AIDS and Behavior

https://doi.org/10.1007/s10461-021-03290-0

ORIGINAL PAPER

Understanding Women’s Vaginal Douching Behaviors and Practices

for Consideration in the Development of a Potential Future Vaginal
Microbicide Douche for HIV Prevention: A Systematic Review
of the Literature
Christine Tagliaferri Rael1   · Doyel Das2 · Jose Bauermeister3 · Cody Lentz1 · Alex Carballo‑Diéguez1 ·
Rebecca Giguere1 · Rachel K. Scott4 · Craig W. Hendrix5

Accepted: 23 April 2021

© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract
Despite clinicians consistently advising against vaginal douching, 29–92% of women worldwide report douching. This review
documents women’s douching practices, motivations for douching, and specific associations (or absence of associations)
between vaginal douche use and vaginal outcomes thought to be associated with douching. Understanding women’s exist-
ing douching behaviors and vaginal health outcomes is critical for developing a safe vaginal microbicide douche that can
be used as HIV pre-exposure prophylaxis (PrEP). A vaginal douche as PrEP could help prevent new HIV infections, since
emerging evidence shows some women discontinue oral PrEP. We performed a systematic review of the literature using the
guidelines for Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). Articles included in the
analysis (N = 48) were published 2009–2019 in English and focused on women’s experiences with douching. Two trained
independent reviewers assessed these articles for content on vaginal douching, including racial/ethnic focus of studies, study
design, sampling, women’s reasons for douching, contents of douche solutions, and associations between vaginal douching
and vaginal health outcomes. Several studies focused on Black women (N = 12 studies) or had no racial/ethnic focus (N = 12).
Just over half of all studies (N = 24) were cross-sectional and involved a self-reported questionnaire and lab samples. Studies
sampled women from health clinics where they were (N = 13) or were not (N = 14) presenting for vaginal health complaints.
Women’s primary motivation for douching was for “general cleanliness” (N = 13), and most douche solutions contained
water (N = 12). There was little empirical agreement between vaginal douche use and most vaginal health outcomes. Future
studies of PrEP vaginal douches should be well controlled and prioritize safety to ensure positive vaginal health outcomes.

Keywords  Microbicides · Vaginal microbicide douche · Topical HIV prevention · Behaviorally congruent · Topical PrEP

Introduction
* Christine Tagliaferri Rael
Cr2857@cumc.columbia.edu
Globally, slightly more than half of all adult people living
1
HIV Center for Clinical and Behavioral Studies at the New with HIV/AIDS (PLWHA) are women [1, 2]. Though access
York State Psychiatric Institute and Columbia University, to systemic HIV pre-exposure prophylaxis (PrEP), e.g., oral
1051 Riverside Dr., New York, NY 10032, USA tenofovir disoproxil fumarate/emtricitabine (F/TDF; Tru-
2
Molecular and Cell Biology, University of California vada™) is growing [3–5], emerging evidence suggests that
Berkeley, Berkeley, USA some women who start this medication later suspend their
3
School of Nursing, University of Pennsylvania, Philadelphia, usage of it, across cultural and demographic groups. For
USA example, in one study of cisgender women (e.g., women
4
MedStar Health Research Institute and MedStar who were assigned female at birth and identify as women)
Washington Hospital Center, Georgetown University School who were prescribed PrEP, around 62.5% terminated use
of Medicine,                 Washington, D.C., USA
at 6 months [6]. In a study in Kenya, only 38% of women
5
Department of Medicine, Johns Hopkins University School who started PrEP continued to use it at 1 month [7]. For
of Medicine, Baltimore, USA

