Impact of Currently Marketed Tampons and Menstrual Cups on Staphylococcus aureus Growth and Toxic Shock Syndrome Toxin 1 Production In Vitro

Appl Environ Microbiol. 2018 May 31;84(12):e00351-18. doi: 10.1128/AEM.00351-18. Print 2018 Jun 15.


Fifteen currently marketed intravaginal protection products (11 types of tampon and 4 types of menstrual cup) were tested by the modified tampon sac method to determine their effect on Staphylococcus aureus growth and toxic shock syndrome toxin 1 (TSST-1) production. Most tampons reduced S. aureus growth and TSST-1 production, with differences based on brand and composition, and the level of S. aureus growth was higher in destructured than in unaltered tampons. We observed higher levels of S. aureus growth and toxin production in menstrual cups than in tampons, potentially due to the additional air introduced into the bag by cups, with differences based on cup composition and size.IMPORTANCE Menstrual toxic shock syndrome is a rare but severe disease. It occurs in healthy women vaginally colonized by Staphylococcus aureus producing toxic shock syndrome toxin 1 using intravaginal protection, such as tampons or menstrual cups. Intravaginal protection induces TSS by the collection of catamenial products, which act as a growth medium for S. aureus Previous studies evaluated the impact of tampon composition on S. aureus producing toxic shock syndrome toxin 1, but they are not recent and did not include menstrual cups. This study demonstrates that highly reproducible results for S. aureus growth and TSST-1 production can be obtained by using a simple protocol that reproduces the physiological conditions of tampon and cup usage as closely as possible, providing recommendations for tampon or cup use to both manufacturers and consumers. Notably, our results do not show that menstrual cups are safer than tampons and suggest that they require similar precautions.

Keywords: Staphylococcus aureus; biofilm; elastomer; fiber; menstrual cup; tampon; toxic shock syndrome toxin 1.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Bacterial Toxins / analysis
  • Bacterial Toxins / biosynthesis*
  • Biofilms
  • Cotton Fiber / analysis
  • Cotton Fiber / microbiology
  • Culture Media
  • Enterotoxins / analysis
  • Enterotoxins / biosynthesis*
  • Female
  • Humans
  • Menstrual Hygiene Products / microbiology*
  • Oxygen / metabolism
  • Shock, Septic / microbiology
  • Shock, Septic / prevention & control
  • Staphylococcal Infections / complications
  • Staphylococcus aureus / growth & development*
  • Staphylococcus aureus / metabolism*
  • Superantigens / analysis
  • Superantigens / biosynthesis*
  • Vagina / microbiology


  • Bacterial Toxins
  • Culture Media
  • Enterotoxins
  • Superantigens
  • enterotoxin F, Staphylococcal
  • Oxygen