Tampon Safety and Toxic Shock Syndrome

According to the grapevine in a North Carolina middle school, tampons not only cause AIDS, but also can be lost in a woman’s body, never to be seen again. Like urban legends, tampon tales get more creative as they’re passed around. The latest stories claim tampons are tainted with cancer-causing toxins and that rayon tampons are especially dangerous. One Internet rumor suggests that manufacturers add asbestos to tampons to promote excessive bleeding and boost sales.

The truth is:

  • tampons cannot get lost forever in your body;
  • rayon tampons are as safe as cotton ones; and
  • asbestos has never had anything to do with fibers that make up tampons.

The Food and Drug Administration (FDA) regulates tampons as medical devices. Tampon design and materials are tested by the agency, and manufacturers conduct a battery of safety studies as well. The FDA also regulates the absorbency ratings for tampons.

Tampons and TSS

Any fear still surrounding tampon use likely dates from a time when TSS was first identified. About half of all cases occur in women using tampons, although the exact link between TSS and tampons remains unclear. Tampons enjoyed a quiet history from their introduction in 1933 until about 1980 when the CDC (Centers for Disease Control) noticed a sharp rise in the number of cases of TSS, a serious and sometimes fatal disease caused by toxin-producing strains of the Staphylococcus aureus bacterium. Experts believe the bacterium releases one or more toxins into the bloodstream.

Between October 1979 and May 1980, 55 TSS cases and seven deaths were reported. Most were among women who experienced onset of illness within a week following their periods. The TSS epidemic reached its peak in 1980 with a total of 813 cases of menstrual-related TSS, including 38 deaths. The CDC carried out national and state-based studies to pinpoint TSS risk factors, and used its national surveillance system to track trends. Research suggested one factor was the use of very highly absorbent tampons made from new materials.

Studies showed that women who used Proctor & Gamble’s Rely tampons were at substantially greater risk for TSS than other tampon users. This brand consisted of polyester foam and a special type of highly absorbent cellulose, a combination no longer used in tampons. Proctor & Gamble voluntarily withdrew that tampon from the market in 1980, and competing manufacturers of tampons made from other superabsorbent materials began removing them as well. The material of the Rely tampon and its absorbency were very different from that of tampons on the market today.

Today tampon manufacturers report to the FDA on absorbency, as well as on the safety of all components of a tampon, including the cover, string and applicator, and on the chemical composition of any fragrances and color additives. Companies conduct clinical tests in tampon users to look for bacterial growth and adverse effects, such as allergies and ulceration, with tampon use. Through toxicological testing, manufacturers must show that the tampon will not enhance the growth of Staphylococcus aureus or increase the production of toxic shock syndrome toxin.

TSS Cases Have Declined Dramatically

Compared with the 813 menstrual TSS cases in 1980, there were only three confirmed cases in 1998 and six in 1997. The substantial drop in TSS rates is attributed to the removal of Rely from the market, and advances in the way FDA regulates tampon materials and absorbency. Women also are much better educated about TSS prevention. Since 1982 all tampon labels have included information about TSS warning signs. And packages include a note that the risk of menstrual TSS can be reduced by not using tampons and by alternating tampons with sanitary napkins. Women are advised to use the lowest absorbency needed to control their flow.

Use the Right Absorbency

In response to CDC findings and FDA regulatory activities, manufacturers standardized and, in some cases, lowered tampon absorbency. Superabsorbent today is much less absorbent than superabsorbent tampons used in 1980, and far fewer women use very high absorbency tampons today than they did in the 1980’s.

Absorbency (the rate at which a tampon absorbs or soaks up menstrual blood) is measured in grams of fluid. Research suggests that the risk of toxic shock syndrome may increase with tampon absorbency. That doesn’t mean you have to steer clear of higher absorbency tampons completely, but you should match absorbency to your flow. For lighter flow, use regular or junior absorbency. If your tampon absorbs as much as it can and has to be changed before four hours, you may want to try a higher absorbency. There’s usually less need for higher absorbency when your period is ending.

When you shop, you’ll find these absorbency terms and ranges on all tampon packages:

  • Junior absorbency: 6 grams and under
  • Regular absorbency: 6 to 9 grams
  • Super absorbency: 9 to 12 grams
  • Super plus absorbency: 12 to 15 grams

According to the American College of Obstetricians and Gynecologists, your tampon is probably too absorbent if the tampon is hard to remove, you experience vaginal dryness, if a tampon shreds, or if it doesn’t need to be changed after several hours. Vaginal dryness and ulcerations may occur when a tampon is too absorbent for your flow.

What are the TSS Warning Signs?

Symptoms of toxic shock syndrome can be hard to recognize because they mimic the flu. If you experience sudden high fever, vomiting, diarrhea, dizziness, fainting, or a rash that looks like a sunburn during your period or a few days after, contact your doctor right away. Also, if you’re wearing a tampon, remove it immediately.

One or two weeks after initial symptoms begin, flaking and peeling of the skin occurs, mainly on the palms and soles. If your doctor determines that your symptoms are TSS, you will probably be sent to a hospital for treatment. With proper treatment, patients usually get well in two to three weeks. Women under 30, especially teenagers, are at a higher risk for TSS, because some females that age may not yet have antibodies to the toxin. Using any kind of tampon — cotton or rayon of any absorbency — puts a woman at greater risk for TSS than using menstrual pads.

Tampon Ingredients

Manufacturers in this country produce tampons made of rayon, cotton, or a blend of the two. Rayon is made from cellulose fibers derived from wood pulp. CDC studies have found no increased risk with rayon versus cotton for the same absorbency and brand of tampon.

Chlorine gas, which can produce a small amount of dioxin, used to be the bleaching agent for rayon used in tampons. But elemental chlorine-free bleaching uses a chlorine dioxide agent. Chlorine dioxide may sound like chlorine gas, but they are not the same. Using a method approved by the Environmental Protection Agency, major tampon manufacturers have tested their products for dioxin. Data show that dioxin levels in tampons range from undetectable to 1 part in 3 trillion, far below the level that occurs through daily environmental exposure, and considerably below the level FDA believes would put consumers at risk. According to the FDA you could end up with dioxin in rayon or cotton simply because of decades of pollution — it can be found in air, water, or the ground before the wood pulp or the cotton is produced, but you already have more dioxin in your body than in any tampon.

Many experts say that the proof of tampon safety lies in its long history. But others want more research into diseases other than toxic shock syndrome. Rep. Carolyn Maloney (D-N.Y.) introduced the Tampon Safety and Research Act in 1997 and again in March 1999. The bill, which was referred to the Subcommittee on Health and Environment, proposes to provide NIH with research support to determine the extent to which dioxin, synthetic fibers, and other additives in tampons pose health risks such as cancer, endometriosis, infertility, and pelvic inflammatory disease. The FDA says that there is there is no indication right now that a large-scale study of tampons’ relations to these diseases is necessary.


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