text: Toxic shock syndrome (TSS) is a rare but potentially fatal disease caused by a bacterial toxin. Different bacterial toxins may cause toxic shock syndrome, depending on the situation. The causative agent is Staphylococcus aureus. A similar condition, called Toxic Shock Like Syndrome (TSLS), is the result of Streptococcus pyogenes infection.\n\nInfection can occur via the skin (e.g. cuts, surgery, burns), vagina (tampon), or pharynx.\n\nThe number of reported toxic shock syndrome cases has decreased significantly in recent years. Approximately half the cases of TSS reported today are associated with tampon use during menstruation, usually in young women, though TSS also occurs in children, men, and non-menstruating women. In the US in 1997 only five confirmed menstrual-related TSS cases were reported, compared with 814 cases in 1980, according to data from the Centers for Disease Control and Prevention (CDC). [1]\n\nAlthough scientists have recognized an association between TSS and tampon use, no firm causal link has been established. Research conducted by the CDC suggested that use of some high absorbency tampons increased the risk of TSS in menstruating women. A few specific tampon designs and high absorbency tampon materials were also found to have some association with increased risk of TSS. These products and materials are no longer used in tampons sold in the U.S. (The materials include polyester, carboxymethylcellulose and polyacrylate).[2] . Tampons made with rayon do not appear to have a higher risk of TSS than cotton tampons of similar absorbency.\n\nVaginal 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. Alternately, women may use a silicone menstrual cup to avoid the negative side-effects of tampons.\n\nIn the late 1970s, Procter and Gamble introduced superabsorbent Rely Tampons[3] , in response to women’s' demands for tampons which could contain an entire menstrual flow without leaking or replacement.[2]\n\nRely used carbomethylcellulose and compressed beads of polyester for absorption. This tampon design could absorb nearly 20 times its own weight in fluid[4] . Further, the tampon would "blossom" into a cup shape in the vagina in order to hold menstrual fluids.\n\nThe super absorbent properties of Rely caused vaginal dryness by absorbing the natural humidity of the vagina. Often this lead to ulcerations in the vaginal wall when the tampon was removed, offering pathways for bacteria to infect the bloodstream[4] . Further, the tampons super absorbency meant that the viscosity of vaginal fluids was enhanced, providing a good environment for bacteria growth[5] . In addition, carboxymethylcellulose (CMC) has features which effectively filter the toxins of Staphylococcus which cause TSS[4] . The recipe for disaster came about as a combination of Staphylococcus aureus naturally benignly occurring in about 5-15% of women[6] , the insertion of the tampon adding oxygen to the normally anaerobic vaginal environment allowing for increased bacterial growth, and the tampon's super absorbency meant that women didn't need to replace them as frequently and so left them in place longer.\n\n"Between the spring of 1980 and January of 1981, forty women died and another 902 women were diagnosed with tampon-related Toxic Shock Syndrome"[5] . In September 1980 Procter and Gamble recalled Rely[1] after the Centers for Disease Control released a report in summer 1980 explaining the bacterial mechanism which lead to TSS, and that Rely tampons was associated with TSS more than any other tampon. As part of the voluntary recall, Pr