Genital organ disease prevention should be initiated
from the moment of birth. In order to keep genital
organs clean they should be carefully washed with
warm water from front to rear using so cloth/sheets.
Apart from using mild baby soap, washing with
medicinal agents, herbal extracts and other agents without
an appropriate doctor prescription is not advisable.
Aer external genital organs washing, perineum and
hips should be carefully wiped with a clean so dedicated
towel18.
e washing should be performed in the morning and
before going to bed.
Special attention should be paid to infection prevention
by observing rules like:
• Washing hands carefully before handling the child
• Never share the same towel or sponge with a child
• Avoid bathing in the same tub with a child
Girls’ clothes and foot wear should not clog movements
or interfere with normal aeration and blood circulation.
A girl should change her underwear every day in order to
avoid irritation of genital organs.
II. Menstrual care
Menstrual blood leads to changes in vaginal pH
(alkaline pH). However the relationship between
vaginal microbiology and menses is complex. In one
study the highest rate of recovery of heavy growth
of non- lactobacillus species occurred at days 1-5 of
menstruation. is heavy bacterial growth could occur
because of additional substrate from menstrual blood
and might represent temporary instability of the vaginal
ora at menses. It has been shown that the menstrual
specimen contained the highest number of bacteria at
the lowest concentration19.
Menstrual Hygiene products include the following:
1. Tampons
Tampons are tubes of tightly packed cotton, rayon, or
a combination of these that are inserted into vagina
with either the help of ngers or an applicator. Natural
sea sponges are a kind of tampon made from naturally
growing sea sponges and are similar to regular tampons.
e use of tampons is not encouraged in societies were
virginity is an issue and women are expected to marry
as virgins. is is because tampons may cause hymen
rupture.
2. Sanitary napkins (cotton and synthetic)
Sanitary napkins are worn externally and are attached
to the underwear. ey can be uncomfortable due to
chang, especially in the summer. Sanitary napkins made
of cotton provoke less skin irritation. Synthetic sanitary
napkins are not environmentally friendly. Washable
sanitary napkins are also available in the market.
More important, whether using tampons or napkins,
a woman should not wear any one of these for more
than 6 hours.
3. Menstrual cups
Menstrual cups can be either disposable or reusable and
are worn internally. e so cup is a exible plastic cap
that is placed around the cervix. It can stay in place for
24 hours. e keeper is a exible cup of natural rubber
and has a life span of at least 10 years. ere are 2 sizes
available: before and aer vaginal child birth. Menstrual
cups are ideal for travelling and where other alternatives
are not easily available.
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BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
III. Peri-coital care
Female genitalia is a conducive environment that allows
transmission of bacteria, secretions, sweat, menses, urine and
fecal waste into the vagina during sexual intercourse. Together
with lack of ventilation, these may lead to infection. It is therefore
important to care for this area without aecting its physiological
characteristics around the time of sexual intercourse20.
Another important fact to bear in mind is that multiple sexual
partners increases the risk of sexually transmitted diseases.
Pre-coital care:
• Cleaning of external genitalia should include the vulva,
as well as the folds of the labia and the clitoris before
coitus.
• Excessive cleaning can be counterproductive because
it destroys the normal ora and increases the risk of
infection.
• Dry the genital area and the folds between the legs so
that there is no irritation or moisture le.
• Hands and nails should be kept clean and neat cut for
a safe sex play.
• e vagina is cleaned by itself; its walls produce a uid
that carries the dead cells and other microorganisms
to the outside. erefore, vaginal douching is not
recommended.
• Do not use perfumes, deodorants directly on skin
before intercourse as they can cause allergic reactions.
Post coital care
• is should involve cleansing of secretions from front to
back using mild non soapy cleanser.
• Post coital douche is not recommended, as it does not
serve as a contraceptive but increases susceptibility to
infections like bacterial vaginosis21.
• Disinfectants or vigorous cleaning with any harsh
materials should be avoided.
• External genitalia should be dried with a dryer if
possible.
• Micturition aer intercourse reduces the incidence of
urinary tract infections.
• Wear loose cotton undergarments. Tight spandex-like
clothes must be avoided at night.
• Sleeping without undergarments is recommended
for keeping the area dry. Moisture and humidity can
encourage bacterial proliferation.
• Powders sprinkling should not be done since they
encourage fungal infections by holding moisture.
