Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching

Efficacy of a Triticum vulgare Extract as a Treatment of Cervical Ectropion: A Prospective Observational Cohort Study

OBJECTIVES

To assess the effectiveness of a topical treatment for cervical ectropion with vaginal ovules containing aqueous extract of Triticum vulgare .

METHODS

Prospective observational cohort study conducted between November 2020 and November 2022 at the colposcopy clinics of 2 different hospitals. Sexually active patients with a colposcopic diagnosis of cervical ectropion, awaiting ablative procedure, were included in the study and prescribed medical therapy with vaginal T. vulgare ovules (group 1) or wait-and-see therapy (group 2). At both enrollment and 2-month follow-up, a symptomatologic evaluation recording the intensity of postcoital bleeding, leucorrhea, and dyspareunia was performed with a Visual Analog Scale (VAS) questionnaire, and a colposcopic examination was performed, calculating the size of the ectropion area.

RESULTS

A total of 116 patients (58 in group 1 and 58 in group 2) were included. Topical treatment with vaginal ovules containing aqueous extract of T. vulgare for 2 months resulted in significant decrease of symptoms related to cervical ectropion and significant reduction of the size of the ectropion area.

CONCLUSIONS

Our results support the efficacy of topical treatment with vaginal ovules containing aqueous extract of T. vulgare for symptomatic cervical ectropion; our study also suggests that expectant management, despite being widely practiced, seems to lead to a worsening of the natural history of ectropion.

Real‑world study of Cerviron® vaginal ovules in the treatment of cervical lesions of various etiologies

Cervical lesions can be caused by pathogens, hormonal changes or by cervical injury. The recommended treatment in all cases is excision. Local re-epithelialization therapy should be initiated preoperatively and postoperatively. The present study assessed the post-market performance and tolerability of Cerviron® ovules in the treatment and management of cervical lesions postoperatively. The study population included 345 participants aged 20-70 years with either a cervical lesion under treatment or with recent surgical removal of a cervical lesion. The degree of re-epithelialization of the cervical mucosa was improved in 73.17% of the patients evaluated during routine colposcopy exams and 92.73% of patients recorded no bleeding. When adding Cerviron® either as monotherapy or in association with other antimicrobials in postoperative care of the cervical ectropion, improved postoperative outcomes such as reduced post-interventional bleeding and a superior quality of healing were observed. The study and its details are registered in www.clinicaltrials.gov under ID NCT05668806.

Pharmacogenomics of drug transporters for antiretroviral long-acting pre-exposure prophylaxis for HIV

The use of antiretrovirals (ARVs) as oral, topical, or long-acting pre-exposure prophylaxis (PrEP) has emerged as a promising strategy for HIV prevention. Clinical trials testing Truvada® [tenofovir disoproxil fumarate (TDF)/tenofovir (TFV) and emtricitabine (FTC)] as oral or topical PrEP in African women showed mixed results in preventing HIV infections. Since oral and topical PrEP effectiveness is dependent on adequate drug delivery and availability to sites of HIV infection such as the blood and female genital tract (FGT); host biological factors such as drug transporters have been implicated as key regulators of PrEP. Drug transporter expression levels and function have been identified as critical determinants of PrEP efficacy by regulating PrEP pharmacokinetics across various cells and tissues of the blood, renal tissues, FGT mucosal tissues and other immune cells targeted by HIV. In addition, biological factors such as genetic polymorphisms and genital inflammation also influence drug transporter expression levels and functionality. In this review, drug transporters and biological factors modulating drug transporter disposition are used to explain discrepancies observed in PrEP clinical trials. This review also provides insight at a pharmacological level of how these factors further increase the susceptibility of the FGT to HIV infections, subsequently contributing to ineffective PrEP interventions in African women.

Assessing colposcopic accuracy for high-grade squamous intraepithelial lesion detection: a retrospective, cohort study

Background

Inappropriate management of high-grade squamous intraepithelial lesions (HSIL) may be the result of an inaccurate colposcopic diagnosis. The aim of this study was to assess colposcopic performance in identifying HSIL+ cases and to analyze the associated clinical factors.

Methods

Records from 1130 patients admitted to Shenzhen Maternal and Child Healthcare Hospital from 12th January, 2018 up until 30th December, 2018 were retrospectively collected, and included demographics, cytological results, HPV status, transformation zone type, number of cervical biopsy sites, colposcopists’ competencies, colposcopic impressions, as well as histopathological results. Colposcopy was carried out using 2011 colposcopic terminology from the International Federation of Cervical Pathology and Colposcopy. Logistic regression modelling was implemented for uni- and multivariate analyses. A forward stepwise approach was adopted in order to identify variables associated with colposcopic accuracy. Histopathologic results were taken as the comparative gold standard.

