Introduction:
Globally around 1.9 billion females are in the reproductive age group (1) of which more than 800 million menstruate every day.(2) Menstruation entails the women to have safe and effective sanitary materials.(3) But in developing countries like India, where 356 million women are in the menstruating age,(4) efforts towards appropriate menstrual hygiene management are hindered by customs and taboos.(5,6) Only 58% of the girls and women aged 15 to 24 used a modern form of menstrual protection like sanitary pads.(7) The materials used differ with setting; sanitary pads are increasingly used in urban setting whereas cloths are preferred by the rural women.(5) Menstrual cup is a least preferred option for Indian women even a century after its invention (5, 6) and its uptake is slower than that of the sanitary pads.(8) A descriptive survey among 300 women in Mangalore, India showed that even though 82% were aware about menstrual cups only 2.6% have used it.(9) Fortunately, some of the well performing districts in the country are now in their move towards menstrual cups.(7,10)
Most of the studies about menstrual cup come from low income countries where alternative options like sanitary napkins are considered unaffordable(11) and a very few research is conducted in Indian context. van Eijk et.al in their systematic review and meta-analysis reported that menstrual cups can be used internationally and had provided evidences on its safety and acceptability. The review had consolidated the data on the experiences of girls and women using menstrual cup from studies published till May 2019. But all the studies covered in the review were done as part of the programs that provided the women with menstrual cups and those studies accompanied some form education on its usage which might have influenced their experience. Although the menstrual cups were reported to be a comfortable and convenient option, it did not bring out the experiences of the women who use the cup on their own free will.(8) Exploring the experiences of the women who use the menstrual cup independently without an external influence will help to understand the motives behind using the cup and the difficulties and challenges faced in the absence of an external support and training. With this view in mind the present study was conceptualized to explore the experiences of women who started to use the menstrual cups with an independent will.
Materials and Methods
The study was conducted with a generic qualitative approach (12) with inductive thematic analysis (13) during the period from January 2020 to February 2020. The setting selected for the study was Kanayannur taluk of Ernakulam district in Kerala, India. The participants of the of the study were women who are permanent residents of the Kanayannur taluk, above 18 years of age, having regular monthly periods and using the menstrual cup with an independent will irrespective of any program intervention for a minimum of three consecutive cycles. Women having missed periods, undergone hysterectomy, having cancer, psychiatric or neurological disorders and menstrual irregularities were excluded from the study. The first three participants were identified through social media group in which the researcher is a member and the other participants were identified through snowball sampling. This helped the researcher to easily identify the subjects and to establish a trusting relationship with them. Data was collected using in depth face-to face interviews in local language with the help of a semi-structured interview schedule. The interviews were conducted either in their house or a convenient place selected by them. The researcher introduced herself to the participants and explained the purpose. The interview started with warm up questions about their menstrual cycle. Open ended questions were used to explore their experiences in using the menstrual cup along with probes on situations for starting, ease and difficulties faced and their comfort. The interviews were audiotaped and lasted for about 45 minutes to one hour. A total of 22 women were interviewed as data saturation was attained after interviewing the nineteenth participant. All the interviews were transcribed into verbatim on the same day.
The data were analyzed through the six phases of the thematic analysis given by Braun and Clarke (2006).(13) In the first phase the researcher had read the data sets several times to get familiarized with it. Secondly the most relevant segments in the data were extracted and were collated to form the initial codes. In the third phase these codes were sorted to form the potential themes. All the collated extracts were reviewed in the fourth phase and the validity of each was checked with the data set. The subthemes formed were grouped based on their similarities to form the main theme. In the fifth phase all the themes were once again reviewed and the report was written in the sixth phase.
In order to establish rigor, prolonged engagement with the data was ensured. The schedule was pilot tested with two women. The researcher has strived to bracket all her presuppositions and was an intensive listener. At the end of each phase, agreement was established between the two researchers and consensus was reached. The thematic summaries were checked with the participants and debriefing was done by another expert in the field.
Ethical considerations: Ethical clearance was obtained from the institutional ethics committee. Written informed consent was obtained from the participants before the interview. The anonymity and confidentiality of the data and the right of the subjects to withdraw from the study at any point of time was assured.
