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Endometriosis and Tampons Question: Dr. Cook, is it true that tampons cause endometriosis? Answer: There are concerns that chemicals (dioxin) in tampons may increase a woman's risk of developing endometriosis. So far, medical studies that would provide a definitive answer to the question of whether the use of tampons increases the risk of getting endometriosis have not been performed. No difference was observed in the few studies that have looked at the incidence of endometriosis in tampon users and non-users. A recent study (Organochlorines and endometriosis: A mini-review Chemosphere, Volume 71, Issue 2, March 2008, Pages 203-210 Jean-Francois Heilier, Jacques Donnez, Dominique Lison) reviewed 12 publications in scientific literature that looked at larger question of the potential association of organochlorines (which includes dioxin) and endometriosis. The authors concluded that peritoneal endometriosis (Stage I and II) does not have an association with organochlorine exposure. Deep-infiltrating endometriosis (Stage III and IV) is associated with higher blood concentrations of dioxin-like compounds. Congresswoman Carolyn B. Maloney introduced The Tampon Safety and Research Act of 1997 (H.R. 2900) on November 7, 1997, and the Tampon Safety and Research Act of 1999 on March 1, 1999. These bills never became law. And unfortunately, at the end of each session of Congress, all proposed bills and resolutions that haven't passed are cleared from the books. Additional information and the entire text of the bill can be found at the Govtrack.us website. Hopefully, some other informed and caring member of Congress will propose similar legislation in the near future. Rayon, a synthetic fiber, is very absorbent and is used in most tampons. Chlorine is used to bleach the rayon during the manufacturing process to give the tampons a "clean" white appearance. The chlorine bleaching process used in the production of the majority of tampons reportedly produces a toxic by-product known as dioxin. Proctor & Gamble, the makers of Tampax, state the chlorine bleaching process does not produce detectable levels of dioxin. Dioxin (TCDD; 2,3,7,8-tetracholorodibenzo-p-dioxin) is thought to be toxic at very low doses. Dioxin is also a by-product of pesticide production and PVC (polyvinyl chloride) pipes. Studies have suggested links between dioxin and cancer, behavioral effects, learning disorders, decreased male sex hormone, diabetes, immune system toxicity, sperm loss, and endometriosis. Several studies have looked at the relationship between endometriosis and dioxin. Reir et. al. published a study in 1993 and again in 1995, documenting an increased incidence of endometriosis in Rhesus monkeys following exposure to dioxin. The monkeys were exposed to dioxin over a period of four years. Ten years later, they underwent laparoscopic evaluation for endometriosis. There were three groups of monkeys in this study; a control group (no exposure to dioxin), a low-dose group (5 ppt dioxin) and a high-dose group (25 ppt of dioxin). Thirty-three percent of the monkeys in the control group had endometriosis, but none had moderate or severe endometriosis. The incidence of moderate to severe endometriosis was 43 percent in the low-dose dioxin group, and 71 percent in the high-dose dioxin group. Clearly, there was an increased incidence of endometriosis with exposure to dioxin, and an increased severity with the dose of dioxin. A study published in Israel in 1997 evaluated the potential association of dioxin and endometriosis in infertile women. The study group was comprised of infertile women with endometriosis, and in the control group were infertile women without endometriosis. Eighteen percent of women in the endometriosis group tested positive for dioxin, while only 3 percent were positive for dioxin in the non-endometriosis group. However, in contrast to the monkey study, the concentration of dioxin did not correlate with the severity of endometriosis. In 1985 Lamb and Berg published a study examining the potential role of tampons in women with endometriosis. The rate of tampon use in 470 women with endometriosis (82 percent) was compared to that of the general population (75 to 83 percent). While there was no statistical difference in the rate of tampon use in this study, the age at initial tampon use was statistically earlier in the endometriosis group. In a 1993 case control study, Darrow et. al. compared tampon use in 104 women with laparoscopically confirmed endometriosis to 100 friends of the patients. Compared to their friends, women with endometriosis under the age of 30 were, on average, 3.6 times as likely to have a history of tampon use of greater than or equal to 14 years. As is evident from the above paragraph, the medical literature is pretty weak when it comes to the issue of endometriosis and tampon use. There is also the theoretical concern of tampons increasing the resistance of outflow of the menstrual fluid, which could result in an increase in the amount of retrograde menstruation. It makes sense that if the tampon is not changed frequently, it can become saturated and may then act as a plug, increasing the back-pressure of blood into the uterus. Alternatively, if the tampon is changed frequently, it acts as a wick and actually helps the flow of blood out of the uterus. As I have discussed previously, the leading theory of the cause of endometriosis is retrograde menstruation. A lot of women use tampons, and thus a definitive answer is needed to the question of whether tampon usage possibly increases the risk of endometriosis. In summary, the chlorine bleaching process traditionally used in the production of tampons creates dioxin. Many health problems, including endometriosis, have been linked to low-dose dioxin exposure. The presence of dioxin in tampons may pose a health risk, but the degree and significance of this risk is unknown. Also, dioxin is concentrated in fat tissue, and thus can be found in food sources such as red meat and fish. A 2005 study (Dioxin and furan levels found in tampons. J Womens Health [Larchmt] 2005 May;14(4):311-5) concluded that "...most of the dioxins...(in tampons) were below the detection limit or estimated detection limits (EDLs)." The elimination of dioxin from tampons may be beneficial to your health, but is probably minor when compared with other potential sources of dioxin, and will not completely eliminate your exposure to this chemical. Feminine pads are an alternative to tampons. While most pads are also bleached with chlorine, and thus may result in dioxin production, this product is placed on the outside of the body, reducing your exposure. If you decide to use tampons, you will have to weigh the evidence and decide for yourself whether you are comfortable using traditional tampons, or would prefer to use “natural” (dioxin-free) tampons. If you feel more comfortable using an unbleached tampon, I have included some links that you might find helpful. I have no association with any of the companies listed, nor am I endorsing any of their products. Natural Tampons: Terra Femme Tampons Glad Rags: |
