So your tampon's out of sight, out of mind ... right? Maybe it shouldn't be. Tampons have been around for almost 70 years, but it wasn't until the addition of synthetic chemicals and the discovery of toxic shock syndrome (TSS) that researchers began to question their safety. In doing so, they've pulled the plug on possible health risks.
Dr. Ilya Sandra Perlingieri, retired professor from San Diego State University and author of the recently released The Uterine Crisis , said women who read the risks of tampon use off the side of a box aren't getting the full story.
"This book is important because we don't get the information," she said. "After literally seeing every woman I know with troubles and tampons being sent out to teenagers...I want to get the word out so women are safe.
"It's a silent crisis," she said. "Chemicals in tampons are invisible and we don't know specifically what pesticides are. Most people do not read medical journals...I've done the research. It's all in the footnotes. I want women to be informed. I'm tired of seeing every single woman I know with serious uterine troubles that we just didn't have [before]. I'm on a mission."
Tampon manufacturers like Procter & Gamble (P&G), however, maintain that tampons aren't the only risk factor associated with cancer, endometriosis and other vaginal problems. And so the debate continues.
Who should women believe?
The string of events
To get a better idea of possible risks, Dr. Philip M. Tierno, Jr., director of clinical microbiology and diagnostic immunology at New York University Medical Center and Mt. Sinai Medical Center in New York City and author of The Secret Life of Germs: Observations and Lessons from a Microbe Hunter , offered his perspective on the history of TSS based on what he discovered in his research.
Tierno studied tampons to get a better understanding of why so many women were being diagnosed with TSS.
"My work really centered on what had changed in [women's] lives in 1980 and before then," he said. "It was the tampon that had changed.
"Most tampons prior to 1977 were made of cotton," he added. "Post-1977, many manufacturers were trying to address a complaint that women were suffering from menstrual byproduct. Women wrote in, saying, 'make the product more absorbent.' "
Manufacturers turned to synthetic ingredients to improve the absorbency of tampons.
"[Companies] had to use synthetic ingredients other than cotton," he said. "They succeeded in making a product that was very absorbent. But the vagina was affected by synthetic products and not the cotton."
Synthetic ingredients included polyester, polyacrylate rayon, carboxymethylcellulose and viscose rayon. "Those were the four synthetic ingredients used with cotton in various permutations," said Tierno.
Tierno realized it was the synthetic ingredients, and not the cotton, that increased the presence of a toxin that causes TSS.
"My discovery centered on what effect these [four ingredients] had on the Staph[ylococcus] aureus [bacterium capable of producing a toxin that can cause illness]," he said. "Its effect amplified [the amount of] TSS toxin produced. To a greater or lesser degree, each of these ingredients amplifies the toxin that brings about TSS, whereas cotton did not."
He said companies tried to blame women for the rise in TSS.
"Of course manufacturers denied that this occurred," he said. "They said it wasn't the fault of the tampon, but, rather, the fault of the women. They tried to cover their own product."
The removal of three out of four of the synthetic ingredients proved to Tierno that what he discovered about the ingredients was true.
"More and more evidence accumulated that I was right," he said. "By 1985, some of the synthetic ingredients were taken out of tampons (polyester, polyacrelite rayon, and carboxymethylcellulose). Viscose rayon, the least problematic of the four, was still in tampons."
Tierno said that tampons are still made with viscose rayon, which can cause TSS.
"To this day, tampons are made of cotton with or without viscose rayon--or should I say the opposite [that viscose rayon is made with or without cotton]?" he said. "Viscose rayon is less absorbent than the others but can still cause TSS."
He said there are various reasons why TSS does not occur at such a high rate today as it did in the 1980s.
"It still occurs, but there's not as great of a risk for three reasons: one, the three worst ingredients were taken out; two, the absorbency of tampons was cut in half; three, women are intelligent with tampons -- they use different absorbencies and with the first sign of a problem, they go to a physician," he said. "And physicians are more aware of TSS [than they were in the past]."
Tierno continues researching tampons today. "I'm still trying to eliminate viscose rayon," he said.
Elaine Plummer has worked at P&G -- makers of Tampax and Rely -- for 22 years and before then as a clinical nurse for 10 years. "I'm a registered nurse, so I understand the concerns women have with their bodies and their health and I have a strong commitment to women's health."
Plummer said TSS can occur whether tampons are made of cotton or rayon.
"TSS is related to all tampon use, whether they're made from rayon or cotton," she said. "One of the concerning things is if women believe they're not at risk for TSS if they use an all-cotton tampon."
