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Menstrual health in adolescents has been understudied in the United States. We aimed to assess patient and provider perspectives surrounding menstrual health management and screening.Our mixed-methods approach consisted of provider surveys, patient surveys, and patient interviews.Participants were recruited from a pediatric gynecology practice or an adolescent medicine clinic at an urban tertiary academic center.Providers were pediatrics faculty or residents. Patients aged 13-24 years were eligible.Participants completed an anonymous survey or semi-structured interview about their experiences with menstrual health.Descriptive statistics and thematic content analysis were used for quantitative and qualitative data, respectively. Convergent parallel analysis elucidated key findings in both data sets.The provider survey response rate was 65% (69/106); 15% (9/69) of providers consistently asked patients about menstrual products, whereas 44% (27/68) were concerned patients could not afford products. The patient survey response rate was 85% (101/119); 19% (19/101) of respondents reported menstrual hygiene insecurity, 55% (55/101) missed commitments during menses, and 45% (45/101) discussed menstrual products with providers. Fifteen patients were invited for qualitative interviews; 10 were conducted, and thematic saturation occurred. Interviews highlighted the importance of comprehensive early menstrual health education and providers' role in menstrual management.Adolescence is a crucial point of entry into health care. Because taboos surrounding menstruation could limit access to health care, menstrual health education must be emphasized. Menstrual health education is provided piecemeal by parents, schools, and providers. Current practice should be reevaluated to consider comprehensive educational approaches in which health care leads.

Ensuring menstrual cup safety is paramount, yet a menstrual cup safety assessment scheme is lacking. This paper presents a quadripartite scheme, showing how it can be applied.The Tampax Menstrual Cup was evaluated in the safety assessment scheme: (1) Biocompatibility and chemical safety of cup constituents. Extractables were obtained under different use condition; exposure-based risk assessments (EBRA) were conducted for extractables exceeding thresholds of toxicological concern. (2) Physical impact to vaginal mucosa. After physical evaluations, the Tampax Cup and another cup were assessed in a randomised double-blinded, two-product, two-period cross-over clinical trial (65 women, mean age 34.2 years). (3) Impact to vaginal microbiota (in vitro mixed microflora assay and evaluation of vaginal swabs). (4) In vitro growth of Staphylococcus aureus and toxic shock syndrome toxin-1 (TSST-1) production.Biocompatibility assessments and EBRA of cup constituents showed no safety concerns. In the randomised clinical trial, all potentially product-related adverse effects were mild, vaginal exams were unremarkable, no clinically relevant pH changes occurred, post-void residual urine volume with and without cup were similar, and self-reported measures of comfort along with reports of burning, itching and stinging between cups were comparable. Cup use had no effect on microbial growth in vitro or in the 62 subjects who completed the trial or on in vitro TSST-1 production.The quadripartite safety assessment scheme allows evaluation of menstrual cup safety. The Tampax Cup is safe and well-tolerated upon intended use. As with all feminine hygiene products, post-market safety surveillance confirmed this conclusion.By ProcterGamble.

Allergic contact dermatitis (ACD) often associated with the topical use of perfumed products, remains one of the most common chronic skin disorders in Western countries. Since labelling of scented menstrual hygiene products (MHPs) is not mandatory, women might be unknowingly exposed to allergens. Given that vaginal mucosae lack the vital barrier function of the skin, skin allergens can easily penetrate and become systemically available and hence women may experience adverse effects in the anogenital region. The aim of this study was therefore to investigate whether women using scented MHPs are at risk of sensitization and hence developing ACD. Hereto, a Quantitative Risk Assessment (QRA) is performed on four well-known skin sensitizing chemicals (α-isomethyl ionone, benzyl salicylate, hexyl cinnamaldehyde and heliotropine) that were previously found leaching from five different scented MHPs including tampons and sanitary pads. The amounts of heliotropine, leached by one of the investigated tampons, exceeded acceptable exposure levels determined with the QRA and could induce sensitization. In addition, although no sensitization is expected for the other three compounds, an allergenic reaction might be provoked in women who are already sensitized. Labelling of allergens on scented MHPs would therefore help consumers to prevent adverse effects linked to ACD.

Evidence of sexual aggression may be obtained from superabsorbent polymer (SAP) sanitary pads, which are used by forensic laboratories for semen evaluation. Semen can be extracted from their upper layers, which are free of SAPs. However, our previous results showed a need to optimize the protocol for semen analysis by considering its extraction from the lower core, often composed of sodium polyacrylate SAPs. SAPs generate a hydrogel, which traps the cellular components, hindering the possibility of obtaining cells and hence their genetic material. Simple filtration has been tried previously, but further maximization by application of a treatment has never been attempted. In this paper, we compare both chemical and physical shredding treatments for maximizing gel-trapped sperm and male cell DNA recaptures from hygienic superabsorbent substrates in sanitary pads, panty-liners or diapers. Our findings suggest that the lower core should be treated to induce a dewaterisation of the SAP hydrogels in order to maximize the extraction of bodily fluids.

