The Continued Challenges in the Diagnosis of Acute Pelvic Inflammatory Disease: Focus on Clinically Mild Disease

Trends in infections detected in women with cervicitis over a decade

Objectives

There is a growing body of evidence that in the absence of Chlamydia trachomatis and/or Neisseria gonorrhoeae, Mycoplasma genitalium and bacterial vaginosis (BV) are associated with cervicitis. We aimed to describe infections detected among cervicitis cases over a decade and establish how commonly M. genitalium and BV were detected among non-chlamydial/non-gonococcal cases to inform testing and treatment practices.

Methods

We conducted a retrospective case-series to determine the number of cervicitis cases diagnosed with genital infections (C. trachomatis, N. gonorrhoeae, M. genitalium and BV) among women attending the largest public sexual health service in Australia from 2011 to 2021. We determined the proportion of cervicitis cases with one or more genital infections detected, and trends in testing and detection of each infection over time.

Results

Over a decade 813 cervicitis cases were diagnosed; 421 (52%, 95%CI: 48%-55%) had no infection detected; 226/729 (31%, 95%CI: 28%-35%) had BV, 163/809 (20%, 95%CI: 17%-23%) C. trachomatis, 48/747 (6%, 95%CI: 5%-8%) M. genitalium, and 13/793 (2%, 95%CI: 1%-3%) N. gonorrhoeae. Of the 665 (82%) cases tested for all four infections, 268 (40%) had one infection and 73 (11%) had >1 infection detected. Of the 517/665 (78%) non-chlamydial/non-gonococcal cases, 164 (32%) had BV and 16 (3%) had M. genitalium as the sole infections detected; a further 13 cases (3%) were co-infected with BV and M. genitalium. The proportion of cases tested for BV (90%) did not change overtime, but detection increased from 32% to 45% (Ptrend < 0.001). The proportion of cases tested for M. genitalium increased from 84% in 2011 to 96% in 2019 (Ptrend = 0.006), with M. genitalium-detection in cervicitis increasing from 3% to 7% (Ptrend = 0.046).

Conclusions

In our study population, chlamydia or gonorrhoea were not detected in ∼75% of cervicitis cases; 1 in 3 of these cases had BV and/or M. genitalium, and both increased in prevalence over time. These data highlight the need for clinicians to consider BV and M. genitalium when assessing and managing cervicitis.

Impact of the COVID-19 Pandemic on Chlamydia, Gonorrhea, and Pelvic Inflammatory Disease Encounters in a United States Uniformed Service Female Beneficiary Population

INTRODUCTION

We sought to evaluate the impact of the COVID-19 pandemic on trends in chlamydia, gonorrhea, and pelvic inflammatory disease (PID) encounter rates within the Military Health System.

MATERIALS AND METHODS

This cross-sectional study queried electronic health records of 18- to 44-year-old female active duty service members and dependents during the pre-pandemic period (January 2018-February 2020), pandemic period 1 (March 2020-March 2021), and pandemic period 2 (April 2021-April 2022). We calculated monthly chlamydia, gonorrhea, and PID encounter rates using ICD-10 codes. We used change point analysis for trends in encounter rates and Poisson regression for differences in rates by age, active duty status, military rank, TRICARE region, and pandemic period.

RESULTS

There were 36,102, 7,581, and 16,790 unique individuals with chlamydia, gonorrhea, and PID encounters, respectively, over the pre-pandemic and pandemic time frames. Chlamydia and gonorrhea encounter rates were highest in ages 18 to 19, in active duty service members, and junior enlisted compared to senior enlisted and officer sponsor rank. Chlamydia and gonorrhea encounter rates varied by TRICARE region. Chlamydia encounter rates were lower in both pandemic periods 1 and 2 compared to the pre-pandemic period, whereas gonorrhea encounter rates were lower only in pandemic period 2 compared to the pre-pandemic period. Trend analysis showed monthly chlamydia encounter rates did not significantly change from January 2018 through August 2020, and then decreased 2.4% monthly through the remainder of the study period (P < .05). Gonorrhea encounter rates did not significantly change from the beginning of the study period through February 2021 and then declined 1.9% monthly through the remainder of the study period (P < .05). Pelvic inflammatory disease encounter rates were highest in ages 18 to 19 and 20 to 24, in the TRICARE North region compared to the South region, in active duty service members compared to non-active duty, and in junior enlisted compared to senior enlisted and officer sponsor rank. Pelvic inflammatory disease encounter rates were lower in pandemic periods 1 and 2 compared to the pre-pandemic period. Pelvic inflammatory disease encounter rates declined 8.0% monthly from January 2020 through April 2020 (P < .05), followed by a 11.0% monthly increase from May 2020 through July 2020 (P < .05) and a 0.9% monthly decrease for the remainder of the study period (P < .05).

