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Vaginal health and hygiene practices and product use in Canada: a national cross-sectional survey Crann, Sara E; Cunningham, Shannon; Albert, Arianne; Money, Deborah M; O’Doherty, Kieran C Mar 23, 2018

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RESEARCH ARTICLE Open AccessVaginal health and hygiene practices andproduct use in Canada: a national cross-sectional surveySara E. Crann1†, Shannon Cunningham2†, Arianne Albert3, Deborah M. Money4 and Kieran C. O’Doherty1*AbstractBackground: The vaginal microbiome influences quality of life and health. The composition of vaginal microbiotacan be affected by various health behaviors, such as vaginal douching. The purpose of this study was to examinethe types and prevalence of diverse vaginal/genital health and hygiene behaviors among participants living inCanada and to examine associations between behavioral practices and adverse gynecological health conditions.Method: An anonymous online survey, available in English and French, was distributed across Canada. The sampleconsisted of 1435 respondents, 18 years or older, living in Canada.Results: Respondents reported engaging in diverse vaginal/genital health and hygiene behavioral practices, includingthe use of commercially manufactured products and homemade and naturopathic products and practices. Over 95% ofrespondents reported using at least one product in or around the vaginal area. Common products and practices includedvaginal/genital moisturizers, anti-itch creams, feminine wipes, washes, suppositories, sprays, powders, and waxingand shaving pubic hair. The majority of the sample (80%) reported experiencing one or more adverse vaginal/genital symptom in their lifetime. Participants who had used any vaginal/genital product(s) had approximatelythree times higher odds of reporting an adverse health condition. Several notable associations between specificvaginal/genital health and hygiene products and adverse health conditions were identified.Conclusions: This study is the first of its kind to identify the range and prevalence of vaginal/genital health and hygienebehaviors in Canada. Despite a lack of credible information about the impact of these behaviors on women’s health, theuse of commercially manufactured and homemade products for vaginal/genital health and hygiene is common. Futureresearch can extend the current exploratory study by identifying causal relationships between vaginal/genital health andhygiene behaviors and changes to the vaginal microbiome.Keywords: Microbiome, Women’s health, Vaginal health, Hygiene products, Vaginal hygiene, Vaginal practicesBackgroundThe vaginal microbiome (the microbial community inthe vagina) influences quality of life, defends againstpathogens, and influences fertility and reproductivesuccess [1–3]. Disruptions in the balance of the micro-bial ecosystem can result in profound health conse-quences. Current microbiome research is working todetermine the microbes that characterize a healthymicrobiome in order to link particular microbialprofiles with adverse gynecological and obstetrical out-comes [2–8]. The composition of vaginal microbiotacan be affected by various health behaviors such asantibiotic use, sexual activity, and behavioral interven-tions such as douching and birth control methods [9,10]. Previous research on vaginal health behaviors hasfocused primarily on vaginal douching. Reports ofdouching prevalence vary, but the US Centre for Dis-ease Control and Prevention reports approximately 20%of women between 15 and 44 years of age had douchedwithin the last year [11]. This practice has been linkedto adverse obstetrical and gynecological health out-comes, such as pelvic inflammatory disease, reduced* Correspondence: kieran.odoherty@uoguelph.ca†Equal contributors1Department of Psychology, University of Guelph, 50 Stone Road E, Guelph,Ontario N1G 2W1, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Crann et al. BMC Women's Health  (2018) 18:52 https://doi.org/10.1186/s12905-018-0543-yfertility, ectopic pregnancy, low-birth rate, pre-termpregnancy, cervical cancer, bacterial vaginosis (BV), andhigher risk for acquisition of sexually transmitted path-ogens [12–17]. For example, a cross-sectional surveywith almost 4000 American women found that amongasymptomatic women, the prevalence of BV was signifi-cantly higher among those who had douched. However,there was no relationship