At Ruby Cup, we believe that fear of the very rare condition called toxic shock syndrome (TSS) should not prevent you from enjoying all of the benefits of switching to a period cup. Our mission is to provide people with better periods. With the right information, you can learn how to have safer, healthier, and easier periods using a period cup, lowering your very small risk of toxic shock syndrome even further.

This article is written by clinician Amy Harris. Read more about Amy Harris at the end of the article.

What is Toxic Shock Syndrome (TSS)

TSS is a life-threatening infection caused by bacteria that usually live on your skin, nose, or mouth. These bacteria cause serious problems when they grow and increase in numbers deeper inside your body, like inside your vagina or bloodstream. In addition, the toxins or poisons these bacteria release into your bloodstream make you very sick very quickly.

Without quick treatment, these toxins can cause organs such as your liver, heart, kidneys to fail. People who are not treated quickly for toxic shock syndrome can have seizures (convulsions), bleeding, and may even die.

If you have any symptoms of toxic shock syndrome, you need to see your doctor or go to the hospital as quickly as possible. Untreated toxic shock syndrome is a medical emergency.

How common is Toxic Shock Syndrome?

Toxic shock syndrome is extremely rare. Out of 100,000 people with periods, less than one person each year will get TSS. It occurs most often among people between 15 to 25 years old who use tampons. You have a greater chance in your lifetime of dying in a bike accident or from being stung by a swarm of angry bees than of dying from toxic shock syndrome.

While all the medical information and numbers we described above may be alarming, it is important to put it all in perspective. Yes, toxic shock syndrome is a dangerous medical condition. But it is also extremely unlikely that you will get TSS using your period cup.

Can menstrual cups cause Toxic Shock Syndrome?

Yes, but very rarely. Studies of rates of TSS in menstrual cup users is still very new. Because TSS happens so infrequently in menstrual cup users, it will take a long time and lots of people who menstruate to switch to period cups to know how the risk of TSS with menstrual cups compares to tampons’ TSS risk. Nevertheless, medical experts agree that, although tampons and menstrual cups can cause TSS, they are safe period products. 

How do super-absorbency tampons cause TSS?

Bacteria may grow on tampons, especially if they are not changed often enough or you do not wash your hands before inserting them. Staphylococcus or Streptococcus bacteria are two types of bacteria found on your hands, skin, and outside your vagina (vulva). On the outside of your body, they can be relatively harmless, but both can cause TSS if they enter into your body through tampon or menstrual cup use, for example.

Super-absorbency tampons do a great job of delivering and trapping these bacteria in your vagina. Using period products such as tampons or menstrual cups can also deliver oxygen into your vagina. Bacteria and oxygen are two necessary ingredients for a TSS infection. Period flow also changes your vagina’s acidity (pH) to one that makes bacteria happier. 

Once this bacteria-friendly home is set up in your vagina, the bacteria may decide to take a trip through the mouth of your uterus (cervix) and venture up into your womb or uterus, causing a more serious infection. Tampons can also cause tiny cuts in the vagina through which bacteria can enter the bloodstream.

The kinds of tampons made in the 1970s and 1980s were much more likely to cause TSS. Research led to safer, less absorbent tampons made of different materials. Public education campaigns also taught people who menstruate to avoid using super tampons on low flow days and changing tampons frequently. The number of TSS cases dropped dramatically.

What are the symptoms of TSS?

Below are a few of the most common symptoms of toxic shock syndrome to look for:

• A sudden high temperature (above 102° Fahrenheit/38.9° Celsius)
• A rash all over your body that looks and feels like a bad sunburn or red dots
• Flu-like symptoms such as a sore throat, headache, cough, general aches
• Confusion, dizziness, or fainting
• Watery diarrhea, vomiting, or feeling sick to your stomach
• Difficulty breathing
• Redness in your eyes
• Peeling skin on the soles of your feet or palms of your hands

What should I do if I think I have TSS?

If you think you might have TSS, call your healthcare provider immediately. Toxic shock syndrome can become life-threatening very quickly, so you must be tested for TSS right away. Don’t sit at home wondering whether you should call your doctor or waiting to get sicker. Instead, let a medical doctor decide whether or not you could have TSS. Doctors diagnose TSS with blood tests, a vaginal examination, and testing your vagina and cervix for the bacteria that can cause TSS.

Do not wait to see if it will get better on its own. Instead, take out any menstrual products straight away. Always mention that you have been using a menstrual cup or tampon and if you have any cuts or boils in the vaginal area.

How can I prevent Toxic Shock Syndrome?

