Infectious Vaginitis, Cervicitis, and Pelvic Inflammatory Disease

The Menstrual Cycle as a Vital Sign: a comprehensive review

Some medical professional organizations have advocated for including the menstrual cycle as a vital sign in adolescence, but not in adulthood. However, documenting menstrual cycle patterns is not routine clinical or research practice. Vital signs are used to predict health outcomes, indicate needed treatment, and monitor a clinical course. They can help identify pathologies, affirm wellness, and are responsive to exposures. Here we review the scientific evidence showing how the menstrual cycle meets these criteria and should therefore be treated as a vital sign. Using key words and controlled vocabulary terms, we carried out multiple literature searches, prioritizing the inclusion of systematic reviews, meta-analyses, and clinical practice guidelines. This review describes how the menstrual cycle is a health indicator, can cyclically impact health conditions, and its associations with long-term post-menopausal health outcomes. We review exposures influencing the menstrual cycle, evidence underlying its use to optimize wellness, and available tools for documenting cycles. Supplementary materials include patient handouts on menstrual cycle tracking, and an index of related clinical practice guidelines and reviews by subject. The menstrual cycle is a vital sign from menarche through menopause, an underutilized but powerful tool for understanding gynecological and general health.

Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Ureaplasma urealyticum infections in males and females of childbearing age in Chengdu, China

Background

Sexually transmitted infections (STIs) are a global public health issue, due to their high prevalence and potential impact on pregnancy outcome and fetal health. The objective of this study is to investigate the prevalence of STI-causative pathogens including Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Ureaplasma urealyticum (UU) as well as the epidemiological characteristics of STIs among males and females of childbearing age in Chengdu.

Methods

This retrospective cross-sectional study involved 15,055 participants of childbearing age including 7,235 males and 7,820 females. All specimens of participants were tested for CT, NG, and UU by nucleic acid amplification tests (NAATs) methods.

Results

27.80% of the participants were infected with at least one of the three pathogens, with significantly higher overall prevalence in females (45.22%) than males (8.98%, p<0.001). Multivariate logistic regression analysis demonstrated that gender was independently associated with both CT positivity (females vs males, OR 2.276, 95% CI 1.724-3.005, p<0.001) and UU positivity (females vs males, OR 8.079, 95% CI 7.183-9.086, p<0.001). Single infections predominated in both males and females (males: 98.15%; females: 93.16%), while mixed infections were more frequent in females (6.84%) than in males (1.85%). CT prevalence was highest in both males and females aged 18-24, followed by aged 25-30 and 31-35. Among aged 18-24, the prevalence of UU in males and NG and UU in females were also higher. Compared to other age groups, mixed infections (CT+NG, CT+UU, NG+UU, CT+NG+UU) were also highest in females aged 18-24. Compared to other clinical diagnostic groups, The prevalence of CT, NG and mixed infection of CT+NG was highest in both males and females in the urogenital inflammation group (p<0.05).

Conclusions

Among the population of childbearing age in Chengdu, China, the prevalence among females was significantly higher than that among males. Single infections predominated in both males and females, while mixed infections occurred more frequently in females. STIs were more prevalent in sexually active young people aged 18-35, especially in the 18-24 age group. CT and NG infections in both males and females may cause urogenital inflammation, and mixed infections of CT+NG further elevate the risk of inflammatory responses.

