COVID’s lingering impact on worker shortages, manufacturing shutdowns, and disruptions in global supply chains that sent parents scrambling for baby formula has now hit tampons.  But the recent scarcity and soaring costs of these feminine hygiene products has surfaced what some advocates contend is a long-standing concern with tentacles of implications for women’s lives.  These products are a necessity, not a luxury, advocates say, and lack of access can lead to disruptions at work or school, emotional stress, infections and potentially even death.

Multi-factors and the future

In part, say manufacturers, tampons are getting more expensive due to inflation.  A year after announcing increased prices on feminine care products, Procter & Gamble representatives said in an April earnings call that ongoing supply chain constraints led to another price hike on the products, which will go into effect in mid-July.

The average price for tampons rose by nearly 10% in the year, Bloomberg reported citing NielsenIQ data, due to the rising costs of the materials used.  The price of pads shot up by about 8%.  The materials that make up tampons and pads, including cotton, rayon, fluff pulp, and plastic, had already been in high demand for use in masks and other medical products during the pandemic.  More recently, extreme drought in Texas, soaring diesel prices, and Russia’s invasion of Ukraine also tightened the supply of those goods.

Making matters worse are product recalls that have hit a 10-year high, cites a recent report from Sedgwick Claims Management Services.  More than 900 million units of inventory were recalled in the first quarter of 2022.

And it’s not just tampons.  Edgewell Personal Care, which owns multiple menstrual product brands, says that its inventory of Carefree and Stayfree liners and pads sank alongside that of its Playtex and o.b. tampons.  The company attributes the lower quantities to staff shortages prompted by Covid variant infection waves, one which hit its US manufacturing facility late last year and another which impacted its Canadian supplier early this year.

Unfortunately, many supply experts don’t see much relief on the horizon.  Vaughn Moore, chief executive of AIT Worldwide Logistics, anticipates that it’s only going to worsen as the year progresses and as peak season approaches for shippers and retailers.  “Capacity is only going to get tighter as we move toward the end of the year,” Moore said.

Worse, short supplies often spur consumer hoarding which exacerbates and prolongs the problem.

Costs beyond money

Costs for these sanitary items are as variable as menstrual cycles.  An online period product calculator published by statistics firm Omni Calculator found the average woman spends about $10 a month on menstrual products, which includes tampons, pads, or menstrual cups.  This doesn’t account for pain pills, wipes, or other menstrual support items.  Prices can vary depending on the brand of items or the heaviness of the menstrual cycle.  The average woman will pay roughly $1,800 over the course of her life if using tampons, or more than $4,750 if she uses pads, according to 2021 research from Pandia Health.

Because research on menstrual health is limited, experts cannot quantify the extent of period poverty in the United States.  However, a 2019 study published in Obstetrics and Gynecology found nearly 64% of low-income women surveyed in St. Louis, Missouri, could not afford menstrual hygiene supplies during the previous year (Sebert Kuhlmann et al. 2019).

Of the survey participants, ~46% of the women could not afford to pay for food and menstrual products, and 21% were unable to afford products on a monthly basis.  One-third of them used cloth, rags, tissues or toilet paper, the journal article cites, while others used children’s diapers or paper towels because they didn’t have pads or tampons.

The inability to afford clean sanitary products can affect women’s mental health.  A study published last year in BMC Women’s Health found that 68% of college students who reported experiencing period poverty monthly also reported moderate or severe depression (Cardoso et al. 2021).

Needing in silence

In her 11 years of practice, Anne L. Banfield, MD, an obstetrician-gynecologist at Davis Health System in West Virginia, stated in a recent interview that she has rarely, if ever, encountered a patient who voluntarily mentioned their struggles to pay for menstrual hygiene products.  Women with low incomes can feel ashamed to talk about their challenges, she observed.

“For many people, poverty imparts a feeling of shame…when they can’t provide for their own needs,” stated Banfield.

Financial barriers, stigma, and poor education around menstrual cycles have forced many into “period poverty,” defined as inadequate access to menstrual hygiene products and education.  Both further deteriorated during the coronavirus pandemic, she notes.

