Toxic shock syndrome or TSS is a serious, sometimes fatal, but thankfully very rare disease. Symptoms include: high fever, skin rash, vomiting and diarrhea;
hypotension, multiorgan dysfunction, which can rapidly progress to an irreversible picture.

The human body is colonized by billions of microorganisms of different species, collectively defined as "microbiota".
The vaginal microbiota is physiologically characterized by a small variety of bacterial species.
They are beneficial and protective germs, which live in balance.

This microflora is dominated by lactobacilli; however, other aerobic bacteria may also be present, including Staphylococcus aureus.
The bacterial density of S. aureus changes dramatically during menstruation, increasing logarithmically in the vagina compared to when not
are menstruating.

Toxic shock syndrome is caused by exotoxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes.
It can follow various staphylococcal or streptococcal infections of the soft tissues.

When does it become a problem? Four main risk factors::

  1. Presence of staph or strep in the vaginal canal. Only a small population has this.
  2. The pH of the vagina must be altered.
    Your vagina is naturally acidic and maintains a pH range of 3.8 to 4.5, a level that
    it generally does not allow harmful bacteria to thrive very easily. However, the blood is lightly
    alkaline (or basic) with a pH of 7.35-7.45. This means that when we menstruate, our menstruation will raise our vaginal pH closer to a neutral state, creating a more comfortable environment for bacteria to live. Fortunately, our bodies are pretty good at keeping harmful bacteria at bay.
  3. Oxygen. Staph bacteria require oxygen to produce the toxin that can cause TSS, and this is where tampons, menstrual cups and other vaginally inserted products come into play.
    Tampons and menstrual cups can introduce oxygen into the vaginal canal, feeding the bacteria present.
    But don't panic! This is completely harmless unless the other three factors listed are present.
  4. Last and most important, the toxic protein must enter the bloodstream to cause TSS. So there must be a point entry such as a sore, cut, or tear in the vaginal tissue. Although the other three factors are in place, without a way to reach the bloodstream, the bacteria and toxin will not cause toxic shock.

While there are some risks, they are considered minimal and unlikely to occur when cupping
is used as recommended. To date, only 2 cases of TSS have been associated with the use of a menstrual cup (the cup has been used since 1930). The first: the user had created a small scratch on the inside of the vaginal canal during the first insertions of the cup. This abrasion allowed bacteria
Staphylococcus to enter the bloodstream. The other user had exceeded the recommended 12 hours.

It is important to remember that toxic shock syndrome is incredibly rare.

Anses, the French Agency for Food, Environmental and Occupational Health and Safety in his studio
showed that TSS is more related to the conditions of use of products.
The risk of developing TSS increases with prolonged use of internal health products
and / or with the use of sanitary products with an absorption capacity higher than necessary.

How to protect yourself?
There are ways we can protect ourselves. Here is a list to follow, also based on advice from experienced doctors:

  • Wash your hands thoroughly with warm soapy water before removing or inserting the cup
  • Check your hands and nails, that there are no cuticles or nails that can cause minor injuries during the insertion phase
  • Clean the cup very well after each use, not just passing it under water. Find delicate and specific soaps such as MeLuna vegetable soap or Merula spray.
    Regarding the cleaning of the cup during menstruation, laboratory studies have shown that a significant amount of S. aureus biofilm remained after 8 hours and 3 washes with water,
    regardless of the model or composition of the cup.
    So only by passing it under water and then reinserting, it would the cup be entering the vaginal canal already contaminated. They recommend as a protocol to keep a spare cup to allow a change away from home.This will let user to sterilize the cup between uses.
  • Remove and wash the cup after 8 hours of continuous use, even if the flow is low.
  • Before insertion apply a small amount of water-based lubricant to the outside of the cup
    to facilitate insertion.
  • Wash the bag where you store the cup.

Take a break from your menstrual cup if::

  • Your cup appears to be too big. You feel too much pressure or it doesn't open well and remains curled up inside you. You will notice immediately because you will have leaks if it does not open well or the pressure leads you to remove it.
    (We will help you find the right size by filling out our QUIZ!).
  • You have a scratch, wound, or cut in the vaginal tissue.
  • You have an infection such as bacterial vaginosis, a yeast infection, or an active sexually transmitted infection.

Resources:
https://www.msdmanuals.com/
https://www.saperesalute.it/
https://www.ncbi.nlm.nih.gov/
https://www.consumerreports.org/