Menstrual blood loss measurement with gynaeseal

Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis

BACKGROUND

Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845.

FINDINGS

Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59-84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72-46·72 (median $23·3, 145 brands).

INTERPRETATION

Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products.

FUNDING

UK Medical Research Council, Department for International Development, and Wellcome Trust.

A systematic review of methods to measure menstrual blood loss

Background

Since the publication over 50 years ago of the alkaline hematin method for quantifying menstrual blood loss (MBL) many new approaches have been developed to assess MBL. The aim of this systematic review is to determine for methods of measuring MBL: ability to distinguish between normal and heavy menstrual bleeding (HMB); practicalities and limitations in the research setting; and suitability for diagnosing HMB in routine clinical practice.

Methods

Embase®™, MEDLINE®, and ClinicalTrials.gov were screened for studies on the development/validation of MBL assessment methods in women with self-perceived HMB, actual HMB or uterine fibroids, or patients undergoing treatment for HMB. Studies using simulated menstrual fluid and those that included women with normal MBL as controls were also eligible for inclusion. Extracted data included study population, results of validation, and advantages/disadvantages of the technique.

Results

Seventy-one studies fulfilled the inclusion criteria. The sensitivity and/or specificity of diagnosing HMB were calculated in 16 studies of methods involving self-perception of MBL (11 pictorial), and in one analysis of the menstrual-fluid-loss (MFL) method; in 13 of these studies the comparator was the gold standard alkaline hematin technique. Sensitivity and specificity values by method were, respectively: MFL model, 89, 98%; pictorial blood loss assessment chart (PBAC), 58–99%, 7.5–89%; menstrual pictogram, 82–96%, 88–94%; models/questionnaires, 59–87%, 62–86%, and complaint of HMB, 74, 74%. The power of methods to identify HMB was also assessed using other analyses such as comparison of average measurements: statistical significance was reported for the PBAC, MFL, subjective complaint, and six questionnaires. In addition, PBAC scores, menstrual pictogram volumes, MFL, pad/tampon count, iron loss, and output from three questionnaires correlated significantly with values from a reference method in at least one study. In general, pictorial methods have been more comprehensively validated than questionnaires and models.

Conclusions

Every method to assess MBL has limitations. Pictorial methods strike a good balance between ease of use and validated accuracy of MBL determination, and could complement assessment of HMB using quality of life (QoL) in the clinical and research setting.

Trial registration

PRISMA registration number: CRD42016032956.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0627-8) contains supplementary material, which is available to authorized users.

Outcome measures for heavy menstrual bleeding

Heavy menstrual bleeding is one of the most commonly encountered gynecological problems. While accurate objective quantification of menstrual blood loss is of value in the research setting, it is the subjective assessment of blood loss that is of greater importance when assessing the severity of heavy menstrual bleeding and any subsequent response to treatment. In this review the various approaches to objective, subjective and semi-subjective assessment of menstrual blood loss will be discussed.

Validation of the menstrual pictogram in women with leiomyomata associated with heavy menstrual bleeding

OBJECTIVE

The menstrual pictogram (MP), a semiquantitative, easy-to-use tool to assess blood loss, was validated against the reference standard of alkaline hematin (AH) quantitation using data pooled from 3 clinical trials.

METHODS

Premenopausal women aged ≥18 years with heavy menstrual bleeding (HMB) associated with uterine leiomyomata were randomized to asoprisnil (10 or 25 mg) or placebo. Patients completed the MP and collected feminine hygiene products for assessment of blood loss by the AH method. Agreement between the MP and the AH method was calculated.

RESULTS

The positive predictive value of the MP total to distinguish women with HMB against the AH total was 91%. The agreement (κ-statistic) between AH and MP totals for classifying patients with ≥50% or <50% decreases in HMB was 0.88 (95% confidence interval [CI], 0.78-0.98), and the MP was 96% sensitive and 92% specific. The methods showed good association for percentage change in blood (intraclass correlation coefficient [ICC] of 0.86, 95% CI, 0.80-0.91) but not for actual blood loss per cycle (ICC of 0.64, [95% CI, 0.55-0.71]); the greatest underestimation occurred for severely stained napkins.

