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Dilation and Curettage

What is Dilation and Curettage?

Dilation and curettage - sometimes referred to by your gynecologist as a "D&C" is a gynecological procedure normally performed through the vagina, wherein the doctor dilates the cervix and inserts a curette through the vagina, and the now dilated cervix, and into the uterus, for cleaning out or scraping the lining of the uterus. This gynecological procedure is normally done while the woman is under general anesthesia.

D&Cs are performed to resolve abnormal menstrual or uterine bleeding wherein a woman's bleeding may be; too much, too often or her menstrual flow may be too heavy.

What are Menstrual Disorders?

Menstrual disorders can be either a temporary or permanent condition.  Both menstrual disorders can interfere with a woman's ability to become pregnant. 

A woman with menstrual disorders needs to see her ob/gyn or family doctor as menstrual disorders may be signs or symptoms of  more serious medical conditions. 

Menstrual disorders can result from conditions that affect a woman's hormone-producing glands and organs that may include her cervix, hypothalamus, ovaries, pituitary gland, uterus, or vagina.

The most common menstrual disorders are:

Amenorrhea - which is the absence of of a woman's menstrual periods.

Dysmenorrhea - also known as painful periods with severe menstrual cramping.

Menorrhagia - excessive menstrual bleeding.

Oligomenorrhea - which is infrequent (less than 8 periods/menstrual cycles per year) menstruation.

Amenorrhea is the absence of menstruation or a woman's monthly menstrual periods. Amenorrhea is classified as either "primary" Amenorrhea, which is the absence of "menarche" a girl's first menstrual period by age 16, or "secondary" Amenorrhea, which is the absence of menstrual periods for more than three to six months in a woman who previously had monthly menstrual periods.

Causes of primary amenorrhea which are normally present at the birth of a baby girl, but are not known until she reaches the age of puberty, and when she should be experiencing menarche.  Conditions causing primary amenorrhea may include genetic or chromosomal abnormalities, and structural abnormalities of the reproductive tract. All of the conditions that lead to secondary amenorrhea can also cause primary amenorrhea. Pregnancy is the leading cause of secondary amenorrhea. 

Among non-pregnant women, ovarian conditions are the most common cause of secondary amenorrhea; these conditions include polycystic ovary syndrome and premature ovarian failure also known as early premature menopause.

The most common reasons for Amenorrhea, skipped menstrual periods or missing menstrual periods include:

*  Emotional stress
*  Excessive exercise or physical stress
*  Poor nutrition
*  Pregnancy
*  Illness

Dysmenorrhea or painful periods is the medical term for severe menstrual cramping. "Primary dysmenorrhea" is not usually associated with other more serious medical conditions. Dysmenorrhea  usually begins when a girl starts having her menstrual periods, and can start as soon as her first period or menarche. 

Menorrhagia - or excessive menstrual bleeding, is normally indicated when a woman's menstruation lasts more than seven to eight days each monthly menstrual period, or if she loses more than 80 milliliters or about 1/3 of a cup of menstrual blood each monthly cycle. A woman's doctor may classify or diagnose her as having dysfunctional uterine bleeding (DUB), which often leads to an iron deficiency or anemia unless she begins taking iron supplements, as prescribed by her doctor.  Iron deficiency, as caused by the excessive menstrual bleeding, may lead to increased fatigue, dizziness, shortness of breath, and in severe cases - angina.

Menorrhagia's most likely causes include:

*  Abortion-related problems
*  Cervical or endometrial polyps
*  Cervical cancer
*  Endometrial cancer.
*  Hormone imbalance
*  Intrauterine Devices (IUDs)
*  Menopause
*  Pelvic inflammatory disease (PID)
*  Perimenopause
*  Premature Ovarian Failure
*  Uterine fibroids or tumors (benign or cancerous)

Oligomenorrhea is another menstrual disorder that refers to infrequent or sporadic menstrual periods which are generally defined to mean fewer than six to eight periods per year.

Alternatives to Hysterectomy: 
New Technologies, More Options

More than 1 in 4 U.S. women will have a hysterectomy by the time they are 60 years old, according to the Centers for Disease Control and Prevention (CDC).

A hysterectomy--removal of the uterus--can be a life-saving operation for women with certain types of cancer or uterine hemorrhage. It can also improve the quality of life for thousands of women each year who experience abnormal uterine bleeding and noncancerous growths of muscle tissue in and around the uterus (fibroids), or the falling of the uterus from its normal position into or outside of the vagina (uterine prolapse).

When the ovaries are also removed, a hysterectomy can relieve the pain of endometriosis--the growth of the tissue lining the uterus (endometrial tissue) outside the uterus.

The United States has one of the highest rates of hysterectomy in the world, with about 5 out of every 1,000 women each year having the operation, according to the CDC. Other industrialized countries show lower rates; in England, for example, the rate is less than 3 per 1,000 women annually. In Norway, it's less than 2 in 1,000.

Some are concerned that many hysterectomies are done unnecessarily in this country. "There are some cases where hysterectomy is the only option, for instance, for some types of cancer," says Anthony Scialli, M.D., director of the obstetrics and gynecology residency program at Georgetown University Hospital in Washington, D.C. "But I think we perform too many hysterectomies. It's a matter of American gynecologists being accustomed to performing a hysterectomy and American women being accustomed to getting one--based on their mother or other female relative having one. The one thing in favor of a hysterectomy is that it works for abnormal uterine bleeding--but it should be the last step, not the first step."

Of the more than 600,000 hysterectomies performed on American women in 1999, more than one-third of them were to treat fibroids or abnormal uterine bleeding.

Today, women have other options--new medications, technologies, and procedures--to treat noncancerous uterine conditions. Some of these less invasive procedures translate into lower risk, quicker recovery, and less expense. And some preserve the ability to get pregnant, unlike hysterectomy.

However, these procedures also have the disadvantage inherent with any new treatment--the lack of data demonstrating long-term safety and effectiveness. "But it's never a bad thing for a woman to ask a doctor for alternatives," says Scialli. "She should ask, 'What other options are there to manage this problem and what are the pros and cons?'"

