ALWAYS menstrual pads? (For our newbies)

[Guest guest]

Hi ladies, this is for all our newbies to read. It's one I saved from Dee. Let's hope and pray her computer gets fixed soon!!! If you currently use ALWAYS brand pads you may want to reconsider... ~Chelle ====================================== Canadian Medical Association; Association médicale

canadienne [Original Research] Eason, a L. SM, MDCM, FRCSC; Feldman, Perle BSc, MDCM, CCFPDr. Eason is assistant professor in the departments of Obstetrics and Gynecology and of Clinical Epidemiology, Montreal GeneralHospital and McGill University, Montreal, Que.; and Dr. Feldman is assistant professor in the Department of Family Medicine, SirMortimer B. -Jewish General Hospital and McGill University, Montreal, Que .Reprint requests to: Dr. a L. Eason, Rm. L10-412, Montreal General Hospital, 1650 Cedar Ave., Montreal QC H3G 1A4AbstractObjective: To report a clinical

association between vulvar irritation or contact dermatitis and the use of Always sanitary napkins.Design: Case series.Setting: A gynecology practice in Montreal.Patients: Women presenting between September 1991 and September 1994 with itching or burning of areas that would be in contact with a sanitary napkin (mons pubis, external surfaces of the vulva and perineum) beginning at least 1 day after the use of the napkins was started and less than 5 days after the use was stopped.Results: Twenty-eight women experienced vulvar itching and burning, often associated with eruptions resembling contact dermatitis, ofthe vulvar and perineal surfaces after using Always sanitary napkins. Twenty-six reported that symptoms disappeared after they stoppedusing that brand of sanitary napkin. Seven women who later used the same brand again reported a recurrence of the vulvar irritation.Conclusion: The findings of this case series reveal

Always sanitary napkins as a potentially important cause of recurrent vulvitis.Physician awareness of the association will enable effective advice and relief for a large number of women suffering "chronic vaginitis." Some years ago each of us observed several patients who presented with similar and unusual histories. These women complained of "vaginal infections every month'', but our clinical and microscopic examinations revealed no evidence of vaginitis. Some of the women had received repeated treatments elsewhere with anti-fungal medications, without a decrease in recurrence of symptoms. All of the women had itching or burning of the mons pubis,

labia and perineum butno associated odour or vaginal discharge and no redness or swelling of the inner labia and vestibule. Symptoms subsided after several days, with or without treatment. In some cases we noted an erythematous papular eruption over the groin, mons pubis and perineum.We suspected contact dermatitis rather than the much more common vulvovaginitis due to Candida albicans, Trichomonas or bacteria. [1,2] However, questioning about the usual suspects like -- exposure to perfumes or deodorants, detergents andfabric softeners, or a change in soap [1-3] -- it revealed no obvious cause.Two clues alerted us to a connection between the symptoms and the use of sanitary napkins. First, in some of the women the sharp margins of the eruption outlined the contact area of a sanitary napkin. In parous women

the clitoral hood and thetips of the labia minora extending beyond the labia majora were often most severely affected. Second, the symptoms started during or a few days after menses; microbial vaginitis usually presents in the premenstrual period and is somewhat relieved during menses. When questioned about the brand of tampons or sanitary napkins they used, the women gave us the same answer: Always sanitary napkins (Procter & Gamble Inc., Toronto). Changing the brand, without specific treatment of the irritation, prevented recurrence of the symptoms.We have not seen this periodic menstrual vulvitis in women using other brands of sanitary napkins. The US Food and Drug Administration (FDA) has received a few reports of similar adverse reactions to Always sanitary napkins (FDA,Washington: Medical Device Report

[list edition], June 1993). Our search of the medical literature revealed two cases of allergy to the perfume used in sanitary napkins [4,5] but no reports of contact dermatitis or irritation associated with any particular brand. When asked, most of our colleagues had not noticed this association; however, those who had recognized it had seen it several times, and others reported cases to us after we alerted them to it.To document this problem and to inform physicians of the diagnosis, we present a series of 28 cases of vulvar irritation associated with the use of Always sanitary napkins.Methods; We reviewed the charts of all women seen in a gynecology practice in Montreal between September 1991 and September 1994 who had presented with symptoms

indicative of contact vulvitis associated with the use of sanitary napkins. Suspected cases had to meet the following criteria: itching or burning of areas that would be in contact with a sanitary napkin (mons pubis, external surfaces of the vulva and perineum) and onset of symptoms at least 1 day after theuse of sanitary napkins was started and less than 5 days after the use was stopped.Patients were interviewed by telephone by their attending physician to obtain more detailed information about their previous and subsequent use of products for menstrual protection, any associated symptoms, other potential causes or risk factors for vulvitis and pertinent aspects of the medical history. To assess the proportion of women in the practice population who used Always sanitary napkins we interviewed a comparison group of women from the same

