Prevalence of menstrual cup usage among reproductive-age women in asian countries: a systematic review and meta-analysis

Abstract

Background

Effective menstrual hygiene management (MHM) is essential for women’s health, especially in low-resource settings. Menstrual cups are an eco-friendly and cost-effective alternative to disposable menstrual products. This study aims to systematically review the prevalence of menstrual cup use across Asian countries, providing insights into its acceptance, and potential for wider adoption.

Methods

The study protocol was registered in PROSPERO (CRD42024546114). A systematic search was conducted in PubMed, Scopus, EMBASE, CINAHL, and Ovid up to June 2023. Study quality was assessed using the Joanna Briggs Institute (JBI) tool. A meta-analysis was performed using Generalized Linear Mixed Models (GLMMs) with logit transformation. Heterogeneity was evaluated using the I² statistic and Cochran’s Q test, and a random-effects model was applied. Publication bias was examined through visual inspection of funnel plots and tested using Begg and Mazumdar’s rank correlation method. Statistical analyses were conducted using the Meta and Metafor packages in R software.

Results

The study identified 3,919 records from various databases, including PubMed (624), Scopus (1,824), EMBASE (998), CINHAL (181), and Ovid (178). After removing 1,641 duplicate records, 2,278 records were screened, out of which 13 studies that reported the prevalence of menstrual cup usage were included in the final analysis. The pooled prevalence of menstrual cup usage was estimated at 2.68% (95% CI: 1.24%–5.67%), based on a total sample size of 257,347 individuals. The pooled estimate did not change significantly in subgroup analysis and sensitivity analysis. However, substantial heterogeneity was observed (I² = 99.6%), indicating significant variation across studies.

Conclusion

Menstrual cup usage among Asian women remains limited and is primarily confined to a specific, educated subgroup. Due to the high heterogeneity of studies, the pooled estimates should be interpreted with caution. Future research should focus on community-based epidemiological studies to gain a better understanding of adoption patterns, address barriers, and promote acceptance among reproductive-aged women.

Trial Registration

The study protocol was registered in PROSPERO (Registration ID: CRD42024546114)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-026-04276-7.

Introduction

The menstrual cup, a reusable, medical-grade silicone or rubber device, offers a sustainable, cost-effective, and environmentally friendly alternative to disposable menstrual products [1–3]. Menstrual cups collect rather than absorb menstrual fluid, reducing the risk of irritation and infection. Menstrual cups are environmentally friendly alternatives to traditional disposable products, significantly reducing waste and consequently minimizing the ecological footprint associated with menstruation [1, 4, 5]. Recent evidence has highlighted the potential health benefits of menstrual cups beyond their economic and environmental advantages. A prospective longitudinal study has reported that the use of menstrual cups is associated with maintaining a healthy vaginal microbiota [6]. Additionally, these cups can hold a greater volume of menstrual fluid, allowing for longer wear time up to 12 h without the need for frequent changes, thereby providing convenience and flexibility in various lifestyles. [7] The cups, which are reusable and designed to create a seal to collect menstrual fluid, offer a more sustainable alternative with a shelf life of 8–10 years [1, 8, 9].

Menstrual health is a crucial yet often overlooked aspect of women's reproductive health, particularly in the Asian region, where cultural taboos, economic constraints, and limited access to menstrual hygiene products pose significant challenges, even among educated populations, including healthcare providers [10, 11]. A recent study conducted in Tamil Nadu, India, among doctors, reported a prevalence of menstrual cup use of only 4.4% [8, 11–13]. Access to safe, hygienic, and affordable menstrual products is essential for maintaining dignity, health, and social inclusion. Traditional menstrual products such as sanitary pads and tampons remain the most commonly used options; however, concerns related to cost, environmental sustainability, and health risks have led to an increasing interest in alternative solutions. [4] According to a report from the United Nations Children’s Fund, UNICEF, in some Asian countries, adolescent girls and adult women are having difficulties in finding clean, private and safe facilities for Menstrual Hygiene Management (MHM) at school and in workplaces [14, 15]. Also did not have sex-segregated toilet facilities, adequate water supply or disposal systems, which would allow for appropriate menstruation management. So, in some parts, girls are not allowed to go to school during their menstruation. Therefore, they are more likely to miss school [13, 15, 16].

