Reviewer ’s report  
 
Title: Vaginal health and hygiene practices and product use in Canada: A national cross 
sectional survey  
 
Version: 1 Date: 12 Apr 2016  
 
Reviewer: Rebecca Brotman  
 
Reviewer's report:  
 
The authors conducted a large online survey (n=1435 respondents) of feminine hygiene practices 
and vaginal symptoms. While it is laudable that the investigators launched such a large study, I 
believe the data can be better clarified and presented. For example, the authors did not clarify a 
time period for the product use or symptoms. "Lifetime use" of a product appears to have been 
evaluated against "ever" report of symptoms. This is a really broad cross tabulation. (If I 
understand the analysis correctly?) The authors appear to have data on symptoms and hygiene 
use in the prior 90 days but they didn't use the data for the bulk of the paper (Table 2)?  Overall, I 
think the authors have a useful dataset but the paper would benefit from being re -analyzed and 
re-presented with restricted temporal windows. Additional specific comments are listed below:  
 
 
 
1) Regarding the references chosen on page 3 line 7 (r ef 2-6), I would refer the authors to 
Dr. Martin's review in Am.J Med.Sci. 2011. Hickey's paper briefly discusses 
epidemiologic factors (antibiotic use, douching, hormonal contraception) but is much 
more focused on ecologic factors. Another good primary re ference for epidemiological 
factors associated with BV are any of the papers from Catriona Bradshaw or Jeanne 
Marrazzo's group.  
 
 
2) With respect to the literature review (lines 16 -20), the authors may find utility in citing 
another important national preval ence survey of douching --- the survey conducted by 
NHANES of over 3000 U.S. women (Koumans et al Sex Transm Dis. 2007).  
 
 
3) Did participants mail vaginal samples to the study PIs? If the authors have samples, they 
can evaluate them for vaginal microbiota o r Gram stain scoring.  
 
 
4) Regarding the IRB approvals in line 16 -17, all authors who are in receipt of data need to 
have institutional approvals. The data are likely de -identified and would be labeled as 
"non human subjects".  
 
 
5) 1471 participants completed  the survey, however how many started the survey and closed 
it out without completing? Do the authors have this data?  
 
 
6) Page 6, Line 20: What time frame is report of these symptoms referring to? I assume this 
is lifetime/ever have these symptoms? A value  of 2.5 seems like quite a low number for 
average number of symptoms a woman had ever experienced in her lifetime. I wonder if 
the way the question was worded that the investigators aren't able to really ascertain the 
question.  
 
 
7) Line 20 on page 8 says " No associations with meaningful effect sizes (i.e., larger than 
0.1) were found between health conditions and internal use of wipes, external use of 
vaginal sprays, deodorant suppositories, internal use of body/hand creams, external use of 
liquid/gel sanit izers, and shaving creams." The participants were asked about lifetime 
health conditions and lifetime ever use of product which is difficult to report. What about 
a cross -tabulation in the past 30 days?  
 
 
8) On page 10, line 9, was yeast infection diagnosis  by self -report from clinician -diagnosis 
or self -diagnosis? (Ferris, Obstet Gynecol 2002).  
 
 
9) The results section is long and mostly reiterated in the tables. I would suggest focusing on 
results of major interest in the text.  
 
 
10) Table 2: Why didn't the a uthors utilize the participants who reported "used 3 months 
prior" in the main text? The authors only analyzed "ever used" in all of their correlation 
assessments?  
 
 
11) Do the authors have data on participant smoking (not just fogging)? BV is highly 
associ ated with smoking.  
 
 
12) Table 4: I understand the authors are from a psychology department and I'm not familiar 
with the methodologies used in the psychology literature. In traditional women's health 
epidemiologic studies, we generally present tables with % and sample size in each group 
and then the p -value for the chi2 statistic ( not the actual chi2 statistic).  
 
 
13) Did the authors build any multivariate models to control for confounding factors?  
 
 
14) Page 16, line 18: I would suggest softening the statemen t that research has identified a 
causal relationship between douches and vaginal infections. To my knowledge, there has 
not been a large randomized controlled trial of douching initiation or douching cessation 
on BV/STI outcomes although my group and other s have published several small and 
some compelling studies (Kurth, Grimley, Norris Turner, Brotman and Klebanoff et al.). 
There have also been a number of observational studies with various methodologies 
which all point to a strong association.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments  to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical revi ew? 
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manusc ript: 
 
Acceptable  
 
 
 
 
 
 
 
 
 
 
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