Article

Bacterial Flora of the Vagina During the Menstrual Cycle

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Abstract

The recent association of menstruation, tampon use, and staphylococcal infection with toxic shock syndrome led us to study the association of menstruation and catamenial product use with changes in vaginal flora. Cultures of the cervical os were obtained in midcycle and during menstruation from 12 women who used napkins and 40 women who used tampons. Staphylococcus aureus was found during midcycle and menstruation in three women, during menstruation alone in six, and during midcycle alone in none, indicating a significant association of S. aureus with menstruation (p = 0.04). No difference was found in the rate of S. aureus colonization during menstruation in tampon users (18%) and napkin users (17%). In a similar study, cultures were taken for S. aureus and other aerobic bacteria from 58 tampon users and 25 users of sea sponges. Staphylococcal colonization was found to be increased during menstruation in both groups. Among the cultures done during menstruation, those from users of sea sponges were found to have significantly higher colonization rates with S. aureus, Escherichia coli and other Enterobacteriaceae. The association of sea sponges with a high rate of S. aureus colonization suggests that they are not an alternative to tampons for women seeking to decrease the risk of toxic shock syndrome.

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... In addition to the use of intravaginal protection, vaginal colonization with TSST-1producing organisms combined with the absence of protective antibodies against TSST-1 represents the major risk factor for the development of MTSS in susceptible women (3). Due to the low incidence of the disease (1/100,000), factors that are associated with an increased risk of MTSS are mainly investigated individually in healthy women (3,(15)(16)(17)(18)(19)(20). Using this strategy, we examined the factors that concur with vaginal colonization by S. aureus in tampon users. ...
... Few published studies have examined the factors that influence vaginal colonization by S. aureus. In these studies, the vaginal sampling was done by swabbing (16)(17)(18)(19)(20), whereas we recently showed that using the vaginal tampon for sampling maximizes the detection of vaginal colonization, especially during menstruation (15). In addition, with regard to MTSS, determination of tampon colonization by S. aureus appears to be more relevant than vaginal swabs because TSST-1 is preferentially produced by S. aureus in the tampon (21,22). ...
... No other significant relationships with tampon colonization by S. aureus were observed in our survey. A history of genital herpes simplex virus infection and socioeconomic status have previously been identified as potential risk factors for vaginal colonization by S. aureus but were not investigated in this study (16)(17)(18). ...
Article
Tampons recovered from a cohort of 737 healthy women (median age 32 years) were analyzed for the presence of Staphylococcus aureus . A total of 198 tampons (27%) were colonized by S. aureus, and 28 (4%) was by a strain producing toxic shock syndrome toxin 1 (TSST-1). S. aureus was detected more frequently in tampons that did not require an applicator for their insertion (74/233 [32%] versus 90/381 [24%]; OR=1.51 [95% CI 1.04-2.17]) and in women who used an intrauterine device for contraception (53/155 [34%] versus 145/572 [27%]; OR =1.53 [95% CI 1.05-2.24]). The S. aureus strains isolated from tampons belonged to 22 different clonal complexes (CCs). The most prevalent CC was CC398 agr1 (n=57, 27%), a clone that does not produce superantigenic toxins, followed by CC30 agr 3 (n=27, 13%) producing TSST-1 (24/27 [89%]), the principal clone of S. aureus involved in menstrual toxic shock syndrome. IMPORTANCE Menstrual toxic shock syndrome (MTSS) is an uncommon severe acute disease that occurs in healthy menstruating women colonized by TSST-1-producing S. aureus who use intravaginal protection, such as tampons and menstrual cups. The catamenial product collected by the protection serves as a growth medium for S. aureus and allows TSST-1 production. Previous studies evaluated the prevalence of genital colonization by S. aureus by vaginal swabbing, but they did not examine tampon colonization. This study demonstrates a high prevalence of tampon colonization by S. aureus, and the presence of the CC30 TSST-1 S. aureus clone responsible for MTSS in tampons from healthy women. The results support the vaginal carriage of this lineage in healthy women. In addition, the higher prevalence of S. aureus within tampons that do not require an applicator indicates a crucial role of hand-washing before tampon handling to decrease the risk of tampon contamination.
Article
