Evaluation of iron deficiency in young women in relation to oral contraceptive use

BACKGROUND

The purpose of this study was to identify the optimal measures for diagnosing iron deficiency (ID) in oral contraceptive (OC) users and nonusers, and to estimate ID frequency in relation to OC use.

STUDY DESIGN

Conventional biomarkers of iron status - serum ferritin, iron, transferrin (Tf) and transferrin saturation (TfS) - were compared with serum soluble Tf receptor (sTfR) and the sTfR/log ferritin ratio (sTfR-F index). Two hundred two healthy menstruating white Italian women (aged 24+/-4.8 years) were analyzed. Serum ferritin concentrations <12 microg/L were considered as ID.

RESULTS

ID was detected in 29.7% (60/202) of the study women. Fifty-nine women were OC users (59/202, 29.2%). OC use did not significantly affect ID prevalence (p=.24). However, OC use markedly increased Tf in OC users, who had an odds ratio (OR) of 9.3 (CI 3.8-22.7, p<.001) for elevated Tf >330 mg/dL. No other iron status measure was affected by OC. Of the markers for ID adjunctive to ferritin, an elevated sTfR-F index >or =1.5 showed the best performance. Specifically in OC users, the elevated sTfR-F index had better sensitivity (81.0% vs. 33.3%), specificity (94.7% vs. 92.1%), efficiency (89.8% vs. 71.2%), positive predictive value (89.5% vs. 70.0%) and negative predictive value (90.0% vs. 71.1%) than a TfS <15%. Additionally, the sTfR-F index allowed the identification of low iron stores in 4.5% (9/202) of women with ferritin > or =12 microg/L.

CONCLUSION

Among healthy OC users and non-OC users, the sTfR-F index had the highest performance for diagnosing ID compared with other serum markers adjunctive to ferritin measurements, whereas sTfR by itself had a low sensitivity. We showed that neither the sTfR nor sTfR-F index was affected by third-generation OC use. The sTfR measurement is useful in the diagnosis of ID, especially in women using OC, where Tf and TfS tests may be misleading.

Association of interleukin-1beta and interleukin-1 receptor antagonist polymorphisms with bacterial vaginosis in non-pregnant Italian women

Bacterial vaginosis (BV) is the most prevalent alteration of vaginal microflora worldwide. BV is a polymicrobial disorder, and its etiology is elusive. Factors predisposing to this recurrent condition are not fully characterized. We aimed to investigate whether interleukin-1beta (IL-1beta) and IL-1 receptor antagonist (IL-1ra) polymorphisms are associated with BV in non-pregnant white Italian women. Genomic DNA was obtained from 164 BV positive, and 406 control women. Two diallelic polymorphisms in the IL-1beta gene (IL-1B) representing C/T base transitions at - 511 and + 3954 positions and a variable number tandem repeats (VNTR) in intron 2 of the IL-1ra gene (IL-1RN) were assessed. We demonstrated that women who were homozygous for - 511 CC or + 3954 TT of the IL-1B gene were at increased risk for BV with an odds ratio (OR) = 1.5 [95% confidence interval (CI) = 1.03-2.14, P = 0.032], and OR = 2.8 (95% CI = 1.37-5.88, P = 0.004), respectively. The haplotype - 511/ + 3954 T-C was protective for BV, with an OR = 0.7 (95% CI = 0.49-0.90, P = 0.009). The IL-1RN VNTR genotype was not associated with BV, although the rare allele 3 showed a trend towards protection (P = 0.049). These data show that host genetic variants at the IL-1beta locus predispose to BV among Caucasian non-pregnant women. Further studies will determine whether these genetic polymorphisms modulate the risk for BV recurrence, and/or BV associated severe adverse outcomes as preterm birth and human immunodeficiency virus transmission.

Modulation of vaginal immune response among pregnant women with bacterial vaginosis by Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, and yeast

OBJECTIVE

This study was undertaken to examine the influence of coinfections on vaginal innate and adaptive immunity, and microbial enzyme activities of pregnant women with bacterial vaginosis (BV).

