Oral contraceptive use and the risk of chlamydial and gonococcal infections

Cyclic processes in the uterine tubes, endometrium, myometrium, and cervix: pathways and perturbations

This review leads the 2023 Call for Papers in MHR: 'Cyclical function of the female reproductive tract' and will outline the complex and fascinating changes that take place in the reproductive tract during the menstrual cycle. We will also explore associated reproductive tract abnormalities that impact or are impacted by the menstrual cycle. Between menarche and menopause, women and people who menstruate living in high-income countries can expect to experience ∼450 menstrual cycles. The primary function of the menstrual cycle is to prepare the reproductive system for pregnancy in the event of fertilization. In the absence of pregnancy, ovarian hormone levels fall, triggering the end of the menstrual cycle and onset of menstruation. We have chosen to exclude the ovaries and focus on the other structures that make up the reproductive tract: uterine tubes, endometrium, myometrium, and cervix, which also functionally change in response to fluctuations in ovarian hormone production across the menstrual cycle. This inaugural paper for the 2023 MHR special collection will discuss our current understanding of the normal physiological processes involved in uterine cyclicity (limited specifically to the uterine tubes, endometrium, myometrium, and cervix) in humans, and other mammals where relevant. We will emphasize where knowledge gaps exist and highlight the impact that reproductive tract and uterine cycle perturbations have on health and fertility.

Prevalence of Chlamydia trachomatis in an asymptomatic female population attending cervical cytology services of three healthcare centers in Medellín, Colombia

Introducción.

La infección de transmisión sexual causada por Chlamydia trachomatis es la más frecuente de etiología bacteriana en el mundo. Aunque puede ser asintomática en la mayoría de los casos, C. trachomatis puede generar diversos problemas de salud reproductiva en mujeres, como cervicitis, endometritis y salpingitis. A pesar de su importancia, en Medellín no se cuenta con suficientes datos epidemiológicos sobre esta infección.

Objetivo.

Determinar la prevalencia de C. trachomatis en mujeres de Medellín, determinar los posibles factores de riesgo y evaluar la relación con la infección por el virus de papiloma humano (HPV).

Materiales y métodos.

Se hizo un estudio transversal multicéntrico para detectar la infección por C. trachomatis en 1.282 mujeres mediante reacción en cadena de la polimerasa (PCR) convencional y el estuche comercial LightMix 480 HT CT/NG™ (Roche, Basilea, Suiza).

Resultados.

La prevalencia total de la infección por C. trachomatis fue de 4,1 % (IC_95% 2,9-5,3). Se encontró una relación significativa de la infección con la edad, el consumo de cigarrillo y el uso de anticonceptivos hormonales.

Conclusión.

La prevalencia de la infección es similar a la reportada en otros lugares del país y del mundo, siendo las mujeres más jóvenes las más afectadas. En cuanto a la presentación del HPV, no se encontró ningún tipo de relación con C. trachomatis.

Hormonal Contraceptives and the Acquisition of Sexually Transmitted Infections: An Updated Systematic Review

BACKGROUND

Evidence suggests that some forms of hormonal contraception (HC) increase women's risk of non-human immunodeficiency virus sexually transmitted infections (STIs), yet evidence has not been reviewed since 2008. We conducted an updated systematic review to incorporate studies published between January 2009 and June 2017 to examine the relationship between HCs and incident or recurrent STIs.

METHODS

We searched PubMed and EMBASE to identify prospective studies comparing risk of Chlamydia trachomatis, Neisseria gonorrhoeae, human papillomavirus (HPV), herpes simplex virus type 2 (HSV-2), Treponema pallidum, or Trichomonas vaginalis, between women using HC versus nonhormonal methods or no methods. We summarize results by type of STI and HC and study quality using an adapted Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Thirty articles met the inclusion criteria. Depo-medroxyprogesterone acetate (DMPA) reduces the risk of trichomoniasis (consistent evidence) and may increase the risk of HSV-2 (strong effect, few studies); inconclusive evidence exists for HPV, chlamydia, gonorrhea, and syphilis. Data on oral contraceptive pills (OCPs; generally not differentiated whether combined or progestin-only pills) suggest that use is associated with a reduced risk of trichomoniasis with inconclusive findings for HSV-2, HPV, chlamydia, gonorrhea, and syphilis. Very few studies included norethisterone enanthate (Net-En) injectable, implants or the levonorgestrel intrauterine device.

CONCLUSIONS

Depo-medroxyprogesterone acetate and OCPs reduce the risk of trichomoniasis and DMPA may increase the risk of HSV-2. However, the potential for confounding cannot be ruled out. Future studies should specify the type of injectable or OCP used to increase understanding of biological pathways; more research is needed on implants and hormonal intrauterine devices.

The complexity of interactions between female sex hormones and Chlamydia trachomatis infections

PURPOSE OF REVIEW

This review focuses specifically on the mechanisms by which female sex hormones, estrogen and progesterone, affect Chlamydia trachomatis infections in vivo and in vitro.

RECENT FINDINGS

Recent data support previous work indicating that estrogen enhances chlamydial development via multiple mechanisms. Progesterone negatively impacts Chlamydia infections also through multiple mechanisms, particularly by altering the immune response. Conflicting data exist regarding the effect of synthetic hormones, such as those found in hormonal contraceptives, on chlamydial infections.

SUMMARY

Numerous studies over the years have indicated that female sex hormones affect C. trachomatis infection. However, we still do not have a clear understanding of how these hormones alter Chlamydia disease transmission and progression. The studies reviewed here indicate that there are many variables that determine the outcome of Chlamydia/hormone interactions, including: 1) the specific hormone, 2) hormone concentration, 3) cell type or area of the genital tract, 4) hormone responsiveness of cell lines, and 5) animal models.

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.

Cervical ectopy: associations with sexually transmitted infections and HIV. A cross-sectional study of high school students in rural South Africa

OBJECTIVES

It has been hypothesised that ectopy may be associated with increased susceptibility to sexually transmitted infections (STIs). In this cross-sectional study, we wanted to explore the association between STIs (including HIV) and cervical ectopy.

METHODS

We included 700 sexually active young women attending randomly selected high schools in a rural district in KwaZulu-Natal, South Africa. The district is endemic of HIV and has a high prevalence of STIs. We did computer-assisted measurements of the ectocervical area covered by columnar epithelium (ectopy) in colposcopic images and STI analyses on cervicovaginal lavage and serum samples. All participating women answered a questionnaire about sexual behaviour and use of contraceptives.

