Longitudinal Association Between Hormonal Contraceptives and Bacterial Vaginosis in Women of Reproductive Age

Contraceptives Association with Vaginal Microbiome and RTI: A Cross-Sectional Survey in Females of Jammu and Kashmir, India

The present study aimed to examine the impacts of use of various contraceptive methods on vaginal microbiome and reproductive tract infections (RTI) in females. A cross-sectional study in Jammu Province of Jammu and Kashmir was conducted in which 796 sexually active married women of reproductive age were recruited as participants. A well-structured questionnaire was used to collect the data and the analysis was performed using linear and binary logistic regression with 95% confidence interval (CI). The p value of < 0.05 was considered as significant. Previous studies have consistently shown that disturbances in the vaginal microbiome can lead to reproductive tract infections in women. The prevalence of contraceptive use and RTI in the studied population was 53.1% (CI 49.6-56.7%) and 44.7% (CI 41.2-48.3%) respectively. Several sociodemographic factors like age, place of residence, educational qualification, religion, and caste of the participant significantly governed the method of contraception used by the females. It was observed from the data obtained that the use of condoms and hormonal oral contraceptives reduced the risk of RTI as they maintain vaginal eubiosis in the females by 1.97-folds (AOR:1.97; CI 1.02-2.86) and 1.68 folds (AOR:1.68; CI 0.78-2.50) respectively. The likelihood of developing RTI increased by 2.31 (AOR:2.31; CI 1.05-3.57), 3.62 (AOR:1.97; CI 1.02-2.86), and 4.97 (AOR:4.97; CI 3.50-6.00) folds in females who opted for IUDs, tubal ligation, and unprotected sex respectively, these methods may interfere with the host vaginal microbiome, alter it and making the female more susceptible to the microbial infections and pathogenic attack. The research proposes that the use of hormonal oral contraceptives and condoms as the means of contraception is a safe method and the females opting for them are less prone to RTI.

The Vaginal Microbiome in Health and Disease-What Role Do Common Intimate Hygiene Practices Play?

The vaginal microbiome is a dynamic, sensitive microenvironment. The hallmark of a 'healthy' vaginal microbiome is currently believed to be one dominated by Lactobacillus spp., which acidifies the vaginal environment and help to protect against invading pathogens. However, a 'normal' microbiome is often difficult, if not impossible, to characterise given that it varies in response to numerous variables, including pregnancy, the menstrual cycle, contraceptive use, diet, ethnicity, and stress. A Lactobacillus-depleted microbiome has been linked to a variety of adverse vaginal health outcomes, including preterm birth (PTB), bacterial vaginosis (BV), and increased risk of sexually transmitted infections. The latter two of these have also been associated with feminine intimate hygiene practices, many of which are practised without any evidence of health benefits. The most extensively studied practice is vaginal douching, which is known to cause vaginal dysbiosis, predisposing women to BV, pelvic inflammatory disease, and PTB. However, little is known of the impact that intimate hygiene practices and associated products have on the vaginal microbiome. This review aims to outline the major factors influencing the vaginal microbiome and common vaginal infections, as well as to summarise current research surrounding the impact of hygiene products and practices on the vaginal microbiome.

Elevated Risk of Bacterial Vaginosis Among Users of the Copper Intrauterine Device: A Prospective Longitudinal Cohort Study

BACKGROUND

Limited evidence suggests that the nonhormonal contraceptive copper intrauterine device (Cu-IUD) may increase bacterial vaginosis (BV) risk, possibly due to increased volume and duration of menses, a common side effect of Cu-IUD use. Although increases in bleeding typically resolve within 6-12 months following initiation, evaluations of the association between Cu-IUD and BV have not included more than 6 months of follow-up.

METHODS

This secondary analysis of a human immunodeficiency virus type 1 prevention trial included 2585 African women ages 18-45 followed for up to 33 months. Women reported contraceptive use each month. BV was evaluated by Nugent score in 6-monthly intervals and, if clinically indicated, by Amsel criteria. Andersen-Gill proportional hazards models were used to (1) evaluate BV risk among Cu-IUD users relative to women using no/another nonhormonal contraceptive and (2) test changes in BV frequency before, while using, and following Cu-IUD discontinuation.

RESULTS

BV frequency was highest among Cu-IUD users at 153.6 episodes per 100 person-years (95% confidence interval [CI]: 145.2, 162.4). In adjusted models, Cu-IUD users experienced 1.28-fold (95% CI: 1.12, 1.46) higher BV risk relative to women using no/another nonhormonal contraception. Compared to the 6 months prior to initiation, BV risk was 1.52-fold (95% CI: 1.16, 2.00) higher in the first 6 months of Cu-IUD use and remained elevated over 18 months of use (P < .05). Among women who discontinued Cu-IUD, BV frequency was similar to pre-initiation rates within 1 year.

CONCLUSIONS

Cu-IUD users experienced elevated BV risk that persisted throughout use. Women and their providers may wish to consider BV risk when discussing contraceptive options.

Connecting the Dots: Translating the Vaginal Microbiome Into a Drug

A Lactobacillus-dominated vaginal microbiota (VMB) has been associated with health and considered an important host defense mechanism against urogenital infections. Conversely, depletion of lactobacilli and increased microbial diversity, amplifies the risk of adverse gynecologic and obstetric outcomes. A common clinical condition that exemplifies dysbiosis is bacterial vaginosis (BV). BV is currently treated with antibiotics, but frequently recurs, due in part to persistent dysbiosis and failure of lactobacilli to repopulate the vagina. New treatment options are needed to address BV. The VMB is relatively simple and optimally dominated by one or several species of Lactobacillus. Lactobacillus crispatus is strongly associated with vaginal health and depleted in dysbiosis. Replenishing the dysbiotic VMB with protective L. crispatus CTV-05 is a promising approach to prevent recurrent infections and improve women's health. Here we discuss confirmation of this approach with the microbiome-based biologic drug, LACTIN-V (L. crispatus CTV-05), focusing on prevention of BV recurrence.

The effect of different contraceptive methods on the vaginal microbiome

Introduction: Following a historical overview, the effect of different contraceptive methods on vaginal microbiome has been reviewed and summarized.Areas covered: Effects of combined hormonal contraceptives (oral or vaginal) and of progestin only (injectable and implantable), intrauterine devices/systems (copper- or levonorgestrel-releasing), on vaginal microbiome. In addition, mention is made of vaginal rings releasing antiviral drugs and lactic acid.Expert opinion: The vaginal microbiota (VM) is unique in that it is normally dominated by Lactobacillus species providing a degree of protection against infections; this however may vary, depending on the species and strains of Lactobacillus. Bacterial Vaginosis represents the most common dysbiosis of the VM and its prevalence can be influenced by use of contraception. Available evidence indicates that, under the influence of oral or systemically administered female sex hormones, there is apromotion of vaginal eubiosis, with aprevalence of ahealthy VM in which Lactobacilli predominate.

The Complex Link between the Female Genital Microbiota, Genital Infections, and Inflammation

The female genital tract microbiota is part of a complex ecosystem influenced by several physiological, genetic, and behavioral factors. It is uniquely linked to a woman's mucosal immunity and plays a critical role in the regulation of genital inflammation. A vaginal microbiota characterized by a high abundance of lactobacilli and low overall bacterial diversity is associated with lower inflammation. On the other hand, a more diverse microbiota is linked to high mucosal inflammation levels, a compromised genital epithelial barrier, and an increased risk of sexually transmitted infections and other conditions. Several bacterial taxa such as Gardnerella spp., Prevotella spp., Sneathia spp., and Atopobium spp. are well known to have adverse effects; however, the definitive cause of this microbial dysbiosis is yet to be fully elucidated. The aim of this review is to discuss the multiple ways in which the microbiota influences the overall genital inflammatory milieu and to explore the causes and consequences of this inflammatory response. While there is abundant evidence linking a diverse genital microbiota to elevated inflammation, understanding the risk factors and mechanisms through which it affects genital health is essential. A robust appreciation of these factors is important for identifying effective prevention and treatment strategies.

