{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T19:24:06Z","timestamp":1789586646595,"version":"build-2803163510"},"reference-count":55,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T00:00:00Z","timestamp":1766361600000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["GR018228"],"award-info":[{"award-number":["GR018228"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Concerns regarding the effects of non-tampon menstrual products on reproductive and urogenital health, particularly the risk of infections, is an area of ongoing investigation. We conducted an updated systematic review to assess the methodological quality of current evidence assessing associations between menstrual product use and reproductive and urogenital tract infections (RUTIs), and offer recommendations for future research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Three databases (PubMed, Web of Science, United States Food and Drug Administration Manufacturer User Facility Device Experience) were searched for relevant published studies or product safety reports up to October 13, 2024. We included studies on menstruators of any age and geography assessing for any reusable\/disposable menstrual pads, menstrual cups, or homemade alternatives worn only for menstrual absorbency compared to other menstrual products or no product use, with outcomes centered on RUTIs. Protocols, reviews, and studies assessing only tampons or non-menstrual absorbents were excluded. Results were evaluated and synthesized using tabular methods according to measures of association, and assessed across four criteria categories 1) product definition, 2) comparator definition, 3) outcome definition, and 4) confounder consideration.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Thirty-one studies were included in this review. Most studies clearly defined outcomes and considered necessary confounders. In contrast, studies with well-defined products (6.5%) and comparator products (9.7%) were uncommon. Just 3.2% and 9.7% of studies fully defined products and comparators, respectively. Ten studies (32.2%) reported some data on four or more confounders, and seventeen (54.8%) defined their infectious outcomes and included laboratory confirmation. A meta-analysis was not possible due to data heterogeneity across product, comparator, and outcome definitions. Overall, associations between menstrual products and RUTIs are inconclusive.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Future studies should 1) clearly define product and comparator type, material, frequency of change, and washing, drying, and storage practices for reusable products, 2) prioritize laboratory or clinician-confirmed outcomes over self-reported symptoms, and 3) adjust for relevant confounders.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0332006","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T18:24:37Z","timestamp":1766427877000},"page":"e0332006","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":1,"title":["Assessing the relationship between menstrual products and reproductive and urogenital tract infections (RUTIs): A systematic review evaluating the evidence and recommendations for future research"],"prefix":"10.1371","volume":"20","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9665-5102","authenticated-orcid":true,"given":"Ana","family":"Krause","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7169-3762","authenticated-orcid":true,"given":"Gregory K.","family":"Zane","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea C.","family":"Rivas-Nieto","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abigail","family":"Mulugeta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9107-1506","authenticated-orcid":true,"given":"Md. Rezaul","family":"Hossain","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"R. Scott","family":"McClelland","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jairam R.","family":"Lingappa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephen E.","family":"Hawes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2025,12,22]]},"reference":[{"key":"pone.0332006.ref001","first-page":"100399","article-title":"Menstrual health: a neglected public health problem","volume":"15","author":"TL Regional Health-Americas","year":"2022","journal-title":"Lancet Reg Health Am"},{"issue":"6","key":"pone.0332006.ref002","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1097\/OGX.0000000000000443","article-title":"Menstrual Hygiene Management in Resource-Poor Countries","volume":"72","author":"AS Kuhlmann","year":"2017","journal-title":"Obstet Gynecol Surv"},{"key":"pone.0332006.ref003","doi-asserted-by":"crossref","first-page":"1018092","DOI":"10.3389\/fpubh.2022.1018092","article-title":"A systematic review of menstrual hygiene management (MHM) during humanitarian crises and\/or emergencies in low- and middle-income countries","volume":"10","author":"K Patel","year":"2022","journal-title":"Front Public Health"},{"issue":"4","key":"pone.0332006.ref004","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0062004","article-title":"A systematic review of the health and social effects of menstrual hygiene