TSS and menstrual cups - an open conversation
Menstrual cups are not known to have increased rate of actually contracting TSS compared to tampons. As with any menstrual product, the most important thing is to use a trusted, verifiable brand and keep the product and your hands clean. Hygiene is your friend :)
Wait, what is TSS though?
You may have heard that Toxic Shock Syndrome (TSS) comes from putting toxins inside your body. However, this is not the case.
The toxins are actually released by a bacteria called Staphylococcal aureus, which can affect all sexes at all times, not just menstruating menstruators. These bacteria can be found as part of the body’s normal flora in around 25% of people but only 1% of ovary-bearers carry the strain that can lead to TSS. 80% of the population also has the antibody to TSS. TSS occurs when this bacteria overstays its welcome and rapidly reproduces inside the body and then the toxins (TSST-1) from the bacteria get released into the bloodstream via a cut or microabrasion. One reason why tampons have been associated with TSS is that they cause microabrasions in the vagina as they are fibrous, meaning they provide a pathway for the toxins from Staph a. (if they were to dangerously multiply) to go to the bloodstream. The collection of all that menstrual fluid in a cosy cotton environment is also the perfect place to raise all these bacteria babies. However, that is also highly unlikely to happen and when managed correctly, most tampon use is safe.
The pure medical grade silicone with which menstrual cups should be made from is no friendly home for rapid bacteria growth. However, a recent study stated that Staph a. can reproduce in menstrual cups. They suggest it's to do with the air that is introduced into the vagina with menstrual cup insertion. Other studies suggest that it may be from the menstrual blood itself, as our vaginas do contain multiple types of bacteria, often including Staph a. anyway. Though all this may sound scary, TSS is very uncommon and can usually be avoided by not leaving menstrual cups in for longer than 12 hours at a time and not scratching yourself internally.
However, if you are wanting to be extra vigilant and have two cups so that you can switch your just used cup with a new sterilised one, then you can do that.
How can vaginas be scratched?
For TSS to occur, toxins from the Staph a. have to enter the bloodstream. Cuts and microabrasions can occur from anything from sex, inserting tampons, tampons themselves, inserting menstrual cups, to sex toys and fingers. However, vaginas are sturdy things really and most of the time, you will be totally safe (as stated before, 25% of people healthily live with Staph a. anyway, and only 1% of ovary bearers carry the specific strain that can potentially lead to TSS).
When inserting your menstrual cup, we recommend you have short nails and wet the cup so it slides in oh so nicely.
The truth behind the #ClitBait
There's always some fear mongering article doing the rounds with its clickbait headline. And, if it does its job well, as it’s difficult to ignore. Recently a French study for instance, has been quoted on menstrual cups having increased risk of TSS.
What a claim. Globally, there have only been two cases of TSS associated with menstrual cup use since the 1930s. Two. One person left their cup in for seven days instead of the recommended 12 hours and the other person had a gash inside their vagina from a bodgy insertion of their cup which became septic when they didn't stop using their cup & the cut was a pathway for overpopulated Staph a. toxins to enter the bloodstream.
What the recent TSS and menstrual cup use article didn’t include
It didn’t use human vaginas, we repeat, it did not use vaginas. Instead, it was performed ‘in vitro’ in test tube conditions cited as "532 mL sterile plastic bags". Now, that's certainly not a vagina - which, has a complex bacterial balance within three layers: the mucous layer, muscular layer and fibrous layer. It is acidic, sitting at a PH of 3.8 - 4.5. It responds to things around it, is biologically alive and looks after itself very well most of the time. Does a test tube do that?
This study is theoretical. All it says is that menstrual cups potentially allow TSS to develop, but it hasn't actually been proven to have happened in this study. Diaphragms and who knows what else potentially allow TSS to develop too. As a commenter on a corresponding Stuff article stated, “this appears to be an entirely theoretical exercise with no real-world research to support it. It's pretty much as useful as saying "if you stand outside there is a greater risk of a meteor hitting you on the head than if you are in a well"”.
Be hygienic and vigilant with any menstrual product and likely, you will be absolutely fine.
Be critical of what you read
We urge you, when you consume the media, think critically - who’s agenda are you reading, what’s not included, who was interviewed, who wasn't? How many clicks is it designed to get?
When it comes to studies, who paid for the study/talk/research, how was it conducted and what biases does it contain? This study in question is legitimate, however, it's only taking into account the microbial count and is not including how many cases of TSS have actually occurred in menstrual cup use, it's just saying that there could be an increased risk. Yes, this is an important finding, however, it's not the full picture.
