Menstrual cup

, cervix, fornix on either side of the cervix, vagina, and pubic bone. Ring-shaped cups lie in the upper portion of the vagina, with the inner edge in the posterior fornix and outer one held in behind the pubic bone, within the pelvic floor. The terminology used for menstrual cups is sometimes inconsistent. This article uses "menstrual cup" to mean all types, and for clarity, distinguishes the two main types as "bell-shaped" and "ring-shaped". The thick-walled bell-shaped cups are the older type, and the term "menstrual cup" is sometimes used to refer only to bell-shaped cups. But in modern formal contexts, such as academic research "menstrual cup" usually refers to both types. The US Food and Drug Administration holds that "A menstrual cup is a receptacle placed in the vagina to collect menstrual flow." The EU legislated that "The product group 'reusable menstrual cups' shall comprise reusable flexible cups or barriers worn inside the body whose function is to retain and collect menstrual fluid, and which are made of silicone or other elastomers." Ring-shaped cups are also called "menstrual discs" and sometimes "menstrual rings", to distinguish them from bell-shaped cups. Bell-shaped cups are sometimes called "menstrual bells". Because bell-shaped cups are commonly depicted as being placed in the vaginal canal, well below the cervix, they are also called "vaginal cups", with the ring-shaped cups called "cervical cups". This may not clearly reflect their position in the body. MRI imaging suggests that, contrary to some manufacturer's depictions, the bell-shaped cups called "vaginal cups" are placed over the cervix, in a position similar to a cervical cap (not to be confused with a cervical cup). Ring-shaped cups, called "cervical cups", also cover the cervix, but have one edge next to the cervix, and the other located further down the vagina, so that the cup is nearly parallel to the long axis of the vagina. and were similar external catamenial sacks of "canoe-like form", which in turn were similar to catamenial sacks which were waterproof rubber undersheet supports for absorbent pads. These were made from india-rubber or gutta-percha, forms of latex. == Use ==

Menstrual cups are favoured by backpackers and other travellers, as they are easy to pack and only one is needed. Disposable and reusable pads do not demand the same hand hygiene, though reusable pads also require access to water for washing out pads. If the hands have come into contact with any chemical that directly trigger sensory receptors in the skin, such as menthol or capsaicin, all traces of the chemical should be removed before touching the mucous membranes. A UN spec recommends that cups should not be shared; they should only ever be used by one person. In some cases, the user may need to twist the cup or flex the vaginal muscles to ensure the cup is fully open. In practice, the rim of a bell-shaped cup generally sits in the vaginal fornix, the ring-shaped hollow around the cervix. Those with deeper fornixes may use insertion techniques such as inserting the cup partway, opening it before the rim passes the cervix, and then pushing it up into place; or they may press the cup to one side and let it open slowly, the rim slipping over the cervix. If correctly sized and inserted, the cup should not leak or cause any discomfort. The stem should be completely inside the vagina. If it can't be positioned inside, the cup can be removed and the stem trimmed. Ring-shaped cups with non-circular rims are designed to be inserted with the widest, deepest part going in first. If they are inserted the wrong way around they may leak. If there are stems or other removal aids, they should be on the end inserted last. Wear A bell-shaped cup may protrude far enough to be uncomfortable if it is too long. It may press too firmly against the bladder, causing discomfort, frequent urination, or difficulty urinating, if it is too firm, or the wrong shape. The cup is emptied after 4–12 hours of use (or when it is full). When using a urine-diverting dry toilet, menstrual blood can be emptied into the part that receives the feces. If any menstrual blood falls into the funnel for urine, it can be rinsed away with water. In the absence of other facilities, menstrual fluid can be emptied into a cathole. This is a single-use hole deep, more than from water (and frequented areas like trails or campsites), ideally dug in organic soil, in an area where the waste will break down fast. Water used to rinse the cup can also be disposed of in the cathole, which is then refilled and concealed. Removal ; the seal must be broken before removing a bell-shaped cup. Many initially find removal difficult, uncomfortable, and even painful, but learn to do it without problems within a few cycles. Slow removal and a firm grip avoid dropping the cup; The shape of the (one-part) stem thus has little effect on how easy the cup is to remove, and many people trim the stem right off for comfort. If it is necessary to track the amount of menses produced (e.g., for medical reasons), a bell-shaped cup allows one to do so accurately before emptying. Ring-shaped menstrual cups are removed by hooking the rim with a finger (from either side), or by pinching it with multiple fingers and pulling. Some ring-shaped cups have a dimple in the bowl, to make it easier to hook the rim from below. Some also have stems, but contrary to bell-shaped cups, these stems attach to the rim of the cup, and can be pulled to break the seal. Others have pull loops that fold flat against the bowl, which can also be pulled to remove. Removing ring-shaped cups is typically done over a toilet in case of spilling; the softer bowl squishes flat during removal, making it very difficult not to spill any menstruum. Cleaning soap). Scents and moisturizers are designed to remain as residues on the hands after washing. Some manufacturers sell and recommend proprietary cleaning products. Mason jars made for home canning are heatproof and designed to be sterilized by boiling; they have been used to steep-sterilize menstrual cups. They have also been used (presumably unsealed) for storage. Mugs have also been used. Washing a menstrual cup in a sink at a public toilet can pose problems, as the handwashing sinks are often in a public space rather than in the toilet cubicle. Accessible loos generally have sinks that can be reached from the toilet, but they may be needed by people with limited mobility. Stain removal Smooth-surfaced cups are easier to clean; moulded text, ridges, bumps, and holes make it a bit more difficult. Some cup makers recommend against the use of hydrogen peroxide. Some menstrual cups are sold colorless and translucent, but several brands also offer colored cups. Translucent cups lose their initial appearance faster than colored – they tend to get yellowish stains with use. It can be harder to see whether a dark-coloured cup is clean. The shade of a colored cup may change over time, though stains are often not as obvious on colored cups. Storage Manufacturers typically suggest letting the cup dry out fully and storing it dry in a breathable container, such as the cloth bag usually provided with the cup. Airtight wraps and containers are counterrecommended, especially if the cup is at all damp. ==Safety==

