Abstract
Objective
The objective of this descriptive study was to quantify the personal hygiene habits/practices and over-the-counter (OTC) products used by postmenopausal women. Specifically, we were interested in any product that would contact the vulva or vagina.
Methods
We performed a cross-sectional study of postmenopausal women seeking routine gynecologic care. We developed questionnaire of personal hygiene habits/practices and OTC products used by women that would contact the vulva or vagina. We recruited postmenopausal women seeking gynecologic care from two separate gynecology practices. Descriptive statistics were performed as appropriate to characterize the frequency of reported treatments and practices.
Results
The questionnaire on OTC treatments and perineal hygiene was completed by 114 postmenopausal women. Fifty-eight women (50.9%) reported using at least one OTC vulvovaginal treatment in the last three months, including barrier treatments, topical anesthetics, powders, and antifungals. Women often used more than one OTC product. Thirty-seven women (32.5%) reported the use of two or more OTC products. Powders were used by 34 women (29.8%). Talcum powder was the most commonly used powder (76.5%, n/N = 26/34). Nine (7.9%) postmenopausal women reported douching in the last three months.
Conclusions
We found that over half of postmenopausal women seeking gynecologic care have used an OTC product for vulvovaginal symptoms in the last three months and 1/3 of women use 2 or more products. Because the use of OTC products is so common, our study highlights the need for detailed history inquiry about OTC product use and perineal hygiene practices.
Keywords: atrophic vaginitis, douching, over-the-counter, postmenopausal, talcum powder
Introduction
Vulvovaginal symptoms are common and have been reported by 9.6% to 44.4% of postmenopausal women.(1–3) Many women self-manage vulvovaginal symptoms with over-the-counter (OTC) medications and other alternative products.(4–8) Unfortunately, many commonly used OTC treatments and perineal hygiene practices (including talcum powder, topical benzocaine and douching) have been shown to be harmful.(7–10) Despite evidence of harm from these products and hygiene practices in the medical literature, women continue to use these products and practices.(9,10) Qualitative and quantitative research documents self-management practices and perineal hygiene habits among college-age women; however, studies among older women are lacking.(11–13)
In addition to the products and practices that have been demonstrated to cause harm, any product that contacts the vulva or vaginal can cause an allergic reaction, contact dermatitis. Avoiding vulvovaginal contact irritants has been advised as a first line treatment for chronic vulvovaginal symptoms.(14,15) Contact irritants can be present in both OTC products and products used for perineal hygiene.
Eliciting information on OTC treatments and perineal hygiene in postmenopausal women is necessary to better understand vulvovaginal symptoms in this population. Provider awareness about the full spectrum OTC products used and perineal hygiene habits in postmenopausal women is critical in order to be able to obtain an accurate history. The objective of this descriptive study was to quantify the personal hygiene habits/practices and OTC products used by postmenopausal women. Specifically, we were interested in any product that would contact the vulva or vagina.
Methods
We performed a cross-sectional study of postmenopausal women seeking routine gynecologic care. Approval was sought and secured through the Institutional Review Board at Yale University.
Instrument development
We developed questionnaire of personal hygiene habits/practices and OTC products used by women that would contact the vulva or vagina. To develop this questionnaire, we conducted two focus groups each with five postmenopausal women ages 54 to 92 with vulvovaginal skin symptoms to discuss OTC product usage and perineal hygiene habits. Information obtained from these focus groups was used to develop a written questionnaire. Some women recognized brand names of products while others recognized generic names (i.e. Monistat® vs. miconazole); therefore both brand and generic names were included.
Over-the-counter treatments and perineal hygiene
Women were asked questions about their use of OTC treatments and perineal hygiene over the last 3 months. OTC products were grouped into five major categories: barrier treatments, powders, topical anesthetics, OTC antifungals, and OTC topical steroids. Women were asked about perineal hygiene habits including douching, sitz baths, soaps, and pubic hair grooming. Absorbent pad use is generally considered both a product used for perineal hygiene and also a product used in the self-management of urinary incontinence and vaginal discharge.(16,17) Women were asked about their current use of absorbent pads. Finally, women who answered “yes” to the question, “Are you currently sexually active?” were asked questions specific to barrier protection and lubrication during coitus.