In Asian regions, MHM are deeply influenced by cultural norms, economic constraints, and access to sanitary products [17, 18]. Many women continue to rely on traditional methods, such as reusable cloth and homemade pads, which, if not managed properly, may pose hygiene risks [13, 19]. In recent years, menstrual cups have emerged as a sustainable and cost-effective alternative, offering benefits for both personal health and environmental conservation [4, 8, 20, 21]. However, the prevalence of menstrual cup use in the Asian context is not known. This study aims to systematically review the prevalence of menstrual cup use across Asian countries, providing insights into its acceptance and potential for wider adoption.

Methodology

Protocol and registration

The study protocol was registered in PROSPERO (Registration ID: CRD42024546114). To the best of our knowledge, no prior systematic review on this topic has been registered or published in the public domain. This systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines [22].

Search Strategy

We prepared database-specific search strategies for MEDLINE/PubMed, SCOPUS, EMBASE, CINAHL, Cochrane, and Ovid databases. The search strategy was formulated to identify articles on the use of menstrual cups in various countries from the Asian continent, published up to June 1, 2023. The search strategy was restricted to the studies published in the English language. We developed our search strategy using the PEO framework, where ‘P’ represented Asian countries, ‘E’ represented the menstrual cup, and ‘O represented usage. We incorporated synonyms for each PEO component and applied relevant MeSH terms from PubMed to enhance the search sensitivity. To ensure comprehensive coverage, we included the names of all individual Asian countries as well as the broader term “Asia,” along with multiple synonyms for menstrual products. This approach helped capture all potentially relevant studies. The complete search strategies and the number of articles retrieved from each database are provided in the supplementary table (Supplementary Table 1).

Study selection criteria

We included studies that reported the prevalence of menstrual cup use among women residing in any country in Asia. We included studies that reported the prevalence of menstrual cups among women aged 10 years or older, with the availability of an actual number of study participants who had ever used or were currently using menstrual cups. “Ever used” refers to women who have tried using a menstrual cup at least once, whereas “current use” refers to women who are using a menstrual cup at the time of the study/survey. The studies did not report the prevalence of menstrual cups; mentioning the prevalence of other safe menstrual product usage was excluded from the study. We included only observational studies for the systematic review and meta-analysis. This meta-analysis excluded review articles, letters to the editor, commentaries, viewpoints, case series, case reports, conference abstracts, and clinical trials.

Steps for selection

Two reviewers (SMB and DKP) independently screened the titles and abstracts of identified records for inclusion in the review. The full text of all records passing the title and abstract screening was retrieved. Two reviewers independently (PB and AR) confirmed final eligibility. Discrepancies in data were resolved either by consensus or by seeking additional information from the author(s) of the study. In case of disagreement between two reviewers (SMB and DKP)/(PB and AR), arbitration was done by the other two authors (VY and EVR).

Quality assessment

We used the 9-item checklist formulated by the Joanna Briggs Institute (JBI) for the quality assessment of the cross-sectional studies. Each item was scored as 0 or 1 based on the information available from the study. We reported the total score for each article. During the quality assessment of the articles, any discrepancies between reviewers were resolved using the same procedures described above for the study selection process. The risk of bias in individual studies is mentioned in the table (Supplementary Table 2).

Data extraction

Two reviewers extracted study details, including the author, publication year, study location, study participants, variables assessed, main findings, and risk of bias. Data extraction was performed using a standardized data extraction format in Microsoft Office Excel.

Statistical procedure

This meta-analysis estimates the prevalence of menstrual cup use across Asian countries. These estimates were derived from selected studies, and a pooled prevalence was subsequently calculated. Generalized Linear Mixed Models (GLMMs) with logit transformation were applied to determine effect sizes for each study, given their appropriateness in this analytical context [23]. Heterogeneity among studies was assessed using the I² statistic and Cochran’s Q test. Due to substantial methodological variations across studies, a random-effects model was employed for analysis [24]. Confidence intervals for individual study effect sizes were computed using the Clopper-Pearson method. All effect sizes and pooled estimates are reported as proportions with 95% confidence intervals. Publication bias was examined through visual inspection of funnel plots and tested using Begg and Mazumdar’s rank correlation method [25, 26]. Data extraction was performed using Microsoft Excel 2021, while statistical analyses were conducted using the Meta and Metafor packages in R software [27, 28].