RESULTS

The mean age was 19.1 years. Ectopy was found in 27.2%, HIV in 27.8%, chlamydia in 25.3% and gonorrhoea in 15.6%. We found that age, parity, chlamydia and gonorrhoea, years since menarche, years since sexual debut and number of sexual partners were associated with ectopy. In multivariate analysis with chlamydia infection as the dependent variable, women with ectopy had increased odds of having chlamydia infection (adjusted OR 1.78, p=0.033). In women under 19 years of age, we found twofold higher odds of being HIV-positive for those with ectopy (OR 2.19, p=0.014).

CONCLUSIONS

In conclusion, cervical ectopy is associated with Chlamydia trachomatis infection and HIV in the youngest women.

Estrogen-dependent changes in serum iron levels as a translator of the adverse effects of estrogen during infection: a conceptual framework

Elevated levels of estrogen often associate with increased susceptibility to infection. This has been attributed to the ability of estrogen to concomitantly enhance the growth and virulence of pathogens and suppress host immunity. But the exact mechanism of how estrogen mediates such effects, especially in cases where the pathogen and/or the immune components in question do not express estrogen receptors, has yet to be elucidated. Here we propose that translating the adverse effects of estrogen during infection is dependent to a significant degree upon its ability to manipulate iron homeostasis. For elevated levels of estrogen alter the synthesis and/or activity of several factors involved in iron metabolism including hypoxia inducible factor 1α (HIF-1α) and hepcidin among others. This leads to the inhibition of hepcidin synthesis in hepatocytes and the maintenance of ferroportin (FPN) integrity on the surface of iron-releasing duodenal enterocytes, hepatocytes, and macrophages. Intact FPN permits the continuous efflux of dietary and stored iron into the circulation, which further enhances pathogen growth and virulence on the one hand and suppresses host immunity on the other. This new conceptual framework may help explain a multitude of disparate clinical and experimental observations pertinent to the relationship between estrogen and infection.

Depot medroxyprogesterone acetate use is not associated with risk of incident sexually transmitted infections among adolescent women

PURPOSE

To determine whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of acquisition of sexually transmitted infections (STIs) in a cohort of healthy adolescents, for whom prospective evidence is sparse.

METHODS

Adolescent women aged 14-17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed. Univariable and multivariable tests of association between STI acquisition during the 3-month diary period and covariates were calculated, using nonlinear mixed-effect logistic regression models to control for repeated measurements.

RESULTS

In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The number of total or unprotected sexual events during the diary period was not associated with the risk of STI. Older age was a protective factor for the development of Chlamydia trachomatis (odds ratio = .85; 95% confidence interval = .76-.96). The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period (odds ratio, range = 1.91-2.62).

CONCLUSIONS

In this U.S.-based cohort of adolescent women, we found no evidence that DMPA use was associated with increased STI risk. Efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.

Assessing the relationship between cervical ectopy and HIV susceptibility: implications for HIV prevention in women

Cervical ectopy, which occurs when the columnar epithelium of the endocervical canal extends outwards into the ectocervix, has been suggested to increase the susceptibility to HIV infection in at-risk women. This study summarizes observational studies, primarily conducted in sub-Saharan Africa, that have assessed a possible causative association between cervical ectopy and HIV acquisition and also examines the biological plausibility as well as other cofactors that may mediate this association. Only about half of the studies reviewed found cervical ectopy to be a significant risk factor for HIV acquisition. The reasons for these divergent results still remain to be fully elucidated. Understanding biological factors that affect HIV susceptibility provide opportunities to identify prevention strategies to reduce the risk of HIV acquisition.

The Pathobiology of Neisseria gonorrhoeae Lower Female Genital Tract Infection

Infection and disease associated with Neisseria gonorrhoeae, the gonococcus, continue to be a global health problem. Asymptomatic and subclinical gonococcal infections occur at a high frequency in females; thus, the true incidence of N. gonorrhoeae infections are presumed to be severely underestimated. Inherent to this asymptomatic/subclinical diseased state is the continued prevalence of this organism within the general population, as well as the medical, economic, and social burden equated with the observed chronic, disease sequelae. As infections of the lower female genital tract (i.e., the uterine cervix) commonly result in subclinical disease, it follows that the pathobiology of cervical gonorrhea would differ from that observed for other sites of infection. In this regard, the potential responses to infection that are generated by the female reproductive tract mucosa are unique in that they are governed, in part, by cyclic fluctuations in steroid hormone levels. The lower female genital tract has the further distinction of being able to functionally discriminate between resident commensal microbiota and transient pathogens. The expression of functionally active complement receptor 3 by the lower, but not the upper, female genital tract mucosa; together with data indicating that gonococcal adherence to and invasion of primary cervical epithelial cells and tissue are predominately aided by this surface-expressed host molecule; provide one explanation for asymptomatic/subclinical gonococcal cervicitis. However, co-evolution of the gonococcus with its sole human host has endowed this organism with variable survival strategies that not only aid these bacteria in successfully evasion of immune detection and function but also enhance cervical colonization and cellular invasion. To this end, we herein summarize current knowledge pertaining to the pathobiology of gonococcal infection of the human cervix.

Hormonal contraception and area of cervical ectopy: a longitudinal assessment

BACKGROUND

The effect of combined oral contraceptives (COCs) and depot-medroxyprogesterone acetate (DMPA) on the area of cervical ectopy is not well understood.

STUDY DESIGN

From 1996 to 1999, we recruited women not using hormonal contraception from two family planning centers in Baltimore, MD. Upon study entry and 3, 6 and 12 months after the initial visit, participants were interviewed and received visual cervical examinations with photography. Ectopy was measured from digitized photographs and was analyzed both continuously and categorically (small [≤0.48 cm(2)] vs. large [>0.48 cm(2)]).

RESULTS

Of 1003 enrolled women, 802 returned for at least one follow-up visit. At 12 months, the numbers of women using COCs, DMPA or no hormonal method at least 50% of the time since the prior visit were 230, 76 and 229, respectively. After multivariable adjustment, COC use (vs. no hormonal use) was associated with large area of ectopy (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.0-3.3). No significant relationship was observed between DMPA and large area of ectopy (OR: 0.5, 95% CI: 0.2-1.3). The incidence of large area of ectopy by contraceptive exposure (COC, DMPA or no hormonal method) was 17.4 (CI: 11.8-24.6), 10.9 (CI: 4.4-22.4) and 4.6 (CI: 2.2-8.4) per 100 woman-years, respectively.

CONCLUSIONS

Use of COCs, but not DMPA, was associated with large area of cervical ectopy. Area of ectopy at baseline was the strongest predictor of area of ectopy at follow-up.

