Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis

Ascension of Chlamydia is moderated by uterine peristalsis and the neutrophil response to infection

Chlamydia trachomatis is a common sexually transmitted infection that is associated with a range of serious reproductive tract sequelae including in women Pelvic Inflammatory Disease (PID), tubal factor infertility, and ectopic pregnancy. Ascension of the pathogen beyond the cervix and into the upper reproductive tract is thought to be necessary for these pathologies. However, Chlamydia trachomatis does not encode a mechanism for movement on its genome, and so the processes that facilitate ascension have not been elucidated. Here, we evaluate the factors that may influence chlamydial ascension in women. We constructed a mathematical model based on a set of stochastic dynamics to elucidate the moderating factors that might influence ascension of infections in the first month of an infection. In the simulations conducted from the stochastic model, 36% of infections ascended, but only 9% had more than 1000 bacteria ascend. The results of the simulations indicated that infectious load and the peristaltic contractions moderate ascension and are inter-related in impact. Smaller initial loads were much more likely to ascend. Ascension was found to be dependent on the neutrophil response. Overall, our results indicate that infectious load, menstrual cycle timing, and the neutrophil response are critical factors in chlamydial ascension in women.

Brazilian Protocol for Sexually Transmitted infections, 2020: pelvic inflammatory disease

Pelvic Inflammatory Disease is a topic included in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Pelvic inflammatory disease is an upper female genital tract acute infection due to canalicular spread of endogenous cervicovaginal microorganisms and especially the sexually transmitted microorganisms. Standing out among the etiological agents involved are Chlamydia trachomatis and Neisseria gonorrhoeae. The main sequelae are chronic pelvic pain, infertility, and ectopic pregnancy. Clinical diagnosis is the most important practical approach. Antibiotic treatment must start immediately after the clinical suspicion. Guidelines for health service managers and health professionals on diagnostic tests, treatment, follow-up, counseling, notification, handling sexual partners and special populations are described. Given the increased availability of the molecular biology techniques in Brazil, C. trachomatis and N. gonorrhoeae screening are recommended as a disease prevention strategy.

Pelvic inflammatory disease is one of the most significant sexually transmitted infections, and in most cases, it is a main consequence of cervicitis.

[Brazilian Protocol for Sexually Transmitted Infections 2020: pelvic inflammatory disease]

Pelvic Inflammatory Disease is a topic included in the Clinical Protocol and Therapeutic Guidelines for Comprehensive Care for People with Sexually Transmitted Infections, published by the Brazilian Ministry of Health in 2020. Pelvic inflammatory disease is an acute infection of the upper female genital tract due to canalicular spread of endogenous cervicovaginal microorganisms, in particular sexually transmitted organisms. Standing out among the etiological agents involved are Chlamydia trachomatis and Neisseria gonorrhoeae. The most important sequels are chronic pelvic pain, infertility and ectopic pregnancy. Clinical diagnosis is the most important practical approach. Antibiotic treatment should start immediately upon clinical suspicion. The article contains guidance for health service managers and health professionals on diagnostic tests, treatment, follow-up, counseling, notification, handling of sexual partnerships and special populations. In view of increased availability of the molecular biology technique in Brazil, C. trachomatis and N. gonorrhoeae screening is recommended as a disease prevention strategy.

Structural Basis for Evasion of Nutritional Immunity by the Pathogenic Neisseriae

The pathogenic Neisseria species are human-adapted pathogens that cause quite distinct diseases. Neisseria gonorrhoeae causes the common sexually transmitted infection gonorrhea, while Neisseria meningitidis causes a potentially lethal form of bacterial meningitis. During infection, both pathogens deploy a number of virulence factors in order to thrive in the host. The focus of this review is on the outer membrane transport systems that enable the Neisseriae to utilize host-specific nutrients, including metal-binding proteins such as transferrin and calprotectin. Because acquisition of these critical metals is essential for growth and survival, understanding the structures of receptor-ligand complexes may be an important step in developing preventative or therapeutic strategies focused on thwarting these pathogens. Much can also be learned by comparing structures with antigenic diversity among the transporter sequences, as conserved functional domains in these essential transporters could represent the pathogens' "Achilles heel." Toward this goal, we present known or modeled structures for the transport systems produced by the pathogenic Neisseria species, overlapped with sequence diversity derived by comparing hundreds of neisserial protein sequences. Given the concerning increase in N. gonorrhoeae incidence and antibiotic resistance, these outer membrane transport systems appear to be excellent targets for new therapies and preventative vaccines.

