Toxic Shock Syndrome: Tampons and More
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. Associated with tampon use since the 1970s, TSS is caused by a toxin released by Staphylococcus aureus ( S. aureus ), in the nose or on the skin by up to 1/3 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 cases of TSS have been 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 late 1970s, 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 make it easier for bacteria to enter into 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 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 US Centers for Disease Control and Prevention confirms that new cases of TSS have indeed declined since the mid-1980s. A number of factors could account for the observed decline, including:
- The decrease in standard-size tampon absorbency
- The standardized labeling required by the US 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 ages 13 to 19, 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 decades, 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 being reported after surgical procedures. These are often the result of a streptococcal rather than a staphlococcal infection. Factors contributing to this increase may be a growing number of outpatient procedures and the use of prosthetic devices, such as heart valves.
Symptoms Occur Suddenly
The symptoms of TSS, which almost always come on very suddenly and occur in women, usually strike during or following a menstrual period. These symptoms include:
- High fever (102°F 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
- Rapid pulse
- Peeling of the skin on the palms or soles
- Extreme fatigue and/or weakness
While relatively rare, TSS can lead to serious complications, especially if left untreated. TSS can lead to ]]>shock]]> , kidney and/or liver failure, paralysis, and ]]>miscarriage]]> . In a very small number of cases, death can result from hypotensive shock. The body's reaction to the toxins can be overwhelming—blood pools near the digestive track, causing the heart and lungs to be deprived of blood and to 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 ."
Urgency: 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.
- Administering of large amounts of fluids (intravenously if necessary) to keep the patient hydrated and control the effects of the fever
- Giving nonaspirin or aspirin pain relievers to control and reduce the fever, as well as aches and pain
- Ordering bedrest
- Prescribing antibiotics to help control the infection
In severe cases, the patient may be hospitalized to allow the doctor to more closely monitor and, if necessary, treat for the possible complications that might develop (ie, ]]>shock]]>, ]]>kidney failure]]>, or liver failure).
Prevention—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 4-8 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.
The American College of Obstetrics and Gynecology
US Food and Drug Administration
Women's Health Matters
Toxic shock syndrome in the United States: surveillance update, 1979-1996. US Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/ncidod/eid/vol5no6/hajjeh.htm . Published October 1999. Accessed June 17, 2009.
Last reviewed June 2009 by ]]>Ganson Purcell Jr., MD, FACOG, FACPE]]>
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