IV. Mons pubis hair care
Hair Removal Products
Hair removal methods include trimming with scissors or
a hair clipper, shaving, depilation, waxing, electrolysis, and
laser hair removal.
Trimming and clipping have few adverse eects as long as
they are done carefully to avoid cutting the delicate skin of the
vulva. Shaving is easy to do at home but can sometimes leave
bumps on the skin. A number of depilatories are formulated
specically for use on the “bikini line.” Use on areas outside
the bikini line, such as the vulva, can lead to irritation.
Waxing plucks the hair from the root, therefore, the results
last longer.
Home products contain combinations of waxes and
resin that makes the wax adhere to the skin. Home
products are formulated for use on the bikini line, and not
on other areas of the genitalia.
2. Electrolysis
Electrolysis uses an electric current to destroy the hair
root. Each hair is treated individually with either a
needle epilator or a tweezers epilator. Home electrolysis
devices are available but it may be dicult to apply the
device accurately to an area that cannot be seen very easily.
erefore, professional electrolysis is preferable. Adverse
eects of electrolysis can include pain during treatment and
swelling and inammation aer treatment. Electrolysis can
cause scarring and changes in skin color in some individuals.
3. Laser hair removal
Laser hair removal is relatively new. As the laser is moved
over the skin, the light passes through and is absorbed by the
melanin (pigment) in the hair follicles. It is believed that the
heat generated by the laser breaks apart the follicle and the
hair falls out over a period of approximately two months. e
treatment is best suited for fair-skinned people with dark hair.
In darker skinned people, the skin pigment can absorb the laser
before it reaches the hair follicle, making the treatment less
eective. Light-colored hair may not contain enough melanin.
Multiple treatments are required to achieve a meaningful hair
reduction of the area. Adverse eects of laser hair removal
include sensitivity of the treated skin. Rarely, peeling, blistering,
and burning of the skin may occur, as well as brown spots or a
slight loss of pigment in areas where the laser has been used.
V. Care during Pregnancy
Hormonal and immune system alterations during pregnancy,
make women more susceptible to genital infections which may in
turn, place both mother and fetus at risk.
Certain cosmetics, on the other hand, can be teratogenic and
hence genital hygiene products should be carefully chosen during
pregnancy.
A pregnant woman should rinse her external genital organs 2-3
times a day using warm water and cleansers containing lactic acid.
ese cleansers not only maintain the physiological pH, they also
enhance natural barriers and are known to be non-teratogenic22.
VI. Postpartum Perineal care:
Evidences for best practice regarding management of perineal
wounds are scant. Studies and reviews appear to concentrate on
the management of perineal pain in the postpartum. ere is
little evidence to support the use of common practices such as ice,
ultrasonic therapy, and leg elevation.
Whether stitches are present or not the following measures can
be suggested:
1.
Plain water should be used to clean the perineum. e addition
of salt, antiseptics or witch hazel as alternative remedies to the
bath water have been researched. ese products have a slight
soothing eect for a few women, but make no dierence in
healing compared with plain water.
2.
Topical cold therapy on the perineum using crushed ice or cold
pads are eective in reducing pain in the rst 24 hours aer
delivery.
3.
Aer 24 hours of delivery moist heat in the form of warm
SAN 17528 Local edit BMJ2.indd 105 8/18/11 10:00 AM
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104
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
Several epidemiological studies have suggested a slight
increase in the risk of ovarian cancer with talcum powder
use. However, other studies showed no association.
II. Vaginal Douching
Vaginal douching is the process of inserting a device
into the vagina for the purpose of ushing liquids inside.
Vaginal douching has been subject to debate in scientic
journals for decades.
e composition of douches varies from purchased
douches to homemade solutions such as water and vinegar.
Regular douching may vary between women in
dierent countries.
Vaginal douching has been implicated in a number of
adverse reproductive health outcomes including increased
risk of pelvic inammatory disease (PID), ectopic
pregnancy, cervical carcinoma, reduced fertility, increased
susceptibility to sexually transmitted infections (STIs),
including HIV infection and bacterial vaginosis, preterm
delivery and, low birth weight infant13,14.
Prospective studies are needed to determine whether
douching is a causal factor for infection (or disease) or is
a rather common behavior among women who are at risk
for these conditions15.
Hence, vaginal douching is not advisable to use for the
purpose of feminine hygiene.