Objective The choice and use of a type of hygienic protection depends on many factors. Due to growing media interest, the field of hygienic protection is evolving, however, to date no study has been carried out on this subject in France. The objective of this study was to evaluate women's practices regarding the use of hygienic protection. Material and methods From 2 June 2019 to 4 January 2020, 1,153 patients responding to a self-report questionnaire were included in a prospective, cross-sectional, observational, single-centre study. The aim of the study was to describe women's practices with regard to menstrual hygiene products and the factors determining their choices, as well as their knowledge of the potential risks associated with these protections and their sources of information. Results Disposable sanitary pads were preferred by 930/1148 (81%) of patients, and menstrual tampons were used half as much (525/1150 (45.6%) of women surveyed)). The new menstrual hygiene products (washable sanitary pads, menstrual panties, and menstrual cups) were used by only 51/1150 (4.4%); 20/1149 (1.7%); 108/1150 (9.4%) of the patients; however, among the 92/1136 (8.1%) of the patients who had recently changed the type of protection, these new protections were the most popular because they were considered more ecological and less harmful to health. Menstrual hygiene products were perceived as a health risk for 924/1129 (81.8%) of patients. Menstrual toxic shock syndrome was knowledeg in only 473/1133 (41.7%) of patients. This lack of knowledge could lead to risky behaviour. The majority of patients said they were not informed about hygiene protection, with only 151//1108 (13.6%) having discussed the subject with a health professional, yet 973/1067 (91.2%) wanted more information. Conclusion This is the first French study on menstrual hygiene products. It showed that traditional sanitary protection was still the most widely used, but there was a growing awareness among patients about the products they used and their potential health risks as well as the consequences for the environment. Patients wanted to receive information on the subject from health professionals as well as manufacturers in order to be able to choose the product deemed the most suitable and in which they have confidence.

Although reproductive-aged women use both menstrual cups and intrauterine devices (IUDs) simultaneously, it is unknown whether concomitant use reduces contraceptive effectiveness. We report seven cases wherein IUD expulsion occurred during concomitant menstrual cup use. Further research is needed to determine mechanisms of expulsion, predictors and strategies to avoid expulsions.

The use of feminine hygiene products is commonplace and chaperones many women for most of their reproductive years. Unless specifically labelled, products are usually not sterile. Any DNA present on their surface could potentially be transferred onto the wearer and subsequently be detected in samples taken from intimate areas during a medical examination. This study investigated whether unused feminine sanitary products normally carry detectable amounts of DNA. Altogether, 52 items of tampons, pads, liners, and wipes were tape lifted and subjected to total and male-specific DNA quantification and STR amplification. Nineteen of these returned quantification values greater than zero. However, only four (one tampon and three liners) displayed one or two Y-STRs, whereas one pad exhibited one autosomal allele and an amelogenin X allele. All peak heights were below 515 RFU. Two liners may have collected partner DNA post purchase since they were not individually wrapped. Thus, feminine sanitary products are normally not a source of DNA.

Mechanical complications from menstrual cups are rare, with only four reported cases of ureteral obstruction. Clinicians should be aware of gynecologic devices in patients with acute abdominopelvic pain because simple removal may obviate the need for further expensive work-up or exposure to ionizing radiation.

The asymmetric wetting membranes have attracted intense attention in liquid directional transportation. However, it is a huge challenge to prepare surface layer membrane for sanitary products with antibacterial and asymmetric wettability by a simple method. Herein, the bacterial cellulose grafted with chitosan (BC-CS) was used as the hydrophilic agent to modify polypropylene nonwoven fabric (PPF) substrate via easy and effective one-sided layer-by-layer spraying to prepare the asymmetric wetting and antibacterial composite membrane (BC-CS/PPF). It showed that the BC-CS/PPF had good physical properties, which was attributed to the strong and uniform physical combination between nano-sized BC-CS and PPF. The sanitary products with BC-CS/PPF surface layer, denoted as BC-CS/PPF sanitary products, also had good absorption and anti-return property. The antibacterial test revealed that BC-CS had an excellent performance against S. aureus and E. coli in the simulated application environment. Moreover, the antibacterial performance was better than that of commercial sanitary products.

To investigate the effect of copper impregnated sanitary towels on the infection rate following vaginal delivery (VD).Single center double blind randomized controlled trial.Women aged 18 or over who had a sutured second-degree tear or episiotomy following VD.All women were randomized to receive either a copper-oxide impregnated sanitary towel (study group) or a non-copper sanitary towel (control group).The primary study outcome was the incidence of wound infection within a 30-day period from VD, assessed via telephone questionnaire. Secondary outcomes were length of hospital stay and risk factors of infection.450 women were enrolled in the study of whom 225 were randomized to the copper impregnated sanitary towel (study group) and 225 to the non-copper sanitary towel (control group) group. Follow-up rate was 98.2%. A total of 102 women (23.1%) developed an infection within 30 days following VD, 19 in the study group (8.6%) and 83 (37.4%) in the control group (P = 0.001, absolute risk reduction (ARR) of 28.8%). The incidence of superficial/deep and organ/space infections was significantly lower in the study group (7.7% vs. 30.2%, P = 0.001 and 4.6% vs. 31.5%, P = 0.001 respectively) with an ARR of 22.5% and 27.0% respectively. Multivariable analysis reported Asian ethnicity and prolonged rupture of membranes as significant risk factors; for the development of infection (OR 1.91, P = 0.03 and OR = 1.97, P = 0.04 respectively).This is the first study to demonstrate a significant reduction in infection rate following VD with the use of copper impregnated sanitary towels.