Results

Data from 1130 patient records were collated and analyzed. Colposcopy was 69.7% accurate in identifying HSIL+ cases. Positive predictive value, negative predictive value, sensitivity and specificity of detecting HSIL or more (HSIL+) were 35.53%, 64.47%, 42.35% and 77.60%, respectively. Multivariate analysis highlighted the number of biopsies, cytology, and transformation zone type as independent factors. Age and HPV subtype did not appear to statistically correlate with high-grade lesion/carcinoma.

Conclusion

Evidence presented here suggests that colposcopy is only 69.7% accurate at diagnosing HSIL. Even though not all HSIL will progress into cancer it is considered pre-cancerous and therefore early identification will save lives. The number of biopsies, cytology and transformation zone type appear to be predictors of misdiagnosis and therefore should be considered during clinical consultations and by way of further research.

Immune cell arrival kinetics to peritoneum and role during murine-experimental trichomoniasis

Trichomonas vaginalis causes trichomoniasis, an inflammatory process related to an increased rate of HIV transmission. In order to study T. vaginalis infection response in a microorganism-free environment, an infection model was established providing a host–parasite interaction system useful to study the interplay between immune cells and the parasite. Infected mice peritoneal cells were immunophenotyped at different times after infection using flow cytometry. Neutrophils and macrophages showed the most relevant increase from third to 12th day post-infection. A high number of B lymphocytes were present on 15th day post-infection, and an increase in memory T cells was observed on sixth day post-infection. The levels of NO increased at day 10 post-infection; no significant influence was observed on T. vaginalis clearance. Increased viability of T. vaginalis was observed when the NETs inhibitors, metformin and Cl− amidine, were administrated, highlighting the importance of this mechanism to control parasite infection (43 and 86%, respectively). This report presents a comprehensive cell count of the immune cells participating against trichomoniasis in an in vivo interaction system. These data highlight the relevance of innate mechanisms such as specific population changes of innate immune cells and their impact on the T. vaginalis viability.

Influence of TLR4 and TLR9 polymorphisms and haplotypes on multiple hrHPV infections and HPV16 copy number in cervical cancer and cervicitis

Genetic polymorphism in pathogen recognition receptors tends to influence infection, disease susceptibility, and progression. We analyzed the association of TLR4 and TLR9 gene polymorphisms with multiple hrHPV infections and HPV16 copy number in cervicitis and cervical cancer. A total of 440 cervical cancer, cervicitis, and healthy individuals were studied using PCR-based assays. Student t-test, chi-square test, Welch's t-test, and Fisher's Exact test were utilized to evaluate the association of HPV infection with polymorphisms. Haploview and FAMHAP were used to analyze haplotype association with HPV infection and viral load. Study results revealed HPV45 infection as the most common one in cervical cancer after HPV16, and one-fourth HPV positive cervical cancer patients possessed multiple HPV infections. Mean HPV16 copy number of 264.4 ± 58.7 and 2.1 ± 3.3 copies/cell was detected in cervical cancer and cervicitis, respectively. TLR4 rs10759931 was protective against multiple hrHPV infections. TLR4 haplotype ACAC was associated with an increased risk of multiple hrHPV infections. TLR9 SNPs rs187084, rs352140, and rs352139 were associated with decreased risk of high HPV16 copy number. Augmentation of efforts for the multivalent HPV vaccination in India is suggested. The analyzed polymorphisms were shown to modulate hrHPV co-infections and HPV16 viral load that warrants further analysis.

The impact of aging on innate and adaptive immunity in the human female genital tract

Mucosal tissues in the human female reproductive tract (FRT) are primary sites for both gynecological cancers and infections by a spectrum of sexually transmitted pathogens, including human immunodeficiency virus (HIV), that compromise women's health. While the regulation of innate and adaptive immune protection in the FRT by hormonal cyclic changes across the menstrual cycle and pregnancy are being intensely studied, little to nothing is known about the alterations in mucosal immune protection that occur throughout the FRT as women age following menopause. The immune system in the FRT has two key functions: defense against pathogens and reproduction. After menopause, natural reproductive function ends, and therefore, two overlapping processes contribute to alterations in immune protection in aging women: menopause and immunosenescence. The goal of this review is to summarize the multiple immune changes that occur in the FRT with aging, including the impact on the function of epithelial cells, immune cells, and stromal fibroblasts. These studies indicate that major aspects of innate and adaptive immunity in the FRT are compromised in a site‐specific manner in the FRT as women age. Further, at some FRT sites, immunological compensation occurs. Overall, alterations in mucosal immune protection contribute to the increased risk of sexually transmitted infections (STI), urogenital infections, and gynecological cancers. Further studies are essential to provide a foundation for the development of novel therapeutic interventions to restore immune protection and reverse conditions that threaten women's lives as they age.

