Ecology of toxic shock syndrome: amplification of toxic shock syndrome toxin 1 by materials of medical interest

Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis

BACKGROUND

Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845.

FINDINGS

Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59-84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72-46·72 (median $23·3, 145 brands).

INTERPRETATION

Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products.

FUNDING

UK Medical Research Council, Department for International Development, and Wellcome Trust.

Menstrual toxic shock syndrome: case report and systematic review of the literature

Menstrual toxic shock syndrome (mTSS) is a life-threatening disease caused by superantigen-producing Staphylococcus aureus. Incidence ranges from 0·03 to 0·50 cases per 100 000 people, with overall mortality around 8%. In this Grand Round, we present the case of a previously healthy 23-year-old menstruating woman who was diagnosed with mTSS after she presented at our hospital with a septic condition for the second time. The diagnosis was confirmed by fulfilment of the clinical criteria outlined by the US Centers for Disease Control and Prevention (CDC; fever, rash, desquamation, hypotension, and multi-system involvement) as well as a nasal swab positive for the S aureus strain and presence of the gene encoding for toxic shock syndrome toxin 1 (TSST-1). In the early 1980s, when mTSS was first described, use of tampons was considered the main risk factor. Today, the complex interplay between pathogenic factors of S aureus, immunological mechanisms of the host, and changes in the vaginal ecosystem during menstruation has broadened current understanding of the disease, and the CDC criteria have appreciable limitations in everyday clinical practice.

Staphylococcal and streptococcal superantigen exotoxins

SUMMARY This review begins with a discussion of the large family of Staphylococcus aureus and beta-hemolytic streptococcal pyrogenic toxin T lymphocyte superantigens from structural and immunobiological perspectives. With this as background, the review then discusses the major known and possible human disease associations with superantigens, including associations with toxic shock syndromes, atopic dermatitis, pneumonia, infective endocarditis, and autoimmune sequelae to streptococcal illnesses. Finally, the review addresses current and possible novel strategies to prevent superantigen production and passive and active immunization strategies.

From convenience to hazard: a short history of the emergence of the menstrual activism movement, 1971-1992

In this article, I explore the early history of contemporary menstrual activism in the United States by looking through the lens of the first seven editions of the feminist women's health classic, Our Bodies, Ourselves (OBOS). This analysis illustrates the development of a critical menstrual consciousness as three key phases of the emerging movement, offers a representation of the dynamic nature of feminist health consciousness, and highlights the importance of linking current activism to its past.

Scanning electron microscopy of hydroxylated polyvinyl acetal and conventional gauze strip nasal packing materials

The application of nasal packing is one of the most commonly performed procedures in rhinology. Various materials have been used as nasal packing, including conventional gauze strips and hydroxylated polyvinyl acetal. Complications related to nasal packing may cause problems that lead to increased morbidity. Among those complications, infectious ones range from localized infection in the nasal cavity to toxic shock syndrome. The purpose of this study was to evaluate conventional gauze strips and hydroxylated polyvinyl acetal nasal packing materials by scanning electron microscopy, to reveal their surface characteristics that would promote or prevent the development of infectious complications. The two types of materials were examined before and after application into the nasal cavity. Scanning electron microscopy demonstrated that hydroxylated polyvinyl acetal material had a smooth surface, whereas conventional gauze strips had an irregular surface with fibers projecting, thus increasing the surface area for bacterial adherence and allowing possible evasion of bacteria from the elements of the immune system within this fibrillar structure.

Influence of lactobacilli on the adhesion of Staphylococcus aureus and Candida albicans to fibers and epithelial cells

The ability of organisms to adhere to and form biofilms on fibrous materials is believed to be an important initiating step in the induction of several diseases, such as toxic shock syndrome. Using an in vitro assay, a moderately hydrophobic strain of Staphylococcus aureus (water contact angle 35 degrees) and a hydrophilic Candida albicans (shown by a hexadecane test) were highly adherent to commercial diaper fibers. The lumen side of the diaper was porous and the fibers were very hydrophobic (> 140 degrees), but the internal section was very hydrophilic (0 degrees), presumably for lus strains was present. Surfaces precoated with lactobacilli inhibited staphylococcal adhesion by 26-97%, and candida by 0-67%. When the lactobacilli were used to challenge adherent pathogens, there was 99% displacement of the S. aureus and up to 91% displacement of C. albicans. Hydrophobic L. acidophilus 76 (54 degrees) and T-13 (80 degrees) were the most effective of five Lactobacillus isolates tested at interference by precoating. The moderately hydrophilic L. casei var rhamnosus GR-1 (33 degrees) was the most effective at displacing the yeast. Experiments with uroepithelial cells also showed that the lactobacilli could significantly interfere with the adhesion of both pathogens to the cells. The results demonstrate the rapidity with which two pathogens adhered to fibers and epithelial cells, and raised the possibility that members of the normal female urogenital flora might interfere with infections caused by these organisms.