Treatment and Management of Bacterial Vaginosis in Pregnancy: Current and Future Perspectives

Bacterial vaginosis accounts for the majority of cases of vaginal discharge and has been consistently linked to an increased risk of preterm delivery. Bacterial vaginosis is characterized by the reduced number or absence of hydrogen peroxide-producing Lactobacillus spp., which promotes the overgrowth of anaerobic bacteria, including Gardnerella vaginalis, Mycoplasma hominis, Bacteroides spp., and Mobiluncus spp. Black race, higher-risk sexual activity, frequent vaginal douching and the substantial reduction of hydrogen peroxide-producing Lactobacillus spp. are the main predictors of bacterial vaginosis development. Clinical- and laboratory-based bacterial vaginosis diagnostic tests are widely used to screen for bacterial vaginosis but, more recently, office-based bacterial vaginosis screening tools have been developed. Although systemic treatment for bacterial vaginosis with metronidazole or clindamycin has been demonstrated to be effective in the short-term cure of bacterial vaginosis, recurrence of bacterial vaginosis within 3 months of treatment is common, and treatment for bacterial vaginosis using these strategies has not been effective in reducing the risk of preterm delivery.

Human and Pathogen Factors Associated with Chlamydia trachomatis-Related Infertility in Women

Chlamydia trachomatis is the most common bacterial sexually transmitted pathogen worldwide. Infection can result in serious reproductive pathologies, including pelvic inflammatory disease, ectopic pregnancy, and infertility, in women. However, the processes that result in these reproductive pathologies have not been well defined. Here we review the evidence for the human disease burden of these chlamydial reproductive pathologies. We then review human-based evidence that links Chlamydia with reproductive pathologies in women. We present data supporting the idea that host, immunological, epidemiological, and pathogen factors may all contribute to the development of infertility. Specifically, we review the existing evidence that host and pathogen genotypes, host hormone status, age of sexual debut, sexual behavior, coinfections, and repeat infections are all likely to be contributory factors in development of infertility. Pathogen factors such as infectious burden, treatment failure, and tissue tropisms or ascension capacity are also potential contributory factors. We present four possible processes of pathology development and how these processes are supported by the published data. We highlight the limitations of the evidence and propose future studies that could improve our understanding of how chlamydial infertility in women occurs and possible future interventions to reduce this disease burden.

Subclinical pelvic inflammatory disease and infertility

OBJECTIVE

The reported incidence of acute pelvic inflammatory disease (PID) has decreased but rates of tubal infertility have not, suggesting that a large proportion of PID leading to infertility may be undetected. Subclinical PID is common in women with uncomplicated chlamydial or gonococcal cervicitis or with bacterial vaginosis. We assessed whether women with subclinical PID are at an increased risk for infertility.

METHODS

A prospective observational cohort of 418 women with or at risk for gonorrhea or chlamydia or with bacterial vaginosis was recruited. Women with acute PID were excluded. An endometrial biopsy was performed to identify endometritis (subclinical PID). After provision of therapy for gonorrhea, chlamydia and bacterial vaginosis participants were followed-up for fertility outcomes.

RESULTS

There were 146 incident pregnancies during follow-up, 50 pregnancies in 120 (42%) women with subclinical PID and 96 in 187 (51%) women without subclinical PID. Women with subclinical PID diagnosed at enrollment had a 40% reduced incidence of pregnancy compared with women without subclinical PID (hazard ratio 0.6, 95% confidence interval 0.4-0.8). Women with Neisseria gonorrhoeae or Chlamydia trachomatis, in the absence of subclinical PID, were not at increased risk for infertility.

CONCLUSION

Subclinical PID decreases subsequent fertility despite provision of treatment for sexually transmitted diseases. These findings suggest that a proportion of female infertility is attributable to subclinical PID and indicate that current therapies for sexually transmitted diseases are inadequate for prevention of infertility.

