Toxic shock syndrome (TSS) is a very serious condition that occurs when bacteria, usually staphylococci (but sometimes streptococci or other bacteria), produces a toxin that enters the blood stream. It can cause fever, low blood pressure, muscle pains, rash, and organ failure. One source of the bacteria is from the vagina during menstruation, the theory being the blood and other environmental changes during menstruation provide a good medium for growth of the bacteria and production of the toxin. Another theory is that the micro trauma associated with tampon insertion and removal makes it easier for the bacteria and toxin to enter the blood stream from the vagina. The bacteria and toxin can also be produced in the vagina after delivery or after gynecologic surgery or can come from a non-gynecologic site (such as a skin infection). The incidence of TSS is 0.5/100,000 overall and 1/100,000 among women ages 15-44.  The highest risk is among women ages 15-24 (approximately 1.5/100,000). The risk of death from menstruation related TSS is 1.8% and 6% for non-menstrual TSS. Non-menstrual TSS is becoming more common.

A clustering of cases associated with menstruation in the 1970’s prompted TSS to be classified as a reportable disease. Initial studies identified an association between tampons and mentrual-TSS, specifically Rely tamponsRely was unique in that it contained carboxymethycellose which, coupled with the unique cup like design, made it REALLY absorbent. Several studies have looked at tampon risk factors and some found no association between tampon absorbency or the frequency of tampon change and some fond an increased risk of TSS with increasing absorbencyRely was pulled from the market and the chemical composition of tampons was changed (they are now far less absorbent). Tampons are now made from cotton or cotton and rayon. Some lab studies suggest that the toxin is less likely to grow with a cotton tampon, but other studies refute this. There is no data that shows a link between rayon tampons and TSS.

What we do know is that the number of cases of TSS associated with menstruation have dropped 99-0611-F1dramatically. Whether this is due to the change in tampon absorbency, change in chemicals, increased awareness of TSS due to changes in product labeling, or another factor (such as a change in the way staphlyococci and other bacteria produce toxins) isn’t know. A large observational study (more than 5,000 cases of TSS identified over 17 years) reported that 89% of women with menstrual TSS used tampons exclusively. Tampon absorbency was available for 41% of women with menstrual-TSS and 28% used regular tampons and 71% used super-absorbency. However, we have no idea how this tampon use pattern compared to controls. For example, in my peer group everyone uses tampons exclusively and they only use super-absorbent. Without an age-matched control group for comparison the data on tampon absorbency means very little.

As far as tampons increasing the risk of TSS because of micro trauma with insertion or removal, other conditions that can cause small breaks in the vagina, such as herpes lesions and skin conditions or having a pessary, don’t seem to be associated with TSS. No link has been identified between menstrual cups (which can be worn for up to 12 hours) and TSS, although menstrual cups are far less common in the US so given the rarity of TSS, it’s not possible to say too much.

So what’s the verdict? While menstrual-related TSS is a known entity and a serious illness, it is very uncommon. The data that linked tampon absorbency with TSS was with tampons that were far more absorbent and manufactured with chemicals not currently in use. There is also no data to say how long is “too long” between tampon changes. We know that forgetting a tampon in the vagina can cause an overgrowth of bacteria, but the exact timing of the transition from good bacteria to potentially dangerous bacteria isn’t know.

Many factors are probably involved in developing TSS. For example, studies now tell us that most women (85%) have protective antibodies against the most common toxin that causes menstrual-TSS and therefore are not at risk for the disease. Interestingly, 98% of women who carry the toxin-producing bacteria (either in their nose, vagina or anus) have antibodies and are therefore immune to the toxin.

The recommendation to avoid using modern tampons overnight and to use the lowest absorbency tampon certainly errs on the side of safety (not necessarily a bad thing) and reduces manufacturer liability, but does not seem to get a thumbs-up or a thumbs-down from the medical literature. An association between modern tampons and menstrual TSS is only suggested by one study that has no control group and no one has proven exactly how tampons are associated with TSS. Given how uncommon TSS is, it is hard to see how there will ever be enough data to say with any scientific certainty that super or regular tampons are safer than super-plus or that tampons should be alternated with pads. However, more studies that look at the immune system may be able to clarify who is not at risk. L2513489

*Remember this post does not represent individual medical advice

Join the Conversation


Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

  1. Thank you for the very interesting summary of TSS. However your advert for Tampax at the end was not welcome. You may not be aware that during the RELY “epidemic” in 1979/80, some of the cases ot TSS were caused by other brands including Tampax. The main cause was that tampons contained CMC a very absorbent material. Today’s tampons contain RAYON, another very absorbent man-made fiber. There is a reaction between the bacteria and rayon that produces the toxin. You correctly identified the resultant progress of TSS after that. You didn’t say that there has been no reports of TSS when using ALL-COTTON tampons. Cotton is less absorbent than rayon and is safe. Research conducted by Dr Jeffrey Parsonnet for Tampax, when they were about to launch their “overnight” tampon found that there were 2 high risk factors: 1 ABSORBENCY (users should use the lowest absorbency for their flow) and 2. CONTINUOUS USE (tampons should be alternated with pads). He said that length of time was NOT a high risk factor. This is because TSS can start within 2 hours, so it’s prudent to change tampons regularly to remove the bacteria/toxins.

    1. It’s not an advert. It’s just a picture of tampons as an illustration for her article which is about, you know, tampons.

      Also, she did talk about rayon VS cotton tampons. She also talked about using tampons exclusively VS alternating with pads. Did you even read the whole article? Not by the sounds of it. But by all means, as a man who’s never used a tampon and probably never conducted any tampon-related research himself, do lecture the gynaecologist about tampon safety.

      1. Hello Leah, do I detect a bit of hostility? I’m only trying to help. Perhaps I should have explained that I have spoken with over 50 women/girls (or mothers who have lost their daughters to tampons) since my own daughter died of TSS in 1991. I needed to raise the danger of RAYON which is a highly absorbent fibre. Although rayon is mixed with cotton to produce tampons with a range of absorbencies, the rayon is still highly absorbent. Girls using the lowest absorbency tampons have still got TSS. Dr Philip Tierno of New York undertook some invitro tests comparing tampons containing rayon with all-cotton tampons and found that all-cotton tampons did NOT produce TSS, whereas tampons containing rayon produced TSST1 toxin..You may be interested to know that tampons are NOT sterile, (unlike a first-aid dressing which is sterile). Tampon manufacturers explained that there is no need as the vagina is not a sterile place. Also it is too expensive for them to sterilise tampons. Just saying.

    2. I don’t think you know how “adverts” even work because if you did, you would know that this isn’t one.

      1. Hello Regina, most people who write articles about tampons show a photo of, you know, tampons. This article happened to show a photo of a TAMPAX packet/box. That constitutes an advert for a particular brand, i.e. Tampax, which is now owned by Procter and Gamble – the company that manufactured Rely tampons. Maybe you need to see the words “Buy this product” before you realise that someone is trying to highlight a particular brand. Come on Regina, get real. If you are concerned about Toxic Shock Syndrome, which can cause pain, organ damage, loss of limbs/digits, long term emotional distress and even death, then you should be criticising tampon manufacturers. But then again, you maybe employed by the tampon industry.

  2. Interesting information. It would be nice to see more studies (longer duration and with a higher sample size, like the one you linked to with 3000 volunteers) done to answer some of the questions/points that you brought up.
    You might be interested in the TSS stories on this site:

  3. I’m old enough to remember all the hoopla around tampon safety and it’s good to know that most of the problems have been addressed. But I’m loving the menstrual cup I started using a few years ago and happy to stay with it.

%d bloggers like this: