Toxic Shock Syndrome (TSS)

11 min read
Illustration of Staphylococcus bacteria associated with toxic shock syndrome

If you think you have toxic shock syndrome (TSS), call triple zero (000) and ask for an ambulance, or go to your nearest emergency department.

If you're using a tampon, menstrual cup, disc, sponge or diaphragm, remove it if you can do so promptly. Don't delay getting emergency help if the product is difficult to remove.

Toxic shock syndrome (TSS) is a rare but serious illness caused by toxins produced by certain bacteria. It can develop quickly and affect several organs.

TSS has been strongly associated with tampon use and rare cases have also been reported with menstrual cups. However, TSS can occur without a period or any menstrual product. Anyone can develop it, including children and men.

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What are the symptoms of toxic shock syndrome?

TSS symptoms often start suddenly and can worsen quickly. They may initially feel similar to flu or another infection.

Possible symptoms include:

  • a sudden high temperature
  • vomiting
  • diarrhoea
  • dizziness or fainting due to low blood pressure
  • headache
  • muscle aches
  • confusion
  • a red rash that can look like sunburn

Symptoms of toxic shock syndrome including fever, vomiting, diarrhoea, dizziness, confusion and rash

Not everyone will have every symptom, and many of these symptoms can occur with more common illnesses. The concern with TSS is that someone can become seriously unwell very quickly.

If you have symptoms that make you concerned about TSS, particularly while using an internal menstrual product or during or soon after your period, don't wait to see whether they improve.

Call triple zero (000) or go to an emergency department.

Remove the internal product if you can do so promptly, but don't delay seeking emergency care if removal is difficult.

Tell the healthcare team which product you were using and approximately when it was inserted.

You can also read healthdirect's toxic shock syndrome information and the Better Health Channel TSS guide.

What causes toxic shock syndrome?

TSS happens when certain bacteria produce toxins that trigger a severe immune response.

The bacteria most commonly involved are:

  • Staphylococcus aureus, commonly called staph
  • Streptococcus pyogenes, or group A strep

These bacteria can normally live harmlessly on the skin, in the nose, groin or vagina. TSS occurs only in rare circumstances when toxin-producing bacteria lead to a severe reaction in the body.

Menstrual TSS has mainly been associated with toxin-producing Staphylococcus aureus.

TSS can also develop following other bacterial infections, including an infected:

  • cut or wound
  • burn
  • boil
  • surgical wound
  • vaginal birth or caesarean birth

Healthdirect notes that menstrual TSS occurs more often in people aged 13 to 24, while non-menstrual TSS is more common in older adults with certain health conditions.

TSS is caused by bacterial toxins. Menstruation itself doesn't cause toxic shock syndrome.

Can tampons, cups, discs and sponges cause TSS?

Internal menstrual products differ in how much evidence we have about TSS.

Tampons

Tampon-associated menstrual TSS is well documented, although TSS remains rare.

The illness is caused by bacterial toxins rather than by the tampon itself, but leaving a tampon in for too long can create conditions that make bacterial growth more likely.

Using a higher absorbency than you need is another avoidable risk factor.

Choose the lowest tampon absorbency that manages your flow and follow the instructions supplied with the product. Read our guide to choosing tampon absorbency.

Menstrual cups

Rare cases of TSS have been reported with menstrual cup use.

A 2019 systematic review and meta-analysis published in The Lancet Public Health included 43 studies involving 3,319 participants and identified 5 reported cases of TSS associated with menstrual cup use.

The researchers couldn't calculate how common TSS is among cup users because the total number of people using menstrual cups wasn't known. The review therefore doesn't tell us whether menstrual cups carry a higher or lower TSS risk than tampons.

In Australia, the Therapeutic Goods Administration requires menstrual cup manufacturers to provide a maximum wear time of no more than 12 hours.

This doesn't mean every cup should always be worn for 12 hours. Some manufacturers specify shorter wear times and your flow may mean you need to empty the cup sooner.

Always follow the instructions supplied with your particular cup.

Read more in Are menstrual cups safe? What the science says.

Menstrual discs

Menstrual discs have been studied less extensively than tampons and cups, so a lack of reported TSS cases shouldn't be interpreted as proof that there is no risk.

Unlike menstrual cups, there isn't one Australian 12-hour regulatory wear limit that applies to every menstrual disc. Wear times are product-specific.

Follow the instructions supplied with your particular disc, including its maximum wear time and cleaning guidance.

Menstrual sponges

Evidence about TSS and menstrual sponges is limited.

Natural sea sponges, synthetic reusable sponges and purpose-made single-use sponge products aren't interchangeable, so their cleaning, replacement and wear-time instructions may differ considerably.

Follow the directions supplied with the exact product you're using rather than applying menstrual cup cleaning or wear-time guidance to a sponge.

Read our guide to using a menstrual sea sponge safely.

Diaphragms

Menstrual TSS has also been associated with contraceptive diaphragms. Follow the insertion, removal and maximum-use instructions supplied with your diaphragm.

External period products

Period pads and period underwear sit outside the vagina and don't carry the recognised menstrual TSS association seen with tampons and menstrual cups.

TSS can still occur for unrelated reasons such as wounds, burns, surgery or other bacterial infections.

Browse our cloth pads and liners or compare period care options in the Menstrual Products Comparison Hub.