Vaginal microbiome-hormonal contraceptive interactions associate with the mucosal proteome and HIV acquisition

Alterations to the mucosal environment of the female genital tract, such as genital inflammation, have been associated with increased HIV acquisition in women. As the microbiome and hormonal contraceptives can affect vaginal mucosal immunity, we hypothesized these components may interact in the context of HIV susceptibility. Using previously published microbiome data from 685 women in the CAPRISA-004 trial, we compared relative risk of HIV acquisition in this cohort who were using injectable depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN), and combined oral contraceptives (COC). In women who were Lactobacillus-dominant, HIV acquisition was 3-fold higher in women using DMPA relative to women using NET-EN or COC (OR: 3.27; 95% CI: 1.24–11.24, P = 0.0305). This was not observed in non-Lactobacillus-dominant women (OR: 0.95, 95% CI: 0.44–2.15, P = 0.895) (interaction P = 0.0686). Higher serum MPA levels associated with increased molecular pathways of inflammation in the vaginal mucosal fluid of Lactobacillus-dominant women, but no differences were seen in non-Lactobacillus dominant women. This study provides data suggesting an interaction between the microbiome, hormonal contraceptives, and HIV susceptibility.

Alterations to the mucosal environment of the female genital tract have been associated with increased HIV acquisition in women. As both the vaginal microbiome and hormonal contraceptives affect mucosal immunity, we investigated their interaction with HIV susceptibility. We characterized the vaginal microbiomes in 685 women from the CAPRISA-004 trial, who utilized three major types of hormonal contraceptives including injectable depot medroxyprogesterone acetate (DMPA), norethisterone enanthate (NET-EN), and combined oral contraceptives (COC). In the 40% of women with Lactobacillus-depleted microbiomes, HIV acquisition was not different between contraceptive groups. However, in the 60% of women with Lactobacillus as the dominant bacterial taxa, HIV acquisition risk was 3-fold higher (in women using DMPA relative to women using NET-EN and COC). Higher serum medroxyprogesterone acetate levels in Lactobacillus dominant women associated with increased cervicovaginal inflammation pathways in the mucosal proteome, biomarkers of which associated with HIV susceptibility. This study provides data suggesting an interaction between the microbiome, hormonal contraceptives, and HIV susceptibility.

Daily Vaginal Microbiota Fluctuations Associated with Natural Hormonal Cycle, Contraceptives, Diet, and Exercise

The vaginal microbiome is a critical component of women’s sexual and reproductive health, with variations in microbial composition, particularly the loss of Lactobacillus species, being implicated in gynecologic and obstetric diseases. Given that the vaginal microbiome is so crucial, why do vaginal microbial profiles vary strikingly from person to person and even change over time within the same person? In the present study, which tracked the daily vaginal microbiomes of young healthy women through different lifestyles, we found that use of a locally released progestin contraceptive, a vegetarian diet, and intense exercise appear to lead to vaginal microbiome alterations and loss of Lactobacillus species. The impact of these vaginal microbiome changes on immediate and long-term health remain to be investigated.

The microorganisms of the vaginal tract are critical for vaginal and reproductive health. However, the regulation of these microorganisms is not well understood. Therefore, we investigated whether different factors regulate the vaginal microbiota of healthy college-aged women (n = 26) with high temporal resolution by collecting daily self-administered vaginal swabs and using 16S rRNA sequencing for bacterial identification. As expected, vaginal microbiota clustered into five predefined community state types. Vaginal microbial diversity, stability, and Lactobacillus abundances were associated with the menstrual cycle and hormonal contraceptive use. Vaginal microbial diversity, as measured using the Shannon index, increased during menses (P < 0.001), while Lactobacillus abundances decreased (P = 0.01). The covariance of these microbial measures with previously established estradiol levels suggests that estrogens can regulate vaginal microbiota. Moreover, the use of hormonal contraceptives may alter the temporal dynamics of the vaginal microbiota and decrease Lactobacillus abundances, depending on hormonal content and release method. Interestingly, intrasample diversity was greater in participants on a vegetarian diet (P = 0.004) and among participants who exercised more (P = 0.04). These findings indicate that ovarian hormones, diet, and exercise can regulate vaginal microbial composition and stability and may impact vaginal and reproductive health.

IMPORTANCE The vaginal microbiome is a critical component of women’s sexual and reproductive health, with variations in microbial composition, particularly the loss of Lactobacillus species, being implicated in gynecologic and obstetric diseases. Given that the vaginal microbiome is so crucial, why do vaginal microbial profiles vary strikingly from person to person and even change over time within the same person? In the present study, which tracked the daily vaginal microbiomes of young healthy women through different lifestyles, we found that use of a locally released progestin contraceptive, a vegetarian diet, and intense exercise appear to lead to vaginal microbiome alterations and loss of Lactobacillus species. The impact of these vaginal microbiome changes on immediate and long-term health remain to be investigated.

Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia

OBJECTIVE

To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis.

METHODS

Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest.

RESULTS

There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54-0.95), candidiasis (aHR 0.75, 95% CI 0.57-1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25-0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65-0.97).

CONCLUSION

We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.

Reviewing the Composition of Vaginal Microbiota: Inclusion of Nutrition and Probiotic Factors in the Maintenance of Eubiosis

The vaginal microbiota has importance in preserving vaginal health and defending the host against disease. The advent of new molecular techniques and computer science has allowed researchers to discover microbial composition in depth and associate the structure of vaginal microbial communities. There is a consensus that vaginal flora is grouped into a restricted number of communities, although the structure of the community is constantly changing. Certain Community-Sate Types (CSTs) are more associated with poor reproductive outcomes and sexually transmitted diseases (STDs) meanwhile, CSTs dominated by Lactobacillus species-particularly Lactobacillus crispatus-are more related to vaginal health. In this work, we have reviewed how modifiable and non-modifiable factors may affect normal vaginal microbiota homeostasis-including sexual behavior, race or ethnicity, and hygiene. Special interest has been given to how the use of probiotics, diet intake, and use of hormone replacement therapies (HRTs) can potentially impact vaginal microbiota composition.

Contraceptive rings promote vaginal lactobacilli in a high bacterial vaginosis prevalence population: A randomised, open-label longitudinal study in Rwandan women

Background

Hormonal contraception has been associated with a reduced risk of vaginal dysbiosis, which in turn has been associated with reduced prevalence of sexually transmitted infections (STIs), including HIV. Vaginal rings are used or developed as delivery systems for contraceptive hormones and antimicrobial drugs for STI and HIV prevention or treatment. We hypothesized that a contraceptive vaginal ring (CVR) containing oestrogen enhances a lactobacilli-dominated vaginal microbial community despite biomass accumulation on the CVR’s surface.

Methods

We enrolled 120 women for 12 weeks in an open-label NuvaRing^® study at Rinda Ubuzima, Kigali, Rwanda. Vaginal and ring microbiota were assessed at baseline and each ring removal visit by Gram stain Nugent scoring (vaginal only), quantitative PCR for Lactobacillus species, Gardnerella vaginalis and Atopobium vaginae, and fluorescent in situ hybridization to visualize cell-adherent bacteria. Ring biomass was measured by crystal violet staining.

