Tampon Safety and Our Monthly Affair with Toxins

Janna Zinzi

While BPA (bisphenol A) is now receiving a lot of attention from environmental and reproductive health advocates, another chemical affecting women's reproductive health is sliding under the radar: Dioxin.

While the pervasive BPA (bisphenol A) is now receiving a lot of attention from environmental and reproductive health advocates, another chemical affecting women’s reproductive health is sliding under the radar. Dioxin, a toxic by-product of chlorine-bleaching in the manufacturing of tampons (and paper products), has been a cause for concern for over 15 years.

A 1994 report for the Environmental Protection Agency (EPA) states that dioxin is linked to cancer (especially breast cancer), an increased risk of endometriosis, pelvic inflammatory disease, infertility and immune system suppression. This same report states that no level of exposure to dioxin is safe, yet women are inserting this chemical directly into their vaginas on a monthly basis for hours or days at a time.

The National Research Center for Women’s and Families said in their July 2009 report:

The FDA says that the exposure to dioxin from tampons today “is many times less than normally present in the body from other environmental sources, so small that any risk of adverse health effects is considered negligible.” However, according to Dr. Philip Tierno, director of clinical microbiology and diagnostic immunology at the New York University Medical Center and a leading expert on the health risks of tampons, even trace amounts of dioxin are cause for concern because tampons come in contact with some of the most absorbent tissue in the body.

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The same report also states that the effects of dioxins are cumulative and can be measured 20 to 30 years after exposure. Statistics show that 53 percent of American women use tampons regularly, and that a woman can use 16,800 tampons in her lifetime. Therefore many women have had significant direct exposure to dioxin.

Even more troubling is that there, as with BPA, there is no federal regulation of this chemical. Tampon manufacturers are required to monitor the levels of dioxins in their products but these records are not available to the public.

In 2008, Representative Carolyn Maloney (D-NY) introduced the Robin Danielson Act (H.R. 5181), legislation for tampon safety. Specifically, it directs the National Institute of Health (NIH) to conduct research on the potential health risks of dioxin, synthetic fibers and other additives in tampons and related feminine products, in addition to requiring the Centers for Disease Control (CDC) to collect and report information on Toxic Shock Syndrome (TSS). This legislation is still pending. So in the meantime, the onus is on the consumer to find alternative products, even though there is little mainstream discussion or awareness of dioxins and their effects on women’s reproductive health.

Even though there is a market for organic tampons and menstrual products, it’s not a guarantee that they are dioxin-free. Tampons that are 100 percent cotton aren’t necessarily entirely safe either because the cotton may be contaminated with pesticides, so labels should specifically state whether or not they were chlorine-bleached. Seventh Generation and Natracare offer these products but they are often more difficult to find (even in large cities) and can be considerably more expensive. Alternative products continue to emerge such as reusable cups and cloth pads but none of these have achieved mainstream use. Accessibility to these options is an issue for low-income women, women outside of urban centers, and immigrant women, so awareness of and disparities in exposure and protection from these chemicals are systemic.

Tampons can be a convenient blessing for active women on their menstrual (moon) cycle but what are the long-term effect for a few hours of temporary comfort?

Analysis Law and Policy

‘Robin Danielson Act’ Would Mandate Independent Testing on Tampon Safety

Mary Emily O Hara

Almost no independent research has investigated the potential health impacts of long-term feminine hygiene product use. Studies have generally taken place through product manufacturers—who aren't required to release the results in full to the public.

Some feminine hygiene products, such as tampons and pads, are privately tested through their manufacturers before they receive the Food and Drug Administration (FDA) approval necessary for market entry. Others, like vaginal wipes and douches, require no specific safety testing at all. In both cases, critics say the process locks the public out of health risk information needed to make informed decisions about products they are using internally on a regular basis.

That’s why Rep. Carolyn Maloney (D-NY) has reintroduced the Robin Danielson Act, a bill named for a woman who died of Toxic Shock Syndrome (TSS) in 1998.

