Tampons

The forerunners of the modern tampon were homemade from various materials, such as papyrus (ancient Egypt), wool (ancient Rome), paper (ancient Japan), plant materials (Hawaii, Asia, Africa), linen vinegar-dipped cloth (France, 18th century), cotton, wool, or linen with a string attached. Modern tampons began with cotton tampons from the Tampax® brand (Procter & Gamble Company, Cincinnati, Ohio, U.S.A.) in 1936 (33). Today's mainstream market offers a large selection of tampon products of varying absorbencies made of cotton, rayon, or a combination of these two materials. They are typically about two inches in length and with a diameter of about a half inch, with a cotton string attached securely to one end for removal after use. Tampons are available with or without applicators (the applicators can be made of cardboard or plastic) and with or without perfumes (i.e., scented or unscented).

Modern tampons have been used safely for many years as convenient products for menstrual protection. Tampons are classified by the FDA as Class 2 medical devices and are, therefore, subject to testing requirements by the FDA (34). In addition, major manufacturers have developed detailed testing plans to ensure the safety of tampons prior to marketing (35). Menstrual tampons require specific labeling to clearly identify the degree of absorbency for the tampon (36).

There are no safety issues if modern tampons are used according to instructions. However, historically, tampon use has been associated with some adverse health consequences and misperceptions about potential health effects.

Table 3 Standardized Tampon Absorbencies

Absorbency range

Terminology of absorbency

<6 g

Junior absorbency

6-9 g

Regular absorbency

9-12g

Super absorbency

12-15 g

Superplus absorbency

15-18 g

Ultra absorbency

>18g

No term

Source: From Ref. 36.

Source: From Ref. 36.

Toxic Shock Syndrome

Toxic shock syndrome (TSS) is a rare but treatable disease that can be life threatening in some individuals. TSS is caused by the release of superantigens (usually TSST-1) from certain strains of Staphylococcus aureus that are present in the body. These superantigens have systemic effects on the host (37). In the 1980s, contracting TSS was associated with using highly absorbent tampons (38,39). Since that time, such superabsorbent products have largely disappeared from the market. Standardized absorbency ratings have been developed (Table 3) and are a required part of labeling for tampon products (36).

Shifts in Vaginal Microflora

The use of tampons does not significantly alter the normal changes that occur in the vaginal microflora during menses, as demonstrated by Onderdonk, et al. (40). These authors evaluated the qualitative and quantitative changes in vaginal microflora during the course of the menstrual cycle. They found no difference in the results from volunteers using tampons composed of different fibers (100% cotton, 70% cotton and 30% viscose rayon, and 100% polyacrylate rayon).

Vaginal Ulcers

With normal, recommended use of tampons, vaginal ulcers do not occur. In some cases, improper insertion of tampons can cause mechanical irritations to the vaginal wall (33). In addition, tampons can cause minor vaginal dryness and irritation if they are too absorbent for the menstrual flow or worn at times other than active menstruation.

Endometriosis

There is no evidence that tampons can lead to or aggravate endometriosis. Endometriosis is a disease in which the tissue lining the uterus, the endometrium, grows outside the uterus in the form of implants, nodules, and cysts. The cause is unknown, but some researchers have speculated that endometriosis may be caused by a backward flow of endometrial cells during menstruation, leading some to speculate that tampons may play a role in the development of this disease. However, this theory has been discounted (33).

Compromising Virginity

Tampons do not compromise virginity. Tampons are used by an estimated 70% of women in the United States, Canada, and much of Western Europe. However, tampon usage in Japan and the rest of the Asia/Pacific region, Latin America, and Africa is estimated at less than 15% (41,42). In some regions, the reasons for the low percentage of women using tampons may include a fear that tampons will compromise virginity. However, there is no evidence that tampon usage significantly alters the size of the opening in the hymen.

Dioxin Exposure

Modern tampons do not contain dioxin. Dioxin is a general term that describes a group of about 30 chemicals that are highly persistent in the environment and have been associated with cancer. They can be produced by a variety of processes, including combustion (as a result of cooking or internal combustion engines) and chlorine bleaching of paper pulp. The United States Environmental Protection Agency has estimated that most dioxin exposure (>95%) occurs through the diet (43). Modern tampons are made of cotton, rayon, or blends of cotton and rayon. The rayon is made from cellulose fibers derived from wood pulp that is bleached to increase the absorbency of the material and to make the product more aesthetically pleasing. However, modern bleaching methods do not involve chlorine bleaching and are dioxin free (44).

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