Here is an update:

Anna van Eijk (main author of the paper) wrote to me:

About the question "How do you explain this huge variation cost for such a simple household item (by a factor of 5!)? Do companies just set the price based on what they think their clients are willing to pay?"
- I am not sure what this is based on, but can be dependent on their market, e.g. the cheapest was from China.

About the difference between menstrual cups and cervical cups:
- Please have a look at "Wikihow. How to use an Instead Softcup" (www.wikihow.com/Use-a-Softdisc-(Instead-Softcup)). Softcups are one time only use, so not very environmental friendly.

About the information on toxic shock syndrome on the Wikipedia page:
- What is reported here is not completely correct. So if you can change it into something like this that would be great: "A review in 2019 identified five cases of toxic shock syndrome in the medical literature; only one had bacteria cultures confirmed from the menstrual cup."


Based on this feedback I have done some further work.
The new wording in the Wikipedia article now says:

A 2019 review found the risk of toxic shock syndrome with menstrual cup use to be low, with five cases identified via their literature search.[30] Data from the United States showed rates of TSS to be lower in women using menstrual cups versus high-absorbency tampons.[30] Infection risk is similar or less with menstrual cups compared to pads or tampons.[30]

I also think it's important that cervical cups (= menstrual discs) are NOT lumped in together with menstrual cups. They are actually a different product. I have now tried to clarify that here:
en.wikipedia.org/wiki/Menstrual_cup#Disposable_menstrual_disc

The difference is in the material and shape and where it sits in the body, i.e. high up on the cervix and not in the vaginal canal. This results in another difference: they can be worn during sexual intercourse, unlike menstrual cups.

I wonder whether menstrual discs need to be disposable or whether they could also be manufactured in a reusable variety. Perhaps not because they may be harder to clean due to their softer material (they have a flexible outer ring and a soft, collapsible center).

Regards,
Elisabeth

Hi Elisabeth,
great to hear you are updating the wikipedia page, thanks indeed for reaching out.

Cervical cups and vaginal cups = menstrual cups … the difference, as per in the article is just their position in the vaginal canal, size, shape, and cervical cups are a softer materials.

We have no idea why the large differences in costs – but an interesting question.

Please do update the adverse event section, as the data included in our paper was well researched.
the pollution/wastage savings made – although note these are estimates as we could not do with huge precision (that would be a study on its own) - were also interesting and worth a mention.

Kind regards

Prof. Penelope Phillips-Howard
Liverpool School of Tropical Medicine
Pembroke Place, Liverpool L3 5QA, UK

Dear Penny,

Thanks for posting your recent review paper here on the forum! As usual, I look at such a paper with a view of updating the Wikipedia article on menstrual cups... I was delighted to see in your article information on costs which I immediately incorporated into the Wikipedia article like this:

The costs for menstrual cups vary widely, from US$ 0.7 to 47 per cup (based on a review of 199 brands of menstrual cups available in 99 countries).[33]

How do you explain this huge variation cost for such a simple household item (by a factor of 5!)? Do companies just set the price based on what they think their clients are willing to pay?

What else from your paper should we include or update in the Wikipedia article?
How about the section on toxic shock syndrome, do I need to update that based on your finding:

We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup.

(is 5 women out of how many women a significant number?)

Actually I just noticed that someone already included a statement from your paper on that, which now reads:

In 2019, toxic shock syndrome was reported in five women, in which bacteria cultures in the menstrual cups were confirmed.[30]

Also I have a question about the "cervical cups" that you have included in your paper. I don't really know what cervical cups are. In Wikipedia we have an article on "cervical caps", is that the same thing? But that's for contraception, not for menstrual flow management (en.wikipedia.org/wiki/Cervical_cap)

If I put cervical cup into Google, it either shows me photos of menstrual cups or gives me information on cervical caps. So what exactly is a cervical cup and how does it differ from a menstrual cup?

Regards,
Elisabeth

Hi all,
we are pleased to share the link to our new paper - a systematic review and meta-analysis of the use, effectiveness, safety of menstrual cups internationally, published in Lancet Public Health - which has got strong coverage on all the media: URL for the main article and the supplementary appendix materials are below:

www.thelancet.com/journals/lanpub/articl...(19)30111-2/fulltext

www.thelancet.com/journals/lanpub/articl...ltext#seccestitle140

Title: Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis

Findings
Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59–84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72–46·72 (median $23·3, 145 brands).

Interpretation
Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products.

Funding
UK Medical Research Council, Department for International Development, and Wellcome Trust.