Detection of high-grade cervical disease among women referred directly to colposcopy after a positive HPV screening test varies with age and cytology findings

Australia's new HPV-based cervical screening program is based on an algorithm that incorporates reflex cytology to guide decisions about further follow-up with colposcopy and, if indicated, biopsy. We reviewed results for 2300 women referred directly for colposcopy after their first positive HPV screening test, to determine the proportion that had underlying histological high-grade abnormality (HGA). Overall, HGA was detected in 24.3% of women. Among HPV16/18 positive women, 18.0% had HGA, increasing from 6.6% among women with negative cytology to 79.7% among women with high-grade squamous lesion or worse, or any glandular lesion on cytology (HSIL+; P-trend < .001). For this latter group, the proportion with HGA was higher among HPV16/18 positive women than among those positive for other oncogenic types (68.8%; P = .029). Among women with ASC-H cytology, 51.8% had HGA, with no difference between HPV groups (P = .314). In analyses by age-groups, detection of HGA was highest, at 36.4%, among women younger than 35 years, then decreased significantly to 5.9%, among women aged 65 to 74 years (P-trend < .001). The relationship of decreasing HGA detection with increasing age was strong for women with negative cytology, and those with ASC-H cytology (P-trend < .001 for each). For women with HSIL+ cytology, detection of HGA was high and stable, regardless of age (P-trend = .211). This report describes the first follow-up colposcopy findings in Australia's new HPV-based cervical screening program. The results demonstrate the additional value of reflex cytology in managing HPV positive women and suggest that further refinement of the risk-based algorithm to account for age may be warranted.

Chlamydia Infection Among Digital Daters and Nondigital Daters

OBJECTIVES

The aim of the study was to investigate whether the use of dating apps is a risk factor for acquiring Chlamydia trachomatis (CT) infections.

METHODS

Patients attending the drop-in facility at the STI clinic at Umeå University Hospital between April 2016 and November 2017 were asked to fill in a survey about their sexual preferences and behaviors, including dating app use.

RESULTS

Of 943 participants, 80 (8.5%) received a CT diagnosis (34 women and 46 men). Dating app users did not seem to have an increased risk of CT infection. Having 3 or more sex partners within the last year was a risk factor for CT only among those not using a dating app. Alcohol use before sex and unprotected sex with a new partner were risk factors for CT infection in the univariate but not in the multivariate analysis.

CONCLUSIONS

Dating app users did not seem to have an increased risk of acquiring CT and for dating app users the seemingly well-established risk factor of having many partners was not valid.

Characterization of women with cervical cancer assisted at Inca by histological type

OBJECTIVE

To determine the distribution of sociodemographic, reproductive, clinical and lifestyle habits in the cohort of women diagnosed with cervical cancer, assisted at Inca between 2012 and 2014, according to the histological type.

METHODS

Retrospective observational study of a hospital cohort of 1,004 women diagnosed with cervical cancer. Data were obtained from the Inca hospital cancer registry, physical and electronic records.

RESULTS

The most frequent histological type was squamous cell carcinoma (83.9%). Approximately 70% of the women aged more than 40 years. The study includes non-white women (67.4%), with less than 8 years of education (51.9%), with onset of sexual activity up to 16 years of age (40.7%), who were pregnant before (95.5%), with more than one pregnancy (82.9%), and more than two children (52.7%); 45.8% of the women were smokers or former smokers. Cervical adenocarcinoma was positively associated with earlier staging (IA-IIA) (OR = 1.79; 95%CI 1.03–3.13), as well as women with ≥ 12 years of education (OR = 6.30; 95%CI 1.97–20,13), who had no children (OR = 3.81; 95%CI 1.20 – 12,08) or who had up to two children (OR = 1.74; 95%CI 1.05 – 2,87).

CONCLUSIONS

The difference between histological types is highlighted, suggesting that women with cervical adenocarcinoma may represent a distinct clinical entity of cervical neoplasia, which may require different approaches from those used in squamous cell carcinoma.

Intravaginal practices and genital human papillomavirus infection among female sex workers in Cambodia

OBJECTIVES

Intravaginal practices (IVPs) include washing, wiping, or inserting something inside the vagina. This study investigates the associations between IVPs and genital human papillomavirus (HPV) infection.

METHODS

We conducted a cross-sectional study of 200 female sex workers aged 18 to 35 years in Phnom Penh, Cambodia. From August to September 2014. Data on sociodemographic characteristics, IVPs, and other behaviors were collected through face-to-face interviews. Self-collected cervicovaginal specimens were tested for 37 HPV genotypes.

RESULTS

Multivariable Poisson regression models showed that a lower number of infecting HPV genotypes were associated with intravaginal washing in the past 3 months (incident rate ratios [IRR] = 0.65, 95% confidence interval [CI]: 0.46-0.94) and often performing intravaginal washing shortly after sex (IRR = 0.89, 95% CI: 0.81-0.99). Intravaginal washing before vaginal sex, intravaginal wiping, and intravaginal insertion were not associated with HPV infection.

CONCLUSION

These findings challenge the existing view that all types of vaginal cleansing are harmful. Specifically, intravaginal washing shortly after sex (mainly with water) may help prevent HPV infection in female sex workers, who have several partners and thus frequently expose to sources of HPV infection with different genotypes.

ANALYSIS OF COMPLICATED CERVICAL ECTOPY CLINICAL COURSE AND RECURRENCE

Physiological cervical ectopy (CE) is commonly found in young women, during pregnancy or intake of oral contraceptives. The complicated (pathological) CE, particularly in conditions of vaginal microbiota disturbances and human papillomavirus (HPV) infection, requires intervention, including optimal treatment and effective relapse prevention approaches. Aim. The aim of the research was to investigate the complicated CE clinical course and recurrence features on the basis of a retrospective analysis of archival medical records in order to optimize the tactics of the complicated CE management and the relapse prevention measures. Materials and methods. In the observational cross-sectional retrospective study using the continuous sampling method were included 740 case reports of women, who underwent inpatient treatment of gynecological pathology in Lviv Municipal Clinical First Aid Hospital in 2006–2017. The inclusion criterion was the presence of firstly diagnosed or recurrent CE. Exclusion criteria: absence of CE colposcopic or morphological confirmation, presence of physiological CE (on conditions of cytological, bacterioscopical, bacteriological and colposcopical abnormalities absence). Subsequently, three groups were formed: control group (n=150) – healthy women, who applied for a regular gynecological examination; group 1 (n=483) – women with firstly diagnosed CE; group 2 (n=257) – women with recurrent CE. Differences in mean values were considered significant with a probability level of at least 95 % (p<0.05). Results. Patients with recurrent CE had more pregnancies (p<0.05) than the ones with firstly diagnosed CE and women of control group. The proportion of women with high parity in group 1 and group 2 was three times higher (p<0.05), than in group 3. The proportion of artificial abortions in patients of groups 1 and 2 was more than two times higher (p<0.05), than in women in the control group, group 2 patients had more miscarriages and missed miscarriages(p<0.05) in comparison to the control group. Menarche in patients with recurrent CE set in later in comparison to women of control group (p<0.05). In group 2, the proportion of women with polymenorrhea was three times higher (p<0.05), than in group 1 and control group respectively. The compromised gynecological history was more often (p<0.05) detected in group 1 and group 2, than in the control group. In patients with recurrent CE a third of gynecologic diseases in the history (32.30±2.92 %) and 23.60±1.93 % - in patients with the firstly diagnosed CE were pelvic inflammatory diseases, significantly (p<0.05) higher in comparison to the control group (3.33±1.47 %). Almost half of patients in group 1 (48.25±2.27 %) and group 2 (47.84±3.13 %) had the history of frequent infectious diseases, this indicator was significantly (p<0.05) higher in comparison to the control group (24.67±3.52 %). In patients with recurrent CE chronic diseases of different etiology were diagnosed more often (p<0.05) - their share made up 8.24±1.72 %, while in patients with firstly diagnosed CE - 4.33±0.92 %, in women of the control group - 1.33±0.94 %.The firstly diagnosed CE was more frequent (in comparison to recurrent CE) (p<0.001) characterized by asymptomatic course, whereas about half of patients with recurrent CE (46.69±3.11 %) presented with different complaints. Cytological indicators of cervicitis were found more often in patients with firstly diagnosed and recurrent CE, than in women of control group, as well as vaginal candidosis (p<0.05). Patients with recurrent CE more often (p<0.05) underwent diathermoconization (24.12±2.67 %) and cryodestruction of the cervix (8.17±1.71 %) in comparison to patients of group 1. The most often performed treatment method in patients of both groups was diathermoconization. Treatment methods aimed to restore the hormonal balance, to normalize the state of vaginal microbiota were rarely found in both group 1 and 2, drugs that affect the reparation and regeneration of the epithelium have not been used in any case. Conclusions. Recurrent symptomatic complicated CE should be interpreted as a complex problem that requires a multi-polar approach aimed at hormonal homeostasis, local immunity, and vaginal biocenosis normalizing. These measures should precede invasive treatment and further create optimal conditions for regeneration of the cervix.

