Toxic shock syndrome is a rare disease associated with a common bacterium. Although recorded cases of toxic shock date back many years, in the late 1970s the disease suddenly reappeared and seemed to be reaching epidemic proportions in this country. Physicians identified several hundred cases, first in children and then in young women, including teenagers, who became very sick at the time of their menstrual periods. Their symptoms included high fever, severe nausea and vomiting, massive diarrhea, a dramatic drop in blood pressure, and sometimes kidney or liver failure.

As cases accumulated, the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention) began tracking this “mystery” disease. In 1978 it was identified as Toxic shock syndrome, and in 1980 researchers linked it to tampon use. Approximately 80 percent of those stricken turned out to be menstruating women, and about 3 percent of the reported cases were fatal. The incidence of Toxic shock syndrome among teenagers was surprisingly high: in 1981, 44 percent of Toxic shock syndrome cases in menstruating women occurred in the age group 10-19 years.

Laboratory tests indicated that the underlying cause was Staphylococcus aureus, a bacterium that normally lives fairly harmlessly on the skin, in the mouth, or in the vagina. Tests of the stricken women showed that staphylococcus bacteria were not present in the bloodstream, as might have been expected. Instead, the blood of Toxic shock syndrome patients contained exotoxins, poisons secreted by the staph bacteria and somehow transmitted into the bloodstream, where they caused the severe symptoms associated with the disease.

Doctors could not offer their patients anything except supportive therapy. Antibiotics could destroy the staphylococcus bacteria and help prevent recurrences; but since the toxins already released by the bacteria had done the damage, antibiotics did not relieve the symptoms. So physicians continued to treat the symptoms, relieving the dehydration that accompanied the vomiting and diarrhea, offering dialysis to people whose kidneys had shut down, and giving antibiotics to prevent the disease from coming back. Most people did well and eventually recovered.

How did tampon use contribute to the epidemic of toxic shock syndrome?

At the time of the epidemic a great deal of research was done on tampons, investigating whether they introduced bacteria to the vagina, changed the vaginal environment so that bacteria could flourish, or in some other way encouraged bacterial growth. Researchers suspected that somehow the tampons changed the environment of the vagina, or themselves provided a place where bacteria could flourish. A new superabsorbent tampon, Rely, had just come on the market. Since a cluster of cases involved Rely, researchers reasoned that the disease might have something to do with the material used in the tampon or the vaginal dryness it created. Maybe this superabsorbent tampon took so much moisture from the vagina that the vaginal tissues were injured by inserting and removing the tampon and became more vulnerable to infection. Or perhaps the tampon itself, with its extrathirsty fibers, provided an oxygen-rich breeding ground for bacteria that produced more and more toxins.

The Rely tampon was taken off the market. Women were warned by the FDA to use the least absorbent tampon that served their needs and to notify their physicians if symptoms of Toxic shock syndrome appeared. After Rely was withdrawn, new cases dropped in number but did not disappear, so the Rely tampon could not have been the sole cause.

The epidemic wound down, though occasional cases of Toxic shock syndrome still occur: fewer than 1 case per 100,000 menstruating women per year. Not all these cases can be attributed to tampon use. We occasionally see Toxic shock syndrome in women and men who have had surgery on their nose or throat and had nasal packing after the operation.

What caused the epidemic? My own explanation for the dramatic appearance of Toxic shock syndrome in the 1970s is that the “brand” of Staphylococcus aureus that appeared then was a strain (called a phage type) that produced potent exotoxins, unlike some other strains. Research has suggested that certain classic phage types were associated with Toxic shock syndrome, but no one knows why we no longer see those phage types. A significant outbreak of Toxic shock syndrome occurred in Australia in the 1920s, when tampons had not yet been invented. That suggests that Toxic shock syndrome is a cyclical disease; it comes and goes like the flu. If that is the case, it may well come back when a form of S. aureus turns up that has toxin-producing capacity.

What are the symptoms of toxic shock syndrome?

The Centers for Disease Control and Prevention has developed a definitive set of symptoms for this syndrome. The most common are high fever (over 102.5 degrees Fahrenheit), vomiting, diarrhea, a sunburn-like rash, a rapid drop in blood pressure, and peeling or sloughing skin, sometimes on the palms of the hands or soles of the feet. Other markers are muscular aches and pains, headaches, sore throat, bloodshot eyes, and confusion. The symptoms can come on rapidly and progress swiftly from discomfort to overwhelming infirmity. Many diseases have some of the symptoms that define Toxic shock syndrome, but their severity and appearance in combination leads doctors to think of Toxic shock syndrome.

One of the first cases in which I participated as an expert witness was a product liability lawsuit brought against tampon manufacturers.

