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This systematic review and meta-analysis aim to synthesize the information on menstrual cup adoption among reproductive-age women in India. A comprehensive search was conducted in four databases following PRISMA 2020 guidelines. A total of 18 articles were included in this review. The findings of the studies were described narratively, and meta-analysis and sensitivity analysis were also performed. The pooled prevalence of knowledge regarding menstrual cups among women in the included studies was 35 percent (CI: 0.23-.49). Just 5 percent (CI: 0.02-0.12) of women use menstrual cups. Only 24 percent (CI: 0.17-0.33) of the women who used menstrual cups reported leakage as one of the key barriers or issues to menstrual cup use. Nevertheless, 62 percent (CI: 0.42-0.78) of non-users have a pooled prevalence expressing willingness to use in the future. The price was found to be both a motivating and discouraging factor for using menstruation cups. Currently, menstrual cup use among Indian women and girls is very low. However, user reviews suggest that menstrual cups are an appealing and safer replacement for conventional period supplies. To fully realize the potential of menstruation cups, significant education, and awareness efforts are required to ensure proper usage. Furthermore, initiatives to lower the initial cost of menstruation cups are critical.

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OBJECTIVES: The increase in intrauterine devices (IUDs) contraception, and the growing use of reusables menstrual hygiene products such as the menstrual cup, necessitates an assessment of the implications of their co-use. The objectives are to assess whether women with IUDs who use menstrual cups have an increased risk of IUD expulsion and/or a change in the risk of upper and lower urogenital tract infections compared to women who use other menstrual hygiene products. METHOD: An observational, prospective, multicenter study was conducted in France between 2020 and 2023. Participants were recruited by health professionals and data were collected by telephone questionnaire at the time of IUD insertion and at one year. The primary endpoints were the occurrence of IUD expulsion and the occurrence of urogenital tract infections in menstrual cup users compared to non-users. RESULTS: One hundred and three women out of 119 included were analyzed, 25 of them were regular menstrual cup users and five experienced IUD expulsion. Among regular users, 12% experienced IUD expulsion compared to 2.6% among non-users, with no statistically significant difference (Chi2=3.65; P=0.056). Regarding urogenital tract infections, nine women (36%) of the regular menstrual cup users had urogenital infections, compared with 27 (34.6%) of the non-users or not regular users, with no statistically significant difference. CONCLUSION: The tendency of menstrual cup users to expel their IUDs is a reason for caution, although it is not sufficient to contraindicate co-use. Physicians should therefore systematically screen such co-use and inform patients of the risks and monitoring instructions.

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BACKGROUND: Menstrual hygiene management poses significant challenges globally, with widespread reliance on disposable sanitary pads contributing to health risks and environmental degradation. Sustainable alternatives like menstrual cups offer promising solutions but face barriers to adoption, including myths and misconceptions. Educational interventions are crucial in promoting eco-friendly menstrual hygiene practices. MATERIAL AND METHODS: A descriptive cross-sectional survey was conducted at All India Institute of Medical Sciences (AIIMS), Nagpur (Central India) among nursing officers from January to February 2022. A structured questionnaire assessed the demographic characteristics, menstrual hygiene practices, knowledge of menstrual cups, and attitude toward their use. RESULTS: Of the 101 participants, the majority were between the age group of 25 and 40 years (71, 70.3%) and were educated up to a Bachelor of Science degree in nursing (79, 78.21%). Overwhelmingly, 97 (96.03%) of the nursing officers used non-biodegradable sanitary pads. Frequent need to change and staining were cited as common difficulties. Although 97 (96.04%) of the participants had heard of menstrual cups, knowledge gaps existed regarding suitability for nulliparous women, material composition, cost, and lifespan. Despite expressing a desire for better alternatives by 56 (55.4%) participants, only one (0.99%) reported current menstrual cup usage, with 60 (59.4%) participants indicating future readiness to use. CONCLUSION: Discovering nurses' menstrual hygiene habits, this study sheds light on their reliance on disposable pads over menstrual cups. Improving the acceptability of menstrual cups hinges on addressing current knowledge gaps such as their feasibility for use by nulliparous women, ease of insertion, cost, and environmental sustainability. Despite hurdles like misinformation, participants show openness to embracing new options with the right guidance and education.

