INTRODUCTION:

Over the course of her lifetime, a woman may use 8000–10,000 different feminine products, and the accumulation of these chemicals in the body can cause serious health issues like reduced immune systems, diabetes, hormone issues, PID, ovarian cancer, infertility, and birth defects. With an estimated 528,000 new cases in 2012, cervical cancer was the seventh most prevalent cancer worldwide and the fourth most common cancer in women.⁴⁷Additionally, scented pads might cause bacterial and yeast infections. Menstrual cups are one potentially affordable solution, however providing this insertable MHM device at schools in low-income countries with poor water, sanitation, and hygiene (WASH) conditions increases the requirement to ensure acceptable hygiene standards.¹

The knowledge that moms have about puberty and associated health issues, as well as the role that parents play in educating adolescents about puberty sanitation, is crucial.⁴⁹

Inside Sanitary Products:

The majority of teenage girls (92%) have menstruated between the ages of 10 and 13.⁴⁸The sanitary pad manufacturing process uses non-pure cotton components. Some pesticides are used when cotton is being made². Manufacturers are not eager to reveal the true composition of their goods. Typically, cotton, rayon that has been bleached, and plastics will be the most crucial ingredients. Aroma and antibacterial agents can be used in addition to these.³Silicone film or polypropylene make up the rear sheet. It contains a polymer powder that acts as an extra, powerful absorbent and gels when moistened. The material is layered as follows: "a sticky adhesive on the outside of an absorbent core material that is sandwiched between a flexible liquid-permeable top sheet and a liquid-impermeable plastic back sheet to allow the napkin to be attached to an undergarment" and is shown in figure 1.⁴

Figure 1. Toxic chemicals inside sanitary pads

Figure 2. Toxic chemicals inside Tampons

Tampon use has issues with their high cost and lack of biodegradability, making them unfriendly to the environment. Dioxin, which is extremely toxic to the human body, is included in the viscose crayon in the tampon. When compared to cotton tampons, these tampons also have extremely high quantities of the toxic shock syndrome toxin.⁵ Toxic chemicals in tampons is shown in figure 2.⁶

The tissues of the vulvar and vagina, which come into close touch with sanitary napkins, are more permeableand moist, suggesting a greater vulnerability to irritants and toxins.⁷The three primary components of sanitary pads currently on the market are:⁸

a) A top sheet that is permeable to liquids: The calming top sheet is comprised of a nonwoven polyethylene/ polypropylene fabric.

b) A cellulosic patch with an absorbent core: The back sheet is a polyethylene film with an adhesive, while the core is a polyacrylate polymer foam.

c) Awaterproof back sheet: Scent is introduced to scented pads between the core and the back sheet.

Menstrual product usage as depicted in figure 3. Most women (over 90%) use disposable sanitary napkins. Only 2% of women who are athletes use menstrual cups during their periods, and only 8% of women use tampons.⁹

Figure 3: Menstrual Product Usage

Table1: Chemicals used in pads of various types

Sr. No	The List of Chemicals Include	Sr.No	The List of Chemicals Include
1	Plastics And Plasticizer	7	Pesticide Residue
2	Dioxins And Furans	8	Genetically Modified Organisms (Gmos).
3	Phthalates	9	Adhesives
4	Bisphenols	10	Moisture Barriers
5	VOC (Volatile Organic Compounds)	11	Absorbents
6	Synthetic Fragrance	12	Binders

Endocrine‑Disrupting Chemicals (EDCS):

Are exogenous chemical substances a common occurrence in current day living. EDCs are substances that are not only naturally present in our environment but also in a variety of consumer products, according to the National Institute of Environmental Health Sciences (2022). When exposed to EDC, the female menstrual cycle can be extremely vulnerable to hormonal imbalance and changes in endocrine function, leading to irregular menstruation.¹⁰There has been worry that consumers of feminine hygiene products might be exposed to EDCs, however there are few research that have looked at this. During the menstrual cycle, sanitary pads, also known as sanitary napkins, are used to absorb blood.¹¹In 2018, 154 women participated in a cross-sectional online survey, and it was discovered that 82% of them used tampons, 59% used pantyliners, and 54% used maxi pads as shown in figure 4.¹²

Figure 4. A cross-sectional online survey

EDCs are substances that enter the body and behave in a manner akin to endogenous hormones, changing endocrine system processes and having a negative impact on human health which include Bisphenol A (BPA), Dioxins, Organochlorine Pesticides, Perchlorate, Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS), Phthalates, Polybrominated Diphenyl Ethers (PBDE), Polychlorinated Biphenyls (PCBS), and Triclosan.

