The microbiota of the vulva and vagina: Ways of washing to optimise the protective function of the vulvo-vaginal microbiota during pregnancy

Abstract

Background: The microbiota of the vulva and vagina has a crucial protective function, which is important for all women and has particular significance in pregnancy. Yet this microbiota is part of a delicately balanced ecosystem, susceptible to extrinsic factors which include the simple matter of how women wash themselves. Clinical observation and anecdotal evidence indicate that women in Aotearoa New Zealand have washing practices that may compromise the naturally acidic vulvo-vaginal environment crucial to optimising the protective function of the microbiota. Aims: The aims of this review are: to determine if there is dissonance between how women are washing their vulva and vagina and recommended washing practices; and to raise awareness of the emerging significance of the vulvo-vaginal microbiota to women’s health, particularly in pregnancy. Method: A literature review was undertaken to discover what is reported (in the published literature) about the ways women wash themselves, products used, and their effect on the vulvo-vaginal microbiota. The evidence behind the “wash with water” recommendation was investigated. Findings: There is a lack of primary research on ways of vaginal washing used by women in Aotearoa New Zealand. Globally, women are routinely using a variety of products that include soap, anti-bacterial wipes, gels and baby wipes, and invasive vaginal washing practices such as douching, flannel scrubs and internal soap cleansing. All washing products, including gentle soap but excluding lactic-acid based gels, alter pH levels when used on either the vulva or the vagina. Washing practices that alter vaginal pH levels can cause a microbial shift into a sub-optimal state that compromises the protective function of the vulvo-vaginal microbiota and is more susceptible to bacterial vaginosis and group B streptococcus vaginal colonisation. The frequency and duration within suboptimal states may be predictors of risk. Conclusion: There is dissonance between the ways women wash their vulva and vagina, and evidence-based advice to just wash with water. The back-to-basics message “just wash with water” promotes a way of washing that optimises the protective function of the vulvo-vaginal microbiota, while also protecting the integrity of vulval skin, and supporting physiological self-cleaning of the vagina.