Editor's note: This is the second in a series of periodic articles exploring health issues that have been underreported or have seen new advances in the treatment of care. In this story - the second of three parts - reporter Amy Yannello looks at the possible connection between dioxin exposure and the use of tampons.

      Fade into a woman walking along the beach, or maybe riding a horse. She looks like she's enjoying herself, despite the fact, intones the announcer, that she's menstruating. She feels fresh. She feels secure.
      She may also be exposing herself to a host of foreign elements, including dioxin - a known carcinogen long linked to cancer and suspected in diseases such as Toxic Shock Syndrome and endometriosis.
      Dioxin is a by-product of the chlorine bleaching process that is used to whiten most tampons, sanitary pads, diapers and other paper and wood products, and break down the wood fibers contained therein.
      For more than 70 percent of American women, dealing with their monthly cycle involves little more than deciding which tampon or sanitary pad to buy - a decision that was probably made soon after they got their first period and was heavily influenced by their mother or their friends.
      Groups like the International Endometriosis Association and the Women's Environmental Network, along with authors Liz Armstrong and Adrienne Scott, say women have been manipulated by corporations into believing that "super white" means "pure." And, consequently, their health may be at risk.
      "As a whole, I think we've been sold the idea that menstruation is disgusting and something to be hidden; we're better off if we ignore it," said Megan Seely, outreach coordinator for Women's Health Specialists, a nonprofit center providing family planning and reproductive health services to women in Placer and Sacramento counties.
      "Tampons aren't sterile, but we've been conditioned to think that if something is white, it is pure and therefore safe to put inside us. It's just not true," Seely said.
      In a report released in the mid-1990s, Washington researchers Stacey and Kirk Johnson wrote, "Despite substantial scientific proof that organchlorines (dioxins among others) are some of the most toxic substances known, the pads and tampons are left unrinsed of these and other toxic residues, individually packaged and sold to women throughout the world."
      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 and 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 that included 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 developed endometriosis 10 years after the dioxin treatment had ended.
      A 1981 study by the Food and Drug Administration (FDA) also found that tampons include elements such as boron, aluminum and copper and compounds like waxes, surfactants, alcohols, acids and nitrogen - all of which can be left behind in the vagina.
      In her introduction to Nancy Friedman's 1981 book, "Everything You Must Know About Tampons," Dr. Cynthia Cooke states that tampon manufacturers and the U.S. government have been "seriously remiss in accepting the veil of proprietary information and refusing to allow women to know exactly what they're putting in their bodies."
      Cooke continues, saying that for women to make informed decisions, "complete product labeling is an absolute prerequisite."
      Armstrong and Scott, authors of the 1992 book, "Whitewash," note that "10 years later, we're no better off. It's funny that labeling of ingredients in cosmetic products such as shampoo, nail polish and soap has been a legal requirement in the United States since 1976, but no similar law governs women's sanitary products."
      Concerned about the lack of "viable" research on the topic, Rep. Carolyn B. Maloney, D-New York, introduced 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 lifetime.
      "The only research that has been done on this issue has been done by the major tampon manufacturers and we don't feel comfortable relying solely on their information," said Maloney press secretary Terese Schlachter.
      "The FDA needs to take this (topic) more seriously. The fact is, if this were a man's health issue, this (government) research would have been done by now. It's just one example of the difficulty involved in getting research done for women's health issues," Schlachter added.
      Maloney's bill has been referred to the House Subcommittee on Health and the Environment.