Results

Bacterial vaginosis (BV) prevalence was 48% at baseline. The mean Nugent score decreased significantly with ring use. The presence and mean log₁₀ concentrations of Lactobacillus species in vaginal secretions increased significantly whereas those of G. vaginalis and presence of A. vaginae decreased significantly. Biomass accumulated on the CVRs with a species composition mirroring the vaginal microbiota. This ring biomass composition and optical density after crystal violet staining did not change significantly over time.

Conclusions

NuvaRing^® promoted lactobacilli-dominated vaginal microbial communities in a population with high baseline BV prevalence despite the fact that biomass accumulated on the rings.

Vaginal Microbiome and Its Relationship to Behavior, Sexual Health, and Sexually Transmitted Diseases

The vaginal microbiota has great significance in maintaining vaginal health and protecting the host from disease. Recent advances in molecular techniques and informatics allow researchers to explore microbial composition in detail and to compare the structure of vaginal microbial communities with behavior and health outcomes, particularly acquisition and transmission of sexually transmitted diseases (STDs) and poor birth outcomes. Vaginal flora have been found to cluster into a limited number of communities, although community structure is dynamic. Certain community types are more associated with poor reproductive outcomes and STDs; communities dominated by Lactobacillus species, particularly Lactobacillus crispatus, are most associated with vaginal health. Modifiable and nonmodifiable factors are strongly associated with community composition, including behavior, race or ethnicity, and hygiene. In this review, we describe the state of the science on the vaginal microbiome and its relationship to behavior, sexual health, and STDs, including determinants of the microbiome that go beyond an individual level.

Effects of combined oral contraceptives, depot medroxyprogesterone acetate and the levonorgestrel-releasing intrauterine system on the vaginal microbiome

OBJECTIVES

Prior studies suggest that the composition of the vaginal microbiome may positively or negatively affect susceptibility to sexually transmitted infections (STIs) and bacterial vaginosis (BV). Some female hormonal contraceptive methods also appear to positively or negatively influence STI transmission and BV. Therefore, changes in the vaginal microbiome that are associated with different contraceptive methods may explain, in part, effects on STI transmission and BV.

STUDY DESIGN

We performed a retrospective study of 16S rRNA gene survey data of vaginal samples from a subset of participants from the Human Vaginal Microbiome Project at Virginia Commonwealth University. The subset included 682 women who reported using a single form of birth control that was condoms, combined oral contraceptives (COCs), depot medroxyprogesterone acetate (DMPA) or the levonorgestrel-releasing intrauterine system (LNG-IUS).

RESULTS

Women using COCs [adjusted odds ratio (aOR) 0.29, 95% confidence interval (CI) 0.13-0.64] and DMPA (aOR 0.34, 95% CI 0.13-0.89), but not LNG-IUS (aOR 1.55, 95% CI 0.72-3.35), were less likely to be colonized by BV-associated bacteria relative to women who used condoms. Women using COCs (aOR 1.94, 95% CI 1.25-3.02) were more likely to be colonized by beneficial H₂O₂-producing Lactobacillus species compared with women using condoms, while women using DMPA (aOR 1.09, 95% CI 0.63-1.86) and LNG-IUS (aOR 0.74, 95% CI 0.48-1.15) were not.

CONCLUSIONS

Use of COCs is significantly associated with increased vaginal colonization by healthy lactobacilli and reduced BV-associated taxa.

IMPLICATIONS

COC use may positively influence gynecologic health through an increase in healthy lactobacilli and a decrease in BV-associated bacterial taxa.

A randomized clinical trial on the effects of progestin contraception in the genital tract of HIV-infected and uninfected women in Lilongwe, Malawi: Addressing evolving research priorities

Hormonal contraception is central in the prevention of unintended pregnancy; however there are concerns that certain methods may increase the risk of HIV acquisition and transmission. Hormonal contraceptives may modify the genital mucosa in several ways, however the mechanisms are incompletely understood. Few studies have examined genital HIV shedding prospectively before and after initiation of hormonal contraception. The effects of hormonal contraception on genital HIV shedding in the setting of antiretroviral therapy (ART) are also unknown. We designed a pilot clinical trial in which HIV-infected and uninfected women were randomized to either depot medroxyprogesterone acetate (DMPA) injectable or levonorgestrel (LNG) implant in Lilongwe, Malawi. The objectives were to: 1) assess the effect and compare the impact of type of progestin contraception (injectable versus implant) on HIV genital shedding among HIV-infected women, 2) assess the effect and compare the impact of type of progestin contraception on inflammatory/immune markers in the genital tract of both HIV-infected and uninfected women, and 3) assess the interaction of progestin contraception and ART by examining contraceptive efficacy and ART efficacy. An additional study aim was to determine the feasibility and need for a larger study of determinants of HIV transmissibility and acquisition. As injectable contraception is widely used in many parts of the world with high HIV prevalence, this study will provide important information in determining the need for and feasibility of a larger study to address these questions that can impact the lives of millions of women living with or at risk for HIV.

The effect of contraceptive methods on reproductive tract infections risk: a cross-sectional study having a sample of 52,481 women

OBJECTIVE

The aim of this study was to investigate the association between specific contraceptives use and reproductive tract infections (RTIs).

STUDY DESIGN

Participants consisted of 52,481 rural married women of reproductive age identified from a cross-sectional study in Anhui Province of China. The questionnaire, gynecological examination, and laboratory inspection were used to collect data. The subgroup analysis was performed to estimate the effect of the specific contraceptives on the specific RTIs.

RESULTS

A total of 49,970 (95.2 %) women used contraceptive methods and 31,390 (59.8 %) women had at least one RTI. Overall, use of intrauterine device (IUD), condom, female sterilisation, rhythm method, and oral contraceptive (OC) were associated with RTIs. In the subgroup analysis, IUD use was a risk factor for endocervicitis, bacterial vaginosis (BV), and trichomoniasis; condom, rhythm method, and OC were associated with endocervicitis; female sterilisation was associated with endocervicitis and trichomoniasis. Moreover, male sterilisation was associated with endocervicitis; withdrawal was a protective factor for endocervicitis and a risk factor for trichomoniasis; subdermal implant was associated with candidiasis and pelvic inflammatory disease (PID).

CONCLUSIONS

All the contraceptive methods may lead to the RTIs. A properly assessment for contraceptive methods use is needed for female reproductive health.

Changes in Vaginal Microbiota and Immune Mediators in HIV-1-Seronegative Kenyan Women Initiating Depot Medroxyprogesterone Acetate

BACKGROUND

Depot medroxyprogesterone acetate (DMPA) is associated with HIV acquisition. We studied changes in vaginal microbiota and inflammatory milieu after DMPA initiation.

METHODS

In a cohort of HIV-negative Kenyan women, we collected monthly vaginal swabs over 1 year before and after DMPA. Using quantitative polymerase chain reaction, we compared quantities of Lactobacillus crispatus, Lactobacillus jensenii, Lactobacillus iners, Gardnerella vaginalis, and total bacterial load (16S ribosomal RNA gene levels). Six vaginal immune mediators were measured with enzyme-linked immunosorbent assay. Trends in the detection and quantity of bacteria were estimated by logistic and linear mixed-effects regression.

RESULTS

From 2010 to 2012, 15 HIV-seronegative women initiated DMPA, contributing 85 visits (median, 6 visits/woman; range, 3-8 visits/woman). The median time of DMPA-exposed follow-up was 8.4 months (range, 1.5-11.6 months). Seven women (46%) had bacterial vaginosis within 70 days before DMPA start. L. iners was detected in 13 women (87%) before DMPA start, but other lactobacilli were rarely detected. Gardnerella vaginalis decreased by 0.21 log10 copies per swab per month after DMPA exposure (P = 0.01). Total bacterial load decreased by 0.08 log10 copies per swab per month of DMPA (P = 0.02). Sustained decreases in interleukin (IL)-6 (P = 0.03), IL-8 (P = 0.04), and IL-1 receptor antagonist (P < 0.001) were also noted. Nine women (60%) had L. crispatus detected post-DMPA, which significantly correlated with reduced IL-6 (P < 0.01) and IL-8 (P = 0.02).

