Susan Dudley, PhD, Salwa Nassar, BA, Emily Hartman, BA
Revised July 2009
A widely circulated rumor spread over the Internet alleges that tampons are contaminated with asbestos and dioxin, and that the rayon in some tampons causes toxic shock syndrome. In response to the email rumor, the Food and Drug Administration (FDA), which regulates the safety and effectiveness of medical devices, issued a statement on its website that the available scientific evidence does not support the rumors and provided information about tampon safety.
Unfortunately, the FDA’s statement also highlights the fact that certain important questions and concerns regarding the safety of tampons have not been adequately addressed. Moreover, the agency’s reassurances are largely based on data that were submitted by tampon manufacturers, but are not publicly available.
Tampons, used by approximately 43 million women in the United Stated today, are usually made of cotton and rayon. Rayon is a synthetic fiber made from wood pulp. During that process, a toxic byproduct known as dioxin is created. Very small amounts of dioxin are in the rayon fiber. In addition, until the late 1990′s a chlorine bleaching process that also produces dioxin was used on both the rayon and the cotton used in tampons.
In 1994, the Environmental Protection Agency (EPA) issued a report that stated that dioxins are known to cause cancer in animals, and probably cause cancer in people. The EPA also has determined that people exposed to high levels of dioxins may be at risk for a damaged immune system, increased risk of pelvic inflammatory disease (PID), and reduced fertility. Recent research on monkeys has linked dioxin exposure with increased risks for developing endometriosis, a painful disease in which uterine tissue is found outside the uterus, frequently leading to infertility. One study found that 80 percent of the monkeys exposed to dioxin developed endometriosis, and that higher levels of exposure caused the development of more severe forms of the disease. Two of the monkeys in the study died of endometriosis.
While the dioxin hazard from bleaching has been reduced in recent years as a result of new bleaching methods, dioxin is still detected in tampons – even those made of 100% cotton. The EPA states that, due to decades of pollution, dioxin can be found in the air, water, and ground; thus, trace amounts of dioxin may be present in the cotton or wood pulp raw materials used to make tampons. According to the results of studies conducted by tampon manufacturers and submitted to the FDA, dioxin levels in the rayon raw materials range from undetectable to 1 part in 3 trillion. More recently, a study sponsored by the FDA Office of Women’s Health and published in 2005 found detectable levels of dioxin in seven brands of tampons, including at least one 100% cotton brand. Although the FDA currently requires tampon manufacturers to monitor dioxin levels in their finished products, the results are not available to the public.
A study by Michel DeVito and Arnold Schecter, published in Environmental Health Perspectives in 2002, concluded that even if all the dioxin in tampons (and diapers) were absorbed into the body, the exposure to dioxin would still be thousands of times less than the dioxin people typically consume in the food they eat. There was no meaningful difference in dioxin exposure from cotton tampons (or diapers) compared to cotton/pulp products. Tampons and diapers sold in health food stores or special ordered were not safer than brand name products. In fact, tampons ordered from a specialty company had much more dioxin than the other tampons.
The FDA says that the exposure to dioxin from tampons today “is many times less than normally present in the body from other environmental sources, so small that any risk of adverse health effects is considered negligible.” However, according to Dr. Philip Tierno, director of clinical microbiology and diagnostic immunology at the New York University Medical Center and a leading expert on the health risks of tampons, even trace amounts of dioxin are cause for concern because tampons come in contact with some of the most absorbent tissue in the body. In addition, the effects of dioxin are cumulative and can be measured 20 to 30 years after exposure. That is particularly troubling because tampons are used by up to 70 percent of menstruating women in the U.S., and it has been estimated that the average woman may use as many as 16,800 tampons in her lifetime. Nevertheless, the study by DeVito and Schecter suggests that women who want to reduce their exposure to dioxin, and policy makers with similar concerns, should focus on reducing dioxin in the food we eat, rather than tampons.
Toxic Shock Syndrome (TSS)
TSS, a rare but potentially fatal disease caused by a bacterial toxin, has also been associated with tampon use. Although the exact connection remains unclear, use of high-absorbency tampons produced with rayon and leaving tampons in for an extended period of time seem to increase the risk of TSS. The disease, which was first described among teenage girls in 1978, primarily strikes tampon users under the age of 30. The TSS epidemic reached a peak in 1980 with a total of 813 cases, including 38 deaths, reported to the Centers for Disease Control and Prevention (CDC).