management","volume":"8","author":"C Sumpter","year":"2013","journal-title":"PLoS One"},{"key":"pone.0332006.ref005","article-title":"Period poverty: why it should be everybody\u2019s business","volume":"6","author":"J Michel","year":"2022","journal-title":"J Glob Health Rep"},{"issue":"9","key":"pone.0332006.ref006","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0257610","article-title":"Exploring menstrual products: A systematic review and meta-analysis of reusable menstrual pads for public health internationally","volume":"16","author":"AM van Eijk","year":"2021","journal-title":"PLoS One"},{"issue":"3","key":"pone.0332006.ref007","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1016\/j.gocm.2022.06.001","article-title":"Intimate hygiene practices and reproductive tract infections: A systematic review","volume":"2","author":"A Daher","year":"2022","journal-title":"Gynecol Obstetr Clin Med"},{"key":"pone.0332006.ref008","volume-title":"ChatGPT-4 (April 4 version)","author":"I Open A","year":"2024"},{"issue":"6","key":"pone.0332006.ref009","first-page":"416","article-title":"Vaginal bacteriology in women with use of sanitary towels and tampons during menstruation","volume":"72","author":"V Unzeitig","year":"2007","journal-title":"Ceska Gynekol"},{"key":"pone.0332006.ref010","volume-title":"Covidence systematic review software","author":"Innovation VH"},{"key":"pone.0332006.ref011","article-title":"Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline","volume":"368","author":"M Campbell","year":"2020","journal-title":"BMJ"},{"issue":"4","key":"pone.0332006.ref012","doi-asserted-by":"crossref","first-page":"624","DOI":"10.1037\/a0028957","article-title":"Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: a systematic review","volume":"80","author":"JAJ Smits","year":"2012","journal-title":"J Consult Clin Psychol"},{"issue":"1","key":"pone.0332006.ref013","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1186\/s12879-018-3384-2","article-title":"Association between unhygienic menstrual management practices and prevalence of lower reproductive tract infections: a hospital-based cross-sectional study in Odisha, India","volume":"18","author":"B Torondel","year":"2018","journal-title":"BMC Infect Dis"},{"issue":"9","key":"pone.0332006.ref014","doi-asserted-by":"crossref","first-page":"4778","DOI":"10.3390\/ijerph18094778","article-title":"Identifying Risk Factors for Lower Reproductive Tract Infections among Women Using Reusable Absorbents in Odisha, India","volume":"18","author":"P Das","year":"2021","journal-title":"Int J Environ Res Public Health"},{"issue":"6","key":"pone.0332006.ref015","article-title":"FLOW (finding lasting options for women): multicentre randomized controlled trial comparing tampons with menstrual cups","volume":"57","author":"C Howard","year":"2011","journal-title":"Can Fam Physician"},{"issue":"6","key":"pone.0332006.ref016","article-title":"Menstrual Hygiene Practices, WASH Access and the Risk of Urogenital Infection in Women from Odisha, India","volume":"10","author":"P Das","year":"2015","journal-title":"PLoS One"},{"issue":"10","key":"pone.0332006.ref017","doi-asserted-by":"crossref","first-page":"801","DOI":"10.1089\/jwh.2014.5031","article-title":"Menstrual Needs and Associations with Sexual and Reproductive Risks in Rural Kenyan Females: A Cross-Sectional Behavioral Survey Linked with HIV Prevalence","volume":"24","author":"PA Phillips-Howard","year":"2015","journal-title":"J Womens Health (Larchmt)"},{"issue":"11","key":"pone.0332006.ref018","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2016-013229","article-title":"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","volume":"6","author":"PA Phillips-Howard","year":"2016","journal-title":"BMJ Open"},{"issue":"7","key":"pone.0332006.ref019","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pmed.1004258","article-title":"Analysis of bacterial vaginosis, the vaginal microbiome, and sexually transmitted infections following the provision of menstrual cups in Kenyan schools: Results of a nested study within a cluster randomized controlled trial","volume":"20","author":"SD Mehta","year":"2023","journal-title":"PLoS Med"},{"key":"pone.0332006.ref020","doi-asserted-by":"crossref","first-page":"102261","DOI":"10.1016\/j.eclinm.2023.102261","article-title":"Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial","volume":"65","author":"G Zulaika","year":"2023","journal-title":"EClinicalMedicine"},{"key":"pone.0332006.ref021","volume-title":"Healthy Habits: Menstrual Hygiene Atlanta","author":"CDC","year":"2024"},{"key":"pone.0332006.ref022","author":"Scottish Government NHS","year":"2025"},{"key":"pone.0332006.ref023","doi-asserted-by":"crossref","first-page":"17455057241240920","DOI":"10.1177\/17455057241240920","article-title":"Urinary and reproductive tract infection symptoms and menstrual hygiene practices in refugee camps in Jordan: A cross-sectional study","volume":"20","author":"J Al Karmi","year":"2024","journal-title":"Womens Health (Lond)"},{"issue":"12","key":"pone.0332006.ref024","first-page":"683","article-title":"Risks of urogenital infections and expulsion associated with the combination