Benzophenones and parabens are synthetic chemicals used in many personal care products, foods and pharmaceuticals. Benzophenones are used to protect the skin and materials from the adverse effects of UV-radiation, and parabens are used as preservatives. Despite their widespread occurrence and proven endocrine disrupting activity, relatively little is known about human exposure to these compounds. In the present work, an analytical method based on sample treatment using dispersive liquid-liquid microextraction (DLLME) for the extraction of six benzophenones (benzophenone-1, -2, -3, -6, -8 and 4-hydroxybenzophenone) and four parabens (methyl-, ethyl-, propyl- and butyl- paraben) from human menstrual blood samples, followed by ultrahigh performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis, is proposed and validated. The method was validated using matrix-matched standard calibration followed by a recovery assay with spiked samples. The limits of detection ranged from 0.1 to 0.3ngmL-1, with recoveries of 93.8% to 108.9%, and precision (evaluated as relative standard deviation) lower than 14% for all selected compounds. This method was successfully applied for the determination of the target compounds in 25 samples of human menstrual blood. Methylparaben and benzophenone-3 were the most frequently detected compounds (96%).

Sanitary pads for menstrual hygiene have a layered design consisting of a fluid permeable surface (topsheet), an absorbent core, and an impermeable backing with adhesive. Most sanitary pads employ cellulose-based cores. This describes the safety evaluation of a menstrual pad with an emollient-treated topsheet and a novel polymeric foam core. A quantitative risk assessment was performed, which included: (1) toxicological evaluation of the raw material components; (2) quantitative exposure assessments of pad constituents, accounting for the fluid handling properties of the product and pertinent conditions of use; and (3) risk characterization for exposure to raw materials (e.g., potential for skin irritation, contact sensitization, or systemic effects, if relevant) and to the physical article itself (potential effects on skin friction, etc.). No significant risk of adverse effects was found. Five years of post-market surveillance substantiates that the product is well-tolerated (1 health complaint reported per 2 million products shipped to market) and surpasses women's expectations for menstrual protection and overall comfort and dryness. This report illustrates how the classical risk assessment paradigm, informed by the impact of product design, functionality and pertinent use conditions, allowed the systematic safety evaluation of a personal hygiene product with a novel, non-cellulosic absorbent foam core technology.

A risk assessment study of dioxins in sanitary napkins produced in Japan was performed. The daily estimated exposure volume to dioxins was compared with the tolerable daily intake (TDI). The concentrations of dioxins such as polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), and dioxin-like polychlorinated biphenyls (DL-PCBs) in seven sanitary napkins were measured using gas chromatography and mass spectroscopy analytical methods. Among the seven napkins, a range of 0.0044-0.076pg TEQ/g dioxins was measured. Daily estimated exposure volume from sanitary napkins was calculated as follows: (dioxin volumes in a sanitary napkin (0.0044-0.076pg TEQ/g)×pulp weight in a sanitary napkin (11.2g)×used napkin numbers/d (7.5)×the number of days/month that women use sanitary napkins (7)×skin absorption rate (0.03)×used years (40))/(average body weight of women (50kg)×the number of days in the month (30)×life years (86)). Daily exposure volumes were estimated to be 0.000024-0.00042pg TEQ/kg/d. For hazard assessment, we used 0.7pg TEQ/kg/d which was the lowest level of TDI among TDI values reported by international agencies. When the daily exposure volume was compared with the TDI, the former was approximately 1666-29,166 times less than the latter. This fact indicated that the risk of exposure to dioxins from sanitary napkins produced in Japan was negligible.

Background High-risk HPV (HR-HPV) are associated with the development of cervical cancer, the most common cancer in women in developing countries. Reliable diagnosis of HR-HPV infection combined with simple procedures to collect and store biological samples, could improve primary screening programs and vaccine strategies in these areas. Objective To evaluate HR-HPV detection in conventional and dried samples. Study design The presence of HR-HPV in 31 women in Republic of Congo (Central Africa) has been investigated by using standard cervical samples and dried cervical samples collected on filter paper and vaginal tampons. The detection of HPV DNA was performed in the Laboratory of virology in Lille (France) by using Hybrid capture 2 and HPV 16/18/45 Probe Set Test. Results 22 standard samples were found positive for the detection of HR-HPV (71%). HPV 16/18/45 was displayed in 15 out of 22 samples positive for HR-HPV (68%). The correlations between HPV detection by using standard samples and samples dried on filter paper and dried tampons were 90.3% (kappa = 0.77) and 80.6% (kappa = 0.5) respectively. The sensitivity and the specificity of HPV detection reached 91% and 89%, respectively, with samples dried on filter paper and were 86% and 67%, respectively, for dried tampons compared with standard samples. Conclusion Dried cervical samples and dried vaginal tampons can represent an alternative to conventional sampling to reduce barriers to large screening programs in developing countries and to facilitate storage and transport to reference centers.

