Menstruation is a normal physiological phenomenon marking the onset of a woman’s reproductive age [1]. Globally, women and girls employ various strategies to manage menstruation and maintain menstrual hygiene and health (MHH). However, many women cannot manage menstruation with dignity or achieve adequate MHH due to factors such as gender inequality, discriminatory social norms, cultural taboos, poverty, and lack of essential services like toilets [2,3]. Studies have shown that a high proportion of young girls and women are often unprepared or lack sufficient awareness about menarche and MHH [4-7]. Traditionally, they have relied on products such as newspapers, cloth, and bamboo fibers to sanitary pads and tampons, which may pose health risks [8,9]. Limited awareness of safe, effective, and affordable menstrual products increases concerns about leakage, spotting, and odor, leading to absenteeism from school and work, which negatively affects the well-being and empowerment of women [4,7]. Thus, safe, efficient, and affordable menstrual management methods are needed.

A range of MHH methods is available, including sanitary pads, tampons, and menstrual cups, with pads being the most widely used. However, sanitary pads and tampons may cause skin irritation, unpleasant odor, and interfere with daily activities and sleep [10]. Disposal challenges lead to inappropriate discarding of pads, resulting in clogged toilets, genital infections, and visual pollution [9,11]. A viable alternative is the menstrual cup—a safe, comfortable, eco-friendly product available in different sizes and shapes. The first non-commercial menstrual cup was patented in 1867 by the Hockert Catamenial Sack in the United States and is now available in over 99 countries [12]. The cup, made from non-toxic and non-allergenic biodegradable silicone, latex, or rubber, collects menstrual blood [12]. It is inserted into the vagina and can be emptied and reinserted every 6–12 hours, depending on the user’s needs. After each cycle, it can be sterilized by boiling for 5–10 minutes. The cups are designed to fit based on factors such as vaginal size, age, flow volume, and parity, providing superior comfort, dryness, and minimal odor [13]. Additionally, they reduce the risk of sexually transmitted diseases and urinary tract infections without disrupting vaginal flora [14,15].

Menstrual cups are available without a prescription, cost-effective, and can be reused for up to 10 years, thus reducing solid waste and supporting environmental sustainability [16]. Studies from other countries have highlighted the advantages of menstrual cups in terms of comfort, quality, blood collection, and MHH maintenance compared to older methods [17,18]. Despite proven benefits, menstrual cups remain one of the least preferred methods for MHH in India, as reported by the latest National Family Health Survey (2019–2021), highlighting the need for further research [19]. Additional studies could provide insights into the acceptability and safety of menstrual cups and help identify best practices for MHH. Few studies have been conducted in India and other developing countries with high unmet MHH needs. In this context, the present study aimed to assess the knowledge, awareness, and practices regarding menstrual cups among reproductive-age women in North India.

This study included 246 participants, the majority of whom were under 30 years old (Table 1). About 51.6% of participants were married, and 67.5% hailed from urban areas. Of the total participants, 77.2% were unemployed, and 66.3% had completed education up to high school. Among those who recalled their age at marriage (n=117 out of 127), 12.6% were married before the age of 20. During menstruation, 89% of participants preferred using sanitary pads, while 9.8% used non-sanitary products, and only 1.2% used menstrual cups. Most participants disposed of their menstrual products in dustbins, but 2.8% washed their products to reuse them.

Menstrual cups could address a substantial gap in the MHH domain and empower women to take better control of their periods. Our study reports several important findings. First, although six in ten women had heard of menstrual cups, fewer than two in 100 actually used them. Second, certain socio-demographic factors significantly influenced the likelihood of being aware of the cup. Finally, limited availability and concerns over side effects were cited as significant barriers to its use.