STUDY DESIGN

The population consisted of 265 singleton pregnant women in early gestation (<20 weeks) with BV (Nugent 7-10) who had vaginal fluid collected for measurement of interleukin-1beta (IL-1beta) and IL-8 concentrations, number of neutrophils, immunoglobulin A against Gardnerella vaginalis (anti-Gvh IgA), and activities of microbial sialidase and prolidase.

RESULTS

Among women with BV, median levels of vaginal IL-1beta (4-fold, P = .005), IL-8 (4-fold, P < .001), and neutrophils (6-fold, P = .013) were greatly increased in women with T vaginalis with respect to women without any coinfection. Yeast increased the level of IL-8 (5-fold, P < .001), but not IL-1beta (P = .239) and neutrophils (P = .060). Chlamydia trachomatis and Neisseria gonorrhoeae had no effect on vaginal cytokines. None of the coinfections influenced vaginal anti-Gvh IgA, sialidase and prolidase activities.

CONCLUSION

The strong proinflammatory cytokine induction by T. vaginalis may contribute to the observed increase in preterm birth among BV positive women coinfected with T. vaginalis treated with metronidazole.

Variation in vaginal immune parameters and microbial hydrolytic enzymes in bacterial vaginosis positive pregnant women with and without Mobiluncus species

OBJECTIVE

This study was undertaken to assess if levels of interleukin-1beta (IL-1beta), IL-8, sialidase, prolidase and immunoglobulin A against Gardenerella vaginalis hemolysin (anti-Gvh IgA) in vaginal secretions differ between BV+ women with (M+) and without (M-) Mobiluncus spp.

STUDY DESIGN

Vaginal secretions were obtained from 265 women at their first prenatal care visit and assessed for all study parameters. Gram stain evaluation using Nugent criteria was performed and coinfection with sexually transmitted infections determined. Differences between BV+/M+ and BV+/M- women were evaluated using the chi2 statistic or Mann-Whitney test.

RESULTS

Of the 265 BV+ women, 43% (n = 113) were M+ of which 97% (n = 110) had Nugent scores of 9 or 10 . BV+/M+ women had elevated levels of sialidase (median value: 4.11 nmol vs 1.91 nmol of converted substrate; P = .003) but no difference in prolidase, anti-Gvh IgA, IL-1beta, IL-8, levels were found between the two groups. BV+/M- women had significantly higher rates of coinfection with Trichomonas vaginalis.

CONCLUSION

BV+/M+ women have higher vaginal concentrations of sialidase and lower rates of T. vaginalis compared with BV+/M- women. Further research is needed to assess the association of this, and other, microbiologic profiles to risk of adverse pregnancy outcome.

Combination of vaginal pH with vaginal sialidase and prolidase activities for prediction of low birth weight and preterm birth

OBJECTIVE

The purpose of this study was to assess if easy to measure vaginal fluid biomarkers are predictive for low birth weight (LBW, <2500 g), very LBW (VLBW, <1500 g), spontaneous preterm at <37 weeks' gestation, and total preterm deliveries (at <37, <35, <32 weeks' gestation).

STUDY DESIGN

Low and high cutoffs for vaginal fluid pH, sialidase, and prolidase activities were examined in a nested case-control study of 579 Danish women (from a study population of 2846 women) with samples collected at mean 17 weeks' gestation. One hundred sixteen LBW (17 VLBW), 117 preterm deliveries (85 spontaneous), and 418 normal term deliveries were analyzed.

RESULTS

Vaginal pH >/=4.7 or pH >/=5 by itself was not associated with LBW or prematurity. Conversely, combination of pH >/=5 and high sialidase activity demonstrated OR 17 (CI 1.8-150) for LBW; OR 31 (CI 1.8-516) for VLBW; along with OR 18 (CI 1.6-204) for preterm at <35 weeks'; and OR 31 (CI 1.9-542) for preterm at <32 weeks' gestation. The combination of pH >/=5 and high prolidase activity demonstrated OR 13 (CI 1.3-122) for LBW; OR 33 (CI 2.0-553) for VLBW, as well as OR 9.2 (CI 0.6-150) for preterm at <35 weeks'; and OR 35 (CI 2.0-586) for preterm at <32 weeks' gestation. In this population, no woman having high sialidase and high prolidase activity had a term birth, or a baby weighting >/=2500 g at birth.