Abnormal Uterine Bleeding

In women younger than 30, most hysterectomies are done to treat abnormal uterine bleeding. Abnormal uterine bleeding can occur as frequent, irregular and unpredictable bleeding, lengthy menstrual periods, bleeding between periods, or a heavy flow during periods. This bleeding may be caused by hormonal imbalances, growth of endometrial tissue into the wrong place, fibroids, or other conditions. And sometimes the bleeding has no identifiable abnormality associated with it.

However it occurs, abnormal uterine bleeding is an inconvenience, and it can be accompanied by painful cramping. It can also be exhausting, embarrassing and--when it results in anemia--dangerous.

After diagnosing the cause of bleeding, doctors usually turn to medications as the first therapy for treating abnormal uterine bleeding. Some estrogens and progestins are approved by the Food and Drug Administration to treat abnormal uterine bleeding in certain circumstances. Although the FDA has not approved oral contraceptives to treat abnormal uterine bleeding, some doctors prescribe them for this purpose. As with other approved medications, doctors may prescribe oral contraceptives "off label" for an unapproved use if, in their professional judgment, a patient will benefit from them.

"Ninety-five percent of abnormal bleeding associated with or without fibroids can be controlled with birth control pills," says Scialli. However, oral contraceptives may not be effective in reducing bleeding to acceptable levels in some women.

Endometrial Ablation

For some who experience abnormal uterine bleeding, a viable alternative to hysterectomy can be endometrial ablation. This procedure--a minimally invasive surgery that uses electrical energy, heat, or cold to destroy the endometrium--may minimize or even stop this bleeding. But the results may not be permanent. "Within 10 years, most women will have some degree of menstrual bleeding return, but not heavy bleeding," says Scialli.

The early techniques of endometrial ablation, introduced in the 1980s and still practiced by many gynecologists, are also known as "operative hysteroscopy" because they use a hysteroscope (a thin, fiber-optic tube for viewing) with an attachment to destroy tissue. The attachment may be a "rollerball" or wire loop through which electrical heat travels to remove (resection) the endometrial lining. After the uterus is filled with fluid to enlarge it for better viewing, the surgeon moves the rollerball back and forth across the lining or uses the wire loop to shave off the tissue. Potential risks of this ablation method include infection, perforation of the uterus, cervical laceration, and absorption of large volumes of fluid (fluid overload) that can lead to death.

In 1997, the FDA approved ThermaChoice, the first non-hysteroscopic ablation device to treat excessive uterine bleeding (menorrhagia) due to benign (noncancerous) causes. In 2001, the FDA approved three more similar devices. These devices are to be used only in women who have not yet reached menopause and whose childbearing is completed.

"Each type of ablation represents a simpler surgical procedure for doctors compared to traditional operative hysteroscopy," says Colin Pollard, a biomedical engineer and chief of the ob/gyn devices branch in the FDA's Center for Devices and Radiological Health. "All of the technologies have some things in common, but each delivers energy differently and each offers different feedback mechanisms to the doctor during the procedure."

The ThermaChoice Uterine Balloon Therapy System, manufactured by Gynecare, a division of Ethicon Inc. of Somerville, N.J., consists of a balloon that is inserted through the neck of the womb (cervix) and into the uterus. Through a catheter connected to a controller console, the balloon is inflated with fluid and heated to 188 F (87 C) for eight minutes to destroy the uterine lining.

The first of the three newer devices--the Hydro ThermAblator manufactured by BEI Medical Systems Inc. of Teterboro, N.J.--delivers hot salt water (saline solution) into the uterus through a tube inserted into the cervix. The hot water destroys the uterine lining in about 10 minutes. The doctor uses a hysteroscope for viewing the uterus during the procedure.

The second device--Her Option Uterine Cryoblation Therapy System made by CryoGen Inc. of San Diego--uses a probe capable of producing temperatures down to minus 148 F (minus 100 C) at the tip. This extreme cold is applied to the tissue for 10 minutes to freeze and destroy the uterine lining. Ultrasound is used to guide and monitor the procedure.

The third device--the NovaSure Impedance Controlled Endometrial Ablation System manufactured by Novacept of Palo Alto, Calif.--uses a metallic mesh triangular electrode that is expanded out of a slender tube into the uterus. A gentle suction brings the tissue into close contact with the triangular electrode, which delivers electrical current to the endometrial tissue, causing its destruction in about 90 seconds. With this method, there is no hysteroscope or ultrasound, so the doctor cannot view the uterus during the procedure.

Not For Everyone

Endometrial ablation is not advised for women who want to have children, and it is not a form of birth control. "Doctors must tell the patient she should still maintain contraception," says Pollard. "If she does get pregnant, it will be a very high-risk pregnancy." If pregnancy were to occur, the cells left lining the uterus may not be adequate for a fetus to attach and grow within the uterus.

The ThermaChoice balloon method has the longest track record of the newer, simpler ablation techniques. A three-year study of this device and one-year studies of the ablation devices approved this year--the Hydro ThermAblator, Her Option, and NovaSure--showed similar rates of effectiveness and were comparable to the effectiveness of operative hysteroscopy (such as the rollerball technique). They all reduced or stopped bleeding in 70 percent to 80 percent of the women tested.

Unlike a hysterectomy, the newer endometrial ablation procedures can be performed with local anesthesia. Ablation is usually done in the hospital on an outpatient basis; however, some women remain overnight to treat the severe abdominal pain they may experience. Most women are able to return to their regular activities several days later.

Common side effects after the procedure include nausea, vomiting, and a vaginal discharge that can last from days to weeks. "Expect to have bleeding up to four to six weeks," says Malcolm Munro, M.D., a professor and gynecologist at UCLA. "With ablation, you are traumatizing the surface whether you use electrosurgery, or burn it or freeze it."

Complications of ablation are rare, but may include blood loss requiring a transfusion, perforation of the uterus, or unintended damage to other internal organs.

Newer approaches to endometrial ablation are currently under investigation; these use other energy sources, such as laser and microwave, to destroy the endometrial tissue.