According the to the FDA, the number of menstrual-related TSS cases has decreased significantly in recent years; there were only six confirmed cases in 1997 and three in 1998. Rana Hajjeh, M.D., a medical epidemiologist with CDC’s division of bacterial and mycotic diseases, attributes the drop in TSS cases to the advances in the way FDA regulates tampon materials and absorbency. In 1982, the FDA required that all tampon labels advise women to use the lowest absorbency needed to control their flow and include TSS warning signs. The agency also standardized absorbency labeling in 1990 so that absorbency terms (e.g. regular, super, etc.) are consistent across brands.
But Tierno points out that the drop in the total number of cases is only apparent when a “strict-case” definition of TSS is used; the actual number of “clinical cases” has not really changed. Another possible reason for this reported decrease is because tampon manufacturers have removed three of the four synthetic ingredients (polyester, carboxymethylcellulose, and polyacrylate rayon) once commonly used in tampons to enhance absorbency. However, highly absorbent viscose rayon is still used.
The removal of the synthetic fibers by manufacturers was due in part to independent research that showed tampons containing synthetic additives increase production of the TSS toxin, and that all-cotton tampons do not. According to Tierno, this suggests that all-cotton tampons decrease the risk of TSS, and are thus safer than rayon and rayon-blend tampons. Considering that a 1994 study found that up to 99 percent of menstruating women diagnosed with TSS were using tampons, and that not enough is known about potential health risks associated with tampon additives, it is clear that more accurate information is needed regarding the hazards of tampons.
The asbestos allegation contained in the Internet rumor has never been confirmed; however, there seems to be a general consensus among health experts and scientists that the allegations are unfounded. The email message claims that manufacturers add asbestos to tampons to promote excessive bleeding in order to sell more of their product. The FDA says it reviews the industry-supplied data on the design and materials of all tampons before they are marketed in the U.S., and that asbestos is not an ingredient in any tampon brand. Moreover, because tampon manufacturers are subject to FDA inspection, the agency assures women that “these inspections would likely identify any procedures that would expose tampon products to asbestos.” Although the FDA states that it has no evidence of asbestos in tampons, the reliability of this claim is uncertain because the agency has historically relied on data provided by manufacturers in determining product safety.
Legislation in Congress
U.S. Representative Carolyn Maloney of New York introduced an important piece of legislation that attempts to address the unresolved health concerns surrounding tampon safety. The Robin Danielson Act (H.R. 5181 in the 110th congress) directs the CDC to collect and report information on toxic shock syndrome. Reporting of TSS to the CDC is currently optional and uneven, and the number of TSS cases and deaths is unknown. The collection and reporting of TSS cases would help increase awareness of the continued risk of contracting the disease. The Robin Danielson Act also requires the National Institutes of Health (NIH) to conduct research to determine the extent to which the presence of dioxin, synthetic fibers, and other additives in tampons and related products pose any health risks to women. As of May 2009, the act has not been reintroduced in the 111th congress.
Several alternatives to tampon use are available to women, including all-cotton tampons and pads that are unbleached or are whitened with hydrogen peroxide and reusable menstrual cups. The use of pads also reduces the risk of TSS. Alternative menstrual products can be found at natural food stores or ordered directly from individual companies. Organic products are sold in some grocery stores and claim to be grown without the use of pesticides and do not use any processed fibers. All-cotton sanitary products, however, may contain pesticide residues that could be absorbed in the same way as dioxin. No research has been conducted to determine whether all-cotton tampons and pads are safer than the more commonly available tampons and pads.
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm070003.htm for the FDA’s report, “Tampons and Asbestos, Dioxin, and Toxic Shock Syndrome”
http://maloney.house.gov/index.php?option=com_issues&task=view_issue_detail&issue=272&Itemid=35 for a summary of Rep. Maloney’s Tampon Safety and Research Act
Archer, JC and others, Dioxin and Furan Levels Found in Tampons, 2005, Journal of Women’s Health, Volume 14, pages 311-315.
De Vito, MJ and Schecter A. Exposure Assessment to Dioxins from the Use of Tampons and Diapers, Environmental Health Perspectives, Vol 110, January 2002, available at http://www.ehponline.org/members/2002/110p23-28devito/EHP110p23PDF.PDF