Is It Safe to Wear a Tampon During a Miscarriage?

Ask Dr. Jen

Hello! I recently learned (unfortunately) that it's recommended women don't use tampons during miscarriage bleeding, due to risk of infection. As the friend who told me this pointed out, it makes an already unpleasant and uncomfortable experience all the more unpleasant and uncomfortable. I was wondering if that's true, and (this is what I couldn't find anywhere online) if that's less true for early miscarriages, like those in the first 6 weeks. 

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Short Take

Avoiding tampons for two weeks after a miscarriage is the recommendation. This is canonical conventional wisdom based on a theoretical risk of infection with tampons, but there is no supporting research. 

Tell Me More

This appears to be one of those medical recommendations that someone wrote in a textbook decades ago, but possibly even a hundred years or more, and it has stayed around since.

The hypothesis is a tampon could increase the risk of infection as the cervix is open to pass tissue. Inserting anything into the vagina, be it a tampon, a sex toy, or a penis, could possibly introduce bacteria that would now have an easier pathway into the uterus. A tampon in the vagina could also provide a site for bacteria that is already present to grow. 

Bacteria can definitely enter the uterus from the vagina and cause infection. Gonorrhea is one example people might be familiar with, but even the typical bacteria in the vagina can cause harm in this way. One that can cause catastrophic infections with a high rate of mortality after miscarriage, induced abortion, and even pregnancy is Clostridium perfringens. I’ve seen this once and I hope I never see it again. Thankfully, it is a rare infection, but that also means what we know about it is based on case reports. I read six case reports for this piece, but none of them mentioned if tampons were involved or not. There is also the risk of toxic shock syndrome with tampons (caused by a toxin produced by the bacteria Staph aureus), although it is believed that the toxin typically enters the blood stream from the vagina not via the uterus. Currently, the risk of menstrual toxic shock syndrome is 1 in 100,000 women per year. How tampons after miscarriage might affect that risk is unknown.

Many people miscarry before they know they are pregnant, especially as bleeding before six weeks is often lighter than a regular period. This means that many people might be unaware they are miscarrying and so are using tampons. One study that looked at menstrual blood loss versus blood loss from a miscarriage before six weeks appears not to have instructed participants to avoid tampons in case they were pregnant, as they used pad and tampon counts to estimate blood loss. 

I have not been able to find any clinical trials or even observational studies to back up the recommendation to avoid tampons after a miscarriage. I asked multiple OB/GYNs if they knew of any studies that I was missing, and each one said no. 

My own personal theory is this is an older recommendation from before the discovery of antibiotics, when infection in the uterus was disastrous and objects in the vagina, such as pessaries, were believed to play a role. Some objects actually did cause infections, for example stem pessaries, a contraceptive with a metal rod that went into the cervix with a metal cap on the outside covering the cervix (imagine a giant thumb tack in the cervix). Infections related to miscarriage would have been more common, even taking unsafe abortion out of the picture. There was no treatment for gonorrhea, so that resulted in catastrophic infections for many. There is also incomplete abortion, a miscarriage that starts but doesn’t complete. The tissue that stays behind combined with an open cervix trying to expel the tissue increases the risk of infection. Today we can do a dilation and curettage in a clean operating room with sterile equipment and administer antibiotics. This was not always the case.

I have some textbooks from the late 1800s and treatment for infection of the uterus (then typically called inflammation or metritis) amounted to little more than torture, and most of it ineffective at that. For example hot water douches, carbolic acid douches, and scarification of the cervix (cutting the cervix to scar it), so obsession about preventing infections is, um, understandable in that context.  

I suspect this legacy of catastrophic infections informed a lot of textbooks in the 1920s and 30s and the information about avoiding anything that might theoretically raise the infection risk stuck. Septic unsafe abortions would only had added to the concern. I am confident that there is more than a whiff of purity culture as well. It is easier to tell someone they should keep a penis out of their vagina if you tell them tampons are risky. 

The hypothesis that tampons after miscarriage or abortion might raise the risk of infection is not an unsound one, it’s just that it unencumbered with data so we don’t know if it is valid or if it’s dogma. It’s also nearly impossible to study. The rate of infection after a first trimester miscarriage and after a first trimester abortion is so low that a massive study would likely be required to prove a risk from tampons.

In one study, 77% of second trimester miscarriages were associated with infection. This means there is more likely to be bacteria in the bleeding that follows. Could this bacteria attach to a tampon and grow and then travel back into the uterus or enter the bloodstream? Possibly. The cervix also stays open for longer after a second trimester miscarriage, so this might further increase the risk. In addition, any second trimester procedure that involves laminaria, seaweed sticks that are placed in the cervix the day before to open the cervix for dilation and evacuation, increases the risk of infection. In the absence of other data, it seems a solid recommendation to avoid tampons for two weeks after a second trimester miscarriage or abortion. 

Given the risk of infection is lower overall with a first trimester miscarriage and that many people probably use tampons with early miscarriages not realizing they are pregnant, the risk of tampon-related infection is likely low, but that is also a hypothesis. It is simply not possibly to quantify the infection risk related to tampons in this situation. When infections do occur, even with modern antibiotics, they can be catastrophic.

The American College of OB/GYN (ACOG) and handouts from multiple institutions recommend avoiding tampons for two weeks after a miscarriage or a pregnancy termination, and this is what most practitioners recommend. Based on the lack of data, it is hard for them to recommend anything else. I appreciate this is a deeply unsatisfying answer.