She said deaths related to TSS should not occur because of our awareness of it.
"No one should have to die from TSS," she said. "TSS is a very rare disease, fortunately, the symptoms are recognizable, and it's treatable."
So what are tampons really made of? Are their ingredients harmful to women?
What's in your tampon?
Tampons are made of a variety of ingredients, Perlingieri said.
"Tampons are not just cotton," she said. "They are made of dyes, fragrances, super-absorbent chemicals."
She said research has found a link between uterine problems and bleached tampons.
"In the last 25 years, millions of women--teens through women in elder years--have uterine-related troubles," she said. "Part of the trouble we know from research is directly related to bleaching of tampons."
Chlorine from bleach eventually turns to dioxin, Perlingieri said.
"All tampons are bleached with the exception of two companies," she said. "Chlorine, whether in laundry, swimming pools, or in tampons, breaks down into a deadly chemical called dioxin."
"Dioxin is one of the most dangerous chemicals on the planet and literally a tablespoon [of it] would kill everyone on the planet," she said. "It's so deadly."
Jill Wood, an instructor in Penn State's women's studies department who received her master's degree studying menstruation and menstrual health, said she does not use tampons as a precaution for her health and safety.
"I don't use commercial tampons," she said. "I don't think the health risks are reasonable. I also eat organic food. Pesticides and dioxins are not safe in food or tampons."
She said tampon companies underestimate the effects of dioxin.
"Tampon manufacturers say that [tampons] are safe and levels of dioxin are so low that they are almost undetectable," she said. "[That may be] true, but we only need a small trace amount for dioxin to do damage. It accumulates in our bodies over our lifetime and it's not something the body can ever get rid of. Ingesting it in food is one thing, but putting it in vaginas is another."
Tierno said chlorine bleach, while safer than other bleaches, is not safe in respect to the large amount of tampons women can use in their lifetime.
"The chemical used to bleach tampons, chlorine dioxide, is better than chlorine bleaches used previously," he said. "Even in small amounts, it is no good and many women use tampons throughout their lives. This is quite significant."
Perlingieri also believes dioxin is unsafe because women use a lot of tampons.
"Women use 11 to 12,000 tampons over their life cycle ... maybe more with teens using them," she said. "All that dioxin going into a woman's bloodstream and all those fibers wandering around in a woman's body--that's part of the toxic brew. Tampon companies have known for decades that the ingredients in products are not safe."
Tierno said companies need to show people data proving their products are safe.
"Is chlorine dioxide better?" he asked. "Manufacturers say, 'yes,' and chemically, it is. There is probably less dioxin, but they have to prove that and show individuals with data. They have not done that as far as I know. It needs to be brought to the attention of consumers that use their products. More studies need to be done."
Tampax tampons do not contain dioxin, Plummer said.
"There's a lot of discussion as to how [tampons are] made and manufactured," she said. "Ours goes through an elemental chlorine-free process and doesn't result in dioxin. There is no dioxin in the process. It's been an industry standard for many years."
Wood said another reason there are many chemicals in tampons is because of how rayon is made.
"Rayon is a whole other problem," she said. "It's made from wood pulp and during the process of converting wood to rayon, hundreds of chemicals that are used are imbedded in tampons."
Pesticides have been around for a long time and are still used today. In fact, Perlingieri said, most people are exposed to anywhere between 87,000 and 100,000 chemicals, most of which are untested.
Tampax maintains that its cotton goes through a process that eliminates any impurities.
"The cotton goes through a purification process also," Plummer said. "The cotton used in tampons doesn't have pesticide residue and cotton and rayon are equally safe materials. The bleaching process helps assure that there aren't any pesticides."
Perlingieri also believes a lot of tampon manufacturers use genetically modified cotton, which resists the effects of antibiotics.
"The latest research has said genetic cotton used for tampons confers resistance to antibiotics," she said. "That means since in the U.S. we have the highest rate of STDs [sexually-transmitted diseases] in the world, that anybody that uses tampons that are genetically modified with cotton and who also have any STD may not respond to the antibiotics."
Do cotton fibers come off of tampons and stay in the vagina after tampon removal? If so, do these fibers adversely affect women's health?
If these (vaginal) walls could talk...
Fibers remain in the vagina after a tampon is removed, Tierno said.
"Fibrous material is left behind," he said. "There are little particulates that come off. Fluid discharge is part of normal movement of the material. Some [fibers are] eliminated with it, but some [are] not."