Here’s what you need to know in light of the new study
Are menstrual cups more dangerous than tampons?
With any menstrual product, there is always a risk of TSS. As far as cases of TSS actually developing from menstrual cup use, no, menstrual cups are not more dangerous than tampons.
Can I leave my cup in for 12 hours?
Yes! 12 hours is the max time that is currently recommended worldwide by most manufacturers and companies.
How do I know my menstrual cup is clean enough?
Follow our user guide for safe use :)
This includes washing your hands, sterilising your cup with boiling water between cycles and wetting the cup with clean tap water for easy insertion.
If you want to have two cups (as recommended by this study in question) so you can sterilise more regularly, do this too.
What about my nails?
We recommend keeping short nails for inserting anything into your vagina, so you don’t cut yourself. If you have long nails, be extra vigilant and take your time.
How safe is my brand of menstrual cup though?
Always only use a trusted, verified menstrual cup, such as a Wā Cup. Our cups are 100% medical grade silicone, plastic, dye, BPA and other nasties free and made with our ISO accredited manufacturing partner in the USA. Wā Cups also have a complete material traceability, right from quartz crystal to Wā Cup in your cooch <3
What do I need to watch out for?
If you get a sudden high fever, low blood pressure, vomiting, diarrhoea, a rash resembling a sunburn (particularly on your palms and soles), confusion, muscle aches, redness of your eyes, mouth and throat or seizures - remove your cup or tampon and seek medical help immediately. TSS is super rare, but it can be fatal.
What's next in this space?
We need further research. Studies like the French one mentioned are so important in keeping us all safe. However, we need more research in this area to provide more clarity. This research was not carried out on humans and consequently misses out all the variables associated with a vagina instead of a plastic bag. It also takes a narrow view and doesn't take into account many other variables (you can read about one of these here). There have only been two recorded cases of TSS and menstrual cup use and both were people not following recommended use.
When media headlines say that "Menstrual Cups are more likely to cause toxic shock syndrome than tampons", assumptions are made. In order for toxic shock syndrome to develop, the person must be colonised with the bacterium Staphylococcal aureus; likely have no or low levels of positive TSS antibody; Staph. a. needs to rapidly reproduce to produce TSST-1 toxin and there must be a port of entry for this toxin into the bloodstream. Tampons can provide this port due to microabrasions from inserting and removing. That menstrual cups are not fibrous and need to be removed less often points to this research not painting the full picture. We all look forward to more research in this space!
Arntfield, S., Bisch, S., Hosseini-Moghaddam, S., & Mitchell, M. (2015). A confirmed case of toxic shock syndrome associated with the use of a menstrual cup. Canadian Journal of Infectious Diseases and Microbiology. Jul-Aug; 26(4): 218–220. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556184/
Badiou, C., Baude, J., Chiaruzzi, M., Muller, D., Lina, G., Nonfoux, L., Prigent Combaret. C., Thioulouse, J., Tristan, A. (2018). Impact of currently marketed tampons and menstrual cups on Staphylococcus aureus growth and TSST-1 production in vitro. Applied and Environmental Microbiology. doi:10.1128/AEM.00351-18
Badiou, C., Baude, J., Chiaruzzi, M., Muller, D., Lina, G., Nonfoux, L., Prigent Combaret. C., Thioulouse, J., Tristan, A. (2018). Impact of currently marketed tampons and menstrual cups on Staphylococcus aureus growth and TSST-1 production in vitro. Applied and Environmental Microbiology. Retrieved from http://aem.asm.org/content/early/2018/04/02/AEM.00351-18.abstract?sid=1978ad71-75be-4357-b721-2abb77c950ca
Craft, J., Gordon, C. (2015). Understanding Pathophysiology (2nd ed.). Chatswood, New South Wales, Australia: Elsevier Australia.
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Parsonnet, J., Goering, R. V., Hansmann, M. A., Jones, M. B., Ohtagaki, K., Davis, C. C., & Totsuka, K. (2008). Prevalence of toxic shock syndrome toxin 1 (TSST-1)-producing strains of Staphylococcus aureus and antibody to TSST-1 among healthy Japanese women. Journal of clinical microbiology, 46(8), 2731-2738.
Wiedaseck, S. (2004). Toxic Shock Syndrome. In Encyclopedia of Women’s Health (pp. 1321-1323). Springer US.
Soucheray, S. (2018, April 24). New toxic shock study touts bad tampon advice, expert says. Centre for Infectious Disease Research and Policy. Retrieved from, http://www.cidrap.umn.edu/news-perspective/2018/04/new-toxic-shock-study-touts-bad-tampon-advice-expert-says