Menstrual product selection and education for adolescents

In the United States, sexual health education in schools is not legally mandated in 23 states. Thus, the level to which menstruation and available products are discussed in school can vary depending on state-specific legislature.¹ Given that menstrual cycles and the associated products can be seen as taboo subjects among peers, educators, and families, adolescents may be unaware of product options less commonly advertised. This article will review the different products available and general considerations individuals should be aware of prior to and during use.² 

Products can be divided into 2 main types: ones that are external to the vagina and those that are inserted into the vaginal canal. Common products that do not require insertion include menstrual pads and period underwear. Products that require insertion include tampons, menstrual cups, and menstrual discs.^2,3 A complete list of commercially available products can be found in the Table.^2-4

Patient preferences and skills will likely determine the product chosen. An additional consideration is how often the individual wants or will be able to change the product. If a patient has a heavier menstrual flow, they have the option to wear an external and internal menstrual product or 2 external menstrual products for extra protection (eg, period underwear with a tampon or a pad). The main caveat to this is that 2 internal menstrual products cannot be used concurrently.

Tampons

Tampons typically need to be changed every 4 to 8 hours, depending on the absorbency of the tampon and the heaviness of menstrual flow.² A tampon may not be necessary during light menstrual flow, which typically involves light spotting. Normal menstrual flow varies from person to person. For most individuals, a heavier menstrual flow often occurs during the first couple of days of menstruation. Tampons are available in a variety of different types and sizes. These sizes indicate the amount of blood the tampon can absorb, with smaller (eg, light, slender) holding approximately 3 mL of blood, regular holding approximately 5 mL of blood, and super (eg, ultra, super) holding up to approximately 12 mL of blood. In general, people with heavier flows may prefer a larger-sized tampon to prevent leakage. Choosing the right size can depend on multiple factors, including time during the cycle and comfort.⁵ 

Leaving a tampon in for longer than 8 hours increases the risk of toxic shock syndrome (TSS), a rare but serious condition.² Signs of TSS to watch for include sudden high fever, vomiting or diarrhea, dizziness or fainting, rash resembling a sunburn (especially on palms and soles), muscle aches, and/or confusion or low blood pressure.⁶ Applicators reduce direct hand-to-vagina contact and lower the risk of introducing bacteria during insertion. Applicators, however, do not eliminate the risk of TSS, as TSS is more closely tied to the length of time the tampon has been inserted and the absorbency level used. To reduce TSS risk, use the lowest absorbency needed and change tampons regularly.⁶

Inserting a tampon involves washing your hands, unwrapping the tampon, and using either a plastic or cardboard applicator (or finger for nonapplicator tampons) to gently guide the tampon into the vaginal canal at an upward angle, following the natural curve of the body.² The tampon should sit comfortably inside the vagina, and the string should hang outside the body for easy removal. If the tampon feels uncomfortable, it may not be inserted far enough and should be repositioned. To remove a tampon, hands should be washed again, and the individual should gently pull the string downward and forward until the tampon slides out. Tampons should never be flushed down a toilet, and used tampons should be wrapped in toilet paper and discarded in the trash.²

There has been recent concern about contamination of tampons with various heavy metals. Shearston and colleagues analyzed multiple tampon types and brands for the presence of many different metals: arsenic, barium, calcium, cadmium, cobalt, chromium, copper, iron, mercury, manganese, nickel, lead, selenium, strontium, vanadium, and zinc. The study analyzed 24 tampon products, with a total of 30 tampon samples. All 16 metals tested were detected at varying concentrations in each of the 30 tampon samples, including toxic metals such as lead and arsenic.⁷ In general, the vaginal epithelium allows for increased chemical absorption into the systemic blood flow due to being highly vascular with a larger surface area.⁸ If exposed vaginally to metals via a contaminated tampon, there is a risk of the metals being absorbed systemically; however, it is unknown to what extent. According to the Centers for Disease Control and Prevention (CDC), there is no safe level of lead in the blood.⁹ For adolescents beginning to menstruate, there is a concern of the long-term effects of lead exposure into adulthood, such as decreases in cognitive function and adverse outcomes on the heart and kidneys.¹⁰ Because of the known harms of lead, the CDC recommends vigilant avoidance of environmental lead exposure when possible.^9,10 Due to these findings, current CDC guidance on lead exposure, and the unknown clinical impact of chronic exposure, the authors were unable to recommend a specific tampon type or brand at this time.^9,11,12

