tampon possible. But, without accurate labeling, this advice rang hollow. How to educate women and protect them from contracting TSS became a contentious labeling issue because corporations were not forthcoming with material ingredients, product absorbency, or a clear warning about TSS. To help women make informed decisions, feminist health advocates sought to provide science-based information about tampon absorbency rates, implement federal standards for descriptions such as “regular” and “super,” and also lobby for legislation demanding that tampon material contents be labeled on the box. In particular, Esther Rome of the Boston Women’s Health Book Collective (BWHBC) imparted feminist-minded standards challenging androcentric methods and models of the lab that determined these absorbencies, exemplifying why science and scientists must be accountable to communities and not just corporate data production.
The book concludes by examining the results and consequences of the bacteriological, technological, medical, journalistic, legal, and political influences on current-day understandings of TSS in the contemporary United States. Most are aware of controversies of hormonal birth control or the questionable safety of breast implants. However, the history of federal regulation of personal hygiene products, and activists’ efforts to improve safety, arguably touched more women than these other more familiar stories. Significantly, the actions of labeling tampon boxes, providing information about material and chemical content, and offering more understandable warnings about TSS remain incomplete. Congresswoman Carolyn Maloney (D-NY) first introduced the Tampon Safety and Research Act in 1997, reintroducing it again in 2003, 2005, 2008, and 2011, to no avail. On May 28, 2014, Menstrual Hygiene Day, she again proposed it as the renamed Robin Danielson Act regarding tampon safety, in recognition of Danielson’s death due to TSS in 1998 at age forty-four. The bill seeks further research into the chemical composition of tampons, additives, and their relationship to TSS since potential health hazards are not well researched or understood. This book supports the rationale for federal regulation and the need for transparent content labeling.
Contemporary Scientific Explanations
Current understandings about TSS are contested and evolving; moreover, succinct recommendations are difficult to crystallize. One hypothesis is that tampons alter the vaginal environment. Michael Osterholm, a Regents Professor at the University of Minnesota, who worked as an epidemiologist at the Minnesota Department of Health during the late 1970s and 1980s, specifically studied different brands of tampons and the relationship of absorbency to TSS. His studies identified higher absorbency tampons and their ability to hold oxygen within the otherwise anaerobic vagina as the key element in promoting toxin production.16 For Osterholm, the oxygenation made all the difference in providing an ideal environment for the S. aureus bacterium to grow. In my interview with him he recalled that many news reports stated that TSS was related to poor hygiene, and therefore the advice was to change tampons frequently. This, he said was wrong. The fresh tampons simply brought in more air, thus fueling the toxin production once it got rolling. His research pointed to all superabsorbent tampons, in which Rely was only one example, boosting the risk for TSS from three-fold to nearly ten-fold as absorptive capacity increased.17
Where Osterholm saw gradients in tampon absorbency as significant, others focused on the material composition of superabsorbent tampons, especially the all-synthetic design of the Rely tampon. Philip Tierno, a microbiologist, contends in his 2004 book The Secret Life of Germs that there were three major factors promoting TSS in women who used noncotton tampons and, in particular, Rely. First were the synthetic components of Rely, consisting of foam cubes and the gelling agent carboxymethylcellulose encased in a polyester pouch. Tierno suggests that the gelled carboxymethylcellulose in essence acted like agar in a petri dish, providing a viscous medium on which the bacterium could flourish. Along with this, the foam cubes offered increased surface area for rapid growth. Second was the changing pH of the vagina during menstruation, to about 7.4. The optimal pH for S. aureus to trigger TSS is 7, or neutral. The relatively acidic, nonmenstrual vagina measures a pH of about 4.2, which keeps S. aureus well in check. Tierno also supported Osterholm’s claim that a tampon introduces air into the usually anaerobic vagina, changing the environmental conditions. Finally, the pyrogenic toxins produced by S. aureus induced fever in humans. This fever of about 102 degrees proved to be the perfect temperature for S. aureus to reproduce and thus create further deadly toxins.18 An additional factor was a woman’s age; many adults had built up immunity to S. aureus and possessed the toxin antibody, while young women and teenagers were more susceptible without a developed immune response. As a result, TSS had a range of presentations from mild flu-like symptoms to literal septic shock.
Even in a recent 2016 interview in People magazine, JoAnn Pinkerson, a professor of obstetrics and gynecology and director of the Midlife Health Center, University of Virginia Health System, discussed how TSS can develop, but not its relationship to tampons. She deconstructed a four-step process of the illness in an attempt to simplify the explanation. The first step “is vaginal colonization with a strain of S. aureus, which can make the toxin,” and not all S. aureus strains do. The bacterium then produces the toxin, and enough must be produced to penetrate “across the vaginal epithelium.” Once this toxin leaves the confines of the vagina and enters the bloodstream, the illness requires “a lack of adequate titers of the neutralizing antibody to the toxin.”19 Though this description helps to explain the mechanism, it does not address the important variable of a tampon used to absorb menstrual fluid and its place within the chain of events leading to TSS. Furthermore, this is still not well comprehended by most women.
Patrick Schlievert, a microbiologist and head of the Microbiology department at the University of Iowa who studied S. aureus and TSS from the very beginning, argues that the particular strain that produced TSST-1 happened to gain traction about the same time that superabsorbents were marketed to women, so that the illness was coincidental.20 This strain made the difference in the presentation of illness, and not necessarily the components of the tampon. In an email conversation with him, he described S. aureus as tremendously adaptive, as a “facultative bacterium.” A facultative bacterium is quite resilient and able to assess changing environmental conditions. He explained, “It has oxidative metabolism for aerobic growth and fermentation for anaerobic growth,” meaning it can still produce its own energy in either aerobic or anaerobic environments. S. aureus can potentially grow in both, but it really flourishes when oxygen is present, introduced in this case by a tampon. In addition, the normally fluctuating pH of the vaginal ecosystem affects bacterial inhabitants, and S. aureus thrives in the less acidic menstrual medium and the newly oxygenated environment provided by a tampon. To add more variables, he explained that different bacteria such as a healthy population of lactobacilli interact with the body and affect vaginal pH levels as well, possibly holding S. aureus at bay during the nonbleeding weeks of the menstrual cycle, or prompting flare-ups during menstruation.21 The last element adding to the virulence of TSS is the powerful toxin, TSST-1, characterized as a protein and superantigen that disrupts and overactivates the immune system.22
In light of such a multifactored process with a menstrual management technology, and scientists’ differing explanations of it even now, it is no wonder confusion and justifiable fear reigned in the late 1970s and throughout the 1980s. Manufacturers currently recommend that women use the least absorbent tampons possible and change them often. This seems sound, yet tampons do not directly cause TSS per se, and limited use will not necessarily prevent the illness. And it is the toxin, not even the presence of the bacterium, that ultimately generates the symptoms. The only way to really prevent TSST-1 production is to avoid S. aureus altogether, which is impossible.
In addition, women are not usually tested to see if they have the antibody to the TSS toxin, which would indicate immunity. Without this antibody, a previous and recovered encounter with TSS indicates increased risk for its virulent expression the second time around, possibly leading to autoimmune issues for some women. Testing for the antibody may help point both to women who are more resilient to the toxin and to those who would need to steer clear of tampons.23 Instead, manufacturers rely on informed women knowing the signs and symptoms of TSS, which are deceptively similar to the common cold and difficult to discern as life threatening. This explains not only my generalized concern as a young teenager about contracting TSS, but also the
