When do girls become young ladies, i.e. start to menstruate?

Many people recognize the transition of a girl into a young lady when she has her first period. "Menarche" is a young lady's first menstruation, or the date she has her first menstrual period, and when she begins menstruating.

A young lady´s first period or menarche usually begins between the ages of 9 and 14, although sometimes as early as 8 and as late as 16. Her first period is also a sign that puberty has begun. For more information about your daughter's puberty, see our article; Puberty: When Your DaughterBecomes a Young Woman.

Special note to Dad´s:

Your daughter needs your love and support now more than ever. Be involved!! Menstruation and growing up is a normal part of YOUR daughter's life and not something to shy away from. Talk with your daughter about these topics, let her know that you know what she will be experiencing and to feel free to ask you any questions she may have, and that if you don't know the answer(s) that you will find it out for her. Don't let your daughter get the answers to her questions from her girlfriends, or other unreliable sources. When she gets her first period, and sees blood coming from her vagina, she may be very frightened. Some girls, who were not prepared by their mothers or fathers for their first period, absolutely thought they were dying. They were scared and afraid. Prepare your daughter; prepare yourself, and have that talk with her!

And when she has her first period, celebrate the day and make a big deal of it… take her out on a special daughter – daddy "date" to her favorite restaurant, buy her flowers, take her shopping…. let her know that you are thrilled about her becoming a young lady!!

How old will I be when I stop menstruation?

Women normally menstruate until they are 45 to 55 years old, when menopause begins. Menopause is when a female stops menstruation. An operation called ahysterectomy, which removes some or all of the female reproductive organs, also stops menstruation.

What happens during menstruation?

Women have thousands of tiny eggs in their ovaries. Each month, or approximately every 21 – 42 days, on average, one of the eggs leaves an ovary and travels through the fallopian tube. When the egg leaves the ovary, this is called ovulation. Normally, the ovaries alternate each month, releasing an egg from the left ovary one month and then releasing an egg from the right ovary the next month.

As the egg travels in the fallopian tube, a soft spongy lining forms in the uterus. This lining is mostly made of tiny blood vessels and is called the endometrium. The lining gives nourishment in case an egg and sperm meet to form an embryo, or baby, that begins to grow in the uterus.

If the egg is not joined by a sperm, the endometrium or lining of the uterus is not needed. It flows out of the vagina. This bleeding is called a period. This whole cycle is called menstruation.

Menstruation is just one part of the menstrual cycle, in which a woman's body prepares for pregnancy each month. A cycle is counted from the first day of one period to the first day of the next. An average cycle is 28 days, but anywhere from 23 to 35 days is normal.

Estrogen and progesterone levels are very low at the beginning of the cycle. During menstruation, levels of estrogen, made by the ovaries, start to rise and make the lining of the uterus grow and thicken. In the meantime, an egg (ovum) in one of the ovaries starts to mature. It is encased in a sac called the Graafian follicle, which continues to produce estrogen as the egg grows.

At about day 14 of a typical 28-day cycle, the sac bursts and the egg leaves the ovary, traveling through one of the fallopian tubes to the uterus. The release of the egg from the ovary is called ovulation. Some women know when they're ovulating, because at mid-cycle they have some pain—typically a dull ache on either side of the lower abdomen lasting a few hours. The medical word for this is mittelschmerz, from the German, meaning middle pain. Some women also have very light bleeding, or spotting, during ovulation.

After the egg is expelled, the sac–now called a corpus luteum—remains in the ovary, where it starts producing mainly progesterone. The rising levels of both estrogen and progesterone help build up the uterine lining to prepare for pregnancy.

The few days before, during and after ovulation are a woman's "fertile period"-the time when she can become pregnant. Because the length of menstrual cycles varies from one person to another, many women ovulate earlier or later than day 14. It's even possible for a woman to ovulate while she still has her period if that month's cycle is very short. Oftentimes, stress can play a role in this occurring.

If a woman has sex with a man during this time and conception occurs (his sperm fertilizes the egg), she becomes pregnant.

The fertilized egg attaches to the uterus, and the corpus luteum makes all the progesterone needed to keep it implanted and growing until a placenta (an organ connecting the fetus to the mother) develops. The placenta then makes hormones and provides nourishment from the mother to the baby.

If an egg is not fertilized that month and the woman doesn't get pregnant, the corpus luteum stops making hormones and gets reabsorbed in the ovary. Hormone levels drop again, the lining of the uterus breaks down, menstruation begins, and the cycle repeats.

In the illustration below, an egg has left an ovary after ovulation and is on its way through a fallopian tube to the uterus.

Feminine Hygiene & Your Monthly Period

Menstrual Bleeding, What´s Normal and What´s Not?

Most menstrual periods last from three to five days, but anywhere from two to seven days is normal. The amount of blood flow varies, too, but for most women, bleeding starts out light at first, followed by heavier flow for a day or two and then another light day or two. Sanitary pads or tampons, which are made of cotton or another absorbent material, are worn to absorb the blood flow.

Sanitary pads are placed inside the panties; tampons are inserted into the vagina.

The amount of bleeding varies from woman to woman because everybody's body has a different way of building up the lining of the uterus. A lighter flow or heavier flow doesn't mean you can't get pregnant as easily or you're never going to get pregnant, or that your periods will always stay the same way. But if you're bleeding excessively-soaking one or more tampons or pads an hour-you should see a doctor to see if there's a problem.

