Abstract
Background:
Sustainable menstruation refers to using environment-friendly products such as menstrual cups, menstrual discs, period underwear, and reusable pads to benefit the nature around us and for our economic benefits. Although it has been several years since menstrual cups came into the market, there is a paucity of data related to their usage, awareness, and hesitancy in the Indian context. This study aims to explore the proportion of young adult menstruators who use sustainable menstrual products, the level of awareness and hesitancy in using these products, and the reasons associated with hesitancy.
Methods:
A cross-sectional study was conducted among 1200 female college students in both medical and nonmedical colleges in Pathanamthitta District, Kerala. Among three medical colleges and 17 arts colleges in Pathanamthitta District, two medical colleges and four Arts colleges (clusters) were randomly selected and all students who were willing to provide consent for the study from the selected colleges were interviewed using a structured interview schedule.
Results:
The mean age of the students was 20.65 ± 3.2 years. The majority [88.8% (1065/1200)] of the students were aware of sustainable menstrual products. However, a vast majority, 94.25% (1131/1200), still used sanitary napkins, and only 5.75%, (69/1200) used menstrual cups. Despite having adequate knowledge about menstrual cups, only 33.6% (403/1200) were willing to switch from sanitary pads to menstrual cups. The reasons cited for hesitancy in using sustainable menstrual products like menstrual cups were fear of pain during insertion, anxiety, and lack of adequate knowledge and confidence in introducing a foreign body into the vagina.
Conclusion:
Most college students were well aware of sustainable menstrual products, including their environmental and economic advantages. Notably, all medical and nonmedical students who used menstrual cups (100%) reported that they made menstruation easier and more cost-effective and expressed willingness to continue their use. However, actual usage remains low, reflecting a gap between knowledge and practice. The reasons cited were anxiety and fear of pain during insertion, which may be addressed by regular awareness campaigns in colleges.
Keywords: Awareness, hesitancy, knowledge, menstruation, sustainable menstrual products
INTRODUCTION
More than 1.8 billion people menstruate every month worldwide; therefore, it is high time we think of sustainable menstruation. A single female, on average, will bleed once a month for approximately 30 years and use a minimum of 5000 sanitary pads or tampons, which either end up in landfill or go into the oceans, harming marine life. Sustainable menstruation refers to using environment-friendly products such as menstrual cups, menstrual discs, period underwear, and reusable pads to benefit the nature around us and for our economic benefits.
Women have been using sanitary napkins for many decades. However, they are not very comfortable, are prone to leakages, and are associated with reproductive tract infections, pelvic inflammatory diseases, and urinary tract infections, which may eventually lead to infertility. With the availability of newer and sustainable menstrual products, it is time to rethink the usage of sanitary napkins and to manage menstruation with sustainable, healthy, cost-effective, and environment-friendly solutions.
Menstrual cups are made of medical-grade silicone/latex/rubber, which seals against the vaginal wall and collects blood during menstruation. The collected blood can be emptied and the cup can be reinserted after washing. There is zero waste generation, no toxic chemicals or plastics and dyes as is present in sanitary napkins, no problems like itching and wetness, and fewer chances of malignancy. In Kerala, Kumbalangi Grama Panchayat was announced as the country’s first sanitary napkin-free panchayat, wherein 5000 menstrual cups were distributed to women aged 18 years and above.[1]
Sustainable menstrual products are more eco-friendly and economical than sanitary napkins. Decomposition of one sanitary napkin would take 500–800 years.[2,3,4] Popular sanitary napkin brands in the country have been reported to discharge non-biodegradable materials like plastic (90%), dioxins and furans, styrene, chloromethane, chloroform, and acetone,[2,5,6,7] which contaminate soil, water, and air and pollute the food chain.[8] A young adult menstruator, on average, would use 15 napkins used/cycle for 12 cycles/year. The cost of sanitary napkins would be at least Rs 70/cycle and hence Rs 4200 for 5 years. On the other hand, a menstrual cup that can be used for 4–5 years costs only around Rs 400.[2,9] Therefore, menstrual cups prove to be at least ten times less expensive than sanitary napkins, easing the economic burden on the users.