The microbiota of the vagina and its influence on women's health and disease

Explorations of the vaginal microbiota (VMB) began over 150 years ago. Using light microscopy and bacterial cultures, the concept of normal versus abnormal microbiota in women began to emerge. The latter became known by the term "bacterial vaginosis" (BV). BV microbiota is dominated by Gardnerella vaginalis and includes a number of anaerobic organisms. In contrast, normal flora is dominated by various Lactobacilli. BV microbiota is associated with vaginal discharge, poor pregnancy outcomes, pelvic inflammatory disease, postoperative wound infections and endometritis after elective abortions. In addition, BV flora predisposes women to infection by human immunodeficiency virus and sexually transmitted diseases. Application of molecular techniques over the past decade has significantly advanced our understanding of the VMB. It is far more complex than previously recognized and is composed of many previously unknown organisms in addition to those already identified by culture. Analyses using high-throughput sequencing techniques have revealed unique microbial communities not previously recognized within the older, established vaginal flora categories. These new findings will inform the design of future clinical investigations of the role of the VMB in health and disease.

Treatment of acute pelvic inflammatory disease

Pelvic inflammatory disease (PID), one of the most common infections in nonpregnant women of reproductive age, remains an important public health problem. It is associated with major long-term sequelae, including tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. In addition, treatment of acute PID and its complications incurs substantial health care costs. Prevention of these long-term sequelae is dependent upon development of treatment strategies based on knowledge of the microbiologic etiology of acute PID. It is well accepted that acute PID is a polymicrobic infection. The sexually transmitted organisms, Neisseria gonorrhoeae and Chlamydia trachomatis, are present in many cases, and microorganisms comprising the endogenous vaginal and cervical flora are frequently associated with PID. This includes anaerobic and facultative bacteria, similar to those associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, have recently also been implicated as a cause of acute PID. As a consequence, treatment regimens for acute PID should provide broad spectrum coverage that is effective against these microorganisms.

A novel guinea pig model of Chlamydia trachomatis genital tract infection

Genital Chlamydia trachomatis infections often result in pelvic inflammatory disease and sequelae including infertility and ectopic pregnancies. In addition to the already established murine models, the development of other animal models is necessary to study the safety and efficacy of prototype vaccine candidates. The intravaginal infection of guinea pigs with C. trachomatis has been tested in three independent studies. The first two studies investigated the effect of hormonal treatment of the animals prior to infection with serovars D and E. The results showed that estradiol treatment was required for sustained infection. The third study conducted an immunization-challenge experiment to explore the feasibility of measuring protection in this guinea pig model. C. trachomatis bacteria were sampled using vaginal swabs and measured by qPCR. Using immunohistochemistry the bacteria were detected in the oviducts 19 days post-infection, indicating that the estradiol treatment resulted in ascending infection. Furthermore, immunization of guinea pigs with live EB formulated with ISCOM matrix led to reduction of cervico-vaginal shedding and diminished the severity of pathology. In this study we have developed a new guinea pig model of C. trachomatis female genital tract infection for the purpose of evaluating potential vaccine candidates.

Association of bacterial vaginosis with adverse fetomaternal outcome in women with spontaneous preterm labor: a prospective cohort study

OBJECTIVE

To compare the fetomaternal outcome in women with spontaneous preterm labor, with or without bacterial vaginosis (BV).

METHODS

One hundred and fifty-two pregnant patients presenting with spontaneous preterm labor between 28 and 35 weeks of gestation were screened for BV using Amsel's criteria and Nugent score, and were divided into two groups of 30 patients each, based on the BV positive or negative screen. Both the groups were followed till puerperium, and the fetal-maternal outcome was studied. The data was analyzed using Chi-square test and Man-Whitney test.

RESULTS

BV was detected in 37 out of 152 women with preterm labor (24.34%). There was a significant increase in the incidence of respiratory distress (14% vs. 6%), requirement of intermittent positive pressure ventilation (IPPV) (14% vs. 5%), admission in neonatal intensive care unit (NICU) (15% vs. 6%), and duration of NICU stay >2 days (15% vs. 6%) in patients with BV. No significant difference was found in the mean birth weight, Apgar score, incidence of neonatal sepsis, perinatal mortality, and postpartum fever between the two groups.