Teenagers often are concerned if they expel blood clots during their periods. This is very normal and not dangerous. The menstrual clots are clumps of pooled blood in the vagina. Sometimes, instead of flowing freely, blood drains from the uterus and stays in the vagina until there's a change in position–say, from sitting to standing.

Young women experiencing their first periods often wonder, "Will my periods ever become“ regular? When a girl starts to menstruate, her period may not come on a regular schedule for several years. Her periods may come three weeks apart, or even months apart.

Why you need to keep track of my periods?

A girl should keep a record so she'll know if her period is late. A late period may be sign of pregnancy or one or medical problems that you should immediately inform/visit your doctor. Also, your doctor can provide you with better care if he/she knows about your periods.

How do I keep track of my periods?

The first day of your period is called Day 1. The period or bleeding usually lasts 3 to 5 days but 7 days is not uncommon. Ovulation (when the egg is released) happens 12 to 16 days before your next period starts. Ovulation, and the days before and after, is the time when you are most likely to get pregnant.

If the female does not get pregnant, her period comes and the whole cycle begins again, with Day 1 starting over again when the next period starts. The whole cycle usually takes 21 to 36 days, but even 42 days is not unusual for a cycle.

Will I get cramps and how bad are they?

Cramps are a common complaint. More than half of menstruating women have cramp-like pain during their periods. The medical term for menstrual pain is dysmenorrhea. Cramps are usually felt in the pelvic area and lower abdomen, but can radiate to the lower back or down the legs.

Many girls have cramps severe enough to keep them home from school. In fact, according to Danforth's Obstetrics and Gynecology, dysmenorrhea is the most frequent cause of absenteeism from school among younger women. Women seem to go through phases when cramps are severe, then get better for several years, and then maybe worsen again. Most women find they have less menstrual pain after having children.

Cramps are like labor pains. Just as the uterus contracts to open up the cervix (neck of the uterus) and push out a baby, it contracts to expel menstrual blood. Often, after several years of menstruating or after childbirth, the cervical opening enlarges. The uterus doesn't have to contract as much to discharge the menstrual flow, so there is less cramping.

Menstrual pain may also come from the bleeding process itself. When the uterine lining separates from the wall, it releases chemicals called prostaglandins. Prostaglandins cause blood vessels to narrow, impeding the supply of oxygen to the uterus. Just as the pain of a heart attack comes from insufficient blood to the muscles of the heart, too little blood to the uterine muscle might cause the pain of menstrual cramps.

Menstrual pain can have other causes, although these are rare among teenagers. They include tumors, fallopian tube infection, andendometriosis, a condition in which fragments of the lining of the uterus become embedded elsewhere in the body.

Cramps are the actual uterus contractions. The uterus, which is like a pear-shaped muscle, helps get rid of the endometrium, or lining of the uterus, since no baby will be growing inside. These contractions that sometimes feel like cramps are the body´s way of shedding, or getting rid the lining of the uterus, through the vagina, and out of the body, as the lining is no longer needed that cycle.

What about cramps?

Some girls have cramps during their periods. For most they are mild and can be helped by exercise, a heating pad or aspirin. If there is a lot of pain, very long a heavy periods, or very irregular periods you should get a checkup.

What can I do to help with cramps?

Cramps are usually mild. They can be helped by exercise, warm bath, use of a heating pad or pain relievers such as aspirin.

If there is a lot of pain, long or "heavy" periods (heavy meaning more bleeding than normal), which means saturating a tampon or pad in less than 2-3 hours, or if you have irregular periods, you should inform your parents and ask them to take you to your doctor for a checkup.

Can I take a bath or shower during my period? What about exercising?

Menstruation is a very normal part of every girl's life. During your period, you can do everything you normally do, including daily baths or showers, exercising, dancing and playing sports are all fine. In fact, you will feel better by continuing your normal routine, and find that warm baths are a great way to help with any cramping you may have.

Should I choose sanitary napkins or tampons for my feminine hygiene choice?

Feminine hygiene products come in all sorts of types, sizes, shapes, absorbencies, smells (vulva and vaginal “deodorant” protection – which we DO NOT recommend using) and materials.

Sanitary napkins or pads absorb the blood from your period on the outside of your vagina. Most sanitary napkins are made with adhesive strips that you simply peel off the backing and then they will stick or adhere to your panties or pantyhose.

Can I still take a bath during my period, or should I take showers instead?

Menstruation is a very normal part of every girl's life. When you get your period, you can continue doing everything you normally do. This includes continuing to take baths or showers. However, some girls may prefer to take showers during the days of their period that bleeding is heavier.

What are sanitary napkins and how do they work?

Sanitary napkins come in different shapes, styles, absorbencies, scents, as well as thickness. Now there are thin pantiliners for light days and pads for heavy days of menstrual bleeding. All sanitary napkins, pads and pantiliners are made with removable strips of paper that reveal adhesive tape that is made to stick to the panties. Other pads and pantiliners have wrap-around "wings" that wrap under the panties to keep it from moving or "bunching." Some young ladies don´t like the feeling of sitting on a pad and may choose a tampon over a pantiliner on their heavy days.

What are tampons and how do I use them?

Like pads and pantiliners, tampons come in many different brands, sizes, styles, thickness, absorbencies and scents. Also like pads and pantiliners, tampons absorb the menstrual blood, except tampons absorb the menstrual blood from inside of the vagina, instead of from the outside. Tampons are placed inside your vagina. Tampons can be used whether or not a girl has had intercourse and tampons cannot get lost inside your body.