Results

The study selection process followed a systematic approach, identifying 3,919 records from various databases. After removing 1,641 duplicate records, 2,278 records were screened, out of which 2,045 were excluded based on relevance. Following screening, 233 articles were sought for retrieval, but 16 could not be retrieved. Subsequently, 217 full articles were assessed for eligibility, of which 204 were excluded, and 13 studies that reported the prevalence of menstrual cup usage were included in the final analysis (Fig. 1).

Fig. 1.

PRISMA Flow Diagram of Study Selection Process

The key characteristics of 13 studies identified for this meta-analysis are summarized in Table 1. The majority of the studies were from India. The study populations were diverse, including adolescent girls, college/university students, nurses, and women of reproductive age, across school, community, and healthcare settings. Sample sizes varied widely, ranging from 127 to 241,983 participants, with the largest being a secondary analysis of NFHS-5 data. All studies employed a cross-sectional design, reflecting the observational nature of evidence of menstrual cup usage (Table 1).

Table 1.

Key Characteristics of Studies Included in the Meta-analysis

No	Study (Author, Year)	Study Population	Study Setting	Sample Size (Total)	Study Design
1	Abraham et al., 2023 [1]	College Students	Kerala, India	196	Cross-sectional
2	Ballal et al., 2020 [8]	Women of Reproductive Age	Mangalore, Karnataka, India	300	Cross-sectional
3	Choi et al., 2021 [12]	Female Nurses (18–45 years)	South Korea (Korea Nurses’ Health Study)	8,658	Cohort-based cross-sectional
4	Devan et al., 2022 [4]	Adult Females (Reproductive Age)	Urban South Kerala, India	350	Cross-sectional
5	Huang et al., 2019 [ 35 ]	Female University Students	Taiwan	1,245	Cross-sectional
6	Joseph et al., 2022 [29]	Urban Women	Bengaluru, India	240	Cross-sectional
7	Karjee et al., 2023 [30]	Young Women (15–24 Years)	India (National Survey)	241,983	Cross-sectional (Secondary analysis of NFHS-5)
8	Lekshmi et al., 2022 [31]	Girls and Women	Four districts (Kancheepuram, Coimbatore, Madurai and Thiruvallur), Tamil Nadu India	400	Cross-sectional
9	Parikh et al., 2022 [18]	Adolescent Girls (University Students)	Gujarat, India	127	Cross-sectional
10	Parmar et al., 2022 [17]	Adolescent School Girls (10–19 years)	Mehsana city, Gujarat, India	398	Cross-sectional
11	Saranya et al., 2019 [32]	Adolescent Girls	Salem, Tamilnadu,India	500	Cross-sectional
12	Sivakami et al., 2019 [33]	School Girls (Government Schools)	Three Indian states (Chhattisgarh, Maharashtra and Tamil Nadu)	2,564	Cross-sectional
13	Srinivasan et al., 2019 [34]	College Students	Bengaluru, India	386	Cross-sectional

The quality assessment of the included studies was conducted using the 9-item Joanna Briggs Institute (JBI) checklist for cross-sectional studies. The methodological quality of the included studies was assessed using a structured 9-item critical appraisal checklist. Out of the 13 studies, 10 were rated as good quality (total score ≥ 5), while three studies-Saranya et al., 2019, Lakshmi et al., 2022, and Parikh et al., 2022-scored ≤ 3 and were considered of poor quality. (Supplementary Table 2).

This meta-analysis included 13 studies [1, 4, 8, 12, 17, 18, 29–35], encompassing a total of 2,57,347 participants and 1,217 events. Using a random-effects logistic regression model with logit transformation, the pooled prevalence of menstrual cup use was 2.68% (95% CI: 1.24% to 5.67%) (Fig. 2).

Fig. 2.

