Human papillomavirus vaccine-associated premature ovarian insufficiency and related adverse events: data mining of Vaccine Adverse Event Reporting System

Artificial intelligence models predicting abnormal uterine bleeding after COVID-19 vaccination

The rapid deployment of COVID-19 vaccines has necessitated the ongoing surveillance of adverse events, with abnormal uterine bleeding (AUB) emerging as a reported concern in vaccinated females. We aimed to develop a machine learning (ML) model to predict post-vaccination AUB in women aged less than 50 years. A large-scale national cohort, the Korean Nationwide Cohort (K-COV-N cohort), was utilized, comprising over 7 million participants. The study employed advanced ML techniques, including ensemble models combining gradient boosting machine and logistic regression, and conducted feature importance analysis. The dataset was meticulously curated, focusing on relevant demographics and variables, and balanced using Synthetic Minority Over-sampling Technique. Using a national cohort of over 2 million COVID-19 vaccinated cases in South Korea, we developed a ML model for AUB prediction. Our study is the first to develop a predictive model for post-vaccination AUB, employing feature importance analysis to identify the key contributing factors. The analysis revealed three primary predictive features: COVID-19 vaccination frequency, NVX-CoV2373 (Novavax) COVID-19 vaccination count, and hemoglobin levels. These findings provide valuable insights into predicting the risk AUB following COVID-19 vaccination, potentially enhancing post-vaccination monitoring strategies.

Risk of heavy menstrual bleeding following COVID-19 vaccination: A nationwide case-control study

BACKGROUND

COVID-19 vaccination has been inconsistently associated with an increased risk of heavy menstrual bleeding in previous studies. This study aimed to assess the risk of heavy menstrual bleeding requiring hospital care following COVID-19 vaccination according to the number of doses received and the time elapsed since vaccination.

METHODS

Using comprehensive data of the French National Health Data System, we carried out a case-control study. Non-pregnant 15-50 years old women who had a hospital discharge diagnosis of heavy menstrual bleeding between May 12, 2021, and August 31, 2022 (cases) were randomly matched to up to 30 controls of same age, place of residence, social deprivation index, and contraceptive use profile at the date of case hospital admission (index date). Conditional logistic regression models were used to estimate the risk of hospital care for heavy menstrual bleeding associated with primary or booster doses and delay since last COVID-19 vaccination at index date, adjusting for socio-demographic characteristics, comorbidities, healthcare use indicators, and recent SARS-CoV-2 infection.

RESULTS

A total of 4610 cases and 89,375 matched controls were included (median age, 42 years). Compared to unvaccinated women, the risk of hospital care for heavy menstrual bleeding was increased in those having received a last dose of primary vaccination in the preceding 1-3 months (Odds Ratio, 1.20 [95% confidence interval, 1.07-1.35]). This association was marked among women residing in the most deprived municipalities (1.28 [1.07-1.52]) and those who were not using hormonal contraception (1.28 [1.11-1.48]). Assuming a causal relationship, a total of 103 cases [54-196] were estimated to be attributable to primary vaccination in France.

CONCLUSION

These findings provide evidence of an increased risk of heavy menstrual bleeding during the three-month period following primary COVID-19 mRNA vaccination. No increased risk was found beyond 3 months after primary vaccination nor following booster doses.

The direct effect of SARS-CoV-2 virus vaccination on human ovarian granulosa cells explains menstrual irregularities

Following administration of the SARS-CoV-2 vaccine, many women worldwide reported short-term menstrual irregularities. Although menstrual bleeding, "the fifth vital sign", is experienced by more than 300 million people on any given day worldwide, these changes were only partially studied. Irregular periods are important well beyond fertility and the discomfort they impose; they are associated with the risk of cardiovascular morbidity, chronic diseases, and premature mortality. Pre-clinical examination of the vaccine polymeric envelope indicates its accumulation in the ovaries. The somatic endocrine cells of the ovarian follicle - the granulosa cells (GCs)-participate in the strict hypothalamic-pituitary-ovarian (HPO) feedback loop that governs the menstrual cycle via endocrine and paracrine regulators, as AMH and Inhibins. We aimed to unravel the direct effect of the COVID-19 vaccine on GCs and link their post-vaccine activity to changes in menstrual patterns. Human primary GCs exposed in-vitro to the Pfizer COVID-19 vaccine BNT162b2, demonstrated no change in their viability but altered mRNA transcripts, specifically of the regulatory key factors: InhibinB was upregulated, whereas AMH was downregulated. We further examined pre- and post-vaccination blood samples from individual women and found a 2-3 folds change in the post-vaccination FSH/InhibinB protein level ratio, compared to their pre-vaccination values. This altered expression of InhibinB could significantly impact the HPO axis in vaccinated women and may ultimately influence the endometrium cyclicity, manifested clinically by the commonly reported changes in menstrual bleeding patterns.

COVID-19 and abnormal uterine bleeding: potential associations and mechanisms

The impact of COVID-19 on menstruation has received a high level of public and media interest. Despite this, uncertainty exists about the advice that women and people who menstruate should receive in relation to the expected impact of SARS-CoV-2 infection, long COVID or COVID-19 vaccination on menstruation. Furthermore, the mechanisms leading to these reported menstrual changes are poorly understood. This review evaluates the published literature on COVID-19 and its impact on menstrual bleeding, discussing the strengths and limitations of these studies. We present evidence consistent with SARS-CoV-2 infection and long COVID having an association with changes in menstrual bleeding parameters and that the impact of COVID vaccination on menstruation appears less significant. An overview of menstrual physiology and known causes of abnormal uterine bleeding (AUB) is provided before discussing potential mechanisms which may underpin the menstrual disturbance reported with COVID-19, highlighting areas for future scientific study. Finally, consideration is given to the effect that menstruation may have on COVID-19, including the impact of the ovarian sex hormones on acute COVID-19 severity and susceptibility and reported variation in long COVID symptoms across the menstrual cycle. Understanding the current evidence and addressing gaps in our knowledge in this area are essential to inform public health policy, direct the treatment of menstrual disturbance and facilitate development of new therapies, which may reduce the severity of COVID-19 and improve quality of life for those experiencing long COVID.

