Editors note: This is the first in a series of periodic articles exploring health issues that have been underreported or have seen new advances in treatment. In this series - today, May 13 and May 20 - staff writer Amy Yannello looks at the possible connection between dioxin exposure and the use of tampons. - Richard Walker, managing editor.

      Something was horribly wrong.
      On Christmas Eve 1997, Ruth felt what she thought was a golf ball-sized mass in her vagina. Her doctor told her that what she felt was actually her cervix, which had been pulled down and to the side because her right ovary had adhered to her colon, causing her cervix and other organs to shift.
      "I was in pain and I was freaking out, thinking 'Oh God, what now?'" said Ruth, who had spent five years battling endometriosis - a disease whose cause is unknown and is characterized by chronic pelvic pain, painful menstrual periods, chronic fatigue and depression.
      It wasn't until three years after her diagnosis in 1994 that she began to question whether the tampons she had used for 15 years had any connection to her painful condition.
      "I was doing research on the Internet about endometriosis and started coming across reports that suggested that dioxin could have been a factor," Ruth told the Press-Tribune, adding that because she feared getting sued by tampon manufactures, she didn't want her last name used.
      "I also read about a study done on Rhesus monkeys which said that when they were fed dioxin they developed (endometriosis). I was shocked that this chemical might be in tampons, yet no one had told women or done anything about it."
      Ruth's fears coincide with what a handful of women's organizations and researchers say: millions of American women put themselves at risk every month when they choose to use conventionally produced tampons. Such choices mean they unknowingly subject themselves to dioxin - a known carcinogen long linked to cancer and suspected in other diseases such as Toxic Shock Syndrome and endometriosis.
      Rep. Carolyn B. Maloney, D-New York, was concerned enough to introduce H.R. 2900 - The Tampon Safety and Research Act of 1997. The bill would direct the National Institutes of Health to conduct research to determine whether the presence of dioxin, synthetic fibers and other additives in tampons pose any health risks to women.
      According to Maloney's research, about 70 percent of American women use tampons; a woman may use as many as 11,400 tampons in her life-time.
      Maloney said she was most concerned about dioxin's long half-life, noting that a woman's body composition may increase her susceptibility to the chemical.
      "Dioxin is stored in fatty tissue - just like that found in the vagina. And the fact is that women have more body fat than men, possibly allowing them to more efficiently store dioxins from all sources, not just tampons. Worse yet, the effects of dioxin are cumulative and can be measured as much as 20 to 30 years after exposure," Maloney said.
      "Why has there been far more testing on the possible health effects of chlorine-bleached coffee filters than on chlorine-bleached tampons and related products? The fact is, women do not have the information they need to make sound decisions about their health," she added.
      In June 1996, Maloney wrote a letter to the Food and Drug Administration, requesting additional information regarding the levels of dioxin in tampons, including records from big-name tampon manufacturers.
      On Jan. 7, 1997 she received a response.
      Diane E. Thompson, associate commissioner for legislative affairs told Maloney that in 1989 and 1995, the FDA requested the four major tampon manufacturers - Tambrands, International Playtex, Personal Products (Johnson & Johnson) and Kimberly-Clark, Corp. - to submit dioxin levels in the rayon and cotton used to manufacture tampons.
      "The data showed that dioxin levels in the raw materials were far below the accepted ... levels," as determined by the EPA, Thompson wrote. Further, tampon manufacturers reported that the "potential lifetime risk of cancer from tampons ... was below one in 10 billion, which is far lower than the threshold of one in (1) million for regulatory action."
      Thompson refused to release to Maloney actual data provided by the manufacturers, claiming that it was "proprietary information," adding that in 1995, FDA officials instructed tampon manufacturers to "certify that they will continue to monitor dioxin levels in their products."
      That's a little like asking the fox to guard the hen house, asserts Willi Nolan, founder of Bio Business, Intl. in Toronto, Canada.
      "As far back as 1989, internal documents show that an FDA scientist reported that 'risks from medical devices, such as tampons (and) menstrual pads' could be 'quite high because they contained dioxin.'" said Nolan, whose company produces and markets non-chlorine-bleached cotton tampons, and acts as a clearing house for information about dioxin-related illness in women.
      According to the March 27, 1989 document, which was discovered by the House Government Operations subcommittee that oversees the FDA, the same scientist concluded that "all possible exposures from all other medical device sources would be dwarfed by the potential tampon exposure; therefore, the most effective risk management strategy would be to assure that tampons and menstrual pads ... contain no dioxin."
      "No one wants to talk about who this scientist is," Nolan said, who said it was "outrageous" that the FDA dismissed its own scientific report, choosing instead to "let the manufacturers monitor themselves."
      "What's always made me outraged is that this assault on women's bodies ... this conspiracy of silence continues to exist - all for profit," she added.

