Title of the article: Lived Experiences of Menstrual Cup Adoption among Reproductive-age Women: A Qualitative Study Exploring Perspectives of Menstrual Cup Users, Non-Users, and Dropouts from Eastern India

Author’s Name:

Running Title: Lived Experiences of Menstrual Cup Users, Non-Users, and Dropouts

Surama Manjari Behera 1✉ Phone+91 9404821837 Phone+91 9668443382 Phone+91 7853889552 Emailsurama.m92@gmail.com Emaile.venkata.rao@gmail.com

Associate Professor

Priyamadhaba Behera

M.D.

1 Phone+91 9910830997 Phone+91 8114825994 Emailcmfm_priyamadhaba@aiimsbhubaneswar.edu.in Emailmdshaneyali@soa.ac.in

Professor

E. Venkata Rao

M.D.

1✉ Emailevenkatarao@soa.ac.in

Md Shaney Ali 1

Professor

Binod Kumar Patro

M.D.

1 Phone+91 9438884013 Emailcmfm_binodp@aiimsbhubaneswar.edu.in

Professor

Venkata Rao

M.D.

1 Department of Community Medicine IMS and SUM Hospital Bhubaneswar India

2 Department of Community Medicine and Family Medicine All India Institute of Medical Sciences Bhubaneswar India

3 Dept of Community Medicine & Family Medicine All India Institute of Medical Sciences Bhubaneswar India

Surama Manjari Behera¹, Priyamadhaba Behera², E. Venkata Rao³, Md Shaney Ali⁴, Binod Kumar Patro⁵

Author’s Affiliations:

*Surama Manjari Behera

¹PhD Scholar, Department of Community Medicine,

IMS and SUM Hospital, Bhubaneswar, India

Email: surama.m92@gmail.com

Mobile: +91 9404821837

ORCID ID- 0000-0002-8569-7323

*Priyamadhaba Behera, M.D.

²Associate Professor, Department of Community Medicine and Family Medicine

All India Institute of Medical Sciences, Bhubaneswar, India

Email: cmfm_priyamadhaba@aiimsbhubaneswar.edu.in

Mobile: +91 9910830997

ORCID ID- 0000-0001-9318-4483

#E. Venkata Rao, M.D.

³Professor, Department of Community Medicine,

IMS and SUM Hospital, Bhubaneswar, India Email: e.venkata.rao@gmail.com evenkatarao@soa.ac.in

Mobile: +91 9668443382, + 91 7853889552

ORCID ID- 0000-0002-1841-352X

Md Shaney Ali

¹PhD Scholar, Department of Community Medicine,

IMS and SUM Hospital, Bhubaneswar, India

Email:

mdshaneyali@soa.ac.in

Mobile: +91 8114825994

ORCID ID- 0009-0006-1445-7230

Binod Kumar Patro, M.D.

⁴Professor, Dept of Community Medicine & Family Medicine

All India Institute of Medical Sciences, Bhubaneswar, India

Email: cmfm_binodp@aiimsbhubaneswar.edu.in

Mobile no: +91 9438884013

ORCID ID- 0000-0003-0019-4522

*Surama Manjari Behera and Priyamadhaba Behera contributed equally and are the joint first authors of the study.

#Corresponding author

Professor E. Venkata Rao, M.D.

Department of Community Medicine,

IMS and SUM Hospital, Bhubaneswar, India Email: e.venkata.rao@gmail.com evenkatarao@soa.ac.in

Mobile: +91 9668443382, + 91 7853889552

ORCID ID- 0000-0002-1841-352X

ABSTRACT (350 words)

Background

Menstrual health and hygiene (MHH) is a fundamental component of women’s reproductive health and human rights. Although menstrual cups (MCs) offer a sustainable, cost-effective, and hygienic alternative to conventional menstrual absorbents, their uptake remains limited in low- and middle-income countries (LMICs). This study aimed to explore the lived experiences of MC users, non-users, and dropouts to identify enablers and barriers influencing menstrual cup uptake and sustained use.

Methods

An inductive qualitative study was conducted among women aged 18–45 years. Purposive, maximum-variation sampling was employed to recruit current MC users, former users (i.e., dropouts), and non-users. In-depth interviews were conducted in participants’ preferred language (Odia, Hindi, or English) using a semi-structured guide. Interviews were audio-recorded, transcribed verbatim, and translated into English. Data were analysed using inductive thematic analysis following Braun and Clarke’s six-phase framework. Ethical approval and written informed consent were obtained prior to the commencement of data collection.

Results

Four broad themes emerged: (1) menstrual hygiene management and menstrual flow concerns, (2) physical comfort, (3) awareness and social influence, and (4) long-term and sustainable use of menstrual cups. Key enablers included dissatisfaction with sanitary pads due to leakage, skin irritation, frequent changing, and disposal challenges; improved awareness and monitoring of menstrual flow with MC use; enhanced physical comfort enabling uninterrupted work, sports, and daily activities; supportive peer and family influence; and perceived long-term cost-effectiveness and environmental benefits. Major barriers included inertia to change and long-standing familiarity with pads; limited local availability and higher one-time cost of menstrual cups; inadequate anatomical knowledge of reproductive tract and lack of hands-on training for insertion and removal; fears of complications such as infection or the cup becoming stuck; cultural taboos and virginity-related myths; and practical challenges related to sterilization, storage, carrying, and emptying the cup-particularly in public, workplace, or during travel with limited sanitation and privacy.

Conclusion

Menstrual cup adoption and sustained use are shaped by a complex interaction of knowledge, social networks, physical infrastructure, and prevailing cultural norms, rather than by individual preference alone. Interventions should extend beyond awareness creation to include hands-on training, early-cycle support, culturally sensitive community engagement involving family influencers, improved supply and affordability mechanisms, and strengthened water, sanitation, and hygiene (WASH) infrastructure.