13
Vol.:(0123456789)

women who do not want to use HIV prevention medication
continuously, on-demand topical HIV prevention modalities
that are behaviorally congruent with existing vaginal cleans-
ing and/or sexual routines could be an attractive alternative.
Vaginal douches that include a PrEP formulation could be
one of these alternatives, since vaginal douching is prevalent
worldwide (29–92% of women reported douching in the past
90 days [8, 9]). In our subsequent review, we define “vaginal
douching” as it is understood by the Department of Health
and Human Services’ Office on Women’s Health: “Douch-
ing is washing or cleaning out the vagina with water or other
mixtures of fluids” [10]. Women could use PrEP vaginal
douches prior to sexual encounters in which they believe
they cannot or will not use other HIV prevention strategies
(e.g., condoms). However, it is critical that concerns for
PrEP vaginal douche safety are central to the development
of this product. Clinicians and other women’s health experts
consistently advise against vaginal douching [11, 12], since
some literature shows that this could increase one’s risk for
vaginitis and HIV acquisition [13].
Understanding the nuance of women’s varied vaginal
douching practices and potential health outcomes would
allow product developers to create a PrEP vaginal douche
that is safe and most consistent with women’s current douch-
ing behavior. At present, however, we know little about spe-
cific vaginal douching behaviors or trends on how douching
practices might influence vaginal health outcomes. That is,
we are not aware of any recent studies that have provided a
review of the literature to document women’s douching prac-
tices, motivations for douching, and specific associations (or
absence of associations) between vaginal douche use and
vaginal outcomes thought to be associated with douching
behavior (e.g., bacterial vaginosis [BV], pelvic inflammatory
disease [PID], candida). Understanding the broad context of
these vaginal douching variables critically informs the devel-
opment of a microbicide formulated as a vaginal douche for
HIV prevention.
Despite clinical recommendations against vaginal
douching [10–17], the existing literature shows that women
continue to do so for a variety of reasons. Most com-
monly, women use vaginal douches because they believe
they contribute to overall cleanliness, will prevent or treat
vaginal odor or infections, and/or facilitate greater cleanli-
ness associated with sex [8, 18, 19]. Globally, researchers
have reported wide-ranging prevalance (from 29 to 92%)
for vaginal douching in the past 90 days [8, 9]. This wide
range can be explained by a number of factors, including
professional occupation (e.g., female sex workers may use
vaginal douches more frequently than other women) [20,
21], sociocultural norms (e.g., in some social and cultural
contexts, vaginal douching is believed to be a routine part of
feminine hygiene) [18, 22], and sociodemographic factors
(e.g., women living in comparatively low-income settings
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AIDS and Behavior
are more likely to use vaginal douches than higher-income
women) [23].
Preliminary studies show that rectal douches (also called
enemas) could have an HIV-preventive effect for anorectal
exposures [24–27] and are acceptable by potential end-users
[28, 29]; these medications could potentially be reformulated
for vaginal use. Specifically, administration of tenofovir via a
rectal douche results in faster and higher drug concentration
in the rectal mucosa than oral administration in clinical stud-
ies without toxicity [30]. Further, the same tenofovir douche
provides greater protection than oral F/TDF in macaque rec-
tal SHIV challenge studies [31]. Though vaginal tissue and
flora are different from those of the rectum, it is possible that
this strategy could be modified for vaginal application. This
could be especially useful for women who already douche,
as this HIV prevention strategy is congruent with their exist-
ing sexual or cleansing routines.
We sought a better understanding of the relationships
between vaginal douche use and vaginal health; in turn, this
could broaden researchers’ HIV prevention toolkit to con-
sider a novel, potentially viable, female-centric, behavio-
rally congruent, non-systemic biomedical HIV prevention
strategy that may have otherwise been dismissed. With this
in mind, we set out to systematically review the scientific
literature to identify (1) women’s motivations to use vagi-
nal douches, (2) which vaginal douching products women
use, (3) relationships between vaginal douche use and
vaginal health outcomes, and (4) characteristics of studies
that examine douching and vaginal health outcomes (e.g.,
study design, sample recruitment). This article reviews the
literature published between 2009 and 2019 on cisgender
women’s vaginal douching practices globally.
Methods
We performed a systematic review of the literature using
the guidelines for Preferred Reporting Items for System-
atic Review and Meta-Analyses (PRISMA) [32]. Figure 1
shows the flow of information through our scientific review,
consistent with PRISMA principles. The primary author
(CR) and a research assistant (DD) searched scientific data-
bases including Google Scholar, PubMed, and the primary
author’s university library (Columbia University) for the
following terms: vaginal douching, intravaginal washing,
and intravaginal cleansing. Additionally, we searched the
“gray literature” (e.g., Google) for these terms. Any dupli-
cates identified in the various databases/search mechanisms
were deleted. Studies included in the current review were,
(1) focused on women, women’s experiences, and vaginal
outcomes associated with douching, and (2) published in
peer-reviewed, English-language journals between 2009 and
2019. Studies on men’s perceptions of vaginal douching or
AIDS and Behavior
Fig. 1  Flow of information
through different phases of a
scientific review
articles focused on holistic healthcare practitioners’ (or ven-
dors who sell holistic healthcare products) relationships to
douching were excluded.
CR conducted the initial search to identify articles that fit
the above criteria to include in the review. Then, DD inde-
pendently completed a second review of the selected articles
to corroborate these inclusions. CR and DD met to discuss
disagreements and determine a finalized selection of texts.
Then, DD acted as lead reviewer of article content. Data
abstraction tables were developed to retrieve study char-
acteristics and the major findings of the reviewed studies.
The study characteristics included: (1) Study-related fac-
tors, including the demographic focus of the study sample
(e.g., specific racial or ethnic populations studied), the study
design (e.g., cross-sectional self-report, observational study,
randomized controlled trial), and the sub-samples of women
who were considered for each study (e.g., recruited women
presenting for vaginal symptoms or a sexually transmitted
disease (STI) at a clinic, women seeking pregnancy care, or
sex workers); (2) women’s reasons for douching and con-
tents of douche solutions; and (3) conditions (e.g., BV, PID,
HPV, candida, and several others) found to be negatively
associated or not negatively associated (e.g., the hypoth-
esized negative relationship was not detected in statistical
models) with douching. The presence or lack of a negative
relationship was abstracted from the Results section text and/
or tables in the manuscripts included in this review. Using
a quantitative synthesis process that focused on carefully
assessing descriptive data and regression results to identify
the study-related factors described above, DD coded arti-
cles to fit the abstraction tables with count data to show the
number of articles that met the above study characteristics.
Then, CR independently coded these articles using the same
abstraction tables and quantitative synthesis process; DD
and CR met to discuss disagreements until consensus and
finalize the tables.
Results
In total, 57 articles were identified through the scholarly
databases mentioned above and assessed for eligibility; we
did not identify any unique peer-reviewed articles in the
“gray literature.” Nine manuscripts were excluded from the
final analysis, resulting in N = 48 articles in the final review
[8, 18–23, 33–72]. Reasons for excluding articles included:
they focused on other peoples’ perceptions of douching (e.g.,
men, holistic health practitioners or vendors) [73, 74], they
summarized the findings of prior vaginal douche-related
research and didn’t provide new study findings [13, 75–79],
or it was unclear how douching fit into the authors’ models
for analysis (e.g., the statistical models did not explicitly
define how douching was considered) [80].
Tables 1, 2, 3, 4 show the specific studies associated
with each finding or category. To avoid duplication, we
do not present these results in the article text. Table 1
provides the racial and demographic foci, study design
information, and participant samples recruited in the 48
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Table 1  Racial demographic focus, study design, and the sample from which human subjects participants were recruited
Racial demographic focus Study design Sample from which human subjects participants were recruited*