Hormonal contraception and HIV-1 transmission

Safe and effective contraceptive choices are essential for women with HIV-1 infection and at risk for HIV-1 infection. Epidemiological and laboratory-based studies suggest that hormonal contraception may influence HIV-1 transmission. Several large studies in high-risk populations indicate that hormonal contraceptive use may modestly increase the risk of HIV-1 acquisition. In addition, HIV-1-infected users of hormonal contraceptives may be more infectious to their uninfected partners, although no studies have directly measured HIV-1 transmission risk from women to men. However, several studies failed to demonstrate a link between contraceptive use and HIV-1 acquisition or transmission, and interpretation of many studies limited by methodological considerations, such as infrequent measurements of contraceptive exposure and HIV-1 status. As a result, many questions remain, and high-quality studies remain needed. It is clear that hormonal contraceptives are not protective against HIV-1 infection and that dual protection with condoms should be the goal for women using hormonal contraception.

Combined hormonal contraception may be protective against Neisseria gonorrhoeae infection

BACKGROUND

The role of hormonal contraception on acquisition of gonorrhea has not been well-characterized, as the transmission dynamics of Neisseria gonorrhoeae are poorly understood. The purpose of this study is to determine the influence of hormonal contraception on gonococcal infection in women exposed to males with gonococcal urethritis.

METHODS

Females aged 15 to 35 years reporting sexual contact to a male partner diagnosed with N. gonorrhoeae were enrolled. Demographic and sexual histories, physical findings, and laboratory tests were collected. Women testing positive and negative for cervical N. gonorrhoeae were compared using chi and Fisher exact tests, with multivariable logistic regression performed on those factors independently associated with gonococcal infection on univariate analysis.

RESULTS

N. gonorrhoeae infection occurred in 68 of 107 (64%) women. Women using combined hormonal contraception were significantly less likely than nonusers to test positive for N. gonorrhoeae (32% vs. 76%; prevalence ratio: 0.42; 95% confidence interval: 0.22, 0.78; P = 0.006). Gonorrhea was also less common in depomedroxyprogesterone acetate users. A new sexual partner was also associated with testing positive for gonorrhea (35% vs. 13%; prevalence ratio: 1.47; 95% confidence interval: 1.13, 1.90; P = 0.004).

CONCLUSIONS

Women using combined hormonal contraceptives or depomedroxyprogesterone acetate were less likely to test positive for N. gonorrhoeae after sexual exposure compared with nonusers. Our data suggest that, in addition to contraceptive benefits, modern hormonal contraception may have a protective effect on the acquisition of N. gonorrhoeae.

Preventing HIV infection in women: a global health imperative

Women account for approximately one-half of all human immunodeficiency virus (HIV) infections worldwide. Sexual transmission is the dominant mode of HIV transmission to women, and there is a concomitant associated epidemic of transmission to infants. The majority of HIV infections in women are in sub-Saharan Africa, with a disproportionate burden in young women <25 years of age. Acquisition and prevention of HIV infection in women is complex and influenced by biological, behavioral, and structural factors. Efforts to reduce the incidence of HIV infection among women in sub-Saharan African could play a substantial role in altering global trajectories of HIV infection. Increasing access to sexual and reproductive health services, addressing gender-based violence and social instability, reducing poverty and the need to engage in sex for survival, and encouraging greater male responsibility are critical short-to-medium-term interventions. Efforts to find a microbicide and HIV vaccine need to be matched with efforts to deepen understanding of acquisition of HIV in the female genital tract to inform development of targeted molecules for prevention of HIV infection.

Neisseria gonorrhoeae survival during primary human cervical epithelial cell infection requires nitric oxide and is augmented by progesterone

Neisseria gonorrhoeae is an obligate human pathogen that causes gonorrhea. We have shown previously that complement receptor 3 and Akt kinase play important roles in mediating cervical infection. At present, there are limited data to indicate how hormonally induced changes to the mucosal epithelia of the female genital tract mediate the course of gonococcal disease. Hence, I have expanded upon previous work to investigate the interaction of gonococci with primary human cervical epithelial (pex) cells under the variable estrogen and progesterone concentrations likely to be encountered in vivo throughout the female menstrual cycle. My data indicated that the ability of gonococci to survive and to replicate within pex cells was increased under progesterone-predominant conditions. Using bacterial survival, immunological, and kinase assays, I show that progesterone functioned in an additive manner with gonococcal phospholipase D to augment Akt kinase activity. This, in turn, resulted in a parallel increase in nitric oxide synthase expression. Nitric oxide production by pex cells was dependent upon Akt activity and was increased under progesterone-predominant conditions. Whereas both inducible and endothelial nitric oxide synthase contributed to nitric oxide production, only inducible nitric oxide synthase activity promoted gonococcal survival within pex cells. Collectively, these data provide the first clues as to how steroid hormones potentially modulate the course of gonococcal disease in women. In addition, these data demonstrate that host-derived nitric oxide likely is not protective against gonococci, in vivo; rather, nitric oxide may be required to sustain cervical bacterial disease.

Prevalence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis in acute mucopurulent cervicitis

The aim of this study was to determine the incidence of N. gonorrhoae (NG) and/or C. trachomatis (CT) in acute mucopurulent cervicitis (MPC). The study included 617 non-pregnant women with MPC, who had not been receiving any antimicrobial treatment. The average age of patients was 22.2 years. There were no statistically significant differences according to place of residence, education, and marital status. Samples for laboratory analysis were collected using a routine procedure; NG was identified using the cytochrome oxidase test and Gram staining. CT was isolated on McCoy cell culture and stained with Lugol solution. NG was isolated in three women (0.8%) and CT in 58 women (9.4%). Fifty-six of the CT-positive patients were nullipara and only two were unipara. All NG-positive patients were also nullipara. The mean number of sexual partners was 2.2 in all study subjects, 2.4 in CT-positive subjects, and 2.9 in NG-positive subjects. Vaginal discharge purity according to Schröder was significantly deteriorated in CT-positive patients (p=0.011). When asked about the use of contraceptives, as many as 32.7% patients answered that they did not use any protection, 39% women used the rhythm method and coitus interruptus, 20% were taking oral contraceptives, 6.1% used mechanical devices, and 1.9% used chemical protection. Previous acute and chronic pelvic inflammatory diseases correlated with MPC (p>0.01). Our statistical analysis suggests that chlamydial infection significantly reduces the purity of vaginal discharge, which is more pronounced in nulliparae. Pap smear was not specific enough to demonstrate chlamydial infection. In view of the MPC findings, the prevalence of CT and NG infection is low.