CONCLUSIONS

Chlamydia, gonorrhea, and PID encounter rates in the Military Health System all declined in the pandemic period. Pelvic inflammatory disease was most influenced by the pandemic onset as demonstrated by an immediate decline in encounter rates followed by an increase several months into the pandemic. Young age, active duty, and junior enlisted status were associated with higher chlamydia, and gonorrhea, and PID encounter rates over the pre-pandemic and pandemic time frames. Lower encounter rates during the pandemic may be related to decreased access to health care services, reduced screening for sexually transmitted infections, or changes in sexual behavior. The less profound decline in gonorrhea encounter rates likely reflects the more symptomatic nature of gonorrhea compared to chlamydia. TRICARE regional differences varied for chlamydia, gonorrhea, and PID encounters.

The Role of Prevotella Species in Female Genital Tract Infections

Female genital tract infections (FGTIs) include vaginal infections (e.g., bacterial vaginosis [BV]), endometritis, pelvic inflammatory disease [PID], and chorioamnionitis [amniotic fluid infection]. They commonly occur in women of reproductive age and are strongly associated with multiple adverse health outcomes including increased risk of HIV/sexually transmitted infection acquisition and transmission, infertility, and adverse birth outcomes such as preterm birth. These FGTIs are characterized by a disruption of the cervicovaginal microbiota which largely affects host immunity through the loss of protective, lactic acid-producing Lactobacillus spp. and the overgrowth of facultative and strict anaerobic bacteria. Prevotella species (spp.), anaerobic Gram-negative rods, are implicated in the pathogenesis of multiple bacterial FGTIs. Specifically, P. bivia, P. amnii, and P. timonensis have unique virulence factors in this setting, including resistance to antibiotics commonly used in treatment. Additionally, evidence suggests that the presence of Prevotella spp. in untreated BV cases can lead to infections of the upper female genital tract by ascension into the uterus. This narrative review aims to explore the most common Prevotella spp. in FGTIs, highlight their important role in the pathogenesis of FGTIs, and propose future research in this area.

Cyclical endometrial repair and regeneration: Molecular mechanisms, diseases, and therapeutic interventions

The endometrium is a unique human tissue with an extraordinary ability to undergo a hormone-regulated cycle encompassing shedding, bleeding, scarless repair, and regeneration throughout the female reproductive cycle. The cyclical repair and regeneration of the endometrium manifest as changes in endometrial epithelialization, glandular regeneration, and vascularization. The mechanisms encompass inflammation, coagulation, and fibrinolytic system balance. However, specific conditions such as endometriosis or TCRA treatment can disrupt the process of cyclical endometrial repair and regeneration. There is uncertainty about traditional clinical treatments' efficacy and side effects, and finding new therapeutic interventions is essential. Researchers have made substantial progress in the perspective of regenerative medicine toward maintaining cyclical endometrial repair and regeneration in recent years. Such progress encompasses the integration of biomaterials, tissue-engineered scaffolds, stem cell therapies, and 3D printing. This review analyzes the mechanisms, diseases, and interventions associated with cyclical endometrial repair and regeneration. The review discusses the advantages and disadvantages of the regenerative interventions currently employed in clinical practice. Additionally, it highlights the significant advantages of regenerative medicine in this domain. Finally, we review stem cells and biologics among the available interventions in regenerative medicine, providing insights into future therapeutic strategies.