Intimate knowledge

PUBLISHED: February 26, 2003 at 1:00 AM CST | UPDATED: August 20, 2021 at 12:48 AM CDT

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(The headline as published has been corrected in this text.)

Seven years ago, a college student approached Carolyn Maloney, a congresswoman from Queens, N.Y., and asked her a question: Are tampons safe?

The young woman, who was working on a class project, wanted to know whether the synthetic materials, chemical glues and dioxin residue from bleaching would cause health problems. Maloney didn’t know the answer, so she did some digging.

She learned: 73 million American women use tampons, and the average woman uses as many as 16,000 tampons during her lifetime. (That’s about 35 tampons a month over the course of 38 years.) Most tampons are made with cotton combined with rayon, a synthetic material first linked to a rare, bacteria-caused illness called toxic shock syndrome that killed 55 women in the late 1970s and early ’80s.

Maloney also discovered that the Food and Drug Administration relies solely on data provided by the feminine products industry for tampon health and safety tests instead of commissioning an independent laboratory to do the testing.

“The government has done more research on the safety of coffee filters than tampons,” Maloney says. “For an issue that is so important to women’s health, women should be able to rely on independent research, not research funded by tampon manufacturers.”

So, Maloney drafted legislation and introduced the Tampon Safety and Research Act in 1997. Its purpose, the bill states, is “to provide for research to determine the extent to which the presence of dioxin, synthetic fibers, and other additives in tampons and similar products . . . pose any risks to the health of women, including risks relating to cervical cancer, endometriosis, infertility, ovarian cancer, breast cancer, immune system deficiencies, pelvic inflammatory disease, and toxic shock syndrome.”

The measure also asks the federal Centers for Disease Control and Prevention to keep better records on toxic shock syndrome (TSS) and seeks to provide basic consumer protections, such as listing ingredients on the outside of packaging.

Although many agree Maloney’s cause is worthwhile, the bill stalled in Congress. In an attempt to jump-start it two years ago, she renamed it the Robin Danielson Act, after a woman who died of toxic shock syndrome. She reintroduced the renamed bill, now known as H.R. 373, on Jan. 27. Currently, the bill awaits action in the House Subcommittee on Health.

Health risks posed by tampons first hit the public radar in 1980, when the CDC confirmed that some of the women who died had used the super-absorbent Rely brand of tampon, made from carboxymethylcellulose, rayon polyacrylate and polyester fibers.

Bacteria that cause TSS can flourish if a woman leaves tampons in too long or uses a brand that is too absorbent. The illness usually starts with flulike symptoms and, unless it is detected early, can be fatal as the bacterial toxin ravages the body and shuts down major organs one by one.

In September 1980, Rely’s maker, Procter & Gamble, took the tampons off the market. Since then, other manufacturers have reduced the rayon content in their products.

Most medical experts believe tampons today are safe, but some say the lower rayon content still poses a health risk.

Although the FDA requires tampon manufacturers to insert a warning about TSS symptoms inside the box, Maloney was surprised to learn they are not required to list the ingredients on the outside of the box, although most now do. So women have had no way of knowing what type of fibers, additives and chemical residues go into the tampons they are placing inside one of the most absorbent parts of their bodies, Maloney said.

Maloney has strong allies in Washington, but many are Democrats like Rep. John Dingell (Mich.). With a Republican-controlled Congress, she fears her bill won’t be going anywhere anytime soon. So why has Maloney’s legislation foundered? Supporters say it’s because Maloney is raising a woman’s issue in a male-dominated arena. Women’s health advocates blame tampon industry lobbyists.

A mom’s worst nightmare

While legislators mull over Maloney’s bill, Helen Danielson fears another mother will lose a daughter.

Her 44-year-old daughter, Robin Danielson, died of toxic shock syndrome in 1998. Robin, a single mother of two teenage girls, was using an ultra-absorbent tampon when she came down with what she thought was the flu.

As a supervisor at the Federal Aviation Administration in Washington, Robin had a demanding career and didn’t make time to go to the doctor. She ignored the fever, chills and aches she felt and pushed through her hectic day. Later she collapsed, exhausted and racked with a fever of 104.8 degrees. Robin’s mom stopped to check on her and decided to call an ambulance. But it was too late. The toxin had ravaged her system beyond repair and she died after 12 days in the hospital.

Danielson’s mom is afraid most people believe toxic shock has not been a problem since Rely was taken off the market. Women are still getting TSS, but the government isn’t sure how many because it has no formal record-keeping system in place.

Doctors who treat TSS are asked to report cases only on a voluntary basis, and many don’t, said CDC spokeswoman Rhonda Smith. That explains why the CDC’s most recent figures, from 1999, showed there were only seven non-fatal cases of TSS in the U.S. “We generally believe TSS is underreported,” Smith said.

If authorities don’t know how many people are dying of TSS, Danielson argues, how can it be prevented? Danielson, who lives in Naples, Fla., often volunteers at local schools to discuss what happened to her daughter and educate teens about safe tampon use.

“In my opinion, the safest tampon is the one not used,” she says. Many high school girls have never heard of toxic shock syndrome, Danielson says, and that scares her.

She believes Maloney’s legislation is not passing because it addresses a woman’s issue.

