Menstrual Cup use among Nulliparous Women: Breaking Taboos and Empowering Communities - A Scoping Review

Abstract

Menstrual cups offer a more comfortable menstruation experience, reducing disruptions to daily activities. They are eco-friendly and more cost-effective than other menstrual products. Our aim of the study was to understand menstrual cup use among nulliparous female and identify the challenges for their adoption and continued usage. Database-specific search strategies were formulated for Ovid, PubMed, Scopus, and Embase by using keywords such as “vaginal cup,” “menstrual cup,” and “nulliparous.” The search was conducted on November 15, 2024, and eligible studies published till November 1, 2024 were searched. Various study designs were considered, while studies that did not mention the proportion of nulliparous females among menstrual cup users were excluded. Out of 40 identified records, 11 studies were included after screening. Studies involving nulliparous females from various regions, including Canada, the USA, India, Colombia, Zimbabwe, and Kenya, suggest that menstrual cups constitute a safe and comfortable option for menstrual hygiene management (MHM). Nulliparous females encounter unique obstacles such as limited awareness of their reproductive systems, fears and restrictions related to the unscientific concept of virginity, and limited accessibility to menstrual cups. These barriers are compounded by minimal technical and social support. Nulliparous females also face specific issues such as increased menstrual bleeding and loss of school or college hours, which can significantly be mitigated by using menstrual cups. Evidence suggests that menstrual cups can be a safe and comfortable option for MHM among nulliparous females. It is essential to debunk social myths and taboos, provide accessibility to menstrual cups, offer training, and build confidence in young females from menarche. Engaging multiple personnel at different levels and receiving supportive guidance from healthcare providers are critical steps to increase public awareness and acceptance of menstrual cups.

INTRODUCTION

Menstrual hygiene management (MHM) is a significant challenge, especially in low- and middle-income countries. Concerns include environmental impact, cost-effectiveness, and potential adverse effects such as discomfort and leakage.[1] In India, a significant number of women, about 25%, face challenges in accessing sanitary methods for MHM. These challenges lead to inadequate menstrual health, which negatively impacts girls’ school participation, empowerment, overall well-being, and even survival.[2] Despite being a natural biological process, menstruation is associated with various social, cultural, and religious restrictions in many countries, potentially impeding the effective implementation of proper menstrual hygiene practices. Click or tap here to enter text.[3] The menstrual cup is a menstrual hygiene product made up of flexible, medical-grade silicon, which is inserted into the vaginal canal for the collection of menstrual fluid rather than absorbing it, making it more hygienic, unlike sanitary pads or tampons, during menstruation.[4,5,6] The cup comes in two different sizes; the smaller one is for nulliparous females or females younger than 30 years, while the larger one is for those who are older and have experienced a vaginal birth.[1] It can be retained for 6–12 hours before emptying the contents and easily cleaned and reused. It significantly reduces the waste generated from hygiene products used during menstrual cycles as it is reusable.[1,7] Hence, menstrual cups are eco-friendly and more cost-effective than other menstrual products, as a single cup lasts 8–10 years.[7,8] However, according to the National Family Health Survey-5 (NFHS-5, 2019–21), in India, only 0.3% of females aged 15–24 years have used menstrual cups.[2] Menstrual cups offer a promising alternative on a global scale to traditional sanitary products such as pads and tampons.[9] The aim of our study was to understand menstrual cup use among nulliparous females and identify the challenges for their adoption and continued usage.

METHODOLOGY

We conducted a scoping review to explore and synthesize evidence regarding the use of menstrual cups among nulliparous females. To ensure a robust and systematic approach, database-specific search strategies were developed for Ovid, PubMed, Scopus, and Embase. The search strategy utilized a combination of carefully selected keywords, including “vaginal cup,” “menstrual cup,” and “nulliparous,” connected using Boolean operators (AND/OR) to maximize the capture of relevant studies. The database searches were conducted on November 15, 2024. To streamline the process, we used Raayan®, a software tool designed for managing systematic reviews, to identify and remove duplicate records and organize the search results efficiently.[10]

Screening and selection process

Following the deduplication process, a thorough screening of titles and abstracts was conducted to assess the relevance of each study. Full-text articles of potentially eligible studies were subsequently retrieved and reviewed in detail to evaluate their alignment with the inclusion criteria. Studies were included if they met the following conditions: (1) were published in English up to November 1, 2024; (2) provided data on menstrual cup usage among nulliparous females; and (3) utilized study designs such as cross-sectional studies, case-control studies, cohort studies, randomized clinical trials, or systematic reviews. Studies that did not explicitly mention the proportion of nulliparous women/females among menstrual cup users were excluded from the review. Our review process adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for scoping reviews to ensure a transparent and methodologically sound approach.

