Menstrual Cups Tss

Menstrual Cups Tss

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Eur J Case Rep Intern Med

v.7(10); 2020

PMC7546563

Published online 2020 Jul 22. doi: 10.12890/2020_001825
Joint Medical Service (Germany), Department of Internal Medicine, Military Hospital Ulm, Ulm, Germany
Received 2020 Jun 18; Accepted 2020 Jun 24.
This article is licensed under a Commons Attribution Non-Commercial 4.0 License
This article has been cited by other articles in PMC.
TSS should be considered in female patients presenting with fever, rash, hypotension and current menses. Prompt initiation of antibiotics and supportive care is critical.
Menstrual cups may be a rare cause of TSS.
Prophylactic antibiotic therapy may reduce the risk of relapse.
Keywords: Menstrual cup, menstrual toxic shock syndrome
Fever: temperature greater than or equal to 102.F° (greater than or equal than 38,9°)
Desquamation: 1–2 weeks after onset of rash
Hypotension: systolic blood pressure less than or equal to 90 mm Hg for adults or less that fifth percentile by age for children aged less than 16 years old
Multisystem involvement (three or more of the following organ systems):
- Gastrointestinal: vomiting or diarrhea at onset of illness
- Muscular: severe myalgia or creatine phosphokinase level at least twice the upper limit of normal
- Mucous membrane: vaginal, oropharyngeal, or conjunctival hyperemia
- Renal: blood urea nitrogen or creatinine at least twice the upper limit of normal for laboratory or urinary sediment with pyuria (greater than or equal to 5 leukocytes per high-power field) in the absence of urinary tract infection
- Hepatic: total bilirubin, alanine aminotransferase enzyme, or asparate aminotransferase enzyme levels at least twice the upper limit of normal laboratory
- Hematologic: platelets less than 100,000/mm 3
- Central nervous system: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent
Blood or cerebrospinal fluid cultures: blood culture may be positive for Staphylococcus aureus
Negative serologies for Rocky Mountain spotted fever, leptospirosis, or measles
1. Low DE. Toxic shock syndrome: major advances in pathogenesis, but not treatment. Crit Care Clin. 2013; 29 (3):651–675. [ PubMed ] [ Google Scholar ]
2. Mitchell MA, Bisch S, Arntfield S, Hosseini-Moghaddam SM. A confirmed case of toxic shock syndrome associated with the use of a menstrual cup. Can J Infect Dis Med Microbiol. 2015; 26 (4):218–220. [ PMC free article ] [ PubMed ] [ Google Scholar ]
3. Tierno PM, Hanna BA. Propensity of tampons and barrier contraceptives to amplify Staphylococcus aureus toxic shock syndrome toxin-I. Infect Dis Obstet Gynecol. 1994; 2 (3):140–145. [ PMC free article ] [ PubMed ] [ Google Scholar ]
4. Davis JP, Chesney PJ, Wand PJ, LaVenture M. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med. 1980; 303 (25):1429–1435. [ PubMed ] [ Google Scholar ]
5. Dixit S, Fischer G, Wittekind C. Recurrent menstrual toxic shock syndrome despite discontinuation of tampon use: is menstrual toxic shock syndrome really caused by tampons? Australas J Dermatol. 2013; 54 (4):283–286. [ PubMed ] [ Google Scholar ]
Articles from European Journal of Case Reports in Internal Medicine are provided here courtesy of European Federation of Internal Medicine
1. Low DE. Toxic shock syndrome: major advances in pathogenesis, but not treatment. Crit Care Clin. 2013; 29 (3):651–675. [ PubMed ] [ Google Scholar ] [ Ref list ]
2. Mitchell MA, Bisch S, Arntfield S, Hosseini-Moghaddam SM. A confirmed case of toxic shock syndrome associated with the use of a menstrual cup. Can J Infect Dis Med Microbiol. 2015; 26 (4):218–220. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
3. Tierno PM, Hanna BA. Propensity of tampons and barrier contraceptives to amplify Staphylococcus aureus toxic shock syndrome toxin-I. Infect Dis Obstet Gynecol. 1994; 2 (3):140–145. [ PMC free article ] [ PubMed ] [ Google Scholar ] [ Ref list ]
4. Davis JP, Chesney PJ, Wand PJ, LaVenture M. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med. 1980; 303 (25):1429–1435. [ PubMed ] [ Google Scholar ] [ Ref list ]
5. Dixit S, Fischer G, Wittekind C. Recurrent menstrual toxic shock syndrome despite discontinuation of tampon use: is menstrual toxic shock syndrome really caused by tampons? Australas J Dermatol. 2013; 54 (4):283–286. [ PubMed ] [ Google Scholar ] [ Ref list ]

