Does exposure to different menstrual products affect the vaginal environment?

The vaginal ecosystem is a key component of women's health. It also represents an ideal system for ecologists to investigate the consequence of perturbations on species diversity and emerging properties between organizational levels. Here, we study how exposure to different types of menstrual products is linked to microbial, immunological, demographic, and behavioural measurements in a cohort of young adult women who reported using more often tampons (n = 107) or menstrual cups (n = 31). We first found that cup users were older and smoked less than tampon users. When analysing health indicators, we detected potential associations between cups use reporting and fungal genital infection. A multivariate analysis confirmed that in our cohort, reporting using cups over tampons was associated with the higher odds ratio to report a fungal genital infection diagnosis by a medical doctor within the last 3 months. We did not detect significant differences between groups in terms of their bacterial vaginal microbiota composition and found marginal differences in the level of expression of 20 cytokines. However, a multivariate analysis of these biological data identified some level of clustering based on the menstrual product type preferred (cups or tampons). These results suggest that exposure to different types of menstrual products could influence menstrual health. Larger studies and studies with a more powered setting are needed to assess the robustness of these associations and identify causal mechanisms.

In Vitro Study to Assess Effective Cleaning Techniques for Removing Staphylococcus aureus from Menstrual Cups.

BACKGROUND: We sought to determine the effectiveness of common cleaning procedures in eliminating S. aureus from silicone menstrual cups. METHODS: In this in vitro study, we tested four cleaning techniques: (1) cold water; (2) cold water and liquid soap; (3) cold water followed by steeping the cup in boiled water for 5 min in a ceramic mug covered with a small plate; and (4) cold water and soap followed by steeping the cup in boiled water as in (3). Human blood was coated to the inner and outer surface of each cup, dried, and incubated with 106S. aureus colony-forming units (CFU/mL). All tests were performed in triplicate. Viable bacterial abundance was measured with decadic dilution and drop plate or surface plating. RESULTS: Bacteria were most effectively eliminated by cleaning cups with soap and water and then steeping in boiled water (0 CFU/cup vs. 2.075 × 108/cup no cleaning, p = 0.005). This was not statistically significantly different from washing cups with water only and steeping 5 min in boiled water (14 CFU/cup). Raised lettering on the outer surface of the menstrual cups resulted in more bacterial recovery from pieces with lettering than without lettering. CONCLUSIONS: These results advance knowledge of between-period menstrual cup cleaning recommendations, suggesting that the logistical challenges of continuous boiling may be eliminated with steeping at least 5 min.

The Impact of Selected Essential Oils Applied to Non-Woven Viscose on Bacteria That Cause Lower Urinary Tract Infections-Preliminary Studies.

Inflammation of the lower urinary tract is a very common problem, which occurs particularly in women. A concept of a biotextronics system for preventive and support treatment of lower urinary tract inflammations was presented. The system includes a non-woven viscose insert for essential oils application. The oils were deposited on the non-woven viscose and incubated in the temperature of 37 °C and served a model for their action in the vapor phase as the element of the biotextronics system. The essential oils used in the research were the following: chamomile (Matricaria chamomilla L.), sage (Salvia officinalis L. and Salvia lavandulaefolia), juniper (Juniperus communis L.), thyme (Thymus vulgaris L.), and mixtures of chamomile oil with oils of each sage species in a 1:1 ratio. The oils were tested against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus epidermidis, Staphylococcus saprophyticus, and Enterococcus faecalis. The best inhibitory effect in vapor phase was noted for chamomile essential oil at the lowest concentration (0.054 µL/cm3). Both mixtures of chamomile and sage acted antagonistically, lowering the antibacterial activity of the individual oils applied solely. Juniper and Salvia officinalis essential oils at the concentrations tested increased the growth of at least one of the bacteria tested. Salvia lavandulaefolia Vahl. essential oil inhibited all bacteria, only at the concentration 0.214 µL/cm3. The thyme oil, at the concentration 0.054 µL/cm3, reduced the growth of all bacterial species tested. Chamomile and thyme essential oils were chosen for further research in the biotextronics pantiliner system.