To validate the semiautomated alkaline hematin technique for rapid measurement of menstrual blood loss on ultrathin sanitary towels with a superabsorbent polymer component.Laboratory study using simulated menstrual fluid (SMF) and Always Ultra Normal, Long, and Night "with wings" sanitary towels.Laboratorium für Klinische Forschung, Germany.None.None.Linearity and blood recovery over a range of SMF volumes applied to towels, the lower limit of reliable detection, and the effect of storing soiled towels for up to 5 weeks at 20°C and 4°C before analysis, were determined. Recovery from 63 SMF samples comprising between 5% to 100% blood and 0.05-35 mL applied volume was compared with duplicates analyzed at Keele Menstrual Disorders Laboratory (manual reference method).Linearity was confirmed, and ≥85% recovery was reproducibly achieved at up to 30 mL applied blood at all tested SMF compositions, except at low volume or high dilution equivalent to4 mL blood. Samples could be stored for 3 weeks at 4°C without loss of recovery. Linear regression analysis showed good agreement with the reference method.The semiautomated alkaline hematin technique is a reliable method for measuring menstrual blood loss from Always Ultra sanitary towels containing superabsorbent polymers.

Objective To develop a preliminary description of military women's menstrual experiences and their awareness of menstrual suppression during deployment. Design Qualitative descriptive with content analysis. Setting Recruitment and sampling occurred at a large U.S. military base from December 2005 to January 2006. Participants Nine women who had been deployed to U.S. military operations. Results Seven themes were generated from the data: (a) Menses is intensified during deployment, (b) It's hard to take care of yourself during your period, (c) Menstrual challenges: heat, dirt, and port-a-potties, (d) Menstruation is an inconvenience when you are deployed, (e) Dealing with menstruation in the military world, (f) Negative aspects of menstruation outweigh the positive during deployment, and (g) Menstrual suppression. Conclusion Menstruation is problematic during deployment and participants expressed interest in menstrual suppression. However, concerns about the side effects and safety of continuous oral contraceptives limited participants' use of this therapy. Education on menstrual hygiene and methods of menstrual cycle control should be provided prior to deployment to prepare women for the experience.

Study Objective To explore the perceptions of perimenarchal females and their mothers regarding tampons and tampon use. Design Descriptive study; convenience sample survey. Setting Diverse pediatric practice setting. Participants 139 females 11-18 years of age and 129 of their mothers/female guardians. Intervention Survey. Main Outcome Measures Frequencies, chi-square tests, t-tests. Results Most adolescents (38%-55%) respond “don't know” to various attitude and knowledge items pertaining to tampon use. Adolescent-mother pairs report similar perceptions about tampon use for adolescents. Mothers and adolescents who have “ever tried” tampons (including 68% and 56% of respondents, respectively) have more favorable attitudes about tampons than those who have not tried tampons. Adolescent females list their mothers as the primary source of tampon information; 70% of adolescents and 66% of mothers report that no doctor has spoken to them about tampon use for the daughter. Conclusions There is a vast educational deficit among both adolescent females and their mothers regarding the use of tampons among youth. Adolescents and their mothers note that few providers have educated 11- to 18-year-old females or their parents about tampons. Providers have the opportunity to influence adolescent health choices and quality of life associated with tampon use.

Objective: To develop and validate a simple method of measuring total menstrual blood loss using a pictorial representation of blood loss, the menstrual pictogram. Design: A prospective evaluation of total menstrual blood loss measurement by the menstrual pictogram compared to the alkaline hematin technique. Setting: Academic menorrhagia research clinic. Patient(s): One hundred twenty-one women; 62 women complaining of heavy menstrual blood loss, 59 women who considered their menstrual blood loss to be normal. Intervention(s): Participants were asked to complete the menstrual pictogram through the period and collect their feminine hygiene products for an alkaline hematin assessment. Main Outcome Measure(s): Percentage agreement between blood loss measured by the gold standard alkaline hematin method and the menstrual pictogram. Extraneous blood loss was measured using a semiquantitative pictorial method. Result(s): The menstrual pictogram had a high level of agreement for blood collected on feminine hygiene products compared with the alkaline hematin method. Some women also lose a significantly large amount of extraneous blood, which is not proportional to the alkaline hematin blood loss assessment. Conclusion(s): The menstrual pictogram provides a simple means of measuring menstrual blood loss. It is no longer appropriate to ignore extraneous blood loss, particularly as there is no correlation between extraneous blood loss and that measured on feminine hygiene products.