They come in applicator and non-applicator styles. There are "slim" or "slender" tampons for young ladies who have never had intercourse, or given birth via vaginal delivery. Tampons are shaped so that they can be easily inserted into your vagina and absorb the menstrual blood before it comes out.

Many women prefer to use a tampon to avoid any possible smells that are associated with menstruation. Menstrual blood that is absorbed by pads and pantiliners are exposed to the air. Not changing a pad or pantiliner frequently enough may produce a menstrual smell that some find objectionable.

Tampon Insertion: How do I Insert a Tampon?

Inserting a tampon the first time takes a little practice. It gets easier with each new period. You may want to go to the bathroom or close your bedroom door as you will want some privacy.

To insert a tampon, remove your panties, remove the wrapper of the tampon, and get into a comfortable position. Using a mirror may help you find your vagina the first few times.

The best positions are those that help expand the vaginal walls inside your vagina, to help ease the tampon into place. Some women like a squatting position; others are comfortable sitting on the toilet. In any case, you will want to spread your legs apart, and then using one hand, spread the labia minora, so that you can see or feel the entrance to your vagina. Keeping your legs apart, while keeping your labia minora separated, slowly insert the tampon toward the small of your back. You may need to use a little vaginal lubricant spread on the outside of the tampon for easier insertion. Insert the tampon until the ridges of the tampon applicator come in contact with the entrance to your vagina. Then, slowly insert or press down on the plunger that pushes the tampon into the correct position inside your vagina.

Once a tampon is properly inserted, you shouldn’t be able to feel it. Don’t worry that the tampon can "fall out" because the walls of your vagina hold it in place.

If you can still feel the tampon, you are either using the wrong size tampon or may not have inserted the tampon far enough from your vagina. After pushing down on the plunger, and inserting the tampon, remove and discard the applicator, BUT NOT IN THE TOILET, THE TOILET MAY EASILY STOP UP AND THEN FLOOD THE BATHROOM AND THE HOUSE!

Before pulling your panties back up, make sure the string on the end of the tampon remains outside of your vagina. You will pull the string to remove the tampon when it’s time to change.

How do I urinate with a tampon in my vagina?

Urinating with a tampon in your vagina is really simple and easy. And when you urinate, this is also the best time to check to see if your tampon needs to be replaced.

To urinate, simply go to the bathroom as you normally would, but before you start urinating, move the tampon string to either the left side or right side of your vulva so that you don’t get urine on the tampon removal string.

Going to the restroom is also a great time to see if your tampon needs to be changed. One way of determining whether your tampon needs to be changed is by tugging slightly on the string. If your tampon seems to not want to come out, it’s probably not time to change your tampon, as it hasn’t absorbed enough menstrual fluid, and is drier, than more wet. If, however, your tampon seems to slide easily, this is an indicator that your tampon is saturated, or has absorbed as much blood as it can hold. Another indicator that it’s time to change your tampon is when your vagina is leaking menstrual blood onto your panties.

How do I Remove the "Saturated" Tampon?

Removing your tampon is also very easy. When you believe your tampon has absorbed as much menstrual blood as it can hold, it’s time to change. Simply pull on the string of the tampon in your vagina. This will remove the saturated tampon. Then discard the used tampon in the trash – NOT IN THE TOILET! You can then insert a new tampon.

SPECIAL NOTE:

NEVER SLEEP OVERNIGHT WITH A TAMPON IN YOUR VAGINA AS THIS MAY CAUSE TOXIC SHOCK SYNDROME.

Most tampons come with a plastic or cardboard applicator to make it easier to put them in. Only the tampon remains inside the body.

For women who have had a vaginal birth, wider tampons are recommended. This is because their vaginas have been enlarged due to vaginal childbirth. If they did use a slender tampon during their period she would normally have leakage. The tampon would not be adequate, a thicker one is needed.

How often should tampons, pantiliners, pads or alternative feminine hygiene product be changed?

Pads, pantiliners, tampons or other alternative feminine hygiene products should be changed often enough so that there is no unpleasant odor or your clothes do not get stained. Changing tampons, pads, pantiliners often can help prevent infections. During the heaviest days of your period, you may need to change them every 3-4 hours.

Depending on how heavy or light your menstrual flow is – which varies during each day of your period, from light bleeding, to heavy, almost “gushing” bleeding, back to light bleeding again – will determine the type(s) of feminine hygiene product you may use. Some women start out by using a pantyliner only. While the menstrual flow increases, they may switch to a pad, and many women find they need to use a pad and a tampon simultaneously for the best feminine hygiene results.

It is very common for women to use a pad as "back-up" to a tampon, as a tampon will leak if it is not changed when it is saturated.

NEVER FLUSH A TAMPON DOWN THE TOILET AS THIS MAY CAUSE SERIOUS PLUMBING PROBLEMS AS WELL AS SERIOUS EMBARRASSMENT AFTER THE PLUMBER DISCOVERS WHAT CAUSED THE PROBLEM!

IMPORTANT! NEVER USE OR APPLY TALCUM POWDER ON OR NEAR YOUR VAGINA OR VULVA OR THAT OF BABY GIRLS. This also includes not using talcum powder on your pad or tampon. Talcum powder use has been linked to cervical, vaginal, ovarian and vulva cancer.

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 immediately.

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. It is preferable to use other methods such as condoms and/or foam.

What is "Toxic Shock" or Toxic Shock Syndrome (TSS)?

