IMPORTANT INFORMATION  FOR TAMPON USERS:

 

Study from France[1], published online on 10.03.2020, studying association of characteristics of tampon use with menstrual toxic shock syndrome in France identified a lack of women’s education about tampon use in French populations.

 

Their findings suggest an increased risk of menstrual toxic shock syndrome in women:

• using a tampon for a duration starting from over 6 hours,
• overnight tampon use, and
• with lack of education about tampon use.

 

Study suggests that maximum wear-time per tampon should be 6 h, not 8 h as the FDA currently recommends.

 

French women have a low level of knowledge about TSS because initial education provided by family members and relatives was disconnected from the risk of TSS.

 

 

MORE DETAILED INFORMATION – especially FOR PROFESSIONALS – EDUCATORS:

Public health policies for TSS prevention should be targeted to adolescents and involve more health professionals as sources of knowledge, because of their in-depth knowledge about TSS.

 

Evidence before this study

Menstrual toxic shock syndrome (TSS) is an uncommon acute illness that occurs in young women with vaginal colonization of TSST-1-producing Staphylococcus aureus and use tampons or other intra-vaginal devices.

 

There is evidence that women who use tampons or other intra-vaginal devices are at risk of menstrual toxic shock syndrome (TSS), with an incidence around 1–3 cases per 100,000 menstruating women.

 

Conditions necessary for menstrual related TSS development are:

• tampon use
• vaginal colonization by a TSST-1-producing aureus strain and
• the absence of protective antibodies against TSST-1.

 

These conditions are much more frequent than the incidence of menstrual related TSS, suggesting that only a minor subset of these predisposed women will actually develop TSS and that OTHER FACTORS ARE INVOLVED IN DISEASE OCCURRENCE, SUCH AS HOW TAMPONS ARE USED.

 

This nationwide, case-control study conducted in France with women that developed menstrual TSS and a control group supports existing evidence that differences in tampon use still contribute to the elevated risk of menstrual TSS.

 

To examine the relationship between tampon use and menstrual TSS in women between 12–30 years of age, a nationwide, case-control study was performed with incident cases in metropolitan areas of France.

 

Study included confirmed and probable cases involving tampons, and with symptom onset occurring within three days of the beginning or end of menses. Control participants comprised women with no past history of menstrual TSS, of 12–30 years of age, and who used tampons as menstrual protection They were enrolled between February 1, 2017 and December 31, 2017. Cases suspected of using only menstrual cups (one woman during the inclusion time) or controls suspected of using only pads or menstrual cups were excluded.

 

Applying our eligibility criteria, a total of 78 cases were identified from the CNRS database. Of the 78 cases contacted, 55 agreed to participate, yielding a 70% positive response rate. Cases were retrospectively contacted in February 2017 and asked to fill the questionnaire according to the use and knowledge they had before they developed the menstrual TSS. Healthy women nationwide were enrolled in the control population. This study was reviewed and accepted by the ethics committee.

 

For this study, the main exposure was tampon use. They relied on the usage precautions cited in the guidance document and the recommendations of the FDA. The variable “tampon use” was evaluated using the following criteria:

• use of tampon outside of menses,
• forgetting to remove a tampon before inserting a new one,
• using a tampon with an absorption level not matching the menstruation flow, and/or
• using a tampon for over 8 h.
• Additionally, it was decided to test the impact of wearing a tampon for over 6 h, which is frequently cited by practitioners.

 

Results

30 patients (55%) met the definition for confirmed TSS and 25 (45%) for probable TSS. Cases age ranged from 12 to 30 years of age, with a median age of 17.9 years. None of the patients had co-morbidities. Medical care in an intensive care unit was required for 47 patients (85%). No patient died from menstrual TSS.

 

Among the 55 cases, 14 (24%) reported using a tampon for over 8 h, and 34 (62%) for over 6 h during the day. The median duration of maximum tampon wear was 8 h. Tampon usage when planning to sleep > 8 h was reported by 40/52 cases (77%). Regarding absorbency choice, 23/53 cases (43%) indicated that they did not select a tampon with an absorption level corresponding to the intensity of their menstruation. Anticipatory use outside of menses was reported by 14 cases (24%), and 4 cases (7%) reported having forgotten to remove a tampon before inserting a new one. Concerning the level of knowledge about menstrual TSS, 19 cases (35%) had heard about menstrual TSS, and 13/54 (24%) knew that improper use of tampons could cause menstrual TSS.

 

Only 21 (38%) had received initial menstrual TSS education before their first tampon use. From this initial education, only 1/21 (5%) learned the early warning signs of menstrual TSS, and 1/21 (5%) learned what to do if these signs occurred. Mothers and other relatives were cited as the primary source of information by 40 cases (73%), followed by self-learning using media (internet, books, journals…) for 16 cases (29%). Only 7 cases (13%) reported having been educated by a health practitioner. Thirty-two cases (58%) had read the instruction form included in the tampon pack, and only 19 (35%) stated that they read and followed those instructions.