Mrs. X, the plaintiff, did not feel at all well when she had her period. She ached all over and felt tired. She also had small spots on her index finger that became irritated during her period, for some reason that has never been understood. Her physician, a general practitioner, told her that her problem was “mild recurrent toxic shock.”

He did a vaginal culture and it revealed that she did have staphylococcus in her vagina, though not Staphylococcus aureus. She had S. epidermis, a strain that has never been associated with Toxic shock syndrome and has not been shown to produce exotoxins. Her doctor treated her with antistaphylococcal medications.

Mrs. X had none of the symptoms listed by the Centers for Disease Control and Prevention as defining Toxic shock syndrome: no fever, no diarrhea, no vomiting, no drop in blood pressure, no peeling of the skin (though she did have itchy bumps on her index finger). She just did not feel well during her period.

This lawsuit lasted a month in federal court. The jury found the manufacturer innocent and dismissed the case, but not before thousands and thousands of tax dollars had been spent because Mrs. X did not feel well during her menstrual period.

On another occasion, I was reviewing a case that involved a lawsuit brought by the wealthy family of a 15-year-old girl.

Caitlin came into the hospital during her menstrual period, extremely sick, with a high fever and an unusual group of symptoms that included peeling skin on her fingertips. The doctors in the emergency room thought her symptoms did not quite fit the picture for Toxic shock syndrome and they were unable to culture staphylococcus

from her vagina. They were concerned about Toxic shock syndrome because of her age and the fact that she had come in during her period. She was treated and recovered quickly, but her family decided to sue the tampon manufacturer.

However, Caitlin’s chart showed that a urine test taken at the time of her admission to the hospital showed a positive result for amphetamines. Her problem was not toxic shock but an amphetamine overdose. Her family dropped the case.

What is the treatment for toxic shock syndrome?

Today, as in the 1970s, there is no real cure for Toxic shock syndrome. It is treated with antibiotics to decrease the number of bacteria that produce the toxins, and to prevent recurrence. If vomiting and diarrhea have caused severe dehydration, then intravenous fluids are sometimes provided.

How can you protect against toxic shock syndrome?

Although, theoretically, anyone is at risk for this disease, women who use high-absorbency tampons, especially teenagers and women in their 20s, seem to be more vulnerable. It makes sense, then, to use the least absorbent tampon that meets your needs. Perhaps you have to use a “super” tampon for the first couple of days of your period, but you can change to a”regular” or even a”junior” size as the flow diminishes.

Second, alternate tampons and pads. If you want to wear tampons during the day, use pads at night or when you are at home. Tampons have real advantages — no odor and no mess — but you may need these advantages more when you are out in the world than when you are at home. Research has shown that it is safe to leave a tampon in place for twelve or thirteen hours, but I recommend that if you do wear a tampon overnight, you start the next day with a pad.

Change your tampons frequently. Don’t wear tampons when you’re not having your period. Avoid superabsorbent tampons. If you do have some sign of Toxic shock syndrome, for example a fever or a rash, remove your tampon immediately, as this may prevent your symptoms from worsening. Call your doctor right away.

Have manufacturers changed the way tampons are made since the epidemic of toxic shock syndrome?

Although the Rely tampon, which included materials to increase absorbency, was recalled, tampon manufacture has not changed much. The standard brands are still made from cotton, rayon, or a combination of the two. Both fibers come from plant materials, though rayon fibers are derived from the cellulose obtained from wood pulp. Several companies make all-cotton and organic-cotton tampons, available at health stores and sometimes at supermarkets. Other cotton tampons, whose fibers are processed without chlorine bleach, are also available at health stores.

Since 1990 the Food and Drug Administration has developed uniform standards for absorbency and required tampon manufacturers to print them on the box, so you can judge the relative absorbency of different brands. Before 1990 the “regular” size of one well-known brand was more absorbent that the “super” size of another. Tampon manufacturers must print a warning about Toxic shock syndrome and advise you to use the least absorbent tampons that work for you.

Are all-cotton tampons safer than rayon tampons?

Higher-absorbency tampons are believed to be riskier than lower-absorbency tampons when the latter will suffice, but no research has suggested that rayon itself is more likely than cotton to foster toxins. Tampon companies, aware of product liability, have tested cotton, rayon, and combinations of the two. They have found that the substance itself is not the problem; the absorbency is what matters.

Is the bleach used to whiten rayon tampons dangerous?

Some women are concerned that the chlorine bleach used to whiten rayon tampons may put the tissues of the vagina in contact with harmful chemicals, particularly dioxin. Research by tampon manufacturers shows that currently manufactured tampons do not release measurable amounts of dioxin into the vagina. No research has shown that tampon use heightens the risk of endometriosis, either spontaneously or through the presence of dioxin.

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