Toxic Shock Syndrome is a rare infection that can happen during a woman's period. Thesymptoms include a sudden fever of over 101 degrees or more, diarrhea (theruns), vomiting (throwing up), muscle aches and a sunburn-like rash. If you havethese 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. 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 orbe 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 bacterialtoxin. (Different bacterial toxins may cause Toxic Shock Syndrome, depending onthe situation, but most often streptococci and staphylococci are responsible.) The number of reported Toxic Shock Syndrome cases has decreasedsignificantly in recent years. Approximately half the cases of Toxic ShockSyndrome reported today are associated with tampon use during menstruation,usually in young women. Toxic Shock Syndrome also occurs in children, men, andnon-menstruating women. In 1997, only five confirmed menstrual-related ToxicShock Syndrome cases were reported, compared with 814 cases in 1980 [accordingto data from the Centers for Disease Control and Prevention (CDC)]. Althoughscientists have recognized an association between Toxic Shock Syndrome andtampon use, the exact connection remains unclear. Research conducted by the CDCsuggested that use of some high absorbency tampons increased the risk of ToxicShock Syndrome in menstruating women. A few specific tampon designs and highabsorbency tampon materials were also found to have some association withincreased risk of Toxic Shock Syndrome. These products and materials are nolonger used in tampons sold in the U.S. Tampons made with rayon do not appear tohave a higher risk of Toxic Shock Syndrome than cotton tampons of similarabsorbency.

Vaginaldryness and ulcerations may occur when women use tampons more absorbent thanneeded for the amount of their menstrual flow. Ulcerations have also beenreported in women using tampons between menstrual periods to try to controlexcessive vaginal discharge or abnormal bleeding. Women may avoid problems bychoosing a tampon with the minimum absorbency needed to control menstrual flowand 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 absorbencyon 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 illnessoccurred during menstruation in 38 (95%) of the 40 women from whom menstrualhistory was obtained. National and state-based studies were initiated todetermine risk factors for this disease. In addition, CDC established nationalsurveillance to assess the magnitude of illness and follow trends in diseaseoccurrence; 3295 definite cases have been reported since surveillance wasestablished (Figure 1).

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

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

Clostridium Sordellii

Toxic Shock Syndrome After Medical Abortion with Mifepristone andIntravaginal 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 medicalabortions with Mifeprex^® (mifepristone, formerly RU-486; Danco Laboratories, New York, New York) and intravaginal misoprosto.

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 ofendometrial infection with Clostridium sordellii, a gram-positive,toxin-forming anaerobic bacteria. In addition, a fatal case of C. sordelliitoxic shock syndrome after medical abortion with mifepristone and misoprostolwas reported in 2001, in Canada

2. All three cases of C. sordellii infectionwere notable for lack of fever, and all had refractory hypotension, multipleeffusions, hemoconcentration, and a profound leukocytosis. C. sordelliipreviously has been described as a cause of pregnancy-associated toxic shocksyndrome.

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 forpatients suspected of having postpartum or postabortion toxic shock syndromeshould include antimicrobials with anaerobic activity against Clostridiumspecies. Health-care providers are encouraged to report any cases of postpartumor postabortion toxic shock syndrome to their state or local health departmentand to CDC at telephone 800-893-0485. Cases potentially associated with use ofmifepristone or misoprostol should also be reported through the FDA MedWatchsystem available at http://www.fda.gov/medwatch/index.htmlor 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:

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

Amultistate active surveillance study in 1986-1987 confirmed the trends detected by national passive surveillance (7). Through active case-finding efforts in anaggregate population of 34 million persons, the rate for menstrual Toxic ShockSyndrome 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 studiesin 1980 (6.2 per 100,000 women 12-49 years of age in Wisconsin (8), 9.0 per100,000 women 12-45 years of age in Minnesota (9), and 12.3 per 100,000 women12-49 years of age in Utah (10)). Active surveillance also confirmed that theproportion of Toxic Shock Syndrome associated with menstruation had decreasedconsiderably: in 1988, menstrual Toxic Shock Syndrome accounted for 55% of casesdetected both by active surveillance (7) and by the passive surveillance system.

Aprinciple reason for the decreased incidence of menstrual Toxic Shock Syndromemay 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 ( greaterthan 15.4 g) were used by 42% of tampon users (9). After the association betweenToxic Shock Syndrome and absorbency was recognized, manufacturers lowered theabsorbency of tampons. In 1982, the Food and Drug Administration (FDA) issued aregulation requiring that tampon package labels advise women to use the lowestabsorbency tampons compatible with their needs. By 1983, tampon absorbencyranged from 6.3-17.2 g (6), and the proportion of tampon users using very highabsorbency tampons had declined to 18%. By 1986, very high absorbency productswere used by only 1% of women who used tampons. Effective March 1990, the FDAinstituted standardized absorbency labeling of tampons, which currently rangefrom 6-15 g.

Tampon composition has also changed since 1980. Rely tampons consisted of polyester foam and cross-linked carboxy methylcellulose, a combination that is no longer used in tampons. Polyacrylate-containing tampons were withdrawn from the marketin 1985. Current tampons are manufactured from cotton and/or rayon. The uniquecomposition of Rely tampons may have been responsible for the increased risk associated with those products (11); however, the role of current tamponcomposition as an independent risk factor for Toxic Shock Syndrome is unclearsince 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 inmenstrual 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 tofurther 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 tamponsis also poorly understood; high absorbency may be a surrogate for another effect. However, the withdrawal of Rely tampons and the subsequent decrease inuse of high absorbency tampons correlate with a marked decrease in incidence of menstrual-related Toxic Shock Syndrome. The rapid demonstration of the risk ofRely and high absorbency tampons resulted in prompt public health interventions and substantial reduction in menstrual Toxic Shock Syndrome.

