I love my global network of physiotherapists (physical therapists) who work with women’s health / pelvic health! As you can imagine, we have some quite interesting conversations! A very lively one recently was about menstrual cups. If you’re not familiar, menstrual cups are one of the alternatives available to menstruating women in lieu of tampons and pads (which can be expensive, rough on the environment, and riddled with chemicals). One of my Aussie colleagues had written a cautionary post a couple years ago and one of my USA colleagues re-posted and commented she had similar concerns, and the lively discussion ensued. If you’ve tried menstrual cups before, you may have your own stories of leaks, messes, or scary moments of not being able to get the dang thing out! The main concern my colleagues were discussing came down to twofold: either end of the spectrum from “tight” pelvic floor muscles to inadequate support and pelvic organ prolapse…and there is some discussion of shape and diameter and length…
And of course, our scientific minds want research. Not much is out there unfortunately. One small trial comparing cups to tampons (Howard 2011) found that, while there was a bit of an initial learning curve, 91% of menstrual cup users would continue after the study, and rates of urogenital health concerns were not significantly different between groups.
Having had some personal experience and counseling patients from various ends of this spectrum, I offer some thoughts:
First thing to understand is that there is a wide wide world of menstrual cups! SO MANY to choose from! There are different brands from different countries, “squishiness” levels, lengths, diameters, capacities, materials, stem type and of course colors. One thing that helped me make my decision was consulting one of the many menstrual cup charts available on the internet. Seriously. Search “menstrual cup chart” and you will see a variety of spreadsheet type documents outlying these various attributes! Let’s say you think you might have a short vaginal vault (or some degree of uterine prolapse that makes it so) so that maybe if you use a tampon, the end of the tampon sticks out a bit – look for a shorter cup. Let’s say you’re younger, haven’t had any vaginal deliveries, or have a, small introitus, you may be interested in one with a smaller diameter (or softer level of squishiness). Do you tend to have a heavier flow, perhaps sometimes leaking through your tampon or pad on your heaviest days? Look for one with the highest capacity that meets your other needs! (you may also want to change the cup sooner than 12 hours on those days and/or wear a backup pad or period panty). As for color, you may think that translucent rainbow sparkles sounds fun, but they tend to stain non-uniformly and honestly look pretty gross….so I’d go with the darkest color you can find that meets your other needs. Trust me on this one.
What about the how-to? This can make the difference between one of these working for you and not. There are quite a few techniques one can employ for getting this thing in. Probably the simplest and most common is to pinch the cup and fold it so that it makes a c-shape. Other folds like the “punch down” are a bit more complicated to execute, but make a smaller shape for initial vaginal insertion. Regardless of the fold you choose, you then put it in place inside the vaginal vault and let go of the fold/pinch so that the material bounces back into it’s circular shape – make sure at this point that it completely encompasses your cervix. If you can feel something outside the cup that somewhat feels like the end of your nose, it’s probably your cervix….and if it’s not inside the opening of the cup, you will have some major leakage going on because the cup is not going to catch anything. If you’re having trouble getting it to pop back open, one of the best tricks is to rinse with cold water for 10 seconds or so before putting it back in – that way the plastic is slightly more stiff and will bounce back to its original shape more easily. If you’re consistently having trouble with this, a stiffer cup material helps.
Now for taking it out. This is where it can get really tricky for a lot of women and I think is the major reason women give up trying menstrual cups. It can be tricky because 1 you have to be able to reach it (none of these that I know of has a string like a tampon), and 2 you need to break the seal/suction. Typically, breaking the seal/suction is done by just pinching the cup and rotating it a bit, while a few models come with a valve to make this easier to do. Reaching it is where the different types of stems come in handy. You want a stem that’s easy to grab while not extending beyond the vaginal vault and irritating the sensitive vulvar vestibule when you move. Some women do well with no stem at all – typically in this case, the cup has a few ridges on the end and you just pinch at those ridges to break the seal. Here’s where things get a bit dicey. A lot of instructions will recommend that you produce a bit of a valsalva (bearing down) to make it easier to get the cup out. Doing this occasionally is not the end of the world. But, for women who already have a bit of prolapse, chronic constipation, more lax connective tissues, or just the natural descent of the uterus that happens at the beginning of the cycle (making the vaginal vault relatively shorter), this is not the best long-term solution. If you’ve never tried one of these things it is a bit tricky to predict what type of stem you will like. Some brands come with a longer stem that is intended to be cut to the point that it is just long enough to reach without having to go spelunking. A ball stem, for example, can be a great compromise between comfort and reachability. You may end up purchasing a few different cups from different brand/size/style before you find the perfect fit. If you have a shorter cup and a longer vaginal vault, you don't have to insert it so far that you have to go spelunking for it - it only needs to form a seal between the rim of the cup and your vaginal wall, without sticking out and irritating the introitus/vulva. Once past the initial learning curve of getting it out without valsalva or yanking on the tissues, I think cups are not a bad idea at all for a mild uterine prolapse or anterior/posterior vaginal wall laxity (cystocele/rectocele). Cups, especially the ones that are a bit stiffer, can even provide a bit of vaginal wall support during the menstrual cycle. If you're unsure whether you fall in a precautionary category or not, let a women's health physio/PT check things out for you and give you a recommendation!
For me, I think the biggest precaution would be women with vulvovaginal pain. Women who have “tight” pelvic floor muscles, pain with gynecological exams, tampon insertion or intercourse, or other sensitivities of the vulva or vagina may or may not be appropriate for using a menstrual cup. The best person to help you make this determination is a women’s health physiotherapist who does intravaginal assessments. I will say for some patients who tolerate vaginal insertion but don’t tolerate all-day tampon wear for instance, one of the softer cups may still be an option. I am not sure if this is still the case, but very recently, the softest cups (such as the “soft” meLuna from Germany) were not available for sale in the USA. Keep this sort of thing in mind and do your research – you may be able to order online from abroad. You may decide to use a bit of organic lubricant on lighter days, or forgo the cup altogether in favor of a pad or period panty. In general, if insertion and/or removal of the cup is painful, a women’s health physio can help not only decide if a cup is a good idea, but help get to the root cause of why it hurts and help you feel and function better!
One final thought is make sure you pay attention to hygiene with these things. In general, we say “the vagina is a self cleaning oven” – meaning please don’t use soap, sprays, douches, etc. Allow the vagina to self-regulate it’s pH and microbial community. Inserting any foreign object does disturb this regulation a bit. Proper cleaning and care of the cup can minimize this (follow the instructions). Just make sure you don’t melt your cup by boiling it too long in a pot of water (oops!). Once you are practiced at managing the cup, you can even travel with them….but I do recommend having a few cycles of practice before you go on a month-long European adventure with a cup or two as your only menstrual supply. When out in public, go into the bathroom with freshly washed hands, and wipe at least the outside of the cup and rim with toilet paper before reinserting. Next time you're in a private bathroom, you can rinse/clean it.
Did that answer a few of your questions? What others do you have?
Howard, C, et. al. FLOW (finding lasting options for women): Multicentre randomized controlled trial comparing tampons with menstrual cups. Canadian family physician, June 2011.