Genital Hygiene Among Women Of Reproductive Age Menstrual Hygiene

In many cultures, menstruation is a taboo subject considered the private province of women (39,40). Theories abound about the historical and cultural underpinnings of this pervasive attitude. Perhaps, the link to reproduction and birth imbues the menstrual cycle with a certain mystique. Bleeding is usually a sign of injury: our ancestors may have viewed cyclical bleeding—without dying— as a supernatural event. The notion that blood flow carries a basic life principle, with both beneficial and harmful consequences, is powerful in some parts of the world (41,42). From the first century Rome to the 19th century England, menstruation was thought to render women periodically dangerous (43). In the 1920s, scientists reported isolating a lethal toxin from menses (44), a finding discredited in the 1950s as an artifact of bacterial contamination (45). As recently as 1985, a quarter of young Australian women believed that menstrual flow rids the body of wastes (46). This view is held by many cultures worldwide. Some orthodox religious traditions consider the menstruating woman to be spiritually unclean (46). Not surprisingly, therefore, social, cultural and religious norms influence menstrual hygiene practices profoundly.

Menstrual Hygiene in the Industrialized World

Habits and practices: The use of disposable sanitary pads, panty liners, and tampons is ubiquitous in Western industrialized countries. The cultural acceptance of disposable external and internal protection in industrialized nations evolved over time. Although invented in 1896, disposable sanitary pads were not successfully introduced to the North American market until 1921. Perhaps for cultural and economic reasons, for two more decades, some women still employed cloth rags to absorb menstrual flow, boiling them for re-use after each menstrual period (47).

In 1936, commercial tampons were introduced in the United States as "a civilized solution to the problem of sanitary protection" (48). In reality, tampons have been used in many cultures since ancient times (47,49). As early as the 15th century BCE, Egyptian women used soft papyrus. Ancient Japanese women made tampons from paper and Roman women employed wool. Some nomadic Africans use absorbent material from indigenous mosses and plant seedpods and traditional Hawaiian women employ furry portions of native ferns. Prior to the commercial introduction of tampons, the more avant-garde women in American culture used natural sea sponges cut to size or made their own tampons from tightly rolled surgical cotton (50).

In Western societies, tampons were initially controversial. The medical and popular literature between 1936 and 1966 cites concerns about the presence of a foreign body in the vagina, the potential for sepsis, and the impact on virginity and sexuality (47). Beginning with women's entry into the workforce during World War II and through the Women's Liberation Movement of the 1970s, tampons became more widely accepted for their convenience and for the increased freedom they provide to participate fully in the workplace, sports, and social activities.

Although product sales figures are available, surprisingly little published information exists on the present-day menstrual hygiene practices in developed countries. Available data indicate that a sizable proportion of women use tampons or tampons and pads in combination. A 1996 survey of 193 women from urban southeast Texas (mean age, 23 years) found that 48% of respondents used tampons exclusively, 19% used sanitary pads, 18% used pads and tampons in combination, and 10% used panty liners (Table 1) (51). Tampons were used intermenstrually by 13% of respondents. Tampons and pads were changed at least every six hours by a majority of women. About 95% reported washing their hands after doing so at least some or most of the time.

A 1999 survey of middle-class Californian women ranging in age from 18 to 96 indicated that tampon use declined from 80% among women younger than 41 years to 72% among menstruating women between the ages of 48 and 57 (Table 2) (52). The frequency of pad and panty liner use was similar in those younger than 41 years (71% and 75%, respectively) and those over 48 (73% and 78%, respectively). For unexplained reasons, the usage prevalence of use of all product types was lowest in the age group of 41 to 47. In the Texas study, 43% of respondents limited bathing during their menstrual period; in the California study, the proportion of women who reported limiting bathing during menstruation declined from 11% in the under 41 age-group to 4%

Table 1 Menstrual Protection Practices Among 193 Texan Women, Aged 18 and Older (1996)

Percent prevalence

Half of Most of Not

Products and practices Never Sometimes the time the time Always reported

Tampons Sanitary pads

Tampon/pad combinations Panty liners Tampons / pads/liners between periods Washing hands after use Limiting bathing during menstruation

Source: From Ref. 51.

11

15.5

11

24

30

11

40

24

7

22

44

9

82

9

1

2

4

3.

70

9

4

12

48

2.

12

19

2.

5

18

6

11

10

3.

0.5

2

among women aged 48 to 57. About half reported handwashing before using sanitary pads and 70% reported doing so after changing them.