Acceptability and safety of the menstrual cup: A systematic review of the literature / Aceptabilidad y seguridad de la copa menstrual: revisión sistemática de la literatura

Objectives: To conduct a systematic review of the literature and assess the acceptability and safety of the menstrual cup as a feminine hygiene product. Materials and methods: A search was conducted in the PubMed, Cochrane Library, Scopus, PopLine and Google Scholar databases for publications be- tween 1966 and July 2019. The terms ("Menstrual" AND "Cup") OR ("Copa" AND "Menstrual") were used. Quantitative, qualitative and mixed studies were included, as well as case series and case reports published in English and Spanish assessing the menstrual cup in women in childbearing age. The studies were selected and the data extracted by two reviewers working independently. Acceptability and safety were assessed as the primary result. The summary of the information is presented in narrative form. Results: Overall, 737 titles were found for initial review and, in the end, 38 studies were included in this work. The acceptability of the menstrual cup ranges between 35 % and 90 %. Between 10 to 45 % of women found it difficult to use. It was described as more comfortable when compared to tampons and pads. Continued use of the cup ranges between 48 and 94 %. In terms of safety, there was one case of toxic shock syndrome, one case of mechanical entrapment, and another case of allergy; and a higher risk of expulsion was found among intrauterine device users. Conclusion: The menstrual cup appears to be a comfortable, safe and efficient option for menstrual hygiene. Further randomized controlled studies and long-term prospective cohort studies are needed in order to determine the risk of complications due to excess bacterial colonization or retrograde menstruation.

TITULO: ACEPTABILIDAD Y SEGURIDAD DE LA COPA MENSTRUAL: REVISIÓN SISTEMÁTICA DE LA LITERATURA. OBJETIVO: Realizar una búsqueda sistemática de la literatura para evaluar la aceptabilidad y seguridad de la copa menstrual como producto de higiene genital femenina. METODOS: Se realizó búsqueda en las bases de datos PubMed, Cochrane Library, Scopus, PopLine y Google Scholar, desde 1966 hasta julio de 2019. Se utilizaron los términos: "Menstrual" AND "Cup" OR "Copa" AND "Menstrual". Se incluyeron estudios cuantitativos, cualitativos y mixtos, series y reportes de caso publicados en inglés y español que hubieran evaluado la copa menstrual en mujeres en edad reproductiva. Los estudios fueron selecciona- dos y los datos fueron extraídos por dos evaluadores de manera independiente. Como resultado primario se evaluó la aceptabilidad y seguridad. La síntesis de información se presenta de manera narrativa. RESULTADOS: Se encontraron 737 títulos para revisión inicial. Finalmente, se incluyeron 38 estudios. La copa menstrual tiene una aceptabilidad que varía entre el 35 y el 90 %. Del 10 al 45 % la encontraron difícil de usar. Fue descrita como más cómoda comparada con el tampón y la toalla higiénica de fabricación industrial. La continuidad de su uso está entre el 48 y el 94 %. En cuanto a la seguridad se presentó un caso de síndrome de choque tóxico, uno de atrapamiento mecánico, uno de alergia al producto y mayor riesgo de expulsión en usuarias del dispositivo intrauterino. CONCLUSIONES: La copa menstrual es una alternativa cómoda, segura y eficiente para la higiene mens- trual. Se requieren más estudios controlados alea- torizados y cohortes prospectivas a largo plazo para determinar el riesgo de complicaciones por una exagerada colonización bacteriana o menstruación retrógrada.

Vaginal Tampon Colonization by Staphylococcus aureus in Healthy Women.

Tampons recovered from a cohort of 737 healthy women (median age, 32 years) were analyzed for the presence of Staphylococcus aureus A total of 198 tampons (27%) were colonized by S. aureus, 28 (4%) by a strain producing toxic shock syndrome toxin 1 (TSST-1). S. aureus was detected more frequently in tampons that did not require an applicator for their insertion (74/233 [32%] versus 90/381 [24%]; odds ratio [OR] = 1.51 [95% confidence interval, 1.04 to 2.17]) and in women who used an intrauterine device for contraception (53/155 [34%] versus 145/572 [27%]; OR = 1.53 [95% confidence interval, 1.05 to 2.24]). The S. aureus strains isolated from tampons belonged to 22 different clonal complexes (CCs). The most prevalent CC was CC398 agr1 (n = 57 [27%]), a clone that does not produce superantigenic toxins, followed by CC30 agr3 (n = 27, 13%), producing TSST-1 (24/27 [89%]), the principal clone of S. aureus involved in menstrual toxic shock syndrome (MTSS).IMPORTANCE Menstrual toxic shock syndrome (MTSS) is an uncommon severe acute disease that occurs in healthy menstruating women colonized by TSST-1-producing S. aureus who use intravaginal protection, such as tampons and menstrual cups. The catamenial product collected by the protection serves as a growth medium for S. aureus and allows TSST-1 production. Previous studies evaluated the prevalence of genital colonization by S. aureus by vaginal swabbing, but they did not examine tampon colonization. This study demonstrated a high prevalence of tampon colonization by S. aureus and the presence of the CC30 TSST-1 S. aureus clone responsible for MTSS in tampons from healthy women. The results support the vaginal carriage of this lineage in healthy women. In addition, the higher prevalence of S. aureus within tampons that do not require an applicator indicates a crucial role for handwashing before tampon handling to decrease the risk of tampon contamination.

