Period panties and menstrual cups, eco-friendly pads and tampons: a more sustainable approach to feminine hygiene

In ancient Egypt, it has been reported that women used tampons made from papyrus [1]. In the Middle Ages, women did not wear undergarments and therefore used no protection. The flow was often freely released while in other eras, menstrual skirts were worn [2].

During the 1920’s, modern FHP were introduced. During the First World War, French nurses discovered that cellulose fibre was more absorbent than cotton for controlling hemorrhages. At the end of the war, Kimberly-Clark used the surplus fibre to create the first Kotex menstrual pads that were held in place with a satin belt or adhesive strip.

In the early 1930’s, Dr. Earle Haas filed a patent for a cotton tampon equipped with a string for easy removal. Pads and tampons then mainly evolved with chemical changes to improve their absorption capacity, the addition of perfumes and the creation of increasingly sophisticated packaging [2].

The rubber menstrual cup made its first appearance in 1937. Its main advantage over pads and tampons was its ability to stay in place for 8 to 12 hours. In the late 1990’s, the silicone menstrual cup, which was softer and malleable, was introduced on the market, followed by the menstrual disc.

With heightening concern for environmental issues and considering the large quantity of trash generated by menstrual pads and tampons containing plastic, an increasing number of “organic” products have emerged. They promise an approach that is theoretically healthier, fragrance- and chemical component-free, and are more easily biodegradable, since they do not contain plastic [3]. Washable menstrual underwear, which significantly reduces waste, is also available, and reminiscent of the menstrual skirts from the previous century [2].

There are many scientific and medical concerns when it comes to FHP. On one hand, there is a concern relating to exposure to potentially hazardous chemical components such as endocrine disruptors and substances able to alter vaginal pH. On the other, an important medical consideration is the rare but serious risk of toxic shock associated with the extended use of tampons and other intravaginal devices.

In 2023, a toxicology research group from INRS-UQAM published an exhaustive review of scientific literature focusing on the presence of hazardous chemical components in FHP and their potential toxic effects [1]. The main finding was twofold: 

• FHP contain myriad chemical components that are potentially hazardous, even in low concentrations
• There is a scarcity of well-structured scientific studies on their long-term effects. 

The problematic chemical components in FHP include a variety of heavy metals such as lead, as well as potential endocrine disruptors like phthalates and parabens. These endocrine disruptors have been associated with health disorders such as endometriosis, transgenerational infertility and breast cancer. Other substances, such as heavy metals, have been linked to neurological problems, irritations, allergies and even skin cancers. 

The safety of most of the potentially toxic components at concentrations found in FHP was assessed using skin absorption tests, often conducted on animals or on human skin. Nonetheless, toxicity studies conducted on the skin cannot fully reflect the complexity of vaginal mucous membranes, which are far more vascularized and exposed to a range of components over a period of around 40 years. According to the authors of the literature review, this limitation should, at the very least, justify the application of the “precautionary approach” until more structured studies can be carried out.

Toxic shock syndrome (TSS) is a rare but potentially fatal complication that occurs with certain bacterial infections such as those caused by Staph. aureus and Group A streptococcus. TSS can affect anyone, including men, children and post-menopausal women [4]. The infamous “flesh-eating disease,” or necrotizing fasciitis, is one example of the effects of toxins released by the aforementioned bacteria.

In women, TSS has been linked to the use of tampons and other devices such as menstrual cups, contraceptive sponges and diaphragms.

The signs and symptoms of TSS include:

• Sudden high fever
• Drop in blood pressure
• Vomiting and diarrhea
• Skin rash resembling a sunburn on the palms of hands or soles of feet
• Muscle pain
• Sores on the eyes and in the mouth or throat
• Headaches, confusion and convulsions

The origins of TSS lie less in the composition of the menstrual tampon and more in the presence, in approximately 1% of women, of toxic bacteria that are naturally present in very low quantities in the vagina. Certain conditions, such as using intravaginal menstrual protection (tampons) for more than six hours, can cause these dangerous bacteria to multiply. The risk of TSS is doubled if a tampon is left in for more than six hours and tripled if it’s left in overnight. It is therefore recommended using another form of menstrual protection overnight and especially, carefully reading the instructions for any products used [5].

Throughout her life, a woman will use between 12,000 and 15,000 FHP, generating 110 to 135 kg of waste. In Quebec alone, this represents more than 2,700 tons of waste per year composed of 90% non-biodegradable plastic that will remain in nature for 500 to 800 years [6,7]. Taking into consideration the cycle of production, transport, use and elimination, non-organic and single-use menstrual pads are the most harmful to the environment. They have the highest “potential for global warming,” mainly due to the manufacture and production of the component polyethylene, a plastic derived from petrol. 

Fortunately, there are several ways to reduce this ecological footprint. The first is to replace single-use FHP with reusable versions. Menstrual cups are considered the best choice in this respect, representing, over a 10-year period, less than 5% of the footprint left by single-use products. The ecological footprint of menstrual discs (also made from silicone) is around the same; however, the impact of menstrual underwear is still unknown.

According to the Réseau québécois d’action pour la santé des femmes (RQASF), menstrual product insecurity refers to the difficulty a woman has in obtaining access to FHP, regularly or even occasionally, due to financial constraints [8].

According to a 2020 survey, 12% of Quebecers have had to face a difficult choice with respect to purchasing FHP or other essential items. During a 2019 cross-Canada survey of women aged 14 to 55, 34% of Quebecers said they had to sacrifice other essentials (rent, food, recreation, clothing, etc.) to purchase FHP [1].

The preferred solution for women’s rights associations is the free supply of FHP and containers for their elimination at all public venues, in the same manner as soap and toilet paper. These venues include libraries, swimming pools, schools and men’s washrooms to offer equitable services to men who are trans and non-binary, etc. It is also recommended that at workplaces, this same program be covered by the employers.

Among the initiatives already in place, Scotland was the first country to introduce a free FHP program in 2020, applicable in both schools and public venues. In Canada, British Columbia was the first province to offer free FHP at its schools in 2019 followed by several other [9]. New Brunswick has been offering FHP at its 63 public libraries since summer 2023 [10].

Since December 15, 2023, the Government of Canada has required that all employers in its jurisdiction, including federal employees, and bank employees, crown corporations, airports and rail terminals, provide their workers with free FHP as well as waste containers [11].

Several Ville de Montréal boroughs have implemented subsidy programs to cover part of the purchase costs for FHP that are less polluting, such as menstrual underwear, washable pads and menstrual cups. For example, the Mercier-Hochelaga-Maisonneuve borough is temporarily offering a 66% refund (up to $50) for citizens in the borough who want to make the change, and a 100% refund (up to $75) for low-income households [12].

In several countries, the elimination of tax on FHP confirms that at least in these nations, FHP cannot be considered as luxury items. In Quebec, these items have been tax-free since 2015. In the United States, 25 states do not apply sales tax to FHP. Shockingly, one European Union policy prohibits member countries from lowering taxes on FHP to under 5% [13]!

Choosing a feminine hygiene product depends on several factors, specifically anatomy and physiology (flow), lifestyle (sedentary, athletic), personal preferences, environmental sensitivity, advertising and, in many cases, available budget. Despite the awkwardness that still shrouds discussions on the topic, it’s encouraging to see that progress is being made with the major aspects of FHP, such as toxicological and environmental, and menstrual product security.