Menstrual Changes Following COVID-19 Vaccination: A Cross-Sectional Study

Background and Objectives: Menstrual changes, including altered cycle length and bleeding patterns, have been reported following COVID-19 vaccination. This study aimed to determine the prevalence and types of menstrual changes occurring after COVID-19 vaccination among female students and staff at a university in Saudi Arabia. Materials and Methods: A cross-sectional study was conducted among women aged 18-39 years who received at least one dose of a COVID-19 vaccine. Eligible participants, including university students and staff, were recruited between May 2022 and November 2022. Participants completed a questionnaire detailing their sociodemographic characteristics, general medical and reproductive history, and menstrual characteristics before and after vaccination. The prevalence of various menstrual changes (cycle length, bleeding days, flow, and mid-cycle spotting) was calculated. The demographic factors associated with menstrual changes were analyzed using chi-squared tests. Results: The 472 included participants had a mean age of 20.9 years, and 95.3% were unmarried. Changes in menstrual cycle characteristics after COVID-19 vaccination were reported by 54.7% of respondents overall. The most common change was in cycle length, followed by the number of menstruation days and bleeding flow. Menstrual changes were not associated with age, BMI, occupation, marital status, or medical history. Changes in intermenstrual bleeding were more frequently reported after the third dose of the Pfizer vaccine compared to the Moderna vaccine (p = 0.014). Conclusions: More than half of the recruited female students and staff reported menstrual changes following COVID-19 vaccination, with altered cycle length being the most common. The potential underlying mechanisms and implications of these menstrual alterations require further investigation. These findings provide evidence of the menstrual side effects of COVID-19 vaccines among women in Saudi Arabia.

Prevalence of menstrual irregularities after coronavirus disease 2019 vaccination: A cross-sectional study in the Eastern Province, Saudi Arabia

BACKGROUND

Reports indicate that there are menstrual cycle disturbances following coronavirus disease 2019 (COVID-19) vaccination. The present study explored the prevalence of menstrual irregularities after COVID-19 vaccination and the association of menstrual irregularities with vaccine type, doses, immediate adverse effects, history of COVID-19 infection, and its severity.

MATERIALS AND METHODS

For this cross-sectional study, 406 women of reproductive age completed an online survey about the postvaccine changes in their menstruation (cycle duration, bleeding days, and bleeding amount), COVID-19 vaccine history (doses, type of vaccine, and immediate adverse effects), history of COVID-19 infection, and its severity. Data was analyzed using SPSS; descriptive statistics were computed and Chi-square test, and binary logistic regression analysis were performed.

RESULTS

Of the total 406 women, 45% reported postvaccine changes in their menstrual cycle. The most common menstrual change was increased dysmenorrhea (68%), followed by an increase in the length of the cycle (52%). There was a significant association between postvaccine menstrual changes and the age, marital status, and family history of menstrual irregularities. No association was observed between postvaccine menstrual changes and COVID-19 vaccine-and COVID-19 infection-related variables. As per the best-fit model of our predictors, the odds of having postvaccine menstrual changes were 0.41 times less in "single" women (confidence interval [CI] = 0.26-0.27; P < 0.001) and 1.714 times greater in women who had a "family history of menstrual irregularities" (CI = 1.092-2.690; P = 0.02), respectively.

CONCLUSION

A substantial number of women complained of postvaccine menstrual changes regardless of their age, type of COVID-19 vaccine, doses, immediate adverse effects, and COVID-19 infection history/severity. Being "single" decreased the probability, whereas having a family history of menstrual irregularities increased the probability significantly of having postvaccine menstrual changes.

Female reproductive health during the COVID-19 pandemic: latest evidence and understanding

PURPOSE

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has imposed a heavy burden on medical systems. In addition to the respiratory system, the virus also causes injuries to other organs and systems such as the gastroenteric system, kidneys, and reproductive system. Female reproductive health requires more attention in this context.

METHODS

We have performed a thorough review of the relevant literature that addresses the impacts of SARS-CoV-2 infection and COVID-19 vaccination on the female reproductive system.

RESULTS

Most evidence shows that SARS-CoV-2 does not infect the female reproductive system. However, the virus may indirectly influence sex hormone concentrations through inflammation associated with cytokine storms and nervous system damage. Menstrual disorders in women infected with SARS-CoV-2 may be caused by down-regulation of angiotensin-converting enzyme 2, abnormal hormone levels, medications, and stress. There is no significant difference in ovarian follicle quality and in vitro fertilization parameters between the pre- and post-COVID-19 vaccination groups. In addition, most symptoms due to side effects of vaccination could recover within a short period of time.

CONCLUSION

SARS-CoV-2 infection affects female reproductive system function through multiple mechanisms. It is recommended that women of childbearing age be vaccinated with COVID-19 vaccine.

Comparison of Intraperitoneal Irrigation With Sodium Bicarbonate Versus Normal Saline in Reducing Pain After Operative Laparoscopy: A Randomized Controlled Trial

Background It has been postulated that sodium bicarbonate can reduce postoperative pain by neutralizing the acidic peritoneal environment created by carbon dioxide. It also prevents phrenic nerve damage and peritoneal irritation. The present study is a randomized controlled trial aimed at studying the effects of sodium bicarbonate in reducing postoperative pain in laparoscopic gynecological surgeries. Materials and methods This was a single-center, prospective, two-arm, double-blinded randomized control trial in which intraperitoneal irrigation with sodium bicarbonate was compared with normal saline in operative laparoscopy. Group I (intervention group) consisted of 40 patients who received intraperitoneal sodium bicarbonate, and Group II (control group) consisted of 40 patients who received normal saline. All procedures were conducted under general anesthesia. Postoperative pain scores were compared between intervention and control groups.  Results The most common indication of laparoscopy was infertility. There was no difference in the duration of surgery between the two arms (p=0.27). The mean value of the visual analog scale (VAS) score at the shoulder tip was found to be significantly reduced in the intervention group at two hours (p=0.02), four hours (p=0.0009), and 12 hours (p=0.0002) after surgery. The mean VAS score at the abdomen and port sites was also found to be significantly reduced in the intervention group in the first 24 hours after surgery (p<0.05). With the increase in the time period from surgery, the mean VAS scores decreased in both intervention and control groups.  Conclusion Intraperitoneal irrigation with sodium bicarbonate is beneficial in reducing postoperative pain in operative laparoscopy. However, multicenter randomized trials with a greater number of participants will be helpful to confirm the findings.

Prevalence of and risk factors for self-reported menstrual changes following COVID-19 vaccination: a Danish cohort study

STUDY QUESTION

Are there some characteristics that render individuals more susceptible to report menstrual changes following the Coronavirus disease 2019 (COVID-19) vaccination?

SUMMARY ANSWER

We found that 30% of menstruating women reported menstrual changes following COVID-19 vaccination and several potential risk factors including stress, vaccine concerns, severe COVID-19 infection, and immediate vaccine symptoms were associated with these reports.

