Is tampon use risky for users of DMPA?
Is use of depot medroxyprogesterone acetate (DMPA, Depo-Provera, Pfizer, New York City) linked to risk of toxic shock syndrome? Contraceptive Technology Update Editorial Advisory Board member Felicia Stewart, MD, adjunct professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California San Francisco and co-director of the Center for Reproductive Health Research & Policy, tackles this question.
Question: We have recently been approached with the proposal that we should direct all of our health care providers statewide that women on Depo-Provera injections be informed that tampon use for intermittent breakthrough bleeding is contraindicated and a risk factor for toxic shock syndrome (TSS). I have reviewed the information in the 18th edition of Contraceptive Technology and the Depo package insert and find no such guidance.
Stewart: There is no evidence for this directive that I know of, and any such advice should be weighed against the major health risks that definitely are associated with decreased use of highly effective contraception, such as Depo-Provera. From a public health perspective, it is unethical to impose a policy that creates unwarranted fear among users and potential users. It is misleading and is likely to discourage women from choosing or continuing their contraceptive method. No matter what the "intentions" of the policy-maker, there is a moral responsibility to consider the intended and unintended consequences of a policy.
TSS is an exceedingly rare problem, and there is no evidence of a recent increase in the problem. It is true that TSS risk is statistically linked to use of tampons, and for that reason tampon packaging recommends changing to a new tampon at least once every 24 hours.1 There is no real evidence for a 24-hour limit, however, and no evidence, or logical reason, for singling out Depo users for special advice.
[Editor’s note: Concurrent opinions supporting Stewart’s answer were offered by medical experts at the Research Triangle Park, NC-based research organization Family Health International (FHI): Ward Cates, MD, MPH, president/chief executive officer of FHI’s Institute for Family Health, and Elizabeth Raymond, MD, MPH, an associate medical director at FHI.]
Reference
- Reduced incidence of menstrual toxic-shock syndrome — United States, 1980-1990. MMWR 1990; 39:421-423.
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