 

The 126 controls ranged from 13 to 30 years of age, with a median age of 18.0 years Twenty (26%) reported using a tampon for over 8 h, and 52 (41%) for over 6 h during the day. The median duration of maximum tampon wear was 6 h. Tampon usage when planning to sleep >8 h was reported by 65/120 controls (54%). Regarding absorbency choice, 41 controls (33%) indicated that they did not select a tampon with an absorption level corresponding to the intensity of their menstruation. Anticipatory use outside of menses was reported by 38 controls (30%), and 12 (10%) reported having forgotten to remove a tampon before inserting a new one.

 

Concerning the level of knowledge about menstrual TSS, 48 controls (38%) had heard about menstrual TSS, and 52 (41%) knew that improper use of tampons could cause menstrual TSS. Only 56 (44%) had received initial education before their first tampon use. From this initial education, only 4/56 (7%) learned the early warning signs of menstrual TSS, and 2/56 (4%) learned what to do if these signs occurred. Mothers and other relatives were cited as the primary source of information by 77 controls (61%), followed by self-learning using media (internet, books, journals…) for 35 controls (29%). Only 13 controls (10%) reported having been educated by a health practitioner. Ninety-eight controls (78%) had read the instruction form included in the tampon pack, and 73 (58%) stated that they read and followed those instructions.

 

Comparison between cases and controls revealed differences in median of maximum tampon-wearing time (8 h vs. 6  h), in the percentage having a maximum tampon-wearing time of >6 h (62% vs. 41%), and in the percentage using tampons during sleep >8 h (77% vs. 54%). Notably, cases were less likely to know the menstrual TSS risk of tampon use (24% vs. 41%), to have read the tampon instructions (58% vs. 78%), and to read and follow the tampon instructions (35% vs. 58%). No difference in educational level or socioeconomic status was observed between the two groups.

 

Education regarding tampon use was strongly related to tampon misuse; therefore, an in-depth analysis of tampon education was performed in the control population. With regards to the usage precautions cited in the guidance document and the FDA recommendations, women educated by their mothers and other relatives were only less inclined to use a tampon when they were planning to sleep (47% vs. 66%).

 

Women who read the instructions from a tampon package reported less frequent tampon use for >8 h (9.6% versus 32%) and during the night (47% vs. 75%). Women who indicated that they read and followed the tampon instructions reported a lower rate of tampon use for >8 h (9.6% vs. 25%) and of tampon use due to anticipation outside of menses (22% vs. 42%). In control population, education from a health practitioner had no impact on tampon proper use, nor did media access (e.g., websites, books, and journals). None of the reported education was associated with a better understanding of the link between tampon use and menstrual TSS.

 

Discussion

Findings suggest that menstrual TSS risk may increase starting at tampon use ≥ 6 h, rather than from 8 h, and that women could be advised to wear a tampon for a maximum of ≤ 6 consecutive hours rather than the currently recommended maximum of ≤ 8 h. Although prior studies have investigated the impact of tampon wearing duration on menstrual TSS occurrence, this topic has not been addressed recently, with the currently marketed tampon varieties. The conclusions of prior studies for maximum hours of tampon wearing time were mainly based on the number of tampons to use per day in patients and in vitro experiments. They were in close agreement with present findings. Results specify (in number of hours) when the risk increase begins and additionally support the current recommendation to use sanitary napkins or menstrual panties rather than tampons during the night, especially for women who sleep for more than 6 h.

 

Compliance of women with FDA recommendations and labelling instructions for tampon use are essential for menstrual TSS prevention. Yet, our present results indicated that while tampon wearing time recommendations are usually followed by women, in keeping with the findings of previous studies, a large majority of respondents did not follow one or more of the labelling recommendations. Study points out a persistent level of tampon misuse practices, and the need to promote safer tampon use.

 

The surveyed also revealed that women had a low level of knowledge about menstrual TSS. To date, few studies have investigated women’s knowledge of menstrual TSS, and many of the available studies were performed in the 1980s. In 1985, a survey reported a lack of knowledge regarding menstrual TSS among adolescents. Present findings suggest that this issue persists today and may be even more prevalent than previously reported.

 

Education on tampon use is still deficient in France. Most notably, it was observed that the majority of women did not receive initial education about tampons prior to use and this education was frequently disconnected to the risk of menstrual TSS. It is important that adequate menstrual hygiene habits be formed at the beginning of adolescence, as such habits will influence adult behaviours. To obtain knowledge about tampon use, adolescents frequently discussed the topic with their mothers or self-trained themselves by reading tampon labels, as previously described. However, the high level of misuse practices suggests that these learning modalities are likely insufficient to teach women about tampon use and menstrual TSS. It was discovered that health professionals were minimally utilized as sources of knowledge about tampon use, despite their in-depth knowledge about it and greater ability to influence behaviours by providing adequate information. Overall, our study results confirmed findings from earlier studies and the absence of progress. Education about tampon use still needs to be improved.

 

18.09.2020

 

 

[1] Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201028/