III. Clothing
Clothing is one of the important factors in prevention
of vulvovaginits. Bacteria and yeast thrive in moist or
damp places. erefore, clothing that increases local heat
and moisture such as nylon underwear and tight-tting
garments including leotards, tights, rubber pants, skintight
jeans, nylon underclothing and tight-tting diapers
can contribute to vaginal infections and prepubertal
vulvovaginitis 16.
Cotton underwear is preferable to synthetic materials
because cotton is very breathable, and allows air to
circulate around the external genitalia. Aeration helps to
keep microorganisms from building up and also helps
maintain sound skin around the vaginal area. In order to
prevent vaginal infections, it is important to change damp
clothes, specially for those women that sweat easily or
exercise oen.
For children, scented or colored toilet paper should not
be used.e child should switch from tight-tting clothing
and underwear made of wool or nylon to loose-tting
clothing, skirts, and cotton underclothing. e underwear
should be changed frequently. Aer bathing, vulvar tissue
should allow to air-dry or be dried very gently with a so
towel without rubbing17.
Female Genital Hygiene
I. Hygiene in childhood
Genital organ disease prevention should be initiated
from the moment of birth. In order to keep genital
organs clean they should be carefully washed with
warm water from front to rear using so cloth/sheets.
Apart from using mild baby soap, washing with
medicinal agents, herbal extracts and other agents without
an appropriate doctor prescription is not advisable.
Aer external genital organs washing, perineum and
hips should be carefully wiped with a clean so dedicated
towel18.
e washing should be performed in the morning and
before going to bed.
Special attention should be paid to infection prevention
by observing rules like:
• Washing hands carefully before handling the child
• Never share the same towel or sponge with a child
• Avoid bathing in the same tub with a child
Girls’ clothes and foot wear should not clog movements
or interfere with normal aeration and blood circulation.
A girl should change her underwear every day in order to
avoid irritation of genital organs.
II. Menstrual care
Menstrual blood leads to changes in vaginal pH
(alkaline pH). However the relationship between
vaginal microbiology and menses is complex. In one
study the highest rate of recovery of heavy growth
of non- lactobacillus species occurred at days 1-5 of
menstruation. is heavy bacterial growth could occur
because of additional substrate from menstrual blood
and might represent temporary instability of the vaginal
ora at menses. It has been shown that the menstrual
specimen contained the highest number of bacteria at
the lowest concentration19.
Menstrual Hygiene products include the following:
1. Tampons
Tampons are tubes of tightly packed cotton, rayon, or
a combination of these that are inserted into vagina
with either the help of ngers or an applicator. Natural
sea sponges are a kind of tampon made from naturally
growing sea sponges and are similar to regular tampons.
e use of tampons is not encouraged in societies were
virginity is an issue and women are expected to marry
as virgins. is is because tampons may cause hymen
rupture.
2. Sanitary napkins (cotton and synthetic)
Sanitary napkins are worn externally and are attached
to the underwear. ey can be uncomfortable due to
chang, especially in the summer. Sanitary napkins made
of cotton provoke less skin irritation. Synthetic sanitary
napkins are not environmentally friendly. Washable
sanitary napkins are also available in the market.
More important, whether using tampons or napkins,
a woman should not wear any one of these for more
than 6 hours.
3. Menstrual cups
Menstrual cups can be either disposable or reusable and
are worn internally. e so cup is a exible plastic cap
that is placed around the cervix. It can stay in place for
24 hours. e keeper is a exible cup of natural rubber
and has a life span of at least 10 years. ere are 2 sizes
available: before and aer vaginal child birth. Menstrual
cups are ideal for travelling and where other alternatives
are not easily available.
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BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
III. Peri-coital care
Female genitalia is a conducive environment that allows
transmission of bacteria, secretions, sweat, menses, urine and
fecal waste into the vagina during sexual intercourse. Together
with lack of ventilation, these may lead to infection. It is therefore
important to care for this area without aecting its physiological
characteristics around the time of sexual intercourse20.
Another important fact to bear in mind is that multiple sexual
partners increases the risk of sexually transmitted diseases.
Pre-coital care:
• Cleaning of external genitalia should include the vulva,
as well as the folds of the labia and the clitoris before
coitus.
• Excessive cleaning can be counterproductive because
it destroys the normal ora and increases the risk of
infection.
• Dry the genital area and the folds between the legs so
that there is no irritation or moisture le.
• Hands and nails should be kept clean and neat cut for
a safe sex play.
• e vagina is cleaned by itself; its walls produce a uid
that carries the dead cells and other microorganisms
to the outside. erefore, vaginal douching is not
recommended.
