Alice's Story
Menstrual Disorders
What are Menstrual Disorders?
Menstrual disorders can be either a temporary or permanent condition. Both menstrual disorders can interfere with a woman's ability to become pregnant.
A woman with menstrual disorders needs to see her ob/gyn or family doctor as menstrual disorders may be signs or symptoms of more serious medical conditions.
Menstrual disorders can be caused by a number of differing problems or reasons. For normal menstruation to occur, a woman's hormonal glands must function normally for menstrual periods to occur.
Menstrualdisorders can result from conditions that affect a woman's hormone-producingglands and organs that may include her cervix, hypothalamus, ovaries, pituitary gland, uterus,or vagina.
The most common menstrual disorders are:
Amenorrhea- which is the absence of of a woman's menstrual periods.
Dysmenorrhea- also known as painful periods with severe menstrual cramping.
Menorrhagia- excessive menstrual bleeding.
Oligomenorrhea - which is infrequent (less than 8 periods/menstrualcycles per year) menstruation.
Toxic Shock Syndrome - starting out with flu-like symptoms, Toxic Shock Syndrome is related to tampon use and the
Amenorrhea is the absence of menstruation or a woman's monthly menstrual periods. Amenorrhea is classified as either "primary" Amenorrhea, which is the absence of "menarche" a girl's first menstrual period by age16, or "secondary" Amenorrhea, which is the absence of menstrual periods for more than three to six months in a woman who previously had monthly menstrual periods.
Causes of primary amenorrhea which are normally present at the birth of a baby girl, but are not known until she reaches the age of puberty, and when she should be experiencing menarche. Conditions causing primary amenorrhea may include genetic or chromosomal abnormalities, and structural abnormalities of the reproductive tract. All of the conditions that lead to secondary amenorrhea can also cause primary amenorrhea. Pregnancy is the leading cause of secondary amenorrhea.
Among non-pregnant women, ovarian conditions are the most common cause of secondary amenorrhea; these conditions include polycystic ovary syndrome and premature ovarian failure also known as early premature menopause.
The most common reasons for Amenorrhea, skipped menstrual periods or missing menstrual periods include:
* Emotional stress
* Excessive exercise or physical stress
* Poor nutrition
* Pregnancy
* Illness
Dysmenorrhea or painful periods is the medical term for severe menstrual cramping. "Primary dysmenorrhea" is not usually associated with other more serious medical conditions. Dysmenorrhea usually begins when a girl starts having her menstrual periods, and can start as soon as her first period or menarche.
Menorrhagia- or excessive menstrual bleeding, is normally indicated when a woman's menstruationlasts more than seven to eight days each monthly menstrual period, or if sheloses more than 80 milliliters or about 1/3 of a cup of menstrual blood eachmonthly cycle. A woman's doctor may classify or diagnose her as having dysfunctionaluterine bleeding (DUB), which often leads to an iron deficiency or anemiaunless she begins taking iron supplements, as prescribed by her doctor. Iron deficiency, as caused by the excessive menstrual bleeding, may lead to increasedfatigue, dizziness, shortness of breath, and in severe cases - angina.
Menorrhagia'smost likely causes include:
* Abortion-related problems
* Cervical or endometrial polyps
* Cervical cancer
* Endometrialcancer.
* Hormoneimbalance
* Intrauterine Devices (IUDs)
* Menopause
* Pelvic inflammatory disease (PID)
* Perimenopause
* Premature Ovarian Failure
* Uterine fibroids or tumors (benign or cancerous)
Oligomenorrhea is another menstrual disorder that refers to infrequent orsporadic menstrual periods which are generally defined to mean fewer than six to eight periods peryear.
Toxic ShockSyndrome (TSS)
Whatis " Toxic Shock" and Toxic Shock Syndrome?
Toxicshock syndrome is a rare infection that can happen during a woman's period. Thesymptoms include a sudden fever of over 101 degrees or more, diarrhea (theruns), vomiting (throwing up), muscle aches and a sunburn-like rash. If you havethese symptoms during you period, see a doctor right away.
Tohelp prevent toxic shock syndrome, you should follow these guidelines:
1. Wash your hands before unwrapping and placing a new tampon in your vagina.
2. Never use super-absorbent or deodorant tampons.
3. Change your tampon at least every 4-6 hours (read the tampon manufacturersinformation inside the box).
4. Do not use tampons all the time and switch to a pad for part of each day.
5. Do not use a birth control sponge or diaphragm during your period. During yourperiod it is preferable to use other methods such as condoms and/or foam.
Thereare allegations that tampons made from rayon, or cotton with rayon, may cause orbe a contributing factor to Toxic Shock Syndrome, as well as vaginal dryness orulcerations of vaginal tissues.
ToxicShock Syndrome is a rare but potentially fatal disease caused by a bacterialtoxin. (Different bacterial toxins may cause Toxic Shock Syndrome, depending onthe situation, but most often streptococci and staphylococci areresponsible.) The number of reported Toxic Shock Syndrome cases has decreasedsignificantly in recent years.
Approximatelyhalf the cases of Toxic Shock Syndrome reported today are associated with tamponuse during menstruation, usually in young women.
ToxicShock Syndrome also occurs in children, men, and non-menstruating women. In1997, only five confirmed menstrual-related Toxic Shock Syndrome cases werereported, compared with 814 cases in 1980 [according to data from the Centersfor Disease Control and Prevention (CDC)].
Althoughscientists have recognized an association between Toxic Shock Syndrome andtampon use, the exact connection remains unclear. Research conducted by the CDCsuggested that use of some high absorbency tampons increased the risk of ToxicShock Syndrome in menstruating women. A few specific tampon designs and highabsorbency tampon materials were also found to have some association withincreased risk of Toxic Shock Syndrome. These products and materials are nolonger used in tampons sold in the U.S. Tampons made with rayon do not appear tohave a higher risk of Toxic Shock Syndrome than cotton tampons of similarabsorbency.
Vaginaldryness and ulcerations may occur when women use tampons more absorbent thanneeded for the amount of their menstrual flow. Ulcerations have also beenreported in women using tampons between menstrual periods to try to controlexcessive vaginal discharge or abnormal bleeding. Women may avoid problems bychoosing a tampon with the minimum absorbency needed to control menstrual flowand using tampons only during active menstruation.
Tohelp women compare absorbency from brand to brand, FDA requires thatmanufacturers measure absorbency using a standard method and describe absorbencyon the package using standardized terms. Thus, the terms "junior,""regular," "super," and "super plus," alwaysdescribe a specific range of tampon absorbency regardless of the brand.
HistoricalPerspectives Reduced Incidence of Menstrual Toxic-Shock Syndrome -- UnitedStates, 1980-1990
InMay 1980, investigators reported to CDC 55 cases of toxic-shock syndrome (TSS)(1), a newly recognized illness characterized by high fever, sunburn-like rash,desquamation, hypotension, and abnormalities in multiple organ systems (2).Fifty-two (95%) of the reported cases occurred in women; onset of illnessoccurred during menstruation in 38 (95%) of the 40 women from whom menstrualhistory was obtained. National and state-based studies were initiated todetermine risk factors for this disease. In addition, CDC established nationalsurveillance to assess the magnitude of illness and follow trends in diseaseoccurrence; 3295 definite cases have been reported since surveillance wasestablished (Figure 1).
InJune 1980, a follow-up report described three studies which detected anassociation between Toxic Shock Syndrome and the use of tampons (3).Case-control studies in Wisconsin and Utah and a national study by CDC indicatedthat women with Toxic Shock Syndrome were more likely to have used tampons thanwere controls. The CDC study also found that continuous use of tampons wasassociated with a higher risk of Toxic Shock Syndrome than was alternating useof tampons and other menstrual products. Subsequent studies established thatrisk of Toxic Shock Syndrome was substantially greater in women who used Relybrand tampons than in users of other brands and that risk increased withincreased tampon absorbency (4-6). In September 1980, Rely tampons werevoluntarily withdrawn from the market by the manufacturer.
In1980, 890 cases of Toxic Shock Syndrome were reported, 812 (91%) of which wereassociated with menstruation. In 1989, 61 cases of Toxic Shock Syndrome werereported, 45 (74%) of which were menstrual. In 1980, 38 (5%) of 772 women withmenstrual Toxic Shock Syndrome died; in 1988 and 1989, there were no deathsamong women with menstrual Toxic Shock Syndrome. Reported by: Meningitis andSpecial Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases,CDC.
OnJuly 22, this notice was posted as an MMWRDispatch on the MMWR website (http://www.cdc.gov/mmwr).
OnJuly 19, 2005, the Food and Drug Administration (FDA) issued a public healthadvisory regarding the deaths of four women in the United States after medicalabortions with Mifeprex® (mifepristone, formerly RU-486; DancoLaboratories, New York, New York) and intravaginal misoprostol (1). Twoof these deaths occurred in 2003, one in 2004, and one in 2005. Two of theseU.S. cases had clinical illness consistent with toxic shock and had evidence ofendometrial infection with Clostridium sordellii, a gram-positive,toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordelliitoxic shock syndrome after medical abortion with mifepristone and misoprostolwas reported in 2001, in Canada (2). All three cases of C. sordellii infectionwere notable for lack of fever, and all had refractory hypotension, multipleeffusions, hemoconcentration, and a profound leukocytosis. C. sordelliipreviously has been described as a cause of pregnancy-associated toxic shocksyndrome (3).
Investigationby FDA, CDC, and state and local health departments into the two most recentlyidentified U.S. deaths after medical abortion is ongoing. Empiric therapy forpatients suspected of having postpartum or postabortion toxic shock syndromeshould include antimicrobials with anaerobic activity against Clostridiumspecies. Health-care providers are encouraged to report any cases of postpartumor postabortion toxic shock syndrome to their state or local health departmentand to CDC at telephone 800-893-0485. Cases potentially associated with ofmifepristone or misoprostol should also be reported through the FDA MedWatchsystem available at http://www.fda.gov/medwatch/index.htmlor telephone 800-FDA-1088.
