Menstruation: Environmental impact and need for global health equity
Synopsis
Menstrual health hygiene equity involves increasing awareness about the global environmental impact of disposable menstrual products and creating equitable opportunity for healthy hygiene products.
Menstruation is a natural and healthy bodily process that occurs for approximately 26% of the global population, with about 800 million people menstruating each day.1, 2 Despite this being a common and vital process, access to menstrual products, clean water, private sanitation facilities, and sexual health education are not secured globally (sometimes known as “period poverty”).3-6 Adequate menstrual hygiene management is an essential sexual and reproductive health right.1, 6 WHO and the United Nations Children's Fund (UNICEF) describe menstrual hygiene management as menstruators having a right to “clean menstrual management material to absorb or collect blood, that can be changed in privacy as often as necessary for the duration of the menstruation period, using soap and water for washing the body as required, and having access to facilities to dispose of used menstrual management materials.”7 The United Nations Educational, Scientific and Cultural Organization (UNESCO) advocates that accurate and timely rights-based education about menstruation is essential for proper menstrual hygiene management, as well as shifting the stigma about menstruation using a positive social norm lens.8
Research has shown that period poverty is a significant concern in lower- and middle–income countries (LMICs), with many areas frequently lacking “water, sanitation, and hygiene” facilities, sometimes referred to as WASH facilities.9 Additionally, access to menstrual products in many LMICs is poor and/or inconsistent.3, 5, 6 Although less researched, there is realization that period poverty is also an important consideration in high-income countries (HICs), particularly affecting those in rural areas, racialized communities, homeless or street-involved situations, and detention centers.4, 10-12 Period poverty attributable to these lacking resources contribute to missing days of school/education, feelings of shame and embarrassment, social isolation, and increased risk of genitourinary infections.3, 10, 13-15 Moreover, the COVID-19 pandemic and associated lockdowns have further heightened period poverty for many individuals and communities globally.16, 17 Fortunately, initiatives are growing around the world in both HICs and LMICs, aimed at raising awareness of period poverty and dismantling barriers to menstrual product access and WASH facilities. For example, in 2020, Scotland became the first country to pass a government bill that requires all schools and public bodies to provide period products for free, as well as committing to providing products to anyone who needs them free of charge.18 Many other regions in New Zealand, Australia, Canada, the US and France are increasing access to free products in schools and other public places,19 and the governments of Kenya, Uganda, and Zambia have also increased access to free products in school settings.19 At this time, however, few initiatives ensure that individuals and communities have different menstrual product options available to them, and there is little focus addressing the global environmental impact of menstrual products.
1 ENVIRONMENTAL IMPACT OF MENSTRUAL PRODUCTS
Many menstruators around the world do not have the luxury of choice when it comes to period products. Additionally, cultural context may contribute to menstrual product use patterns; for example, in some environments the use of internal menstrual hygiene materials (i.e. tampons) are thought to be culturally inappropriate.8, 20, 21 When an individual is in a circumstance that does allow them choice of menstrual products, many factors contribute to their decision making (Table 1).22 The most commonly used menstrual product worldwide is the disposable menstrual pad.21
| Product availability |
| Cost |
| Reliability |
| Peer pressure/influence |
| Cultural considerations |
| Family |
| Environmental impact |
Measuring the environmental impact of menstrual products is complex, and there is a stark lack of scientific literature exploring these issues. There are many different potential indicators of environmental impact, such as calculations of fossil fuel depletion, mineral use, and gas emissions in product-manufacturing processes; the global warming potential (i.e. carbon footprint); and the amount of menstrual waste created.23 In other words, the global environmental impact of menstrual products comes from the use of raw materials, energy, and water during the actual manufacturing processes, the ingredients used in the products themselves (cotton versus plastics), and their packaging (usually plastics), and how many products are used and disposed of worldwide.23, 24