• Do not use perfumes, deodorants directly on skin
before intercourse as they can cause allergic reactions.
Post coital care
• is should involve cleansing of secretions from front to
back using mild non soapy cleanser.
• Post coital douche is not recommended, as it does not
serve as a contraceptive but increases susceptibility to
infections like bacterial vaginosis21.
• Disinfectants or vigorous cleaning with any harsh
materials should be avoided.
• External genitalia should be dried with a dryer if
possible.
• Micturition aer intercourse reduces the incidence of
urinary tract infections.
• Wear loose cotton undergarments. Tight spandex-like
clothes must be avoided at night.
• Sleeping without undergarments is recommended
for keeping the area dry. Moisture and humidity can
encourage bacterial proliferation.
• Powders sprinkling should not be done since they
encourage fungal infections by holding moisture.
IV. Mons pubis hair care
Hair Removal Products
Hair removal methods include trimming with scissors or
a hair clipper, shaving, depilation, waxing, electrolysis, and
laser hair removal.
Trimming and clipping have few adverse eects as long as
they are done carefully to avoid cutting the delicate skin of the
vulva. Shaving is easy to do at home but can sometimes leave
bumps on the skin. A number of depilatories are formulated
specically for use on the “bikini line.” Use on areas outside
the bikini line, such as the vulva, can lead to irritation.
Waxing plucks the hair from the root, therefore, the results
last longer.
Home products contain combinations of waxes and
resin that makes the wax adhere to the skin. Home
products are formulated for use on the bikini line, and not
on other areas of the genitalia.
2. Electrolysis
Electrolysis uses an electric current to destroy the hair
root. Each hair is treated individually with either a
needle epilator or a tweezers epilator. Home electrolysis
devices are available but it may be dicult to apply the
device accurately to an area that cannot be seen very easily.
erefore, professional electrolysis is preferable. Adverse
eects of electrolysis can include pain during treatment and
swelling and inammation aer treatment. Electrolysis can
cause scarring and changes in skin color in some individuals.
3. Laser hair removal
Laser hair removal is relatively new. As the laser is moved
over the skin, the light passes through and is absorbed by the
melanin (pigment) in the hair follicles. It is believed that the
heat generated by the laser breaks apart the follicle and the
hair falls out over a period of approximately two months. e
treatment is best suited for fair-skinned people with dark hair.
In darker skinned people, the skin pigment can absorb the laser
before it reaches the hair follicle, making the treatment less
eective. Light-colored hair may not contain enough melanin.
Multiple treatments are required to achieve a meaningful hair
reduction of the area. Adverse eects of laser hair removal
include sensitivity of the treated skin. Rarely, peeling, blistering,
and burning of the skin may occur, as well as brown spots or a
slight loss of pigment in areas where the laser has been used.
V. Care during Pregnancy
Hormonal and immune system alterations during pregnancy,
make women more susceptible to genital infections which may in
turn, place both mother and fetus at risk.
Certain cosmetics, on the other hand, can be teratogenic and
hence genital hygiene products should be carefully chosen during
pregnancy.
A pregnant woman should rinse her external genital organs 2-3
times a day using warm water and cleansers containing lactic acid.
ese cleansers not only maintain the physiological pH, they also
enhance natural barriers and are known to be non-teratogenic22.
VI. Postpartum Perineal care:
Evidences for best practice regarding management of perineal
wounds are scant. Studies and reviews appear to concentrate on
the management of perineal pain in the postpartum. ere is
little evidence to support the use of common practices such as ice,
ultrasonic therapy, and leg elevation.
Whether stitches are present or not the following measures can
be suggested:
1.
Plain water should be used to clean the perineum. e addition
of salt, antiseptics or witch hazel as alternative remedies to the
bath water have been researched. ese products have a slight
soothing eect for a few women, but make no dierence in
healing compared with plain water.
2.
Topical cold therapy on the perineum using crushed ice or cold
pads are eective in reducing pain in the rst 24 hours aer
delivery.
3.
Aer 24 hours of delivery moist heat in the form of warm
SAN 17528 Local edit BMJ2.indd 105 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
106
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
sitz baths (not tub bathing) may reduce local discomfort and
promote healing23,24. Sitz bath, also called hip bath is a type of
bath in which only the hips and buttocks are soaked in water
or saline solution.
4.