CONCLUSIONS

BV is a risk factor for increased neonatal morbidity. More research is needed for designing appropriate screening and treatment guidelines for prevention of adverse outcomes associated with BV.

Treatment strategies for pelvic inflammatory disease

BACKGROUND

Pelvic inflammatory disease (PID) is one of the most common infections seen in nonpregnant reproductive-age women. It is a major public health problem associated with substantial medical complications (e.g., infertility, ectopic pregnancy, and chronic pelvic pain) and healthcare costs. Prevention of these long-term sequelae requires treatment strategies that are based on the microbiologic etiology of acute PID.

OBJECTIVE

To determine appropriate antimicrobial regimens for the treatment of acute PID based on published literature.

METHODS

Clinical trials published since 2002 were assessed conducting a systematic search of the literature on the treatment of acute PID using PubMed (National Library of Congress). The search was limited to articles written in English and published from 1 January 2002 to 30 June 2008.

RESULTS

Acute PID is a polymicrobic infection caused by both sexually transmitted organisms (primarily Neisseria gonorrhoeae and Chlamydia trachomatis) and microorganisms found in the endogenous flora of the vagina and cervix. The latter include anaerobic bacteria and facultative bacteria, many of which are associated with bacterial vaginosis. Genital tract mycoplasmas, most importantly Mycoplasma genitalium, may also be implicated in the etiology of acute PID. Because of this polymicrobial nature, currently available evidence, as well as recommendations by the CDC, support the use of broad-spectrum regimens (oral or parenteral) that provide adequate coverage against these microorganisms.

The association between clinical and pathological features in histologically identified chronic endometritis

Although described originally as the sine qua non for endometriosis, plasma cells have been identified in the endometrium in a variety of other situations. This study of patients who did and did not have plasma cells in their endometrium was carried out to establish the association between the clinical presentations and a variety of pathological characteristics, particularly the presence of inflammatory cells including plasma cells in the endometrium. There was no evidence of an association between any of the presenting clinical conditions and the distribution, intensity or frequency of inflammation, including the component cell types (lymphocytes, eosinophils, plasma cells and neutrophil polymorphs) or stromal pigment, although there was an association between a history of abnormal bleeding and reactive changes in the surface endometrium (P = 0.0259). Thus this study confirms the findings of others that there is no specific clinical syndrome that is associated with the presence of plasma cells in the endometrium.

Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines

Pelvic inflammatory disease (PID) is a substantial cause of reproductive morbidity in young women. A systematic review of the literature related to PID management was performed in preparation for the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. This search was conducted using PubMed and was limited to articles written in English and published between 1 January 2002 and 31 January 2005 that were related to PID treatment. Studies were evaluated for new data on PID with regard to site, route, and timing of antimicrobial administration; regimen adherence; experience in adolescents and women >35 years of age; coinfection with human immunodeficiency virus; and management of sex partners. Strong evidence suggests that neither site nor route of treatment administration affects the short- or long-term major outcome of women with mild or moderate clinical presentations. Data on these outcomes in women with more severe clinical presentations are inadequate to provide guidance as to the preferred agents or route of administration. Important contributions to the literature that impact the 2006 guidelines are described in this article.

Expression of toll-like receptors 2, 3, 4, and 9 genes in the human endometrium during the menstrual cycle

Innate immunity in the endometrium has fundamental significance for reproduction. Although toll-like receptors (TLRs) play central roles in innate immune responses, their expression in the human endometrium remains to be fully elucidated. We have examined the gene expression of TLR2, TLR3, TLR4, and TLR9 in endometrial tissues by real-time quantitative PCR and in situ hybridization. The expression levels of the four genes in endometrial tissues varied in a similar pattern during the menstrual cycle; the levels were high in the perimenstrual period and low in the periovulatory period. Expression of the four genes was detected in both epithelial cells and stromal cells throughout the menstrual cycle. Expression levels were higher in epithelial cells for TLR3 and in stromal cells for TLR4, while they were comparable in epithelial cells and stromal cells for TLR2 and TLR9. These findings imply that differential spatio-temporal expression patterns of TLRs subserve proper innate immunity of the endometrium.

