Until recently, menstruation wasn’t spoken of in mixed company. Those with menstrual cycles have been taught how to hide and disguise the symptoms of their cycle. Often, that’s all they are taught. Cultural shifts are changing this. Activists and menstruators everywhere are working to normalize this, well. . . normal body function. In modern times, there are increasing concerns about the products used and the safety of them. Sure, our modern world has ushered in more convenient and efficient products, but are they safe? What do we know of the short and long-term effects of these products and the chemicals they contain? 

There seems to be a large polarity of opinions, and even science, surrounding the safety and toxicity of various menstrual products. I imagine the truth is somewhere in between these two extremes. I wanted to see what I could find on the topic and sift through the large body of information. 

 

First, there are 2 types of ingredients in menstrual products that are concerning. The first being additives such as dyes, gels, fragrances and adhesives. The second category includes contaminants that may be toxic such as pesticide residues in cotton or toxic byproducts created during the manufacturing process.

As far as additives go, I didn’t find specific studies on the dyes, fragrances and adhesives involved with menstrual products. It seems to be well known that these things are, at the very least, irritating to some. Most companies now provide fragrance-free options in response to consumer concerns.

 

As far as contaminants go, I found information on dioxins, glychosphate, benzophenones, and parabens. I’m going to focus here on these concerns.

 

DIOXIN
One long standing concern is whether the process of purifying and bleaching the cotton and rayon with chlorine may leave traces of dioxin behind. Even the Food and Drug Administration (FDA) acknowledges that chlorine dioxide, though elementally chlorine free, can still “theoretically generate dioxins at extremely low levels,” and, according to the Environmental Protection Agency (EPA), “no safe level for dioxin exposure exists.” The compound is 10 times more likely to cause cancer than was believed in 1994, according to the EPA, and even background levels may lead to health effects like developmental delays, birth defects, hormone disruption, and immune cell suppression. The toxin accumulates in humans with repeated exposures, particularly in body fat and breast milk, and 16,800 tampons over the course of a lifetime certainly qualifies as high exposure. (1) According to one article I found, it appears that in the United States, exposure through diet is far greater than exposure from using tampons or diapers (2), but again, according to the EPA, there is no safe level for dioxin exposure. 

There is actually quite a bit of research available addressing the connection between endometriosis and dioxin and dioxin-like PCB’s (polychlorinated biphenyl). The conclusion of one study states, 

“Evidence from animal studies, nonhuman primates and rodents, suggests that endometriosis is associated with exposure to TCDD (Tetrachlorodibenzo-p-dioxin) as well as dioxin-like PCB’s. These findings are relevant to human endometriosis because exposure of the general human population to these compounds has been documented… Additional studies in human and animals are warranted to investigate the potential association between exposure to these toxicants and endometriosis and elucidate the mechanism of action of dioxin in the pathophysiology of this disease.” (3) 

A major roadblock in many of the human studies is that there isn’t yet a non-surgical way to diagnose endometriosis. Another study states, “Among the numerous toxicants identified within human cord blood, 2,3,7,8-TCDD has been widely studied because it is considered to be the most highly toxic environmental contaminant ever manufactured.” (4) 

 

GLYPHOSATE
A relatively new contaminant that is cause for concern is glyphosate. Glyphosate is an herbicide applied to cotton (among many other plants) to regulate plant growth and ripen fruit. The common trade name of this is Roundup. There are public health concerns about glyphosate in the cotton that creates tampons and other products. According to an collaborative statement on the dangers of glyphosate in the journal Environmental Health, 

“Initial toxicity testing suggested that GBH’s (glyphosate-based-herbicides) posed relatively low risk to non-targets species, including mammals, leading regulatory authorities worldwide to set high acceptable exposure limits…. Animal and epidemiology studies published in the last decade, however, point to the need for a fresh look at glyphosate toxicity. Furthermore, the World Health Organization’s International Agency for Research on Cancer recently concluded that glyphosate is ‘probably carcinogenic to humans.’” (5) 