Washing the perineum aer every visit to the toilet. It is
extremely helpful to use a small jug to pour warm water over
the perineum during and aer passing urine. is can help to
prevent stinging.
5.
Using toilet paper to pat dry over and around the stitches from
front to back.
6.
Changing sanitary pads frequently to reduce the risk of
infection.
7.
Keeping the area dry by using breathable materials e.g. cotton or
disposable briefs, worn with loose trousers or a skirt.
Other factors that can help good perineal hygiene
1.
Perform pelvicoor muscle exercises which can strengthen
pelvic organs such as bladder and bowel and also speed up the
healing process by increasing the blood ow to these muscles
2.
Creams or sprays containing local anesthetic are not eective
3.
Preparations containing steroids should be avoided as they can
slow down healing
4.
Increase ber anduid intake to avoid constipation
5.
Avoid sitting for long period of time and to rest as much as
possible
6.
Expose the wound to air to prevent it from becoming moist
7.
Eating healthy to replace the vitamins and minerals needed to
regain energy and help healing
VII. Hygiene for climacteric and older women
Compliance with hygienic rules and periodic visits to the doctors
throughout life may helpwill ensure a trouble-free course during
the climacteric period.
Washing of the whole body with water at room temperature,
heat baths (35-37 °С) and staying in the open air would be very
benecial. Mild physical exercises especially for women who are
engaged in mental work would contribute to a milder climacteric
syndrome. Great attention should be paid to cleanness of the skin
particularly that of genital organs. Daily intimate washing with
warm water should become customary.
e primary hazard for women in climacteric period is
malignant neoplasms of the genital organs. Prophylactic
examinations, careful and regular self-examination and timely
treatment are basic rules for successful management of malignant
neoplasms.
General Recommendations
e following is a summary of e INTIMATE FEMININE
HYGIENE Guidelines for the Middle East and Central Asia region:
1.
All women at all ages are in need of a daily intimate feminine
hygiene to keep their genital area clean and dry.
2.
e vulva and vagina are common aected areas for contact
dermatitis and should be kept away from environmental
irritants or caused by certain hygienic products.
3.
It is highly recommended to use hypoallergenic liquid cleansing
agents with mild detergent eects and acidic pH ranging
between 4.2 and 5.6.
4.
Bar soaps and bubble baths are of abrasive nature and with high
alkaline pH and should be avoided. Lactic acid based soaps with
low pH have been shown to augment skin homeostasis and are
helpful in cases of genital infections as adjuvant therapy.
5.
Vaginal douching is not recommended due to its adverse
obstetrical and gynecological eects
6.
To avoid excessive moisture and allow reasonable ventilation
of the genital area, wearing loose tting cotton underwear
and minimize wearing tight clothes is recommended.
Undergarments should be changed frequently.
7.
Talcum powder should not be used; perfumes and deodorants
should be used sparingly, preferably aer allergy testing.
8.
Menstrual care should include using tampons and sanitary
pads, as preferred, but frequent changing is essential.
9.
Pre and post coital cleansing of the genital area especially
the clitoris and the vulvar folds from front to back is
recommended. Vigorous vulvar cleansing and vaginal
douching are strongly discouraged.
10.
Removal of pubic hair should be based on safe techniques and
done with care to avoid sensitivity and scarring.
11.
Postpartum care should include frequent cleansing, drying
and using pads as necessary. Maintain dryness over the suture.
Do not use creams on the suture. is prohibited.
12.
Child genital care requires the caregiver to wash hands
beforehand, the use of separate towels for children and not
sharingto share the same bath tub with children.
Validated by the Peer Review Panel:
Dr. Ellie Attieh, Obstetrics & Gynecology, Lebanon
Dr. Mohamed Abdel Moneim, G.P., UAE
Dr. Alawi Attas, Dermatologist, Saudi Arabia
References
1.
Practical Guide To Clinical Procedures For Female Genital Hygiene. [In Portuguese, GUIA PRÁTICO DE
CONDUTAS. Higiene Genital Feminina, Federação Brasileira das Associações de Ginecologia e Obstetrícia,]
Brazilian Federation of Gynecology and Obstetrics; 2009. 29 pp. Available at http://missali.site.med.br/fmfiles/
index.asp/::XPR3638::/Guia_de_Higiene_Feminina.pdf Accessed 8 July 2011
2.
Farage MA, Maibach HI. Morphology and physiological changes of genital skin and mucosa. Curr Probl
Dermatol. 2011;40:9-19.