CONCLUSION

In this Danish population, mid-gestation findings of vaginal fluid elevated pH with sialidase and/or prolidase were associated with LBW, VLBW, and early preterm at <35 or <32 weeks' gestation.

Vaginal Immunity in Bacterial Vaginosis

Vaginal immunity in response to microbial perturbation is still poorly understood and may be crucial for protection from adverse outcomes associated with bacterial vaginosis (BV). BV is the most prevalent vaginal disorder in adult women worldwide. However, its pathogenesis is still elusive. In BV-positive women, inflammatory signs are scant--approximately 50% of women are asymptomatic. The number of vaginal neutrophils in the BV-positive patient is not increased with respect to healthy women. In contrast, vaginal interleukin (IL)-1beta levels are largely increased. Recent findings indicate that microbial hydrolytic enzymes could be responsible for dampening the expected proinflammatory response cascade after IL-1beta increase. In other words, BV causes a large increase of vaginal IL-1beta, which is not paralleled by an increase of IL-8 levels, suggesting that BV-associated factors specifically dampen IL-8. The impairment of IL-8 increase may explain the absence of neutrophil increase in most women exposed to a massive abnormal anaerobic vaginal colonization (BV). Among BV-positive women, vaginal innate immunity is strongly correlated to a specific adaptive immune response: the immunoglobulin A (IgA) against the hemolysin produced by Gardnerella vaginalis (anti-Gvh IgA), which is the main bacterium present in BV. High anti-Gvh IgA levels are protective for adverse pregnancy outcomes. However, an exaggerated inflammatory response, mainly attributed to genetic polymorphisms, is also implicated in BV-associated adverse outcomes.

Interrelationships of interleukin-8 with interleukin-1beta and neutrophils in vaginal fluid of healthy and bacterial vaginosis positive women

Vaginal innate immunity in response to microbial perturbation is still poorly understood and could be crucial for protection from adverse outcomes. We investigated the relationship between interleukin (IL)-8, IL-1beta and neutrophils in vaginal fluid obtained from 60 healthy women and 51 women who were bacterial vaginosis (BV) positive. Concentrations of IL-8 and IL-1beta were highly correlated with counts of neutrophils in vaginal fluid of the entire population examined (111 subjects). Vaginal IL-1beta concentrations were significantly higher (P < 0.001) in BV positive women. There was no significant difference in IL-8 levels or number of neutrophils between healthy controls and BV positive women. None of the healthy controls with high neutrophil counts (> or =75th percentile, 14 average count per field) had high concentrations of IL-1beta (> or =75th percentile, 220 pg/ml), whereas 84% of BV positive women with high neutrophil counts had high IL-1beta concentrations (P < 0.001). On the contrary, no difference in the percentage of subjects with elevated concentrations of IL-8 (> or =75th percentile, 2842 pg/ml) was found between healthy and BV positive women with high numbers of neutrophils (55.5% of healthy versus 53% of BV positive women). Our findings show that BV causes a large increase in IL-1beta concentrations which is not paralleled by an increase in IL-8 concentrations in vaginal fluid, suggesting that BV-associated factors more specifically dampen IL-8 rather than IL-1beta. The lack of an increase in IL-8 may explain the absence of an increase in neutrophil numbers in most women exposed to abnormal vaginal colonization (BV).

Determination of immunoglobulin A against Gardnerella vaginalis hemolysin, sialidase, and prolidase activities in vaginal fluid: implications for adverse pregnancy outcomes

A nested case-control study of low birth weight and preterm delivery was performed with singleton women. Immunoglobulin A (IgA) against the Gardnerella vaginalis hemolysin (anti-Gvh IgA) and sialidase and prolidase activities were determined in vaginal fluid at 17 weeks of gestation. Sialidase positivity and bacterial vaginosis with high prolidase activity were associated with 2- and 11-fold increased risks for low birth weight, respectively. No woman with bacterial vaginosis plus a strong anti-Gvh IgA response had an adverse outcome.

Vaginal hydrolytic enzymes, immunoglobulin A against Gardnerella vaginalis toxin, and risk of early preterm birth among women in preterm labor with bacterial vaginosis or intermediate flora

OBJECTIVE

The purpose of this study was to determine whether the microbial hydrolytic enzymes, sialidase and prolidase, and immunoglobulin A against the Gardnerella vaginalis cytolysin (anti-Gvh IgA) increase the risk for early preterm birth (< or =34 weeks of gestation) among women with bacterial vaginosis or intermediate flora.

