Jocelyn J. Fitzgerald, MD

There has been increasing awareness of a need for creating a more patient-centered experience with outpatient gynecology; however, very little data exist about what interventions are important to patients. Given social media’s ease of use and ability for widespread access to a diverse group of users, it has the potential to be a powerful tool for qualitative research questions without the difficulties of cost, transportation, transcription, etc. required of a focus group. Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of “likes” that, at scale, can provide a reliable measure of public support or engagement for a particular concept.¹ Particularly for topics that are controversial or novel, X (formerly Twitter, and referred to as Twitter intermittently throughout this article based on the time the study was conducted), with 300 million monthly users,² has become a popular tool for general and health care ̶ focused content and sentiment analysis.^3,4 This study presents a qualitative analysis of themes from a crowdsourced request on Twitter to design the ideal outpatient gynecologic experience that subsequently went “viral”.^5,6

Why the need for our research question on patient-centered gyn care

While the body of literature on patient-centered health care has grown rapidly in recent years, a patient-centered outpatient gynecology experience has not yet been described in the medical literature.

Patient-centered office design, driven by cultural sensitivity, has been shown in other studies to be both appreciated by established patients and a viable business strategy to attract new patients.⁷ Topics such as pain control, trauma-informed care in gynecologyclinics,⁸ and diverse representation in patient materials and illustrations⁹ have been popular topics in medicine and in the lay press. Our primary aim in our research was to utilize feedback from the question posed to quantify and rank patient-centered interventions in a gynecology office. These themes and others that emerged in our analysis were used to suggest best-practice guidelines for the outpatient gynecology experience (see “Checklist for ObGyn outpatient experience improvement").

What we asked social media users. The survey query to social media users, “I have the opportunity to design my office from scratch. I’m asking women: How would you design/optimize a visit to the gynecologist’s office?” was crowd-sourced via Twitter on December 5, 2021.⁵ Given a robust response to the query, it provided an opportunity for a qualitative research study exploring social media users’ perspectives on optimizing outpatient gynecologic care, although the original question was not planned for research utilization.

What we found

By December 27, 2021, the original tweet had earned 9,411 likes; 2,143 retweets; and 3,400 replies. Of this group, we analyzed 131 tweets, all of which had 100 or greater likes on Twitter at the time of the review. The majority of analyzed tweets earned between 100 ̶ 500 likes (75/131; 57.3%), while 22.9% (30/131) had 501 ̶ 1,000 likes, 11.5% (15/131) had >2,000 likes, and 8.4% (11/131) had 1,001 ̶ 1,999 likes.

Identified themes within the tweets analyzed included: medical education, comfort improvements, continuity of care, disability accommodations/accessibility, economic accessibility, nonbinary/transgender care and inclusivity, general layout/floorplan, hospitality, aid for intimate partner violence, childcare accessibility, multi-disciplinary care access, pain/anxiety control, sensitivity toward pregnancy loss/fertility issues, privacy issues, professionalism, representation (subdivided into race, LGBTQIA+, age, and weight/body type), trauma-informed care, and acknowledgement of voluntary nulliparity/support for reproductive choices (TABLE 1). TABLE 2 lists examples of popular tweets by selected themes.

Frequent themes. The most frequently occurring themes within the 131 analyzed tweets (FIGURE 1) were:

• hospitality (77 occurrences)
• comfort improvements (75 occurrences)
• general layout/floorplan (75 occurrences)
• pain/anxiety control (55 occurrences)
• representation (53 occurrences).

Popular themes. Defined as those with more than 1,000 likes at the time of analysis (FIGURE 2), the most popular themes included:

• privacy issues (48.5% of related tweets with >1,000 likes)
• voluntary nulliparity (37.0% of related tweets with >1,000 likes)
• general layout/floorplan (33.4% of related tweets with >1,000 likes)
• representation (32.1% of related tweets with >1,000 likes)
• hospitality (31.3% of related tweets with >1,000 likes).

A sub-analysis of themes related to specific types of representation—race, LGBTQIA+, age, and weight/body type was performed. Tweets related to diverse weight/body type representation occurred most frequently (19 code occurrences; FIGURE 3). Similarly, tweets related to the representation of diverse races and the LGBTQIA+ community each comprised 26% of the total representation-based tweets. In terms of popularity as described above, 51.4% of tweets describing racial representation earned >1,000 likes (FIGURE 4).