Racial category # Articles Study design # Articles Human Subjects Sample # Articles

Black women 12 Cross-Sectional: self-reported questionnaire and lab samples 24 Health facility (not presenting for vaginal or STI complaints, 14
• US-based population [8, 55] taken [20, 21, 23, 34, 36, 37, 39, 40, 43, 45, 48, 51, 53, 54, 59, or reason for visit unreported) [8, 23, 33, 43, 44, 49, 51, 52,
• Africa-based population [18, 20, 34, 38, 43, 45, 56, 59, 72] 60, 62, 64, 66, 67, 69, 70, 72, 95] 57, 58, 60, 62, 66, 68]
• Caribbean Islands-based population [19]
No Racial/Ethnic Focus [22, 35, 37, 41, 47, 50, 52, 54, 60, 65, 12 Cross-Sectional: self-reported questionnaire only (no laboratory 16
70, 95] samples taken) [8, 18, 19, 22, 33, 37, 38, 41, 42, 44, 47, 49,
57, 58, 63, 68]
Asian women; all studies were conducted with women based in 11 Observational or longitudinal study [40, 52, 56, 65] 4 Health facility (presenting for vaginal complaints (e.g., odor, 13
Asia [18, 21, 36, 39, 40, 51, 53, 62, 67, 69, 71] itching, burning, abnormal discharge), or STI) [19, 23, 34,
39, 45, 48, 50, 59, 64, 69–71, 95]
Latinx/Hispanic women [42, 57, 58, 61, 63, 66] 6 Sex workers [20, 21, 36, 53, 56, 61, 67, 72] 8
• US-based population [42, 57, 58, 63]
• Latin America-based population [61, 66]
Turkish women; all studies were conducted with women based 6 Randomized Controlled Trial (RCT) [50, 55, 61] 3 Pregnant women [54] 1
in Turkey [23, 33, 44, 48, 49, 68]
Other (e.g., non human subjects research) [46, 64] 2 Other [35, 46] 2 Other [18, 22, 35, 37, 38, 40–42, 47, 63, 65] 11

*Category does not add up to 49, since two studies in this review did not conduct human subjects research
**Note that Racial Demographic Focus, Study Design, and Sample from which Human Subjects Participants were Recruited are distinct categories from one another; side-by-side presentation
of these results does NOT indicate stratification
AIDS and Behavior
AIDS and Behavior
Table 2  Women’s reasons for douching and contents of douche solution
Reasons for douching
General cleanliness [8, 19, 21, 23, 38, 42, 48, 49, 55, 57, 58, 61, 68]
Prevent or treat odor [8, 18, 20, 21, 23, 33, 42, 56, 58, 61, 68]
Sex-related hygiene (e.g., cleaning before or after sex) [18–20, 38, 49, 55, 57, 58, 61, 68]
Prevent or treat infection [8, 19–21, 38, 53, 56, 58, 61, 68]
Cleaning after menses [21, 38, 55, 56, 58, 68]
Prevent pregnancy [20, 21, 33, 38, 49, 68]
Other (religious duty, traditional habit), vaginal drying/tightening [8, 19, 21, 33, 38, 48, 49, 56, 68]
Contents of douche solution
Water [8, 19, 21, 33, 39, 40, 49, 56, 59, 66, 67, 70]
Water + soap [19, 33, 38, 45, 48, 49, 56, 59, 61, 67, 70]
Commercially prepared [8, 40–42, 50, 57, 58, 61, 70]
Water + vinegar [8, 21, 33, 57, 58, 61, 70]
Water + lemon or lime juice [20, 61]
Water + perfumes or herbs [61]
Other or multiple agents [21, 33, 39, 45, 49, 56–59, 66, 67]
Categories do not add up to 49, since categories in this table were not mutually exclusive
articles. Several studies focused on Black women (N = 12),
Asian women (N = 12), or had no ethnic focus (N = 11).
Just over half of all included studies (N = 24) were cross-
sectional in design and involved a self-reported question-
naire and lab samples. Almost another one-third (N = 16)
were cross-sectional and only utilized self-reported
questionnaires. Over one-quarter of the articles sampled
(N = 14) recruited participants from health facilities where
they were not presenting for vaginal health concerns or
the reason for their visit was not reported; another quarter
(N = 13) sampled populations of women who were pre-
senting for vaginal complaints, and N = 8 studies sampled
sex workers.
Women’s reasons for vaginal douching and the reported
contents of their douche solutions are presented in Table 2.
Slightly more than a quarter of the articles (N = 13) reported
that women used vaginal douches for general cleanliness.
Nearly a quarter (N = 11) douched to prevent or treat vagi-
nal odor, for sex-related hygiene (N = 10), or to prevent or
treat infection (N = 10). Almost a quarter of the manuscripts
(N = 12) reported that douche solutions contained plain
water, water and soap (N = 11), or other or multiple agents
(e.g., disinfectants; N = 11).
Table 3 summarizes the vaginal health conditions that
the studies found to be negatively associated with douch-
ing, as well as the vaginal health outcomes that were found
to have positive or no associations with vaginal douching.
Most vaginal health conditions had mixed results or results
that were not replicated. For example, six studies found that
using vaginal douches was negatively associated with BV,
while four studies found that it was not. Additionally, six
# Articles
13
11
10
10
6
6
9
# Articles
12
11
9
7
2
1
11
studies found that vaginal douching was negatively associ-
ated with current or past STI status (including HIV), while
eight studies found that it was not. Results were also mixed
for human papilloma virus (HPV; one study found a nega-
tive association, three found no negative association) and
candida (negative association in six studies, no negative
association in two studies). Trichomoniasis, ovarian cancer,
and low-grade squamous intraepithelial lesions (LSIL) were
found to be negatively associated with vaginal douching in a
single report for each outcome. However, these results were
not replicated in other studies in this review. On the other
hand, there was no negative association detected between
vaginal douching and preterm birth (N = 4) or ectopic preg-
nancy (N = 2); these results were not contradicted. Other
relationships between vaginal douching and vaginal health
outcomes [e.g., pelvic inflammatory disorder (PID), changed
vaginal flora, changed vaginal pH, herpes simplex 2, vaginal
odor, and urinary tract infection (UTI)] were represented
in both the associated and not associated categories, one to
two times each. No articles included in this review examined
vaginal douching’s relationship with vaginitis, cervical can-
cer, or reduced fertility.
Table 4 presents an overall summary of each article and
its findings, relative to the goals of this review.
Discussion
Women engage in douching behaviors across sociocultural
and geographic settings. From the current literature review,
there is little empirical agreement between vaginal douche
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Table 3  Vaginal douching and association with specific vaginal health outcomes
Vaginal health outcomes found to be ­positivelya associated with douching