Antimicrobial Resistance in Maternal Infections During Pregnancy

Background: An imbalance in the vaginal microbiota, often characterized by reduced lactobacilli, paves the way forth for opportunistic bacteria from the gastrointestinal tract. The presence of aerobic bacteria in the genital tract during pregnancy can have negative outcomes on the pregnancy. Peripartum infections, when not adequately managed, can significantly impact maternal and neonatal health. Antimicrobial resistance poses an escalating global health threat, with newborns particularly vulnerable. Methods: This study constitutes a retrospective observational analysis, encompassing all microbial strains isolated from pregnant women admitted to the "Pius Brînzeu" Clinical County Emergency Hospital in Timișoara, Romania for various infectious diseases over one year. We analyzed 274 samples from 246 pregnant women, of which 242 were cervical samples, 23 urine cultures, 3 wound secretions, 3 amniotic fluids, 1 peritoneal cavity fluid, 1 sputum, and 1 hemoculture. Results: In cervical samples, Group B Streptococcus (GBS) was the most prevalent, representing 42.46% of the isolates. E. coli was the second most frequent at 30.16%, followed by K. pneumoniae at 11.9%, S. aureus at 8.73%, C. albicans at 2.78%, and other species at 3.97%. A total of 9.63% of cervical GBS isolates exhibited resistance to penicillin, while 23.36% were identified as multi-drug resistant (MDR). Methicillin-resistant S. aureus (MRSA) and MDR S. aureus strains were identified in 50% and 54.54% of the S. aureus-positive cervical samples, respectively. Conclusions: Recognizing the implications of maternal infection or colonization, especially with antimicrobial resistance bacteria, aids in assessing risks during pregnancy.

Improving Vaginal Health with a Zinc-Containing Vaginal Hydrogel

Vulvovaginal symptoms affect up to 39% of women. These symptoms have a significant impact on quality of life and are often linked to imbalances in the vaginal microbiota. This study evaluates the therapeutic efficacy of a zinc-containing hydroxyethyl cellulose-based hydrogel in 37 women with different vulvovaginal symptoms (itching, burning, irritation, pain, dryness, discharge, and odor). Over 12 weeks, participants applied the gel intravaginally with both assessments conducted at baseline and follow-ups. Results revealed substantial improvements in symptoms, including reductions in vaginal discharge, itching, and burning, as measured by the Vulvovaginal Symptom Questionnaire (VSQ-21), with scores decreasing from 10.78 ± 3.66 at baseline to 3.17 ± 4.16 at week 12 (p < 0.01). Vaginal Health Index (VHI) scores improved significantly, from 20.78 ± 1.74 at baseline to 23.64 ± 2.59 (p < 0.01). Cervicovaginal lavage (CVL) zinc levels decreased from 110 ± 102 µg/L at baseline to 62 ± 48 µg/L at week 4 (p < 0.01), increased to 80 ± 55 µg/L at week 8 (p = 0.04), and reached 99 ± 92 µg/L by week 12 (NS). A correlation analysis showed an inverse relationship between baseline CVL zinc levels and VSQ-21 scores (r = -0.3586, p = 0.034), while no significant correlation was observed with VHI scores (r = -0.0187, p = 0.9545). Vaginal pH levels decreased significantly, dropping from 4.03 ± 0.42 to 3.71 ± 0.48 (p < 0.01). These findings support the gel's role as an effective, nonhormonal, drug-free, and local adjunct treatment for a variety of vulvovaginal symptoms.

Clinical Characteristics of Vaginal Trichomoniasis Infection and Metronidazole Resistance in Vaginitis Patients

Objective

This study aims to investigate the clinical characteristics of vaginal trichomoniasis infection among vaginitis patients and assess their resistance to metronidazole.

Methods

We conducted a retrospective study involving 687 vaginitis patients who visited our hospital from April 2022 to June 2024. Clinical data were collected through questionnaires that included information on age, occupation, season of infection, marital status, contraceptive methods, and frequency of vulvar hygiene. Vaginal secretions were examined for trichomoniasis, and the characteristics of the infection were analyzed. Multivariate logistic regression was employed to identify factors influencing vaginal trichomoniasis infection. Infected vaginal trichomonas samples were cultured in vitro, and metronidazole gradient concentration plates were prepared to determine the minimum lethal concentration (MLC) of metronidazole against vaginal trichomonas, allowing for an assessment of resistance.

Results

Out of 687 vaginitis patients, 65 were diagnosed with vaginal trichomoniasis, resulting in an infection rate of 9.46%. Significant differences in infection rates were observed based on age, occupation, season of infection, marital status, contraceptive methods, and frequency of vulvar hygiene (P < 0.05).