Data extraction

Key characteristics of the included studies—such as the first author, publication year, study setting, population, and findings related to menstrual cup use among nulliparous females—were tabulated [Table 1].

Table 1.

Characteristics and Key Findings of Studies on Menstrual Cup Use and Challenges Among Nulliparous Females/Women (11 studies)

First Author, Year		Title		Study Setting		Study Population		Study findings on menstrual cup use and challenges among nulliparous female/women
Wiebe ER et al., 2012[11]		Does using tampons or menstrual cups increase early IUD expulsion rates		Canada		Healthy female volunteers (53 were nulliparous)		A significant number of nulliparous women used menstrual cups in this study.
Donoso MB et al., 2019[12]		Normality ranges of menstrual fluid volume during reproductive life using direct quantification of menses with vaginal cups		Columbia		Healthy female volunteers between 20 and 49 years (six participants were nulliparous)		The amount of menstrual blood loss was less among nulliparous women compared to parous females.
Mason L et al., 2019[13]		Comparing the use and acceptability of menstrual cups and sanitary pads by schoolgirls in rural Western Kenya		Kenya		School students aged 14–16 years		Girls had initial problems using the cup but reported that difficulties with insertion, removal, and comfort reduced over time.
Tembo M et al., 2020[14]		Menstrual product choice and uptake among young women in Zimbabwe: A pilot study		Zimbabwe		Young women aged 16–24 years		Menstrual cups on young women’s virginity were identified as a significant barrier to adoption.
Divakar H et al., 2020[15]		Menstrual health and hygiene- Study of knowledge attitudes and practices of obgyns on usage of menstrual cups		India (Karnataka)		Obstetricians and gynecologists		Despite evidence of the advantage of menstrual cups, health care provider lacks the convection and confidence to advise menstrual cups to girls and women. A recent 2018 report elicits the lack of education and awareness among the providers as well as consumers in our country as primary reasons for women not convincingly using menstrual cups. Awareness among healthcare providers on advocacy of eco-friendly measures to promote menstrual health and hygiene should be improved. It is all the more important that better researched educational advice be delivered to the consumers by the health care providers.
Singh R et al., 2022[16]		Study of Adaptability and Efficacy of Menstrual Cups in Managing Menstrual Health and Hygiene: A Descriptive Longitudinal Study		India (Bihar)		Women of more than 18 years of age		Adaptability increases gradually through proper counseling, peer support, practice, and consistency. Third time onwards, insertion and removal become easier for women. After the third cycle, 68% of participants agreed to continue using menstrual cups in our study. Awareness campaigns are also necessary for society.
Sreedevi C et al., 2022[6]		Experience and adaptability of menstrual cup as a menstrual hygiene management method among its users in Kerala		India (Kerala)		Women aged more than 18 years		More awareness campaigns and better availability of cups should be there in the community. Making available wash facilities in public places is also important to ensure better health and menstrual management.
Bowman N et al., 2023[17]		Menstrual cup and risk of IUD expulsion – a systematic review		Systematic review and meta-analysis		Systematic review and meta-analysis		Nulliparous women were using menstrual cup. Studies were from developed countries.
George M et al., 2023[18]		Assessment of knowledge and attitude towards menstrual cup usage among adolescent girls		India (Kerala)		Adolescent girls		The usage of menstrual cup was not only based on its knowledge but also based on its promotion, popularity, and support from family members
Davile M et al., 2024[19]		Exploring menstrual hygiene practices and awareness of menstrual cups among nursing professionals: A cross-sectional study		India (Maharashtra)		Nursing officers (84.15% were nulliparous)		Only one participant used a menstrual cup. They were aware that it could be used in nulliparous women, but they were not using it.
Brown JE et al., 2024[20]		Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial		United States of America		Sexually active participants aged 16–40 years		Eighty-four percent participants in this study were nulliparous female who used menstrual cup.

RESULTS

A total of 40 records were identified through database searches, including 12 from PubMed, 17 from Scopus, nine from Ovid, and two from Embase. Additionally, six records were identified through citation searching, bringing the initial total to 46. After removing six duplicate records, 34 unique records remained for screening. During the screening process, 27 records were excluded based on relevance or eligibility criteria, leaving 13 reports for retrieval. All 13 reports were successfully retrieved, with no instances of reports being unavailable. These reports were further assessed for eligibility, and two were excluded—one because the full text was not available in English, and another because it did not measure the intended outcome of interest. As a result, 11 studies met the inclusion criteria and were included in the final review [Figure 1].

Figure 1.