practice,matched for date of visit, age within 5 years, referral status and reason for using sanitary product (e.g., menses, urinary incontinence or discharge).ResultsThirty-four women met the symptoms criteria, and all had been using Always sanitary napkins. After the interviews, five women were excluded because of coexisting chronic vulvar or vaginal conditions (recurrent herpes, known local skin allergies and chronic introital dyspareunia). Their symptoms diminished after they stopped using the Always napkins, but we excluded them because of the confounding causes of the vulvitis. An additional woman was excluded because subsequent use of Always napkins was well tolerated.The 28 remaining women ranged in age from 20 to 64 years (median 32 years).

Twenty-four women used the sanitary napkins during menses only; the other four used them every day. The women were asked about menstrual-protection methods, use of sanitary napkins for other reasons and episodes of menstrual or postmenstrual vulvar itching or burning during the 6 months before the index episode. Thirteen women had symptoms with their first exposure to the product;reactions in the others developed only on repeat exposure. Symptoms were typically recurrent: 19 of the women had had four or more episodes of symptoms, and 8 of the 20 women who had used the product for at least 6 months had had symptoms every month during that time. Symptoms were first

noticed 1 to 9 days (median 3 days; interquartile range [iQR] 2 to 4 days) after use of the sanitary napkins was started during each menses and lasted for a median of 4.5 days (IQR 4 to 7 days). The four women who used the napkins every day had constant irritation. Of the 28 women 13 also had erythematous papular eruption.Symptoms did not disappear immediately after the women stopped using the sanitary napkns; rather, the itching and burning lasted for a median of 3 days (IQR 2 to 5 days) afterward. In six of the women the symptoms began 1 to 2 days after napkin use was stopped. All of these women experienced only postmenstrual itching and burning of the vulva on at least three occasions.Before the index visit none of the women had identified the sanitary napkins as a possible cause of their symptoms: most reported "vaginal infection every month." We informed patients at the end of the index visit of the possible cause of their symptoms and advised them to

suspend use of the product. Twenty-three of the 28 women switched to another product for the next 3 months and had no further vulvar irritation. Three women continued to use Always napkins and had recurrent irritation at each menses until they discontinued its use, whereupon symptoms disappeared. One woman continued to use Always napkins for 3 months after the index visit without a problem, but when she used them again later she experienced irritation. Another woman could not recall whether she had had recurrent irritation during the 3 months after switching brands, but she did later reuse. Always napkins and experienced irritation. Seven women later used Always napkins again and experienced recurrent vulvar itching and

burning.C. albicans or bacterial vaginitis was present at the index visit in 5 of the 28 women. Although these women had a potential microbial cause of vulvitis, the clinical picture was that of contact or irritant dermatitis. All five had at least 3 months of exclusively menstrual or postmenstrual irritation. Cyclic symptoms continued in one of the five patients after treatment for Candida and resolved only after use of Always napkins was stopped.Only 1 of the 28 women reported using scented napkins; 7 were unsure whether they were scented. None used talcum powder, feminine hygiene spray or douches. None had recently changed brands of soap, laundry detergent or fabricsoftener. None had lichen sclerosis or vulvar epithelial hyperplasia (VIN) Three had a history of nonvulvar eczema or psoriasis

but had no active disease at the time of the index visit. None of the women was using vulvar or vaginal medications when the irritation began. Six had a history of contact dermatitis not involving the vulvar area, and five had a history of skin manifestations related to drug allergy. No patient had diabetes. The vulvar symptoms were not related to obesity: the median body mass index was 22.8 (IQR 20.9 to 24.2), which was within normal limits. None of the women used spermicide; five were exposed to condoms without resulting irritation.In the comparison group of 29 patients from the same practice, 8 (28 percent) were using Always napkins; 1 reported that they caused vulvar irritation but that she liked the "wings" feature. Eleven (38 percent) were using another brand ofnapkin, and 10 (34 percent) were using

