Is the fear of toxic shock syndrome preventing you from using a convenient menstrual product that gives you the freedom to continue your active lifestyle when ‘Aunt Flo’ pays a visit?

Menstrual products like tampons may be a risk factor for toxic shock syndrome (TSS).¹ However, by following the product instructions, handling tampons with clean hands, and wearing a tampon for less than 6 hours only on period days, you can eliminate the risk of tampon-related toxic shock syndrome.

Read this article to learn how a tampon could cause menstrual-related toxic shock syndrome and how to reduce the risk of TSS by adhering to tampon safety guidelines.

What is toxic shock syndrome? Key facts you should know

Toxic shock syndrome (TSS) is a rare illness that occurs suddenly and could be life-threatening if not treated.²

Staphylococcus aureus or Streptococci strains of bacteria that thrive on your skin, throat, or mouth can produce infectious toxins, causing the sudden onset of this disease.²

Under specific circumstances, infection by the toxins (poisonous bacterial chemical substances) provokes an overactivated immune response, causing the following symptoms suddenly:²

• Fever (> 39 °C)
• Sunburn-like rash (see 📷️)
• Low blood pressure
• Disorientation

One could also present an early sign of fever and chills with:²

• Nausea and vomiting
• Muscle pain
• Headache
• Sore throat

The infection presenting these signs and symptoms can progress into sepsis and multi-organ failure.²

Types and causes of toxic shock syndrome

To understand the causes of TSS, the opportunistic nature of Staphylococcus aureus or Streptococci strains should be known.

As mentioned, bacteria like S. aureus are normally present in/on us. However, when a cut on the skin or a weakened immune system compromises our body’s lines of defence, the bacteria exploit the situation and enter the host (e.g., bloodstream), infecting it.

The immune system reacts to the multiplying bacteria within the body or their toxins by unleashing the cytokine storm (excessive fighting), causing the symptoms of TSS. 

Toxic shock syndrome: Non-menstrual vs menstrual types

Several factors may damage the body’s lines of defence. The factors posing a potential risk for TSS are categorised as non-menstrual and menstrual.^{1, 2}

Retained nasal packs for nosebleeding and dialysis catheters, post-surgical infections, burns, recent influenza infection, and immunocompromised (impaired immune system) states are non-menstrual risk factors for TSS.^1,2,3

While people assigned male at birth (AMAB), people assigned female at birth (AFAB), and newborns are susceptible to TSS by non-menstrual causes, only AFAB individuals using menstrual products during menstruation, like a tampon, are at risk of menstrual TSS.¹

Understanding menstrual-type toxic shock syndrome

In the 1980s, the use of superabsorbent tampons (Rely tampons) by AFAB led to an American public health crisis associated with TSS.¹ The market discontinued the 'killer tampons' due to their association with TSS.

Studies then pointed to S. aureus and its toxins responsible for TSS.⁴

How menstrual products cause TSS

Menstrual products like tampons can promote the growth of S. aureus in an environment that is already conducive during menstruation (3 days before, during, and after menstruation).⁴

Lactobacilli (bacteria) play a crucial role in maintaining vaginal health and keeping the pathogenic microbes in check.⁴

However, hormonal changes before menstruation affect lactobacilli and their role in maintaining an acidic pH. The shift in pH allows the growth of S. aureus in large numbers.⁴

During menstruation, a vaginal pH between 6.8 and 7.2 and a body temperature of 37 °C promote S. aureus growth and its toxin production.⁴

Additionally, using a tampon during menstruation can introduce oxygen into the vagina, which otherwise lacks oxygen. This oxygen supports the toxin production by S. aureus, a key factor in TSS.⁴

Meanwhile, our body's strong defence system fights off anything unusual. Healthy AFAB produces antibodies to neutralise S. aureus toxins.⁴ Yet, a damaged defence barrier may fail to barricade infectious invaders.

For context, tampons with different absorption capacities misused during menstruation can cause tears in the vagina. These tears provide the opening required for S. aureus and its toxins to enter the bloodstream and cause infection.¹

The above findings should not discourage you. From choosing the right tampon, reading the instructions for proper tampon insertion and removal, to following the safety guidelines, you can efficiently reduce the risk of any infection, including menstrual-type TSS.

Tampon safety tips to prevent menstrual toxic shock syndrome

Tampons are convenient, effective, and safe menstrual products when used properly. Also, tampon manufacturers must comply with the regulations set by government regulatory bodies to ensure that the tampons on the market are safe and meet stringent quality standards.

Regulatory bodies—Medicines and Healthcare products Regulatory Agency (MHRA) in the United Kingdom and the U.S. Food and Drug Administration (FDA) in the United States of America—regulate tampons as medical devices.⁵

As the manufacturers ensure the quality of the product (tampon), here are a few tips to ensure safe and hygienic tampon use by you.

Choose the right tampons for your needs

Tampons, made of cotton, rayon, or a blend, are designed for easy insertion, good fit and absorption of menstrual discharge, and easy removal without leaving behind any tampon fibres in the vaginal canal.⁴

Your menstrual flow type (very light, light, moderate, or heavy) should guide your choice of tampons. The tampon size corresponds to the absorbency of the tampons to manage the flow type. 

Tip: Look for the absorbency label (see 📷️) on the tampon pack to help you choose the right tampon.

Why should you use the lowest absorbency tampon?

