Ask the Doctors by Eve Glazier, M.D. and Elizabeth Ko, M.D

Cases of Menstrual-Related Toxic Shock Have Dropped Steeply

Dear Doctor: I recently read about a woman who lost a leg from toxic shock syndrome and might lose another one. How is this possible? I thought toxic shock was related to using tampons.

Dear Reader: Toxic shock syndrome is a rare but potentially fatal illness in which toxins produced by certain bacteria cause an immune response that is so powerful, it becomes life-threatening. And although toxic shock syndrome first made headlines in the late '70s and early '80s, when it caused the deaths of hundreds of women who used superabsorbent tampons that were left in place for many hours, the fact is that it can develop in people of any sex and any age.

Most often, toxic shock syndrome is a reaction to the toxins produced by Staphylococcus aureus -- also referred to as staph -- bacteria. (Although it can also be triggered by group A streptococcus, or strep bacteria, that is less frequent.) The S. aureus bacterium, one of the most common agents of infection in humans, can enter the body through cuts, burns or recent surgery. It causes urinary tract infections, pneumonia, gastroenteritis, meningitis, septic arthritis and a host of skin infections. In toxic shock syndrome, the bacteria produce small proteins known as superantigens, which rev up the immune system to a dangerous degree. The resulting response is so powerful that the body goes into shock.

Symptoms include high fever, a dangerous drop in blood pressure, vomiting or diarrhea, mental confusion, headache, profound fatigue or unconsciousness, and a cascade of organ failure. One of the earliest symptoms can be a sunburnlike rash that appears on the palms of the hands, soles of the feet, the lips and mouth, or the eyes. It's an extremely grave condition that often requires hospitalization for supportive care to help with breathing, liver and kidney function and blood pressure. Source control of the infection is crucial to recovery.

Because the vagina is a warm, moist environment, tampons, diaphragms, menstrual cups and menstrual sponges can all provide a medium on which bacteria can grow and proliferate. The surge of toxic shock cases 40 years ago was tied to a specific brand of superabsorbent tampon that was shaped like a cup. Due to a certain chemical additive, it was advertised to be able to hold 20 times its own weight of liquid. The idea was you could leave a single tampon in place for days. The result was basically an internal petri dish, primed for dangerous bacteria to flourish.

With a change to tampon materials, as well as warnings against leaving them in place for more than eight hours, cases of menstrual-related toxic shock have dropped to about one per 100,000 people. By contrast, between 1979 and 1996, there were 5,296 reported cases. To protect yourself, choose the low-absorbency tampons and change them every six to eight hours. Safest of all, skip tampons altogether. And if you experience any of the symptoms associated with toxic shock, seek medical care immediately.

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