Food and Drug Administration. FDA Public Health Advisory: sepsis and medical abortion. Rockville, Marylan: Food and Drug Administration, Center for Drug Evaluation and Research; 205. Available at http://www.fda.gov/cder/drug/advisory/mifeprex.htm.
Sinave C, Le Templier G, Bluin D, Leveille F, Deland E. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002;35:1441--3.
McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol 1989;161:987--95.
EditorialNote: The number of Toxic Shock Syndrome cases reported annually to CDC hasdecreased substantially in the 10-year period since menstrual Toxic ShockSyndrome was first recognized. Changes in public awareness and diminishedattention to Toxic Shock Syndrome in the medical literature might have resultedin reduced diagnosis and reporting. However, reporting of non-menstrual ToxicShock Syndrome has remained constant during this time while menstrual ToxicShock Syndrome reporting has decreased.
Amultistate active surveillance study in 1986-1987 confirmed the trends detectedby national passive surveillance (7). Through active case-finding efforts in anaggregate population of 34 million persons, the rate for menstrual Toxic ShockSyndrome was determined to be 1.0 per 100,000 women 15-44 years of age (7). Thisrate represented a substantial reduction from rates reported in similar studiesin 1980 (6.2 per 100,000 women 12-49 years of age in Wisconsin (8), 9.0 per100,000 women 12-45 years of age in Minnesota (9), and 12.3 per 100,000 women12-49 years of age in Utah (10)). Active surveillance also confirmed that theproportion of Toxic Shock Syndrome associated with menstruation had decreasedconsiderably: in 1988, menstrual Toxic Shock Syndrome accounted for 55% of casesdetected both by active surveillance (7) and by the passive surveillance system.
Aprinciple reason for the decreased incidence of menstrual Toxic Shock Syndromemay be decreases in the absorbency of tampons. In 1980, when tampon absorbency(in vitro) ranged from 10.3-20.5 g (4), very high absorbency products ( greaterthan 15.4 g) were used by 42% of tampon users (9). After the association betweenToxic Shock Syndrome and absorbency was recognized, manufacturers lowered theabsorbency of tampons. In 1982, the Food and Drug Administration (FDA) issued aregulation requiring that tampon package labels advise women to use the lowestabsorbency tampons compatible with their needs. By 1983, tampon absorbencyranged from 6.3-17.2 g (6), and the proportion of tampon users using very highabsorbency tampons had declined to 18%. By 1986, very high absorbency productswere used by only 1% of women who used tampons. Effective March 1990, the FDAinstituted standardized absorbency labeling of tampons, which currently rangefrom 6-15 g.
Tamponcomposition has also changed since 1980. Rely tampons consisted of polyesterfoam and cross-linked carboxymethylcellulose, a combination that is no longerused in tampons. Polyacrylate-containing tampons were withdrawn from the marketin 1985. Current tampons are manufactured from cotton and/or rayon. The uniquecomposition of Rely tampons may have been responsible for the increased riskassociated with those products (11); however, the role of current tamponcomposition as an independent risk factor for Toxic Shock Syndrome is unclearsince composition may vary even for a particular brand and style of tamponmarketed at a given time.
Otherfactors may have contributed to decreased reports of menstrual-related ToxicShock Syndrome. For example, public awareness of the syndrome may cause women toseek medical care earlier in their illness; milder disease may not meet thesurveillance case definition of severe multisystem illness. Increased variety inmenstrual products and concern related to Toxic Shock Syndrome may have resultedin fewer women using tampons or fewer using tampons continuously.
Currentpublic health efforts to prevent menstrual-related Toxic Shock Syndrome includetampon package labels and package inserts which describe early signs andsymptoms of Toxic Shock Syndrome and warn the consumer about the risk associatedwith tampons. Tampon users are encouraged to select lower absorbency products tofurther decrease risk of Toxic Shock Syndrome. Standardized absorbency labelingpermits consumers to compare absorbency between brands.
Theprecise mechanism by which Rely tampons increased the risk of Toxic ShockSyndrome is unknown. The increased risk associated with high absorbency tamponsis also poorly understood; high absorbency may be a surrogate for anothereffect. However, the withdrawal of Rely tampons and the subsequent decrease inuse of high absorbency tampons correlate with a marked decrease in incidence ofmenstrual-related Toxic Shock Syndrome. The rapid demonstration of the risk ofRely and high absorbency tampons resulted in prompt public health interventionsand substantial reduction in menstrual Toxic Shock Syndrome.
TamponTruth's and Tragedies
The Following Information Courtesy of: http://www.tamponalert.org.uk
andin Memory of Alice Kilvert, who died at the age of 15 due to
Tampon use and Toxic Shock Syndrome
AliceKilvert, aged 15, died on Tuesday, 26th November 1991 of tampon-related ToxicShock Syndrome at Trafford General Hospital, Manchester.
Alice'ssymptoms were initially very mild and did not cause any undue concern. On theSunday prior to her death she complained of a headache which persisted, buteased with aspirin. During Sunday evening she was able to watch television, butshe was sick during the night. Although very pale on Monday morning, she went toschool in order to start her mock GCSE exams, but was taken home as she appearedto be developing influenza.. Alice went straight to bed and by tea time she hada slight temperature. At 7pm she was alert enough to talk about the earlyevening TV she had missed, but by 10pm she seemed vague and confused and alittle faint.
The nextmorning Alice's breathing was shallow and she had a higher temperature, so theemergency doctor was called. The doctor phoned for an ambulance for Alice to betaken to hospital, but when the ambulance staff tested for blood pressure, itwas so low it hardly registered. She arrived at hospital at 9am and hercondition was diagnosed as either TOXIC SHOCK SYNDROME or meningitis, andtreatment began. She was taken into Intensive Care and put onto a ventilator asher breathing was giving cause for concern. However, the strain on her heartbrought on two cardiac arrests. She did not recover from the second one and diedat 1pm.
MoreStories on Women and Girls who
Died or Were Injured due to Tampon use and
Tampon-induced Toxic Shock Syndrome
1.KATIE OF NOTTINGHAMSHIRE.
In the summer of 1990, Katie, then aged 15, went on holiday to Devon with herfamily. It was a holiday that she'll never forget.
One morning she woke up with a headache and feeling shivery. Her mother thoughtthat it could be flu and suggested that she should stay in bed. During the dayher symptoms worsened as her temperature rose; she had aching muscles, a stiffneck and a sore mouth.
By tea time she became breathless and she was so weak that she needed assistanceto go to the toilet. Her parents sent for the doctor, who diagnosed a virus andprescribed antibiotics. That night Katie's temperature soared to 102 degrees.The next morning she felt awful and had a severe headache. Her mother noticed ared rash on her leg. Katie's eyes were pink and sticky and her skin was turningyellow. The doctor was called again. He took one look at her and called for anambulance. She was rushed to hospital.
At the hospital, the doctors performed a lumber puncture to test for meningitisand took a blood sample to test for glandular fever. Then the doctor discoveredthat Katie was menstruating and took a vaginal swab for testing. By now, herjoints were swollen, her mouth was blistered, her liver and kidneys were failingand her veins and arteries had gone into spasm. She was transferred to IntensiveCare.
The next morning a microbiologist had identified that Katie was suffering fromToxic Shock Syndrome, brought on by the tampons she had been using. She wasbeing treated by the right antibiotics, and the doctors said that they wouldjust have to wait and hope. Katie remained conscious for the three days that shewas in Intensive Care. The pain was excruciating. She was transferred to a wardand after a week she was strong enough to go home with the aid of a wheelchair.
Katie felt weak for months. Thick layers of skin peeled off her hands and feet.This was as a result of the blood supply being cut off from her extremitiesduring her illness. Then her hair started to fall out in clumps. This lasted forsix months, and it has never grown back to its previous thickness. She realizedthat her memory wasn't as good and her ability to concentrate had diminished.
Katie remembers being told at school that Toxic Shock Syndrome is caused byleaving a tampon in too long. Now she knows differently. Any woman or girl whouses tampons can get TSS. That's why she'll never use tampons again. It might berare, but you never know who it might strike next.
Posted30/12/2000
2.JEAN OF SURREY.
Jean was 46 when she suffered from Toxic Shock Syndrome. It was the second dayof her period and she was using tampons. She'd had a headache all day thatwouldn't go away, so she decided to go to bed early that evening. Jean couldn'tsleep and her headache intensified. Suddenly she was vomiting and suffering fromdiarrhea. Jean thought that it must be food poisoning. The next day, Jean feltno better, although the sickness and diarrhea had stopped. When she began tolapse into unconsciousness her daughter telephoned the doctor, who immediatelysummoned an ambulance. By this time Jean's lips had a bluish tinge and she washaving breathing difficulties. She went into a coma on the way to hospital asher blood pressure plummeted.
In Intensive Care, Jean needed a ventilator and dialysis as her kidneys hadceased to function. Doctors noticed that the tips of her fingers and toes wereturning black with gangrene. Over the next three weeks Jean was so weak that sheonly had a 20% chance of survival. Because of the drugs her weight balloonedfrom 10 stone to 13 stone. Her blonde hair turned grey and her green eyes turnedblue. The gangrene spread to her knee, nose and the back of her head. Jean wentinto stress and was given a tracheotomy to help her to breathe. Her veins werecollapsing and it was almost impossible to insert the necessary drips.
At this point the doctor asked Jean's husband if he could try an experimentaldrug which he hoped would increase her extremely low blood pressure. Withinminutes Jean started to respond and her blood pressure began to increase. Shewas going to make it, although she was still critically ill. Two days later sheopened her eyes and asked where she was. She noticed her black toes. Jean spentsix months in hospital and eventually had her toes amputated. Her feet were verypainful and she had to get used to walking again. Now she wears special shoesand occasionally uses a walking stick. Jean finds it difficult to concentrateand has problems with her short-term memory.
