Virtually every lady of a certain age that I have been seeing in clinic in recent months has been on HRT. And it’s great that supply issues have now, hopefully, been sorted and that GP’s do not need to perform any tests to confirm that an individual is approaching menopause. Moreover, HRT can now be started as soon as menopausal symptoms are experienced, after having had a discussion over the pros and cons with your GP, of course.
I’m sure any female of childbearing age will confirm that saying goodbye to menstruation is a good thing. As a December issue of the Economist states, up to 300 million women in the world at any one point in time are menstruating. They go on to state that three-quarters of those menstruating will be using some sort of menstrual product ie tampon, pad, cup etc and that the average woman who uses such products will use around 15,000 of them during her menstrual lifetime. If you have heavy periods, then the use will be much much more.
[Period pains. 17th December 2022, The Economist; page 81-82.]
It is interesting how the article goes on to talk about the investigation and regulation behind the composition of menstrual products, pointing out that drugs and foodstuffs, two other classes of product routinely inserted into the body, have much more rigorous regulation.
Also, regulatory practices differ across the world. For example, in America, menstrual products are treated as medical devices of category I or II by the Food and Drug Administration (FDA), in the EU they are uncategorised general products, in Japan they are “quasi-drugs”.
So in the EU, as they are classified as general products, ingredient disclosure is not mandatory. It is small comfort that despite them being classified as medical devices in the US, ingredient declaration is also not required in the US. The FDA’s only advice is that scented menstrual products should display a warning about allergic reactions and irritations.
Why all the worry?
I think it is due to reports from across the globe over the years and highlighted on social media of women complaining of symptoms ranging from shorter periods, increased cramps, itching, burning and rashes with the use of certain pads and pantyliners. In France, one survey found 81% of respondents felt that tampons posed a health risk.
Is this backed up by any evidence?
From a dermatologist’s point of view, our main concern when it comes to menstrual products is of the development of allergic contact dermatitis to allergeneic ingredients in these products.
The genital area has delicate skin and the close folded nature of the area renders it more moist, more susceptible to friction and more permeable than skin elsewhere. It is easy to irritate the skin in the genital area and once irritated, it gets inflamed and allergens (and infections) can enter more easily.
What allergeneic ingredients are implicated?
The main allergeneic ingredients are those found in fragrances and unfortunately, these are not only found in menstrual products but also in vaginal douche products and wet wipes.
But there are fragrances in cosmetics and they don’t cause a problem.
Cosmetics are under different regulation in the EU. Under this regulation, 26 allergeneic ingredients must be indicated on the packaging when its concentration exceeds 0.01% in rinse-off products and is above 0.001% in leave on products, and obviously this does not apply to menstrual products as they are classified as general products.
One recent study looked at four common skin sensitisers which were found to be leaching from scented menstrual products. Looking at a reasonable use scenario of six tampons per day, they deduced that women using these tampons could be at risk of allergic contact dermatitis.
[Marcelis Q, Gatzios A, Deconinck E et al. Quantitative risk assessment of allergens leaching from menstrual hygiene products. Regul Toxicol Pharmacol 2022 Nov;135:105260.]
Another study looked at 10 scented menstrual products which included tampons, panty liners and sanitary pads. Eight allergeneic fragrances were found in these products and five of these contained at least one allergen above 10 microgram/gram.
[Desmedt B, Marcelis Q Zhilivoda D et al. Sensitising fragrances in absorbent hygiene products. Contact Dermatitis 2020 May;82(5):279-282.]
There are other allergeneic compounds implicated in vulval allergic contact dermatitis too.
Yes, these also include certain medications eg local anaesthetics, certain topical steroids, preservatives and adhesives.
[Salzano, G, Galletta F, Caminiti L et al. Vulvar contact dermatitis caused by sensitization to colophonium in a patient with type 1 diabetes. Contact Dermatitis 2021 Sept;85(3):364-366.]
So where to from here?
Once an individual is sensitised to these compounds, there is no cure. The management of allergic contact dermatitis is allergen avoidance and hence it is extremely important that ingredient information is displayed.
The article in the Economist does state that the Swedish Institute for Standards, a think tank, has proposed creating a world-wide standard for menstrual products and this idea has already passed an initial vote at the International Organisation for Standardisation (ISO).
So there is hope for the future!
Dr Sandy Flann, Consultant Dermatologist.