Toxic shock syndrome. “I started to menstruate and stories of nightmarish bacteria were everywhere”

«I am so old that I remember the panic over toxic shock syndrome (TSS, toxic shock syndrome) at the turn of 1979 and 1980. I had just started menstruating, and the stories of a nightmarish bacterium eating women alive were heard literally everywhere. TSS has scared many women from tampons, and this fear has been used by various people claiming that a woman becomes fallen if she puts something in her vagina before her possible future husband’s penis enters, writes Dr. Jen Gunter, author of The Vagina Bible ».

1. Toxic shock, TSS, is an acute intoxication of the body with a toxin that has entered the bloodstream
2. The symptoms of TSS are fever, inflammation of the skin which then peels off, drop in blood pressure, vomiting and diarrhea.
3. In the XNUMXs, Procter & Gamble decided to enter the tampon market with a new product – Rely super absorbent tampons.
4. “It absorbs everything, even stress” – that was the advertising slogan of the tampons. «I used Rely when I was fourteen and I remember the tampon absorbed so much blood that when I pulled it out it felt like I was giving birth to a big peach! I must have contracted microtraumas while removing it from the vagina »- recalls the author of the book
5. Soon, cases of toxic shock syndrome related to the use of tampons began to be reported
6. You can find more such stories on the TvoiLokony home page

Below we present an excerpt from the «Vagina Bible» by Dr. Jen Gunter.

«The fear of TSS also drives magazine sales, increases online click-through rates and serves as a weapon for those who promote” natural “hygiene products as better. If we add the cultural taboos about menstruation and the bizarre social conspiracy of silence about it, we have the perfect climate to mislead people.

Fortunately, there is an antidote, which is facts.

What is toxic shock syndrome?

Toxic shock, TSS, is an acute intoxication of the body with a toxin that has entered the bloodstream. A toxin is a substance produced by living organisms; bacteria, plants and animals can make it. Viper venom is a good example.

Toxic shock is caused by toxins produced by two types of bacteria: group A streptococci, which are responsible for strep throat, and staphylococci, specifically staphylococcus aureus. Group A streptococci do not live in the vagina, so they do not cause menstrual TSS (mTSS; group B streptococci infest the vagina but do not produce a toxin). TSS-1 toxin produced by staphylococcus aureus is responsible for the majority of cases of TSS. Shock is classified as menstrual if it occurs during the period or within three days after the end of the period. Non-menstrual TSS affects both men and women equally and usually follows surgery or an injury such as a burn. The incidence of this disease is approximately 0,3 per 100 people per year.

The symptoms of TSS are fever, inflammation of the skin which then peels off, drop in blood pressure, vomiting and diarrhea.. Internal organs may cease to function, and limb blood flow to limbs may result in amputation (which is fortunately very rare). On average, the patient stays in the hospital for six days, and some women are in such bad condition that they end up in the ICU. With good medical care, the risk of death is less than 4 percent. TSS survivors may experience relapses and severe health problems, or may experience memory loss. This is a serious disease.

Between 1979 and 1980, there were 1264 cases of mTSS in the United States, and 72 women, 6 percent of this number, died. Now the incidence of mTSS has dropped markedly, and the rate is 1 in 100 women of childbearing age. In 000, the last year we fully know about, 2015 women in the United States developed toxic shock syndrome. Most of these conditions were likely linked to menstruation, but information is lacking.

The origin of menstrual toxic shock (mtSS)

Staphylococcus aureus is a bacterium that lives on the human body and does not normally cause any problems. About 10 percent of women of reproductive age have staphylococci in the vagina (tampons have no effect on this)and 1 percent have a strain that produces the TSS-1 toxin. They are at risk of developing mTSS.

Menstruation – what to buy and what to measure?

The vaginal staphylococcal colony increases during menstruation, and iron from the blood increases the amount of toxin produced. Fortunately, the human body is endowed with natural defenses against shock: 80 percent of women have antibodies that neutralize TSS-1 (young women are more likely to get mTSS because they’ve had less time to develop antibodies), and some women have no vaginal tissues. receptors that the toxin must attach to in order to enter the bloodstream.

Considering that 70 percent of women have used tampons at least once, 1 percent of women are carriers of the TSS-1-producing bacteria, and less than 0,01 percent of women develop mTSS each year, our defenses are quite effective.

Rely Tampons – An Important Lesson in the History of Women’s Hygiene

In the XNUMXs, Procter & Gamble decided to enter the tampon market with a new product that would deal a blow to the competition. Previously, all tampons looked similar – a cotton roller, sometimes with some viscose, which, while absorbing blood, increased mainly in length. At Procter & Gamble, they invented a new type of tampon, called Rely. It was made of polyester foam cut into small particles and of carboxymethylcellulose, a thickener also used in food products (a good example is that if something is good to eat, it doesn’t necessarily have to be good for the vagina), sealed in something like a bag from tea. The advertising slogan read: “It absorbs everything, even stress”. I used Rely when I was fourteen, and I remember the tampon absorbed so much blood that when I pulled it out it felt like I was giving birth to a big peach! I must have contracted microtraumas while removing it from the vagina.