of an IUD and a menstrual cup","volume":"52","author":"J Madar","year":"2024","journal-title":"Gynecol Obstet Fertil Senol"},{"issue":"1","key":"pone.0332006.ref025","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1002\/ijgo.12983","article-title":"The impact of menstrual hygiene management on adolescent health: The effect of Go! pads on rate of urinary tract infection in adolescent females in Kibogora, Rwanda","volume":"148","author":"H Janoowalla","year":"2020","journal-title":"Int J Gynaecol Obstet"},{"issue":"2","key":"pone.0332006.ref026","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0247554","article-title":"Menstrual hygiene management practices and associated health outcomes among school-going adolescents in rural Gambia","volume":"16","author":"HM Nabwera","year":"2021","journal-title":"PLoS One"},{"issue":"11","key":"pone.0332006.ref027","doi-asserted-by":"crossref","first-page":"6690","DOI":"10.4103\/jfmpc.jfmpc_510_21","article-title":"Awareness about reproductive tract infection, its relation with menstrual hygiene management and health seeking behaviour: A cross-sectional study among adolescent girls of Lucknow","volume":"11","author":"A Singh","year":"2022","journal-title":"J Family Med Prim Care"},{"issue":"3","key":"pone.0332006.ref028","doi-asserted-by":"crossref","first-page":"141","DOI":"10.3109\/02813438509013935","article-title":"Vaginal discharge and Gardnerella vaginalis. Predisposing factors","volume":"3","author":"JG Hansen","year":"1985","journal-title":"Scand J Prim Health Care"},{"issue":"2","key":"pone.0332006.ref029","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1097\/00001648-199603000-00013","article-title":"Risk factors for vulvovaginal candidiasis: a case-control study among university students","volume":"7","author":"AM Geiger","year":"1996","journal-title":"Epidemiology"},{"issue":"1","key":"pone.0332006.ref030","doi-asserted-by":"crossref","first-page":"34","DOI":"10.4103\/0970-0218.94020","article-title":"Community-based study of reproductive tract infections among women of the reproductive age group in the urban health training centre area in hubli, karnataka","volume":"37","author":"SS Balamurugan","year":"2012","journal-title":"Indian J Community Med"},{"issue":"2","key":"pone.0332006.ref031","doi-asserted-by":"crossref","first-page":"83","DOI":"10.4103\/0253-7184.120537","article-title":"Prevalence of symptoms suggestive of reproductive tract infections\/sexually transmitted infections in women in an urban area of Ludhiana","volume":"34","author":"PS Philip","year":"2013","journal-title":"Indian J Sex Transm Dis AIDS"},{"key":"pone.0332006.ref032","doi-asserted-by":"crossref","DOI":"10.7717\/peerj.16430","article-title":"Assessing the link between hygienic material use during menstruation and self-reported reproductive tract infections among women in India: a propensity score matching approach","volume":"11","author":"M Chakrabarty","year":"2023","journal-title":"PeerJ"},{"issue":"3","key":"pone.0332006.ref033","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1016\/S1083-3188(98)70134-2","article-title":"Tampon use in young women","volume":"11","author":"HA Omar","year":"1998","journal-title":"J Pediatr Adolesc Gynecol"},{"key":"pone.0332006.ref034","doi-asserted-by":"crossref","first-page":"12","DOI":"10.1186\/1471-2334-5-12","article-title":"Bacterial vaginosis, vaginal flora patterns and vaginal hygiene practices in patients presenting with vaginal discharge syndrome in The Gambia, West Africa","volume":"5","author":"E Demba","year":"2005","journal-title":"BMC Infect Dis"},{"issue":"3","key":"pone.0332006.ref035","doi-asserted-by":"crossref","first-page":"242","DOI":"10.1136\/sti.2004.011684","article-title":"Bacterial vaginosis in relation to menstrual cycle, menstrual protection method, and sexual intercourse in rural Gambian women","volume":"81","author":"L Morison","year":"2005","journal-title":"Sex Transm Infect"},{"issue":"2","key":"pone.0332006.ref036","doi-asserted-by":"crossref","first-page":"162","DOI":"10.1097\/00001648-199503000-00013","article-title":"First-time urinary tract infection and sexual behavior","volume":"6","author":"B Foxman","year":"1995","journal-title":"Epidemiology"},{"issue":"2","key":"pone.0332006.ref037","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1097\/OLQ.0b013e3181bc063c","article-title":"Personal hygienic behaviors and bacterial vaginosis","volume":"37","author":"MA Klebanoff","year":"2010","journal-title":"Sex Transm Dis"},{"key":"pone.0332006.ref038","first-page":"55","article-title":"Factors associated with recurrent bacterial vaginosis","volume":"55","author":"TE Klatt","year":"2010","journal-title":"J Reprod Med"},{"issue":"6","key":"pone.0332006.ref039","first-page":"654","article-title":"History, clinical findings, sexual behavior and hygiene habits in women with and without recurrent episodes of urinary symptoms","volume":"77","author":"K Tchoudomirova","year":"1998","journal-title":"Acta Obstet Gynecol Scand"},{"issue":"3","key":"pone.0332006.ref040","first-page":"219","article-title":"Characteristics of urinary tract infection caused by coagulase-negative Staphylococcus in a group