Our findings on awareness are consistent with several other studies in India. Although many women had heard of the cup, there was a gap in specific knowledge: fewer than one-third knew the insertion method, the correct way to clean the cup, or its mechanism of action. A similar finding was reported in a study by Meghana and Gomathy [20] in 2021, where 80% of participants had heard of menstrual cups, but only 5.8% had good knowledge about them. Another study by Arshad Ali et al. [24] found comparable results, with only 11.4% of the general population having complete knowledge about menstrual cups. In our study, 89% of participants used sanitary pads, aligning with findings from other studies. This could be due to the greater advertising of sanitary pads through traditional mass media and social media, which is still relatively limited for menstrual cups [25]. Increased exposure to media, including commercials, videos, and advertisements on mobile phones, television, radio, and newspapers, could help promote the use of menstrual cups. Our results further indicated that mass media was the most common source of information (47%), followed by family and friends (10%). Our clinical experience also suggests that women from rural areas or those from disadvantaged backgrounds tend not to seek consultations regarding sexual and reproductive health, such as MHH, due to cultural restrictions. They often rely on informal knowledge received from mass media or family members. Consequently, social marketing could be essential in increasing demand for menstrual cups and promoting sustainable MHH practices. We also found a significant association between knowledge of menstrual cups and socio-demographic characteristics such as area of residence, religion, and age at marriage. Participants who married after age 20, resided in urban areas, and practiced Hinduism were more likely to have better knowledge about menstrual cups. A similar finding was observed in a study conducted in Kerala [26]. This may be because urban populations have better access to higher education, sanitation facilities, adequate water availability, and health information through mass media, all of which contribute to increased awareness of menstrual cups. In some religions, talking about sexuality and MHH is still prohibited. Girls are often not provided adequate information about pubertal changes at home or school, resulting in unhealthy practices and misconceptions regarding menstrual hygiene management.

Our study found that menstrual cup usage was very low, with only three participants out of 246 using them. In low- and middle-income countries, menstrual cups face resistance due to conservative views and cultural taboos. Additionally, the popularity of sanitary pads and a lack of knowledge about menstrual cups make them less preferred. Concerns about insertion, the sensation of a foreign body, and for unmarried girls, additional fears related to virginity, serve as further deterrents. Information on leakage, acceptability, and safety of menstrual cups could help women make informed choices. Menstrual cups are available in various sizes and brands, with smaller sizes recommended for teenagers and nulliparous women, and larger sizes for multiparous women [27]. Proper knowledge about size and fit is essential, as smaller cups may result in leakage, while larger cups may cause discomfort. Due to the low number of users, usage patterns could not be statistically associated with socio-demographic characteristics, but our clinical experience suggests some disparities in MHH practices. For example, the requirement to touch the vagina for cup insertion is often viewed as ritually impure, which can discourage some girls from using it.

We also observed that inadequate knowledge (93%) was the primary barrier to menstrual cup use, followed by limited availability, lack of knowledge about the method of use, the sensation of a foreign body in the vagina, fear of spontaneous expulsion, and fear of spillage. Similar barriers have been reported in studies conducted in India and abroad [12,26,28]. Educating girls from the onset of puberty may help alleviate fears surrounding reproductive anatomy and reduce menstruation-related stress. Evidence suggests that group training, peer support, and school-based education programs can promote menstrual cup use, emphasizing the need to implement these strategies in future interventions [29].