Risks of “stretching out” tampon usage

Although they may seem relatively simple, tampons are regulated by the US Food and Drug Administration (FDA) as medical devices.  They’re made of cotton, rayon, or a blend of the two.  To be cleared by the FDA, tampons must pass tests for absorbency, strength, and integrity, and they should not promote the growth of certain harmful bacteria in the vagina.  Further, according to the FDA, tampons are meant to be used a single time and then thrown away,

Even if patients are having difficulty locating a preferred brand of tampons, it’s important they be reminded to adhere to safety guidelines:

• FDA-cleared tampons are meant to be used one time and thrown away.  Tampons should not be reused or worn for more than 8 hours.
• Patients should be advised to change tampons every 4 to 8 hours and to use the lowest-absorbency tampon possible.  If patients can wear 1 tampon for up to 8 hours without changing it, its absorbency may be too high, according to the agency.
• Longer duration tampon use increases the risk of toxic shock syndrome (TSS), a rare, life-threatening complication of certain bacterial infections, according to the Cleveland Clinic.  Although low, the risk is higher if women wear a tampon longer than 8 hours or use higher-absorbency tampons.  The National Organization for Rare Disorders estimates that TSS related to tampon use occurs in about 1 in 100,000 menstruating women. Symptoms of TSS may include a sudden fever (usually of 102 degrees or more), vomiting, diarrhea, fainting or feeling like fainting when standing up, dizziness, or a rash that looks like a sunburn.  If any of these symptoms occur during a patient’s period or soon after, they should be advised to stop using tampons and to seek medical attention right away.

• Some brands of tampons come with a date stamped on the package, but that is not an expiration date mandated by the FDA of the sort found on latex condoms. Tampax brand tampons, for instance, are marked with a “shelf life” date of 3 or 5 years, which P&G describes as the “time period during which a product is expected to meet our high standards for quality” when stored in a cool, dry place. But according to medical providers, that doesn’t mean tampons are necessarily unsafe or ineffective beyond that date. In theory, cotton could absorb some bacteria or mold, but there is no scientific data behind their shelf-life dates, Barbara Wilkinson, MD, an obstetrician and gynecologist with Brigham and Women’s Hospital and an instructor at Harvard Medical School, stated in a recent interview with The New York Times.

Values-based choices

Menstrual care products are personal, practically by definition.  Various practices and products are passed down by family and trusted friends, carefully explained to young patients, or hastily taught in bathroom stalls.  Once women find a product that works for them, they tend to stick with it.  As some consider switching to reusable menstrual products, factors like cost, accessibility and long-held personal preferences could be barriers.

For some women, however, the shortage may offer an occasion to rethink long-held approaches to their periods.

Nichole Tyson, MD, the chief of pediatric and adolescent gynecology at Stanford Children’s Health, states that most of the young patients she sees use pads when they get their first period.  But some teenagers are shifting to methods that require less maintenance and are better for the environment, and they are talking more and more to each other about how to use them.  Dr. Tyson relates that one of her patients said a friend recently taught her how to insert a menstrual cup in the school bathroom.

While some patients may find the tampon shortage stressful, Jessica Atrio, MD, a board-certified obstetrician gynecologist at Montefiore and Albert Einstein School of Medicine in New York and the Associate Director of the Fellowship in Family Planning, thinks this might be an opportunity for patients who use tampons to re-examine their product choices and how well they align with their personal values.

“People should be assured that they have agency in these decisions,” she said, noting, for example, the possibility of switching from tampons to reusable options for environmental reasons.  According to National Geographic statistics, in 2018 alone, US consumers bought 5.8 billion tampons.  Over the course of a lifetime, a single menstruator will use somewhere between 5,000 and 15,000 pads and tampons—the vast majority of which will wind up in landfills as plastic waste.

For patients struggling to find tampons in their area, more sustainable options like reusable pads, menstrual cups, and period underwear may present affordable and environmentally friendly alternatives.

Pads

Many women already use sanitary pads (napkins) to supplement tampons either on days when their flow is especially heavy, or while sleeping, said Lauren Streicher, MD, a clinical professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine.

There are disposable and reusable pad options.  Dignity Period, a nonprofit based in St. Louis, distributes washable, reusable pads to schools, food pantries, libraries, and other community partners across the country.  As tampon supplies have waned, executive director Angie Wiseman has seen an uptick in interest in Dignity Period’s organic, reusable cotton pads.  One $12.50 pack contains 4, which should last the user 12 to 18 months provided they are washed according to instructions.  By comparison, a year’s supply of the most popular tampon brands, would run from $225 to $250.

But Dr. Streicher acknowledges that pads aren’t for everyone.  Some women don’t like the sensation of wetness they can cause, while those with vulvar conditions, such as genital psoriasis or vulvodynia, can experience significant discomfort and irritation.  Pads can also keep women from engaging in certain activities, like swimming or intense exercise.

Menstrual cups and discs

Menstrual cups and discs—flexible, reusable devices made from medical-grade silicone or latex and inserted into the vagina to collect menstrual blood—have seen a surge in popularity in recent years.  Cups and discs tend to fall in the $25 to $35 range.

“You place the menstrual cup over your cervix, and it collects menstrual blood for about 12 hours,” explains Dr. Streicher.

