During the early 1980s, the word tampon became briefly synonymous with terror. Doctors began to document cases of a then little-known condition linked to the feminine care product, called toxic shock syndrome. Thousands of such cases and around a hundred deaths were reported before the crisis was ultimately contained. But how? And why isn’t toxic shock such a big deal these days?
Toxic shock syndrome can be caused by certain infections. As the name implies, it’s not the germs themselves that are directly responsible for the syndrome, but the particular toxins they can spew out. These toxins are superantigens, meaning they can send our T cells—immune cells that try to recognize potential threats to the body—into overdrive, triggering a massive overreaction by the immune system that damages the body on a widespread level. In severe cases, this assault can send our blood pressure plummeting (the titular shock), shut down organs, and ultimately turn fatal.
A toxic mix
Toxic shock was first identified in 1978 in a group of seven children, though the first medical accounts of it likely date back decades earlier. At the time, it was seen as a rare complication of infection from Staphylococcus aureus bacteria, though we would later learn that Streptococcus pyogenes infections could also cause a very similar syndrome. A year later, doctors and epidemiologists from Minnesota, Wisconsin, and other states began to notice clusters of suspected toxic shock in young girls and women. They soon notified the Centers for Disease Control and Prevention, and in May 1980, the CDC published a report that would set off a firestorm of media attention and public fright.
The CDC had collected reports of 55 cases and seven deaths dating back to October 1979 from local health departments and doctors in 13 states. People would initially experience symptoms like high fever, vomiting, and diarrhea, with life-threatening shock sometimes following in as little as two days. Nearly all the cases involved young women and most had tested positive for S. aureus. It didn’t take long for the CDC and others to notice that many victims had recently menstruated and used tampons. By that September, researchers reported that women had been using one particular tampon brand more commonly than others: Proctor and Gamble’s Rely tampons, which had launched in the U.S. two years earlier.
Rely tampons were marketed as superabsorbent tampons, able to contain about twenty times their weight in fluid; the product also unfolded into a cup shape inside the vagina to stave off leakage. This added absorbency was designed to make the tampon last longer and many users followed suit, leaving them in for hours or even throughout their entire period. But it also provided an opening for toxic shock to occur.
S. aureus bacteria commonly live in or on our bodies without usually causing any trouble, including the strains that can cause toxic shock. As it turns out, these bacteria only produce the toxin, called TSS toxin 1, or TSST-1, in the presence of oxygen. Normally, the vagina is an oxygen-free zone, but the introduction of a tampon into it can bring along some air, setting the stage for these bacteria to become toxic. The higher absorbency and longer use time of Rely tampons provided S. aureus even more oxygen to play with, while the blood pooled in the tampon might have also helped the bacteria grow quicker.
The defeat of toxic shock
Once the connection between Rely and toxic shock was made apparent by the CDC, action soon followed. That same September, Proctor and Gamble agreed to recall Rely and it never returned to the market (the company reportedly paid out at least $US58 million in the many legal settlements reached with former Rely users). But Rely wasn’t the sole culprit; any kind of higher absorbency tampon could increase a menstruating woman’s risk of toxic shock, moreso if left in for longer periods of time than usual. According to data cited by the CDC, as many as 42% of women at the time were using these tampons.
Between 1980 to 1982, 1,660 cases of tampon-related toxic shock syndrome were documented by the CDC, along with 88 deaths (a 5% fatality rate). But the removal of Rely increased public awareness of the link between high-absorbency tampons and toxic shock, and new regulations eventually beat back the threat.
In 1982, for instance, the Food and Drug Association mandated labeling to all tampon products that advised women to use the lowest absorbency tampons possible for their needs. Tampon manufacturers also adopted consistent product standards that lowered absorbency across the board. To this day, tampons cleared by the FDA are only made of cotton, rayon, or a mix of the two, rather than the carboxymethylcellulose and polyester blend used in Rely. And any new brands have to be tested to make sure they won’t help S. aureus bacteria grow. Over the following decade, reported cases of toxic shock associated with tampons starkly dropped and have since never reached the levels seen in 1980.
There are other factors that make tampon-associated toxic shock possible. Menstruation lowers the pH of the vagina, for instance, making it easier for S. aureus bacteria to thrive. Our preexisting defenses matter, too. Most people seem to have antibodies to TSST-1 by puberty, but those who don’t are at greater risk for developing toxic shock. That said, only a small percentage of women even regularly carry S. aureus in their vagina (estimates vary between 5% to 10%).
A real but rare risk today
These factors mean that toxic shock was never set to become a widespread epidemic, even among tampon users in the early 1980s. Nowadays, menstrual-related toxic shock is thought to affect less than one in every 100,000 menstruating women annually (the non-menstrual version is even rarer). But there have been occasional spikes, such as a cluster of five cases reported in Wisconsin between 2022 to 2023, up from the typical zero or one case seen in the state a year. Much like before, most of these cases were tied to the use of super-absorbent tampons.
The advice needed to reduce your chances of toxic shock from using tampons has basically remained the same since the 1980s: Use the lowest-absorbency tampons for your particular situation; change them regularly (usually four to eight hours), and perhaps consider using a pad or other menstrual device at night if you typically sleep longer than eight hours. These are just guidelines and the risk of toxic shock is very low to begin with, so you shouldn’t panic if you happen to leave a tampon longer than usual every once in a while.