I first got interested in alternative menstrual products for environmental reasons in high school. In college I got involved with a women's health class taught by students and learned a lot more about them. As my interest grew, I compiled more resources, offered a full semester class on menstrual health and politics, and was called upon by many people for information on the various products out there. This is a version of the brochure I created. It was updated in 2006.

Contents:
What's Wrong With Tampons?
Alternatives Internal Cloth Pads Better Disposables
Beyond Alternative Products

What's Wrong with Tampons?
First things first. Why would you want to choose an alternative menstrual product anyway? The following summary of problems with the traditional products (easily remembered as RED SCAM) are some of most common reasons women have.

• Rayon/TSS. Viscose rayon, a major component of almost all commercial tampons, provides a hospitable place for the bacteria that causes Toxic Shock Syndrome (TSS) to grow. Combining the presence of rayon with an irritated vaginal area and/or weakened immune system resulting from the other items on this list can increase the danger of toxic shock. TSS has not gone away since the outbreak in the 1980s. Dr. Philip Tierno, TSS specialist, says that for every TSS case that gets officially counted as such there are five more that don’t quite make one of the official criteria (fever one degree too low, etc.).

• Environment. Tampons and pads are disposable, and highly packaged. Even “flushable” products do not biodegrade before they hit sewage-treatment plants, but they do clog pipes! In addition, the pulp bleaching process for both products releases dioxins into the environment.

• Dioxin. The chlorine bleaching process that is used to make tampons white (so they appear sterile) has been found to leave behind residues of dioxins, which are chemicals that are both very toxic and carcinogenic, that environmentalists have been fighting to keep out of waterways for years. The EPA has been unable to set any safe level of dioxin, which is most dangerous with numerous repeat exposures.

• Structure. Tampons are structured to be so absorbent they often over-absorb vaginal secretions as well as menstrual blood, leading to drying, mini-ulcers, and release of tiny rayon fibers. Those fibers have been speculated to be associated with cervical cancer. Petaled applicators can scratch vaginal walls, and the string provides a way of wicking bacteria into the vagina.

• Chemicals. Other residues have been found regularly to leach from tampons, including pesticides, waxes, surfactants, dyes, aluminum, copper, boron, etc. The gelling chemical in pads has been shown to cause irritation when used in babies’ diapers. Tampons are not required to have their ingredients on their boxes.

• Advertising. The companies themselves have promoted shame and secrecy for women about menstruation through their advertising, which is particularly directed at young girls. As an example, after decades of promoting how odorless tampons are, they have introduced “deodorant” tampons that have added nothing but another irritant (cheap perfume). They have acted in bad faith when responding to the TSS and dioxin issues.

• Money. A woman using tampons spends over $2,000 (and rising) on them in a lifetime. Tampon companies have recently made such moves as bragging to shareholders about such “improvements” as reducing the number of tampons per box and raising the price. Over time, some of the reusable alternatives can save women lots of money, as well as directing the money they do spend to smaller independent businesses and individual entrepreneurs.

So you want to try something else?
There are many alternatives that women use, and they each address each of these issues to varying degrees. From my experience and research, here’s my own personal summary of the options and how good they are for you, the planet, and your pocketbook. (Please note: I know someone for whom each of the options below is the perfect and only fit for them. So try them out. Don't just take my word for it.)

Internal Non-Tampon Products
As far back as the softened papyrus tampons of ancient Egypt, some women have used internal menstrual products. Many women prefer internal products to cloth pads for the same reasons they would prefer tampons to disposable pads--freedom of movement, comfort.

The Options
A. Menstrual Cups, reusable. These cups are shaped like a large cervical cap, and worn somewhat lower in the vagina than a cervical cap would be. They are folded twice lengthwise to insert, and then released, forming a suction that holds it in place. To remove, use the tab on the bottom to get hold of it, and pinch the bottom to release the suction. Rinse out, or wipe out with toilet paper, and reinsert. Empty several times a day, depending on your flow. Once you get the hang of it, they leak rarely. If you are having trouble with leaks try: putting the cup higher up, being careful not to let it unfold until it’s in the position you want, moistening the rim with a little water, and giving it a circular twist once it’s in place. Holds one fluid ounce, often compared to a super-plus tampon. Comes in two sizes, before childbirth and after childbirth/after age 30.

The rubber version (The Keeper) has been around the longest. For those with latex allergies, go for a silicone one (Diva Cup, Moon Cup, or Lunette). They can all be sanitized between uses in a mild vinegar solution. If desired, the silicone ones can be boiled.

B. The Instead Softcup. If the reusable cups are like big cervical cap, this is like a disposable diaphragm. One lasts 12 hours. The Instead is one-size-fits-all. Insert by folding once lengthwise, and pushing up and back, so it rests over the cervix and is held in place by the pubic bone. The special medical plastic is supposed to mold to the vagina's contours inside. Remove by hooking a finger under the rim and drawing out. Empty and dispose of.