KEYWORDS:

Menstrual Cup

Menstrual Health and Hygiene

Lived Experiences

India

1. BACKGROUND

Menstrual health and hygiene (MHH) is an essential yet often neglected component of women’s reproductive health and human rights. Access to appropriate menstrual materials, accurate information on hygienic practices, and a supportive environment enables women and girls to manage menstruation with dignity, confidence, and free from shame or stigma. Inadequate access to menstrual products, limited awareness, cultural taboos, and poor sanitation facilities contribute to health risks, school absenteeism, and social stigma [1, 2].Globally, around 500 million women and girls worldwide do not have access to menstrual products or adequate facilities for proper menstrual hygiene management (MHM) [3]. Traditionally, menstruation has been managed using materials such as cloth and disposable sanitary pads. Although these methods remain widely used in low- and middle-income countries (LMICs), they are often associated with limitations related to cost, accessibility, comfort, and hygiene [4, 5].

Sanitary pads are convenient but expensive and generate significant non-biodegradable waste due to their plastic content. Tampons offer comfort and discretion but are less available and add to environmental pollution through synthetic materials and packaging. Reusable Cloth, on the other hand requires proper washing and drying to ensure hygiene but often used in unhygienic conditions, leads to potential health risks [5–7]. Menstrual cups have emerged as a sustainable alternative for menstrual hygiene management. A menstrual cup is a reusable, bell-shaped device made of medical-grade silicone, inserted into the vagina to collect menstrual blood. It can be worn for up to 4–12 hours depending on flow, making them more convenient and cost-effective over time [2, 8]. Despite its environmentally friendly and cost-effective nature, the uptake of menstrual cups remains limited, particularly in low- and middle-income countries (LMICs) [9, 10].

There is limited qualitative evidence examining the experiences of menstrual cup users, dropouts, and non-users in low- and middle-income countries (LMIC) contexts. Existing studies have largely focused on clinical effectiveness or acceptability within pilot settings, often overlooking the nuanced sociocultural and everyday challenges women face in real-world use [8, 11, 12]. This gap underscores the need for in-depth, contextually informed exploration of menstrual cup practices. Understanding women's lived experiences is crucial for identifying both the facilitators and barriers that influence adoption, sustained use, and discontinuation. Accordingly, this study aimed to explore the lived experiences of women aged 18–45 years across user, non-user, and dropout groups. The findings are expected to generate context-specific evidence to inform programmatic strategies, policy development, and community-based menstrual health interventions aimed at improving menstrual hygiene management.

2. METHODS

Study design

This qualitative study employed an inductive approach to explore the lived experiences of women aged 18–45 years in relation to the use of MC. Instead of testing predefined hypotheses or applying predetermined coding frameworks, the analysis was guided by participants’ narratives, allowing themes and interpretations to emerge directly from their experiences.

2.2. Study setting and participants

Eligible participants were biologically female, aged 18–45 years, and resident in the study area. The study purposively sought participants representing three experience groups: current MC users, former users (dropouts), and non-users, to capture a range of perspectives. A total of 14 women participated; they represented varied socio-demographic backgrounds (students, homemakers, employed women, women from Self-help Groups (SHGs), and women from urban and rural areas).

2.3. Sampling and recruitment

A purposive, maximum-variation sampling strategy was used to identify information-rich cases across the three user groups and different socio-demographic contexts. Recruitment was facilitated through community health workers and menstrual health promotion groups. Inclusion criteria were tailored to each group (e.g., current users: used MC for at least last three menstrual cycles; dropouts: had tried MC previously but were not currently using it; non-users: never used MC). Data collection continued until data saturation was reached.

2.4. Data-collection techniques and tools

The primary data collection method was in-depth interviews (IDIs), which enabled the confidential and detailed exploration of sensitive topics. A semi-structured interview guide was developed with open-ended prompts to elicit participants’ menstrual histories, first impressions of MCs, motivations for trying or not trying MCs, practical experiences of use, hygiene and safety perceptions, social and cultural influences, reasons for discontinuation, and suggestions for intervention.

The interview guide was pre-tested with a small group not included in the final analysis and refined for clarity and cultural appropriateness.

[Supplementary File 1] Interviews were conducted in the participant’s preferred language (Odia/Hindi/English) in a private setting, lasted approximately 45–60 minutes, and were audio-recorded with permission.

2.5. Data management, transcription, and translation

Audio recordings were transcribed verbatim and translated into English for analysis. Transcripts were checked against recordings for accuracy and completeness. Field notes and memos were linked with corresponding transcripts to preserve context during analysis. All identifiable information was removed from transcripts to maintain confidentiality.

2.6. Data analysis

Data were analysed using inductive thematic analysis, following Braun and Clarke’s iterative six-phase process (familiarization, coding, theme development, review, definition/naming, and reporting) [13], with an explicit data-driven orientation:

2.6.1. Familiarization: Team members read transcripts and field notes multiple times and created reflective memos.

2.6.2. Open coding: Initial codes were generated from the data (line-by-line where helpful) without imposing pre-existing categories. Codes captured actions, meanings, experiences and contexts as expressed by participants.

2.6.3. Code development and consolidation: Codes were compared and grouped into broader categories based on similarity and patterning; a working codebook was developed and revised iteratively.

2.6.4. Theme generation: Categories were organized into candidate themes that represented coherent, meaningful constructs grounded in participants’ accounts.

2.6.5. Review and refinement: Themes were reviewed against the raw data to ensure internal consistency and distinction between themes; subthemes were created where needed.

2.6.6. Finalization and reporting: Themes were named and defined with supporting quotes; analytic narratives linked the themes to the research aims.

2.8. Ethical considerations

Ethical approval

was obtained from the Institutional Ethics Committee prior to data collection.

Written informed consent was obtained from all participants; participants were informed of their right to withdraw at any time. Confidentiality and anonymity were maintained through de-identification of transcripts and secure storage of audio files and notes.

