Toxic Shock Syndrome¹ (TSS) is a serious, systemic illness, meaning that it affects the whole body. It is potentially life-threatening, and can lead ultimately to organ failure.

Although anybody can acquire TSS through localised infections following, for example, burns, boils, insect bites or surgery, about half of the reported cases in the United Kingdom are associated with the use of tampons by menstruating women.

Tampon-related TSS was first identified in the USA during the late 1970s when a number of deaths were directly linked to a specific brand of super-absorbent tampon, which was subsequently withdrawn from sale. The deaths occurred in people who had left the tampons in for periods exceeding 12 hours or so.

There are probably around 40 cases of tampon-related TSS² per year in the UK, and it is believed that 22 deaths occurred in the UK between 1990 and 2000. The overall death rate is 10%. However, due to the early symptoms of TSS being similar to influenza, it is believed that many less severe cases go unreported.

Although both internal and external sanitary protection products are available, internal absorptive methods (tampons and completely natural products such as sea sponges) are increasing in popularity, particularly among the younger age groups. As its name implies, tampon-related TSS is associated exclusively with internal absorptive methods of sanitary protection. There are about 13.4 million women in the UK with active menstrual cycles. Hence, along with other methods of sanitary protection, millions of tampons are used each month³. Given the relatively few cases in comparison to the large number of women potentially at risk, tampon-related TSS is considered to be a rare occurrence.

TSS can be caused by two different microbes (bacteria), Staphylococcus aureus and Streptococcus pyogenes- although the incidence due to Streptococcus is less common⁴.

The S. aureus bacterium, discovered more than 100 years ago, is carried harmlessly by at least one in three people in the nose, gut, armpit or vagina.

Certain strains of S. Aureus can colonise tampons and overgrow, in the process producing a toxin known as TSS-T1. The vagina is a very susceptible place for rapid absorption of toxin. The toxin gets into the bloodstream and circulates around the body, totally overwhelming the body's immune system to produce acute organ damage - especially of the kidneys and lungs. Younger people are particularly at risk, as their immune system is not fully developed, and two-thirds of all cases of TSS occur in women under the age of 25.

Although in Britain there is at least one tampon-related death per year from TSS, as mentioned earlier, the syndrome can affect people of all ages and sexes without tampon involvement. These range from women who have just given birth and newborn babies to post-operative patients and young children who have acquired a quite superficial injury in the garden. Jim Henson, creator of The Muppets, died from the syndrome, due to Streptococcus, in 1990.

Mechanism of Infection

In order to produce toxins, there must be an environment conducive for the bacteria to grow; and either a blood-soaked conventional tampon or a product such as a sea sponge can provide an ideal substrate.

There must also be a route for the toxin to enter the bloodstream and this could be provided by tiny abrasions in the vagina walls caused when a tampon is slid in or out.

Super-absorbent tampons were particularly implicated in the early cases of TSS because women tended to leave them in place for longer, which gave the bacteria more time to grow and produce the toxin. Furthermore, being somewhat larger, super-absorbent tampons were more likely to scrape the walls of the vagina, leading to abrasions.

Symptoms of TSS

The average time for TSS symptoms to appear is two to three days after an infection with Staphylococcus or Streptococcus, although this can vary depending on the cause of the infection.

The symptoms of Tampon-Related TSS always appear after a period starts, but the onset is very fast and symptoms are often severe. It may be only 24 hours from the first appearance of symptoms to admission to a hospital's Intensive Care Unit.

The early symptoms of TSS are typically described as 'flu-like' and usually include some or all of the following:

• Sudden high temperature (>38.8 degrees C), followed by the slow pulse and low blood pressure of shock
• Vomiting and diarrhoea
• Dizziness/light-headedness
• Sunburn-like rash
• Bright red colouring of the eyes, throat and vagina
• Severe muscle aches

If the syndrome is not recognised quickly and treated, kidney and other organ failure can ensue, resulting in death.

As the early symptoms can be very subtle and have been described as 'flu-like'; and also the rash and associated symptoms can be mistaken for something else, such as scarlet fever, affected women and their GPs may not react quickly enough. Furthermore, many women experience similar mild symptoms around the time of their period.

If you have these symptoms and suspect that they may be tampon-related, you should remove the tampon immediately and then immediately seek professional medical advice; explaining that you are menstruating and have used a tampon.

Anyone who has had tampon-related TSS in the past should not use tampons again without taking medical advice.

Clinical Diagnosis and Treatment

Clinical diagnosis must be made very quickly - before the results of any confirmatory blood tests or signs of skin peeling, because the effects of TSS are reversible only before a certain point. Treatment is usually by antibiotics and rehydrating fluids. Some doctors also administer immunoglobulin (derived from donated blood) because it contains a high concentration of donor's antibodies.

There is currently research into treatments which can neutralise the toxin.

How to Reduce the Risk from Tampon-Related TSS

• Consider not using internal absorptive sanitary protection (eg, tampons) at all
• Change your tampon every four to six hours
• Use the lowest possible absorbency at each stage of your period
• Use a sanitary towel at night and towards the end of your period
• Wash your hands particularly before insertion of the tampon.