Tweet demographics. Seven (7/131; 5.3%) of the tweet authors were verified Twitter users and 35 (35/131; 26.7%) authors reported working in the health care field within their Twitter profile description.

Continue to: Implementing our feedback can enhance patient experience and care...

 

 

Implementing our feedback can enhance patient experience and care

Our study provides a unique view of the patient perspective through analyzed crowdsourced public opinion via Twitter. To our knowledge, an optimized patient-centered outpatient gynecology experience has not previously been described in the medical literature. Optimizing the found domains of hospitality, comfort measures, pain and anxiety control, privacy, and diverse representationin the outpatient gynecologic experience within the outpatient care setting may ultimately result in improved patient satisfaction, patient well-being, and adherence to care through maximizing patient-centered care. We created a checklist of suggestions, including offering analgesics during office-based procedures and tailoring the floorplan to maximize privacy (FIGURE 5), for improving the outpatient gynecology experience based on our findings.

Prior data on patient satisfaction and outcomes

Improving patient satisfaction with health care is a priority for both clinicians and hospital systems. Prior studies have revealed only variable associations between patient satisfaction, safety, and clinical outcomes. One study involving the analysis of clinical and operational data from 171 hospitals found that hospital size, surgical volume, and low mortality rates were associated with higher patient satisfaction, while favorable surgical outcomes did not consistently correlate with higher Hospital Consumer Assessment of Healthcare Provers and Systems (HCAHPS) scores.¹⁰ Smaller, lower-volume hospitals earned higher satisfaction scores related to cleanliness, quietness, and receiving help measures.¹⁰ It has also been shown that the strongest predictors of patient satisfaction with the hospital childbirth experience included items related to staff communication, compassion, empathy, and respect.¹¹ These data suggest that patient satisfaction is likely more significantly impacted by factors other than patient safety and effectiveness, and this was supported by the findings of our analysis. The growing body of literature associating a sense of psychological and physical safety within the health care system and improved patient outcomes and experience suggests that the data gathered from public commentary such as that presented here is extremely important for galvanizing change within the US health care system.

In one systematic review, the relationship between patient-centered care and clinical outcomes was mixed, although generally the association was positive.¹² Additionally, patient-centered care was often associated with increased patient satisfaction and well-being. Some studies suggest that patient well-being and satisfaction also may be associated with improved adherence and self-management behaviors.^12,13 Overall, optimizing patient-centered care may lead to improved patient satisfaction and potentially improved clinical outcomes.

Additionally, increasing diverse representation in patient materials and illustrations may help to improve the patient experience. Louie and colleagues found that dark skin tones were represented in only 4.5% of 4,146 images from anatomy texts analyzed in 2018.¹⁴ Similarly, a photogrammetric analysis of medical images utilized in New England Journal of Medicine found that only 18% of images depicted non-white skin.¹⁵ More recent efforts to create a royalty-free digital gallery of images reflecting bodies with diverse skin tones, body shapes, body hair, and age as well as transgender and nonbinary people have been discussed in the lay press.⁹ Based on our findings, social media users value and are actively seeking diversity in representation and imagery during their outpatient gynecology experience.

Opportunities for future study

Our research utilized social media as a diverse and accessible source of information; however, there are significant opportunities to refine the methodologic approach to answering the fundamental question of creating the patient-centered gynecologic experience. This type of study has not yet been conducted; however, the richness of the information from this current analysis could be informative to survey creation. Future research on this subject outside of social media could bolster the generalizability of our conclusions and the ability to report on qualitative findings in the setting of known patient demographics.

Social media remains a powerful tool as evidenced by this study, and continued use and observation of trending themes among patients is essential. The influence of social media will remain important for answering questions in gynecology and beyond.

Our work is strengthened by social media’s low threshold for use and the ability for widespread access to a diverse group of users. Additionally, social media allows for many responses to be collected in a timely manner, giving strength to the abstracted themes. The constant production of data by X users and their accessibility provide the opportunity for greater geographic coverage in those surveyed.⁴ Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of likes and retweets that may provide a reliable measure of public support or engagement.¹

Future studies should examine ways to implement the suggested improvements to the office setting in a cost-effective manner and follow both subjective patient-reported outcomes as well as objective data after implementation, as these changes may have implications for much broader public health crises, such as maternal morbidity and mortality.