How can you lower your TSS risk when using period products?

Good product hygiene and following wear-time instructions can reduce avoidable risks, although no routine can make the risk of TSS zero.

If you use tampons

  • Wash your hands before and after inserting or removing a tampon.
  • Use the lowest absorbency that comfortably manages your flow.
  • Change the tampon regularly and follow its packaging instructions.
  • Healthdirect advises changing a tampon every 3 to 4 hours or when it's full and never leaving one in for longer than 8 hours.
  • Never insert more than one tampon at a time.
  • Use tampons only during your period.
  • Remove the last tampon at the end of your period.
  • If you're likely to sleep for more than 8 hours, choose an external product overnight instead.

If you use a menstrual cup

  • Wash your hands before insertion and removal.
  • Empty the cup according to its instructions or sooner if it becomes full.
  • Don't exceed the manufacturer's stated maximum wear time.
  • Clean and sanitise the cup according to the manufacturer's instructions.
  • Inspect the cup regularly and replace it if the manufacturer recommends it or if the product becomes damaged.

If you use a menstrual disc

  • Wash your hands before insertion and removal.
  • Follow the maximum wear time supplied with your specific disc.
  • Remove or empty it sooner if your flow requires it.
  • Clean reusable discs exactly as their manufacturer directs.
  • Never wash and reuse a product labelled single-use.

If you use a menstrual sponge

  • Use a traceable product intended for menstrual use.
  • Inspect a reusable sponge before each insertion.
  • Follow the supplier's wear-time, cleaning, drying and replacement instructions.
  • Don't assume boiling, steaming or other cleaning methods intended for silicone cups are suitable for a sponge.
  • Never reuse a sponge labelled single-use.

Our guide to how long you can wear a menstrual cup or disc explains why a maximum wear time shouldn't automatically be treated as a target.

What if you leave a tampon or cup in too long?

Going past a product's recommended wear time doesn't mean that you have TSS.

Wash your hands and remove the tampon, cup, disc or other internal product as soon as you can do so comfortably.

If you can't remove it easily, don't use tweezers or another object inside the vagina. See a doctor for help.

Healthdirect recommends medical assessment for a retained tampon or other vaginal object if you can't remove it yourself or you develop symptoms such as:

  • unusual vaginal discharge
  • a strong or unpleasant smell
  • itching
  • redness or swelling
  • pelvic pain

See healthdirect's retained tampon guidance or our guide to what to do if your menstrual cup is stuck.

If you have a retained internal product together with fever, rash, dizziness, confusion, muscle aches, diarrhoea, difficulty breathing or other symptoms that make you concerned about TSS, seek emergency care immediately.

How is toxic shock syndrome treated?

TSS needs treatment in hospital.

Treatment usually includes antibiotics for the underlying bacterial infection. Depending on how unwell someone is, treatment may also include:

  • fluids through a drip
  • medicines to support blood pressure
  • oxygen
  • intensive care
  • surgery to treat severely infected tissue in some cases

Early diagnosis and treatment are important because TSS can affect multiple organs and become serious quickly.

TSS can occur again. If you've previously had toxic shock syndrome, speak with the healthcare professional who treated you before using tampons, menstrual cups or other internal products again.

Frequently asked questions

Is toxic shock syndrome common?

No. Toxic shock syndrome is very rare, but it is a medical emergency because it can progress rapidly and become life-threatening.

Can you get TSS while using a menstrual cup?

Yes. Rare cases of toxic shock syndrome have been reported with menstrual cup use. The available evidence doesn't allow us to reliably compare the rate of TSS among cup users with the rate among tampon users.

Can you get TSS even if you change your tampon regularly?

Yes. Following tampon absorbency and wear-time guidance reduces avoidable risks but doesn't make the possibility of TSS zero.

Is it safe to wear a menstrual cup for 12 hours?

Only if the instructions for your particular menstrual cup allow up to 12 hours and your flow doesn't require you to empty it sooner. In Australia, cup instructions cannot specify a maximum wear time longer than 12 hours, but manufacturers can recommend a shorter time.

Can you wear a menstrual disc for 12 hours?

It depends on the disc. Wear times are product-specific, so follow the instructions supplied with your exact product rather than assuming every disc has a 12-hour limit.

Can you get TSS from a pad or period underwear?

Pads and period underwear are external products and don't carry the same recognised menstrual TSS association as tampons and menstrual cups. TSS can still occur from other bacterial infections unrelated to period products.

Can men get toxic shock syndrome?

Yes. Toxic shock syndrome can affect anyone, including children and men. It can occur after bacterial infections associated with wounds, burns or surgery and isn't limited to menstruation.

Understanding TSS without fearing your period products

Toxic shock syndrome is rare and most people use period products without developing it.

The practical priorities are to:

  • know the sudden symptoms that can indicate TSS
  • treat suspected TSS as an emergency
  • follow the wear-time and hygiene instructions for your specific product
  • choose the lowest tampon absorbency suitable for your flow
  • remove internal products promptly if you've accidentally left them in too long

For more help with product care, wear times and troubleshooting, explore our Period Care and Pelvic Health Guides.

You can also browse menstrual cups, menstrual discs and menstrual sponges.

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Sources and further reading

This article provides general health information and isn't a substitute for individual medical advice. Suspected toxic shock syndrome requires emergency assessment.