WHAT IS KNOWN ALREADY

Studies suggest that COVID-19 vaccination might temporarily prolong menstrual cycle length by less than 1 day. Specific characteristics may trigger menstrual changes in temporal relation to the vaccination simply by chance or render women more vigilant to potential menstrual changes after being vaccinated. However, research investigating potential risk factors for reporting menstrual changes following COVID-19 vaccination is limited.

STUDY DESIGN, SIZE, DURATION

A population-based Danish cohort study. Data were collected from May 2021 to December 2021 as a part of the BiCoVac Cohort with the aim of examining non-specific effects following COVID-19 vaccination. The main study population included 13 648 menstruating women aged 16-65 years who completed all surveys, received their first dose of a COVID-19 vaccine during the data collection period, and completed questions related to their menstrual cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Potential risk factors included 14 biological, physical, or psychological measures. Information on most potential risk factors was self-reported and collected before the participants' first COVID-19 vaccination. Information about any menstrual change following COVID-19 vaccination was self-reported at the end of the data collection period. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95% CIs for the association between each potential risk factor and reporting menstrual changes following COVID-19 vaccination.

MAIN RESULTS AND THE ROLE OF CHANCE

Any menstrual change following COVID-19 vaccination was reported by 30% of menstruating women. Most of the potential risk factors were associated with reports of menstrual changes following COVID-19 vaccination. In particular, higher odds were found among women who reported ≥5 immediate vaccine symptoms; OR 1.67 [1.50-1.86], had had a prior severe COVID-19 infection; OR 2.17 [1.40-3.35], had a high-stress level at baseline; OR 1.67 [1.32-2.10], or were concerned about COVID-19 vaccines prior to vaccination; OR 1.92 [1.50-2.45]. Lower odds were found among women with regular menstrual cycles using hormonal contraception; OR 0.71 [0.65-0.78].

LIMITATIONS, REASONS FOR CAUTION

We were unable to address the causal effect of COVID-19 vaccination on the reported menstrual changes, as information about menstrual changes was not available among non-vaccinated women.

WIDER IMPLICATIONS OF THE FINDINGS

The study identified several potential risk factors for reporting menstrual changes following COVID-19 vaccination. Further studies are needed to establish causal associations and the clinical impact of self-reported menstrual changes.

STUDY FUNDING/COMPETING INTEREST(S)

The BiCoVac data collection was funded by TrygFonden (id-number: 153678). No competing interests are declared.

TRIAL REGISTRATION NUMBER

N/A.

Identifying a causal link between prolactin signaling pathways and COVID-19 vaccine-induced menstrual changes

COVID-19 vaccines have been instrumental tools in the fight against SARS-CoV-2 helping to reduce disease severity and mortality. At the same time, just like any other therapeutic, COVID-19 vaccines were associated with adverse events. Women have reported menstrual cycle irregularity after receiving COVID-19 vaccines, and this led to renewed fears concerning COVID-19 vaccines and their effects on fertility. Herein we devised an informatics workflow to explore the causal drivers of menstrual cycle irregularity in response to vaccination with mRNA COVID-19 vaccine BNT162b2. Our methods relied on gene expression analysis in response to vaccination, followed by network biology analysis to derive testable hypotheses regarding the causal links between BNT162b2 and menstrual cycle irregularity. Five high-confidence transcription factors were identified as causal drivers of BNT162b2-induced menstrual irregularity, namely: IRF1, STAT1, RelA (p65 NF-kB subunit), STAT2 and IRF3. Furthermore, some biomarkers of menstrual irregularity, including TNF, IL6R, IL6ST, LIF, BIRC3, FGF2, ARHGDIB, RPS3, RHOU, MIF, were identified as topological genes and predicted as causal drivers of menstrual irregularity. Our network-based mechanism reconstruction results indicated that BNT162b2 exerted biological effects similar to those resulting from prolactin signaling. However, these effects were short-lived and didn't raise concerns about long-term infertility issues. This approach can be applied to interrogate the functional links between drugs/vaccines and other side effects.

COVID-19 Vaccine Adverse Event Detection Based on Multi-Label Classification With Various Label Selection Strategies

Analyzing massive VAERS reports without medical context may lead to incorrect conclusions about vaccine adverse events (VAE). Facilitating VAE detection promotes continual safety improvement for new vaccines. This study proposes a multi-label classification method with various term-and topic-based label selection strategies to improve the accuracy and efficiency of VAE detection. Topic modeling methods are first used to generate rule-based label dependencies from Medical Dictionary for Regulatory Activities terms in VAE reports with two hyper-parameters. Multiple label selection strategies, namely one-vs-rest (OvsR), problem transformation (PT), algorithm adaption (AA), and deep learning (DL) methods, are used in multi-label classification to examine the model performance, respectively. Experimental results indicated that the topic-based PT methods improve the accuracy by up to 33.69% using a COVID-19 VAE reporting data set, which improves the robustness and interpretability of our models. In addition, the topic-based OvsR methods achieve an optimal accuracy of up to 98.88%. The accuracy of the AA methods with topic-based labels increased by up to 87.36%. By contrast, the state-of-art LSTM- and BERT-based DL methods have relatively poor performance with accuracy rates of 71.89% and 64.63%, respectively. Our findings reveal that the proposed method effectively improves the model accuracy and strengthens VAE interpretability by using different label selection strategies and domain knowledge in multi-label classification for VAE detection.

COVID-19 vaccination and menstrual cycle characteristics: A prospective cohort study

We prospectively examined the association between COVID-19 vaccination and menstrual cycle characteristics in an internet-based prospective cohort study. We included a sample of 1,137 participants who enrolled in Pregnancy Study Online (PRESTO), a preconception cohort study of couples trying to conceive, during January 2021-August 2022. Eligible participants were aged 21-45 years, United States or Canadian residents, and trying to conceive without fertility treatment. At baseline and every 8 weeks for up to 12 months, participants completed questionnaires on which they provided information on COVID-19 vaccination and menstrual cycle characteristics, including cycle regularity, cycle length, bleed length, heaviness of bleed, and menstrual pain. We fit generalized estimating equation (GEE) models with a log link function and Poisson distribution to estimate the adjusted risk ratio (RR) for irregular cycles associated with COVID-19 vaccination. We used linear regression with GEE to estimate adjusted mean differences in menstrual cycle length associated with COVID-19 vaccination. We adjusted for sociodemographic, lifestyle, medical and reproductive factors. Participants had 1.1 day longer menstrual cycles after receiving the first dose of COVID-19 vaccine (95 % CI: 0.4, 1.9) and 1.3 day longer cycles after receiving the second dose (95 % CI: 0.2, 2.5). Associations were attenuated at the second cycle post-vaccination. We did not observe strong associations between COVID-19 vaccination and cycle regularity, bleed length, heaviness of bleed, or menstrual pain. In conclusion, COVID-19 vaccination was associated with a ∼1 day temporary increase in menstrual cycle length, but was not appreciably associated with other menstrual cycle characteristics.