C. Cervical Caps and Diaphragms. Some women just use the birth control products themselves for menstrual blood. They work similarly as the two products above, except they hold less, and the cervical cap would hold blood closer to the cervix than the reusable cups. It may be an advantage that they are personally fitted.

D. The Sponge. Small sea sponges, often with floss tied around to act like a tampon string, have been around and in use for decades. Boil before use and between cycles. When changing just squeeze/rinse out and reinsert. Some doctors suggest a sponge should only be used for a couple cycles and then disposed of. Alternatives include cosmetic sponges (such as are used to apply foundation) and even household sponges cut in strips.

Things to think about
Convenience/Comfort: All of these except the Instead are more convenient than disposables in that you do not have to remember to carry extras around with you while you are menstruating. The Instead is one-size-fits-all, whereas diaphragms must be fitted. I personally found the Instead hard to use--too big, uncomfortable and leaky, but it worked well for other people I know. I have also known several people who found even the smaller of the reusable cups too big (luckily they all have a money-back guarantee). I have heard reports of the sponge leaking quite a bit with the muscle contractions of heavy exercise. The others can be worn during any activity (except that reusable cups don’t work well with penis-vagina intercourse.)

Health: None of these products have the absorbency or fiber-loss problems of tampons, nor do they pose a dioxin risk. Sea sponges have the potential to have ocean pollution, fungus, or oil in them, which is why they should be boiled first, but none of the other methods should have problems with leaching chemicals.

Anything internal carries some increased risk of infection, merely because your fingers will be entering the vagina and there will be slight decrease in the cleansing flow of secretions. This risk can be reduced by washing the hands before inserting, and by careful cleaning of the products. The risk in all cases is much lower than with tampons. If using a diaphragm or cervical cap for contraception has caused you problems with cystitis (unrelated to the spermicide) then you might want to be careful with all of these methods.

Since none of these methods contain rayon, the TSS risk is very low. The sponge is the only one that has ostensibly been associated with any cases of TSS at all, and it has been associated with “less than 1% of menstrual TSS cases.” There has been no testing on cervical caps and diaphragms. The Instead company has had extensive tests done and found it to be safe. Menstrual cups were first introduced in the middle part of this century and doctors hailed them then as safe. When they were revived in the late ‘80s they did not undergo extra testing, but they are FDA accepted, and there have been no reported problems.

Environment: The Instead is big, plastic, disposable, and over-packaged. Thumbs down. The sponge lasts longer, but still only a few months. Reusable cups last for at least ten years and come minimally packaged.

Politics: Menstrual cups makers tend to emphasize the health/environmental aspects of switching, but not get into challenging the culture of shame around menstruation. The Instead pushes convenience during heavy physical activity and “clean” sex (assumed heterosexual).

Money: Reusable cups cost $32-$35 plus shipping from their makers, but are often much cheaper through a reseller. Many cloth pad sellers sell them at good prices and will throw in a free pad as a sample. Keepers can be ordered wholesale by potential distributors (gather a group of friends for a co-op!) for significant discounts. Divacup requires that you have an “established” business for wholesale prices. The Instead is available in packages of 6 for around $3 or 14 for around $7. A starter kit with 3 cups, a coupon, and an instructional video can be ordered for $3 S&H.

How to Get Them:

• The Keeper. (But check out the cloth pad sites for better prices.)
• Silicone cups: The Moon Cup, Divacup. (Check out the cloth pad sites for better prices.) Also there’s the Lunette, from Finland.
• Instead Softcup. Sold in big-box retailers and online stores like drugstore.com. Starter kit from their site.
• Cervical caps and diaphragms: from a clinic or your gynecologist. Probably only dispensed for the purpose of birth control.
• Sponges: Urban Armor or Vermont Diaper Company.

Cloth Pads
Cloth pads are what most of the world uses, not to mention most of your not-too-distant ancestors. They are used both as a primary product, and to supplement or interchange with internal methods. They are good for women who find it uncomfortable to insert anything into the vagina, but are used by many others as well.

Cloth pads are more absorbent than most disposable pads, and some can be refolded to last even longer before changing. Used ones can be soaked for a bit in cold water, or just rinsed out, and then tossed in the regular laundry. Many women like to use the soak water to water their gardens or houseplants.

The Options
A. Make your own: Many women sew their own pads. Flannel is soft and absorbent, and can be layered with terry cloth from an old towel to make a really absorbent pad. There is an incredible range of options and styles. One woman suggested to me ordering a few pads first, and then using those as your model. Another suggested using the cuffs of old flannel shirts to make buttoning 'wings'.