Results
Among the participants, twelve were graduates and ten were post-graduates. The women from urban and rural areas were eight and fourteen respectively. All of them were married. Fifteen women had given birth through normal delivery, six had undergone caesarian section and one was nulliparous. Currently two women were using copper-T, an intrauterine contraceptive device (IUCD) and menstrual cup simultaneously. Nineteen women came to knew about menstrual cups from their friends and others got information through social media. The other socio-demographic characteristics are given in Table 1.
Table 1: Socio-demographic characteristics of the participants [n=22] |
Participant |
Age in years |
Occupation |
Number of cycles using menstrual cup |
1 |
35 |
Nurse |
5 |
2 |
38 |
Unemployed |
18 |
3 |
31 |
Teacher |
10 |
4 |
37 |
Engineer |
24 |
5 |
34 |
Engineer |
24 |
6 |
36 |
Clerk |
18 |
7 |
42 |
Nurse |
5 |
8 |
33 |
Teacher |
12 |
9 |
34 |
Unemployed |
6 |
10 |
40 |
Teacher |
12 |
11 |
44 |
Unemployed |
30 |
12 |
42 |
Clerk |
18 |
13 |
33 |
Unemployed |
12 |
14 |
40 |
Clerk |
18 |
15 |
30 |
Nurse |
9 |
16 |
43 |
Clerk |
18 |
17 |
25 |
Unemployed |
36 |
18 |
41 |
Nurse |
5 |
19 |
41 |
Nurse |
5 |
20 |
33 |
Nurse |
5 |
21 |
38 |
Engineer |
12 |
22 |
49 |
Clerk |
18 |
After in depth thematic analysis 33 refined codes were extracted and were categorized under ten sub-themes based on the similarity in their meaning. These sub-themes were further categorized under the four main themes-experiences that led to the use of menstrual cup, experiences during the initial use of menstrual cup, experiences while getting adapted with menstrual cup and experiences with the subsequent use of menstrual cup [Table 2].
| Table 2: Codes, subthemes and main themes emerged from the data analysis |
Codes |
Sub-themes |
Themes |
-
Menstrual bleeding not manageable with pad
-
Staining of the clothes
-
Need frequent pad changes
-
Feeling hot and irritated when using pad
-
Itching and rashes in the thighs and vagina
-
Private area always soiled with blood
-
Need to secure before disposing
-
Lack of facilities for disposing
|
-
Excessive menstrual bleeding
-
Discomfort with the previous menstrual absorbent
-
Problem in disposing the menstrual absorbent
|
Experiences that led to the use of menstrual cup |
-
Enthusiastic and eager to try
-
Fear and anxiety before and during insertion
-
Insecurity feeling
-
Becoming conscious about presence of the cup
-
Doubt in position and technique of insertion
-
Pain during insertion and removal
-
Difficulty in taking out, thought of seeking medical care
|
|
Experiences during the initial use of menstrual cup |
-
Understanding how the cup suits for self
-
Severe pain and congestion with incorrect insertion
-
Displacement of the menstrual cup
-
Keeping additional pad for fear of leakage
-
Need time to get adapted with the cup
-
Regular emptying- holding time identified out of experience
-
Friend’s experiences and support influenced a lot
-
Demonstration videos in the social media
|
|
Experiences while getting adapted with menstrual cup |
-
Hygienic practices for preventing infections
-
Getting the menstrual cup ready for next cycle
-
Special care when using along with IUCDs
-
Convenient and comfortable to use
-
Identify the amount of menstrual bleed
-
Durable and affordable
-
Can go eco-friendly
-
Comfortable environment needed for emptying and reinserting the cup
-
Dislike continuous use
-
Difficulty in getting the cup ready for initial use
|
-
Caution taken while using menstrual cups
-
Differences felt from the previous menstrual absorbent
-
Problems faced while using the cup
|
Experiences with the subsequent use of menstrual cup |
Experiences that led to the use of menstrual cup
Excessive menstrual bleeding, discomfort with the previous menstrual absorbent and problem in disposing the menstrual absorbent were the three sub-themes that came under the main theme of experiences that led to the use of menstrual cups.