Complex ecological interactions of Staphylococcus aureus in tampons during menstruation.

Menstrual toxic shock syndrome (mTSS) is a severe disease that occurs in healthy women vaginally colonized by Staphylococcus aureus producing toxic shock toxin 1 and who use tampons. The aim of the present study was to determine the impact of the composition of vaginal microbial communities on tampon colonisation by S. aureus during menses. We analysed the microbiota in menstrual fluids extracted from tampons from 108 healthy women and 7 mTSS cases. Using culture, S. aureus was detected in menstrual fluids of 40% of healthy volunteers and 100% of mTSS patients. Between class analysis of culturomic and 16S rRNA gene metabarcoding data indicated that the composition of the tampons' microbiota differs according to the presence or absence of S. aureus and identify discriminating genera. However, the bacterial communities of tampon fluid positive for S. aureus did not cluster together. No difference in tampon microbiome richness, diversity, and ecological distance was observed between tampon vaginal fluids with or without S. aureus, and between healthy donors carrying S. aureus and mTSS patients. Our results show that the vagina is a major niche of. S. aureus in tampon users and the composition of the tampon microbiota control its virulence though more complex interactions than simple inhibition by lactic acid-producing bacterial species.

Impact of Currently Marketed Tampons and Menstrual Cups on Staphylococcus aureus Growth and Toxic Shock Syndrome Toxin 1 Production In Vitro.

Fifteen currently marketed intravaginal protection products (11 types of tampon and 4 types of menstrual cup) were tested by the modified tampon sac method to determine their effect on Staphylococcus aureus growth and toxic shock syndrome toxin 1 (TSST-1) production. Most tampons reduced S. aureus growth and TSST-1 production, with differences based on brand and composition, and the level of S. aureus growth was higher in destructured than in unaltered tampons. We observed higher levels of S. aureus growth and toxin production in menstrual cups than in tampons, potentially due to the additional air introduced into the bag by cups, with differences based on cup composition and size.IMPORTANCE Menstrual toxic shock syndrome is a rare but severe disease. It occurs in healthy women vaginally colonized by Staphylococcus aureus producing toxic shock syndrome toxin 1 using intravaginal protection, such as tampons or menstrual cups. Intravaginal protection induces TSS by the collection of catamenial products, which act as a growth medium for S. aureus Previous studies evaluated the impact of tampon composition on S. aureus producing toxic shock syndrome toxin 1, but they are not recent and did not include menstrual cups. This study demonstrates that highly reproducible results for S. aureus growth and TSST-1 production can be obtained by using a simple protocol that reproduces the physiological conditions of tampon and cup usage as closely as possible, providing recommendations for tampon or cup use to both manufacturers and consumers. Notably, our results do not show that menstrual cups are safer than tampons and suggest that they require similar precautions.

Examining the safety of menstrual cups among rural primary school girls in western Kenya: observational studies nested in a randomised controlled feasibility study.

