Women have their periods three to seven days a month – for 30 to 40 years. That’s about 3000 days of their life; provided they are not pregnant or breastfeeding. The body loses between 30 and 80 milliliters of menstrual blood each time a tampon is used. That’s about as much as two spoonfuls of vinegar or just under half a glass of water.
To catch the fluid, most women use tampons, about one in five use pads or panty liners. Every tenth woman now also uses menstrual cups. This is the result of a recent survey conducted by the opinion research institute Civey for "Spektrum.de" has accomplished. A new trend is period underwear. So far, however, only two percent of the respondents use them. How hygienic are such panties? How well menstrual cups? What is the risk of contracting Toxic Shock Syndrome (TSS) from a tampon?? And what actually flows out of the vagina every few weeks? The most important questions and answers at a glance.
This article is contained in Spektrum Kompakt, Hygiene
What is menstrual blood?
"This is the upper layer of the uterine lining," explains Doris Scharrel, a gynecologist and state chair of the Professional Association of Gynecologists in Schleswig-Holstein – more specifically, the functional endometrium. This builds up during the female cycle each month until ovulation and is interspersed with fine blood vessels, mucous vesicles and connective tissue structures, among other things. That layer "provides the bed in which the fertilized egg can implant," Scharrel says.
If fertilization fails to occur, the upper layer of the uterine lining becomes redundant: The egg dissolves, and the body expels the functional endometrium via the cervix into the vagina. In other words: the woman bleeds – at least in a figurative sense. "The fluid that is flushed from the body during menstruation is red," says Scharrel, "but it is only about one-third blood." Accordingly, the term bleeding is actually somewhat misleading.
What if girls and women do not wipe away the liquid?
"Body-warm blood is an excellent nutrient medium for germs," says Christian Albring, president of the professional association of gynecologists, "regardless of which orifice it comes out of."Staphylococci and streptococci – bacteria that are always present in small numbers on our skin – are particularly fond of it, and intestinal bacteria can also spread in warm blood. "If menstrual blood starts to smell unpleasant, it’s a sign of germs that don’t belong there," explains the gynecologist. Those who want to avoid the smell should change the pad and wash thoroughly in the intimate area. But even if it smells because of the germs, the risk of getting sick is low because the pathogens are outside the body.
How often women should wash the vagina during their period? And how?
This depends above all on personal sensation. If a woman wears sanitary pads and her vulva is hairy, the blood collects in the external intimate area, can clump on the hairs and start to smell. "If this bothers you, you should change the pad and wash the vulva," says Scharrel. Girls and women who use tampons or menstrual cups and are shaved would have less of an odor problem. "Which does not mean, however, that one is better or worse than the other," emphasizes the gynecologist.
When it comes to care, the formula is: Less is more! Lukewarm to body-warm water is perfectly adequate for cleaning. In addition, women should only wash their external intimate area. Gynecologist Scharrel particularly advises against vaginal rinses: "They destroy the lactic acid bacteria, also called lactobacilli, which protect the intimate area from intestinal bacteria, and upset the germ flora of the vulva."
If you want, you can also use pH-neutral wash lotions for the external intimate area. These have a similar pH value to the skin and do not destroy the protective acid mantle. The acid mantle is a thin film of moisture and fats secreted by our sweat and sebaceous glands. Depending on the region of the body, it has a pH value of around 4, which means it is slightly acidic. The pH value of the intimate area is usually also 4 and protects the non-keratinized, sensitive skin of the vulva from the intestinal germs. Care products with a pH value above 7 are called alkaline, they are taboo for intimate care – not only for women, but also for men.
Now what about tampons – hygienic or not?
Now and then it is said that tampons contain pesticides or carcinogenic substances. According to a recent "oko-Test" study from 2020, however, this concern is unfounded. Most of the tampon brands tested scored "very good". Only one brand contained organohalogen compounds, some of which can cause allergies. In another, the retraction thread was not sufficiently tear-resistant, and in a third, the tampon proved to be a little too soft when inserted. Controversial ingredients such as optical brighteners, pesticides or formaldehyde were not detectable in any brand.
"Freshly unwrapped and inserted with clean fingers, tampons are absolutely hygienic," confirms gynecologist Albring. The only important thing is to remove them when they have soaked up the menstrual fluid and not to leave them in the vagina for longer than eight hours (see "What is Toxic Shock Syndrome?")?").
What is toxic shock syndrome??