You can use tampons of different absorbency levels during menstruation to match your menstrual flow. But using a lower absorbency tampon will decrease the risk of menstrual TSS.^4,6

Tampons with absorbancy unsuited for your menstrual flow can lead to a dry tampon, making it difficult to remove or causing vaginal injury during tampon removal.⁷

The FDA reiterates the increased risk of menstrual TSS if: 

• You can wear a tampon for 8 hours without changing
• You wear a tampon on days of spotting or not menstruating

The above indicates a tampon of unwanted high absorbance in your vagina, promoting bacterial growth and toxin production and could develop vaginal dryness, microtrauma, cuts, or ulceration, increasing the risk of S. aureus toxin infection and menstrual TSS.^6,7

Safe tampon use starts with the instructions

The menstrual TSS epidemic of the 1980s, owing to the super-absorbent Rely tampons, attracted the attention of researchers and media to answer ‘why tampons were associated with menstrual-type TSS?’^4,6

Since then, regulatory authorities have required the tampon manufacturers to notify consumers about the leaflet containing important information and instructions for use within the box.⁵

The quality specifications developed by the United Nations Children’s Fund (UNICEF) for tampons require the leaflet to contain the following instructions for use:

• Follow all labelled directions
• Use low-absorbency tampons to suit the menstrual flow
• Use tampons appropriately only when menstruating
• Wash hands thoroughly before and after inserting or removing a tampon to reduce the spread of bacteria 
• Use or insert only one tampon at a time
• Methods to insert and withdraw the tampon with or without an applicator
• Wear time per tampon (4-8 h)
• Ensure the removal of the last tampon once menstruation has stopped
• Do not use tampons during vaginal sexual intercourse
• Do not use tampons for purposes other than menstruation (bleeding soon after or within the first 24 h after intrauterine device insertion, vaginal discharge, vaginal medication, and during vaginal infections or irritation)
• Avoid overnight tampon usage altogether or for more than 8 hours
• Disposal instructions for the used tampon (do not flush tampons, applicator tubes or wrappers)

Despite these measures, research has found that young AFAB neither read nor follow tampon instructions (in the case of reading).⁸ Being oblivious only increases the risk of TSS.

Tip: Always read the leaflet in the tampon pack carefully.

Avoid risks: Change tampons every 4 to 6 hours

Remember the ABC of tampon safety:

• Absorbency (go low)
• Be Clean (wash hands)
• Change Often

Going for low absorbency will prevent dry tampons, thereby vaginal injury, and encourages you to change regularly into a fresh tampon. Changing your tampons once every 4 to 6 hours significantly lowers the risk of menstrual TSS.^6,8

Studies in 2020 reported many healthy AFAB (who used tampons) had the toxin-producing S. aureus colonising their vagina.^8,9

The presence of these bacteria on the soiled tampons emphasises the need to wash your hands while handling new or soiled tampons.⁹

The risk of developing menstrual TSS is determined by the presence of toxin-protective antibodies in the AFAB and how the tampons are used.⁸

Hence, the study establishes the maximum tampon wear time as 6 hours and discourages overnight tampons for menstruation to reduce the risk of developing menstrual TSS.^6,8

Tip: Change your tampon every 4 to 6 hours, not 8 hours.

Menstrual TSS: Educate yourself for better health

The tampon industry continues to educate and raise its consumers’ awareness of the rare but serious illness, TSS.

However, the guardians must provide initial education on safe tampon use, precautions, the risk of menstrual TSS, its symptoms, and recommend actions for symptoms to their ward (young AFAB).⁸

Research emphasises the importance of public health policies and educational programs designed for adolescents by health professionals to prevent menstrual TSS.⁸

In addition, articles like this on Klarity Health Library provide comprehensive materials for education.

FAQs

Why should I not use more than one tampon?

Using more than one tampon hinders frequent changing of tampons, increasing the risk of menstrual TSS. It's not advisable to use more than one tampon, as the first one could lodge deeper in your vaginal canal. 

A tampon deep into the vagina can further spread the toxin-producing bacteria or cause vaginal dryness and injury, thus increasing the risk of TSS. 

A tampon has a withdrawal string for easy removal.⁴ A second tampon increases the likelihood of an inaccessible tampon string, thereby complicating its removal. 

If you cannot remove a tampon, do not panic. Try removing it yourself by following these instructions. If you can’t get it out yourself, seek help immediately from healthcare staff.

Can I use sustainable, reusable tampons?

Reusable organic tampons are sustainable menstrual products, free of pesticides and chemicals.¹⁰ However, the FDA does not regulate these products. The FDA has only approved single-use, individually wrapped tampons that ensure the hygienic quality of the menstrual product.

The FDA discourages reusable tampons as they have additional risks of microbial infections. Product hygiene is the sole responsibility of the user and may pose a risk for menstrual TSS.

Summary

• AFAB using tampons during menstruation are at risk of menstrual TSS
• Tampons inserted in the vagina during menstruation provide the oxygen required for toxin production by S. aureus growing there
• The risk of developing menstrual TSS can be reduced with safe and hygienic tampon use
• Choose a tampon that meets your menstrual flow type, preferably of lower absorbancy, that encourages frequent tampon changing (every once in 4 to 6 hours) and avoids vaginal injury during tampon removal
• Read the leaflet in the tampon packs containing important information and instructions for use
• Handle the tampons only after washing your hands clean
• Educate yourself and your ward with the right information