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Toxic shock syndrome is a rare but severe condition that’s associated with using tampons—though tampons aren’t the only cause—and, yes, it can lead to organ failure and become life-threatening. It’s caused by an infection with a strain of Staphylococcus aureus that, when present in high enough levels, produces the TSST-1 toxin that can wreak a lot of havoc. For women to get TSS from a tampon, they’d have to have this strain of S. aureus in their vaginal flora and leave a tampon in long enough that the staph bacteria produced the toxin. Then they’d have to lack sufficient antibodies to fight it off. Rare, but it happens.
There were only 40 reported cases of TSS in the United States in 2016. But after high-profile cases of TSS made headlines in recent years, including one from VICE, some women said they were switching to cotton-only tampons—which some experts hypothesized were safer than ones made with synthetic fibers like rayon. Others said it didn’t make a difference—or swore off tampons in favor of non-absorbent, silicone menstrual cups (a report published in 2015 detailed the case of a Canadian woman who developed TSS a few days after using a menstrual cup, but otherwise there hadn’t been any research linking cups to the condition).
For a paper published in Applied and Environmental Microbiology, French researchers tested 11 types of tampons of different absorbencies and four kinds of menstrual cups in a laboratory set-up designed to reproduce conditions inside the vagina. (No, it’s not the same as testing the products in actual vaginas, but it’s a reproducible experiment which means other researchers could try to verify their results.) The brands included Tampax, OB, Natracare (all cotton), and different sizes from two French cup brands, be’Cup and MeLuna.
The researchers put the products in sterile bags—which is apparently known as "the tampon sac method"—along with a solution containing S. aureus and observed the differences in S. aureus growth and production of the TSS-1 toxin over 8 hours. (There was a control group using solution without staph.)
What did the study say about tampons?
All of the tampons tested promoted the growth of S. aureus and the toxin, and cotton-only tampons actually produced more of the toxin than did cotton blends or synthetic tampons. And the levels didn’t correspond to tampon absorbency.
Microbiologists say that oxygen helps staph bacteria multiply. Gerard Lina, a physician and professor of microbiology at the University Claude Bernard and lead author of the study, said in a release that space between the tampon fibers, which contribute to additional air entering the vagina, represented a “major site” of staph growth and toxin production in the experiment. The team also found that cotton-only tampons were less structured than synthetic ones, meaning they had more space between fibers, which allows more air into the vagina, which is, in a word, bad.
What did the study say about cups?
The researchers found higher levels of S. aureus and TSS-1 in the cups than they did in the tampons; the larger cup sizes had the highest levels. The researchers also believe that air introduced into the vagina via menstrual cup insertion is a concern because again, it helps staph breed. (Inserting a cup is basically sticking a scoop of air up there.)
They also found that a “significant” film of staph remained on the cups eight hours after they were rinsed with water three times, which means that people might be reinserting a contaminated cup if they’re not using soap or a cleaning solution before putting the thing back in. Given this finding, the authors recommended people have a second cup so they can boil it between uses.
Currently, cup brands do not tell users to bust out the saucepan after emptying their cup. Some cups sold in the US like the Diva Cup and Lunette do say to wash well with warm water and either soap or their special wash before reinserting (though who knows how many people follow those instructions), but others only say to rinse, which is what the researchers did. The Moon Cup says to rinse or wipe before reinserting and the Blossom Cup only says to rinse but to clean it before storing. Between periods, makers of the Moon Cup do suggest boiling for five to seven minutes or using sterilizing solution or tablets. The Diva cup says to use oil-free soap or boil for five to ten minutes “as needed.” We contacted Diva Cup, Lunette, Blossom Cup, and Moon Cup for comment on the study and will update this story if we hear back.
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What should I do now?
Cotton tampons look just as risky as synthetic and cups probably aren’t any safer than tampons, so don’t buy them under the impression that you’re safer from TSS. "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," Lina said. The authors concluded: “Notably, our results do not show that menstrual cups are safer than tampons and suggest that they require similar precautions.” Lina told Consumer Reports that he’s observed two cases of TSS linked to cups in the last three years.
Jen Gunter, a board-certified gynecologist who frequently writes on health issues, tells Tonic that “women should not think cotton is safer.” Gunter, who was not involved in the research, says the study supports the idea that it’s the introduction of air that matters the most with tampons and TSS risk, adding that this is why she’s so against Goop’s promotion of vaginal jade eggs that could be porous and trap air. (Gunter frequently takes Goop’s health claims to task.)
Gunter, who wrote about the 2015 case report of TSS linked to a cup, says the study shows that cups also carry a risk. “The menstrual cup data suggests that the risk is equal if not even potentially greater (still likely low, though) as there was greater adherence [of staph bacteria on the cup],” she says. Gunter agrees with the authors’ recommendation to have at least two cups. “I think women who want the lowest risk of TSS should have more than one cup so they can boil between uses,” she says. We shouldn’t have to say this, but this advice applies to reusable cups, not disposable ones—do not boil those and reuse them, as they’re only made for one use in the first place.
What else can I do to avoid TSS?
TSS risk has a lot to do with who has staph bacteria in their vaginal flora, which, by the way, changes throughout your cycle, so it’s not like you can just get a test once and know if you’re at risk.
Whatever product you’re using for your period, follow the instructions. Don’t leave anything in your vag longer than instructed and, if you’re a cup person, get a second one and properly sanitize it between uses. Experts also recommend using the lowest absorbency tampon that will hold you over for four to eight hours; changing more frequently than that is just introducing more oxygen and could lead to insertion trauma, especially on light days. And the authors of this study suggested using the smallest cup possible.
If you have any symptoms of TSS (like high fever, rash, muscle aches, vomiting, or diarrhea) during or a few days after your period, you should call your doctor right away and tell them that you’ve been using a tampon or a cup.
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Update 4/30/18: Lunette CEO and founder Heli Kurjanen provided the following statement:
We have read the study manuscript in great detail and we find it problematic; number of cup brands tested was low (Lunette not included), it was done in vitro (potentially introducing additional air) and the cleaning method used (washed only with water).
We at Lunette have always been knowledgeable about the risks of TSS and mentions of it have been in our user guide from the very beginning. These are made based on FDA’s regulations and guidance for tampons. Currently, we are adding even more information about TSS on our website. It is important to know that TSS is an extremely rare, potentially fatal disease occurring in men, women and children.
The fact is that for TSS to occur, the toxin (TSST-1) must enter the bloodstream. The most direct avenue is through a cut, abrasion or micro-scratch. There is an important difference between tampons and menstrual cups. Tampons can cause micro-scratches as they can dry the vagina (up to 35% of the fluid they absorb are natural secretions for lubrication). Menstrual cups differ in that they do not absorb the natural secretions, and do not cause micro-scratches.
Menstrual cups have been a trusted period care product for decades.
Globally only 2 cases of TSS relating to menstrual cup use have been reported. At least of one of cases was due to very prolonged use as the menstrual cup was left within the vagina for 18 hours rather than the recommended 12-hour maximum. Neither of the cases were related to Lunette Menstrual Cups.
Good hygiene practice is important.
Before handling anything that will be inserted into the vagina or removed from it, wash your hands thoroughly – including under your fingernails - to avoid the introduction of bacteria. Lunette Menstrual Cups should be cleaned before and after your cycle, and after emptying/ before reinsertion. Rinse the cup first in cold water, and then wash with hot water and Lunette Feelbetter Cup Cleanser designed specifically for silicone cups. After your period, sanitise the cup by boiling it in a large pot of water for 5-10 minutes.