Risk factors for ectopic pregnancy in Germany: a retrospective study of 100,197 patients

Aim: The goal of this study was to identify potential risk factors for ectopic pregnancy in women followed in German gynecological practices.

Methods: The present study included pregnant women diagnosed with ectopic pregnancy and pregnant women without ectopic pregnancy followed in 262 gynecological practices between January 2012 and December 2016. The effects of demographic and clinical variables on the risk of developing ectopic pregnancy were estimated using a multivariate logistic regression model.

Results: This study included 3,003 women with ectopic pregnancy and 97,194 women without ectopic pregnancy. The mean age was 31.4 years (SD=5.9 years) in ectopic pregnancy patients and 31.1 years (SD=5.6 years) in non-ectopic pregnancy patients. Women aged 36–40 (OR=1.12) and 41–45 years (OR=1.46) were at a higher risk of ectopic pregnancy than women aged 31–35 years. Prior ectopic pregnancy was strongly associated with a risk of recurring ectopic pregnancy (OR=8.17). Prior genital surgery (OR=2.67), endometriosis (OR=1.51), and eight other gynecological diseases were also positively associated with ectopic pregnancy (ORs ranging from 1.19 to 2.06). Finally, there was a 1.80-fold increase in women previously diagnosed with psychiatric disorders.

Conclusions: Prior ectopic pregnancy and prior genital surgery were strongly associated with ectopic pregnancy in women followed in German gynecological practices. Psychiatric diseases had an additional impact on the risk of ectopic pregnancy.

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.

Genital inflammation, immune activation and risk of sexual HIV acquisition

PURPOSE OF REVIEW

Women who have genital inflammation are at increased risk of sexual HIV infection. The purpose of this review is to evaluate the mechanisms for this relationship, causes of genital inflammation, and strategies to manage this condition.

RECENT FINDINGS

We have recently shown in a cohort of South African women that HIV seroconversion was associated with persistently raised genital inflammatory cytokines (including MIP-1α, MIP-1β, and IP-10). Elevated inflammatory cytokine concentrations may facilitate HIV infection by recruiting and activating HIV target cells and disrupting the mucosal epithelial barrier. Bacterial vaginosis and sexually transmitted infections (STIs), which are predominantly asymptomatic in women, cause lower genital tract inflammation and increased HIV acquisition risk. In Africa, where syndromic management of STIs and bacterial vaginosis is standard-of-care, the substantial burden of asymptomatic infections has likely contributed to high-HIV incidence rates.

SUMMARY

A genital inflammatory profile contributes to the high risk of HIV acquisition in African women. STIs and bacterial vaginosis are poorly managed in Africa and other developing nations and as such remain major drivers of persistent genital inflammation and HIV acquisition among these women.

Determinants of Chlamydia, Gonorrhea, and Coinfection in Heterosexual Adolescents Attending the National Public Sexually Transmitted Infection Clinic in Singapore

BACKGROUND

Amidst recent trends in rising rates of chlamydia and gonorrhea among Singaporean adolescents, there are limited data on risk factors associated with these infections that may inform prevention strategies in this population.

METHODS

A cross-sectional study of chlamydia and gonorrhea positivity was conducted among 1458 sexually active heterosexual adolescents between 14 and 19 years old attending the national public sexually transmitted infection clinic from 2006 to 2013. The association with demographic and behavioral characteristics was assessed by crude prevalence ratio, and negative binomial regression modeling was used to obtain adjusted prevalence ratios (aPRs).

RESULTS

Chlamydia positivity was found in 23.6% of males and 36.6% of females, gonorrhea positivity in 33.1% of males and 15.9% of adolescent girl, and coinfection positivity in 10.2% of males and 10.1% of females. In multivariable analysis, chlamydia was positively associated with being Malay (aPR, 1.6; 95% confidence interval [CI], 1.1-2.1) and inconsistent condom use for vaginal sex (aPR, 6.5; 95% CI = 2.4-17.4) in males and with being Malay (aPR, 1.9; 95% CI = 1.5-2.4), inconsistent condom use for vaginal sex (aPR, 2.0; 95% CI = 1.1-3.9), and number of lifetime partners in females (aPR, 1.1; 95% CI = 1.0-1.1). Gonorrhea was positively associated with being Malay (aPR, 3.2; 95% CI = 2.4-4.4), inconsistent condom use for vaginal sex (aPR, 5.4; 95% CI = 2.1-14.4), and number of lifetime partners (aPR, 1.1; 95% CI = 1.0-1.1) in males and with being Malay (aPR, 3.7; 95% CI = 2.4-5.7) in females. Malays had a higher proportion of sexual risk behaviors compared with the non-Malays.