between BV prevalence anddouching among symptomatic women. This study alsofound a significant association between BV prevalenceand the use of feminine cleansing wipes, but no associ-ation with sprays [18]. Research examining Americanwomen’s vaginal practices beyond douching found thatthose who douched were more likely to use other com-mercially available vaginal products such as sprays,wipes, powders, and bubble bath for feminine cleaning[19]. Cross-sectional studies in the US have reportedbetween 42 and 53% of women had used sprays, be-tween 17 and 50% used feminine wipes, between 23and 46% used anti-itch products, and 2% used deodor-ant suppositories [20, 21]. The use of products in thevaginal area for cleansing and other purposes has alsobeen documented in a number of African and Asiancountries [22, 23].For the efficacy of medical interventions to be opti-mized, they need to be applied in the context of know-ledge of social and cultural practices that shape relevanthealth behavior. As microbiome research is progressing,it is important to understand the impact of various vagi-nal practices on vaginal microbiota and subsequenthealth outcomes. The purpose of the current research isto develop a comprehensive understanding of the diver-sity and frequency of vaginal/genital health and hygienebehaviors. This paper reports on findings from a largenation-wide online survey of Canadian participants’ vagi-nal/genital health and hygiene behaviors and health con-ditions. The purpose of this paper is to: i) describe thetypes and prevalence of vaginal/genital symptoms andhealth conditions; ii) describe the types and prevalenceof health and hygiene practices; iii) and identify associa-tions between product use and adverse health condi-tions. As microbiome research continues to advance ourunderstanding of the connection between vaginal micro-biome and human health, our aim was to identify healthand hygiene behaviors that may influence the health ofthe vaginal microbiome. This research is a first step inimproving our understanding of the role of human be-havior on the composition of the vaginal microbiome.MethodsSurvey developmentResearch ethics approval was obtained from the Univer-sity of Guelph Research Ethics Board. A comprehensivesurvey about vaginal/genital health and hygiene practicesand product use was initially developed via (1) a reviewof the academic literature; (2) an internet search for va-ginal/genital hygiene products and practices; and (3)cataloguing of vaginal/genital hygiene products availablefor sale at local drugstores. Five focus groups were con-ducted over 6 months to obtain feedback on survey clar-ity, cultural sensitivity, and comprehensiveness. Resultsfrom the focus groups were used to inform changes tothe survey design and content.The final version asked questions about frequency ofuse of various products in and around the vaginal area,including products marketed specifically for use in thevaginal area (i.e., washes, wipes, sprays, powders, de-odorants, suppositories, anti-itch creams, moisturizers/lubricants, douches, and menstrual products) and gen-eral products (i.e., baby wipes, body creams, baby oil).Use of vaginal/genital health and hygiene products in-ternal to the vagina and external to the vagina were re-ported at 3 months prior to completing the survey.Respondents could provide information on their motiva-tions for using products in open-ended text boxes. Otherquestions included history of vaginal/genital symptomsand adverse health condition diagnoses (reported withinthe 6 months prior to completing the survey), history ofvarious vaginal/genital health and hygiene practices, andsexual health history, among other topics. Text boxesallowed respondents to share specific information aboutproducts, practices, and experiences not captured in theresponse options.RecruitmentThe anonymous online survey, available in English andFrench, was launched in October 2012 and was avail-able until May 2014. The survey was open to individ-uals 18 years of age and older living anywhere in theworld, but recruitment targeted a Canadian sample.The study was advertised as “women’s health and hy-giene” but eligibility was not based on participant gen-der identity and as such the survey was not limited toparticipants who identified as “woman” or “female.” In-formed consent was obtained prior to the start of thesurvey. Advertisements were posted on Canadian citywebpages of online