In this “Statement of Concern directed to scientists, physicians, and regulatory officials around the world,” These scientists are calling on new data and science in order to assess the health concerns of GBH’s. Human exposure is on the rise as it is the most heavily applied herbicide in the world, and usage is also on the rise. Although I did not find any specific studies on glyphosate and tampons, when I Googled “glyphosate and tampons” there was huge polarity in the results. People seem to be strongly on one side or the other. It’s obvious that definitive and unbiased information is needed. According to the 2018 paper “Critical Review of the Effects of Glyphosate Exposure to the Environment and Humans through the Food Supply Chain,” it is “evident that new studies and independent research must be performed in order to clearly define the seriousness of glyphosate exposure to carcinogenicity and genotoxicity… In fact, there is too great a discrepancy between the opinions of the various scientific institutions, mainly because of their different economic and social interests.” (6)

 

 

OTHER TOXINS AND TESTING
As a part of my research, I interviewed Alethea Maki, an Acupuncturist and Oriental Medicine Practitioner to see if Traditional Chinese Medicine (TCM) had anything to say on the topic of toxicity and menstrual products. She said that she didn’t recall learning anything in her training about products specifically. Her personal and professional experience was that the chemicals in tampons were abrasive and permeated into the tissues. Permeation promotes toxicity and what TCM would call ‘dampness’ or ‘stasis’. She talked about endometriosis being connected to blood stasis, which is amplified with toxicity. Further, yeast and bacterial vaginosis are caused by an accumulation of dampness. She talked about how TCM considers menstrual fluid as very sacred and containing “life force energy.” In her opinion, chemicals in tampons do contribute to blood stasis and therefore issues such as endometriosis, yeast infections, and bacterial vaginosis (BV). She helps her clients who experience such issues transition to alternatives such as menstrual cups, free bleeding, or sea sponges. 

A routine way to assess the safety of intravaginal products is through colposcopic inspection of the vagina. However, according to a 2013 study published in Archives of Gynecology and Obstetrics, “colposcopic findings occur frequently in healthy women, raising questions about their relevance to intravaginal safety.” (7) The same study concluded that assessing inflammation and dryness associated with menstrual tampons by placing them “Behind-The-Knee” was a valuable alternative to the vagina. This is because of “practical disadvantages that limit the utility of colposcopy for evaluating menstrual tampons… Among the disadvantages is the presence of background micro trauma, and the inability to assess effects during menstruation and importantly, the question of whether assessments after this are sufficiently sensitive to detect small inflammatory changes.”  Most alarmingly, this study observed, “scoring erythema [redness] in the Behind-The-Knee test immediately after product removal increased the level of visually discernible inflammation sixfold.“ 

Another study I encountered was based on research about parabens and benzophenones. (8) Note that these chemicals themselves aren’t in menstrual products. They are, however, common in many cosmetics and personal care products. In this study, the researchers tested six different benzophenones and four different parabens in menstrual blood from 25 volunteers living in southern Spain. All of these compounds were detected, with Methylparaben and Benzophenone-3 being the most common. Also according to this article, another “recent epidemiological study conducted on 600 women reported an association between BP-1 exposure and endometriosis.” While benzophenones and parabens themselves aren’t in menstrual products, I included this information for a couple of reasons. First, it speaks to the idea of toxicity that Alethea Maki mentioned. Second, it speaks directly to how toxicity and sexual health are related, as these chemicals showed up in menstrual blood. 

 

LACK OF REGULATION AND LACK OF INDEPENDENT STUDIES
The Food and Drug Administration regulates menstrual products as medical devices along with dental floss and condoms. Because of this categorization, companies are not required to list the ingredients of their products.

On May 11, 2017, a bill called H.R. 2426 – Menstrual Products Right to Know Act of 2017 was introduced into The House of Representatives, sponsored by Representative Grace Meng of New York. This bill would have required menstrual product ingredients to be listed on the product labels. The bill was referred to the Subcommittee on Health the next day, but nothing appears to have been accomplished from there. As of September 28, 2018, no related bill information had been received for H.R.2416. (9) At least one company, however, has listed the ingredients of their products on their websites. We will go into that a little later.