A Personal Choice

A woman must decide what she expects from a treatment for abnormal uterine bleeding. "Women need to know that articulating their problem is important for treatment," says Munro. "With abnormal bleeding, the desired outcomes vary. Some women want no period, some want a predictable period. Some want to slow the bleeding, for others pain is more important than volume. Some want to maintain their ability to get pregnant. Some don't want scars; some don't care about scars. Time off is a consideration. All of these factors are impossible for a doctor to aggregate for the patient. The woman has to make the decision."

Many women are satisfied with the outcomes of their endometrial ablations. But others, like Melissa Otto of Minneapolis, are disappointed.

Otto's hormonal introduction to womanhood--when she was 12--was frightening. Shortly after the onset of menstruation, her monthly period became very heavy and lengthy. By the time she was 14, Otto was extremely anemic from the blood loss. "The doctors told my parents not to worry--that eventually I'd regulate and have a normal period. They said 'Let's just treat the anemia for now.'"

But Otto's bleeding was no more regular by the time she reached her 20s. Medical tests ruled out fibroids and other abnormalities. Despite trying many different types of birth control pills prescribed by her doctor, her periods continued to get heavier. They came about every 23 days and lasted for 12 to 13 days. Otto spotted during the 10 days a month she wasn't bleeding heavily.

In desperation, Otto tried hormone injections, homeopathic remedies, chiropractic medicine, blood-building supplements, and acupuncture. Nothing worked.

In May 1999 when she was 31, Otto had an endometrial ablation. Her doctor used a laser to destroy the endometrial tissue. After five weeks of watery discharge and spotting, Otto's periods resumed and became frequent and lengthy once more.

In July 2000, Otto checked into the hospital for a second endometrial ablation--this time a balloon ablation. Four weeks later, her period returned--a little lighter--but still long.

After 20 years of problem periods, a dozen different doctors, hormone treatments, two ablations, and a bout of cervical cancer along the way, Otto had had enough. In March 2001, she had a hysterectomy, and Otto says that she is very happy with the results.

Fibroids

Uterine fibroids may be a cause of abnormal uterine bleeding. About 30 percent of women between 25 to 45 are diagnosed with fibroids, according to the federal Agency for Healthcare Research and Quality.

For unknown reasons, fibroids are diagnosed in black women two to three times more frequently than in white women, and fibroids account for about twice the number of hysterectomies among black women than among white women, according to the CDC. About 200,000 hysterectomies each year are performed in the United States to treat fibroids.

Also called myomata or leiomyomata, fibroids can vary from microscopic size to the size of a melon, and no one knows what causes them.

Most fibroids do not cause symptoms and require no treatment other than regular monitoring by a physician. But some fibroids can cause heavy bleeding, debilitating pain, or both. If fibroids press on the bladder or bowel, they can cause frequent urination, constipation, painful bowel movements, and hemorrhoids.

Large fibroids may cause an enlarged uterus, resulting in a protruding abdomen. "When the uterus reaches the size of a melon, a doctor would most likely recommend a hysterectomy," says Dena Hixon, M.D., a gynecologist in the FDA's Center for Drug Evaluation and Research. No treatment other than hysterectomy can guarantee that uterine bleeding or fibroids won't recur.

Treatment Options

There are medications that will temporarily shrink fibroids. If heavy bleeding accompanies the fibroids and causes anemia, a doctor may prescribe an injection that temporarily stops estrogen production for up to three months before surgery. Most fibroids are stimulated to grow by estrogen, and without it, fibroids usually shrink. These injections, called gonadotropin-releasing hormone (GnRH) agonists, act by causing a sort of medical menopause, says Hixon. "These are drugs with significant risks and side effects that are most appropriately used when other common alternatives are inadequate or not appropriate for the individual." Because of their significant side effects, including loss of bone density, hot flashes, and mood swings, the FDA has approved GnRH agonists for use only for three months. Without surgery, the fibroids are likely to regrow after the drug is stopped.

Women with fibroids that cause pain, discomfort or bleeding have surgical options to hysterectomy. These include surgically removing only the fibroids (myomectomy), cutting off the blood supply to the fibroids (embolization), and shrinking the fibroids using electric current (myolysis). Myolysis is not currently widely used, and no long-term studies on safety and effectiveness have been done on this procedure. The most appropriate treatment for each woman will depend on the size and location of the fibroids, the severity of symptoms, and future childbearing plans.

Before treating fibroids, a gynecologist should perform a pelvic exam and sonogram, says Thomas Lyons, M.D., a gynecologist at the Center for Women's Care and Reproductive Surgery in Atlanta. If abnormal bleeding occurs a physician should also take a sample of the uterine lining to check for cancerous cells or other problems that may warrant a different treatment.

Sampling can be done by dilation and curettage (D&C) or by endometrial biopsy. D&C is a procedure that involves dilating the cervix and scraping the uterine lining. In an endometrial biopsy, a thin hollow tube is inserted through the cervix and into the uterus. Cells in the uterine lining are pulled through the tube by suction and later tested in a lab.

Uterine sarcoma, a rare cancer, cannot be diagnosed by testing samples of endometrial cells. Nevertheless, sampling is recommended to check for other cancers or disease before treating fibroids or abnormal uterine bleeding.

Myomectomy

A myomectomy is a surgery to cut away the fibroids without removing the uterus, so that a woman can maintain her ability to bear children. "It's major surgery and has the same disadvantages as hysterectomy as far as pain, disability, and scarring are concerned," says Scialli. "But if a woman wants to get pregnant, myomectomy is currently the method with the best track record." A myomectomy tends to weaken the uterine wall; children born after the procedure may need to be delivered by cesarean section.

In some cases, a myomectomy may be a more complicated procedure than a hysterectomy. "After you remove the fibroids, you have to reconstruct the uterus," says Lyons.