In terms of the raw materials in disposable menstrual products, pads can contain up to 90% plastic, which largely end up in landfills.24 Disposable pads and tampons are most often made of cotton with rayon or other synthetic fibers and plastics such as polyester. Tampons can contain amounts of plastic within the core of the cotton tampon and may come with plastic applicators. Pads often contain even more synthetic plastic material than tampons, such as leak-proof bases and/or extra absorbent strips.25 After use, tampons, applicators, and pads are either thrown out as solid waste or end up in the water systems if flushed down the toilet; if disposed as solid waste, these products end up in landfills or are burnt in incinerators to generate energy.23 While in a landfill, disposable pads are estimated to take 500 to 800 years to break down, and materials such as plastic never truly biodegrade.22, 23, 26 This is of major concern given that each menstruator will use and dispose of between 5000 and 15 000 pads and tampons in their lifetime.25 From research that is available comparing the environmental impacts of different sanitary products, the disposable menstrual pad appears to cause the highest environmental impact, because of the amount of mineral/fossil fuel depletion caused by its production, its estimated carbon footprint, and the amount of wet and dry waste it produces.23 However, single-use tampons, especially those with plastic applicators, also significantly contribute to overall plastic waste. Even products that are marketed as “recyclable” such as some plastic tampon applicators, end up in landfills because of the presence of organic matter/blood after use, making them nonacceptable in some recycling facilities.24 Differing municipal waste management practices and lack of consensus about how to classify menstrual waste contributes to unclear best practices in how to discard and dispose of used products, which may lead to unsafe disposal practices.27 In addition to the disposable products themselves, the packaging of these products is also a major source of waste, as roughly 400 pounds of period product packaging is thrown out per menstruator per lifetime.26
The world's oceans and marine biology are also affected by period products. During the breakdown process of disposable products and their plastic packaging, microplastics are produced. Microplastics have been found to alter marine ecosystems and pose a serious threat to ocean biomes.22 Moreover, when menstrual products are flushed down the toilet, they directly affect marine environments; single-use menstrual products and their packaging are one of the most commonly found items on beaches and within the ocean.22, 24, 28
2 ENVIRONMENTAL BENEFITS OF REUSABLE MENSTRUAL PRODUCTS
There are menstrual products that create less of a burden on the environment as compared with the disposable pads and tampons mentioned above. Organic cotton–only pads and tampons are available in some areas and, while they are single-use and disposable in nature, these products use only organic cotton and are plastic-free. In general, natural materials such as cotton biodegrade much more quickly than synthetic fibers, making organic cotton, plastic-free menstrual products much more environmentally friendly as they will not accumulate in landfills to the same degree as other products. An important consideration, however, is that cotton crops are known to use massive amounts of water relative to other crops and require pesticides in order to grow, causing other serious impacts on the environment.29 Reusable menstrual products available include reusable pads, period underwear/pants, and menstrual cups.22, 29 Table 2 describes these reusable products in more detail.
|
Reusable pads can be made with synthetic or natural fibers and last about 5 years.22 Individuals who choose reusable pads also require access to clean water in order to be able to wash these products after use. |
|---|---|
|
Period underwear or pants can be made of synthetic or natural fibers and are quoted to last about 2 years; as with the reusable pads, period underwear must be washed after use.22 |
|
Menstrual cups are made of medical grade silicone or rubber and can last up to 10 years; cups are placed internally by the user and the cup collects menstrual blood.22, 25, 29 Individuals who use menstrual cups require water access for washing the cup as well, although less water is required as compared with washing a reusable pad. The reusable menstrual cup has been estimated to have the lowest impact on the environment by far, especially for waste.23, 24 |
- a Original art work by Madelyn Frank.
3 BARRIERS AND ACCESSIBILITY OF REUSABLE MENSTRUAL PRODUCTS
Lack of awareness concerning the environmental impacts of disposable menstrual products is one important barrier to their use. A recent study that explored the level of knowledge individuals have about the environmental impact of menstrual products found a relatively low awareness of these issues.22 Interestingly, however, authors found a link between environmental awareness and period product choice; those with a higher environmental awareness of menstrual products were more likely to choose more eco-friendly products, such as the menstrual cup.22 Given more information about environmental impacts, some may choose to try menstrual cups or other reusable products, or they may choose disposable tampons without applicators and/or products made from natural fibers such as organic cotton.