Some of the top global players in the feminine hygiene industry active in the US market include:

-Edgewell Personal Care Company

-Johnson & Johnson


-Kimberly-Clark Corporation

-PayChest, Inc.

-Proctor & Gamble
(10)

Let’s look into each of these corporations, one at a time. Edgewell Personal Care Company has Playtex, CareFree, Stayfree, and o.b. brands under their umbrella. After searching their websites (11), I found no information on ingredients of any of their products listed. The Playtex website has a question about chemicals in tampons in their FAQ section, and they seem to skirt the question with this response: “We all know how easy it is for the wrong information to get passed on the Internet. However, there are government organizations like Health Canada that have strict requirements for the production of tampons to make sure they are free from any harmful materials.”

Johnson & Johnson has a long history of being in our homes and our bodies. I was unable to find any specific menstrual products on their website. (12) Looking deeper, it appears that the above company, Edgewell, acquired these products from Johnson & Johnson.

Kimberly-Clark Corporation is the parent company of Kotex and U by Kotex. After searching the websites for information about these products, (13) I didn’t find any mention of any product ingredients whatsoever.

I didn’t find a website for PayChest, Inc., but did find information about stocks and investments, as well as news about a new flushable sanitary pad. We will see what comes of that.

Proctor & Gamble provides more information than any other company about their product giants, Tampax and Always. It surprised me to find that the websites for both product lines provide nearly every ingredient in those products. (14) Initially, it appears that they have done a good job ensuring safety and providing transparency. Maybe this is due to the recall of their product Rely in September, 1980 following a CDC report connecting it with Toxic Shock Syndrome (TSS). (15)

The most interesting things I found on tampax.com was a link provided after this statement: 

“We do extensive safety assessments to make sure the millions of women who use Tampax each day can do so with confidence. We have our assessments reviewed by these independent experts who oversee tampon safety. These experts have confirmed that our tampons and the materials used to make them can be used safely.”

The link that follows brings you to a study published in Infectious Diseases in Obstetrics and Gynecology. (16) The objective of this study is to “confirm the safety of a new experimental Tampax tampon and applicator compared with that of a currently marketed Tampax tampon and applicator using comprehensive gynecological and microbiological assessments.” That’s right – they assess the safety of a new Tampax tampon by comparing it exclusively to a currently marketed Tampax tampon. The conclusion? The study “supports a comparable safety profile for the experimental tampon and a currently marketed tampon.” This is the only evidence they’ve provided to back up the safety of their product. Superficially, it looks as though they’ve done the legwork to prove the safety of their products, but if you look just a little deeper, the evidence is not so comforting. 

Always Pads, the other huge product from Proctor & Gamble, also lists all ingredients of their pad on their website. The company also addresses several other safety topics. In response to a question about whether scented pads are safe or if they’ll cause irritation, the website claims that the products meet the safety standards of the International Fragrance Association. I wonder what this association knows of vulvar health. 

Next, the Always site addresses a question about chlorine bleaching. The company states, several times, that it does not use chlorine bleach any longer in their purification process because trace amounts of pollutants, like dioxin, were formed. The company now uses an alternative method that it doesn’t say much about, other than that hydrogen peroxide is used in the process. The site also mentions that no dyes are used in their products, but the pigments that are used are tested and safe. I’m not sure what the difference between pigments and dyes are. Always products do come in fragrance-free alternatives. 

Lastly, regarding Always Pads, the company cites a study on their website in response to questions of safety. (17) Much of the research looks great. For example, the study states, “…No systemic toxicity concerns exist for the topsheet” of the pad. Getting into the deeper foam core used in the pad, there was “no evidence of vaginal irritation in rabbits.” I am not sure why these tests went from humans to rabbits. I don’t think the rabbits would complain if they experienced irritation. The study says that after a five-day test for vaginal irritation on rabbits they concluded it was non-irritating because there was no mortality, no body weight differences, no macroscopic vaginal erythema (redness), edema, or discharge. I don’t find this to be conclusive evidence at all. It is possible that an animal or human can be exposed to toxic material and not die within five days, have any weight changes, or have any redness, swelling or discharge. They literally rubbed a rabbit’s vulva with a pad and found no negative consequences from that. 