Menstrual cups are a safe option for managing menstruation, with risks comparable to or lower than alternatives (with the possible exception of the risk of intrauterine device (IUD) displacement). They are safe in in low-, middle-, and high-income settings. So far there is no data on IUD displacement in people using ring-shaped cups, which do not suction to the cervix in the way bell-shaped cups can. Rare issues The number of menstrual cup users is unknown. This makes it hard to estimate the rate of rarer health problems related to cups. There are few reports, and rare problems are unlikely to turn up in a randomized study. Endometriosis affects 10–15% of menstruators. An online survey on the topic, with nine respondents, found three people who had used a menstrual cup and developed endometriosis. TSS associated with menstrual cup use appears to be very rare, probably because menstrual cups are not absorbent, do not irritate the vaginal mucosal tissue, and so do not measurably change the vaginal flora. but results from similar studies are conflicting, and results from in-vivo studies do not show cause for concern. ==Size, shape, and flexibility==

There are no standards for the measurement or size-labelling of menstrual cups, and each manufacturer uses their own system. Menstrual blood loss of more than 80mL per month is considered heavy menstrual bleeding, and grounds for consulting a doctor. Some manufacturers sell several sizes of cup that are all the same length. Cups must be short enough that the cervix does not push the cup into contact with the vulva, where it may be uncomfortable. If the cervix sits particularly low There also exist cups with valves in the stem, which can be slowly drained without removing the cup. The UN counterrecommends hollow stems, because solid stems are easier to clean. The maximum capacity for large cups is about 50mL (ring-shaped cups generally hold a bit more than bell-shaped cups). The outside diameter of the rim will also affect seal and comfort. Sizing Cervix height is measured by touching the cervix with a fingertip, and using the thumb against the finger to mark the inner edge of the vaginal opening; the distance from the thumbnail to the tip of the finger is the height of the cervix. Cervix height varies slightly over the month, and is usually lowest on the first day of bleeding; minimum height is used for sizing menstrual cups. This forcers buyers to guess whether a cup will fit. A regulatory requirement for quantitative measurements, including a Young's modulus measurement of firmness, has been suggested. Research into what measurements would be most useful for selecting a well-sized cup is also needed. However, there is no medical evidence for sizing based on age or parity. Ring-shaped cups or discs Ring-shaped cups (also called menstrual discs or rings) Ring-shaped cups are sized differently than bell-shaped cups. Fit is much less individual; the flexible bowl makes depth unimportant, and any ring-shaped cup between 60-70mm diameter will fit most people adequately. Sizing is measured in the same way as it is for contraceptive diaphragms, which fit in the same position. A study of circular-rim diaphragms failed to find any proxy factor (like parity or weight) which would allow prediction of the size of diaphragm someone needed; it was necessary to take a measurement. As with contraceptive diaphragms, some "one-size-fits-all" cups have slightly oval or pear-shaped rims, and some have rims that arch (as seen from the side), increasing the range of sizes that fit. A contraceptive diaphragm using these techniques was found to fit 98% of volunteers in a multicenter study (everyone with a size of 65-80mm). A disc which is too big or too small will leak. enable bloodless period sex, and are more comfortable for some users. Disadvantages include messier removal Notches reduce cup volume. Removal aids like pull loops make ring-shaped