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Toxic Shock Syndrome

The Facts

Toxic shock syndrome (TSS) is caused by toxins released by certain strains of common bacteria. Although anyone can experience TSS, it occurs most often in healthy adults. The wound through which the bacteria gain entry is often minor or unnoticeable. Toxic shock syndrome has become linked with the use of tampons. TSS develops quickly and may be fatal. Still, this disease is fairly rare.


Toxins released by particular strains of extremely common families of bacteria called Staphylococcus and Streptococcus cause TSS. These bacteria are everywhere, including on our mucous membranes such as the throat, mouth, nose, and vagina. Most strains are harmless, but some bacteria release a threatening toxin (poison) into the blood.

Sepsis is a body-wide response to infection caused by bacteria or other substances. Septic shock is a serious case of sepsis, where the body goes into shock (life-threatening low blood pressure). TSS is a special form of septic shock caused by the toxins of the Staphylococcus and Streptococcus bacteria.

Toxic shock syndrome can occur when women use tampons, especially "super-absorbent" ones. Toxic shock sprang to public attention in 1980, when over 700 women were infected around North America. Most of these women had recently switched to a new super-absorbent tampon. It's still not clear why this type of tampon increases the risk of TSS, but it may be related to a "drying" of the vagina. Women who leave a diaphragm in place for more than 24 hours are also at an increased risk of TSS. Notably, the women with the highest risk of developing TSS for these reasons already have a bacterial colonization of staphylococcus in the vagina and develop TSS with prolonged use of these devices.

Many cases of TSS aren't related to tampon use, but occur after surgery, accidental injury, or childbirth. Cases due to Streptococcus usually arise following surgery, but sometimes infections of the skin can result in TSS.  Staphylococcus is generally responsible in tampon-related cases.

Symptoms and Complications

TSS symptoms come on suddenly. Symptoms can include:

  • confusion
  • extreme fatigue and weakness
  • high fever of 39°C to 40.5°C (102°F to 105°F)
  • headache
  • influenza-like symptoms
  • low blood pressure
  • pain
  • red eyes
  • severe diarrhea
  • shortness of breath
  • sore throat
  • vomiting
  • widespread red rash

In severe cases, the symptoms get rapidly worse over the next 24 to 48 hours. Huge amounts of fluid and vital minerals leak into tissues and are lost to the vital organs. The blood supply decreases and blood pressure drops. This can produce fainting and possibly coma. Breathing problems can occur, and the blood and organs may not receive enough oxygen. After 1 to 2 weeks, the skin may start to peel, especially on the palms of the hands and soles of the feet. Also, blood may not clot properly, which increases the risk of bleeding.

Many organs are severely threatened by the bacterial poison. The muscles, kidneys, liver, heart, and lungs can all be damaged by the infection, but can recover with treatment.

It's believed by experts that there are many mild cases of tampon-related toxic shock that never progress to the more drastic symptoms listed above. They go unreported or are mistaken for diseases like influenza and gastroenteritis.

Making the Diagnosis

Your doctor will ask you about your symptoms and perform a physical exam. Your doctor will also order blood tests and may send a blood or tissue sample to a laboratory to be checked for bacteria. It is important to rule out other conditions that may cause similar symptoms.   Other tests such as computed tomography (CT) or magnetic resonance imaging (MRI) scans may also be done.

Treatment and Prevention

People with TSS need immediate intensive care. Any tampons or diaphragms must be removed from the vagina. The basis of treatment is replacing lost fluids, orally or intravenously, with a special mixture of liquids and electrolytes (e.g., sodium, potassium). Some people may need a machine called a ventilator to help them breathe. Medications to increase blood pressure may be needed.

Wounds and any source of infection will be rinsed with water. Infected wounds will be cleaned and infected tissue may be removed if needed.

Antibiotics are given intravenously (into a vein) as well, especially to reduce the risk of the infection recurring. Human antibodies (immunoglobulin) may also help for severe cases.

Luckily, toxic shock syndrome is less common now than it was in the 1980s, because the most dangerous tampons have been withdrawn from the market. Women can minimize their chances of getting TSS by:

  • alternating between tampons and pads during heavy bleeding
  • changing tampons every 4 to 6 hours
  • observing good general hygiene, especially around the vagina
  • removing the last tampon as soon as the menstrual bleeding ends
  • wearing external pads at night
  • using the least absorbent tampons possible

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