The vaginal microbiome influences quality of life, defends against pathogens, and influences fertility and reproductive success[i].
Shifts in the balance of the microbial system can result in profound health changes, and research in this area is focused on the determination of microorganisms that characterise a healthy microbiome to then correlate certain microbial profiles with adverse symptoms in gynecological and obstetrics[ii].
The composition of the vaginal microbiota can be affected by several health factors, from the use of antibiotics and contraceptive methods to sexual activity and the method of vaginal washing[iii].
As microbiome research advances, it is important to understand the impact of various vaginal hygiene practices on the microbiota and the associated health consequences.
Most common intimate hygiene practices and associated risk
Several studies that analyse intimate hygiene behaviours focus especially on vaginal irrigation, with indications that its use varies, with data from the US Centers for Disease Control and Prevention (CDC) reporting that about 20% of women aged between 15 and 44 use this method at least once a year[iv].
This practise is related to several negative obstetric and gynaecological effects, including pelvic inflammatory disease (DIP/PID), decreased fertility, ectopic pregnancy, premature birth, cervical cancer, bacterial vaginosis (also called vaginitis or BV) and an increased risk of sexually transmitted pathogen infection[v].
According to a survey with data from nearly 4,000 American women, women who have vaginal irrigation have more symptoms of bacterial vaginosis than those who do not. The same indicators also show that, despite this, there is no correlation between vaginal lavage and the incidence of BV. The data from this sample verifies the existence of a significant association between the prevalence of bacterial vaginitis and the use of intimate wipes[vi].
Research carried out on the vaginal hygiene practises of American women, in addition to irrigation, concluded that those who used irrigation techniques were more likely to use other vaginal wash products, such as sprays, wipes, powders, and washing solutions[vii].
Prevalence studies in the US report that about 42 to 53% of women use sprays, 17 to 50% use intimate wipes, and 23 to 46% use antipruritic products[viii].
Although there is no clear justification for why the use of common intimate hygiene products is related to an increased incidence of infections and changes in vaginal health, it is clear that their use is correlated with an increased risk of these conditions, with the use of disinfectant wash solutions being associated with a greater risk of fungal infections and bacterial vaginosis, the use of intimate or baby wipes with a greater risk of UTIs, and the use of moisturizers/lubricants with an increased incidence of both alterations, at the same time that vaginal irrigations were associated with all the aforementioned alterations.
 Pelvic Inflammatory Disease
 Bacterial Vaginosis
 Usually called vaginal deodorant and of low use in Europe
 Also called transverse or vertical
[i] Vaginal microbiome of reproductive-age women. Proc Natl Acad Sci U S A. 2011 Mar 15;108 Suppl 1:4680-7. doi: 10.1073/pnas.1002611107.
Vaginal microbiome and epithelial gene array in post-menopausal women with moderate to severe dryness. PLoS One. 2011;6(11):e26602. doi: 10.1371/journal.pone.0026602. Epub 2011 Nov 2.
Probiotic strategies for the treatment and prevention of bacterial vaginosis. Expert Opin Pharmacother. 2010 Dec;11(18):2985-95. doi: 10.1517/14656566.2010.512004.
[ii] The Vaginal Microbiome: Current Understanding and Future Directions. J Infect Dis. 2016 Aug 15;214 Suppl 1:S36-41. doi: 10.1093/infdis/jiw184.
Characterization of the vaginal microbiota of healthy Canadian women through the menstrual cycle. Microbiome. 2014 Jul 4;2:23. doi: 10.1186/2049-2618-2-23.
Resolution and characterization of distinct cpn60-based subgroups of Gardnerella vaginalis in the vaginal microbiota. PLoS One. 2012;7(8):e43009. doi: 10.1371/journal.pone.0043009.
The microbiota of the vagina and its influence on women’s health and disease. Am J Med Sci. 2012 Jan;343(1):2-9.
[iii] The influence of behaviors and relationships on the vaginal microbiota of women and their female partners: the WOW Health Study. J Infect Dis. 2014 May 15;209(10):1562-72. doi: 10.1093/infdis/jit664.
Understanding vaginal microbiome complexity from an ecological perspective. Transl Res. 2012 Oct;160(4):267-82. doi: 10.1016/j.trsl.2012.02.008.
[iv] Centre for Disease Control and Prevention. Key statistics from the national survey of family growth. 2013.
[v] Vaginal douching and reduced fertility. Am J Public Health. 1996 Jun;86(6):844-50.
Vaginal douching and adverse health effects: a meta-analysis. Am J Public Health. 1997 Jul;87(7):1207-11.
Factors linked to bacterial vaginosis in nonpregnant women. Am J Public Health. 2001 Oct;91(10):1664-70.