CONCLUSIONS

Ethnicity and high-risk sexual behaviors are important determinants of chlamydia, gonorrhea, and coinfection for adolescents attending this clinic. Targeted interventions are needed to lower the prevalence of high-risk sexual behaviors for the Malay adolescents in this clinic.

Combination Emtricitabine and Tenofovir Disoproxil Fumarate Prevents Vaginal Simian/Human Immunodeficiency Virus Infection in Macaques Harboring Chlamydia trachomatis and Trichomonas vaginalis

Genital inflammation associated with sexually transmitted infections increases susceptibility to human immunodeficiency virus (HIV), but it is unclear whether the increased risk can reduce the efficacy of pre-exposure prophylaxis (PrEP). We investigated whether coinfection of macaques with Chlamydia trachomatis and Trichomonas vaginalis decreases the prophylactic efficacy of oral emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF). Macaques were exposed to simian/human immunodeficiency virus (SHIV) vaginally each week for up to 16 weeks and received placebo or FTC/TDF pericoitally. All animals in the placebo group were infected with SHIV, while 4 of 6 PrEP recipients remained uninfected (P= .03). Oral FTC/TDF maintains efficacy in a macaque model of sexually transmitted coinfection, although the infection of 2 macaques signals a modest loss of PrEP activity.

Is Cryotherapy Friend or Foe for Symptomatic Cervical Ectopy?

OBJECTIVE

To evaluate the success rates and clinical outcomes of cervical cryotherapy applied to cervical ectopy for symptomatic relief.

SUBJECTS AND METHODS

A total of 124 women who underwent cryotherapy for symptomatic treatment of cervical ectopy were included in this study. Indications for treatment were: abundant leucorrhoea (n = 114), post-coital bleeding (n = 22), recurrent cervicitis (n = 30) and pelvic pain (n = 12). Cryotherapy consisted of the use of carbon dioxide at -89°C to destroy the ectopic columnar epithelium by freezing, and it was transmitted to the ectopy through a flat cryoprobe. No routine anaesthesia or analgesia was administered. All patients were questioned about the status of their symptoms after 6 weeks of treatment.

RESULTS

The highest success rate was obtained in patients with abundant leucorrhoea (n = 102; 89.5%), while the lowest success rate was achieved in subjects with pelvic pain (n = 7; 58%). After treatment, no severe complications were observed, except for hydrorrhoea for a few days. Success rates were 9 times lower in patients who had 3 or more cervicitis episodes per 6 months.

CONCLUSION

In this study, the success rate of cryotherapy was highest in patients with abundant leucorrhoea and lowest in patients with pelvic pain and recurrent cervicitis. Hence, we recommend that clinicians perform the procedure in such patients without much delay.

Therapeutic effects of traditional Chinese medicine in patients with symptomatic cervical ectopy

PURPOSE

The aim of this study is to evaluate the treatment and efficacy of Badushengjigao, a traditional Chinese medicine (TCM) formula, for symptomatic cervical ectopy.

METHOD

A patient self-selected two group comparison study was performed. One hundred patients with symptomatic cervical ectopy admitted to the Central Hospital of E-Zhou (Hubei, China) between July 2013 and July 2014 were enrolled in the study. The patients treated with Badushengjigao were the study group and the patients treated with policresulen suppository were the control group. The medicine was administered through vagina. Patients received a three-month follow-up (once a month). The treatment results were evaluated and analyzed by variance analysis and X(2) test.

RESULTS

The curative rates of the two groups with symptomatic cervical ectopy grade 1 shows no statistical significance. As for grade 2 and grade 3, the curative rates of the study group (phase 2: 72.0%; phase 3: 62.5%) are higher than that of the control group (phase 2: 44.4%; grade 3: 54.5%) with statistical difference (P < 0.05). The study group has less adverse effects (2.5 ± 1.3 days of vagina bleeding, 6 cases of abdominal pain and 2 cases of increased discharge) than the control group (12.5 ± 1.1 days of vagina bleeding, 15 cases of abdominal pain and 42 cases of increased discharge) with distinctive statistical difference (P < 0.01).

CONCLUSION

The TCM formula, Badushengjigao, seems to be more effective than policresulen suppositories in treating symptomatic cervical ectopy phase 2 and phase 3. We suggest that it could be used as an alternative method for symptomatic cervical ectopy treatment, but further study is needed.

Cervicitis aetiology and case definition: a study in Australian women attending sexually transmitted infection clinics

OBJECTIVES

Studies examining cervicitis aetiology and prevalence lack comparability due to varying criteria for cervicitis. We aimed to outline cervicitis associations and suggest a best case definition.