PRISMA flow chart depicting the selection process of articles

Studies involving nulliparous women from various regions, including Canada, the USA, India, Colombia, Zimbabwe, and Kenya, suggest that menstrual cups can be a safe option for MHM. These findings highlight the potential of menstrual cups to address the menstrual hygiene needs of nulliparous women across different cultural, social, and economic contexts. The findings from the reviewed studies on the challenges faced by nulliparous females in using menstrual cups were categorized into four key domains for better understanding. These domains are: limited anatomical and physiological awareness, the “virginity” myth, accessibility and technique, and support systems for menstrual cup usage. Each of these themes highlights distinct barriers that influence the adoption and effective use of menstrual cups among this population. A detailed description of each domain is provided below [Table 1].

Limited anatomical and physiological awareness

Nulliparous women, predominantly adolescent girls and young adult women, often exhibit a significant lack of knowledge about their reproductive anatomy and physiology. This knowledge gap encompasses crucial aspects of their bodies, including the vulva, vagina, and cervix.[21] The primary factor contributing to the hesitancy in trying menstrual cups is the fear driven by this inadequate understanding of their anatomy.[14] This fear is compounded by widespread misinformation and persistent myths surrounding menstrual health, making it even more challenging for nulliparous women to consider menstrual cups as a viable option.[9]

The “Virginity” myth

Virginity is primarily a social construct that lacks a scientific basis.[9] The background behind this concern is the belief that the hymen, which is said to tear with the first sexual intercourse of the female, could be affected by the insertion of the menstrual cup as well. This belief threatens the human and reproductive rights of females.[22] Additionally, the hymen could break or stretch out due to high-intensity exercises such as cycling or horse riding apart from sexual intercourse alone.[13,23]

Accessibility

In our society, where discussing menstrual health is still frowned upon, menstrual products’ accessibility, especially that of menstrual cups, is limited. Though menstruation hygiene products are essential, discussions about them are frequently stigmatized, restricting their access.[6,24] It is imperative to tackle these obstacles and foster a conversation regarding menstrual health to ensure that everyone can access the supplies and knowledge required to manage menstrual hygiene appropriately.[15]

Technique and support system for menstrual cups

In nulliparous women, there is an increased need for a proper explanation of the insertion, usage, and cleaning of menstrual cups.[13,25] This is especially important due to limited awareness of the anatomical parts involved and the steps required for its proper use.[9,21] A supportive system that provides clear instructions and guidance can help nulliparous women feel more confident and comfortable using menstrual cups.[16,25]

DISCUSSION

Studies from various regions around the world indicate that menstrual cups provide a safe and comfortable option for MHM among nulliparous females, irrespective of sociodemographic differences.[4,5,16] For clarity, the discussion is divided into two parts: the first part focuses on the benefits of menstrual cups for nulliparous female [Figure 2], while the second part explores empowering strategies to encourage the adoption of menstrual cups among nulliparous females [Figure 3].

Figure 2.

Benefits of menstrual cup for nulliparous females

Figure 3.

Strategies for nulliparous females embracing menstrual cups

Benefits of menstrual cups for nulliparous females

Reduced incidence of adverse effects

The presence of menstrual cups has no impact on the vaginal flora. Indeed, evidence suggests a lower incidence of urogenital infections, encompassing bacterial vaginosis, compared with sanitary pads or tampons.[6,26] Compared to other menstrual products, reduced rashes are reported in females using menstrual cups (often a known adverse reaction associated with products such as sanitary pads).[9]

Enhanced comfort

Menstrual cups provide comfort and ease while participating in high-intensity/movement activities such as sports. Most women who used the product recommended it to other women. Additionally, this leads to a less stressful and more comfortable transition after menarche.[16,27]

Improved attendance

It is known that following menarche, the first few menstrual cycles have increased menstrual bleeding. This could lead to missed school or college days. Studies have shown better comfort and reduced need for leave from school or college in participants who used menstrual cups.[28,29] Additionally, this could lead to an overall improvement in the experience in these first few months.[16]

Eco-friendly

Environmentally, menstrual cups are a much friendlier choice. Disposable sanitary products generate substantial waste every cycle, contributing to environmental pollution and landfill accumulation. By reducing the need for frequent purchases, menstrual cups help minimize this waste, making them a sustainable option that supports ecological conservation.[1,15]

Cost-effectiveness

The menstrual cup offers a significant financial advantage. One of the most notable benefits is their long-lasting nature; a single menstrual cup can be used for several years, making it a cost-effective option compared to disposable alternatives.[8] In contrast, products such as pads and tampons must be purchased repeatedly throughout the year, leading to continuous expenditure.[30]

Empowering strategies for embracing menstrual cups among nulliparous female

Menstrual cups are often regarded as superior to pads or cloths in terms of convenience and discretion in washing, drying, and storage, as well as comfort, leak protection, odor control, quality, and duration of use.[6] The strategies to improve the uptake of menstrual cups among nulliparous women are described below.