Objective: To examine variation in feminine hygiene practices as a function of increasing age. Design: A nonexperi mental, descriptive research design with study sample stratified by age. Participants: Women over 18 years of age. Of 713 women who completed and returned the feminine hygiene practices questionnaire, 180 were younger than 41 years, 171 were 41–48 years, 184 were 49–57 years, and 178 were 58 years or older. All participants were members of a California professional home economics organization. Main Outcome Measures: A 40-item feminine hygiene practices questionnaire dealing with body cleansing practices, feminine products usage, and both general and specific menses collection and protection practices. Results: Significant age-related differences were found in several areas of body cleansing and feminine products usage, including sponge bathing and use of feminine and deodorant spray, wet wipes, and panty liners. In all age groups, 20–30% of women reported douching, even in the face of continued reports of the dangers in this practice. In addition, reduced numbers of women (n = 245) in all age groups reported washing hands before using tampons or pads, although more [n = 314) reported washing their hands afterward. Conclusions: Continuing education about proper feminine hygiene practices, especially regarding douching and handwashing before and after genitourinary contact, will be important across all age groups. JOGNN , 29 , 625–633; 2000.

Objective: To determine the association between simple clinical parameters and objective menstrual blood volume. Study Design: A cohort study, in a London teaching hospital. Women complaining of menorrhagia (207) and those who considered their menstruation to be normal (47) were studied. Those with no demonstrable gynaecological pathology had their menstrual blood loss measured using the alkaline haematin technique. Results: Only 49% of 207 women complaining of menorrhagia had a loss of 80 ml or more. There was an increasing incidence of objective menorrhagia with increasing duration of bleeding and use of more sanitary protection items. Increasing height, age and number of intrauterine pregnancies were all associated with increasing menstrual blood volume. Haemoglobin fell with increasing menstrual blood loss. Conclusions: Despite these clinical associations it is difficult to establish the quantity of menstrual bleeding with certainty without an objective assessment.

To study the prevalence of tampon use among young females, the factors and persons influencing this choice, the role of primary care physicians, and the potential association of tampon use with sexually transmitted diseases and urinary tract infections.An anonymous questionnaire regarding the use of feminine hygiene products was completed by 250 female college students between 17 and 21 years of age and 90 primary care physicians. Percentages were calculated for most outcome measurements and Fisher's Probability Exact Test was used to compare groups.Of the participants, 19% use pads, 29% use tampons, and 52% use both, with a total of 81% using tampons alone or in combination. The choice was influenced mostly by the woman herself or her mother. Only 22% reported that their physician discussed tampon usage with them. Incidence of sexually transmitted diseases was not significantly different between those using pads and tampons. In the pad group, 12% reported urinary tract infections versus 32% in the other group (P = 0.007). Among physicians, only 30% said they discussed hygiene products, although 52% of them thought it was medically important. Of the female physicians, 71% use tampons alone or in combination; 29% exclusively use pads, with 92% citing fear of toxic shock syndrome as a reason for their choice.The majority of young women use tampons based on own decision or maternal influence for comfort, convenience, and appearance. Physician input in this regard is not routinely provided, probably because of lack of agreement about the importance of the subject among physicians. Based on participants' report in this survey, the incidence of urinary tract infections seems to be significantly higher among tampon users than among pad users. Physicians should assume a more active role in explaining the appropriate use, benefits, and potential risks of feminine hygiene products.

Adult feminine hygiene practices are the focus of this exploratory descriptive study. In a sample of 193 women, the typical respondent lived in the Southeast and was a single student who was 23 years of age, and White. Body cleansing, feminine hygiene, and menses management practices were examined. It was found that handwashing varied according to bodily involvement or specific feminine hygiene practices. Assorted menses management products were used for menses management and were used when the woman was not menstruating. The results of this study suggest that it might be possible for health care providers to teach women safe and economical health care practices, such as not douching and handwashing before and after use of menses management products to prevent infections.

Toxic Shock Syndrome (TSS) is a potentially fatal illness caused by a particular strain of Staphylococcus aureus. The clinical presentation is similar to that of septic shock. The incidence of TSS peaked in the late 1970s and early 1980s, probably as a result of availability of super absorbent tampons. Although most commonly associated with menstruation, the overall incidence of menstrual and nonmenstrual TSS in men and women ranges from 1 to 3 per 100,000. There are almost equal numbers of menstrual and nonmenstrual cases of TSS identified annually. S. aureus, the causative microorganism in cases of TSS, has been isolated from many body tissues. Toxic shock syndrome presents as a flu-like illness with high fever, vomiting, diarrhea, general malaise, and muscle weakness. Nursing and medical management focus on controlling or preventing potentially serious complications, such as adult respiratory distress syndrome, renal failure, electrolyte imbalances, disseminated intravascular coagulation, encephalopathy, and cardiomyopathy. Judicious use of tampons and barrier contraceptive devices may decrease the risk of developing TSS.