STUDY DESIGN

Two hundred eighteen afebrile women in preterm labor with intact membranes had a vaginal Gram stain performed, and sialidase, prolidase, and anti-Gvh IgA concentrations were determined.

RESULTS

Women with bacterial vaginosis or intermediate flora had significantly higher sialidase and prolidase concentrations than women with normal flora. Among women with bacterial vaginosis or intermediate flora, the women with sialidase had a higher rate of early preterm birth (P =.05). Sialidase had a sensitivity of 43% and specificity of 77% for early preterm birth. Prolidase and anti-Gvh IgA did not predict early preterm birth.

CONCLUSION

Women in preterm labor with bacterial vaginosis or intermediate flora and detectable sialidase are at increased risk of early preterm birth.

Correlation of local interleukin-8 with immunoglobulin A against Gardnerella vaginalis hemolysin and with prolidase and sialidase levels in women with bacterial vaginosis

Mucosal immune system activation may represent a critical determinant of adverse consequences associated with bacterial vaginosis (BV), such as sexual human immunodeficiency virus transmission, upper genital tract infections, postsurgical infections, and adverse pregnancy outcomes. Concentrations of sialidase, prolidase, and anti-Gardnerella vaginalis hemolysin (Gvh) immunoglobulin A (IgA) were higher in vaginal fluids of 75 fertile women with BV, compared with concentrations in vaginal fluids of 85 healthy control subjects. Interleukin (IL)-8 levels were positively associated with anti-Gvh IgA response and inversely correlated with high levels of prolidase and sialidase in women with BV. IL-8 concentration was strongly associated with leukocyte count in both healthy and BV-positive women. The absence of leukocytes in most women with BV likely is due to lack of IL-8 induction. Parallel impairment of innate and adaptive mucosal immune factors, likely through microbial hydrolytic effects, may allow for the ascent of microorganisms to the upper genital tract and may facilitate viral infections.

Prevalence of bacterial vaginosis and vaginal flora changes in peri- and postmenopausal women

Our aim was to evaluate the prevalence of bacterial vaginosis and decrease in lactobacillus colonization in women 40 years old or older in relation to menopausal status by evaluation of Gram-stained smears. A total of 1,486 smears from Italian Caucasian women aged 40 to 79 years were examined. Women were classified as follows: fertile (regular cycles) (n = 328), perimenopausal (irregular cycles) (n = 237), and postmenopausal (n = 921), including 331 women on estroprogestinic hormone replacement therapy (HRT). The prevalences of bacterial vaginosis (assessed as a Nugent score of >or=7) in fertile (9.8%) and perimenopausal (11.0%) women were not statistically different, whereas the prevalence was significantly lower overall in postmenopausal women (6.0%) (P = 0.02). Specifically, 6.3% of postmenopausal women without HRT and 5.4% of postmenopausal women with HRT were positive for bacterial vaginosis. The Nugent score system was not adequate for evaluating the normal and intermediate vaginal flora in women over the age of 40 years. High numbers of peri- and postmenopausal women had no lactobacilli and no bacterial-vaginosis-associated microorganisms. This nonpathological absence of lactobacilli in women with a Nugent score of 4 was scored as 4*, and this group was considered separately from the intermediate flora group. A score of 4* was obtained for 2.1% of fertile women, 11.4% of perimenopausal women, 44.1% of postmenopausal women without HRT, and 6.9% of postmenopausal women with HRT. The physiological reduction in lactobacillus colonization of the vagina in postmenopausal women does not cause an increase in bacterial-vaginosis prevalence. Reversion of lactobacillus flora to premenopausal levels due to HRT does not increase the prevalence of bacterial vaginosis in postmenopausal women.

Correlation of local interleukin-1beta levels with specific IgA response against Gardnerella vaginalis cytolysin in women with bacterial vaginosis

PROBLEM

Mucosal immune system activation may represent a critical determinant of adverse sequelae correlated with bacterial vaginosis, as HIV sexual transmission, upper genital tract infections, cervicitis, endometritis, postsurgical infections, and adverse pregnancy outcomes as preterm delivery (PTD), low birth weight (LBW).