BV [20, 41, PID [33, 64] HPV [37] Candida Trich [20] Ovarian Preterm Birth Changed Changed Current or Ectopic preg Vaginal Herpes 2 [21] Odor [68] LSIL [39] UTI [41]
42, 52, 59, 62] [20, 41, 68, Cancer [47] Vag Flora Vag pH [66] Past STI discomf
69, 71, 96] [70] status (includ- [19, 23, 48,
ing HIV) 49, 51, 53, 68]
[20, 21, 42,
53, 65, 67]

6 2 1 6 1 1 0 2 1 6 0 7 1 1 1 1
Vaginal health outcomes not found to be positively associated with douching

BV PID [42] HPV Candida Trich [21] Ovarian Preterm Birth Changed Changed Current or Ectopic preg Vaginal Herpes 2 [45] Odor [50] LSIL UTI [42]
[35, 45, 56, 95] [36, 40, 45, 72] [64, 95] Cancer [44, 54, 64, 68] Vag Flora Vag pH [43] Past STI sta- [64, 68] discomf
[46, 56] tus (including [19, 44, 95]
HIV) [8, 21,
41, 42, 60,
63, 67, 95]

5 1 3 2 1 0 4 2 1 8 2 3 1 1 0 1

*
 Positively means vaginal douching was found to be at least partially responsible for the given vaginal health outcome
AIDS and Behavior
 Table 4  Summary of literature review
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-
nal health outcomes
AIDS and Behavior

Alcaide et al. (2017) No racial/ethnic focus Health facility—pre- Cross-Sectional; Biologi- None given Water; water + soap Positive association
senting for vaginal cal outcome data commercially prepared; between vaginal douch-
complaints water + vinegar ing and changed vaginal
flora
Arbour et al. (2009) No racial/ethnic focus Other Cross-Sectional; Self- None given None given Article does not assess
reported data relationships between
vaginal douching and
vaginal health outcomes
Arfiputri et al. (2018) Asian women Health facility—pre- Other None given None given Positive association
senting for vaginal between vaginal douch-
complaints ing and candida
Arslantas et al. (2010) Turkish women Health facility—not Cross-Sectional: Self- Prevent or treat odor; Water; water + soap; Positive association
presenting for vaginal reported data prevent pregnancy; water + vinegar; other between vaginal douch-
complaints (or reason other (religious duty, or multiple agents ing and pelvic inflamma-
for visit unreported) traditional habit, vagi- tory disease (PID)
nal drying/tightening)
Aubyn et al. (2013) Black women Health facility—pre- Cross-Sectional; Biologi- None given None given Article does not assess
senting for vaginal cal outcome data clear relationships
complaints between vaginal douch-
ing and vaginal health
outcomes
Brotman et al. (2010) No racial/ethnic focus Other Other; Biological out- None given None given Vaginal douching was not
come data found to be positively
associated with bacterial
vaginosis (BV)
Bui et al. (2016) No racial/ethnic focus Other Cross-Sectional; Self- None given None given Vaginal douching was
reported data found to be positively
associated with human
papilloma virus (HPV)
Bui et al. (2018) Asian women Sex workers Cross-Sectional: Self- None given None given Vaginal douching was not
reported data found to be positively
associated with HPV
Carter et al. (2013) Black women Health facility—pre- Cross-Sectional; Self- General cleanliness; sex- Water; water + soap Study found that there
senting for vaginal reported data related hygiene (e.g., was both the presence
complaints cleaning before or after of a positive asso-
sex); prevent or treat ciation between vaginal
infection; other (reli- douching and vaginal dis-
gious duty, traditional comfort, and the absence
habit), vaginal drying/ of a positive association
tightening between vaginal douch-
ing and this vaginal