Myomectomy can be performed in several different ways, depending on the size and location of the fibroids. In a laparotomy, a surgeon can go into the uterus through an incision in the abdomen. In another approach, a laparoscopy, the surgeon inserts a telescope-like instrument (laparoscope) through the navel and inserts other instruments through very small incisions in the abdomen. Scialli does not generally recommend a laparoscopic myomectomy for women having a subsequent pregnancy because it may weaken the uterine wall more than a myomectomy done through a larger abdominal incision.

Another method of myomectomy involves using a hysteroscope and small surgical instruments inserted into the uterus through the cervix to cut out the fibroids. Sometimes, the surgeon uses a special type of hysteroscope called a resectoscope. This instrument has a built-in wire loop and uses electrical current to cut out the fibroid. Even after a myomectomy, fibroids can still be a problem, says Scialli. "I've seen patients who never have fibroids return and patients whose fibroids recur every bit as badly within a year."

Uterine Fibroid Embolization

Uterine fibroid embolization (UFE)--also called uterine artery embolization (UAE)--is a minimally invasive procedure that blocks the arteries carrying blood to the fibroids. Because the procedure is performed by a specially trained physician called an interventional radiologist, a woman should first be examined by a gynecologist, says Lyons. The gynecologist will take the patient's medical history and perform tests to rule out any problems that may be causing the bleeding and that would require a different treatment.

In the procedure, which is done under local anesthesia, the radiologist threads a small tube (catheter) from the groin into the uterine artery. The radiologist then injects a dye into the artery and views moving X-ray images on a monitor to see the flow of blood to the fibroids. Very small particles, called embolic agents, are slowly injected through the catheter to the uterine artery in order to block the blood supply to the fibroids. (See "Uterine Fibroid Embolization.") A clot forms around the particles, which are about the size of grains of sand and are usually made from plastic (polyvinyl alcohol) or gelatin sponge.

"Uterine artery embolization is a procedure that doctors have been doing as long as 20 years, but not specifically for uterine fibroids," says the FDA's Pollard. "The procedure has been used for postpartum hemorrhaging and to stop bleeding when treating some kinds of cancer."

Since the mid-1990s, the use of uterine artery embolization to treat fibroids has grown. According to the Society of Cardiovascular and Interventional Radiology, more than 10,000 procedures have been done worldwide, of which about 8,600 were performed in the United States. Three deaths have been reported.

Although the FDA has not cleared the UFE procedure for general use, it is being studied in FDA-approved clinical trials. "It is not a trivial procedure and is not without risks," says Pollard. "And we're not sure how those risks weigh up against drug therapy, myomectomy, and hysterectomy." Potential risks include infection, ovarian failure leading to early menopause, and expulsion of the fibroid from the uterus at a later date, requiring another procedure. Additional risks include leakage of the embolic particles out of the blood vessels, complications from radiation exposure, blood clotting in the veins of the inner thigh or leg (deep vein thrombosis), blockage of an artery in the lungs (pulmonary embolus), and death.

Unlike a hysterectomy, UFE leaves the uterus intact, with the potential for childbearing. However, current research is lacking on the ability to become pregnant and carry a baby to full-term, says Pollard.

More Data Needed

Compared to hysterectomy, minimally invasive surgeries to treat uterine problems are relatively unknown territory. "While these are promising technologies, we don't have data on their long-term safety, effectiveness, and fertility," says Amy Allina, program director of the National Women's Health Network, a nonprofit women's health advocacy organization in Washington, D.C. "It's a matter of choice. I don't consider any of these options perfect for everybody."

Nevertheless, women today do have a multitude of good options to choose from to maintain their health, says Lyons. "Information about these options is out there but individuals must access this knowledge in order to take advantage of these choices. Be proactive and know all you can know to best serve yourself and your families."

For More Information

National Women's Health Network
514 10th St., N.W., Suite 400
Washington, DC 20004
202-628-7814
www.womenshealthnetwork.org

National Women's Health Information Center
1-800-994-WOMAN (1-800-994-9662)
TDD: 1-888-220-5446
www.4woman.gov

National Uterine Fibroids Foundation
1-877-553-NUFF (1-877-553-6833)
www.nuff.org

Endometriosis Association
1-800-992-3636
www.endometriosisassn.org

What About Menstrual Hygiene?

Menstrual Hygiene deals with a woman's special healthcare needs and requirements during her monthly menstruation or menstrual cycles.  These areas of special concern include choosing the best "period protection," or feminine hygiene products, how often and when to change her feminine hygiene products, bathing, care of her vulva and vagina, as well as the supposed benefits of vaginal douching at the end of each menstrual period.

Why Should I, My Wife, or My Daughter(s) Use
Organic Cotton Tampons?

Tampon Facts and Information About Tampon Usage in the United States

About 70% of the 73 million women are of menstruating age in the U.S. use tampons.

Lifetime tampon usage is about 11,400 (5 days X 5 tampons X 38 years)

In the U.S., women between 11 and 60 years of age reported 216 cases of menstrual TSS reported in 1993; 244 cases in 1994

The risk of TSS is higher for women under 30 years old; 60% of patients are between 15 and 24 years of age

The fatality rate of TSS is 3% to 5%, but it is estimated that only 10% of cases of TSS are reported, as many women suffer only flu-like symptoms

Absorbency enhancers in tampons can cause peeling of the mucous membrane, vaginal dryness, ulcers, and lesions

Perfumes and fragrances in some tampons are reported to cause vaginal irritation, allergic reactions, and disruptions of a woman's microbial balance

"Tampon users were demonstrated to be 18 times more likely to develop menstrual TSS as non-users", Infectious Diseases in Obstetrics & Gynaecology, 1993, Gilles R.G. Monif

"of [Toxic Shock] cases occurring in menstruating women, up to 99% were using vaginal tampons", Obstetrics and Gynaecologic Infectious Disease, 1994, James McGregor and James Todd, (Chapter 21 - Toxic Shock Syndrome)

"Vaginal inflammation can result from rayon fibres from tampons becoming embedded in vaginal walls", Journal of Obstetrics and Gynaecology, 1980

Tampons made chiefly of rayon have some levels of dioxin.  