tampons.Discussion The clinical picture of recurrent menstrual or postmenstrual vulvitis, described by some of the patients as "repeated yeast infections" or "chronic vaginitis," was always associated with the same brand of sanitary napkin. It is improbable that this was a chance occurrence: the Canadian market share of Always napkins in 1993 was about 30 percent (Ontario Consumer Information Office, Procter & Gamble, Toronto: unpublished data), and the proportion of women in thecomparison group who used this brand was 28 percent.Despite the rather striking pattern of recurrence, none of the women in the study group had made the connection between their sanitary napkins and the irritation. Few physicians are aware of this potential problem with Always napkins, although colleagues we have since alerted have confirmed our observations. We suspect that this relatively common reaction has escaped notice for several reasons. In our experience, it did not always occur with the initial use of the product or immediately upon exposure, and symptoms tended to persist and to worsen after the women stopped using the napkins. In some cases the symptoms began after the end of their menses. If the dermatitis is mistaken for Candida vulvitis, which is similar in appearance although not in distribution, its resolution coincident with antifungal therapy may mislead the patient and her physician into believing that it was a yeast infection. Indeed, we saw several patients who had been treated for"monthly recurring yeast infection" that resolved after

the correct diagnosis. <--- (NOTE THIS) Clinicians are generally unaware of the possibility that unscented sanitary napkins can cause contact dermatitis. Although Pincus [3] and others [6-8] have mentioned the possibility of allergy to the rubber or perfumes used in sanitary products, contact dermatitis to sanitary napkins is not mentioned in major gynecology or dermatology textbooks or in texts on diseases of the vulva. [1,2,7,9] Since almost all of the women in our study used unscented napkins, the cause of their symptoms was likely different from that in the previously reported cases--irritant rather than allergic.Many of our patients like Always sanitary napkins because of their length, the "wings" that protect the underwear and the wicking of blood away from the

surface through the Dry Weave plastic. This plastic, which lies directly in contact with the skin, may chafe and result in irritant dermatitis in some women. However, the timing and duration of symptoms suggest an allergic reaction to some component of the sanitary napkin. From our study we cannot determine whether the reactionswere primarily an irritant or an allergic contact dermatitis. Further investigation, including patch testing to various components of the Always napkins, is under way to elucidate the mechanism responsible for the vulvitis.Certain questions about the syndrome cannot be answered within the framework of a case series. The spectrum of severity and the prevalence cannot be identified, since

women making their own diagnosis would simply change productswithout consulting their physician, and the proportion of women using Always napkins who have experienced vulvar irritation cannot be estimated. Hanke-Baier and associates [10] observed skin irritation from Always Excel Plus andanother sanitary pad in 256 women and reported "up to moderate erythema" of the contact area during menstruation but did not provide data or analysis by type of pad. Because our case definition included Always use, we could not determinethe proportion of cases of menstrual or postmenstrual vulvitis attributable to this brand. However, the novelty of this pattern alerted us to the diagnosis, and in our experience the vulvitis

has been associated with the use of this product inalmost all cases.Our findings reveal a potentially important cause of recurrent vulvitis that has hitherto escaped notice. Because of the widespread use of Always sanitary napkins in Canada, physician awareness of the association will enable effective adviceand relief for a large number of women suffering from "chronic vaginitis."REFERENCES1. Hewitt J, Pelisse M, Paniel B: Diseases of the Vulva, McGraw Hill, London, England, 1991: 29-32, 49-51 [Context Link]2. Kase NG, Weingold AB, Gershenson DM: Principles and Practice of Clinical Gynecology, 2nd ed, Churchill Livingstone, New York,1990: 583-586 [Context Link]3. Pincus SH: Vulvar dermatoses and pruritis vulvae. [review] Dermatol Clin 1992; 10: 297-308 [Context Link]4. Larsen WG: Sanitary napkin dermatitis due to the perfume. Arch Dermatol 1979; 115: 363 [Medline Link] [Context Link]5. Sterry W,

Schmoll M: Contact urticaria and dermatitis from self-adhesive pads. Contact Dermatitis 1985; 13: 284-285 [Medline Link][Context Link]6. Maiback HI, Dannaker CJ, Lahti A: Contact skin allergy. In Middleton E Jr, CE, Ellis EF et al (eds): Allergy, Principles and Practice,4th ed, Mosby, St Louis, 1993: 1605-1648 [Context Link]7. Wilkinson JD, Rycroft RJG: Contact dermatitis. In Champion RH, Burton JL, Ebling FJG (eds): Rook/Wilkinson/Ebling Textbook ofDermatology, 5th ed, Blackwell Scientific Publications, Oxford, England, 1992: 611-716 [Context Link]8. Ridley CM: The Vulva, Churchill Livingstone, Edinburgh, 1988 [Context Link]9. HW, Wentz AC, Burnett LS: Novak's Textbook of Gynecology, 11th ed, & Wilkins, Baltimore, 1988 [Context Link]10. Hanke-Baier P, Johannigmann J, Levin R et al: Evaluation of vaginal and perineal area during the use of external sanitary protectionthroughout the menstrual

cycle. Acta Obstet Gynecol Scand 1994, 73: 486-491 [Medline Link] [Context Link]