Menstrual toxic shock syndrome

Syndrome du choc toxique menstruel

“Do you know about toxic shock syndrome ( TSS )? » This is one of the questions asked to a sample of 1,065 women in 2017 as part of a survey 1 commissioned by ANSES (National Agency for Food, Environmental and Occupational Health Safety ). The survey focused on the use of intimate protection and perception of risks. Of the entire panel, 73% declared either not knowing about this disease at all, or having heard of it but without knowing what it was precisely. A statistic which highlights the lack of information on the infectious risk incurred by menstruating people using internal hygienic protectiontampons , menstrual cups and sponges – during their period . However, even if it occurs very rarely, menstrual toxic shock can have dramatic consequences: failure of certain organs, gangrene, death. But what exactly is menstrual TSS ? Under what circumstances can it occur? What are the symptoms ? What precautions should be taken to protect against this infection ? All the explanations in this article.

Please note : reading this article does not exempt you from consulting a doctor if you have any questions or symptoms. ; only a healthcare professional is authorized to make a diagnosis.

What is menstrual toxic shock syndrome?

Staphylococcal toxic shock of menstrual origin

Menstrual toxic shock syndrome (TSS) is an infectious disease characterized by serious, rapidly progressing symptoms that can lead to death: high fever, very low blood pressure, skin rash, digestive problems, dysfunction of several organs.
It is an acute and massive immune reaction of the body. It is caused by the passage and diffusion in the blood circulation of a toxin (i.e. a toxic substance) produced by a bacteria called Staphylococcus aureus, naturally present in the vaginal microbial flora of part of the female population.
Since for this type of toxic shock, the bacteria involved is part of the staphylococci family and it develops from the vagina during menstruation, the condition is also called “staphylococcal toxic shock of menstrual origin (CTS- M)”.

Staphylococcus aureus: the bacteria responsible for menstrual toxic shock syndrome Staphylococcus aureus , the bacteria responsible for menstrual TSS. Scanning electromicrograph of the bacteria Staphylococcus aureus : THE NIAID , CC BY 2.0 , via Wikimedia Commons

A toxic shock linked to internal hygienic protections

This syndrome is called “menstrual” because it occurs during the menstrual period for people who are menstruating. It is associated with inappropriate use 2 of so-called “internal” or “intravaginal” hygienic protections, that is to say, which are inserted into the vagina to collect the menstrual flow. This category includes tampons, cups and menstrual sponges. Wearing this type of device for too long, more than 6 hours in a row 3 , or choosing a model with too high an absorption capacity 2 are unsuitable uses that promote the occurrence of menstrual SCT.

Wearing a tampon for too long increases the risk of menstrual toxic shock syndrome

A very rare but potentially very serious bacterial infection

In France, around twenty cases of menstrual toxic shock syndrome have been reported each year since 2011. Even if the incidence is low, the consequences of menstrual TSS can be tragic.

In response to infection, the body goes into survival mode; it favors the vital organs, to the detriment of the extremities which are less irrigated. There is then necrosis of the fingers or toes, or even the feet. Amputation is necessary. This is what happened to American model Lauren Wasser, who had her right leg amputated in 2012 and then her left leg in 2018 following a toxic shock caused by a tampon. Sometimes, this can lead to death, as for Maëlle, a 17-year-old Belgian girl, victim in 2020 of TSS also linked to a tampon.

Extremely serious, these cases are however described as extremely rare by doctors since menstrual toxic shock syndrome can only be triggered in very specific and limited circumstances.

Lauren Wasser, amputee of both legs following menstrual TSS due to a sanitary tampon Lauren Wasser, amputee of both legs following menstrual TSS caused by a sanitary tampon. Photography: Lauren Wasser, Facebook

Causes of menstrual toxic shock syndrome: why and how does it develop?

Menstrual TSS is caused by the bacteria Staphylococcus aureus or S. aureus , also called Staphylococcus aureus. But not by any strain: only the one that produces a toxin called staphylococcal toxic shock toxin or “TSST-1” for Toxic Shock Syndrom Toxin-1 . A small proportion of the female population (1 to 4%) naturally welcomes this strain of S. aureus into their vaginal microbiota 4 . This bacterial presence, normally harmless, can become dangerous when certain conditions are met.