Tampon Truth's and Tragedies

The Following Information Courtesy of  http://www.tamponalert.org.uk and in Memory of Alice Kilvert, who died at the age of 15 due to Tampon use and Toxic Shock Syndrome 
 

Alice's Story

Alice Kilvert, aged 15, died on Tuesday, 26th November 1991 of tampon-related ToxicShock Syndrome at Trafford General Hospital, Manchester. Alice's symptoms were initially very mild and did not cause any undue concern. On the Sunday prior to her death she complained of a headache which persisted, but eased with aspirin. During Sunday evening she was able to watch television, but she was sick during the night. Although very pale on Monday morning, she went to school in order to start her mock GCSE exams, but was taken home as she appeared to be developing influenza.. Alice went straight to bed and by tea time she hada slight temperature. At 7pm she was alert enough to talk about the early evening TV she had missed, but by 10pm she seemed vague and confused and alittle faint. The next morning Alice's breathing was shallow and she had a higher temperature, so the emergency doctor was called. The doctor phoned for an ambulance for Alice to betaken to hospital, but when the ambulance staff tested for blood pressure, it was so low it hardly registered. She arrived at hospital at 9am and her condition was diagnosed as either TOXIC SHOCK SYNDROME or meningitis, and treatment began. She was taken into Intensive Care and put onto a ventilator asher breathing was giving cause for concern. However, the strain on her heart brought on two cardiac arrests. She did not recover from the second one and died at 1pm.

More Stories on Women and Girls who Died or were Injured due to Tampon-induced Toxic Shock

KATIE OF NOTTING HAMSHIRE
Posted on 30/12/2000

In the summer of 1990, Katie, then aged 15, went on holiday to Devon with herfamily. It was a holiday that she'll never forget. One morning she woke up with a headache and feeling shivery. Her mother thoughtthat it could be flu and suggested that she should stay in bed. During the dayher symptoms worsened as her temperature rose; she had aching muscles, a stiffneck and a sore mouth.

By tea time she became breathless and she was so weak that she needed assistanceto go to the toilet. Her parents sent for the doctor, who diagnosed a virus andprescribed antibiotics. That night Katie's temperature soared to 102 degrees.The next morning she felt awful and had a severe headache. Her mother noticed ared rash on her leg. Katie's eyes were pink and sticky and her skin was turningyellow. The doctor was called again. He took one look at her and called for anambulance. She was rushed to hospital.

At the hospital, the doctors performed a lumber puncture to test for meningitisand took a blood sample to test for glandular fever. Then the doctor discoveredthat Katie was menstruating and took a vaginal swab for testing. By now, herjoints were swollen, her mouth was blistered, her liver and kidneys were failingand her veins and arteries had gone into spasm. She was transferred to Intensive Care.

The next morning a microbiologist had identified that Katie was suffering fromToxic Shock Syndrome, brought on by the tampons she had been using. She wasbeing treated by the right antibiotics, and the doctors said that they wouldjust have to wait and hope. Katie remained conscious for the three days that shewas in Intensive Care. The pain was excruciating. She was transferred to a wardand after a week she was strong enough to go home with the aid of a wheelchair.

Katie felt weak for months. Thick layers of skin peeled off her hands and feet.This was as a result of the blood supply being cut off from her extremitiesduring her illness. Then her hair started to fall out in clumps. This lasted forsix months, and it has never grown back to its previous thickness. She realizedthat her memory wasn't as good and her ability to concentrate had diminished.

Katie remembers being told at school that Toxic Shock Syndrome is caused byleaving a tampon in too long. Now she knows differently. Any woman or girl whouses tampons can get TSS. That's why she'll never use tampons again. It might berare, but you never know who it might strike next.

JEAN OF SURREY
Posted on 30/12/2000

Jean was 46 when she suffered from Toxic Shock Syndrome. It was the second dayof her period and she was using tampons. She'd had a headache all day that wouldn't go away, so she decided to go to bed early that evening. Jean couldn't sleep and her headache intensified. Suddenly she was vomiting and suffering from diarrhea. Jean thought that it must be food poisoning. The next day, Jean feltno better, although the sickness and diarrhea had stopped. When she began tolapse into unconsciousness her daughter telephoned the doctor, who immediately summoned an ambulance. By this time Jean's lips had a bluish tinge and she was having breathing difficulties. She went into a coma on the way to hospital asher blood pressure plummeted.

In Intensive Care, Jean needed a ventilator and dialysis as her kidneys had ceased to function. Doctors noticed that the tips of her fingers and toes were turning black with gangrene. Over the next three weeks Jean was so weak that she only had a 20% chance of survival. Because of the drugs her weight ballooned from 10 stone to 13 stone. Her blonde hair turned grey and her green eyes turned blue. The gangrene spread to her knee, nose and the back of her head. Jean went into stress and was given a tracheotomy to help her to breathe. Her veins were collapsing and it was almost impossible to insert the necessary drips.

At this point the doctor asked Jean's husband if he could try an experimental drug which he hoped would increase her extremely low blood pressure. With in minutes Jean started to respond and her blood pressure began to increase. Shewas going to make it, although she was still critically ill. Two days later sheopened her eyes and asked where she was. She noticed her black toes. Jean spent six months in hospital and eventually had her toes amputated. Her feet were very painful and she had to get used to walking again. Now she wears special shoes and occasionally uses a walking stick. Jean finds it difficult to concentrate and has problems with her short-term memory.

