IMG_1620 (1)Many women have heard about tampons and the association with toxic shock syndrome (TSS). Some women choose menstrual cups because they think they may be a safer alternative. However, a new case report details for the first time menstrual-associated TSS related to using a menstrual cup. Let’s look at what that may or may not mean.

Menstrual toxic shock syndrome (TSS) is a life threatening condition due to infection with Staphylococcus aureus (SA). While SA is a common bacteria (30-50% of us have it on our skin), the kind associated with TSS produces something called a super antigen – this is a toxin (yes, a real toxin, not the Dr. Oz type non-toxins that alternative medicine providers call toxins) that triggers the immune system to go haywire. The classic presentation of toxic shock syndrome is fever, muscle aches, a sore throat, swelling, and a rash that peels 1-2 weeks after it starts. A cascade of events with the immune system causes the organs to start shutting down and can affect the ability of the blood to clot. These are very bad things. Even with aggressive treatment some people will die and many will suffer severe long-term health consequences.

Use of tampons has been associated with TSS, although the exact mechanisms are not well-known. Theories involve a combination of the following:

  • Accumulation of blood in the tampon. Blood is an excellent culture media – we grow many bacteria in the lab in blood. The vagina has oxygen and carbon dioxide making it a good environment to support growth – so basically a bloody tampon in the vagina is an excellent petri dish. Tampons with higher absorbency may pose a greater risk.
  • Increase in vaginal pH from use of tampons – possibly altering the growth of bacteria or other changes in the local immune system of the vagina. I never understood how this could be tested as blood has an elevated pH and when you are on your period whether you have a tampon in or not there is blood pretty much everywhere.
  • Microscopic trauma from tampon insertion/removal (trauma allows bacteria and toxins to enter the blood stream).

But it’s not a simple as a direct cause and effect where tampons and TSS are concerned – recurrent TSS after tampons have been discontinued has been described. Also, younger women are at greatest risk for menstrual-associated TSS, so there may be antibodies that accumulate over time or other age-related changes that offer protection.

The incidence of menstruation=associated TSS is 0.69/100,000 and when not associated with menstruation the incidence is 0.32/100,000. So it’s very rare (low probability, high consequence), but menstruation does double the risk.

Some people wonder if menstrual cups might offer a lower risk for women who don’t want to use pads as they are silicone, which does not support bacteria growth. One study shows the cup doesn’t increase vaginal pH.  However, now that TSS has been associated with a menstrual cup it’s clear we don’t know what we don’t know.

TSS is very rare and menstrual cup use in North America is low, so we will see fewer reports than with tampons although that may change with time.

What this ultimately means is that menstrual cups are also associated with TSS, whether this is a different mechanism or a lower or higher risk than with tampons is not known. Whether you should clean the cup more often than the recommended 12 hours (which does seen arbitrary) is also not known.

I wouldn’t do anything different with just one case report, but I do think we should now make no assumptions that cups are safer than tampons.

Chose your menstrual products based on what works best for you. Always chose the lowest absorbency possible (although I know all those perimenopausal women are rolling their eyes – because, well, sometimes super plus just isn’t super enough!).  Wash your hands before putting in a menstrual cup or tampon. Don’t leave them in for more than 12 hours.  Try to avoid tampons or a cup if you are just spotting as very low flow increases the trauma with insertion.





Join the Conversation


  1. TSS is also not the sole safety concern with tampon use that has seen many people switch over to cups, also cups are still theoretically safer. Cups are less likely to cause abrasions, impact pH, encourage bacterial growth, fiber loss, or to contain potentially harmful ingredients and contaminates (in previous post you address latest scare, but until we can fully analyse risks short-term and long-term via cumulative exposure via independent safety tests there is still concern – we’re one step closer with news this week that manufacturers are going to disclose ingredients).

