TSS: everyone has heard of it. But how dangerous is this Toxic Shock Syndrome (TSS) really? Does it make a difference which menstrual product you use? Is there less risk with tampons made from biological cotton? Can menstrual cups also cause what’s commonly known as ‘the tampon disease’? What has period poverty to do with TSS? Read the whole story here.

What is TSS?

Toxic Shock Syndrome (TSS) is a pretty rare, acute, bacterial infection that’s usually caused by the Staphylococcus aureus (staph) bacteria, and sometimes also by the group A streptococcus (strep) bacteria. Normally, these micro-organisms are harmless. Most people (both women and men) carry them without knowing, for example on their skin or in their mucous membranes. And these two definitely aren’t the only bacteria you carry. The human skin, with an average surface area of 1.8m², is home to about 1.5 billion of them. In total, these bacteria, together with fungi and viruses, make up about 1.5 kilos of your body weight.

Generally, the micro-organisms all of us carry with us don’t cause any trouble. However, sometimes the natural balance gets disturbed and one of these bacteria strains tries to take over. In those cases, the Staphylococcus aureus can cause all kinds of health problems; skin infections such as impetigo and acne, but also for example pneumonia, osteomyelitis and bloodstream infections. The Streptococcus pyogenes (aka the feared ‘flesh-eating’ bacteria) can lead to erysipelas, impetigo and puerperal fever. And in very rare cases, an overgrowth of one of these two bacteria will lead to TSS.

How to recognise TSS?

• TSS symptoms include flu-like symptoms (like a headache, chills, muscle ache and sore throat), a high fever, vomiting, diarrhoea, sunburn-resembling rash, redness of the eyes, trouble breathing, dizziness and fainting due to low blood pressure.
• If you have the above symptoms while menstruating and you’re using tampons or other internal menstrual products, quit using them and visit a GP. If TSS is diagnosed in time, it can be easily treated with antibiotics. When untreated however, you can get into a shock (hence the name), organs can get damaged or shut down and eventually it could even cause death.
• Don’t panic: TSS is extremely rare. Yearly, between 3 and 15 cases per 100.000 menstruating women occur. In 5% of these cases the disease is fatal. No need to throw away all your tampons (just make sure to change them in time!).

What’s the connection between TSS and tampons?

The reason TSS is also called ‘the tampon disease’, is that in the end of the seventies a lot of women who got TSS were using Rely tampons (Procter & Gamble). These tampons were made of synthetic fibres and were extremely absorbing. Users kept the super absorbing white sticks in for longer, thus creating the perfect climate for the Staphylococcus aureus bacteria, which in order to become a source of infection need a good breeding ground, warmth, oxygen, and also time. In 1980, the Rely tampons were taken off the shelves after the Center for Disease Control published a report which linked them to TSS. Sharra L. Vostral wrote an extensive essay about this issue.

TSS and other menstrual products

So yes, there is a link between TSS and the usage of tampons. But you’re carrying the bacteria that can cause TSS on your body anyway. So you can also get it when using other menstrual products such as (washable) pads and period underwear, sponge tampons and menstrual cups. For the very simple reason that it’s also possible to get TSS if you don’t use any menstrual products at all. In order for TSS to occur, the Staphylococcus or Streptococcus bacteria have to grow and produce toxins, which then have to enter the bloodstream, either through a small wound or irritation. Nowadays menstruating women count for only about half of all TSS cases; the other half occurs in menopausal women, children and men.

Does it actually matter what type of menstrual product (or which tampon) you use? Menstrual cups don’t absorb any fluid, so they don’t dry out the vagina and/or cause small wounds or abrasions in the vaginal mucous membrane. Logically, they thus come with a lower TSS risk. That, at least, was what everyone thought. However, a French study that was published in the Applied and Environmental Microbiology magazine in April 2018, pointed into a different direction.

This study, which was held at the Université Claude Bernard in Lyon and led by professor of microbiology Gérard Lina, investigated 11 types of tampons and four menstrual cups. They tested which materials showed the fastest growth of Staphylococcus aureus and the toxin TSST-1 that’s produced by these bacteria. The bacteria they used, came from a tampon of a patient who had TSS back in 2014.

Reason for this research is that the composition of tampons has changed a lot in recent years and many previous studies date back decennia. Also, most other studies don’t include menstrual cups, even though back in 2015 there has been a confirmed case of TSS associated with the use of a menstrual cup. Hence it was time for a new evaluation of intravaginal protection products. And one with new results. Particularly when comparing it to the American study from 1994 by microbiologists Philip M. Tierno and Bruce A. Hanna which tested 20 varieties of tampons (made of cotton, rayon, polyester or a combination of these materials) as well as a polyurethane contraceptive sponge, a latex diaphragm, and a polymer menstrual cup. The results of this research indicated that all-cotton tampons come with a lower TSS risk than their synthetic counterparts.