Excessive menstrual bleeding
The women expressed their difficulty in managing excessive menstrual bleeding with the pad. It had led to staining of their clothes that demanded frequent pad changes. “Before one year, I had severe bleeding, the situation was so worse, that I couldn’t manage with pads. For me, how to get out of this was the first thing.” (P10) Another participant commented, “It will take around two hours for me to reach the office. I fear to get up from my seat. I will slowly turn back to see for any staining” (P11)
Discomfort with the previous menstrual absorbent
More than half of them had discomfort while using the pads. The common problems pointed out by them were itching and rashes in and around their private parts. They also had a wet feeling and the area was always soiled with blood. “Pads were very much irritating for me. I had severe itching and there were rashes in my private area.”(P1) The area is always red, I abhor it. When going to toilet, I always keep tissues in my hand. (P4)
Problems in disposing the menstrual absorbent
The women found it difficult to dispose the menstrual absorbent due to spatial constraints and it the need to be secured before disposal. “Here it is difficult to dispose the pad. It’s not possible for me to burn. The houses are so nearby”. (P16) Another woman said, “Disposing. It was a big headache, it need to be wrapped, need to be taken out and burned”. (P15)
Experiences during the initial use of menstrual cup
The emotional feelings during initial use and the difficulties with the insertion and removal were the two subthemes.
Emotional feelings during initial use
A few women stated that they were excited to use the menstrual cups whereas eighteen of them had expressed their tension and anxiety before using the cup. But after the insertion all have commented that they felt like a foreign body sitting inside. Even some of them were not able to sleep well during night.
“I was eagerly waiting to see what it will be and how it will be.” (P10)
“I was more worried before inserting. I was thinking, till where it will go? Will it be able to take out? Like that a fear. After insertion, I felt like something sitting over there.” (P14)
Difficulties with the insertion and removal of menstrual cup
Most of them experienced difficulty in inserting the cup. They told that the position was not getting correct, whereas three of them told that insertion was not much difficult as they followed the user manual correctly. The women also experienced pain while inserting and removing the cup. They even had difficulty in removing the cup and thought of seeking medical care. “The first insertion, I really got frightened. Taking out was more difficult. I don’t know what all happen. Now I know it will come out. But that day I had a fear.” (P2)
Experiences while getting adapted with menstrual cup
This theme was formed by adjoining the two subthemes getting familiarised with the cup and peer and social media influence.
Getting familiarised with the cup
It took for the women nearly two to three cycles to get familiarized with the cup and to understand how it suits for them. All of them told that initially they were not able to keep the cup in correct position and it had resolved with practice. “It took long time for me to get adjusted. Initially when I placed, it didn’t become correct. Four times I changed back to pad.” (P8) Incorrect position has led to displacement of the cup and leakage. They have managed it by taking and reinserting the cup and also keeping a pad for support when they go out. “Initially when I used, there was leaking. It didn’t turn out to be a problem. I had kept a pad also.” (P6)
A few women experienced pain and pelvic congestion with incorrect position. “Sometimes when I place, I feel pain at peak level, just like delivering a baby. I don’t know whether it is because of the period or due to the cup. Then I will remove it and will try to keep it comfortably. Then I feel relaxed.” (P21)
The menstrual cup needs to be emptied at regular intervals and the women told that the holding time can be identified only with experience.“How long you keep or how frequent you change that will depend on your body. Some need to empty in the evening, some in the afternoon, likewise is the case with pad also.” (P22)
Two of them have told that the tail of the cup was a little long for them and they have removed it.
“The tail was very much irritating. It touches frequently. I cut it off completely. Now it is okay”.(P17)
Peer and social media influence
The women told that peer support had helped them a lot to adjust with the cup and they also had watched many videos about menstrual cup in social media.
“My friend explained me how to place it. The insertion was easy. The only thing was, initially I have placed the maximum towards out. So when I sit, I felt like something throbbing inside. Then she told me to insert little more in; afterwards no problem.” (P16)
Experiences with the subsequent use of menstrual cup
The three subthemes under this main theme were caution taken while using menstrual cup, differences felt from the previous menstrual absorbent and problems faced while using the menstrual cup.
