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General gynecology
Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents

https://doi.org/10.1016/j.ajog.2008.06.026Get rights and content

Objective

The objective of the study was to examine the association between douching and 4 sexually transmitted infections (STIs).

Study Design

We followed up 411 high-risk human immunodeficiency virus-infected and uninfected female adolescents aged 12-19 years over a median 3-year period, both by time from study entry/first STI-free visit until an incident STI for participants who never, intermittently, and always douched and also by reported douching at a given STI-free visit and incidence of STI at the next visit, using adjusted Cox proportional hazards models to calculate hazard ratios (HR).

Results

The time to STI was shorter for adolescents who always (HR, 2.1; 95% confidence interval [CI], 1.2-3.4) and intermittently (HR, 1.5; 95% CI, 1.0-2.2) douched, compared with never-douchers. An adjusted hazard for STI was 1.8 times larger for always-douchers (95% CI, 1.1-3.1) and 1.4 times larger for intermittent douchers (95% CI, 0.9-2.0), compared with never-douchers. When classifying by follow-up after an STI-free visit, always-douchers had a shorter STI-free time than never-douchers (HRadj, 2.1; 95% CI, 1.5-3.1).

Conclusion

Counseling to discourage douching may reduce STI risk in adolescents.

Section snippets

Study participants

This study included all adolescent females aged 12-19 years at baseline from an observational study called the Reaching for Excellence in Adolescent Care and Health (REACH) Project of the Adolescent Medicine HIV/AIDS Research Network. Investigators recruited both HIV-infected and HIV-uninfected adolescents at 16 locations in 13 US cities from March 1996 through November 1999. The study cohort enlisted youth who were infected with HIV through sex or drug-taking behaviors (ie, perinatally

Demographic characteristics

The original REACH cohort contained 411 nonvirginal female adolescents, of whom 262 (63.7%) were HIV positive and 147 were HIV negative as per the selection criteria of the parent cohort study. The annual retention rate for HIV-infected youth in this cohort was 95%. The female annual retention rate for HIV-uninfected adolescents was 88%, with older HIV-uninfected female adolescents having the lowest retention rates.37 In our douching substudy, 43 of the 411 participants were not eligible

Comment

In this prospective cohort of HIV-infected and high-risk uninfected adolescent girls and young women followed up for a median of 3 years, douching was an independent risk factor for STI acquisition. This finding supports the hypothesis that regular douching contributes to the risk of STI acquisition among high-risk female adolescents because the douching behaviors measured in this prospective study antedated the incident STI.

The study addresses directly 1 of the principal limitations in much of

Acknowledgments

The authors acknowledge the contributions of the investigators and staff of the Adolescent Medicine HIV/AIDS Research Network (1994-2001) and the youth who participated in the research. Participating investigators and staff are listed elsewhere (J Adolesc Health 2001;29(Suppl):5-6).

The 16 locations in 13 US cities in which the study was conducted as follows: University of Miami (2 locations), Miami, FL; Children's Hospital of Philadelphia, Philadelphia, PA; Tulane Medical Center, New Orleans,

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      Patient-delivered partner therapy has been found to be as effective as standard notification, and is an option in states where this strategy is permissible.50,51 Douching is not effective in reducing trichomoniasis; on the contrary, this practice may be a risk factor for T vaginalis and other sexually transmitted infections.2,52 Neither trichomoniasis nor T vaginalis infection is a nationally notifiable condition in the United States.53

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      Studies in the early to mid-1990s mentioned vaginal practices among risks for heterosexual transmission of STI and HIV in relation to women’s sexual relationships (Awusabo-Asare, Anarfi, & Agyeman, 1993), preferences in sexual experiences (Brown & Brown, 2000; Brown, Ayowa, & Brown, 1993; Civic & Wilson, 1996; Dallabetta et al., 1995; Orubuloye, Caldwell, & Caldwell, 1995; Runganga, Pitts, & McMaster, 1992) and disturbances of vaginal flora (Karim, Karim, Soldan, & Zondi, 1995; Sandala et al., 1995). Subsequent discussions correlated vaginal practices – generally labeled “dry sex” despite evidence of diversity in motivations for the practices beyond reducing of vaginal lubrication – with other factors such as bacterial vaginosis (Atashili, Ndumbe, Adimora, & Smith, 2008), and other STI (La Ruche et al., 1999; Rottingen, Cameron, & Garnett, 2001; Tsai, Shepherd, & Vermund, 2009). Indeed, some studies in the Great Lakes region of Africa cite preference for vaginal lubrication in preparation for sex (Vincke, 1991).

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    Cite this article as: Tsai CS, Shepherd BE, and Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009;200:38.e1-38.e8.

    Ms Tsai is now a medical student at Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL.

    The REACH study was funded by grant U01-HD32842 from the National Institute of Child Health and Human Development with cofunding from the National Institute on Drug Abuse, the National Institute of Allergy and Infectious Diseases, and the National Institute of Mental Health. Support for the analytic work was received from the Vanderbilt-Meharry Center for AIDS Research through grant P30AI054999 from the National Institute of Allergy and Infectious Diseases.

    Reprints not available from the authors.

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