Vaginal symptoms and bacterial vaginosis (BV): how useful is self-report? Development of a screening tool for predicting BV status

Vaginal complaints compel an evaluation of bacterial vaginosis (BV), however, many cases of BV are asymptomatic. We evaluated the sensitivity and specificity of vaginal symptoms in the diagnosis of BV and examined the utility of creating a BV screening tool using clinical, behavioural and demographic characteristics. A total of 1916 pregnant women were included in this analysis. In total, 757 women screened positive for BV and over one third of BV-positive women presented without any lower genital tract symptoms (39.4%). African American race, abnormal vaginal odour, and smoking were independently related to BV positivity. A BV screening tool including these three factors was fairly predictive of BV status with the area under the ROC curve equal to 0.669. This three-item prediction rule may be useful in identifying high- risk pregnant women in need of BV screening and, given the high specificity, accurately identify the group of BV-negative pregnant women.

Preconceptional antibiotic treatment to prevent preterm birth in women with a previous preterm delivery

This article addresses the question of whether the uterine cavity is normally sterile and reviews the difficulties in conducting microbiologic studies of the endometrium, the limitations of conventional microbiologic techniques (cultivation-dependent), and the potential contribution of molecular microbiology to examine microbial diversity and burden of the endometrium. Issues pertaining to the diagnosis of chronic endometritis and the need for information about the prognostic value of this finding in subsequent pregnancies are discussed. The results of a randomized clinical trial of antibiotic administration versus placebo in women with a previous preterm birth are reviewed and commentary is provided. The emerging picture is that microbial-host interactions in the endometrial cavity are important for reproductive success. This is a US government work. There are no restrictions on its use.

Comparison of Acute and Subclinical Pelvic Inflammatory Disease

OBJECTIVE

The objective of this study was to compare the demographic, clinical, and microbiologic findings in women with subclinical pelvic inflammatory disease (PID) and women with acute PID.

STUDY

A cross-sectional study was performed using cohorts from 2 separate studies of 1293 women at risk for PID. Most participants were recruited from emergency departments, sexually transmitted disease clinics, and family planning clinics in metropolitan centers. We compared demographic, clinical, and microbiologic findings among women with acute PID, women with subclinical PID, and women without endometritis (controls). Statistical analyses included chi-square for categorical variables, calculation of odds ratio and 95% confidence intervals, and polychotomous logistic regression when appropriate.

RESULTS

Similar proportions of women with acute and subclinical PID tested positive for cervical Chlamydia trachomatis (odds ratio [OR], 1.1; 95% confidence interval, 0.6-2.0) and had bacterial vaginosis (OR, 0.7; 95% CI, 0.2-1.8). The rate of cervical Neisseria gonorrhoeae infection in women with subclinical PID was intermediate between the rates in women with acute PID and controls (21% vs. 49% vs. 7%, respectively, P <0.001, test for trend). Endometrial recovery of N. gonorrhoeae and C. trachomatis in women with subclinical PID was also seen at intermediate levels. Similar distributions of teenagers, women who smoked or used illicit drugs, and women engaging in sexual intercourse during menses were found in each group. Proportions of women with subclinical PID who were black and with lower education levels were intermediate between the proportions of these characteristics in women with acute PID and controls.

CONCLUSION

Demographic and microbiologic characteristics of women with subclinical and acute PID are comparable. These findings suggest that the pathophysiological mechanisms of acute and subclinical PID are similar.

In vivo assessment of human vaginal oxygen and carbon dioxide levels during and post menses