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Mensuration cup is a mensural hygiene product about which people are less aware. Despite having many advantages there hasn't been much uptake. Research suggests that this is because of less accessible information. To overcome this, menstrual cup brands are creating several firm-created contents on YouTube. This study aimed at understanding and classifying the type of information available in 27 firm-created content about menstrual cup. The thematic analysis resulted in three themes Speaker & Language, Content presented, Type of information shared, contributing to the identification of promotional gaps, to be used by brands in building perspective towards menstrual cup.

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Cytokines are important mediators of immunity in the female genital tract, and their levels may be associated with various reproductive health outcomes. However, the measurement of cytokines and chemokines in vaginal fluid samples may be influenced by a variety of factors, each with the potential to affect the sensitivity and accuracy of the assay, including the interpretation and comparison of data. We measured and compared cytokine milieu in samples collected via Softcup® menstrual cup versus vulvovaginal swabs. One hundred and eighty vulvovaginal swabs from CAPRISA 088 and 42 Softcup supernatants from CAPRISA 016 cohorts of pregnant women were used to measure the concentrations of 28 cytokines through multiplexing. Cytokines measured in this study were detectable in each of the methods however, SoftCup supernatants showed consistently, higher detectability, expression ratios, and mean concentration of cytokines than vulvovaginal swabs. While mean concentrations differed, the majority of cytokines correlated between SoftCup supernatants and vulvovaginal swabs. Additionally, there were no significant differences in a number of participants between the two sampling methods for the classification of genital inflammation. Our findings suggest that SoftCup supernatants and vulvovaginal swab samples are suitable for the collection of genital specimens to study biological markers of genital inflammatory response. However, the Softcup menstrual cup performs better for the detection and quantification of soluble biomarkers that are found in low concentrations in cervicovaginal fluid.

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OBJECTIVES: To assess the impact of health educational intervention on perceptions of menstrual cup usage among female students enrolled in a degree college in Bangalore district. METHODS: An interventional study was conducted among female students studying in a degree college in peri-urban Bangalore. Universal sampling was followed and a prior face validated questionnaire was administered to the students after to assess their perceptions, followed by a health education intervention. The subjects were followed up after a period of one month, to assess the impact of health education in changing their perception towards menstrual cups. RESULTS: Among 83 study participants with mean age 19.5±0.95 years, post intervention we found a 42 % increase in the total awareness score and a 35 % increase in total attitude score towards menstrual cup use. There was an increase by 36.1 % (p<0.001) among participants who considered menstrual cup better than sanitary napkins. A reduction by 27.7 % (p=0.024) of reported fear of pain and discomfort while using menstrual cup was noted. CONCLUSIONS: There was a significant improvement in the overall awareness about how to use a menstrual cup, advantages, and attitude towards the usage of menstrual cups following the health educational intervention. Health education was found to have a positive impact on perceptions of menstrual cup.

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OBJECTIVE: To evaluate menstrual cup use and intrauterine device (IUD) expulsion. STUDY DESIGN: We performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length. RESULTS: This analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5-8.6%) and 133 (12.7%, 95% CI 10.7-14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16-8.46) and <25 years (aOR 1.59, 95% CI 1.07-2.34). CONCLUSIONS: We found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type. IMPLICATIONS: Menstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.

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OBJECTIVE: To evaluate the knowledge, attitudes, and behaviors of Turkish women of reproductive age toward menstrual cup. METHODS: This descriptive study was conducted via online platforms with 301 Turkish women between March-June 2023. The Participant Information Form was used to collect the data. A p value of <0.05 was considered. RESULTS: The mean age of the participants was 26.42 ± 7.81 years. The most common used menstrual hygiene product was sanitary pad. Of the women, 72.1 % have heard of the menstrual cup before, however, only 6.6 % of the women used menstrual cups. The 42.9 % of the women who use the menstrual cup had difficulty in using it. The most common concern of women who did not use menstrual cups was that they thought they were uncomfortable and did not know how to use them. Factors such as age, marital status, place of residence, occupation, previous pregnancy and finding the menstrual hygiene product used comfortable was found statistically significantly correlated with the menstrual cup usage. CONCLUSION: In our study, very few of the women use menstrual cups, and nearly half of them stated that they had difficulty in using it. The participants who did not use the menstrual cup most frequently did not know how to use the cup and did not use it because they thought the cup was uncomfortable. It is essential to increase the awareness of reproductive age women about the menstrual cups.

