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TSS and Menstrual Cups

What is Toxic Shock Syndrome?

Toxic shock syndrome (TSS) is an extremely rare but serious illness linked to tampon use. It is caused by Staphylococcus aureus or pyogenes, a bacteria which causes infection and, if it makes its way into the blood stream, can cause serious organ damage and illness. Symptoms of TSS include; headaches, muscle weakness, muscular pain, dizziness, fainting, rash, vomiting, diarrhoea, fever, and chills. The term TSS was first used in 1978 by The Lancet, to describe acute illness in children who were displaying the complex symptoms of the illness. TSS can be a risk following surgery or childbirth, not just tampon use, however most people associate TSS with tampons. Between 1970 - 1982, 1660 cases of TSS were recorded, 92% of cases were during the onset of the menstrual cycle. It was during this time that stricter guidelines were put in place for use and manufacturers looked at what the tampons were made from. 
 
About 20% of women do not produce the anti-bodies to fight against TSS, and for those women it's important to be aware of the risks and how to use a menstrual cup correctly to reduce the risk of TSS. 

Case of TSS with menstrual cup use

The Centers for Disease Control and Prevention (CDC) in the United States have reported that between 1979 - 1996, 74% (n=3,919) of all reported TSS cases, were as a result of menstrual TSS. The CDC states that the remainder of cases were non-menstrual related, and were reported after surgical procedures, were postpartum or postabortion or were nonsurgical cutaneous lesions. There were no cases reported that were attributable to menstrual cup use. They also reported that a higher risk of TSS was associated with only using tampons rather than using tampons also in conjunction with pads. Since the 1980's cases of TSS related to tampon use have steadily declined.

Statistics relating to menstrual cups and TSS were not able to be found on the CDC website. In addition, the only clearly reported case of TSS linked with menstrual cup use that we've been able to find in all our research is outlined below. In 2015, there was a case of TSS reported in a 37 year old women who had used a menstrual cup for the first time. The authors discussed the probable factors for the development of TSS, an abrasion to the mucosal lining during one of her initial insertions and the abundance of menstrual fluid from unusually high flow which acted as a medium for the growth of S. aureus. Silicone itself does not support microbiological growth and in itself was not involved in the growth of the bacteria. The abrasion to the mucosal lining of the vagina would have been an entry site to the blood stream for S. aureus.

Staph aureus and menstrual cups

New research released in April 2018, found that similar precautions are recommended for cup users as with tampons. They found increased S. aureus growth with the incubation of menstrual cups with a special growth medium inside a sterile plastic bag. The researchers speculated that that the S. aureus growth may have been due to the extra oxygen in the bag, because of the shape of the menstrual cup.
 
The physiological conditions of the vagina were replicated as best as possible for the investigation. Physiologically, we know that vaginas are made to be robust, having a complex microbiome made up of predominantly bacteria but also other microorganisms. The study has shown that S. aureus, the bacteria responsible for TSS can be grown in the environment they used in a laboratory, however it did not show that TSS will result from the use of a menstrual cup. The authors advised that because the study showed that S. aureus can grow, precautions should be taken. Ensuring that you follow instructions for use is vitally important for any menstrual hygiene product, menstrual cups included. The authors also advised that the use of a second sterilized cup could be considered for use when changing a cup.
 
The investigators also indicated that if the cup overflows the S. aureus will come in contact with the vaginal mucosa, thus contributing to the development of TSS by having access to the blood stream. This mechanism indicates that following the time constraints of leaving menstrual cups in, and more importantly, understanding flow and emptying the cup at appropriate time intervals is very important. 

Following instructions

It's imperative to always follow the instructions of any menstrual products that are used internally, both tampons and menstrual cups. Never leave a menstrual cup in for longer than 12 hours and always thoroughly wash your hands before inserting. Sterilize the cup before use. If you have access to a sink then wash your cup with hot water and soap after removal, however it's okay to simply wipe your cup if you're not in a toilet with a hand basin. If you have two cups, you can keep one sterilized and on hand to use after removing a used cup. Gerard Lina, the lead author behind the research identifying menstrual cups as posing a similar risk of TSS as tampons, recommends only using a menstrual cup for around 6 hours to reduce your risk of TSS.

Do menstrual cups protect from TSS?

With all menstrual care products there is no zero risk of TSS. With proper use and cleaning a menstrual cup, the chances of TSS are small.