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Reporting a Medication Error

Unintentional Ingestion of Boric Acid Vaginal Suppositories

Published November 1, 2023

It’s happened again. A woman swallowed a boric acid suppository instead of inserting it vaginally to relieve symptoms from a vaginal infection. We published information about a similar case in 2018. In this latest case, a woman with a vaginal infection was told by her doctor to use boric acid suppositories. A suppository is a type of medicine that is inserted directly into your body. These are used either rectally (such as a glycerin suppository used for constipation), in the urethra (for male sexual dysfunction), or, as with boric acid, in the vagina, where it may help relieve symptoms that often accompany an infection from a bacteria or yeast, such as a bad odor. Boric acid suppositories are sold over-the-counter (OTC) and do not require a prescription.

Figure 1. Consumers may overlook a warning statement near the bottom of the label on OTC boric acid vaginal suppositories.

The confusing part is that boric acid suppositories come as a powder inside a gelatin capsule that looks like medicine capsules that are normally swallowed with a glass of water. To someone with an infection, these boric acid capsules may look more like an oral antibiotic than a suppository. In the report we received, the patient swallowed one of the suppositories. Later, when she read the container label more carefully, she realized the capsules were suppositories meant for vaginal insertion. There was also a warning on the container that the woman missed. The warning said, “For vaginal use only, not for oral consumption. If swallowed, get medical help and call poison control right away.” The woman decided to go to an emergency room.

According to Poison Control, the small amount of boric acid in a single capsule would not be enough to cause harm. However, taking large amounts of boric acid may result in stomach issues, kidney problems, or death. Fortunately, the woman did not suffer any serious problems. Besides cases reported to ISMP, a search of the Internet revealed numerous other cases of women accidentally swallowing boric acid suppositories.  

Here's what you can do: Do not mistake boric acid suppositories for oral medicine. Look for products that come with an applicator (a device to help insert the suppository into the vagina). This may help show that the medicine is a suppository, not a capsule. Read product labels carefully and turn the container around so you can read the Drug Facts panel that lists important information about OTC medicines. Never store boric acid products or any other product next to medicines that are to be taken by mouth. If you are having vaginal symptoms such as itching, discharge, or odor, get help from a healthcare professional who can diagnose the issue and recommend proper treatment, which may be a prescription medicine which would be more effective than boric acid.

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