Jean says that it's a miracle that she's alive today. She has enormous admiration for the doctors, nurses and of course her family who were with her all the time. Jean says that she will never use a tampon again. She has told all her friends and neighbors not to believe those trendy tampon adverts on the TV."Tampons nearly killed me and they will kill others," she says.

JUDY OF OXFORD SHIRE
Posted on 30/12/2000

udy, a 27 year old mother, had been using tampons since she was 12. Her episode of Toxic Shock Syndrome began 10 weeks after the birth of her second daughter. She woke up on the third day of her period feeling tired and her head was spinning, but she had to look after her new baby and her 2 year old daughter. By evening she was exhausted and went to bed really early and just slept. The next morning, Judy got up and felt fine. But an hour after her husband had gone to work she had no strength to do anything. She vomited twice and had severe diarrhea. She phoned her mother to look after the girls and went back to bed.She felt worse and worse before eventually getting off to sleep.

The next morning was the same. Judy was fine until after her husband had left for work. A sudden attack of diarrhea hit her before she could reach the toilet. Once again she asked her mother to look after the children, and her mother also called the doctor. Judy was taken to the hospital by her sister-in-law and nearly fainted. Her legs were so painful and weak that she needed a wheelchair. Her skin was yellow. Judy was admitted to the infectious diseases ward for tests and the diarrhea was still running out of her. Within the hour they had put two drips into her. The doctors had found her tampon by now and had taken it away for testing. She had a rash on her lower legs and feet.

By the next morning, and numerous doctors later, they had diagnosed Toxic Shock Syndrome. Judy was put on even more drips and had heart and kidney checks. Her fingers and toes tingled all the time, like a burning sensation. The skin on her fingers and toes later peeled off and it was terrifying and very painful. A week in hospital and she was fit enough to go home.

Judy had to take tablets and return to hospital for heart and kidney checks andblood tests. She seemed to recover quite well, but lost her sense of taste for about 5 weeks. She was under health surveillance for 6 months and received the all clear. Then Judy's hair started falling out. It didn't leave her bald, butit was very thin in places. This lasted about two months before getting back to normal. Judy says that not enough people know about the dangers of tampons and Toxic Shock Syndrome. She will never use tampons again, and there's no way she'd lether daughters use them either.

ANNETTE OF MIDDLESEX
Posted on 30/12/2000

Annette was a healthy 17 year old at boarding school in Surrey. One Friday, in June 1989, just seven weeks before her 18th birthday, she felt a bit under the weather. She had just started her period and was using high absorbency tampons. By Sunday, she was in the school sick bay, and her worried parents were driving to visit her. Annette had a high temperature, severe headache and "appeared distant". However, it wasn't until the Wednesday that she was rushed to hospital, with what doctors thought was a burst appendix.

In the early hours of the Thursday, she was put onto a ventilator, and her parents had what was to be their last conversation with Annette. The doctors advised her parents that she was suffering from toxic shock syndrome, a disease that they had never heard of. During the night Annette's condition suddenly deteriorated and she suffered twomassive heart attacks and died.

KAREN OF HAMPSHIRE
Posted on 30/12/2000

One Thursday in January 1991, 20 year old Karen became ill with sickness and diarrhea. Although she was not aware of the connection, she was having her period and using tampons. She called the doctor who initially diagnosed gastro-enteritis and gave her some medicine. Karen continued vomiting, suffered severe diarrhea and was in agony, and on Sunday the doctor suspected appendicitis and she was rushed to hospital. As she was severely dehydrated, Karen was immediately put on a drip, whilst the diagnosis was being made.

The next morning (Monday), Karen felt fine and was laughing and joking with her parents. However, her mother noticed that her breathing was labored and that she had a red rash on her leg. But by 3 pm, Karen's condition worsened and she was given oxygen. By 9 pm she had lapsed into unconsciousness and transferred to Intensive Care. The medical staff did not know what was causing the problem, although toxic shock was considered. She had 15 tubes going into and out of her. At 10 pm Karen suffered a cardiac arrest, and the IC staff resuscitated her, but her condition was critical. At 1 among the Tuesday morning, Karen had a last injection to stimulate her blood flow, and her parents were told that this was her last hope. Tragically,Karen died at 2.15 am from Toxic Shock Syndrome due to tampons.

DELYSE OF BUCKING HAMSHIRE
Posted on 30/12/2000

Delyse was a 32 year old secretary. Early in August 1993, Delyse' menstrual period started and she began using tampons as usual. However, this time it was to have tragic consequences. On Saturday morning, Delyse suddenly started vomiting, had severe diarrhea and a high temperature. She thought that she was suffering from food poisoning. Later that day her partner called the doctor, who diagnosed flu. On theMonday, Delyse went back to her GP who diagnosed gastritis – inflammation of the lining of the stomach.

Her condition worsened and on Tuesday she was admitted to the local hospital with a suspected burst appendix. Delyseseemed to be in a stable condition whilst the diagnosis began, but within 24hours, she was rushed into Intensive Care, then onto a ventilator as her lungs had collapsed. She was then transferred to a specialist hospital nearby, whereher condition improved slightly. When her vital organs, including liver and kidneys, failed, Delyse was put onto a dialysis machine. After 5 weeks of fighting for her life, Delyse suffered a massive brain haemorrhage anddied on 9th September.