B. Bought pads: The diversity of cloth pads available far exceeds the diversity of disposable ones. They come in mini through maxi, foldable, with wings that snap, with sleeves and liners, with Velcro, with fleece and wool and polyurethane backings, in organic cotton, etc…

Things to think about
Convenience/Comfort: You will obviously want to have fresh pads and a plastic bag (or the carry bags that many companies provide/sell) for used ones on hand, especially if you are on the go. Some lined pads with snaps can be folded up used-side in without a need for a bag. Used pads do need to be soaked or rinsed before the day is out or they will smell. However, many women who have used pads will tell you that it is much less of a hassle than you might imagine, since they can be thrown in the laundry after the first rinse, and once they are rinsed and dried they can even wait in your laundry pile happily with the rest of your clothes. A little vinegar or OxyClean in the soaking water helps prevent bad staining. Cloth pad users all agree that cloth pads are much softer than disposable ones, if sometimes a little more bulky, and there's no glue to catch and pull on pubic hairs.

Health: Cloth pads have practically no health risks.

Environmental: Cloth pads last for at least two years, and probably much more if you don’t mind accumulated stains. They can be found from many places made out of organically grown cotton. If you sew your own, then that counts as recycling!

Money: Depending on whether they will be your primary method and how heavy and long you bleed, buying a set of pads for your needs can range from $10 to $100. You can calculate how long the payback period would be, but in the long run they still end up saving you money. And making them, of course, is free.

Politics: Cloth pad sellers are more likely than sellers of internal methods to celebrate menstruation as natural and not a source of embarrassment. Their philosophies (often reflected in the designs on their pads) range from spiritual/goddess/earth mother to riot grrrl/punk/anti-oppression to practical, money-saving stay-at-home-mom. Many are small woman-owned microbusinesses.

How to get them:
Patterns
http://pacificcoast.net/%7Emanymoons/howto.html

Reviews and links to a huge swath of retailers
http://www.diaperpin.com/diapers/itemlist.asp?subcat=PADS

Selected sites
Urban Armor. Brightly colored pads with radical images and slogans (like “Pussy Power!”)
Daisy Girl Designs. Fleece lined to prevent soak throughs.
Amazpads. Water resistant liner and soaker pad, in two-part or all-in-one styles.

The “Better” Disposables
Many companies have responded to the problems with tampons by trying to improve the tampon itself. While they may not eliminate the structural health risks as much as the other alternatives, they are making a significant step. These products are good for people who have difficulty dealing with blood, and many people I know also recommend them to mothers or younger sisters who are hesitant about the other alternatives.

Things to think about:
Health: When shopping for a better tampon, look for these features (not all brands will have all features) :
-- all cotton: cotton is a less hospitable place for TSS to grow
-- not bleached, or oxygen-bleached: no dioxin residue
-- not chemically treated: less leaching of residues
-- “long-fiber” cotton: less likely to release the tiny fibers that are
associated with mini-ulcers and cervical cancer
-- no applicator: fingers can position tampons better with less risk of
cuts
-- organically grown cotton: less likely to have pesticide residues
Environment: Still disposable, and if you mail-order that may increase packaging. However, oxygen bleaching or no bleaching cuts down on toxic pollution as compared to usual manufacturing. Organically grown cotton decreases pesticide use (cotton is the major user of pesticides in the U.S.), and no-applicator tampons create less waste.
Money: Likely to be somewhat more expensive than your usual brand.
Politics: These companies tend to mostly focus on the problem of dioxin in tampons, for obvious reasons. Tampax naturals appeals to some sort of “natural” fad without allowing any criticism at all of their normal versions.

How to find them
In natural foods stores and co-ops, and on the Internet through mainstream and alternative e-stores.

Beyond New Products

Speak Up
If you’re pissed about the health dangers you’ve been exposed to, contact the major “feminine hygiene” companies and tell them how you feel, and how you’d like to see them change their products and their practices.

You can demand an end to chlorine bleaching of the wood pulp and cotton that goes in to their tampons, a disclosure of ingredients (after all, shampoo and nail polish have to have their ingredients on the label!), and a full range of safety testing. Or you can demand that all their tampons meet all of the guidelines in the "better" disposables section.

Tell them that you will not use their products until they change, but it's probably not wise to mention small companies that you are switching to, because large corporations are notorious for going after small manufacturers. You can always say you are sewing your own cloth pads.

Remember to request a response, but don't be surprised if the letter you get denies that there might be anything wrong with their products! (It’ll probably include tampon coupons though.)
Also look for current toll-free comment numbers on the boxes.

Report Problems
Have you experienced health problems from tampons? If you have had an unreported case of TSS (mild or serious!) or have had other health problems, such as vaginal dryness, that you link with tampons, REPORT THEM TO THE FDA. Most people do not know that there is a record kept of these complaints, so the ones received count for a lot.

To register a complaint: Tampons are considered a medical device, so they are regulated by the FDA’s Center for Devices and Radiological Health. They encourage you to get a form filled out by your doctor, but you can also self-report.

For More Information
Tampaction. Youth-led action campaign.
SPOT. Has a great archive of articles on tampon dangers. Tracy has been maintaining this site for over 10 years.
Bloodsisters. Canadian girl-power menstrual-activism site. Connected with Urban Armor.