Previous in vitro and in vivo animal studies showed that O(2) and CO(2) concentrations can affect virulence of pathogenic bacteria such as Staphylococcus aureus. The objective of this work was to measure O(2) and CO(2) levels in the vaginal environment during tampon wear using newly available sensor technology. Measurements by two vaginal sensors showed a decrease in vaginal O(2) levels after tampon insertion. These decreases were independent of the type of tampons used and the time of measurement (mid-cycle or during menstruation). These results are not in agreement with a previous study that concluded that oxygenation of the vaginal environment during tampon use occurred via delivery of a bolus of O(2) during the insertion process. Our measurements of gas levels in menses showed the presence of both O(2) and CO(2) in menses. The tampons inserted into the vagina contained O(2) and CO(2) levels consistent with atmospheric conditions. Over time during tampon use, levels of O(2) in the tampon decreased and levels of CO(2) increased. Tampon absorbent capacity, menses loading, and wear time influenced the kinetics of these changes. Colonization with S. aureus had no effect on the gas profiles during menstruation. Taken collectively, these findings have important implications on the current understanding of gaseous changes in the vaginal environment during menstruation and the potential role(s) they may play in affecting bacterial virulence factor production.

Impact of treatment for bacterial vaginosis on prematurity among Brazilian pregnant women: a retrospective cohort study

CONTEXT AND OBJECTIVE

Bacterial vaginosis has been associated with prematurity and other perinatal complications. However, the efficacy of the treatment for preventing such complications has not yet been well established. The objective of this study was to evaluate the impact of treatment for bacterial vaginosis on a low-risk population of Brazilian pregnant women, in order to prevent prematurity and other perinatal complications.

DESIGN AND SETTING

Observational retrospective cohort study, at the Obstetric and Gynecology Department, Universidade Estadual de Campinas (Unicamp).

METHODS

Vaginal bacterioscopy results from 785 low-risk pregnant women were studied. Three different groups of women were identified: 580 without bacterial vaginosis during pregnancy, 134 with bacterial vaginosis treated using imidazoles (metronidazole, tinidazole, or secnidazole) during pregnancy, and 71 with bacterial vaginosis not treated during pregnancy. The diagnosis of bacterial vaginosis was based on Nugent's criteria, from the vaginal bacterioscopy performed during the first prenatal care visit.

RESULTS

The frequency of prematurity was 5.5% among the women without bacterial vaginosis, 22.5% among those with untreated bacterial vaginosis and 3.7% among those with treated bacterial vaginosis. The risk ratios for perinatal complications were significantly higher in the group with untreated bacterial vaginosis: premature rupture of membranes, 7.5 (95% CI: 1.9-34.9); preterm labor, 3.4 (95% CI: 1.4-8.1); preterm birth, 6.0 (95% CI: 1.9-19.7); and low birth weight, 4.2 (95% CI: 1.2-14.3).

CONCLUSION

The treatment of bacterial vaginosis significantly reduced the rates of prematurity and other perinatal complications among these low-risk Brazilian pregnant women, regardless of the history of previous preterm delivery.

Endometrial plasma cells: do they indicate subclinical pelvic inflammatory disease?

BACKGROUND

Subclinical pelvic inflammatory disease (PID) is a common condition among women with lower genital tract infection and is believed to be responsible for a greater proportion of PID-related sequelae than acute PID. Subclinical PID is diagnosed histologically after endometrial biopsy. In the literature, many different histologic criteria have been used to define subclinical PID.

GOAL

To determine if endometrial plasma cells are commonly found in women at low likelihood of PID.

STUDY

A cross-sectional study of 33 women undergoing tubal ligation and at low likelihood of PID was performed. At the time of tubal ligation, study participants underwent visualization of pelvic organs and an endometrial biopsy, which was analyzed for the presence of neutrophils and plasma cells. Demographic, clinical, and microbiologic data were compared among women with and without endometrial plasma cells.

RESULTS

Endometrial plasma cells were identified in one third (33%) of the asymptomatic, fertile, healthy women in our cohort. The presence of plasma cells was not associated with lower genital tract infection, including bacterial vaginosis. Laparoscopic evidence of fallopian tube damage was similar in patients with and without endometrial plasma cells (22% in each group).

CONCLUSION

Plasma cells are commonly found in the endometria of healthy women and may not represent upper genital tract inflammation.

The antimicrobial treatment of subacute endometritis: a proof of concept study

OBJECTIVE

Our purpose was to evaluate the antimicrobial therapy effect on clinical and laboratory findings among women at risk for endometritis.

STUDY DESIGN

A prospective antimicrobial treatment trial of 153 women was performed to characterize subacute endometritis and to determine the treatment effect on endometritis resolution.