Wood suggests students set up an experiment to see how easily fibers come off of tampons. Take a glass of warm water, she said, and put a tampon in it. "[Keep it in the glass] as long as you would leave a tampon in[side your vagina]," she said.
After you remove it from the glass, observe all the fibers that remain. "Are you willing to risk having all of those fibers inside of you?" she asked.
Even worse, Wood said, are the fibers left behind in the process of removing the tampon.
"You're pulling a tampon out through such a tiny hole and it's rubbing against the sides of the vagina," she said. "This is another reason why it is important to use the correct absorbency level. With the combination of high absorbency and decreased flow of menstruation, the risk increases for leaving fibers behind during tampon removal."
This can lead to the formation of ulcerations, Wood said.
"Ulcerations are caused by the combination of the chemicals [in tampons] and the tampon being dry when coming out of the vagina," she said. "The chemicals are almost eating away at the vaginal tissue. This is also why you should not use an absorbency higher than necessary."
These ulcerations can increase a woman's risk for STDs, said Wood. "Ulcerations put you more at risk for STDs by creating little portals to the bloodstream," she said.
Tampax maintains that fibers usually do not remain in the vagina and even if they do, the tampon's ingredients are safe. "Fibers that remain are washed out in the normal cleansing process of the vagina," Plummer said. "And ingredients Tampax are made of are not harmful to the body at all."
If it's possible for tampons to cause ulcerations, is it possible that tampon usage can lead to diseases later on in a woman's life?
Unwrapping the Myths
Perlingieri believes tampons are one of the reasons for increasing vaginal problems.
"We now have staggering rates of endometriosis, fibroids, PID [Pelvic Inflammatory Disease], TSS and 1.7 million hysterectomies performed this past year--the most [ever]," she said. "Twenty-five years ago, these were rare illnesses for women."
But Tampax tampons have been used safely for a long time and that tampons are no longer associated with cervical cancer, Plummer said.
"Tampax has been used by women for over 65 years, from women around the world," she said. "For a while, tampons were blamed for cervical cancer. There's information now that it's caused by a virus and we have the Pap test to help diagnose if a woman has it."
She said there are various reasons why women get cancer and endometriosis, and tampons are not the only risk factor.
"Endometriosis hurts, is painful, and can impact on a woman's ability to have children," she said. "Some women maybe believe it's caused by tampons. But it's related to a lot of other things like diet, stress, and age of child bearing."
What's the story behind Rely tampons?
A Dry Run
Plummer said Procter & Gamble removed Rely from shelves as TSS became a prevalent issue.
"Rely Tampons were introduced in 1974," she said. "In the mid-80s, there was an increase in TSS cases. Procter & Gamble voluntarily removed it from the market."
She said Rely was recalled as a precaution. "At that time P&G fully complied with the marketing of Rely," she said. "All ingredients went through extensive safety testing in leading labs ... to be sure the product was safe to use. At the time we withdrew, it was the only responsible action to take. There was an increase in reported cases and a lack of scientific evidence."
In 1993, Penn State alumna Alecia Swasy, then writing for The Wall Street Journal, published Soap Opera, a book about what went on behind the scenes at P&G. Swasy wrote the book based on interviews of then current as well as former P&G employees.
The book offers several examples of P&G failing to inform women about the risks of tampons with such a high absorbency level. In one instance, Swasy said a man whose wife died of TSS soon after using Rely tampons read in court a memo between P&G employees electing not to provide warnings on tampon boxes. They were worried such warnings were premature and would scare the public.
Plummer said some of the book's information about Rely is inaccurate.
"[Soap Opera] says we ignored early signs--absolutely not true," she said. "Rely and its components were tested a decade before it came out. And the FDA [Food and Drug Administration] approved of it. TSS was rare and not known of at the time."
There was no scheme behind Rely and its ingredients, Plummer said.
"What happened with Rely was handled responsibly," she said. "TSS was not even discovered before that time. It wasn't a conspiracy or anything like that. It's unfortunate that there are things written that don't really tell the truth and commitment of people that believe in the safety of the product."
And TSS still exists today, Plummer said, years after Rely was taken off shelves. "[TSS is] still around today, even when Rely was removed, and that's why it's important for everyone to know it's still around."
Whether or not Rely played a role in the incidents of TSS that occurred while it remained on store shelves, who would be to blame for allowing the product to be marketed in the first place?
To Rely or not to Rely
Perlingieri said many were aware of dioxin's harmful effects.
