A recent TikTok video went viral with the false claim that the titanium dioxide used in L. brand organic tampons is responsible for miscarriages, cancer and a host of other medical problems.
Titanium dioxide, or TiO2, is a naturally occurring mineral comprised of titanium and oxygen.
L. brand tampons use titanium dioxide as pigment in the thread that attaches the string to the absorbent part of the tampon. According to the company, TiO2 represents less than 0.1% of all the ingredients they use to manufacture their tampons.
Despite a small percentage of TiO2 present in the product, low toxicity risk and an unsupported cause-and-effect example are both factors that led me to debunk this claim.
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When it comes to assessing toxicity, the dose and route matter
TiO2 It is mined from the Earth and then processed into an inorganic solid white compound most commonly used as a pigment in paints, food coloring, sunscreen and cosmetic products. It is the most widely used white pigment because of its brightness and very high refractive index – meaning that its "brilliant whiteness" does not allow light to pass through.
There are many substances, including medications, that we safely encounter or consume on a regular basis. But if we are exposed to these same substances via a different route than how they are intended, or at a higher dose, they can be toxic.
In the emergency room, I assess five primary routes of exposure for a substance when assessing for toxicity: inhalation, skin contact, eye contact, ingestion and absorption. Let’s look at what can happen with an acute TiO2 exposure:
Inhalation: can cause irritation of nose and throat at high concentrations
Skin: can cause mild irritation
Eyes: can cause mild irritation as a “foreign body sensation” but tearing and blinking can safely remove the particles
Ingestion: likely not harmful at the low levels we typically encounter it.
The last route – absorption – is the route of question when it comes to the TiO2 in tampons. But TiO2 is insoluble in water – meaning that it cannot be dissolved into smaller particles. So, titanium dioxide on the tampon string is not going to be dissolved and absorbed by menstrual blood; and certainly, will not be absorbed into the body.
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Correlation, not causation
The TikTok user who posted the video makes the claim that TiO2 has been linked to cancer and multiple gynecological issues. She does this by citing another TikTok video in which that user claimed to have excessive vaginal bleeding, ovarian cysts and “uterine damage” after using L. brand tampons.
Both TikTok users are falling prey to the “correlation, not causation” trap. I’ve written multiple times in this column about how an observed association between two events or variables does not necessarily mean that one caused the other. Cause-and-effect can only be established by rigorous randomized-control, double-blind clinical research trials or meta-analyses of multiple smaller studies, for example.
As an emergency room doctor, there would be many possible (and more likely) emergency room causes of excessive menstrual bleeding that I would evaluate a patient for. Titanium dioxide exposure would not be on that list.
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Long-term risk of titanium dioxide?
Some country-level occupational health and safety organizations cite a lack of high-quality studies from which they can draw any concrete conclusions about the long-term risks of titanium dioxide exposure.
Regarding risk of cancer, there is an oft-cited study that shows that chronic high-level exposure of inhaled TiO2 could be linked to lung cancer in rats. However, there are no trials to validate this finding in humans. And it would be a stretch to correlate a possible connection in rats to a true cause-and-effect in humans. And remember, this is inhaled TiO2 at very high levels – much higher than the small amount of TiO2 in the strings of tampons.
The European Food Safety Authority in 2021 expressed concern that TiO2 particles in food additives could accumulate over time in the body and ruled that it “could no longer be considered safe” as a food additive. The agency could not “rule out” potential damage to DNA, but this is much different than the agency stating there was an identified cause and effect. TiO2 was nevertheless banned as a food additive in the EU as of this month. Meanwhile, in the US, the FDA continues to allow for safe use of TiO2 as a food additive as long as manufacturers provide evidence that it is safe at its intended level of use.
The bigger issue: Social media health misinformation is unchecked
I am less concerned with the level of titanium dioxide in tampons than I am with how social media users dangerously, and unchecked, amplify misinformation. With 8 million views, this instance shows the impact of a TikTok despite the actual evidence to the contrary. Once that social media seed is planted, it is extremely difficult to convince people otherwise.
I believe we all have a responsibility to better and more critically appraise social media content, particularly with regard to health and medical information.
Here are five steps you can start applying today:
Take a step back. Remember, a lot of these videos quickly go viral because of their shock value, which triggers many viewers to repost without fully understanding the topic for themselves. Often, these videos falsely assert a cause and effect between two events or variables without any actual proof.
Consider the source. Is the user who posted the video an expert in the field or topic they are discussing? If not, take a minute and search the topic online; major respected news outlets will oftentimes report on viral social media posts and interview experts in the field.
Do your homework. My go-to source? PubMed.gov – a National Library of Medicine source of more than 34 million citations for biomedical literature. Here you can find scientific studies that researched the issue you are interested in.
Understand risk. We do a poor job overall of understanding risk. We want risk-free options in our daily choices for food, medicine and products we use, but there is rarely a zero risk-free choice. The best you can do is to review the available evidence and determine what risk you can live with.
Make an informed choice. Boom! Congratulations for making a critical appraisal of a social media video.
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Michael Daignault, MD, is a board-certified ER doctor in Los Angeles. He studied Global Health at Georgetown University and has a Medical Degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps Volunteer. Find him on Instagram @dr.daignault
This article originally appeared on USA TODAY: Titanium dioxide in tampons: What you need to know