What is toxic shock syndrome (TSS) and how is it connected to tampons?

When you first got your period, learning how to use a tampon may have had quite a learning curve. With the new experience came questions like, “What should it feel like? Did I insert it right? And why do tampon boxes warn of toxic shock syndrome?”

Toxic shock syndrome, or TSS, is a condition you may have learned about during health class or saw for the first time on the side of a tampon box. What is it, and what does it have to do with tampons?

It can sound scary, but it helps to know that toxic shock syndrome is a rare condition that you can avoid. Keep reading to learn more about TSS, what causes it and the steps you can take to prevent it.

What is toxic shock syndrome?

Toxic shock syndrome is a rare illness caused by one or more bacterial infections. In the United States, the likelihood of TSS is only around 1 to 3 people out of 100,000. Although it’s rare, it’s important to know that toxic shock syndrome can cause serious health concerns. The infections that cause TSS can release toxins into the blood and organs – like the heart, lungs, liver and kidneys. This can lead to severe illnesses and organ failure, and in even rarer circumstances, TSS can be fatal.

While it can affect men, toxic shock syndrome is a condition that most commonly affects women. It has a long association with tampon use and menstrual periods, but those are not the only causes. TSS may also result from open wounds, foreign objects in your body, or recent procedures like childbirth or surgery.

Symptoms of toxic shock syndrome

How can you tell if you have toxic shock syndrome? Toxic shock syndrome shares symptoms with several illnesses, including the common cold. When you feel sick, you usually expect the symptoms to clear up in a few days. And while a cold will usually go away on its own, TSS will not.

The onset of TSS symptoms would be sudden, and it usually happens within days of the bacteria entering your bloodstream. The best way to protect yourself is to look for TSS symptoms, document them, and contact your healthcare provider. Based on your symptoms, they’ll be able to recommend scheduling an appointment or seeking immediate medical attention.

The symptoms of toxic shock syndrome may look like other infections, with the most common symptoms being:

• Chills
• Confusion and disorientation
• Diarrhea
• Fatigue
• Fever higher than 102° F
• Headache
• Low blood pressure
• Muscle aches and pains
• Nausea and vomiting
• Red, flat rash that covers most of your body
• Redness around eyes, mouth, throat and vagina

Different bacteria can cause different symptoms. While there is some overlap, the above symptoms are more commonly associated with TSS caused by the S. aureus bacteria. Streptococcal TSS can cause shock, bleeding problems and difficulty breathing. Clostridium sordellii usually doesn't cause a fever. However, it can cause other flu-like symptoms, abdominal tenderness and swelling from fluid buildup. We’ll talk more below about the different types of bacteria.

What causes toxic shock syndrome?

There are several risk factors for TSS, but the main cause is bacteria – especially when it comes to tampon use.

How tampons can cause toxic shock syndrome

Bacteria can grow on almost anything. It can begin growing on a tampon while it’s in your body if it isn’t changed often enough or if the absorbency level is too high. In both situations, the bacteria can become trapped in your vagina and enter your uterus.

Additionally, if the absorbance level of the tampon is too high, it can cause your tampon to stay dry and stick to the walls of your vagina. Not only will this cause some discomfort during removal, but it can also cause tiny tears on your vaginal walls. The bacteria can enter these tears and get into your bloodstream, leading to TSS.

Other causes of TSS

Toxic shock syndrome is most commonly associated with tampon use, but it isn’t only connected to using menstrual products. TSS can be caused by foreign material, like gauze. The infection can also come from a history of using birth control devices, childbirth, surgical wounds or skin infections. Proper care of any wounds or incisions can help you avoid TSS.

Bacteria’s role in toxic shock syndrome

Harmful bacteria cause toxic shock syndrome. Bacteria has an immediate negative connotation, but it’s a natural part of your body. In fact, bacteria outnumber the human cells the average adult has, 38 trillion to 30 trillion. Good bacteria help your body absorb nutrients, break down food and fight off harmful bacteria, like the ones that cause TSS.

Three bacteria are responsible for causing toxic shock syndrome: Staphylococcus aureus, Streptococcus pyogenes and Clostridium sordellii.

Staphylococcus aureus

Staphylococcus aureus (S. aureus) is the most common bacteria that causes TSS. It’s part of your body’s normal bacteria and can exist without causing an infection. Because it’s not a foreign bacteria, most of us develop antibodies to prevent and fight against infection. However, in people who develop TSS, chances are they haven’t developed the antibodies against it.