13
health outcome


Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-

13
nal health outcomes

Chu et al. (2011) Asian women Health facility—pre- Cross-Sectional; Biologi- None given Water; other or multiple Positive association
senting for vaginal cal outcome data agents between vaginal douch-
complaints ing and low-grade
squamous intraepithelial
lesion (LSIL)
Chu et al. (2013) Asian women Other Observational or longitu- None given Water; commercially Vaginal douching was not
dinal study; Biological prepared found to be positively
outcome data associated with HPV
Crann et al. (2018) No racial/ethnic focus Other Cross-Sectional: Self- None given Commercially prepared Positive association
reported data between vaginal douch-
ing and BV, candida, and
urinary tract infection
(UTI)
Vaginal douching was not
found to be positively
associated with current or
past STI status (including
HIV)
De La Cruz et al. (2009) Latinx/Hispanic women Other Cross-Sectional: Self- General cleanliness; Commercially prepared Positive association
reported data prevent or treat odor between vaginal douch-
ing and BV, and current
or past STI status (includ-
ing HIV) (specifically,
VAGINAL DOUCHING
was positively associated
with gonorrhea)
Vaginal douching was
not found to be posi-
tively associated with
PID, UTI, or current or
past STI status (includ-
ing HIV) (specifically,
VAGINAL DOUCHING
was not positively associ-
ated with chlamydia)
DiClemente et al. (2012) Black women Health facility—not Cross-Sectional: Self- General cleanliness; Water; commercially pre- Vaginal douching was not
presenting for vaginal reported data prevent or treat odor; pared; water + vinegar found to be positively
or STI complaints, (or prevent or treat infec- associated with current or
reason for visit unre- tion; Other (religious past STI status (including
ported) duty, traditional habit), HIV)
vaginal drying/tighten-
ing
AIDS and Behavior
 Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-
nal health outcomes
AIDS and Behavior

Donders et al. (2016) Black women Health facility—not Cross-Sectional; Biologi- None given None given Vaginal douching was not
presenting for vaginal cal outcome data found to be positively
complaints (or reason associated with changed
for visit unreported) vaginal pH
Ekpenyong et al. (2014) Black women Other Cross-Sectional: Self- General cleanliness; Water + soap Article does not assess
reported data Sex-related hygiene relationships between
(e.g., cleaning before vaginal douching and
or after sex); prevent or vaginal health outcomes
treat infection; cleaning
after menses; prevent
pregnancy; Other (reli-
gious duty, traditional
habit), vaginal drying/
tightening
Erbil et al. (2012) Turkish women Health facility—not Cross-Sectional: Self- None given None given Vaginal douching was not
presenting for vaginal reported data found to be positively
complaints (or reason associated with preterm
for visit unreported) birth and vaginal dis-
comfort
Esber et al. (2016) Black women Health facility—pre- Cross-Sectional; Biologi- None given Water + soap; Other or Vaginal douching was not
senting for vaginal cal outcome data multiple agents found to be positively
complaints associated with BV, HPV,
or herpes simplex 2
Esim et al. (2010) No Racial/Ethnic focus Health facility—pre- Cross-Sectional; Biologi- None given None given Vaginal douching was not
senting for vaginal cal outcome data found to be positively
complaints associated with BV, can-
dida, current or past STI
status (including HIV),
or vaginal discomfort
Fashemi et al. (2013) Other (e.g., non human Non-human subjects Biological outcome data None given None given Vaginal douching was not
subjects research) research found to be positively
associated with changed
vaginal flora
Gonzalez et al. (2016) No Racial/Ethnic focus Other Cross-Sectional: Self- None given None given Positive association
reported data between vaginal douch-
ing and ovarian cancer
Güzel et al. (2011) Turkish women Health facility—pre- Cross-Sectional; Biologi- General cleanliness; Water + soap Positive association
senting for vaginal cal outcome data Other (religious duty, between vaginal
complaints traditional habit), vagi- douching and vaginal
nal drying/tightening discomfort

13


Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-

13
nal health outcomes

Hacialioglu et al. (2009) Turkish women Health facility—not Cross-Sectional: Self- General cleanliness; Water; water + soap; Positive association
presenting for vaginal reported data Sex-related hygiene other or multiple agents between vaginal
complaints (or reason (e.g., cleaning before douching and vaginal
for visit unreported) or after sex); prevent discomfort
pregnancy; Other (reli-
gious duty, traditional
habit), vaginal drying/
tightening
Hassan et al. (2011) No Racial/Ethnic focus Health facility—pre- Randomized Controlled None given Commercially prepared Vaginal douching was not
senting for vaginal Trial (RCT); Biological found to be positively
complaints outcome data associated with odor
Heng et al. (2010) Asian women Health facility—not Cross-Sectional; Biologi- None given None given Positive association
presenting for vaginal cal outcome data between vaginal
complaints (or reason douching and vaginal
for visit unreported) discomfort
Klebanoff et al. (2010) No Racial/Ethnic focus Health facility—not Observational or longitu- None given None given Positive association
presenting for vaginal dinal study; Biological between vaginal douch-
or STI complaints (or outcome data ing and BV
reason for visit unre-
ported)
Li et al. (2015) Asian women Sex workers Cross-Sectional: Biologi- Prevent or treat infection None given Positive association
cal outcome data between vaginal douch-
ing and current or past
STI status (including
HIV), and vaginal dis-
comfort
Low et al. (2010) Black women Sex workers Cross-Sectional; Biologi- None given None given Vaginal douching was not
cal outcome data found to be positively
associated with HPV
AIDS and Behavior
 Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-
nal health outcomes
AIDS and Behavior

