'It's like a burden on the head': Redefining adequate menstrual hygiene management throughout women's varied life stages in Odisha, India

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities.

A study on the microbial quality of sealed products for feminine hygiene

Introduction

Sanitary tampons have been in existence for over 60 years. Their use may present certain health risks, potentially associated with an abnormal change of microbial flora in the vagina (e.g., toxic shock syndrome). Tampon production and marketing are regulated differently in different countries. In Australia, Canada and the USA, tampons are classified as Class-II medical devices and their marketing requires pre-clinical and clinical studies, including microbiological trials. In Europe, tampons are considered consumer products and safety-related data are provided only if the manufacturer deems them to be useful. Sterility of these products is not requested by law; thus they may represent a potential vehicle for microorganisms. Due to the lack of data on microbial characteristics of tampons, an analytical investigation was carried out to characterize and quantify the microbial flora present on sealed tampons of various brands present on the market in Italy.

Methods

Traditional cultural methods were used to characterize and quantify bacteria and fungi. Identification of colonies was performed with biochemical techniques.

Results

Results showed low microbial concentrations in 93% of the positive samples. A rare presence of opportunistic pathogens was detected and a few samples (6%) were characterized by bacterial species of human origin.

Conclusions

In the light of these data, the examined tampons were found to have good hygienic quality. Nevertheless, to minimize the microbial risks linked to the use of these products, strict hygienic rules during their production and manipulation have to be adopted.

Zespoł Ekspertów Polskiego Towarzystwa Ginekologicznego. [Statement of the Polish Gynecological Society Expert Group on the use of ellen probiotic tampon]

The group of experts representing the Polish Gynecologic Society has issued this Statement based on the review of available literature on the potential benefits of the use of ellen probiotic tampon. It has been firmly proven that during menstrual bleeding the vaginal flora undergoes profound changes prodisposing to both bacterial and fungal infections. Safety of menstrual tampons has been studied for over 60 years. According to the current state of knowledge, the use of tampons does not lead to any clinically significant change in the vaginal flora. The link between tampon use and Toxic Shock Syndrome (TTS) was revealed in 1978 after introduction of superabsorbent tampons to the United States market. Following the replacement of carboxymethylcellulose and polyester based tampons by the new generation of cotton based tampons, cases of tampon connected TSS are extremely rare in the US. The proper use of modern tampons is considered to be safe. Ellen tampon features dioxin and chlorine free natural fibres treated with the acidic acid producing probiotic Lacto Naturel (LN), which contains a combination of patented benevolent bacteria that can strengthen women's defense against vaginal infections. Both in vivo and in vitro studied have shown that ellen probiotic tampons are able to succesfully colonize vagina with the LN probiotic bacteria which then coexist with endogenous Lactobacilli present in the patients vaginal ecosystem. The ellen probiotic tampon constitutes an innovative solution of the vaginal probiotic application during menses. The use of this product is aimed to maintain natural vaginal flora as well as its pH during menstrual bleeding. According to the available clinical data, the potential benefits of the probiotic tampon use include: prevention of the vaginal/vulval discomfort as a result of frequent swimming poll use, maintaning of the therapeutic effect of antibacterial/antifungal vaginal treatment and prevention of the recurrent infections, prevention of iatrogenic vaginal flora imbalance after an antibiotic treatment.

Dioxin and Furan Levels Found in Tampons

BACKGROUND

Human exposure to dioxins and furans through diet and other sources has been of concern for many years. One specific concern, related to exposure in women's health, is the possible link to endometriosis. Although there are differences in opinion about this link, the concern from the public is real. Congressional interest has prompted investigations to determine the amounts of dioxins and furans present in feminine hygiene products available within the United States.

METHODS

Tampon samples were analyzed via Gas Chromatography/High Resolution Mass Spectrometry (GC/HRMS) using a Micromass AutoSpec Ultima high resolution mass spectrometer at 10,000 mass resolution. As data were confirmed and quantified using direct isotope dilution, only the 17 2,3,7,8-chlorine-containing dioxin and furan concentrations were calculated from these analyses.

RESULTS

A total toxic equivalence (TEQ), using the World Health Organization's toxic equivalency factor (TEF) values, was calculated for each sample. The calculated TEQs for samples were not statistically different from those of the calculated TEQs using the average limit of detection (LOD) values.

CONCLUSIONS

Data show results similar to those reported by DeVito and Schecter (Environ Health Perspect 2002;110:23) in that most of the dioxins and furans were below the detection limit or estimated detection limits (EDLs).

Clinical safety-in-use study of a new tampon design

Objective: To confirm the safety of a new experimental Tampax^® tampon and applicator compared with that of a currently marketed Tampax^® tampon and applicator using comprehensive gynecological and microbiological assessments.

Methods: A 2-month, single-blind, randomized, crossover study was conducted in which each subject served as her own control. Safety was evaluated by comparing potential product-related irritation (using colposcopic examination and subject diary data), assessment of vaginal discharge, vaginal pH, and effects on selected microorganisms (yeast, Escherichia coli ,Staphylococcus aureus and group B streptococci) obtained by vaginal swab cultures after normal menstrual use in the experimental and control groups.

