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Do period products affect our skin?
Our skin is a functioning organ. It is not just a tarp or a covering for the body as it was considered in ancient times. It is actively interacting with the environment, independently functioning such as for vitamin D production, and interacting with internal organs. Among its many functions are interacting hormonally and immunologically with the body and the environment. It stands to reason that if our skin is exposed to a product, there is a chance or potential for some level of interaction to occur.
Period products come into close contact with our skin. In particular, certain period products come into close contact with mucosal skin. Mucosal skin is thinner and tends to line the digestive tract, reproductive tract, and respiratory organs. The labia majora, the outer part of the labia, is considered keratinized skin. The skin lining the labia minora is mucosal skin. This is the area that is just internal to the labia majora and surrounds the vagina. The type of skin can influence the susceptibility of the skin to products it comes into close contact with.
What types of period products are there?
Period products consist primarily of :
- Sanitary pads
- Panty liners
- Period underwear
- Period cups
The most common period products consist of tampons, sanitary pads, and pantyliners. These products are generally intended to play a particular role during the menstrual cycle to absorb the discharge. Although predominantly used during the menstrual cycle, increasingly they are also used to absorb light bladder leakage throughout the month as well.
Period underwear is an undergarment that absorbs menstrual discharge and can be washed and re-worn.
Period cups consist of a silicone or rubber cup inserted into the vagina to collect menstrual discharge.
Period products often contain various additives to serve specific roles. These include:
- Odor protection
- Preservatives to maintain freshness and reduce overgrowth of microorganisms while in the packaging
- Protection of clothing
How is odor protection achieved?
Odor protection is generally achieved through added scents and fragrances and/or antimicrobial agents. The concentrations and particular scents are not routinely disclosed to consumers. Several studies have demonstrated the presence of numerous allergenic scents in period products. These scents may play a role in odor protection for some but for others, the interaction of the discharge with these scents can produce a foul odor.
MARKETING CLAIM TO NOTE:
To truly find a product without fragrance look for the words “fragrance-free”. The word “unscented” does not necessarily mean there is no fragrance. Unscented just means there is not a noticeable scent. There could actually be a scent or fragrance added to mask the base scent of the ingredients. Products listed as “fragrance-free” may actually have a noticeable smell but this is only because the fragrance was not added to mask the scent of the base ingredients. You can see how frustrating this can be to navigate for consumers. Many products will also carefully state as a marketing claim that they do not contain “synthetic fragrances”. This means nothing for a consumer that has sensitive skin.
What role do preservatives play in period products?
Another route to odor protection is the use of antimicrobials in period products.
Nanosilver, fibers with charged materials, and other antimicrobial treatments may be used in the process of producing certain layers of the period product. Parabens and TCC (Trichlocarbon) may be used in period products as a preservative for their antimicrobial properties. Although Parabens and TCC are in a category of potentially endocrine-disrupting chemicals, the presence of these chemicals in products is regulated by the FDA to ensure that concentrations in products stay below concentrations with potentially toxic effects.
Period products are considered Class II Medical Devices and regulated in this capacity. All of the studies I came across evaluating the presence of these chemicals found the concentrations to be below potentially toxic levels for period products that contain them.
Why are antimicrobial agents added to period products?
Antimicrobials may be added to products for multiple reasons. These can have a preservative effect to inhibit the overgrowth of bacteria, yeast, and/or other organisms within the packaging. Antimicrobials can be added to period products or clothing items for odor management while the product is in use.
There is the potential for antimicrobials to be added for a treatment benefit as well. However, this type of claim would be regulated by the FDA and require disclosure of the antimicrobial agent and concentration of the agent on the packaging as an active ingredient. The Treated Articles Exemption Act from the Environmental Protection Agency excludes treated textiles from FDA regulation based on the claims made as long as the product is not intended to actively provide medical treatment for the individual using it.
For products that do claim odor protection or antimicrobials present, be mindful that the delicate bio flora balance in the vaginal area is intended to protect the skin from an overgrowth of potentially disease-causing yeast or bacteria. By using products that have antimicrobial activity, this delicate balance can be disrupted and actually result in recurrent yeast infections or other challenges.
Is it a good idea to seek paraben-free period products or TCC-free products?
If a product states that it is paraben-free or TCC(Trichlocarbon)-free, my immediate concern would be what exactly the product substitute for using these antimicrobial preservatives is. If there are no preservatives added, then there is a risk that the product could overgrow bacteria and other organisms while in the packaging before use depending on how it is sealed. This has happened in the hair industry with ammonia-free products. Ammonia is added to hair dyes to swell the hair follicle to help hair dye penetrate the cuticle and attach more effectively. Even though we often hear about ammonia-free products, it is difficult to say if these are actually better. Ultimately these products will still use some kind of alkalinizing ingredients to achieve the same result.
How do period products address absorbency?
Sanitary pads and pantyliners that focus on absorbency to collect blood during the period often consist of three layers.