Bisphenols:

The main member of this class, bisphenol A (BPA), is a synthetic plastic with a carbon basis.According to the U.S. Environmental Protection Agency (EPA) (2022), EDCs can cause developmental abnormalities, disruptions in reproduction, an increased risk of cancer, and problems with the immunological and brain systems.All of the goods contained more than one paraben, more than 95% of the products contained bisphenols, and 8–50% of the products contained TCC.Breast, ovarian, endometrial, and cervical cancers, which are thought to be highly susceptible to variations in hormone levels, are among the preneoplastic or neoplastic lesions that are linked to disturbances in estrogen functions in females.¹³

According to several studies, food contamination accounts for more than 90% of human exposure to BPA, with the remaining 10% coming via dust consumption, skin absorption, or dental procedures.¹⁴¹⁵Studies on rats treated with BPA for three months compared to controls revealed an increase in the percentage of ovarian tissue occupied by antral follicles and a decrease in the percentage of corpora lutea, which is suggestive of fewer oocytes.^{16 17}According to statistics from 2018, ovarian cancer was the seventh most common malignancy.¹⁸BPA mimics the effects of estrogen, hence several studies have established a link between exposure to BPA and ovarian cancer.^{19 20}Females in India use indigenous sanitary pads since company-made ones are too expensive, and they typically contain potentially dangerous chemicals like Bisphenol A and Bisphenol S that interfere with fetal development.²¹

Phthalates

In the United States, phthalate metabolites have been found in the urine of more than 90% of the population, and they are more prevalent in pregnant women and Black women than in White women.²²When these substances are introduced to the female body, they can have a number of negative effects, including infertility, monthly irregularities, and menopause.²³BPAs and phthalates are examples of xenoestrogens, which are EDCs with structural similarities to estrogen and the ability to bind to estrogen receptor sites.²⁴These kinds of items may contain EDCs like phthalates as well as chemical additives used to make sanitary napkins that contain, contain phthalates, or are contaminated with them.²⁵ Because sanitary napkins and other feminine hygiene items come in direct touch with the vulva and other membranes, there is concern that they could be a source of exposure. Chemicals can be absorbed by the vagina and vulva very quickly.Nine phthalates, six parabens, eight bisphenols, and triclocarban (TCC) were measured in pads, pantyliners, tampons, wipes, bactericidal creams and solutions, and deodorant sprays and powders in a 2019 study in Albany, New York.²⁶

The products had detectable levels of the nine phthalates in more than 90% of the feminine hygiene items that were examined, the researchers discovered.Over 98% of the top layers of sanitary napkins that come into touch with the skin and were found to have phthalates in 86% of the items tested for phthalates.²⁷collected sanitary napkins from Japan, South Korea, the United States, the United Kingdom, Australia, and Germany and measured the presence of 15 phthalates in them. Six phthalates were found in every sample of sanitary napkin, while six more phthalate types were discovered in significant concentrations in 54.2–76.4% of the samples.²⁸Chemicals manufactured in large quantities, phthalates are widely used. Consumer goods incorporate them as plasticizers. Human health issues have been brought up by their widespread use and exposure. Exposure to phthalates has been linked to a number of illnesses, but most notably reproductive abnormalities, according to research.²⁹

Diseases of the reproductive system, such as malignancies that are hormone-dependent, infertility, and low fecundity. 8–12% of couples worldwide in 2015 experienced infertility or low fertility³⁰, and 6.7% of females were infertile.³¹The endocrine-disrupting effects of phthalates in females have been demonstrated in both in vivo and in vitro investigations. In these experiments, female mice and rats were used to study the effects of phthalates on ovarian function. Phthalates altered the development of the follicles by reducing the number of antral follicles and inhibiting their growth in mice. Girls' changing ages of puberty may be related to phthalate exposure. Pregnancy dysfunction is another condition affecting female reproduction linked to phthalate exposure.³²

Dioxin:

Dioxin is a carcinogen, and exposure to it can have a variety of harmful consequences, including chloracne, effects on the nervous system, thyroid hormones, and liver, as well as impacts on the development of teeth, teeth, and the reproductive system ("Dioxins and dioxin-like substances")Only sanitary goods marketed in China included levels of 1,2,3,7,8-pentachlorodibenzo-p-dioxin and 2,3,7,8-tetrachlorodibenzo-p-dioxin that were harmful to women's health.³³Feminine napkins are convenient and simple to use, but they contain dioxin and chlorine, which can lead to rashes.³⁴ Ovarian cancer may be caused by dioxin found in menstruation pads.²¹