"Rayon tampons amplify the growth of the Toxic Shock Syndrome bacteria TSST-1" American Society for Microbiology Journal, May 1994, Dr. Philip Tierno of NYU Medical Center

Dioxin levels once thought acceptable are now reported to adversely affect the reproductive and immune systems, "A Health Assessment Document for Dioxin", published by the Environmental Protection Agency, 1996

"Cotton tampons offer no protective advantage over cotton/rayon tampons with regard to protection from TSS" Journal of Infectious Diseases, October 1995 (study by Dept. of Microbiology, University of Minnesota.

The Truth About Tampons
By Catherine-Elliott Lopez

Fall 1998

Swedish studies have shown a link between tampons containing dioxin, and other chlorine by-products, and an increased risk of cancers of the female reproductive tract (especially the uterus, ovaries and bladder). 

Rayon itself poses another risk. Unknown to most women, rayon and rayon-cotton blend fibers are widely used in commercial feminine hygiene products. Rayon used to make tampons is usually treated with chemicals to increase the absorption capability. 

These super absorbent fibers then absorb not only the menstrual blood, but normal vaginal secretions as well, causing drying, and ulceration of vaginal tissues. The fibers can also become imbedded in the vaginal walls. Rayon fibers have been scientifically proven to amplify the production of Toxic Shock Syndrome Toxin TSST1. 

Toxic Shock Syndrome is a rare bacterial illness that caused over 50 deaths between 1979 and 1980. Unlike medical grade cotton, upon which the TSS toxin will not grow, the rayon acts like a petri dish encouraging bacterial growth. What makes these toxic residues even more disturbing, is that they come in direct contact with some of the most absorbent tissue in a woman's body. 

According to a doctor at New York University Medical Center, almost anything placed on this tissue, including Dioxin, gets absorbed into the body. 

Why is it acceptable to have toxic substances in our feminine hygiene products? The tampon industry is convinced that women need bleached white products. They seem to think that we view this as "pure" and "clean." The fact is, if Dioxin puts women at risk for cancer and Dioxin is stored in fatty tissue (just like that found in the vagina), and a woman uses as many as 11,000 tampons in her lifetime, could the long term use of tampons increase cancer risk? 

An FDA report said that "the most effective risk-management strategy would be to assure that tampons, and menstrual pads, contain no Dioxin." Although the FDA currently requires tampon manufacturers to monitor Dioxin levels, the results are not available to the public. The dioxin tests, are done by the manufacturers themselves, who insist their products are safe. Tampon manufacturers are not required to disclose ingredients to consumers, although many will do so voluntarily. 

How much Dioxin exposure is considered safe for humans? Why has there been more research done on the possible health effects of chlorine-bleached coffee filters than on chlorine bleached tampons and related products? Women need to demand that more research be done on these issues. We have a right to know about any potential hazards associated with tampons and related products. It is only when women fully understand the consequences that we can make informed decisions regarding our health and well being. 

Writer's note: Currently there are only a few non-chlorine bleached all cotton tampons available in the US. Ask about them at your local store, if they are not available, ask them to special order!

The Pros And Cons Of Tampons
The type of tampon you choose may affect your health By Laurel Kallenbach

Today's average woman uses an estimated 12,000 tampons in her lifetime, a convenience that allows an unprecedented freedom to be active and confident in avoiding embarrassing leaks. We've come a long way since rags pinned into undergarments or belted-on bulky pads were the norm, but with our freedom comes risk. There are potential problems attached to tampon use that every consumer should know about: Chlorine-bleached products, as some tampons are, contain traces of carcinogenic dioxins. Highly absorbent tampons may still cause toxic shock syndrome, a potentially fatal bacterial infection that occurs when tampons are worn for too long. There are even environmental ramifications, including pesticides sprayed on cotton crops and pollution created when tampon ingredients are bleached.

But, there are safe and ecological alternatives that enable women to still benefit from tampons. Here, natural is the rule of thumb. "Plainer is just better when it comes to tampons," says Pam Chandler, a family nurse practitioner and certified nurse midwife who practices at the holistic clinic Wellspring for Women in Boulder , Colo. Chandler encourages patients to use nonchlorine-bleached, 100 percent-organic cotton tampons and pads. "We're lucky to have healthier choices," she says.

Dioxin Dilemma

The most urgent tampon health concern is that chlorine-bleached and rayon-containing products carry trace amounts of dioxin, an extremely toxic chemical that is associated with cancer of the stomach, sinus lining, liver and lymph system. Many people are familiar with the danger of dioxins from publicity about Agent Orange and the Love Canal catastrophe. Tampons are linked to carcinogenic dioxin formed during the bleaching process that manufacturers use to purify and whiten both raw cotton and the wood pulp that goes into synthetic fibers such as rayon, a common fiber in tampons. "You find trace amounts of dioxin in some tampons, which have maximal contact with the vagina's mucous membrane, which absorbs substances directly into the bloodstream," explains Philip Tierno, MD, director of clinical microbiology and immunology at New York University Medical Center . To ensure that your tampon is free of dioxin, switch to a brand that's nonchlorine-bleached, rayon-free, and made of 100 percent-organic cotton. Though cotton is a natural fiber, the majority of cotton crops are heavily treated with insecticides, pesticides and herbicides. Organically grown cotton is not.

Check your tampon box for a list of ingredients. Whereas natural brands state that they're nonchlorine bleached, some conventional brands mention little on the subject, because along with the Food and Drug Administration (FDA) and the Environmental Protection Agency (EPA), they believe chlorine-dioxide bleaching is safe.

Tierno disagrees: While trace quantities of dioxin aren't in and of themselves a problem, tampons aren't your only exposure. "The problem is that measurable amounts of dioxins are everywhere, including food and water. Some portion of the dioxin that enters your bloodstream lodges in the body's fat cells and stays there a long time," he says. "This residual effect becomes progressively larger as you're exposed to even more dioxins."

The only way to avoid vaginally absorbed dioxin, Tierno says, is to eliminate chlorine-bleached and rayon-containing tampons and switch to peroxide-bleached products instead. Tierno also says if the label on your tampon box doesn't say "nonchlorine-bleached," it's possible that it contains chlorine. Most manufacturers proudly promote the fact that their product doesn't contain chlorine.