Luo et al. (2016) Asian women Sex workers Cross-Sectional; Biologi- General cleanliness; pre- Water; water + vinegar; Positive association
cal outcome data vent or treat odor; pre- other or multiple agents between vaginal douch-
vent or treat infection; ing and herpes simplex
cleaning after menses; 2, and current or past STI
prevent pregnancy; status (including HIV)
Other (religious duty, (specifically, vaginal
traditional habit), vagi- douching was positively
nal drying/tightening associated with HIV,
gonorrhea, and chla-
mydia)
Vaginal douching was not
found to be positively
associated with trich, and
current or past STI status
(including HIV) (specifi-
cally, vaginal douching
was not found to be
positively associated with
syphilis)
Luong et al. (2010) No Racial/Ethnic focus Pregnant women Cross-Sectional; Biologi- None given None given Vaginal douching was not
cal outcome data found to be positively
associated with preterm
birth
Mairiga et al. (2010) Black women Sex workers Cross-Sectional: Self- Prevent or treat odor; Water + lemon or lime Positive association
reported data sex-related hygiene juice between vaginal douch-
(e.g., cleaning before ing and BV, candida,
or after sex); prevent or trich and current or past
treat infection; prevent STI status (including
pregnancy HIV)
Mark et al. (2010) Black women Health facility—not Cross-Sectional; Self- General cleanliness; sex- None given Article does not assess
presenting for vaginal reported data related hygiene (e.g., relationships between
complaints (or reason cleaning before or after vaginal douching and
for visit unreported) sex); cleaning after vaginal health outcomes
menses
Martin-Hilber et al. Black women Other Cross-Sectional; Self- Prevent or treat odor; None given Article does not assess
(2010) reported data sex-related hygiene relationships between
(e.g., cleaning before or vaginal douching and
after sex) vaginal health outcomes

13


Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-

13
nal health outcomes

Masese et al. (2013) Black women Sex workers Observational or lon- Prevent or treat odor; pre- Water; water + soap; Vaginal douching was not
gitudinal study; Self- vent or treat infection; other or multiple agents found to be positively
reported data cleaning after menses; associated with BV or
other (religious duty, changed vaginal flora
traditional habit), vagi-
nal drying/tightening
McKee et al. (2009) Latinx/Hispanic women Health facility _ not Cross-Sectional; Self- General cleanliness; Commercially prepared; Article does not assess
presenting for vaginal reported data prevent or treat odor; water + vinegar; other relationships between
complaints (or reason sex-related hygiene or multiple agents vaginal douching and
for visit unreported) (e.g., cleaning before vaginal health outcomes
or after sex); prevent or
treat infection; cleaning
after menses
McKee et al. (2009) Latinx/Hispanic women Health facility—not Cross-Sectional; Self- General cleanliness; sex- Commercially prepared; Article does not assess
presenting for vaginal reported data related hygiene (e.g., water + vinegar; other relationships between
complaints (or reason cleaning before or after or multiple agents vaginal douching and
for visit unreported) sex) vaginal health outcomes
Nwadioha et al. (2011) Black women Health facility—pre- Cross-Sectional; Biologi- None given Water; water + soap; Positive relationship
senting for vaginal cal outcome data other or multiple agents between vaginal douch-
complaints ing and BV
Ott et al. (2009) No Racial/Ethnic focus Health facility—not Cross-Sectional; Biologi- None given None given Vaginal douching was not
presenting for vaginal cal outcome data found to be positively
complaints (or reason associated with current
for visit unreported) or past STI status
Pines et al. (2018) Latinx/Hispanic women Sex workers Randomized Controlled General cleanliness; Water + soap; com- Article does not assess
Trial (RCT); Biological prevent or treat odor; mercially prepared; relationships between
outcome data sex-related hygiene water + vinegar; vaginal douching and
(e.g., cleaning before water + lemon or lime vaginal health outcomes
or after sex); prevent or juice; water + perfumes
treat infection or herbs
Ranjit et al. (2018) Asian women Health facility- not Cross-Sectional; Biologi- None given None given Positive association
presenting for vaginal cal outcome data between vaginal douch-
complaints (or reason ing and BV
for visit unreported)
Redding et al. (2010) Latinx/Hispanic women Other Cross-Sectional; Self- None given None given Vaginal douching was not
reported data found to be positively
associated with current
or past STI status
AIDS and Behavior
 Table 4  (continued)
Authors (year) Racial—demographic Population Study design; outcome Reasons for douching Contents of douche Key associations between
focus type for key associations solution vaginal douching and vagi-
nal health outcomes
AIDS and Behavior

Shaaban et al. (2015) Other (e.g., non human Samples taken from Biological outcome data None given None given Positive association
subjects research) tissue of women who between vaginal douch-
had accessed a health ing and PID
facility (presenting for Vaginal douching was not
vaginal complaints found to be positively
(e.g., odor, itching, associated with candida,
burning, abnormal preterm birth, or ectopic
discharge), or STI) pregnancy
Sunay et al. (2011) Turkish women Samples taken from both Cross-Sectional; Biologi- General cleanliness; None given Positive association
populations reporting to cal outcome data prevent or treat odor between vaginal
a health facility douching and vaginal
discomfort
Tsai et al. (2009) No Racial/Ethnic focus Other Observational or longitu- None given None given Positive association
dinal study; Biological between vaginal douch-
outcome data ing and current or past
STI status (including
HIV)
von Glehn et al. (2017) Latinx/Hispanic women Health facility—not Cross-Sectional; Biologi- None given Water; other multiple Positive relationship
presenting for vaginal cal outcome data agents between vaginal douch-
complaints (or reason ing and changed vaginal
for visit unreported) pH
Wang et al. (2009) Asian women Sex workers Cross-Sectional: Biologi- None given Water; water + soap; Vaginal douching was
cal outcome data other or multiple agents positively associated
with HIV in high risk sex
work venues, but was not
positively associated with
HIV in low-risk sex work
venues
Yanikkerem et al. (2016) Turkish women Health facility—not Cross-Sectional; Self- General cleanliness; None given Positive association
presenting for vaginal reported data prevent or treat odor; between vaginal douch-
complaints (or reason sex-related hygiene ing and candida, vaginal
for visit unreported) (e.g., cleaning before discomfort, and odor
or after sex); prevent or Vaginal douching was not
treat infection; cleaning found to be positively
after menses; prevent associated with preterm
pregnancy; other (reli- birth or ectopic preg-
gious duty, traditional nancy
habit), vaginal drying/
tightening