CONCLUSIONS

Initiation of DMPA led to sustained shifts in vaginal bacterial concentrations and levels of inflammatory mediators. Further studies are warranted to outline components of the vaginal microbiota influenced by DMPA use and impact on HIV susceptibility.

A Study of the Vaginal Microbiome in Healthy Canadian Women Utilizing cpn60-Based Molecular Profiling Reveals Distinct Gardnerella Subgroup Community State Types

The vaginal microbiota is important in women’s reproductive and overall health. However, the relationships between the structure, function and dynamics of this complex microbial community and health outcomes remain elusive. The objective of this study was to determine the phylogenetic range and abundance of prokaryotes in the vaginal microbiota of healthy, non-pregnant, ethnically diverse, reproductive-aged Canadian women. Socio-demographic, behavioural and clinical data were collected and vaginal swabs were analyzed from 310 women. Detailed profiles of their vaginal microbiomes were generated by pyrosequencing of the chaperonin-60 universal target. Six community state types (CST) were delineated by hierarchical clustering, including three Lactobacillus-dominated CST (L. crispatus, L. iners, L. jensenii), two Gardnerella-dominated (subgroups A and C) and an “intermediate” CST which included a small number of women with microbiomes dominated by seven other species or with no dominant species but minority populations of Streptococcus, Staphylococcus, Peptoniphilus, E. coli and various Proteobacteria in co-dominant communities. The striking correspondence between Nugent score and deep sequencing CST continues to reinforce the basic premise provided by the simpler Gram stain method, while additional analyses reveal detailed cpn60-based phylogeny and estimated abundance in microbial communities from vaginal samples. Ethnicity was the only demographic or clinical characteristic predicting CST, with differences in Asian and White women (p = 0.05). In conclusion, this study confirms previous work describing four cpn60-based subgroups of Gardnerella, revealing previously undescribed CST. The data describe the range of bacterial communities seen in Canadian women presenting with no specific vaginal health concerns, and provides an important baseline for future investigations of clinically important cohorts.

Effects of a One Year Reusable Contraceptive Vaginal Ring on Vaginal Microflora and the Risk of Vaginal Infection: An Open-Label Prospective Evaluation

BACKGROUND

A contraceptive vaginal ring (CVR) containing Nestorone® (NES) and ethinyl estradiol (EE) that is reusable for 1- year (13 cycles) is under development. This study assessed effects of this investigational CVR on the incidence of vaginal infections and change in vaginal microflora.

METHODS

There were 120 women enrolled into a NES/EE CVR Phase III trial and a microbiology sub-study for up to 1- year of cyclic product use. Gynecological examinations were conducted at baseline, the first week of cycle 6 and last week of cycle 13 (or during early discontinuation visits). Vaginal swabs were obtained for wet mount microscopy, Gram stain and culture. The CVR was removed from the vagina at the last study visit and cultured. Semi-quantitative cultures for Lactobacillus, Gardnerella vaginalis, Enterococcus faecalis, Staphylococcus aureus, Escherichia coli, anaerobic gram negative rods (GNRs), Candida albicans and other yeasts were performed on vaginal and CVR samples. Vaginal infections were documented throughout the study.

RESULTS

Over 1- year of use, 3.3% of subjects were clinically diagnosed with bacterial vaginosis, 15.0% with vulvovaginal candidiasis, and 0.8% with trichomoniasis. The detection rate of these three infections did not change significantly from baseline to either Cycle 6 or 13. Nugent scores remained stable. H2O2-positive Lactobacillus dominated vaginal flora with a non-significant prevalence increase from 76.7% at baseline to 82.7% at cycle 6 and 90.2% at cycle 13, and a median concentration of 107 colony forming units (cfu) per gram. Although anaerobic GNRs prevalence increased significantly, the median concentration decreased slightly (104 to 103cfu per gram). There were no significant changes in frequency or concentrations of other pathogens. High levels of agreement between vaginal and ring surface microbiota were observed.

CONCLUSION

Sustained use of the NES/EE CVR did not increase the risk of vaginal infection and was not disruptive to the vaginal ecosystem.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00263341, NCT00455156.

Making inroads into improving treatment of bacterial vaginosis - striving for long-term cure

Bacterial vaginosis (BV) is one of the great enigmas in women's health, a common condition of unknown aetiology, which is associated with significant morbidity and unacceptably high recurrence rates. While it remains unclear whether BV recurrence is predominantly due to failure of current antibiotic regimens to eradicate BV-associated bacteria (BVAB) and biofilm, a failure of some women to re-establish a resilient Lactobacillus-dominant vaginal microbiota, reinfection from sexual partners, or a combination of these factors, it is inherently challenging to make significant inroads towards this goal. In this review, we will outline why BV is such a clinical and epidemiologic conundrum, and focus on several key approaches that we believe merit discussion and clinical research, including strategies to: i) prevent reinfection (partner treatment trials), ii) boost favourable vaginal Lactobacillus species and promote a Lactobacillus-dominant vaginal microbiome (hormonal contraceptive and probiotic trials) and iii) disrupt vaginal BV-associated biofilm.

Effects of estroprogestins containing natural estrogen on vaginal flora

Estroprogestins with "natural oestrogen" has represented a new option in terms of combined hormonal contraception. So, the aim of this study is to investigate how estroprogestins with natural estrogen may modify the vaginal niche. In literature, very few studies focused on the interaction between hormonal contraception and vaginal milieu. This is a prospective comparative study. We enrolled 60 women from January 2013 to September 2013, 30 of them were administered estradiol valerate dienogest (E2V+DNG - Klaira®) in a quadriphasic regimen, while the other 30 women were administered 17-β estradiol with nomestrol acetate (EV+NOMAC - Zoely®) in a monophasic regimen. After a baseline study of vaginal milieu at recruitment of patients (Gram stain with Nugent score, vaginal pH, vaginal wet mount for the quantification of leukocytes, Lactobacilli and/or presence of Candida), we performed the same follow-up after six months of estroprogestin therapy. Our results showed that the women treated with E2V+DNG had a trend of an improvement of vaginal health in terms of increase of lactobacillar flora and reduction of vaginal pH in place of women treated with EV+NOMAC that showed a reduction of cervical mucus. Finally, our data about the effects on vaginal flora exerted by two estroprogestin pills (EPs) containing a natural estrogen suggest slight, but interesting differences in terms of vaginal ecology. These differences could be related to the type of estrogen, type of progestin, regimen of administration and, after all, to the net balance between estrogenic and progestin component of the EPs.

Prevalence and correlates of bacterial vaginosis in different sub-populations of women in sub-Saharan Africa: a cross-sectional study

BACKGROUND

Clinical development of vaginally applied products aimed at reducing the transmission of HIV and other sexually transmitted infections, has highlighted the need for a better characterisation of the vaginal environment. We set out to characterise the vaginal environment in women in different settings in sub-Saharan Africa.

METHODS

A longitudinal study was conducted in Kenya, Rwanda and South-Africa. Women were recruited into pre-defined study groups including adult, non-pregnant, HIV-negative women; pregnant women; adolescent girls; HIV-negative women engaging in vaginal practices; female sex workers; and HIV-positive women. Consenting women were interviewed and underwent a pelvic exam. Samples of vaginal fluid and a blood sample were taken and tested for bacterial vaginosis (BV), HIV and other reproductive tract infections (RTIs). This paper presents the cross-sectional analyses of BV Nugent scores and RTI prevalence and correlates at the screening and the enrolment visit.