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Toxic shock syndrome (TSS) is a rare inflammatory response syndrome associated with an infection by toxigenic strains of Staphylococcus aureus or group A β-haemolytic Streptococcus . We report a rare case of menstrual TSS associated with usage of a menstrual cup. The diagnosis was established through case definition criteria and supported by vaginal cultural growth of Staphylococcus aureus with evidence of TSS toxin 1 (TSST-1). The patient received prophylactic intravaginal clindamycin in an individual approach to reduce the risk of recurrence. No relapse was reported in the 12 months following discharge.
We report the case of a 33-year-old woman presenting to the emergency department with acute onset of fever, rash and hypotension. Her initial vital signs were remarkable for a low blood pressure of 80/54 mmHg, 39°C body surface temperature, heart rate of 134 bpm, respiratory rate of 25 breaths per minute and oxygen saturation of 95% while breathing ambient air.
On physical examination, an altered mental status, a diffuse erythematous macular rash on her trunk and aphthous ulcerations in the oral cavity were noted.
Laboratory assessments on admission revealed elevated inflammatory markers, acute kidney injury and elevated lactate levels.
On further evaluation of the medical history at the emergency department, the patient reported having unusual persistent vaginal burning and pain during the last 3 days of menstruation, which began 4 days before presentation. She was using a menstrual cup, which was changed, boiled and disinfected twice a day during usage. The patient had been using this very same cup for the previous 4 years.
Having obtained blood cultures, the patient was started on a broad-spectrum antibiotic (piperacillin and tazobactam) and intravenous fluids. Despite adequate fluid therapy, additional vasopressors were necessary because of persistent hypotension in the medical intensive care unit.
Bedside echocardiography and abdominal ultrasound did not show any evidence of cardiac vegetations or acute intra-abdominal pathology. The left ventricular ejection fraction was normal. A chest x-ray in the supine position revealed reticular nodular opacities ( Fig. 1 ).
X-ray of the chest on Day 1 of hospitalization in the supine position showing bilateral pulmonary reticular nodular opacities
A vaginal examination revealed no foreign bodies but was painful. An additional vaginal swab for culture purposes was obtained during that examination. In reviewing the recent medical history, the physical examination and the laboratory findings, we suspected menstrual toxic shock syndrome (mTSS) and added clindamycin to suppress toxin synthesis ( Table 1 ).
The CDC case definition for TSS. Probable TSS meets the laboratory criteria and 4 of the 5 clinical criteria. Confirmed TSS meets the laboratory criteria and all 5 of the clinical criteria, unless the patient dies before desquamation occurs
CDC: Centers for Disease Control and Prevention; TSS: toxic shock syndrome
The clinical course was complicated by ARDS with correlating CT findings ( Fig. 2 ) and cardiogenic shock, confirmed by a highly reduced ejection fraction and global hypokinesia as observed with bedside echocardiography.
Computed tomography of the chest showing bilateral opacities consistent with acute respiratory distress syndrome on Day 2 of hospitalization