3. RESULTS

The ages of the participants ranged from 19 to 40 years, with the median age being 22.5

years. The details of their demographic characteristics are presented in Table 1.

Table 1

Socio-demographic Characteristics of IDI Participants
Participant	Age (In Years)	Occupation	Average Cycle used MC (if applicable)
1.	22	Student (Eng.)	48
2.	22	Athlete	48
3.	29	Physician	24
4.	29	Self-help Group Supervisor	72
5.	20	Law Student	36
6.	20	Student (Nursing)	24
7.	19	Student (Medical)	18
8.	40	Housewife	24
9.	20	Housewife	Non-user
10.	21	Student (Nursing)	Non-user
11.	29	Entrepreneur	Non-user
12.	23	Student (Medical)	Non-user
13.	24	Nursing Officer	Drop out (after 12 cycles)
14.	29	Research officer	Drop out (after 27 cycle)

The data analysis revealed several themes that act as enablers and barriers to the use of menstrual cups among women. These themes are organized into four main themes: “Menstrual hygiene management and menstrual flow concerns,” “Physical comfort,” “Awareness and social influence,” and “Long-term and sustainable use of menstrual cups.” Additionally, there are twenty-one sub-themes that provide further insights into these themes as presented in Table 2.

Table 2

Enablers and Barriers Influencing Menstrual Cup Adoption and Sustained Use Among Reproductive-age Women
Theme	Sub-theme Why MC? (Enablers)	Codes	Sub-theme Why not MC? (Barriers)	Codes
1. Menstrual hygiene management and menstrual flow concerns	1.1 Experiences with other menstrual absorbent 1.2 Awareness of bleeding amount and patterns in MC cup use 1.3 Support during initial cycles and comfort after adoption	• Need frequent pad changes with heavy menstrual flow • Feeling soggy and irritated when using a pad • Leakage with a sanitary pad • Frequent skin rashes with the pad • No separate dustbins available to dispose of pads • Need to wrap in a newspaper before disposing of • Can know the amount of bleeding with MC easily • Monitor pattern of bleeding with MC • Useful in heavy menstrual flow • Eager to try • Handholding required during initial days of MC use • Initial MC use adjustment difficulties • Guidance required for insertion and removal • Social media video is not sufficient • Understand the cup size • Choosing the appropriate cup size is key • Nil Staining of the cloth • Better leakage protection • Fewer rashes compared to before • More comfortable pad-free days	1.1.1 Inertia of change 1.1.2 Easy availability and accessibility of other menstrual absorbent products 1.1.3 Lack of adequate knowledge Regarding MC use 1.1.4 Complication concerns with MC use	• Used since menarche, no need to learn anything new • Fear of trying new products • Do not want to discuss much regarding it • Simple to wear and dispose of- perceived comfort in the pad • Sanitary pads are freely available under the programme • Sanitary pads are typically available in pharmacies • Logistic convenience • MC not found easily • MC is expensive for a first-time purchase • Doubt in the position and technique of insertion • Anxiety of fitting of cup • Fear of Pain during insertion • Fear and anxiety during both insertion and removal • Lack of anatomical knowledge of the female private parts • Have seen it but never tried it • Fear of the cup getting stuck • Fear of infection • Risk of infections with improper cleaning of the MC • Leakage due to the wrong size of the cup • Will not know when to change the cup
2. Physical comfort	2.1 Physical activity friendly 2.2 Enhanced comfort and reduced skin irritation .	• Never missed the gym after starting to use an MC • Swimming can be done during the Menstrual period with MC • My outdoor games are not affected after use of MC • MC is more comfortable than pads or tampons after getting used to it • Got comfortable with MC after the first three cycles • Relaxed working environment during MC use • Less skin rashes after use of MC • Less skin irritation with MC • Less Itching and rashes in the vaginal area	2.1.1 Sleep Disruptions with MC 2.1.2 Physical discomfort and technical difficulties in the initial period .	• Sleep disruptions due to feeling a different sensation while using the MC at night • Fear of leakage during sleep • Waking up to check cup MC • Initial Discomfort and Adaptation of MC • More Challenging, change an MC during working hours • Insertion difficulty • Anxiety of fitting of cup • May get stuck in the vagina • Difficulty in taking out- need medical help • Fear and anxiety before and during insertion • Requires hand-holding support in initial cycles
3 Awareness and social influence	3.1 Positive peer and family support 3.2 Social media influence	• Friends experience motivated to use the MC • Mother’s guidance to use MC at menarche • My Sister educated and supported me in the use of MC • Social Media encouragement • Social media and YouTube videos help to learn how to use the MC • Can participate in and enjoy all festivals after starting the use of MC • Social media helps me to know about this new thing-MC	3.1.1 Virginity myths 3.1.2 Cultural taboos and misconceptions	• MC use leads to virginity loss • May get stuck in the vagina • Insertion fear • Family and society favour pad use • My husband will not allow MC use • No access to the kitchen for the sterilization of an MC • Storing a menstrual blood-stained product is a sin • Handling menstrual blood with the hand feels dirty • Lack of community-level awareness
4 Long-term and sustainable use of MC	4.1 Improved Odour & sense of cleanliness 4.2 Able to work & play during menstruation period 4.3 Cost-effective and Eco-friendly	• No odour of blood after adopting MC • No feeling of sogginess • No Staining of cloth • Understand the cup size to avoid leakage • Routine work is not affected during menstruation • Does not require frequent change like pad • Even in heavy bleeding, you will be emptying MC after 5–6 hours. • Sports activity is not affected during menstruation • Never missed the gym after starting to use an MC • MC is Durable and affordable • One-time cost with long duration use • MC is environmentally friendly • No problem with monthly disposal • Not to worry about purchasing Sanitary pads regularly • Effective with less cost in long-term use	4.3.1 Difficulties in MC Carrying & emptying 4.3.2 Challenges of insertion and removal of MC 4.3.3 Challenges of sterilisation and storage of MC	• Discomfort in Carrying Used MC • Awkwardness of carrying a Used MC along with other belonging • Getting the Cup ready for the next cycle • Lack of Proper hygiene and water facilities to Clean the MC in a workplace • Lack of proper facilities to clean the cup, especially in public restrooms or during travel. • Always fear of falling the cup in toilet • Emptying of MC in public toilet is not advisable • Insertion/Reinsertion of MC in public toilet is difficult • No adequate privacy for MC use • Fear of Pain during insertion • Fear and anxiety during both insertion and removal • Need time to get adapted to the cup • Difficulty in folding the cup correctly initially • Problems with forming a seal or removing the cup at the start • Tedious maintenance • Cleaning and sterilization are time-consuming • Not confident of the sterilisation process of MC • Need for a separate vessel for sterilisation • Denial from mother-in-law to use the kitchen to clean the MC • Have to store MC in secret places, hiding from other family members

