Toxic shock syndrome can cause serious illness, but few people know the symptoms. Learn the warning signs of toxic shock—and what to do if you think you have it.

By Nancy Rones
Updated January 08, 2018
Tampon on pink background
Credit: Lili K./Getty Images

When was the last time you read the little paper insert that comes in every tampon box? Let us guess: Not since you first started using tampons. Every month, millions of us ignore the warning about toxic shock syndrome inside our tampon boxes—in part because cases of toxic shock rarely make the news these days. But we weren’t always so blasé about the life-threatening illness toxic shock syndrome, or “TSS.” In the early 80’s, a spike in cases linked to highly absorbent tampons made headline news, and toxic shock syndrome symptoms became common knowledge to tampon-users.

Once tampon manufacturers adjusted absorbency to safer levels, reports of toxic shock syndrome decreased and for most of us, the disease fell off our radar. Problem is, dismissing toxic shock syndrome as a disease of the past or something that will never happen is risky.

“Even though over the years the incidence of menstrual TSS has come down fivefold to 2 to 3 cases per 100,000 women, it hasn’t disappeared,” says Patrick M. Schlievert, Ph.D., Professor of Microbiology and Immunology at the University of Iowa Carver College of Medicine in Iowa City, Iowa. “There are still many deaths associated with the two kinds of toxic shock syndromes.”

Tampons may have thrust toxic shock into the spotlight, but lack of awareness has left many believing that tampons alone cause the disease. Not the case. A number of scenarios can lead to toxic shock syndrome, and anyone can be a victim. More reason to be on guard: Because toxic shock syndrome isn’t common, health professionals may not instantly recognize the signs; with this condition, you don’t want to waste time. The best way to protect your health? Get to know toxic shock syndrome and its symptoms. Just in case.

What is Toxic Shock Syndrome?

This potentially fatal illness typically starts with an infection by a strain of bacteria that releases potent toxins into your bloodstream; your immune system responds to these toxins with a massive overactivation that results in the symptoms of toxic shock syndrome, explains Dr. Schlievert. As the condition progresses, your body can lose its ability to properly pump blood because of capillary leak, which may lead to shock, amputation, multi-organ shutdown, and death.

There are two types of bacteria that usually cause toxic shock syndrome: Staphylococcus aureus, commonly called “staph,” and Group A streptococci, known as “strep.”

On any given day, we may carry staph around in our noses (and other mucus membranes), on our skin and other areas on the body without ill effect, but with the right environment, a toxin-producing strain of staph aureus can spiral into staphylococcal toxic shock syndrome in those who are susceptible.

Staphylococcus aureus is usually the perpetrator behind menstrual toxic shock syndrome, when symptoms occur within three days of the start or end of your period, and is associated with tampon use. (Staph can also lead to nonmenstrual TSS at an infection site, including surgical wounds, cold sores, and the respiratory tract after the flu.) Staphylococcal toxic shock syndrome has about a 3% fatality rate.

Streptococcal toxic shock syndrome is more aggressive—and more deadly: only about half of those diagnosed survive. It can follow any infection—strep throat, a postpartum infection, cellulitis—and has been associated with necrotizing fasciitis, often called flesh-eating disease, says Dr. Schlievert.

Toxic Shock Syndrome Causes

Not everyone is susceptible to toxic shock syndrome. “About 80 percent of people in this country develop antibodies against the toxins, which provides protection from the disease,” says Dr. Schlievert.

For the 20 percent who are susceptible (still a huge number), here’s how you can get toxic shock syndrome:

“With menstrual toxic shock syndrome, tampon use of any kind is associated with risk, but high-absorbency tampons are larger and introduce and trap a lot of oxygen in the vagina,” says Dr. Schlievert. The larger the tampon, the more oxygen it introduces to the vaginal environment. That oxygen, says Dr. Schlievert, helps staph bacteria create the toxins that cause toxic shock syndrome. (Studies have found that menstrual cups can pose the same problem.)

Outside of menstrual-related TSS, toxic shock syndrome can develop on top of another infection, such as the flu, infections relating to childbirth, and sinusitis. Or you can be exposed to strep or staph though contaminated surfaces, such as grocery carts, or most frequently through close contact with another person who is “carrying” the bug, says William Schaffner, an infectious diseases specialist at Vanderbilt University School of Medicine, Nashville, Tennessee. He notes that kids are often infected with group A strep. Trace amounts of trouble-making bacteria can invade your bloodstream through a break in your skin, whether a burn, cut, or surgical site.

Common Toxic Shock Syndrome Symptoms

The progression and symptoms of toxic shock syndrome varies some between people and can depend on whether you have staph or strep toxic shock syndrome. “Strep TSS can develop within hours, whereas staph TSS can take days to peak,” says Dr. Schlievert. In its early stages, toxic shock syndrome symptoms might be confused with the flu. Watch for these common signs of toxic shock syndrome:

  • High fever
  • Dizziness upon standing that persists (due to low blood pressure)
  • Vomiting
  • Diarrhea
  • Achiness
  • Disorientation
  • Skin rash that looks like sunburn and that over time, may lead to skin peeling on the palms and soles
  • Red, inflamed eyes
  • Intense pain at site of an infected wound (with strep)

How to Prevent TSS

During menstrual periods, use the least absorbent tampons as possible, and change them every 4 to 8 hours; overly frequent changes may introduce more oxygen that promotes toxins, but leaving tampons in too long encourages an overgrowth of bacteria. Try to alternate pads and tampons, and opt for pads for overnight use.

Good hygiene with frequent hand-washing and wiping down potentially contaminated surfaces can lower risk, says Dr. Schaffner. Keep any wounds clean and covered, and watch for signs of infection. Getting your flu shot not only minimizes your chances for the nasty viral infection, but also for contracting a secondary staph infection that makes toxins, warns Dr. Schlievert.

What to Do if you Think You Have TSS

If you suspect toxic shock syndrome, it’s important to see a health provider—your primary care provider, an urgent care clinic, or an emergency room—as soon as possible. “As with any infectious disease, the sooner you get it attended to, the more likely you’ll have good results,” says Dr. Schaffner. “The main treatment for TSS are antibiotics to kill off the staph or strep, so more toxin isn’t produced. Then we deal with existing symptoms with good supportive care in the hospital, since patients are often severely ill with multiple organs affected.”

Knowing the symptoms and suggesting the possibility of toxic shock syndrome when seeking medical care may lead to a faster diagnosis. It's a lifesaving move.