Forest Plot of 13 included Studies in the Meta-analysis

The pooled estimate of the prevalence of menstrual cup use did not differ significantly in sensitivity analysis after excluding poor-quality studies, nor in subgroup analysis. The model incorporated a maximum-likelihood estimator for between-study variance (tau²), accounting for the wide variability in prevalence reported across studies. The analysis was conducted using events per 100 observations (%) as the summary measure. There was substantial heterogeneity among the included studies, with an I² value of 99.6% (95% CI: 99.6% to 99.7%), tau² = 1.9429, and H = 16.88 (95% CI: 15.72 to 18.12), indicating very high between-study variability. The heterogeneity was statistically significant, as shown by both the Wald test (Q = 3418.41, df = 12, p < 0.0001) and the likelihood ratio test (LRT = 2107.99, df = 12, p < 0.0001). In subgroup analysis, the pooled estimate of the prevalence of menstrual cup use for Indian studies was 2.64% (95% CI: 1.07% to 6.37%), while that for non-Indian studies was 2.73% (95% CI: 1.25% to 5.86%) (Fig. 3).

Fig. 3.

Subgroup Analysis: Forest Plot Comparing Studies from India and Other Countries

The test for subgroup differences was non-significant (χ² = 0.00, df = 1, p = 0.9601). A sensitivity analysis was performed by excluding three poor-quality studies to evaluate the robustness of the pooled estimate. The prevalence of menstrual cup use in good-quality studies was 2.22% (95% CI: 1.11%–4.42%), compared to 4.70% (95% CI: 0.47%–33.81%) in poor-quality studies. The overall pooled prevalence was 2.68% (95% CI: 1.24%–5.67%), which closely aligns with the estimate from good-quality studies (Fig. 4).

Fig. 4.

Sensitivity Analysis: Forest Plot Excluding Poor Quality Studies

This suggests that the overall findings are not significantly affected by the inclusion of lower-quality studies. The funnel plot showed asymmetry, raising the possibility of publication bias; however, this must be interpreted cautiously given the high heterogeneity and the limited number of studies [36] (Fig. 5).

Fig. 5.

Funnel Plot for Assessing Publication Bias

Discussion

This is the first meta-analysis quantifying menstrual cup prevalence in Asia. The findings of this meta-analysis highlight key trends and challenges in menstrual cup (MC) use as a part of MHM in Asian countries. Despite its potential as a cost-effective and environmentally sustainable alternative to conventional menstrual hygiene products, the adoption of MCs is low and remains limited to specific subgroups within the population, primarily those with higher education levels [8, 12, 37]. Menstrual cup use in Asia is largely restricted to women from educated backgrounds, such as university students, healthcare workers, and college students [1, 4, 5]. Most studies assessing MC use are conducted within these populations, with limited data from the general community. This selective representation makes it challenging to understand broader societal acceptance and barriers to use among diverse socio-economic groups. Moreover, the prevalence of MC use is reported in two forms: "ever used" and "currently using," with a few groups of women trying MCs but discontinuing them due to a primary lack of support/handholding during the initial period of their use [4, 37]. Most of the included studies on menstrual cup use reported current use of menstrual cup. Emerging qualitative evidence from Asian settings highlights several socio-cultural and infrastructural barriers to menstrual cup uptake, including taboos around vaginal insertion, concerns related to virginity, and limited access to private sanitation facilities [10, 38, 39].

Substantial heterogeneity was observed across the included studies due to wide variations in sample size, population characteristics, and measurement approaches. Sample sizes ranged from small community-based surveys to very large national datasets, such as Karjee et al. (2023), which included over 240,000 participants. Differences in study populations (e.g., adolescents vs. adults; school-based vs. community-based samples) and variations in how menstrual cup use was assessed (ever-use vs. current-use) further contributed to this heterogeneity. Additionally, the studies originated from diverse socio-cultural contexts across Asia. Therefore, the pooled estimate should be interpreted with caution, given the high level of heterogeneity.

Comparison with Existing Literature

Among the included studies, prevalence estimates ranged from as low as 0.3% [30]-reported in a community-based household survey as high as 41.5% [31], observed in a convenient urban sampling. This stark contrast underscores the influence of study quality and population representativeness on prevalence estimates. Community-based studies, which are more reflective of real-world adoption patterns, tend to report much lower usage rates compared to online or convenience-based surveys, which may overrepresent educated or urban populations with higher awareness and access to menstrual cups [30].