Effectiveness and cost-effectiveness of human papillomavirus vaccination strategies among men who have sex with men in China: a modeling study

Introduction

The health and economic benefits of human papillomavirus (HPV) vaccination targeted at men who have sex with men (MSM) in developing settings have been rarely assessed. This study aimed to evaluate the effectiveness and cost-effectiveness of different HPV vaccination strategies among MSM in China.

Methods

A Markov model was developed to simulate HPV transmission dynamics among a total of 30.73 million MSM in China. The corresponding natural history included 6 states: susceptible, infected with low-risk subtypes, high-risk subtypes, anogenital warts and anal cancer, and deaths from anal cancer. MSM were divided into three age groups with cut-off points of 27 and 45 years. Alternative vaccination strategies were built by allocating bivalent, quadrivalent, nine-valent, or no vaccine to each of the groups. We generated the prevented infections and deaths by vaccination compared with baseline (no vaccination) and calculated incremental cost-effectiveness ratios (ICERs) to determine the optimal strategy.

Results

The model showed that in 10 years, at baseline, the existing cases of anogenital warts would reach 5,464,225 (IQR, 4,685,708-6,174,175); that of anal cancer would reach 1,922.95 (1,716.56-2,119.93), resulting in 940.55 (732.27-1,141.87) deaths. Under 50% vaccination coverage among one age group, the prevented cases of anogenital warts were maximized with quadrivalent vaccines allocated to MSM aged 27-45 years; that of anal cancer were maximized when offering nine-valent vaccines to the same group. Under 50% vaccination coverage among all groups, the lowest ICER (34,098.09 USD/QALY, 31,146.54-37,062.88) was reached when only quadrivalent vaccines were provided. Based on this strategy, when the annual vaccination rate increased by 30%, the ICER (33,521.75 USD/QALY, 31,040.73-36,013.92) would fall below three times China's per capita GDP. When the vaccine price decreased by 60%, the ICER was reduced to 7,344.44 USD/QALY (4,392.89-10,309.23), indicating good cost-effectiveness taking China's per capita GDP as a threshold.

Conclusions

HPV vaccination can effectively reduce the prevalence and mortality of related diseases among MSM in China, especially quadrivalent vaccines for anogenital warts and nine-valent vaccines for anal cancer. MSM aged 27-45 years were the optimal group for vaccination. Annual vaccination and appropriate adjustment of vaccine price are necessary to further improve the cost-effectiveness.

Association between SARS-CoV-2 vaccination and healthcare contacts for menstrual disturbance and bleeding in women before and after menopause: nationwide, register based cohort study

OBJECTIVES

To evaluate the risks of any menstrual disturbance and bleeding following SARS-CoV-2 vaccination in women who are premenopausal or postmenopausal.

DESIGN

A nationwide, register based cohort study.

SETTING

All inpatient and specialised outpatient care in Sweden from 27 December 2020 to 28 February 2022. A subset covering primary care for 40% of the Swedish female population was also included.

PARTICIPANTS

2 946 448 Swedish women aged 12-74 years were included. Pregnant women, women living in nursing homes, and women with history of any menstruation or bleeding disorders, breast cancer, cancer of female genital organs, or who underwent a hysterectomy between 1 January 2015 and 26 December 2020 were excluded.

INTERVENTIONS

SARS-CoV-2 vaccination, by vaccine product (BNT162b2, mRNA-1273, or ChAdOx1 nCoV-19 (AZD1222)) and dose (unvaccinated and first, second, and third dose) over two time windows (one to seven days, considered the control period, and 8-90 days).

MAIN OUTCOME MEASURES

Healthcare contact (admission to hospital or visit) for menstrual disturbance or bleeding before or after menopause (diagnosed with the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes N91, N92, N93, N95).

RESULTS

2 580 007 (87.6%) of 2 946 448 women received at least one SARS-CoV-2 vaccination and 1 652 472 (64.0%) 2 580 007 of vaccinated women received three doses before the end of follow-up. The highest risks for bleeding in women who were postmenopausal were observed after the third dose, in the one to seven days risk window (hazard ratio 1.28 (95% confidence interval 1.01 to 1.62)) and in the 8-90 days risk window (1.25 (1.04 to 1.50)). The impact of adjustment for covariates was modest. Risk of postmenopausal bleeding suggested a 23-33% increased risk after 8-90 days with BNT162b2 and mRNA-1273 after the third dose, but the association with ChAdOx1 nCoV-19 was less clear. For menstrual disturbance or bleeding in women who were premenopausal, adjustment for covariates almost completely removed the weak associations noted in the crude analyses.

CONCLUSIONS

Weak and inconsistent associations were observed between SARS-CoV-2 vaccination and healthcare contacts for bleeding in women who are postmenopausal, and even less evidence was recorded of an association for menstrual disturbance or bleeding in women who were premenopausal. These findings do not provide substantial support for a causal association between SARS-CoV-2 vaccination and healthcare contacts related to menstrual or bleeding disorders.

The effects of Covid-19 mRNA vaccine on adolescence gynecological well-being

KEY MESSAGE

Menstruation of adolescent girls might be influenced by Covid-19 mRNA vaccine, however, the ovarian reserve estimated by AMH is not compromised.

BACKGROUND

Recent studies have suggested that the acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccine causes menstrual abnormalities which led to concerns regarding its influence on the reproductive system. This study aims to investigate the influence of the SARS-CoV-2 mRNA vaccine on gynecologic well-being and future fertility of adolescent girls.

METHODS

This is a prospective cohort study conducted at a university affiliated medical center between June and July 2021. Adolescent girls aged 12-16 years who were vaccinated by two Pfizer-BioNTech Covid-19 vaccines (21 days apart) were included in the study. All participants completed a computerized questionnaire regarding their general medical and gynecological background at recruitment and 3 months later. Blood samples were collected for AMH levels before and 3 months following the first mRNA vaccine RESULTS: The study group consisted of 35 girls, and of them, follow-up was completed by questionnaire and AMH sampling in 35 (90%) and 22 (56%) girls, respectively. Among the 22/35 girls who reported regular menstruation before vaccination, seven (31.8%) experienced irregularities post-vaccination. Four of the eight pre-menarche girls included in the study reported on menarche on follow-up. Median AMH levels were 3.09 (IQR 1.96-4.82) μg/L and 2.96 (2.21-4.73) μg/L at baseline and after 3 months, respectively (p = 0.07). After controlling for age, BMI and presentation of side effects, no association was demonstrated to the change in AMH levels (AMH2-AMH1).