METHOD OF STUDY

Levels of interleukin-1beta (IL-1beta), anti-Gardnerella vaginalis hemolysin (Gvh) IgA, pH, Nugent score, and number of leukocytes were measured in vaginal fluids of 60 fertile women with bacterial vaginosis and of 64 healthy controls.

RESULTS

Vaginal IL-1beta levels were nearly 13-fold higher in women with bacterial vaginosis (BV) and were associated with anti-Gvh IgA response. IL-1beta was positively correlated with leukocyte counts in the smear both in healthy and bacterial vaginosis positive women.

CONCLUSIONS

Induction of the proinflammatory cytokine IL-1beta may be a necessary event to elicit an innate immune response to control anaerobic genital tract infections. High levels of vaginal IL-1beta are associated with mounting of an antigen-specific mucosal immune response in women with bacterial vaginosis. Parallel induction of innate and adaptive immune response may be associated with protection from ascent of micro-organisms to the upper genital tract, and from acquiring viral infection through the vaginal tract.

High concentrations of inhibin A and inhibin B in ovarian serous cystadenoma: relationship with oestradiol and nitric oxide metabolites

Inhibin production has been demonstrated in malignant epithelial ovarian tumours, but secretion of inhibins by benign cystadenoma has not yet been reported. The present study evaluated the concentrations of inhibin A and inhibin B and the relationship with oestradiol and nitric oxide metabolites in fluid collected from benign ovarian serous cystadenomas (n = 15). In addition, follicular fluid samples (n = 14) from women with regular ovulatory cycles undergoing ovarian stimulation for IVF were studied as a reference group. High concentrations of inhibin A (median = 89.3 ng/ml) and inhibin B (median = 116.1 ng/ml) were found in the cystic fluid of ovarian serous cystadenomas. These inhibin concentrations were even higher than in follicular fluid of stimulated follicles (inhibins A and B = 41.2 and 46.8 ng/ml respectively; P: < 0.001), whereas oestradiol was approximately 18-fold lower in cystic fluid than in follicular fluid (median = 34 versus 622 pg/ml, P: < 0.001). In ovarian cysts, the concentrations of inhibin A and oestradiol were inversely correlated (r = -0.678, P: = 0.008). Cystic fluid samples containing the highest concentrations of NO(2)(-)/NO(3)(-) (45-60 micromol/l) had lower inhibin A and higher oestradiol concentrations than those samples containing lower concentrations (10-25 micromol/l) of NO(2)(-)/NO(3)(-). It is concluded that high amounts of dimeric inhibins are present in ovarian serous cystadenoma. The source of inhibins and the determinants of the inverse association of inhibin A with oestradiol and nitric oxide remain to be determined.

Impairment of the mucosal immune system: IgA and IgM cleavage detected in vaginal washings of a subgroup of patients with bacterial vaginosis

The integrity of the immunoglobulins in vaginal washings of patients with bacterial vaginosis was examined to answer the question of the lack of immune response against Gardnerella vaginalis cytolysin. Clinically diagnosed patients (n=100) were recruited and their vaginal washings examined by Western blotting. Many showed IgA and IgM partially or extensively degraded. According to the degradation pattern, the patients were subdivided into 4 subsets, from intact (score 0) to completely degraded IgA (score +3). Statistical analysis of the data showed a correlation between IgA degradation and absence of immune response to G. vaginalis cytolysin. The extent of IgA degradation correlated also with the sialidase (but not with the prolidase) activity level. All women showed intact IgG and human serum albumin and no trypsin-like activity. Patients with bacterial vaginosis having high sialidase activity and extensive IgA degradation in their secretions could incur more dangerous infections and adverse pregnancy outcomes.

Immunoglobulin A response against Gardnerella vaginalis hemolysin and sialidase activity in bacterial vaginosis

OBJECTIVE

The aim of this study was to investigate the correlation between the immunoglobulin A immune response to Gardnerella vaginalis hemolysin and sialidase activity in vaginal fluids from patients with bacterial vaginosis.