Jean says that it's a miracle that she's alive today. She has enormousadmiration for the doctors, nurses and of course her family who were with herall the time. Jean says that she will never use a tampon again. She has told allher friends and neighbors not to believe those trendy tampon adverts on the TV."Tampons nearly killed me and they will kill others," she says.
Posted30/12/2000
3.JUDY OF OXFORDSHIRE.
Judy, a 27 year old mother, had been using tampons since she was 12. Her episodeof Toxic Shock Syndrome began 10 weeks after the birth of her second daughter.She woke up on the third day of her period feeling tired and her head wasspinning, but she had to look after her new baby and her 2 year old daughter. Byevening she was exhausted and went to bed really early and just slept. The nextmorning, Judy got up and felt fine. But an hour after her husband had gone towork she had no strength to do anything. She vomited twice and had severediarrhea. She phoned her mother to look after the girls and went back to bed.She felt worse and worse before eventually getting off to sleep.
The next morning was the same. Judy was fine until after her husband had leftfor work. A sudden attack of diarrhea hit her before she could reach the toilet.Once again she asked her mother to look after the children, and her mother alsocalled the doctor. Judy was taken to the hospital by her sister-in-law andnearly fainted. Her legs were so painful and weak that she needed a wheelchair.Her skin was yellow. Judy was admitted to the infectious diseases ward for testsand the diarrhea was still running out of her. Within the hour they had put twodrips into her. The doctors had found her tampon by now and had taken it awayfor testing. She had a rash on her lower legs and feet.
By the next morning, and numerous doctors later, they had diagnosed Toxic ShockSyndrome. Judy was put on even more drips and had heart and kidney checks. Herfingers and toes tingled all the time, like a burning sensation. The skin on herfingers and toes later peeled off and it was terrifying and very painful. A weekin hospital and she was fit enough to go home.
Judy had to take tablets and return to hospital for heart and kidney checks andblood tests. She seemed to recover quite well, but lost her sense of taste forabout 5 weeks. She was under health surveillance for 6 months and received theall clear. Then Judy's hair started falling out. It didn't leave her bald, butit was very thin in places. This lasted about two months before getting back tonormal.
Judy says that not enough people know about the dangers of tampons and ToxicShock Syndrome. She will never use tampons again, and there's no way she'd lether daughters use them either.
Posted30/12/2000
4.ANNETTE OF MIDDLESEX
Annette was a healthy 17 year old at boarding school in Surrey. One Friday, inJune 1989, just seven weeks before her 18th birthday, she felt a bit under theweather. She had just started her period and was using high absorbency tampons.By Sunday, she was in the school sick bay, and her worried parents were drivingto visit her. Annette had a high temperature, severe headache and "appeareddistant". However, it wasn't until the Wednesday that she was rushed tohospital, with what doctors thought was a burst appendix.
In the early hours of the Thursday, she was put onto a ventilator, and herparents had what was to be their last conversation with Annette. The doctorsadvised her parents that she was suffering from toxic shock syndrome, a diseasethat they had never heard of.
During the night Annette's condition suddenly deteriorated and she suffered twomassive heart attacks and died.
Posted30/12/2000
5.KAREN OF HAMPSHIRE.
One Thursday in January 1991, 20 year old Karen became ill with sickness anddiarrhea. Although she was not aware of the connection, she was having herperiod and using tampons. She called the doctor who initially diagnosedgastro-enteritis and gave her some medicine. Karen continued vomiting, sufferedsevere diarrhea and was in agony, and on Sunday the doctor suspectedappendicitis and she was rushed to hospital. As she was severely dehydrated,Karen was immediately put on a drip, whilst the diagnosis was being made.
The next morning (Monday), Karen felt fine and was laughing and joking with herparents. However, her mother noticed that her breathing was labored and that shehad a red rash on her leg. But by 3 pm, Karen's condition worsened and she wasgiven oxygen. By 9 pm she had lapsed into unconsciousness and transferred toIntensive Care. The medical staff did not know what was causing the problem,although toxic shock was considered. She had 15 tubes going into and out of her.At 10 pm Karen suffered a cardiac arrest, and the IC staff resuscitated her, buther condition was critical.
At 1 amon the Tuesday morning, Karen had a last injection to stimulate her blood flow,and her parents were told that this was her last hope.
Tragically,Karen died at 2.15 am from Toxic Shock Syndrome due to tampons.
Posted30/12/2000
6.DELYSE OF BUCKINGHAMSHIRE.
Delyse was a 32 year old secretary. Early in August 1993, Delyse' menstrualperiod started and she began using tampons as usual. However, this time it wasto have tragic consequences.
OnSaturday morning, Delyse suddenly started vomiting, had severe diarrhea and ahigh temperature. She thought that she was suffering from food poisoning. Laterthat day her partner called the doctor, who diagnosed flu.
On theMonday, Delyse went back to her GP who diagnosed gastritis - inflammation of thelining of the stomach. Her condition worsened and on Tuesday she was admitted tothe local hospital with a suspected burst appendix.
Delyseseemed to be in a stable condition whilst the diagnosis began, but within 24hours, she was rushed into Intensive Care, then onto a ventilator as her lungshad collapsed. She was then transferred to a specialist hospital nearby, whereher condition improved slightly. When her vital organs, including liver andkidneys, failed, Delyse was put onto a dialysis machine.
After 5weeks of fighting for her life, Delyse suffered a massive brain haemorrhage anddied on 9th September.
Posted30/12/2000
7.SHARON OF COUNTY DURHAM.
Sharon, a keen sportswoman, died of Toxic Shock Syndrome two months after givingbirth to her second child.
Herhusband Anthony recalls the joy and the tragedy of eight weeks in late 1991.
Twentysix year old Sharon used tampons for her first period after the birth ofRebecca. It started one Sunday when she began to feel very tired.
ByMonday, Sharon was suffering with diarrhea, vomiting and a prickly red rash. Thedoctor was called and diagnosed a virus.
OnThursday, her condition had deteriorated. Now, Sharon's fingernails and lipswere turning blue, the rash was like sunburn and she was having breathingdifficulties.
Sharon was rushed to hospital. Her condition improved slightly, but then herkidneys collapsed and she was transferred to Intensive Care. Doctors diagnosedtoxic shock syndrome, caused by the tampon that she had been using.
Thedeadly toxins were causing all sorts of problems as they poisoned every part ofher body. Her lungs were beginning to fail and she was transferred to theRegional specialist hospital where a lung transplant was considered. However,Sharon was too ill to undertake this operation. Doctors fought so hard to saveher life, but after eight weeks of intensive care, Sharon suffered a cardiacarrest and died
Posted30/12/2000
8.SHANE OF BRISTOL.
Thirty three year old mother of two, Shane, died of tampon-related Toxic ShockSyndrome in March 1994.
OnFriday 4th March, Shane said she didn't feel well. During the early hours ofSaturday morning she began vomiting and felt awful. She asked her mother to lookafter the children.
BySunday she was suffering severe diarrhea, she had a red rash and was now semiconscious. She had a high temperature, her breathing was labored, and she hadpus coming from her eyes. At 9 am her husband phoned the doctor who suggestedthat it was a stomach bug. Shane's husband insisted that the doctor must visit,but on arrival, the doctor confirmed a stomach bug, and suggested paracetamol tolower her temperature.
By Monday, Shane's condition had not improved and her mother called the doctoragain. The doctor took one look at Shane and called an ambulance. She arrived athospital at 3 pm and went straight into Intensive Care. But after six cardiacarrests, Shane died at 5.30 pm.
Posted30/12/2000
9.PAMELA OF EDINBURGH.
OneSunday in March 1993, Pamela aged 34, took to her bed with a severe sore throat.At the time she knew that a lot of people round about had flu, so she thoughtthat she must be getting it too.
OnMonday morning she felt really faint. Her husband went off to work, but askedPamela's mother to phone the doctor. The doctor diagnosed a sore throat andprescribed penicillin. Although Pamela was able to talk coherently to thedoctor, she can't remember the rest of the day, not even talking strangely toher husband when he arrived home from work. She felt so tired. The doctor wastelephoned again and he suggested looking to see if Pamela had spots on herfeet! She did have. The doctor called 'round again and got her admitted tohospital with suspected meningitis.
Luck waswith Pamela that evening because the Specialist on duty had seen Toxic ShockSyndrome before. The tampon that had been removed when Pamela was admitted tothe hospital was tested positively for Staphylococcus aureus and TSS wasdiagnosed.
Ten daysof hospital treatment saved Pamela's life, but she was so weak that she had toleave the hospital in a wheelchair and learn how to walk again.
It tookmonths to recover physically and even longer to recover mentally. She lost a lotof her hair, her skin started peeling off and she ached all over. She had beenusing tampons since she was 17, but will never again use tampons.
Posted30/12/2000
10.FIONA OF ROSS-SHIRE.
On Newyears Eve 1990, 22 year old Fiona, woke up with crippling period pain. Hermother phoned work to let them know that Fiona would not be in today. As the daywore on Fiona became worse and started vomiting. At tea time the doctor wascalled and flu was diagnosed. But over the next few hours, Fiona's conditiondeteriorated. She started with diarrhea, her temperature soared and shedeveloped a rash all over her neck. A worried mother called the doctor again at2 am, and again flu was diagnosed.
The nextmorning, Fiona was unconscious and the ambulance was called. On arrival at thehospital, meningitis was first suspected, (but it wasn't until 3 months laterthat tampon-related toxic shock syndrome was confirmed). Fiona's temperature hadrocketed and she was surrounded by bags of ice. The intensive care staff workedthrough the day, but at 3 am the next morning, Fiona suffered a cardiac arrest.The team managed to save Fiona, but the shattering news was that Fiona may bebrain damaged, blind and paralyzed in all four limbs.
In thenext two weeks Fiona fought for her life. Her kidneys failed and she neededdialysis, and her toes turned black with gangrene and would have to beamputated.