The same common sense tips for good period cup care you are probably already doing also keep you safe from toxic shock syndrome. To lower your risk for toxic shock syndrome:

• Wash your hands thoroughly before and after handling your menstrual cup 
• Empty your menstrual cup at least every 8 hours.
• Keep your nails clean and short to avoid scratching yourself when inserting your cup.
• Rinse your cup well inside and out every time you empty it (take a small bottle of water with you into the stall if you are in a public bathroom without individual sinks). 
• Disinfect your menstrual cup after every period. 
• Use menstrual cups for period flow only. Do not use menstrual cups for vaginal discharge.
• Wash your period cup storage bag regularly. 

Don’t use intravaginal menstrual products if you have had TSS. People who have had TSS once are more likely to get it again. If you have any type of skin infection near your vulva or skin in your genital area, wait until it heals before using your menstrual cup.

Will sanitizing my period cup lower my risk of Toxic Shock Syndrome?

Yes. While infection is much more likely to come from bacteria on your hands than on your cup, research shows that steaming your menstrual cup in boiling water for 5 minutes kills more of the bacteria responsible for TSS. We have made it even easier for you — Ruby Cup designed an easy-to-use, medical-grade silicone period cup sterilizer for you to use once a month at the end of your period. You can also purchase our effective period cup sanitizer with your first cups as part of the Ruby Cup Saver Pack.

With the correct information about safely using and cleaning your Ruby Cup, you can enjoy the full benefits of using a period cup without worrying about toxic shock syndrome. While TSS is serious, it is rare and fully curable if diagnosed and treated early. At Ruby Cup, our innovative, body- and planet-friendly period cup impacts lives. We are here to help you have better and safer periods. If you have more questions concerning TSS and menstrual cups, please contact us at rubycares@rubycup.com.

Toxic Shock Syndrome and Menstrual Cup FAQ’s

What is Toxic Shock Syndrome (TSS)?

Toxic shock syndrome is a rare but life-threatening infection caused by certain bacteria. These bacteria can infect people who menstruate and use period products such as tampons, menstrual cups, and discs. Only about half of all cases of toxic shock syndrome occur in people who menstruate. Toxic shock syndrome is treatable and curable if diagnosed right away.

Can you get Toxic Shock Syndrome using a menstrual cup?

Yes, you can get toxic shock syndrome if you use a menstrual cup. However, TSS happens very rarely — out of 100,000 people who menstruate, less than one person per year will get TSS. Washing your hands before inserting and removing your period cup, changing your period cup every 8 hours, and sanitizing your period cup at the end of your menses will lower your risk for TSS even more.

Which period products can cause TSS?

Any period product inserted into the vagina can cause TSS — tampons, menstrual cups, and menstrual discs. Contraceptive sponges and diaphragms for birth control can also cause TSS. As you try to decide whether tampons or menstrual cups are better for you, consider that the risk of menstrual cups causing TSS is extremely low when used and cleaned correctly.

How soon do toxic shock syndrome symptoms appear?

TSS symptoms appear suddenly, usually about two days after the bacteria infect your body. Very quickly you will start to feel very unwell. It is important to contact your doctor or be checked out by a healthcare provider as soon as the first symptoms start.

How is toxic shock syndrome treated?

People diagnosed with TSS need to be hospitalized to receive medicines to kill the toxic bacteria (antibiotics) through an IV directly into their bloodstream. The hospital is the safest place for people with TSS because it can be so dangerous. Hospitals also treat TSS patients with intravenous (IV) fluids and other medications to raise their blood pressure if it is low.

Are there any menstrual products with low Toxic Shock Syndrome risk?

There is not enough data yet to know for sure whether menstrual cups have a lower risk of causing TSS in menstruating people than tampons. What matters most is that there is a very low risk of TSS with any menstrual product inserted into the vagina (cups, discs, tampons) and that you can lower your risk by taking steps to avoid infection such as:

• Wash your hands before inserting and removing your cup
• Properly clean your menstrual cup
• Wear your Ruby Cup for 8 hours or less, rinse the cup with cold water inside and outside, then you can reinsert

Written by Amy Harris. 

Amy Harris is a certified nurse-midwife with more than a decade of clinical experience in reproductive health clinics, hospitals, and private OB/GYN practices. Amy holds a Masters of Science in Maternal and Child Health from Harvard School of Public Health and completed her nursing and midwifery training at Yale School of Nursing and Boston University School of Public Health. Passionate about empowering women through health education, Amy puts her public health training to work as a dedicated women’s health writer.