RESULTS

At the screening visit 38% of women had BV defined as a Nugent score of 7-10, and 64% had more than one RTI (N. gonorrhoea, C. trachomatis, T. vaginalis, syphilis) and/or Candida. At screening the likelihood of BV was lower in women using progestin-only contraception and higher in women with more than one RTI. At enrolment, BV scores were significantly associated with the presence of prostate specific antigen (PSA) in the vaginal fluid and with being a self-acknowledged sex worker. Further, sex workers were more likely to have incident BV by Nugent score at enrolment.

CONCLUSIONS

Our study confirmed some of the correlates of BV that have been previously reported but the most salient finding was the association between BV and the presence of PSA in the vaginal fluid which is suggestive of recent unprotected sexual intercourse.

Interplay between the temporal dynamics of the vaginal microbiota and human papillomavirus detection

BACKGROUND

We sought to describe the temporal relationship between vaginal microbiota and human papillomavirus (HPV) detection.

METHODS

Thirty-two reproductive-age women self-collected midvaginal swabs twice weekly for 16 weeks (937 samples). Vaginal bacterial communities were characterized by pyrosequencing of barcoded 16S rRNA genes and clustered into 6 community state types (CSTs). Each swab was tested for 37 HPV types. The effects of CSTs on the rate of transition between HPV-negative and HPV-positive states were assessed using continuous-time Markov models.

RESULTS

Participants had an average of 29 samples, with HPV point prevalence between 58%-77%. CST was associated with changes in HPV status (P<.001). Lactobacillus gasseri-dominated CSTs had the fastest HPV remission rate, and a low Lactobacillus community with high proportions of the genera Atopobium (CST IV-B) had the slowest rate compared to L. crispatus-dominated CSTs (adjusted transition rate ratio [aTRR], 4.43, 95% confidence interval [CI], 1.11-17.7; aTRR, 0.33, 95% CI, .12-1.19, respectively). The rate ratio of incident HPV for low Lactobacillus CST IV-A was 1.86 (95% CI, .52-6.74).

CONCLUSIONS

Vaginal microbiota dominated by L. gasseri was associated with increased clearance of detectable HPV. Frequent longitudinal sampling is necessary for evaluation of the association between HPV detection and dynamic microbiota.

Longitudinal analysis of vaginal microbiome dynamics in women with recurrent bacterial vaginosis: recognition of the conversion process

Bacterial vaginosis (BV) affects ∼ 30% of women of reproductive age, has a high rate of recurrence, and is associated with miscarriage, preterm birth, and increased risk of acquiring other sexually transmitted infections, including HIV-1. Little is known of the daily changes in the vaginal bacterial composition as it progresses from treatment to recurrence, or whether any of these might be useful in its prediction or an understanding of its causes. We used phylogenetic branch-inclusive quantitative PCR (PB-qPCR) and Lactobacillus blocked/unblocked qPCR (Lb-qPCR) to characterize longitudinal changes in the vaginal microbiota in sequential vaginal self-swabs from five women with recurrent BV, from diagnosis through remission to recurrence. Both patients with acute BV samples dominated by G. vaginalis recurred during the study with similar profiles, whereas the three patients with acute BV samples dominated by other anaerobes did not recur or recurred to an intermediate Nugent score. L. iners dominated remission phases, with intermittent days of abnormal microbial profiles typically associated with menses. The exception was a newly discovered phenomenon, a sustained period of abnormal profiles, termed conversion, which preceded symptomatic acute BV. Species known to have antagonistic activity towards Lactobacillus were detected in pre-conversion samples, possibly contributing to the decline in Lactobacillus. Lb-qPCR scores define two categories of response in the initial post-treatment visit samples; scores <5 may correspond with poor response to treatment or rapid recurrence, whereas scores >8 may predict delayed or no recurrence. Amsel criteria or Nugent scores did not have this potential predictive capability. Larger studies are warranted to evaluate the prognostic potential of detecting conversion and poor Lb-qPCR scores at the post-treatment visit of recurrent BV patients.

Microbiome, sex hormones, and immune responses in the reproductive tract: challenges for vaccine development against sexually transmitted infections

The female and male reproductive tracts are complex eco-systems where immune cells, hormones, and microorganisms interact. The characteristics of the reproductive tract mucosa are distinct from other mucosal sites. Reproductive tract mucosal immune responses are compartmentalized, unique, and affected by resident bacterial communities and sex hormones. The female and male genital microbiomes are complex environments that fluctuate in response to external and host-associated stimuli. The female vaginal microbiota play an important role in preventing colonization by pathogenic organisms. Sex hormones and their duration of exposure affect the composition and stability of the microbiome as well as systemic and mucosal immune responses. In addition to the characteristics of the pathogen they are targeting, successful vaccines against sexually transmitted pathogens must take into account the differences between the systemic and mucosal immune responses, the compartmentalization of the mucosal immune responses, the unique characteristics of the reproductive tract mucosa, the role of the mucosal bacterial communities, the impact of sex hormones, and the interactions among all of these factors.

Hormonal contraception is associated with a reduced risk of bacterial vaginosis: a systematic review and meta-analysis

Objective

To examine the association between hormonal contraception (HC) and bacterial vaginosis (BV) by systematic review and meta-analysis.

Methods

Medline, Web of Science and Embase databases were searched to 24/1/13 and duplicate references removed. Inclusion criteria 1) >20 BV cases; 2) accepted BV diagnostic method; 3) measure of HC-use either as combined oestrogen-progesterone HC (combined), progesterone-only contraception (POC) or unspecified HC (u-HC); 4) ≥10% of women using HC; 5) analysis of the association between BV and HC-use presented; 6) appropriate control group. Data extracted included: type of HC, BV diagnostic method and outcome (prevalent, incident, recurrent), and geographical and clinic-setting. Meta-analyses were conducted to calculate pooled effect sizes (ES), stratified by HC-type and BV outcome. This systematic review is registered with PROSPERO (CRD42013003699).

Results

Of 1713 unique references identified, 502 full-text articles were assessed for eligibility and 55 studies met inclusion criteria. Hormonal contraceptive use was associated with a significant reduction in the odds of prevalent BV (pooled effect size by random-effects [reES] = 0.68, 95%CI0.63–0.73), and in the relative risk (RR) of incident (reES = 0.82, 95%CI:0.72–0.92), and recurrent (reES = 0.69, 95%CI:0.59–0.91) BV. When stratified by HC-type, combined-HC and POC were both associated with decreased prevalence of BV and risk of incident BV. In the pooled analysis of the effect of HC-use on the composite outcome of prevalent/incident/recurrent BV, HC-use was associated with a reduced risk of any BV (reES = 0.78, 95%CI:0.74–0.82).

Conclusion

HC-use was associated with a significantly reduced risk of BV. This negative association was robust and present regardless of HC-type and evident across all three BV outcome measures. When stratified by HC-type, combined-HC and POC were both individually associated with a reduction in the prevalence and incidence of BV. This meta-analysis provides compelling evidence that HC-use influences a woman’s risk of BV, with important implications for clinicians and researchers in the field.

Hormonal contraception decreases bacterial vaginosis but oral contraception may increase candidiasis: implications for HIV transmission

OBJECTIVE

A 2012 WHO consultation concluded that combined oral contraception (COC) does not increase HIV acquisition in women, but the evidence for depot medroxyprogesterone acetate (DMPA) is conflicting. We evaluated the effect of COC and DMPA use on the vaginal microbiome because current evidence suggests that any deviation from a 'healthy' vaginal microbiome increases women's susceptibility to HIV.

