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.