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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 inuenced 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. Specic 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 oend 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, scientic,
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 womens wellbeing.
ese guidelines are written aer 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.
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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 dierentiated.
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
stratied 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 inuence 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, ossication 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
vaginal ora due to appearance of lactobacilli. Increased levels
of estrogen are also responsible for the increased amount of
clear, stretchy cervical secretions seen around ovulation. Aer
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, stratied
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.
Aer menopause, tissue atrophy ensues. Low estrogen
causes the normal cells lining the vagina to be replaced by
dierent 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 orice.
e urethra bulges slightly around the surrounding vestibular
skin anterior to the vagina and posterior to the clitoris. e
urethras orice is anked on either side by two small labia.
Skenes 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 shas, 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
glandse 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 stratied
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 stratied
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. Aer menopause, the transformation
zone usually recedes entirely into the endocervical canal.
Production of cervical mucus is under hormonal inuence.
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
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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 aect 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, dierent 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