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Toxic Shock Syndrome or TSS for short, is the most dangerous “side effect” of using period products. It rarely occurs, but it is a life-threatening syndrome. Many women and especially girls still know too little about the TSS. The main trigger are toxins from bacteria that develop on tampons. But new studies on menstrual cups also provide clues that they can also trigger a TSS. But how exactly is the TSS generated and how do I recognize it?
Important note: This text cannot replace a doctor's visit or personal medical advice. Toxic Shock Syndrome is a very rare but serious illness that can occur during menstruation. If you feel sick, please contact a doctor. Our article describes in detail the disease of the TSS, which leads to uncertainty by some readers. Here, too, it makes sense to speak to a doctor. Please always contact your doctor if you have any questions, problems or if you are unsure. Our medical texts are written by specialists (e.g. medical journalists, doctors, medical students shortly before the end of their studies, doctoral students in medical fields); however, we cannot guarantee the correctness or liability for the content.
The TSS is triggered by toxic substances released by bacteria. These substances are called toxins. A very special toxin is responsible for the TSS, which is formed by the bacterium Staphylococcus aureus. Not all Staphylococcus aureus bacteria produce this poison, only 1% of the strains can produce it. The toxin over-activates immune cells and releases proteins in the body that create an extremely powerful immune response throughout the body. In medicine, it is said that the toxin acts as a superantigen. This means that the body starts a massive reaction the first time it comes into contact with this toxin (Hof and Dörries 2017). The TSS is one of the most serious diseases that can be caused by Staphylococcus aureus.
In addition to the toxin, other parts of the bacterium can also contribute to the clinical picture or the bacteria themselves enter the bloodstream. This should be considered during therapy, but plays a subordinate role in the development of the symptoms.
The bacteria can multiply in different places. In the 1970s and 1980s, the Toxic Shock Syndrome became known as tampon disease. The bacteria can grow well on foreign bodies in the vagina. The prerequisite for this is that the Staphylococcus aureus bacteria can already be found in the vaginal flora. It is assumed, however, that the bacteria were brought into the vagina by inserting tampons by hand (Chiaruzzi et al. 2020). Today we know that not only tampons can trigger a TSS. Other vaginal foreign bodies, such as menstrual cups, can also be the source. Regardless of the menstrual period, TSS can occur in wounds or burns, after childbirth or other inflammations (Gottlieb et al. 2018).
In addition to staphylococci, streptococci can also cause a similar clinical picture due to toxins, the so-called STSS. However, this is seldom the case with the use of tampons, but is caused through a strep infection in another part of the body. This does not increase the risk of STSS during your period.
The TSS is rare, which makes it difficult for scientists to find clear data on incidence and mortality. The numbers therefore fluctuate in the scientific literature. The frequency with which TSS occurs is often given based on the incidence. This is often classified at 1/200 000. This means that in one year one out of 200,000 people will develop a TSS (Lang et al. 2003).
How often a TSS is fatal can be recognized by the mortality. In the literature there are numbers between 1 - 11% (Lang et al. 2003). An American study found that the risk of dying from TSS is lower if the TSS is caused by a foreign body in the vagina (Strom et al. 2017).
Since the TSS is dangerous, every woman should know the main symptoms. For patients without any other serious illness, the TSS is often triggered by foreign bodies in the vagina. This means that the symptoms start suddenly while using a tampon or menstrual cup. Theoretically, other vaginal foreign bodies are also possible, for example menstrual sponges or diaphragms for contraception (see above).
Out of nowhere, patients develop a high fever with vomiting, diarrhea and muscle pain. A typical rash up to states of confusion can also occur. At the beginning, a TSS can therefore be confused with an infection. However, the symptoms often get worse so quickly and go beyond normal gastrointestinal flu. In such cases, the emergency services or a doctor should be contacted immediately. It is important that women tell health professionals straight away that they are on their menstrual period.
There are no typical risk factors for TSS. Large studies show that it is more common in young women than in other age groups or in men (Strom et al. 2017).
The bacterium Staphylococcus aureus is detected by around 15 to 40% of the healthy population in the nasopharynx. So the germ occurs in many people. However, this germ colonization is not absolutely necessary to develop a TSS. The prerequisite for the TSS, on the other hand, is a colonization of germs in the vagina, whether this can be transmitted by hands, e.g. after contact with the nose, has not been precisely researched (Chiaruzzi et al. 2020).
In order to determine a TSS, the patients are extensively examined in the clinic and blood samples are taken. The diagnosis can be made in the clinic based on the symptoms or by detecting the pathogens from blood or a smear . By definition, the function of several organs must also be restricted in order to be able to make the diagnosis.
Low blood pressure, a fast pulse, and a high temperature are measured as signs of shock. Many bleeding are also indicative of a circulatory disorder.
Unfortunately, a TSS is still too often recognized as such too late today, which is why it is important to educate doctors about this rare clinical picture (Inokuchi et al. 2015).
Toxic Shock Syndrome is an acute illness caused by bacterial toxins. These can be created, among other things, when using tampons. The toxins trigger an acute immune reaction in the body, which can be life-threatening under certain circumstances.
The toxins lead to an extreme immune reaction, which is harmful to the body itself. The patients suffer from high fever and low blood pressure. It can happen that organs are no longer properly supplied with blood and, in the worst case, lose their function.
TSS occurs very suddenly and leads to very severe symptoms. Fever, nausea with vomiting, and headache can also be found in other diseases, but occur in TSS to an mostly unknown degree. Patients who suffer from TSS are seriously ill.
It is important to change the tampon regularly. Today all manufacturers have added an information sheet to their products, on which the correct application is explained. Clean hands during insertion are important. The TSS does not occur with sanitary napkins or period underwear.