Gynaeseal is a re-usable diaphragm tampon made from latex which forms a unique cervico-vaginal seal and isolates menstrual loss. In a prospective study involving 80 women, Gynaeseal was offered in combination with the Billings Ovulation Method in an advised birth control system. This system included: use of the diaphragm tampon during the menstruation-fertile phase interphase; periodic abstinence during the overtly fertile phase of the cycle; and if extreme reliability was required, for a further 2 days after the Billings method 'rules' allow resumption of intercourse. The diaphragm tampon successfully complemented the Billings Ovulation Method with 44 women (60.4%) assessing the GOM System as being as good, or better than, currently available reversible methods. It functioned effectively as a tampon with 50% (31 women) stating that they used the product as a contraceptive. One woman claimed an unplanned pregnancy. No significant medical complications were recorded. The product has major advantages as a tampon: it is easily and accurately inserted because of the efficient applicator; it isolated menstrual loss within a collection chamber; it protects the cervix; and it facilitates sexual activity. Based on a minimum effective diameter (62mm), the diaphragm tampon does not interfere with the normal physiology of the vagina. There appeared to be no significant distortion of normal adult pelvic anatomy, and properly placed, no sensation of the diaphragm tampon's presence. Regarding insertion of the diaphragm tampon using the spiral-curved applicator: 31 women (42.5%) had little or no difficulty; 29 (39.7%) moderate difficulty; 13 (17.8%) experienced serious difficulty; and 7 (8.7%) were unable to use the product.Gynaeseal is a reusable diaphragm tampon made from latex which forms a unique cervicovaginal seal and isolates menstrual loss. In a prospective study involving 80 women. Gynaeseal was offered in combination with the Billings Ovulation Method in an advised birth control system. This system included use of the diaphragm tampon during menstruation-fertile phase interphase; periodic abstinence during the overtly fertile phase of the cycle; and if extreme reliability was required, for a further 2 days after the Billings method "rules" allow resumption of intercourse. The diaphragm tampon successfully complemented the Billings Ovulation Method with 44 women (60.4%) assessing the GOM system as being as good, or better than, currently available reversible methods. It functioned effectively as a tampon with 50% (31 women) stating that the product was superior to fiber tampons. 33 women (45.3%) stated that they used the product as a contraceptive. One woman experienced an unplanned pregnancy. No significant complications were recorded. The product has major advantages as a tampon--it is easily and accurately inserted with its efficient applicator; it isolates menstrual loss within a collection chamber; it protects the cervix; and it facilitates sexual activity. Based on a minimum effective diameter (62 mm), the diaphragm tampon does not interfere with the normal physiology of normal adult pelvic anatomy, and properly positioned, no sensation of the diaphragm tampon using the spiral-curved applicator, 31 women (942.5%) had little or no difficulty; 29 (39.7%) moderate difficulty; 13 (17.8%) experienced serious difficulty; and 7 (8.7%) were unable to use the product.

Since late 1979 to early 1980, when toxic shock syndrome achieved notoriety, a substantial body of data has demonstrated that vaginal Staphylococcus aureus infections, particularly those occurring during menstruation, account for most cases of toxic shock syndrome in women of reproductive age. Among those patients with onset during menstruation, tampon use has been identified as the most important risk factor. Although menstrually associated cases have been observed among users of all brands and styles of tampons, the use of selected "super absorbent" brands and styles has been associated with an increased risk of toxic shock syndrome. Although the tampon characteristics responsible for the associated risk of toxic shock syndrome remain poorly understood, both absorbency and chemical composition appear to be important variables in this relationship. In response to studies demonstrating this relationship and legal pressures, tampon manufacturers have removed chemical constituents previously used to enhance absorbency, such as polyester foam, carboxymethylcellulose, and polyacrylate rayon, and have markedly reduced tampon absorbency. Coinciding with these changes, the reported number of menstrually related cases of toxic shock syndrome has dropped substantially, although they continue to account for 50% to 70% of all cases of toxic shock syndrome in women of reproductive age.

Objective To validate the menstrual pictogram (superabsorbent polymer-c version) for Always Ultra-slim feminine towels containing superabsorbent polymers. Design Prospective, multicenter, evaluator-blinded study. Setting Three gynecology research clinics in the United Kingdom. Patient(s) Women with self-perceived light, normal, or heavy menstrual periods who had not previously used a graphical method to assess their menstrual loss. Intervention(s) One hundred twenty-two women were asked to complete the menstrual pictogram throughout two menstrual periods and collect their feminine towels for measurements of menstrual blood loss (MBL) by the alkaline hematin method and total menstrual fluid loss (MFL) by fluid weight. Main Outcome Measure(s) Agreement of menstrual pictogram MBL and MFL scores with alkaline hematin and towel weight, respectively. The percentage blood fraction was determined at various volumes of menstrual discharge. Result(s) Alkaline hematin and fluid weight were highly correlated (r = .97). However, the percentage blood fraction progressively increased with total MFL and MBL score. After correction for this incremental rise in blood fraction, the menstrual pictogram gave a sensitivity of 82% and a specificity of 92% for a diagnosis of heavy menstrual bleeding. Conclusion(s) The menstrual pictogram (superabsorbent polymer-c version) provides a simple means of measuring MBL in the clinical setting.