OBJECTIVE: Examine the safety of menstrual cups against sanitary pads and usual practice in Kenyan schoolgirls. DESIGN: Observational studies nested in a cluster randomised controlled feasibility study. SETTING: 30 primary schools in a health and demographic surveillance system in rural western Kenya. PARTICIPANTS: Menstruating primary schoolgirls aged 14-16 years participating in a menstrual feasibility study. INTERVENTIONS: Insertable menstrual cup, monthly sanitary pads or 'usual practice' (controls). OUTCOME MEASURES: Staphylococcus aureus vaginal colonization, Escherichia coli growth on sampled used cups, toxic shock syndrome or other adverse health outcomes. RESULTS: Among 604 eligible girls tested, no adverse event or TSS was detected over a median 10.9 months follow-up. S. aureusprevalence was 10.8%, with no significant difference over intervention time or between groups. Of 65 S.aureus positives at first test, 49 girls were retested and 10 (20.4%) remained positive. Of these, two (20%) sample isolates tested positive for toxic shock syndrome toxin-1; both girls were provided pads and were clinically healthy. Seven per cent of cups required replacements for loss, damage, dropping in a latrine or a poor fit. Of 30 used cups processed for E. coli growth, 13 (37.1%, 95% CI 21.1% to 53.1%) had growth. E. coli growth was greatest in newer compared with established users (53%vs22.2%, p=0.12). CONCLUSIONS: Among this feasibility sample, no evidence emerged to indicate menstrual cups are hazardous or cause health harms among rural Kenyan schoolgirls, but large-scale trials and post-marketing surveillance should continue to evaluate cup safety.

Bacterial biofilms in the vagina.

A bacterial biofilm is a structured community of bacteria in a self-produced extracellular matrix, adherent to an inert surface or biological tissue. The involvement of biofilm in a bacterial infection implies that the infection is difficult to treat and that the patient will probably experience relapses of the condition. In bacterial vaginosis (BV), the lactobacilli concentration decreases, while the bacterial load of other (facultative) anaerobic bacteria increases. A hallmark of BV is the presence of clue cells, now known as the result of a polymicrobial biofilm formed in vaginal epithelial cells. Current knowledge of the individual roles of bacterial species involved in polymicrobial BV biofilms or interactions between these species are not fully known. In addition, knowledge of the composition matrix and triggers of biofilm formation is still lacking. Bacteria are able to attach to the surface of indwelling medical devices and cover these surfaces with biofilm. Vaginally inserted devices, such as tampons, intra-uterine devices and vaginal rings, can also be colonized by bacteria and be subjected to biofilm formation. This might hamper release of active product in case of drug-releasing devices such as vaginal rings, or promote the presence of unfavorable bacteria in the vagina. This paper reviews current knowledge of biofilms in the vaginal environment.

Toxic shock syndrome: major advances in pathogenesis, but not treatment.

Toxic shock syndrome (TSS) is primarily the result of a superantigen-mediated cytokine storm and M protein-mediated neutrophil activation, resulting in the release of mediators leading to respiratory failure, vascular leakage, and shock. Mortality for streptococcal TSS still hovers at 50%. There is evidence to support a role for intravenous immunoglobulin (IVIG) in the treatment of streptococcal TSS. An observational study suggests that an initial conservative surgical approach combined with the use of immune modulators, such as IVIG, may reduce the morbidity associated with extensive surgical exploration in hemodynamically unstable patients without increasing mortality.

[Statement of the Polish Gynecological Society Expert Group on the use of ellen probiotic tampon]. / Stanowisko Zespolu Ekspertów Polskiego Towarzystwa Ginekologicznego dotyczace stosowania probiotyku w tamponie ellen.

The group of experts representing the Polish Gynecologic Society has issued this Statement based on the review of available literature on the potential benefits of the use of ellen probiotic tampon. It has been firmly proven that during menstrual bleeding the vaginal flora undergoes profound changes prodisposing to both bacterial and fungal infections. Safety of menstrual tampons has been studied for over 60 years. According to the current state of knowledge, the use of tampons does not lead to any clinically significant change in the vaginal flora. The link between tampon use and Toxic Shock Syndrome (TTS) was revealed in 1978 after introduction of superabsorbent tampons to the United States market. Following the replacement of carboxymethylcellulose and polyester based tampons by the new generation of cotton based tampons, cases of tampon connected TSS are extremely rare in the US. The proper use of modern tampons is considered to be safe. Ellen tampon features dioxin and chlorine free natural fibres treated with the acidic acid producing probiotic Lacto Naturel (LN), which contains a combination of patented benevolent bacteria that can strengthen women's defense against vaginal infections. Both in vivo and in vitro studied have shown that ellen probiotic tampons are able to succesfully colonize vagina with the LN probiotic bacteria which then coexist with endogenous Lactobacilli present in the patients vaginal ecosystem. The ellen probiotic tampon constitutes an innovative solution of the vaginal probiotic application during menses. The use of this product is aimed to maintain natural vaginal flora as well as its pH during menstrual bleeding. According to the available clinical data, the potential benefits of the probiotic tampon use include: prevention of the vaginal/vulval discomfort as a result of frequent swimming poll use, maintaning of the therapeutic effect of antibacterial/antifungal vaginal treatment and prevention of the recurrent infections, prevention of iatrogenic vaginal flora imbalance after an antibiotic treatment.