The majority of studies available in the literature have assessed the knowledge and attitude toward menstrual cup use [4, 5, 40, 41]. A significant limitation in the current literature is the absence of community-based studies on MC use. Most existing research focuses on specific groups rather than capturing perspectives from rural, low-income, or marginalized communities [12, 13, 40, 42]. This lack of data prevents a comprehensive understanding of barriers such as cultural beliefs, accessibility, affordability, and infrastructural challenges like inadequate sanitation facilities.

Implications for Practice

Despite these challenges, menstrual cups remain a crucial component of MHM within various health programs, underscoring their importance in promoting safe and sustainable menstrual practices. However, their inclusion in large-scale public health interventions remains limited, as most government-led initiatives in Asia continue to prioritize disposable sanitary napkins [9, 34]. Integrating menstrual cups into public health programs and UNICEF’s MHM initiatives could enhance awareness, accessibility, and acceptability among diverse population groups [30].

The findings of this review have important implications for public health practice and policy. Targeted education initiatives delivered through schools, community health workers, self-help groups, and adolescent health platforms can address misconceptions, improve understanding of menstrual cup safety and benefits, and support informed choice. However, menstrual practices in many Asian settings are strongly influenced by family norms, religious beliefs, and intergenerational knowledge transfer, which may limit acceptance of intravaginal menstrual products. Cultural beliefs related to virginity and restrictive household dynamics-such as limitations on kitchen access during menstruation, challenges in boiling or sterilizing the cup, and the need to conceal its use-constrain both acceptability and sustained use, particularly among younger, unmarried, or newly married women. In addition, regional inequities in water, sanitation, and hygiene (WASH) infrastructure, including inadequate access to private sanitation facilities, pose barriers to continued use in rural and resource-limited contexts. These findings highlight the need for culturally appropriate, context-specific strategies that address social norms, household constraints, and infrastructural limitations alongside education-based interventions. Integrating peer-led approaches and culturally sensitive counselling, and strengthening the capacity of frontline health workers to provide accurate guidance on menstrual cup use, may further support uptake at the community level [37]. Further prospective community-based studies are needed to inform policy-relevant, context-adapted implementation strategies across diverse Asian settings.

Limitations

This systematic review and meta-analysis have several limitations that should be acknowledged. First, the search was restricted to English-language publications, which may have introduced language bias and led to the exclusion of relevant studies published in local Asian languages. Second, most included studies relied on self-reported menstrual cup use, which is subject to recall and social desirability biases. Third, the number of eligible studies was relatively small (n = 13), which limits the statistical power and robustness of the pooled estimates. Additionally, the available literature is heavily India-centric, with most included studies originating from India and only limited data from other Asian countries such as Korea and China. This geographic imbalance restricts the representativeness of the study populations and limits the generalizability of the findings across the wider Asian region.

Conclusion

The findings indicate that menstrual cup usage remains low among Asian women, primarily confined to a specific, educated subgroup. Moreover, given the heterogeneity in study methodologies, the reliability of pooled prevalence estimates warrants careful consideration. Future research should prioritize large-scale, community-based studies to explore adoption trends, identify barriers, and develop strategies to promote menstrual cup use beyond educated populations.

Abbreviations

CI

Confidence Interval

GLMMs

Generalized Linear Mixed Models

JBI

Joanna Briggs Institute

MC

Menstrual Cup

MHM

Menstrual Hygiene Management

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SOA

Siksha ‘O’ Anusandhan

Authors’ contributions

Conceptualisation-SMB, PB, DKP, AR, EVR, BKP & SK. Conducted the study-SMB, PB, DKP, AR, SD, JS, VY, EVR, MS & BKP. Analysis-SMB, PB, VY, DKP & BKP. Writing the first draft of the manuscript- SMB, PB, EVR. Review and finalize the manuscript for submission- SMB, PB, DKP, AR, SD, JS, VY, EVR, MS & BKP. All authors have read and approved the manuscript for submission.

Funding

Open access funding provided by Siksha 'O' Anusandhan (Deemed To Be University)

Data availability

The data are held by the primary and corresponding authors and can be accessed upon request.

Declarations

Ethics approval and consent to participate

The study received approval from the institute's ethics committee (SOA, Bhubaneswar), with a wide reference number/IEC/IMS.SH/SOA/2022/427 dated 14th October 2022. The study adhered to the standards outlined in the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interest

The authors declare no competing interests.