“We need more dedicated and substantial research to address unanswered health concerns regarding the safety of feminine hygiene products,” Maloney told Rewire. “American women spend well over $2 billion per year on feminine hygiene products, and the average woman will use over 16,800 tampons and pads over the course of her lifetime. Despite this large investment and high usage, there has been limited research on the potential health risks these products may pose to women.”

The legislation would require the National Institutes of Health (NIH) to allocate resources for independent research into the potential hazards posed by synthetic fibers and chemicals currently present in many of the feminine hygiene products on the market. It would also mandate research to confirm data submitted to the FDA by manufacturers. The results of all future independent studies would be submitted to Congress, the Environmental Protection Agency (EPA), and the Consumer Product Safety Commission as well as the FDA. These findings would also be available to the public.

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Maloney first introduced the Tampon Safety and Research Act in 1997, the year before Danielson died. The bill was re-named and has been brought before Congress a staggering nine times in total. Each time Maloney reintroduces the bill, it’s killed before it can get near a vote. It is currently in the Committee on Energy and Commerce.

A spokesperson for Maloney wasn’t able to comment on why the bill has been shot down so many times, but Chris Bobel, president of the Society for Menstrual Cycle Research, wrote in her 2010 book New Blood: Third-Wave Feminism and the Politics of Menstruation that the bill’s repeated failure could be “a result of activist inattention.” In Bobel’s interviews with feminine hygiene safety activists, she wrote, few seemed to set their sights on legislative action and instead focused on pressuring manufacturers through boycotts and other methods. With increasing public attention being paid to the policies surrounding hygiene products and alternatives to them, that may change—as might any congressional reluctance to engage with reproductive medical issues.

Regardless of activists’ strategy for approaching the topic, Bobel notes they are largely concerned about the health effects of feminine hygiene and menstrual products—especially because so few studies have been done using human subjects. According to everyone interviewed for this story, almost no independent research has investigated potential health impacts of long-term feminine hygiene product use, aside from the many studies on TSS. Bobel says anthropologists and other social scientists have frequently examined the culture around menstruation, but most medical research has centered on reacting to ongoing outbreaks of TSS rather than examining unknown outcomes.

And, health advocates point out, the research that has been done has taken place through product manufacturers. Part of the problem is that tampons and pads are considered “medical devices,” which means companies test them before submitting the results to the FDA as part of their pre-market approval (PMA) documents. PMAs—including testing results—are not readily available to consumers. Furthermore, the FDA does not require companies to list the ingredients on these products.

According to the FDA’s 2005 guidance, a tampon manufacturer submitting a PMA should test for potential health risks including adverse tissue reaction, vaginal injury, vaginal infection, and TSS. Preclinical toxicology and microbiology are “recommended” as well. Those submitting PMAs for pads should address adverse tissue reaction as well. Because so much of the testing data is kept secret, it’s unclear how strictly the FDA enforces the guidelines, much less what the actual results are.

“What’s clear is that there is so little data,” Bobel told Rewire. “We don’t have access to industry data that’s reported to the FDA because they aren’t obligated to release the results of their studies to the consumer. And that’s standard, but it means that consumers can’t make authentically informed choices. So there’s no transparency or accessibility.”

The FDA guidance also says nothing about long-term health effects relating to chemical leakage, which some scientists see as a potential problem concerning tampons in particular.

Philip Tierno, a microbiologist at New York University and author of The Secret Life of Germs, has been conducting independent research on TSS for years. TSS, caused by the bacteria Staphylococcus aureus, became epidemic around 1980. The health crisis was traced to the use of Proctor & Gamble’s Rely tampon, which was comprised of a synthetic blend encased in polyester. Tierno explained that the ingredient carboxymethylcellulose was primarily responsible for encouraging bacterial growth because of the way it “gelled” the liquids inside the vagina.

But toxic shock isn’t the only harm women face when it comes to feminine hygiene products, Tierno argues; it’s just the only disease that has been proven to be linked to them.

“There are many other leachables that come from fibers, and they leach out chemicals whether [the fibers are] organic or inorganic, and [they] clog the liver,” said Tierno. “If you have a woman who has no or low antibodies, not only are the leachables being absorbed, but other chemicals that come into play when the liver is clearing toxins.”

