Toxic shock syndrome: tampons and more

by Rick Alan

Media attention brought toxic shock syndrome to the forefront of women's health in 1980. Although the number of cases has decreased dramatically over the past 20 years, women still need to take precautions against this fast-moving infection.

Toxic shock syndrome (TSS) almost always strikes women, not men. While it can be extremely serious, it is also quite rare. For example, during the combined years of 1979 through 1996, the total number of cases of TSS reported to the U.S. Centers for Disease Control and Prevention (CDC) was less than 5300—an average of only 300 cases per year.

Associated with tampon use since the 1980s, TSS is caused by a toxin released by Staphylococcus aureus (S. aureus), a common bacterium harbored by up to one-third of the population. Although TSS can affect anyone, more than 90% of cases occur in women under the age of 40, and begin during a woman's menstrual period. The few other occurring cases of TSS are related to exposure to a Staphylococcus infection contracted during surgery or after suffering a burn or open wound. Although most people have naturally occurring antibodies that protect them from this toxin, some do not, and it is in these people that infection by S. aureus bacteria can lead to TSS.

The tampon-TSS connection

In the early 1980s, tampons—especially the super-absorbent type—were linked to an increased susceptibility to TSS, especially in women under age 25. Although the exact relationship between tampon use and TSS is still not known, it is believed that tampons may cause very small cuts, lacerations, or ulcerations in the vaginal wall, which makes it easier for bacteria to enter the bloodstream.

Researchers believe that super absorbent tampons cause the greatest degree of risk because they can actually adhere to the vaginal wall and thus cause an even greater degree of damage to the vaginal surface when removed. And some recent studies have shown that tampons containing rayon fibers may actually increase the production of the toxin that causes TSS.

The decline in TSS cases

The CDC has confirmed that new cases of TSS have indeed declined since 1986. A number of factors could account for the observed decline, including:

  • The decrease in tampon absorbency
  • The standardized labeling required by the U.S. Food and Drug Administration
  • Greater awareness of TSS among women
  • The proliferation of educational materials for women, including tampon package inserts

However, at least 40% of menstrual TSS cases continue to affect women 13 to 19 years old, an age group not as likely to be aware of the risk for TSS and for whom further education may be needed.

Over the last few years, two changes have occurred in tampon use and composition that may also be related to the decline in the number of new cases. All-cotton tampons have been introduced and successfully marketed as an alternative product and tampons marketed specifically for overnight use have also been introduced.

An increase in surgical cases

One of the important changes in new cases of TSS is the increasing proportion of nonmenstrual cases reported after surgical procedures. The factors contributing to this increase may be due to an increase in outpatient procedures and the use of prosthetic devices—such as heart valves—as hospitalizations in the United States due to infections from prosthetic devices and postoperative infections increased significantly from 1980 to 1994.

Symptoms come on suddenly

The symptoms of TSS, which almost always come on very suddenly and in women, almost always strike during or following a menstrual period. These symptoms include:

  • High fever (102 degrees or higher)
  • Rash (usually looking like a sunburn)
  • Diarrhea and/or vomiting
  • Drop in blood pressure
  • Sore throat
  • Blood-shot eyes
  • Dizziness or fainting
  • Muscular aches and pains
  • Confusion
  • Rapid pulse
  • Peeling of the skin of the palms or soles
  • Extreme fatigue and/or weakness

While relatively rare, TSS can lead to serious complications, especially if left untreated. These generally include shock and kidney and/or liver failure, paralysis and miscarriage. In a very small number of cases, death can result from hypotensive shock, whereby the body's reaction to the toxins released into the blood is so acute that the heart and lungs become so overburdened that they stop working.

Diagnosis: distinguishing TSS from similar illnesses

\"Most of the symptoms caused by TSS can also be caused by other conditions or diseases, such as Rocky Mountain spotted fever and measles,\" says Jacques Carter, MD, general internist and public health specialist at Boston's Beth Israel Deaconess Medical Center. \"However, when a high fever and a number of the other symptoms associated with TSS suddenly strike during or soon after a woman's menstrual period, doctors will generally suspect TSS and begin treatment while simultaneously searching to see if another condition or disease is the underlying cause. In addition, doctors will in many cases order a lab culture of the vagina, which can often detect the presence of S. aureus.\"

Treating TSS immediately

While the treatment for TSS is relatively simple, it must be implemented quickly. Therefore, it is critical that any woman who is suddenly struck with a high fever and one or more of the other symptoms associated with TSS during or soon after a menstrual period immediately remove her tampon (if still present), and then call her physician to seek medical attention.

Treatment includes:

  • Administration of large amounts of fluids (intravenously if necessary) to keep the patient hydrated and control the effects of the fever
  • Non-aspirin or aspirin pain relievers to control and reduce the fever as well as aches and pain
  • Plenty of bed rest
  • Antibiotics to help control the infection
  • In severe cases, hospitalization—to more closely monitor and, if necessary, treat the patient for the possible complications that might develop (i.e., shock, kidney failure or liver failure)

Prevention is the best bet

Like most medical conditions, the best treatment for TSS is prevention. To that end, all women should take the following preventative measures:

  • Use an applicator rather than your fingers to insert tampons, and avoid using plastic applicators.
  • Wash your hands before inserting a tampon.
  • Use tampons with as low a degree of absorbency as is practical, and don't use super-absorbent tampons unless instructed to do so by your doctor.
  • Change your tampon every four to eight hours.
  • When practical, use a pad instead of a tampon.
  • Don't use tampons that contain rayon fibers.

Finally, though TSS is not contagious, it can strike the same person more than once. If you've had TSS before, don't use tampons again without first getting approval from your doctor.