classifieds (e.g., Kijiji). Recruitmentemails with a request to help disseminate the studywere sent to Canadian organizations and groups with apossible interest in the research (e.g., women’s healthorganizations, sexual and gender diversity groups, olderwomen’s groups, Indigenous women’s groups). Socialmedia (i.e., Facebook, Twitter), including paid Facebookadvertising, was used to promote the survey around thecountry. A participant recruitment firm was hired alsoto assist in recruiting participants from particulardemographics.Crann et al. BMC Women's Health  (2018) 18:52 Page 2 of 8Participant demographicsIn total, 1471 individuals completed the survey. An add-itional 233 individuals started but did not submit the sur-vey. The analysis includes the 1435 participants who wereliving in Canada at the time they completed the survey.The majority of participants (98.6%) identified as cisgenderwomen, one identified as a transwoman (0.1%), eight iden-tified as transmen (0.6%), and 11 provided no answer(0.8%). See Table 1 for additional participant demographics.Data analysisGiven the exploratory nature of this study, descriptiveanalysis focused on frequencies of behaviors and adversehealth conditions. Univariate and multivariate logisticregression analyses were used to test associations betweenproduct use and adverse health conditions. Associationswere estimated using odds ratio and 95% confidence inter-vals. Due to small cell counts, the internal and externalproduct variables were collapsed into dichotomous prod-uct variables and all STIs (trichomoniasis, gonorrhea,chlamydia, genital herpes, genital warts, and syphilis) werecollapsed into a single dichotomous variable. Dichotom-ous composite variables were created for the primary out-come (participant report of any type of adverse healthcondition) and the primary risk factor (participant reportof use of any vaginal/genital health and hygiene product).A univariate logistic regression model was fit to test thisrelationship. To test for potential confounding demo-graphic factors, a series of univariate logistic regressionmodels were fit to test for a relationship between selecteddemographic factors of interest (ethnic/racial identity, age,education level, and sexual orientation) and adverse healthconditions. Significant demographic variables at the p< .05 level were entered into a multivariate logistic regres-sion model to test the relationship between product useand adverse health conditions. Finally, univariate logisticregression models were fit to test the associations betweeneach product and each adverse health condition. Missingdata (i.e., the participant did not complete the question)were excluded from analysis. Statistical package SPSS 23.0[24] was used for the analysis.ResultsThe results are reported in three sections: (1) respon-dents’ reported vaginal/genital symptoms and healthconditions, (2) respondents’ reported vaginal/genitalhealth and hygiene behaviors, and (3) associationsbetween commonly used vaginal/genital health andhygiene products and adverse health conditions.Symptoms and health conditionsVaginal/genital symptoms included itching (74.5%),burning (50.2%), unusual discharge (45.2%), redness(34.9%), irritation/rash (21.3%), swelling (17.9%), andsores (10.7%). Eighty percent reported having experi-enced at least one symptom ever in their lifetime.Almost 36% reported having ever experienced one totwo symptoms, 32.2% reported between three and foursymptoms, and 17.8% reported five or more symptoms,with 3.1% reporting experiencing each of the sevensymptoms at least once in their lifetime. The mediannumber of symptoms reported was 2.0.Over half of the sample reported having been clinicallydiagnosed at least once in their lifetime (“ever diag-nosed”) with a yeast infection/candida (54.1%) and aurinary tract infection (UTI) (56.1%). Approximately12% reported bacterial vaginosis (BV) diagnosis at leastonce in their lifetime. Diagnosis of a sexually transmittedinfection (STI) was reported by a smaller proportion ofTable 1 Participant demographicsAge N (%)18-25 years 451 (31.4)26-35 years 305 (21.2)36-45 years 216 (14.8)46-55 years 239 (16.7)56-65 years 149 (10.4)66-75 years 62 (4.3)76+ years 16 (1.1)Sexual OrientationHeterosexual 1234 (86)Lesbian 39 (2.7)Bisexual 99 (6.9)Questioning/uncertain 22 (1.5)Other 37 (2.6)Ethnic/racial IdentityWhite 1282 (89.3)Aboriginal 48 (3.3)Black 30 (2.1)Central/South American 7 (0.5)South