3.
Williams T, Callen J, Owen L. Vulvar disorders in the prepubertal female. Pediatr. Ann. 15(8), 588-589 (1986)
4.
Farage M, Maibach H. Lifetime changes in the vulva and vagina. Arch Gynecol Obstet. 2006 273(4):195-202.
5.
Aroutcheva A, et al. Defense factors of vaginal lactobacilli. Am J Obstet Gynecol 2001;185(2):375-9.
6.
Eschenbach DA, Thwin SS, Patton DL et al. Influence of the normal menstrual cycle on vaginal tissue, discharge
and microflora. Clinical infectious disease 2000; 30; 901-7.
7.
American Congress of Obstetricians and Gynecologists. ACOG Practice Bulletin Number 72, Vaginitis. Obstet
Gynecol. 2006 May;107(5):1195-1206
8.
Center for Diseases Control. Sexually Transmitted Diseases Treatment Guidelines. CDC, 2006. Available at http://
www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm. Accessed by 9 July 2011.
9.
French L, Horton J, Matousek M. Abnormal vaginal discharge: Using office diagnostic testing more effectively.
J Fam Prac 2004; 53(11):890-4
10.
Lambers H, Piessens S, Bloem A.et al et al. Natural skin surface pH is on average below 5, which is beneficial for
it’s resident flora. International Journal of Cosmetic Science 2006; 28:359-370
11.
Tansupasiri A, Puangsricharern A, Itti-arwachakul A, Asavapiriyanont S. Satisfaction and Tolerability of
Combination of Lactoserum and Lactic Acid on the External Genitalia in Thai Women. J Med Assoc Thai 2005;
88 (12): 1753-7.
12.
Nguyen Thi Ngoc Phuong et.al. A clinical Trial on assessment of the effectiveness and tolerability of Lactacyd
FH when used as adjunctive External Vaginal wash to standard treatment of Bacterial Vaginosis. Data on file.
Vietnam 2001
13.
Martino, Jenny L. & Surasak Youngpairoj, Sten H. Vermund. vaginal douching: personal practices and public
policies. Journal of women’s health 2004; 13( 9:1048-1065.
14.
Grimley DM, Oh MK, Desmond RA, et al. An intervention to reduce vaginal douching among adolescent and
young adult women: A randomized, controlled trial. Sex Transm Dis. 2005;32(12):752-75.
15.
Klebanoff MA, Nansel TR, Brotman RM, Zhang J, Yu KF, Schwebke JR, Andrews WW. Personal Hygienic behaviors
and bacterial vaginosis.. Sex Transm Dis. 2010 Feb;37(2):94-9.
16.
Klebanoff MA, Nansel TR, Brotman RM, Zhang J, Yu KF, Schwebke JR, Andrews WW. Personal Hygienic behaviors
and bacterial vaginosiBV. Sex Transm Dis. 2010 Feb;37(2):94-9.
17.
Runeman B, Forsgren-Brusk U, Larko O, Larsson P, Faergemann J. The Vulvar Skin Microenvironment: Impact of
Tight-fitting Underwear on Microclimate, pH and Microflora. Acta Derm Venereol 2005; 85: 118–122.
18.
Murphy Goodwin T. Management of Common Problems in Obstetrics and Gynecology. 2010, fifth edition,
Willey Blackwell, Oxford. Page 227-250
19.
Blume-Peytavi U, Cork MJ, Faergemann, Szczapa J, Vanaclocha F, Gelmetti C. Bathing and cleansing in
newborns from day 1 to first year of life: recommendations from a European round table meeting. Journal of
the European Academy of Dermatology and Venereology 23 (3, 751–759
20.
Ison CA. Factors Affecting the Microflora of the Lower Genital Tract of Healthy Women. In: Hill M, et al. Human
Microbial Ecology. Boca Raton, Florida : CRC Press ; 1989. p.111-130.
21.
Fosch S, Fogolín N, Azzaroni E, Pairetti N, Dana L, Minacori H, Tita I, Redona M, Gribaudo G. Vulvovaginitis:
correlation with predisposing factors, clinical manifestations and microbiological studies. Rev Argent Microbiol.
2006 Oct-Dec;38(4):202-5. In Spanish.
22.
Amaral R, Giraldo PC, Gonçalves AK, Junior JE, Santos-Pereira S, Linhares I, Passos MR. Evaluation of hygienic
douching on the vaginal microflora of female sex workers. Int J STD AIDS. 2007 Nov;18(11), 770-3.
