“Patients come to me every day asking me what kind of sanitary protection to use.” But Dr. Jean-Marc Bobo, an infectious disease specialist and andrologist at the Alfred Fournier Institute (Paris), cannot answer this question. And for good reason, the only scientific paper dealing with this issue was from Montpellier and has just been published in the journal Molecular Ecology. But even they need to be taken with caution. “The study initially focused on primary papillomavirus infections, and we took the opportunity to conduct a sanitation-based analysis,” explains researcher Nicolas Tessandier, first author of the publication. Thus, the main study is not intended to answer the question that concerns Dr. Bobot’s patients. In spite of everything and in anticipation of dedicated works, several interesting points deserve our attention.
Slightly more fungal infections in cup users
Researchers are comparing the vaginal microbiota and immune system in 138 menstrual cup (or “cup”) or tampon users. Regardless of being older and smoking less, cup drinkers are also more likely to report being diagnosed with a yeast infection in the past three months. However, the subjects’ vaginal microbiota were the same, as was the amount of 20 cytokines, molecules secreted by the immune system.
Could this apparent increased risk of fungal infection come from the protection itself? Or a variable not collected during the study? The question remains open, and the biases of the study are numerous. “For example, it could be that cup-wearing women go to the gynecologist more often and are therefore more likely to be diagnosed with vaginal infections,” suggests Nicolas Tessandier. Sociocultural profiles or participants’ antibiotic consumption, parameters that could also have an impact, were also not provided. “This study sends a signal that there may be an increased risk of fungal infection when using cups, but it does not confirm this.”
A case of toxic shock, which was facilitated by the improper use of internal hygienic protective equipment.
When it comes to women’s health, health protection has mostly been studied in relation to the risk of a rare but terrible toxic shock. If users of cups and tampons are known to be at greater risk of toxic shock than others, then the fault lies not with the protection itself, but with its misuse, supports Gerard Lina, professor of microbiology at the Claude Bernard University (Lyon). “There is no indication that one defense will be better than another when used correctly. Some instructions for the cups say they can be stored overnight, which is nonsense. They must be sterilized before each use and changed after a maximum of 6 hours.” In addition, especially after 8 hours of continuous wear, the risk of toxic shock increases.
USE THE MENSTRUAL CUP PROPERLY. “It is best to have several well-sterilized cups,” says Professor Gerard Lina, “so that a potentially contaminated cup is never inserted. Be careful not to stick to soap and water: To get rid of stubborn bacterial biofilms, washing with soap and then a five-minute immersion in boiling water is most effective, says Dr. Jean-Marc Bobo. And, of course, do not forget to wash your hands before inserting.
The higher incidence of vaginal yeast infections (due to microscopic Candida) seen in cup users may be due to the development of Candida biofilms on a poorly cleaned cup or to a dysbiosis of the vaginal microbiota common during menstruation. Dysbiosis, or an imbalance in the microbiota, also appears to be associated with toxic shock. “Microbiota dysbiosis may contribute to toxic shock, which is more common in women with a history of vaginosis,” Prof Gerard Lina cautiously notes.
Vaginal flora vulnerable during menstruation
However, significant changes in the vaginal flora occur during menstruation, making this period particularly delicate and potentially vulnerable to possible exposure to vaginal defenses. “A sudden drop in estrogen levels reduces the supply of glycogen, which is the fuel for lactobacilli, a family of bacteria that make up 60% of the vaginal microbiota at normal times,” describes Dr. Jean-Marc Bobo. A percentage that then drops to around 40%. By maintaining a pH of 3.5 to 4.5 through the production of lactic acid, lactobacilli are the guarantors of the balance of the vaginal microbiota. Their decrease during menstruation leads to an increase in the pH of the vagina from 4.5 to 7, which promotes the growth of most other types of bacteria.
In this case, the wall of the vagina is exfoliated in the same way as the uterus, and becomes thinner. To facilitate the “healing” of these tissues, the number of pro-inflammatory cytokines is increased, accompanied by immune cells. Unfortunately, these cells are targets for vector-borne infections. “That’s why the risk of contracting an STI (sexually transmitted infection – approx. ed.) increases when sexual intercourse occurs during menstruation,” explains Dr. Jean-Marc Bobo.
Although the Montpellier study noted no difference in the composition of the vaginal microbiota between cup and tampon users, the immune profile appears to have changed slightly. “Women using the cup had fewer pro-inflammatory cytokines than those who used the tampon,” concludes the infectious disease specialist. It is currently not possible to confirm or interpret these results.
“The Great Void” in non-fiction
“Today, we do not have a study that would allow us to recommend such protection, and not another,” regrets Dr. Jean-Marc Bobo. Moreover, internal remedies (cup and tampon) are not the only ones that can affect women’s health. “The microbiota of the labia minora of the vulva also changes during menstruation. The effect of external protection (sanitary napkin, editor’s note) that keeps blood in contact with the vulva is also unknown.” To fill this “large gap” in the literature, a larger study is already in preparation. Aimed at changing the vaginal microbiota and its inflammatory and immune environment (eg cytokines) after the use of several types of correctly used menstrual protection, currently only funded up to 500,000 euros, an amount “very insufficient given the importance of the issue” – regrets Nicolas Tessandier With funding, it should provide the first answers to these important questions for the world’s 1.8 billion menstruating women.