The cumulative risks of dioxin are unknown. While a single tampon may contain only 0.1 parts per trillion of dioxin, the fact that most women use between 10,000 and 15,000 tampons in a lifetime increases the exposure. "A trace quantity of dioxin is not acceptable in a tampon, because a woman does not expose herself to a single tampon," Tierno says. "It's trace quantity upon trace quantity upon trace quantity, multiplied by the number of tampons per month, multiplied by the number of months in a year, multiplied by 40 years of menstruation. Then add in all the dioxins you get from your diet, plus all the ones occurring in the environment."

Earth-friendly Options

The environmental impact of the manufacturing of feminine products is another reason to use organic tampons. While cotton tampons may seem better than synthetic, most cotton undergoes industrial bleaching in a polluting process that dumps dioxins, along with other hazardous organochlorines, into the water supply. Organic cotton tampons and pads are treated with hydrogen peroxide instead of bleach, making them a safer alternative. If the label states that the product is third-party certified organic, that means the cotton has been grown without pesticides on land where no pesticides have been applied for at least three years.

In response to concerns over dioxin in tampons and their impact on the environment, the EPA and some manufacturers have worked to find a better way of purifying wood pulp and cotton without creating dioxins. The result is chlorine-dioxide bleaching, a process that has replaced the elemental chlorine-gas method of the past but still generates low trace levels of dioxins.

The packaging of tampons is another troublesome environmental issue. Most are encased in a paper or cellophane wrapper, contain a cardboard or plastic applicator, and are packed in boxes. Though you can't recycle cotton tampons, there are waste-saving alternatives to dealing with menstruation, such as washable natural sponge tampons and cloth pads, and reusable, but awkward, vaginally inserted menstrual cups that collect flow.

Toxic Shock: Still A Risk

In the '70s and '80s, toxic shock syndrome ( TSS ) struck thousands of women. The crisis peaked in 1980 with 814 cases of TSS , of which 38 women died, most due to extended use of the high-absorbency Rely tampon. Today, women still get TSS , though cases are rarely publicized. Yet tampon safety is once again a national issue, in part due to the efforts of Rep. Carolyn Maloney, D-N.Y., who introduced a bill to address the health problems associated with tampon use. The Robin Danielson Act (HR 360) is named after a 44-year-old woman who died in 1998 from TSS because she didn't recognize her symptoms. The bill directs the National Institutes of Health to conduct reliable, independent research to determine the health risks posed by the presence of synthetic fibers, dioxin and other additives in tampons.

TSS is caused when staph or strep bacteria grow in the vagina, usually encouraged by the presence of a higher absorbency tampon or one that has been inserted more than eight hours. The bacteria produce toxins that are absorbed into the bloodstream, which can cause a severe drop in blood pressure (shock) and/or organ failure, especially of the liver and kidneys. In some cases, TSS is fatal. Its symptoms are similar to the flu, including a high fever, vomiting and diarrhea, muscle aches, dizziness or fainting, a red rash, headaches, bloodshot eyes and sore throat.

"Highly absorbent tampons, especially those containing synthetic fibers, increase the amounts of toxin present in the vagina," says Tierno.

In the mid-'70s, synthetic fibers were used in tampons because manufacturers wanted to produce more absorbent, leak-resistant products. Since then, three of the four problematic synthetics have been eliminated from tampons. "The only one left is viscose rayon," Tierno says.

To minimize your risk of contracting TSS , choose a tampon made of 100 percent cotton, preferably organic. "You're at the lowest risk possible with cotton," says Tierno. "In my research, every synthetic fiber amplified toxin development, whereas cotton did not."

Most precautions for guarding against TSS are simple, says holistic nurse practitioner Pam Chandler, a specialist in women's health care. Wear a tampon for a maximum of six to eight hours to avoid bacterial growth. However, she recommends leaving it in for at least two hours. "If you remove a tampon too soon, it won't be saturated," she says. "Then you risk scraping the dry, fragmented cotton across the vaginal mucosa, irritating it and setting the scenario for infection." Also, using a tampon overnight, when planning to sleep longer than eight hours, is risky. At night, consider wearing a pad instead, she advises.

Choosing a tampon with proper absorbency is crucial to preventing TSS . "At the beginning of your period, if your flow is heavy, you may need Super Absorbency so you don't have to change tampons too often," says Chandler . When the flow slows, however, don't be tempted to continue with a Super because it's more convenient. Switch to a lower absorbency tampon instead. Also, use tampons only during menstruation.

Careful Liberation

Within the last couple of years, a rash of e-mails warned women that tampon manufacturers put asbestos in their tampons to make women bleed more in hopes of selling more product. Tierno says the rumor was false. "I have been privy to every manufacturer's records over the last 21 years, and I have never seen anything related to asbestos in tampons," he says.

Though the asbestos scare amounted to nothing but an urban myth, true additives to be concerned about are fragrances and deodorants. Perfumes may mask odors, but some women suffer allergic reactions to them. "Without question, a deodorized tampon is dangerous," asserts Tierno, adding that deodorants encourage overgrowth of certain bacteria, upset the vagina's normal flora and irritate the mucous membrane.

The main point, when it comes to tampon use, is to stay informed and weigh the options. "Over the years, tampons have allowed women to be more active and fuss less during their periods," says Chandler , who points out that while this is liberating, it also makes it easy to take their use for granted.

What is Toxic Shock Syndrome?

Toxic shock syndrome is a rare infection that can happen during a woman's period. The symptoms include a sudden fever of over 101 degrees or more, diarrhea (the runs), vomiting (throwing up), muscle aches and a sunburn-like rash. If you have these symptoms during you period, see a doctor right away.

To help prevent toxic shock syndrome, you should follow these guidelines:

1.  Wash your hands before unwrapping and placing a new tampon in your vagina.

2.  Never use super-absorbent or deodorant tampons.

3.  Change your tampon at least every 4-6 hours (read the tampon manufacturers information inside the box).

4.  Do not use tampons all the time and switch to a pad for part of each day.

5.  Do not use a birth control sponge or diaphragm during your period. During your period it is preferable to use other methods such as condoms and/or foam.  