Another detail I found when looking into information about the authors of the Always Pad study cited above is that it clearly shows that they are working for The Proctor & Gamble Company. This is most definitely a conflict of interest, and even shows through in the writing of the study: “This article describes the safety assessment process for our most significant product innovation in the category to date, the introduction of a thin, non-cellulosic absorbent foam core.”

In August 2014, a nonprofit out of Missoula, Montana commissioned testing of four types of Always Pads. (18) The certified laboratory STAT Analysis Corporation analyzed the products for volatile organic compounds, and “these data represented the first publicly available test results of this kind for these products.” The methodology included “analysis of the samples for volatile organic compounds…conducted by gas chromatography/mass spectrometry with EPA Method TO-15 using headspace containers.” The results? The Always pads were found to contain several chemicals of concern, including the following: 

Styrene: a carcinogen
Chloromethane: a reproductive toxicant
Chloroethane: a carcinogen
Chloroform: a carcinogen, reproductive toxicant, neurotoxin
Acetone: an irritant

The results of the testing indicate that both scented and unscented Always pads emit toxic chemicals, including chemicals identified by the U.S. Department of Health and Human Services National Toxicology Program, The Agency for Toxic Substances and Disease Registry, and the State of California Environmental Protection Agency as carcinogens, and reproductive and developmental toxins. None of these chemicals are disclosed on the product by the manufacturer.

Comparing the peer-reviewed study written by Proctor & Gamble employees, in which rabbit vaginas were observed instead of human vaginas and the independent testing was commissioned by a nonprofit, I would sooner trust the science of the STAT Analysis Corporation. Other than what is said in the self-serving statements issued by Always and Tampax, it is unknown whether these products contain dangerous dioxins from chlorine bleaching. It’s also reasonable to be concerned about glyphosate on all cotton products that are treated with the chemical. 

As I sought to research menstrual products and health, I didn’t want to focus exclusively on the health of menstruators—our environment is another entity that is greatly impacted by menstrual products as well. It’s not hard to find information on disposable products of all kinds and how horribly they are impacting our planet. I find the amount of waste humans create overwhelmingly repulsive. I may not change the world, but for me personally, I’m going to do whatever I can to reduce such waste. Green Living: The Environmental Magazine addresses the dangers of chlorine bleaching this way: “…Nor is the environment off the hook. The Worldwatch Institute calls elemental chlorine free bleaching a “‘low-tar cigarette’ approach to the problem of organo-chlorine pollution, reducing (not eliminating) pollution, and not addressing the fundamental problem–the continued use of chlorine…Hydrogen peroxide, oxygen or ozone work just as well, though any bleaching still uses energy and water unnecessarily.” (19)

Proctor & Gamble’s Tampax appears to show concern about the safety of women’s health as well as the environment on their website, which includes this statement:

“We look for materials that deliver the safety and satisfaction women demand while reducing the impact of our products on the environment. Tampax tampons are made primarily of sustainable grown cotton and Tampax Pure and Clean tampons are made primarily with a 100% cotton core, so using one of our tampons helps take care of you and the environment.” 

Sounds great, perhaps. To me, it sounds like fluff. It’s unclear what they mean by “sustainable grown cotton,” and surely it is still treated with Roundup. Also, how exactly does this help care for women and the environment? Under the “We Care About The Environment” tab of the website, the company claims to have reduced solid waste from its processing plants by 70% since 2010, with 8 out 10 plants being “zero waste.” I hope that’s true, because that’d be great! Under the “How You Can Help” section about environmental concerns, the company’s only advice is to make sure tampons are put in trash cans and not flushed down toilets. 

It is clear that with the variety of available products now on the market, many menstruators are turning to alternatives beyond conventional tampons and pads, for whatever reason. These products include reusable pads, tampons, cups, sponges, and absorbent underwear. Many of these products are made from organic materials. Another available option is what’s called “free bleeding” where no products are used at all. This may require someone to possibly change their lifestyle to stay home or in nature, and to be more present and intimately connected to their body.