Study limitations. Our study is limited by the inherent biases and confounders associated with utilizing data derived from social media. Specifically, not all patients who seek outpatient gynecologic care utilize social media and/or X; using a “like” as a surrogate for endorsement of an idea by an identified party limits the generalizability of the data.

The initial Twitter query specified, “I’m asking women”, which may have altered the intended study population, influenced the analysis, and affected the representativeness of the sample through utilizing non ̶inclusive language. While non-binary/transgender care and inclusivity emerged as a theme discussed with the tweets, it is unclear if this represents an independent theme or rather a reaction to the non–inclusive language within the original tweet. ●

There has been increasing awareness of a need for creating a more patient-centered experience with outpatient gynecology; however, very little data exist about what interventions are important to patients. Given social media’s ease of use and ability for widespread access to a diverse group of users, it has the potential to be a powerful tool for qualitative research questions without the difficulties of cost, transportation, transcription, etc. required of a focus group. Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of “likes” that, at scale, can provide a reliable measure of public support or engagement for a particular concept.¹ Particularly for topics that are controversial or novel, X (formerly Twitter, and referred to as Twitter intermittently throughout this article based on the time the study was conducted), with 300 million monthly users,² has become a popular tool for general and health care ̶ focused content and sentiment analysis.^3,4 This study presents a qualitative analysis of themes from a crowdsourced request on Twitter to design the ideal outpatient gynecologic experience that subsequently went “viral”.^5,6

Why the need for our research question on patient-centered gyn care

While the body of literature on patient-centered health care has grown rapidly in recent years, a patient-centered outpatient gynecology experience has not yet been described in the medical literature.

Patient-centered office design, driven by cultural sensitivity, has been shown in other studies to be both appreciated by established patients and a viable business strategy to attract new patients.⁷ Topics such as pain control, trauma-informed care in gynecologyclinics,⁸ and diverse representation in patient materials and illustrations⁹ have been popular topics in medicine and in the lay press. Our primary aim in our research was to utilize feedback from the question posed to quantify and rank patient-centered interventions in a gynecology office. These themes and others that emerged in our analysis were used to suggest best-practice guidelines for the outpatient gynecology experience (see “Checklist for ObGyn outpatient experience improvement").

What we asked social media users. The survey query to social media users, “I have the opportunity to design my office from scratch. I’m asking women: How would you design/optimize a visit to the gynecologist’s office?” was crowd-sourced via Twitter on December 5, 2021.⁵ Given a robust response to the query, it provided an opportunity for a qualitative research study exploring social media users’ perspectives on optimizing outpatient gynecologic care, although the original question was not planned for research utilization.

What we found

By December 27, 2021, the original tweet had earned 9,411 likes; 2,143 retweets; and 3,400 replies. Of this group, we analyzed 131 tweets, all of which had 100 or greater likes on Twitter at the time of the review. The majority of analyzed tweets earned between 100 ̶ 500 likes (75/131; 57.3%), while 22.9% (30/131) had 501 ̶ 1,000 likes, 11.5% (15/131) had >2,000 likes, and 8.4% (11/131) had 1,001 ̶ 1,999 likes.

Identified themes within the tweets analyzed included: medical education, comfort improvements, continuity of care, disability accommodations/accessibility, economic accessibility, nonbinary/transgender care and inclusivity, general layout/floorplan, hospitality, aid for intimate partner violence, childcare accessibility, multi-disciplinary care access, pain/anxiety control, sensitivity toward pregnancy loss/fertility issues, privacy issues, professionalism, representation (subdivided into race, LGBTQIA+, age, and weight/body type), trauma-informed care, and acknowledgement of voluntary nulliparity/support for reproductive choices (TABLE 1). TABLE 2 lists examples of popular tweets by selected themes.

Frequent themes. The most frequently occurring themes within the 131 analyzed tweets (FIGURE 1) were:

• hospitality (77 occurrences)
• comfort improvements (75 occurrences)
• general layout/floorplan (75 occurrences)
• pain/anxiety control (55 occurrences)
• representation (53 occurrences).

