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Toxic Shock Syndrome

Toxic shock syndrome is an acute, potentially fatal infection caused by staph or strep bacteria. Both types of bacteria can live harmlessly on your skin and in your nose and mouth—it is when there’s an overgrowth within the body that problems occur. The condition is commonly linked to the use of highly absorbent tampons during menstruation.

Toxic shock syndrome is a rare yet dangerous condition that can lead to organ failure and sudden death if left untreated. While infections can occur for no obvious reason, practising good hygiene habits is an effective way to protect yourself.

Prevalence of toxic shock syndrome

Although rare, toxic shock syndrome (TTS) is a potentially fatal condition caused by the overgrowth of staphylococcus aureus (staph) bacteria or, in some cases, group A streptococcus (strep) bacteria. Toxic shock syndrome can affect anyone, but due to the use of internal menstrual products such as tampons and menstrual cups, or birth control methods such as sponges and diaphragms, women are at higher risk.


Staphylococcus aureus bacteria is often found in the upper respiratory tract. In most individuals, it’s harmless. In others, it causes common infections such as sinusitis, skin rashes, and pimples. In severe cases, staph bacteria can cause pneumonia, meningitis, sepsis, and other life-threatening conditions.

Group A streptococcus bacteria can cause common infections such as strep throat. In other cases, group A strep has been known to cause scarlet fever, rheumatic fever, and other severe and potentially lethal illnesses.

For many years, almost all cases of TTS were linked to high absorbency tampons. However, even after their removal from the market, the condition continues to affect 3 to 6 people per 100,000 in the USA, including 1 in 100,000 menstruating women.

For TSS to occur, bacteria need favourable conditions to grow and proliferate. Staph and strep bacteria flourish in a warm and moist environment. If a cut or tear is present in the skin, bacteria enters the bloodstream where it releases toxins. Highly absorbent tampons are the perfect place for bacteria to flourish, especially if the tampons are made of polyester foam and are left inside the body for a long time. Although uncommon, sponges, menstrual cups, and diaphragms can also facilitate bacterial infection if left inside the body for longer than 12 hours. However, time is not the only factor—other things, such as underlying illnesses, can increase the risk of infection. Recently, a woman in California was rushed to the hospital after getting TSS from a tampon, even though she changed her tampon every two hours.


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Symptoms of toxic shock syndrome

Usually, the symptoms of toxic shock syndrome appear suddenly and require immediate medical attention. If you are menstruating or have recently had surgery or sustained an injury that broke the skin, seek immediate medical attention if you notice any of the following symptoms:

  • A sudden drop in blood pressure
  • Sudden fever (over 39ºC)
  • Muscle aches
  • Nausea, vomiting, and diarrhoea
  • Headaches
  • Seizures
  • Confusion
  • Rash on the body, tongue, or mouth

Fatalities from toxic shock syndrome are caused by organ failure that is the result of toxins in the blood. The toxins released by staphylococcus aureus or group A streptococcus bacteria deprive essential organs of oxygen, causing the body to go into shock. Often, women neglect the first symptoms because they associate them with common symptoms of menstruation, such as nausea or muscle aches. If you are using highly absorbent tampons and notice unusual symptoms, you might be at risk of TSS.


Who is prone to toxic shock syndrome?

Although anyone can get toxic shock syndrome, it mostly affects young menstruating women. According to some sources, 30% of women who have had TSS are likely to get it again. Changes in vaginal pH are also linked to an increased risk of TSS. Normal vaginal pH is moderately acidic, between 3.8 and 4.5. Both staph and strep bacteria thrive in a more neutral pH environment—around 6 and 8. Other risk factors include:

  • Damaged skin, especially if left untreated
  • Recent surgery
  • Recent childbirth
  • Viral infections, such as herpes or the flu

Most patients recover within two to three weeks. In severe cases, patients are admitted to the ICU (intensive care unit) and treated immediately with antibiotics, intravenous fluids, and blood pressure medication. If necessary, doctors might need to remove infected tissue.

