What is my daughter's risk of getting TSS and how can she avoid it?

Younger females, such as those under 30, may be at a higher risk for TSS because they have not yet formed antibodies^[1] to the staph toxin. Therefore, it's important for you and your daughter to be vigilant for TSS. However, it's also important to know that there now are actually very few TSS cases reported each year.

Toxic Shock Syndrome became a hot topic in 1980 when 813 cases of menstrual-related cases of TSS—and

The symptoms of TSS include fever, vomiting, dizziness, diarrhea, fainting, a sunburn-like rash, muscle aches, sore throat, headache, joint pain, red eyes, and sensitivity to light.

38 deaths—were reported. Research ended up showing that use of a specific type of tampon that is no longer on the market put women at a higher risk of TSS than use of other tampons. This tampon was made with a new combination of materials including polyester foam and a highly absorbent cellulose that enhanced absorption. Although not all TSS cases occurred in women who used this specific type of tampon, it clearly played an important role. Therefore, it was removed from the market, along with other new, highly absorbent tampons of similar substances.

Because of the discontinued use of these types of tampons, as well as the Food and Drug Administration's regulation of tampon materials and absorbency, there has been a dramatic drop in the number of TSS cases. In 1997, only six cases were confirmed, and in 1998, only three cases. Nevertheless, the FDA recommends that women take the following steps to avoid tampon problems:

• Follow the package directions for insertion;

• Choose the lowest absorbency that will handle your menstrual flow;

• Change your tampon at least every 4 to 8 hours;

• Consider alternating pads with tampons;

• Don't use tampons between periods; and

• Know the warning signs of Toxic Shock Syndrome.

I would add the following recommendations:

• Keep your tampon clean by keeping it in its wrapper until you're ready to use it. A small carrying case is helpful. It doesn't have to look like a tampon container.

• Wear sanitary pads at night, if possible. If the flow is heavy and you have to change during the night, it's okay to use a tampon for up to 8 hours so that your sleep is not interrupted.

In my 20 years of practice, I have seen only one case of Toxic Shock Syndrome. However, every couple of months I see at least one patient who has forgotten that she inserted a tampon a few days, or even a few weeks, earlier. The patient invariably comes in because she has noticed a really bad odor coming from her vagina. A really bad odor. And yet, none of these patients has ever developed any health problems from the forgotten tampon. Needless to say, however, I strongly encourage all of my patients to keep track of their tampon use. Not only does it reduce the risk of TSS, it also reduces the risk of vaginitis and pelvic infections.

What myths about tampons are circulating on the Internet?

When your daughter starts using tampons, she'll probably rely on the Internet or her friends to get information about them. You should know that tall tales abound when it comes to tampons, and questionable Web sites often add unfounded, unproven, and just plain wrong information. Therefore, it's important for you to be able to set the record straight. In doing so, you should remember the following facts to combat common, but completely silly, rumors:

1. Tampons CANNOT be lost forever in a woman's body. A tampon remains in the vagina no matter what. It cannot migrate anywhere else.

2. Tampons do NOT cause AIDS.

3. Manufacturers do NOT add asbestos or other materials to tampons to cause an increase in menstrual bleeding, which then boosts sales.

4. Tampons do NOT contain hazardous levels of dioxins which are cancer-causing agents and which are claimed to be produced through the tampon bleaching process. (The bleaching process is designed to clean and purify the raw materials used in tampons. In conjunction with the Environmental Protection Agency, tampon manufacturers tested their products for dioxin. The levels of dioxin in tampons ranged from undetectable to 1 part in 3 trillion, far below the level that occurs through daily environmental exposure and considerably below the level the FDA believes would put consumers at risk.)

5. Tampon use does NOT affect virginity.

Are there helpful tips for inserting tampons?

Now that you know all of this information about tampons, it's time to tell you the secret to effortlessly inserting tampons so that you can pass it along to your daughter.

But guess what? The secret is that there really is no secret. We gynecologists don't have any special insights or methods that we learned in medical school or elsewhere. (Sorry about that.) However, the tips and steps listed below can be quite helpful to you and your daughter.

• First, your daughter should read the instructions in the tampon package. The pictures that accompany the directions can be particularly helpful.

• You should tactfully ask your daughter whether she wants help inserting a tampon for the first time. It's her decision.

• Your daughter should try her first tampon on one of the days that her menstrual flow is the heaviest. This helps to ensure that dryness is not an issue during insertion or removal.

• Your daughter should start out using "slim" or "slender" tampons because they tend to be more comfortable. Also, it would probably be wise for her to choose a tampon with a rounded, smooth applicator because they typically are more comfortable than applicators with blunt ends.

• She may want to apply a small amount of lubrication such as K-Y Jelly to the applicator tip because it can help ease the insertion.

• Your daughter should find a position that is comfortable for her to insert the tampon. Most women insert a tampon while sitting on the toilet, but other women, especially adolescents, may find it's easier if they remain standing in the bathroom and place one foot up on the toilet seat.

• Your daughter should relax as she inserts the tampon. Tensing the vaginal muscles causes resistance to the tampon, thereby making insertion more uncomfortable.

• She should hold the applicator between her thumb and her middle finger. Her index finger should be kept free so that she can push in the tampon.

• Using her other hand, she should separate the labia^[2] (lips) of her vagina and insert the tampon applicator into the vaginal opening.

• Some adolescents find that a small hand mirror is initially helpful in locating the vaginal opening.

• Using her index finger, she should push the tampon all the way in while holding the applicator steady with her thumb and forefinger.

• She should then remove the applicator, being careful not to pull on the tampon string.

• Your daughter can remove the tampon at any time simply by pulling on the string.

It's important for your daughter to know that once the tampon is inserted she shouldn't feel it or even sense that it's there. If it's constantly making its presence known, it may be positioned incorrectly or not be inserted far enough. The best thing to do in that case is to remove the tampon and try again with a new one. Remind your daughter that practice makes perfect with tampon use, and with time it will become a comfortable routine— during a rather uncomfortable time of the month.

• [1] Microscopic particles in the body that fight infection. Antibodies are manufactured by the body in response to vaccinations. For example, the HPV vaccines promote antibody production to help fight off an HPV infection.
• [2] The folds of tissue on the vulva. There are two sets of labia, the labia majora (outer) and the labia minora (inner).