Participants and Data Collection
After developing the questionnaire, we recruited postmenopausal women seeking gynecologic care from two separate gynecology practices between June 2011 and August 2011. Women were approached for inclusion in this study after consenting for participation in a study to validate the psychometric properties of a questionnaire examining vulvovaginal symptoms in postmenopausal women.(18) Target recruitment was 120 women for the original study.
Menopause was defined as the cessation of menses for 12 consecutive months or having both ovaries surgically removed. This definition was confirmed by patient self-report. Women were excluded if they had known vulvar dermatoses including: Lichen Sclerosus, Lichen Planus, Psoriasis, Behcet’s disease, Hidradenitis Suppurativa, ano-rectal Crohn’s disease, or genital Herpes Simplex virus. Exclusion criteria were first elicited by self-report and confirmed with the participant’s medical record.
Urinary incontinence was defined as an affirmative answer to either question 2 or question 3 of the Urinary Distress Inventory-6 (UDI-6): “Do you experience… urine leakage related to a feeling of urgency?” and “Do you experience…urine leakage related to physical activity, coughing, or sneezing?”(19)
The questionnaire was a self-administered written instrument completed after informed consent was obtained. Descriptive statistics were performed as appropriate to characterize the frequency of reported treatments and practices. Statistical analysis was conducted using STATA 11.0 (StatCorp, Inc, College Station, TX).
Results
The questionnaire on OTC treatments and perineal hygiene was completed by 114 postmenopausal women. Six women were approached and declined participation for an overall response rate of 95%. The mean age of was 66.1 years (±11.0). (Table 1) The majority of women identified their race/ethnicity as non-Hispanic white (94.0%). Non-Hispanic Black women represented 3.5% of the cohort and Hispanic women represented 2.6% of the cohort. Any urinary incontinence was reported by 70 women (61.4%).
Table 1.
Demographics and clinical characteristics of postmenopausal women seeking gynecologic care
| Variable | Total N=114 | |
|---|---|---|
| Age, years, (mean, ±SD) | 66.1 ±11.0 | |
|
| ||
| Race/ethnicity | ||
| White, non-Hispanic | 103 (90.4) | |
| Black, non-Hispanic | 4 (3.5) | |
| Hispanic | 3 (2.6) | |
| Other | 4 (3.5) | |
|
| ||
| BMI (kg/m2, mean, ±SD) | 28.5 ±6.3 | |
|
| ||
| Vaginal parity (median, IQR) | 3 (2, 3) | |
|
| ||
| Tobacco use | ||
| Current user | 5 (4.4) | |
|
| ||
| Any urinary incontinence | 70 (61.4) | |
| Stress urinary incontinence | 55(48.3) | |
| Urgency urinary incontinence | 51 (44.7) | |
|
| ||
| Current sexual activity | 50 (43.9) | |
All values listed as n (%) unless otherwise indicated
SD = standard deviation; BMI = Body mass index; IQR = Interquartile range
Over-the-counter treatments
Fifty-eight women (50.9%) reported using at least one OTC vulvovaginal treatment in the last three months, including barrier treatments, topical anesthetics, powders, and antifungals. Women often used more than one OTC product. Thirty-seven women (32.5%) reported the use of two or more OTC products. Twenty-eight (24.6%) women reported the use of barrier treatments.(Table 2) Of women using barrier products, petroleum-based products (46.4%, n/N =13/28) were the most commonly used, followed by zinc oxide (42.3%, n/N =12/28). Powders were used by 34 women (29.8%). Talcum powder was the most commonly used powder (76.5%, n/N = 26/34). We did not find a statistical difference in Talcum powder use based on BMI (29.0 kg/m2 ±.1.2 vs. 28.3kg/m2 ±.70; p = .64) or urinary incontinence (27.1% vs. 15.9%; p =.16). The use of topical anesthetic products was reported by 14 women (12.3%). Use of OTC antifungals and OTC topical steroid treatments were also reported. Sixteen postmenopausal women (14.0%) reported any use of antifungal products in the last 3 months, either prescription or OTC products. Of the women reporting antifungal product use, 43.8% of women (n/N = 7/16) reported only using OTC antifungal products, 50% of women (n/N = 8/16) used both OTC antifungal products and prescription treatment, and 6.3% of women (n/N = 1/16) only used prescription treatments.