From knowledge to action - encouraging the adoption of menstrual cups through education

Education and awareness are pivotal in introducing and popularizing menstrual cups among women.[16] Due to limited exposure, many women may not be familiar with menstrual cups or lack a comprehensive understanding of how to use them effectively.[31] By offering education on the anatomy of the female reproductive system along with a focus on menstrual cups, misconceptions and myths surrounding their usage can be addressed.[31,32] These efforts demystify menstrual cup usage and empower women with accurate information, encouraging greater adoption and acceptance of this sustainable menstrual hygiene solution.[16,24,32,33]

Beyond the cost and distance - ensuring equitable access to menstrual cups

Access and affordability are significant barriers hindering the widespread adoption of menstrual cups, particularly among low-income countries. The cost of menstrual cups can pose a challenge for those with limited financial resources, rendering them inaccessible to many. Access to menstrual cups may be further restricted in rural areas, where resources are often scarce.[31] To address this issue, it is imperative to make menstrual cups more readily available and affordable, particularly in underserved regions.[6] Implementing subsidy programs or community-based distribution networks can help improve access to menstrual cups for women across socioeconomic backgrounds.[32,33]

Bridging the gap - a culturally sensitive approach to the promotion of menstrual cups

In India, cultural and religious beliefs can lead to discomfort or hesitation among some females when considering the use of menstrual cups. Adopting a culturally sensitive approach that respects and acknowledges these beliefs is crucial to promoting menstrual cups.[24,30] This involves understanding the diverse cultural contexts and traditions influencing menstrual hygiene practices and tailoring educational efforts accordingly. Efforts to encourage menstrual cups should include engaging with community leaders, religious figures, and influencers who can help bridge the gap between traditional practices and modern menstrual hygiene solutions.[15,24,25] Additionally, creating educational materials that are culturally relevant and delivered in local languages can foster greater acceptance. Providing platforms for women to share their experiences and concerns is essential, ensuring their voices are heard and respected.[6,18]

Shattering myths - empowering menstrual cup users

Addressing myths and misconceptions surrounding menstrual cups is pivotal for enhancing acceptance and usage among women in LMICs. Common misconceptions, such as the belief that using menstrual cups can compromise virginity or that they are not suitable for heavy menstrual flow, need to be debunked.[9,12,14] By addressing these misconceptions and offering accurate information, particularly with the guidance of female healthcare providers, we can empower women with knowledge and encourage them to view menstrual cups as a viable menstrual hygiene option.[15,16,24,25] This proactive approach facilitates informed decision-making and cultivates greater acceptance and utilization of menstrual cups, improving menstrual health outcomes.

Building confidence from day one - assisting new menstrual cup users

Support and guidance are essential for women who are new to using menstrual cups, particularly during the initial stages of adoption. Offering comprehensive information on inserting and removing the cup and addressing common concerns such as leaks and discomfort can significantly enhance women’s confidence in using menstrual cups effectively.[32,33] By offering handholding support and fostering a supportive environment, we can empower women to embrace menstrual cups as a sustainable and comfortable menstrual hygiene option for the long term.[25,30]

Navigating challenges in hygiene and sanitation for menstrual cups

Enhancing hygiene practices and offering guidance on cup maintenance in diverse settings can significantly improve its efficacy. Though menstrual cups present a sustainable and practical solution for maintaining hygiene during periods, the need for clean water and private sanitation facilities poses a significant hurdle. By promoting hygiene practices tailored to the local context, we can empower women with the knowledge and skills to effectively clean and sanitize menstrual cups in any environment.[6]

Ensuring the safe use of menstrual cups

Although complications related to menstrual cup use are typically rare, it is prudent to uphold proper hygiene through a few recommended precautions to minimize the risk of infections or adverse reactions.[7,34] Before using the menstrual cup at the start of each cycle, make sure to sterilize it by boiling or using steam sterilizers. It is crucial to thoroughly wash your hands both before and after handling the cup to maintain hygiene. Additionally, always inspect the cup carefully before insertion to ensure that it is in good condition.[15] Between menstrual periods, store the cup in a clean, dry place to keep it ready for use.

CONCLUSION

Menstrual cups can be used by nulliparous women. Mothers are often the primary source of information about menstruation. Key predictors of better menstrual practice are maternal awareness, post-puberty menstrual talks with family, and the type of menstrual hygiene method used. Therefore, a comprehensive health education program involving mothers is crucial to dispel misconceptions and taboos associated with menstruation, making it a positive experience. Additionally, involving teachers and parents and engaging community leaders and influencers who can help bridge the gap between traditional practices and modern menstrual hygiene solutions about reproductive health is essential. Healthcare providers can offer supportive guidance by encouraging and educating nulliparous women on using menstrual cups as a reliable product. Promoting menstrual cups requires introducing them to society and understanding their use, safety, efficacy, and willingness to recommend them, helping young women navigate their menstrual experiences comfortably and confidently.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.