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Toxic Shock Syndrome and our fear of tampons

ByJennifer Shelley

Sep 21, 2018

Opening a box of tampons for the first time can be intimidating. You may not have used them before, you may be quite young and you may be scared about whether or not they’ll hurt to use. The first item that will reveal itself upon tearing open the lid will not provide much comfort.

Since the 1980s, every box of tampons sold in the UK has been required to contain a leaflet detailing Toxic Shock Syndrome, or TSS. The symptoms are scary. They can include high temperature/fever, sickness, increased blood pressure, the whites of your eyes/lips/tongue turning bright red, dizziness and fainting, breathing difficulties, and it can be fatal, if not treated properly. Many cases end up in intensive care, requiring antibiotics and treatment to prevent or control organ failure. There have been many cases reported in the media, most of which detail treatment that was nearly too late and brave young women who just managed to survive.  

However, if TSS is a disease restricted to tampon-users, then why was a man, someone who never experienced menstruation, the most widely publicised victim of the disease?

Jim Henson (creator of the Muppets) succumbed to TSS in 1990 following multiple organ failure. In fact, one-third of all Toxic Shock cases are in males. So if it is not tampons, then what is it?

Most of the informational leaflets gifted in a box of tampons will explain that the disease is caused by bacteria and the toxins that they produce, hence ‘toxic’ shock. The finer details, however, are not described. 50 per cent of cases that originate from infected burns, boils and insect bites are not mentioned at all. The crucial element for TSS is that it must break through our usual protective layer. Burns, boils, insect bites and cuts all break through the skin. Tampons, piercings or splinters introduce a foreign object, thus breaking the protective layer. These breaches in security are where the bacteria gain access to the bloodstream and release the required toxins into our bodies.

The two types of bacteria that cause TSS are Streptococcus pyogenes (Strep) and Staphylococcus aureus (Staph). Staph, which causes all ‘menses’ TSS (the cases caused by tampons) and also most non-menses cases, is also responsible for most basic skin infections and MRSA (methycillin resistant Staphylococcus aureus). Not all versions of the bacteria cause MRSA. Usually, it lives harmlessly on the surface of the skin or inside the noses of much of the population.

It only causes problems once it gains access to our blood. Staph produces certain enterotoxins including Toxic Shock Syndrome Toxin –1 (TSST-1) and enterotoxins A, B and C. These toxins are known as ‘superantigens’, meaning that they can stimulate the immune system to a point where it is out of control. Once inside the human body, they induce the production of molecules in the blood called ‘cytokines’ which cause massive amounts of inflammation. As the inflammation spreads, body temperature rises, as does blood pressure. The cytokines cause more cytokines to be produced, further exacerbating the fever, blood pressure and resulting organ failure. This is known as a ‘cytokine storm’. As bizarre as it seems, the symptoms and occasional fatalities of TSS are not direct effects of the bacteria. They are the result of our immune system becoming out of control when it has been overstimulated by the Staph.

Strep causes much fewer, although generally more fatal, cases of Toxic Shock Syndrome using slightly different toxins. The Strep-causing disease is sometimes called Toxic Shock-Like Syndrome (TSLS) to highlight the differences in the bacteria. The toxins that Strep produces are called streptococcal pyrogenic exotoxins (SPE) A, B and C. Literally, streptococcal fire-starting external toxins A, B and C. They act in much the same way that the Staph toxins do, with many of the same results.

Neither of these bacteria is sex-specific. In fact, researchers have only found one key factor in determining whether a person develops TSS/TSLS or not. It is the amount of antibodies that they have against the toxins in their blood. Everyone has an amount in reserve, but this varies from person to person. In fact, one of the possible treatments of TSS is injecting pooled antibodies from another person into the patient.

These diseases are still heavily associated with tampon use. How has this happened?  

Quite regularly in science, public opinion develops from a highly-reported, frightening epidemic. In the case of menses TSS, this came in 1979 and 1980 when a new tampon was released that claimed to be able to absorb a whole period worth of blood. It was to be inserted and then left there for the entire duration of the bleed. It contained carboxymethylcellulose – an ingredient in biscuits and ice cream – that enabled the tampon to absorb twice its weight in liquid. It also provided the perfect environment for growing bacteria. It was warm, wet and full of nutrients. The number of TSS incidents rocketed, with 95 per cent of the 55 patients reported in May 1980 being tampon-users. It has been reported that the cases totalled 3,295 by the end of 1980. People were scared, quite rightly, which led to carboxymethylcellulose (and polyester) being banned from tampons and the information campaign to be started.

The incidences of menses TSS dropped almost as quickly as they had shot up. TSS patient numbers went back down to the usual rate of 300-350 per year, including non-menses cases. But it was too late for the public; the disease had been inevitably linked with tampons.

TSS is not a harmless disease. The symptoms are scary, and the treatment is intensive. Being terrified of tampon use, however, is not the best way to prevent it. Not unless you also wrap yourself in bubble wrap and do everything in your power to prevent burns, scratches or insect bites. Using a menstrual cup, 100 per cent organic cotton tampons, sponges or any other form of sanitary product that goes inside will also not be much use in preventing the disease either. The best advice is to change whatever you are using regularly and be aware of the symptoms. But not too aware. Going to A&E with slightly raised blood pressure and no other symptoms won’t get you a lot of sympathy – especially if the high blood pressure is a side-effect from stress about tampons.


Image Credit: Menstruationstasse.com via Flickr

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