SHARON OF COUNTY DURHAM
Posted on 30/12/2000

Sharon, a keen sports woman, died of Toxic Shock Syndrome two months after giving birth to her second child. Her husband Anthony recalls the joy and the tragedy of eight weeks in late 1991. Twentysix year old Sharon used tampons for her first period after the birth of Rebecca. It started one Sunday when she began to feel very tired. By Monday, Sharon was suffering with diarrhea, vomiting and a prickly red rash. The doctor was called and diagnosed a virus.

On Thursday, her condition had deteriorated. Now, Sharon's fingernails and lips were turning blue, the rash was like sunburn and she was having breathing difficulties. Sharon was rushed to hospital. Her condition improved slightly, but then herkidneys collapsed and she was transferred to Intensive Care. Doctors diagnosedtoxic shock syndrome, caused by the tampon that she had been using.

The deadly toxins were causing all sorts of problems as they poisoned every part ofher body. Her lungs were beginning to fail and she was transferred to the Regional specialist hospital where a lung transplant was considered. However, Sharon was too ill to undertake this operation. Doctors fought so hard to save her life, but after eight weeks of intensive care, Sharon suffered a cardiac arrest and died.

SHANE OF BRISTOL
Posted on 30/12/2000

Thirty three year old mother of two, Shane, died of tampon-related Toxic Shock Syndrome in March 1994. On Friday 4th March, Shane said she didn't feel well. During the early hours of Saturday morning she began vomiting and felt awful. She asked her mother to lookafter the children.

By Sunday she was suffering severe diarrhea, she had a red rash and was now semiconscious. She had a high temperature, her breathing was labored, and she hadpus coming from her eyes. At 9 am her husband phoned the doctor who suggested that it was a stomach bug. Shane's husband insisted that the doctor must visit,but on arrival, the doctor confirmed a stomach bug, and suggested paracetamol tolower her temperature.

By Monday, Shane's condition had not improved and her mother called the doctor again. The doctor took one look at Shane and called an ambulance. She arrived athospital at 3 pm and went straight into Intensive Care. But after six cardiac arrests, Shane died at 5.30 pm.

PAMELA OF EDINBURGH
Posted on 30/12/2000

One Sunday in March 1993, Pamela aged 34, took to her bed with a severe sore throat.At the time she knew that a lot of people round about had flu, so she thought that she must be getting it too. On Monday morning she felt really faint. Her husband went off to work, but asked Pamela's mother to phone the doctor. The doctor diagnosed a sore thro at and prescribed penicillin. Although Pamela was able to talk coherently to the doctor, she can't remember the rest of the day, not even talking strangely toher husband when he arrived home from work. She felt so tired. The doctor wastelephoned again and he suggested looking to see if Pamela had spots on herfeet! She did have. The doctor called 'round again and got her admitted tohospital with suspected meningitis.

Luck was with Pamela that evening because the Specialist on duty had seen Toxic Shock Syndrome before. The tampon that had been removed when Pamela was admitted tothe hospital was tested positively for Staphylococcus aureus and TSS was diagnosed. Ten days of hospital treatment saved Pamela's life, but she was so weak that she had to leave the hospital in a wheelchair and learn how to walk again.

It took months to recover physically and even longer to recover mentally. She lost a lot of her hair, her skin started peeling off and she ached all over. She had been using tampons since she was 17, but will never again use tampons.

FIONA OF ROSS SHIRE
Posted on 30/12/2000

On New years Eve 1990, 22 year old Fiona, woke up with crippling period pain. Hermother phoned work to let them know that Fiona would not be in today. As the daywore on Fiona became worse and started vomiting. At tea time the doctor was called and flu was diagnosed. But over the next few hours, Fiona's condition deteriorated. She started with diarrhea, her temperature soared and she developed a rash all over her neck. A worried mother called the doctor again at2 am, and again flu was diagnosed.

The nextmorning, Fiona was unconscious and the ambulance was called. On arrival at thehospital, meningitis was first suspected, (but it wasn't until 3 months later that tampon-related toxic shock syndrome was confirmed). Fiona's temperature had rocketed and she was surrounded by bags of ice. The intensive care staff worked through the day, but at 3 am the next morning, Fiona suffered a cardiac arrest.The team managed to save Fiona, but the shattering news was that Fiona may be brain damaged, blind and paralyzed in all four limbs.

In the next two weeks Fiona fought for her life. Her kidneys failed and she needed dialysis, and her toes turned black with gangrene and would have to be amputated. Three months later, Fiona started to come out of her coma. She couldn't speak, but she could hear and smile. Fiona stayed in hospital over the next year and was on drips and dialysis, and having physiotherapy and speech therapy. She was transferred to a Nursing home to be close to her parents. As a result of using a tampon, Fiona is totally blind, confined to a wheelchair, unable to use her arms and only has limited speech.

FAQ's About

Tampons and Toxic Shock Syndrome

I thought that you only got TSS if you forgot to change your tampon. Is this true?

Any woman may develop TSS when using tampons as directed by the manufacturer's instructions if she is carrying the particular strain of bacteria that produces toxins and if she has not developed immunity to these toxins. The exact combination of circumstances in which toxin production occurs in the vagina of individual women is not known. It is therefore not possible to state any completely safe time limits on the use of a tampon, although it could be assumed that the longer a tampon is left in place or the more tampons are used continuously, the greater the chance of toxin production starting. This is whywe recommend keeping tampon use to a minimum and breaking the use regularly by using a sanitary towel/pad.

