Toxic shock syndrome is a potentially fatal condition that starts with a staphylococcal or streptococcal strain of bacteria.

Women aged 15 to 25 years who use tampons during menstruation appear to have a higher risk of developing toxic shock syndrome (TSS), but it can happen to anyone.

The condition was first noted as a health hazard for women of reproductive age in 1980, when several healthy women from different states died, following an unexplained illness that involved a fever, shock, and multiple organ failure.

Various cases had been noted since the 1920s, but in 1980, TSS became a notifiable disease.

TSS is rare. Small studies suggest that it affects around 3 women of reproductive age in every 100,000 every year in the United States.

In 1980, the annual incidence was around 6 in every 100,000 women aged 19 to 44 years, in the U.S. However, after 1986, following the introduction of federal regulations and the removal of super-absorbent tampons from the market, the numbers decreased, according to the National Organization for Rare Diseases (NORD), and they may be as low as 1 in every 100,000.

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Tampon use can increase the risk of TSS.

The two types of TSS are:

  • Staphylococcal TSS, caused by the Staphylococcus aureus (S. aureus) bacteria
  • Streptococcal TSS (STSS), caused by group A Streptococcus, or “strep,” bacteria

Signs and symptoms of TSS develop suddenly and progress quickly. The first indication is normally a sudden, high fever.

The following normally appear within a few hours:

  • Vomiting
  • Diarrhea
  • Sunburn-like skin rash, particularly on the palms and soles
  • Redness of eyes, mouth and throat
  • Fainting
  • Feeling faint
  • Muscle aches
  • Dizziness
  • Confusion
  • Hypotension, or low blood pressure
  • Seizures
  • Headaches

The condition can progress to kidney failure, shock, and death within 48 hours.

Anyone who has been using tampons or who has a skin wound or infection and experiences the signs and symptoms described above, or if you have a skin or wound infection, should call a doctor immediately. Any tampon should be removed immediately.

A significant number of cases of TSS involve tampon use, and especially “super absorbent” tampons. Soft-tissue injuries that can also lead to TSS include the complications of childbirth, an injury or burn, a localized infection, such as a boil, or the use of a contraceptive sponge.

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A group A strep infection can lead to TSS.

Tampon use is implicated in 55 percent of cases, but another 15 percent are linked to childbirth and infected wounds.

From December 2015 to March 2016, five cases of menstrual-related TSS were reported in Michigan State. Four of the women were using super-absorbency tampons.

The bacteria that cause TSS are not uncommon. Between 20 percent and 30 percent of all humans carry S. aureus on their skin and nose, usually without complications. Most people have antibodies to protect them. It may be that some people do not develop the necessary antibodies.

One possibility is that the super-absorbent tampons, the ones that stay inside the body the longest, become breeding grounds for bacteria.

Another is that the tampon fibers scratch the vagina, making it possible for bacteria to get through and into the bloodstream.

Either the action or the composition of the tampons, combined with pre-existing staphylococcal bacteria in the vagina, probably trigger the disease.

However, both there is no compelling evidence to support either of these.

Streptococcal TSS can develop after minor trauma, or surgery, or as a result of a viral infection or the use of non-steroidal anti-inflammatory drugs (NSAIDS).

The bacteria enter the body through wounds, localized infections, the vagina, the throat, or burns. The bacteria produce toxins that enter the bloodstream and spread to all the organs. They interfere with the process of the blood pressure regulation, leading to hypotension, or low blood pressure.

Hypotension can cause shock, including the symptoms of dizziness and confusion. The toxins also attack tissues, including organs and muscles. Kidney failure is a common complication.

TSS does not only develop in young menstruating women. It can affect older women, men, and children. Women who have been using a diaphragm or a contraceptive sponge have a slightly higher risk of developing TSS. Anyone with a staph or strep infection has the potential to develop TSS, but it is rare for this to happen.

As TSS is rare, most doctors will never see a case. It is important for doctors to recognize when symptoms may indicate TSS, because the disease progresses rapidly.

The doctor will look for the most common symptoms, and check for signs of organ failure.

Blood and urine tests help determine organ function or organ failure.

The doctor may look for the following signs:

  • A temperature above 39 to 40.5 degrees Celsius or 102.02 degrees Fahrenheit
  • Dangerously low blood pressure
  • A skin rash
  • Evidence that at least three organs have been affected by the infection

Specimens will be taken for investigation from any lesions, for example in the nose, throat, vagina, or the blood. Imaging such as CT or MRI can reveal tissue damage.

TSS is a reportable disease. Cases of Staphylococcal TSS must be reported to the appropriate agency within 3 days of first being diagnosed or suspected.

Any suspected outbreak of Streptococcal TSS (STSS) must be reported immediately to the relevant authorities.

The medical team’s aim is to fight the infection as well as supporting any body functions that the infection may have affected. The patient will be hospitalized and may be placed in an intensive care unit.

Treatment may include:

  • Oxygen: The patient will usually be given oxygen to support breathing
  • Fluids: These can prevent dehydration and bring blood pressure back up to normal
  • Kidneys: A dialysis machine can treat kidney failure by filtering toxins and waste out of the bloodstream
  • Damage to skin, fingers, or toes: Treatment may include draining and cleaning wounds in these locations, and, in severe cases, amputation
  • Antibiotics: The can be given by IV, directly into the bloodstream
  • Immunoglobulin: Samples of donated human blood with high levels of antibodies can be administered to fight the toxin, sometimes alongside antibiotics

Patients normally respond to treatment within a couple of days, but they may have to spend several weeks in the hospital.

The risk of developing TSS is very low, but there appears to be a significant link between tampon use and absorbency and TSS risk.

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Using a menstrual cup may not reduce the risk of TSS.

When using tampons, women are advised to:

  • Wash their hands thoroughly before inserting a tampon
  • Use the lowest absorbency tampons for their period flow
  • Change tampons at least as regularly as directed on the pack
  • Avoid using more than one tampon
  • Insert a fresh tampon when going to bed and replace it immediately in the morning
  • Remove the tampon as soon as menstruation has ended
  • Switch from tampons to sanitary towels or panty liners at times during their period
  • Use minipads instead of tampons if the flow is light

Women who use a diaphragm, cap or contraceptive sponge should follow the manufacturer’s instructions carefully, regarding how long to leave the device inside the vagina.

Some women choose to use menstrual cups instead of tampons, but cases of TSS have also been linked to the use of this device.

The chance of staphylococcal TSS being fatal is less than 3 percent, but recurrence is common, because having it does not cause the person to develop an immunity.

In streptococcal TSS, mortality is between 20 percent and 60 percent, even with aggressive treatment.

Most patients make a full recovery, but since TSS is rare, there is little information about the long-term effects. There have been reports of persistent muscle weakness and psychological effects, such as difficulty concentrating, memory loss, and emotional changes.

Women who have already had TSS should consider using an alternative method of contraception and avoiding tampon use.