Caution taken while using menstrual cup
Hand hygiene and cleanliness of the cup were taken cared by the women as they were identified as significant in preventing infections. “Before inserting, I always wash my hands with soap or else there is chance of infection”. (P17) Two women had reported that they had infection as they didn’t maintain proper hygiene. One woman had infection during the initial use and the other after six cycles and both got resolved with treatment. “First time when I used, I had infection. There was increased discharge and itching. From my experience, I understood two things; every time I need to wash the cup properly. Then after four hours I should empty the cup, even if there is bleeding or not.” (P20)
The women who used copper-T and menstrual cup simultaneously told that they took caution while inserting and removing the cup. One had put the copper-T before nine months and other before two years. “When removing the cup, I have a little pain compared to before. I don’t know whether both touch each other. I will remove the cup after feeling the thread (of the copper-T) only, or else it may break”. (P15)
Differences felt from the previous menstrual absorbent
The women expressed immense satisfaction in using the menstrual cup than their previous absorbents. They told that the cup was so comfortable that they had just felt it as an ordinary day. “We will be much free during the time. In the evening, I used to light the lamp and pray. If its pad, I know, I am not supposed to; this I will forget. Many times unknowingly I had lit the lamp.” (P7) The women said that they don’t have any discomfort as with the pad, no restrictions in the movement and found it convenient during travelling also. “Absence of smell is the greatest difference (P10) “My life changed, I am free. I can climb any height; I used to dance with it.” (P15) “It is comfortable to sleep. Before I used to lie as I was in coffin”. (P20) “This is very safe, even if when we go for a travel, while going for a tea, we can enter the bathroom and change it, no one will notice”. (P22)
They also found it economical, durable, readily available and eco-friendly. “I brought this for INR 350, since 2.5yrs I am using this; before that I need minimum three packets of pad for a cycle”. (P11) “It’s always available in our hands”. (P4) “Wastage is less. No issues like that of pad degradation. No need to burn”. (P6) The amount of blood loss can be correctly identified and was found beneficial for the women. “It became useful when I went to doctor for treatment of heavy bleeding. I could tell her exactly how much bleeding I had”. (P10)
Problems faced while using the menstrual cup
The women expressed dislike in changing the menstrual cup in a public toilet which is not clean. “I have not changed it anywhere else than my toilet. I don’t like it. The problem is we don’t know how much clean it is”. (P21)
Four of them told that they dislike using it continuously during a cycle. Dryness in the area, concern about complications and insertion during the last days for a little bleeding were the reported reasons. “The area will be dry. When it is taken out I feel like plastic touching my body”. (P18) “I have concern about how friendly this material will be with my body? Whatever it may be, it’s a manmade material”. (P21) “Why to insert it for a little, a thought like that. So I use pad on the last day”. (P7)
Three women expressed their difficulty in getting the cup ready on the first day as they don’t carry it while they go out and needs some time to get it ready. "I always keep a pad in my bag, it may not be possible to get the cup ready or insert when I am somewhere out”. (P20) “On the starting day; there is problem with getting the cup ready. It will take some time to boil and get it cooled. For that time I need a pad”. (P7)
Discussion
The present study was conducted to explore the experiences of the women related to the use of menstrual cups. The experiences that led the women to use menstrual cup were excessive menstrual bleeding, discomfort with the previous absorbent and difficulty in disposing. The women in the present study told that the bleeding was unmanageable and has led to staining of their clothes. Chintan et.al(14) and Tellier et.al(15) in their study commented that the participants reported staining of their clothes while using the pads and other materials which got resolved after using the cup. The women who attended the current study had itching, rashes and wetness in the area when using sanitary napkins. The findings were consistent with the experiences of the women from Kenya(16) and Uganda(15), where nearly half of them had preferred menstrual cup because of the problems with their usual menstrual products. Another motive for using menstrual cup was the difficulty with pad disposal and this was not commented by other studies. The difficulty expressed in those studies was related to cleaning the cloth napkins used during menstruation.(15,16)
Before the initial use of cup, a few women were excited whereas majority was anxious. The initial insertion and removal was difficult for them and after insertion it felt like a foreign body. A similar finding was pointed by Stewart et.al where the women using mooncup reported painful and uncomfortable insertion and difficulty with removal. They felt uncomfortable when the cup was placed inside.(17) The studies conducted in India(14,18) reported that the women had difficulty while inserting whereas the removal was easy. The insertion and removal was easy for the women as commented by North et.al(19). The studies conducted in Uganda(15) and Kenya(16) found that most of the women were excited to try the cup and only a few were afraid. But after insertion they told that they felt like something holding inside. The easy insertion, removal and the excitement to try the cup in those studies may be because the cup was either introduced as a part of a program or product review and accompanied detailed instructions on using it.