Conclusion

The infection rate of vaginal trichomoniasis is notably higher in younger vaginitis patients compared to middle-aged and elderly individuals, with a peak occurrence in spring. Higher rates were also noted among farmers, married individuals, those using oral contraceptives or no contraception, and those with infrequent vulvar cleaning. Additionally, resistance to metronidazole was identified in some cases. Clinical efforts should prioritize prevention and treatment strategies for high-risk populations.

Evaluating the epidemiology of vaginitis in a contemporary cohort: a population-based study

Introduction

Bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and Trichomonas vaginalis (TV) commonly cause infectious vaginitis in women, especially those of reproductive age. Characterization of the epidemiology of infectious vaginitis in a contemporary population-based cohort was done to determine the longitudinal age-standardized and sex-based testing, positivity, and incidence rates and ratios of infectious vaginitis in a large Canadian healthcare region.

Methods

We conducted a population-based cohort study from March 2015 through March 2018 using the Alberta Precision Laboratories (APL) microbiology database. Calgary 2016 census data was used to calculate incidence rates (IR) and ratios (IRR) for cases and testing rates.

Results

For testing and positivity, female sex, and younger age groups were associated with increased risk of BV, VVC, and TV infections. The annual mean population in 2016 was 1,411,660 individuals (50.3% female). A total of 40,259 cases/293,853 tests (13.7%) of BV, 32,894 cases/293,853 tests (11.2%) of VVC, and 2018 cases/342,986 tests (0.7%) of TV were identified. The overall IR for BV ranged from 0 to 609 cases per 10,000 person-years. The overall IR for VVC ranged from 0 to 445 per 10,000 person-years. The overall IR for TV ranged from 0 to 27 per 10,000 person-years. The highest age-specific testing positivity rate and IR rate for BV and VVC occurred in women aged 20-34 years and 20-34 years. For TV, female IR for BV, VVC, and TV remained stable during the study.

Discussion

These unique regional data provide insight for the development of appropriate age-specific clinical testing criteria according to relative risk of acquisition of each vaginitis agent.

How to Effectively Communicate Dismal Diagnoses in Dermatology and Venereology: From Skin Cancers to Sexually Transmitted Infections

Background/Objectives: One of the problematic situations dermatologists face with their patients is communicating dismal diagnoses. Examples are the diagnosis and prognosis of skin cancers like melanoma and Merkel cell carcinoma and the disclosure of the chronic nature of a disease that requires long-term therapies or can lead to scarring or disfiguring conditions. Likewise, receiving a diagnosis of a sexually transmitted infection can be a shocking event that can also put into question the patient's relationship with his/her partner/partners. Some oncology and internal medicine protocols have been developed to support delivering distressing information. Regrettably, no consensus guidelines exist in dermatology, sexually transmitted infections, or other medical specialties. Methods: The protocols available in the literature to guide the disclosure of a dismal diagnosis have been reviewed in the present work. Results: The different protocols consist of several steps, from 5 to 13, and most of them are summarized by acronyms, such as "SPIKES", "ABCDE", and "BREAKS". The frameworks are listened to and explained in the manuscript. Conclusions: These communication models are suggested to be adapted to dermatology and sexually transmitted infections. Indeed, several studies demonstrated that training in communication skills and techniques to facilitate breaking bad news may improve patient satisfaction and physician comfort.

Predictive Value of Netrin-1 Expression and Ultrasonic Blood Flow in Cervical Intraepithelial Neoplasia Severity

Objective

To analyze the relationship and predictive value of Netrin-1 expression and ultrasonic blood flow parameters with the severity of cervical intraepithelial neoplasia (CIN).

Methods

A retrospective analysis was performed on 115 patients diagnosed with CIN and 37 patients with chronic cervicitis, all of whom underwent surgical intervention. The expression levels of Netrin-1 were evaluated through immunohistochemical staining and quantitative fluorescence PCR. Doppler ultrasound was employed to quantify flow index (FI), vascularization index (VI), and vascularization flow index (VFI) using VOCAL software. Statistical analyses, including correlation analysis, logistic regression, and receiver operating characteristic (ROC) curve analysis, were conducted to assess the predictive value of Netrin-1 expression and ultrasound-derived blood flow parameters.