The activation of the immune system lead to changes in all organ systems. For this reason, some organs can no longer function properly. The kidneys are often affected, which can lead to kidney failure. These complications must be treated and monitored in an intensive care unit.
If a TSS is suspected, the tampon should be removed immediately. It may be useful to keep the tampon in order to be able to detect the pathogen. In any case, a clinic should be visited and the patient should be closely monitored. The area of the body where the bacteria grew should be medically cleaned. Antibiotics are important to prevent bacteria from growing further.. In severe cases, certain antidotes against the toxins can be given.
In addition, measures are important to control the symptoms, sufficient fluids and treatment of the organ disorder (Gottlieb et al. 2018).
As the concept oftampon disease came up, many products were made of extremely absorbent material and thus offered an optimal environment for bacterial growth. For this reason, manufacturers have changed the structure and contents of tampons over the past few decades in order to minimize the risk of TSS. Studies with new tampons show that modern materials even reduce the growth of bacteria and thus also the formation of toxins (Nonfoux et al. 2018).
Various studies in the laboratory examined which ingredients tampons must have in order to prevent bacterial growth as well as possible. The studies showed many differences (Chiaruzzi et al. 2020; Nonfoux et al. 2018; Reiser et al. 1987). Tampons made of pure cotton were compared with products made of viscose or cotton-viscose mixtures. Unfortunately, due to the different results, it can not be said which tampons are actually better.
To reduce the risk of TSS during your period, there are a few simple tips that should be followed. A tampon should always be inserted and removed with clean hands (Chiaruzzi et al. 2020). The packaging of the individual tampon should not be damaged, otherwise the tampon should be thrown away. The most important measure is to change the tampon regularly. Manufacturers recommend using a new tampon after a maximum of 8 hours. If necessary, the tampon should of course be changed more often.
If you want to be on the safe side and don't want to take any risks, you can use sanitary towels or period underwear during your period. There is no risk of developing a TSS here. The method of the free bleeding can do without tampons too and is therefore an alternative. By the method of the free bleeding the menstruating person bleeds in the toilet at regular intervals determined by the body. Therefore no period products are necessary.
Since tampons are disposable, they create a lot of waste over the life with the period. Not only the tampons themselves, but also the plastic packaging pollutes the environment. In addition, tampons can run into money over time. The above-mentioned period products can represent alternatives in this case. So there are a few reasons not to use tampons. However, it is important that the risk of a TSS remains very low and that proper hygiene plays a major role.
When the clinical picture of TSS became known in the 70s and 80s, it was often called thetampon disease. However, there is a fair amount of competition for tampons these days. Menstrual sponges and especially menstrual cups are very popular. Since they are also inserted into the vagina, bacteria can multiply and produce toxins here too. Theoretically, a TSS could therefore occur.
For menstrual cups, cases have been described in the scientific literature in which women suffered a TSS (Mitchell et al. 2015). It is unclear whether there is a difference in the risk of TSS between menstrual cups and tampons. There is a lack of large-scale, high-quality studies. In a laboratory experiment (Nonfoux et al. 2018) an analysis of various studies assessed menstrual cups as a safe option during menstruation (van Eijk et al. 2019). However, further studies are necessary to finally clarify the question.
For the menstrual cup (and also for diaphragms) the same recommendations apply as for tampons. In addition, they should be sufficiently cleaned with clean water when emptying. They should definitely be boiled once after your period.
The vast amount of knowledge we have about health these days and which is available to us at any time via the Internet often leads to excessive demands. Reports of women who have suffered from Toxic Shock Syndrome repeatedly lead to great uncertainty. It can sometimes be difficult for the individual to properly categorize this flood of information. When you have questions about your period, gynecologists are experienced contacts who can answer questions. Nevertheless, it is up to every woman to decide which products are suitable for her during the period, after all, you should feel good as much as possible.
Chiaruzzi, Myriam, et al. (2020), 'Vaginal Tampon Colonization by Staphylococcus aureus in Healthy Women', Applied and Environmental Microbiology, 86 (18), e01249-20.
Gottlieb, M., Long, B., and Koyfman, A. (2018), 'The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature', J Emerg Med, 54 (6), 807-14.
Hof, Herbert and Dörries, Rüdiger (2017), Medizinische Mikrobiologie (Georg Thieme Verlag KG).
Inokuchi, R., et al. (2015), 'Toxic shock syndrome', BMJ Case Rep, 2015.
Lang, C., et al. (2003), 'Intensivmedizinische Besonderheiten beim toxischen Schocksyndrom ("toxic-shock-syndrome", TSS)', Der Anaesthesist, 52 (9), 805-13.
Mitchell, Michael A, et al. (2015), 'A confirmed case of toxic shock syndrome associated with the use of a menstrual cup', Canadian Journal of Infectious Diseases and Medical Microbiology, 26 (4), 218-20.
Nonfoux, Louis, et al. (2018), 'Impact of Currently Marketed Tampons and Menstrual Cups on Staphylococcus aureus Growth and Toxic Shock Syndrome Toxin 1 Production In Vitro', Applied and Environmental Microbiology, 84 (12), e00351-18.
Reiser, RF, Hinzman, SJ, and Bergdoll, MS (1987), 'Production of toxic shock syndrome toxin 1 by Staphylococcus aureus restricted to endogenous air in tampons', Journal of Clinical Microbiology, 25 (8), 1450-52.
Strom, MA, Hsu, DY, and Silverberg, JI (2017), 'Prevalence, comorbidities and mortality of toxic shock syndrome in children and adults in the USA', Microbiol Immunol, 61 (11), 463-73.
van Eijk, Anna Maria, et al. (2019), 'Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis', The Lancet Public Health, 4 (8), e376-e93.
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