In our study, only three women were using menstrual cups. Other studies have shown that women accepted menstrual cups after proper counseling and adequate knowledge of their correct usage and cleaning [18]. A study from Kerala reported that 50% of participants were willing to use menstrual cups if provided for free [26]. Upon further probing, menstrual cup users in our study mentioned that they initially faced difficulty with insertion, which resolved after 2–3 cycles. Similar issues were reported in a study from eastern India, where the mean total satisfaction score improved gradually from the first cycle to subsequent cycles [18,29]. The study also highlighted that menstrual cups are a preferable alternative to sanitary pads for MHH, eco-friendly, and can be cleaned with minimal water in private for reuse, while sanitary pads require disposal by wrapping in a newspaper, contributing to waste generation. A study among adolescent girls in Uganda reported higher acceptability of menstrual cups over other products due to increased comfort, independence, mobility, and reduced leakage [30]. Additionally, a prospective study observed a declining trend in school absenteeism, as menstrual cup use alleviated concerns about menstrual health [29]. Our participants did not report adverse effects from menstrual cup use; however, previous studies have occasionally noted side effects such as discomfort or pain due to improper placement, internal pressure, leaking from incorrect size or shape, or allergic reactions to the cup material. Toxic shock syndrome (TSS) due to vaginal Staphylococcus aureus bacteria, though extremely rare with menstrual cup use, has been documented [31]. Causes include blood accumulation in polyester foam cubes, chips of carboxymethylcellulose, increased vaginal pH during menstruation from 4.2 to approximately 7.4, and the presence of both oxygen and carbon dioxide, which promote S. aureus growth [32]. TSS toxin 1 produced under these conditions can enter the bloodstream, leading to symptoms like fever, vaginal discharge, myalgias, hypotension, diffuse erythroderma, and multi-organ dysfunction. Therefore, users should be adequately counseled on timely emptying and sterilizing the cup before each use.

The study has novelty and specific strengths and limitations. While many studies document menstrual cup experiences among women of reproductive age, this is the first from North India to highlight low awareness in a representative sample. Regional disparities in sexual and reproductive health in India are well documented, making such studies essential. While many previous studies limited their independent variables, our study’s inclusion of variables is grounded in a comprehensive literature review, allowing deeper insights into factors affecting awareness. Additionally, the study uses a robust statistical approach, exploring awareness odds through adjusted binary logistic regression. Our findings are generalizable and offer strong guidance for policy. However, as a hospital-based study, there is a risk of selection and information bias. The study was conducted at a single center, limiting generalizability. Due to the low number of menstrual cup users, we couldn’t assess predictors of use and satisfaction. Similarly, with few users, generalization of user experience is limited. The cross-sectional design prevents conclusions on long-term usage patterns and awareness changes over time. Furthermore, the study did not include men and boys, who play a crucial role in influencing the attitudes and behaviors of partners, sisters, or others who menstruate.

This study has several policy implications and emerging recommendations. Our analysis reveals that despite menstrual cups being eco-friendly and user-friendly, their use is limited because most potential users lack awareness. This points to the need for stronger advocacy on MHH and menstrual cup use. Creating a supportive and enabling environment for rural women and girls to use menstrual cups by addressing stigma, discrimination, and restrictions is crucial. Media exposure can play an essential role in increasing awareness and acceptance. Menstrual health education should begin at the start of puberty, with mothers and teachers serving as role models. Acceptability is significantly enhanced when menstrual cups are distributed or used following awareness and counseling sessions, as seen in “Project Thinkal” during the 2018 Kerala floods, where sanitary pad disposal was a severe issue in relief camps [33]. Thus, awareness campaigns involving peripheral health workers, teachers, and adolescent peer group leaders should be conducted to promote menstrual cup use so that all women have access and can benefit.

Future studies should focus on generating evidence on menstrual cup acceptability, feasibility, sustainability, advantages, disadvantages, and barriers or enablers. In addition, various stakeholders—including boys, men, parents, teachers, and healthcare professionals—should be involved to share perspectives on menstrual cups as a means to improve gender equity, reduce intersectional inequality, and foster equity within families, schools, and communities.

In conclusion, this study shows that although many participants had heard of menstrual cups, they lacked sufficient knowledge about them. With targeted awareness programs that address usage barriers, relieve discomfort, and encourage family and peer support, menstrual cup use can be scaled up. This study provides data that can inform local policy and serve as a research agenda for menstrual cups as a cost-effective, eco-friendly, and sustainable solution for menstrual hygiene, contributing to Swachh Bharat Abhiyan.