Risk of preterm birth that is associated with vaginal douching. Am J Obstet Gynecol. 2002 Jun;186(6):1345-50.
A longitudinal study of vaginal douching and bacterial vaginosis – a marginal structural modeling analysis. Am J Epidemiol. 2008 Jul 15;168(2):188-96. doi: 10.1093/aje/kwn103.
Intravaginal practices, vaginal infections and HIV acquisition: systematic review and meta-analysis. PLoS One. 2010 Feb 9;5(2):e9119. doi: 10.1371/journal.pone.0009119.
[vi] The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health. Sex Transm Dis. 2007 Nov;34(11):864-9.
[vii] Vaginal douches and other feminine hygiene products: women’s practices and perceptions of product safety. Matern Child Health J. 2006 May;10(3):303-10. Epub 2006 Mar 23.
[viii] Adult feminine hygiene practices. Appl Nurs Res. 1996 Aug;9(3):123-9.
Beyond douching: use of feminine hygiene products and STI risk among young women. J Sex Med. 2009 May;6(5):1335-40. doi: 10.1111/j.1743-6109.2008.01152.x.
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Female Intimate Hygiene
Vulvovaginal candidiasis (VVC, commonly known as vaginal candidiasis) is a fungal infection caused by Candida species typically C. albicans[i]. According to epidemiological data[ii], approximately 70% of all women will have at least one episode of VVC in their lifetime.
The disease is characterized by an acute inflammation of the vulva and vaginal mucosa induced or accompanied by an overgrowth of Candida organisms (usually ubiquitous and commensal[iii]).
The signs and symptoms are usually characterised by lumpy white discharge which adheres to the vaginal walls, erythema, edema, and abrasions in the vulva and vagina, usually accompanied by dyspareunia[iv].
The triggering of most VVC cases is associated with diverse predisposing or triggering factors such as the use of antibiotics, increased levels of oestrogens (use of oral contraceptives, hormone replacement therapies, pregnancy), poorly controlled diabetes mellitus ,sexual activity, and the use of excessively tight clothing[v].
On the other hand, about 8 to 10% of women are susceptible to recurrence of this problem (VVC)[vi] and experience approximately 4 or more episodes per year. This recurrent infectious process is usually idiopathic and independent of the potential risk factors. These cases usually require long-course regimens of antifungal use over a number of months (sometimes years) and which still do not efficiently prevent recurrence[vii].
According to data obtained in 2019[viii] from 248 non-pregnant women, most participants (78%) indicate a clinical history of VVC, and 34% are already defined as VVC patients. The most commonly experienced signs and symptoms are itching, burning and flushing in both diseases, and the most common risk factors are the use of antibiotics, followed by sexual intercourse, climate/humidity changes, and the use of feminine hygiene products. However, most women (73%) point out that they do not know the cause, stating that the diagnosis was obtained clinically/by the doctor, and the other women reported having been self-diagnosed. The most common treatment is over-the-counter drugs.
A physician’s diagnosis of VVC with pelvic examination and laboratory tests, using antifungals as treatment, especially in the case of VVCR, shows 71% of patients require continuous pharmacological treatment (sometimes with the inclusion of oral antibiotics) in order to control symptomatology, though the problem is not fully eradicated.
Ozone Therapy as a Solution
Ozone therapy in the treatment of recurrent Candida albicans[ix]
The aim of this study was to verify the efficacy of dietary adjustments and ozone therapy in the treatment of VVC.
A total of 150 patients with vulvovaginitis, aged between 30 and 50 and with at least 6 months of disease evolution, participated in this study, having no response to the usual pharmacological treatment and positive cultures for Candida albicans.
The treatment was based on colon hydrotherapy with ozonated water (10 sessions), performed with daily application of intravaginal ozone insufflations at a concentration of 20 μg/mL and a speed of 0.2 L/min for 10 minutes (10 sessions), application of ozonated oil with peroxide levels between 400 and 600 mEq for 10 days and 4 auto-hemotherapies at a concentration of 2.0 μg 1x/week.
At the end of treatment, the vaginal microbiota was rebalanced with the use of vaginal tablets of Lactobacillus for 7 days and oral tablets of Lactobacillus for 1 month. It was verified that 85% of the patients showed a favourable response to treatment and 10% remained asymptomatic for 1 year, whilst 5% of the patients did not respond to treatment.
These indicators conclude that Intravaginal Ozone Therapy offers an effective alternative to conventional treatment with fungicides, offering not only a solution that leads to remission of symptoms, but also demonstrates negative vaginal cultures and exudates in patients with vulvovaginitis, whilst increasing igA and Lactobacillus in the vaginal mucosa and hence showing potentiation without having any disruptive effect on saprophytes.