I’ve compiled some, but surely not all, of the products that can be used by anyone wanting to avoid the conventional modern products.

Reusable cloth pads, such as Luna Pads and Glad Rags.

Reusable underwear

Reusable tampons

Sea Sponges

Softcup

Cups
-Diva Cup
-Lunette
-The Keeper
-The Fleurcup
-MoonCup 

It is a very personal choice to decide what products are best for you and your body. More unbiased, factual information is needed for the public to make healthy and informed decisions.

If you, or someone you know, would like more guidance regarding menstruation and/or products, please contact me at highersexeducation@gmail.com

Written by Melissa Hite in 2018

References:

1. Jennifer Bogo. March/April 2001. Green Living: The Environmental Magazine. Vol 12, Issue 2, p40.
2. Michael J DeVito, Arnold Schecter, February 2002. Environmental Health Perspectives. “Exposure Assessment to Dioxins from the Use of Tampons and Diapers.”
3. Sherry Rier, Warren G. Foster, August 14, 2003. “Environmental Dioxins and Endometriosis.”
4. Kaylon L Bruner-Tran, Kevin G. Osteen, April 2010. “Dioxin-Like PCB’s and Endometriosis.” Systems Biology in Reproductive Medicine.
5. John Peterson Myers, Michael N Antoniou, Bruce Blumberg, Lynn Carroll, Theo Colborn, Lorne G Everett, Michael Hansen, Philip J Landrigan, Bruce P Lanphear, Robin Mesnage, Laura N Vandenberg, Frederick S vom Saal, Wade V Welshons, and Charles M Benbrook. February 2016. Environmental Health. “Concerns over use of glyphosate-based herbicides and risk associated with exposures: a consensus statement.” 
6. Vincenzo Torretta, Ioannis A Katsoyiannis, Paola Viotti, and Elena Cristina Rada. March 24, 2018. “Critical Review of the Effects of Glyphosate Exposure to the Environment and Humans through the Food Supply Chain.” www.mdpi.com/2071-1050/10/4/950.pdf
7. Miranda A Farage, Kenneth W Miller, William J Ledger. March 2013. Archives of Gynecology and Obstetrics. “Assessing menstrual tampon irritation using the ‘Behind-The-Knee’ test.” https://pubmed.ncbi.nlm.nih.gov/23179806/
8. Jiménez-Díaz I, Iribarne-Durán LM, Ocón O, Salamanca E, Fernández MF, Olea N, Barranco E. November 2016. Journal of Chromatography B: Analytical Technologies in the Biomedical & Life Sciences, Vol. 1035, pp. 57-66. “Determination of personal care products – benzophenones and parabens – in human menstrual blood.”
9. See congress.gov/bill/115th-congress/house-bill/2416/all-info 
10. March 2018, “Global Feminine Hygiene Products Industry,” Reportlinker.com
11. See playtexplayon.com, carfreeliners.com, stayfree.com and ob-tampons.com
12. See jnj.com
13. See kimberly-clark.com, ubykotex.com
14. See us.pg.com, tampax.com, always.com
15. Hanrahan S. 1994. “Historical Review of Menstrual Toxic Shock Syndrome.” Women & Health.
16. Stacey E. Shehin, Michaelle B. Jones, Anne E. Hochwalt, Frank C. Sarbaugh, and Stephen Nunn. April 2003. Infectious Diseases in Obstetrics and Gynecology
    Volume 11, Issue 2, pp. 89-99. “Clinical Safety-in-Use Study of a New Tampon Design.”
17. Kara E. Woolley, Anne E. Hochwalt. October 2015. Regulatory Toxicology and Pharmacology, Volume 73, Issue 1. “Safety assessment of sanitary pads with polymeric foam absorbent core.”
18. www.womensvoices.org/feminine-care-products/detox-the-box/always-pads-testing-results/

Jennifer Bogo, Green Living, p. 40.