WHAT REALLY CAUSES TOXIC SHOCK SYNDROME?

I just want to de-mystify TSS. As women, we are taught to worry about it, but no one ever explains what *really* causes it. We are told "leaving a tampon in too long" is to blame... but why? How does it really happen? There seems to be a lot of confusion surrounding the issue. People ask questions like, "Why is it that my friend got TSS after leaving a tampon in for 8 hours, but I regularly fall asleep with a tampon in for 12 hours and nothing bad has ever happened?"

That's because it's caused by bacteria. Tampons don't come contaminated with bacteria out of the box. The bacteria is either naturally occurring in the vagina or introduced from unwashed hands. A tampon (or anything that leaves blood in too long and prevents air circulation...even a menstrual cup) just facilitates the growth of the bacteria (due the way the old blood changes pH, lack of oxygen encourages anaerobic bacteria growth, and red blood cells provide a food source for Beta hemolytic bacteria).

So the reason why some women seem more prone than others is because some women will have the bacteria already colonized in or on their bodies and others don't. Some have compromised immune systems and others don't. Likewise, people have different handwashing and hygeine practices.

🚨 MEET THE CULPRIT(s): Staphylococcus aureus 🆚 Streptococcus pyrogenes

Staphylococcus aureus is commensally colonized in approximately 30% of the population. The methicillin-resistant strain, "MRSA" is found colonized in approximately 2% of the population. If you are one of third of women who carry Staph. aureus, you may never know because it usually won't cause symptoms until it enters your body. Most cases of TSS are caused by Staph.areus, but some are caused by Streptococcus pyrogenes. TSS caused by Strep. pyrogenes usually occurs in people who have pre-existing skin infections. Women who have taken antibiotics recently may also be more susceptible, as they tend to kill "good" Lactobacilli which would normally keep pathogenic bacteria in check.

TSS caused by Streptococcus pyrogenes (sometimes referred to as "TSLS") triggers a rapid onset of symptoms and carries a 50% chance of death. These are the more serious cases you hear about. Compare that to TSS caused by Staphylococcus aureus, which only carries a 5% chance of death.

The less deadly form of TSS generally causes a characteristic rash that resembles a sunburn and peels after 10-14 days. This is addition to fever, malaise, and confusion (which are common signs of infection in general). The more deadly form of TSS is less likely to cause the sunburn-like rash. So if you think you might have TSS, have severe pain and DON'T have a rash, get checked out right away!

In my experience, Staph aureus is more likely to come from unwashed hands. It's halotolerant (not killed by the salt in sweat like other bacteria) and it survives well on external skin. This is evidenced by 2 famous cases of men contracting TSS -- Clive Barker and Mike Von Erich -- one after visiting the dentist and one after shoulder surgery. In both cases, bacteria from the skin was introduced into the body during the procedures. In fact, ONE THIRD of TSS cases occur in MEN! No vagina needed! No tampon to blame! ♂️🤔

Staph. aureus is a facultative anaerobe, so it will survive in an oxygenated environment (like on your hands), but once it gets introduced into an anaerobic environment, it thrives. The hemolysins in Staph.aureus (enzymes that split open red blood cells) also function better in an anaerobic environment. This is part of why bacteria that is relatively harmless on your skin can cause problems when it gets into your blood or trapped in an environment where there is little air flow. This illustrates why it's so important to:

1. Let your vagina "breathe." 🌬️ Keeping a tampon in (or menstrual cup, or anything else you can insert that traps blood, moisture, and prevents oxygen from getting in) for too long will allow pathogenic bacteria that thrive under anaerobic conditions to grow out of control and cause problems. Blood, in particular, attracts dangerous Beta-hemolytic bacteria and raises vaginal pH, which further encourages pathogenic bacteria.

2. Wash your hands! 🙌 When you handle a tampon with unwashed hands, any bacteria on your hands can get into your vagina, which can then get into the rest of your body. Each species of bacteria will behave differently in different conditions. So a bacteria that doesn't cause any noticeable problems on your skin or in your digestive tract can still make you sick if it gets into your vagina.

3. Absorbency and materials may also make a difference. A study conducted by Philip M. Tierno Jr. concluded that 100% cotton tampons were less likely to create the conditions in which Staphylococcal TSS can grow. Cotton offers better breathability and thus less anaerobic conditions, compared to standard rayon/cotton blends. Other studies, however, have concluded all-cotton carries the same risk (which is still pretty low). 100% organic tampons have had the best overall results in studies though. To minimize your risk when using tampons, use the lowest absorbency that still does the job, and change promptly (every 4-8 hours) -- and it never hurts to give your vagina a breather!

👉 Remember, technically ANY FOREIGN OBJECT can introduce bacteria into the vagina. This includes menstrual cups, sponges and diaphragms. Though the risk tends to be higher with tampons because of how they allow blood to continue to make contact with the vaginal epithelium, menstrual cups can still introduce bacteria into the vagina if it's on your hands or skin around the opening of the vagina. Any infection resulting from vaginally-colonized bacteria will likely be more localized to the cervix if you're using a cup.

Thanks for reading! Happy bleeding 🌊👋

Do you ever worry about Toxic Shock Syndrome?