Asian 21 (1.5)East Asian 24 (1.7)Chinese 24 (1.7)Middle Eastern/Arab 19 (1.3)Other 27 (1.8)Highest Level of EducationLess than high school 17 (1.2)High school diploma or equivalent 251 (17.5)Some post-secondary 319 (22.2)Diploma program completed 206 (14.4)Degree program completed 405 (28.2)Post-graduate completed 235 (16.4)Note: Participants could select more than one ethnic/racial identityCrann et al. BMC Women's Health  (2018) 18:52 Page 3 of 8the sample: HPV (6.0%), trichomoniasis (2.2%), genitalwarts (6.1%), genital herpes (3.8%), chlamydia (5.6%),gonorrhea (2.2%), and syphilis (0.3%). Approximately 6%of the sample reported having ever been diagnosed withcervical cancer.Vaginal/genital health and hygiene product use andpracticesRespondents reported using a wide variety of commerciallymanufactured and homemade health and hygiene products(Table 2) and engaging in diverse health and hygiene prac-tices (Table 3). The analysis presented in this paperexcludes menstrual products. Approximately 95% of thesample reported using at least one product in the vaginal/genital area. The number of products used by respondentsranged from 0 to 14 (M = 3.80, SD = 2.18). Respondents re-ported using vaginal/genital health and hygiene productsboth on the outer genital area (externally) and in the vagina(internally). Products were more likely to be used exter-nally than internally, with the exception of some productssuch as suppositories and douches that are intended forinternal use. Over 90% of respondents had ever used (life-time use) one or more products externally, while 64%reported using one or more products internally.Commercially manufactured and advertised productsspecified as “feminine” or for vaginal health and/orhygiene included douches, wipes, washes, sprays, powders,moisturizers/lubricants, deodorant suppositories, tabletsuppositories (e.g., probiotics, tablets or ovules for vaginalinfections) and anti-itch creams. Products used in thegenital area but not intended or marketed for such useincluded hand sanitizers, body lotion, baby oil, baby wipes,and shaving cream. With the exception of douches, whichincluded both commercially manufactured and home-made douches, products used by respondents were mostlycommercially manufactured. Survey respondents (21.3%)reported using a variety of different commercially manu-factured and homemade vaginal douches. Of those partici-pants, 19.6% (n = 45) had used at least one type ofhomemade or commercially manufactured douche in the6 months prior to completing the survey. Participants alsoprovided information about other products used in thevaginal or genital area not otherwise captured by the sur-vey. Fifteen percent indicated they had used other prod-ucts, and half of those participants (49.8%) had used theproduct in the last 3 months. The most common of theseproducts included medicated creams, sprays, and gels(2.7%), cooking oils (1.6%), yogurt (topical and suppositor-ies) (1.4%), garlic clove suppositories (1.1%), probiotic sup-positories (0.8%), prescription suppositories (0.08%),depilatory creams (0.8%), and petroleum jelly (0.7%).Frequency of use ranged considerably across the differ-ent products, with a sizable portion of participants usinga product in or around the vaginal area at least once perday. For example, among participants who reportedusing wipes externally in the past 3 months (N = 271),30% used the product at least once a day. A similar per-centage of participants (N = 37, 29.7%) reported usingwipes internally at least once per day in the past 3months. Similarly high rates of daily use were found withseveral other products. For example, 46.7% of partici-pants who reported using powders externally (N = 30),35.4% of participants who reported using washes exter-nally (N = 65), and 18.4% of participants who reportedTable 2 Types and prevalence of vaginal health and hygiene product useProduct Ever used (N = 1435) Used 3 months priorInternalN (%)ExternalN (%)InternalN (%)ExternalN (%)Vaginal moisturizers/lubricants 583 (40.6) 430 (30) 289 (20.1) 220 (15.3)Vaginal tablets 500 (34.8) – 43 (3) –Anti-itch creams 370 (25.8) 715 (49.8) 44 (3.1) 134 (9.3)Vaginal wipes 60 (4.2) 602 (42) 37 (2.6) 273 (19)Vaginal washes/cleansers 58 (4.0) 168 (11.7) 11 (0.8) 66 (4.6)Baby/antiseptic wipes 37 (2.6) 597 (41.6) 17 (1.2) 260 (18.1)Hand/body lotion 28 (2.0) 304 (21.2) 6 (0.4) 170 (11.8)Baby oil 28 (2.0) 149 (10.4) 5 (0.3) 37 (2.6)Vaginal deodorant