Although it has been several years since menstrual cups came into the market, there is paucity of data related to their usage, awareness, and hesitancy in the Indian context. A literature search using PubMed, Google Scholar, and IndMED with the keywords “menstrual cup,” “sustainable menstrual products,” “awareness,” “hesitancy,” and “India” (2015–2024) revealed less than a dozen Indian studies, mostly limited to urban or single-institution samples. This paucity underscores the need for contextual data on awareness and potential barriers for usage of SMPs.
This study aims to explore the level of awareness, hesitancy, and reasons for hesitancy in using sustainable menstrual products among college students and also to compare the differences among medical and nonmedical college students in the district. College students were selected as they represent young, educated menstruators who can influence menstrual choices and community awareness. Comparing medical and nonmedical students helps explore whether health-related formal education affects awareness and hesitancy.
METHODS
A cross-sectional study was conducted among the young adult menstruators belonging to the medical and nonmedical colleges of Pathanamthitta district in the year 2022–23, after obtaining approval from the Institutional Review Board (IEC/2022/10/287). Informed consent was obtained from all participants before the survey.
Due to a lack of data on the prevalence of usage of sustainable menstrual products, we conducted a pilot study in our college on 100 female participants and the proportion of menstrual cup users was found to be 8%. Based on the formula 4pq/d2, the sample size was calculated as 1150. So, the sample size was rounded off to 1200.
The study participants included 1200 college students from medical and nonmedical colleges in Pathanamthitta District. Among three medical colleges and 17 arts colleges in Pathanamthitta District, two medical colleges and two Arts colleges (clusters) were randomly selected to collect the samples. As the sample size was not achieved from the first selected two arts colleges, two more arts colleges were randomly selected again for data collection. Data collection was carried out through multiple visits to the selected colleges by a team of trained medical student volunteers. These volunteers were oriented and trained by the study investigators on the objectives, interview techniques, and standardized data collection. College visits were scheduled based on the convenience of the institutions, with coordination support from community social workers who liaised with college authorities to facilitate access and organize sessions. All the students willing to consent to the study from the selected colleges were interviewed using a structured interview schedule.
A participant was considered aware of sustainable menstrual products if she was able to correctly name at least one sustainable menstrual product (such as a menstrual cup, reusable cloth pad, or period underwear) when asked during the interview.
We used the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) Checklist for reporting this study.
Statistical analysis was done on SPSS v. 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Categorical variables were expressed as percentages/counts, and continuous variables were expressed as mean ± standard deviation. Chi-square was used to test for associations. A P value < 0.05 was considered to be statistically significant.
RESULTS
The study was conducted on 1200 female college students belonging to the medical and arts colleges in Pathanamthitta District. The mean age of the students was 20.65 ± 3.2 years. The majority [88.8% (1065/1200)] of the students were aware of sustainable menstrual products, 67% knew that sustainable menstrual products were more environment-friendly than sanitary napkins, and 57.4% knew that menstrual cups were less expensive than sanitary pads [See Table 1].
Table 1.
Knowledge of sustainable menstrual products
| Variables | Number |
|---|---|
| Awareness of sustainable menstrual products | |
| Yes | 1065 (88.8%) |
| No | 135 (11.2%) |
| Knowledge of menstrual cups being cost-effective, environment-friendly, and better for health than sanitary napkins | |
| Yes | 804 (67%) |
| No | 396 (33%) |
| Knowledge that a menstrual cup can be used for an average of 3–5 years. | |
| Yes | 760 (63.3%) |
| No | 440 (36.7%) |
| Knowledge of the cost of Menstrual Cups | |
| Less than Rs500 | 689 (57.4%) |
| Rs 500–Rs 1000 | 431 (35.9%) |
| More than Rs 1000 | 80 (6.7%) |
However, a vast majority, 94.25% (1131/1200), still used sanitary napkins, while only 5.75% (69/1200) used menstrual cups, and 0.1% used period underwear. Among the medical students, only 5.2% (31/600) and among the nonmedical students, only 6.3% (38/600) used sustainable menstrual products. Despite having adequate knowledge about menstrual cups, only 33.6% (403/1200) were willing to switch from sanitary pads to menstrual cups. Fear of pain during and after insertion was cited (35.2%) as the most important reason associated with hesitancy in using sustainable menstrual products [See Table 2].