In the United States, personal hygiene products are regulated by the FDA, the Food and Drug Administration, which classifies them as medical products. The manufacturer of any new product on the market that differs significantly from those already approved must submit the test results to the agency before the novelty is introduced to the market. Technically speaking, personal hygiene products need not so much be approved as assessed by the FDA.

Procter & Gamble notified Rely prior to the entry into force of these procedures, so the tampons were approved without evaluation. There was an intense advertising campaign, and by the end of the 25s, about XNUMX percent of American women were using Rely. Until cases of menstrual toxic shock began to appear.

The Rely tampon was badly designed. The pieces of foam gave the bacteria plenty of room to multiply, and the patchy structure allowed more air to enter the vagina than a normal tampon. The thickener, cellulose, turned out to be an excellent medium for bacteria. Other manufacturers emerged adding absorbent material, polyacrylate, to their tampons to compete with Rely, which made the situation with mTSS even worse.

Rely was withdrawn from the market on September 22, 1980 and the number of TSS cases began to decline. In 1985, the use of polyacrylate in tampons was discontinued in the United States.

Remember your Rely story every time you see information about a new “groundbreaking” tampon or menstrual cup somewhere on crowdfunding platforms. Bold inventions can turn out to be dangerous. If a new product differs significantly from those on the market, it should be positively assessed by relevant institutions.

If Rely is no longer available for sale, why do mTSS still occur?

All tampons, vaginal (contraceptive) sponges, caps and menstrual cups increase the risk of menstrual toxic shock. We don’t know exactly why this is happening, but the most likely factors are:

Introduction of oxygen and carbon dioxide into the vagina during insertion

Both oxygen and carbon dioxide accelerate the multiplication of bacteria. Menstrual cups can introduce more air into the vagina than tampons.

Creating an environment for the multiplication of bacteria that do not produce TSS-1.

While other bacteria do not produce a toxin, they do produce carbon dioxide (a product of metabolism) that promotes the development of staphylococci.

Fibers on which bacteria thrive.

Past studies have suggested that cotton creates a less favorable environment for bacteria than viscose or rayon, but more recent studies that recreate the low-oxygen conditions of the vagina show that staphylococci multiply faster on cotton-only tampons. So it cannot be assumed that cotton is safer.

In silicone and polyethylene menstrual cups, bacteria can form a biofilm.

Biofilm is a protective coating that bacteria surround itself to avoid being recognized and destroyed by the body’s defenses. The research shows that bacteria fare slightly worse on polyethylene cups than on silicone ones.

High absorbency

The more absorbent the tampon, the greater the risk of mTSS.

Injuries on insertion or removal

Injury can create an opportunity for the toxin to enter the bloodstream directly, bypassing defense mechanisms.

Practical tips – how to reduce the risk of developing mtSS

When using vaginal intimate hygiene products, it is not possible to completely eliminate the danger, but if we consider how many women use tampons and how few of them develop mTSS, the risk of contracting the disease is low. In England it has been estimated to be now lower than the risk of shock from other causes. One idea is to realize that in the United States, the probability of contracting mTSS each year is roughly equal to the probability of dying from lightning. For some, the risk will be low, for others the risk is high, although I always remind my patients that we do things that are far more risky every day than wearing tampons or a menstrual cup. For example, nearly XNUMX pedestrians are killed on the roads in America every year, yet we do not prohibit anyone from going for a walk. Just by removing pubic hair, you can develop abscesses and more serious infections. Any interference in the body carries some risks and we all have to make the right decisions.

Young women are primarily at risk of developing mTSS. This does not mean that 24-year-olds should avoid tampons – this is just information that should be considered when making choices about our body. Even among women under the age of 2, the risk of developing mTSS is lower than 100 in 000 women each year.

Below you will find some practical tips for using tampons.

1. Choose the lowest absorbency. Some manufacturers sell boxes of different sizes. If you only have a super or super plus size at home (women in their forties will understand), you probably use a tampon that is too absorbent for less bleeding days (if you have one).
2. Don’t assume purely cotton tampons are safer. Recent studies show that cotton-rayon blend is safer. However, it is not known whether the experiments performed in the laboratory translate directly into reality.
3. Watch out for injuries when putting on and removing tampons. Using lower absorbency tampons on less bleeding days can help you avoid them.
4. The recommendation to change tampons at least every seven hours is not based on scientific evidence, but it seems reasonable. Changing tampons more often will not reduce the risk and may even increase it, as more frequent applications are more air and carbon dioxide injected into the vagina, and more injuries.