    We’re not sure of TSS instances with tampon use, the means of collecting data was just too flawed – too many misdiagnosed cases or cases simply not being reported, in the 70’s and 80’s the CDC statistics had various issues with reporting and presentation of data on TSS that saw figures grossly under-representing scale of the TSS outbreak. I’ve seen TSS experts put TSS occurrence as high as 1 in 700 women in their lifetime will develop TSS, verses statistics via tampon manufacturers at something more like 1 in 17,000+ – are we to compare this one case of TSS with menstrual cup use to the 1 in 700 or the 1 in 17,000+ cases with tampon use?

    I’ve personally gone with the theory that TSS risk was so low with menstrual cup use that there was no risk – not ideal, I know – if pushed I would liken the risk of TSS with menstrual cups to the risk of TSS with diaphragms. TSS occurs at a rate of 2.4 cases per 100,000 women using diaphragms, almost exclusively when the device is left in place longer than 24 hours – if you consider bacteria and toxin growth is exponential the risk of developing TSS from leaving a menstrual cup for the maximum 12 hours is significantly less than 2.4 cases per 100,000.

    1. You can’t draw any conclusions about the risk being lower with cups vs, tampons, incidence is so low. We may know over time.

      I’m aware of no studies that camp are abrasions with cups vs tampons

  2. Hi Dr. Gunter, I’m really glad you posted this because I have been having some interesting symptoms lately. Here’s the backstory: I have gone on and off NuvaRing three times over the past 10 years. In the last 5 years I’ve developed a friable (ectropion) cervix and I bleed during intercourse roughly 50% of the time adjusting for where I am in my cycle. I stopped birth control completely in April 2015 and have had to readjust to not being on birth control. Since then I’ve started bleeding more frequently during intercourse and I am now suspecting that it’s coming from both my cervical tissue and if I’m close to my period or ovulation, menstrual bleeding.

    Okay now for the DivaCup role. I started the DivaCup two months ago. It was hard to insert at first but got easier with practice. It is very convenient. This past month however I only stopped bleeding for 5 days out of the whole cycle. I’m still spotting and now starting my next period. I’ve been to my doctor and I’m awaiting a visit to a GYN. I’m starting to think that having ANYTHING (DivaCup, NuvaRing, Tampons) inside the vagina for any extended period of time can lead to a friable cervix, maybe even tissue damage, and infection. I’m on a “nothing in the vagina” order from the doctor until I’m asymptomatic. I hope that it will not only stop the bleeding for some period of time but also correct my friable cervix if that’s even possible. Any thoughts on that? Also, would it be possible for you to please address a friable cervix in a future post? Thank you so much.

  3. Thank you for this blog post! There is so much conflicting information out there and I always appreciate your measured, science-based responses to news reports about women’s health issues.

  4. I have suffered TSS with a Mooncup, specifically.
    The problem was caused by the dried blood in the anti-suction holes in the rim, which incubated the bacteria, despite being boiled/sterilised and washed at recommended intervals.
    I spent nearly a week in hospital on strong IV antibiotics and a warning that I might die over the weekend; fortunately I survived.

    1. This is just what I needed to read. I suffered from TSS with tampons when I was 16, roughly 10 years ago. I went through the same thing…over a week in the hospital and the nurses telling me that I could die. How scary! Since then, I have only ever used pads. Having to go from tampons to pads was hard to accept, but whatever I needed to do to stay healthy and alive, I’ll do. Now having discovered the menstrual cup, i thought, “finally something better than pads and seems safe!” Although, my doctor wasn’t budging on allowing me to try a cup. After reading your post, I won’t question my doctor again. Pads it is from here on out. 😦

      1. awww I understand what you two are saying :/ Three years ago while using tampons one night I developed super high fever, confusion, cramps and I started talking nonsense. Since I had no access to a hospital that night I had to wait to the next day, take the bus and go into the hospital. They sedated me for an entire day and gave me a bunch of drugs of antibiotics. Finally my body seemed to respond well and they sent me home not without telling me that if my symptoms came back to go back right away. Although they didnt tell me it was a toxic shock I think it was a very very slight one. I kept using tampons but just realized last week (after 3 years!) that once you have the bacteria you have it forever and you can have toxic shock again. Threw all my tampons away that day. I am very active and I was researching the menstrual cup as an alternative… but yeah…. if its not 100% safe I think i’ll just stick to pads and take those days of the month as a “retreat”, that is what nature intended after all. Thanks for sharing your experiences ❤

    2. Oh I hope that got reported. There was only one case in the literature of a cup possibly causing TSS. I have used menstrual cups for a long time but I think now I’ll just stick with cloth pads.

