The first systematic review and meta-analysis of the international use of menstrual cups; including 43 studies and data from 3,300 women and girls publish in The Lancet Public Health journal, suggests they are safe and result in similar; or lower, leakage than disposable pads or tampons. Four studies within the review (293 participants) compare leakage between different sanitary products, and found that levels similar between menstrual cups and pads and tampons; while one found that leakage was significantly less.
Globally, menstruation can affect girls’ schooling and women’s experience of work; increase their disposition to urogenital infections if they use poor quality sanitary products; and even make both women and girls a target of sexual violence; or coercion when they don’t have the funds to buy them. There are an increasing number of initiatives in both high- and low-income countries to combat ‘period poverty’; so it is essential that policy makers know which sanitary products to include in menstrual health program and puberty education materials.
“Despite the fact that 1.9 billion women globally are of menstruating age; spending on average 65 days a year dealing with menstrual blood flow, few good quality studies exist that compare sanitary products,” says senior author Professor Penelope Phillips-Howard from the Liverpool School of Tropical Medicine, UK. “They aimed to address this by summarizing current knowledge about leakage; safety, and acceptability of menstrual cups, comparing them to other products where possible.”
Experiences of menstrual cups
The study combines data from medical studies and grey literature such as conference abstracts; reports and theses for which participants reported their experiences of menstrual cups or their willingness to use them. The authors selected 43 studies involving 3,319 participants in both low- and middle-income countries; (LMICs) (15 studies) and high-income countries (28 studies).
They also compiled global information on the availability and costs of menstrual cups; conduct preliminary estimates on waste savings, and examine puberty education materials to assess the extent to which menstrual cups are refer to as an option. The authors note that the quality of the studies included was low; and call for more, quality research in this area, and note that further studies needed on cost-effectiveness and environmental effects between different menstrual products.
In the review, some of the information was taken from reports not publish in peer-reviewed journals; and the focus of some studies was to evaluate other topics. Some data were from older studies, when reporting requirements were less stringent; or with menstrual cups that are no longer available. Most of the studies depend on self-reporting; which might have overestimated use of the menstrual cup.
Comparisons of leakage
Menstrual cups collect blood flow, rather than absorbing it as with pads and tampons. Like tampons, they are inserted into the vagina, before being emptied every 4-12 hours. There are currently two types: a vaginal cup which is generally bell-shaped; and a cervical cup which is place around the cervix high in the vagina like a diaphragm for contraception. The materials used to make them are medical grade silicone; rubber, latex or elastomer and can last up to 10 years.
The current review identifies the products usually used in LMICs, which include cloths; cotton wool, tissue paper and other pieces of material, as well as disposable pads. Leakage and chaffing are a common concern. Four studies in the review, involving 293 participants, made direct comparisons of leakage between menstrual cups and disposable pads or tampons.
Leakage was similar in three studies and significantly less among menstrual cups for one study. In some studies, leaking was associated with abnormally heavy bleeding; unusual anatomy of the uterus, need of a larger cup size, incorrect placement of the cup; and the cup becoming full. There was no increased risk of infection associated with using menstrual cups among European, North American, and African women and girls.
Combination with intrauterine devices
In four studies involving a total of 507 women, use of the menstrual cup show; no adverse effects on vaginal flora. In studies that examined the vagina and cervix during follow-up, no tissue damage was identify from use of a menstrual cup. Difficulty in removing cups, requiring professional assistance, reported twice for vaginal cups and 47 times for cervical cups. Some women use them in combination with intrauterine devices and, in 13 cases; removing the cup associated with an IUD becoming dislodged.
Results from 13 of the studies suggest that around 70% of women want; to continue using menstrual cups once they were familiar with how to do so. Interview-based studies revealed that practice, peer support and training are key to participants finding them successful. In six qualitative studies; participants suggested that adopting the menstrual cup required a familiarisation phase; over several menstrual cycles. The authors note that information and follow-up on correct use might need to form a part of menstrual health program.
The review suggests that awareness of menstrual cups as an option is low. Three studies in high-income countries found that only 11-33% of women are aware of them. Among 69 websites containing educational materials on puberty in 27 countries, 77% mentioned disposable pads and 65% mentioned tampons, while only 30% mentioned menstrual cups and 22% mentioned reusable pads.