About a quarter of American women begin using sanitary protection before their period starts and about one-third continue use for several days after flow ends. Panty liners are the most common product choice for intermenstrual use, although all three forms of protection are reportedly employed before and after the menstrual period. Tampon use is prevalent among American adolescents

Table 2 Menstrual Protection Practices by Age Among 180 Middle-Class Californian Women (1999)

Percent frequency

<41 years old 41-47 years 48-57 years Products and practices (n = 180) (n = 171) (n = 83)

Natural sea sponges

2

2

1

Reusable cotton pads

0

1

1

Tampons

81

63

72

Sanitary pads

71

61

73

Tampon/pad combinations

54

47

51

Panty liners

75

60

78

Tampons/pads/liners between periods

14

12

24

Wash hands after using

94

75

94

Limit bathing during menses

11

3

4

Source: From Ref. 52.

Source: From Ref. 52.

and young women. Surveys conducted in the 1990s indicate that 70% of adolescents and 81% of college students used tampons alone or in combination with pads (53,54). Mothers and friends were the most influential in determining the teenagers' choice of tampon use (54,55). Clinicians report that American girls are expressing an interest in tampons at an earlier age and that athletes are particularly eager to use tampons (56).

A Texas-based survey conducted in the late 1980s among Caucasian, African American, and Mexican American women indicated that significantly more Caucasian women used tampons alone (26%) or with pads (36%) than African American women (57). Proportionately, more African American women used tampons alone (16%) or with pads (27%) as compared to Mexican Americans, 11% of whom used tampons alone and 21% of whom used tampons with pads. In this study population, tampon use started in the teenage, but the highest usage frequency of tampon usage, either alone (26%) or with pads (33%), occurred in the age group of 20 to 29.

Published information on the number of menstrual products used annually is scarce. A toxicological risk assessment published by the Danish National Institute for Public Health and the Environment reported the average yearly consumption rates per user group as 325 menstrual sanitary pads, 598 panty liners, and 50 postpartum sanitary pads (58).

Health implications: The principal health concern related to tampon use is its association with menstrual toxic shock syndrome (TSS). TSS is a rare but recognizable and treatable disease (see Table 3 for signs and symptoms) (59). Women aged 15 to 24 are the highest risk group for menstrual TSS, with adolescents making up a significant proportion of cases (60,61). The reported incidence of menstrual TSS peaked in the early 1980s and has since declined significantly (60,62). All tampons are associated with a low risk for menstrual TSS; the risk is independent of chemical composition per se, but increases with tampon

Table 3 Signs and Symptoms of Toxic Shock Syndromea

A sudden high fever (usually 102°F or higher)

Vomiting

Diarrhea

A rash that looks like sunburn

Dizziness

Muscle aches

Fainting or near fainting when standing up aFive clinical criteria are fever, hypotension, rash, desquamation, and abnormalities in three or more organ systems. Desquamation may not be apparent with early treatment and discharge. Source: From Ref. 59.

absorbency (63). Other hygiene practices, such as bathing frequency, douching, and the use of feminine deodorants, are not associated with menstrual TSS risk (64).

Although a full understanding of the pathogenesis of menstrual TSS is still being sought, one of the most important individual risk factors is whether a woman has serum antibodies to TSS toxin (65). Most women have substantial levels of antibody and are at low risk for the disease (60,66).

Today, millions of women use tampons safely. Physicians consider them a reasonable choice for girls and women who express a preference and are able to use them appropriately (50,56). Because young girls may be less aware of the risk factors for menstrual TSS, adolescent education is important. In the United States, statements on package inserts suggest that women use the lowest tampon absorbency required to absorb their level of flow; they may substitute tampons of lower absorbency or sanitary pads as their menstrual flow tapers. Beginners must remember to remove that last tampon: the forgotten tampon is the most common vaginal foreign body complaint in adolescents (67).

Tampons are regulated as medical devices by the U.S. Food and Drug Administration (FDA). The FDA recently promulgated revised nomenclature for tampon standardized absorbency labeling (Table 4) (68,69). The FDA recommends that tampons not be worn 24 hours a day, 7 days per week, but alternated with pad use (62). Although supporting scientific evidence is lacking, women are advised to change tampons often (every four to eight hours). Package inserts suggest that tampons can be used overnight up to eight hours.