The Effect of Treatment with Ozonated Olive Oil vs Clotrimazole on Vulvovaginal candidiasis[x]
This study, which took place in the Department of Gynecology of the Mashhad School of Medicine at the University of Medical Sciences in Mashhad, Iran, aimed to compare the effects of ozonated olive oil vs clotrimazole on the treatment of vulvovaginal candidiasis.
A total of 100 patients who had been referred to the clinic after confirmation of having vulvovaginal candidiasis, were randomized into two groups (1 to be treated with ozonated olive oil (OA) and the other with clotrimazole).
Patients underwent treatment with either OA or clotrimazole for 7 days and were evaluated at the beginning and end of the intervention by means of anamnesis and paraclinical examinations. The study verified changes in the degree of pruritus, burning sensation, and leukorrhea using a questionnaire that patients filled out at the beginning and end of the treatments.
The results showed that both groups expected a significant reduction in symptoms, plus both vaginal cultures for candidiasis were negative, with no significant differences between the two groups regarding symptoms of pruritus and leukorrhea.
The clotrimazole group experienced fewer symptoms of a burning sensation than the OA group
The study concluded that considering the potential efficacy of ozonated oil in improving the clinical symptoms and paraclinical aspects of treatment in patients with vulvovaginal candidiasis, the treatment may be an effective topical form in these patients.
Antifungal activity of Olive Oil and Ozonated Olive Oil on Candida spp. and Saprochaete spp.[xi]
In this study, we aimed to verify the inhibition ability of ozonated olive oil on the growth of 38 strains of Candida albicans, Candida glabrata, Candida krusei and Candida parapsilosis, as well as on Saprochaete capitata.
Two different samples of ozonated olive oil (OZO1 with 1352 mmol—mEq/kg and OZO2 with 1053 mmol—mEq/kg) and two olive oil samples (OL1 with 392 mmol—mEq/kg and OL2 with 370 mmol—mEq/kg) were used with different biochemical parameters, which were analysed and compared according to their antifungal capacity, and fluconazole was used as the control.
The antifungal activity, from the highest to the lowest OZO1 > OZO2 > OL1 ≥ OL2, showed that ozonated olive oil can help in the fungal control, even in cases that are resistant to fluconazole.
Activozone Intimate Hygiene
Formulated with a balanced blend of ozonated vegetable oils and very mild natural surfactants derived from amino acids and oat extract, this formulation is sulfate-free, perfumeless, and contains no essential oils, respecting the pH of the intimate area and respective microbiome whilst deeply moisturizing.
Intended for daily intimate hygiene, it favours the protection of the most sensitive mucous membranes, sanitizes, soothes, relieves, and calms discomfort, promoting rapid rebalancing of the microbiota of the skin and mucous membranes.
[i] Epidemiology and pathogenesis of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol. 1985 Aug 1;152(7 Pt 2):924-35.
[ii] Vulvovaginal candidiasis: epidemiologic, diagnostic, and therapeutic considerations. Am J Obstet Gynecol. 1998 Feb;178(2):203-11.
[iii] An intravaginal live Candida challenge in humans leads to new hypotheses for the immunopathogenesis of vulvovaginal candidiasis. Infect Immun. 2004 May;72(5):2939-46.
[iv] Pathogenesis and treatment of recurrent vulvovaginal candidiasis. Clin Infect Dis. 1992 Mar;14 Suppl 1:S148-53.
[v] Vaginitis. N Engl J Med. 1997 Dec 25;337(26):1896-903.
[vi] Pathogenesis and treatment of recurrent vulvovaginal candidiasis. Clin Infect Dis. 1992 Mar;14 Suppl 1:S148-53.
[vii] Candida infections of the genitourinary tract. Clin Microbiol Rev. 2010 Apr;23(2):253-73. doi: 10.1128/CMR.00076-09.
[viii] Current patient perspectives of vulvovaginal candidiasis: incidence, symptoms, management and post-treatment outcomes. BMC Womens Health. 2019 Mar 29;19(1):48. doi: 10.1186/s12905-019-0748-8.
[ix] Ozonoterapia en el tratamiento de la vulvo-vaginitis recurrente por Candida albicans. Revista Española de Ozonoterapia vol. 5, nº 1. pp 99-107, 2015. ISSN: 2174-3215
[x] The Effects of Ozonated Olive Oil and Clotrimazole Cream for Treatment of Vulvovaginal Candidiasis. Altern Ther Health Med. 2016 Jul;22(4):44-9.
[xi] Antifungal Activity of Olive Oil and Ozonated Olive Oil Against Candida Spp. and Saprochaete Spp. The Journal of the International Ozone Association. Volume 39, 2017 – Issue 6. doi.org/10.1080/01919512.2017.1322490