cups easier to remove without spilling, but they may chafe, Adding ribs (linear thicker areas) to the membrane makes it easier to mould. It also stiffens the membrane. Stiffer membranes may be more noticeable during sex, and smoother, softer ones less noticeable. It is anecdotally claimed that the increase in surface area from the ridges allows ridged cups to hold more blood; and that they may reduce effective natural vaginal lubrication when worn during sex. Texture may also be added to the outside of the membrane for grip, A thin spot in the rim can let the rim fold more tightly for insertion and removal. Some ring-shaped cups also have concentric grooves on the outside of the rim; these can be harder to clean than an ungrooved rim. Sizing Size can be measured in the same way as for contraceptive diaphragms; At this depth the side walls of the vagina are quite stretchy, While North American manufacturers do not generally give dimensions, third-party tables of disc diameters are available online. European manufacturers generally do give the metric dimensions of their products online. For circular rims, the outside rim diameter should match the diaphragm size. For oval and slightly egg-shaped rims, the sizing should be similar, but taking an average of the two rim dimensions. For complex three-dimensional rims, the manufacturer should indicate the size range the cup will fit. ==Materials and color==

Cups are made from rubbers (elastomers). Most are made from silicone rubber; some are made from latex or thermoplastic rubber. Plastics can also be medical-grade. Some jurisdictions require the use of medical-grade materials, but others do not. Where permitted, cups may be made of cheaper food-grade materials. The same make and model of cup may be made of different materials in different legal jurisdictions. In many jurisdictions, menstrual products need not list ingredients. Some places, including some US states, have enacted laws requiring food-style ingredient lists, with the percentage of each ingredient. These laws include menstrual cups, and have been supported by some cup manufacturers. Base materials Latex . Early cups were made from latex manufactured from plant sap (usually gutta-percha or indiarubber). Latex is biodegradable. Latex allergy is common; around 4% of the general population worldwide has it, and repeated exposure makes a person more likely to develop it. Biologically-sourced latex may be brown or amber-coloured (see natural rubber). Latex can harden over time. Menstrual cups made from silicone are reusable for up to 10 years. A UN specification requires medical-grade silicone. While silicone rubbers, as polymers, are inert and hypoallergenic, the corresponding monomers are not. Silicone menstrual cups must therefore be fully cured before use. Heat accelerates curing. The firmness of a cup will be affected by the firmness of the material, but also its shape and dimensions. Plastic , In jurisdictions where cups are classed as medical devices, the colourants generally also have to be medical-grade, and fuse permanently to the raw material so that they cannot leach out. In jurisdictions where menstrual cups are classed as consumer devices, colourants need not be medical-grade. Some manufacturers use colourants certified for use in plastics intended to come in contact with food, for use in toys, and for use in consumer electronics. In some cases, a broader range of colours are available in jurisdictions where menstrual cups are not classed medical devices, and food-grade dyes can be used. The same brand and model of product may be made with different grades of colourant in different jurisdictions. Because silicone rubbers are relatively expensive, some dodgier manufacturers mix cheaper fillers into their silicone. These fillers are typically not tested for safety. Such cups may or may not whiten when stretched only a small amount. ==Manufacturing==