In the 1980s, menstrual toxic shock syndrome (mTSS) became a household topic, particularly among mothers and their daughters. The research performed at the time, and for the first time, exposed the American public as well as the biomedical community, in a major way, to understanding disease progression and investigation. Those studies led to the identification of the cause, Staphylococcus aureus and the pyrogenic toxin superantigen TSS toxin 1 (TSST-1), and many of the risk factors, for example, tampon use. Those studies in turn led to TSS warning labels on the outside and inside of tampon boxes and, as important, uniform standards worldwide of tampon absorbency labeling. This review addresses our understanding of the development and conclusions related to mTSS and risk factors. We leave the final message that even though mTSS is not commonly in the news today, cases continue to occur. Additionally, S. aureus strains cycle in human populations in roughly 10-year intervals, possibly dependent on immune status. TSST-1-producing S. aureus bacteria appear to be reemerging, suggesting that physician awareness of this emergence and mTSS history should be heightened.
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The effect of vaginal tampons on the microbial flora during menstruation has recently been studied by several investigators. However, little information regarding the qualitative effects attributable to particular tampon fibers is available. The purpose of the present study was to compare the effects of polyacrylate rayon tampons and cotton-viscose rayon blend tampons on the qualitative bacterial counts obtained from tampons and concomitant vaginal swabs and to determine whether either of these tampon types alters the qualitative makeup of the vaginal microflora when compared with the microflora in the same women using all-cotton tampons or external catamenial pads. Tampon and swab samples were obtained as described previously (A. B. Onderdonk, G. R. Zamarchi, M. L. Rodriguez, M. L. Hirsch, A. Muñoz, and E. H. Kass, Appl. Environ. Microbiol. 53:2774-2778). The genus and species of the six dominant bacterial species in each sample were identified, if possible. A statistical evaluation of the qualitative makeup of the microflora revealed that the same numerically dominant phenotypes were present regardless of sample type, sample time, or catamenial product. Predictable changes in total numbers among the dominant species were also noted when the data were evaluated by day of menstrual cycle. The correlation between the total numbers of each dominant species present was evaluated by day of cycle, and the findings are discussed.
Chapter
Toxic shock syndrome (TSS) is an acute, multisystem febrile illness caused by Staphylococcus aureus. The currently accepted criteria for confirming a case of Tss include fever, hypotension, a diffuse erythematous macular rash, subsequent desquamation, evidence of multisystem involvement, and lack of evidence of another likely cause of the illness (Table 1).
Chapter
Staphylococcal toxic shock syndrome (TSS) is an acute, multisystem febrile illness caused by Staphylococcus aureus. A similar illness caused by group A streptococcal infections is discussed in Chapter 34.
Article
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Article
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Article
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Healthy women with normal menstrual cycles were randomly assigned to use either a test tampon during cycle 1 and a reference tampon during cycle 2 or a reference tampon during cycle 1 and a test tampon during cycle 2. Tampons were identical except for their cover materials: apertured film for the test tampon and nonwoven fleece for the reference tampon. Product use was doubly blinded. Qualitative and quantitative analyses of vaginal cultures were done pre-, mid-, and postmenstrually for a broad panel of microorganisms, colposcopy was performed, and diary reports were collected; 101 of 105 enrolled subjects completed the study. Midmenstrual findings for a variety of organisms differed from pre- and postmenstrual observations whether subjects were using test or reference tampons. No statistically significant differences were noted in prevalence or colony counts at premenstrual versus mid- and postmenstrual visits for most microorganisms. Prevalences of Gardnerella and anaerobic gram-negative rods were significantly different between tampons at the premenstrual visit, when unusually low values were observed for the test and reference tampons, respectively. None of the changes or differences in microflora were considered to be clinically significant. It is noteworthy, however, that declines in the prevalence and abundance of Lactobacillus during the menstrual periods were less pronounced during the use of both test and reference tampons than those reported from previous studies. Colposcopy showed no abnormal findings with either tampon and no changes in vaginal or cervical epithelial integrity. Thus, all evidence from both microbiological and colposcopic evaluations indicates that the apertured film cover of the test tampon is as safe as the nonwoven cover of the reference tampon.
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