Toxic Shock Syndrome (TSS) is a serious condition and is often associated with the use of tampons – more specifically, those that are left in the vagina for too long. The disease is caused by a specific strain of streptococcus or staphylococcus. These germs are everywhere on the skin. If they enter the bloodstream in large quantities through an injury and release their toxins there, the blood vessels can dilate and clotting fails. Typical TSS symptoms are headache, dizziness and fever (more than 39 degrees Celsius). If left untreated, it can lead to circulatory shock with organ failure and death.
However, women should not worry too much about the disease. TSS actually occurs extremely rarely. In Germany, there are only between 50 and 80 cases per year. Most adults are immune to the pathogens and their toxins due to previous minor skin infections. In addition: It is true that almost half of the TSS cases in Germany occur in women; however, the bacterial infection can also be triggered by the use of menstrual cups, by complications with a diaphragm or in the postpartum period, writes the Robert Koch Institute. Infections caused by skin diseases, burns and surgical wounds can also trigger TSS. For women and men.
Women should adjust the size of the tampon to the intensity of their bleeding. If a woman bleeds only slightly and uses a very large, absorbent tampon, it can absorb the vaginal secretion that protects the vagina from invading germs. Women should also not change it too often: "If the tampon is not yet fully absorbed, but almost dry, minimal lesions can develop in the skin of the vagina due to friction, which in turn increases the risk of infection," explains the gynecologist. "You don’t have to change the tampon every time you go to the toilet," confirms Scharrel: "After all, the vagina, urethra and bowel are separate organs, each with their own openings."When urinating, women can therefore simply hold the tampon band to the side. To find out whether the cotton pad is full, the gynecologist recommends gently pulling on the tape: "If the tampon can be moved easily, it is usually fully soaked." Then it is called: change.
How recommendable are menstrual cups??
The same applies to cups as to tampons: they must be clean. Once removed, women should therefore rinse the menstrual cup thoroughly with water. Those who are on the go can also wipe them out with special cleaning wipes, they say. After the period, the cup should also be boiled in a pot of water. "If women adhere to these guidelines, menstrual cups are hygienic," says Scharrel.
In terms of questionable ingredients, the cups are also in no way inferior to the tampons, as the "oko-Test" 2020 showed. The scientists and researchers actually found substances of concern in only one of 15 brands. Whether a woman reaches for a tampon or a menstrual cup during her period is therefore up to each individual. From a gynecological point of view, there is nothing to be said against either of the two variants, says "oko-Test".
There is one restriction, however: According to some manufacturers, the cups may remain in the vagina for up to twelve hours. Gynecologist Albring advises against this. He recommends removing menstrual cups like tampons after eight hours at the latest. Because the longer the blood is collected in the vagina, the easier it is for potentially pathogenic germs and bacteria to multiply. Menstrual cups have also led to cases of TSS, he said.
If the vagina is acutely infected, menstrual cups should be avoided. And women who use IUDs should use tampons or pads rather than cups. This is because they may pull out the IUD with the menstrual cup or the contraceptive may slip in such a way that it becomes unsafe to use.
Menstrual hygiene – a taboo
Being able to talk openly about menstrual hygiene is important. But this is not possible everywhere. Around 130 million girls worldwide do not go to school, some of them because of their periods, according to the World Health Organization (WHO). In some countries, young girls and women have to move into so-called "menstrual huts" during the period, some schools have no water and sanitary facilities, and often women simply don’t have the money for the necessary hygiene products. "Period poverty" is the name given to this phenomenon.
Europe is not excluded from it. In the Netherlands, for example, about ten percent of girls and young women cannot afford pads or tampons, according to the WHO. In Scotland, period poverty affects a good one in four female students in some regions. In a pilot project, the Scottish government is now ensuring that pads and tampons are available in the toilets of schools and universities. There are no reliable figures on period poverty for Germany, which doesn’t mean it doesn’t exist here at home.
However, the countries most affected are those in the Global South. Many women use rags or socks during menstruation, which increases the risk of reproductive and urinary tract infections. Menstrual hygiene and health is a fundamental human right," says the WHO, calling on governments worldwide to take action.
What about menstrual sponges?
The sponges are not only reusable, but are usually made of biological material or medical silicone. Like tampons, they are inserted into the vagina and absorb the menstrual fluid there. When the sponge is full, it is pressed out of the vagina by the tension of the pelvic floor muscles. Some women also attach a ribbon to the sponge and pull it out by it. Before it is used again, it is rinsed out under water, just like the menstrual cup. To prevent tissue and blood residues from remaining, manufacturers recommend soaking the sponge in vinegar water and/or water with a three-percent hydrogen peroxide solution from the pharmacy for one to two hours after menstruation.