Table 2. Theme and Sub-themes of MC Use Among Women

3.1. Menstrual hygiene management and menstrual flow concerns

3.1.1. Enablers:

3.1.1.a. Previous Experiences with Menstrual Absorbent

Participants expressed multiple concerns with the use of sanitary pads, particularly during heavy menstrual flow. The need for frequent pad changes was commonly reported. The prolonged use of pads often resulted in a soggy and uncomfortable feeling, sometimes accompanied by skin irritation. Leakage emerged as a frequent worry, further intensifying discomfort and embarrassment. The participants expressed concern about recurrent skin rashes associated with pad use, citing issues with material quality and skin sensitivity.

Beyond personal discomfort, participants reported challenges with disposal practices. The absence of separate dustbins in toilets forced women to wrap pads in newspapers before discarding them, reflecting inadequate facilities for safe and dignified disposal. Collectively, these previous experiences with the sanitary pad use led to the adoption of MC.

“Periods are a nightmare for me. I have very sensitive skin, so I get skin rashes easily. Normally, I use an XL (very large) size sanitary pad; however, there is still a chance of leakage during sleep at night. At home, these stains are quite okay for me as my mother washes my bedsheets and used clothes, but in the hostel, it is very embarrassing.” (Participant, MC user, 20 years)

“In my hospital duty hours as well as in hostels, there are no separate bins to dispose of the used sanitary pads. As a result, I have to dispose of them in the common dustbin, or sometimes I have to carry them wrapped in newspaper on the way back from the shift. It feels very dirty and embarrassing for me, you know.” (Participant, MC user, 19 years)

3.1.1.b. Awareness of bleeding amount and patterns in MC use

The Participants highlighted that using an MC provided greater awareness of their menstrual bleeding. Unlike pads, the cup allowed them to directly see and quantify the amount of blood collected, helping them to understand their flow more accurately. This visibility was perceived as useful in monitoring individual bleeding patterns over time. Women experiencing heavy menstrual flow particularly valued the cup, as it enabled them to assess both the quantity and pattern of bleeding, supporting better self-management of their menstruation.

After I started using an MC, it almost stopped staining clothes. I could easily judge my pattern of bleeding and clean my cup before it gets filled. In the initial days of use, for the first two to three times, it got overflowing, which left stains on my clothes. But once I get used to it, after two or three cycles of use, I have never experienced any stains or overflow of menstrual blood.

(Participant, MC user, 19 years)

3.1.1.c. Support during initial cycles and comfort after adoption

Participants were keen to adopt MC, but they needed handholding support during the initial cycles. Many participants reported difficulties in insertion, removal, and overall adjustment in the early use days, highlighting the need for personalized assistance and guidance. Social media tutorial videos were considered insufficient; moreover, practical demonstrations and counselling are more effective in continuing the use of MC.

When I started using a menstrual cup, I was a little confused about the insertion and removal of the cup. I learnt it from the available YouTube videos. Still, it was quite difficult for me to place it properly. Then I sought advice from my friend who had been using it. She gave me an MC demonstration and taught me how to determine if it is positioned correctly.

(Participant, MC user, 24 years)

The correct selection of cup size was identified as crucial for both comfort and effectiveness.

Over time, with continued use, participants reported a clear shift toward comfort and satisfaction. They experienced fewer leakages, no staining of cloth, and reduced rashes compared to pads. Ultimately, menstrual cup adoption provided more comfortable, pad-free days, enhancing both convenience and confidence.

“I saw the advertisement of MC on Instagram and ordered a small size from online. but when I started using it, I have frequent leakages and stain. I was worried that I must be doing something wrong. So, I searched for the solution on the internet. From there I got to know about the different sizes of cup available. In confusion and self-doubt, if I am doing the right thing or not, I ordered the medium size. After using that I have experienced no leakages and less frequent change of cup.” (Participant, MC user, 22 years)

3.1.2. Barriers:

3.1.2.a. Inertia of change

Participants described a strong inertia in shifting away from sanitary pads. Pads were perceived as a familiar and convenient option, having been used since menarche without requiring additional learning or adaptation. Fear of trying new products, particularly those involving insertion, such as menstrual cups, contributed to resistance to change. Moreover, the hesitation to openly discuss menstrual products further reinforced the continuation with pads. The ease of wearing and disposing of sanitary pads was perceived as a form of comfort, making them the default choice despite known problems such as leakage and skin rashes.

“From the time I got my first period, I have always used sanitary pads. I know how to use them, when to change them, and how to dispose of them. I don’t feel the need to learn something new.” (Participant, MC non-user, 21 years)

“We don’t usually talk openly about periods or menstrual products. Since everyone around me uses pads, I also continue using them without much thought.” (Participant, MC non-user, 29 years)

3.1.2.b. Easy availability and accessibility of other menstrual absorbent

Participants highlighted the role of availability and affordability in shaping menstrual absorbent choices. Sanitary pads were widely accessible, provided free under government programmes, and easily purchasable in local pharmacies, making them the most convenient option. This logistical ease reinforced continued use despite discomforts. In contrast, menstrual cups were not readily available in local markets, and their relatively higher one-time cost discouraged first-time users. These combined challenges of access and affordability limited the wider adoption of menstrual cups compared to pads.