There are allegations that tampons made from rayon, or cotton with rayon, may cause or be a contributing factor to Toxic Shock Syndrome, as well as vaginal dryness or ulcerations of vaginal tissues.

Toxic Shock Syndrome is a rare but potentially fatal disease caused by a bacterial toxin. (Different bacterial toxins may cause Toxic Shock Syndrome, depending on the situation, but most often streptococci and staphylococci are responsible.) The number of reported Toxic Shock Syndrome cases has decreased significantly in recent years. Approximately half the cases of Toxic Shock Syndrome reported today are associated with tampon use during menstruation, usually in young women. Toxic Shock Syndrome also occurs in children, men, and non-menstruating women. In 1997, only five confirmed menstrual-related Toxic Shock Syndrome cases were reported, compared with 814 cases in 1980 [according to data from the Centers for Disease Control and Prevention (CDC)]. Although scientists have recognized an association between Toxic Shock Syndrome and tampon use, the exact connection remains unclear. Research conducted by the CDC suggested that use of some high absorbency tampons increased the risk of Toxic Shock Syndrome in menstruating women. A few specific tampon designs and high absorbency tampon materials were also found to have some association with increased risk of Toxic Shock Syndrome. These products and materials are no longer used in tampons sold in the U.S. Tampons made with rayon do not appear to have a higher risk of Toxic Shock Syndrome than cotton tampons of similar absorbency.

Vaginal dryness and ulcerations may occur when women use tampons more absorbent than needed for the amount of their menstrual flow. Ulcerations have also been reported in women using tampons between menstrual periods to try to control excessive vaginal discharge or abnormal bleeding. Women may avoid problems by choosing a tampon with the minimum absorbency needed to control menstrual flow and using tampons only during active menstruation.

To help women compare absorbency from brand to brand, FDA requires that manufacturers measure absorbency using a standard method and describe absorbency on the package using standardized terms. Thus, the terms "junior," "regular," "super," and "super plus," always describe a specific range of tampon absorbency regardless of the brand.

Historical Perspectives Reduced Incidence of Menstrual Toxic-Shock Syndrome -- United States, 1980-1990

In May 1980, investigators reported to CDC 55 cases of toxic-shock syndrome (TSS) (1), a newly recognized illness characterized by high fever, sunburn-like rash, desquamation, hypotension, and abnormalities in multiple organ systems (2). Fifty-two (95%) of the reported cases occurred in women; onset of illness occurred during menstruation in 38 (95%) of the 40 women from whom menstrual history was obtained. National and state-based studies were initiated to determine risk factors for this disease. In addition, CDC established national surveillance to assess the magnitude of illness and follow trends in disease occurrence; 3295 definite cases have been reported since surveillance was established (Figure 1).

In June 1980, a follow-up report described three studies which detected an association between Toxic Shock Syndrome and the use of tampons (3). Case-control studies in Wisconsin and Utah and a national study by CDC indicated that women with Toxic Shock Syndrome were more likely to have used tampons than were controls. The CDC study also found that continuous use of tampons was associated with a higher risk of Toxic Shock Syndrome than was alternating use of tampons and other menstrual products. Subsequent studies established that risk of Toxic Shock Syndrome was substantially greater in women who used Rely brand tampons than in users of other brands and that risk increased with increased tampon absorbency (4-6). In September 1980, Rely tampons were voluntarily withdrawn from the market by the manufacturer.

In 1980, 890 cases of Toxic Shock Syndrome were reported, 812 (91%) of which were associated with menstruation. In 1989, 61 cases of Toxic Shock Syndrome were reported, 45 (74%) of which were menstrual. In 1980, 38 (5%) of 772 women with menstrual Toxic Shock Syndrome died; in 1988 and 1989, there were no deaths among women with menstrual Toxic Shock Syndrome. Reported by: Meningitis and Special Pathogens Br, Div of Bacterial Diseases, Center for Infectious Diseases, CDC.

Clostridium sordellii Toxic Shock Syndrome After Medical Abortion with Mifepristone and Intravaginal Misoprostol --- United States and Canada, 2001--2005

On July 22, this notice was posted as an MMWR Dispatch on the MMWR website (http://www.cdc.gov/mmwr).

On July 19, 2005, the Food and Drug Administration (FDA) issued a public health advisory regarding the deaths of four women in the United States after medical abortions with Mifeprex^® (mifepristone, formerly RU-486; Danco Laboratories, New York, New York) and intravaginal misoprostol (1). Two of these deaths occurred in 2003, one in 2004, and one in 2005. Two of these U.S. cases had clinical illness consistent with toxic shock and had evidence of endometrial infection with Clostridium sordellii, a gram-positive, toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordellii toxic shock syndrome after medical abortion with mifepristone and misoprostol was reported in 2001, in Canada (2). All three cases of C. sordellii infection were notable for lack of fever, and all had refractory hypotension, multiple effusions, hemoconcentration, and a profound leukocytosis. C. sordellii previously has been described as a cause of pregnancy-associated toxic shock syndrome (3).

Investigation by FDA, CDC, and state and local health departments into the two most recently identified U.S. deaths after medical abortion is ongoing. Empiric therapy for patients suspected of having postpartum or postabortion toxic shock syndrome should include antimicrobials with anaerobic activity against Clostridium species. Health-care providers are encouraged to report any cases of postpartum or postabortion toxic shock syndrome to their state or local health department and to CDC at telephone 800-893-0485. Cases potentially associated with use of mifepristone or misoprostol should also be reported through the FDA MedWatch system available at http://www.fda.gov/medwatch/index.html or telephone 800-FDA-1088.

References

1. Food and Drug Administration. FDA Public Health Advisory: sepsis and medical abortion. Rockville, Maryland: Food and Drug Administration, Center for Drug Evaluation and Research; 2005. Available at http://www.fda.gov/cder/drug/advisory/mifeprex.htm.