Table 2.
Reasons cited for hesitancy to switch over to menstrual cups
| Reason for hesitancy | Number of students |
|---|---|
| Fear of pain | 422 (35.2%) |
| Comfortable with sanitary pads | 283 (23.6%) |
| Anxiety about introducing a foreign object into the body | 202 (16.8%) |
| Lack of knowledge on how to properly use the product | 200 (16.7%) |
| Fear of leakage | 172 (14.3%) |
| Fear of infection | 150 (12.5%) |
| Fear of getting stuck in the vagina | 138 (11.5%) |
| Fear of getting lost inside the uterus | 89 (7.4%) |
| Fear that it may get detached on its own. | 83 (6.9%) |
| Fear of structural damage to reproductive organs | 48 (4.0%) |
| Fear of hymen tear | 46 (3.8%) |
| Cultural stigma | 46 (3.8%) |
| Unsupportive family | 46 (3.8%) |
| Not commonly used among peer groups | 28 (2.3%) |
| Lack of availability | 25 (2.1%) |
The majority of the students (71.9%) received information on sustainable menstrual products from social media. Awareness regarding sustainable menstrual products was significantly higher in nonmedical students when compared to medical students (91.2% vs 86.5%, P – 0.010). Fear of infection (25.2% vs 16.4%, P – 0.003), fear of hymen tears (7% vs 3.6%, P – 0.030), and fear of menstrual cups being detached (15.5% vs7.1%, P – 0.001) were significantly higher in medical students when compared to nonmedical students. The only hesitancy factor that was higher in nonmedical students was the fear of pain (43.6% vs 72.4%, P – 0.001) during the insertion of the menstrual cup [See Table 3]. A few of them were anxious about the leakage, insertion difficulty, and time taken for insertion [See Table 4]. However, the majority of the menstrual cup users said that they had no problems associated with its usage. All who used menstrual cups agreed that they have made their periods easier and more economical and preferred to continue using them.
Table 3.
Differences among Medical and Nonmedical students regarding awareness and factors related to hesitancy in using Sustainable Menstrual Products
| Variables | Medical students | Nonmedical students | P |
|---|---|---|---|
| Awareness of Sustainable Menstrual Products | |||
| Yes | 519 (86.5%) | 547 (91.2%) | 0.010 |
| No | 81 (13.5%) | 53 (8.8%) | |
| Usage of sustainable menstrual products | |||
| Yes | 31 (5.2%) | 38 (6.3%) | 0.324 |
| No | 569 (94.8%) | 562 (93.6%) | |
| Willingness to switch over to sustainable menstrual products (after excluding existing users) | |||
| Yes | 194 (33.9%) | 210 (36.3%) | 0.391 |
| No | 379 (66.1%) | 369 (63.7%) | |
| Fear of pain on using Menstrual cups | |||
| Yes | 181 (43.6%) | 234 (72.4%) | 0.001 |
| No | 192 (56.4%) | 131 (27.6%) | |
| Fear of infection on using Menstrual Cups | |||
| Yes | 94 (25.2%) | 60 (16.4%) | 0.003 |
| No | 279 (74.8%) | 305 (83.6%) | |
| Fear of Menstrual Cups being detached | |||
| Yes | 58 (15.5%) | 26 (7.1%) | 0.001 |
| No | 315 (84.5%) | 339 (92.9%) | |
| Fear of Hymen Tear | |||
| Yes | 26 (7%) | 13 (3.6%) | 0.030 |
| No | 347 (93%) | 352 (96.4%) |
Table 4.
Problems/difficulties faced by a menstrual cup user
| Difficulties reported by a menstrual cup user | Medical and Paramedical (%) | Nonmedical (%) |
|---|---|---|
| No problems | 71.4 | 82.0 |
| Anxiety on leakage | 7.1 | 13.0 |
| Pain during every insertion | 3.5 | 4.0 |
| Difficult insertion | 3.5 | — |
| Urge to urinate | 7.1 | — |
| Night-time leakage | 3.5 | — |
| Time to manage insertion | 3.5 | — |
DISCUSSION
From the current study, it is clear that the majority of the younger generation is aware of sustainable menstrual products (88.8%), their availability, their environment friendliness, and their economic benefits. This reflects the health literacy pattern and the thrust on women’s health and gender equality in the state of Kerala. The young female population may be well aware of the current menstrual and sexual health practices. It was also quite surprising to see that the knowledge of sustainable menstrual products was higher in nonmedical college students when compared to medical students.