Threemonths later, Fiona started to come out of her coma. She couldn't speak, but shecould hear and smile. Fiona stayed in hospital over the next year and was ondrips and dialysis, and having physiotherapy and speech therapy. She wastransferred to a Nursing home to be close to her parents. As a result of using atampon, Fiona is totally blind, confined to a wheelchair, unable to use her armsand only has limited speech.
For moreinformation on the above stories, please contact:
FAQ'sAbout Tampons and
Toxic Shock Syndrome
Ithought that you only got TSS if you forgot to change your tampon. Is this true?
Any woman may develop TSS when using tampons as directed by the manufacturer'sinstructions if she is carrying the particular strain of bacteria that producestoxins and if she has not developed immunity to these toxins.
Theexact combination of circumstances in which toxin production occurs in thevagina of individual women is not known. It is therefore not possible to stateany completely safe time limits on the use of a tampon, although it could beassumed that the longer a tampon is left in place or the more tampons are usedcontinuously, the greater the chance of toxin production starting. This is whywe recommend keeping tampon use to a minimum and breaking the use regularly byusing a sanitary towel/pad.
Allknown victims of TSS followed the manufacturers instructions on usageimplicitly, but they still became seriously ill or even died.
We thinkthat there are several reasons why people think that a "forgottentampon" causes Toxic Shock Syndrome:-
Many women have been admitted to hospital with TSS whilst still using a tampon. They had become seriously ill extremely quickly and had not been physically capable of removing or changing their tampon.
The term "retained tampon" in medical reports, refers to a tampon being in place on admission to hospital. It is not an indication of length of use.
It blames the tampon user, who was too ill to defend herself; it exonerated the tampon manufacturers and it reassured dedicated tampon users.
It made it easier for newspaper editors (usually men) to explain why someone was ill.
Can you catch TSS from other people?
No. TSS is not a contagious disease.
What is the link between TSS and tampon use?
The link is not clearly understood.
However, tampon research highlights three high RISK FACTORS: highabsorbency tampons, continuous tampon use and low body immunity.
TamponAbsorbency: the higher the absorbency the higher the risk; the lower the absorbency the lower the risk. That is why a woman should always use the lowest absorbency tampon for her menstrual flow. It also accounts for the high number of deaths due to super-absorbent tampons in 1980.
Continuous tampon use: women should not use tampons continuously during a period. It is recommended that the most convenient time to break the continuous use is at night, by using a sanitary towel/pad.
Low immunity: this is the factor that you cannot control as it may vary from time to time. It is generally understood that immunity improves with age therefore girls are at a higher risk that older women.
Is it possible to get TSS more than once?
Yes. A person who has had TSS can develop it again. If a women or girl has had TSS in the past, it is advisable not to use tampons again.
Menstrual TSS recurs in around 30% of cases. Dr Mary Andrews of the Dartmouth-Hitchcock Medical Centre in New Hampshire, advises that symptoms were most likely to return in women who were not treated during their first attack, and continued to use tampons. Two thirds of Dr Andrews' study group experienced a recurrence within 5 months, although only 16% of women who were treated had recurring symptoms of TSS.
ToxicShock Syndrome Symptoms
Whatare the symptoms of TSS?
Symptoms can be similar to flu or food poisoning, but they can become seriousvery quickly.
Thesymptoms of TSS include one or more of the following:
Always begin AFTER a menstrual period starts.
Early symptoms may include headache, and/or sore throat,
aching muscles and high temperature (fever).
Followed by vomiting, watery diarrhea,
Confusion and dizziness
A red, sunburn-like, rash on chest, abdomen or thighs
Very low blood pressure.
Please note: Only one or two of the above symptoms may occur. They do not necessarily occur all at once and may not persist.
Whatshould I do if I get these symptoms?
If you have any of these symptoms and are using a tampon you should, remove andsave your tampon and seek immediate medical attention (preferably at anemergency HOSPITAL). Tell the doctor that you have been using tampons andsuspect TSS (Take a TSS information leaflet with you).
Don't worry about wasting the doctor's time, you could be saving your life.
What Is The Treatment For TSS?
Withearly diagnosis, TSS can generally be effectively treated with antibiotics andother medication to counteract the symptoms.
ProfessorJoan Chesney, Head of Paediatrics at the University of Tennassee said inSeptember 1997 that concerns that Staphylococcus aureus could become resistantto antibiotics have so far proved unfounded. Tests on TSS-associated strains ofS-aureus at the Dartmouth-Hitchcock Medical Center in New Hampshire failed tofind any methicillin-resistant Staphylococcus aureus (MRSA), the strain whichhas caused so many problems for hospitals in Europe and America. All 62 samplesfrom menstrual and non-menstrual cases referred to the D-H Medical Centerbetween 1984 and 1995, were susceptible to two key antibiotics - oxacillin andclindamycin - although only a handful would have responded to treatment withpenicillan.
Standardtherapy for TSS continues to be on high-dose antibiotics, usually with a betalactam agent, with or without clindamycin or a related drug. You also need tostop toxin production which can be best done with a protein synthesis inhibitorsuch as clindamycin, gentamycin, erythromycin or clarithromycin. Introvenousfluids are another essential aspect of management, but doubts remain over thevalue of introvenous immunoglobulin (IVIG) injections as they carry the risk ofside-effects.
Choosing the RightTampon Absorbency or "Size"
Whenusing tampons, it's important to choose the lowest absorbency necessary for yourmenstrual flow. Because the amount of flow varies from day to day, it is likelythat you will need to use different absorbencies on different days of yourperiod. Selecting the right absorbency comes with experience, but as a guide, ifa tampon absorbs as much as it can and has to be changed before 4 hours, thenyou may want to try a higher absorbency. On the other hand, if you remove atampon and after 4-6 hours white fibre is still showing, you should choose alower absorbency.
Researchindicates that tampons should not be used continuously during a period as continuoususe is a high risk factor. The most obvious time to break thiscontinuous use is at night. AKTA recommends the use of a sanitary towel atnight. However, if you choose to use a tampon at night, choose the lowestabsorbency needed, insert a fresh one just before going to bed and remove it assoon as you wake up in the morning. Slim line tampons are quite absorbent fortheir size, so it is highly recommended that young girls do not use tampons atnight.
1. CDC. Toxic-shock syndrome--United States. MMWR
1980;29:229-30.
2.Todd J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated withphage-group-1 staphylococci. Lancet 1978;2:1116-8.
3.CDC. Follow-up on toxic-shock syndrome--United States. MMWR 1980;29:297-9.
4.Osterholm MT, Davis JP, Gibson RW, et al. Tri-state toxic-shock syndrome study:I. Epidemiologic findings. J Infect Dis 1982;145:431-40.
5.Schlech WF, Shands KN, Reingold AL, et al. Risk factors for development of toxicshock syndrome: association with a tampon brand. JAMA 1982;248:835-9.
6.Berkley SF, Hightower AW, Broome CV, Reingold AL. The relationship of tamponcharacteristics to menstrual toxic shock syndrome. JAMA 1987;258:917-20.
7.Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shocksyndrome in the United States, 1986. Rev Infect Dis 1989;2(suppl S1):S35-42.
8.Davis JP, Chesney PJ, Wand PJ, LaVenture M, the Investigation and LaboratoryTeam. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors,and prevention. N Engl J Med 1980;303:1429-35.
9.Osterholm MT, Forfang JC. Toxic-shock syndrome in Minnesota: results of anactive-passive surveillance system. J Infect Dis 1982;145:458-64. 10. Latham RH,Kehrberg MW, Jacobson JA, Smith CB. Toxic shock syndrome in Utah: a case-controland surveillance study. Ann Intern Med 1982;96:906-8. 11. Broome CV.Epidemiology of TSS in the United States: overview. Rev Infect Dis 1989;2 (supplS1):S14-21.
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Morethan 1 in 4 U.S. women will have a hysterectomy by the time they are 60 yearsold, according to the Centers for Disease Control and Prevention (CDC).
Ahysterectomy--removal of the uterus--can be a life-saving operation for womenwith certain types of cancer or uterine hemorrhage. It can also improve thequality of life for thousands of women each year who experience abnormal uterinebleeding and noncancerous growths of muscle tissue in and around the uterus(fibroids), or the falling of the uterus from its normal position into oroutside of the vagina (uterine prolapse).
Whenthe ovaries are also removed, a hysterectomy can relieve the pain ofendometriosis--the growth of the tissue lining the uterus (endometrial tissue)outside the uterus.
TheUnited States has one of the highest rates of hysterectomy in the world, withabout 5 out of every 1,000 women each year having the operation, according tothe CDC. Other industrialized countries show lower rates; in England, forexample, the rate is less than 3 per 1,000 women annually. In Norway, it's lessthan 2 in 1,000.
Someare concerned that many hysterectomies are done unnecessarily in this country."There are some cases where hysterectomy is the only option, for instance,for some types of cancer," says Anthony Scialli, M.D., director of theobstetrics and gynecology residency program at Georgetown University Hospital inWashington, D.C. "But I think we perform too many hysterectomies. It's amatter of American gynecologists being accustomed to performing a hysterectomyand American women being accustomed to getting one--based on their mother orother female relative having one. The one thing in favor of a hysterectomy isthat it works for abnormal uterine bleeding--but it should be the last step, notthe first step."
Ofthe more than 600,000 hysterectomies performed on American women in 1999, morethan one-third of them were to treat fibroids or abnormal uterine bleeding.
Today,women have other options--new medications, technologies, and procedures--totreat noncancerous uterine conditions. Some of these less invasive procedurestranslate into lower risk, quicker recovery, and less expense. And some preservethe ability to get pregnant, unlike hysterectomy.
However,these procedures also have the disadvantage inherent with any new treatment--thelack of data demonstrating long-term safety and effectiveness. "But it'snever a bad thing for a woman to ask a doctor for alternatives," saysScialli. "She should ask, 'What other options are there to manage thisproblem and what are the pros and cons?'"
