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Toxic Shock Syndrome: what are the risks with a menstrual cup?

Toxic Shock Syndrome (or TSS) comes back to the forefront regularly and rightly so, it is frightening. Our responsibility is to inform as much as possible about its symptoms, causes and related risks.

TOXIC SHOCK SYNDROME: WHAT IS IT?

Between 15 and 30% of the population (men and women combined) carry a bacterium, Staphylococcus aureus, which is mainly found in the nose, throat, digestive tract, perineal area and skin. It is present in the vagina of about 10% of women. This bacterium is immobile: it colonizes by multiplication. To develop, it prefers neutral pH (around 7) and air-rich environments. Most carriers are healthy (they have no symptoms because they have developed antibodies) or cause only mild infections (panaris, sinusitis, food poisoning…) But some strains of Golden Staphylococcus can secrete a toxin called TSST-1 which can pass into the bloodstream through several pathways, When the TSST-1 toxin has passed into the bloodstream AND the carrier is not immune (which is rare but happens mostly in young people), the body reacts very quickly and acutely by putting several organs on “standby” (liver, lungs, kidneys …): This is the Toxic Shock Syndrome (TSS). And when this TSS is proven to be linked to menstruation, it is called TSS-M. But it can also occur after an injury or an operation, it is not an infection exclusively related to periodic protection.

WHO MAY BE AFFECTED BY THE TSS-M ?

The risk factors are relatively unknown. A priori, there would be more risks to develop a TSS:

  • If you are immunosuppressed (chemotherapy, viruses or congenital immunosuppression).
  • If you are a victim of a chronic disease (cystic fibrosis, cancer, diabetes, …)
  • If you don’t have antibodies specific to TSST-1 (but that’s hard to know)

 

WHAT ARE THE SYMPTOMS OF THE TSS?

The symptoms of TSS may occur all together, or only some of them. This is one of the explanations for the fact that many people do not alert to TSS from the start: because it strongly resembles the flu to begin with. So TSS can manifest itself as :

  • a sudden fever (over 38.9°C),
  • vomiting and/or diarrhea,
  • a sore throat,
  • muscle pain,
  • rashes that look like sunburns,
  • Dizziness or even fainting while standing.

After these first symptoms, Shock as such occurs: blood pressure drops, the heart accelerates. The toxin diffuses into the organs and weakens them. This can lead to coma, amputations (such as the high-profile case of the model Lauren Wasser) or even death. TSS is therefore extremely serious, even if it remains rare, and can be treated if taken in time with antibiotics.

I Wear a menstrual cup, WHAT DO I RISK?

If you believed that for a long time, you now know that the cup doesn’t protect you from TSS. Indeed, in August 2015 was published the first and only documented case of TSS on a cup carrier in Canada (the report can be found in the sources of this article) Here is a summary of all cases of TSS recorded in France (bearing in mind that in England, there is an average of 40/year, half of which occurred during menstruation, in the USA 100/year, slightly less than half of which occurred during menstruation). casSCTFrance

WHAT DOES THIS GRAPH TELL US?

The TSS has been increasing sharply over the past 20 years, but there is also a good chance that the cases are recovering better since we started talking about it. In total, there are nearly 200 cases recorded related to the wearing of tampons in France alone. Beside this, only 1 case occurred with a cup in the world in 2015 (1) That said, given that the cup is much less used than stamps, it is important to remain attentive to its impact on the TSS.

WHAT DO THE STUDIES TELL US ABOUT THE LINK BETWEEN MENSTRUAL CUP AND TSS?

A first study(2) was conducted involving cups in 1994. by a team from New York University specializing in the study of Golden Staphylococci (see sources of this article) The methodology used was to place a strain of S-Aureus particularly known to produce TSST-1 toxin on different periodical protections and to observe their production of TSST-1 toxin. In this study, S-Aureus bathed in a neutral liquid with lactobacilli, the “good bacteria” that make up 80% of the vaginal flora. For the cup (the Tassaway brand was used), the conclusion was indisputable:

“Tassaway Menstrual Cups are made of non-absorbent polymer. S-Aureus did not produce TSST-1 when grown on a Tassaway. …] It is not surprising that no toxins were found with Tassaway Menstrual Cups. They are made of polymer, a non-absorbent material that appears to be inert. In addition, they do not allow Staphylococcus aureus to adhere to their surface”.

A second study was published in 2018. : it is a French study by the National Reference Centre (CNR) for S-Aureus, in Lyon, which made a lot of noise. It cannot be published because it is “under licence”, but it has been read carefully. The methodology was relatively equivalent to the first study, except that the researchers chose to bathe S-Aureus in Brain-Heart Infusion (BHI) without lactobacilli. For the record, BHI is often used for bacterial culture, and it is an infusion of beef or pig brain and heart. According to this second study, organic cups and tampons would promote toxin production more than “traditional” tampons, but would remain within extremely low thresholds. Unfortunately, they did not compare how, with equivalent material, they came to the opposite conclusion of the New York team. Is it because of the material of the tested cups? It was the BeCup (which is made of medical silicone but we have no information on the type of medical silicone used) and the Meluna (made of TPE, a polymer from petrochemistry). Can the culture medium play a role, especially the absence of lactobacilli, since we know the primordial importance of bacteria on vaginal balance? Are there other parameters that could have influenced the results?

WHAT CAN I DO, IF I WEAR A CUP, AGAINST THE TSS?

Already, don’t panic, there is only 1 case listed in the world since the creation of the cup. Once we said this :

STILL A LOT OF QUESTIONS.

The way this CNR study was announced, conducted, and so on, raises questions for us. And we are not alone! Since we write much less well than an essayist AND we agree with her absolutely on everything, we advise you to read this excellent article (in french) written by Elise Thiébaut.

Sources : – Complete study on the proliferation of TSST-1 on the different periodic protections (1) Description of the case of TSS with a cup – 1962 study highlighting low bacterial proliferation on a cup vs. tampons and pads – Comparison of SCT-M and non-M in France between 2003 and 2006 : One in five mortality in non-menstrual toxic shock syndrome versus no mortality in menstrual cases in a balanced French series of 55 cases.

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