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Toxic Shock Syndrome: A Condition I Never Understood Until Now

November 12 2020 | Written by Miranda Vanhaarlem (She/Her)

I saw Toxic Shock Syndrome as an ominous boogeyman creature. We are all warned about it from our Sexual Education classes, the commercials we watch, and the back of our tampon product boxes, but if we don’t have personal experiences with it, do we understand it? I used tampons exclusively for the first 8 years that I menstruated, and I definitely left a tampon in for over 8 hours. Whether I was sleeping or on my lighter flow days, I simply forgot about it.  I even once put two tampons in at the same time without noticing. At a certain point in my life, and especially on lighter days,  it became normal to forget about changing tampons. Well, after researching about TSS, I can say that I will be more aware going forward. 

What is Toxic Shock Syndrome?

Toxic Shock Syndrome, commonly known as TSS, is a condition that is caused by the release of a toxin through the overgrowth of the bacteria Staphylococcus aureus (Staph) or Streptococcus pyogenes (Strep). The TSS toxin then enters the bloodstream which can be fatal. While we often heard about TSS affecting menstruators who commonly use tampons, it can affect all individuals who come in contact with the bacteria. For example, there can be an overgrowth of bacteria while recovering from surgery or through various types of infections. In the case of menstruation and  menstrual products such as tampons or menstrual cups, it is mainly caused by Staph bacteria. 

It is a common misconception that tampons are to blame for TSS, and that leaving a tampon in for over 8 hours will result in TSS. A review from the Department of Gender and Women’s Studies and Department of History at the University of Illinois states the following; 

“Tampons alone do not cause TSS. Specifically, the bacterium Staphylococcus aureus (S. aureus) is responsible for TSS, and its role and complicated relationship to the tampon have vanished from the message.”

If the bacteria Staph is responsible for TSS, where do tampons come into the picture? The use of tampons increases the risk of TSS in two ways; 

  1. When blood flow is lighter, the material in tampons can stick to the walls of the vagina, which can lead to tiny abrasions when removed; leaving a perfect environment for bacteria.

  2. Tampons that are left in the vagina for a long time can encourage the bacteria to grow; this risk is even further increased while using super-absorbent tampons. 

We also have to take into consideration the pH levels of the vagina. When an individual is not menstruating, the vaginal pH level is usually between 3.8 and 4.5, making the vagina slightly acidic. The good part about having a slightly acidic vagina is that it makes it more difficult for harmful bacteria to thrive in. Blood, however, has a pH level of 7.4. Are you putting two and two together? During your period, your vaginal pH levels are elevated, making the vagina less acidic and more conducive to bacterial growth. 

The History of Toxic Shock Syndrome & Tampon Use

By the 1970s tampons were considered common sanitary products, with over 70% of American menstruators using tampons, and popular brands such as Tampex and Playtex already well known. These companies often used cotton combined with rayon (cellulose fiber that is made from natural sources of cellulose, such as wood), in order to make their tampons because it was cost-effective and efficient when it came to absorption. Because certain menstrual companies were already established and had reliable consumers, in order to make waves in the tampon world, something had to change. This is when Procter & Gamble come into the picture. 

The history of TSS and its relationship with tampons is a long and twisted road, but it basically comes down to one word: Rely. Crafted by Proctor and Gamble in August of 1978, Rely seemed to provide a solution to the one complaint with tampons at the time; leakage. Unlike other tampons at the time which only expanded lengthwise, Rely worked with vaginal anatomy by expanding widthwise as well. As we can see below, Rely even absorbs the worry.

Rely tampons were made with polyester beads and carboxymethylcellulose instead of cotton, which made them extremely absorbent. As pictured in the ad above, Rely tampons expanded vertically and horizontally, almost forming a cup inside the vagina, which helped prevent leaks, but it also turned out to be a feature that increased bacterial infections

Remember the two ways that tampons increase the risk of TSS that were mentioned above? Let’s take a look at each one and connect them to Rely.

1. When blood flow is lighter, the material in tampons can stick to the walls of the vagina, which can lead to tiny abrasions when removed.

Rely tampons were extremely absorbent, leaving the vagina dryer than normal. This led to tiny abrasisions being left on the vaginal wall when Rely tampons were inserted and removed, which gave the bacteria the space it needed to grow. 

2. Tampons that are left in the vagina for a long time can encourage the bacteria to grow; this risk is even further increased while using super-absorbent tampons. 

Rely tampons' whole marketing strategy was that they were super absorbent meaning you could leave them in for extended periods of time, allowing the bacteria time to grow. 

Rely used mass marketing as a form to sell their products and ended up distributing 45 million sample boxes across the USA. 

Tampons that have all the qualities to allow Staph to grow + 45 million sample boxes = The outbreak of TSS in the 1980s.

The above newspaper article from March of 1981 shows that Rely tampons were not recalled until September of 1980 and, even after they were recalled, cases of TSS still occurred. It wasn’t until after 1984 that researchers realized TSS was associated with the use of higher absorbecy tampons. A study at the Centers for Disease Control and Prevention in Atlanta, Georgia found that 5000 individuals in the United States contracted TSS between 1979 to 1996, and that menstrual TSS accounted for 74% of these cases. As shown in the graph below, since the initial outbreak in 1978, the number of cases of TSS for menstruating individuals has reduced drastically due to the lowering of absorbency levels, the FDA’s (Food and Drug Administration) requirement of labelling on tampon packaging, and the removal of polyacrylate.

Should I still be scared of TSS?

To be aware of TSS is the key. One should not be scared of TSS but educated on the preventative measures that can be taken and the side effects of TSS. Government agencies like the FDA as well as tampon companies have worked together since the 1980s to identify recommendations to reduce the risk of TSS. Their recommendations consist of the following; 

  1. Limit wear-time per tampon to no more than 8 hours - a recommendation that one changes tampon every 4-8. 

  2. Advise against the use of tampons “overnight.”

  3. Use the lowest absorbency tampon that you can.

  4. Wash your hands before inserting a tampon.

  5. Do not use tampons when you’re not on your period. 

TSS Signs and Symptoms

It is important to be aware of how you are feeling when you are menstruating, especially if you use tampons and/or a menstrual cup exclusively. As mentioned above, TSS associated with menstrual products is usually caused by Staph infections. The signs and symptoms one may notice are the following; 

  1. Fever

  2. Flu-like symptoms; headache, fatigue, sore throat and cough 

  3. Rash; similar to a sunburn 

  4. Gastrointestinal symptoms; diarrhea

  5. Muscle pain 

  6. Dizziness or fainting

If you are experiencing any of these symptoms of TSS, visit your healthcare provider immediately. 

Even though TSS is rare nowadays, it is still important to understand the variables that are involved; one being the use of tampons. It is also important to recognize that Staph bacteria has ideal conditions where it is more likely to thrive and that super-absorbent tampons can create this environment. If you would like a quick summary of TSS, click here.