By Jane Harrison-Hohner, RN, RNP
While menstruation has been going on since time began, the majority of menstrual products designed to deal with monthly flows have been developed within the past century or so. Others, like sea sponges and cloth pads, have been used for centuries. Have you ever wondered about changing your mode of coping with “Aunt Flow”? It seems that women often revisit this issue when some new risk is identified with their current sanitary product. For example, last month there was a recall for a specific lot of Kotex Natural Balance Security Unscented Tampons when a gram negative bacteria, Enterobacter sakazakii, was found during the manufacturing process. Thus, it seems like an apt time to review many of the newest and oldest options for “sanitary protection”.
Pads and Cloths
The first widely available, disposable sanitary pad was developed in 1921 by Kimberly-Clark. Like their other product (“Kleenex” disposable handkerchiefs), the “Kotex” pad became a noun describing other brands of cellulose-containing disposable pads. These were held in place with safety pins in underpants or used with a belt where the long ends of the pads were held snugly by small metal clips. It was not until 1970 that pads were made that incorporated a strip of adhesive so as to adhere to underwear.
Coincidentally, at around this same time, the feminist movement and back-to-the-land women revived an interest in washable cotton pads. This resurgence of interest in washable, re-usable pads has meant that one can purchase a variety of pad sizes and thicknesses, even at Walmart, which offers them online.
Previously, women made do with rags or made flannel pads or diapers for menstrual protection. These could be discretely soaked in cold water prior to adding them to the family wash. Now I have seen ads for bowls specifically designed to collect that soaking water for reuse in the garden!
Looking beyond historical interest, have there been any documented medical concerns with pad use? The few published studies have addressed the problems of “sanitary napkin contact dermatitis”. A case series of 28 women were reported to have developed marked irritation of their vulva after using a specific type of pad (Always®). The irritation abated when this brand of pad was not used, and appeared again among the few women who decided to resume use of Always pads. A Japanese physician demonstrated dermatitis in some pad users that was curable by switching to tampons. It was postulated that a combination of wet conditions and friction could expose thin skin to normally occurring bacteria. Overall, pads seem to be safe, but the use of disposable pads (like disposable diapers) can add to landfill mass.
Women may have been inserting absorbent materials in their vagina (e.g., sea sponges, rolls of soft wool or paper) for millennia, but the first commercially produced, disposable tampon came to market in 1933. It was called Tampax. Like Kotex or Kleenex, it then became a noun to describe other tampons. Initially, tampons contained either cotton or rayon. Rayon is made from cellulose fibers, which come from wood pulp. According to an FDA website, previous studies have not identified any differences in tampon safety between the two materials within the same absorbency rating.
A question that frequently arises is: “Will using a pad offer protection from the bacteria associated with Toxic Shock Syndrome?” Beginning around 1980, Toxic Shock Syndrome (TSS) was reported with increasing frequency in menstruating women using tampons. Its symptoms included a fever of greater than 102 degrees, vomiting/diarrhea, low blood pressure and a sun burn like rash on the palms of the hand which later peeled like a sunburn. TSS, both menstrual and that associated with pneumonia and skin infections, is caused by a super-antigen-producing strain of one of our normal skin bacteria (Staph aureus). Like many skin bacteria, Staph aureus can be found in the vaginas of between 10-30% of healthy women. But far fewer women will test positive for the super-antigen producing subtype. This might explain why only 70-100 cases of TSS (both menstrual and nonmenstrual) are reported in the USA per year.
This low incidence of women who carry the super-antigen subtype may also explain the differing results between the various studies of tampon bacteria over the past thirty years. In an early study, no difference was found in the number of women with vaginal staph aureus during menstruation whether tampons or pads were utilized. Among women randomly assigned to either sanitary pads or tampons who then switched over to the other product, the number of “normal staph” bacteria were elevated with tampon use. Yet tampon users also had higher counts of the “good” lactobacilli vaginal bacteria. A. B. Onderdonk and colleagues found that tampon samples had decreased numbers of bacteria compared to vaginal swabs. More recently, a Czech study of 100 women concluded that there were lower levels of bacteria during tampon use, and that vaginal ecology returned to normal more quickly in tampon users compared to pad users.
Another possible explanation for the differences between studies might be the type of tampons used. Compared to the initial materials used for absorption, newer materials including polyester foam, carbomethylcellulose and polyacrylate rayon were added to dramatically increase flow capacity. Following increased reports of TSS, such materials were removed in 1984 as super-absorbent tampons were linked to TSS risk. Thereafter, increased absorption could come from increased physical size of the tampon.
After an 18% increase in TSS was noted in the Twin Cities of Minnesota from 2002-2003, Philip Tierno posited that the rise might be due to an increased usage of the much larger tampons. Since 1999, the FDA has established new, standardized guidelines for tampon absorbency:
- Light or Junior (<6 gm of fluid)
- Regular (6-9 gm)
- Super (9-12 gm)
- Super-plus (12-15 gm)
- Ultra (15-18 gm)
Perhaps women were using the larger tampons and were thus able to leave them in place for many more hours (e.g., overnight).
One of the most compelling studies on menstrual TSS was very recently published. Tampons used by four healthy women who had vaginal staph aureus and two women with a known history of TSS were cut into ¼-inch segments and tested. Some of the pieces had blood, others none. All women had evidence of the super-antigen subtype, and that the “supertoxins” could be found in parts of the tampon where no blood was yet present. The authors concluded, “We established that TSS T-1 [super-antigen subtype] causation of menstrual TSS is more complicated than previously thought.”
What about using tampons touted to promote natural pH balance? Eighty-one women completed a study that included testing for bacterial vaginosis (BV), yeast, pH, and a colposcopy to examine vaginal tissues. No significant differences were found between standard tampons vs. those using a pH corrected gel.
Currently the FDA recommends:
- Choose the lowest absorbency for your flow
- Change tampons at least every 4-8 hours
- Consider alternating pads with tampons
- Don’t use tampons between menstrual periods
- Know the symptoms of TSS