What Is Toxic Shock Syndrome?

It's that time of the month — you're menstruating, and you reach for a tampon from a box you've bought and grabbed from countless times. Since it's a robotic action, you may not have noticed the rather aggressive warning on the box regarding toxic shock syndrome, which can develop if you leave a tampon in for a prolonged period of time. Even if you are aware of the warning, you likely didn't think much of it.

But is toxic shock syndrome something you should actually worry about when using tampons? If so, what do you need to do to avoid it? Here's everything tampon users need to know.

What Is Toxic Shock Syndrome?

"Toxic shock syndrome is a bacterial infection that can cause severe illness due to toxins that enter the bloodstream and lead to inflammation," explains Jessica Shepherd, M.D., M.B.A., F.A.C.O.G. In an extreme scenario, toxic shock syndrome can result in amputations of fingers, toes, or limbs, or even death, according to John Hopkins Medicine.

Toxic Shock Syndrome Symptoms

• High fever above 102F (always a symptom of toxic shock syndrome)
• Chills
• Watery diarrhea
• Rash resembling a bad sunburn or red dots on the skin
• Low blood pressure
• Eye redness
• Peeling of the skin on the soles of the feet or palms of the hands

Toxic Shock Syndrome Causes

You likely think of toxic shock syndrome as strictly tampon-related, but "because TSS occurs when bacteria gets into the bloodstream, it can occur other ways than menstruation," says Dr. Shepherd. For example, "infections can occur with other areas such as infected surgical wounds, mastitis [infection of the breast tissue], lung abscess, or primary bacteremia. Also, it has been noted to occur following childbirth by vaginal delivery and cesarean section."

When it comes to menstruation-related toxic shock syndrome, tampons aren't the only product at fault. Any product that collects menstrual blood could allow the toxic shock syndrome-causing bacteria to grow if left in for too long — and that includes menstrual cups, according to the University of Washington Medicine. That said, menstrual cup-associated toxic shock syndrome is extremely rare (even more so than TSS from tampons). There have only been two cases reported globally, according to menstrual cup company Lunette.

The bacteria that causes menstruation-related toxic shock syndrome (most commonly Staphylococcus aureus bacteria) typically becomes trapped in the vagina after it grows on tampons (especially if they're left in there too long) and then can be introduced into the bloodstream through tiny tears in the vagina caused by tampons (especially the removal of those that are too dry), she explains. That's why the recommendation is to never use a tampon for more than eight hours, says Dr. Shepherd. "Improper usage can facilitate TSS development," she says, including wearing a tampon for too long or wearing a tampon that's more absorbent than is needed (i.e. using a "super" tampon even if you have a light flow). (

How Likely Are You to Get Toxic Shock Syndrome When Using Tampons?

Toxic shock syndrome was first identified by doctors in 1978, and in 1980, the Centers for Disease Control and Prevention reported 812 total cases of toxic shock syndrome associated with menstruation. Soon after, there were changes to how tampons were made, and the number of reported cases of menstruation-related toxic shock syndrome decreased significantly; by 1989, there were already significantly fewer cases; CDC only reported 45 menstruation-related toxic shock syndrome cases.

What was going on with tampons in the '80s? For one, the maximum absorbency rate of tampons (the amount of liquid a tampon can absorb) was much higher then. In 1980, tampons on the market absorbed anywhere from 10.3 to 20.5 grams, with "very high absorbency" tampons (absorbing at least 15.4 grams) being used by 42 percent of tampon users, according to the CDC. By 1986, only 1 percent of tampon users utilized the "very high absorbency" kind, and today, tampons absorb a maximum of 18 grams, according to the FDA. Super absorbent tampon use has been historically associated with toxic shock syndrome for two possible reasons. First, if you use a super-absorbent tampon for a flow that's not heavy enough to require that level of absorbency, it's more likely to be dry when you remove it, thus making tiny cuts in the vaginal canal where bacteria can enter. Second, using a super-absorbent tampon means you can leave it in for significantly longer, but doing so gives bacteria more time to grow.

The increased risk associated with higher-absorbency tampons may also be due to the materials that were formerly used in super-absorbent tampons, but luckily a lot has changed. "Most tampons today are made of cotton or a cotton/rayon blend," says Taylor Sparks, founder of Organic Loven. But in the '80s, some companies (namely RelyPr) used polyester foam, which was known for its absorption rate, but which may also enhance bacterial growth, says Sparks. RelyPr used polyester foam and carboxymethylcellulose (cellulose gum), and the CDC submits that the "unique composition" of materials "may have been responsible for the increased risk associated with those products." RelyPr tampons were voluntarily pulled from the market in 1980, and tampons made from polyacrylate (a type of plastic) were also withdrawn from the market in 1985, according to the CDC.

Today, though toxic shock syndrome is significantly less common today than it was during the '80s, cases still exist. Now, estimates put the incidence rate between 1-4 in 100,000 women, says Shepherd. For context, that's means there's about a 0.00001-0.00004 percent risk of gettingmenstruation-related toxic shock syndrome.

With all these important changes made to tampons in the U.S., the risk of contracting toxic shock syndrome has become super low — that said, it's still important to know how to prevent it from ever happening to you.

How to Prevent Toxic Shock Syndrome

Great news: A lot of people actually have antibodies that protect them from the bacteria most commonly associated with menstruation-related toxic shock syndrome, according to the University of Washington Medicine. You would need to be missing those antibodies as well as create the ideal environment for bacteria growth in order to get toxic shock syndrome.

That said, practicing good menstrual hygiene can help reduce your risk even further. To reiterate, you should change your tampon (or menstrual cup) at least every eight hours and stick to the absorbency level that's appropriate for your flow at that time, says Dr. Shepherd.

What to Do If You Think You Have Toxic Shock Syndrome

When in doubt, make an appointment with your ob-gyn, says Dr. Shepherd. "And if there is any fever or rash that is apparent, go to urgent care or the emergency room," she says. Symptoms may initially resemble an oncoming cold, so you might not think much of them, but if you're menstruating and using a tampon, they're worth keeping an eye on, since symptoms can escalate quickly. Once initial symptoms occur, hypotension (low blood pressure) generally develops within 24 to 48 hours, which includes organ failure shortly after, says Dr. Shepherd. If toxic shock syndrome progresses to one of these more severe stages, you may need to be admitted to the hospital so you can get antibiotic treatment and blood cultures to monitor the bacteria and ensure it isn't spreading.