While some people can get TSS from a minor cut, only a small minority of the population will be affected by toxic shock. Most people produce sufficient antibodies to fight off S. aureus or strep bacteria. However, that is not an excuse to ignore basic hygiene recommendations. Even if your body has shown resilience before, the state of your immune system is always changing; under certain circumstances, it will be more susceptible to infections.

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The history of toxic shock syndrome

Toxic shock syndrome was documented as a threat to menstruating women after a highly publicized outbreak in 1979–80. In the US, otherwise healthy women were admitted to the hospital for toxic shock, which caused widespread concern.


During the outbreak, the prevalence of the condition was 6 menstruating women per 100 00.

Eventually, doctors came to the conclusion that certain feminine hygiene products were the primary factor leading to TSS.

The outbreak came on the heels of the growth of the tampon market in the 1970s when many women were suddenly able to choose highly absorbent tampons as a solution for heavy periods. Proctor & Gamble began test-marketing a new tampon brand Rely in 1975; it contained a new super-absorbent synthetic material that could absorb more blood before leaking. Sadly, due to insufficient research and testing before 1976, many tampons on the market were not entirely sterile, which in some cases made them a breeding ground for strep and staph bacteria.

Between 1976 and 1996, 5296 toxic shock syndrome cases were reported—93% of these were in menstruating women. Eventually, menstrual hygiene companies stopped using highly absorbent materials that were proven harmful and switched to more natural ingredients such as cotton. Due to these changes, more rigorous medical testing, and increased menstrual hygiene education, the number of TSS cases has dropped to 1 per 100 000 menstruating women.

Since the outbreak, tampon manufacturers have been pushed to agree on standard tampon definitions such as light, regular, and heavy to avoid promoting a product as super absorbent. Nowadays, tampons and other menstrual hygiene products undergo multiple rounds of testing to ensure they don’t contain harmful toxins.

Why is toxic shock syndrome still a problem?

Although very rare, toxic shock syndrome is still associated with menstrual care products. Since all hygiene products need to meet medical requirements, it is believed that toxic shock occurs because of changes in vaginal pH during menstruation. In general, any foreign object inserted in a vagina poses the risk of disrupting the natural microflora. As tampons absorb blood, they can also host bacteria. If a dry tampon is pushed inside the vaginal canal, it can cause the skin to tear, making it easier for bacteria to reach the bloodstream.


Toxic shock prevention

Although you can't be too sure you're protected from bacterial infections, you can lower your chances of getting a toxic shock by following a few simple steps:

  • Change tampons regularly, most producers recommend changing tampons every 8 hours, but depending on your flow, you might want to replace it every 4 to 6 hours.
  • Avoid using highly absorbent tampons.
  • Don’t sleep with a tampon.
  • Always wash your hands before and after changing tampons or other sanitary products.
  • Handle tampons as little as possible before insertion.
  • Ensure proper intimate hygiene during your period.
  • If you have had TSS, consider using another feminine hygiene product instead of tampons—particularly one that doesn’t go inside the vaginal canal.
  • If you have cuts, burns, surgical incisions, or bruises, keep them clean to avoid infection.
  • If you notice the symptoms mentioned above, seek medical attention immediately. The less time the condition has had to develop, the more likely you are to make a full recovery.

In non-fatal but serious cases, toxic shock syndrome can leave sufferers with mental and physical reminders long after they have recovered. Take care of yourself by implementing proper hygiene, especially during your period. Don’t neglect unusual symptoms such as fever or body aches during menstruation. Noticing what’s going on in your body can save your life.

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https://www.nhs.uk/conditions/toxic-shock-syndrome/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640799/pdf/10603216.pdf
https://healthcare.utah.edu/healthfeed/postings/2018/07/tss.php#:~:text=In%20the%20U.S.%2C%20TSS%20is,1%20in%20100%2C000%20menstruating%20women.%E2%80%9D
https://www.ncbi.nlm.nih.gov/books/NBK459345/#:~:text=TSS%20was%20classically%20associated%20with,100%2C000%20in%20the%20United%20States
https://www.mayoclinic.org/diseases-conditions/toxic-shock-syndrome/symptoms-causes/syc-20355384
https://www.webmd.com/women/guide/understanding-toxic-shock-syndrome-basics#1
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