Many of the most toxic tampon ingredients—like the carboxymethylcellulose in Rely tampons—were banned in the 1980s after testing showed a direct connection between them and TSS. But Tierno says many products still include viscose rayon: the bleached wood pulp derivative that produces dioxins, the “leachable” about which he is most concerned. He believes that rayon and synthetics in general are responsible for ongoing cases of TSS, and that the disease can only be avoided by using all-cotton tampons or shunning their use altogether in favor of pads.

According to the EPA, most people have trace amounts (low parts per trillion) of dioxins in their systems. Dioxins are normally absorbed in these tiny amounts through food and water, and enters the environment through things like industrial waste processes and forest fires.

The EPA notes, however, that dioxins can be potentially harmful at moderately increased doses. “At body burden levels 10 times or less above those attributed to average background exposure, adverse non-cancer health effects have been observed both in animals and, to a more limited extent, in humans,” reads a posting about dioxin on the agency’s website. “In animals these effects include changes in hormone systems, alterations in fetal development, reduced reproductive capacity, and immunosuppression. Effects specifically observed in humans include changes in markers of early development and hormone levels. At much higher doses, dioxins can cause a serious skin disease in humans called chloracne.”

In a patient alert from 2013, the FDA stated that “trace amounts” of dioxins had been found in tampons on the market; manufacturers must also provide the FDA with test results of the dioxin levels in their products from independent laboratories. Though the FDA pointed out that the dioxin levels in these tampons were very low, Tierno told Rewire that no studies have ever examined the impacts of dioxin accumulation in the body over a lifetime.

“You have to do some research. There is no research taking place on things like dioxin except at the hands of the manufacturers [during the FDA’s pre-market approval requirements], which is like the fox taking care of the henhouse,” Tierno said. “They aren’t looking at long-term effects. We need data to be able to glean information that can serve as the basis for predicting what can occur.”

The overall lack of a push for research on these issues becomes more glaring when one compares the way feminine product safety is assessed to other products used regularly and internally, such as toothpaste.

For example, in December 2013, concerns about the presence of a chemical called triclosan in Colgate Toothpaste prompted the FDA to begin an ongoing review of its safety risks. The agency hasn’t concluded its study, but in the meantime the governor of Minnesota enacted a law banning triclosan, which has been shown to mimic hormones in animal testing, from all products sold in the state beginning in January 2017. Last year, the European Union voted to ban triclosan from three industrial product groups and is assessing its safety in hygiene products.

In the wake of the controversy, toothpaste manufacturers, such as Proctor & Gamble, which makes Crest, began labeling their oral care products as “100 percent triclosan free.” However, according to a 2013 research study from Women’s Voices for the Earth, several non-toothpaste products on the market—especially feminine wipes, washes, and sprays—could contain either triclosan or similar endocrine disruptors, as well as other ingredients that have been linked to endocrine disruption or other health problems. Yet there has been little focus on feminine hygiene products as sources of these chemicals, especially when contrasted with the widespread reaction to triclosan in toothpaste.

What’s more, because the FDA regards feminine wipes, washes, and douches as “cosmetics,” each product does not require specific testing to get the agency’s approval.

By mandating that the NIH support and fund research into any health risks stemming from all feminine hygiene products—including links between those products and common health conditions—the Robin Danielson Act seeks to close this research gap. It would also require studies examining products’ effect on reproduction: fetal and childhood development as impacted by regular feminine hygiene product use.

“The reality is menstrual health has been considered a taboo subject for far too long,” Maloney said. “It’s time that feminine hygiene products are researched so that we can ensure that complete and accurate information is being collected and made readily accessible. My legislation will give women the ability to make more informed decisions as they seek to lead healthy lives.”

CORRECTION: This article has been updated to clarify the confirmed ingredients found in feminine hygiene products.

Commentary Environment

The Bipartisan Chemical Safety Reform Bill Is an Improvement—But It’s Still Not Good Enough

Elizabeth Arndorfer

Chemical safety reform presents a rare opportunity for legislators on both sides of the aisle to work together to protect the health and well-being of women and their families. Unfortunately, bipartisan does not always mean better. 