23.
Cluett E R, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. Cochrane
Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub2.
24.
Cluett ER, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. The
Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000111.pub2.
25.
Postnatal Care: CG 37. The National Institute for Health and Clinical Excellence (NICE) Guidelines. (UK); July 2006.
Available at http://www.nice.org.uk/nicemedia/pdf/CG37NICEguideline.pdf Accessed July 9, 2011
26.
American College of Obstetricians and Gynecologists. Care of the vulva: Intrapartum and Postpartum care of
the mother. In: Guidelines for Perinatal CareG 2008; page 164.
SAN 17528 Local edit BMJ2.indd 106 8/18/11 10:00 AM
REPRINTED FROM BMJ ME 2011;19:99106
106
LOCAL PRACTICE
BMJ Middle East | SEPTEMBER 2011 | VOLUME 19
sitz baths (not tub bathing) may reduce local discomfort and
promote healing23,24. Sitz bath, also called hip bath is a type of
bath in which only the hips and buttocks are soaked in water
or saline solution.
4.
Washing the perineum aer every visit to the toilet. It is
extremely helpful to use a small jug to pour warm water over
the perineum during and aer passing urine. is can help to
prevent stinging.
5.
Using toilet paper to pat dry over and around the stitches from
front to back.
6.
Changing sanitary pads frequently to reduce the risk of
infection.
7.
Keeping the area dry by using breathable materials e.g. cotton or
disposable briefs, worn with loose trousers or a skirt.
Other factors that can help good perineal hygiene
1.
Perform pelvicoor muscle exercises which can strengthen
pelvic organs such as bladder and bowel and also speed up the
healing process by increasing the blood ow to these muscles
2.
Creams or sprays containing local anesthetic are not eective
3.
Preparations containing steroids should be avoided as they can
slow down healing
4.
Increase ber anduid intake to avoid constipation
5.
Avoid sitting for long period of time and to rest as much as
possible
6.
Expose the wound to air to prevent it from becoming moist
7.
Eating healthy to replace the vitamins and minerals needed to
regain energy and help healing
VII. Hygiene for climacteric and older women
Compliance with hygienic rules and periodic visits to the doctors
throughout life may helpwill ensure a trouble-free course during
the climacteric period.
Washing of the whole body with water at room temperature,
heat baths (35-37 °С) and staying in the open air would be very
benecial. Mild physical exercises especially for women who are
engaged in mental work would contribute to a milder climacteric
syndrome. Great attention should be paid to cleanness of the skin
particularly that of genital organs. Daily intimate washing with
warm water should become customary.
e primary hazard for women in climacteric period is
malignant neoplasms of the genital organs. Prophylactic
examinations, careful and regular self-examination and timely
treatment are basic rules for successful management of malignant
neoplasms.
General Recommendations
e following is a summary of e INTIMATE FEMININE
HYGIENE Guidelines for the Middle East and Central Asia region:
1.
All women at all ages are in need of a daily intimate feminine
hygiene to keep their genital area clean and dry.
2.
e vulva and vagina are common aected areas for contact
dermatitis and should be kept away from environmental
irritants or caused by certain hygienic products.
3.
It is highly recommended to use hypoallergenic liquid cleansing
agents with mild detergent eects and acidic pH ranging
between 4.2 and 5.6.
4.
Bar soaps and bubble baths are of abrasive nature and with high
alkaline pH and should be avoided. Lactic acid based soaps with
low pH have been shown to augment skin homeostasis and are
helpful in cases of genital infections as adjuvant therapy.
5.
Vaginal douching is not recommended due to its adverse
obstetrical and gynecological eects
6.
To avoid excessive moisture and allow reasonable ventilation
of the genital area, wearing loose tting cotton underwear
and minimize wearing tight clothes is recommended.
Undergarments should be changed frequently.
7.
Talcum powder should not be used; perfumes and deodorants
should be used sparingly, preferably aer allergy testing.
8.
Menstrual care should include using tampons and sanitary
pads, as preferred, but frequent changing is essential.
9.
Pre and post coital cleansing of the genital area especially
the clitoris and the vulvar folds from front to back is
recommended. Vigorous vulvar cleansing and vaginal
douching are strongly discouraged.
10.
Removal of pubic hair should be based on safe techniques and
done with care to avoid sensitivity and scarring.
11.
Postpartum care should include frequent cleansing,