CONCLUSIONS

Although menstruation of adolescent girls might be influenced by Covid-19 mRNA vaccine, it seems that the ovarian reserve estimated by AMH is not compromised.

CLINICAL TRIAL REGISTRATION

National Institutes of Health (NCT04748172).

COVID-19 vaccination and changes in the menstrual cycle among vaccinated persons

OBJECTIVE

To describe the characteristics of people who experience changes to their menstrual cycle after COVID-19 vaccination.

DESIGN

Longitudinal study.

PATIENT(S)

We recruited a volunteer sample with and without a history of SARS-CoV-2 infection who enrolled in the Arizona COVID-19 Cohort (CoVHORT) study and participated in a reproductive sub-cohort who were pre-menopausal, not pregnant, and had received a COVID-19 vaccine in 2021 (n = 545).

EXPOSURE(S)

Demographic and reproductive characteristics were collected via self-reports.

MAIN OUTCOME MEASURE(S)

Information on self-reported changes in the menstrual cycle after COVID-19 vaccination was collected from May 2021 to December 2021. We looked at demographic and reproductive characteristics as predictors of menstrual cycle change.

RESULT(S)

The majority of our vaccinated sample received the Pfizer-BioNTech vaccine (58%), and were 26-35 years old (51%), non-Hispanic (84%), and White (88%). Approximately 25% of vaccinated participants reported a change in their menstrual cycle after vaccination; the majority reported changes after their second dose (56%) as compared with their first (18%) and third (14%) doses. The most commonly reported changes were irregular menstruation (43%), increased premenstrual symptoms (34%), increased menstrual pain or cramps (30%), and abnormally heavy or prolonged bleeding (31%). High self-reported perceived stress levels compared with low perceived stress (OR, 2.22; 95% CI 1.12-4.37) and greater body mass index (OR, 1.04; 95% CI 1.00-1.07) were associated with greater odds of experiencing the menstrual cycle changes after the vaccination. Participants having a history of SARS-CoV-2 infection were less likely to report changes in their menstrual cycle after vaccination compared with the participants with no history of SARS-CoV-2 infection (OR, 0.58; 95% CI 0.32-1.04).

CONCLUSION(S)

Among vaccinated participants, approximately 25% of them reported predominantly temporary changes in the menstrual cycle, however, we are unable to determine whether these changes are due to normal cycle variability. The COVID-19 vaccines are safe and effective for everyone, including pregnant people and people trying to conceive; hence, these findings should not discourage vaccination.

Spontaneous reports of primary ovarian insufficiency after vaccination: A review of the vaccine adverse event reporting system (VAERS)

BACKGROUND

Since 2012, reports of primary ovarian insufficiency (POI) temporally associated with receipt of human papillomavirus (HPV) vaccine have been published leading to questions about a potential causal association. A Vaccine Safety Datalink study did not find an increased risk for POI after vaccination. We reviewed the Vaccine Adverse Event Reporting System (VAERS) to describe POI reports.

METHODS

We searched VAERS, a U.S. passive surveillance system, for domestic POI reports received from 01/01/1990 to 12/31/2017 after any vaccination. The search used both Medical Dictionary for Regulatory Activity Preferred Terms and a text-based search for POI and its symptoms. All reports were reviewed, and the American College of Obstetricians and Gynecologists (ACOG) guidelines for POI diagnosis were applied. Data mining for disproportionate reporting was conducted.

RESULTS

Six hundred fifty-two reports met the search criteria and clinical review identified 19 POI reports. Most reports (n = 16) were received between 2013 and 2017. The median age at vaccination was 14.5 years (range 10-25 years) and the median interval between first dose of vaccination and reporting the event to VAERS was 43 months (range 4-132 months; mean 59.6 months). Four reports met ACOG diagnostic criteria; one with an underlying cause (47XXX chromosomal abnormality) reported. Eleven reports documented menstrual irregularity ≥ 3 months; 5 had ≥ 1 laboratory test result used to diagnose POI. Eighteen of 19 reports described receipt of HPV vaccine with or without other vaccines. Other vaccines reported were meningococcal conjugate vaccine, hepatitis A, varicella and tetanus toxoid, reduced diphtheria toxoid and acellular pertussis. Disproportionate reporting was found for three relevant coding terms after HPV vaccination.

CONCLUSIONS

POI is rarely reported to VAERS. Most reports contained limited diagnostic information and were submitted after published cases of POI following HPV vaccination. Results of our review do not suggest a safety concern.

The effect of COVID-19 vaccinations on menstrual cycle and serum anti-Mullerian hormone levels in reproductive age women

The aim of this prospective cohort study was to investigate the effect of coronavirus disease 2019 (COVID-19) vaccinations on menstrual cycle and ovarian reserve in reproductive aged-women. Health care providers (n = 258) vaccinated with inactivated (CoronaVac) and mRNA based (Pfizer-BioNTech®) COVID-19 vaccines were included. All subjects completed a gynaecological and menstrual history questionnaire and Anti-Mullerian Hormone (AMH) levels were measured in serum samples collected before first vaccination and at 1st, 3rd, 6th and 9th months. The prevalence of new-onset menstrual dysregulation following vaccination was 20.6% and it was statistically significant compared to baseline (p = 0.001). Menstrual pattern turned back to normal in 59.6% of vaccinated women. Serum AMH levels gradually decreased until 6th month of follow-up compared to baseline (p < 0.001). A significant increase in serum AMH level was observed at 9th month of follow-up compared to 6th month follow-up levels (p < 0.001). The decrease in serum AMH level was statistically significant regardless of serum anti SARS-CoV-2 antibody levels, subgroups of age, occupation, menstrual dysregulation following vaccination and presence of gynaecological diseases. In conclusion, vaccination against SARS-CoV-2 causes a transient decrease on serum AMH levels and moderate irregularities in menstrual pattern increasing with age and is mostly reversible.