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Introduction: Menstrual cups are considered a viable alternative to other menstrual hygiene products in many developed countries yet majority of women in India use pads and cloth for their menstrual hygiene. Methodology: This prospective interventional questionnaire-based study was conducted among 100 women who tried cups for three menstrual cycles with the aim of highlighting the challenges posed by socio-cultural factors in India which prevent menstrual cups from becoming a mainstream menstrual hygiene product. Results: Familiarity with pads delayed the switch to menstrual cups even among women who were aware of their benefits. The thought of vaginal insertion was the foremost deterrent along with uncertainty of cup size, need for privacy to sanitise the cup, fear of leakage and infections and familial disapproval. Adaptations to the nuances of cup use were fast and undemanding. No major health concerns were reported with the use of cups. Discussion: Cultural factors in India pose various challenges to menstrual cup usage. Yet majority of women are likely to continue using menstrual cups after trying them. Women well-versed with sexuality and reproductive health face fewer difficulties and show better compliance. Conclusion: The foremost challenges found by this study are unique to the Indian context and continue to influence the choice of menstrual product.

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Introduction: One of the challenges to menstrual hygiene management in resource-limited settings is limited access to safe and affordable menstrual hygiene products. An alternative to the widely used sanitary pads is the menstrual cup, which has received less attention in low- and middle-income countries. This study was carried out to assess the perception on menstrual cup usage among teens and reproductive age group women assess attending a tertiary care institute in a rural setup in Andhra Pradesh. Methodology: A prospective cross-sectional study was conducted among 164 teenage and reproductive age group women attending the Outpatient Department of Obstetrics and Gynecology with the help of a semi-structured, pretested and pre-piloted questionnaire to assess the perception of menstrual cup usage among the participants. Data were analyzed statistically using software, menstrual cup knowledge score was calculated based on data obtained from questionnaire. Results: Most of the study participants (87.8%) were using sanitary pads during menstruation. Cloth was also used by some of the participants (11.59%). Only one participant (0.61%) was reported using menstrual cup. Majority of the participants [121 (73.7%)] reported that they had never heard of menstrual cup, whereas 43 [(26.3%)] study participants reported that they were aware of menstrual cup. Only 2(4.65%) out of 43 participants had a good knowledge on menstrual cup whose knowledge score was 12. Five (11.63%) out of 43 participants had got 0 score and remaining participants got the score between 0 and 12. Conclusion: Most of the women were not aware of menstrual cup and even if they know about it, they do not have good knowledge about it. Awareness regarding menstrual cup should be promoted through media and awareness programs to reach everyone.

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BACKGROUND: Sanitary napkins form a major source of solid waste, the disposal of which often results in environmental pollution. Menstrual cups are an eco-friendly and cost-effective alternative to sanitary pads that have yet to gain much popularity among Indian women. The current study aims to assess the knowledge, attitude, and experiences of using the menstrual cup among medical students in a college in north Kerala, India.  Methods: This cross-sectional study was conducted among 109 female medical students. Data was collected through an online platform and analyzed using Epi Info version 7.2 (Centers for Disease Control and Prevention, Atlanta, GA). RESULTS: Though all the participants had heard about the menstrual cup before, only 14 (12.8%) were using it either alone or in conjunction with sanitary pads. The majority of the participants had a positive attitude towards the usage of menstrual cups with 91.74% considering it a better alternative to other sanitary products, Among the several concerns expressed by the participants, 58.7% were concerned about the insertion of a foreign material into their bodies. CONCLUSIONS: Though most of the participants displayed a positive attitude towards the menstrual cup, the number of participants who had ever tried it was very low. There are several apprehensions regarding the cup that need to be addressed before it can be expected to gain popularity.