13
 AIDS and Behavior

use and most vaginal health outcomes. Specifically, this

vaginal douching and vagi-
Key associations between

between vaginal douch-

means that some associations are found in only one study,
nal health outcomes
or are mixed (e.g., some studies find an association between
Positive association

ing and candida

vaginal douche use and a negative health outcome, while
others do not). This is likely due to three things that have a
high likelihood of introducing bias, including, (1) a lack of
consistent attention to potential confounders, including the
contents of douching solutions and douching frequency, (2)
less than ideal sampling conditions (e.g., recruiting partici-
pants from populations that already report negative vaginal
health outcomes or are at increased risk for negative vagi-
Contents of douche

nal health outcomes), and (3) reliance on a cross-sectional

design or self-reported data.
None given

Thus, the literature around vaginal douching behavior and

solution

vaginal health outcomes is conflicting. This is problematic,

since potential new microbicide rectal douches that are cur-
rently in clinical trials could feasibly be reformulated for
vaginal use. Specifically, these products could provide cis-
Reasons for douching

gender women who are unable or unwilling to use systemic

HIV prevention medications with a short-term, female-con-
Cross-Sectional; Biologi- None given

trolled, safe, and behaviorally congruent biomedical HIV

prevention strategy. However, current messaging around
douching could negatively affect both scientific and com-
munity interest in developing such products, as well as end-
type for key associations

users’ willingness to use them.

Study design; outcome

It is possible that using a vaginal douche that is clini-

cal outcome data

cally developed to rigorously demonstrate safety and effi-

cacy, rather than one purchased over-the-counter or using
homemade ingredients, could have fewer or no negative
vaginal health outcomes and could curtail viremia. In a study
published in 2006, researchers found that douching with a
clinically developed stainless steel device and tap water did
not change the vaginal ecology (as observed by Lactobacilli
Health facility—pre-
senting for vaginal

scores from Nugent slides and vaginal pH determination)

[81]. Additionally, among women who complained of per-
complaints
Population

ceived vaginal odor, douching with the stainless steel device/

tap water was successful in ameliorating the issue [50, 81].
Another randomized controlled trial that used the same
device to evaluate its effectiveness for treating perceived
vaginal odor with no infectious cause of vaginitis, found that
Racial—demographic

this vaginal douche was able to effectively treat perceived

odor without changing Nugent and Lactobacillus scores
Asian women

[50]. Other studies have found that douching after inter-

course could reduce the infectious load of sexually trans-
focus

mitted pathogens, such as HPV [40, 82], which has impli-

cations for an HIV prevention microbicide douche. Studies
examining other delivery modalities of topical microbicides
(e.g., ring, gels) have shown that these products are safe for
Table 4  (continued)

vaginal use with respect to potential adverse events [83–85].

Zeng et al. (2018)
Authors (year)

Though these studies may open the door to the possibility of

vaginal microbicide douches, future research on these prod-
ucts should ensure that the devices and douching liquids
used are carefully controlled and tested.