In India, two thirds of cervical cancer patients had poor menstrual hygiene habits. Dioxin, a dangerous toxin found in some napkins, is the root of complex problems including cervical cancer.⁹The bacteria in the vagina are upset by scented pads, which results in bacterial vaginosis.³⁵The most common concerns are itchiness, swelling, and redness; other times, the buildup of heat and moisture in the sanitary napkin promotes bacterial growth. Using sanitary pads for longer than six hours can cause an epidemic of vaginal and urinary tract infections. Dioxin buildup in our bodies affects our ability to reproduce.³⁶Chemicals like BPA and BPS disrupt embryonic development. Ovarian cancer is made more common by dioxins. Dioxin exposure over a brief period of time might affect liver function and discolor the skin.Commercial feminine hygiene products contain harsh chemicals like dioxins as deodorizers and bleaching agents, endangering human body systems and resulting in adverse effects like diabetes, ovarian cancer, immune system damage, pelvic inflammatory disease, and decreased fertility.³⁷

VOC (Volatile organic compounds):

Styrene, chloromethane, chloroethane, chloroform, and acetone are only a few of the volatile organic compounds (VOCs) that are present overall³⁸, which are classified as carcinogens³⁹, phthalates, dioxins, dioxin-like compounds, furans⁴⁰, and methyl dibromo glutaronitrile (MDBGN),8 Volatile organic chemicals, which serve as the napkins' aroma, are present in most commercially available sanitary napkins. Between the SAP (super absorbent polymer) layer and the impermeable back sheet, there are these scents as well as adhesive. Styrene, chloromethane, chloroethane, and acetone are examples of commonly used volatile organic compounds (VOCs) that are susceptible to carcinogenic effects.³⁸

Super adsorbent polymer (sodium polycarbonate) and its metabolites, including glycerol propoxy triacrylate, tri allylamine, divinyl toluene, and polyethylene glycol monoallyl, were present in the sanitary napkins that were widely advertised. The existence of these metabolite products is detrimental to the health of women.⁴¹36 of the 98 target VOCs that were tested in the urine samples were found. VOC concentrations did not change statistically significantly during the course of the menstrual cycle. After taking into account many factors, tampon users had significantly higher levels of 2-butanone ( = 1.58 log ng/g, 95% confidence interval [CI]: 0.16-3.00, p = 0.03) and methyl isobutyl ketone ( = 0.63 log ng/g, 95% confidence interval [CI]: 0.03-1.22, p = 0.04) than pad users. Women had greater urine amounts of n-nonane, benzene, and toluene calculated from menstrual products.⁴²Nine blood volatile organic compounds (VOCs) were substantially raised and one VOC decreased in the PCOS group compared to the control group in a study of rats with PCOS and controls to identify potential specific blood VOC biomarkers. The most effective VOC potential biomarkers for PCOS rats were 4-ethylphenol and capric (decanoic) acid, which also had the highest effects on clustering. Variations in the blood VOCs of PCOS rats could be brought on by alterations in the endocrine system, followed by metabolic and inflammatory abnormalities.⁴³

Furans:

Additionally, producers spray Furan, a hazardous pesticide that persists for a long time in cotton fibers, while growing cotton in the fields. While manufacturers of sanitary napkins take precautions to ensure that their products do not cause allergic reactions, certain women may experience skin irritations due to their very sensitive skin. Businesses are working to increase sanitary pads' ability to absorb. India offers inexpensive local sanitary pads, albeit at the expense of material quality. Unhygienic sanitary pads could contribute to the development of E. coli.⁴⁴

Safety:

A) Menstrual cups:

Because they are constructed of FDA-approved food grade silicone, menstrual cups are completely safe to use and pose no risks to reproductive health. According to medical studies, cups are a safer option to using tampons and napkins to manage menstruation because they provide far fewer health hazards.⁴⁵ However, some girls might find it difficult to use menstruation cups, thus organic pads can be used as an alternative.

B) Biodegradable Sanitary pads:

These sanitary pads advertise that they are compostable, eco-friendly, and biodegradable. These are produced by a few businesses in India utilizing organic cotton, banana fiber, bamboo fiber, and water hyacinth fiber. It is true that they might serve as a starting point for reducing plastic waste and discovering the numerous menstruation product alternatives that are out there. Any disposable menstruation product that is only used for 3 to 6 hours will ultimately have a detrimental effect on the environment owing to trash generation and treatment. However, compared to non-biodegradable disposable sanitary napkins, it has an enormously smaller carbon footprint because it decomposes in 3 to 6 months.⁴⁶

C) Washable Cloth Pads:

These sanitary pads are renewable and environmentally beneficial, but because the sun's heat naturally sterilizes them, they must be cleaned and dried in a hygienic manner outside. To prevent contamination, they must be kept in sterile, dry areas. They are reusable and do not generate disposable waste after each usage.