CONCLUSION

In this study, the MP distinguished women with HMB and adequately assessed improvements with therapy.

Preclinical, clinical, and over-the-counter postmarketing experience with a new vaginal cup: menstrual collection

BACKGROUND

Menstrual cups have been available for decades, but their use is limited by bulky design and the need for multiple sizes. The Softcup® (Instead, Inc., San Diego, CA) is a simple single-size disposable over-the-counter (OTC) menstrual cup that compresses to tampon shape to facilitate insertion and can be worn during coitus. This report describes preclinical evaluation, clinical testing, and postmarketing monitoring of the Softcup.

METHODS

Preclinical testing complied with U.S. Food and Drug Administration (FDA) guidelines and used standard United States Pharmacopoeia methodologies for assessment of potential toxicity. Clinical testing enrolled 406 women in seven U.S. centers. A detailed written questionnaire assessed safety, acceptability, and effectiveness for menstrual collection. Study safety parameters included pelvic examinations, Pap smears, colposcopy, urinalysis, vaginal pH, wet mounts, gram stain, and vaginal microflora cultures. Postmarketing surveillance of over 100 million Softcups has been conducted by the manufacturer and by the FDA Medwatch system.

RESULTS

No toxicity or mutagenicity was observed in preclinical evaluations. In clinical testing, after three cycles of cup use, 37% of subjects rated the cup as better than, 29% as worse than, and 34% as equal to pads or tampons. The cup was preferred for comfort, dryness, and less odor. Cups received lower ratings for disposal and convenience. Eighty-one percent of enrolled women were able to insert and remove their first cup using only written instructions. Use difficulties resulting in study discontinuations included cramping (1%), leakage (1%), and improper fit (3%). No safety parameters were adversely affected. No significant health risks were reported during postmarketing surveillance.

CONCLUSIONS

These results demonstrate that a single-size vaginal device has no significant health risks and is acceptable to many women without the need for fitting or other medical services.

Women's experience of using the Mooncup

The Mooncup is a menstrual cup that is an alternative to conventional sanitary protection. We aimed to determine whether the Mooncup is tolerated by asking 53 healthy female volunteers to record the frequency of changing sanitary protection and leakage over three menstrual cycles with regular sanitary protection and three cycles with the Mooncup. We measured the frequency of leakage and changing the Mooncup along with acceptability of the Mooncup. A total of 126 baseline cycles and 71 cycles with the Mooncup were recorded. The Mooncup leaked 0.5 times less frequently and required to be changed 2.8 times less frequently, on average, during one menstrual period than regular sanitary protection. Of the participants, 55% will carry on using the Mooncup for sanitary protection. Thus, we have concluded that, the Mooncup is acceptable for most women but could not be used for the objective measurement of menstrual blood loss because of the leakage that did occur.

Determination of total menstrual blood loss

OBJECTIVE

To develop and validate a simple method of measuring total menstrual blood loss using a pictorial representation of blood loss, the menstrual pictogram.

DESIGN

A prospective evaluation of total menstrual blood loss measurement by the menstrual pictogram compared to the alkaline hematin technique.

SETTING

Academic menorrhagia research clinic.

PATIENT(S)

One hundred twenty-one women; 62 women complaining of heavy menstrual blood loss, 59 women who considered their menstrual blood loss to be normal.

INTERVENTION(S)

Participants were asked to complete the menstrual pictogram through the period and collect their feminine hygiene products for an alkaline hematin assessment.

MAIN OUTCOME MEASURE(S)

Percentage agreement between blood loss measured by the gold standard alkaline hematin method and the menstrual pictogram. Extraneous blood loss was measured using a semiquantitative pictorial method.

RESULT(S)

The menstrual pictogram had a high level of agreement for blood collected on feminine hygiene products compared with the alkaline hematin method. Some women also lose a significantly large amount of extraneous blood, which is not proportional to the alkaline hematin blood loss assessment.

CONCLUSION(S)

The menstrual pictogram provides a simple means of measuring menstrual blood loss. It is no longer appropriate to ignore extraneous blood loss, particularly as there is no correlation between extraneous blood loss and that measured on feminine hygiene products.