“There are too many men in Congress,” Danielson says. “But if they had to see their wife or daughter die like our daughter did, they would take up the issue.”

Phil Tierno, director of microbiology and diagnostic immunology at New York University Medical Center, agrees. Tierno, author of “The Secret Life of Germs” (Pocket Star, $25), has published TSS research studies in several medical journals, including the British journal The Lancet.

“If this particular syndrome affected men, this research would have been done a long time ago and Carolyn Maloney’s bill would have been passed,” Tierno says.

A strong feminine products industry lobby also has been a factor, Tierno believes. He says it’s cheaper and easier for tampon manufacturers to use rayon instead of using 100 percent cotton, which is vulnerable to pests, natural disasters and unpredictable prices.

Tierno’s research, which generated controversy in the tampon industry and the scientific community, was published in The Lancet in 1981 and 1985 in response to the Rely cases. His experiments showed the bacteria that causes toxic shock grows more rapidly on the more absorbent rayon fibers than on cotton.

Some concerned about dioxin

Advocates from the Milwaukee-based Endometriosis Association also believe lobbyists for the tampon industry are blocking Maloney’s bill.

“They don’t want attention brought to issues like dioxin and TSS because they sell a lot of tampons and make a lot of profits,” says Lynn Castrodale, the association’s director of environmental health.

The organization believes there may be a link between dioxin exposure and endometriosis, although some scientists theorize there is a genetic component to endometriosis, making some women more likely to have it than others.

When manufacturers bleach the cotton used in tampons, trace amounts of dioxin are left on the fibers, but they are too small to be considered a health threat, according to Procter & Gamble senior scientist Jay Gooch.

Tampons on the market today are safe because the amount of dioxin they contain is below the detectable limit, says John McKeegan, a spokesman for o.b. tampon manufacturer Johnson & Johnson.

FDA spokeswoman Sharon Snider said her agency’s scientists analyzed all of the studies on tampon safety–including both industry and outside data–and concluded they do not pose a threat to consumers.

“We have evaluated this very closely and all of the valid data has brought us to this conclusion,” Snider says. “If we thought there was any reason to be concerned, we would have taken action.”

But Endometriosis Association members are concerned that even at very low levels dioxin in tampons could contribute to the painful reproductive disease that affects an estimated 6 million women and often leads to infertility.

The organization believes the risk posed by dioxin outweighs any benefits tampons may provide, Castrodale says.

The association points to a 1993 University of Wisconsin study by Dr. Sherry Rier on the link between endometriosis and dioxin involving rhesus monkeys that developed endometriosis after eating food contaminated with dioxin. The monkeys with the highest levels of the chemical in their bodies developed the most severe cases of endometriosis.

Other scientists argue the exposure to dioxin in tampons is so minute, it’s not worth worrying about.

Critics like Procter & Gamble’s Gooch point out the monkeys were eating the most toxic form of dioxin, called TCDD, which is not found in tampons on the market today.

Research on dioxin and tampons also raises other questions.

Risks considered negligible

In a 2001 research paper published in Reproductive Toxicology, Dr. Anthony Scialli, a Georgetown University gynecology professor, found the level of dioxin in tampons is lower than the background levels of the chemical in the typical American’s body from dietary sources. (Plastic and paper factories release dioxin into the air and water as a byproduct of manufacturing. It then makes its way into cattle feedlots, streams and farm fields.)

“You have more dioxin in your blood if you are having a menstrual period than in the tampon itself,” Scialli says. “The fact is, your body is already contaminated with dioxin.”

But Endometriosis Association executive director Mary Lou Ballweg says nobody is sure exactly what level of dioxin exposure causes the disease, and its effects are cumulative over time.

“We think it makes sense to err on the side of caution,” Ballweg says. For many women with endometriosis that means giving up all bleached paper and personal hygiene products–including tampons. Ballweg believes every little bit helps, because dioxin can cause health problems at very low levels.

Meanwhile, Maloney, who recently was re-elected to a two-year term, says she still feels just as strongly about the issue.

With all of the conflicting scientific research, women are confused, Maloney says. Her bill would provide them with some clear-cut answers and consumer protection.

“I introduced this legislation so American women can make educated consumer decisions about a product that has the potential to endanger their health and lives,” Maloney says. “Seventy-three million American women use tampons, but there is no research to support the absolute safety of this product.”

Yale study fuels tampon debate

A gynecologist from the Yale School of Medicine fueled more debate on tampon safety when he published a May 2002 study showing tampon use and sex during menstruation may protect against endometriosis.

Tampons and the uterine contractions associated with orgasm may help draw menstrual fluid out of the uterus, preventing the back flow linked to endometriosis, Dr. Harvey Kliman reported.

But experts from the Endometriosis Association say the study is flawed.

A survey of 2,000 women is not as conclusive as a peer-reviewed clinical trial, they argue. Also, they believe the survey design produced biased results.

Many women with endometriosis avoid tampons and sex during menstruation because they are painful, the agency argues. So it would make sense that women who reported more tampon use and sexual activity during their periods would not have endometriosis.

Popular tampon brands

Brand: Kotex

Absorbency and range in grams: Super, 9-12

Ingredients: Cotton and rayon; polypropylene cover; rayon, polyester or cotton string

TSS warning on box: Yes