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Introduction: Menstrual cups (MC) are a reusable feminine hygiene product. A recent publication suggested that Staphylococcus aureus (S. aureus) biofilms can form on MCs which may lead to increased risk of menstrual Toxic Shock Syndrome (mTSS). Additionally, there is concern that buildup of residual menses may contribute to microbial growth and biofilm formation further increasing mTSS risk. Quantitative and qualitative analysis of in vitro tests were utilized to determine if S. aureus biofilm could form on MC in the presence of the keystone species Lactobacillus after 12 h of incubation. The methodology was based on a modification of an anaerobic in vitro method that harnesses the keystone species hypothesis by including a representative of vaginal lactic acid bacteria. Methods: MCs were incubated anaerobically for 12 h in Vaginal Defined Media (VDM) with the two morphologically distinct bacteria, Lactobacillus gasseri (L. gasseri) and S. aureus. Colony Forming Units (CFU) for each organism from the VDM broth and sonicated MC were estimated. In addition, a separate experiment was conducted where S. aureus was grown for 12 h in the absence of L. gasseri. Qualitative analysis for biofilm formation utilized micro-CT (µ-CT) and cryogenic scanning electron microscopy (Cryo-SEM). Results: Samples collected from the media control had expected growth of both organisms after 12 h of incubation. Samples collected from VDM broth were similar to media control at the end of the 12-h study. Total S. aureus cell density on MC following sonication/rinsing was minimal. Results when using a monoculture of S. aureus demonstrated that there was a significant growth of the organism in the media control and broth as well as the sonicated cups indicating that the presence of L. gasseri was important for controlling growth and adherence of S. aureus. Few rod-shaped bacteria (L. gasseri) and cocci (S. aureus) could be identified on the MCs when grown in a dual species culture inoculum and no biofilm was noted via µ-CT and cryo-SEM. Additionally, efforts to model and understand the validity of the current labeled recommendations for MC cleaning in-between uses are supported. Discussion: The data support continued safe use of the Tampax® cup when used and maintained as recommended.

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INTRODUCTION: Streptococcus pneumoniae infrequently causes genital tract infections but - in particular predisposing circumstances - it can be a transient part of vaginal flora and thus pelvic infections can occur. Possible conditions associated with pneumococcal pelvic-peritonitis include the use of intrauterine contraceptive devices, recent birth and gynecologic surgery. The underlying mechanism of these occurrences is likely to be the ascending infection from the genital tract via the fallopian tubes. CASE PRESENTATION: We present a case of pelvic-peritonitis and pneumonia due to Streptococcus pneumoniae in a healthy young woman wearing a menstrual endovaginal cup. Following the radiological findings of a cystic formation in the right ovary and ascites effusions in all peritoneal recesses an emergency exploratory laparoscopy with right ovariectomy was performed. After resolution of abdominal sepsis, parenchymal consolidation complicated into necrotizing pneumonia, hence the patient underwent a right lower lobectomy. DISCUSSION: The menstrual cup is a self-retaining intravaginal menstrual fluid collection device, considered as a safe alternative to tampons and pads, which use is associated with rare adverse effects. Few cases of infectious disease have been described, where the underlying mechanism may consist of bacterial replication within the blood accumulated in the uterine environment, with subsequent ascension into the genital tract. CONCLUSION: In the rare occurrence of pneumococcal pelvic-peritonitis considering all possible infectious sources is paramount, as is assessing the possible involvement of intravaginal devices, increasingly used nowadays but of which potential complications are still poorly described.

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Background: Menstrual cups (MCs) are increasingly used to collect cervicovaginal secretions to characterise vaginal mucosal immunology, in conjunction with high vaginal swabs (HVS) for metataxonomics, particularly in HIV transmission studies. We hypothesised that both methods of collecting bacterial biomass are equivalent for 16S rRNA gene sequencing. Material and Methods: Cervicovaginal fluid (CVF) samples from 16 pregnant women with HIV-1 (PWWH) were included to represent the major vaginal bacterial community state types (CST I-V). Women underwent sampling during the second trimester by liquid amies HVS followed by a MC (Soft disc™) and samples were stored at -80°C. Bacterial cell pellets obtained from swab elution and MC (500 µL, 1 in 10 dilution) were resuspended in 120 µL PBS for DNA extraction. Bacterial 16S rRNA gene sequencing was performed using V1-V2 primers and were analysed using MOTHUR. Paired total DNA, bacterial load, amplicon read counts, diversity matrices and bacterial taxa were compared by sampling method using MicrobiomeAnalyst, SPSS and R. Results: The total DNA eluted from one aliquot of diluted CVF from an MC was similar to that of a HVS (993ng and 609ng, p=0.18); the mean bacterial loads were also comparable for both methods (MC: 8.0 log10 16S rRNA gene copies versus HVS: 7.9 log10 16S rRNA gene copies, p=0.27). The mean number of sequence reads generated from MC samples was lower than from HVS (MC: 12730; HVS:14830, p=0.05). The α-diversity metrices were similar for both techniques; MC Species Observed: 41 (range 12-96) versus HVS: 47 (range 16-96), p=0.15; MC Inverse Simpson Index: 1.98 (range 1.0-4.0) versus HVS: 0.48 (range 1.0-4.4), p=0.22). The three most abundant species observed were: Lactobacillus iners, Lactobacillus crispatus and Gardnerella vaginalis. Hierarchical clustering of relative abundance data showed that samples obtained using different techniques in an individual clustered in the same CST group. Conclusion: These data demonstrate that despite sampling slightly different areas of the lower genital tract, there was no difference in bacterial load or composition between methods. Both are suitable for characterisation of vaginal microbiota in PWWH. The MC offers advantages, including a higher volume of sample available for DNA extraction and complimentary assays.