“I know the benefits of MC use, but they are not available in the local market like the pads. Only online purchase option is there. If I need it on an urgent basis I can’t get it easily. One packet of pad costs me 50/- but one MC is 700–1000/-, it is costly.” (Participant, MC non-user, 22 years)

3.1.2.c. Lack of adequate knowledge regarding Menstrual Cup use

Among the participants lack of adequate knowledge was a major barrier to adoption of menstrual cups. Many expressed uncertainties about the correct position and technique of insertion, accompanied by fears of pain and discomfort. Anxiety persisted not only during insertion but also with the thought of removal, reflecting limited confidence in handling the product.

“During every cycle, in the first two days of period, having a heavy flow fear of leakage is always there. So, I prefer to use both pad as well as a MC. In a hurried situation, every time I am have to experience severe pain while removing the cup. After 2–3 attempts insertion of MC is easy as compared with removal of cup.” (Participant, MC dropout, 29 years)

Underlying this hesitation was a broader gap in anatomical knowledge of the female reproductive system, which further contributed to apprehension. Although some participants had seen menstrual cups, they had never attempted to use them, indicating that awareness without experiential knowledge did not translate into adoption.

“I tried twice but was not able to insert it correctly. After two failed attempt my perception on MC is … what if it gets stuck inside while using it or what if its blood is spilled on the dress while taking it out.” (Participant, MC dropout, 24 years)

3.1.2.d. Complication concerns with Menstrual Cup use

Participants expressed concerns regarding potential complications with menstrual cup use. A common fear was that the cup might get stuck during use, creating anxiety around insertion and removal. Concerns about infections were also prominent, particularly linked to improper cleaning practices. The incorrect MC size increased the risk of leakage, which further contributed to participants’ hesitation. Additionally, uncertainty about how frequently to change the cup further contributed to anxiety. Collectively, these perceived risks represent significant barriers to adoption, underscoring the need for clear guidance and education on safe MC use.

“There is always a risk involved in inserting some foreign body inside one’s body. If it is not cleaned or boiled properly, there is a chance of getting infection. Being a hostel resident, it is not easy for me every time make the cup period ready. So, I prefer to use a pad. During our class hours we do not get enough time to clean and change the cup maintaining proper hand hygiene.” (Participant, MC non-user, 21 years)

3.2. Physical comfort

3.2.1. Enablers:

3.2.1.a. Physical activity friendly

Participants noted that menstrual cups positively impacted their ability to participate in physical activities. Unlike pads, cups allowed uninterrupted participation in gym sessions, swimming, and outdoor games, even during menstruation. The secure fit and reliable leakage protection provided by menstrual cups contributed to increased confidence and comfort, reducing activity-related limitations often experienced with traditional absorbents. This benefit was especially appreciated by women who did regular exercise or participated in sports.

“As a sportsperson, I prefer using a menstrual cup. In kabaddi, I have to run a lot, and earlier during my periods I used to hesitate to play because I couldn’t focus on the game, my attention was always on possible period stains. After I started using the cup, those problems disappeared.” (Participant, MC user, 22 years)

“Earlier, heavy menstrual flow often kept me from going to the gym. But now I use a medium-sized cup, and I don’t skip a single day during my periods. I feel much more confident than before.” (Participant, MC user, 22 years)

3.2.1.b. Enhanced comfort and reduced skin irritation

Participants reported that menstrual cups offered superior comfort compared to pads or tampons once they became accustomed to their use, typically after the first three cycles. The cup contributed to a more relaxed working and daily environment, as it minimized discomfort and distractions associated with traditional absorbents. Importantly, menstrual cup use was associated with reduced skin irritation, rashes, and itching in the vaginal area, enhancing overall menstrual hygiene experience and physical comfort.

“I used to get skin rashes when I was using a pad. But with MC my periods are now rash-free and I can do my clinical duties without any worries.” (Participant, MC user, 20 years)

3.2.2. Barriers:

3.2.2.a. Sleep Disruptions with Menstrual Cup

Some participants reported experiencing sleep disturbances during the initial period of using MC. The unfamiliar sensation of the cup at night led to discomfort and restlessness. Anxiety about potential leakage prompted some women to wake up during the night to check the cup, disrupting sleep patterns. These experiences suggest that while menstrual cups offer many daytime advantages, initial adaptation may temporarily affect sleep quality.

“During the initial days of using the menstrual cup, I found it difficult to sleep comfortably at night. The unfamiliar feeling made me anxious about leakage, and I would wake up repeatedly to check or empty the cup, which disturbed my sleep ” (Participant, MC dropout, 24 years)

3.2.2.b. Physical discomfort and technical difficulties in the initial period

Participants described several physical and technical challenges during the initial period of menstrual cup use. Insertion and removal were reported as difficult, with some fearing that the cup might get stuck, potentially requiring medical assistance. Changing the cup during working hours was perceived as more challenging, and the initial discomfort contributed to anxiety before and during use. Many participants emphasized the need for handholding support and guidance in the early cycles to build confidence and adapt successfully to the menstrual cup.

“ I started using a menstrual cup after a friend guided me on how to choose and use it. While insertion was manageable, removal was extremely painful, and I became afraid that the cup might get stuck. The experience made me anxious and discouraged me from continuing, especially without proper guidance during the initial cycles.” (Participant, MC non-user, 29 years)

3.3. Awareness and social influence

3.3.1. Enablers

3.3.1.a. Positive peer and family support

The participants believed that encouragement and guidance from peers and family members played a significant role in their adoption of menstrual cups. Friends’ positive experiences served as motivation to try the cup, while mothers and sisters provided direct education, guidance, and support, particularly during menarche or initial use. Such interpersonal support helped reduce anxiety, facilitated learning proper techniques, and increased confidence in menstrual cup use, demonstrating the importance of social encouragement in menstrual health practices.