Table 2.
Over-the-Counter products used on vulva or vagina in the past 3 months
| Products | Total N = 114 |
|---|---|
| Barriers | 28 (24.6) |
| Petroleum ointment | 13 (11.4) |
| Zinc oxide ointment | 12 (10.5) |
| Lanolin ointment | 9 (7.9) |
| Glycerin moisturizer | 2 (1.8) |
|
| |
| Powders | 34 (29.8) |
| Talcum powder | 26 (22.8) |
| Zinc oxide powder | 7 (6.1) |
| Cornstarch powder | 3 (2.6) |
|
| |
| Topical Anesthetics | 14 (12.3) |
|
| |
| OTC antifungals | 15 (13.2) |
| Antifungal cream | 13 (11.4) |
| Antifungal suppositories | 2 (1.8) |
|
| |
| OTC steroids | 8 (7.0) |
| Hydrocortisone cream | 7 (6.1) |
| Hydrocortisone ointment | 4 (3.5) |
All values listed as n(%). Women could be included in more than one category.
OTC = over-the-counter
Petroleum includes Vasoline™, Acid mantel™ cream and Aquaphor® ointment.
Zinc oxide ointment includes Desitin®, Calmoseptine® ointment and Triple Paste® ointment.
Lanolin ointment includes all Vitamin A&D ointments.
Glycerin moisturizer includes Vagisil® feminine moisturizer.
Talcum powder includes all Baby powders.
Zinc oxide powder includes Gold Bond® body powder.
Cornstarch includes Vagisil® feminine powder.
Topical anesthetics include benzocaine cream, lanocaine, vagicaine and Vagisil® anti-itch cream.
Prescription treatments for vulvovaginal symptoms
Systemic estrogens were used by 10 (8.9%) women.(Table 3) Three (2.6%) women used systemic estrogen/progesterone therapy. Topical prescription estrogens use was reported by 25 (21.9%) women. Only one (0.9%) postmenopausal woman reported treatment for bacterial vaginosis within the last 3 months. Prescription topical corticosteroid use was reported by 11 (9.6%) women.
Table 3.
Prescription treatments reported by postmenopausal women seeking gynecologic care in the past 3 months
| Products | Total N = 114 |
|---|---|
| Estrogens | 25 (21.9) |
| Estrogen Type | |
| Premarin | 6 (5.3) |
| Estrace | 14 (12.3) |
| Vagifem | 3 (3.2) |
| Estring | 1 (0.9) |
| Femring | 1 (0.9) |
|
| |
| Antifungals | 9 (7.9) |
| Antifungal Type | |
| Miconazole | 6 (5.3) |
| Terazol | 1 (0.9) |
| Boric acid suppositories | 2 (1.8) |
|
| |
| Bacterial Vaginosis | |
| Metronidazole | 1 (0.9) |
|
| |
| Topical Steroids | 11 (9.6) |
| Topical Steroid Type | |
| Hydrocortizone1 | 7 (6.1) |
| Triamcinolone2 | 2 (1.8) |
| Clobetasol 3 | 2 (1.8) |
All values listed as n(%)
No women used terazol suppositories, nystatin ointment, nystatin powder, clindamycin vaginal preparations, topical gabapentin, topical amitriptyline, or Mycology II® (nystatin and triamcinolone) ointment
Perineal hygiene habits
Nine (7.9%) postmenopausal women reported douching in the last three months. (Table 4) Thirty percent of postmenopausal women reported using pre-moistened cleansing wipes for toilet hygiene in addition to toilet paper. The majority of postmenopausal women (78.1%, n/N = 89/114) did not report performing any pubic hair grooming.