Heterosexual spread of HIV infection

Sexual transmission is the most common route of spread of human immunodeficiency virus (HIV), with heterosexual transmission of HIV infection accounting for 90% of those infected in 1992 and over 75% of the 10–12 million of those infected to date worldwide. Yet, heterosexual transmission is poorly understood. Since HIV can be transmitted from HIV-infected people who are asymptomatic as well as from those who have the acquired immunodeficiency syndrome (AIDS), we must better define the potential for transmission of HIV from HIV-infected individuals as well as the factors which influence the susceptibility of HIV-uninfected individuals.

Contraception and HIV infection in women

BACKGROUND

More than 15 million women, many of reproductive age, were infected with human immunodeficiency virus (HIV) at the end of 2007. As the HIV epidemic evolves, heterosexual intercourse is increasingly risky: the risk of infection in exposed young women is 4- to 7-fold higher than in young men and nearly half a million newborns annually have HIV. This review aims to show the effect of contraceptive choices on risk of HIV and on the course of disease in women with HIV.

METHODS

Relevant citations were selected by agreement between the authors after a search of MEDLINE using the terms HIV/AIDS and contraception.

RESULTS

Risk of transmission of HIV varies from 1 in 200 to 1 in 10 000 coital incidents, depending in part on the integrity of the vaginal epithelium. Consistent use of male condoms has been proven to reduce horizontal transmission of HIV by 80% among HIV-serodiscordant couples. Hormonal contraception may increase the risk of HIV acquisition in high-risk women such as commercial sex workers, but not in women at low risk of HIV. While hormonal contraception did not affect progression of disease in two cohort studies involving 370 women, in a randomized trial among women not receiving antiretroviral medication, clinical disease accelerated in the oral contraception group (13.2/100 woman-years) compared with the copper intrauterine devices group (8.6/100 woman-years; hazard ratio, 1.5; 95% confidence interval, 1.04-2.1). Hormonal contraception does not interfere with antiviral drug effectiveness.

CONCLUSIONS

All the available reversible contraceptive methods can generally be used by women at risk of HIV infection and by HIV-infected women. Further studies are needed to investigate the safety and efficiency of hormonal contraception in women living with HIV/AIDS.

Hormonal contraception, sexual behaviour and HIV prevalence among women in Cameroon

Background

Data on the effect of contraceptive methods, other than the condom, on HIV acquisition is not clear. The aim of this study was to describe hormonal contraceptive use, sexual behaviour and HIV prevalence among women in Cameroon in order to provide baseline information for future analytical studies.

Methods

This is a cross-sectional descriptive study based a nationally representative sample of 4486 sexually active women aged 15–49 years who participated in the 2004 Cameroon Demographic and Health Survey.

Results

The overall HIV prevalence was 7.4% (332/4486). The HIV prevalence was higher in the 25–35 year age group (10.03%), urban residents (9.39%), and formerly married (18.48%), compared to their compatriots. The prevalence was lower in women with five or more living child (3.67%), women in the low wealth index category (3.79%) and women who had no formal education (3.37%). The HIV prevalence was higher among women who had two or more partners in the last 12 months (10.26%) and women who reported to have had four or more partners in their lifetime (12.40%). The prevalence of HIV was higher among current hormonal contraceptive users (6.63%) compared to the current non-users (3.06%), among ever users of hormonal contraception (13.27%) compared to the never users (7.11%).

Conclusion

We conclude that the prevalence of HIV among sexually active women in Cameroon varies according to sociodemographic characteristics, sexual behaviour and hormonal contraceptive use. Our findings underscore the need to counsel women using hormonal contraception to be aware that hormonal methods do not protect against HIV infection. Given the biologic plausibility of the link between hormonal contraception and HIV infection, future research should focus on carefully designed prospective studies to establish the temporal relationship and estimate the incidence of HIV infection among women using and not using hormonal contraceptive methods.

Evidence for benefits from treating cervical ectopy: literature review

CONTEXT AND PURPOSE

Uterine cervical ectopy (cervical erosion) is today considered to be a physiological condition, but there still seems to be a strong tendency towards treating it. The purpose of this study was to review the medical literature for evidence regarding benefits from treating cervical ectopy.

METHODS

The following databases were reviewed: Medical Literature Analysis and Retrieval System Online (Medline), Excerpta Medica Database (Embase), Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs) and Cochrane Library databases. In addition, six medical textbooks were consulted.

RESULTS

The review showed that: 1) there is probably an association between ectopy and higher risk of Chlamydia trachomatis, human papillomavirus and human immunodeficiency virus infection; 4) there is probably an association between ectopy and cervical intraepithelial neoplasia; 5) there is an association between ectopy and mucous discharge and nocturia; and 6) there is no evidence of an association between ectopy and cervical cancer, or of protection against cervical cancer associated with ectopy treatment.

CONCLUSIONS

1) No data were found in the medical literature to support routine treatment for ectopy; 2) Treatment could be recommended for symptom relief, but more symptoms are attributed to ectopy than could be demonstrated in a controlled study; 3) Further studies to test the hypothesis of protection against cervical cancer associated with treatment are necessary.

Cervical infection with Chlamydia trachomatis and Neisseria gonorrhoeae in women from ten areas in four continents. A cross-sectional study

OBJECTIVES

Better information on the prevalence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection is needed in many world areas.

STUDY DESIGN

Cross-sectional study of population-based samples of nonpregnant women aged 15 to 44 years in Nigeria, Colombia, Argentina, Vietnam (2 areas), China, Thailand (2 areas), Korea, and Spain. 5,328 consenting women aged 15 to 44 years participated. Exfoliated cervical cells were collected and testing for CT and NG and human papillomavirus (HPV) was done using PCR-based assays.

RESULTS

Age-standardized CT prevalence ranged between 0.2% (95% confidence interval, CI: 0.0-0.7%) in Spain and 5.6% (95% CI: 3.4-7.8%) in Nigeria. NG ranged between 0% (with broad CIs) in several areas and 2.6% (95% CI: 1.0-4.2%) in Nigeria. Prevalence of CT in all areas combined was greater in women aged 15 to 24 (4.5; 95% CI: 3.4-5.8%) than 25 to 44 (2.6; 95% CI: 2.1-3.1%), whereas NG prevalence was similar in the 2 age groups (0.3%). The only significant risk factors were NG infection (for CT), CT infection (for NG) and infection with high-risk HPV types (for both).