Inwomen younger than 30, most hysterectomies are done to treat abnormal uterinebleeding. Abnormal uterine bleeding can occur as frequent, irregular andunpredictable bleeding, lengthy menstrual periods, bleeding between periods, ora heavy flow during periods. This bleeding may be caused by hormonal imbalances,growth of endometrial tissue into the wrong place, fibroids, or otherconditions. And sometimes the bleeding has no identifiable abnormalityassociated with it.
Howeverit occurs, abnormal uterine bleeding is an inconvenience, and it can beaccompanied by painful cramping. It can also be exhausting, embarrassingand--when it results in anemia--dangerous.
Afterdiagnosing the cause of bleeding, doctors usually turn to medications as thefirst therapy for treating abnormal uterine bleeding. Some estrogens andprogestins are approved by the Food and Drug Administration to treat abnormaluterine bleeding in certain circumstances. Although the FDA has not approvedoral contraceptives to treat abnormal uterine bleeding, some doctors prescribethem for this purpose. As with other approved medications, doctors may prescribeoral contraceptives "off label" for an unapproved use if, in theirprofessional judgment, a patient will benefit from them.
"Ninety-fivepercent of abnormal bleeding associated with or without fibroids can becontrolled with birth control pills," says Scialli. However, oralcontraceptives may not be effective in reducing bleeding to acceptable levels insome women.
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Gynecare ThermaChoice Uterine Balloon Therapy System uses a balloon filled with heated sugar (dextrose) solution. (Courtesy of GYNECARE, a division of ETHICON INC., Somerville, N.J.) |
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Hydro ThermAblator uses heated salt water (saline solution). (Courtesy of BEI Medical Systems Inc., Teterboro, N.J.) |
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Her Option Uterine Cryoblation Therapy System uses a cryosurgical probe to apply extreme cold. (Courtesy of CryoGen, Inc., San Diego) |
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NovaSure Impedance Controlled Endometrial Ablation System delivers electrical current to a triangular metallic mesh electrode to vaporize the endometrium. (Courtesy of Novacept, Inc., Palo Alto, Calif.) |
Forsome who experience abnormal uterine bleeding, a viable alternative tohysterectomy can be endometrial ablation. This procedure--a minimally invasivesurgery that uses electrical energy, heat, or cold to destroy the endometrium--mayminimize or even stop this bleeding. But the results may not be permanent."Within 10 years, most women will have some degree of menstrual bleedingreturn, but not heavy bleeding," says Scialli.
Theearly techniques of endometrial ablation, introduced in the 1980s and stillpracticed by many gynecologists, are also known as "operativehysteroscopy" because they use a hysteroscope (a thin, fiber-optic tube forviewing) with an attachment to destroy tissue. The attachment may be a "rollerball"or wire loop through which electrical heat travels to remove (resection) theendometrial lining. After the uterus is filled with fluid to enlarge it forbetter viewing, the surgeon moves the rollerball back and forth across thelining or uses the wire loop to shave off the tissue. Potential risks of thisablation method include infection, perforation of the uterus, cervicallaceration, and absorption of large volumes of fluid (fluid overload) that canlead to death.
In1997, the FDA approved ThermaChoice, the first non-hysteroscopic ablation deviceto treat excessive uterine bleeding (menorrhagia) due to benign (noncancerous)causes. In 2001, the FDA approved three more similar devices. These devices areto be used only in women who have not yet reached menopause and whosechildbearing is completed.
"Eachtype of ablation represents a simpler surgical procedure for doctors compared totraditional operative hysteroscopy," says Colin Pollard, a biomedicalengineer and chief of the ob/gyn devices branch in the FDA's Center for Devicesand Radiological Health. "All of the technologies have some things incommon, but each delivers energy differently and each offers different feedbackmechanisms to the doctor during the procedure."
TheThermaChoice Uterine Balloon Therapy System, manufactured by Gynecare, adivision of Ethicon Inc. of Somerville, N.J., consists of a balloon that isinserted through the neck of the womb (cervix) and into the uterus. Through acatheter connected to a controller console, the balloon is inflated with fluidand heated to 188 F (87 C) for eight minutes to destroy the uterine lining.
Thefirst of the three newer devices--the Hydro ThermAblator manufactured by BEIMedical Systems Inc. of Teterboro, N.J.--delivers hot salt water (salinesolution) into the uterus through a tube inserted into the cervix. The hot waterdestroys the uterine lining in about 10 minutes. The doctor uses a hysteroscopefor viewing the uterus during the procedure.
Thesecond device--Her Option Uterine Cryoblation Therapy System made by CryoGenInc. of San Diego--uses a probe capable of producing temperatures down to minus148 F (minus 100 C) at the tip. This extreme cold is applied to the tissue for10 minutes to freeze and destroy the uterine lining. Ultrasound is used to guideand monitor the procedure.
Thethird device--the NovaSure Impedance Controlled Endometrial Ablation Systemmanufactured by Novacept of Palo Alto, Calif.--uses a metallic mesh triangularelectrode that is expanded out of a slender tube into the uterus. A gentlesuction brings the tissue into close contact with the triangular electrode,which delivers electrical current to the endometrial tissue, causing itsdestruction in about 90 seconds. With this method, there is no hysteroscope orultrasound, so the doctor cannot view the uterus during the procedure.
Endometrialablation is not advised for women who want to have children, and it is not aform of birth control. "Doctors must tell the patient she should stillmaintain contraception," says Pollard. "If she does get pregnant, itwill be a very high-risk pregnancy." If pregnancy were to occur, the cellsleft lining the uterus may not be adequate for a fetus to attach and grow withinthe uterus.
TheThermaChoice balloon method has the longest track record of the newer, simplerablation techniques. A three-year study of this device and one-year studies ofthe ablation devices approved this year--the Hydro ThermAblator, Her Option, andNovaSure--showed similar rates of effectiveness and were comparable to theeffectiveness of operative hysteroscopy (such as the rollerball technique). Theyall reduced or stopped bleeding in 70 percent to 80 percent of the women tested.
Unlikea hysterectomy, the newer endometrial ablation procedures can be performed withlocal anesthesia. Ablation is usually done in the hospital on an outpatientbasis; however, some women remain overnight to treat the severe abdominal painthey may experience. Most women are able to return to their regular activitiesseveral days later.
Commonside effects after the procedure include nausea, vomiting, and a vaginaldischarge that can last from days to weeks. "Expect to have bleeding up tofour to six weeks," says Malcolm Munro, M.D., a professor and gynecologistat UCLA. "With ablation, you are traumatizing the surface whether you useelectrosurgery, or burn it or freeze it."
Complicationsof ablation are rare, but may include blood loss requiring a transfusion,perforation of the uterus, or unintended damage to other internal organs.
Newerapproaches to endometrial ablation are currently under investigation; these useother energy sources, such as laser and microwave, to destroy the endometrialtissue.
Awoman must decide what she expects from a treatment for abnormal uterinebleeding. "Women need to know that articulating their problem is importantfor treatment," says Munro. "With abnormal bleeding, the desiredoutcomes vary. Some women want no period, some want a predictable period. Somewant to slow the bleeding, for others pain is more important than volume. Somewant to maintain their ability to get pregnant. Some don't want scars; somedon't care about scars. Time off is a consideration. All of these factors areimpossible for a doctor to aggregate for the patient. The woman has to make thedecision."
Manywomen are satisfied with the outcomes of their endometrial ablations. Butothers, like Melissa Otto of Minneapolis, are disappointed.
Otto'shormonal introduction to womanhood--when she was 12--was frightening. Shortlyafter the onset of menstruation, her monthly period became very heavy andlengthy. By the time she was 14, Otto was extremely anemic from the blood loss."The doctors told my parents not to worry--that eventually I'd regulate andhave a normal period. They said 'Let's just treat the anemia for now.'"
ButOtto's bleeding was no more regular by the time she reached her 20s. Medicaltests ruled out fibroids and other abnormalities. Despite trying many differenttypes of birth control pills prescribed by her doctor, her periods continued toget heavier. They came about every 23 days and lasted for 12 to 13 days. Ottospotted during the 10 days a month she wasn't bleeding heavily.
Indesperation, Otto tried hormone injections, homeopathic remedies, chiropracticmedicine, blood-building supplements, and acupuncture. Nothing worked.
InMay 1999 when she was 31, Otto had an endometrial ablation. Her doctor used alaser to destroy the endometrial tissue. After five weeks of watery dischargeand spotting, Otto's periods resumed and became frequent and lengthy once more.
InJuly 2000, Otto checked into the hospital for a second endometrialablation--this time a balloon ablation. Four weeks later, her period returned--alittle lighter--but still long.
After20 years of problem periods, a dozen different doctors, hormone treatments, twoablations, and a bout of cervical cancer along the way, Otto had had enough. InMarch 2001, she had a hysterectomy, and Otto says that she is very happy withthe results.
Uterinefibroids may be a cause of abnormal uterine bleeding. About 30 percent of womenbetween 25 to 45 are diagnosed with fibroids, according to the federal Agencyfor Healthcare Research and Quality.
Forunknown reasons, fibroids are diagnosed in black women two to three times morefrequently than in white women, and fibroids account for about twice the numberof hysterectomies among black women than among white women, according to theCDC. About 200,000 hysterectomies each year are performed in the United Statesto treat fibroids.
Alsocalled myomata or leiomyomata, fibroids can vary from microscopic size to thesize of a melon, and no one knows what causes them.
Mostfibroids do not cause symptoms and require no treatment other than regularmonitoring by a physician. But some fibroids can cause heavy bleeding,debilitating pain, or both. If fibroids press on the bladder or bowel, they cancause frequent urination, constipation, painful bowel movements, andhemorrhoids.
Largefibroids may cause an enlarged uterus, resulting in a protruding abdomen."When the uterus reaches the size of a melon, a doctor would most likelyrecommend a hysterectomy," says Dena Hixon, M.D., a gynecologist in theFDA's Center for Drug Evaluation and Research. No treatment other thanhysterectomy can guarantee that uterine bleeding or fibroids won't recur.
