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Even Organic Cotton Tampons Can Cause Toxic Shock: Study

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FRIDAY, April 20, 2018 (HealthDay News) -- Although still exceedingly rare, menstrual toxic shock syndrome can be dangerous and has been tied to the use of tampons.

And new research finds that the type of fibers used in manufacturing tampons doesn't seem to matter -- 100-percent cotton or synthetic-fiber varieties were each linked to toxic shock.

One alternative to tampons, the menstrual cup, was also linked with the growth of Staphylococcus aureus, a bacterium that helps spur the syndrome, the researchers reported.

"Our results did not support the hypothesis suggesting that tampons composed exclusively of organic cotton could be intrinsically safer than those made of mixed cotton and rayon, or viscose, or tampons composed entirely of viscose [which is used in the manufacture of rayon]," concluded study lead researcher Dr. Gerard Lina. He's professor of microbiology at the University Claude Bernard in Lyon, France.

Toxic shock syndrome is caused by an immune system reaction to bacterial toxins such as S. aureus or the streptococcus bacteria. Symptoms include fever, rash, low blood pressure and fatigue, and the condition can quickly progress to coma and even death through multiple organ failure.

Toxic shock syndrome first gained notoriety in the 1970s, after an outbreak of severe cases were tied to the use of Procter & Gamble's super-absorbent Rely tampon. These tampons utilized compressed beads of polyester for absorption. P&G issued a voluntary recall of Rely in 1980, but investigations showed that toxic shock could be spurred by other brands of tampons, as well.

In reaction to such cases, some women switched away from tampons with synthetic fibers, to 100-percent cotton brands.

But are these more natural-fiber tampons safer? To find out, Lina's group tracked the growth of S. aureus, as well as the production of toxic shock syndrome toxin, in 15 currently marketed tampons under laboratory conditions.

The investigators found no differences in microbial growth or toxin production, regardless of which type of fiber the tampon was composed of. Instead, structural differences in the fiber bed seemed to matter.

Under microscopic examination, "we observed that space between the fibers that contributes to intake of air in the vagina also represents the major site of S. aureus growth and [toxin] production," Lina explained in a news release from the American Society for Microbiology.

Menstrual cups -- used by some women as an alternative to tampons -- were also implicated in toxic shock. These devices encouraged greater growth of S. aureus and toxin as compared to use of the menstrual pad, Lina noted. That's probably because the cups allowed for more "aeration," a condition conducive to S. aureus growth, he said.

The bacterium also forms a "biofilm" in the cup, discouraging easy sterilization, Lina added.

The bottom line: "Tampon use continues to be associated with menstrual toxic shock syndrome, and a case of menstrual toxic shock syndrome has been described associated with a menstrual cup," Lina said.

Still, toxic shock syndrome remains extremely rare, no matter what menstrual product a woman chooses to use, the researchers noted. According to the U.S. Centers for Disease Control and Prevention, incidence of the syndrome is less than one case per million people.

Two experts in women's health stressed that women do need to be educated about the risk, however.

"Awareness of toxic shock syndrome needs to be raised for all patients who use intravaginal devices for menstruation," said Dr. Jennifer Wu.

"Many patients erroneously think that 'organic' or all-cotton tampons do not have risks of toxic shock syndrome," said Wu, an obstetrician/gynecologist at Lenox Hill Hospital in New York City.

"The use of menstrual cups has risen recently," she added. "While many patients have heard of toxic shock with tampon use, they often have never thought of any risks associated with the menstrual cup. Frequent changes of tampons and the menstrual cup must be emphasized to patients."

Dr. Jill Rabin helps direct women's health at Northwell Health in New Hyde Park, N.Y. She agreed that "in order to reduce the risk of toxic shock syndrome, changing one's tampon more frequently and strict attention to hygiene is indicated. If a menstrual cup is used, it should be boiled between menstrual cycles to remove any bacteria."

Rabin advised "using the smallest possible cup size" and washing the menstrual cup with soap and water during the cycle.

"If tampons and menstrual cups are used, be sure to see your doctor at the first sign of any fever, chills or rash, and of course, remove the cup or tampon immediately," she added.

The new study was published April 20 in the journal Applied and Environmental Microbiology.

More information

The Mayo Clinic has more about toxic shock syndrome.

SOURCES: Jennifer Wu, M.D., obstetrician/gynecologist, Lenox Hill Hospital, New York City; Jill Rabin, M.D., co-chief, division of ambulatory care, Women's Health Programs-PCAP Services, Northwell Health, New Hyde Park, N.Y.; American Society for Microbiology, news release, April 20, 2018
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