Table 4.
Vaginal and Vulvar Hygiene in postmenopausal women in the past 3 months
| Total N = 114 | |
|---|---|
| Douching | 9 (7.9) |
| Vinegar | 7 (6.1) |
| Povidone Iodine | 0 |
| Other | 2 (1.8) |
|
| |
| Sitz Baths | 7 (6.1) |
| Tap water | 4 (3.5) |
| Baking soda | 1 (0.9) |
| Witch Hazel | 2 (1.8) |
|
| |
| Toilet Hygiene | |
| Baby wipes | 35 (30.7) |
| Witch Hazel pads | 3 (2.6) |
| Pericare bottle | 1 (0.9) |
|
| |
| Cleansing (soap type) | |
| Bar soap | 79 (69.3) |
| Liquid soap | 7 (6.1) |
| Body wash | 26 (22.8) |
| Other | 2 (1.8) |
| Antibacterial soap (yes) | 31 (27.7) |
| Method of cleaning | |
| Hand | 25 (45.4) |
| Washcloth | 24 (43.6) |
| Sponge | 3 (5.5) |
| Other | 3 (5.5) |
| Soap brand | |
| Dove | 48 (44.9) |
| Dial | 16 (15.0) |
| Irish Springs | 11 (10.3) |
| Other | 32 (29.9) |
|
| |
| Pubic Hair Grooming | |
| Shave | 19 (19.7) |
| Wax | 2 (1.8) |
| Trim (electric hair trimmer) | 4 (3.5) |
All values listed as n(%)
Vinegar douche includes Summer’s Eve® Extra Cleansing and Massengill® Extra Cleansing
Povidone Iodine douche includes Summer’s Eve® Medicated
Witch Hazel pads includes Tucks® medicated pads
No women reported laser hair removal or epilation.
Absorbent products
Over 50% of women (n/N = 60/114) used pantiliners, pads, or diapers for garment protection. (Table 5) Just under half of postmenopausal women (47%, n/N = 28/60) who did use absorbent products reported the use of products specifically marketed for menstrual hygiene, not incontinence.
Table 5.
Absorbent products used by postmenopausal women seeking gynecologic care in the past 3 months
| Total N = 114 | |
|---|---|
| Absorbent products | 60 (52.6) |
| Pantiliners | 36 (31.6) |
| Pads | 27 (23.7) |
| Diapers | 5 (4.4) |
|
| |
| Type of pad | |
| Menstrual | 28 (24.6) |
| Urinary incontinence brand name | 19 (16.7) |
| Urinary incontinence generic | 13 (11.4) |
All values listed as n(%)
Products used during sexual activity
Fifty women reported current sexual activity. Forty-six percent (n/N = 23/50) of sexually-active postmenopausal women reported using a product for lubrication with coitus.(Table 6) No women reported the use of natural oils (vegetable oil, olive oil, hazelnut oil, etc.) for lubrication. Partner male condom use with coitus was reported by 9.6% (n/N = 5/50) of women. No postmenopausal women reported spermicide use or female condom use.
Table 6.
Products used during sexual activity in the past 3 months
| Total N = 50 | |
|---|---|
| Lubrication | 23 (46.0) |
| Lubrication Type | |
| KY® Jelly | 12 (24.0) |
| Astroglide® | 7 (14.0) |
| Massage oil | 4 (8.0) |
| RepHlens® | 0 |
| Barrier protection | |
| Male condoms | 5 (9.6) |
All values listed as n(%)
No women reported spermicide use.
No women reported female condom use.
No women reported natural oils (olive oil or vegetable oil) for lubrication.
Discussion
In summary, we found that over half of postmenopausal women seeking gynecologic care have used an OTC product for vulvovaginal symptoms in the last three months and 1/3 of women use 2 or more products. Because the use of OTC products is so common, our study highlights the need for detailed history inquiry about OTC product use and perineal hygiene practices in the treatment of postmenopausal women.