CONCLUSIONS

The prevalence of CT and, most notably, NG was relatively low in a variety of countries. Our findings, however, do not apply to subsets of high-risk women who are likely to be underrepresented in our population-based samples.

The influence of hormonal contraceptive use on HIV-1 transmission and disease progression

Women account for nearly one-half of new human immunodeficiency virus type 1 (HIV-1) infections worldwide, including the majority of infections in Africa. Biological and epidemiological studies suggest that hormonal contraceptive use could influence susceptibility to HIV-1, as well as infectivity and disease progression for those who become infected. However, not all studies have shown this relationship, and many questions remain. Safe and effective contraceptive choices are essential for women with and at risk for HIV-1 infection. Thus, understanding the effect, if any, of hormonal contraception on HIV-1 disease among women is a public health priority.

Pregnancy and the risk of HIV-1 acquisition among women in Uganda and Zimbabwe

OBJECTIVE

Several studies have suggested that pregnancy is associated with an increased risk of HIV-1 acquisition. We used data from a large, prospective study of hormonal contraception and HIV-1 to evaluate the effect of pregnancy on the risk of HIV-1 acquisition.

DESIGN

A multicenter prospective cohort study.

METHODS

We examined 4439 women from family planning sites in Uganda and Zimbabwe contributing 31 369 follow-up visits during 1999-2004. Participants were aged 18-35 years, and had received pregnancy and HIV-1 testing quarterly for 15-24 months. Using proportional hazards modeling, we compared the time to HIV-1 acquisition among four groups: pregnant women, non-pregnant lactating (NP/L) women, and women neither pregnant nor lactating (NP/NL) who were either using or not using hormonal contraception.

RESULTS

A total of 211 participants became HIV-1 infected (2.7 per 100 woman-years; wy), including 13 pregnant women (1.6 per 100 wy), 33 NP/L women (2.7 per 100 wy), 126 NP/NL women using hormonal contraception (2.9 per 100 wy), and 39 NP/NL women not using hormonal contraception (2.7 per 100 wy). In multivariable analysis adjusting for site, age, living with partner, risky sexual behaviors, and incident vaginal, cervical and herpes simplex virus 2 infections, neither pregnant, NP/L, nor NP/NL women using hormonal contraception were at an increased risk of HIV-1 acquisition compared with NP/NL women not using hormonal contraception.

CONCLUSION

Neither pregnancy nor lactation placed women at increased risk of HIV-1 acquisition in this multisite, prospective study of African women. This information is important in planning interventions to reduce HIV-1 acquisition among women.

Hormonal contraception and the risk of HIV acquisition

BACKGROUND

Combined oral contraceptives (COC) and depot-medroxyprogesterone acetate (DMPA) are among the most widely used family planning methods; their effect on HIV acquisition is not known.

OBJECTIVE

To evaluate the effect of COC and DMPA on HIV acquisition and any modifying effects of other sexually transmitted infections.

METHODS

This multicenter prospective cohort study enroled 6109 HIV-uninfected women, aged 18-35 years, from family planning clinics in Uganda, Zimbabwe and Thailand. Participants received HIV testing quarterly for 15-24 months. The risk of HIV acquisition with different contraceptive methods was assessed (excluding Thailand, where there were few HIV cases).

RESULTS

HIV infection occurred in 213 African participants (2.8/100 woman-years). Use of neither COC [hazard ratio (HR), 0.99; 95% confidence interval (CI), 0.69-1.42] nor DMPA (HR, 1.25; 95% CI, 0.89-1.78) was associated with risk of HIV acquisition overall, including among participants with cervical or vaginal infections. While absolute risk of HIV acquisition was higher among participants who were seropositive for herpes simplex virus 2 (HSV-2) than in those seronegative at enrolment, among the HSV-2-seronegative participants, both COC (HR, 2.85; 95% CI, 1.39-5.82) and DMPA (HR, 3.97; 95% CI, 1.98-8.00) users had an increased risk of HIV acquisition compared with the non-hormonal group.

CONCLUSIONS

No association was found between hormonal contraceptive use and HIV acquisition overall. This is reassuring for women needing effective contraception in settings of high HIV prevalence. However, hormonal contraceptive users who were HSV-2 seronegative had an increased risk of HIV acquisition. Additional research is needed to confirm and explain this finding.

Chlamydia trachomatis infection in the family planning clinical setting across New South Wales

Background: Following a small pilot study in 2003, a study was set up to determine the prevalence of genital Chlamydia trachomatis infection in young women presenting to Family Planning NSW centres across New South Wales and to evaluate the characteristics of those infected. Methods: A cross-sectional survey of 621 consecutive women aged from 16 to 24 years was carried out over a 3-month period in 2004 at five Family Planning NSW centres. Urine samples were tested for C. trachomatis using the polymerase chain reaction (PCR) method. Women with a positive result were reviewed and treated. Results: Of 925 eligible clients, 621 (67%) were recruited to the study. Chlamydia trachomatis was detected in 35 of the 621 recruits (5.6%, 95% CI 3.8–7.4). The prevalence at the Hunter centre was significantly higher than the combined prevalence at the other four participating centres (9.7% compared with 3.9%; P = 0.008). Two characteristics were identified as independent predictors of infection in this study: ‘reporting a recent change of partner in the past three months’ (crude odds ratio (OR) 3.33, 95% CI 1.67–6.64) and ‘reporting three or more partners in the past year’ (crude OR 3.69, 95% CI 1.83–7.46). Reported condom use, a history of one or more sexually transmissible infections and current combined oral contraceptive pill use were not associated with infection in this study. Conclusions: The prevalence of C. trachomatis infection is sufficiently high to support targeted testing of 16–24-year-old women in the Family Planning NSW setting and informs the development of a national screening strategy.

Intravaginal practices, bacterial vaginosis, and women's susceptibility to HIV infection: epidemiological evidence and biological mechanisms

Intravaginal practices such as "dry sex" and douching have been suggested as a risk factor that may increase women's susceptibility to HIV infection. These behaviours appear common in different populations across sub-Saharan Africa, where practices include the use of antiseptic preparations, traditional medicines, or the insertion of fingers or cloths into the vagina. We systematically review the evidence for the association between women's intravaginal practices and HIV infection. Although a number of cross-sectional studies have shown that prevalent HIV infection is more common among women reporting intravaginal practices, the temporal nature of this association is unclear. Current evidence suggests that bacterial vaginosis, which is a likely risk factor for HIV infection, may be a mediator of the association between intravaginal practices and HIV. Although biologically plausible mechanisms exist, there is currently little epidemiological evidence suggesting that intravaginal practices increase women's susceptibility to HIV infection. Further research into factors that increase women's susceptibility to HIV will help to inform the design of vaginal microbicides and other HIV prevention interventions.