Risk of Premature Ovarian Insufficiency after Human Papilloma Virus Vaccination: A PRISMA Systematic Review and Meta-Analysis of Current Evidence

(1) Background: Premature ovarian insufficiency (POI) has been linked to human papilloma virus (HPV) vaccination in small case-reports. The aim of this meta-analysis was to evaluate the risk of POI after HPV vaccination. (2) Methods: Electronic searches in MEDLINE Scopus, LILACS, ClinicalTrials.gov, EMBASE, PROSPERO, Cochrane CENTRAL and other registries were searched from inception to September 2022. Inclusion criteria were cohort studies of female children or adolescents vaccinated with quadrivalent (4vHPV), bivalent (2vHPV) or 9-valent (9vHPV) vaccine and compared to unvaccinated, other HPV vaccine, or vaccinated with other childhood vaccine girls. Primary outcome was risk of POI after vaccination. (3) Results: Four studies, including 1,253,758 patients, were included. Overall, there was no significant risk for POI between 4vHPV and controls (unvaccinated or other vaccines) (RR 0.47 (95% CI 0.14 to 1.59) I² = 75%), or unvaccinated only controls (RR 0.75 (95% CI 0.22 to 2.49) I² = 26%). One study reported a significant reduction of POI risk for 4vHPV relative to the other childhood vaccinations (RR 0.03 (95% CI 0.00 to 0.21)); meanwhile, one study showed no increased risk with 4vHPV relative to 2vHPV and 9vHPV (RR 0.93 (95% CI 0.33 to 2.64)). (4) Conclusions: 4vHPV vaccination does not seem to increase risk of POI relative to unvaccinated people or other childhood vaccines. No difference was seen with 4vHPV vaccine relative to 2vHPV and 9vHPV. Moreover, the risk of POI after HPV vaccination is relatable to worldwide incidence, giving reassurance about safety.

A retrospective evaluation of side-effects associated with the booster dose of Pfizer-BioNTech/BNT162b2 COVID-19 vaccine among females in Eastern Province, Saudi Arabia

BACKGROUNDS

The development of several types of vaccines to avert COVID-19 has taken place. Despite several reports of undesirable reactions noted post-COVID-19 vaccine administration, later remains one of the best prevention and management tools in fighting the spread of the virus and its variants and reducing the harshness of this viral attack. The purpose of the current paper was to explore the side-effects experienced by the females in the Eastern Province of Saudi Arabia directly after receiving the booster dose of the Pfizer-BioNTech/BNT162b2 COVID-19 vaccine.

METHODS

A descriptive cross-sectional study among adults living in the East-ern Province, Saudi Arabia was applied. A survey link was, distributed through WhatsApp, SMS, or e-mail to community members. Respondent's demographic information was acquired, as well as information about any local and systemic side-effects reported following booster dose of BioNTech/BNT162b2 COVID-19 vaccine.

RESULTS

A total of 72.36% (432/597) of the respondents who participated in this study reported at least one side-effect. Pain and redness at the injection site (75.93%), myalgia (71.99%), headache (53.24%), fever (33.56%), and fatigue (43.78%) were the highest frequently stated side-effects. Furthermore, 9.25% of the respondents had to see a physician due to side effects, plus merely four participants were admitted to the hospital. The respondents working in the non-healthcare-related sector had a 1.677-fold more possibility of side effects in comparison with the other respondents (adjusted odds ratio = 1.677; 95% CI = 1.363, 2.064).

CONCLUSIONS

All reported side-effects were mild to moderate. These findings might persuade pessimists and refusers to get the COVID-19 vaccine. Myalgia and pain or redness at the site of injection were the most common reported side-effects in our study.

Association between RNAm-Based COVID-19 Vaccines and Permanency of Menstrual Cycle Alterations in Spanish Women: A Cross-Sectional Study

Introduction: The purpose of this study was to delve more deeply into the medium and long-term relation between mRNA-based vaccines and changes in menstrual pain, cycle length, and amount of bleeding in Spanish women. Material and Methods: A total of 746 women (63% between 18−30 and 37% between 31−45 years old) participated in the study. A numerical rating scale was used for recording pain intensity, a pictorial chart for menstrual bleeding, and data from menstrual cycle duration, type of vaccine, number of doses and time from vaccination. Results: Sixty-five per cent of the women perceived changes in their menstrual cycle after receiving the vaccines, irrespective of type of vaccine or number of doses; all p values were >0.05. Most of them (n = 316 out of 484) reported more than one alteration in their menstrual cycle. Almost half of the participants had been vaccinated over 5 months (45%), 3−4 months (15%) 2−3 months (26%), and one month or less (13%) before. The percentage of women that reported alterations remained strongly constant across time, p > 0.05, ranging from 64 to 65%. Conclusions: Reported alterations in Spanish women after COVID vaccination remained more than 5 months after the last dose.

Prognostic value of SOX9 in cervical cancer: Bioinformatics and experimental approaches

Among gynecological cancers, cervical cancer is a common malignancy and remains the leading cause of cancer-related death for women. However, the exact molecular pathogenesis of cervical cancer is not known. Hence, understanding the molecular mechanisms underlying cervical cancer pathogenesis will aid in the development of effective treatment modalities. In this research, we attempted to discern candidate biomarkers for cervical cancer by using multiple bioinformatics approaches. First, we performed differential expression analysis based on cervical squamous cell carcinoma and endocervical adenocarcinoma data from The Cancer Genome Atlas database, then used differentially expressed genes for weighted gene co-expression network construction to find the most relevant gene module for cervical cancer. Next, the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses were performed on the module genes, followed by using protein–protein interaction network analysis and Cytoscape to find the key gene. Finally, we validated the key gene by using multiple online sites and experimental methods. Through weighted gene co-expression network analysis, we found the turquoise module was the highest correlated module with cervical cancer diagnosis. The biological process of the module genes focused on cell proliferation, cell adhesion, and protein binding processes, while the Kyoto Encyclopedia of Genes and Genomes pathway of the module significantly enriched pathways related to cancer and cell circle. Among the module genes, SOX9 was identified as the hub gene, and its expression was associated with cervical cancer prognosis. We found the expression of SOX9 correlates with cancer-associated fibroblast immune infiltration in immune cells by Timer2.0. Furthermore, cancer-associated fibroblast infiltration is linked to cervical cancer patients’ prognosis. Compared to those in normal adjacent, immunohistochemical and real-time quantitative polymerase chain reaction (qPCR) showed that the protein and mRNA expression of SOX9 in cervical cancer were higher. Therefore, the SOX9 gene acts as an oncogene in cervical cancer, interactive with immune infiltration of cancer-associated fibroblasts, thereby affecting the prognosis of patients with cervical cancer.

Investigating trends in those who experience menstrual bleeding changes after SARS-CoV-2 vaccination

Early in 2021, many people began sharing that they experienced unexpected menstrual bleeding after SARS-CoV-2 inoculation. We investigated this emerging phenomenon of changed menstrual bleeding patterns among a convenience sample of currently and formerly menstruating people using a web-based survey. In this sample, 42% of people with regular menstrual cycles bled more heavily than usual, while 44% reported no change after being vaccinated. Among respondents who typically do not menstruate, 71% of people on long-acting reversible contraceptives, 39% of people on gender-affirming hormones, and 66% of postmenopausal people reported breakthrough bleeding. We found that increased/breakthrough bleeding was significantly associated with age, systemic vaccine side effects (fever and/or fatigue), history of pregnancy or birth, and ethnicity. Generally, changes to menstrual bleeding are not uncommon or dangerous, yet attention to these experiences is necessary to build trust in medicine.