[Cases of menstrual toxic shock syndrome in the Czech Republic in 1997-2011]. / Prípady menstruální formy syndromu toxického soku v Ceské republice v letech 1997-2011.

AIM: To determine toxigenicity and other basic characteristics of 47 strains of Staphylococcus aureus referred to the National Reference Laboratory for Staphylococci (NRL) as suspected causative agents of menstrual toxic shock syndrome (MTSS). MATERIAL AND METHODS: S. aureus strains were collected from 11 administrative regions of the Czech Republic in 1997-2011. The diagnosis was based on phenotypic (reverse latex agglutination test) and genotypic (polymerase chain reaction) methods. RESULTS: Forty-four S. aureus strains were producers of toxic shock syndrome toxin 1 (TSST-1), either alone or in combination with staphylococcal enterotoxin. Three strains only produced enterotoxin (B, C, and H). CONCLUSION: MTSS is a serious multisystem disease. In this study, MTSS often had a severe course requiring intensive care. All MTSS patients used vaginal tampons that had been identified in the literature as a risk factor for MTSS. The case of MTSS in a 36-year-old woman caused by an enterotoxin H positive strain of S. aureus is probably the first to be reported in the world.

Pilot study of the utility and acceptability of tampon sampling for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis infections by duplex realtime polymerase chain reaction in United Kingdom sex workers.

We aimed to evaluate the acceptability of self-collected tampon samples for the screening of female sex workers for sexually transmitted infections. We recruited 65 sex workers, and 63 agreed to provide tampon samples. The tampon samples were processed by realtime polymerase chain reaction (PCR) targeting Neisseria gonorrhoeae and Chlamydia trachomatis. Urethral and endocervical swabs were also obtained from 61 of 63 participants and tested using culture (N. gonorrhoeae) and the BD ProbeTec strand displacement amplification (SDA) (C. trachomatis) assay. Tampon sampling was preferred by 95% of the women and all favoured being tested away from genitourinary medicine clinics; the most common reasons cited were avoidance of embarrassment (40%) and convenience (30%). Besides near-universal acceptability of tampon sampling, the tampon sampling-PCR approach described in this study appeared to have enhanced sensitivity compared with conventional testing, suggesting the possibility of a residual hidden burden of N. gonorrhoeae and/or C. trachomatis genital infections in UK female sex workers.

Staphylococcus aureus exotoxins are present in vivo in tampons.

Staphylococcal toxic shock syndrome toxin 1 (TSST-1) is the cause of menstrual toxic shock syndrome (mTSS) associated with vaginal colonization by Staphylococcus aureus. In this pilot study, we measured TSST-1 and alpha-toxin, another exotoxin, on used tampons from four healthy women with S. aureus on tampons and from two women with tampon-associated mTSS. Tampons from all six women were sectioned into approximately 0.5-cm(3) pieces, some containing menstrual blood and some lacking menstrual blood. The pH of tampon sections with or without menstrual blood was neutral. S. aureus CFU were present in tampon sections at approximately equivalent counts (total counts were 1 x 10(8) to 2 x 10(9) CFU/tampon). TSST-1 (2 to 80 microg/tampon) and alpha-toxin (28 to 30 microg/tampon) were present only in the sections containing little or no menstrual blood (low hemoglobin density). In the tampons from TSS patients, the cytokine gamma interferon (IFN-gamma) was detected only in menstrual-blood-containing sections, whereas the chemokines macrophage inflammatory protein 3alpha and interleukin-8 were detected in all sections. Thus, IFN-gamma was being produced systemically, whereas the chemokines were being produced both locally by epithelial cells and systemically. The data show that S. aureus exotoxins can be identified in tampons ex vivo in sites with low hemoglobin density.

Vaginal Staphylococcus aureus superantigen profile shift from 1980 and 1981 to 2003, 2004, and 2005.

We determined vaginal Staphylococcus aureus superantigens. Staphylococci were quantified from tampons/diaphragms in 2003 to 2005, with counts compared to those determined in 1980 and 1981. In 2003 to 2005, more women were colonized than in 1980 and 1981 (23 versus 12%). Enterotoxins G and I and enterotoxin-like superantigens M and N declined, but enterotoxin-like superantigens K, L, and Q increased.