Can Menstrual Cups or Discs Cause Toxic Shock Syndrome?
Yes, menstrual cups and discs can cause toxic shock syndrome (TSS), though this is rare. Multiple case reports have documented TSS occurring with menstrual cup use, caused by toxin-producing Staphylococcus aureus colonizing the vagina 1, 2, 3.
Mechanism and Risk
TSS occurs when S. aureus bacteria colonizing the vagina produce toxic shock syndrome toxin 1 (TSST-1), which activates the immune system and can lead to multiorgan failure 1, 2.
The mechanism with menstrual cups appears similar to tampon-associated TSS, where the intravaginal device creates conditions favorable for bacterial toxin production 3.
While historically TSS gained notoriety as "tampon disease" caused by S. aureus exotoxins 4, the same pathophysiology applies to any intravaginal menstrual product that allows bacterial colonization and toxin production 1, 2.
Clinical Presentation
Patients present with sudden onset of high fever, hypotension (systolic BP ≤90 mm Hg in adults), and multiorgan involvement within the first 48 hours 4. Key features include:
Multiorgan dysfunction characterized by two or more of the following: renal impairment (creatinine ≥2 mg/dL), coagulopathy (platelets ≤100,000/mm³), liver involvement (transaminases ≥2x upper limit of normal), acute respiratory distress syndrome, generalized erythematous rash that may desquamate, or soft-tissue necrosis 4.
Additional symptoms include vomiting, diarrhea, and rapid progression to shock 5.
The case-fatality rate may exceed 50% 4.
Diagnosis and Management
Diagnosis is established through CDC case definition criteria and confirmed by vaginal culture growing S. aureus with evidence of TSST-1 2.
Prompt initiation of antibiotics (directed against S. aureus) and supportive care is critical 2.
Prophylactic intravaginal clindamycin may be considered to reduce recurrence risk 2.
Clinical Implications
TSS should be considered in any menstruating female patient presenting with fever, rash, hypotension, and current menses, regardless of whether they use tampons, menstrual cups, or discs 2. The absolute risk remains low, but the severity of the condition warrants awareness among both clinicians and patients using these products 1, 3.