suppositories 20 (1.4) – 4 (0.3) –Liquid/gel sanitizers 12 (0.8) 26 (1.8) 2 (0.2) 11 (0.8)Vaginal sprays 8 (0.6) 81 (5.6) 3 (0.3) 14 (1.0)Vaginal powders 8 (0.6) 78 (5.4) 4 (0.3) 30 (2.1)Shaving cream – 719 (50.1) – 361 (25.2)Other (listed in text box)Crann et al. BMC Women's Health  (2018) 18:52 Page 4 of 8using baby wipes externally (N = 256) reported doing soat least once per day in the past 3 months. There werealso several products, including deodorant suppositoriesand internal use of hand creams, baby oil, and gel saniti-zers, that were not used daily by any participants.Practices related to vaginal/genital health and hygieneincluded sexual practices (e.g., inserting sex toys into thevagina, G-spot injections), aesthetic practices (e.g., cos-metic surgery, waxing pubic hair, vaginal bleaching), andcultural/religious practices (e.g., traditional genitalcutting).Associations between product use and adverse healthconditionsIn this section, we examine the associations betweenparticipants’ use of vaginal/genital health and hygieneproducts and adverse vaginal/genital health conditions.Participants who reported use of any vaginal/genital healthand hygiene product(s) had approximately three timeshigher odds of reporting any adverse health condition (re-ported history of BV, yeast infection, UTI, or STI) (OR =3.2, 95% CI: 2.4-4.2) (p < .01). Univariate and multivariateanalyses to test for confounding demographic factors arepresented in Table 4. Participant age and sexual orientationwere added to the model, but had no significant effect onthe relationship between product use and health condition(OR = 3.2, 95% CI: 4.5-4.3) (p < .01).Several significant associations were found betweenthe use of specific vaginal/genital health and hygieneTable 3 Types and prevalence of vaginal practicesVaginal health and hygiene practice Ever used(N = 1435)N (%)Insertion of sex toys 562 (39.2)Waxing genital area 380 (26.4)Genital surgery (reasons otherthan cosmetic)34 (2.4)Genital piercing 24 (1.7)Traditional genital cutting 20 (1.4)Pubic hair colouring 15 (1.0)Genital cutting (for reasonsother than traditional)13 (0.9)Genital tattoo 12 (0.8)Anal bleaching 7 (0.5)Vajazzling (the application ofstick-on gemstones to thegenital area)6 (0.4)Vaginal bleaching 6 (0.4)Genital cosmetic surgery 6 (0.4)Smoking/fogging/steaming totighten vagina5 (0.3)Injection to enhance G-spot 4 (0.3)Other Practices (from text box) 89 (6.2)Episiotomy/stitches for tearduring childbirth21 (1.4)Other medical procedure 18 (1.3)Shaving 13 (0.9)Laser hair removal 9 (0.6)Traditional labia stretching 1 (0.07)Table 4 Univariate and multivariate logistic regression analysisof any type of adverse health conditionPredictor variables Univariate MultivariateOR (CI 95%) p OR (CI 95%) pAny product use 3.2 (2.4-4.2) .00** 3.2 (4.5-4.3) .00**Ethnicity .76White referenceBlack 1.3 (0.5 – 3.4)Chinese 0.8 (0.3 – 2.7)East Asian 0.3 (0.1 – 2.1)South Asian 0.5 (0.2 – 2.0)Latin/S/Cen American 0.8 (0.1 – 6.8)Aboriginal 0.4 (0.6 – 4.1)Middle Eastern 0.08 (0.9 – 2.9)Mixed 0.8 (0.3 – 2.7)Other 0.9 (0.3 – 3.4)Education Level .21Less than high school 0.6 (0.2 – 2.3)High school diploma 0.7 (0.4 – 1.0)Some post-secondary 1.1 (0.7 – 1.5)Diploma complete 0.8 (0.5 – 1.2)Degree complete 1.0 (0.7 – 1.4)Post-graduate complete referenceAge .00** .00**Less than 25 years 1.5 (0.4 - 5.5) 1.4 (0.4 – 5.3)26-35 years 1.5 (0.4 – 5.6) 1.2 (0.3 – 4.6)36-45 years 1.4 (0.4 – 5.2) 1.1 (0.3 – 4.2)46-55 years 0.9 (0.2 – 3.2) 0.8 (0.2 – 3.0)56- 65 years 0.6 (0.1 – 0.3) 0.5 (0.1 – 2.1)66- 75 years 0.2 (0.1 – 2.7) 0.6 (0.1 – 2.7)76+ years referenceSexual Orientation .00** .01*Heterosexual reference 1.1 (0.5 – 2.4)Lesbian 1.3 (0.6 – 2.7) 1.3 (0.5 – 3.6)Bisexual 1.3 (0.5 – 3.4) 2.3 (1.5 – 3.6)Questioning/Uncertain 2.7 (1.7 – 4.1) 1.2 (0.6 – 2.5)Other 1.4 (0.7 – 2.8)Dependent variable: Any adverse health condition** p < .01* p < .05Crann et al. BMC Women's Health  (2018) 18:52 Page 5 of 8products (anti-itch creams, moisturizers/lubricants, gelsanitizers, feminine wipes, baby wipes, feminine washes/gels, and douches) and a previous diagnosis of either BV,yeast infection, or UTI. Participants who reported usinganti-itch cream had almost 18 times higher odds ofreporting a yeast infection (OR = 17.8, 95% CI: 11.9-26.5) (p < .01), 5 times higher odds of reporting BV (OR= 4.8, 95% CI: 2.1-10. 