Thereare medications that will temporarily shrink fibroids. If heavy bleedingaccompanies the fibroids and causes anemia, a doctor may prescribe an injectionthat temporarily stops estrogen production for up to three months beforesurgery. Most fibroids are stimulated to grow by estrogen, and without it,fibroids usually shrink. These injections, called gonadotropin-releasing hormone(GnRH) agonists, act by causing a sort of medical menopause, says Hixon."These are drugs with significant risks and side effects that are mostappropriately used when other common alternatives are inadequate or notappropriate for the individual." Because of their significant side effects,including loss of bone density, hot flashes, and mood swings, the FDA hasapproved GnRH agonists for use only for three months. Without surgery, thefibroids are likely to regrow after the drug is stopped.
Womenwith fibroids that cause pain, discomfort or bleeding have surgical options tohysterectomy. These include surgically removing only the fibroids (myomectomy),cutting off the blood supply to the fibroids (embolization), and shrinking thefibroids using electric current (myolysis). Myolysis is not currently widelyused, and no long-term studies on safety and effectiveness have been done onthis procedure. The most appropriate treatment for each woman will depend on thesize and location of the fibroids, the severity of symptoms, and futurechildbearing plans.
Beforetreating fibroids, a gynecologist should perform a pelvic exam and sonogram,says Thomas Lyons, M.D., a gynecologist at the Center for Women's Care andReproductive Surgery in Atlanta. If abnormal bleeding occurs a physician shouldalso take a sample of the uterine lining to check for cancerous cells or otherproblems that may warrant a different treatment.
Samplingcan be done by dilation and curettage (D&C) or by endometrial biopsy.D&C is a procedure that involves dilating the cervix and scraping theuterine lining. In an endometrial biopsy, a thin hollow tube is inserted throughthe cervix and into the uterus. Cells in the uterine lining are pulled throughthe tube by suction and later tested in a lab.
Uterinesarcoma, a rare cancer, cannot be diagnosed by testing samples of endometrialcells. Nevertheless, sampling is recommended to check for other cancers ordisease before treating fibroids or abnormal uterine bleeding.
Amyomectomy is a surgery to cut away the fibroids without removing the uterus, sothat a woman can maintain her ability to bear children. "It's major surgeryand has the same disadvantages as hysterectomy as far as pain, disability, andscarring are concerned," says Scialli. "But if a woman wants to getpregnant, myomectomy is currently the method with the best track record." Amyomectomy tends to weaken the uterine wall; children born after the proceduremay need to be delivered by cesarean section.
Insome cases, a myomectomy may be a more complicated procedure than ahysterectomy. "After you remove the fibroids, you have to reconstruct theuterus," says Lyons.
Myomectomycan be performed in several different ways, depending on the size and locationof the fibroids. In a laparotomy, a surgeon can go into the uterus through anincision in the abdomen. In another approach, a laparoscopy, the surgeon insertsa telescope-like instrument (laparoscope) through the navel and inserts otherinstruments through very small incisions in the abdomen. Scialli does notgenerally recommend a laparoscopic myomectomy for women having a subsequentpregnancy because it may weaken the uterine wall more than a myomectomy donethrough a larger abdominal incision.
Anothermethod of myomectomy involves using a hysteroscope and small surgicalinstruments inserted into the uterus through the cervix to cut out the fibroids.Sometimes, the surgeon uses a special type of hysteroscope called a resectoscope.This instrument has a built-in wire loop and uses electrical current to cut outthe fibroid. Even after a myomectomy, fibroids can still be a problem, saysScialli. "I've seen patients who never have fibroids return and patientswhose fibroids recur every bit as badly within a year."
Uterinefibroid embolization (UFE)--also called uterine artery embolization (UAE)--is aminimally invasive procedure that blocks the arteries carrying blood to thefibroids. Because the procedure is performed by a specially trained physiciancalled an interventional radiologist, a woman should first be examined by agynecologist, says Lyons. The gynecologist will take the patient's medicalhistory and perform tests to rule out any problems that may be causing thebleeding and that would require a different treatment.
Inthe procedure, which is done under local anesthesia, the radiologist threads asmall tube (catheter) from the groin into the uterine artery. The radiologistthen injects a dye into the artery and views moving X-ray images on a monitor tosee the flow of blood to the fibroids. Very small particles, called embolicagents, are slowly injected through the catheter to the uterine artery in orderto block the blood supply to the fibroids. (See"Uterine Fibroid Embolization.") A clot forms around theparticles, which are about the size of grains of sand and are usually made fromplastic (polyvinyl alcohol) or gelatin sponge.
"Uterineartery embolization is a procedure that doctors have been doing as long as 20years, but not specifically for uterine fibroids," says the FDA's Pollard."The procedure has been used for postpartum hemorrhaging and to stopbleeding when treating some kinds of cancer."
Sincethe mid-1990s, the use of uterine artery embolization to treat fibroids hasgrown. According to the Society of Cardiovascular and Interventional Radiology,more than 10,000 procedures have been done worldwide, of which about 8,600 wereperformed in the United States. Three deaths have been reported.
Althoughthe FDA has not cleared the UFE procedure for general use, it is being studiedin FDA-approved clinical trials. "It is not a trivial procedure and is notwithout risks," says Pollard. "And we're not sure how those risksweigh up against drug therapy, myomectomy, and hysterectomy." Potentialrisks include infection, ovarian failure leading to early menopause, andexpulsion of the fibroid from the uterus at a later date, requiring anotherprocedure. Additional risks include leakage of the embolic particles out of theblood vessels, complications from radiation exposure, blood clotting in theveins of the inner thigh or leg (deep vein thrombosis), blockage of an artery inthe lungs (pulmonary embolus), and death.
Unlikea hysterectomy, UFE leaves the uterus intact, with the potential forchildbearing. However, current research is lacking on the ability to becomepregnant and carry a baby to full-term, says Pollard.
Comparedto hysterectomy, minimally invasive surgeries to treat uterine problems arerelatively unknown territory. "While these are promising technologies, wedon't have data on their long-term safety, effectiveness, and fertility,"says Amy Allina, program director of the National Women's Health Network, anonprofit women's health advocacy organization in Washington, D.C. "It's amatter of choice. I don't consider any of these options perfect foreverybody."
Nevertheless,women today do have a multitude of good options to choose from to maintain theirhealth, says Lyons. "Information about these options is out there butindividuals must access this knowledge in order to take advantage of thesechoices. Be proactive and know all you can know to best serve yourself and yourfamilies."
NationalWomen's Health Network
514 10th St., N.W., Suite 400
Washington, DC 20004
202-628-7814
www.womenshealthnetwork.org
NationalWomen's Health Information Center
1-800-994-WOMAN (1-800-994-9662)
TDD: 1-888-220-5446
www.4woman.gov
NationalUterine Fibroids Foundation
1-877-553-NUFF (1-877-553-6833)
www.nuff.org
EndometriosisAssociation
1-800-992-3636
www.endometriosisassn.org
What About Menstrual Hygiene?
MenstrualHygiene deals with a woman's special healthcare needs and requirements duringher monthly menstruation or menstrual cycles. These areas of specialconcern include choosing the best "period protection," or femininehygiene products, how often and when to change her feminine hygiene products,bathing, care of her vulva and vagina, as well as the supposed benefits ofvaginal douching at the end of each menstrual period.
WhyShould I, My Wife, or My Daughter(s) Use
Organic Cotton Tampons?
TamponFacts and Information About Tampon Usage in the United States
About70% of the 73 million women are of menstruating age in the U.S. use tampons.
Lifetimetampon usage is about 11,400 (5 days X 5 tampons X 38 years)
Inthe U.S., women between 11 and 60 years of age reported 216 cases of menstrualTSS reported in 1993; 244 cases in 1994
Therisk of TSS is higher for women under 30 years old; 60% of patients are between15 and 24 years of age
Thefatality rate of TSS is 3% to 5%, but it is estimated that only 10% ofcases of TSS are reported, as many women suffer only flu-like symptoms
Absorbencyenhancers in tampons can cause peeling of the mucous membrane, vaginal dryness,ulcers, and lesions
Perfumesand fragrances in some tampons are reported to cause vaginal irritation,allergic reactions, and disruptions of a woman's microbial balance
"Tamponusers were demonstrated to be 18 times more likely to develop menstrual TSS asnon-users", Infectious Diseases in Obstetrics & Gynaecology, 1993,Gilles R.G. Monif
"of[Toxic Shock] cases occurring in menstruating women, up to 99% were usingvaginal tampons", Obstetrics and Gynaecologic Infectious Disease, 1994,James McGregor and James Todd, (Chapter 21 - Toxic Shock Syndrome)
"Vaginalinflammation can result from rayon fibres from tampons becoming embedded invaginal walls", Journal of Obstetrics and Gynaecology, 1980
Tamponsmade chiefly of rayon have some levels of dioxin.
"Rayontampons amplify the growth of the Toxic Shock Syndrome bacteria TSST-1"American Society for Microbiology Journal, May 1994, Dr. Philip Tierno of NYUMedical Center
Dioxinlevels once thought acceptable are now reported to adversely affect thereproductive and immune systems, "A Health Assessment Document forDioxin", published by the Environmental Protection Agency, 1996
"Cottontampons offer no protective advantage over cotton/rayon tampons with regard toprotection from TSS" Journal of Infectious Diseases, October 1995 (study byDept. of Microbiology, University of Minnesota.
The Truth About Tampons
By Catherine-Elliott Lopez
Fall1998
Swedish studies have shown a link between tampons containing dioxin, and other chlorine by-products, and an increased risk of cancers of the female reproductive tract (especially the uterus, ovaries and bladder).
Rayon itself poses another risk. Unknown to most women, rayon and rayon-cotton blend fibers are widely used in commercial feminine hygiene products. Rayon used to make tampons is usually treated with chemicals to increase the absorption capability.