Results

FI, VI, and VFI increased with CIN grade, showing significant differences between CIN II, CIN III, and the control group (P < 0.05). Netrin-1 levels were negatively correlated with FI, VI, and VFI (correlation coefficients of -0.287, -0.309, and -0.298; P < 0.05). Logistic regression indicated that Netrin-1 positivity was a protective factor against CIN III, while FI, VI, and VFI were risk factors. The AUC for Netrin-1 was 0.712, with sensitivity and specificity of 76.4% and 79.5% (P < 0.05).

Conclusion

Netrin-1 expression is significantly reduced in CIN patients, whereas Doppler ultrasound-derived blood flow parameters-FI, VI, and VFI-are markedly elevated. Both Netrin-1 levels and these ultrasound parameters exhibit a strong correlation with the severity of cervical lesions. Notably, Netrin-1 is negatively correlated with FI, VI, and VFI. Furthermore, Netrin-1 positivity serves as a protective factor against CIN III lesions, while elevated levels of FI, VI, and VFI are associated with increased risk for these lesions. The expression levels of both Netrin-1 and ultrasound parameters provide valuable predictive insights for the early screening, diagnosis, and prevention of cervical cancer.

Rapidly evolving pelvic lymphangioleiomyomatosis (LAM) mimicking bilateral hydrosalpinx: report of a rare case and literature review

Lymphangioleiomyomatosis (LAM) represents a rare neoplasm affecting almost exclusively women of reproductive age. This condition mainly affects the lungs, but extrapulmonary locations such as the pelvis and the retroperitoneum are possible. Clinical evaluation and ultrasound imaging are usually non-specific, and the diagnosis is obtained through surgical excision and histopathological examination. We report a very rare case of abdominal LAM in a young female patient. A thorough literature review of this rare condition with emphasis on gynecologic implications will be presented. The patient was referred for gynecologic consultation due to pelvic pain and infertility. Unfortunately, despite prompt diagnosis and treatment, the course of the disease was severe and led to patient's exitus in a short time. We encountered an extremely rare deadly pathology mimicking a very common gynecologic condition. The gynecologist must always be alert of possible unexpected conditions that will require prompt attention.

Causal Relationship Between Endometriosis and Pelvic Inflammatory Diseases: Mendelian Randomization Study

Objective

This study explores the causal relationship between endometriosis and pelvic inflammatory diseases (PID).

Methods

The study utilized genome-wide association study (GWAS) datasets for endometriosis ("finn-b-N14_ENDOMETRIOSIS") and PID ("finn-b-N14_OTHFEMPELINF"). Subsequently, two-sample Mendelian randomization (MR) analyses were conducted using inverse variance weighting (IVW), Egger regression (MR-Egger), and weighted median (WM) methods. Heterogeneity was evaluated using Cochran's Q test, and in case of detected outliers, they were removed for re-evaluation of MR causality.

Results

From the endometriosis GWAS dataset, 33 single nucleotide polymorphisms (SNPs) were selected as instrumental variables. All three methods, IVW (OR = 1.39, P < 1×10-8), MR-Egger (OR = 1.41, P = 0.003), and WM (OR = 1.37, P = 1.16×10-5) confirmed a causal relationship between endometriosis and PID. The association between endometriosis and pelvic inflammation remained unaffected by the exclusion of individual SNPs. Lastly, Cochran's Q test and funnel plots showed no evidence of SNP asymmetry.

Conclusion

The results of the MR analysis support a potential causal relationship between endometriosis and an increased risk of PID.