In the European Union, where disposable tampons are regulated as "articles," the European Disposables and Nonwoven Association (EDANA) implemented a voluntary Code of Practice in 2001 that provides for a harmonized system of categorizing tampon absorbency throughout Europe and for package

Table 4 Tampon Absorbency Ratings (U.S. Food and Drug Administration)

Absorbency range in gramsa

Descriptive term for absorbency

Less than 6

Light

6-9

Regular

9-12

Super

12-15

Super plus

15-18

Ultra absorbency

Above 18

None

aThese ranges are defined, respectively, as follows: Less than or equal to 6 g; greater than 6 g up to and including 9 g; greater than 9 g up to and including 12 g; greater than 12 g up to and including 15 g; greater than 15 g up to and including 18 g; and greater than 18 g. Source: From Refs. 68, 69.

aThese ranges are defined, respectively, as follows: Less than or equal to 6 g; greater than 6 g up to and including 9 g; greater than 9 g up to and including 12 g; greater than 12 g up to and including 15 g; greater than 15 g up to and including 18 g; and greater than 18 g. Source: From Refs. 68, 69.

inserts on TSS symptoms and safe tampon usage. The EDANA code of practice has been adopted by all major European tampon manufacturers.

Between 1977 and 1989, reports on vaginal ulcers associated with tampon use appeared in the medical literature (70-77). Most often associated with the prolonged use of superabsorbent tampons, these microlesions were typically asymptomatic and healed spontaneously. A more recent case involving prolonged use presented as intermenstrual bleeding (78). Ulceration can be avoided by choosing tampons with an appropriate absorbency and using the products as recommended (50).

In recent years, research on the health effects of sanitary pads has appeared in the medical literature. External sanitary protection is not generally associated with significant health concerns. An industry-sponsored series of prospective trials of pads and panty liners, conducted in North America and Europe between 1984 and 2003, found no evidence that modern products cause adverse gynecological effects, adverse dermatological effects on the vulva or perineum, or clinically meaningful changes in the isolation frequencies or cell densities of vaginal and vulvar microflora (79). The 12 separate trials included a cumulative total of 1600 adult and adolescent participants.

Anecdotal reports of contact dermatitis to pads exist (80-84). Such problems are usually transient, secondary to another condition such as a vulvar dermatosis or infection, or due to a preexisting sensitivity to perfume, raw materials, or adhesives (82-84). A woman who has a prior sensitivity to such materials may be unable to tolerate exposure from other sources; she should try an alternative version from the same product line or another brand.

Manufacturers avoid materials that induce contact sensitization by controlling the composition and quality of raw materials used in these products and by conducting toxicological risk assessments of the raw materials (85,86). Confirmatory, repeat insult patch testing prior to market introduction (87) and the use diagnostic patch tests both prior to marketing and in postmarket surveillance systems are important complements to the safety assurance process (79,88).

It has been suggested that pads may increase the risk of UTIs by transferring intestinal flora such as Escherichia coli to the vulva (50). No meaningful evidence exists for this hypothesis. Because enteric microbes often reside on the perineum and external labia majora in the absence of the introital or the urethral colonization, their mere presence is not a risk factor for infection (89-91). The most important risk factor for recurrent UTI in women of reproductive age is sexual intercourse (92,93), which promotes colonization of the introitus and the urethra with uropathogenic E. coli in susceptible women (94,95). Host factors play a major role in determining individual susceptibility to this disease (96-98). Clinical trials in women wearing pads under a variety of conditions have failed to show a clinically significant change in genital microbial populations associated with their use (79).

It is also postulated that external sanitary pads and liners, nylon underwear, pantyhose, and tight clothing may trap heat and moisture in the genital region, creating an environment for yeast to multiply. Several epidemiological studies assessed a possible link to vulvovaginal candidiasis (VVC), but the weight of the evidence fails to support the theory (99). For example, two retrospective case-control studies involving University students (one with 157 and the other with 1300 participants) found no association of VVC with tight-fitting clothing, synthetic fabric underwear, panty hose, type of menstrual protection, or pad use between periods (100,101). A prospective study of 163 sex workers found no link between recurrent VVC and tight clothing or synthetic underwear (102), and a survey of perianal colonization with Candida species, a potential reservoir for urogenital recolonization, found no correlation between recurrent VVC and the use of tight-fitting trousers or synthetic fabric underwear (103).