The present study found out that it took some time for the women to get familiarized with the cup and it became comfortable with practice. They initially had pain, displacement and leakage with incorrect position. Friends and social media influenced them in getting adapted. van Eijk etal. in their systematic review reported that the user familiarization with the cup occurred over time with practice and peer support.(8) North et.al(19)had pointed that the women in their study experienced cramping pain which got relived after removing the cup. The problem of leakage resolved after two to three cycles. The Indian studies(14,18) reported that the insertion and removal of the cup became more comfortable for the women over time with practice. Tellier et.al(15) in their study pointed out that peer support helped the women in getting adapted with the menstrual cup. An interesting finding in the present study was that some women had cut the tail of the cup so as to make it suit for them. None of the studies had a similar finding whereas Shihanta et.al(20) and Chintan et.al (14) in their studies have reported that few women have discontinued the cup as it was unfitting for them.
The interviews with the women revealed that they took at most care in maintaining hygiene while inserting, removing and cleaning the cup so as to prevent any infection. The Kenyan women who participated in a feasibility study on menstrual cups maintained strict hygiene for preventing infections.(16) Two women in the present study had reported infection which was similar to the study conducted in Gujarat (18) where two out of the 158 participants reported fungal or bacterial infection. Howard et.al(21) found a low prevalence of bacterial vaginosis with cups while no hygienic issues were reported by North et.al (19) and Tellier et.al.(15) Two women who were using menstrual cup and IUCD simultaneously took caution when removing the cup. Seale et.al had pointed out that IUCD expulsion occur due to the vacuum created when cup is in position and unintentional pulling out of IUCD string while removing the cup.(22) The women in the current study have so far not experienced any expulsion whereas Seale et.al’s report pointed IUCD expulsion among seven women. (22)
When compared with their previous menstrual absorbents, the women in the present study were satisfied with the cup as it was comfortable, convenient, economical, durable, eco-friendly and readily available. There was no foul odor, no restriction in doing activities and it correctly identified the amount of menstrual bleeding. The comments were similar with the previous studies in which the cup was found comfortable, free of irritations, bad odor, no interference with the activities, less leakage, less frequent changes, economic and ecofriendly.(8,15-19) van Eijk et.al commented that the menstrual cup was useful for the women with menorrhagia.(8)
The women in this study disliked changing the cup in an unclean environment. Stewart et.al (17) has reported that the women disliked changing the menstrual cup in public toilets where facilities were limited. Few women in the present study reported that they dislike frequent insertion and removal and continuous use owing to dryness in the area. Some women expressed difficulty in getting the cup ready for the first use and a concern over future side effects. Dislike towards frequent insertions and removal was reported by women from Kenya (16) and United Kingdom.(17) Dryness was reported by a few women from Gujarat but they found frequent emptying convenient.(18) None of the studies have reported concern towards side effects and difficulty in getting the cup ready for initial use.
To the knowledge of the researchers this is the first study from South India which has explored the experiences of women using menstrual cup at their own will and not introduced by an external agency. This study could explore the experiences of the women using the cup for a long duration and the number of cycles used varied between five and 36. The findings of this study differed from the previous literature mainly in terms of experiences of the women during the initial insertion. The lack of education and training on the use of menstrual cup had made the initial insertion and adaptation difficult. The findings of this study will be a guiding light for the woman who wish to use the menstrual cup on their own will and demands an intensive education and support from the provider. Even the policy makers and program managers who wish to include the menstrual cup as a menstrual hygiene management option can consider these findings while developing their training protocol. One of the limitations of this study was that the researcher couldn’t gather the data from unmarried women even though they must have been using menstrual cups; because inserting materials inside vagina before marriage is considered scandalous in Indian society.(6) As the study was done with a qualitative approach the generalization of the findings can only be considered by admitting the limitations.
Conclusion
Menstrual cup is a comfortable option for the women who face difficulties with their usual sanitary materials and it is plausible for those who have constraints with its disposal. The findings of the study demand providing the women with adequate awareness on the use of menstrual cup and further research is needed to ensure the safety and to rule out its long term impact.
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