Menstrual cups

Menstrual cups require knowledge of both insertion and removal techniques. Unlike tampons, menstrual cups collect rather than absorb and are inserted into the vaginal canal to form a seal through suction. Proper placement is important for comfort and to prevent leakage. Menstrual cups come in various sizes and firmness levels. Selection typically depends on factors such as age, whether the individual has given birth vaginally, cervix height, and menstrual flow volume. For example, smaller sizes are often recommended for younger individuals or those who have not had vaginal births, while larger sizes may be appropriate for those over 30 years old or who have given birth vaginally.¹³ Removal of the menstrual cup requires breaking the seal or suction before pulling the cup out. This is typically done by pinching the base of the menstrual cup. If an individual has an intrauterine device (IUD), failing to break the menstrual cup seal before removal increases the risk of IUD displacement or dislodging.¹⁴ Once the menstrual cup has been removed, the menstrual blood can be emptied into the toilet.

As menstrual cups are reusable, it is important to properly clean the cup with mild, unscented soap and lukewarm water every time the cup is removed to be emptied. Cups should generally be emptied every 8 to 12 hours, but they may need to be emptied more often depending on an individual’s menstrual flow. After the menstrual cycle has ended, the menstrual cup should be boiled in water for 5 to 10 minutes and then stored in a clean case or pouch.^2-4 In rare cases, menstrual cups have been associated with TSS.⁶ The risk of developing TSS can be significantly lowered if the menstrual cups are properly emptied and cleaned as detailed above.

Menstrual discs

Menstrual discs are inserted vaginally and sit between the space behind the cervix and pubic bone. When placed properly, the disc can stay inserted for up to 12 hours. The discs are available in different sizes and materials, which should be selected based on patient comfort. Additionally, menstrual discs are available in reusable or single-use options. As with cups, choosing the right size will depend on factors such as cervix height, age, and menstrual flow.³

Removal is done by hooking a finger under the rim of the disc to remove the disc horizontally. This method should reduce any leakage of blood during removal. Once removed, the blood collected in the disc can be flushed down a toilet, and the disc can be cleaned or disposed of, depending on whether a reusable or single-use disc was used. Before the first use, it is recommended that the disc be sterilized by putting it in boiling water for 5 to 10 minutes. Sterilization is also recommended at the end of each menstrual cycle or at least prior to the next one. After removal of a reusable disc, the disc should be washed with gentle soap and water or water alone, making sure to avoid the use of scented or harsh cleaning products. A specific menstrual disc cleaning solution is also available to use if desired.³ Similar to the menstrual cup, there is a risk of TSS with the menstrual disc, so it is crucial to adhere to cleaning and emptying practices described above.⁶

Menstrual pads

Menstrual pads are single-use products and thus do not have the cleaning requirements that many of the reusable products do. As mentioned previously, pads do not require insertion into the vaginal canal. Pads have 2 sides: one with a sticky adhesive to keep the pad in place in the underwear and the other with absorbent padding to collect menstrual blood. Some pads will also have wings on the sides that allow for extra adhesion to the underwear.² 

Menstrual pads should be changed roughly every 4 to 8 hours, as they still pose a risk of bacterial buildup.¹⁵ There are many options available for menstrual pads, including overnight pads.¹⁶ Some brands of overnight menstrual pads list use for up to 12 hours.¹⁷ More frequent changing of pads is, in general, good practice, and during the day, an 8-hour maximum wear time per menstrual pad should be instituted.¹⁶ Similar to tampons, menstrual pads should never be flushed down a toilet, and used pads should be wrapped in toilet paper and discarded in the trash.

Period (menstrual) underwear

Period underwear can be worn for up to 12 hours. As the name suggests, they can be treated like regular underwear and washed and reused. There are many companies that sell period underwear, and each has its own recommendations for cleaning and changing frequency. Generally, people with heavier menstrual flows will have to change the period underwear more often, especially if they are only using the period underwear. Using period underwear and an additional period product, such as a pad or tampon, could lessen the frequency of period underwear changing needed. Uniformly, period underwear should be washed between uses per the manufacturer’s instructions.² 

Period underwear poses no risk for developing TSS. However, there was a report of the presence of per- and polyfluoroalkyl substances (PFAS) with a period underwear brand called Thinx.¹⁸ PFAS have been linked to adverse health effects, such as reducing fertility and the likelihood of pregnancy, as well as altering estradiol and progesterone levels in women.^19,20 It is important for users to look into various period underwear brands and their product designs to ensure that no harmful chemicals, such as PFAS, are added.