Streptococcus pyogenes

Streptococcus pyogenes (S. pyogenes) is another TSS-causing bacteria, but it usually happens as a secondary infection from another condition. The primary infection is most commonly seen in children and elderly adults who’ve recently had chickenpox or other skin infections, or who have a weak immune system.

Clostridium sordellii

Similar to S. aureus, Clostridium sordellii (C. sordellii) is another naturally occurring bacteria found in your body – more specifically, the vagina. In the vagina, this bacteria won’t cause an infection, but that’s not the case if it enters your uterus. During your period, childbirth or another gynecological procedure, C. sordellii can enter your uterus and lead to an infection that causes TSS.

How is toxic shock syndrome diagnosed?

Watching your symptoms can offer a pretty clear indication of whether you have TSS or not. If you think you’re showing TSS symptoms, call your primary care doctor or clinician and schedule an appointment at their earliest availability.

During diagnosis, your doctor will first review all your symptoms. They will conduct a physical examination to check for fever, low blood pressure, rashes and skin redness. Make sure to share whether you’ve experienced any unseen symptoms, such as confusion, headache, muscle aches and nausea. Your doctor needs to know all the ins and outs of your symptoms for accurate diagnosis. Based on your symptoms, they’ll be able to determine if your case of TSS has advanced to a multisystem organ infection – whether or not the infection is affecting multiple organs.

After checking your symptoms, your doctor may perform a series of diagnostic tests. They may use one or a combination of blood cultures, blood tests and urine tests.

Your doctor may use blood cultures to identify the type of bacteria that caused the TSS. Blood tests will reveal how the illness affects your body. For example, blood tests can measure organ function and cell count while giving an overall look into how healthy you are. Once your doctor can confirm TSS, they’ll immediately move to treatment.

Treatment for toxic shock syndrome

The first step to treating toxic shock syndrome is to remove the device – if any – that caused your infection. This could be a tampon, contraceptive device or nasal packing.

Treatment for TSS varies based on what your doctor was able to discover during diagnosis to treat your specific symptoms and stop the infection. Based on your symptoms, your doctor may recommend:

• Antibiotics administered intravenously to fight infection and control bacteria growth
• Surgical cleaning for treating infected wounds
• Heart medication to treat low blood pressure
• Oxygen for treating respiratory issues
• Dialysis to treat kidney failure
• Fluids administered intravenously to prevent shock and organ damage

What can I do to avoid TSS?

Toxic shock syndrome and its connection to tampons isn’t anything new. It was discovered in the late 1970s when highly absorbent tampons were widely used. Since then, manufacturers have changed how they make tampons. Because most – if not all – tampon brands now offer multiple absorbency options, tampon-related TSS has declined. While TSS may be rare, it’s still important to know how you can prevent it.

Menstruating women are most at risk for TSS, but fortunately, you can take steps to lower your risk of menstrual TSS.

Avoid highly absorbent tampons

Your tampon use should always depend on your flow. You may gravitate toward high-absorbency tampons to avoid a leak, but this significantly increases your risk of TSS. Instead, change your tampons more often on days when your flow is heavier. Don’t get discouraged if you’re having trouble figuring out which absorbency to use. It may take some trial and error, but feel free to reach out to your women’s health specialist for help.

Change tampons frequently

Remembering to change your tampons regularly is key to preventing menstrual TSS. Tampons should be changed every 4-8 hours. And if you can’t remember whether you put one in or not, check! While a tampon can get pushed far up your vaginal canal, you can’t lose it. Just make sure you wash your hands thoroughly before trying to retrieve it.

Use other menstrual products

Tampons are one of the most common menstrual products, but you should consider using other options when you get your period like pads, menstrual cups and period underwear. The best product for your period can change from morning to night and may depend on factors like comfort, your level of activity, your flow and the time of day. Again, if you’re having trouble figuring out which to try, your women’s health specialist can help you weigh the pros and cons.

Avoid wearing tampons if you don’t have your period

You should only wear tampons if you have your period. Postpartum bleeding may look like menstrual bleeding, but it’s not. And tampon use isn’t recommended for it. Instead, use very absorbent pads or adult diapers. You should also avoid tampon use if you experience light spotting as part of an irregular period.

Talk to your doctor about TSS and how to prevent it

Toxic shock syndrome is rare, but it’s a risk for every menstruating person who uses tampons. It can be scary when you consider the possible risks of tampons, but they are safe when used correctly. Switch your tampons regularly, choose a proper absorbency and talk to your doctor. Not only can they offer more information on TSS and its symptoms, but they can also give you knowledge and tips to help you feel confident about using tampons and preventing TSS.