Comparing use and acceptability of menstrual cups and sanitary pads by schoolgirls in rural Western Kenya


  • Linda Mason Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool UK
  • Elizabeth Nyothach Centre for Global Health Research, Kisian Campus, KEMRI Kenya
  • Anna Maria van Eijk Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool UK
  • David Obor Centre for Global Health Research, Kisian Campus, KEMRI Kenya
  • Kelly T. Alexander Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool UK
  • Isaac Ngere District Medical Office, Gem District, Yala, Siaya County, Kenya
  • Kayla Laserson Division of Global Health Protection, Center for Global Health, CDC India Country Office, New Delhi, India
  • Penelope Phillips-Howard Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool UK



Africa, Adolescent health, Menstrual cups, Sanitary pads, Schoolgirls, Sexual and reproductive health


Background: Girls in low and middle-income countries (LMIC) lack access to hygienic and affordable menstrual products. We explore Kenyan schoolgirls’ use and views of the cup compared to girls provided with disposable sanitary pads for a feasibility study.

Methods: Schoolgirls aged 14-16 years, received a menstrual cup in 10 schools or 16 pads/month in another10 schools. All were trained by nurses on puberty, hand washing, and product use. They self-completed a net book survey at baseline and twice a term during a year follow-up. We examined their reported ease of insertion and removal, also comfort, soreness, and pain with product use. An aggregate ‘acceptability’ score was compiled for each product and girls’ socio-demographic and menstrual characteristics were compared.

Results: 195 participants received cups and 255 pads. Mean age was 14.6 years, menarchial age was 13.6 years, with an average 3.8 days menses per month. Cup use was 39% in month 1, rising to 80% by month 12 (linear trend p<0.001). Pad use rose from 85% to 92% (linear trend p=0.15). Measures of cup acceptability demonstrated girls had initial problems using the cup but reported difficulties with insertion, removal and comfort reduced over time. Girls using pads reported fewer acceptability issues. At baseline, approximately a quarter of girls in the pad arm reported inserting pads intravaginally although this was significantly lower among girls with prior experience of pad use (aRR 0.62; 0.45-0.87).

Conclusions: While a smaller proportion of girls provided with cups used them in the first months compared to girls given pads, reported use was similar by study-end, and early acceptability issues reduced over time. Girls in LMIC may successfully and comfortably use cups, but require instruction, support and some persistence.


Sommer M. Where the education system and women's bodies collide: The social and health impact of girls' experiences of menstruation and schooling in Tanzania. J Adolesc. 2010;33(4):521-9.

McMahon SA, Winch PJ, Caruso BA, Obure AF, Ogutu EA, Ochari IA, et al. 'The girl with her period is the one to hang her head' Reflections on menstrual management among schoolgirls in rural Kenya. BMC Int Health Hum Rights. 2011;11(1):7.

Mason L, Nyothach E, Alexander K, Odhiambo FO, Eleveld A, Vulule J, et al. 'We keep it secret so no one should know' - a qualitative study to explore young schoolgirls attitudes and experiences with menstruation in rural Western Kenya. PLoS One. 2013;8(11):e79132.

Phillips-Howard P, Nyothach E, ter Kuile F, Omoto J, Wang D, Zeh C, et al. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural western Kenya. BMJ open. 2016;6:e013229.

Hennegan J, Dolan C, Wu M, Scott L, Montgomery P. Measuring the prevalence and impact of poor menstrual hygiene management: a quantitative survey of schoolgirls in rural Uganda. BMJ open. 2016;6(12):e012596.

Sommer M, Caruso BA, Sahin M, Calderon T, Cavill S, Mahon T, et al. A Time for Global Action: Addressing Girls' Menstrual Hygiene Management Needs in Schools. PLoS Med. 2016;13(2):e1001962.

Sommer M. Menarche: a missing indicator in population health from low-income countries. Public health reports. 2013;128(5):399-401.

