There’s a spectrum of bad healthcare documentaries on Amazon from giving outright dangerous advice to just run-of-the-mill fear mongering. A few months ago I watched a documentary in the latter category, Tampon: Our Closest Enemy. Tampon: Our Closest Enemy is a French documentary produced by Audrey Gloaguen and it released in 2017. While I’ve been wanting to review it for a while now, researching would’ve taken a lot of time. I have significant knowledge deficits in the realm of vaginas and tampons for obvious reasons. That was until Dr. Jen Gunter released her book The Vagina Bible, which is a comprehensive guide on everything vulvar and vaginal. I couldn’t write a standalone review on it because there’s nothing to really say about it: it’s well-written, authoritative, comprehensive, and inexpensive. Dr. Gunter debunks many of the same myths about toxic shock syndrome and tampons that are perpetuated in Tampon: Our Closest Enemy. After reading the relevant sections in The Vagina Bible, the lines between myth and medicine were markedly less blurred when re-watching Tampon: Our Closest Enemy, so I figured why not use one to review the other?

Toxic Shock Syndrome and Rely

The first half of Tampon: Our Closest Enemy is dedicated to menstrual toxic shock syndrome (mTSS), an incredibly rare, life-threatening condition caused by the immune system’s reaction to a toxin in the blood stream. There are two basic categories of toxic shock syndrome by cause, menstrual and non-menstrual. The incidence of TSS overall is estimated to be between 0.8 to 3.4 cases per 100,000 people per year. According to the CDC the annual average incidence of menstrual toxic shock syndrome (mTSS) varied between 0.03-0.05 for every 100,000 people. Other papers have reported numbers as high as 0.52 cases per 100,000 people per year, it really depends on what year the study was conducted and how the data was collected. The bottom line is that TSS and mTSS are incredibly rare to begin with. So what’s the deal with mTSS?

There are lots of different types of bacteria living on and in your body. Most of which don’t cause any trouble… until they do. The main cause of mTSS is a type of bacteria is called Staphylococcus aureus (S. aureus), and only some women carry S. aureus vaginally. Just as we all have different genes, strains of bacteria carry different genes. Only specific strains of S. aureus can produce the toxins that cause mTSS. The specific toxin is TSST-1 is a protein that is a superantigen. A superantigen over-activates your immune system and triggers what can only be described as a full-on meltdown. In the case of mTSS this over activation causes high-fever, dangerously low blood pressure, muscle pain, kidney failure, coma, and death.

The film tries to portray the case of the Rely tampon TSS-outbreak as the rule and not the exception. Back in the 1975, Proctor and Gamble brought the Rely tampon to market, a first-of-it’s kind super absorbent tampon. Rely was a bit different in it’s composition, it used methylcarboxycellulose, which is often used to thicken food products, in a polyester casing. The problem with Rely’s composition is that it provides the perfect place for S. aureus to grow and cause mTSS, which is laid out in detail in Yale Biology. When fluids were absorbed by the Rely Tampon, the methylcarboxycellulose gelled and the foam cubes offered increased surface area for S. aureus to grow. During menstruation, the pH of the vagina is elevated to around 7.4 which made the Rely tampon the perfect environment for S. aureus to reproduce. Then finally, if that wasn’t enough, the toxins that cause mTSS also cause fever, and the increased body temperature makes S. aureus grow even faster to release even more toxins. When you consider all of that, it’s becomes hard to dream up a more worst-case scenario when considering mTSS risk.

The Rely tampon at the time was and still is the worst-case scenario when talking about the mTSS risk, and is brought up pretty much every time menstrual toxic shock syndrome is discussed. After a drastic increase in mTSS cases, medical societies began to investigate. Two studies by the CDC were conducted and the second one found that the women who used the Rely tampon had nearly 8 times the risk of developing mTSS. This lead to a lot of deaths, and many people sued Proctor and Gamble successfully, which Tampon: Our Closest Enemy talks about for quite a while. Rely was ultimately removed from the market in 1980.

The problem with Tampon: Our Closest Enemy is that it leaves women with more questions than answers. Dr. Gunter leaves women with practical advice about how to lower their TSS risk:

  • Use the lowest absorbency.
  • Don’t assume all-cotton tampons are safer. Some studies suggest a rayon blend may be safer.
  • Be mindful of trauma with insertion and removal. Using a less-absorbent tampon on lighter days may help.
  • The recommendation to change a tampon every eight hours is not based in hard science but seems to be the best expert advice for now.