Table 2: Eco-friendly sanitary products

Product	Biodegradable sanitary pads	Washable Cloths pads	Menstrual cups
Sustainability	*Raw Materials:* produced from organic cotton, water hyacinth, bamboo, banana, and, in certain cases, a bioplastic layer. *Waste Management System:* Burying waste in a pit to compost. *Quality Standards:* BIS IS 5405 Performance and Hygiene Parameters (currently under revision) Compostability: ISO 170888 or IS 5404, both of which are being revised by government-approved testing facilities (Menstrual Waste Management, n.d.).	*Raw Materials:* The back of the pad is typically created with a PUL (polyurethane laminate) leak-proof layer and is constructed from organic cotton fabric or bamboo fiber. *Waste Management System: Since they are manufactured with biodegradable materials, they will break down naturally. Quality Standards:* BIS specifications are in development (Menstrual Waste Management, n.d.).	*Raw Materials: Silicone with a medical grade. Waste Management System:* Silicone made for medical use cannot be composted. The best possible methods for disposing of menstruation cups after they are no longer needed are recycling and thermal breakdown. *Quality Standards:* BIS specifications are in development (Menstrual Waste Management, n.d.).
Accessibility	*Cost: Costs range from Rs. 20 to 250 for a single pad. While the cheapest goods are comparable in price to the cost of commercial disposable plastic sanitary napkins, the average priced and more expensive products are not economically viable for the majority of women in the country. For an average user, this amounts to Rs.1920- 24000 annually. It should be mentioned, nonetheless, that the majority of highly regarded products are priced between Rs. 20 and Rs. 40. Availability in rural areas:* through non-governmental organisations. In villages and urban slums, the majority of manufacturing facilities employ rural women.	*Cost:* Typically, a pad costs between Rs. 100 and 300. For a monthly reuse cycle, four pads cost between Rs. 400 and Rs. 1200. Although the consumer may incur a large upfront cost, it is thought to be economical in the long term. *Availability in rural areas:* being made accessible by NGOs. The majority of manufacturing facilities are located in urban slums and villages and employ rural women.	Cost: Normally, it costs between 1000 and 4000 rupees. reusable for up to 10 years and cost-effective because you only pay once. In the first year of use, the investment is repaid. *Availability in ruralareas:* Although not widely available, the Green The Red campaign and the NGOs connected to it have helped some rural communities.
Longevity	Life Span: Single usage	Life Span:Single usage	Life Span:Single usage

CONCLUSION:

Despite being as old as humanity, menstrual hygiene has recently become more important as a result of society's willingness to face its issues.⁵⁰Up to 20% of reproductive-age women have premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), which in 3-8% of cases significantly impairs social or professional functioning.⁵¹Only 43.33% of participants knew the actual process of menstruation, indicating that their level of awareness regarding the cause of menstruation was low.⁵²The person's dental health may suffer as a result of menopause symptoms. Burning mouth syndrome, dry mouth, and other oral symptoms are the most bothersome^.53It is thought that menstrual pain is ischemic because of artery spasm.⁵⁴Ladies refraining from attending religious institutions while they are menstruating.⁵⁵We have no idea why the holy men felt compelled to label menstruation women as "unclean."⁵⁶The most common reason for persistent short-term absences from school is dysmenorrhea.⁵⁷People are reluctant to talk about this subject.⁵⁸The menarche is a significant milestone in the lives of teenage girls.⁵⁹Hazardous chemicals are used in commercial sanitary products.Which compounds are regarded as the most dangerous include dioxin, phthalates, bisphenols, and voc. These chemicals are to blame for the systemic harm they do to humans and for lowering fertility. The kinds of chemicals that are contained in sanitary goods and how they influence the human body should be known to the public. Menstrual cups, organic pads, and washable clothing pads can all be used to stop such potential reproductive issues while also protecting the environment.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank Dr. Mohini Upadhye for guidance.

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Received on 09.02.2023 Modified on 11.04.2023

Res. J. Pharmacology and Pharmacodynamics.2023;15(3):112-118.

DOI: 10.52711/2321-5836.2023.00021