Miiro G, Rutakumwa R, Nakiyingi-Miiro J, Nakuya K, Musoke S, Namakula J, et al. Menstrual health and school absenteeism among adolescent girls in Uganda (MENISCUS): a feasibility study. BMC Womens Health. 2018;18(1):4.

van Eijk AM, Sivakami M, Thakkar MB, Bauman A, Laserson KF, Coates S, et al. Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open. 2016;6(3):e010290.

Phillips-Howard PA, Caruso B, Torondel B, Zulaika G, Sahin M, Sommer M. Menstrual hygiene management among adolescent schoolgirls in low- and middle-income countries: research priorities. Global health action. 2016;9:33032.

Wilson E, Reeve J, Pit A. Education. Period. Developing an acceptable and replicable menstrual hygiene intervention. Development in Practice. 2014;24(1):63-80.

Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM. Sanitary pad interventions for girls' education in Ghana: a pilot study. PLoS One. 2012;7(10):e48274.

Hennegan J, Dolan C, Wu M, Scott L, Montgomery P. Schoolgirls' experience and appraisal of menstrual absorbents in rural Uganda: a cross-sectional evaluation of reusable sanitary pads. Reprod Health. 2016;13(1):143.

Beksinska ME, Smit J, Greener R, Todd CS, Lee ML, Maphumulo V, et al. Acceptability and performance of the menstrual cup in South Africa: a randomized crossover trial comparing the menstrual cup to tampons or sanitary pads. J Womens Health (Larchmt). 2015;24(2):151-8.

Hyttel M, Thomsen C, Luff B, Storrusten H, Nyakato V, Tellier M. Drivers and challenges to use of menstrual cups among schoolgirls in rural Uganda: a qualitative study. Waterlines. 2017;36(2):109-24.

Oster E, Thornton R. Determinants of technology adoption: Peer effects in menstrual cup up-take. Journal of the European Economic Association. 2012;10(6):1263-93.

Averbach S, Sahin-Hodoglugil N, Musara P, Chipato T, van der Straten A. Duet for menstrual protection: a feasibility study in Zimbabwe. Contraception. 2009;79(6):463-8.

Secor-Turner M, Schmitz K, Benson K. Adolescent Experience of Menstruation in Rural Kenya. Nurs Res. 2016;65(4):301-5.

Lawan UM, Yusuf NW, Musa AB. Menstruation and menstrual hygiene amongst adolescent school girls in Kano, Northwestern Nigeria. Afr J Reprod Health. 2010;14(3):201-7.

Das P, Baker KK, Dutta A, Swain T, Sahoo S, Das BS, et al. Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India. PLoS One. 2015;10(6):e0130777.

Adinma ED, Adinma JI. Menstrual characteristics amongst south-eastern Nigerian adolescent school girls. West Afr J Med. 2009;28(2):110-3.

Tegegne TK, Sisay MM. Menstrual hygiene management and school absenteeism among female adolescent students in Northeast Ethiopia. BMC Public Health. 2014;14:1118.

Sommer M, Kjellén M, Chibesa Pensulo C. Girls’ and women’s unmet needs for menstrual hygiene management (MHM): the interactions between MHM and sanitation systems in low-income countries. Journal of Water, Sanitation and Hygiene for Development. 2013.

Garg R, Goyal S, Gupta S. India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls - issues and challenges. Maternal and Child Health Journal. 2012;16:767-74.

Garikipati S, Boudot C. To Pad or Not to Pad: Towards Better Sanitary Care for Women in Indian Slums. J Internat Develop. 2017;29(1):32-51.

Crofts T, Fisher WA. Menstrual Hygiene in Ugandan Schools and investigation of low-cost sanitary pads. J Water, Sanitation Hyg Develop. 2012;2:50-8.

Sommer M. Ideologies of sexuality, menstruation and risk: girls' experiences of puberty and schooling in northern Tanzania. Cult Health Sex. 2009;11(4):383-98.