“During my 12th grade, one day, some NGO workers visited our school and told us about the various menstrual products. That day, I got to know about the MC in my school. When I came back home, I shared with my mother, and surprisingly, the very next day, my mother bought a small-sized cup for me and taught me how to use it, how to sterilise it, and how to store it in a safe place. I have been using the cup for the last 4 years. My mother gives me all the support whenever I need it.” (Participant, MC user, 22 years)

“I learned about the MC from my friend. She is an MC user who showed me her cup and demonstrated all its proper use. In my first use, I felt pain while removing the cup and shared my experience with her and decided not to use the cup any further. But she motivates me and makes me understand the mistake I was making. After 2–3 cycles of use, I got used to using the cup, and I have been using it since last year.” (Participant, MC user, 40 years)

3.3.1.b. Social media influence

Participants described social media as a significant source of awareness and motivation for the use of MC. Platforms like YouTube provided instructional videos that helped women understand the process of insertion and removal; however, many noted that these were insufficient without personal guidance. Social media also provided encouragement through testimonials and success stories, which helped reduce apprehension and inspired women to try the cup.

“I saw the menstrual cup videos on YouTube advertisement. Out of curiosity, I searched for it further. There are many YouTube videos available to learn from. I was excited to try a new product. So, I ordered it from Amazon and started using it. I take it as a challenge and a user of MC for the last 9 months.” (Participant, MC user, 24 years)

Importantly, participants associated cup use learned via social media, with greater freedom to participate fully in social and cultural activities, including festivals, without menstrual restrictions.

“In our home, there are many restrictions during the period days. We cannot perform any puja or attend any festivals. However, from the time I started using an MC, I sometimes forgot and would still perform my daily puja. My grandmother never got to know if I have my periods, so I can easily participate in all the functions and festivals without any hesitation.” (Participant, MC user, 20 years)

3.3.2 Barriers:

3.3.2.a. Virginity myths

Participants reported that myths and misconceptions surrounding virginity posed a major barrier to menstrual cup adoption. A common belief was that using the cup could lead to loss of virginity, reflecting deep-rooted cultural taboos linked to the hymen and purity. Alongside this, fears of the cup getting stuck in the vagina and anxiety around insertion reinforced reluctance to try the product. These misconceptions highlight the intersection of cultural beliefs and knowledge gaps, which significantly shape menstrual health choices.

“As I have heard, the cup can be used only by those who are married or have given birth to a baby....and I am a virgin ....and I think it will widen our vaginal canal as well as enlarge our uterus. I want to use a menstrual cup, but I feel uncomfortable thinking about how to use it and how to insert and remove the cup, having blood inside it.” (Participant, MC non-user, 29 years)

3.3.2.b. Cultural taboos and misconceptions

Cultural taboos and misconceptions emerged as powerful influences discouraging menstrual cup use. Family and societal norms strongly favoured pad use, with some participants noting explicit restrictions from husbands against adopting the cup.

“I got to know about the MC from my sister-in-law, who also gifted me one. She shared her experience, and I was also quite excited to use it. But my husband refused to use it, as a foreign thing to be inserted in the vagina, increasing chances of getting an infection.” (Participant, MC dropout, 29 years)

Practices around sterilization were also shaped by taboos, women reported being barred from kitchen access during menstruation, making it difficult to boil the cup for cleaning.

Cleaning the cup is a significant challenge for me both at home and in the hostel. At home, I am not allowed to sterilise the cup in the kitchen, as we do our puja in the kitchen itself. In the hostel, to overcome the sterilisation problem, I had to buy an electric steriliser, which is very costly.

Deeply ingrained beliefs, such as the notion that storing a menstrual blood-stained product is sinful or that handling menstrual blood with one’s hands is dirty, further reinforce negative perceptions. Limited community-level awareness perpetuated these myths and stigma, collectively constraining wider acceptance of menstrual cups.

3.4. Long-term and sustainable use of the Menstrual Cup

3.4.1. Enablers:

3.4.1.a. Improved Odour & sense of cleanliness

Participants described a marked improvement in their sense of cleanliness after adopting menstrual cups. Unlike pads, the cup eliminates the odour of menstrual blood and reduces the feeling of sogginess, contributing to greater comfort throughout the day. Women also valued the absence of cloth staining, which previously caused embarrassment and inconvenience. They emphasized that correct understanding and selection of cup size was important to prevent leakage, thereby ensuring a cleaner and more hygienic menstrual experience overall.

“I don’t feel the sogginess like I used to with pads, using a menstrual cup is much more comfortable. I haven’t had any itching or rashes since I started using it.” (Participant, MC user, 22 years)

3.4.1.b. Able to work & play during the menstrual period

Participants reported that using an MC helped them continue their usual work and leisure routines during their periods. Unlike pads, which needed to be changed often, the cup could be worn for longer periods-even with heavy flow, without any discomfort or leakage. This made it workplace and travel-friendly. Women also noted that activities like sports and gym workouts were not affected, which boosted their confidence and sense of physical freedom.

“When I used pads, I had to change them every 2–3 hours because I was afraid of getting rashes. But with a menstrual cup, I don’t need to change it so often. It keeps me leakage free for 6 to 8 hours. Since switching to a cup, I can comfortably do my daily activities like going to the gym and swimming.” (Participant, MC user, 24 years)

3.4.1.c. Cost-effective and Eco-friendly

Participants recognized menstrual cups as both cost-effective and environmentally sustainable. Unlike sanitary pads that require regular purchase, the cup involves a one-time cost with prolonged use, making it a more economical choice over time. Women also appreciated the reduced burden of disposal, as the cup eliminated the need to manage sanitary waste on a monthly basis. Its eco-friendly nature was highlighted as an added advantage, contributing to reduced environmental pollution from non-biodegradable pad waste. Collectively, these attributes positioned the menstrual cup as a financially viable and environmentally responsible alternative.