Hormonal contraceptive use and risk of sexually transmitted infections: a systematic review

Previous research has suggested that hormonal contraceptive users, compared with nonusers, may be at increased risk for acquiring sexually transmitted infections (STIs). We searched the MEDLINE and EMBASE databases for all articles from January 1966 through February 2005 for evidence relevant to all hormonal contraceptives and STIs (including cervical chlamydial and gonococcal infection, human papillomavirus, trichomoniasis, herpes and syphilis). We used standard abstract forms and grading systems to summarize and assess the quality of 83 identified studies. Studies of combined oral contraceptive and depot medroxyprogesterone use generally reported positive associations with cervical chlamydial infection, although not all associations were statistically significant. For other STIs, the findings suggested no association between hormonal contraceptive use and STI acquisition, or the results were too limited to draw any conclusions. Evidence was generally limited in both amount and quality, including inadequate adjustment for confounding, lack of appropriate control groups and small sample sizes. The observed positive associations may be due to a true association or to bias, such as differential exposure to STIs by contraceptive use or increased likelihood of STI detection among hormonal contraceptive users.

Estrogens and glucocorticoids have opposing effects on the amount and latent activity of complement proteins in the rat uterus

The mammalian uterus faces unique immunological challenges. It must nurture and protect the semiallogenic fetus from attack by the maternal immune system while guarding against infection by pathogens that compromise fetal and maternal health. Complement has recently been implicated in the etiology of pregnancy loss, but its regulation by steroid hormones and its role in host defense in the uterus are not clearly defined. Here we use biochemical, functional, and physiological assays to elucidate the regulation of complement proteins in the rat uterus. We demonstrate that estrogens (17 beta-estradiol) and glucocorticoids (dexamethasone) have major, but opposing, effects on the amount and latent activity of complement effectors in the uterus. Treatment with 17 beta-estradiol induced vasodilation and an increase in vascular permeability, which resulted in extravasation of plasma and complement into the uterus, rather than de novo complement biosynthesis. In vitro assays revealed that 17 beta-estradiol induced a potent bactericidal activity in uterine luminal fluid and that the antibacterial component was complement. These proinflammatory and immunomodulatory effects were evident within 4 h of treatment and were blocked by coadministration of dexamethasone. We also found that estrogen effects on the vasculature were mediated in part by activation of the contact system and bradykinin B1 receptors. These results indicate that complement plays a central role in innate immunity in the female reproductive tract and suggest that estrogens or glucocorticoids might be used therapeutically to enhance or inhibit complement-dependent processes in the uterus.

Vaginal douching: personal practices and public policies

BACKGROUND

Vaginal douching is associated with adverse reproductive health outcomes, yet both health providers and women are often poorly informed about details of this practice.

METHODS

We searched the English language articles in the MEDLINE database (1965-March 2004) to describe vaginal douching products, policies of professional organizations, predictors of douching practice, douching methods used, timing of use, and motivation. A key report was obtained from the Food and Drug Administration (FDA) via the Freedom of Information Act. Additional product information was obtained from manufacturers. Primary key terms for the literature search included (vagina OR vaginal) and (douche OR douching). Health effects of douching are reviewed briefly; personal practices and public policies are highlighted.

RESULTS

From the literature search, we identified 432 papers, of which 150 were reviewed in detail. Contrary to the assumptions of many health professionals, douching products are only loosely regulated by the FDA. Few professional organizations have clearly stated policy statements regarding douching. In the United States, the prevalence of douching varies considerably by race (more common among African Americans) and age cohort (more common in women born earlier). Internationally, vaginal douching is common in some cultures and is rare in others. Opinions of mothers, peers, and health professionals, in addition to marketing of commercial products, affect douching behavior.

CONCLUSIONS

Regulation of vaginal douching products and public education efforts on douching behavior need to be reassessed. Because of the preponderance of evidence that suggests an association between vaginal douching and adverse reproductive health outcomes, professional and public health associations should consider educational and policy activities to discourage women from douching.

Hormonal contraceptive use, cervical ectopy, and the acquisition of cervical infections

BACKGROUND AND OBJECTIVES

Several previous studies have suggested that hormonal contraception could be associated with increased risk of cervical infections. However, few high-quality prospective studies have examined this relationship.

GOAL

The goal of this study was to measure the effect of oral contraceptives (OC) and depot-medroxyprogesterone acetate (DMPA) on the acquisition of cervical chlamydial and gonococcal infections.

STUDY

Women attending 2 reproductive health centers in Baltimore, MD, were enrolled into a prospective cohort study. Participants were 15 to 45 years and were initiating OCs or DMPA or not using hormonal contraception. Interviews, physical examinations, and testing for incident cervical infections were conducted at 3, 6, and 12 months.

RESULTS

The analysis included 819 women. Most were single (77%) and nulliparous (75%); 43% were black. Median age was 22 years. During the study, 45 women acquired a chlamydial or gonococcal infection (6.2 per 100 women-years). DMPA use (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.6-8.5), but not OC use (HR, 1.5; 95% CI, 0.6-3.5), was significantly associated with increased acquisition of cervical infections after adjusting for other risk factors. Cervical ectopy was not an important mediator of cervical infection risk.

CONCLUSIONS

DMPA use, but not OC use, appeared to be significantly associated with increased acquisition of cervical chlamydial and gonococcal infections.

Hormonal contraception and risk of cervical infections among HIV-1-seropositive Kenyan women

OBJECTIVE

To evaluate the relationship between hormonal contraceptive use and the acquisition of cervical sexually transmitted infections (STI) among HIV-1-infected women.

DESIGN

A prospective cohort study of 242 commercial sex workers in Mombasa, Kenya, followed from the time of HIV-1 infection.

METHODS

At monthly follow-up visits, sexual behavior and contraceptive use were recorded, and laboratory screening for STI was performed. Multivariate Andersen-Gill proportional hazards models were constructed to examine the association between the use of hormonal contraception and the occurrence of cervical STI.

RESULTS

The median duration of follow-up after HIV-1 acquisition was 35 months, and 799 person-years of follow-up were accrued. After adjustment for demographic factors and sexual behavior, women using the injectable contraceptive depot medroxyprogesterone acetate were at increased risk of Chlamydia trachomatis infection [hazard ratio (HR) 3.1, 95% confidence interval (CI) 1.0-9.4, P = 0.05] and cervicitis (HR 1.6, 95% CI 1.0-2.3, P = 0.03) compared with women using no contraception. The use of oral contraceptive pills was associated with an increased risk of cervicitis (HR 2.3, 95% CI 1.4-3.8, P = 0.001). Hormonal contraception was not associated with an increased risk of infection with Neisseria gonorrhoeae.