Understanding the Trauma of Menstrual Irregularity After COVID Vaccination: A Bird's-Eye View of Female Immunology

The intricacies in various signaling routes involved in the menstrual cycle can be impacted by internal as well as external stimuli, and the role of stress, be it physical, psychological, or social, in disturbing the process could be debilitating for a woman. The global endeavor of vaccination rose to protect individuals from the severity of COVID-19, but a conjunction of a short-lived menace of menstrual disturbance in the female population came out as an unsettling side effect. An understanding of the immunological panorama in the female reproductive tract (FRT) becomes important to fathom this issue. The close-knit microenvironment in the FRT shows active microbiota in the lower FRT, but the latest findings are ascertaining the presence of low-biomass microbiota in the upper FRT as well. Concerted signaling, wherein inflammation becomes an underlying phenomenon, results when a stressor elicits molecules of the inflammatory cascade. Learning lessons from the gut microbiota, we need to address the exploration of how FRT microbiota would impose inflammation by manipulating the immune response to vaccines. Since there is a prominent sex bias in the immune response to infectious diseases in women and men, the role of sex hormones and cortisol becomes important. The treatment regimen may be considered differently in women who also consider their ovarian cycle phases. Women exert robust immune response to antigenic encounters via cell-mediated and humoral arms. The inclusion of women in vaccine trials has been marginalized over the years, which resulted in unwanted high dosage administration of vaccines in women.

SARS-CoV-2 mRNA vaccination (BNT162b2) has no adverse effect on elective oocyte cryopreservation outcomes

Research question

Do elective oocyte cryopreservation outcomes in women 1–13 months after SARS-CoV-2 vaccination alter compared with unvaccinated women and do different time intervals between vaccination and ovarian stimulation impact these outcomes?

Design

This retrospective cohort study, conducted in a university-affiliated IVF centre, included 232 elective oocyte cryopreservation cycles of vaccinated and unvaccinated patients, without previous infection with the SARS-CoV-2 virus, between December 2020 and January 2022. Two control groups – pre-pandemic (January 2019 to February 2020) and intra-pandemic (December 2020 to January 2022) unvaccinated groups – were compared with the vaccinated group, further divided into four subgroups (under 3, 3–6, 6–9 and 9–13 months). The primary outcome was the elective oocyte cryopreservation cycle outcomes – number of retrieved and number of mature oocytes.

Results

The vaccinated group demonstrated comparable outcomes with regards to number of retrieved and mature oocytes compared with the pre-pandemic and intra-pandemic unvaccinated groups (12.6 ± 8.0 versus 13.0 ± 8.2 and 12.5 ± 7.4 retrieved and 10.1 ± 6.9 versus 9.5 ± 6.4 and 10.1 ± 6.3 mature oocytes, respectively; not significant for both). Similar results were noted in a comparison between the intra-pandemic unvaccinated group and the four vaccinated subgroups. No correlation was found between the parameter of days from vaccination and cycle outcomes. Similarly, analysis of covariance showed no association between vaccination status and timing and number of mature oocytes.

Conclusions

The SARS-CoV-2 vaccination does not alter the outcomes of elective oocyte cryopreservation procedures. This is true even in a relatively long time interval of 9 to 13 months from vaccination.

A decade of discovery: the stunning progress of premature ovarian insufficiency research in China

Premature ovarian insufficiency (POI) is one of key aspects of ovarian infertility. Due to early cession of ovarian function, POI imposes great challenges on the physiological and psychological health of women, and becomes a common cause of female infertility. In the worldwide, there has been a special outpouring of concern for about four million reproductive-aged women suffering from POI in China. Driven by advances in new technologies and efforts invested by Chinses researchers, understanding about POI has constantly been progressing over the past decade. Here, we comprehensively summarize and review the landmark development and achievements from POI studies in China spanning 2011 to 2020, which aims to provide key insights from bench to bedside.

Human papillomavirus vaccination at the national and provincial levels in China: a cost-effectiveness analysis using the PRIME model

BACKGROUND

Human papillomavirus (HPV) vaccines have been proven effective against cervical cancer. However, HPV vaccination is not included in the Chinese immunization program. This study aimed to assess the cost-effectiveness of incorporating different HPV vaccines into immunization programs at the Chinese national and provincial levels.

METHODS

The Papillomavirus Rapid Interface for Modeling and Economics model was used to estimate the possible cost and social and economic benefits of adopting various HPV vaccination immunization strategies in 31 provinces in Mainland China in 2019. Demographic and regional economic data were obtained from the national and provincial Statistical Yearbook. The cost of vaccines was gathered from the centralized procurement information platform of all Chinese provinces. Treatment costs, epidemiological data, and other model parameters were obtained from published literature. The cost of vaccination, treatment costs saved, net costs, cases and deaths averted, life years saved, disability-adjusted life years (DALYs) prevented, and incremental cost-effectiveness ratios were predicted both provincially and nationally. Deterministic sensitivity analyses were used to explore model uncertainty.

RESULTS

The net cost of vaccinating with the domestic bivalent HPV vaccine was the lowest. At the national level, after bivalent or quadrivalent HPV vaccination, the number of cases and deaths averted due to cervical cancer were 12,545 and 5109, respectively, whereas the 9-valent HPV vaccine averted 28,140 cases and 11,459 deaths. HPV vaccines were cost-effective at a national level (maximum cost US$ 18,165 per DALY gained.) compared to the 3 times GDP per capita (US$ 30,837). Bivalent HPV vaccines were cost-effective in all 31 provinces. Imported quadrivalent and 9-valent HPV vaccines were cost-effective in 29 provinces, except Heilongjiang and Gansu. The univariate sensitivity analysis showed that the results were robust when the model parameters were changed, and that the discount rate was the main factor affecting the baseline results.

CONCLUSIONS

This study provides evidence that the inclusion of HPV vaccination in the immunization program would be cost-effective at a national level and in most provinces. Provinces with a higher population have more prevented cases, deaths, and DALYs. The economics of HPV vaccination at the provincial level differs from that at the national level, and provinces with an inability to pay should seek help from state subsidies.