Oduor C, Alexander K, Oruko K, Nyothach E, Mason L, Odhiambo F, et al. Schoolgirls’ experiences of changing and disposal of menstrual hygiene items and inferences for WASH in schools. Waterlines. 2015;34(4):397-411.

North B, Oldham M. Preclinical, Clinical, and Over-the-Counter Postmarketing Experience with a New Vaginal Cup: Menstrual Collection. J Womens Health. 2011;20(2).

Howard C, Rose CL, Trouton K, Stamm H, Marentette D, Kirkpatrick N, et al. FLOW (finding lasting options for women): multicentre randomized controlled trial comparing tampons with menstrual cups. Can Fam Physician. 2011;57(6):e208-15.

Stewart K, Powell M, Greer R. An alternative to conventional sanitary protection: would women use a menstrual cup? J Obstet Gynaecol. 2009;29(1):49-52.

Stewart K, Greer R, Powell M. Women's experience of using the Mooncup. J Obstet Gynaecol. 2010;30(3):285-7.

Oster E, Thornton R. Menstruation, Sanitary Products and School Attendance: Evidence from a Randomized Evaluation. Am Econ J Appl Economics. 2011;3(1):91-100.

Nyothach E, Alexander K, Oduor C, Mason L, Oruko K, Odhiambo F, et al. Handwashing for menstrual hygiene management among primary schoolgirls in rural western Kenya. Waterlines. 2015;34(4):279-95.

Alexander K, Oduor C, Nyothach E, Laserson K, Amek N, Eleveld A, et al. Water, Sanitation and Hygiene Conditions in Kenyan Rural Schools: Are Schools Meeting the Needs of Menstruating Girls? Water. 2014;6:1453-66.

Mason L, Laserson K, Oruko K, Nyothach E, Alexander K, Odhiambo F, et al. Adolescent schoolgirls’ experiences of menstrual cups and pads in rural western Kenya: a qualitative study. Waterlines. 2015;34(1):15-30.

Juma J, Nyothach E, Laserson KF, Oduor C, Arita L, Ouma C, et al. Examining the safety of menstrual cups among rural primary school girls in western Kenya: observational studies nested in a randomised controlled feasibility study. BMJ open. 2017;7(4):e015429.

Cohen D, Atieno-Odhiambo E. Siaya: The Historical Anthropology of an African Landscape. London: James Currey, Ltd; 1989.

Odhiambo FO, Laserson KF, Sewe M, Hamel MJ, Feikin DR, Adazu K, et al. Profile: The KEMRI/CDC Health and Demographic Surveillance System--Western Kenya. International journal of epidemiology. 2012;41(4):977-87.

Cheng M, Kung R, Hannah M, Wilansky D, Shime J. Menses cup evaluation study. Fertility And Sterility. 1995;64(3):661-3.

Ellis A, Haver J, Villasenor JON, Parawan A, Venkatesh M, Freeman MC, et al. WASH challenges to girls' menstrual hygiene management in Metro Manila, Masbate, and South Central Mindanao, Philippines. Waterlines. 2016;35(3):306.

Scorgie F, Foster J, Stadler J, Phiri T, Hoppenjans L, Rees H, et al. Bitten By Shyness: Menstrual Hygiene Management, Sanitation, and the Quest for Privacy in South Africa. Med Anthropol. 2016;35(2):161-76.

Adinma ED, Adinma JI. Perceptions and practices on menstruation amongst Nigerian secondary school girls. Afr J Reprod Health. 2008;12(1):74-83.

Everson N, Ednah B. Menstrual hygiene - A salient hazard in rural schools: A case of Masvingo district of Zimbabwe. Jàmbá. J Disaster Risk Studies. 2016;8(2):e1-e8.

van Eijk AM, Laserson KF, Nyothach E, Oruko K, Omoto J, Mason L, et al. Use of menstrual cups among school girls: longitudinal observations nested in a randomised controlled feasibility study in rural western Kenya. Reprod Health. 2018;15(1):139.






Original Research Articles