CONCLUSION

The use of hormonal contraception by HIV-1-infected women was associated with an increased risk of cervicitis and cervical chlamydia infection. HIV-1-seropositive women using hormonal contraception should be counseled about the importance of consistent condom use to prevent both STI and HIV-1 transmission.

Sexually transmitted infections and contraceptives: selective issues

It is important to examine the successful completed research and use it to move forward in practice to halt the almost 50% unintended pregnancy rate in the United States and the continued worldwide epidemic of HIV and other STIs. A significant development has been the evidence supporting the IUD as a valuable contraceptive option available to many women, including women who are HIV infected, with no increased risks of infertility or PID. Evidence exists that OCPs may increase chlamydial infection acquisition and cervicitis, but it is unlikely that OCP use is associated with PID. The lack of female-controlled dual method protection remains a void, but with the introduction of products such as FemCap and Reality condom and the continuing progress of microbicides and spermicides, the future is brighter. Clearly research into the interactions of STIs and contraceptives must continue to discern how best to approach a resolution to these public health concerns that affect women and the global population.

Innate immune defences in the human endometrium

The human endometrium is an important site of innate immune defence, giving protection against uterine infection. Such protection is critical to successful implantation and pregnancy. Infection is a major cause of preterm birth and can also cause infertility and ectopic pregnancy. Natural anti-microbial peptides are key mediators of the innate immune system. These peptides, between them, have anti-bacterial, anti-fungal and anti-viral activity and are expressed at epithelial surfaces throughout the female genital tract. Two families of natural anti-microbials, the defensins and the whey acidic protein (WAP) motif proteins, appear to be prominent in endometrium. The human endometrial epithelium expresses beta-defensins 1-4 and the WAP motif protein, secretory leukocyte protease inhibitor. Each beta-defensin has a different expression profile in relation to the stage of the menstrual cycle, providing potential protection throughout the cycle. Secretory leukocyte protease inhibitor is expressed during the secretory phase of the cycle and has a range of possible roles including anti-protease and anti-microbial activity as well as having effects on epithelial cell growth. The leukocyte populations in the endometrium are also a source of anti-microbial production. Neutrophils are a particularly rich source of alpha-defensins, lactoferrin, lysozyme and the WAP motif protein, elafin. The presence of neutrophils during menstruation will enhance anti-microbial protection at a time when the epithelial barrier is disrupted. Several other anti-microbials including the natural killer cell product, granulysin, are likely to have a role in endometrium. The sequential production of natural anti-microbial peptides by the endometrium throughout the menstrual cycle and at other sites in the female genital tract will offer protection from many pathogens, including those that are sexually transmitted.

Hormonal contraception and risk of sexually transmitted disease acquisition: results from a prospective study

OBJECTIVES

To examine the relationship between use of oral contraceptive pills or depot medroxyprogesterone acetate and sexually transmitted disease acquisition.

STUDY DESIGN

Prospective cohort included 948 Kenyan prostitutes. Multivariate Andersen-Gill proportional hazards models were constructed, adjusting for sexual behavioral and demographic variables.

RESULTS

When compared with women who were using no contraception, users of oral contraceptive pills were at increased risk for acquisition of chlamydia (hazard ratio, 1.8; 95% confidence interval, 1.1-2.9) and vaginal candidiasis (hazard ratio, 1.5; 95% confidence interval, 1.2-1.9) and at decreased risk for bacterial vaginosis (hazard ratio, 0.8; 95% confidence interval, 0.7-1.0). Women using depot medroxyprogesterone acetate had significantly increased risk of chlamydia infection (hazard ratio, 1.6; 95% confidence interval, 1.1-2.4) and significantly decreased risk of bacterial vaginosis (hazard ratio, 0.7; 95% confidence interval, 0.5-0.8), trichomoniasis (hazard ratio, 0.6; 95% confidence interval, 0.4-1.0), and pelvic inflammatory disease (hazard ratio, 0.4; 95% confidence interval, 0.2-0.7). Consistent condom use was associated with significantly decreased risk of gonorrhea, chlamydia, genital ulcer disease, bacterial vaginosis, and pelvic inflammatory disease.

CONCLUSIONS

The use of oral or injectable hormonal contraception altered susceptibility to sexually transmitted diseases, which may in turn influence transmission of human immunodeficiency virus type 1. Consistent condom use was protective with regards to sexually transmitted disease and should be encouraged for the prevention of sexually transmitted disease and human immunodeficiency virus type 1 among women who use hormonal contraception.

Properties of a new acid-buffering bioadhesive vaginal formulation (ACIDFORM)

Vaginal prophylactic methodology may prevent heterosexual transmission of the HIV and other sexually transmitted disease-causing organisms as well as unplanned pregnancies. A new delivery system (ACIDFORM) was designed with acid-buffering, bioadhesive, and viscosity-retaining properties to (1) maintain the acidic vaginal milieu (the low pH inactivates many pathogens and spermatozoa), (2) form a protective layer over the vaginal/cervical epithelium (minimizing contact with pathogenic organisms), and (3) provide long-term vaginal retention. A Phase I clinical study with ACIDFORM provided initial information about its safety and showed the formation of a layer over the vaginal/cervical epithelium [1; Amaral et al., Contraception 1999;60:361-6]. To study the properties of the gel (without active ingredient) in more detail, ACIDFORM's acid-buffering, bioadhesive, viscosity-retaining, and spermicidal properties were compared in vitro to marketed formulations, and its long-term stability was assessed. ACIDFORM, either when titrated with NaOH or when mixed directly with semen, is highly acid buffering and much more effective than Aci-Jel, a commercial acid-buffering vaginal product. ACIDFORM adheres well to two model membranes (excised sheep vagina and cellophane) and is more bioadhesive than Conceptrol, Advantage S, Replens, Aci-Jel, and K-Y jelly. On dilution, ACIDFORM also retains its viscosity better than these marketed products. ACIDFORM is spermicidal and is stable for at least 2 years. These results suggest that ACIDFORM has advantages over presently marketed vaginal delivery systems. The gel may either be useful by itself as an antimicrobial contraceptive product or as a formulation vehicle for an active ingredient with antimicrobial and/or contraceptive properties.