Objective To determine whether the menstrual pictogram (the superabsorbent polymer-c or SAP-c version) can reliably estimate blood and total menstrual fluid volumes on prestained Always Ultra slim feminine towels (Proctor & Gamble) that contain superabsorbent polymers. Design Randomized blinded study using simulated menstrual fluid (SMF: 50% blood, 50% saline mixture). Setting Gynecology research clinic. Patient(s) 12 premenopausal women with regular menstrual cycles who had not previously used a graphical method to assess menstrual loss. Intervention(s) None. Main Outcome Measure(s) Assignment of 135 prestained towels containing known volumes of 0.5–25.0 mL of SMF to five pictorial icons of the menstrual pictogram, and correlation of pictogram scores to blood recovered from towels by the alkaline hematin method and total fluid applied to towels by measurement of soiled towel weight. Result(s) There was a high level of agreement between individual scores. For 112 (83%) of 135 towels, the participants' readings either completely concurred or differed by only a single icon. There was a statistically significant correlation between the volume of blood applied (SMF/2) and that recovered by alkaline hematin, and volume of fluid applied and soiled towel weight. Conclusion(s) The menstrual pictogram (SAP-c version) is a potential diagnostic tool for heavy menstrual bleeding and would be suitable for testing in a clinical trial.

Most of the recent cases of toxic shock syndrome (TSS) reported have occurred in menstruating women and adolescents although some cases have been reported in nonmenstruating women, children, and men. The disease is characterized by sudden onset of high fever, vomiting, and diarrhea and can rapidly progress to hypotension and shock. Tampon use has been linked to development of toxic shock syndrome, and Staphylococcus aureus has been cultured from a significant number of cases. The exact roles played by both Staphylococcus aureus and tampons in the pathogenesis of toxic shock syndrome remains unknown. Tampons also have been associated with other health problems in women. Nurses can advise preventive measures to reduce the risks of developing toxic shock syndrome and other tampon-related problems.

A progesterone antagonist (RU486) was administered to macaque monkeys by an intravaginal tampon for the achievement of both menstrual induction and absorption. The study was conducted in three parts: (1) postcoital treatment beginning 3 days after potential fertilization; (2) treatment on extended cycle days 34 to 37 after a "missed" menstrual flow after mating; and (3) luteal phase (cycle days 22 to 25) treatment in noncoital cycles. Our findings demonstrate pregnancy prevention and/or interruption when these treatments are employed.

Diagnostic bias could have occurred in the tampon/toxic shock syndrome association if the original diagnostic judgments by physicians or the subsequent diagnostic selections by investigators were influenced by knowledge of the patient's gender, menstrual history, or catamenial product. To determine whether such diagnostic bias can occur, a set of descriptive vignettes was prepared for six cases (Series X) having diverse resemblances to toxic shock syndrome or Kawasaki's disease. For each vignette in Series X, a paired case in a complementary Series Y was described in identical text except for different information about gender, menstrual history, or tampon use. Either Series X or Series Y was sent to a randomly selected sample of internists, family practitioners, and infectious disease subspecialists. The physicians were asked to provide a diagnosis for each case, using their own nomenclature or choosing from a list of 22 diagnostic possibilities. Six weeks later, respondents were asked to provide diagnoses for the complementary series of cases. Regardless of medical specialty or type of series received first, the 368 responding physicians were more likely to diagnose toxic shock for menstruating tampon-users or menstruating women than for non-menstruating women or men. In the most striking difference, toxic shock was diagnosed in 85 percent of instances when the case was described in a menstruating tampon-user, but in 23 percent of instances when the same case was described in a man (odds ratio = 18.8). Since the current epidemiologic data may be seriously distorted by diagnostic bias, the results indicate the need for scientifically valid investigations of the toxic shock syndrome/tampon relationship.

The magnitude of menstrual blood loss and the incidence of menorrhagia associated with 2 plastic intrauterine devices (IUDs), THE Lippes loop and standard-size Dalkon shield, were compared with a copper T device (TCu 300). In order to evaluate long-term as well as short-term effects, blood loss was measured at postinsertion levels of 6, 12, and 18 months in 72 women wearing the Lippes loop, in 73 wearing the Dalkon shield, and in 82 with TCu 300. Increases in the mean blood loss over controls (35.3 ml) for the Lippes loop at 6, 12, and 18 months were 112%, 60%, and 95%, respectively. Corresponding increases for the Dalkon shield were 71%, 112%, and 86%; those for the TCu 300 were 54%, 56%, and 41%. There was significantly less bleeding with the TCu 300 than with either of the other 2 devices (p.05). The Lippes loop and the Dalkon shield were associated with fluctuating blood loss values whereas blood loss with the TCu 300 was relatively stable at all study periods.

One of the most common side effects during the use of IUDs is increased and prolonged menstrual bleeding. This increase in blood loss was verified by estimating the menstrual blood loss in women using the Cu-T 200. There was a significant increase in blood loss in both nulliparous and parous women even one year after the insertion of the IUD. Because of this blood loss, an increased incidence of iron deficiency could be expected. However, no significant changes could be registered in the concentration of haemoglobin, serum iron, or total iron binding capacity. Thus, the food iron absorption seemed to balance the increased iron losses during one year in the studied material of healthy Swedish women.