Indeed, women carrying staphylococci aureus producing the TSST-1 toxin are exposed to the risk of menstrual SCT if:
  • they wear intravaginal hygienic protection for a prolonged period of time during their periods;
  • they are not fortunate enough to have previously developed anti-TSST-1 antibodies, that is to say agents capable of neutralizing the toxin.
The menstrual cup: internal hygienic protection that can cause toxic shock syndrome
This phenomenon is explained by the blockage and stagnation of the menstrual flow in the vaginal cavity when internal periodic protection is in place. The non-evacuated menstrual blood then becomes a culture medium favorable to the development of staphylococci aureus producing the TSST-1 toxin:
  • the pH is modified and approaches a neutral pH;
  • the temperature increases and is around 40°C;
  • nutrients present in menstruation are available.

The longer the internal hygienic protection is kept, the more bacteria multiply in this natural incubator that the vagina has become. When they reach a significant concentration, they begin to secrete and release the TSST-1 toxin. The latter ends up passing through the vaginal wall and enters the bloodstream. The body then reacts to the diffusion of this toxic substance by developing the symptoms of menstrual toxic shock.

Symptoms of menstrual TSS: how to recognize it?

The diagnosis of menstrual toxic shock syndrome is often difficult, because the first manifestations are easily confused with those of the flu or gastroenteritis:

Pay attention to the symptoms of menstrual toxic shock syndrome

  • a feeling of general weakness;
  • a sudden fever above 39°C;
  • headaches ;
  • muscle pain;
  • digestive problems, such as nausea, vomiting or diarrhea.
More specific and increasingly serious symptoms appear as the infection progresses:
  • a red throat and eyes;
  • a scarlet rash resembling a sunburn, followed by intense peeling;
  • low blood pressure;
  • kidney damage;
  • liver damage;
  • neurological disorders, such as disorientation or altered consciousness;
  • gangrene.

Treatment of menstrual toxic shock syndrome

When a menstruating person presents several of these symptoms while she is menstruating, she should immediately remove her sanitary protection. Then, she needs to consult urgently. Usually hospitalization is necessary. Depending on the diagnosis, several treatments may be provided by the medical profession, including:
  • intravenous treatment to raise and stabilize blood pressure;
  • antibiotic treatment to eliminate the bacteria and stop the secretion of the toxin.

Recommendations for preventing menstrual TSS

Women who use tampons or a menstrual cup to manage their periods can significantly reduce the risk of developing menstrual TSS by following the following recommendations:
Washing your hands: a recommendation to avoid menstrual toxic shock syndrome
  • read the instructions for use of these intravaginal devices and follow the instructions given;
  • systematically wash your hands with soap before inserting and removing internal intimate protection;
  • change the tampon or empty the menstrual cup very regularly, every 4 hours to 6 hours;
  • wash the cup thoroughly before reinserting it into the vagina, first in cold water then in hot water, with a specific soap if possible;
  • alternate as much as possible between internal and external protection;
  • favor external periodic protection at night, such as menstrual panties;
  • use sanitary protection only during the period, and not a few days before in anticipation to avoid leaks or to collect other vaginal discharge;
  • choose tampons with a minimum absorption capacity adapted to the menstrual flow;
  • no longer use tampons or menstrual cups if you have a history of menstrual SCT.
menstrual lingerie nairobi

If you didn't know about menstrual toxic shock syndrome before reading this article, you will no longer be unfamiliar with it. Adopting period panties can be a great way to protect yourself against the risk of menstrual TSS. Worn alternately with internal protection or continuously throughout the cycle, Perdième menstrual panties are there to offer you total safety.

Written by cd


  1. Handles. (2019, December). Safety of intimate protection products - Revised opinion from ANSES - Revised collective expert report . Appendix 6: Additional information related to the Opinion Way study - Survey carried out by the company Opinion Way from June 26 to July 4, 2017 with a sample of 1,065 settled women aged 13 to 50, representative of the French female population , by online questionnaire.
  2. Intimate protection: composition and toxic shock, all our recommendations .
  3. Civil Hospices of Lyon. Period-related toxic shock syndrome . University Hospital Lyon.
  4. Handles. (2019, December). Safety of intimate protection products - Revised opinion from ANSES - Revised collective expert report . Page 80/261.