    Representatives of the two major tampon manufacturers - Procter & Gamble (who makes Tampax) and Playtex Products, Inc. - maintain that there are "no detectable levels" of dioxin in their products.
      The companies - which account for roughly 55 percent and 25 percent of the market share respectively - also point to a 1990 study and a 1996 reassessment done by the U.S. Environmental Protection Agency (EPA) that states "the lifetime cancer risk from exposure to dioxin in tampons (is) estimated to be less than one in 1 billion."
      But independent tests performed on 10 Playtex Super-Plus Absorbency tampons by MAXIM Technologies, Inc. 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.
      The Playtex tampons tested contained 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.
Jeffrey Brown, vice president of research and development for Playtex Products, Inc., said that he "couldn't comment on an arbitrary lab's testing and results," but that his own documents contradict those findings.
      "Frankly, I'm impressed that someone could detect something at the picogram level. But our tests - which use the EPA's detectable levels of one part per trillion (1 ppt) - show that we have no dioxin at a detectable level," said Brown, adding that ENVIRON, Corp. - a risk assessment company in Virginia - conducts tests for both Playtex and the federal government.
      In its report to the Congressional Research Service, ENVIRON maintained that even using the "maximum theoretical dioxin exposure a woman might receive if dioxin is actually present" at 1 ppt, and all of it was absorbed into her body, it would equal "less than 1 percent" of the average daily intake a woman would be exposed to through her normal diet.
      DeVito agreed, in theory, saying that an average woman is exposed to 150 picograms of dioxin per day through her diet. With an additional 5.6 picograms of dioxin coming from her tampons, her exposure would increase to 155.6 picograms. Using MAXIM's figures, however, 3.5 percent of her dioxin exposure would come from tampons, during a normal five-day cycle.
      "When averaged over a month, however, her exposure from tampons would decrease to .93 percent," DeVito said, noting, however, that because of dioxin's long half-life, long-term exposure could present a problem.
      "If you're exposed to 1 picogram of dioxin today, in 11 years, you'll still have half a picogram in you," he added.
      When asked to respond to an internal FDA memo found in 1989 by a congressional subcommittee that shows an FDA scientist reporting that "risks from medical devices, such as tampons (and) menstrual pads" could be "quite high because they contained dioxin," Brown and others cited the more recent EPA studies, saying they preferred to rely on "official, published" reports.
      However, 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."
      "Again, the EPA and the FDA have studied this and have concluded that even if dioxin was present, it wouldn't be a threat and would be dwarfed by the amount of dioxin found in a normal diet," Brown said.
      Elaine Plummer, spokeswoman for Procter & Gamble, which purchased Tambrands, Inc, - the makers of Tampax - said her company uses an "elemental chlorine-free" bleaching process in producing its tampons.
      "Our global policy requires our suppliers to (certify) that their fiber purification process will not lead to the presence of dioxin," said Plummer, adding that because Procter & Gamble purchased Tambrands, Inc. in 1997, she could not verify the policies of the previous company.
      "There are risks in everything you do ... but there's a lot of misinformation out there and it can be very misleading and very scary to women. I would hope that when they choose menstrual products, they would rely on valid scientific sources to make those decisions."
      Plummer said she didn't "see a need" for Maloney's bill.
      "The EPA has already published a conclusion on this. As for the animal studies ... there's no reliable evidence that has proved a causal link between using tampons and developing endometriosis," Plummer said.
      Citing the ENVIRON study again, Playtex's Brown said, "If monkeys or rats developed endometriosis after being fed (dioxin-laden) food, it doesn't tell us much because the doses were a million times higher than what a woman would be exposed to by using a tampon."
      Plummer added, "I can say without a doubt that we have no dioxin - not even trace levels - in our products. I'm a registered nurse and I use tampons and I don't want women to be concerned about something they needn't be concerned about. There are other health issues out there that  deserve attention.
      "Tampax has a heritage of safe and trusted performance and it's important to us to tell our consumers that this product can be used safely."

      To Mary Lou Ballweg, executive director of the International Endometriosis Association, manufacturers are missing the point - and so is the government.
      "You have to remember that until the mid-1990s, discussion about dioxin was looked at through the cancer paradigm - how much cancer was produced by how much exposure," Ballweg said. "But now we have, new research that shows that these chemicals have hormonal and immune system effects at a tiny fraction of the level necessary for cancer. It's a whole different framework."
      "It is incorrect to say that the doses given to animals are a million times higher. The Rhesus monkeys, for example, were given doses of five parts per trillion (5 ppt) and they developed endometriosis ... and 5 ppt is definitely within the range of exposure for many Americans."
      Deborah Gravelle, owner of Woman Kind - a Santa Rosa-based company that produces reusable, dioxin-free, menstrual pads - said American culture is partly to blame for the proliferation of  "unhealthy" products.
      "The byproducts of chlorine bleaching was known years ago in England and Canada and movements to (get rid of) that process started. But people here have turned a blind eye, mainly because we're a disposable society."
      "As a woman, I'm very angry that the government has refused to do anything about this. It will be impossible to fight the huge companies head on, because the situation is very similar to the tobacco industry right now. But I can do what I'm doing - providing an alternative through my company."
      "It all comes down to education," Gravelle said.
      "If just 1 percent of the women who hear about this call and order (products) from an alternative manufacturer, we can start to change things. It's important to get the message out, especially to young girls; we can no longer afford to keep doing this to our bodies."
      Ballweg agreed, adding, "It is an axiom of a free marketplace that consumers have access to information about the products they purchase, so why are menstrual products any different? If anything, we should have more information because these products are used in a way that could risk their health."

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