Material must be treated carefully during manufacture to avoid contaminating it. ISO certification is used for silicone manufacturing processes, ==Regulation==

Regulation varies by jurisdiction. Some international standards are used in multiple jurisdictions, especially those from the International Standards Association. Menstrual cup manufacturers seek and advertise ISO 13485 certification. Canada Canada regulates menstrual cups (like tampons and other insertables) as Class II medical devices. In Canada this means that they must be licensed by Health Canada before being advertised, imported, or sold. There are standards for materials and manufacturing facilities; getting accreditation and meeting the requirements can take years. There is also separate strong regulation of sustainability claims. This regulation raises costs for Canadian manufacturers; large manufacturers have made statements approving of the regulatory environment, though they complain about online competition from laxer jurisdictions. Menstrual cups that meet the regulatory requirements to be sold in the United States may not be able to meet the requirements in Canada. under the General Product Safety Directive). This means that manufacturers, by selling them, guarantee that they are safe, but do not face more oversight than manufacturers of other consumer products. Some menstrual cups carry the EU Ecolabel, which requires minimum standards for packaging, pollution, emission reduction, and toxic substances in the finished product. The EU has the power to order the removal of unsafe products, including from online shops. Manufacturers inside and outside the EU may voluntarily use the CE mark on packaging to assert that a product meets EU regulations. South Korea Menstrual cups are categorized as "quasi-drugs" in South Korea. US The US regulates menstrual cups as Class II medical devices, but this does not mean the same thing as in Canada. The manufacturers of the silicone, the manufacturer that shapes it into cups, and the vendor, must all be registered with the FDA (using a 510(k) premarket notification Menstrual cups, unlike tampons, do not require premarket review. Some cups claim to be "FDA approved". The Food and Drug administration does not approve Class II medical devices, only Class III medical devices. Menstrual cups are categorized as class II, not class III, so they cannot be "approved", only "cleared", and these claims are inaccurate. The FDA requires certain product labelling on (or in) all packaging. ==Cost==

The costs for menstrual cups vary widely, from US$0.70 to $47 per cup, with a median cost of $23.35 (based on a 2019 review of 199 brands of menstrual cups available in 99 countries). The same 2019 review looked at costs across seven countries and found that, over 10 years, a menstrual cup costs $460.25 less than 12 disposable pads per period and $304.25 less than 12 tampons per period. Despite the long-term cost savings, the upfront cost of a menstrual cup is a barrier for some. ==Environmental impact==

Since they are reusable, menstrual cups help to reduce solid waste. Some disposable menstrual pads and plastic tampon applicators can take 25 years to break down in the ocean and can cause a significant environmental impact. Biodegradable sanitary options are also available, and these decompose in a short period of time, but they must be composted, and not disposed of in a landfill. When considering a 10-year time period, waste from consistent use of a menstrual cup is only a small fraction of the waste of pads or tampons. Given that the menstrual cup is reusable, its use greatly decreases the amount of waste generated from menstrual cycles, as there is no daily waste and the amount of discarded packaging decreases as well. After their life span is over, silicone cups can be burned or sent to a landfill. Alternatively, one brand offers a recycling program and some hospitals are able to recycle medical grade silicone, including cups. Cups made from TPE can be recycled in areas that accept #7 plastics. Rubber cups are compostable. The water used to rinse the cups can be disposed of in the same way. This reduces the amount of wastewater that needs to be treated. In developing countries, solid waste management is often lacking. Here, menstrual cups have an advantage over disposable pads or tampons as they do not contribute to the solid waste issues in the communities or generate embarrassing refuse that others may see. == History ==