"The companies know it, the FDA knew it, and they have basically omitted this from reports on tampons and I believe it's intentional," she said. "If we don't know information, we can't act on it."
The public, she said, is not aware of any of this because information is not publicized.
"There has been a revolving door policy between government agencies and most businesses for decades," she said. "Because of that, a lot of information is not available. It's not reported. People are uninformed. The companies don't have to list the ingredients and they don't."
Perlingieri believes that companies are motivated by money and are not concerned for the welfare of their customers.
Because of this, Wood said, women should make sure products are safe before using them.
"I don't know how they can say it's safe," she said. "They owe it to women that spend money on their products to show definitive research that it's safe. If they don't have definitive evidence that it's safe, you shouldn't use it until they can prove they're safe. It's not a malicious intent, but [companies] have vested interest in women buying their products."
She said manufacturers lead customers into believing products are reliable.
"I think [companies] have an interest in wanting people to think their products are safe," she said. "They've looked at research, but don't have to show tampons are safe. They say their tampons are as safe as others. That's like saying, 'Marlboro Lights are as safe as Camel Lights.' "
In fact, the FDA doesn't do research, but rather, merely reviews what is presented to them, Tierno said.
"The FDA is only going on the basis of evidence that accumulates," he said. "They don't do research, themselves, to prove something. They go on the body of evidence before them. A device has to go under certain amounts of scrutiny. Tampons used in 1933 in America were originally cotton. It wasn't until manufacturers started messing around with ingredients circa 1976 and 1977, amplifying their ingredients."
Plummer said the FDA provides information on its Web site about tampons.
"The FDA regulates the safety of [tampons]," she said. "They regulate the safety of the data. They have information on their Web site about tampon safety."
She also questioned the motivation behind other people's research.
"There's a lot of information from people out there who are concerned from their own perspective," she said. "Maybe they have had a medical issue. But this misleads women about health problems."
Plummer said tampons have changed greatly over the years.
"Since 1980 [when Rely was taken off shelves], lots has changed in the marketing of tampons," she said. "Back then, there were not consistent absorbencies. For example, super absorbency in one company could be another level of absorbency for another. Today there are certain standard weights for each level. These are standard across all companies."
A regular tampon holds about 6 to 9 grams of fluid, a super absorbency tampon holds 9 to 12 grams of fluid and a super plus absorbency tampon holds about 12 to 15 grams of fluid, Plummer said.
Tampax maintains that it doesn't sell unsafe products and that workers meet often to discuss their products.
"Importantly, we have a scientific advisory board made up of external experts in all the key areas necessary in understanding TSS," Plummer said. "They meet with us regularly to go over research that they're doing to help us understand and give feedback on what we're doing. Dr. James Todd, who discovered TSS, is on our board, as well."
Plummer's daughter even uses Tampax tampons.
"On a personal level, I wouldn't let my daughter use them if they weren't safe. That's bottom-line assurance."
So how can women stay safe if they choose to use tampons?
Not ready to go with the flow?
Wood offered tampon users tips to avoid health complications.
"If you still want to use tampons, stay safe. One, don't use ones with deodorant; two, use only the absorbency you need -- for example, don't use super-plus on a light day; and three, change them as often as possible to avoid the risk of TSS."
Women should also consider using alternatives to mainstream tampons, Wood said.
"Organic tampons are even better," she said. "There are no pesticides used to grow the cotton and no rayon, which commercial tampons have."
She also said that they are not bleached, "Also, they don't bleach with chlorine."
Perlingieri believes it is unnecessary to use feminine products with deodorant. "Who needs the uterus deodorized?" she asked. "It has a natural ph and the chemicals alter the natural ph."
She said the deodorant's ingredients may not even be listed on the product's packaging.
"Companies are not required to put down what's in it," she said. "Sometimes it just says, 'fragrance.' If I was 20 [years old] and I knew this information, I would never use these products again....Where are the ethics?"
People should be careful about what they use, Wood said.
"Environmentalists use something called the 'precautionary principle,'" she said. "This means if you don't know how harmful something is, then err on the side of caution."
Consumers should be smart shoppers, Tierno said.
"Don't think the FDA is going to do your homework," he said. "The consumer has to do investigation of its own. Use products in particular needs of lifestyle and alternate with pads. The vagina was meant to be an open, draining space."
Wood said people should be more aware of the effects of the products they use.
"In my classes, when the students realized the risks of using tampons, they freaked out, asking, 'Why didn't I know this before?'" she said.
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