Dear Mr Mughal

Thank you for your feedback on our study.

By 'transactional sex' we mean girls that have sexual intercourse with males who provide them with money or products that they cannot afford. They are not 'commercial sex' workers. We think 'transactional sex' is not the best way of describing for the girls in our study area, however, as the girls are impoverished and vulnerable, and thus can be coerced by males into having sex to obtain basic necessities (such as sanitary pads). We would like to further study and better understand this as a social, wellbeing and public health issue.

To my knowledge, there are no studies in Muslim countries, or among a range of populations with different cultures, which is indeed a shortfall. There is likely a hesitancy to test among some cultures because an insertable product may be considered unacceptable by the community, and leaders - but as there is no actual data we do not know if this is true or not.

Best wishes
Penelope Phillips-Howard
Liverpool School of Tropical Medicine

Hello Dirk,

You bring up an interesting point regarding the hymen and its connotations with virginity. This is an issue that Femme International has come across, and one of the reasons menstrual cups should not be distributed without an education component.

In our workshops, we have a section on the hymen, talking about what it is and how it is never truly 'closed' as that would completely block off the vagina, and emphasising that virginity has to do with sexual acts whereas the hymen is tissue. Sensitising the greater community (including boys, parents, etc) increases uptake of menstrual cup use.

Also, we have found that primary-age girls prefer reusable pads, whereas older girls and women are more likely to prefer a cup.

Cheers,
Jen

Dear Penelope,
Thank you for this very interesting information.
2 Questions:

1. What was the percentage of girls who got RTI?*
2. It is sometimes feared to give menstrual cups to Primary School girls, as the cup might damage the hymen. Any information on this from your study?

Regards
Dirk

Dirk Ullerich
Welthungerhilfe Moroto/ Uganda


* RTI = Reproductive tract infection (added by moderator)

Dear Dr Penelope,

This is an interesting and informative study. However, I do not quite understand, what do you mean by “transactional sex.” Is it dating, or the commercial sex?

Is there a similar study in a Muslim country? How would the religious beliefs impact, or influence, your study.

Best regards,

F H Mughal

Dear colleagues

We have now just published the results of our pilot study which explored the acceptability, use and safety of menstrual cups and sanitary pads against 'usual practice'controls among primary schoolgirls in rural Kenya.

You can access the full article using the web-link below:
bmjopen.bmj.com/cgi/content/full/bmjopen...x9evDkwP&keytype=ref

Title:
Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya

In summary - we conducted a feasibility study on the effect of menstrual hygiene on schoolgirls' school and health (reproductive/sexual) outcomes,using a 3-arm single-site open cluster randomized controlled study design in 30 primary schools in rural western Kenya. Girls recruited were provided a menstrual cup, or monthly sanitary pads, against ‘usual practice’ controls. All participants received puberty education pre-intervention, and hand wash soap during intervention. Schools received hand wash soap. We measured school attrition (drop-out, absence) as primary outcomes, and sexually transmitted infection (STI) and reproductive tract infection (RTI) as key secondary outcomes, and toxic shock syndrome, and vaginal Staphylococcus aureus as safety outcomes. Of 751 girls enrolled we were able to follow-up 644 girls for a mean of 10.9 months. Cups or pads did not reduce school dropout risk. Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey was significantly lower in cup and pad users compared with controls. Overall RTI prevalence did not differ, but 71% of RTI were from bacterial vaginosis, which was significantly less prevalent in girls using cups compared with pads, and lower also than controls among girls followed for 9 months or longer. No adverse events were identified. The paper discusses the strengths and weaknesses of the methods used, and the possible implications of the study results (recognising it was a pilot study not a full trial).

Our study concluded that menstrual cups and sanitary pad provision to schoolgirls for ∼1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, but in this small sample there was no evidence of association with school dropout. A large-scale trial on menstrual cups is warranted.

We hope you find the article interesting, and hope it contributes toward the scanty literature available on the potential health effects of menstrual hygiene products.

With best wishes

Dr Penelope A Phillips-Howard
Department of Clinical Sciences
Liverpool School of Tropical Medicine, Liverpool, UK

I have often read similar statements to the one of Emmanuel who said

many of them have dropped out of school due to menstrual hygiene related cases.

But then I read in this blog post that this is a "myth", see here:

forum.susana.org/forum/categories/24-men...-india-mythri-speaks

I copy here the first part of that blog post but please see there to read the full piece:

Assumption #4. Girls in developing countries are dropping out of school due to lack of menstrual products and toilets

Having functional toilets in schools is an absolute must, not just for girls. But, unnecessarily connecting it to menstrual hygiene seems more agenda driven than real. Let’s look at what existing studies reveal.

A comparison of data owing to school absenteeism during menstruation in developing nations shows that the percentage of girls who remain absent during menstruation is around 12.1% in China [21], 15.6% to 24.2% in Nigeria [19, 20], 24% in India [17] and 31% in Brazil [22].

If the current hypothesis – that school absenteeism is due to lack of toilets or Sanitary Napkins – is true, then surely developed countries must have little or no absenteeism. However, data indicates that it is no different in developed countries.

Studies indicate that 17% teenagers in Canada [23], 21% in Washington D.C [24], 24% in Singapore [25], 26% in Australia [26] and 38% in Texas [27] miss school owing to menstruation.

What do people who have studied this aspect in depth say about this? Is it right or is it wrong? Is it exaggerated perhaps in order to get more funding for MHM for WASH in schools?

Elisabeth

Dear friends,
I hope this annual 5th conference will figure out most of the problems our girls experience in schools because many of them have dropped out of school due to menstrual hygiene related cases.