13
AIDS and Behavior
Carefully controlling vaginal douche devices and liquids
used for PrEP would address some of these issues identified
in our research. Additionally, future studies should attempt
to control an important potential key confounder: douching
frequency. In current studies, rectal tissue TVF-DP concen-
trations exceed four oral dose/week concentrations for three
days. Though we can only speculate, as vaginal douches
for PrEP (excluding gels [86], which are a distinct prod-
uct) are not yet in development, it is feasible that vaginal
douche products could have a similar duration. Nonhuman
primate studies have demonstrated that vaginal tenofovir
douches achieve concentrations associated with vaginal pro-
tection from SHIV challenge [25]. Given that vaginal and
rectal tissue are distinct from one another, it is critical that
researchers consider this when reformulating rectal douches
for vaginal use. This is particularly true, given that we are
only beginning to understand how the vaginal microbiome
may interact with PrEP medications. Furthermore, existing
literature on internally applied products for PrEP (e.g., gels,
rings) may offer some insight into considerations for PrEP
vaginal douches. These include ensuring that the application
process is easy, that medications and the douching device do
not cause discomfort during or after application, that dos-
ing regimens are realistic and simple to follow, and that the
product does not negatively impact sex (e.g., does not cause
painful or uncomfortable intercourse) [87]. Products that
are perceived as incompatible with menses or that enable
partners to detect that the product has been used would pose
additional barriers to consistent use [88].
Regardless, researchers should ensure that participants
in trials are clear on how often they should use vagi-
nal douche PrEP products, and ensure that the timing of
douching delivery protocols are as consistent as possible
with women’s existing douching preferences. Specifically,
to create a douching product that is behaviorally congru-
ent with women’s existing preferences, it will be necessary
to develop a product to deliver protective concentrations of
PrEP drugs when dosed in a variety of ways. Furthermore,
given women’s frequency of douching and motivations to
douche, it will be critical to find a non-toxic and safe drug
designed for continuous vaginal douche use.
Vaginal douche users often use these products for their
perceived cleansing properties (e.g., for general cleanli-
ness, prevention or treatment of odor, cleaning after sex).
This theme is further reflected in the contents of douche
solutions, which often include water mixed with other
cleaning agents (e.g., soap, vinegar). Existing research
on hair loss and acne shows that potential end-users
could be especially willing to use medications when
they have a positive effect on appearance [89, 90]. Given
this, potential messaging around PrEP vaginal douches
could highlight this product’s vaginal cleansing effects
and its perceived positive impact on vaginal presentation,
in addition to its HIV prevention properties, to generate
greater appeal.
Future studies of vaginal douches for PrEP should
follow protocols similar to rigorously designed and con-
ducted vaginal microbicide development studies. Specifi-
cally, these studies should use a prospective, randomized
controlled trials design. It appears that much of the litera-
ture around vaginal douche use relies excessively on self-
report and cross-sectional designs, which introduces bias.
Furthermore, participants in PrEP vaginal douching stud-
ies should be drawn from samples similar to those used in
other PrEP trials. In particular, these participants should
include healthy, non-pregnant women who have been
treated for vaginal concerns or other STIs prior to enroll-
ment; this would help to minimize the effect of sampling
bias, since women in other studies on vaginal douches are
frequently recruited from groups that already have or are
more likely to have existing vaginal complaints.
Vaginal microbicide douches have the potential to offer
a behaviorally congruent HIV prevention option to women
across multiple socialcultural and geographic contexts.
Previous studies have found that intravaginal product use,
including douches, is common in settings on the African
continent [91]. In sub-Saharan Africa, where more than
70% of the world’s HIV infections are concentrated [92]
and 56% of new adult HIV infections are diagnosed in
women [93], this potential future product may be espe-
cially impactful. Future studies on this topic should con-
sider the perspectives and preferences of women living in
high HIV prevalence settings in sub-Saharan Africa.
Lastly, future researchers could consider sex workers
as a “special population” related to douching. Though we
can only speculate because it is beyond the scope of the
review, it is possible that sex workers may have different
douching needs, preferences, and practices. This could
necessitate the development of a douche formulation that
is specifically designed to be used within the context of
sex work or high-risk intercourse. For example, it may be
necessary to formulate a douching product for sex workers
that provides a higher TFV-DP concentration, saturates
vaginal tissue with protective medication more quickly,
and can be used on a more frequent basis.
Conclusions
Despite perceptions in the medical community that douch-
ing results in negative vaginal health outcomes, the rela-
tionship between vaginal douche use and vaginal health
may be more complex. The existing research has mostly
failed to consider important potential confounders of
this relationship, including douching frequency and the
13

contents of douching liquids. Additional bias has been
introduced to existing research through poor sampling
practices (e.g., sampling participants from populations
who already have or are more likely to have vaginal com-
plaints), as well as a reliance on a cross-sectional designs
and/or on self-reported data. Taken together, these issues
have prevented researchers from achieving consensus with
regard to vaginal douching and vaginal health outcomes.
Thus, much of what we think we know about vaginal
douche use is based on science conducted under less than
ideal conditions.
On the other hand, well controlled studies of vaginal
douching and vaginal health have shown that douching, in
some contexts, has favorable outcomes [81]. Given this,
it is worthwhile to consider the possibility of a vaginal
microbicide douche for HIV prevention, since this product
could be used on-demand when women are experiencing
risk (e.g., rather than taking medication continuously), is
topical (e.g., as this is not systemic, it could reduce drug
exposure and systemic symptoms), and is behaviorally
congruent with existing vaginal/sexual practices (e.g., it
would not require a behavior change—only a minor vari-
ation in the specific product used). Other topical vaginal
products (e.g., rings) are effective at preventing HIV when
used as directed and have acceptable safety profiles [84,
85, 94]. Thus, it is possible that other vaginally delivered
topical microbicides, such as a douche, could be similarly
effective. In light of current work with rectal microbicide
enemas, a pharmaceutical grade vaginal PrEP douche with
a rigorously demonstrated safety and efficacy profile, could
be vastly different than douching with unregulated prod-
ucts. As such, future studies should consider developing
this topical, on-demand, female-controlled, non-systemic,
behaviorally congruent HIV prevention strategy.
Author Contributions  CTR, JB, CWH, and AC-D conceptualized this
manuscript; CTR and DD performed the literature review; CTR drafted
the manuscript, and CTR, JB, CWH, and AC-D, and RKS, along with
RG, DD, and CL critically revised the work.
Funding  The first author is supported by a K01 Award (K01
MH115785; Principle Investigator: Christine Rael, Ph.D.) from the
National Institute of Mental Health at the HIV Center for Clinical and
Behavioral Studies at the NY State Psychiatric Institute and Colum-
bia University (P30 MH43520; Center Principle Investigator: Robert
Remien, Ph.D.). The content is solely the responsibility of the authors
and does not necessarily represent the official views of the National
Institute of Mental Health or the National Institutes of Health.
Declarations  18. Martin Hilber A, Hull TH, Preston-Whyte E, Bagnol B, Smit
Conflict of interest  Dr. Craig Hendrix has received financial support
for clinical research from Gilead, Merck, and ViiV/GSK. He has also
served in the past on scientific advisory boards for Gilead, Merck,
ViiV/GSK, and Population Council. Dr. Rachel Scott has received
13
AIDS and Behavior
funds to complete investigator-sponsored research from Gilead. The
remaining authors have no conflicts to declare.
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