Menstrual Cups: Use and Safety From a Pelvic PT’s Perspective
There is a LOT of vagina, blood, and general menstrual talk in this blog (obviously). You’ve been warned.
Women are swimming in a sea of options when it comes to availability of things we can stuff into our vaginas during menstruation. In the last several years, products like cups and discs have become more popular due to less environmental impact when compared to one time use pads and tampons. And the fact that cups and discs can be worn 12 hours is certainly appealing. And mess free sex? Possibly another reason to switch. And with switching to new products comes questions and concerns. I am hoping this blog will give you more information and lead you to making the best decision for your needs.
Unfortunately in the world of women’s health, there isn’t a ton of research to support our informed decision making processes (surprise, surprise). This is mostly because women’s bodies are complex, require longer studies which costs more $$ and who really gives a shit (it wasn’t until 1993 that federal law mandated women be included in NIH-research). Why research women when they can just extrapolate research from men and assume it also holds true for women? So trust me when I say there is scant research on the topic of menstrual products and safety.
To start, we can use a comparative study by Howard in 2011 which looked at menstrual cup wearers vs. tampon wearers. The main results of this small study were that there were no differences in pelvic health concerns when comparing the two groups (read: no group had more issues with prolapse). One thing to note is that prolapse in general is fairly common in women, especially postpartum women (BTW, once postpartum always postpartum, so no timeline here). As more women are wearing cups and as we have more info/awareness/diagnosis/support around prolapse, there tends to be an unwarranted correlation here. Also, we know that Toxic Shock Syndrome risk is very low using cups. We used to think it was zero risk, but have at least one case reported.
But, I still have some thoughts about how to ensure these products are actually safe.
And first and possibly most important is that size really does matter. So, if you feel like you have a longer vaginal vault then a longer cup is probably needed. Short space between the opening of your vagina and your cervix (tip of the uterus)? Like, can you poke your cervix with your finger? Then a shorter cup length will be needed. Do you prefer one more firm or squishy? This will depend on your anatomy and the walls of the vagina. Do you have shorter fingers? Then one with a longer stem might be important. Note that discs, which are different from cups, do not have stems. So you have to be really comfortable going fishing high up in your vag behind your pubic bone for the edge of the disc, hook it with your finger to pull it out.
Most women can get cups in eventually but will take some trial and error. With the cup, you can use the c-curve or the punch down fold (google!), depending on your needs.. With the disc, you just fold in half slide it up and back until it hits the back wall of your vag and finish by pushing the front of the disc all the way up and under the pubic bone. I like to have women create an open feeling in their vagina with their breath (inhale, open the doors to the vagina!). Once the cup or disc is in place, the cervix should be right in the middle. It may take some practice to get it comfortably in place and without leakage! This is where we can get some help from a panty liner or period underwear (<—affiliate link). Use code THAT_PELVIC_LADY10OFF for 10% off order!).
Now the getting it out bit. This is where women can come up against some trouble. Unlike a tampon that we just pull out by a string, we cannot just pull the cup out by its stem. There is some debate about whether the cup actually suctions vs. seals, but in the end, I am not too worried about that. If it is suction/sealed and we pull it straight down, it will likely pull pelvic contents gently with it. We must break the seal first before pulling (a pinch and twist is nice. Some cups come with valves!).
Often-times, the cup feels really far up there and so we must use the stem to pull it down before we can even break the seal. If this is happening, please see section on how fit/size matters. Also, we are being advised to ‘bear down a bit’ like we are pooping to help get this thing out. I think a light bearing down in this manner is not inherently dangerous and probably no more risk than our daily pooping or farting. However, if you have to really push/strain and do this EVERY TIME to get it out and are vulnerable to prolapse (postpartum, chronic constipation, have a small asymptomatic prolapse etc)...then no good. As mentioned above, instead of bearing down, I like to help women create more space and openness in the vaginal area by releasing the pelvic muscles vs. pushing the pelvic muscles down. Also note that just before and during our bleeding, hormonal influence makes these pelvic structures a bit more vulnerable. The uterus/cervix will already drop a bit and pelvic muscles aren’t quite as resilient in this phase!
WE MUST ALSO BE CAREFUL TO NOT SUCTION OR PULL THE STRING OF AN IUD! THIS CAN HAPPEN ALTHOUGH SEEMS RARE
Avoiding these dilemmas with the cup is one reason why I personally switched to a disc. I have a slight bladder prolapse and I could feel it bulge every time I was bearing down to get that damn thing out (even with attempting my “opening the doors to the vagina” party trick). I just could not figure out how to avoid this with the cup and didn’t want to continue investing money beyond the 3 cups that already didn’t work for me.
So I researched. and decided to trial a one time use Flex disc (<—-affiliate link. I still felt better about 1 disc vs. 4-6 tampons/applicators however the disc rim is a ‘biocompatible polymer’ whatever that means). The pros for me were the ease with getting it in and out, less leakage and I couldn’t feel the stem (because it doesn’t have one). The cons are that it is actually quite messy (wow, that much blood exits my body in 10-12 hours? How I am still upright?). Much more messy for me than the menstrual cup because the disc has to tip a bit on its way out. So, for me, absolutely not an option to do this in a public bathroom. I solved this problem by taking it out in the shower (since it is only every 12 hours!). As already mentioned, you have to be comfortable with getting your fingers up high, finding the rim, hooking it and pulling it out. I am a pelvic PT. I know this anatomy fairly well but I know anyone can do it with some practice. So, I finally switched to this reusable disc. The cons with this particular disc is that it is more flimsy (the Flex was firm and knew where it was going) plus I occasionally need lube with this disc to get the material to slide.
Please make sure you rinse and wash your cup or disc each time. Our vulvas have a wonderful microbiome that keeps us clean and pH balanced, so please use nothing other than water and possibly mild soap when cleaning your vulva and cups. We don’t need to disrupt what already works so well!
Also, we know nothing. Due to lack of research, we just truly don’t know. So we just have to continue to suss out what feels OK for our bodies and what does not. Every female body is unique. If you have concerns about your pelvic health or menstrual cup/disc wearing, please consult with your OBGyn or Pelvic PT who can certainly give you more unique guidance.
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