Tips for using menstrual cups:

1. Don’t assume they’re safer than tampons. One study found that they were more likely to promote staphylococcal multiplication and the production of TSS-1 toxin than tampons.
2. Choose the smallest size that suits its purpose. This means buying different sizes of cups for days with more and less bleeding.
3. Always have two cups at your disposal as amo rinsing the cup is not enough to remove the toxin. It should be boiled before wearing it, so it’s best to always have a clean one on hand.

Sea sponges

Sponges are aquatic organisms made of spongin protein. They don’t have developed organs like lungs, kidneys, or heart; they nourish and breathe, filtering seawater through body cavities which together form a large surface area. Sponges are very absorbent – about two-thirds of their body is empty space that can trap fluid. In addition, the spongin swells and therefore nothing leaks out. Sponges expand in all directions when exposed to water. In a word, it’s a natural version of Rely tampons – lots of room for bacteria to grow, lots of air-filled spaces, super absorbency and size increase, which can cause micro-injuries when withdrawn.

Cleaning the sponge properly is also a challenge. We know that the ones used in the kitchen need to be thrown into the washing machine every now and then and washed in hot water with bleach to get rid of the bacteria, but no one has researched how to remove staphylococcus aureus or the toxin it produces. I tried boiling a sea sponge for an hour and the result was that it hardened, shrunk and changed color.

A 1982 study found that women who used sea sponges as a tampon had significantly more bacteria, including staphylococcus, in their vagina during menstruation than women who used tampons or pads. There was no such difference between bleeds, so this marked proliferation of potentially dangerous bacteria can be combined with the use of a sea sponge. We don’t know how sponges affect the production of TSS-1 by bacteria. Research conducted by the FDA in the XNUMXs revealed that the nooks and crannies of the sponge contain various microscopic debris and debris (which is not surprising considering the sponges nourish themselves by filtering seawater).

In the US, sponges are prohibited from being offered as a personal hygiene item, and the FDA has issued warnings about this to many vendors. There is no evidence that sponges are safe, and I believe that anyone suggesting they are safe is being unethical.

Polyurethane foam products

In some countries, you can buy menstrual sponges made of the same foam as Rely’s tampons. The same foam is also used in contraceptive vaginal sponges which increase the risk of mTSS. Some women use makeup sponges as a menstrual emergency room.

While we do not know how or why the foam in Rely tampons contributed to mTSS, the use of products made of the same material as the unsafe tampon seems at least unwise. I could not find any published studies on the safety of using polyurethane foam products (tampons or makeup sponges), but I did the following experiment: I put a sponge in water and it released a really large amount of stored air compared to a tampon with an absorbent capacity great plus. This is bad news. Personally, I would avoid any intimate hygiene products made of foam.

Tampony dziergane

I heard there are women who knit or crochet their own tampons; they are also available for purchase on Etsy (I’ve spent many hours exploring the maze known as “vaginal Etsy”). Such tampons are usually made of cotton. Nobody has ever reported them to the FDA, and there is no data on whether they can irritate the vaginal mucosa, affect the growth of bacteria, or the production of the TSS-1 toxin.

Although they are described as 1% cotton, this does not mean that they are similar to tampons sold in drugstores. I bought three and it struck me how loosely they are knitted – a lot of air can get into the vagina during insertion, and this promotes the production of TSS-XNUMX toxin. It is also not known how to disinfect them to get rid of bacteria and neutralize toxins.

Another problem – as if that was not enough – is the absorbency. None of the three tampons I bought have absorbed more than 5 milliliters of liquid, which means they are less absorbent than standard tampons from drugstores.

I wouldn’t bother with them.

Can tampons or menstrual cups be safer?

Think that in the United States, hundreds of thousands of women use tampons and cups. The likelihood of menstrual toxic shock is 1 in 100, which is one in 000 women per year. So it would be a challenge to carry out studies showing that there is something safer than the products currently on the market would be a challenge. Rare cases are very difficult to investigate, but that doesn’t mean manufacturers shouldn’t try. Laboratory data showing that a certain product reduces the production of TSS-100 toxin would be a good start. You could also experiment with materials that prevent bacteria from forming biofilm, or with products that put less air into the vagina and reduce injury when inserted and removed.

There is no test to predict who is more likely to develop mTSS and who is less. There is also no test for early stage menstrual toxic shock. The next step could therefore be to find out who is the carrier of the TSS-1 toxin producing strain of staphylococcus by testing for antibodies, or to develop a test to detect developing shock, as early medical intervention increases the patient’s chances.

THE FACTS

1. Only 1 percent of women are exposed to mTSS. They are carriers of a vaginally-inhabited staphylococcus aureus capable of producing the TSS-1 toxin.
2. The introduction of vaginal air appears to be key to the development of toxic shock syndrome, but other factors may also be involved.
3. Don’t assume menstrual cups are safer than tampons.
4. Cotton tampons are no safer than tampons made of a cotton-rayon or viscose blend.
5. Do not use sea sponge tampons.