Relationships between the vaginal microbiota and genitourinary syndrome of menopause symptoms in postmenopausal women: the Study of Women's Health Across the Nation

In silico molecular docking and predictive ADME properties, in vitro antioxidant scavenging capacities, and in vivo pharmacological activities to study the potential of Pterocarpus mildbraedii's Harms (Fabaceae) in preventing vaginal dysbiosis and risk factors for cardiovascular disease in an estropause rat model

Vaginal dysbiosis (VaD) is a common issue among menopausal women, who are particularly susceptible to cardiovascular disease (CVD). Pterocarpus sp. are known to induce estrogen-like activities, which are the key pathways for menopause-related disorders. This study aims to evaluate the potential of Pterocarpus mildbraedii water extract on VaD and CVD risk factors using an estropause (EP) rat model. Furthermore, predictive ADME properties and molecular docking with target proteins were assessed to develop alternative medicinal treatments for menopause. The secondary metabolites in P. mildbraedii water extract (Pm) were analyzed using UHPLC-MS and quantitative phytochemistry methods. The extract's ability to scavenge free radicals was evaluated using DPPH, ABTS, and FRAP tests. Molecular docking assessed the extract's binding ability to various receptors. SwissADME and Molinspiration were utilized to predict its pharmacokinetic and bioactivity properties. Subsequently, the therapeutic potential of Pm was assessed in rats, focusing on its estrogen-like, eubiotic, and cardioprotective activities. UHPLC-MS enables us to identify several compounds. Predictive ADME analyses have indicated that most compounds comply with Lipinski's Rule of Five for oral drugs. Additionally, they inhibit CYP1A2 and bind to several receptors and enzymes through conventional hydrogen bonding. In rats, ovariectomy-induced EP reduced glycogen levels and vaginal lactic acid and decreased in the population of Lactobacillus spp., which is characteristic of VaD. This condition also increases CVD risk factors. Overall, this study underscores the potential of Pterocarpus mildbraedii in preventing VaD and CVD risk factors related to hypoestrogenism. This extract positions itself as a promising alternative treatment for menopause-related disorders.

Aesthetic Gynecology and Mental Health: What Does It Really Mean for Women?

Body image, a complex interplay of perceptions, thoughts, and feelings about one’s physical appearance, has been a subject of extensive research. It is a dynamic construct that evolves throughout a woman’s lifespan, influenced by a multitude of biological, psychological, and sociocultural factors. From adolescence, marked by the onset of puberty and societal pressures to conform to specific beauty standards, to adulthood and the physical changes associated with aging, women’s body image undergoes significant transformations. Aging is a universal process that affects all organs, including the female genitalia. The vaginal tract undergoes significant atrophy due to declining estrogen levels, particularly during and after menopause. Aesthetic gynecology offers a range of procedures to address both functional and aesthetic concerns related to aging genitalia. Aesthetic gynecology, a burgeoning field within women’s health, provides various procedures aimed at enhancing genital appearance and function. It also helps balance the hormonal and anatomical changes that every woman experiences over time. The goal is to strengthen each patient’s intimate well-being and self-esteem, enabling them to experience intimacy peacefully. While often driven by concerns about physical attractiveness and sexual satisfaction, the psychological implications of these procedures are complex and multifaceted. It is crucial to recognize the interplay between psychological factors and the decision to undergo these procedures. Collaboration between surgeons and mental health professionals can ensure that candidates are psychologically prepared and have realistic expectations. By adopting a patient-centered approach and conducting rigorous research, healthcare providers can ensure that aesthetic gynecology is used as a tool for empowerment rather than exploitation. This article explores the intricate relationship between psychological well-being and aesthetic gynecology, examining how these procedures can impact body image, self-esteem, and overall quality of life.

Assessment of the vaginal microbiota before and after use of hyperosmolal lubricant during transvaginal ultrasound

BACKGROUND

Vaginal lubricants are commonly used during sexual activity and clinical procedures such as transvaginal ultrasound. Epidemiologic and laboratory studies indicate hyperosmolal water-based lubricants may disrupt the vaginal microbiota, particularly the beneficial Lactobacillus spp. These bacteria play a critical role in protecting against sexually transmitted infection acquisition and other adverse gynecologic and obstetric outcomes.

OBJECTIVE

We sought to evaluate changes in the composition of the vaginal microbiota before and after a single exposure to lubricant over a 10-week period among pre-, peri-, and postmenopausal patients referred for transvaginal ultrasound.

STUDY DESIGN

One hundred four participants self-collected mid-vaginal swabs daily between baseline and transvaginal ultrasound (∼1 week), immediately before transvaginal ultrasound ("pre-transvaginal ultrasound"), and 6 to 12 hours after transvaginal ultrasound ("post-transvaginal ultrasound"). Participants attended a follow-up visit ∼2 to 5 days after transvaginal ultrasound ("post-transvaginal ultrasound follow-up"), continued to self-sample twice-weekly for 9 weeks, and attended a final clinical visit in week 10. Microbiota composition was characterized by 16S ribosomal RNA gene amplicon sequencing (V3-V4) and assigned to community state types (low-Lactobacillus vs Lactobacillus-dominated). Yue-Clayton theta indices defined similarity between daily successive samples between baseline and transvaginal ultrasound and overall stability of the vaginal microbiota before and after transvaginal ultrasound. Analysis of Compositions of Microbiomes II determined differentially abundant taxa in post-transvaginal ultrasound samples vs pre-transvaginal ultrasound samples. Generalized linear mixed models evaluated the odds of having a low-Lactobacillus microbiota after transvaginal ultrasound with samples before transvaginal ultrasound as the reference for each participant.

RESULTS

A majority of the cohort was premenopausal (85/104, 82%) and self-reported Black race (65/104, 62%). Over the short-term (1 week), there was no immediate changes in the composition of the microbiota of daily successive samples following transvaginal ultrasound. In contrast, over the longer-term (participants followed for 10 weeks), the vaginal microbiota was less stable within intervals after transvaginal ultrasound vs the interval before. There were no changes in the odds of a low-Lactobacillus microbiota after transvaginal ultrasound among all participants in this 10-week longitudinal study. However, in specific groups such as peri/postmenopausal participants (N=19, adjusted odds ratio: 3.22, 95% confidence interval:1.16-8.98) and those with a history of bacterial vaginosis (N=58, adjusted odds ratio: 1.73, 95% confidence interval:1.10-2.72), there was a higher likelihood of persisting in a low-Lactobacillus state throughout the follow-up period.

CONCLUSION

Peri- and postmenopausal individuals and those with a history of bacterial vaginosis show a sustained decrease in protective Lactobacillus spp. after a single exposure to hyperosmolal vaginal lubricant. Reformulating water-based lubricants to reduce osmolality and toxicity may be beneficial.

Assessment and Treatment of Vaginitis

Vaginitis is the presenting symptom at millions of office visits each year in the United States. Although treatment of sporadic cases is often straightforward, recurrent cases present both diagnostic and treatment challenges. Molecular diagnostic tests are likely superior to in-office microscopy for most clinicians and most cases. In both recurrent bacterial vaginosis and recurrent vulvovaginal candidiasis, national treatment guidelines recommend an extended treatment duration with one of the first-line agents. In cases in which such treatment is not successful, vaginal boric acid is likely the cheapest and easiest alternative option. New antifungal medications offer additional but limited treatment options. Probiotics are not recommended for prevention of vulvovaginal candidiasis; however, vaginal products containing Lactobacillus crispatus may have promise for recurrent bacterial vaginosis. Trichomoniasis should be treated with a 1-week course of metronidazole; this is the only sexually transmitted infection for which treatment recommendations vary by sex. In cases in which patients do not respond to initial treatment, the diagnosis should be reconsidered, and other potential causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia should be considered.

Association between vaginal microbiota and vaginal inflammatory immune markers in postmenopausal women

OBJECTIVE

In premenopausal individuals, vaginal microbiota diversity and lack of Lactobacillus dominance are associated with greater mucosal inflammation, which is linked to a higher risk of cervical dysplasia and infections. It is not known if the association between the vaginal microbiota and inflammation is present after menopause, when the vaginal microbiota is generally higher-diversity and fewer people have Lactobacillus dominance.

METHODS

This is a post hoc analysis of a subset of postmenopausal individuals enrolled in a randomized trial for treatment of moderate-severe vulvovaginal discomfort that compared vaginal moisturizer, estradiol, or placebo. Vaginal fluid samples from 0, 4, and 12 weeks were characterized using 16S rRNA gene sequencing (microbiota) and MesoScale Discovery (vaginal fluid immune markers: IL-1b, IL-1a, IL-2, IL-6, IL-18, IL-10, IL-9, IL-13, IL-8, IP10, MIP1a, MIP1b, MIP3a). Global associations between cytokines and microbiota (assessed by relative abundance of individual taxa and Shannon index for alpha, or community, diversity) were explored, adjusting for treatment arm, using linear mixed models, principal component analysis, and Generalized Linear Mixed Model + Microbiome Regression-based Kernel Association Test (GLMM-MiRKAT).

RESULTS

A total of 119 individuals with mean age of 61 years were included. At baseline, 29.5% of participants had a Lactobacillus -dominant vaginal microbiota. Across all timepoints, alpha diversity (Shannon index, P = 0.003) was highly associated with immune markers. Individual markers that were associated with Lactobacillus dominance were similar to those observed in premenopausal people: IL-10, IL-1b, IL-6, IL-8 (false discovery rate [FDR] < 0.01), IL-13 (FDR = 0.02), and IL-2 (FDR = 0.09). Over 12 weeks, change in alpha diversity was associated with change in cytokine concentration (Shannon, P = 0.018), with decreased proinflammatory cytokine concentrations observed with decreasing alpha diversity.

CONCLUSIONS

In this cohort of postmenopausal individuals, Lactobacillus dominance and lower alpha diversity were associated with lower concentrations of inflammatory immune markers, as has been reported in premenopausal people. This suggests that after menopause lactobacilli continue to have beneficial effects on vaginal immune homeostasis, despite lower prevalence.

An effective non-hormonal option with high tolerability for mild to moderate symptoms of vaginal dryness associated with menopause

OBJECTIVES

The efficacy and tolerability of a non-hormonal pessary (that forms an oil-in-water emollient with the vaginal fluid) were assessed for the treatment of symptoms of vaginal dryness associated with menopause.

STUDY DESIGN

Seventy-nine postmenopausal women (mean age 60.8 ± 6.5 years) with mild to moderate symptoms of vaginal dryness (including dyspareunia) were enrolled in this open-label, prospective, post-market clinical follow-up trial, conducted in 2022 by one research center in Germany. The investigational pessary was applied for the first 7 days once daily and the subsequent 31 days twice a week, at bedtime. A treatment-free period of 6 days completed the trial.

MAIN OUTCOME MEASURES

During the trial, participants filled out questionnaires that enabled the calculation of a total severity score for subjective symptoms of atrophy-related vaginal dryness and impairment of daily as well as sexual life. Furthermore, vaginal health index and safety were studied.

RESULTS

A rapid and significant reduction in the severity scores for symptoms was observed over the 38-day course of treatment and beyond. Quality of life assessed by DIVA (day-to-day impact of vaginal aging) questionnaire, dyspareunia and vaginal health index also clearly improved. The tolerability was mainly rated as "good to very good" by the investigator and 94.9 % of participants. The vast majority were very satisfied with the simple and pleasant handling. No serious adverse events occurred.

CONCLUSION

Overall, the presented data suggest that the investigated non-hormonal pessary is an effective and well tolerated treatment option for vaginal symptoms associated with dryness, thus improving quality of life for women, even those who are sexually active.

CLINICALTRIALS

gov identifier NCT05211505.