These super absorbent fibers then absorb not only the menstrual blood, but normal vaginal secretions as well, causing drying, and ulceration of vaginal tissues. The fibers can also become imbedded in the vaginal walls. Rayon fibers have been scientifically proven to amplify the production of Toxic Shock Syndrome Toxin TSST1.
Toxic Shock Syndrome is a rare bacterial illness that caused over 50 deaths between 1979 and 1980. Unlike medical grade cotton, upon which the TSS toxin will not grow, the rayon acts like a petri dish encouraging bacterial growth. What makes these toxic residues even more disturbing, is that they come in direct contact with some of the most absorbent tissue in a woman's body.
According to a doctor at New York University Medical Center, almost anything placed on this tissue, including Dioxin, gets absorbed into the body.
Why is it acceptable to have toxic substances in our feminine hygiene products? The tampon industry is convinced that women need bleached white products. They seem to think that we view this as "pure" and "clean." The fact is, if Dioxin puts women at risk for cancer and Dioxin is stored in fatty tissue (just like that found in the vagina), and a woman uses as many as 11,000 tampons in her lifetime, could the long term use of tampons increase cancer risk?
An FDA report said that "the most effective risk-management strategy would be to assure that tampons, and menstrual pads, contain no Dioxin." Although the FDA currently requires tampon manufacturers to monitor Dioxin levels, the results are not available to the public. The dioxin tests, are done by the manufacturers themselves, who insist their products are safe. Tampon manufacturers are not required to disclose ingredients to consumers, although many will do so voluntarily.
How much Dioxin exposure is considered safe for humans? Why has there been more research done on the possible health effects of chlorine-bleached coffee filters than on chlorine bleached tampons and related products? Women need to demand that more research be done on these issues. We have a right to know about any potential hazards associated with tampons and related products. It is only when women fully understand the consequences that we can make informed decisions regarding our health and well being.
Writer's note: Currently there are only a few non-chlorine bleached all cotton tampons available in the US. Ask about them at your local store, if they are not available, ask them to special order!
ThePros And Cons Of Tampons
The type of tampon you choose may affect your healthBy Laurel Kallenbach
Today'saverage woman uses an estimated 12,000 tampons in her lifetime, a conveniencethat allows an unprecedented freedom to be active and confident in avoidingembarrassing leaks. We've come a long way since rags pinned into undergarmentsor belted-on bulky pads were the norm, but with our freedom comes risk. Thereare potential problems attached to tampon use that every consumer should knowabout: Chlorine-bleached products, as some tampons are, contain traces ofcarcinogenic dioxins. Highly absorbent tampons may still cause toxic shocksyndrome, a potentially fatal bacterial infection that occurs when tampons areworn for too long. There are even environmental ramifications, includingpesticides sprayed on cotton crops and pollution created when tampon ingredientsare bleached.
But,there are safe and ecological alternatives that enable women to still benefitfrom tampons. Here, natural is the rule of thumb. "Plainer is just betterwhen it comes to tampons," says Pam Chandler, a family nurse practitionerand certified nurse midwife who practices at the holistic clinic Wellspring forWomen in
DioxinDilemma
The most urgent tampon health concern is that chlorine-bleached andrayon-containing products carry trace amounts of dioxin, an extremely toxicchemical that is associated with cancer of the stomach, sinus lining, liver andlymph system. Many people are familiar with the danger of dioxins from publicityabout Agent Orange and the
Checkyour tampon box for a list of ingredients. Whereas natural brands state thatthey're nonchlorine bleached, some conventional brands mention little on thesubject, because along with the Food and Drug Administration (FDA) and theEnvironmental Protection Agency (EPA), they believe chlorine-dioxide bleachingis safe.
Tiernodisagrees: While trace quantities of dioxin aren't in and of themselves aproblem, tampons aren't your only exposure. "The problem is that measurableamounts of dioxins are everywhere, including food and water. Some portion of thedioxin that enters your bloodstream lodges in the body's fat cells and staysthere a long time," he says. "This residual effect becomesprogressively larger as you're exposed to even more dioxins."
Theonly way to avoid vaginally absorbed dioxin, Tierno says, is to eliminatechlorine-bleached and rayon-containing tampons and switch to peroxide-bleachedproducts instead. Tierno also says if the label on your tampon box doesn't say"nonchlorine-bleached," it's possible that it contains chlorine. Mostmanufacturers proudly promote the fact that their product doesn't containchlorine.
Thecumulative risks of dioxin are unknown. While a single tampon may contain only0.1 parts per trillion of dioxin, the fact that most women use between 10,000and 15,000 tampons in a lifetime increases the exposure. "A trace quantityof dioxin is not acceptable in a tampon, because a woman does not expose herselfto a single tampon," Tierno says. "It's trace quantity upon tracequantity upon trace quantity, multiplied by the number of tampons per month,multiplied by the number of months in a year, multiplied by 40 years ofmenstruation. Then add in all the dioxins you get from your diet, plus all theones occurring in the environment."
Earth-friendlyOptions
The environmental impact of the manufacturing of feminine products is anotherreason to use organic tampons. While cotton tampons may seem better thansynthetic, most cotton undergoes industrial bleaching in a polluting processthat dumps dioxins, along with other hazardous organochlorines, into the watersupply. Organic cotton tampons and pads are treated with hydrogen peroxideinstead of bleach, making them a safer alternative. If the label states that theproduct is third-party certified organic, that means the cotton has been grownwithout pesticides on land where no pesticides have been applied for at leastthree years.
Inresponse to concerns over dioxin in tampons and their impact on the environment,the EPA and some manufacturers have worked to find a better way of purifyingwood pulp and cotton without creating dioxins. The result is chlorine-dioxidebleaching, a process that has replaced the elemental chlorine-gas method of thepast but still generates low trace levels of dioxins.
Thepackaging of tampons is another troublesome environmental issue. Most areencased in a paper or cellophane wrapper, contain a cardboard or plasticapplicator, and are packed in boxes. Though you can't recycle cotton tampons,there are waste-saving alternatives to dealing with menstruation, such aswashable natural sponge tampons and cloth pads, and reusable, but awkward,vaginally inserted menstrual cups that collect flow.
ToxicShock: Still A Risk
In the '70s and '80s, toxic shock syndrome (
"Highlyabsorbent tampons, especially those containing synthetic fibers, increase theamounts of toxin present in the vagina," says Tierno.
Inthe mid-'70s, synthetic fibers were used in tampons because manufacturers wantedto produce more absorbent, leak-resistant products. Since then, three of thefour problematic synthetics have been eliminated from tampons. "The onlyone left is viscose rayon," Tierno says.
Tominimize your risk of contracting
Mostprecautions for guarding against
Choosinga tampon with proper absorbency is crucial to preventing
CarefulLiberation
Within the last couple of years, a rash of e-mails warned women that tamponmanufacturers put asbestos in their tampons to make women bleed more in hopes ofselling more product. Tierno says the rumor was false. "I have been privyto every manufacturer's records over the last 21 years, and I have never seenanything related to asbestos in tampons," he says.
Thoughthe asbestos scare amounted to nothing but an urban myth, true additives to beconcerned about are fragrances and deodorants. Perfumes may mask odors, but somewomen suffer allergic reactions to them. "Without question, a deodorizedtampon is dangerous," asserts Tierno, adding that deodorants encourageovergrowth of certain bacteria, upset the vagina's normal flora and irritate themucous membrane.
Themain point, when it comes to tampon use, is to stay informed and weigh theoptions. "Over the years, tampons have allowed women to be more active andfuss less during their periods," says
Whatis Toxic Shock Syndrome?
Toxicshock syndrome is a rare infection that can happen during a woman's period. Thesymptoms include a sudden fever of over 101 degrees or more, diarrhea (theruns), vomiting (throwing up), muscle aches and a sunburn-like rash. If you havethese symptoms during you period, see a doctor right away.
Tohelp prevent toxic shock syndrome, you should follow these guidelines:
1. Wash your hands before unwrapping and placing a new tampon in your vagina.
2. Never use super-absorbent or deodorant tampons.
3. Change your tampon at least every 4-6 hours (read the tampon manufacturersinformation inside the box).
4. Do not use tampons all the time and switch to a pad for part of each day.
5. Do not use a birth control sponge or diaphragm during your period. During yourperiod it is preferable to use other methods such as condoms and/or foam.
Thereare allegations that tampons made from rayon, or cotton with rayon, may cause orbe a contributing factor to Toxic Shock Syndrome, as well as vaginal dryness orulcerations of vaginal tissues.
ToxicShock Syndrome is a rare but potentially fatal disease caused by a bacterialtoxin. (Different bacterial toxins may cause Toxic Shock Syndrome, depending onthe situation, but most often streptococci and staphylococci areresponsible.) The number of reported Toxic Shock Syndrome cases has decreasedsignificantly in recent years. Approximately half the cases of Toxic ShockSyndrome reported today are associated with tampon use during menstruation,usually in young women. Toxic Shock Syndrome also occurs in children, men, andnon-menstruating women. In 1997, only five confirmed menstrual-related ToxicShock Syndrome cases were reported, compared with 814 cases in 1980 [accordingto data from the Centers for Disease Control and Prevention (CDC)]. Althoughscientists have recognized an association between Toxic Shock Syndrome andtampon use, the exact connection remains unclear. Research conducted by the CDCsuggested that use of some high absorbency tampons increased the risk of ToxicShock Syndrome in menstruating women. A few specific tampon designs and highabsorbency tampon materials were also found to have some association withincreased risk of Toxic Shock Syndrome. These products and materials are nolonger used in tampons sold in the U.S. Tampons made with rayon do not appear tohave a higher risk of Toxic Shock Syndrome than cotton tampons of similarabsorbency.
Vaginaldryness and ulcerations may occur when women use tampons more absorbent thanneeded for the amount of their menstrual flow. Ulcerations have also beenreported in women using tampons between menstrual periods to try to controlexcessive vaginal discharge or abnormal bleeding. Women may avoid problems bychoosing a tampon with the minimum absorbency needed to control menstrual flowand using tampons only during active menstruation.