METHODS

We conducted a systematic review and reanalysed the Hormonal Contraception and HIV Acquisition (HC-HIV) study. Vaginal microbiome outcomes included bacterial vaginosis by Nugent scoring, vaginal candidiasis by culture or KOH wet mount and microbiome compositions as characterized by molecular techniques.

RESULTS

Our review of 36 eligible studies found that COC and DMPA use reduce bacterial vaginosis by 10-20 and 18-30%, respectively. The HC-HIV data showed that COC and DMPA use also reduce intermediate microbiota (Nugent score of 4-6) by 11% each. In contrast, COC use (but not DMPA use) may increase vaginal candidiasis. Molecular vaginal microbiome studies (n=4) confirm that high oestrogen levels favour a vaginal microbiome composition dominated by 'healthy' Lactobacillus species; the effects of progesterone are less clear and not well studied.

CONCLUSION

DMPA use does not increase HIV risk by increasing bacterial vaginosis or vaginal candidiasis. COC use may predispose for vaginal candidiasis, but is not believed to be associated with increased HIV acquisition. However, the potential role of Candida species, and vaginal microbiome imbalances other than bacterial vaginosis or Candida species, in HIV transmission cannot yet be ruled out. Further in-depth molecular studies are needed.

Consistent condom use increases the colonization of Lactobacillus crispatus in the vagina

BACKGROUND

Non-hormonal contraception methods have been widely used, but their effects on colonization by vaginal lactobacilli remain unclear.

OBJECTIVE

To determine the association between non-hormonal contraception methods and vaginal lactobacilli on women's reproductive health.

METHODS

The cross-sectional study included 164 healthy women between 18-45 years of age. The subjects were divided into different groups on the basis of the different non-hormonal contraception methods used by them. At the postmenstrual visit (day 21 or 22 of the menstrual cycle), vaginal swabs were collected for determination of Nugent score, quantitative culture and real-time polymerase chain reaction (PCR) of vaginal lactobacilli. The prevalence, colony counts and 16S rRNA gene expression of the Lactobacillus strains were compared between the different groups by Chi-square and ANOVA statistical analysis methods.

RESULTS

A Nugent score of 0-3 was more common in the condom group (93.1%) than in the group that used an interuterine device(IUD) (75.4%), (p=0.005). The prevalence of H2O2-producing Lactobacillus was significantly higher in the condom group (82.3%) than in the IUD group (68.2%), (p=0.016). There was a significant difference in colony count (mean ± standard error (SE), log10colony forming unit (CFU)/ml) of H2O2-producing Lactobacillus between condom users (7.81 ± 0.14) and IUD users (6.54 ± 0.14), (p=0.000). The 16S rRNA gene expression (mean ± SE, log10copies/ml) of Lactobacillus crispatus was significantly higher in the condom group (8.09 ± 0.16) than in the IUD group (6.03 ± 0.18), (p=0.000).

CONCLUSION

Consistent condom use increases the colonization of Lactobacillus crispatus in the vagina and may protect against both bacterial vaginosis (BV) and human immunodeficiency virus (HIV).

Vaginal health in contraceptive vaginal ring users - A review

BACKGROUND

To provide an overview of the available data from clinical studies of vaginal conditions in women who use a vaginal ring as a contraceptive.

METHODS

A systematic review of the literature.

RESULTS

Millions of women have already used the ethylene vinyl acetate vaginal ring that releases ethinylestradiol and etonogestrel for contraception. Because of its small size, more than four out of five women using the ring report that they do not feel it, even during sexual intercourse. No colposcopic or cytological changes have been observed in users, although approximately 10% have increased vaginal discharge. While in vitro studies have shown adhesion of Candida yeasts to the vaginal ring surface, clinical studies have not demonstrated a greater incidence of Candida infections compared to users of equivalent oral contraceptives. Some clinical studies suggest a lower incidence of bacterial vaginosis. No interaction exists between concomitant use of the vaginal ring and other drugs or products for vaginal use.

CONCLUSION

The use of a contraceptive vaginal ring does not alter the vaginal ecosystem and therefore does not substantially affect vaginal health.

Prevalent and incident bacterial vaginosis are associated with sexual and contraceptive behaviours in young Australian women

Background

To determine prevalence and incidence of bacterial vaginosis (BV) and risk factors in young sexually-active Australian women.

Methods

1093 women aged 16–25 years were recruited from primary-care clinics. Participants completed 3-monthly questionnaires and self-collected vaginal smears 6-monthly for 12-months. The primary endpoint was a Nugent Score = 7–10 (BV) and the secondary endpoint was a NS = 4–10 (abnormal flora [AF]). BV and AF prevalence estimates and 95% confidence intervals (95%CI) were derived, and adjusted odds ratios (AOR) calculated to explore epidemiological associations with prevalent BV and AF. Proportional-hazards regression models were used to examine factors associated with incident BV and AF.

Results

At baseline 129 women had BV [11.8% (95%CI: 9.4–14.2)] and 188 AF (17.2%; 15.1–19.5). Prevalent BV was associated with having a recent female partner [AOR = 2.1; 1.0–4.4] and lack of tertiary-education [AOR = 1.9; 1.2–3.0]; use of an oestrogen-containing contraceptive (OCC) was associated with reduced risk [AOR = 0.6; 0.4–0.9]. Prevalent AF was associated with the same factors, and additionally with >5 male partners (MSP) in 12-months [AOR = 1.8; 1.2–2.5)], and detection of C.trachomatis or M.genitalium [AOR = 2.1; 1.0–4.5]. There were 82 cases of incident BV (9.4%;7.7–11.7/100 person-years) and 129 with incident AF (14.8%; 12.5–17.6/100 person-years). Incident BV and AF were associated with a new MSP [adjusted rate ratio (ARR) = 1.5; 1.1–2.2 and ARR = 1.5; 1.1–2.0], respectively. OCC-use was associated with reduced risk of incident AF [ARR = 0.7; 0.5–1.0].

Conclusion

This paper presents BV and AF prevalence and incidence estimates from a large prospective cohort of young Australian women predominantly recruited from primary-care clinics. These data support the concept that sexual activity is strongly associated with the development of BV and AF and that use of an OCC is associated with reduced risk.

Recurrence of bacterial vaginosis is significantly associated with posttreatment sexual activities and hormonal contraceptive use

BACKGROUND

Bacterial vaginosis (BV) recurrence posttreatment is common. Our aim was to determine if behaviors were associated with BV recurrence in women in a randomized controlled trial (RCT).

METHODS

Symptomatic 18- to 50-year-old females with BV (≥3 Amsel criteria and Nugent score [NS] = 4-10) were enrolled in a 3-arm randomized double-blind RCT Melbourne Sexual Health Centre, Australia, in 2009-2010. All 450 participants received oral metronidazole (7 days) and were equally randomized to vaginal clindamycin, lactobacillus-vaginal probiotic or vaginal placebo. At 1, 2, 3, and 6 months, participants self-collected vaginal smears and completed questionnaires. Primary endpoint was NS = 7-10. Cox regression was used to estimate hazard ratios (HRs) for risk of BV recurrence associated with baseline and longitudinal characteristics.

RESULTS

Four hundred four (90%) women with postrandomization data contributed to analyses. Cumulative 6-month BV recurrence was 28% (95% confidence interval [CI], 24%-33%) and not associated with treatment. After stratifying for treatment and adjusting for age and sex frequency, recurrence was associated with having the same pre-/posttreatment sexual partner (adjusted HR [AHR] = 1.9; 95% CI, 1.2-3.0), inconsistent condom use (AHR = 1.9; 95% CI, 1.0-3.3), and being non-Australian (AHR = 1.5; 95% CI, 1.0-2.1), and halved with use of an estrogen-containing contraceptive (AHR = 0.5; 95% CI, .3-.8).