Computerized planimetry versus clinical assessment for the measurement of cervical ectopia

OBJECTIVE

As part of a study to assess the role of cervical ectopia in the acquisition of cervical infections, we determined the reliability of cervical ectopia measurements made by computer planimetry and by clinical (visual) assessment.

STUDY DESIGN

We conducted pelvic examinations of 1004 women seeking contraceptive services at two health centers in Baltimore. After application of acetic acid, clinicians estimated the relative area of ectopia by visual inspection and took cervical photographs. Two independent raters measured the absolute and relative areas of ectopia from the digitized images by means of an analytic software program. Agreement levels between raters, between multiple readings by the same rater, and between the two measurement methods were quantified by means of the intraclass correlation coefficient and weighted kappa.

RESULTS

Intrarater agreement was excellent for computer planimetry measurements of the absolute (intraclass correlation coefficient, 0.97) and relative (intraclass correlation coefficient, 0.89) areas of ectopia. Interrater agreement was also high for computer planimetry measurements of the absolute (intraclass correlation coefficient, 0.83) and relative (intraclass correlation coefficient, 0.85) areas of ectopia. Agreement levels were moderate between clinician assessment and computer planimetry measurements of the relative area of ectopia (kappa = 0.48), but agreement was better when clinical assessment was limited to observations by a single, experienced clinician.

CONCLUSION

Measurement of cervical ectopia by computer planimetry was highly reliable and appears appropriate for assessment of the role of ectopia in the acquisition of cervical infections. Clinical assessment of cervical ectopia may be used when computer planimetry is not available.

Relationship of hormonal contraception and cervical ectopy as measured by computerized planimetry to chlamydial infection in adolescents

BACKGROUND

Adolescents are at increased risk for chlamydial infection and its sequelae. Hormonal contraception and cervical ectopy were previously suggested risk factors for chlamydia.

GOAL

To determine if chlamydia is more prevalent in female participants with greater ectopy and in hormonal contraceptive users.

STUDY DESIGN

Ninety-seven adolescent females aged 11 to 20 years were recruited from two Baltimore inner-city clinics. After administering a reproductive history questionnaire, endocervical specimens were tested for Chlamydia trachomatis by polymerase chain reaction. After acetic acid application to the cervix, cervical photographs were taken, the area of ectopy was quantified by computerized planimetry, and ectopy was categorized as none (0mm2), mild (< 22mm2), and moderate (> 22mm2). The likelihood of chlamydia by ectopy and type of hormonal contraceptive use was determined by logistic regression adjusted for age and sexual partners.

RESULTS

The odds of chlamydial infection was similar in persons with mild ectopy compared with no ectopy (adjusted odds ratio [OR], 0.76; 95% CI, 0.14-4.03), and in persons with moderate ectopy compared with no ectopy (adjusted OR, 1.94; 95% CI, 0.40-9.39). The likelihood of chlamydia was higher in depot-medroxyprogesterone acetate users compared with nonhormone users (adjusted OR, 5.44; 95% CI, 1.25-23.6). Oral contraceptive users did not have an increased likelihood of chlamydia (adjusted OR, 0.92; 95% CI, 0.10-8.78).

CONCLUSION

Using a new, reliable, and standardized technique to quantify cervical ectopy, the authors did not find an elevated prevalence of chlamydial infection in adolescents with cervical ectopy. Depot-medroxyprogesterone acetate use may increase the risk of chlamydial infection compared with combined estrogen-progestin oral contraceptives.

Histologic development of cervical ectopy: relationship to reproductive hormones

BACKGROUND AND OBJECTIVES

Cervical ectopy has been proposed as a risk factor for chlamydial infection, HIV, and other sexually transmitted diseases (STDs). Ectopy is a histologic phenomenon resulting from a complex interplay of morphologic and hormonal processes. Reproductive hormones influence the production of ectopy during late fetal life, puberty, pregnancy, and with use of oral contraceptives. Ectopy is modified over time by squamous metaplasia and epitheliazation, low pH, trauma, and possibly by cervical infection.

STUDY DESIGN

The authors review the histologic development of ectopy from late fetal life to menopause to understand STD risk.

RESULTS

Ectopy is often assessed and quantified by direct, unaided observation during speculum examinations. This method may result in inaccurate estimates and misclassification with the transformation zone.

CONCLUSION

Valid, reproducible measures of ectopy are necessary for epidemiologic studies to examine the impact of exogenous hormonal contraceptives on the development of ectopy and on potential infection risk.

The effect of one injection of Depo-Provera on the human vaginal epithelium and cervical ectopy

Two studies in rhesus monkeys have shown that progesterone implants, Depo-Provera and Norplant, were associated with vaginal thinning. Progesterone implants have also been associated with an increased risk of simian immunodeficiency virus (SIV) acquisition. This study in 16 women was done to assess vaginal epithelial thickness and number of cell layers from biopsies taken in the untreated follicular and luteal phases, and at 1 month and 3 months after administration of Depo-Provera. There was no significant change over time in either parameter from biopsies obtained in the luteal phase compared with those at either time after Depo-Provera administration. There was also no change in the mean number of Langerhans cells in vaginal wall specimens and no change in cervical ectopy. It appears that women do not respond to exogenous progestins with the dramatic vaginal thinning seen in rhesus monkeys.

Cervical ectopy and the transformation zone measured by computerized planimetry in adolescents

OBJECTIVE

To determine whether cervical ectopy and the transformation (T) zone were larger in adolescents using oral contraceptives (OCs) compared to depot medroxyprogesterone acetate (DMPA).

METHOD

Cervical photographs were taken on 91 adolescents in Baltimore, Maryland. Ectopy and T zone size were measured using computerized planimetry. Patients provided reproductive and sexual history. Correlates of ectopy and T zone size were identified by proportional odds and linear regression models, respectively.

RESULT

Twenty-five women had no ectopy. Parity was independently associated with greater ectopy (OR 3.9, 95% CI 1.37-11.11). Predictors of smaller ectopy were douching (OR 0.23, 95% CI 0.09-0.65), and shorter sexual history (OR 0.20, 95% CI 0.05-0.74). Neither OC or DMPA were associated with ectopy. Predictors of greater T zone size were years since menarche (13.8 mm2/year, P = 0.003) and OCs (54.7 mm2, P = 0.05). DMPA predicted a smaller T zone (-67.0 mm2, P = 0.01).

CONCLUSION

Computerized planimetry provides standardized measurements. Douching and sexual activity may decrease ectopy through increased squamous metaplasia. Hormonal contraceptives were not associated with ectopy in adolescents. However, long-term progestin use may decrease T zone size.