Popular themes. Defined as those with more than 1,000 likes at the time of analysis (FIGURE 2), the most popular themes included:

• privacy issues (48.5% of related tweets with >1,000 likes)
• voluntary nulliparity (37.0% of related tweets with >1,000 likes)
• general layout/floorplan (33.4% of related tweets with >1,000 likes)
• representation (32.1% of related tweets with >1,000 likes)
• hospitality (31.3% of related tweets with >1,000 likes).

A sub-analysis of themes related to specific types of representation—race, LGBTQIA+, age, and weight/body type was performed. Tweets related to diverse weight/body type representation occurred most frequently (19 code occurrences; FIGURE 3). Similarly, tweets related to the representation of diverse races and the LGBTQIA+ community each comprised 26% of the total representation-based tweets. In terms of popularity as described above, 51.4% of tweets describing racial representation earned >1,000 likes (FIGURE 4).

Tweet demographics. Seven (7/131; 5.3%) of the tweet authors were verified Twitter users and 35 (35/131; 26.7%) authors reported working in the health care field within their Twitter profile description.

Continue to: Implementing our feedback can enhance patient experience and care...

 

 

Implementing our feedback can enhance patient experience and care

Our study provides a unique view of the patient perspective through analyzed crowdsourced public opinion via Twitter. To our knowledge, an optimized patient-centered outpatient gynecology experience has not previously been described in the medical literature. Optimizing the found domains of hospitality, comfort measures, pain and anxiety control, privacy, and diverse representationin the outpatient gynecologic experience within the outpatient care setting may ultimately result in improved patient satisfaction, patient well-being, and adherence to care through maximizing patient-centered care. We created a checklist of suggestions, including offering analgesics during office-based procedures and tailoring the floorplan to maximize privacy (FIGURE 5), for improving the outpatient gynecology experience based on our findings.

Prior data on patient satisfaction and outcomes

Improving patient satisfaction with health care is a priority for both clinicians and hospital systems. Prior studies have revealed only variable associations between patient satisfaction, safety, and clinical outcomes. One study involving the analysis of clinical and operational data from 171 hospitals found that hospital size, surgical volume, and low mortality rates were associated with higher patient satisfaction, while favorable surgical outcomes did not consistently correlate with higher Hospital Consumer Assessment of Healthcare Provers and Systems (HCAHPS) scores.¹⁰ Smaller, lower-volume hospitals earned higher satisfaction scores related to cleanliness, quietness, and receiving help measures.¹⁰ It has also been shown that the strongest predictors of patient satisfaction with the hospital childbirth experience included items related to staff communication, compassion, empathy, and respect.¹¹ These data suggest that patient satisfaction is likely more significantly impacted by factors other than patient safety and effectiveness, and this was supported by the findings of our analysis. The growing body of literature associating a sense of psychological and physical safety within the health care system and improved patient outcomes and experience suggests that the data gathered from public commentary such as that presented here is extremely important for galvanizing change within the US health care system.

In one systematic review, the relationship between patient-centered care and clinical outcomes was mixed, although generally the association was positive.¹² Additionally, patient-centered care was often associated with increased patient satisfaction and well-being. Some studies suggest that patient well-being and satisfaction also may be associated with improved adherence and self-management behaviors.^12,13 Overall, optimizing patient-centered care may lead to improved patient satisfaction and potentially improved clinical outcomes.

Additionally, increasing diverse representation in patient materials and illustrations may help to improve the patient experience. Louie and colleagues found that dark skin tones were represented in only 4.5% of 4,146 images from anatomy texts analyzed in 2018.¹⁴ Similarly, a photogrammetric analysis of medical images utilized in New England Journal of Medicine found that only 18% of images depicted non-white skin.¹⁵ More recent efforts to create a royalty-free digital gallery of images reflecting bodies with diverse skin tones, body shapes, body hair, and age as well as transgender and nonbinary people have been discussed in the lay press.⁹ Based on our findings, social media users value and are actively seeking diversity in representation and imagery during their outpatient gynecology experience.

Opportunities for future study

Our research utilized social media as a diverse and accessible source of information; however, there are significant opportunities to refine the methodologic approach to answering the fundamental question of creating the patient-centered gynecologic experience. This type of study has not yet been conducted; however, the richness of the information from this current analysis could be informative to survey creation. Future research on this subject outside of social media could bolster the generalizability of our conclusions and the ability to report on qualitative findings in the setting of known patient demographics.

