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"We have read for you": The importance of vulvovaginal area care

Women use various products for intimate hygiene as part of their daily routine; however, there is a lack of information about vulva cleansing and how personal hygiene practices can affect it.

The importance of using feminine washers, suitable for minimizing the risk of vulvovaginal disorders and improving overall intimate health, is often underestimated. Women should be encouraged to choose a carefully formulated, clinically proven external detergent that provides antimicrobial protection without having a negative impact on the natural vulvovaginal microbiota.

The vulva is the first line of defense to protect the genitals. Contaminants often accumulate in vulvar folds and increase humidity. Furthermore, sweating, menstruation, pads, overly tight and synthetic clothing and hormonal fluctuations influence vulva microbial growth.

The vulva skin, that is to say, the external part of the genital system, is more susceptible to topical agents as it is covered by a thin layer containing large hair follicles, this makes permeability easier for microbes and irritants.

The vagina, on the other hand, is the fibromuscular canal that extends from the uterine cervix to the external opening in the vulva and is mainly composed of smooth muscles covered with a non-keratinized epithelial lining. This lining up to the menopause has a certain thickness, with folds that are kept moist by the secreted fluid through the vaginal wall and by the cervical and vestibular mucus.

Maintainance of the microbiota balance plays a key role in general vulvovaginal health. Some studies on healthy women have shown that the vulva microbiota is differentiated and may include staphylococci, micrococci, diphtheroids, lactobacilli, streptococci, yeasts and faecal (but useful) species. Vulvar flora can also influence the proliferation of exogenous pathogens (coming from outside) that cause vaginal and urinary tract infections.

At one time, it was thought that a healthy vagina contained mainly the lactobacillus species, Gram-positive bacilli that produce lactic acid, in an acidic environment (pH 3-4). These lactobacilli are the allies in the prevention of vagina colonization by other bacteria through the competition for epithelial cell receptors and thus maintain a healthy vaginal ecosystem. However, the composition of healthy vaginal flora is more variable than initially thought and, in some healthy women, lactobacilli are absent and replaced by other producers of lactic acids such as Atopobium vaginae, Megasphaera spp., and/or Leptotrichia spp.

In some cases, women of reproductive age are colonized by potentially pathogenic species (eg Gardnerella vaginalis, Staphylococcus aureus, Candida albicans) without presenting any pathology. The definition of healthy vaginal microbiome is therefore a more complex matter than initially thought.

Furthermore, the microbiome can be influenced by various internal factors (age, hormonal changes such as menstruation and pregnancy) and by various external factors (for example, hygiene practices, sexual relations, antibiotic use and hormone replacement therapy).

The vulvar pH has values around 4.7, while the vagina has an average pH of 3.5. This is determined by the total sum of lactic acid production by the vaginal mucosa and by the microbial flora. Various factors can influence the pH, including the already mentioned endogenous and exogenous factors.

The normal vaginal flora, vaginal acid pH and secretions are all components of the innate defense mechanisms that protect against vulvovaginal infections. Saprophytic bacteria (physiological) help to maintain an acidic pH and compete with exogenous pathogens to adhere to the vaginal mucosa. They also reject pathogens by producing antimicrobials compound such as bacteriocin.

Vaginal fluids from five women were collected in one study. These fluids showed in vitro activity against non-resident bacterial species including Escherichia coli e Group B Streptococcus.

In this regard, it is good to say that the evaluation of the presence of streptococcus is particularly important for pregnant women since it often colonizes the vagina through the gastrointestinal tract and increases the risk of premature birth, neonatal meningitis and even fetal death. It can also cause bacteriuria and urinary tract infections, upper genital tract infections and postpartum endometritis.

In a study of pregnant women, the high vaginal pH without the presence of a vaginal infection was associated with preterm birth.

The altered vaginal pH, which is too high, has also been associated with a risk of infection with human papilloma virus (HPV) higher than 30% compared to those with normal pH and consequent low-grade squamous intraepithelial lesions (LSIL).

After menopause and with the decrease in estrogen levels, the vaginal pH increases; the alkaline pH is associated with an increase in colonization with pathogenic microbes.

The importance of vaginal lactic acid should be emphasized as it is closely related to vaginal health, inhibits the growth of bacteria associated with bacterial vaginosis and probably plays a role in local immune defense. Vaginal epithelial cells also produce a range of compounds with antimicrobial activity (for example, lysozyme and lactoferrin).

In a large study during which women suffering from vulvovaginal infections used female washers containing natural plant extracts for 4 weeks, a positive clinical effect was shown with reduced vaginal pH, remission of symptoms such as burning and itching and greater sexual activity compared to the pre-treatment period.

Women regularly use intimate hygiene products as part of their daily cleaning routine. There are currently several women intimate hygiene products that can be used for cleaning and/or odor control, but some may alter the normal pH/microbiota level needed to protect us against infections.

The products considered most appropriate for intimate health are those containing lactic acid, with an acidic pH that increases skin homeostasis and may serve as adjunctive therapy in women with vaginal infections or when taking antibiotics and cortisones.

The clinical practice guidelines recommend that women use neutral pH and hypoallergenic cleanser for daily cleaning. These detergents must be carefully formulated for a delicate use, without affecting the natural flora.

After the data emerging from recent studies on their efficacy, the use of probiotic lactobacilli to manage and prevent vaginal infections has become the most accredited therapeutic option. The polymicrobial nature of vaginitis makes the response to antibiotic therapies extremely variable, determining a 50% relapse, certainly creating numerous bacterial resistance and not favoring a restoration of the vaginal ecosystem, causing a further deterioration.

Since all vaginal infections are due to an alteration of the bacterial flora in which there is an increase in pathogens and a decrease in lactobacilli, why, instead of fighting pathogens with therapies that have certain side effects, a high incidence of relapses and the formation of increasingly aggressive antibiotic-resistant bacterial strains, don’t we act on the opposite side, restoring the original quantities of vaginal and vulvar lactobacilli, hindering the transmission of sexually transmitted diseases such as gonorrhea, chlamydia, syphilis, trichomoniasis, and HIV and HPV?

The use of a pH 4 soap containing Morinda citrifolia*, Calendula officinalis, Aesculus hyppocastanus, Aloe barbadensis, Citrus grandis for daily hygiene and a vaginal douching once a week containing Lattobacilli, D-Mannose, Morinda Citrifolia would be excellent.

*traditionally in Hawaiian and Polynesian cultures, this plant was considered sacred and was venerated as a source of life. The indigenous kahuna healers, who used indigenous herbs and plants, used to call it "tree of life", "plant that kills pain" and also "headache tree". All parts of Noni (bark, roots, leaves, flowers and fruits) have been used in herbal medicine for their medicinal properties. Noni has anti-inflammatory and pain-relieving effects, normalizes cell regeneration, regulates the action of the immune system and has antimicrobial and cicatrizing properties.


Role of female intimate hygiene in vulvovaginal health: Global hygiene practices and product usage. Ying Chen, Elizabeth Bruning, Joseph Rubino and Scott E Eder

Obstetrician Sara Furno

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