Conclusion

To summarize, the choice of menstrual product is a personal decision. One’s choice of menstrual product can and likely will change over time. Understanding comfort and skill level, along with personal preferences, such as need for cleaning and changing requirements, is key to choosing the best-suited product for the individual. Knowing the available options allows for consideration of all of the above. Health care providers should continue to follow emerging news and research about potentially harmful contaminants in menstrual products, ensuring individuals receive accurate, up-to-date guidance on safe menstrual practices.

References

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2. Your first period. American College of Obstetricians and Gynecologists. Updated June 2025. Accessed October 9, 2025. https://www.acog.org/womens-health/faqs/your-first-period
3. Menstrual discs. New Jersey Department of Health. Accessed October 9, 2025. https://www.nj.gov/health/womenshealth/reproductive-health/periods-menstruation/period-products/menstrual-discs.shtml
4. 6 types of period products: know your options. FSA Store. Accessed October 9, 2025. https://fsastore.com/articles/learn-6-types-of-period-products-know-your-options.html
5. What’s the best tampon size to use? Cleveland Clinic. May 10, 2023. Accessed October 9, 2025. https://health.clevelandclinic.org/best-tampon-size-to-use
6. Schlievert PM, Davis CC. Device-associated menstrual toxic shock syndrome. Clin Microbiol Rev. 2020;33(3):e00032-19. doi:10.1128/CMR.00032-19
7. Shearston JA, Upson K, Gordon M, et al. Tampons as a source of exposure to metal(loid)s. Environ Int. 2024;190:108849. doi:10.1016/j.envint.2024.108849
8. Yang Z, Wu X, Wang H, Zhou J, Lin X, Yang P. Vagina, a promising route for drug delivery. J Drug Deliv Sci Technol. 2024;93:105397. doi:10.1016/j.jddst.2024.105397
9. About childhood lead poisoning prevention. Centers for Disease Control and Prevention. August 21, 2025. Accessed October 9, 2025. https://www.cdc.gov/lead-prevention/about/index.html
10. Jomova K, Alomar SY, Nepovimova E, Kuca K, Valko M. Heavy metals: toxicity and human health effects. Arch Toxicol. 2025;99(1):153-209. doi:10.1007/s00204-024-03903-2
11. Proulx E. First study to measure toxic metals in tampons shows arsenic and lead, among other contaminants. UC Berkeley Public Health. July 3, 2024. Accessed October 9, 2025. https://publichealth.berkeley.edu/news-media/research-highlights/first-study-to-measure-toxic-metals-in-tampons-shows-arsenic-and-lead 
12. Treisman R. A study found toxic metals in popular tampon brands: here’s what experts advise. NPR. July 11, 2024. Accessed October 9, 2025. https://www.npr.org/2024/07/11/nx-s1-5036484/tampons-heavy-metals-study
13. Sharkey L. The ultimate guide to menstrual cup sizing. Healthline Media. July 20, 2022. Accessed October 9, 2025. https://www.healthline.com/health/menstrual-cup-sizing#key-factors
14. Bowman N, Thwaites A. Menstrual cup and risk of IUD expulsion – a systematic review. Contracept Reprod Med. 2023;8(1):15. doi:10.1186/s40834-022-00203-x
15. Your changing body: puberty in girls. American College of Obstetricians and Gynecologists. Updated June 2022. Accessed October 9, 2025. https://www.acog.org/womens-health/faqs/your-changing-body-puberty-in-girls
16. Welcome to the product gallery. Girls Helping Girls. Period. Accessed October 9, 2025. https://girlshelpinggirlsperiod.org/menstrual-product-guide/
17. U by Kotex Balance Ultra Thin Pads with Wings, Extra Heavy Overnight. U by Kotex. Accessed October 9, 2025. https://www.ubykotex.com/en-us/products/pads/ultra-thin/balance-extra-heavy-overnight-with-wings
18. Treisman R. Thinx settled a lawsuit over chemicals in its period underwear: here’s what to know. NPR. January 19, 2023. Accessed October 9, 2025. https://www.npr.org/2023/01/19/1150023002/thinx-period-underwear-lawsuit-settlement
19. PFAS and your health. Agency for Toxic Substances and Disease Registry. July 22, 2025. Accessed October 9, 2025. https://www.atsdr.cdc.gov/pfas/about/index.html
20. Cohen NJ, Yao M, Midya V, et al. Exposure to perfluoroalkyl substances and women's fertility outcomes in a Singaporean population-based preconception cohort. Sci Total Environ. 2023;873:162267. doi:10.1016/j.scitotenv.2023.162267