Another important barrier to the use of reusable products is overall cost. Depending on location, the cost varies significantly: reusable menstrual underwear can cost between $15 to more than $40 per pair,30 commercial reusable menstrual pads between $9 to more than $40,31, 32 and menstrual cups approximately $25 per cup or more33; this upfront cost is a major barrier for many individuals and communities. That said, some argue that increasing access to reusable menstrual products is also an important step in further reducing period poverty for those in LMICs, highlighting the overall cost-effectiveness of this approach.34, 35 One study estimates that purchasing a menstrual cup is 5% to 7% of the cost of disposable pads and tampons over an individual's life cycle,36 making increasing access to menstrual cups economically effective to menstruators around the world. Similarly, as most reusable cloth pads can be washed and reused for 5 to 10 years and most period underwear for 2 to 6 years, the cost per menstrual cycle is also significantly lower than using disposable products.37 Some LMIC communities, supported by different international and local non-governmental and community-based organizations, are tackling the issue of access and cost-effectiveness by teaching local groups of women how to make reusable pads locally.38 Moreover, in Ethiopia, menstrual cups and reusable pads such as the “Afripad” are being disseminated to areas where there is little access to period products.39
Another important consideration is that individuals using reusable products need access to proper water sources as the safety and hygiene of those products are mostly dependent on the user's ability to wash and dry the product regularly. Additionally, the taboo that exists around menstruation is also a barrier for some menstruators to feel comfortable washing and drying their products in the open.37, 40 That said, one systematic review exploring international studies on menstrual cup leakage, acceptability, availability, and safety found that menstrual cups are a safe, cost-effective option that are being used internationally, including in some LMICs.36
In addition to being more cost-effective over time, reusable menstrual pads, underwear, and cups may also be part of the solution for product distribution challenges, as providing disposable single-use monthly menstrual supplies (as well as the associated monthly waste management concerns) is a significant issue in many areas around the world.41
4 MENSTRUAL SUPPRESSION
Decreasing heavy menstrual bleeding and menstrual bleeding in general may also indirectly reduce the environmental effects of different menstrual hygiene management approaches, since this would reduce the number of period products an individual requires if using disposable menstrual products. Menstrual suppression is a well-studied and underpromoted health benefit of hormonal contraception. Increasingly, studies on women who work in austere environments, such as military deployment and astronauts, favor menstrual suppression to address the barriers to menstrual hygiene in their working and living environments.42, 43 Research in this arena has focused primarily on continuously taken oral contraceptive pills to induce amenorrhea.42 Research has also shown that some women have selected and shown satisfaction with long-acting reversible contraceptives (LARCs) to achieve reduced menstrual flow and amenorrhea.43 LARCs may be a preferred method as it does not require daily compliance, and disposal of packaging is mitigated. While considering hormonal contraceptive options in the context of impacting period poverty, it is paramount to maintain the principals of contraceptive counseling focusing on patient autonomy, confidentiality, and individualization of care.44 Unfortunately, the availability of contraception is impacted by one's environment, and those that optimize menstrual hygiene may be the same ones that impact access to menstrual suppression. Additionally, the environmental benefits of menstrual suppression to reduce the need for menstrual hygiene products must be weighed against the detrimental impact of pharmaceutical production and packaging of contraceptives.
5 FUTURE DIRECTIONS
Menstruators around the world need affordable, consistent access to their choice of menstrual products. To ensure that individuals truly have an informed choice, they require access to unbiased information and education about all of the potential menstrual products available (including reusable products), as well as increased awareness about the environmental impacts of disposable products.37 In some LMICs, menstrual product distribution policies and programs have helped in general with product accessibility and affordability, although they have mostly focused on disposable menstrual pads. The role of government, policy-makers, and for-profit manufacturers/industries in organizing menstrual product distribution processes to LMICs is complex and needs further examination to ensure unbiased approaches and increased exposure to all types of products.37, 41 Product distribution and access strategies must also engage communities in identifying their preferred products41, 45 and allow for increased exposure to lesser-known products, such as the menstrual cup, in order to have an opportunity to trial the products and learn to use them.36, 41, 46 Furthermore, product accessibility cannot be the sole focus of such initiatives without also considering other essential components to improve menstrual health management including enhancing access to clean water supply, proper waste disposal infrastructure, and access to education aimed at reducing the negative stigma of menstruation.27, 40
Finally, more robust academic studies are needed to explore the extent of the environmental burden of all menstrual products and hygiene habits in order to better inform product users and policy-makers. As menstruation continues to be a taboo topic in most areas around the world, it will be essential to continue to combat the stigma surrounding menstruation in order to more adequately research the scope of the environmental impact of different approaches to menstrual management. Only when we decrease menstrual stigma and achieve open and diverse conversations that consider impacts of menstruation from people around the globe will we be able to move towards a more sustainable future in menstrual hygiene management.
AUTHOR CONTRIBUTIONS
Drs Harrison and Tyson both designed, planned, wrote, edited, and approved this commentary.
CONFLICT OF INTEREST
The authors have no conflicts of interest.