CONCLUSIONS

Risk of BV recurrence was increased with the same pre-/posttreatment sexual partner and inconsistent condom use, and halved with use of estrogen-containing contraceptives. Behavioral and contraceptive practices may modify the effectiveness of BV treatment.

CLINICAL TRIALS REGISTRATION

ACTRN12607000350426.

Vaginal infections update

Vaginal symptoms are one of the leading reasons that women visit their health care providers. Women often self-diagnose and may treat themselves inappropriately. This article describes the etiology, risk factors, symptoms, diagnosis, and treatment of the 3 most common vaginal infections: bacterial vaginosis, trichomoniasis, and vulvovaginal candidiasis.

The impact of stressful life events on unprotected anal intercourse among gay and bisexual men

We investigated the hypothesis that gay and bisexual men experiencing stressful life events are more likely to engage in risky sexual behavior. Data were from a cohort study of 155 HIV-positive and 207 HIV-negative men in Ontario, Canada (1998-2007). We quantified the relation between stressful life events and unprotected anal intercourse with a non-regular partner. In the past 6 months, 19% reported unprotected intercourse (HIV+: 28%; HIV-: 13%) and 58% reported one or more stressful life events (HIV+: 64%; HIV-: 55%). Among HIV-negative men, the odds of unprotected intercourse increased by 1.15 for each additional event (95%CI 1.06, 1.24). Among HIV-positive men, those who reported the event "problems due to alcohol or drugs" were 1.80 (95%CI 1.27, 2.56) times more likely to report unprotected intercourse. Interventions to assist men to cope with stress may help to prevent population spread of HIV and improve overall health.

Normal vaginal flora, disorders and application of probiotics in pregnancy

PURPOSE

To assess the effectiveness of vaginal administration of the probiotic Lactobacillus rhamnosus BMX 54 in preventing the occurrence of abnormal vaginal flora and the alteration of parameters relevant to the progression of pregnancy.

METHODS

Sixty pregnant women were assigned randomly to the untreated arm of the study (n = 30) or received (n = 30) vaginal application of one tablet containing Lactobacillus rhamnosus BMX 54, once a week for 12 weeks. Every 4 weeks (T0-T3), vaginal and cervical swabs were collected and pH, and quantity and quality of vaginal discharge measured as well as consistency, length and dilatation of cervix, and level of the presenting part of the foetus relative to interspinous diameter.

RESULTS

In untreated women, there was a significant trend towards increase in the presence of pathogenic microorganisms in the vaginal and/or cervical swabs (p < 0.05), and in average pH values (p < 0.05), amount (p < 0.05) and "whiff test" positivity (p < 0.05) of vaginal discharge. Significant trend was also found for decrease in length (p < 0.0001) and increase in dilatation (p < 0.05) of cervix, as well as for lower position of the foetus (p < 0.0001). In the group treated with Lactobacillus rhamnosus BMX 54, none of these values significantly changed throughout the observation period, with the exception of cervical length that was significantly decreased at T3 (p < 0.01).

CONCLUSIONS

During pregnancy, vaginal administration of Lactobacillus rhamnosus BMX 54 is effective in preventing the development of abnormal vaginal microflora, lowering of the presenting part of the foetus and modifying cervical parameters that could represent risk factors of vulnerability to preterm delivery.

Risk of bacterial vaginosis in users of the intrauterine device: a longitudinal study

BACKGROUND

Users of the intrauterine device (IUD) may be at increased risk for bacterial vaginosis (BV). Our objective was to compare the incidence of BV in women using the IUD with women using combined oral contraceptives (COC), the contraceptive vaginal ring, and the contraceptive patch.

METHODS

We prospectively recruited women negative for BV at baseline. Monthly, for 6 months, participants returned a self-obtained vaginal smear for Gram stain by mail. BV was diagnosed by a Nugent score ≥7. We performed Cox proportional hazards regression to investigate associations between demographic and behavioral characteristics, contraceptive method, and incident BV.

RESULTS

We enrolled 153 women negative for BV at baseline; 90 (59%) women who chose the IUD and 63 (41%) who chose COC, ring, or patch. There were 35 women with BV at one or more time points. The incidence of BV was 37.0% among IUD users and 19.3% in COC, ring, and patch users (P = 0.03). In the univariate analysis, race, IUD use, intermediate flora, and irregular vaginal bleeding were significantly associated with BV. In the adjusted model, IUD users were no more likely to acquire BV (hazards ratio [HRadj]: 1.28, 95% confidence interval [CI]: 0.53-3.06) than COC, ring, and patch users. The associations between intermediate flora and irregular bleeding and BV remained significant (HRadj: 3.30, 95% CI: 1.51-7.21, and HRadj: 2.54, 95% CI: 1.03-6.24, respectively).

CONCLUSIONS

The association between IUD use and BV appears to be mediated by irregular vaginal bleeding. Intermediate flora is associated with an increased incidence of BV.

Evaluation of Syracuse Healthy Start's program for abnormal flora management to reduce preterm birth among pregnant women

Randomized trials of bacterial vaginosis (BV) treatment among pregnant women to reduce preterm birth have had mixed results. Among non-pregnant women, BV recurs frequently after treatment. Randomized trials of early BV treatment for pregnant women in which recurrence was retreated have shown promise in reducing preterm birth. Syracuse's Healthy Start (SHS) program began in 1997; in 1998 prenatal care providers for pregnant women living in high infant mortality zip codes were encouraged to screen for abnormal vaginal flora at the first prenatal visit. Vaginal swabs were sent to a referral hospital laboratory for Gram staining and interpretation. SHS encouraged providers to treat and rescreen women with bacterial vaginosis or abnormal flora (BV). We abstracted prenatal and hospital charts of live births between January 2000 and March 2002 for maternal conditions and treatments. We merged abstracted data with local electronic data. We evaluated the effect of BV screening before 22 weeks gestation, treatment, and rescreening using a retrospective cohort study design. Among 838 women first screened before 22 weeks, 346 (41%) had normal flora and 492 (59%) women had BV at a mean of 13 weeks gestation; 202 (24%) did not have treatment documented and 290 (35%) received treatment at a mean of 15 weeks gestation; 267 (92%) of those treated were re-screened. Among pregnant women with early BV, 42 (21%) untreated women and 28 (10%) treated women delivered preterm (Odds Ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.7)). After adjustment for age, race, prior preterm birth and other possible confounders, treatment remained associated with a reduced risk of preterm birth compared to no treatment (aOR = 0.5, 95% CI 0.3-0.9); the aOR for women with normal flora was not significantly different.

CONCLUSION

Screening, treatment, and rescreening for BV/abnormal flora between the first prenatal visit and 22 weeks gestation showed promise in reducing preterm births and deserves further study.

Association between semen exposure and incident bacterial vaginosis

Objective. To identify correlates of incident bacterial vaginosis (BV) diagnosed with Nugent scoring among high-risk women. Study Design. We conducted both cohort and case-crossover analyses, stratified by HIV infection status, based on 871 HIV-infected and 439 HIV-uninfected participants in the HIV Epidemiology Research Study, conducted in 4 US sites in 1993–2000. Results. BV incidence was 21% and 19% among HIV-infected and -uninfected women, respectively. Fewer correlates of BV were found with case-crossover than with cohort design. Reporting frequent coitus (regardless of consistency of condom use) was correlated with BV in cohort analyses but not in case-crossover analyses. The sole correlate of BV in both types of analyses was the detection of spermatozoa on Gram stain, which is a marker of semen exposure. Conclusion. The inconsistent association between condom use and BV in prior studies could be from reporting bias. We found evidence of a relationship between semen exposure and incident BV.