RESULTS

After antimicrobial treatment, significant reductions occurred in abnormal bleeding (60% vs 29%), mucopurulent cervicitis (20% vs 6%), uterine tenderness (20% vs 6%), and histologic endometritis (38% vs 4%), all P<.001. In women with prior pelvic inflammatory disease (PID), endometritis was present in 43% with and 28% without current Chlamydia trachomatis or Neisseria gonorrhoeae. In women without prior PID, endometritis was present in 23% with and 12% without current C trachomatis or N gonorrhoeae (P=.002 for trend).

CONCLUSIONS

In women without a clinical diagnosis of PID, antimicrobial therapy decreased abnormal clinical findings and histologic endometritis. Prior PID is additive with current cervical infection as a risk for endometritis.

Infections of the female genital tract

This article discusses infections of the female genital tract, including vaginitis, sexually transmitted diseases, and endometriosis, and includes methods of diagnosis, treatment, and specific management strategies for these infections.

Endometritis does not predict reproductive morbidity after pelvic inflammatory disease

OBJECTIVE

We investigated the association between endometritis and reproductive morbidity.

STUDY DESIGN

Participants were 614 women in the PID Evaluation and Clinical Health (PEACH) Study with pelvic pain, pelvic organ tenderness, and leukorrhea, mucopurulent cervicitis, or untreated cervicitis. We compared women with endometritis (>or=5 neutrophils or >or=2 plasma cells), Neisseria gonorrhoeae or Chlamydia trachomatis upper genital tract infection (UGTI) or both to women without endometritis/UGTI for outcomes of pregnancy, infertility, recurrent pelvic inflammatory disease (PID), and chronic pelvic pain (CPP), adjusting for age, race, education, PID history, and baseline infertility.

RESULTS

Endometritis/UGTI was not associated with reduced pregnancy (odds ratio [OR] 0.8, 95% CI 0.6-1.2) or elevated infertility (OR 1.0, 95% CI 0.6-1.6), recurrent PID (OR 0.6, 95% CI 0.4-0.9), or CPP (OR 0.6, 95% CI 0.4-0.9). PEACH participants with and without endometritis/UGTI had higher age- and race-specific pregnancy rates than 1997 national rates.

CONCLUSION

Among women with clinically suspected mild-to-moderate PID treated with standard antibiotics, endometritis/UGTI was not associated with reproductive morbidity.

Colposcopic and Cytologic Findings Among Women with Abnormal Vaginal Flora

OBJECTIVE

The purpose of our study was to evaluate the association of abnormal vaginal flora with pathological colposcopic and cytological findings.

MATERIALS AND METHODS

A total of 100 women of reproductive age were examined. Pregnant women were excluded. Each patient completed a self-administered questionnaire regarding sexual history and vaginal symptoms. All participants underwent a gynecological examination and colposcopy. Pap smear of the cervix and samples of vaginal discharge for microbiological analysis were obtained before the colposcopic examination. Statistical analysis was performed using Fisher exact test, chi test, and multifactorial analysis of variance.

RESULTS

Results of colposcopic examination were normal in more than 70% of all examined women, except in women with bacterial vaginosis where < 30% had normal results. Of all the women examined only 1 did not have normal (class II) Pap smear results.

CONCLUSIONS

Our study indicates that women with abnormal vaginal flora more often have pathological colposcopic findings, such as leukoplakia, vaginal hyperemia, and chronic cervicitis.

Endometritis: the clinical-pathologic syndrome

OBJECTIVE

The purpose of this study was to evaluate histologically proved endometritis as a clinical syndrome that is distinct from laparoscopically confirmed salpingitis.

STUDY DESIGN

This was a cross-sectional study of 152 women in an urban hospital with a suspected pelvic inflammatory disease. All women provided a standardized medical history and underwent physical examination, endometrial biopsy, and laparoscopy. We defined endometritis by the presence of plasma cells in endometrial stroma and neutrophils in the endometrial epithelium.