8) (p < .01), and two times higherodds of reporting a UTI (OR = 2.2, 95% CI: 1.4-3.5) (p< .01) than participants who had not used anti-itchcreams. Participants who reported using moisturizers/lu-bricants had 2.5 times higher odds of reporting a yeastinfection (OR = 2.5, 95% CI: 1.8-3.5) (p < .01) and 50%higher odds of reporting a UTI (OR = 1.5, 95% CI: 1.0-2.1) (p = .03) than participants who had not used mois-turizers/lubricants. Participants who reported using gelsanitizers had almost 8 times higher odds of reporting ayeast infection (OR = 7.61, 95% CI: 2.3-25.2) (p < .01)and almost 20 times higher odds of reporting BV (OR =19.5, 95% CI: 4.9-77.9) (p < .01) than participants whohad not used gel sanitizers. Participants who reportedusing feminine wipes had almost double the odds ofreporting a UTI (OR = 1.9, 95% CI: 1.3-2.7) (p <. 01).Similarly, participants who reported using baby wipeshad almost 60% higher odds of reporting a UTI (OR =1.6, 95% CI: 1.1-2.3) (p = .02). Participants who reportedusing feminine washes/gels had almost 3.5 times higherodds of reporting BV (OR = 3.4, 95% CI: 1.2-10.1) (p= .03) and almost 2.5 times higher odds of reporting aUTI (OR = 2.4, 95% CI: 1.4-4.3) (p < .01). Finally, partici-pants who reported using a douche in the previous6 months had almost 3 times higher odds of reporting ayeast infection (OR = 2.9, 95% CI: 1.5-5.6) (p < .01), 7times higher odds of reporting BV (OR = 7.0, 95% CI:2.3-22.0) (p < .01), and more than 2.5 times higher oddsof reporting a UTI (OR = 2.6, 95% CI: 1.3-5.2) (p < .01)than participants who had not douched.Adverse health conditions were not significantly asso-ciated with the use of deodorant sprays, powders, babyoils, hand/body creams, or deodorant suppositories. Nosignificant associations were found between having anSTI and the use of any particular vaginal/genital healthand hygiene product.DiscussionThe results of this cross-sectional survey identified thehigh prevalence of particular vaginal/genital health andhygiene behaviors among individuals living in Canada,and identified the most commonly used commerciallymanufactured and homemade products and practices,including anti-itch creams, feminine wipes, femininewashes/gels, douches, baby wipes, moisturizers/lubricants,tablet suppositories, and pubic hair removal practices.While douching has been the focus of previous research,and douching prevalence in the current study was consist-ent with national surveys in the US [11, 18] (around 21%of the sample), the prevalence of other products in thecurrent study, particularly anti-itch creams, moisturizers/lubricants, feminine wipes, and baby wipes in and aroundthe vaginal area, was higher than douching. This isconsistent with the proliferation of a range of differentcommercially manufactured products for vaginal/genitalhealth and hygiene now available in most drug andgrocery stores.With respect to symptom prevalence, most participantshad experienced at least one vaginal/genital symptom intheir lifetime; the most common of which were itching,burning, and unusual discharge. Approximately half of thesample reported experiencing adverse vaginal/genitalhealth conditions such as yeast infection, BV, and UTI.Finally, several notable associations were found betweenthe use of particular vaginal/genital health and hygieneproducts and various adverse vaginal/genital healthconditions.A better understanding of the types and prevalence ofvaginal/genital health and hygiene behaviors is a neces-sary first step toward understanding the relationshipsbetween these behaviors and adverse health conditions,and ultimately their role in the health of the vaginalmicrobiome. This is particularly important given estab-lished connections between vaginal conditions such asBV and other serious sexual health conditions such asHIV and other STIs [25–27] and adverse pregnancy out-comes such as preterm birth and endometriosis [28–30].While we are unable to make claims about the causaldirection of these relationships, our study shows thatparticipants who had used any vaginal/genital health andhygiene product(s) in the 3 months prior had approxi-mately three times higher odds of reporting any adversehealth condition, controlling for age and sexual orienta-tion. We also identified several key associations betweenspecific products and adverse health conditions to bemore fully explored in future research. While some asso-ciations were expected, such as the use of anti-itchcreams in relation to yeast infections (a common symp-tom of which is genital itch), other