Phase 2a study assessing colonization efficiency, safety, and acceptability of Lactobacillus crispatus CTV-05 in women with bacterial vaginosis

BACKGROUND

Bacterial vaginosis (BV) is a common vaginal infection caused by a lack of endogenous lactobacilli and overgrowth of pathogens that frequently recurs following antibiotic treatment.

METHODS

A phase 2a study assessed colonization efficiency, safety, tolerability, and acceptability of Lactobacillus crispatus CTV-05 (LACTIN-V) administered by a vaginal applicator. Twenty-four women with BV were randomized in a 3:1 ratio of active product to placebo. Participants used LACTIN-V at 2 × 10 colony-forming units (cfu)/dose or placebo for 5 initial consecutive days, followed by a weekly application over 2 weeks. They returned for follow-up on Days 10 and 28.

RESULTS

Sixty-one percent of the 18 women randomized to the LACTIN-V group were colonized with L. crispatus CTV-05 at Day 10 or Day 28. Among LACTIN-V users with complete adherence to the study regimen, 78% were colonized at Day 10 or Day 28. Of the 120 adverse events (AEs) that occurred, 108 (90%) and 12 (10%) were of mild and moderate severity, respectively. AEs were evenly distributed between the LACTIN-V and placebo group. Of the total AEs, 93 (78%) were genitourinary in origin. The most common genitourinary AEs included vaginal discharge (46%), abdominal pain (46%), dysuria (21%), pollakiuria (21%), vaginal odor (21%), and genital pruritus (17%). No grade 3 or 4 AEs or serious AEs occurred and no deep epithelial disruption was seen during colposcopic evaluation. The product was well tolerated and accepted.

CONCLUSIONS

LACTIN-V colonized well, and was safe and acceptable in women treated for BV.

Evidence of African-American women's frustrations with chronic recurrent bacterial vaginosis

PURPOSE

The purpose of this study was to explore the impact of recurrent bacterial vaginosis (BV) and its treatment on quality of life (QOL), acceptance of current treatment options, and psychosocial issues related to lifestyle practices associated with BV.

DATA SOURCES

Qualitative and quantitative data were obtained from 23 African American women with recurrent BV. Participants completed a short survey, developed by the researchers based on a prior study which examined factors associated with recurrent BV, and a one-on-one interview assessing the impact of BV, current treatment modalities, and lifestyle practices related to recurrent BV.

CONCLUSIONS

Emerging themes suggest that recurrent BV is associated with psychosocial issues that are currently not addressed in a typical office visit. Reported feelings of shame and embarrassment often cause women to engage in hypervigilant routines of hygiene that negatively impact their professional, personal, and intimate relationships, significantly affecting their QOL.

IMPLICATIONS FOR PRACTICE

Without proper education, advice, and support, BV is perpetuated by lifestyle practices leading to recurrent infection and associated symptoms. With proper guidance, it is expected that women with recurrent BV will see an improvement in their QOL, with fewer complications from BV infection, and healthy relationships with intimate partners, family, and friends.

Personal hygienic behaviors and bacterial vaginosis

BACKGROUND

Vaginal douching is consistently associated with bacterial vaginosis (BV), but whether it is a cause or result of BV remains unknown. The association between BV and other feminine hygienic behaviors is less studied; if BV symptoms caused behavior change then all hygiene behaviors might be more common among women with BV. Lack of association between nondouching hygiene behavior and BV would argue against reverse causation.

METHODS

In the Longitudinal Study of Vaginal Flora 3620 women had 13,517 visits where BV (Nugent score) was assessed. Associations between hygienic behavior and BV were assessed by Poisson regression.

RESULTS

After adjusting for demographic and sexual behavior factors, neither type of underwear (nylon vs. cotton prevalence ratio (PR) 1.05, 95% CI: 0.97-1.13), menstrual protection (tampons vs. pads; PR: 1.04, 95% CI: 0.95-1.12; pads and tampons vs. pads 1.00, 95% CI: 0.92-1.07), use of pads or panty liners when not menstruating (PR: 0.99, 95% CI: 0.95-1.05), nor weekly or greater use of hygiene spray (PR: 1.01, 95% CI: 0.94-1.09), powder (PR: 1.02, 95% CI: 0.96-1.07) or towlettes (PR: 1.03, 95% CI: 0.94-1.13) were strongly associated with BV. PR for daily versus less than daily bathing and showering were 1.06 (95% CI: 1.02-1.12) and 1.04 (95% CI: 1.00-1.09). Douching remained associated with BV (PR for weekly or greater vs. never 1.17, 95% CI: 1.09-1.26) and was not substantially impacted by adjustment for other hygienic behavior.

CONCLUSIONS

Douching, but not other feminine hygiene behaviors, is significantly associated with BV, providing additional evidence that douching may be causally associated with BV and is not simply a response to BV symptoms.

Race of male sex partners and occurrence of bacterial vaginosis

BACKGROUND

Whether bacterial vaginosis (BV) is sexually transmitted is uncertain. Also it is unknown why BV is approximately twice as prevalent among black as among white women. An association of BV with a characteristic of the male sex partner, such as race, might support sexual transmission as well as account for the observed ethnic disparity in BV.

METHODS

Three thousand six hundred twenty nonpregnant women 15 to 44 years of age were followed quarterly for 1 year. At each visit, extensive questionnaire data and vaginal swabs for Gram's staining were obtained. The outcome was transition from BV-negative to positive (Nugent's score > or =7) in an interval of 2 consecutive visits.

RESULTS

BV occurred in 12.8% of 906 sexually active intervals to white women-24.8% of intervals when the woman reported a black partner and 10.7% when all partners were white. Among white women, there was a 2-fold increased risk for BV incidence with a black, compared with a white partner (risk ratio [RR] 2.3, 95% confidence interval 1.6-3.4; adjusted RR 2.2, 95% confidence interval 1.5-3.4), but differed according to condom use. In the presence of consistent condom use, the adjusted RR was 0.7 (0.3-2.4); it was 2.4 (1.0-6.2) in the presence of inconsistent use; and 2.7 (1.7-4.2) in the absence of condom use. Black women could not be studied, as there were insufficient numbers who reported only white male sex partners.

CONCLUSION

The association of BV occurrence with partner's race, and its blunting by condom use, suggests that BV may have a core group component and may be sexually transmitted.

Temporal Shifts in Microbial Communities in Nonpregnant African-American Women with and without Bacterial Vaginosis

Bacterial vaginosis (BV) has been described as an increase in the number of anaerobic and facultatively anaerobic bacteria relative to lactobacilli in the vaginal tract. Several undesirable consequences of this community shift can include irritation, white discharge, an elevated pH, and increased susceptibility to sexually transmitted infections. While the etiology of the condition remains ill defined, BV has been associated with adverse reproductive and pregnancy outcomes. In order to describe the structure of vaginal communities over time we determined the phylogenetic composition of vaginal communities from seven women sampled at multiple points using 16S rRNA gene sequencing. We found that women with no evidence of BV had communities dominated by lactobacilli that appeared stable over our sampling periods while those with BV had greater diversity and decreased stability overtime. In addition, only Lactobacillus iners was found in BV positive communities.

A prospective study of risk factors for bacterial vaginosis in HIV-1-seronegative African women

BACKGROUND

Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1.

METHODS

We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV.

RESULTS

Participants completed a median of 378 (interquartile range 350-412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73).

CONCLUSIONS

Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women.