Social media remains a powerful tool as evidenced by this study, and continued use and observation of trending themes among patients is essential. The influence of social media will remain important for answering questions in gynecology and beyond.

Our work is strengthened by social media’s low threshold for use and the ability for widespread access to a diverse group of users. Additionally, social media allows for many responses to be collected in a timely manner, giving strength to the abstracted themes. The constant production of data by X users and their accessibility provide the opportunity for greater geographic coverage in those surveyed.⁴ Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of likes and retweets that may provide a reliable measure of public support or engagement.¹

Future studies should examine ways to implement the suggested improvements to the office setting in a cost-effective manner and follow both subjective patient-reported outcomes as well as objective data after implementation, as these changes may have implications for much broader public health crises, such as maternal morbidity and mortality.

Study limitations. Our study is limited by the inherent biases and confounders associated with utilizing data derived from social media. Specifically, not all patients who seek outpatient gynecologic care utilize social media and/or X; using a “like” as a surrogate for endorsement of an idea by an identified party limits the generalizability of the data.

The initial Twitter query specified, “I’m asking women”, which may have altered the intended study population, influenced the analysis, and affected the representativeness of the sample through utilizing non ̶inclusive language. While non-binary/transgender care and inclusivity emerged as a theme discussed with the tweets, it is unclear if this represents an independent theme or rather a reaction to the non–inclusive language within the original tweet. ●

There has been increasing awareness of a need for creating a more patient-centered experience with outpatient gynecology; however, very little data exist about what interventions are important to patients. Given social media’s ease of use and ability for widespread access to a diverse group of users, it has the potential to be a powerful tool for qualitative research questions without the difficulties of cost, transportation, transcription, etc. required of a focus group. Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of “likes” that, at scale, can provide a reliable measure of public support or engagement for a particular concept.¹ Particularly for topics that are controversial or novel, X (formerly Twitter, and referred to as Twitter intermittently throughout this article based on the time the study was conducted), with 300 million monthly users,² has become a popular tool for general and health care ̶ focused content and sentiment analysis.^3,4 This study presents a qualitative analysis of themes from a crowdsourced request on Twitter to design the ideal outpatient gynecologic experience that subsequently went “viral”.^5,6

Why the need for our research question on patient-centered gyn care

While the body of literature on patient-centered health care has grown rapidly in recent years, a patient-centered outpatient gynecology experience has not yet been described in the medical literature.

Patient-centered office design, driven by cultural sensitivity, has been shown in other studies to be both appreciated by established patients and a viable business strategy to attract new patients.⁷ Topics such as pain control, trauma-informed care in gynecologyclinics,⁸ and diverse representation in patient materials and illustrations⁹ have been popular topics in medicine and in the lay press. Our primary aim in our research was to utilize feedback from the question posed to quantify and rank patient-centered interventions in a gynecology office. These themes and others that emerged in our analysis were used to suggest best-practice guidelines for the outpatient gynecology experience (see “Checklist for ObGyn outpatient experience improvement").

What we asked social media users. The survey query to social media users, “I have the opportunity to design my office from scratch. I’m asking women: How would you design/optimize a visit to the gynecologist’s office?” was crowd-sourced via Twitter on December 5, 2021.⁵ Given a robust response to the query, it provided an opportunity for a qualitative research study exploring social media users’ perspectives on optimizing outpatient gynecologic care, although the original question was not planned for research utilization.

What we found

By December 27, 2021, the original tweet had earned 9,411 likes; 2,143 retweets; and 3,400 replies. Of this group, we analyzed 131 tweets, all of which had 100 or greater likes on Twitter at the time of the review. The majority of analyzed tweets earned between 100 ̶ 500 likes (75/131; 57.3%), while 22.9% (30/131) had 501 ̶ 1,000 likes, 11.5% (15/131) had >2,000 likes, and 8.4% (11/131) had 1,001 ̶ 1,999 likes.