“I am quite happy to shift to MC from pad completely. No worries about disposing the used pads, whether during clinical duty, at home, or while travelling. Before that, I used to spend 100–200 rupees every month, but I purchased the cup, a one-time investment, for Rs.500, which I have been using for the last two years.” (Participant, MC user, 22 years)

3.4.2. Barriers:

3.4.2.a. Difficulties in Menstrual Cup Carrying & Emptying

Despite recognizing its benefits, participants reported practical challenges with carrying and emptying the menstrual cup. Many people felt discomfort and awkwardness when handling or storing a used cup alongside their personal belongings, particularly when preparing it for the next use. Inadequate hygiene and water facilities at workplaces, public restrooms, or during travel made cleaning difficult, reinforcing barriers to convenient use outside the home. Women also expressed fears of dropping the cup into the toilet or facing unhygienic conditions while emptying it in public settings, which discouraged its use in such contexts. These challenges underscore the need for supportive infrastructure and practical solutions to make menstrual cup use more feasible in everyday life.

“You can use a sanitary pad in public toilets without much concern since it doesn’t require direct contact with any surface. But when using a menstrual cup, you need a clean washroom and enough water. I remember once while traveling, I accidentally dropped my cup in the toilet and lost it. I went to the nearby market but couldn’t find a replacement. So, when I travel, I prefer using pads instead of a cup.” (Participant, MC user, 24 years)

3.4.2.b. Challenges of insertion and removal of the MC

Participants reported significant challenges with inserting and removing menstrual cups, particularly during the initial cycles. Fear of pain and anxiety during both insertion and removal created hesitation and a lack of confidence. Many struggled with folding the cup correctly and achieving a proper seal, which sometimes led to discomfort or leakage. Removal was also initially perceived as difficult, with some participants fearing that the cup might not come out easily. Practical barriers, such as a lack of privacy in public toilets, further complicate the process of reinsertion or emptying when outside the home. Overcoming these difficulties required time, adaptation, and often guidance, highlighting the importance of supportive instruction during the transition to menstrual cup use.

“During my period, travel is a nightmare for me. Even changing a pad needs a clean toilet and water facility to clean my hands. However, you can imagine the condition of railway toilets or public toilets, which are often dirty and frequently lack water. I can’t think of using an MC during my travel, as I travel frequently to my hometown.” (Participant, MC non-user, 29 years)

3.4.2.c. Challenges of sterilisation and storage of the MC

Participants identified sterilization and storage as key challenges in using menstrual cups. Many described the maintenance process as tedious and time-consuming, with uncertainties about whether the sterilisation was adequate.

“Sometimes I face a problem with sterilizing the cup, which involves boiling it and then letting it cool. I'll be in a hurry for my class, and the cup was still too hot to use. In that time, I prefer a pad to use." (Participant, MC non-user, 23 years)

The requirement for a separate vessel to boil the cup created additional inconvenience. Cultural taboos further complicated the process; some women reported being denied access to the kitchen by family members, especially mothers-in-law, for sterilisation.

“Before marriage, in my mother’s home, there was a separate vessel to boil the cup in the kitchen, but after my marriage, I am not allowed in the kitchen during my period days. For this reason, I discontinued using a cup. Also, not allowed to store the cup in the common wardrobe area with the clothes.” (Participant, MC dropout, 29 years)

Beyond cleaning, discreet storage was another concern, as participants often felt the need to hide the cup from other family members. These practical and socio-cultural barriers around sterilisation and storage limited the ease of use and long-term acceptability of menstrual cups.

4. DISCUSSION

This qualitative study explored the lived experiences of MC users, dropouts, and non-users across diverse socio-demographic groups. Our results demonstrate that menstrual cup uptake and sustained use are shaped by a multifaceted interaction of practical, sociocultural, and infrastructural determinants. Major enablers included dissatisfaction with existing absorbents (frequent pad changes, leakage, rashes, disposal problems), greater awareness and perceived amount of bleeding with the cup, improved physical comfort (including during physical activity), favourable peer/family support and social-media-driven awareness, and perceived long-term cost and environmental benefits. Major barriers included inertia to change and long-standing familiarity with pads; limited availability and the higher one-time cost of menstrual cups; insufficient anatomical knowledge and practical skills for insertion and removal; fears of complications such as infection or the cup becoming “stuck”; and deeply rooted cultural taboos, including virginity-related myths. Additionally, women faced notable logistical challenges during menstruation, such as sterilization, storage, and difficulties carrying or emptying the cup in public or workplace settings, particularly among those constrained by social or household norms and lacking adequate sanitation infrastructure.

4.1 Comparison with Existing Evidence

The thematic patterns identified in this study align closely with recent qualitative and mixed-methods evidence from LMICs [5, 10, 14]. Consistent with our findings under menstrual hygiene management and menstrual flow concerns, previous studies report that improved comfort, better leakage control, reduced skin irritation, and enhanced awareness of menstrual flow act as key enablers of menstrual cup use[2, 9, 15, 16]. Similarly, themes related to physical comfort-including the ability to engage in physical activity, work, and daily routines without interruption-have been widely documented as important facilitators of adoption and continued use[9, 15]. In line with our awareness and social influence theme, existing literature highlights the role of knowledge, peer experiences, family support, and social media in motivating women to initiate menstrual cup use and navigate the early learning phase[2, 17]. Conversely, barriers reported in this study are consistent with those documented across Asia and sub-Saharan Africa. Cultural myths surrounding menstruation and virginity, concerns related to hygiene and infection, technical difficulties with insertion and removal, and structural constraints arising from inadequate water, sanitation, and privacy infrastructure have been shown to limit both acceptability and sustained use of menstrual cups [16–20].