identified associa-tions point to important areas for future research. Mostnotably, the use of gel sanitizers was associated withhigher odds of having a yeast infection and BV, the useof both feminine and baby wipes was associated withhigher odds of UTI, and vaginal moisturizers/lubricantswas associated with higher odds of both yeast infectionand UTI. Additionally, and consistent with previousresearch [12–17], douching was associated with higherodds of yeast infection, BV, and UTI.There are several explanations for the relationshipsbetween product use and adverse health conditions thatare worth considering. In some cases, women may beCrann et al. BMC Women's Health  (2018) 18:52 Page 6 of 8using certain products to address symptoms or healthconditions. In light of the high rates of reported symp-toms, participants already experiencing gynecologicalconditions may be seeking out over-the-counter orhomemade remedies for symptoms management or ces-sation. Women who, for example, suspect a yeast infec-tion may be seeking over the counter anti-itch creams tomanage the condition. Alternatively, vaginal/genitalsymptoms and health conditions may present as a resultof using certain products. As one example, our studyfound that participants who used gel sanitizers hadalmost 8 times higher odds of reporting a yeast infectiondiagnosis than those participants who had not used gelsanitizers. It is possible that gel sanitizers, which ofteninclude dyes and other chemical ingredients, cause orexacerbate the yeast infection through disruption of thenatural vaginal microbiome or through micro-abrasionscaused inside the vagina. It will be important for futurescientific and medical research to explore the associa-tions identified in the current study because determiningthe specific nature of the relationship is critical forinforming clinical practice. Regardless of the direction ofthe relationship between product use and health condi-tions, education and outreach about product efficacyand safety is necessary.Strengths and limitationsThis is the first study to collect comprehensive data ondiverse vaginal/genital health and hygiene behavioramong respondents living in Canada. Previous researchexamining vaginal/genital practices and their impact onvaginal ecology or health outcomes has narrowly focusedon specific behaviors, such as douching. Our aim was torecruit a large Canadian sample that resembled nationaldemographic statistics within a reasonable timeframe.While our sample was close to resembling nationalstatistics across several key demographics, including eth-nicity, sexual orientation, and education (e.g., 89% Whitein sample compared to 83% nationally), we were not assuccessful as we had intended in the number of partici-pants we recruited residing in Quebec and those 40 yearsand older. Despite this limitation, this research providesthe first account of vaginal/genital health and hygienebehaviors at the national level. Although these findingsmay generalize to individuals living in Canada, furtherscientific research with more complex statistical analysisis necessary.In future research, temporal periods for engaging invaginal/genital health and hygiene behaviors and inci-dence of symptoms and health conditions should beconsistent to ensure meaningful interpretation of ana-lysis. Additional information, such as menopausal statusand the use of hormonal therapies, would be of furtherbenefit. Finally, given the exploratory nature of thesedata and the small number of participants who reportedusing certain products, our analysis was limited to descrip-tion and regression analysis and as such causal relationshipscannot be inferred. Although several of the effect sizes forparticular associations seemed quite large, it was difficult toget a precise estimate due to small cell counts in somecases and these should be interpreted with caution. Futureresearch using prospective or case control designs can buildon these preliminary correlational findings to assess causallinks between vaginal/genital health and hygiene behaviorsand vaginal/genital symptoms and adverse healthconditions.ConclusionsThe purpose of this exploratory study was to identify thetypes and prevalence of vaginal/genital symptoms, healthconditions, and health and hygiene behaviors amongCanadians. This research can inform medical researchersand practitioners about the diversity and prevalence of va-ginal symptoms, adverse gynecological health