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BACKGROUND: The menstrual cup is a safe, cost-effective, and environmentally friendly menstrual product which is increasing in usage, especially in younger women. The potential risk for concomitant menstrual cup use to increase IUD expulsion has been raised over the last 10 years, however, few studies assess this. This systematic review aims to identify, appraise and synthesize the current specific evidence on menstrual cup use and risk of partial or total IUD expulsion. METHODS: PubMed, and the Cochrane Library were searched for publications available in English, until February 20th, 2021. Quantitative and qualitative studies, systematic reviews and case series reports were included. Websites of menstrual cup manufacturers LenaCup®, DivaCup®, Lunette®, AllMatters® and Saalt® were searched for warnings relevant to IUD expulsion. RESULTS: Seven studies were included in this review, comprising 73 partial or total IUD expulsion events in patients with IUD contraception using menstrual cups. The case study reports included two individuals who each experienced two and three expulsions respectively. Of the seven publications, three reported expulsion rates of 3.7%, 17.3% and 18.6%. Time to expulsion ranged from less than one week to two and a half years. These three studies disagree on whether there is a statistically significant association between menstrual cup use and IUD expulsion. CONCLUSION: There is a possible association between menstrual cup use and increased risk of IUD expulsion and this information should be shared with patients. However evidence is scarce and high-quality randomised controlled trials are needed to address this risk and the impact of factors such as age, menstrual cup removal technique, pelvic anatomy, IUD type, and measures such as cutting the IUD strings short or delaying menstrual cup use for a period post-insertion. This research gap is limiting patients' ability to make informed choices regarding intrauterine contraception and menstrual management and must urgently be addressed in the context of rising IUD and menstrual cup use, particularly among a younger demographic who are seeking highly effective contraception.

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OBJECTIVE: To identify the determinants of menstrual cup use among medical students in Brazil. METHODS: A cross-sectional study with an online survey regularly applied to matriculate women from Medical School in January 2021. RESULTS: Of 277 women, 164 participated. The mean age was 22.26 ± 3.21 years. In all 136 women preferred external pads, 60 internal pads, 28 menstrual cups, and 11 did not use. Using a 1-10 scale, price, efficacy, sustainability, practice, vaginal health status, hygiene, and importance of internal genital integrity were investigated. Thirty-seven (22.56%) women related the use of menstrual cups in the last year. Using any method to reduce menstruation had an adjusted odds ratio (aOR) of 0.310 (95% confidence interval [CI] 0.122-0.787). Concern about the environmental biodegradation had an aOR of 6.369 (95% CI 1.372-29.562); concern about intimal health had an aOR 1.996 (95% CI 1.183-3.368); and concern about internal genital integrity had an aOR of 0.824 (95% CI 0.682-0.995) for menstrual cup use. CONCLUSION: The significant independent factors for the use or adherence to menstrual cups were: women using a method to reduce their menstrual flow; concerning biodegradation; concerning vaginal health; with no concerns about manipulating their genitalia. The menstrual cup was used by 22.56% of a medical school in Brazil among undergraduate women.

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The aim was to assess and report the effects of menstrual cup on pelvic floor muscles (PFM) function and tone, as well as check the acceptability after a period of three menstrual cycles in healthy young women. The data collected in assessments and reassessments included the International Consultation on Incontinence Questionnaire - Vaginal Symptoms (ICIQ-VS) questionnaire, evaluation of PFM function through PERFECT Scheme, PFM muscle tone, and PFM manometry (Peritron 9300®). A diary regarding the overall colletor acceptability and satisfaction was collected. Ten healthy young women completed the study. There was an improvement in the mean values of maximal voluntary contraction (MVC) (p = 0.032), a decrease in the vaginal resting pressure (VRP) (p = 0.05), and an increase in the number of repetitions of sustained muscle contractions (p = 0.042). Seven women reported some discomfort while using the vaginal cup only in the first cycle while three revealed discomfort during the whole experiment. This study provides preliminary case-based evidence that the use of the vaginal cup for a period of three menstrual cycles changes the VRP, MVC, and PFM tone, as well as improves the repetitions of PFM assessed by digital palpation. Moreover, the women reported the use of vaginal cup as a positive experience.