Authors: Anna Maria van Eijk, PhD, Garazi Zulaika, MPH, Madeline Lenchner, MSc, Linda Mason, PhD, Prof Muthusamy Sivakami, PhD, Elizabeth Nyothach, MSc, Holger Unger, PhD, Kayla Laserson, ScD, Prof Penelope A Phillips-Howard, PhD

Here it is (I hope I have done it the right way)

Dear Marianne,

Thanks for your post! I am glad you like the Wikipedia article on menstrual cups that we had worked on (en.wikipedia.org/wiki/Menstrual_cup). Don't worry about the deadline by the way, it is never too late to improve Wikipedia articles further. :-)

Thanks for pointing out that error! I have now removed reference to that second case because the reference cited does not talk about a second case. The other reference just went to Lunette's website which isn't a reliable source. You mention a MAUDE report. Is that a proper publication that we can cite? If so, could you post it here on the forum?

The text as it currently reads says now:

A widely reported study showed that in vitro, bacteria associated with toxic shock syndrome (TSS) are capable of growing on menstrual cups.[28][29][30] There has been one confirmed case of TSS associated with the use of the menstrual cups.[31] This case was a woman who had a history of Hashimoto’s thyroiditis and chronic menorrhagia.[31]

Kind regards,
Elisabeth

Although we have passed the deadline, we would like to draw your attention to our website (womena.dk/), where we collect grey and peer reviewed research, building on our own work, as well as global research and FAQs on specific topics womena.dk/faqs/.

Your wikipedia article is excellent!

For the issue of TSS, that was our first FAQ, and we have come to the same conclusion as you, which is reassuring. One small detail: you state 'In the second case, the menstrual cup had been left in for 7 days' and refer to a Lunette website. We did write to Lunette, and they sent me the MAUDE report, which seems to say 18 hours. They will change the text on their website accordingly. If you are interested, please write This email address is being protected from spambots. You need JavaScript enabled to view it.

Several important topics are coming up here, and even more emerge as I've read the journal articles being posted here. Thank you. I'm getting quite an education.

I can see how valuable it would be for people on the front lines of MHM training to have this information. I'm thinking very specifically of women I know who do MHM programs in their own Districts-- for urban poor schools in Ghana. They rely on Wikipedia, and so do the school girls they are educating about MHM options. We want these programs to benefit from the best knowledge available.

Instead of tackling the MHM page for our World Toilet Day deadline, I'm putting it on the list for World Water Day in March. Thank you for posting to this discussion, and please keep the ideas coming. Sanitation Wikipedia needs MHM expertise: please email me if you can be persuaded to help out.

Re the issue of safety, the quoted article by Mitchell et al (2015) notes that TSS, caused by Staph. aureus,
was first diagnosed in children in 1978, and occurs in both children, men and women. The incidence of TSS is low - deVries et al (2011) estimate it at 0.52/100,000 in a US population in the period 2000-2006, down from 13.7/100,000 in 1980.

To calculate risk/safety, it would be useful to have global data on numbers of users of cups (or other methods). I cannot find any (can anyone help?). Given that there are more than 100 brands for sale on the net, and an upsurge in availability in shops, I am assuming the numbers are high (millions?).

Mitchell et al (2015) note plausible biological reasons the TSS could have developed, including that the women concerned had an increase in vaginal pH from 4.2 to 7.4. North and Oldham (2011) in a wider study find no increase in pH for women using the cup.

The study already posted by Phillips-Howard et al. (2016) in Kenya concludes that provision of menstrual cups and sanitary pads for approximately 1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, than those using 'usual practice',

Gérard Lina is a long term researcher on safety of tampons. He recently did a laboratory testing of swabs from women using tampons or cups. He has not yet published his results, and has 'deplored' that early French and British media articles misrepresented his findings as indicating increased risks, whereas his laboratory analyses found neither the tampons or cups to promote bacterial growth or production of toxins. He finds both products to be good and recommended for use. www.lemonde.fr/sante/article/2017/07/07/...5157515_1651302.html

It is very important to update the section on TSS, based on the findings from the first recorded case of TSS associated with menstrual cup use. The authors conclude that previous claims that menstrual cups are 'TSS safe' do not hold true and that the menstrual cup does, in fact "appear to provide a necessary milieu for S aureus growth during menstruation"


www.ncbi.nlm.nih.gov/pmc/articles/PMC4556184/

an article by Beksinska et al www.ncbi.nlm.nih.gov/pubmed/25682816 and by Hyttel et al www.developmentbookshelf.com/doi/full/10...2/1756-3488.16-00013

Hi,

I see no reason to delete old citations, unless they are wrong.

Best wishes,
Chris