conditions,and importantly, vaginal/genital health behaviors that maybe relevant to abnormal microbial profiles as microbiomeresearch advances. Future biological research can extendthe current study by identifying causal relationships be-tween vaginal health and hygiene behaviors and changesto the vaginal microbiome.Our findings will help inform healthcare professionalsand the public about possible areas of concern regardingproducts and practices. Previous research has identified alink between douches and vaginal infections, and as thisand other relationships between health and hygiene behav-iors and adverse gynecological outcomes are further exam-ined, it will be important for healthcare providers, publichealth units, and governments to respond accordingly toinform the public and put in place necessary warning labelsand restrictions. Our study shows that a large number ofrespondents use products inside the vagina even when theproduct is not intended for use in the genital/vaginal areaor product labels warn against internal use (e.g., vaginalwashes and wipes). Should future research find some prod-ucts to be safe and effective for addressing vaginal symp-toms and health conditions, healthcare providers willsimilarly want to discuss this with patients. The increasingavailability and variety of vaginal health and hygiene prod-ucts requires oversight and regulation regardless of thecausal nature of the relationship between products andhealth conditions. Evidence-based information about thesafety and efficacy of these products is paramount to ensur-ing women’s health. This information can assist women inmaking informed choices when choosing products or par-taking in various health, social, and/or cultural practices.AbbreviationsBV: Bacterial vaginosis; HPV: Human papillomavirus; STI: Sexually transmittedinfection; UIT: Urinary tract infectionCrann et al. BMC Women's Health  (2018) 18:52 Page 7 of 8AcknowledgementsThank you to the participants who participated in focus groups and contributedto the development of the survey and those participants who completed thesurvey online. Thank you to Dr. Paula Barata for her valuable feedback during thedevelopment phase and Krista Bullock and Jennifer Reniers for their assistancewith data analysis. Thank you to the VOGUE Research Team and the Discourse,Science, Publics Research Group.FundingThis research was funded by a Canadian Institutes of Health Research (CIHR)Grant. The funding body was not involved in the study design; collection,analysis, or interpretation of data; or manuscript writing.Availability of data and materialsThe datasets used and/or analysed during the current study available fromthe corresponding author on reasonable request.Authors’ contributionsSC2 and KO conceptualized the project. SC2 carried out survey developmentand recruitment. SC1 contributed to recruitment and conducted data analysis.SC2 and SC1 wrote the first draft of the manuscript. AA assisted with statisticalanalysis and reviewed the manuscript. KO supervised the project and reviewedthe manuscript. DM provided clinical expert oversight to the gynecologiccomponents of the survey development and analysis and reviewed and editedthe manuscript. All authors read and approved the final manuscript.Ethics approval and consent to participateEthics approval was obtained from the University of Guelph Research EthicsBoard (REB# 11 DC009) prior to the start of this study. Participants in this studyread an approved consent form and gave their consent to participate in thestudy by clicking “I consent” at the beginning of the online survey. This methodof consent was approved by the University of Guelph REB.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.Author details1Department of Psychology, University of Guelph, 50 Stone Road E, Guelph,Ontario N1G 2W1, Canada. 2Department of Medicine, University of Alberta,36 Lester Cres, St. Albert, Alberta T8N 2C1, Canada. 3Women’s HealthResearch Institute, BC Women’s Hospital and Health Centre, Vancouver,British Columbia V6H 3N1, Canada. 4Department of Obstetrics andGynecology, Faculty of Medicine, University of British Columbia, 2329 WestMall Road, Vancouver, British Columbia V6T 1Z4, Canada.Received: 16 October 2015 Accepted: 14 March 2018References1. MacPhee RA, Hummelen R, Bisanz JE, Miller JE, Reid G. Probiotic strategiesfor treatment and prevention of bacterial vaginosis. 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