Research suggests that leakage with menstrual cups is similar to or lower than what women experience with pads or tampons.

Vili Petrova, 42, the founder and president of Lena Cup, a company that produces menstrual cups that emphasize ease for first-time users, said, “with that shortage, people are once again exploring all alternatives and not wanting to be dependent” in case there is a prolonged shortage.

Sustainability was a priority when she designed the Lena Cup, and environmental concerns have been fueling more interest in the product in recent years.  A menstrual cup can be a one-time purchase that can last years with proper care, “so it eliminates the use of thousands of pads and tampons in one lifetime,” according to Ms. Petrova.

She acknowledges that many people have questions about menstrual cups.  “Why is it $25?  Is it sanitary?  How am I going to keep it clean?  Is it healthy?  Is it safe?  All understandable questions that I myself have had before,” she said.

Finding the right menstrual cup can take some trial and error, and there may be a learning curve with insertion.

“Just because one menstrual cup doesn’t work for you, doesn’t mean all won’t,” counsels John Horton, MD, an assistant professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine.  “Just like any product, there are differences with different shapes or brands.  It may take one or two to find the right one for you.”

(If possible, he recommends that patients should have a backup form of menstrual protection on hand when trying out a new product like a menstrual cup.)

Period underwear

Some women are switching to period underwear, a type of undergarment engineered to absorb menstrual blood.  Period underwear use absorbent materials, like microfiber polyester, to soak up menstrual blood.  “I’m seeing more and more women, especially my younger patients, really embracing this option,” Dr. Wilkinson says.

There are many reusable brands on the market, most of which indicate their capacity by how many tampons’ worth of menstrual blood they can hold, she explains.

Dr. Tyson notes that there are more brands of period underwear available now.  “I think that’s a great space that a lot of people are exploring,” she says.

However, period underwear can be cost prohibitive (some popular bands are $30 to $40 per pair) and cannot be put in the dryer.

Karla Welch, founder and chief executive of The Period Company, a manufacturer of period underwear, credits the tampon shortage for the spurred interest in her brand’s underwear based on website visits and sales metrics.

“No one should not have access to a sustainable product,” Ms. Welch says. “So often, sustainable products are priced out for a lot of people.”  She also acknowledges that some people need to use tampons or aren’t able to use sustainable products.  But for those open to trying alternatives, Ms. Welch said, “this is our opportunity to really convert people.”

National Geographic verifies that there’s growing interest tampon alternatives in the US, citing data from a recent survey that ~60% of the women questioned were considering a reusable product and about 20% were currently users.

Overall, Dr. Horton believes the tampon shortage is a reminder that menstrual hygiene is a broadly important topic.  Talking about it helps to “demystify it,” he said, so that everyone—not just those who have periods—can get a better sense of the costs and logistical challenges associated with menstrual hygiene.

Clinicians’ Bonus:  More To Know

Resources to share with your patients

• The Alliance for Period Supplies, a program of National Diaper Network, is a national organization working to ensure that individuals in need have access to essential period products required to participate fully in daily life. This organization, sponsored by U by Kotex, helps collect and distribute period supplies to those in need by partnering with over 75 programs nationwide.  Anyone who needs period products can text 211 or visit 211.org to find a location giving out free tampons and pads.

• I Support the Girls is nonprofit whose mission says it best: People shouldn’t have to choose between feeding themselves and their personal health. They help provide menstrual products and bras and to the homeless across North America.  You can find more information on where to donate menstrual products and bras here.

• PERIOD. is a youth-fueled nonprofit that “strives to eradicate period poverty and stigma through service, education, and advocacy.” Through the distribution of menstrual products, promotion of youth leadership, and championing of menstrual equity in policy, PERIOD. aims to center those disproportionately affected by period poverty and support local efforts for menstrual equity.

• Thinx, Inc., a feminine hygiene company which Kimberly-Clark Corporation acquired a majority stake in in February, offers a line of period underwear, which can replace or back up traditional menstrual products, such as tampons, pads, and menstrual cups. Each pair is washable, reusable and features a 4-layer technology that is “antimicrobial, moisture wicking, absorbent, and leak-resistant.”

• Lunette is a Finland-based producer of menstrual cups, which are user-friendly, hygienic, reusable, and ecological alternatives to pads and tampons. Menstrual cups can be used for up to 10 years and thus significantly reduce amounts of waste.  Other menstrual cup companies include DivaCup, Ruby Cup, and Softcup.

• Founded in 1995, Aisle (formerly Lunapads) based in Vancouver, British Columbia, manufactures washable feminine hygiene products, including cloth menstrual pads and underwear, and distributes a commercial menstrual cup via its website.
  

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  The contents of this feature are not provided or reviewed by NPWH.