Identified themes within the tweets analyzed included: medical education, comfort improvements, continuity of care, disability accommodations/accessibility, economic accessibility, nonbinary/transgender care and inclusivity, general layout/floorplan, hospitality, aid for intimate partner violence, childcare accessibility, multi-disciplinary care access, pain/anxiety control, sensitivity toward pregnancy loss/fertility issues, privacy issues, professionalism, representation (subdivided into race, LGBTQIA+, age, and weight/body type), trauma-informed care, and acknowledgement of voluntary nulliparity/support for reproductive choices (TABLE 1). TABLE 2 lists examples of popular tweets by selected themes.

Frequent themes. The most frequently occurring themes within the 131 analyzed tweets (FIGURE 1) were:

• hospitality (77 occurrences)
• comfort improvements (75 occurrences)
• general layout/floorplan (75 occurrences)
• pain/anxiety control (55 occurrences)
• representation (53 occurrences).

Popular themes. Defined as those with more than 1,000 likes at the time of analysis (FIGURE 2), the most popular themes included:

• privacy issues (48.5% of related tweets with >1,000 likes)
• voluntary nulliparity (37.0% of related tweets with >1,000 likes)
• general layout/floorplan (33.4% of related tweets with >1,000 likes)
• representation (32.1% of related tweets with >1,000 likes)
• hospitality (31.3% of related tweets with >1,000 likes).

A sub-analysis of themes related to specific types of representation—race, LGBTQIA+, age, and weight/body type was performed. Tweets related to diverse weight/body type representation occurred most frequently (19 code occurrences; FIGURE 3). Similarly, tweets related to the representation of diverse races and the LGBTQIA+ community each comprised 26% of the total representation-based tweets. In terms of popularity as described above, 51.4% of tweets describing racial representation earned >1,000 likes (FIGURE 4).

Tweet demographics. Seven (7/131; 5.3%) of the tweet authors were verified Twitter users and 35 (35/131; 26.7%) authors reported working in the health care field within their Twitter profile description.

Continue to: Implementing our feedback can enhance patient experience and care...

 

 

Implementing our feedback can enhance patient experience and care

Our study provides a unique view of the patient perspective through analyzed crowdsourced public opinion via Twitter. To our knowledge, an optimized patient-centered outpatient gynecology experience has not previously been described in the medical literature. Optimizing the found domains of hospitality, comfort measures, pain and anxiety control, privacy, and diverse representationin the outpatient gynecologic experience within the outpatient care setting may ultimately result in improved patient satisfaction, patient well-being, and adherence to care through maximizing patient-centered care. We created a checklist of suggestions, including offering analgesics during office-based procedures and tailoring the floorplan to maximize privacy (FIGURE 5), for improving the outpatient gynecology experience based on our findings.

Prior data on patient satisfaction and outcomes

Improving patient satisfaction with health care is a priority for both clinicians and hospital systems. Prior studies have revealed only variable associations between patient satisfaction, safety, and clinical outcomes. One study involving the analysis of clinical and operational data from 171 hospitals found that hospital size, surgical volume, and low mortality rates were associated with higher patient satisfaction, while favorable surgical outcomes did not consistently correlate with higher Hospital Consumer Assessment of Healthcare Provers and Systems (HCAHPS) scores.¹⁰ Smaller, lower-volume hospitals earned higher satisfaction scores related to cleanliness, quietness, and receiving help measures.¹⁰ It has also been shown that the strongest predictors of patient satisfaction with the hospital childbirth experience included items related to staff communication, compassion, empathy, and respect.¹¹ These data suggest that patient satisfaction is likely more significantly impacted by factors other than patient safety and effectiveness, and this was supported by the findings of our analysis. The growing body of literature associating a sense of psychological and physical safety within the health care system and improved patient outcomes and experience suggests that the data gathered from public commentary such as that presented here is extremely important for galvanizing change within the US health care system.

In one systematic review, the relationship between patient-centered care and clinical outcomes was mixed, although generally the association was positive.¹² Additionally, patient-centered care was often associated with increased patient satisfaction and well-being. Some studies suggest that patient well-being and satisfaction also may be associated with improved adherence and self-management behaviors.^12,13 Overall, optimizing patient-centered care may lead to improved patient satisfaction and potentially improved clinical outcomes.