The French study compared tampons made of cotton, rayon, polyester and a combination of these materials and cups made of thermoplastic polymer (TPE) and silicone. Their conclusion: it doesn’t really matter what material the tampon is made of, and, contrary to what was previously believed biological cotton isn’t automatically safer. ‘Our results did not support the hypothesis suggesting that tampons composed exclusively of organic cotton could be intrinsically safer than those made of mixed cotton and rayon,’ said research leader Lina. Not the material, but the amount of air that’s between the fibres seemed to raise the risk of bacterial growth. Another notable finding: when compared to tampons, menstrual cups would have a slightly higher TSS risk.

The reason for this, according to the study, is that together with a menstrual cup also oxygen is inserted into the vagina, something which would stimulate bacterial growth. Because of that, it’d be best to use the smallest size cup possible. The research also indicated that even rinsing a cup three times isn’t enough to get rid of the bacteria; Staphylococcus aureus would attach itself to the cup like a biofilm.

Don’t panic: TSS is extremely rare. Yearly there are between 3 and 15 cases per 100.000 menstruators

Salient detail: in 2017 research leader Lina already exposed the results of the study, which then wasn’t finished yet. These so-called ‘preliminary results’ created a lot of commotion and led to conspiracy theories. Biological tampons and menstrual cups were rapidly taking over the menstrual product market. Was it perhaps an attempt to stop this developmenSuppliers of sustainable menstrual products in any case react surprised when hearing the results of the study.

The French study has been done in a laboratory. It isn’t sure Staphylococcus aureus bacteria and TSST-1 will expand at the same rate in real life (read: in the body of a menstruator), where an army of good bacteria will be waiting to keep these harmful ones in check. The human immune system hasn’t been taken into account in this research. In order to make a really good risk assessment, more research is needed. Until then, like always, use your common sense. And make sure you have a healthy vaginal environment. And that’s something you can influence yourself, both with the menstrual products you choose and the way you use them.

Play it safe

• Change your tampon regularly, and always when it’s saturated. On days that your flow is heavier, change more frequently. Check this by gently pulling on the rope. If you feel movement, it’s time for a change.
• Never keep in a tampon, sponge tampon or menstrual cup for longer than the maximum time that’s indicated on the package.
• Use the smallest size tampon possible, with the lowest absorbency rate and one that doesn’t pill.
• When using an internal menstrual product overnight, insert it just before going to bed and change (in case of a tampon) or rinse (when it’s a menstrual cup) immediately after waking up.
• Don’t just use internal menstrual products, alternate between intravaginal protection ((sponge) tampons and cups) and (washable) sanitary pads or period panties.
• Sterilise your menstrual cup before and after every menstruation, according to the instructions on the packaging.
• Invest in good quality cups that are made of medical-grade silicone. Regularly check the cup for any damage, such as cuts or abrasions where bacteria can accumulate.
• Thoroughly rinse and clean the cup with water between every use. When cleaning, pay special attention to the suction holes near the rim. For this, you could also use the menstrual cup supplier’s special wash gel or cup wipes.
• Don’t just wash your hands after inserting a menstrual cup, sponge tampon or tampon (with or without applicator), but also before. The Staphylococcus aureus bacteria can live anywhere on your body, including on your hands and under your nails.

TSS in the media

The chance of it going wrong is minimal. But when it happens, it can go really wrong. In 2013, a 16-years-old Belgian girl died from the consequences of TSS and in 2017 another 16-years-old girl passed away during a school camp in Canada. Both TSS cases got press coverage all over the world. In 2015, the American model Lauren Wasser told her story in the media. She lost her right lower leg and the toes of her left foot to TSS in 2012 and sued tampon manufacturer Kotex, stating the warnings in fine print on their packaging weren’t clear enough. The most famous male TSS victim is puppeteer Jim Henson, known from The Muppets and Sesame Street. He died in 1990.

Every tampon package comes with a TSS warning. That, together with the absorption grade, is about the only thing manufacturers are required to print on their packaging. You’d think that by now everyone knows you shouldn’t keep tampons in for too long. However, the problem is that not everybody has enough products to manage their menstruation. Women in developing countries, refugees, homeless, and convicts, for example. In some American prisons tampons are practically unaffordable, which leads to a higher risk on all kinds of health problems, including TSS. Period poverty also exists in Europe and the USA. The USA are struggling with a tampon shortage at the moment. Lack of menstrual products, because of supply chains shortages or because of money problems, period poverty has a direct impact on health. Period!

Period! is an independent, online magazine about all aspects of menstruation. Period! is not intended as a substitute for medical advice. If you’re suffering from medical complaints, always visit your doctor or GP. Editorial articles can contain affiliate links. Sponsored collaborations can be found in the category Spotlight. Do you have any questions? Check our Contact page.

Photo by Josefin on Unsplash Picture in the middle: Shutterstock. 

LATEST UPDATE: 20-6-2022.

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