Tohelp women compare absorbency from brand to brand, FDA requires thatmanufacturers measure absorbency using a standard method and describe absorbencyon the package using standardized terms. Thus, the terms "junior,""regular," "super," and "super plus," alwaysdescribe a specific range of tampon absorbency regardless of the brand.
Historical Perspectives Reduced Incidence of Menstrual Toxic-Shock Syndrome -- United States, 1980-1990
InMay 1980, investigators reported to CDC 55 cases of toxic-shock syndrome (TSS)(1), a newly recognized illness characterized by high fever, sunburn-like rash,desquamation, hypotension, and abnormalities in multiple organ systems (2).Fifty-two (95%) of the reported cases occurred in women; onset of illnessoccurred during menstruation in 38 (95%) of the 40 women from whom menstrualhistory was obtained. National and state-based studies were initiated todetermine risk factors for this disease. In addition, CDC established nationalsurveillance to assess the magnitude of illness and follow trends in diseaseoccurrence; 3295 definite cases have been reported since surveillance wasestablished (Figure 1).
InJune 1980, a follow-up report described three studies which detected anassociation between Toxic Shock Syndrome and the use of tampons (3).Case-control studies in Wisconsin and Utah and a national study by CDC indicatedthat women with Toxic Shock Syndrome were more likely to have used tampons thanwere controls. The CDC study also found that continuous use of tampons wasassociated with a higher risk of Toxic Shock Syndrome than was alternating useof tampons and other menstrual products. Subsequent studies established thatrisk of Toxic Shock Syndrome was substantially greater in women who used Relybrand tampons than in users of other brands and that risk increased withincreased tampon absorbency (4-6). In September 1980, Rely tampons werevoluntarily withdrawn from the market by the manufacturer.
In1980, 890 cases of Toxic Shock Syndrome were reported, 812 (91%) of which wereassociated with menstruation. In 1989, 61 cases of Toxic Shock Syndrome werereported, 45 (74%) of which were menstrual. In 1980, 38 (5%) of 772 women withmenstrual Toxic Shock Syndrome died; in 1988 and 1989, there were no deathsamong women with menstrual Toxic Shock Syndrome. Reported by: Meningitis andSpecial Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases,CDC.
OnJuly 22, this notice was posted as an MMWR Dispatch on the MMWR website(http://www.cdc.gov/mmwr).
OnJuly 19, 2005, the Food and Drug Administration (FDA) issued a public healthadvisory regarding the deaths of four women in the United States after medicalabortions with Mifeprex® (mifepristone, formerly RU-486; DancoLaboratories, New York, New York) and intravaginal misoprostol (1). Twoof these deaths occurred in 2003, one in 2004, and one in 2005. Two of theseU.S. cases had clinical illness consistent with toxic shock and had evidence ofendometrial infection with Clostridium sordellii, a gram-positive,toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordelliitoxic shock syndrome after medical abortion with mifepristone and misoprostolwas reported in 2001, in Canada (2). All three cases of C. sordellii infectionwere notable for lack of fever, and all had refractory hypotension, multipleeffusions, hemoconcentration, and a profound leukocytosis. C. sordelliipreviously has been described as a cause of pregnancy-associated toxic shocksyndrome (3).
Investigationby FDA, CDC, and state and local health departments into the two most recentlyidentified U.S. deaths after medical abortion is ongoing. Empiric therapy forpatients suspected of having postpartum or postabortion toxic shock syndromeshould include antimicrobials with anaerobic activity against Clostridiumspecies. Health-care providers are encouraged to report any cases of postpartumor postabortion toxic shock syndrome to their state or local health departmentand to CDC at telephone 800-893-0485. Cases potentially associated with use ofmifepristone or misoprostol should also be reported through the FDA MedWatchsystem available at http://www.fda.gov/medwatch/index.htmlor telephone 800-FDA-1088.
Food and Drug Administration. FDA Public Health Advisory: sepsis and medical abortion. Rockville, Maryland: Food and Drug Administration, Center for Drug Evaluation and Research; 2005. Available at http://www.fda.gov/cder/drug/advisory/mifeprex.htm.
Sinave C, Le Templier G, Blouin D, Leveille F, Deland E. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002;35:1441--3.
McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol 1989;161:987--95.
EditorialNote: The number of Toxic Shock Syndrome cases reported annually to CDC hasdecreased substantially in the 10-year period since menstrual Toxic ShockSyndrome was first recognized. Changes in public awareness and diminishedattention to Toxic Shock Syndrome in the medical literature might have resultedin reduced diagnosis and reporting. However, reporting of non-menstrual ToxicShock Syndrome has remained constant during this time while menstrual ToxicShock Syndrome reporting has decreased.
Amultistate active surveillance study in 1986-1987 confirmed the trends detectedby national passive surveillance (7). Through active case-finding efforts in anaggregate population of 34 million persons, the rate for menstrual Toxic ShockSyndrome was determined to be 1.0 per 100,000 women 15-44 years of age (7). Thisrate represented a substantial reduction from rates reported in similar studiesin 1980 (6.2 per 100,000 women 12-49 years of age in Wisconsin (8), 9.0 per100,000 women 12-45 years of age in Minnesota (9), and 12.3 per 100,000 women12-49 years of age in Utah (10)). Active surveillance also confirmed that theproportion of Toxic Shock Syndrome associated with menstruation had decreasedconsiderably: in 1988, menstrual Toxic Shock Syndrome accounted for 55% of casesdetected both by active surveillance (7) and by the passive surveillance system.
Aprinciple reason for the decreased incidence of menstrual Toxic Shock Syndromemay be decreases in the absorbency of tampons. In 1980, when tampon absorbency(in vitro) ranged from 10.3-20.5 g (4), very high absorbency products ( greaterthan 15.4 g) were used by 42% of tampon users (9). After the association betweenToxic Shock Syndrome and absorbency was recognized, manufacturers lowered theabsorbency of tampons. In 1982, the Food and Drug Administration (FDA) issued aregulation requiring that tampon package labels advise women to use the lowestabsorbency tampons compatible with their needs. By 1983, tampon absorbencyranged from 6.3-17.2 g (6), and the proportion of tampon users using very highabsorbency tampons had declined to 18%. By 1986, very high absorbency productswere used by only 1% of women who used tampons. Effective March 1990, the FDAinstituted standardized absorbency labeling of tampons, which currently rangefrom 6-15 g.
Tamponcomposition has also changed since 1980. Rely tampons consisted of polyesterfoam and cross-linked carboxymethylcellulose, a combination that is no longerused in tampons. Polyacrylate-containing tampons were withdrawn from the marketin 1985. Current tampons are manufactured from cotton and/or rayon. The uniquecomposition of Rely tampons may have been responsible for the increased riskassociated with those products (11); however, the role of current tamponcomposition as an independent risk factor for Toxic Shock Syndrome is unclearsince composition may vary even for a particular brand and style of tamponmarketed at a given time.
Otherfactors may have contributed to decreased reports of menstrual-related ToxicShock Syndrome. For example, public awareness of the syndrome may cause women toseek medical care earlier in their illness; milder disease may not meet thesurveillance case definition of severe multisystem illness. Increased variety inmenstrual products and concern related to Toxic Shock Syndrome may have resultedin fewer women using tampons or fewer using tampons continuously.
Currentpublic health efforts to prevent menstrual-related Toxic Shock Syndrome includetampon package labels and package inserts which describe early signs andsymptoms of Toxic Shock Syndrome and warn the consumer about the risk associatedwith tampons. Tampon users are encouraged to select lower absorbency products tofurther decrease risk of Toxic Shock Syndrome. Standardized absorbency labelingpermits consumers to compare absorbency between brands.
Theprecise mechanism by which Rely tampons increased the risk of Toxic ShockSyndrome is unknown. The increased risk associated with high absorbency tamponsis also poorly understood; high absorbency may be a surrogate for anothereffect. However, the withdrawal of Rely tampons and the subsequent decrease inuse of high absorbency tampons correlate with a marked decrease in incidence ofmenstrual-related Toxic Shock Syndrome. The rapid demonstration of the risk ofRely and high absorbency tampons resulted in prompt public health interventionsand substantial reduction in menstrual Toxic Shock Syndrome.
CDC. Toxic-shock syndrome--United States. MMWR
1980;29:229-30.
2.Todd J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated withphage-group-1 staphylococci. Lancet 1978;2:1116-8.
3.CDC. Follow-up on toxic-shock syndrome--United States. MMWR 1980;29:297-9.
4.Osterholm MT, Davis JP, Gibson RW, et al. Tri-state toxic-shock syndrome study:I. Epidemiologic findings. J Infect Dis 1982;145:431-40.
5.Schlech WF, Shands KN, Reingold AL, et al. Risk factors for development of toxicshock syndrome: association with a tampon brand. JAMA 1982;248:835-9.
6.Berkley SF, Hightower AW, Broome CV, Reingold AL. The relationship of tamponcharacteristics to menstrual toxic shock syndrome. JAMA 1987;258:917-20.
7.Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shocksyndrome in the United States, 1986. Rev Infect Dis 1989;2(suppl S1):S35-42.
8.Davis JP, Chesney PJ, Wand PJ, LaVenture M, the Investigation and LaboratoryTeam. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors,and prevention. N Engl J Med 1980;303:1429-35.
9.Osterholm MT, Forfang JC. Toxic-shock syndrome in Minnesota: results of anactive-passive surveillance system. J Infect Dis 1982;145:458-64. 10. Latham RH,Kehrberg MW, Jacobson JA, Smith CB. Toxic shock syndrome in Utah: a case-controland surveillance study. Ann Intern Med 1982;96:906-8. 11. Broome CV.Epidemiology of TSS in the United States: overview. Rev Infect Dis 1989;2 (supplS1):S14-21.
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