      1. I don’t think mine was reported, but I think the problem could have been avoided by cleaning out the ventilation holes with a pin, carefully and thoroughly, before boiling/sterilising the Mooncup.
        I did carry on using one (bought a new one obviously), and had no further problems, until finally the menopause solved all my problems 🙂

    3. How did you find out the cup was the culprit? Did they take it and test the blood in the holes?

  5. New cup users should be told in no uncertain terms that you need to wash your cup really well with soap every time you empty it and disinfect it between periods to prevent bacteria from accumulating. Silicone is not a growth *medium* for bacteria, but bacteria can form self-adhesive biofilms on lots of different kinds of surfaces.

    That’s why I don’t use mine for camping even though that seems to be one of the situations cups are advertised as being good for. Rather use tampons for a few days than try to give a cup a really good scrub with a single dipper of water and trying not to drop the soap while squatting over a hole in the middle of the jungle. Gross.

    1. Okay,
      It’s called don’t be a wimp. Menstrual cups > tampons or pads because they can last such a long time and while there may be a few instances of REPORTED TSS . Just use your head. Trust me, I’m definitely not the most cleanly person, but in over 6 years of using a cup I’d say their pretty damn convenient and safe in the long run. Just wash it with a mild soap at the end of every cycle. Vaginas are pretty damn tough. Just putting this out there because people are so apprehensive to using a cup. It’s fine, they work beautifully once you get used to it of course. No need to be so sterile about everything, it’ll be okay.

  6. I know everyone should find the best way for your body as we are all different. Sometimes the best way for others may not be the best way for you. On the side note, tampons have the highest reported risk amongst tampons, pads and cups. However, do note that pads are also not 100% safe. They are not any safer than cups. Everything has its risk, it is just the extent of it. Know your body and its reaction are most important.

  7. Don’t be afraid to boil your cup. Some cup producers discourage it and although it may shorten the life of an expensive product, if you feel more comfortable boiling it, then by all means do so.
    Also, the vagina has some pretty powerful stuff in it. Don’t ever douche because it kills the good bacteria. I can’t tell you how many pairs if underwear have been bleached or had holes put in them after only a few uses from the powerful bacteria.

  8. my company required a form some time ago and was told about an excellent service with lots of form templates . If you are wanting it as well , here’s a link “”

  9. I know this is really late, but I have a question re: menstrual cups. I’ve been using a cup for nearly 12 years now and love it. It’s been a great solution for me since tampons make my vagina itch really badly and disposable pads irritate my vulva. Cloth pads have been the only thing I can use other than cups. My question is, would it be safe to use a cup in a country where the water is not potable? I’ll be on my period while I’m in Ecuador and will need to figure something out to wash my cup. And before you suggest using birth control to control my period, I can’t due to my age and a history of migraines. So, thoughts on cleaning a menstrual cup in non-potable water?

      1. That’s a thought. Thanks! Someone else suggested I try Seventh Generation tampons to see if they make me itch too so I’m trying them with my next cycle to see since that will be easier than anything else on my trip.

  10. I’ve only ever used pads. Sure, I’ve tried tampons a few times but seeing that warning on the box for the first time at 11 traumatized me for life and now I have a phobia of tampons. The last time I tried to overcome my phobia was a little more than three years ago, I couldn’t work up the courage to use a tampon ever since. Sure, pads are the pariah of period products, yes, they are gross, bulky and messy, but at least they won’t kill me.

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