RESULTS

Of 152 women who were enrolled, 43 women had neither endometritis nor salpingitis; 26 women had endometritis alone without salpingitis, and 83 women had salpingitis. Those women with endometritis alone more often had douched recently, had a current intrauterine device, and were in menstrual cycle day 1 to 7, compared with women with no endometritis or salpingitis (P =.007,.04,.005, respectively) or women with acute salpingitis (P =.03,.01,.02, respectively). Infection with Neisseria gonorrhoeae and/or Chlamydia trachomatis was found more frequently in women with endometritis alone than in women with no endometritis or salpingitis (P <.001) and less frequently than in women with salpingitis (P =.05). Lower quadrant, adnexal, cervical motion, rebound tenderness, peritonitis, tenderness score, fever, and laboratory abnormalities that indicated inflammation and detection of gonorrheal or chlamydial infection were significantly less common in women with endometritis alone than in women with salpingitis but were somewhat more common in women with endometritis alone than among women with no salpingitis or endometritis.

CONCLUSION

Among women with suspected pelvic inflammatory disease, the histopathologic manifestations of endometritis were associated with clinical manifestations, infection, and specific risk factors that were intermediate in frequency between women with salpingitis and women with neither endometritis nor salpingitis.

Clinical predictors of endometritis in women with symptoms and signs of pelvic inflammatory disease

OBJECTIVE

Careful detection and treatment of pelvic inflammatory disease are essential for the prevention of adverse sequelae. The purpose of this study was to evaluate the diagnostic test characteristics of clinical criteria for the diagnosis of pelvic inflammatory disease.

STUDY DESIGN

We performed a cross-sectional analysis of the baseline characteristics of 651 patients enrolled in a multicenter randomized treatment trial for pelvic inflammatory disease. Clinical and laboratory findings were recorded for all patients, and endometrial sampling was performed. We calculated sensitivity and specificity and performed receiver operating characteristic curve analysis and multivariate logistic regression, using histologic endometritis as the criterion standard.

RESULTS

The minimal criteria for pelvic inflammatory disease, as recommended by the Centers for Disease Control and Prevention, had a sensitivity of 83%, in comparison with a 95% sensitivity for adnexal tenderness (P =.001). Of the supportive clinical criteria, the finding most highly associated with endometritis was a positive test result for Chlamydia trachomatis or Neisseria gonorrhoeae (adjusted odds ratio, 4.3; 95% confidence interval, 2.89--6.63). A multivariate logistic regression model indicated that combinations of criteria significantly improve the prediction of endometritis.

CONCLUSION

Sensitivity can be maximized by using the presence of adnexal tenderness as a minimal criterion for the diagnosis of pelvic inflammatory disease, and supportive criteria are helpful in estimating the probability of endometritis.

Interactions of Neisseria gonorrhoeae with mature human macrophage opacity proteins influence production of proinflammatory cytokines

The pathological features of ascending gonococcal infection suggest that proinflammatory mediators secreted by tissue-resident macrophages are important components of the host response. Challenge of fully differentiated, mature macrophages with variants of Neisseria gonorrhoeae strain P9 or purified bacterial surface components (pili, lipooligosaccharide, and outer membrane vesicles) induced the secretion of interleukin 6 (IL-6), tumor necrosis factor alpha, growth-related protein alpha, macrophage inflammatory protein 1alpha (MIP-1alpha), and RANTES cytokines but had no effect on IL-8 production. No secretion of IL-1beta, epithelial-derived neutrophil attractant 78, granulocyte-macrophage colony-stimulating factor, IL-10, or IL-12 cytokines was observed. Notably, the P9-Opa(b) protein, in comparison to P9-Opa(a), increased the association of gonococci with macrophages and elevated the secretion of cytokines. Thus, variation in Opa protein expression by the gonococcus may be a determining factor in the severity of pelvic inflammatory disease.

Gynecologic Complications of Bacterial Vaginosis: Fact or Fiction?

Bacterial vaginosis is a complex alteration of vaginal flora causing mild symptoms in women characterized by a milky vaginal discharge associated with a fishy odor worsened after unprotected vaginal coitus. It is the most common cause of vaginitis. It is now clear that this seemingly harmless disorder causing nuisance symptoms is linked to a number of important adverse reproductive tract sequelae, including the obstetrical sequelae of preterm labor and delivery. Literature published over the past year continue to support the association of bacterial vaginosis with adverse gynecologic sequelae in women.