Upson et al. 2022 - menstrual-product environmental chemical exposure review

Upson, Shearston, and Kioumourtzoglou reviewed menstrual products as a potential source of environmental chemical exposure from an epidemiologic perspective. The paper is secondary evidence: it summarizes product-chemistry studies and three human biomonitoring studies, but it does not generate new product concentration data. Its metal-specific value is context around Singh et al. 2019 whole-blood cadmium, lead, and mercury in tampon users, not primary tampon occurrence.

Key numbers

• Use-pattern framing: the review says menstrual bleeding occurs on average every 24-38 days from menarche to menopause. Under assumptions of 13 cycles per year, 5 bleeding days per cycle, and 4 menstrual products per day, menstruators could use more than 10,000 menstrual products over a lifetime.
• U.S. market framing: tampon and menstrual-pad sales exceeded $2.8 billion in 2018, with nearly 600 million units sold.
• Review inclusion: the authors restricted the review to studies with enough information to understand scientific methods and results. They excluded risk assessments that did not measure chemicals in menstrual products and methods papers that did not provide product concentration values.
• Product-chemistry evidence: the review says 23 studies measured chemicals in menstrual products; all reviewed product studies detected environmental chemical concentrations, though risk conclusions differed across studies.
• Exposure assessment: of the 23 product studies reviewed, 13 conducted exposure assessment and risk characterization. Over half estimated average daily exposure over an average month (30 days) or over a lifetime rather than only on product-use days.
• Human epidemiology evidence: only 3 epidemiologic studies had investigated menstrual-product use and environmental chemical concentrations measured in women at the time of the review.
• Phthalate epidemiology: Branch et al. 2015 used NHANES 2001-2004 data in women ages 20-49 years (n=739 unweighted) and reported that vaginal douche users had MEP concentrations 52% higher than non-users (95% CI: 19%, 94%). The review reports no associations for tampon or sanitary-napkin use in that study.
• VOC epidemiology: Ding et al. 2020 used NHANES 2001-2004 data in women ages 20-49 years (n=2432 unweighted) and reported 36% higher whole-blood ethylbenzene in feminine-powder users (95% CI: 0% to 83%) and 81% higher 1,4-DCB in women who douched two or more times in the past six months (95% CI: 2% to 221%).
• Metal epidemiology: Singh et al. 2019 studied premenopausal women ages 18-44 years in the Western New York BioCycle Study (n=259) and evaluated tampon use against whole-blood Cd, Pb, and Hg. Any tampon use during up to two menstrual cycles was associated with a 25% higher geometric mean mercury concentration, with adjusted ratio 1.25 and 95% CI: 0.93-1.68; no associations were observed with cadmium or lead concentrations.
• Metal-product evidence gap at the time: the review states that no prior studies had evaluated the presence of metals in tampons before the Singh et al. biomonitoring work.
• Microbiome/TSS context: the review describes the Rely tampon toxic-shock-syndrome case example, including a reported 10-15% case-fatality ratio and possible mechanisms involving oxygen, pH, S. aureus, menses, and lack of antibodies to toxin.
• Research recommendations: the paper recommends empirical data on vaginal and vulvar absorption, epidemiologic research with exposure measurements timed with menses, consideration of menstrual products in gynecologic-condition studies, and publication of NGO/consumer-organization testing in searchable scientific venues.

Methods (brief)

This is a peer-reviewed narrative review. The authors summarized studies in which enough information was available to evaluate scientific methods and results, drawing from peer-reviewed articles, government reports, consumer-association work, and environmental-organization studies. They grouped the evidence into product-chemistry studies, exposure/risk characterizations, and three epidemiologic studies linking menstrual-product use to measured environmental chemicals in women. The paper does not report a formal PRISMA search, pooled meta-analysis, new laboratory method, LOD/LOQ values, or new product sampling.

Speciation: cadmium and lead are reported as whole-blood metals in a cited epidemiologic study. Mercury is reported as whole-blood mercury; the review does not identify methylmercury, so this page uses tHg and does not infer MeHg.

Implications

Certification (HMTc): This source should not contribute primary product occurrence values to menstrual-product metals pools. It is useful B-tier secondary context for exposure pathways, literature gaps, and the BioCycle tampon-use biomonitoring signal, with Singh et al. 2019 and later tampon-metal occurrence studies remaining the appropriate primary sources.

Courses: The review is useful for teaching exposure-boundary discipline: a product may plausibly contact permeable vulvar/vaginal tissue, but biomonitoring associations and narrative review summaries are not equivalent to product concentration data.

App: The source can support menstrual-product context cards about exposure pathways and research gaps. It should not be presented as proof of metal contamination in a product category, and it should not be used for brand ranking.

Microbiome: The paper discusses menstrual toxic shock syndrome, S. aureus, vaginal pH, oxygenation, menstrual fluid, and the vaginal microbiome as exposure-context mechanisms. It does not report a new microbiome measurement.

Wiki pages this source may touch

• menstrual-tampons
• menstrual-pads
• feminine-wipes
• feminine-deodorants
• douches-vaginal-irrigation
• dusting-talc-powders-adult
• cadmium
• lead
• mercury-total

Verification notes

• PDF text was extracted with pdftotext -layout to /tmp/mfk_june8_menstrual_products_environmental_exposure.txt. The title/DOI page, abstract, introduction, environmental-chemical review methods, product-study comments, epidemiologic-study sections, Table 1, Table 2, recommendations, and conclusions were checked against this page.
• DOI 10.1007/s40572-022-00331-1, exact title, raw handle MFK_menstrual-products-as-a-source-of-environmental, and candidate cite key upson2022-menstrual-products-exposure-review were searched before creation; no existing source page was found.
• Numbers are copied from the review and its tables without conversion. Percent changes and confidence intervals remain source-side epidemiologic summaries, not product concentration values.
• Speciation: the source reports whole-blood Cd, Pb, and Hg in the cited Singh et al. study. It does not provide methylmercury or inorganic mercury, so this page records tHg context and does not infer MeHg.
• Brand firewall: no brand-linked values are reported in this page. Product types are kept at category level.
• Evidence tier: B because the paper is peer-reviewed and useful secondary evidence, but it is a narrative review and not a primary occurrence or systematic-review dataset.
• Routing: npm run evidence:source-routes exited 0. The source generated 6 product routing rows, was absent from routing_unresolved.csv, and had only the expected advisory routing_malformed.csv entry for empty optional ingredients.

Page history

The five most recent substantive edits to this page. The full version history lives in git; when DOI minting comes online (see schema docs), each entry below will also link to a version-pinned DataCite DOI.