A recent study linked patient-reported and nonlaboratory confirmed cases of recurrent VVC in women on the maintenance antifungal therapy with wearing panty liners in the same week or in the week before an episode (104). Statistical associations suggesting a temporal link to panty liner use are fraught with confounding factors. For example, patient-reported diagnoses are unreliable and diagnoses based solely on signs and symptoms can be inaccurate in 50% to 70% of the time (105,106). Moreover, panty liner use may be temporally (though not causally) linked to urogenital infections, because absorption of vaginal discharge is a common reason for using these products. Moreover, panty liners are worn in anticipation of the onset of menses; because patients often report an exacerbation of VVC symptoms just prior to menstruation, this temporal coincidence could contribute to a spurious statistical association. Panty liner use to absorb postcoital discharge may also result in a noncausal association with VVC, because monthly intercourse frequency, intercourse frequency in the weeks preceding infection, and oral intercourse frequency in the month prior to infection have been associated with both episodic and recurrent cases (101,107,108).

Prospective, examiner-blind clinical trials in the general population failed to show a connection between panty liner use and an increased risk of vulvo-vaginal infection. An industry-sponsored, six-month, prospective clinical trial involving 204 women comparing daily panty liner users to nonusers found no increase in the prevalence of vaginal or vulvar colonization with Candida species and no evidence for symptomatic infection based on culture results (109). A trial comparing the microbiological effects of daily use of thick and ultrathin menstrual pads for two months led to the same conclusion (110).

Menstrual Hygiene in the Developing World

In the developing world, cloth and household absorbent materials (cotton wool, tissue, gauze) are often used for menstrual protection, particularly in the rural areas and among economically disadvantaged groups. Economic factors favor the use of reusable cloth. Moreover, in many cultures, girls are committed to the traditions and practices learned from their mothers and other female relatives.

Traditional beliefs also discourage the use of tampons. For example, the notion that unimpeded blood flow is related to good health permeates many indigenous cultures worldwide (41,42,111,112). Such traditions hold that the menstrual flow is necessary to rid the body of toxins and to dispel unclean substances introduced by intercourse.

Finally, pervasive taboos exist against revealing that one is menstruating. This can discourage the use of disposable pads or tampons, as well as participation in household and social activities. Some traditional religious cultures segregate women during the menstrual period and women undergo ritual cleansing after flow ceases.

Habits and practices: In Latin America, rural women typically use cloth for menstrual protection. Because the woman washes the cloth herself, she believes that she maintains good hygiene and gains control against revealing odor and infection. Cloth is both economical and reusable, an advantage for those with limited disposable income. Moreover, cultural taboos exist against disposing of blood-soaked materials; hence, discreet washing and reusing of cloth are the most acceptable practices. Less traditional women who choose disposable protection may choose cotton wool, tissue, or gauze instead of cloth, because they consider these materials more economical than commercial products and because they are readily available in the home.

Among schoolgirls in India, mothers, female relatives, textbooks, and magazines are principal sources of menstrual information (113-115). Schools are a source of information less frequently than in the United States (116). Rural Indian girls' understanding of menstrual physiology is quite rudimentary (113,114,116). The use of cloth as a menstrual absorbent predominates among urban and rural schoolgirls; urban girls cite lack of confidence as the main reason for not choosing commercial pads. Menstrual absorbents are typically washed or disposed of in the Dhoby (a pond or river bank used for public laundry) or in a canal. Girls take special baths to promote hygiene and may consume certain foods to promote menstrual flow and, therefore, good health.

It is impossible to generalize about African practices because traditional customs and attitudes vary among sub-Saharan communities (42). For example, traditional Nigerian culture does not encourage family discussions of sexuality. A study involving 352 schoolgirls found that a large proportion were inadequately informed about menstruation, although girls whose parents had at least secondary school education had received instruction on menstruation and hygiene from their parents (117). Half the girls used tissue paper as absorbent; 22% used sanitary pads, 12% used cloth, and 3% used tampons.

In traditional Zimbabwean society, menstruation is associated with desires of the flesh and is considered spiritually unhygienic (112). At menarche, a girl first informs her grandmother of the event, who then informs the mother. Cloth or cotton wool is used commonly to absorb menses, and it is the grandmother who teaches the girl how to prepare her pads and pleat them so they will not show. Women with higher levels of education understand menstrual cycle physiology; less educated women view menstruation as an occurrence that signals the ability to bear children, cleanses the system, and helps maintain a trim abdomen. Menstruating women refrain from intercourse.