METHODS

A cross-sectional study of 558 women at three sexually transmitted infection clinics in Sydney, Australia, 2006-2010, examined pathogen and behavioural associations of cervicitis using three cervicitis definitions: 'microscopy' (>30 pmnl/hpf (polymorphonuclear leucocytes per high-powered field on cervical Gram stain)), 'cervical discharge' (yellow and/or mucopurulent cervical discharge) or 'micro+cervical discharge' (combined 'microscopy' and 'cervical discharge').

RESULTS

Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Trichomonas vaginalis (TV) and Neisseria gonorrhoeae (NG) had the strongest associations with cervicitis definitions 'micro+cervical discharge': CT adjusted prevalence ratio (APR)=2.13 (95% CI 1.38 to 3.30) p=0.0006, MG APR=2.21 (1.33 to 3.69) p=0.002, TV APR=2.37 (1.44 to 3.90) p=0.0007 NG PR=4.42 (3.79 to 5.15) p<0.0001 and 'cervical discharge': CT APR=1.90 (1.25 to 2.89) p=0.003, MG APR=1.93 (1.17 to 3.19) p=0.011, TV APR=2.02 (1.24 to 3.31) p=0.005 NG PR=3.88 (3.36 to 4.48) p<0.0001. Condom use for vaginal sex 'always/sometimes' reduced cervicitis risk: ('micro+cervical discharge') APR=0.69 (0.51 to 0.93) p=0.016. Combined population attributable risk % (PAR%) of these four pathogens was only 18.0% with a protective PAR% of condoms of 25.7%. Exposures not associated with cervicitis included bacterial vaginosis, Mycoplasma hominis, Ureaplasma urealyticum, herpes simplex virus 1&2, cytomegalovirus, Candida, age, smoking and hormonal contraception.

CONCLUSIONS

Cervicitis was associated with CT, MG, TV and NG with combined PAR% of these pathogens only 18% in this setting, suggesting other factors are involved. Condoms significantly reduced cervicitis risk. Cervicitis definitions with best clinical utility and pathogen prediction were 'cervical discharge' and 'micro+cervical discharge'.

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.

Progesterone-based intrauterine device use is associated with a thinner apical layer of the human ectocervical epithelium and a lower ZO-1 mRNA expression

Currently, whether hormonal contraceptives affect male to female human immunodeficiency virus (HIV) transmission is being debated. In this study, we investigated whether the use of progesterone-based intrauterine devices (pIUDs) is associated with a thinning effect on the ectocervical squamous epithelium, down-regulation of epithelial junction proteins, and/or alteration of HIV target cell distribution in the human ectocervix. Ectocervical tissue biopsies from healthy premenopausal volunteers using pIUDs were collected and compared to biopsies obtained from two control groups, namely women using combined oral contraceptives (COCs) or who do not use hormonal contraceptives. In situ staining and image analysis were used to measure epithelial thickness and the presence of HIV receptors in tissue biopsies. Messenger RNA levels of epithelial junction markers were measured by quantitative PCR. The epithelial thickness displayed by women in the pIUD group was similar to those in the COC group, but significantly thinner as compared to women in the no hormonal contraceptive group. The thinner epithelial layer of the pIUD group was specific to the apical layer of the ectocervix. Furthermore, the pIUD group expressed significantly lower levels of the tight junction marker ZO-1 within the epithelium as compared to the COC group. Similar expression levels of HIV receptors and coreceptors CD4, CCR5, DC-SIGN, and Langerin were observed in the three study groups. Thus, women using pIUD displayed a thinner apical layer of the ectocervical epithelium and reduced ZO-1 expression as compared to control groups. These data suggest that pIUD use may weaken the ectocervical epithelial barrier against invading pathogens, including HIV.

Behavioral Decision Research Intervention Reduces Risky Sexual Behavior

Although adolescents are at disproportionate risk for sexually transmitted infections, most sex education programs have shown little effect on sexual behavior. An interactive video intervention developed by our team has been identified as one of a few programs that have been documented to reduce sexually transmitted infections in this population. Building on behavioral decision research, we used a mental models approach to interview young women about their sexual decisions, finding, among other things, the strong role of perceived social norms. We based our intervention on these results, aiming to help young women identify and implement personally and socially acceptable decision strategies. A randomized controlled trial found that the video reduced risky sexual behavior and the acquisition of chlamydia infection. We recently revised the video to suit more diverse audiences, and upgraded it to modern standards of cinematography and interactivity. It is now in field trial.