Over the following 9 days vasopressor therapy was tapered. The patient was extubated on the 10th day of hospitalization as desquamation of the soles and palms began ( Fig. 3 ).
Beginning of desquamation on Day 10 after hospitalization for the left (A) and right (B) thumbs
Despite negative vaginal swab and skin cultures after antibiotic treatment we opted for topical usage of intravaginal clindamycin for 14 days as an individual approach to reduce the risk of recurrence as the patient had been through a severe course of mTSS.
No further recurrence was reported in the following 12 months and a full recovery of systolic function was achieved.
Positive culture samples were sent to a reference laboratory, which revealed Staphylococcus aureus (MSSA, clonal complex 22, spa type t1368) with evidence of TSS toxin 1 (TSST-1) in the latex agglutination test.
Systemic infections with Staphylococcus aureus are associated with an increased mortality, particularly in toxin-induced systemic multi-organ failure such as with mTSS. The causative agent of staphylococcal-induced TSS is TSST-1, an exotoxin within the superantigen family. By bypassing antigen processing, superantigens can induce clonal T-cell proliferation resulting in massive cytokine release and organ damage [ 1 ] . Menstrual cups are made of silicon or rubber and are being increasingly used as a popular alternative to tampons. At the time of writing this report, menstrual cups have been reported only once in the literature as a cause of mTSS [ 2 ] .
The pathogenesis of mTSS associated with menstrual cups is still elusive and may be multifactorial in origin. Although the accumulation of blood may provide a medium for bacterial growth, an in vitro trail showed no detectable production of TSST-1 in menstrual cups [ 3 ] .
To reduce the risk of relapse of mTSS, discontinuation of tampon usage is recommended. However, relapse can occur in the absence of tampon usage and negative vaginal swab cultures [ 4 , 5 ] . Davis and colleagues observed recurrence of mTSS in 5 out of 30 women who discontinued tampon use during menses in a 5-month period after the initial episode [ 4 ] .
Despite the high recurrence rate, there are only a few general recommendations regarding antibiotic prophylaxis in women with mTSS. One possible prophylactic approach is the use of oral contraceptives (OC), which may reduce the risk of recurrence by preventing menstruation [ 5 ] . Dixit and colleagues opted for oral rifampicin and clindamycin instead of OC in a 14-year-old girl who continued to experience recurrences despite avoiding tampons. The rationale behind the antibiotic therapy was to clear a presumptive staphylococcal carrier state. The girl stayed free of recurrence [ 5 ] .
With respect to our patient, we opted for topical usage of intravaginal clindamycin as an individual approach to reduce the risk of relapse.
In summary, it can be stated that mTSS is a rare disease and may be associated with menstrual cups. Antibiotic prophylaxis after mTSS may reduce recurrence but further research is still necessary.
Radiographic images used with kind approval of the Radiologic Department (Military Hospital Ulm).
Conflicts of Interests: The Authors declare that there are no competing interests.
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Menstrual Cup Linked to Toxic Shock Syndrome, New Study Finds