In China, menstrual practices are influenced by the concept of Yin and Yang (118). Yin, the negative female force, represents darkness, coldness, and emptiness. Yang, the positive male force, promotes light, warmth, and fullness. These opposing forces must be balanced for health and harmony to prevail. The most symbolic blending of Yin and Yang is the union of wife and husband.

Because sexuality is a taboo subject in traditional Chinese culture, menstrual information is not discussed proactively. However, strict behavioral norms are imparted once girls reach menarche: "hot" Yang foods are eaten to strengthen the body and "cold" Yin foods are avoided. Similarly, hair should not be washed, as it induces cold.

Urban Chinese women typically use commercial sanitary pads for menstrual protection. Tampons are commercially available; however, some Chinese clinicians express a concern that tampons may promote cervical ectopy. In the Chinese medical paradigm, cervical ectopy is traditionally viewed as "chronic cervicitis," an ulceration or erosion of the ectocervix thought to predispose women to infection. Western culture considers cervical ectopy a physiologically normal, hormonally regulated phenomenon that regresses with age (119-121).

Cloth is used in rural parts of China (122). Women wash the cloth and reuse it repeatedly, but for traditional reasons, never dry the cloth in the sun. In poorer districts, women may resort to paper and unwashed cloth to meet their needs.

Health implications: Because data from the developing world are lacking, definitive statements cannot be made about the impact of indigenous menstrual hygiene practices on gynecological health. Inadequate menstrual hygiene has been implicated as a risk factor for genital tract infection, particularly when cloth rags are used and washed in contaminated water (123). A study in rural China (where cloth is typically used as menstrual absorbent) found a strong statistical link between menstrual hygiene, genital hygiene, and cervical cancer risk; the use of commercial sanitary pads was a protective factor (122).

Most statistics on gynecological morbidity in developing countries are derived from antenatal and family planning clinic patients or from studies on populations at risk for sexually transmitted diseases (STDs) (115,124-127). Population-based studies are rare and limited resources make the conduct of large, systematic studies difficult. Moreover, cultural barriers may inhibit women from discussing intimate problems or revealing symptoms that may be stigmatizing (128).

Menstrual Practices in Orthodox Judaism and Traditional

Islamic Societies

In Orthodox Jewish society, ritual law regarding menstruation is defined in Leviticus (one of the five books of the Hebrew Torah) and further interpreted in the Mishnah (39,129). A menstruating woman becomes "niddah" and is considered spiritually unclean (tame'ah) just prior to the beginning of flow, during menstruation, and for seven days afterward (130). Standards for ritual practice vary among Orthodox sects. In the most conservative interpretations, the menstruating woman is segregated from her husband and forbidden contact with the synagogue and sacred objects. Some traditions uphold the custom that a menstruating woman may not prepare food or wine. After checking for the absence of flow for seven days after the menstrual period, the woman undergoes a ritual bath or immersion (Mikvah) to reinstate spiritual and marital cleanliness. Orthodox Jewish girls get menstrual information from mothers and girlfriends (129). In Israeli Orthodox schools, the wife of a rabbi may present lectures on sexual development, marriage, and motherhood.

In Islamic societies, menstrual practices depend on the degree of cultural and religious conservatism, which differs among countries and between urban and rural regions. In conservative cultures, menarche signals that the girl is becoming a young woman and must observe the tradition of modest dress (hijab) and separation of the sexes (131). The Quran dictates certain restrictions be placed on the menstruating woman (39,132). Sexual intercourse is prohibited during the menstrual period. The menstruating woman is considered spiritually unclean with regard to religious duties until she completes a ritual washing; therefore, while menstruating, she is exempt from entering a mosque, from ritual prayer and fasting, and from making the pilgrimage to Mecca (Hajj).

A Muslim girl learns about menstruation from her mother, her sisters, and religious books (131). In conservative societies, menstruation is strictly a woman's issue, never to be discussed in the presence of men. The mother informs the father privately of the girl's menarche. Sanitary napkins are the most commonly used menstrual protection product; a virgin woman, for fear of losing her virginity, does not use a tampon. Some girls refrain from exercise and many ordinary activities due to fear of pain or increased blood loss (133). Some believe that they should not bathe until the end of the menstrual period. In one study, Saudi girls reported refraining from changing their sanitary protection at school or work for up to eight hours, for fear of increasing blood loss or, paradoxically, of trapping menstrual flow within the body (131,133). A ritual wash is performed at the end of the menstrual period. Traditional beliefs hold that hot drinks, including indigenous herbs, will relieve pain and prevent blood clotting within the body, but that cold foods should be avoided.

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