However, a vast majority, 94.25% (1131/1200), of the students continued to use sanitary napkins, even though only less than a quarter of them (23.6%) were comfortable using them. This has been the trend in India as the majority of girls still use sanitary napkins as the absorbent for menstrual blood.[10] As per our study report, only 5.75% of the young adult menstruators used any sort of sustainable menstrual products like the menstrual cups. This is a discrepancy in terms of knowledge translated to practice and needs to be rectified. Even though the awareness level was high, the usage of sustainable menstrual products was abysmally low. Even when 67% of the young menstruators knew that it was cost-effective and environment-friendly, hesitancy in using these products indicates the lack of adequate awareness programs to tackle hesitancy issues.
In a study conducted by Oster et al. in Nepal, the main causes of hesitancy among users of menstrual cups were fear, lack of education regarding its usage, and uneasiness while coming into contact with blood and genital tissues during insertion.[11,12] Our study also revealed that the main reasons for not using sustainable menstrual cups were fear of pain during insertion (35.2%), anxiety, and lack of adequate knowledge and confidence (16.7%) in introducing a foreign body into the vagina. However, 100% of the menstrual cup users in our study affirmed that the menstrual cup had made their periods easier even though they had faced some initial difficulties and wished to continue using it. This is similar to the results of the study conducted by Kakani et al.[13] Although not generalizable to all populations, our study offers insight into determinants of acceptance of sustainable menstrual products among young women.
Almost 10% of the college students reported that cultural stigma, fear of hymen tears, and lack of usage of menstrual cups by peers prevented them from switching over to menstrual cups. It is time that we overcome the taboo associated with menstruation and invest more time and effort in promoting the use of sustainable menstrual products. One such example would be again from the state of Kerala, in the district of Ernakulam, where promotion campaigns for using sustainable menstrual products and menstrual hygiene have been spearheaded by the Member of Parliament, named the ‘Cup of Life’ program. Under this program, 100,001 menstrual cups were distributed in the district, which has been touted as the world’s largest menstrual hygiene campaign, creating a Guinness world record.[14]
Menstrual hygiene management is crucial to a woman’s health, and there has been a great deal of advocacy, both from the government and nongovernmental organizations, encouraging women to adopt hygienic practices during menstruation. One of them was to advocate the use of safe menstrual products like sanitary napkins. However, menstrual waste management is in crisis in India. Under the Solid Waste Management Rules, 2016, menstrual hygiene products are categorized as dry waste and there are rules in place for both consumers and manufacturers regarding disposal that are aimed at sustainability. On the ground, the practice of these rules, however, is still not widespread. Therefore, we recommend these organizations to promote the awareness and use of sustainable options that are convenient, affordable, environment-friendly,[15,16,17] and a safe way to manage menstruation.
CONCLUSION
This study highlights the levels of awareness, hesitancy, and usage of sustainable menstrual products among college students. Most young adult menstruators demonstrated good awareness of sustainable menstrual options, recognizing their environmental benefits and cost-effectiveness. However, actual usage remained low, revealing a clear gap between knowledge and practice. The main reasons for hesitancy in adopting products such as menstrual cups included fear of pain during insertion, anxiety, inadequate knowledge, and lack of confidence in introducing a foreign body into the vagina. Notably, all menstrual cup users reported that, despite initial challenges, the product made their menstrual experience easier and more convenient, and they expressed willingness to continue its use.
Author contributions
S.M.V and G.M.C – conceptualized and designed the work
L.S, A.P – Acquired data
S.M.V, L.S, A.P wrote the manuscript
P.T, S.M.V prepared the tables and figures
J.N.S, A.I.B, G.M.C – Revised the manuscript
All authors reviewed the manuscript.
Human Ethics and Consent to Participate declarations
Based on Declaration of Helsinki Ethical Principles. Informed Consent has been taken from the study participants.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
ICMR STS Project.
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