Toxic shock syndrome (TSS) is a rare and severe immune response caused when toxins from bacteria enter the bloodstream via damaged skin (after surgery or childbirth, from burns, skin lesions, etc.). Almost all cases are attributed to Staphylococcus aureus and Streptococcus pyogenes. Organs can shut down and it can be fatal if left untreated.
Approximately half of all cases are among people who don’t menstruate.
Most cases of menstrual toxic shock syndrome (mTSS) are caused by Staphylococcus aureus.
Staphylococcus aureus
Staphylococcus aureus is a part of the normal skin flora of about a quarter of the population. Some Staphylococcus aureus strains can produce toxins that can act as superantigens, which trigger acute and sudden immune system responses—about 50 to 3000 times the normal immune response. Staphylococcus aureus prefers a neutral pH (7) and an oxygen- and carbon dioxide-rich environment to develop and overgrow. Around 80% of people develop antibodies against some of the common superantigens by adulthood, and some people lack the receptor on their vaginal tissues needed for the toxin to attach to cells and gain entry to the bloodstream. Studies have reported vaginal colonisation rates for toxigenic Staphylococcus aureus ranging between 1 and 4%. With around 20% of people who are not immune, approximately 0.2–0.8% of the population may need to be particularly vigilant regarding risk of mTSS.
pH levels
- Normal vaginal pH is 3.5–4
- The pH of vulvar skin is 5.3–5.6
- Menstrual blood has a pH of 7.35
- The pH of ejaculate is 7.2–8.0
Biofilm
Staphylococcus aureus has an ability to create biofilm on catheters, prosthetic heart valves, artificial joints, as well as menstrual cups and discs made from silicone and thermoplastic elastomer (TPE). Staphylococcus aureus thrives but does not divide rapidly within these biofilms. One study suggests that menstrual cups made of TPE may induce less biofilm than those made of silicone.
Symptoms of toxic shock syndrome are sudden and include:
- fever
- dizziness or fainting (low blood pressure)
- vomiting
- diarrhea
- aching muscles
- headaches
- confusion
- tiredness
- red eyes, lips, tongue, and throat
- a red peeling rash similar to sunburn found on the hands and feet
- seizures
Perspective
The incidence of menstrual toxic shock syndrome in the United States has been calculated to be 1.05 per 100,000 menstruating people. In the UK the figure is approximately 0.3 per 100,000. Dr. Jen Gunter notes that the risk of getting mTSS each year in the U.S. is about the same as the risk of dying after being hit by lightning.
Cases
There have been no cases of death from mTSS associated with menstrual cup or disc use. There are approximately eight recorded cases of mTSS related to menstrual cups with hospitalisation and recovery.
| Year | Location | Link |
|---|---|---|
| 2015 | Canada | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556184/ |
| 2019 | France | https://www.medisite.fr/maladies-infectieuses-temoignage-sa-coupe-menstruelle-lui-a-cause-un-choc-toxique.5614235.862410.html |
| 2020 | Germany | https://www.ejcrim.com/index.php/EJCRIM/article/view/1825/2259 |
| 2021 | Lebanon | https://www.sciencedirect.com/science/article/pii/S221425092100127X |
Five cases in a meta-analysis from 2019 were reported here (which may include some of the above listed):
https://pubmed.ncbi.nlm.nih.gov/31324419/
Precautions
- Wash your hands regularly, including before and after inserting a menstrual cup or disc
- Avoid basic/alkaline pH soaps
- Empty and clean your cup or disc every 12 hours
- Boil your cup or disc for 5 minutes at least once per cycle
- Alert a doctor early and remove your menstrual cup or disc if you develop symptoms of TSS
Sources
- Gunter, Jen. The Vagina Bible. Random House Canada, 2019.
- Parsonnet, Jeffrey, Hansmann, Melanie A, Delaney, Mary L, et al. “Prevalence of toxic shock syndrome toxin 1-producing Staphylococcus aureus and the presence of antibodies to this superantigen in menstruating women.” National Library of Medicine, September 2005, https://pubmed.ncbi.nlm.nih.gov/16145118/.
- Parsonnet, Jeffrey, Goering, Richard V., Hansmann, Melanie A., et al. “Prevalence of Toxic Shock Syndrome Toxin 1 (TSST-1)-Producing Strains of Staphylococcus aureus and Antibody to TSST-1 among Healthy Japanese Women.” Journal of Clinical Microbiology, August 2008, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2519460/.
- Puzigaća, Luca. “Staphylococcus aureus.” YouTube, uploaded by Osmosis, 14 October 2020, https://www.youtube.com/watch?v=wdo3E2w0cI8.
- Thomasy, Hannah. “Toxic Shock Syndrome: Way Beyond Tampons.” YouTube, uploaded by SciShow, 10 October 2018, https://www.youtube.com/watch?v=AOLzM_pDbas.