Ultimately, the risk of mTSS is very low even in the worst case scenario but Tampon: Our Closest Enemy makes it seem like a hidden pandemic. It’s important to note that menstrual cups also carry a risk of mTSS, and mTSS can also just happen. The film makes a big deal out of questioning why the tampon industry doesn’t disclose the risk of mTSS with the use of their products and why more research isn’t done to assess the safety of tampons with regards to mTSS risk. But companies do have information on their sites about the TSS risk of tampons and the ingredients that they use. The problem is that the risk of mTSS is 1 in 100,000 women, so low that it’s incredibly difficult to assess the efficacy of any change made to products to prevent it. While it’s something that women should be aware of, it’s like warning them about the risks of a shark attack.

Toxins in tampons? Not quite

The second half of Tampon: Our Closest Enemy talks about toxins in tampons and how manufacturers are “hiding” the composition of tampons. The film mostly focuses on dioxins and dioxin-like compounds. Dioxins are highly toxic compounds that are usually the byproduct of manufacturing processes, but dioxin-like compounds also include things such as PCBs. Dioxins have been found to be carcinogenic and can damage the immune and nervous systems. The film states that a state Secretary imposed tests on various brands of tampons in 2016 and found that there were synthetic fibers and dioxins in the tampons. I’m unsure why the detection of synthetic fibers was presented as a “gotcha!” moment. Many tampons are made of synthetic fibers, so it’s like finding out that your computer has processor in it. After the results of the tests they passed the data onto the European Environmental Agency to investigate further and take any necessary action. The film presents it as a slam dunk that there’s dangerous toxins in tampons:

Very low levels. Potentially take any necessary action. When such measured language is used, it would easy to forget that dioxins are one of the worlds most dangerous chemicals according to the World Health Organization.

Dioxins are listed under the WHO’s chemicals of major public health concern. However, as Dr. Gunter explains in The Vagina Bible, the level of dioxins is so low it’s a joke. In a 2002 study published in Environmental Health Perspectives, researchers analyzed the level of dioxins in a variety of tampon brands. While they found detectable levels of dioxins in all of the tampons, there was no detectable amount of the most potent dioxin: 2,3,7,8-tetrachlorodibenzo-p-dioxin. They also determined that the level of dioxins present in the tampons was between 30,000 and 200,000 times lower than what’s found in food.

Surely Gloaguen has come across that study right? It is the second result when you search “dioxins in tampons” on google. Anyway, Gloaguen went all the way to the US to the town of Perry, Florida to talk to someone who used to work for Georgia Pacific, a cellulose product manufacturer. The woman Gloaguen interviewed showed a copy of an MSDS for one of the chemicals Georgia Pacific uses to bleach wood pulp. It turns out that Georgia Pacific really uses chlorine dioxide to bleach paper products. The part that’s so strange about Tampon: Our Closest Enemy is that almost everything is presented as if it’s some sort of secret and that the tampon industry is trying to hide. What was shown on screen was presumably one of the many MSDS’ that are freely accessible to any employee; any employee working in a factory can walk to their safety supervisor and figure out where to get this information. Employers are required by law to provide their employees with the types of chemicals they use and the risks of those chemicals. It’s far from a secret either that companies use chlorine dioxide to bleach paper products, chlorine dioxide bleaching has its own section in the “Bleaching of wood pulps” Wikipedia page.

While chlorine dioxide is a very, very nasty chemical, the process of chlorine dioxide bleaching is safe and there have been very few accidents. Everything in manufacturing sounds super scary, and that’s because everything in manufacturing kind of is. That’s why they have safety meetings every month, that’s why they have all of those safety procedures. Besides, the dangerous chemicals and machinery aren’t even the scariest part of working in manufacturing, you never known when your boss is going to ask you to work with Rockwell’s software. The bottom-line is that while there may be trace amounts of dioxins in tampons, it’s not anything to worry about and many companies have moved to a chlorine-free bleaching process anyways.