One hundred and sixty-three cases are reviewed in which uterine tamponade was employed for postpartum bleeding; the incidence of its use was once in 66 deliveries. The efficacy of uterine packing for atony depends upon its proper application and its employment early in the course of postpartum hemorrhage. Dry gauze packing placed with a mechanical packer from the uterine fundus to the introitus is recommended. No death from hemorrhage due to atony occurred and hysterectomy was not required for atony in 10,833 consecutive cases. No serious complications followed packing and future childbearing did not seem to be affected. It is concluded that judicious use of the uterine pack is of continuing value in modern obstetrics.

Portacaval shunting for the relief of portal hypertension and portal stasis has proved to be an effective, rational, and relatively safe procedure to protect patients from untimely death due to hemorrhage, and to protect the liver from the deleterious effects of recurring hemorrhage and wasting ascites. A characteristic feature of cirrhosis is the architectural distortion which, with progressive disease, inevitably leads to obstruction to the inflow of portal blood. Obstruction to portal blood flow frequently results in the development of esophageal varices which are disposed to rupture, causing hemorrhage. In patients having portal block, portal venous pressure is elevated. The establishment of a portacaval shunt, employing either the portal vein anastomosed directly to the vena cava, or the splenic vein (following splenectomy) anastomosed end to side with the left renal vein, affords a large channel having a low resistance to blood flow, and capable of shifting a large volume of blood rapidly from the high-pressure (portal system) to the low-pressure (caval) system, and thereby effecting a reduction in portal pressure with relief of portal stasis. In 1943, we undertook a study of portacaval shunting. To date the experience has been expanded to embrace 262 shunted patients. The site of portal block was intrahepatic, due to cirrhosis of the liver, in 203 patients (77.4 per cent) and extrahepatic, due to a block in the portal vein outside of the liver, in 59 patients (22.6 per cent). The shunting procedure was accomplished in the first 117 patients having cirrhosis of the liver with a postoperative mortality rate of 23 per cent. The mortality rate in the remaining 86 patients was 15 per cent. The decrease in mortality rate is attributed primarily to improvement in the preoperative preparation of patients. The high incidence of liver failure in association with hemorrhage is discussed with special reference to emergency management. An efficient nasogastric balloon tube is presented with detailed instructions on its use for the emergency arrest of hemorrhage and in the preparation of patients for operation. Patients who show a tendency to immediate recurrence of bleeding after the customary four days of balloon tamponage and tube feeding are classified as refractory, and treatment is continued until their status can be ascertained on the basis of clinical behavior and dependable hepatic function tests. Many, after one week or ten days of tube feeding, are proved to have well-compensated livers, their tendency to hemorrhage being the result primarily of severe portal hypertension. In such patients the definitive operation of portacaval shunting can be carried out forthwith. More difficult patients are those in whom ten days or two weeks of treatment does not relieve impairment of liver function, and in whom the operation must be postponed or abandoned. It is with this group that suture of the esophageal varices may be carried out at a propitious time. Our present policy, however, is to continue with tamponage and tube feeding in those patients who are adapted to it, because after a few more weeks, many will improve to a point that shunting may be proceeded with at a reasonable risk. Early in our experience with portacaval shunting for portal hypertension the complication of ascites diagnosed clinically was encountered in 41.5 per cent of the cases. The presence of ascites may in itself be taken as a sign of decompensation of the liver, and, if unstabilized before operation, materially increases operative risk. Portal pressure was elevated to hypertensive levels in all patients with ascites; however, there was no quantitative relationship between the degree of portal hypertension and the severity of the ascites. An early appreciation of this lent encouragement to a view that portal stasis (the relief of which regularly follows the establishment of a portacaval shunt) and not the change in portal pressure was the responsible factor in the subsidence of ascites in a few early cases of long-standing ascites operated upon. This view is corroborated by the work of Hunt, who has shown that the speed of blood flow in the portal vein is increased from 5 cm. per second (about the average determined speed in patients with cirrhosis of the liver) to 12 cm. per second following a direct anastomosis of the portal vein to vena cava, end to side. The normal speed of flow of the blood in the portal vein was determined to be about 10 cm. per second. The indications for portacaval shunting and the evaluation of operative risk with respect to hepatic function tests are discussed.

The etiology of toxic shock syndrome (TSS) has been extensively investigated in recent years. It is generally accepted that the causative organism is Staphylococcus aureus . Certain strains of this bacterium produce one or more toxins which are thought to be responsible for the sumptoms associated with TSS. There is no general agreement, however, as to why menstruating women who use tampons are of particular risk for developing this disease. More recently, TSS has also been associated with the use of absorbent contraceptive sponges. In this paper I will present evidence that the introduction of oxygen into the vaginal cavity during tampon insertion is responsible in part for the development of TSS. Furthermore, I will discuss several methods for the safe removal of this exogenous oxygen.