4.2 Interpretation and implications

The results highlight that menstrual cup adoption is not driven solely by individual preference but is rather mediated by knowledge, social networks, physical infrastructure, and cultural norms. Several important interpretive points emerge:

Practical advantages matter-but so does the learning curve. While many participants appreciated the cup’s superior leakage protection, reduced skin irritation, and compatibility with physical activity and work, these benefits were typically realized only after an initial adjustment period. Users often require guidance, practice, and the right size selection to gain confidence and comfort. This highlights the importance of early-cycle support, including practical demonstrations, supervised practice, and troubleshooting, as essential components of any effective MC promotion strategy.

Knowledge gaps and skill deficits emerged as central barriers to MC use. Participants’ apprehensions about MC insertion and removal were closely linked to limited anatomical understanding and the absence of hands-on training. Although social media content and instructional videos increased awareness, they could not replace direct, contextualized guidance or address the personalized guidance women required. These findings suggest that effective interventions should integrate clear, evidence-based information with practical training and opportunities for supervised practice when needed.

Cultural beliefs and household dynamics shape feasibility: Myths surrounding virginity and normative household restrictions, such as being prohibited from entering the kitchen while menstruating to boil or sterilize the cup, or needing to hide the cup from family members, limited both acceptability and sustained use, particularly among younger, unmarried, or newly married women. These findings highlight that without culturally sensitive community engagement involving key family influencers (mothers, mothers-in-law, and husbands), demand-generation efforts are likely to result in only limited and short-lived uptake.

Infrastructure and public-space constraints substantially limit the real-world usability of MCs. Difficulties in carrying, emptying, and sterilizing the cup in workplaces, schools, hostels, and during travel highlight the broader importance of adequate sanitation, privacy, and safe water access conditions fundamental to women’s dignity and menstrual health rights. Promoting menstrual cups without simultaneously addressing these structural gaps risks heightening anxiety, inconvenience, and eventual discontinuation. Practical solutions-such as discreet carry cases, portable sterilizers, and designated clean water points-may help mitigate some challenges but will require deliberate programmatic investment.

Cost and supply chain factors play a crucial role in the adoption of MC. Although menstrual cups are cost-effective over the long term, their higher one-time purchase cost and limited local availability discourage many first-time users. Expanding access through social marketing approaches, such as subsidies or integration into public supply systems, alongside improved local retail availability, could enhance the affordability and accessibility of MC for reproductive-age women.

4.3 Strengths and limitations

Strengths of this study include the use of purposive sampling across current users, dropouts, and non-users, which enabled the triangulation of diverse perspectives.

Conducting in-depth interviews in participants’ preferred languages enhanced comfort and depth of responses. The use of an inductive analytic approach ensured that themes were grounded in participants' lived experiences, yielding rich contextual insights, particularly regarding household norms, cultural beliefs, and infrastructural constraints, which are highly relevant for programmatic implementation.

Limitations include the restricted geographic scope, which may limit the generalizability of findings beyond similar settings. Recruitment through health workers and menstrual health promotion groups may have introduced a selection bias toward women who are already somewhat informed about menstrual products. Social desirability bias could have influenced participants’ accounts of hygiene practices or motivations. We were able to include only two participants who experienced menstrual cup dropout in this group, and a larger sample size may have provided more comprehensive insights. Additionally, although rigorous transcription and translation procedures were followed, subtle linguistic and cultural nuances may have been lost in translation.

5. CONCLUSIONS

Menstrual cup adoption and sustained use are shaped by a complex interaction of knowledge, social networks, physical infrastructure, and prevailing cultural norms, rather than by individual preference alone. While MCs offer clear advantages in terms of comfort, mobility, cost-effectiveness, and environmental sustainability, their real-world uptake remains constrained by limited skills and information, deeply rooted cultural beliefs, restrictive household norms, inadequate sanitation and privacy, and supply-chain barriers affecting access and affordability. Early-cycle hand-holding, accurate information, and supportive peer and family environments emerged as critical facilitators of continued use.

These findings highlight that promoting MCs requires more than simply generating awareness. Effective strategies must adopt a rights-based and gender-sensitive approach that integrates hand-holding support during the initial two to three cycles, culturally responsive community engagement involving key family influencers, improved supply and affordability mechanisms, and strengthened water, sanitation, and hygiene (WASH) infrastructure.

LIST OF ABBREVIATIONS

LMICs

Low- and Middle-Income Countries

Menstrual Cup

MHM

Menstrual Hygiene Management

SHGs

Self Help Groups

SOA

Siksha ‘O’ Anusandhan

WASH

Water, Sanitation, and Hygiene

Ethics approval and consent to participate:

Ethical approval for the study was obtained from the Institutional Ethics Committee of SOA, Bhubaneswar (Ref. No. IEC/IMS.SH/SOA/2022/427), dated 14 October 2022.

The study was conducted in accordance with the principles outlined in the Declaration of Helsinki.

Consent for publication:

Not applicable

Acknowledgement

None

Author Contribution

SMB, PB, EVR, and BKP conceptualized the study. Data collection was conducted by SMB. Data analysis was performed by SMB, PB, and SA. The first draft of the manuscript was written by SMB, PB, SA, and EVR. All authors contributed to reviewing and finalizing the manuscript. All authors read and approved the final version for submission.

Data Availability

The data is held by the primary and corresponding authors and can be accessed upon request to the primary and corresponding author.

Funding Information:

It was a non-funded study.

Competing Interest:

None

Electronic Supplementary Material

Below is the link to the electronic supplementary material

Supplementary Material 1

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Lived Experiences of Menstrual Cup Adoption among Reproductive-age Women: A Qualitative Study Exploring Perspectives of Menstrual Cup Users, Non-Users, and Dropouts from Eastern India