Menstrual cups may have been inspired by other types of vaginal inserts used throughout history. Vaginal inserts had various purposes from birth control, enabling abortions, to supporting a prolapsed uterus. Leona Chalmers patented the first usable commercial cup in 1937. Other menstrual cups were patented in 1935, 1937, and 1950. The Tassaway brand of menstrual cups was introduced in the 1960s, but it was not a commercial success. Early menstrual cups were made of rubber. The first menstrual-cup applicator was mentioned in a 1968 Tassaway patent; there are also 21st-century versions, but they have not been a commercial success, . No medical research was conducted to ensure that menstrual cups were safe prior to introduction on the market. Early research in 1962 evaluated 50 volunteers using a bell-shaped cup. The researchers obtained vaginal smears, gram stains, and basic aerobic cultures of vaginal secretions. Vaginal speculum examination was performed, and pH was measured. No significant changes were noted. This report was the first containing extensive information on the safety and acceptability of a widely used menstrual cup that included both preclinical and clinical testing and over 10 years of post-marketing surveillance. In 1987, another latex rubber menstrual cup, The Keeper, was manufactured in the United States. This proved to be the first commercially viable menstrual cup and it is still available today. The first silicone menstrual cup was the UK-manufactured Mooncup in 2001. Most menstrual cups are now manufactured from medical grade silicone properties. An early menstrual disc, the Gynaeseal, was developed by Dr John Cattanach in 1989, but never found commercial success. Designed by Audrey Contente, the disposable disc was made of Kraton. As of 2021, there were ten brands of discs available for purchase in various markets. Menstrual cups are regarded as a low-cost and environmentally friendly alternative to sanitary cloth, expensive disposable pads, or "nothing" – the reality for many women in developing countries. Girls provided with menstrual cups had a lower prevalence of sexually transmitted infections than control groups. Also, the prevalence of bacterial vaginosis was lower among cup users compared with menstrual pad users or those continuing other usual practice. ==Society and culture==

Public funding for menstrual cups The municipality of Alappuzha in Kerala, India launched a project in 2019 and gave away 5,000 menstrual cups for free to residents. The purpose of this was to encourage the use of these cups instead of non-biodegradable menstrual pads to reduce waste production. In 2022, the Spanish government began distributing free menstrual cups through public institutions (such as schools, prisons, and health facilities). In March 2024, Catalonia, in Spain, started supplying free menstrual cups as part of the "My period, my rules" initiative. The universal public healthcare system supplied one menstrual cup, one pair of period underwear, and two packages of reusable cloth menstrual pads per person, available through local pharmacies. The program covers 2.5 million people and cost the Catalan government €8.5 million (3.40 euros / US dollars per person). The program was undertaken for equity, poverty reduction, taboo reduction, and environmental benefits. It is expected to reduce waste from single-use menstrual hygiene products, which had been 9000 tons per year, according to the Catalan government. Developing countries Menstrual cups can be useful as a means of menstrual hygiene management for people in developing countries where access to affordable sanitary products may be limited. A lack of affordable hygiene products means inadequate, unhygienic alternatives are often used, which can present a serious health risk. Menstrual cups offer a long-term solution compared to some other menstrual hygiene products because they do not need to be replaced monthly. Cultural aspects Menstrual hygiene products that need to be inserted into the vagina can be unacceptable for cultural reasons. There are myths that they interfere with female reproductive organs and that they cause females to "lose their virginity". Some ring-shaped menstrual cups are no bulkier than a tampon when folded as recommended. This can discourage youths from using cups. Despite common cultural beliefs, the state of a hymen cannot be used to prove or disprove virginity. Penile penetration does not lead to predictable changes to female genital organs; after puberty, hymens are highly elastic and can stretch during penetration without trace of injury. Females with a confirmed history of sexual abuse involving genital penetration may have normal hymens. Young females who say they have had consensual sex mostly show no identifiable changes in the hymen. Hymens rarely completely cover the vagina, hymens naturally have irregularities in width, and hymens can heal spontaneously without scarring. Many women do not bleed on having vaginal sex for the first time, hymens may not bleed significantly when torn, and vaginal walls may bleed significantly when torn. There has been one news report of the stem of a bell-shaped cup passing outwards through a small side hole in a septate hymen (a hymen with more than one opening), causing pain on attempted removal. The woman had the problem diagnosed and the cup removed at a hospital. She had previously used the cup without problems for four years. Some examine their hymen with a mirror before using a menstrual cup. == See also ==