Results: In total, 110 women completed the study. There were no significant differences between the groups that used either the experimental or control tampon with regard to prevalence or mean cell density for the selected microorganisms. No differences were observed in the incidence or severity of erythema, in abrasion or ulceration of the cervix, vagina, introitus, vulva or perineum, or in mean vaginal pH and discharge assessments. There were equivalent low incidences of reported symptoms such as discomfort during insertion, wear or removal, and a similar low incidence of burning, stinging or itching during use of either the control or experimental tampon. There was a more favorable overall product rating for the experimental tampon (p = 0.003).

Conclusions: This approach provides a combination of gynecological, microbiological and self-reported (diary recall) methodologies in order to assess tampon safety during use more thoroughly than has previously been reported, and it supports a comparable safety profile for the experimental tampon and a currently marketed tampon.

Final rule

The Food and Drug Administration (FDA) is issuing a final rule that amends its menstrual tampon labeling regulation to add the term "ultra" absorbency for tampons that absorb 15 to 18 grams (g) of fluid with the syngyna test. At present, FDA requires standardized terms to be used for the labeling of a menstrual tampon to indicate its particular absorbency. This rule enables consumers to compare the absorbency of one brand and style of tampon with the absorbency of other brands and styles. FDA is issuing this final rule under the Federal Food, Drug, and Cosmetic Act (the act) to ensure that labeling of menstrual tampons is not misleading. Elsewhere in this issue of the Federal Register, FDA is proposing to change the standardized menstrual tampon term "junior" to "light".

A diaphragm tampon applied to an ovulation method in a birth control system

Gynaeseal is a re-usable diaphragm tampon made from latex which forms a unique cervico-vaginal seal and isolates menstrual loss. In a prospective study involving 80 women, Gynaeseal was offered in combination with the Billings Ovulation Method in an advised birth control system. This system included: use of the diaphragm tampon during the menstruation-fertile phase interphase; periodic abstinence during the overtly fertile phase of the cycle; and if extreme reliability was required, for a further 2 days after the Billings method 'rules' allow resumption of intercourse. The diaphragm tampon successfully complemented the Billings Ovulation Method with 44 women (60.4%) assessing the GOM System as being as good, or better than, currently available reversible methods. It functioned effectively as a tampon with 50% (31 women) stating that they used the product as a contraceptive. One woman claimed an unplanned pregnancy. No significant medical complications were recorded. The product has major advantages as a tampon: it is easily and accurately inserted because of the efficient applicator; it isolated menstrual loss within a collection chamber; it protects the cervix; and it facilitates sexual activity. Based on a minimum effective diameter (62mm), the diaphragm tampon does not interfere with the normal physiology of the vagina. There appeared to be no significant distortion of normal adult pelvic anatomy, and properly placed, no sensation of the diaphragm tampon's presence. Regarding insertion of the diaphragm tampon using the spiral-curved applicator: 31 women (42.5%) had little or no difficulty; 29 (39.7%) moderate difficulty; 13 (17.8%) experienced serious difficulty; and 7 (8.7%) were unable to use the product.

Toxic shock syndrome and tampons

There has been a substantial reduction in the incidence of toxic shock syndrome in the 10 years since the association between tampons and toxic shock syndrome was first recognized. The decreased incidence is real, and not the result of decreased reporting to the passive surveillance system. The decreased incidence of menstrual toxic shock syndrome can primarily be explained by changes in the absorbency and composition of tampons available to the consumer. The reduction in the occurrence of menstrual toxic shock syndrome can be attributed to the withdrawal of Rely brand, which consisted of a unique composition, and subsequently to the lowering of absorbency of all brands of tampons. The conclusions of the early studies of toxic shock syndrome pointed the way to prompt public health interventions and resulted in the prevention of substantial morbidity.

Toxic shock and tampons. Evaluation of the epidemiologic evidence

The main evidence that tampons are an etiologic cofactor in the development of toxic shock syndrome (TSS) comes from epidemiologic case-control studies. The patients chosen as cases in those studies were assembled from reports submitted to health agencies in response to publicity that may have influenced physicians to diagnose TSS and to submit reports particularly in situations where the patient was a menstruating tampon user. When the submitted reports were checked for fulfillment of TSS diagnostic criteria, and when cases or controls were asked about antecedent tampon usage, suitable scientific precautions were not used to achieve "blinded" objective decisions. Since these biases would have distorted the statistical relationships, the etiologic role of tampons in TSS has not been scientifically proved.

Risk factors for development of toxic shock syndrome. Association with a tampon brand

In September 1980, we interviewed by telephone 50 patients with menstrually associated toxic shock syndrome (TSS) who had onset of illness in July or August 1980. These women were asked to provide information about the type of menstrual sanitary products used during the menstrual period associated with their illness. We also interviewed 150 age-matched control subjects, who were asked the same questions for the menstrual period that occurred in the same month as the illness of the matched case. All 50 cases, but only 125 of 150 controls, used tampons. Among women using tampons, cases were more likely to have used Rely brand tampons when compared with controls. No differences were found between cases and controls in the absorbency of tampon products used. No other factors studied through analysis of a follow-up questionnaire mailed five months after the first study were found to be significantly associated with the development of menstrually associated TSS.