of young women","volume":"20","author":"L Leibovici","year":"1984","journal-title":"Isr J Med Sci"},{"issue":"58","key":"pone.0332006.ref041","doi-asserted-by":"crossref","first-page":"97955","DOI":"10.18632\/oncotarget.18901","article-title":"Risk factors for human papillomavirus infection prevalent among Uyghur women from Xinjiang, China","volume":"8","author":"G Abulizi","year":"2017","journal-title":"Oncotarget"},{"issue":"6","key":"pone.0332006.ref042","doi-asserted-by":"crossref","first-page":"253","DOI":"10.4103\/2305-0500.361221","article-title":"Prevalence and risks of reproductive tract infections among women of urban slums in North India","volume":"11","author":"M Singh","year":"2022","journal-title":"Asian Pacific J Reproduct"},{"key":"pone.0332006.ref043","doi-asserted-by":"crossref","first-page":"716537","DOI":"10.3389\/fcimb.2021.716537","article-title":"High Prevalence of Lactobacillus crispatus Dominated Vaginal Microbiome Among Kenyan Secondary School Girls: Negative Effects of Poor Quality Menstrual Hygiene Management and Sexual Activity","volume":"11","author":"SD Mehta","year":"2021","journal-title":"Front Cell Infect Microbiol"},{"issue":"5","key":"pone.0332006.ref044","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1136\/sti.2008.035543","article-title":"Bacterial vaginosis in female facility workers in north-western Tanzania: prevalence and risk factors","volume":"85","author":"K Baisley","year":"2009","journal-title":"Sex Transm Infect"},{"key":"pone.0332006.ref045","doi-asserted-by":"crossref","first-page":"2050312119850400","DOI":"10.1177\/2050312119850400","article-title":"\u201cMenstrual blood is bad and should be cleaned\u201d: A qualitative case study on traditional menstrual practices and contextual factors in the rural communities of far-western Nepal","volume":"7","author":"S Thapa","year":"2019","journal-title":"SAGE Open Med"},{"key":"pone.0332006.ref046","volume-title":"Menstrual hygiene matters: A resource for improving menstrual hygiene around the world. Report No. 2012","author":"S House","year":"2012"},{"key":"pone.0332006.ref047","author":"WHO, UNICEF, ECH E, Climate Change and Health, WSH W, Sanitation, Hygiene and Health"},{"issue":"3","key":"pone.0332006.ref048","doi-asserted-by":"crossref","DOI":"10.1128\/CMR.00032-19","article-title":"Device-Associated Menstrual Toxic Shock Syndrome","volume":"33","author":"PM Schlievert","year":"2020","journal-title":"Clin Microbiol Rev"},{"key":"pone.0332006.ref049","doi-asserted-by":"crossref","first-page":"100308","DOI":"10.1016\/j.eclinm.2020.100308","article-title":"Association of characteristics of tampon use with menstrual toxic shock syndrome in France","volume":"21","author":"A Billon","year":"2020","journal-title":"EClinicalMedicine"},{"issue":"5","key":"pone.0332006.ref050","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pgph.0003226","article-title":"Asymptomatic infections with Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis among women in low- and middle-income countries: A systematic review and meta-analysis","volume":"4","author":"C Fortas","year":"2024","journal-title":"PLOS Glob Public Health"},{"issue":"2","key":"pone.0332006.ref051","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1093\/aje\/kwn103","article-title":"A longitudinal study of vaginal douching and bacterial vaginosis--a marginal structural modeling analysis","volume":"168","author":"RM Brotman","year":"2008","journal-title":"Am J Epidemiol"},{"issue":"5","key":"pone.0332006.ref052","doi-asserted-by":"crossref","first-page":"1058","DOI":"10.1093\/infdis\/174.5.1058","article-title":"Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections","volume":"174","author":"SE Hawes","year":"1996","journal-title":"J Infect Dis"},{"issue":"2","key":"pone.0332006.ref053","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1093\/epirev\/mxf004","article-title":"Vaginal douching: evidence for risks or benefits to women\u2019s health","volume":"24","author":"JL Martino","year":"2002","journal-title":"Epidemiol Rev"},{"issue":"8","key":"pone.0332006.ref054","doi-asserted-by":"crossref","DOI":"10.1016\/S2468-2667(19)30111-2","article-title":"Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis","volume":"4","author":"AM van Eijk","year":"2019","journal-title":"Lancet Public Health"},{"issue":"6","key":"pone.0332006.ref055","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0232935","article-title":"Measurement in the study of menstrual health and hygiene: A systematic review and audit","volume":"15","author":"J Hennegan","year":"2020","journal-title":"PLoS One"}],"container-title":["PLOS One"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0332006","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T18:24:50Z","timestamp":1766427890000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0332006"}},"subtitle":[],"editor":[{"given":"Alison","family":"Parker","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2025,12,22]]},"references-count":55,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,22]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0332006","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,22]]}}}