Some OTC products can cause adverse reactions in women. For example, topical benzocaine, a common ingredient in OTC products marketed for itch relief, has been shown to cause severe contact dermatitis of the vulva.(7,8) Absorbent products for garment protection are commonly used by postmenopausal women for the self-treatment of incontinence and for perineal hygiene.
After the cessation of menses, we found that postmenopausal women commonly use absorbent products, including both menstrual hygiene products and products marketed for anti-incontinence protection. Severe contact vulvitis has been caused by the ingredients in absorbent products and pads, including rosins, colophony, and methyldibromo glutaronitrile.(20–24) We found that over 50% of postmenopausal women used pantiliners, pads, or diapers for garment protection in the last 3 months.
Besides products that cause allergic reactions, other products have been shown to cause harm. The use of Talc powder, the main ingredient in baby powder, on the perineum has been questioned as early as the 1960s when it was found to be biologically similar to asbestos.(9) Talc-use is associated with an increased risk of gynecologic malignancies, especially ovarian neoplasms, and talc particles have been found in the pathologic specimens of gynecologic malignancies.(25–28) Despite the evidence against the use of talcum powder in the medical literature, talcum powder is widely available in the United States. We found 22.8% of postmenopausal women report talcum powder use within the last 3 months. This highlights the need for both provider awareness and patient education.
Another practice that has been shown to cause harm is douching. The practice of douching leads to a disturbance of the normal vaginal flora which allowing for an increase in bacteria vaginosis and other pathogenic organisms, including sexually transmitted infections.(10) Douching is highly discouraged in the medical literature; however, the practice of douching is still common. Twenty-five to 70% of reproductive-aged women report douching.(29–34) Douching has been implicated as an independent risk factor for pelvic inflammatory disease, sexually transmitted diseases, cervical cancer and ectopic pregnancy in reproductive aged women.(29–31) We found 8% of postmenopausal women reported douching within the last 3 months.
Accurate diagnosis is essential to the appropriate treatment of vulvovaginal symptoms. Contact dermatitis is the most common cause of chronic vaginitis in women.(35) Other causes of vaginitis and vulvar pruritus include recurrent vulvovaginal candidiasis, atrophic vaginitis, vulvar vestibulitis, Lichen Simplex Chronicus and Lichen Sclerosus.(35) The multiple causes of chronic vaginitis and vulvar pruritus in women highlight the need for accurate diagnosis, especially when self-treatment with OTC antifungal preparations may worsen symptoms if contact dermatitis is the true cause.(7,8)
Our report of the treatments utilized by postmenopausal women was limited by the women we surveyed. This study was limited by the recruitment of postmenopausal women actively seeking gynecologic care which limits the generalizability of our findings. Women not seeking gynecologic care may have different OTC product use and perineal hygiene practices. We have only included 114 women which may lead to some percentages reported being smaller or larger than actual OTC product use or perineal hygiene practices in the United States. However, due to limited data on this topic, especially in postmenopausal women, we believe our findings add valuable insight to practices of postmenopausal women. Additionally, our study included older women (mean age 66 years) with a low number of minorities participating. We hypothesize that different cultures may have different hygiene practices. This is an area for future study. Because this research project was limited to baseline data collection and women were not followed prospectively overtime, a causal relationship between OTC products and vulvovaginal skin symptoms cannot be established in this study. Despite these limitations, this project adds valuable insight to the self-management strategies of vulvovaginal symptoms in postmenopausal women.
Conclusion
Our study highlights the need for provider to ask postmenopausal women about OTC product use and perineal hygiene habits. Specifically, we found that over half of women use some form of OTC product. The practice of douching and talcum powder use was reported by 8% and 23% of postmenopausal women, respectively. Provider awareness to encourage inquiry about these practices is important as well as targeted interventions decrease known harmful practices in women of is warranted.
Acknowledgments
Dr. Erekson was supported by the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30 AG021342 NIH/NIA). This work was supported by an award from the National Institutes on Aging (R03AG042363-01).
Footnotes
No conflicts of interested have been identified.
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