Deciphering the role of female reproductive tract microbiome in reproductive health: a review

Relevant studies increasingly indicate that female reproductive health is confronted with substantial challenges. Emerging research has revealed that the microbiome interacts with the anatomy, histology, and immunity of the female reproductive tract, which are the cornerstone of maintaining female reproductive health and preventing adverse pregnancy outcomes. Currently, the precise mechanisms underlying their interaction and impact on physiological functions of the reproductive tract remain elusive, constituting a prominent area of investigation within the field of female reproductive tract microecology. From this new perspective, we explore the mechanisms of interactions between the microbiome and the anatomy, histology, and immunity of the female reproductive tract, factors that affect the composition of the microbiome in the female reproductive tract, as well as personalized medicine approaches in managing female reproductive tract health based on the microbiome. This study highlights the pivotal role of the female reproductive tract microbiome in maintaining reproductive health and influencing the occurrence of reproductive tract diseases. These findings support the exploration of innovative approaches for the prevention, monitoring and treatment of female reproductive tract diseases based on the microbiome.

Recurrent Infectious Vaginitis: A Practical Approach for the Primary Care Clinician

Recurrent infectious vaginitis can lead to significant morbidity, patient frustration, and health care costs. The most common causes are bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC); however, other infectious and noninfectious etiologies should be considered in patients with recurrent symptoms. A detailed history and physical examination with appropriate testing at the time of symptoms is critical to establishing a correct diagnosis. Management options for recurrent BV and VVC are limited. Complex cases including those with atypical symptoms, negative testing for common causes, refractory symptoms despite appropriate therapy or recurrences during suppressive therapy will require referral to specialist care.

Heat stress alters the ovarian proteome in prepubertal gilts

Heat stress (HS) occurs when exogenous and metabolic heat accumulation exceeds heat dissipation; a thermal imbalance that compromises female reproduction. This study investigated the hypothesis that HS alters the ovarian proteome and negatively impacts proteins engaged with insulin signaling, inflammation, and ovarian function. Prepubertal gilts (n = 19) were assigned to one of three environmental groups: thermal neutral with ad libitum feed intake (TN; n = 6), thermal neutral pair-fed (PF; n = 6), or HS (n = 7). For 7 d, HS gilts were exposed to 12-h cyclic temperatures of 35.0 ± 0.2 °C and 32.2 ± 0.1 °C, while TN and PF gilts were housed at 21.0 ± 0.1 °C. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed on ovarian protein homogenates. Relative to TN gilts, 178 proteins were altered (P ≤ 0.05, log2foldchange ≥ 1) by HS, with 76 increased and 102 decreased. STRING gene ontology classified and identified 45 biological processes including those associated with chaperone protein refolding, cytoplasmic translational initiation, and immune activation; with a protein-protein interaction web network of 158 nodes and 563 edges connected based on protein function (FDR ≤ 0.05). Relative to PF, HS altered 330 proteins (P ≤ 0.05, log2foldchange ≥ 1), with 151 increased and 179 decreased. Fifty-seven biological pathways associated with protein function and assembly, RNA processing, and metabolic processes were identified, with a protein-protein interaction network of 303 nodes and 1,606 edges. Comparing HS with both the TN and PF treatments, 72 ovarian proteins were consistently altered by HS with 68 nodes and 104 edges, with biological pathways associated with translation and gene expression. This indicates that HS alters the ovarian proteome and multiple biological pathways and systems in prepubertal gilts; changes that potentially contribute to female infertility.

Comparison of databases useful for the analysis of vaginal microbiota in Japanese women using next-generation sequencing data (QIIME 2 software)

AIMS

Approximately 10% of children are born prematurely, and bacterial vaginosis during pregnancy is associated with preterm delivery. Highly accurate species-level vaginal microflora analysis helps control bacteria-induced preterm birth. Therefore, we aimed to conduct a bioinformatic analysis of gene sequences using 16S databases and compare their efficacy in comprehensively identifying potentially pathogenic vaginal microbiota in Japanese women.

METHODS AND RESULTS

The 16 s rRNA databases, Silva, Greengenes, and the basic local alignment search tool (BLAST) were compared to determine whether the classification quality could be improved using the V3-V4 region next-generation sequencing (NGS) sequences. It was found that NGS data were aligned using the BLAST database with the QIIME 2 platform, whose classification quality was higher than that of Silva, and the combined Silva and Greengenes databases based on the mutual complementarity of the two databases.