Big tampon conspiracy? This is fear mongering

Tampon: Our Closest Enemy gets into absurd conspiracy theory territory very quickly starting about halfway through. Gloaguen makes it seem like big-tampon is trying to hide the secret dangers of their products, when in reality the levels of dioxins in tampons are of no risk to women’s health, and the risk of TSS is very, very small. Midway into the film, Gloaguen drops this bombshell:

In order to operate with impunity, the industry had to silence politicians and female consumers. To dissuade anyone from trying to find out more about their products, the industry had an ultimate strategic weapon: the taboo surrounding menstruation.

The problem is that the tampon industry doesn’t have anything to hide really. While they aren’t required by law to post the ingredients in tampons, many have them on the box or on their website. They’re generally made up of rayon or cotton in the core with a polypropylene string and polyester thread. As for trace amounts of stuff like dioxins, phthalates, and pesticides; companies are required to prove to the FDA that their products have pesticide and contaminant levels that are safe for human use before they can go to market. There is no conspiracy by the tampon industry to silence women or politicians, especially using social engineering on a grand scale. No matter how ridiculous it may seem, Tampon: Our Closest Enemy tries to make it seem that way:

So we often see happy women, wearing white, very active. We never see blood. We see blue liquid. If we see the product, it is always pre-use, never post use. Behind this veil of purity, the industry operates as it wishes.

This ignores the entire regulatory environment surrounding menstruation products. These statements all seem reasonable the way they’re presented in the film. But when you actually evaluate them on their merit, they don’t make much sense. Of course tampon companies are going to show the pre-use presentation of a tampon, do you really want to see a post-use tampon in a commercial? It would be quite…unaesthetic. Tampon companies are going to show women wearing white, and because that makes them seem clean. It’s just marketing, and it’s not any different than how any other industry markets their products. To portray the marketing as part of a grand conspiracy is just ridiculous, senseless fear-mongering.

Conclusion: Effort inequality

The dichotomy between The Vagina Bible and Tampon: Our Closest Enemy perfectly illustrates the problem of trying to communicate science, particularly medicine. Getting science communication right is hard and doesn’t pay very well. It really seems like Gloaguen was more focused on getting 45 minutes’ worth of content fit for television than presenting the facts. The risk of developing mTSS is so low it’s hard to definitively answer what women can do to reduce their risk or how to assess a new tampon for mTSS risk before it goes to market. Furthermore, tampons don’t contain any level of “toxins” worth considering and their composition is displayed on the box most of the time. It’s a lot easier and more profitable to take the science out of context, blow things out of proportion, or make stuff up.

If you search toxic tampons on the internet, you will find dozens of articles telling women to be wary of toxic tampons. The very first search result that I got when searching “toxic tampons”, was an article on Goop suggesting that tampons were toxic and you should buy organic tampons. By pure coincidence, Goop also sells organic tampons. While Gloaguen doesn’t try to sell women on organic tampons or other products, she doesn’t leave women with anything to go on. So the only thing the film accomplishes is attempting to scare women over nothing, and potentially push them to seek out products that are more expensive, and potentially less effective for no reason. Also, it’s important to remember that scaring people over nothing is still a harm in itself. I don’t think it’s healthy for people to be constantly afraid, as if everything in the world is out to kill them all the time.

It’s a lot harder to break down nonsense health claims on the internet than it is to make nonsense health claims on the internet. The barrier to entry is non-existent, and you can create your own website or video channel in a few minutes. There’s no peer review and you can say whatever you want, scientific accuracy is not required. You might hear a claim that sounds like complete nonsense, and there might be some evidence to back it. But you might not know how important that evidence is, or its quality. That’s why I like The Vagina Bible so much, it’s a single comprehensive source on a topic from an expert. Dr. Gunter breaks down a lot of research on really complicated topics and explains them in a way that’s easy to understand.

Tampon: Our Closest Enemy is a just another in a long-line of documentaries that are meant to make for 45 minutes of compelling television rather than informing viewers. The reality is that tampons are safe, and they are safety tested. While bad things have happened in the past such as the Rely tampon, it’s important to remember that the risk of developing mTSS was still very low. Safeguards have been put in place since then. There’s no great hidden risk to tampons being covered up by Big Tampon™, anyone that tells you otherwise is trying to sell you something. As for The Vagina Bible, it’s exactly what it claims to be. If that’s not high enough praise, I don’t what is.



Posted by Braden MacBeth

I'm a software engineer in Pennsylvania.