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Background: Menstruation and menstrual health management remains a challenge worldwide, largely owing to gender inequality, social and cultural stigma, inaccessibility, and poverty. Menstrual cups may offer solutions to the many challenges. The role of medical students in the promotion of women's health cannot be understated. Objectives: To investigate the understanding and perception of medical students on the use, safety, and efficacy of the menstrual cup as a menstrual hygiene product. Methods: This was a prospective, cross-sectional, quantitative study conducted at the University of the Witwatersrand on medical students. Questionnaires were emailed to students. The study was approved by the Wits HREC (M200885). Statistical software SPSS® 23.0 was used. Results: Two hundred and fifteen participants were recruited. One hundred and seventy-eight were included and analyzed; 58.93% had a basic understanding of the menstrual cup as a menstrual hygiene product (p < 0.001). There was an association between the gender of the respondents and knowledge of the device (p < 0.0001). Females were 7.467 times more likely to have heard about it. There was an association between gender and understanding the cost-effectiveness (p = 0.01), the year of study, and understanding of how it works (p = 0.012). The majority perceived the menstrual cup as convenient in terms of use, comfort, hygiene, and safety. Conclusion: It is important that the menstrual cup is not only introduced to society but also promoted and receives endorsement by healthcare workers. There is an understanding regarding the use, safety, and efficacy of the MC and a willingness to advise for use.

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Objective: To analyze the relative value of providing menstrual cups and sanitary pads to primary schoolgirls. Design: Cost-effectiveness and cost-benefit analyses of three-arm single-site open cluster randomized controlled pilot study providing menstrual cups or sanitary pads for 1 year. Participants: Girls 14-16 years of age enrolled across 30 primary schools in rural western Kenya. Methods: Cost-effectiveness analysis was conducted based on the health effects (reductions in disability-adjusted life years [DALYs]) and education effects (reductions in school absenteeism) of both interventions. The health and education benefits were separately valued and compared with relative program costs. Results: Compared with the control group, the cost of menstrual cups was estimated at $3,270 per year for 1000 girls, compared with $24,000 for sanitary pads. The benefit of the menstrual cup program (1.4 DALYs averted, 95% confidence interval [CI]: -4.3 to 3.1) was higher compared with a sanitary pad program (0.48 DALYs averted, 95% CI: -4.2 to 2.3), but the health effects of both interventions were not statistically significant likely due to the limited statistical power. Using point estimates, the menstrual cup intervention was cost-effective in improving health outcomes ($2,300/DALY averted). The sanitary pad intervention had a cost-effectiveness of $300/student-school year in reducing school absenteeism. When considering improvements in future earnings from reduced absenteeism, the sanitary pad program had a net benefit of +$68,000 (95% CI: -$32,000 to +$169,000). Conclusions: The menstrual cup may provide a cost-effective solution for menstrual hygiene management in low-income settings. This study outlines a methodology for future analyses of menstrual hygiene interventions and highlights several knowledge gaps that need to be addressed. Trial registration: ISRCTN17486946.

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BACKGROUND: We sought to determine the effectiveness of common cleaning procedures in eliminating S. aureus from silicone menstrual cups. METHODS: In this in vitro study, we tested four cleaning techniques: (1) cold water; (2) cold water and liquid soap; (3) cold water followed by steeping the cup in boiled water for 5 min in a ceramic mug covered with a small plate; and (4) cold water and soap followed by steeping the cup in boiled water as in (3). Human blood was coated to the inner and outer surface of each cup, dried, and incubated with 106S. aureus colony-forming units (CFU/mL). All tests were performed in triplicate. Viable bacterial abundance was measured with decadic dilution and drop plate or surface plating. RESULTS: Bacteria were most effectively eliminated by cleaning cups with soap and water and then steeping in boiled water (0 CFU/cup vs. 2.075 × 108/cup no cleaning, p = 0.005). This was not statistically significantly different from washing cups with water only and steeping 5 min in boiled water (14 CFU/cup). Raised lettering on the outer surface of the menstrual cups resulted in more bacterial recovery from pieces with lettering than without lettering. CONCLUSIONS: These results advance knowledge of between-period menstrual cup cleaning recommendations, suggesting that the logistical challenges of continuous boiling may be eliminated with steeping at least 5 min.

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