Vaccines

The safety of COVID-19 vaccines, as was the case last year, remains a large part of the focus in this volume. COVID-19 placed a large magnifying glass on both vaccines, specifically vaccine safety. This was most readily apparent as the number of records in VAERS ballooned to about 10 times the size from 2020 to 2021 (Vaccine Adverse Event Reporting System (VAERS), 2022) [S]. While we have added and/or improved VAERS during COVID-19, including adding or improving other vaccine safety surveillance tools like v-safe and vaccine safety datalink (Blumenthal, Phadke, et al., 2021) [MC], there is still room for improvement in these pharmacovigilance tools (Rizk et al., 2021) [r]. A major global initiative in this realm is the Global Vaccines Safety Blueprint 2.0 (GVSB2.0) (Organization, 2021, pp. 2021–2023) [S]. We wholeheartedly endorse these initiatives, which could significantly improve vaccine safety.

As noted in past SEDA issues, clinicians should be mindful of the risks of AEs and SAEs associated with each individual vaccine.

The Role of Noncoding RNA in the Pathophysiology and Treatment of Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is defined as a loss of ovarian function before the age of 40 years, with a prevalence rate estimated at approximately 1%. It causes infertility and is related to serious long-term health consequences, including reduced life expectancy, increased cardiovascular risk, decreased bone mineral density and neurological disorders. There is currently no effective therapy for POI that is widely available in clinical practice; therefore, the treatment of patients with POI is based on hormone replacement therapy. One of the recent advances in the understanding of the pathophysiology of POI has been the role of microRNAs (miRNAs) and other noncoding RNAs (ncRNAs) in the disease. Moreover, intensive research on human folliculogenesis and reproductive biology has led to the development of novel promising therapeutic strategies with the use of exosomal miRNAs derived from mesenchymal stem cells to restore ovarian function in POI patients. This narrative review focuses on the new studies concerning the role of ncRNAs in the pathogenesis of POI, together with their potential as biomarkers of the disease and targets for therapy.

Association Between Human Papillomavirus Vaccination and Primary Ovarian Insufficiency in a Nationwide Cohort

IMPORTANCE

Anecdotal case reports have suggested an association between human papillomavirus (HPV) vaccination and primary ovarian insufficiency, but observational studies of HPV and primary ovarian insufficiency are rare, and their findings do not support an association. However, available studies have been limited by statistical power, and concerns about infertility after vaccination are associated with lower levels of uptake of the cancer-preventing vaccine in many countries.

OBJECTIVE

To evaluate the risk of primary ovarian insufficiency after quadrivalent human papillomavirus (4HPV) vaccination.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study with follow-up from 2007 to 2016 used nationwide data for 996 300 Danish-born girls and women aged 11 to 34 years. Cox proportional hazards regression was used to estimate hazard ratios (HRs) of primary ovarian insufficiency diagnoses by 4HPV vaccination status with adjustment for age, calendar period, and a propensity score summarizing health care use. Data were analyzed from October 2020 to January 2021.

EXPOSURES

Receiving 4HPV vaccination compared with receiving no vaccination.

MAIN OUTCOMES AND MEASURES

The main outcome was hospital contacts for primary ovarian insufficiency, and the main outcome measures were HRs comparing rates of primary ovarian insufficiency among vaccinated and unvaccinated individuals.

RESULTS

During 6 781 166 person-years of follow-up among 996 300 girls and women aged 11 to 34 years (505 829 vaccinated individuals [50.8%] and 490 471 unvaccinated individuals [49.2%]), 144 individuals were diagnosed with primary ovarian insufficiency, including 54 individuals diagnosed after 4HPV vaccination. The median (interquartile range) age of primary ovarian insufficiency diagnosis was 26.94 (12.68) years. The adjusted HR of primary ovarian insufficiency comparing 4HPV vaccination to no vaccination was 0.96 (95% CI, 0.55-1.68).

CONCLUSIONS AND RELEVANCE

This study found no association between HPV vaccination and primary ovarian insufficiency. However, given the rarity of the outcome in this study, the presence of a clinically relevant increase in rate of diagnosis cannot be excluded.

Autoimmune Diseases in Patients with Premature Ovarian Insufficiency-Our Current State of Knowledge

Premature ovarian insufficiency (POI), previously known as premature ovarian failure or premature menopause, is defined as loss of ovarian function before the age of 40 years. The risk of POI before the age of 40 is 1%. Clinical symptoms develop as a result of estrogen deficiency and may include amenorrhea, oligomenorrhea, vasomotor instability (hot flushes, night sweats), sleep disturbances, vulvovaginal atrophy, altered urinary frequency, dyspareunia, low libido, and lack of energy. Most causes of POI remain undefined, however, it is estimated that anywhere from 4-30% of cases are autoimmune in origin. As the ovaries are a common target for autoimmune attacks, an autoimmune etiology of POI should always be considered, especially in the presence of anti-oocyte antibodies (AOAs), autoimmune diseases, or lymphocytic oophoritis in biopsy. POI can occur in isolation, but is often associated with other autoimmune conditions. Concordant thyroid disorders such as hypothyroidism, Hashimoto thyroiditis, and Grave's disease are most commonly seen. Adrenal autoimmune disorders are the second most common disorders associated with POI. Among women with diabetes mellitus, POI develops in roughly 2.5%. Additionally, autoimmune-related POI can also present as part of autoimmune polyglandular syndrome (APS), a condition in which autoimmune activity causes specific endocrine organ damage. In its most common presentation (type-3), APS is associated with Hashomoto's type thyroid antibodies and has a prevalence of 10-40%. 21OH-Antibodies in Addison's disease (AD) can develop in association to APS-2.

Vaccines

In this volume of the Side Effects of Drugs Annual, although other vaccines will be covered, the safety of COVID vaccines is the focus as COVID-19 has led to heightened attention on vaccine safety in general. As such, this chapter will be more relevant than ever before. As noted in past SEDA issues, clinicians should be mindful of the risks of AEs and SAEs associated with each vaccine.

Potential Effects of Human Papillomavirus Type Substitution, Superinfection Exclusion and Latency on the Efficacy of the Current L1 Prophylactic Vaccines

There are >200 different types of human papilloma virus (HPV) of which >51 infect genital epithelium, with ~14 of these classed as high-risk being more commonly associated with cervical cancer. During development of the disease, high-risk types have an increased tendency to develop a truncated non-replicative life cycle, whereas low-risk, non-cancer-associated HPV types are either asymptomatic or cause benign lesions completing their full replicative life cycle. HPVs can also be present as non-replicative so-called “latent” infections and they can also show superinfection exclusion, where cells with pre-existing infections with one type cannot be infected with a different HPV type. Thus, the HPV repertoire and replication status present in an individual can form a complex dynamic meta-community which changes with respect to both time and exposure to different HPV types. In light of these considerations, it is not clear how current prophylactic HPV vaccines will affect this system and the potential for iatrogenic outcomes is discussed in light of recent outcome data.