can you get TSS toxic shock syndrome menstrual cup risk

What are the risks of Toxic Shock Syndrome (TSS) with a menstrual cup?

Toxic Shock Syndrome (or TSS) is regularly in the news and rightly so, it is a scary topic. Our responsibility is to inform as much as possible about its symptoms, causes and risks.

What is Toxic Shock Syndrome (TSS)?

Between 15 and 30% of the population (both men and women) are carriers of a bacterium, the Golden Staphylococcus (or Staphylococcus aureus), which is found mainly 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 colonises by multiplication. It prefers neutral pH (around 7) and air-rich environments to develop.

The majority of carriers are healthy (they have no symptoms because they have developed antibodies) or only cause benign infections (panariasis, sinusitis, food poisoning, etc.)

But some strains of Staphylococcus aureus can secrete a toxin called TSST-1 which can enter the bloodstream through several routes, such as a skin wound (including surgical incision) or wearing internal protection.

When the TSST-1 toxin has entered the bloodstream AND the carrier is not immune (which is rare but occurs mainly in young people), the body reacts very quickly and acutely by putting several organs on "standby" (the liver, lungs, kidneys, etc.): this is Toxic Shock Syndrome (TSS)

And when this TSS is proven to be related to menstruation, it is called M-TSS. But it can also occur after an injury or an operation, it is not an infection related exclusively to menstrual protection.

Who can be affected by the SCT-M? 

The risk factors are not well known. A priori, there would be more risks to develop TSS:

  • If you are immunocompromised (chemotherapy, virus or congenital immunosuppression)
  • If you have a chronic condition (cystic fibrosis, cancer, diabetes, etc.)
  • If you don't have specific antibodies to TSST-1 (but it's hard to tell

The factors of TSS are varied and serious but can be treated if detected early

The symptoms of TSS may occur all together, or only some.

This is one of the explanations for the fact that many people are not alerted at the onset of TSS: because at the beginning it strongly resembles the flu.

TBS can be manifested by :

  • Sudden fever (over 38.9°C),
  • vomiting and/or diarrhoea,
  • Sore throat,
  • muscle pain,
  • skin rashes that look like sunburn,
  • Dizziness or even fainting when standing.

After these initial symptoms, the actual shock occurs: blood pressure drops, the heart speeds up. The toxin spreads to the organs and weakens them.

This can lead to coma, amputations (as in the high-profile case of model Lauren Wasser) and even death. 

TSS is therefore extremely serious, although rare, and can be treated if caught early with antibiotics.

That's why it's good that we're talking about it more and more.

The risks of developing TSS while wearing a menstrual cup are very low, but not non-existent

Although it was believed for a long time, we now know that the cup does not protect you from TSS.

Indeed, in August 2015, the first and only documented case of TSS in a cup carrier was published in Canada (the report can be found in the sources of this article)

Here is a summary of all the cases of TSS recorded in France over the last few years, bearing in mind that in England there are on average 40 cases per year, half of which occur during menstruation, and in the USA 100 cases per year, a little less than half of which occur during menstruation.

number of cases of toxic shock syndrome TSS in france from 1994 to 2017

This graph shows that CTS has been rising sharply over the last 20 years, but it is also likely that cases have been rising better since we started talking about it.

In total, there have been nearly 200 documented cases of tampon-related injuries in France alone. That said, given that the cup is much less widely used than tampons, it is important to remain attentive to its impact on TSS.

Clinical studies on the link between menstrual cup and TSS are contradictory

A first study (2) was conducted involving cups in 1994 by a team from the University of New York specialising in the study of Golden Staphylococci (available in the sources of this article)

The methodology employed was to place a strain of Staphylococcus aureus particularly known to produce TSST-1 toxin on different sanitary pads and observe their production of TSST-1 toxin.

In this study, the Golden Staph was bathed in a neutral liquid containing lactobacilli, the "good bacteria" that make up 80% of the vaginal flora. For the cup (the Tassaway brand was used), the conclusion was clear:

"Tassaway Menstrual Cups are made of a non-absorbent polymer. Staphylococcus aureus did not produce TSST-1 when grown on a Tassaway. [...] Not surprisingly, no toxins were found with Tassaway menstrual cups. They are made of polymer, an apparently inert, non-absorbent material. Furthermore, they do not allow Staphylococcus aureus to adhere to their surface.

A second much-publicised study was published in 2018: a French study by the Centre National de Référence (CNR) des Staphylocoques, in Lyon, which caused a stir.

We cannot publish it because it is "licensed", but we read it carefully. The methodology was relatively equivalent to the first study, except that the researchers chose to bathe the Golden Staph in Brain-Heart Infusion (BHI) without lactobacilli. 

For the record, BHI is often used for bacterial culture, and is an infusion of beef or pig brain and heart. 

According to this second study, organic cups and tampons were found to be more conducive to toxin production than "traditional" tampons, but at extremely low levels.

Unfortunately, they did not explain how, with equivalent material, they arrived at the opposite conclusion to that of the New York team. Is it because of the material of the cups tested? They were 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 petrochemical polymer).

Could the culture medium play a role, especially the absence of lactobacilli, since we know how important bacteria are to the vaginal balance...? Are there other parameters that could have influenced the results?

Finally, only a few precautions need to be taken if you use a menstrual cup to protect yourself from TSS.

First of all, don't panic, there is only 1 case recorded in the world since the creation of the cup.

This does not preclude taking these few precautions:

  • Wash your hands well before handling the cup, as Staphylococcus aureus can be found on the skin.
  • Do not wash the cup with a basic or alkaline pH soap, as Staphylococcus aureus likes to grow in neutral pH (whereas the vagina has a pH between 4 and 6, so it is acidic). You can use La Mousse or Les Wipes Luneale , and don't hesitate to consult our articles which explain how to clean the menstrual cup effectively and why you should pay attention to the composition of intimate cleansers.
  • Choose a cup thatfits your flow so that there is as little air as possible in your vagina (Staphylococcus aureus thrives best in air)
  • Be aware of any symptoms you may experience.
  • Don't forget your cup after 8am, especially at the end of your period when it is less full.

There are still many questions to be answered in order to fully understand Menstrual Toxic Shock Syndrome

The way in which this study of the CNR was announced, carried out, etc... raises questions for us. And we are not the only ones! As we write much less well than an essayist AND we agree with her on everything, we advise you to read this excellent article by Elise Thiébaut on Médiapart. Really, read it! It's a bit long (because the subject is technical) but it's extremely well written and very complete...

Sources: - Complete study on the proliferation of TSST-1 on different periodical protections (in English) (1) Description of the case of STC with a cup (in English) - Complete point on STC (in French) - Study of 1962 highlighting the low bacterial proliferation on a cup vs. tampons and pads (in English) - Comparison of SCT-M and nonM 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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  • Hello
    I have just realised with horror that I have kept my cup for more than 15 days without realising it.
    I went to the toilet this afternoon and felt a strange sensation. I panicked for a moment until I realised it was my cup coming out. Problem: my period ended on the 6th and it's now the 22nd, so I seem to have put it on for the night and the next morning, not feeling it anymore, I forgot about it.
    2 questions
    Is it common for the cup to turn inside out to the point where you can't feel it anymore? Does this mean that it does not fit me?
    Can there be any consequences to keeping my cup for so long?
    It's the weekend so I can't reach my gynaecologist.
    I need to know if this is just an anecdote or if I should be worried
    Thank you.

    Hélène Fort on

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