All known victims of TSS followed the manufacturers instructions on usage implicitly, but they still became seriously ill or even died. We think that there are several reasons why people think that a "forgotten tampon" causes Toxic Shock Syndrome:

1. Many women have been admitted to hospital with TSS whilst still using a tampon. They had become seriously ill extremely quickly and had not been physically capable of removing or changing their tampon.

2. The term "retained tampon" in medical reports, refers to a tampon being in place on admission to hospital. It is not an indication of length of use.

3. It blames the tampon user, who was too ill to defend herself; it exonerated the tampon manufacturers and it reassured dedicated tampon users.

4. It made it easier for newspaper editors (usually men) to explain why someone was ill.

Can you catch TSS from other people?

No. TSS is not a contagious disease.

What is the link between TSS and tampon use?

The link is not clearly understood. However, tampon research highlights three high RISK FACTORS: highabsorbency tampons, continuous tampon use and low body immunity.

Tampon Absorbency: the higher the absorbency the higher the risk; the lower the absorbency the lower the risk. That is why a woman should always use the lowest absorbency tampon for her menstrual flow. It also accounts for the high number of deaths due to super-absorbent tampons in 1980.

Continuous tampon use: women should not use tampons continuously during a period. It is recommended that the most convenient time to break the continuous use is at night, by using a sanitary towel/pad.

Low immunity: this is the factor that you cannot control as it may vary from time to time. It is generally understood that immunity improves with age therefore girls are at a higher risk that older women.

Is it possible to get TSS more than once?

Yes. A person who has had TSS can develop it again. If a women or girl has had TSS in the past, it is advisable not to use tampons again. Menstrual TSS recurs in around 30% of cases. Dr Mary Andrews of the Dartmouth-Hitchcock Medical Centre in New Hampshire, advises that symptoms were most likely to return in women who were not treated during their first attack, and continued to use tampons. Two thirds of Dr Andrews' study group experienced a recurrence within 5 months, although only 16% of women who were treated had recurring symptoms of TSS.

Toxic Shock Syndrome Symptoms

What are the symptoms of TSS?

Symptoms can be similar to flu or food poisoning, but they can become seriousvery quickly. The symptoms of TSS include one or more of the following:

1. Always begin AFTER a menstrual period starts.

2. Early symptoms may include headache, and/or sore throat,

3. Aching muscles and high temperature (fever).

4. Followed by vomiting, watery diarrhea,

5. Confusion and dizziness

6. A red, sunburn-like, rash on chest, abdomen or thighs

7. Very low blood pressure.

Please note: Only one or two of the above symptoms may occur. They do not necessarily occur all at once and may not persist.

What should I do if I get these symptoms?

If you have any of these symptoms and are using a tampon you should, remove and save your tampon and seek immediate medical attention (preferably at anemergency HOSPITAL). Tell the doctor that you have been using tampons andsuspect TSS (Take a TSS information leaflet with you). Don't worry about wasting the doctor's time, you could be saving your life.

What Is The Treatment For TSS?

With early diagnosis, TSS can generally be effectively treated with antibiotics andother medication to counteract the symptoms. Professor Joan Chesney, Head of Paediatrics at the University of Tennassee said in September 1997 that concerns that Staphylococcus aureus could become resistant to antibiotics have so far proved unfounded. Tests on TSS-associated strains of S-aureus at the Dartmouth-Hitchcock Medical Center in New Hampshire failed to find any methicillin-resistant Staphylococcus aureus (MRSA), the strain whichh as caused so many problems for hospitals in Europe and America. All 62 samples from menstrual and non-menstrual cases referred to the D-H Medical Center between 1984 and 1995, were susceptible to two key antibiotics – oxacillin and clindamycin – although only a handful would have responded to treatment with penicillan.

Standardtherapy for TSS continues to be on high-dose antibiotics, usually with a betalactam agent, with or without clindamycin or a related drug. You also need tostop toxin production which can be best done with a protein synthesis inhibitorsuch as clindamycin, gentamycin, erythromycin or clarithromycin. Introvenousfluids are another essential aspect of management, but doubts remain over thevalue of introvenous immunoglobulin (IVIG) injections as they carry the risk ofside-effects.

Choosing the Right Tampon Absorbency or "Size"

When using tampons, it's important to choose the lowest absorbency necessary for your menstrual flow. Because the amount of flow varies from day to day, it is likely that you will need to use different absorbencies on different days of your period. Selecting the right absorbency comes with experience, but as a guide, ifa tampon absorbs as much as it can and has to be changed before 4 hours, then you may want to try a higher absorbency. On the other hand, if you remove atampon and after 4-6 hours white fibre is still showing, you should choose alower absorbency.

Research indicates that tampons should not be used continuously during a period as continuoususe is a high risk factor. The most obvious time to break this continuous use is at night. AKTA recommends the use of a sanitary towel atnight. However, if you choose to use a tampon at night, choose the lowest absorbency needed, insert a fresh one just before going to bed and remove it as soon as you wake up in the morning. Slim line tampons are quite absorbent fortheir size, so it is highly recommended that young girls do not use tampons at night.

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 withphage-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 toxicshock syndrome: association with a tampon brand. JAMA 1982;248:835-9.

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

7. Gaventa S, Reingold AL, Hightower AW, et al. Active surveillance for toxic shocksyndrome 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 LaboratoryTeam. 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 anactive-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-controland 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 (supplS1):S14-21.

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