CONCLUSIONS

The reference database selected during the bioinformatic processing influenced the recognized sequence percentage, taxonomic rankings, and accuracy. This study showed that the BLAST database was the best choice for NGS data analysis of Japanese women's vaginal microbiota.

Bacterial infection and microbiota in carcinogenesis and tumor development

Microbiota colonize exposed body tissues (e.g., gastrointestinal tract, skin, lungs, female genital tract, and urogenital tracts) and unexposed sites (e.g., breast). Persistent bacterial infection in the host lead to the development of multiple disease. They are implicated in the pathogenesis of various complex diseases, including diabetes, atherosclerosis, autoimmune diseases, Alzheimer's disease, and malignant diseases. Amounting studies have demonstrated the role of bacterial infection in carcinogenesis. The study of microbiota in tumorigenesis is primarily focused on lung cancer, colorectal cancer (CRC), breast cancer, gastric cancer, and gynecologic tumors, and so on. Infection of Helicobacter pylori in gastric cancer carcinogenesis is recognized as class I carcinogen by the World Health Organization (WHO) decades ago. The role of Fusobacterium nucleatum in the development of colorectal cancer is extensively investigated. Variable bacteria have been cultured from the tumor tissues. The identification of microbiota in multiple tumor tissues reveal that bacterial infection and microbiota are associated with tumor development. The microbiota affects multiple aspects of carcinogenesis and tumor development, including favoring epithelial cells proliferation, establishing inflammatory microenvironment, promoting metastasis, and causing resistance to therapy. On the other hand, microbiota can shape a tumor surveillance environment by enhancing cell activity, and sensitize the tumor cells to immune therapy. In the present review, the roles of microbiota in multiple malignancies are summarized, and unraveling the mechanisms of host-microbiota interactions can contribute to a better understanding of the interaction between microbiota and host cells, also the development of potential anti-tumor therapeutic strategies.

Therapeutic effects of fenticonazole on bacterial vaginosis in mice

Bacterial vaginitis (BV) is a syndrome of increased vaginal discharge, fishy smelling leucorrhea, and itching and burning vulva caused by the microecological imbalance in the vagina induced by mixture of Gardnerella vaginalis (GV) and some anaerobic bacteria. Fenticonazole, an imidazole derivative and antimicrobial compound, has been demonstrated to exert effective therapeutic effects in mixed vaginitis. Accordingly, our study was designed to explore the potential role of fenticonazole in GV-infected BV mouse models. Female C57/BL6 mice were injected intraperitoneally with β-estradiol 3 days before and on the day of GV infection to maintain a pseudoestrus state. On the day of infection, mice were intravaginally inoculated with 20 µl of a suspension of GV (6 × 106 CFU/ml). Fenticonazole was administered as 2% vaginal cream (0.2 mg each mouse) by intravaginal application once a day for 3 days beginning the day of infection. At day 3 postinfection, the mice were sacrificed and vaginal washes were harvested. GV proliferation and Lactobacillus content were calculated in the vaginal lavage. Neutrophil counts in the vaginal lavage were observed through Pap staining. Myeloperoxidase (MPO) activity and proinflammatory cytokine (TNF-α, IL-1β, IL-6, iNOS, COX2, and NF-κB) levels in vaginal tissues were measured by ELISA and western blotting. Vaginal tissues were stained by hematoxylin and eosin (H&E) to examine the exfoliation of vaginal epithelial cells. GV infection increased GV proliferation and neutrophil counts but reduced Lactobacillus content in the vaginal lavage, as well as enhanced MPO activity, proinflammatory cytokine levels, and the exfoliation of vaginal epithelial cells in vaginal tissues of BV mouse models. However, administration of fenticonazole significantly ameliorated the above phenomena. Fenticonazole greatly improves the symptoms of GV-induced BV in mouse models.