Additionally, increasing diverse representation in patient materials and illustrations may help to improve the patient experience. Louie and colleagues found that dark skin tones were represented in only 4.5% of 4,146 images from anatomy texts analyzed in 2018.¹⁴ Similarly, a photogrammetric analysis of medical images utilized in New England Journal of Medicine found that only 18% of images depicted non-white skin.¹⁵ More recent efforts to create a royalty-free digital gallery of images reflecting bodies with diverse skin tones, body shapes, body hair, and age as well as transgender and nonbinary people have been discussed in the lay press.⁹ Based on our findings, social media users value and are actively seeking diversity in representation and imagery during their outpatient gynecology experience.

Opportunities for future study

Our research utilized social media as a diverse and accessible source of information; however, there are significant opportunities to refine the methodologic approach to answering the fundamental question of creating the patient-centered gynecologic experience. This type of study has not yet been conducted; however, the richness of the information from this current analysis could be informative to survey creation. Future research on this subject outside of social media could bolster the generalizability of our conclusions and the ability to report on qualitative findings in the setting of known patient demographics.

Social media remains a powerful tool as evidenced by this study, and continued use and observation of trending themes among patients is essential. The influence of social media will remain important for answering questions in gynecology and beyond.

Our work is strengthened by social media’s low threshold for use and the ability for widespread access to a diverse group of users. Additionally, social media allows for many responses to be collected in a timely manner, giving strength to the abstracted themes. The constant production of data by X users and their accessibility provide the opportunity for greater geographic coverage in those surveyed.⁴ Crowdsourced public opinion also has the advantage of producing qualitative metrics in the form of likes and retweets that may provide a reliable measure of public support or engagement.¹

Future studies should examine ways to implement the suggested improvements to the office setting in a cost-effective manner and follow both subjective patient-reported outcomes as well as objective data after implementation, as these changes may have implications for much broader public health crises, such as maternal morbidity and mortality.

Study limitations. Our study is limited by the inherent biases and confounders associated with utilizing data derived from social media. Specifically, not all patients who seek outpatient gynecologic care utilize social media and/or X; using a “like” as a surrogate for endorsement of an idea by an identified party limits the generalizability of the data.

The initial Twitter query specified, “I’m asking women”, which may have altered the intended study population, influenced the analysis, and affected the representativeness of the sample through utilizing non ̶inclusive language. While non-binary/transgender care and inclusivity emerged as a theme discussed with the tweets, it is unclear if this represents an independent theme or rather a reaction to the non–inclusive language within the original tweet. ●

Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.¹ Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.

Who uses feminine hygiene products?

According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.¹ Predictably, women who douche are more likely to perceive douche products as safe.¹

Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,² while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.^1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.⁴

Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.^1,2

Modern marketing approaches

From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”⁵ and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.⁶

Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”

Continue to: Effects of feminine hygiene products on the vaginal microbiome...

 

 

Effects of feminine hygiene products on the vaginal microbiome

Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,^7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.^1,2

The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.⁹ This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.^9,10

Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora¹⁰ despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.¹¹ Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.¹⁰ Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.¹⁰

A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.⁷ Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.⁸ Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.¹²

Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.³ This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.

Understand the products to help educate patients

Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,¹ unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.

It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●

Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.¹ Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.

Who uses feminine hygiene products?

According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.¹ Predictably, women who douche are more likely to perceive douche products as safe.¹

Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,² while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.^1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.⁴

Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.^1,2

Modern marketing approaches

From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”⁵ and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.⁶

Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”

Continue to: Effects of feminine hygiene products on the vaginal microbiome...

 

 

Effects of feminine hygiene products on the vaginal microbiome

Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,^7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.^1,2

The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.⁹ This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.^9,10

Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora¹⁰ despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.¹¹ Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.¹⁰ Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.¹⁰

A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.⁷ Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.⁸ Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.¹²

Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.³ This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.

Understand the products to help educate patients

Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,¹ unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.

It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●

Feminine hygiene products have been commercially available for decades. They are commonly marketed to reduce odor or clean vaginal discharge and menses. Multiple formulas are available as topical washes, wipes, creams, sprays, powders, deodorants, and douches.¹ Products on the market range from those used externally on the vulva, such as wipes and sprays, to liquid solutions used intravaginally, such as washes and douches.

Who uses feminine hygiene products?