2. Sinave C, Le Templier G, Blouin D, Leveille F, Deland E. Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease. Clin Infect Dis 2002;35:1441--3.

3. McGregor JA, Soper DE, Lovell G, Todd JK. Maternal deaths associated with Clostridium sordellii infection. Am J Obstet Gynecol 1989;161:987--95.

Editorial Note

Editorial Note: The number of Toxic Shock Syndrome cases reported annually to CDC has decreased substantially in the 10-year period since menstrual Toxic Shock Syndrome was first recognized. Changes in public awareness and diminished attention to Toxic Shock Syndrome in the medical literature might have resulted in reduced diagnosis and reporting. However, reporting of non-menstrual Toxic Shock Syndrome has remained constant during this time while menstrual Toxic Shock Syndrome reporting has decreased.

A multistate active surveillance study in 1986-1987 confirmed the trends detected by national passive surveillance (7). Through active case-finding efforts in an aggregate population of 34 million persons, the rate for menstrual Toxic Shock Syndrome was determined to be 1.0 per 100,000 women 15-44 years of age (7). This rate represented a substantial reduction from rates reported in similar studies in 1980 (6.2 per 100,000 women 12-49 years of age in Wisconsin (8), 9.0 per 100,000 women 12-45 years of age in Minnesota (9), and 12.3 per 100,000 women 12-49 years of age in Utah (10)). Active surveillance also confirmed that the proportion of Toxic Shock Syndrome associated with menstruation had decreased considerably: in 1988, menstrual Toxic Shock Syndrome accounted for 55% of cases detected both by active surveillance (7) and by the passive surveillance system.

A principle reason for the decreased incidence of menstrual Toxic Shock Syndrome may be decreases in the absorbency of tampons. In 1980, when tampon absorbency (in vitro) ranged from 10.3-20.5 g (4), very high absorbency products ( greater than 15.4 g) were used by 42% of tampon users (9). After the association between Toxic Shock Syndrome and absorbency was recognized, manufacturers lowered the absorbency of tampons. In 1982, the Food and Drug Administration (FDA) issued a regulation requiring that tampon package labels advise women to use the lowest absorbency tampons compatible with their needs. By 1983, tampon absorbency ranged from 6.3-17.2 g (6), and the proportion of tampon users using very high absorbency tampons had declined to 18%. By 1986, very high absorbency products were used by only 1% of women who used tampons. Effective March 1990, the FDA instituted standardized absorbency labeling of tampons, which currently range from 6-15 g.

Tampon composition has also changed since 1980. Rely tampons consisted of polyester foam and cross-linked carboxymethylcellulose, a combination that is no longer used in tampons. Polyacrylate-containing tampons were withdrawn from the market in 1985. Current tampons are manufactured from cotton and/or rayon. The unique composition of Rely tampons may have been responsible for the increased risk associated with those products (11); however, the role of current tampon composition as an independent risk factor for Toxic Shock Syndrome is unclear since composition may vary even for a particular brand and style of tampon marketed at a given time.

Other factors may have contributed to decreased reports of menstrual-related Toxic Shock Syndrome. For example, public awareness of the syndrome may cause women to seek medical care earlier in their illness; milder disease may not meet the surveillance case definition of severe multisystem illness. Increased variety in menstrual products and concern related to Toxic Shock Syndrome may have resulted in fewer women using tampons or fewer using tampons continuously.

Current public health efforts to prevent menstrual-related Toxic Shock Syndrome include tampon package labels and package inserts which describe early signs and symptoms of Toxic Shock Syndrome and warn the consumer about the risk associated with tampons. Tampon users are encouraged to select lower absorbency products to further decrease risk of Toxic Shock Syndrome. Standardized absorbency labeling permits consumers to compare absorbency between brands.

The precise mechanism by which Rely tampons increased the risk of Toxic Shock Syndrome is unknown. The increased risk associated with high absorbency tampons is also poorly understood; high absorbency may be a surrogate for another effect. However, the withdrawal of Rely tampons and the subsequent decrease in use of high absorbency tampons correlate with a marked decrease in incidence of menstrual-related Toxic Shock Syndrome. The rapid demonstration of the risk of Rely and high absorbency tampons resulted in prompt public health interventions and substantial reduction in menstrual Toxic Shock Syndrome.

References

1. CDC. Toxic-shock syndrome--United States. MMWR

1980;29:229-30.

2. Todd J, Fishaut M, Kapral F, Welch T. Toxic-shock syndrome associated with phage-group-1 staphylococci. Lancet 1978;2:1116-8.

3. CDC. Follow-up on toxic-shock syndrome--United States. MMWR 1980;29:297-9.

4. Osterholm MT, Davis JP, Gibson RW, et al. Tri-state toxic-shock syndrome study: I. Epidemiologic findings. J Infect Dis 1982;145:431-40.

5. Schlech WF, Shands KN, Reingold AL, et al. Risk factors for development of toxic shock syndrome: association with a tampon brand. JAMA 1982;248:835-9.

6. Berkley SF, Hightower AW, Broome CV, Reingold AL. The relationship of tampon characteristics to menstrual toxic shock syndrome. JAMA 1987;258:917-20.

7. Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shock syndrome in the United States, 1986. Rev Infect Dis 1989;2(suppl S1):S35-42.

8. Davis JP, Chesney PJ, Wand PJ, LaVenture M, the Investigation and Laboratory Team. Toxic-shock syndrome: epidemiologic features, recurrence, risk factors, and prevention. N Engl J Med 1980;303:1429-35.

9. Osterholm MT, Forfang JC. Toxic-shock syndrome in Minnesota: results of an active-passive surveillance system. J Infect Dis 1982;145:458-64. 10. Latham RH, Kehrberg MW, Jacobson JA, Smith CB. Toxic shock syndrome in Utah: a case-control and surveillance study. Ann Intern Med 1982;96:906-8. 11. Broome CV. Epidemiology of TSS in the United States: overview. Rev Infect Dis 1989;2 (suppl S1):S14-21.

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