Examining the safety of menstrual cups among rural primary school girls in western Kenya: observational studies nested in a randomised controlled feasibility study

Jane Juma, Elizabeth Nyothach, Kayla F Laserson, Clifford Oduor, Lilian Arita, Caroline Ouma, Kelvin Oruko, Jackton Omoto, Linda Mason, Kelly T Alexander, Barry Fields, Clayton Onyango, Penelope A Phillips-Howard, Jane Juma, Elizabeth Nyothach, Kayla F Laserson, Clifford Oduor, Lilian Arita, Caroline Ouma, Kelvin Oruko, Jackton Omoto, Linda Mason, Kelly T Alexander, Barry Fields, Clayton Onyango, Penelope A Phillips-Howard

Abstract

Objective: Examine the safety of menstrual cups against sanitary pads and usual practice in Kenyan schoolgirls.

Design: Observational studies nested in a cluster randomised controlled feasibility study.

Setting: 30 primary schools in a health and demographic surveillance system in rural western Kenya.

Participants: Menstruating primary schoolgirls aged 14-16 years participating in a menstrual feasibility study.

Interventions: Insertable menstrual cup, monthly sanitary pads or 'usual practice' (controls).

Outcome measures: Staphylococcus aureus vaginal colonization, Escherichia coli growth on sampled used cups, toxic shock syndrome or other adverse health outcomes.

Results: Among 604 eligible girls tested, no adverse event or TSS was detected over a median 10.9 months follow-up. S. aureusprevalence was 10.8%, with no significant difference over intervention time or between groups. Of 65 S.aureus positives at first test, 49 girls were retested and 10 (20.4%) remained positive. Of these, two (20%) sample isolates tested positive for toxic shock syndrome toxin-1; both girls were provided pads and were clinically healthy. Seven per cent of cups required replacements for loss, damage, dropping in a latrine or a poor fit. Of 30 used cups processed for E. coli growth, 13 (37.1%, 95% CI 21.1% to 53.1%) had growth. E. coli growth was greatest in newer compared with established users (53%vs22.2%, p=0.12).

Conclusions: Among this feasibility sample, no evidence emerged to indicate menstrual cups are hazardous or cause health harms among rural Kenyan schoolgirls, but large-scale trials and post-marketing surveillance should continue to evaluate cup safety.

Keywords: Escherichia coli; Kenya; Staphylococcus aureus; hygiene; menstrual cups; menstrual hygiene management; toxic shock syndrome.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1
Figure 1
Participants’ flow diagram for Menstrual Solution study and Staphylococcus aureus survey.
Figure 2
Figure 2
Menstrual cup distributed to girls in cup-allocated schools.
Figure 3
Figure 3
Flow diagram for action of suspected menstrual toxic shock syndrome event. AK, Aga Khan; FP, focal point; TSST, toxic shock syndrome toxin; VR, village recorder (field staff).

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