According to a 2006 study, the majority of women who use douches started using them between age 15 and 19 years, but some women initiate this practice habit as early as age 10 to 14.¹ Predictably, women who douche are more likely to perceive douche products as safe.¹

Demographic data on douche utilization are mixed: Some studies show that there are no significant racial differences in douching practices,² while others have found that Black and African American women are more likely to practice douching than White and Hispanic women.^1,3 Studies have shown a significant difference in attitudes toward douching and knowledge of normal vaginal symptoms among US racial demographics, although this must be examined through the historical context of racism and the lens of medical anthropology.⁴

Women cite that common reasons they use feminine hygiene products are to feel clean, to control odor, and to use after menses and intercourse.^1,2

Modern marketing approaches

From wipes to soaps to douches, feminine hygiene products often are advertised to promote “funk-free periods”⁵ and “freshness,” fostering an environment in which women and men develop unrealistic standards for what is considered normal genital odor and resulting in poor body image.⁶

Recently, Vagisil (Combe Incorporated) marketing efforts faced backlash from the ObGyn community for targeting younger populations with a specific product line for adolescents called OMV! In addition, attention has been drawn to VCF vaginal odor eliminating film (Apothecus Pharmaceutical Corp), small stamp-sized dissolving films that are placed in the vaginal canal in contact with the epithelium. This product has entered the market of feminine hygiene products accompanied by slogans of eliminating “feminine odor” and providing “confidence for women to be intimate.”

Continue to: Effects of feminine hygiene products on the vaginal microbiome...

 

 

Effects of feminine hygiene products on the vaginal microbiome

Frequent use of feminine hygiene products has been associated with recurrent vaginitis, bacterial vaginosis, and general irritation/itch,^7,8 which can cause more discharge and odor. Ironically, this may result in women using the product more frequently since they often seek out these products to eliminate odor and discharge.^1,2

The pH of the vagina changes during a woman’s lifetime, but in the reproductive years, the normal pH range is typically 3.8 to 4.4.⁹ This range allows for a normal vaginal flora to form with bacteria such as Lactobacillus species and Gardnerella vaginalis, while feminine hygiene products have a wide range of pH.^9,10

Regardless of the formulation, most feminine hygiene products contain ingredients and compositions that potentially are detrimental to the health of the vulva and vagina. Many products contain acidic ingredients, such as citric acid, lactic acid, and dehydroacetic acid, that can alter the vaginal pH and weaken the vaginal barrier by wiping out normal vaginal flora¹⁰ despite being advertised for use on “sensitive areas” (TABLE). Lactic acid also has been found to increase diverse anaerobic bacteria in the vaginal microbiome.¹¹ Some feminine hygiene products have been shown to suppress Lactobacillus growth at 2 hours after use and to kill all lactobacilli at 24 hours.¹⁰ Shifts in microbiota numbers often occur when the vaginal pH has been altered, as is frequently the case with feminine hygiene products. In the absence of microbiome bacteria, the presence of vaginal hygiene products has been shown to increase interleukin-8 (IL-8), suggesting a proinflammatory reaction.¹⁰

A study in the United Kingdom found that women who used bubble bath, antiseptics, or douche products had a higher incidence of bacterial vaginosis compared with women who did not use such products.⁷ Women in Canada who used feminine hygiene products were more likely to report adverse conditions, including yeast infections, bacterial vaginosis, urinary tract infections, and sexually transmitted diseases.⁸ Furthermore, a significant association exists between vaginal douching and endometrial infection by bacterial vaginosis–associated organisms.¹²

Additionally, a study that analyzed volatile organic compound levels in the blood with the use of feminine hygiene products revealed a significant positive dose-exposure relationship between the frequency of vaginal douching in the last 6 months and concentrations of 1,4-dichloromethane, one of the volatile organic compounds.³ This points to the issue of not only disruption of pH and vaginal flora but also to the introduction of harmful substances that can further disrupt the vaginal barrier.

Understand the products to help educate patients

Use of feminine hygiene products is common among women. While women depend on the market to filter out products that are considered unsafe or may have harmful side effects,¹ unfortunately that is not necessarily the case. With increasingly more feminine products on the market and the target demographic becoming younger, women of all ages are susceptible to misinformation that could affect their vaginal health long term.

It is vital that clinicians understand the topical effects of these products in order to properly educate and counsel patients. Ultimately, research on feminine hygiene products is limited and, as more products come to market, we must continue to reassess the effects of topical products on the vaginal epithelium and vulvar tissues. ●