Acquaintance and Acceptance of Menstrual Cups among Women of Reproductive Age: A Hospital-Based Cross-Sectional Study from North India
Article information
Abstract
Background
Menstrual hygiene is crucial to a woman’s physical, social, and mental well-being. The menstrual cup offers a safe and effective solution but still requires wider adoption. This study aims to assess awareness, practices, and barriers regarding the use of menstrual cups among women of reproductive age.
Methods
A cross-sectional study was conducted among 246 participants, randomly selected from outpatient settings of a tertiary care hospital in 2022. Non-pregnant menstruating women were included, while those with pelvic infections or cognitive impairments were excluded. After explaining the study’s purpose and ensuring anonymity, data were collected using a structured questionnaire adapted from previous studies conducted in India and abroad. Knowledge and practices were depicted using descriptive statistics, while factors affecting awareness were analyzed using a multivariable binary logistic regression analysis approach.
Results
Approximately 64.2% of participants were aware of menstrual cups, but only three were users. Participants living in urban areas, practicing Hinduism, and marrying after the age of 20 years showed higher awareness. Users rated the cup as comfortable, with no skin irritation, foul odor, or dryness. The primary barrier to use was insufficient knowledge.
Conclusion
There is a gap in awareness and usage of menstrual cups, especially in low- and middle-income countries like India. Preliminary feedback from users is encouraging, suggesting that menstrual cups could offer a cost-effective, eco-friendly, and sustainable way to improve menstrual hygiene.
INTRODUCTION
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.
METHODS
1. Study Design
The study employed a cross-sectional design conducted between August 1, 2022, and September 30, 2022.
2. Study Settings
The study was conducted in the Obstetrics and Gynecology outpatient department (OPD) of All India Institute of Medical Sciences, Bathinda in the Malwa region of Punjab. The institute provides a comprehensive range of preventive, promotional, curative, and rehabilitative services to a large number of patients daily.
3. Study Population
Menstruating women within the reproductive age range (15–45 years) were invited to participate. Exclusion criteria included women with known pelvic inflammatory disease or sexually transmitted infections, adolescent girls who had not yet attained menarche, menopausal women, and women who did not provide informed consent.
4. Sample Size and Sampling Technique
A sample size of 246 was determined using the single population proportion formula, based on an estimated 80% awareness prevalence of menstrual cups from previous data in South India, with a 95% confidence interval and a 5% margin of error [20]. Data were collected using a systematic random sampling technique. Two OPD days per week were selected for data collection, averaging 40 eligible participants per day. To ensure quality in data collection and counseling, only 10 participants per day were included. A sampling interval of four was defined, with the first participant selected randomly between 1 and 4, and subsequent participants selected by applying the sampling interval.
5. Study Protocol
Each participant meeting the inclusion criteria was verbally informed about the study. Anonymity was ensured for all responses. After explaining the study’s purpose, informed consent was obtained, followed by face-to-face interviews where participants completed questionnaires. For participants unable to read or write, the first author read questions in their native language and recorded their responses.
6. Study Tool
Data were collected using a structured questionnaire adapted from previous studies with established validity and reliability [21,22]. The questionnaire was translated from English to Punjabi and back-translated following the World Health Organization’s standard methodology [23]. Three Obstetrics and Gynecology consultants not involved in the study evaluated the content validity of the tool, and necessary modifications were made based on their feedback. A pilot test on 20 women, excluded from the final analysis, was conducted to assess reliability, yielding a Cronbach’s α of 0.743. The final tool recorded socio-demographic information (age, educational status, socio-economic status, occupation) in the first section, while the second section evaluated knowledge, attitude, and practices related to menstrual cups. To assess knowledge, usage experiences, and barriers, participants were asked a total of 28 questions, divided into three sections:
1) Knowledge (eight questions)
“Have you heard of the menstrual cup? Where did you hear about it? Are you using it? Do you know how to insert it? Are you aware of its mechanism? Do you know the cleaning method? How often should it be emptied? How long can a single cup last?”
2) Practices (13 questions)
“How long have you been using the cup? What product did you previously use? What is the cost? What material is it made from? Where did you buy it? How did you learn to insert it? Did you initially face insertion issues? Do you experience pain on insertion/removal? How do you clean it? How often? Do you feel it as a foreign body? Has it ever dislodged without notice? Does it interfere with daily activities?”
3) Barriers (seven questions)
“Lack of awareness, lack of education, limited availability, lack of usage knowledge, fear of blood spilling during washing, feeling of a foreign object, potential for dislodgement.”
7. Statistical Analysis
Data were entered into MS Excel, and following data cleaning and coding, analyzed using the IBM SPSS Statistics for Windows ver. 28.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to outline participants’ socio-demographic characteristics, with proportions supported by 95% confidence intervals. Knowledge was assessed by assigning binary values (0 for no, 1 for yes), with categorical variables represented by proportions and continuous variables by mean and standard deviations. Bivariate analysis assessed associations between socio-demographic variables and menstrual cup awareness. Further, multivariable binomial regression analysis was used to evaluate the likelihood of awareness, generating adjusted odds ratios with 95% confidence intervals. A P-value of less than 0.05 was considered statistically significant.
8. Ethical Committee Approval
The study commenced following approval from the Institute’s Research Cell and Ethics Committee (IRB no., EC/NEW/INST/2020/1308), with approval number IEC/AIIMS/BTI/198.
RESULTS
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.
Socio-demographic and reproductive characteristics of the study participants
1. Knowledge Regarding Menstrual Cups
About 64.2% of participants had heard about menstrual cups, but only 28.9% understood the mechanism of action, 19% knew the insertion method, and 12.2% knew the correct cleaning procedure (Table 2). Mass media (including newspapers, television, radio, or social media) was the most commonly reported source of information about menstrual cups (47.6%). Binary logistic regression analysis revealed that urban residence, religion, and older age at marriage were significant predictors positively influencing awareness of menstrual cups (Table 3). Factors such as the mother’s occupation were non-significant in unadjusted analysis and were therefore excluded from the final model, while other variables like education level, parity, and mode of delivery were rendered non-significant in the adjusted analysis. Only three participants were using menstrual cups during their menstrual cycles. None of these women reported any difficulty with insertion following training, any sensation of a foreign body, or interference with daily routines.
Knowledge regarding menstrual cups among the study participants
Multivariate binary logistic regression analysis depicting socio-demographic characteristics affecting study participants’ awareness of menstrual cups
2. Barriers to the Use of Menstrual Cups
Among women not using menstrual cups, the most commonly perceived barrier was a lack of knowledge about the cups (93.0%), followed by limited availability (79.8%), unfamiliarity with the method of use (55.1%), concern over the sensation of a foreign body (47.7%), fear of spontaneous expulsion (32.9%), and fear of spillage during daily activities (30.5%) (Table 4).
Barriers to adequate usage of menstrual cups among study participants who were not using menstrual cups at the time of the survey
DISCUSSION
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.
Notes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING
Data collection was funded by the Indian Council of Medical Research, New Delhi (India) as a part of the Short Term Students Scholarship project (reference number: 2022-02148, year 2022).