      Endometriosis affects nearly 6 million women and girls in the U.S. and Canada alone, according to the National Endometriosis Association.
      Because no public studies had been performed, Ruth paid nearly $1,000 to MAXIM Technologies, Inc., a private lab in St. Paul, Minnesota, to test the dioxin levels in 10 Playtex Super-Plus Absorbency tampons.
      "I can now prove that there is dioxin in the tampons I was using," Ruth said. "All humans are exposed to dioxin - in the food they eat, in cleaning solvents, their dry cleaning ... but with women getting an extra dose because they use tampons, it just might be enough to push us over the edge to develop this disease, where others may not."
      "For years, tampon manufacturers have said 'Oh, ignore it. There's not enough dioxin in there to worry about'. But I think this exposure is very serious and since they wouldn't release their studies, I had my own done," she added.

      Dioxin is a by-product of the chlorine bleaching process that is used to make tampons, sanitary pads, diapers and other paper and wood products "super white."  Like Ruth, scientists are quick to point out that humans are exposed to dioxin everyday - primarily through their diet, but also through their contact with cleaning solvents, paper products and dry cleaning.
      Because dioxin bonds with fatty tissue, humans who consume beef, poultry and fish end up digesting the chemical.
      As reported by Charlotte Brody in "Everyone's Backyard" - a publication of the Center for Health, Environment and Justice - dioxin is classified as a "known human carcinogen" by the International Agency for Research on Cancer, an arm of the World Health Organization.
      In addition to endometriosis, the Women's Environmental Network in London reports that possible side effects of dioxin exposure in humans includes: immune system damage, especially in children; damage to the liver, kidneys and digestive tract; miscarriage and sterility and low sperm count in men.
    Results from the tests performed on Ruth's tampons showed trace levels of the chemical, according to Mike DeVito, a toxicologist at the U.S. Environmental Protection Agency, who evaluated the results at the request of The Press-Tribune.
      DeVito cautioned, however, against drawing a direct correlation between the dioxin contained there and the development of endometriosis in humans.
      "To put it into perspective, you have to remember that humans ingest dioxins everyday through their food supply," he said.
      According to the EPA, the average woman weighs about 50 kilograms and ingests between 50 to 150 picograms of dioxin per day through their diet. The Playtex tampons tested contain between .6 to .7 picograms of dioxin. Assuming that all the dioxin came off the tampon and was absorbed, and assuming an average woman used eight tampons per day for five days a month, DeVito said that 3.5 percent of a woman's total daily exposure to dioxins were coming from the tampons she used.
      "That's assuming that she is normally exposed to 150 picograms of dioxin a day. Add another 5.6 picograms per day based on her tampon use, and you've increased her daily exposure during that period to 155.6 picograms.
      "But when you average this over an entire month, you get .93 percent of your daily dioxin exposure coming from tampons - a significantly lower number," DeVito said, adding that while he "doubts" all the dioxin contained in the tampon is absorbed, he also can't verify the amount that is available to come off.
      Does this mean that tampons present no danger to women's health?
      "There's nothing out there right now that you can point to that clearly states that exposure to dioxin causes endometriosis. On the other hand, there's no research out there that clearly proves that it doesn't. Frankly, the evidence is weak on both sides," DeVito said.
      Yet, DeVito admits that dioxin has an "extremely long half-life" - able to last in the body for as long as 11 years.
      "So, if you get exposed to 1 picogram today, in 11 years, you'll have half a picogram in you," he noted.
      Despite the lack of evidence on the affects of dioxin in humans, significant evidence exists showing that laboratory animals exposed to the chemical have developed endometriosis, in addition to various cancers.
      Perhaps most widely cited is a 15- year study done on a colony of 24 female Rhesus monkeys in Wisconsin. Led by Sherry E. Rier, a team of scientists, including representatives from the University of Wisconsin and the University of South Florida, exposed the colony to dioxin-laden food for four years. Seventy-nine percent of the monkeys had developed endometriosis 10 years after the dioxin treatment had
ended.
      "The incidence of endometriosis was directly correlated with dioxin exposure and the severity of disease was dependent upon the dose administered," Rier wrote in,an Aug. 17, 1993 report.
      "This ... study indicates that latent female reproductive abnormalities may be associated with dioxin exposure in the rhesus. Therefore, the effects of this toxin may be more diverse than previously recognized," she reported, adding that between 1989 and 1992, three monkeys died. Autopsies showed that all three had "widespread to severe" cases of the disease at the time of their deaths.
      DeVito said the studies deserve closer inspection.
      "It's rather compelling evidence that dioxin can produce those results in monkeys. However, we're still uncertain about its effects on humans. But it seems to me that it's something to be concerned about. And clearly, the relationship between exposure to dioxin and endometriosis requires a lot more work," DeVito said.
      Mary Lou Ballweg, executive director of the National Endometriosis Association (EA) said that while "you can't claim a direct link" the animal studies show that a link exists.
      "You can't say that if a woman has endometriosis and she's used tampons all her life that that's why she has the disease," Ballweg said. "However, the animal studies are very strong and they show that dioxin has caused endometriosis, so even though there's only trace amounts on the tampons it's still very important for women to be aware of this.
      "I think the bigger issue is why the FDA hasn't required tampon manufacturers to list this and other ingredients on their products."

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