Chemical safety reform presents a rare opportunity for legislators on both sides of the aisle to work together to protect the health and well-being of women and their families. Unfortunately, bipartisan does not always mean better. 

This week two bills were introduced in the U.S. Senate to improve chemical safety in the country: one by Sens. Barbara Boxer (D-CA) and Ed Markey (D-MA) and one by Sens. Tom Udall (D-NM) and David Vitter (R-LA). Although the Boxer-Markey bill does more to combat hazardous substances in our environment, the Udall-Vitter bill is getting far more congressional support. However, the Udall-Vitter legislation does not sufficiently protect reproductive health, particularly for the most vulnerable communities. 

Mounting scientific evidence indicates that the products we use every day—as well as the air, soil, and water around us—contain chemicals that harm our reproductive health. Studies on animal subjects have linked chemicals in the environment to male and female infertility; reduced sperm count and quality; alterations in ovarian function and menstruation; endometriosis; altered prostate development; and puberty onset. In addition, researchers have linked environmental chemicals to altered fetal development, miscarriage, and preterm birth in humans.

Moreover, the harm caused by chemicals in our environment is not shared equally. Low-income communities and communities of color are much more likely than other groups to be directly exposed to harmful chemicals at work, at home, and through consumer products. Increased exposure to these chemicals puts these communities at greater risk for reproductive health problems. For instance, almost 25 percent of Black girls and 15 percent of Latina girls had breast development by age 7 in one long-term study out of San Francisco, compared to just 10 percent of white girls. 

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Both Republicans and Democrats agree that the current regulatory system is seriously flawed, providing the Environmental Protection Agency (EPA) with little power to remove even the most dangerous chemicals from the market. And while the Udall-Vitter bill improves current law by providing a health-based safety standard that must consider the impact of chemicals on vulnerable communities such as those living near a factory or pregnant women, it significantly undercuts this improvement with an overreaching preemption clause.

Preemption is the constitutional doctrine that, in certain issues of national importance, federal law must take precedence over state laws. Under the current Toxic Substances Control Act (TSCA), the preemption clause allows a state to regulate a chemical until the EPA actually imposes a restriction it—at which point the state is generally prevented from acting.

This is important because in the absence of effective federal regulations, states have stepped in to protect citizens from harmful chemicals. There are more than 150 laws in 35 states that restrict or regulate chemicals. 

The Udall-Vitter legislation departs significantly—and harmfully—from current preemption in TSCA. Under this proposed bill, states would not be able to take action after a chemical has been designated by the EPA as “high priority.” This means that before the EPA has taken any action to restrict or limit the use of a high priority chemical, states would be blocked from taking action on it. This would create what the California Attorney General called a “regulatory void” in an open letter regarding the Udall-Vitter bill. And this is bad for reproductive health.

Given the timelines outlined in the legislation, it could take the EPA at least five-to-seven years to complete a safety assessment of a chemical. Since the states’ hands are tied during this time, the chemical industry will have every incentive to stall EPA action through litigation and other shenanigans. Years could tick by with no action, with continued exposure to dangerous chemicals and with continued potential harm to reproductive health, fetal development, and fertility. And this is for “high priority” chemicals—chemicals that we have good reason to believe are harmful to our health. 

In contrast, the Boxer-Markey bill enables states to continue to protect its citizens from harmful chemicals in the absence of federal action. No loophole. No regulatory void.

The Safer Chemicals Healthy Families Coalition, a diverse coalition of 450 public health, environmental, labor, and business organizations (of which RHTP is a member), have asked the proponents of the Udall-Vitter bill to fix the preemption problem so that it would occur only after the EPA imposes restrictions on a chemical. So far, those requests have been ignored.

While there are other troubling aspects of the Udall-Vitter bill, the disingenuous interplay between the better safety standard and the much worse preemption, underscores that this legislation—despite being bipartisan—is not an improvement for reproductive health.

In the coming weeks, we urge senators who care about reproductive health, fetal development, and infertility to support the Boxer-Markey legislation or work to get much needed changes to the Udall-Vitter bill.