- Top sheet
- Absorbent layer
- Barrier sheet or layer to protect clothing and garments
The top sheet is intended to wick moisture to the absorbent layer. The absorbent layer often contains super absorbent polymers (SAPs).
When these types of products are referenced as made of organic cotton, this does not necessarily mean that the product is purely 100% organic cotton. This claim is just a claim and often references the top layer. Organic cotton alone cannot absorb the volume of blood and discharge most require during the heaviest days of their period. The presence of super absorbent polymers is often required.
Why do some of the newer period products use organic cotton?
Organic cotton has gained in popularity owing to the fact that it is grown without the use of toxic synthetic pesticides and fertilizers. However, to be labeled as organic, the only criteria to meet is to utilize USDA-certified organic crops in production. The word organic can still be ascribed to cotton that utilizes certified organic crops even if it has been chemically modified with finishes or dyes. (USDA, 2019). This is another example of speaking to intent- if your goal is to buy organic cotton pads to avoid added chemicals in the production process, only undyed organic cotton may potentially meet your goals. The organic cotton used in tampons and other period products IS bleached. It is bleached with peroxide, not chlorine. The concern about bleaching with chlorine in non-organic cotton-containing period products is the risk of dioxin production which has a potential link to endometriosis. However, most studies have confirmed that the amount of dioxin present is well below toxic levels making it difficult to assess this risk.
How about the barrier sheet or layer, what is this made of?
The water-resistant last layer of the period product often contains plastic-containing compounds to serve its purpose- protecting clothing from leakage. The polypropylene and polyethylene in these products will often contain phthalate as a plasticizer to make the material more pliable to conform to underwear. If this is not present, a substitute would need to be present. Some products may use plant starches and other thickening agents to attempt to serve the same purpose. Again, the precise plant and specific product used in its place are rarely disclosed by these brands.
What about tampons, these only have the absorbent layer. Can they be 100% organic cotton?
Organic cotton tampons, do have the potential to be made with 100% organic cotton. Many will tout a BPA -free applicator and paper packaging. My biggest concern about these products is their ability to maintain freshness and reduce the chances of bacterial contamination without any preservative, especially if packaged in just paper. Tampons are inserted and in close contact with thin non-keratinized mucosal skin. The risk of exposure to a contaminant from the manufacturing or from the distribution process is possible This makes me suspect that some form of preservative is present, however, these companies tend to only disclose what they do not have and do not necessarily state what they do contain as a substitute.
What are menstrual cups?
Menstrual cups tend to be made of silicone, rubber, latex, or other compressible elastomers. There are versions that are meant for vaginal insertion and others placed higher in the vagina close to the cervix similar to a diaphragm. These cups are ideally compressible to allow for vaginal insertion and can collect about 10 to 40 mL of discharge. They need to be drained between 2 to 6 times daily depending on flow. Although single-use versions exist, most can be reused.
Interestingly, menstrual cups are not routinely referenced as a period product in spite of favorable experiences by those who have adopted use. There is a learning curve to insertion, use, and reuse. These have not been associated with a higher rate of infection compared to other period products and can actually collect more blood than other period products. In areas where access to period products may be limited based on resources or socioeconomic factors, menstrual cups may be a cost-effective alternative.
Why do dermatologists need to understand period products?
As a dermatologist that manages thousands of patients routinely with rashes, hypersensitivity reactions, recurrent yeast infections, along with other genitourinary challenges of unclear etiology, the challenges we face in pinpointing cause based on nondisclosures places patients in the ongoing challenge of trial and error to find alternatives.
Given that period products are regulated by the FDA as Class II medical devices requiring companies to submit detailed risk assessments of components and safety profiles, the best advice I can offer patients in choosing a period product is to choose products based on efficacy and not claims. Choose products that serve the specific needs you are seeking and adequate discharge control. If a product can do so in a category that avoids specific ingredients that are concerning to you, then it is reasonable to consider. However, to run the risk of inadequate protection based solely on trying to seek organic cotton products, for example, without clearly understanding what is in the product (and not just what is not in the product) can lead to challenging cycles to get through.
Have you ever encountered a challenging situation that involved period products or a patient?
There is one side story I did want to share as I think it highlights how important this topic is. I had a patient I had known since she was a teenager. In her mid-20s shortly after she was engaged to her boyfriend of many years, she started to develop a rash over her labia and vagina. She went to her gynecologist and was flatly told it was herpes. She could not understand how this was possible and started to worry about her relationship. She did not respond to the treatment provided but was so embarrassed at first that she did not seek further treatment. She actually came to see me for acne and she reluctantly mentioned she had been dealing with a rash. When I examined her she had clear evidence of contact dermatitis. I allergy-tested her and she came back as allergic to parabens. We then created a patch test out of the period products she used routinely and she came back as allergic to these. At the time, there were limited options on the market for products that disclosed components and she ended up finding a brand based on trial and error. She has not dealt with the rash since.