Beware of Tampons! The Truth Behind Toxic Shock Syndrome
Summary of Disease
Toxic Shock Syndrome (TSS) is a rare life-threatening disease that can affect all organs in the body caused by toxins secreted by bacteria, like staphylococcus, that enter the human body. Characterized by abnormally low blood pressure, sudden high fever, rashes, nausea, vomiting and diarrhea,1 TSS is estimated to affect 3-6 people per 100,000 annually in the U.S.2 Although this disease can affect anyone, most TSS cases occur in menstruating females in association with the use of sanitary products like tampons, sponges, diaphragms and cervical caps.3 Menstrual TSS is caused by the colonization of toxin-secreting bacteria strains that may enter the bloodstream through the uterus or vaginal lining.1 Therefore, creating awareness about menstrual hygiene is essential in decreasing the amount of TSS cases in North America.
Etiology and Pathology
TSS is caused by toxigenic strains of Staphylococcus aureus or Streptococcus pyogenes bacteria.4 Once inside the body, these bacteria produce superantigens and release substances that may damage tissues and weaken the immune system. Antigens are foreign substances that cause an immune response in the human body while superantigens are a class of antigens that results in the excessive activation of the immune system.5
The exact mechanism of the TSS is unknown, but associated toxic shock is likely due to excessive release of cytokines, which are proteins secreted by immune cells to activate white blood cells, boosting the body’s immune and inflammation responses. However, the continuous release of cytokines can lead to a cytokine storm where the induced immune responses begin damaging uninfected organs and tissues.6 Ultimately, TSS can cause severe inflammation damages to local tissue structures, resulting in persistent organ dysfunction and even cell death.4
The National Organization for Rare Disorders estimates that TSS related to tampon use occurs in about 1 in 100,000 menstruating women.2 When more than a third of all cases involve women under the age of 19 and up to 30% of women patients have relapses of the disease,3 this becomes a critical issue of menstruation hygiene. When the same tampon is used over long term, the humid environment becomes the perfect breeding ground for bacteria. Although the disease occurs most often in the setting of menstruation, non-menstrual TSS may also occur in men, women or children in association with soft tissue infections, post-surgical infections, burns, and retained foreign bodies.7
Symptoms
The most common symptoms of Toxic Shock Syndrome include a sudden high fever, sore throat (pharyngitis), redness in eyes (conjunctivitis), headaches, fatigue, severe muscle aches (myalgia), diarrhea, vomiting, seizures, and disorientation. A sunburn-like skin rash may also develop over the body within a few hours of onset with later peeling (desquamation) of skin on the palms and soles. In addition, dizziness, nausea and dehydration from low blood pressure (hypotension) is a common symptom of severe TSS.1,3,4 When blood pressure is too low, blood flow to the organs and tissues decreases and less oxygen is available. Without adequate oxygen supply to body tissues, tissue damage can occur causing the disease to progress relatively quickly, leading to complications such as damage to the kidneys, heart and lungs.8 Hence, early diagnosis and appropriate treatment of TSS can reduce the potential of developing life-threatening complications.
Diagnosis
Although there is not yet a specific diagnostic test for toxic shock syndrome, doctors can make a diagnosis based on the physical examination of symptoms or conduct blood or urine tests to detect traces of bacteria causing the infection. Since the toxic shock syndrome can affect multiple organs, doctors may order additional tests, such as a CT scan, lumbar puncture or chest X-ray to confirm the diagnosis, assess the degree of damage and rule out other infections.1
For menstrual TSS in association with menstrual product use, a small tissue sample may also be collected from the vagina and cervix to isolate infection-causing bacteria. For non-menstrual TSS, samples may be obtained from the associated wound sites, which are then cleaned and treated.4
Prognosis
TSS symptoms usually appear after 3 to 5 days in menstruating women using tampons and as soon as 12 hours after invasive surgical procedures.9 If left untreated, complications such as liver, kidney, and heart failure may occur. As a result, individuals diagnosed with the disease may need to be monitored in intensive care for several days for signs of shock and organ damage.10
Despite having life-threatening complications, TSS is treatable when diagnosed early. Doctors often prescribe an intravenous (IV) antibiotic to fight bacterial infection, IV fluids and electrolyte replacement to fight dehydration, and medication, such as fludrocortisone and midodrine, to stabilize blood pressure.1
Prevention
Menstrual TSS can be prevented through proper menstrual hygiene: tampons should not be left inside the body for more than four hours, and women using contraceptive devices are cautioned to follow all package instructions.3 In addition, individuals using tampons, diaphragms and contraceptive devices should be aware of the symptoms of TSS and seek prompt medical attention if symptoms, such as vomiting, headache, muscle pain, high fever and redness in the eyes, mouth and vagina, do occur.
The Centers for Disease Control and Prevention, Genetic and Rare Disease (GARD) Information Center, National Institute of Allergy and Infectious Diseases, and the World Health Organization (WHO) can provide more information and resources regarding toxic shock syndrome.
Rianne Chen
**Works Cited:**
1. Mayo Clinic. Toxic Shock Syndrome - Symptoms And Causes. [online] Available at:
2. Mitchell, L., 2018. What You Need To Know About Toxic Shock Syndrome. [Blog] Health University of Utah, Available at:
3. WebMD. The Basics Of Toxic Shock Syndrome. [online] Available at:
4. Rare Disease Database. 2009. Toxic Shock Syndrome - NORD (National Organization For Rare Disorders). [online] Available at:
5. Kalland, T., Dohlsten, M., Antonsson, P. and Soögaard, M., 1998. Superantigens. Encyclopedia of Immunology, pp.2239-2243.
6. Seishima, M., Kato, G., Shibuya, Y. and Matsukawa, S., 2009. Cytokine profile during the clinical course of toxic shock syndrome. Clinical and Experimental Dermatology, 34(8), pp.e632-e635.
7. Ross, A. and Shoff, H., 2020. Toxic Shock Syndrome. [online] NCBI. Available at:
8. Haefner, H. and Crum, C., 2018. Benign Conditions of the Vagina. Diagnostic Gynecologic and Obstetric Pathology, pp.258-274.
9. HealthLink BC. 2020. Toxic Shock Syndrome. [online] Available at:
10. Stephens, C., 2018. Toxic Shock Syndrome: Symptoms, Diagnosis, And Treatment. [online] Healthline. Available at:
Cite This Article:
Chen R., Kozak A., Nakhoul R., Chharawala V., Lombo L., Liang A. Beware of Tampons! The Truth Behind Toxic Shock Syndrome. Illustrated by Chharawala V. Rare Disease Review. September 2021. DOI:10.13140/RG.2.2.35637.19688
