TSS: the facts, calmly

Canadian tampon boxes carry a short statement about toxic shock syndrome, or TSS. Health Canada requires it “Anywhere on the outer label”, in English and in French. This Column puts the health sources’ own words around that statement. Each source is named and dated. Where sources differ, both are shown. Nothing here is the Editor’s advice.

What TSS is

Health Canada calls TSS “a rare, but serious infection that occurs when toxins made by certain strains of Staphylococcus aureus bacteria (Staph) get into the bloodstream.”

HealthLink BC, British Columbia’s provincial health service, names two bacteria whose toxins can cause it: Staphylococcus aureus and Group A Streptococcus. It says “TSS develops suddenly”, and that “It can quickly affect several different organs including your liver, lungs and kidneys.”

TSS is not only about periods. Health Canada says: “Tampons do not cause Toxic Shock Syndrome, and the disease is not limited to menstruating women. Men, non-menstruating women, and children can also get TSS.” HealthLink BC says: “it can occur in anyone. Only half of the cases of TSS are linked to menstruation.”

Tampons and cups: what each source says

Tampons. Health Canada’s page (2015) says: “Over the last number of years, only a few cases have been reported, and of these, about half were associated with tampon use.” It adds: “Greater tampon absorbency appears to be a factor”. In the United States, the FDA describes TSS as “a rare but serious bacterial infection associated with tampon use, especially when tampons are left in place too long.”

Cups. HealthLink BC says TSS “has been linked to tampon and menstrual cup use by menstruating individuals”. It also says “tampons and menstrual cups do not cause TSS”, though people using them “are at higher risk”. The NHS, in the UK, says: “It can happen when using a tampon or menstrual cup, or from an infected wound.”

One more point, from Health Canada: “The material of manufacture, whether cotton or rayon, has not been found to be a risk factor.” That is a finding about risk. It is not advice about which product to choose.

Who is more at risk

Health Canada says: “Younger women (under the age of 30) are at greater risk than older women because they have not yet developed the antibodies to the toxin that causes TSS.”

HealthLink BC lists risk factors. In its words, they include:

• “Past history of SA toxic shock syndrome”
• “Prolonged use of a tampon, especially the super absorbent type, or menstrual cup”
• “Use of contraceptive sponges, diaphragms or intrauterine devices”

It also lists vaginitis, burns, skin infections or injuries (including a wound from surgery), and recent respiratory infections.

The NHS says: “Your chances of getting TSS are higher if you’ve had it before.”

A note on words: some sources we cite here say “women”, “men”, “menstruating individuals”, “pads” or “sanitary pads”. We keep each source’s words so we report its findings accurately. The Reading Room is for everyone who menstruates.

The signs, source by source

These are the signs the sources list. They are not a checklist for telling TSS apart from anything else.

HealthLink BC adds a time frame: symptoms “usually develop in 3 to 5 days in individuals who are menstruating and using tampons or menstrual cups.”

In the United States, the FDA’s consumer page lists “a sudden fever (usually 102°F or more), vomiting, diarrhea, fainting or feeling like you are going to faint when standing up, dizziness, or a rash that looks like a sunburn.”

In the UK, the NHS also lists “a raised skin rash that feels like sandpaper”, and the palms, soles, tongue and whites of the eyes turning “bright red”.

If the signs appear

After the box, one line from HealthLink BC: “TSS cannot be treated at home. Hospital care is required…”

Lowering the risk, in the sources’ words

Each source’s advice is kept separate, in its own words.

Health Canada:

• “Use the lowest absorbency that will meet your needs.”
• “Do not use tampons until your period begins.”
• “Wash your hands before and after inserting a tampon.”
• “Remember to remove each and every tampon.”
• “Alternate the use of tampons with external protection, like pads and liners.”

HealthLink BC:

• Follow the package inserts, “including directions on cleaning and replacement”.
• “Using tampons with the lowest absorbency that you need. The risk of TSS is higher with super absorbent tampons.”
• “Wearing tampons/menstrual cups and sanitary pads at alternate times.”

The FDA, in the United States: “If you can wear one tampon up to 8 hours without changing it, the absorbency may be too high.”

The NHS, in the UK: “follow the instructions when using tampons, menstrual cups… and do not leave them in longer than needed or recommended”.

On wear time and nights, the sources use different words. The plate below sets them side by side, with no opinion from the Editor.

If you have had TSS before. Health Canada says: “Do not use tampons, if you have ever been diagnosed with TSS.” Health Canada’s labelling guidance says the tampon label or insert must advise users to “seek medical attention before using menstrual tampons again if Toxic Shock Syndrome warning symptoms have occurred in the past”. In the UK, the NHS says “your doctor may advise you not to use tampons, contraceptive caps or diaphragms.” One cup maker’s instructions say to “consult your physician prior to using [the cup] if you have been previously diagnosed with TSS.”

If a cup is hard to remove, see “Menstrual cups, explained gently” and talk to a healthcare provider.

A short history

Health Canada says: “In the early 1980s, there was an epidemic of Toxic Shock Syndrome in North America that was associated with the use of a high-absorbency tampon and strains of toxin-producing bacteria.” It adds: “The incidence of TSS has dropped significantly since the epidemic in the early 1980s.” In the United States, the FDA says: “TSS cases associated with tampons have declined significantly over the years.”

The rules, by country

What this is not

This Column set out what named health sources say about TSS, in their own words. It cannot tell you whether you have TSS. It does not compare the risk of one format with another, and it makes no claim about any product or material. It is not an emergency service.