Tampon use has long been associated with this rare disease, but this alternative may carry the same risks

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If you’re of a certain age, you may remember all the news reports about toxic shock syndrome (TSS), a rare but potentially deadly condition caused by a type of bacteria that produce toxins. Though it was first discovered in 1978, it became a household word in 1980, when 812 cases were reported among women who used tampons during their periods.
These numbers dropped swiftly over the years, thanks to changes in manufacturing practices (superabsorbent tampons were thought to be the cause). By 1989, only 61 cases of TSS were reported, and in 2016, just 40.
But TSS is still a threat. There was an outbreak of five cases in Michigan in 2016, for example, and last November actress and model Lauren Wasser made headlines when she revealed that she’d lost her leg from toxic shock syndrome stemming from tampon use.
In recent years, menstrual cups—flexible cups that are inserted into the vagina during a period to collect menstrual blood—have been touted as a safer alternative to tampons. Now, a new study published in the journal Applied and Environmental Microbiology suggests that menstrual cups may also raise the risk of TSS.
The study authors tested 15 different tampons and menstrual cups in a laboratory to see whether they promoted the growth of Staphylococcus aureus—the bacteria behind most cases of toxic shock syndrome—as well as the toxin that the bacteria produces, called TSST-1. The toxin is what triggers an inflammatory cascade of chemicals in the body that result in fever , low blood pressure , skin rash, and, in the most severe cases, organ failure.
Both tampons and menstrual cups create a breeding ground for S. aureus because they introduce oxygen into the vaginal canal, and in the presence of oxygen, S. aureus can multiply to high enough levels to produce the toxin, says Patrick Schlievert, Ph.D., chair of microbiology at the University of Iowa’s Carver College of Medicine.
The shape and volume of menstrual cups, however, allows more oxygen to enter, says study author Gérard Lina, M.D., Ph.D., president of the French Society for Microbiology. The bacteria then build up on the cup, which makes it harder to sterilize.
“People believe that menstrual cups can’t cause toxic shock syndrome, but unfortunately, that is wrong,” says Lina, adding that he has observed two cases in France during the past three years. In 2015, an article published in the Canadian Journal of Infectious Diseases and Medical Microbiology reported on a confirmed case of TSS from a menstrual cup.
All the tampons in the test also promoted the growth of S. aureus and its toxin. But contrary to past research, Lina and his team found that tampons made of organic cotton, which were thought to carry a lower risk of TSS than other types, produced more of the toxin than tampons made of cotton and rayon, cotton and viscose, or viscose alone.
“The structure of the all-cotton tampons was less stable than the others,” says Lina, explaining that tampons with more structure may be less likely to promote the growth of S. aureus and the toxin because they allow less oxygen in.
Consumer Reports reached out to several menstrual-cup manufacturers but has not heard back from any. One company, Lunette, says on its blog : “Menstrual cups have been a trusted period care product for decades. In fact, globally only 2 cases of TSS relating to menstrual cup use have been reported and this was due to very prolonged use (inserted for 7 days rather than the recommended 12 hour maximum)… Like with any period care product you cannot have zero risk of TSS. But a clean, properly-used menstrual cup means the chances are very small.”
S. aureus is a very common bacteria—up to half of all healthy adults and children carry it on their skin, or in their vagina or rectum, without ever developing any symptoms.
But during a woman’s period, the warm, moist environment encourages the bug to breed, as does tampon or menstrual cup use.
When enough S. aureus develops, it begins to secrete the toxin TSST-1. But again, this isn’t a problem for most women. “My research has shown that about 80 percent of women naturally make antibodies to TSST-1, so their bodies are able to fight against it,” Schlievert says.
But for the 20 percent who can’t, TSST-1 can grow unchecked, reaping huge damage. “That’s why if you get toxic shock syndrome once, we think you’re more susceptible to recurrences,” he says.
This may also be one reason younger women, especially adolescents, appear to be more susceptible to TSS. “The presence of these antibodies increases with age,” says Jennifer Gunter, M.D., an OB-GYN in the San Francisco Bay Area who has covered the topic of TSS in depth on her blog.
Teens are also more likely to wear two tampons at a time and then forget to take one out, Schlievert says. If you have a teenager who wants to wear a tampon or a menstrual cup, it’s important to go over the risks with her and make sure she’s using it correctly.
If you currently use a menstrual cup or tampons, there’s no need to switch to pads. “It’s important to remember that toxic shock syndrome is incredibly rare—I have never seen any cases, and I’ve been in practice for almost four decades,” reassures Mary Jane Minkin, M.D., clinical professor of obstetrics and gynecology at Yale University School of Medicine.
But if you do use either, it’s wise to still take some precautions. Here’s what our experts suggest.
Use the lowest-absorbency tampon you can. While the French study seemed to suggest that certain materials may be safer than others, “it really comes down t
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