Menstrual Cup Cleaning Practices

Menstrual cup cleaning practices A mixed methods study of published instructions and key informant interviews Executive summary In many cultures, the onset of menstruation marks a girl’s coming of age, yet it can be a source of shame, stigma, and heightened health risk. Millions of women lack the products, knowledge, and social support systems to safely and effectively manage their menstruation. Therefore, menstrual cups, which provide a cost savings and potential health advantages, are increasingly being viewed as a viable alternative to other menstrual health products. However, there is a dearth of effective standards and processes to reduce the risk of irritation and infection from improper cleaning of menstrual cups during and between use. In an effort to close this gap, PATH conducted a rapid landscape and qualitative analysis of menstrual cup products and cleaning instructions with a focus on determining their feasibility for women and adolescent girls in low-resource settings. The principal objective of the review was to identify existing evidence-based cleaning processes and products and key research gaps to inform evidence-based, practical menstrual cup cleaning recommendations and future research. We conducted a search of the literature related to menstrual cup products, cleaning products, and practices; organizations promoting or distributing menstrual cups; and the websites of manufacturers, consumer sales outlets, and menstrual health advocates. We also received referrals and suggestions from manufacturers and public health organization staff and conducted key informant interviews with representatives of four menstrual cup manufacturers, one social enterprise, and six organizations implementing menstrual health and menstrual cup distribution programs. Of 34 menstrual cups identified, 24 were included in our analysis. Eighteen came with the specific recommendation to boil prior to the first use; however, the recommended boiling time varied widely. The instructions for all 24 cups included recommended cleaning during a menstrual cycle; rinsing the cup with mild soap and water was the most frequently recommended practice. Additional cleaning practices during the cycle included wiping the cup with clean tissues or proprietary wipes, boiling, sterilizing in a steam- based menstrual cup sterilizer, or soaking the cup in a sterilization solution. Actively boiling or soaking the menstrual cup in boiled water between menstrual cycles was recommended by 23 manufacturers as a primary or optional practice. Secondary cleaning approaches included using chemical tablets/solutions, sterilization via microwave, wiping off with proprietary wipes or isopropyl alcohol, and using a steam- based menstrual cup sterilizer or an ultraviolet light sterilizer. Key informants reported that users typically boil their menstrual cup before initial use and between cycles. Most users rinse their cups with water during their menstrual cycle. The importance of washing hands before touching, removing, or inserting the cup was frequently highlighted as a necessary practice. The majority of manufacturers recommended storing menstrual cups in the bag provided with the cup or in a breathable cotton bag to prevent the growth of bacteria. The majority also provided the instruction to avoid storing cups in plastic bags, in airtight containers, in areas with direct sunlight, or near anything scented, which could lead to bacterial growth, concentration of odors, and damage to the cup material. However, key informants noted that some users store their menstrual cup in a sealed container because they are wary of rats and cockroaches damaging the cup. Key informant feedback also indicated that privacy and fear of theft by family members are key concerns for some users, so they keep their cup under a mattress or in an underwear closet or chest, as examples. Several products were recommended by manufacturers for cleaning menstrual cups, including chemical tablets, mild soaps, and sterilization devices. Menstrual cup instructions specifically mentioned materials and practices users should avoid; among them, scented soaps, corrosive or harsh cleaners, and petroleum-based lubricants. However, discrepancies became evident when comparing the materials and practices users should avoid with the recommended cleaning practices suggested in all menstrual cup instructions. For example, several chemical cleaners were recommended by some manufacturers for cleaning menstrual cups at various stages of the use process yet discouraged by others. Some manufacturers recommended sterilizing in a microwave, and others recommended against this. And no evidence was provided to validate the rationale for the various cleaning practices. Finally, using broad terms such as “harsh” may not provide users with enough guidance on which cleaners to avoid. Key informants agreed that strong cleaning products should not be used; this was reported as generally recognized by most users. Possible barriers to continued use of menstrual cups: Limited access to clean running or potable water is a possible impediment to the use of menstrual cups, although informants described women as “resourceful” and therefore able to obtain water to rinse and clean their cups. Informants also noted that access to mild soaps could prove challenging. Obtaining containers for boiling menstrual cups was noted as an issue for many users—either a dedicated container, which may not be affordable, or a cooking pot, due to lack of privacy in the kitchen and stigma related to menstruation. Some women and girls improvise, using discarded paint cans, for example, however, these may contain harmful residue that could be transferred to the cup. Seldomly have distributors provided a container for cleaning their menstrual cup; therefore, informants felt this was not a sustainable solution. Finally, some users are concerned about contamination from their cup touching a common surface when they need to clean it in a public restroom when they are “on the road.” Conclusions and next steps: • Manufacturers should standardize cleaning terminology to internationally agreed-upon definitions. The terms “sterilization,” “disinfection,” and “sanitization” are used interchangeably, inconsistently, and sometimes incorrectly in menstrual cup cleaning recommendations. Terms should correlate with the level of microbial inactivation needed and evidence included to inform users of the rationale for those recommendations. • Publicly accessible evidence is needed to create consumer confidence in the recommended cleaning practices. Recommendations for cleaning menstrual cups before, during, and after each menstrual cycle do not include the evidence and reasons for these practices. Manufacturers have an opportunity to educate and raise consumer confidence by commissioning and publishing independent studies of their products that verify the effectiveness of their recommended cleaning practices. A harmonized set of hygiene criteria could establish a normative standard for the product category. • Menstrual cup manufacturers should reconsider their menstrual cup cleaning instructions to reflect the contextual realities of women and adolescent girls in low- and middle-income countries (LMICs). Boiling menstrual cups is widely recommended by manufacturers; however, feedback from users in LMICs indicates that a dedicated menstrual cup cleaning pot or fuel to boil the cup are not accessible to all LMIC users. USB-powered sterilizers, proprietary menstrual cup cleaning solutions—even sufficient water for daily cup washing—are out of reach for millions of users, particularly those in informal or non-urban LMIC settings. Manufacturers should work with menstrual health implementing organizations and cup distributors to develop instructions that are applicable to users in LMICs and do not place undue cost burden or require inaccessible cleaning inputs. • Comprehensive introduction strategies are needed to encourage uptake and consistent use of menstrual cups. For many first-time users, menstrual cups represent a significant departure from “traditional” menstrual hygiene products (e.g., sanitary pads). Introduction strategies should consider a holistic approach to engaging new and repeat users, including but not limited to menstrual, sexual, and reproductive health education; market requirements for sustained distribution; and establishment of peer support networks to allow for trusted sources and flow of information. • A human-centered design process should be employed to collect user perceptions and gain understanding of the contextual realities around menstrual cup cleaning and storage and the feedback incorporated into cleaning and storage instructions. This would improve the appropriateness of instructions and inform and improve messaging around cup maintenance, reducing the burden on users of trying to guess the best cleaning practices. Background Period poverty and the importance of menstrual hygiene management The onset of menstruation is a landmark event in a girl’s life. In many cultures, it marks her maturity and coming of age, yet it is dually a source of shame, stigma, and sometimes a heightened health risk for women and girls across the globe. An estimated 500 million women worldwide (roughly a quarter of the globe’s reproductive-age women) lack the products, knowledge, and social support systems to safely and effectively manage their menstruation.1 This burden is felt especially in low-resource settings. With few effective and affordable options

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