STUDY DESIGN

Nonpregnant women who were examined at a gynecologic clinic, in an age range of 18 to 62 years, were enrolled. The study population comprised 131 healthy volunteers, 32 women with bacterial vaginosis that was positive for immunoglobulin A to Gardnerella vaginalis hemolysin, 40 women with bacterial vaginosis that was negative for immunoglobulin A to Gardnerella vaginalis hemolysin, and 19 women with Candida vaginitis. Bacterial vaginosis was diagnosed by clinical criteria and Gram stain.

RESULTS

Sialidase activity was present in 75% (54/72) of patients with bacterial vaginosis. Women having bacterial vaginosis and lacking a specific immunoglobulin A response had a significantly higher level of sialidase activity than patients who had an immune response against Gardnerella vaginalis hemolysin. Sialidase activity was detected in 87% (35/40) of the former subgroup of patients with bacterial vaginosis and in 59% (19/32) of women of the latter subgroup. No sialidase activity was measured in patients with candidiasis. Specificity of the assay for healthy controls was 95% (124/131 women without sialidase activity).

CONCLUSIONS

Sialidases produced by Prevotella bivia and other microorganisms present in the microflora of patients with bacterial vaginosis are very likely a virulence factor not only by destroying the mucins and enhancing adherence of bacteria but also by impairing a specific immunoglobulin A immune response against other virulence factors such as cytotoxin from Gardnerella vaginalis.

Specific immune response against Gardnerella vaginalis hemolysin in patients with bacterial vaginosis

OBJECTIVE

Our goal was to study the mucosal host response in bacterial vaginosis by evaluating the presence of a specific immune response elicited against the Gardnerella vaginalis hemolysin in vaginal fluids of patients and by verifying its correlation with usual criteria adopted to diagnose bacterial vaginosis.

STUDY DESIGN

A total of 123 white women attending the gynecologic care unit for urogenital complaints or for screening of uterine malignancies (Papanicolaou test) aged from 20 to 60 years, nonmenstruating, were enrolled. Bacterial vaginosis was diagnosed by clinical criteria and a Gram stain score > 6.

RESULTS

We performed the determination of the antibody response in vaginal fluid against the hemolysin produced by G. vaginalis, a common agent present in bacterial vaginosis. The purified G. vaginalis toxin was a suitable antigen for detecting the presence of an immune response in the vaginal fluids of patients with bacterial vaginosis regardless of the strain of G. vaginalis present. A specific immunoglobulin A response was detected in 60% of women with overt bacterial vaginosis (Gram stain score > 6) and in 18.5% of women with intermediate vaginal flora (Gram stain score 4 to 6). The specificity of the test was 91%.

CONCLUSIONS

We found a correlation between the specific local immune response to G. vaginalis toxin and bacterial vaginosis. The highly purified form of the toxin is able to discriminate disorders from the opportunistic colonization by G. vaginalis.

Sequence-specific DNA recognition by the thyroid transcription factor-1 homeodomain

The molecular basis for the DNA binding specificity of the thyroid transcription factor 1 homeodomain (TTF-1HD) has been investigated. Methylation and ethylation interference experiments show that the TTF-1HD alone recapitulates the DNA binding properties of the entire protein. Studies carried out with mutant derivatives of TTF-1HD indicate a precise correspondence of some of its amino acid residues with specific bases in its binding site, allowing a crude orientation of the TTF-1HD within the protein-DNA complex. TTF-1HD shows an overall geometry of interaction with DNA similar to that previously observed for Antennapedia class HDs, even though the binding specificities of these two types of HDs are distinct. We demonstrate that the crucial difference between the binding sites of Antennapedia class and TTF-1 HDs is in the motifs 5'-TAAT-3', recognized by Antennapedia, and 5'-CAAG-3', preferentially bound by TTF-1. Furthermore, the binding of wild type and mutants TTF-1 HD to oligonucleotides containing either 5'-TAAT-3' or 5'-CAAG-3' indicate that only in the presence of the latter motif the Gln50 in TTF-1 HD is utilized for DNA recognition. Since the Gln at position 50 is an essential determinant for DNA binding specificity for several other HDs that bind to 5'-TAAT-3' containing sequences, we suggest that utilization by different HDs of key residues may depend on the sequence context and probably follows a precise hierarchy of contacts.