Cervical Ectropion and Intra-Uterine Contraceptive Device (IUCD): a five-year retrospective study of family planning clients of a tertiary health institution in Lagos Nigeria

Background

Cervical ectropion (also known as cervical erosion) is a common finding on routine pelvic examination during the fertile years. The decision to treat or not remains controversial. According to studies in support of routine treatment of cervical erosion, there is a possible relationship between squamous metaplasia and squamous cell carcinoma of the cervix. To determine the prevalence of cervical ectropion and associated risk factors among clients with intra-uterine contraceptive devices (IUCDs) attending a family planning clinic of a tertiary health institution in Lagos, Nigeria.

Methods

A 5-year retrospective study was conducted by assessing existing clinic records from years 2007–2011. Clients with IUCDs undergo routine pelvic examination during check-up visits. A total of 628 clients’ records were seen within the stated time frame. This study was approved by the ethical committee of the Lagos State University Teaching Hospital (LASUTH) and the collected data were analyzed using SPSS version 19.0.

Results

The mean age of the IUCD users was 34.7 ± 6.52 years, while 517 (82.3%) had secondary education. On routine pelvic examination, seventy-nine clients (12.6%) had cervical ectropion. Thirty-nine (6.2%) clients had presented with a history of abnormal vaginal bleeding while 12.1% had vaginal discharge. Treatments offered to cases of cervical ectropion include cervical painting with gentian violet (89.9%) and antibiotics prescription (58.2%). On bivariate analysis, previous hormonal contraceptive use (P = 0.041) and vaginal discharge (P < 0.001) were significantly associated with developing cervical ectropion. Clients with ectropion were significantly more likely to receive prescriptions for antibiotics (P < 0.001).

Conclusion

Less than one fifth of the clients had cervical erosion. However, routine pelvic examination could aid the detection and control of latent reproductive health problems such as cervical ectropion which may require further investigations for example, pap smears, to exclude potentially lethal conditions and to determine appropriate treatment modality.

Biological and behavioral risks for incident Chlamydia trachomatis infection in a prospective cohort

OBJECTIVE

To identify biological and behavioral risks for incident Chlamydia trachomatis among a prospective cohort of young women followed frequently.

METHODS

Our cohort of 629 women from two outpatient sites was seen every 4 months (October 2000 through April 2012) for behavioral interviews and infection testing. C trachomatis was tested annually and any time patients reported symptoms or possible exposure using commercial nucleic acid amplification tests. Analyses excluded baseline prevalent C trachomatis infections. Risk factors for incident C trachomatis were assessed using Cox proportional hazards models. Significant risks (P<.10) from bivariate models were entered in a multivariate model adjusted for four covariates chosen a priori (age, race or ethnicity, condom use, study site). Backward stepwise elimination produced a final parsimonious model retaining significant variables (P<.05) and the four adjustment variables.

RESULTS

The 629 women attended 9,594 total visits. Median follow-up time was 6.9 years (interquartile range 3.2-9.8), during which 97 (15%) women had incident C trachomatis. In the final multivariate model, incident C trachomatis was independently associated with human papillomavirus at the preceding visit (P<.01), smoking (P=.02), and weekly use of substances besides alcohol and marijuana (P<.01) since the prior visit. Among 207 women with available colpophotographs (1,742 visits), cervical ectopy was not a significant risk factor (P range=.16-.39 for ectopy as continuous and ordinal variables).

CONCLUSION

Novel risks for C trachomatis include preceding human papillomavirus, smoking, and substance use, which may reflect both biological and behavioral mechanisms of risk such as immune modulation, higher-risk sexual networks, or both. Improved understanding of the biological bases for C trachomatis risk would inform our strategies for C trachomatis control.

Cervicitis of unknown etiology

Cervicitis has been described by some as the female counterpart of urethritis in men. Over the years a number of clinical and microscopy-based definitions have been suggested in the literature. Clinical manifestations include mucopurulent discharge from the cervix, cervical friability (easy bleeding from the cervix with passage of a swab) and cervical ectopy. Microscopic definitions involving the use of Gram stain of cervical secretions have included either more than 10 white blood cells (WBCs) or more than 30 WBCs per high-power field. Combinations of these clinical and microscopic findings have been used in attempts to increase the accuracy of cervicitis diagnosis. When cervicitis was initially recognized as a clinical entity, several investigators reported the primary pathogens causing cervicitis as Neisseria gonorrhoeae and Chlamydia trachomatis. It is now well established that most cases of cervicitis are not caused by these two organisms. Most cases of cervicitis are of unknown etiology.

Hormonal contraception for women exposed to HIV infection

BACKGROUND

Concern about a possible association of hormonal contraception with HIV acquisition has been raised by three types of evidence. Firstly, high-dose progestogen treatment greatly increases HIV acquisition in female non-human primates. Secondly, biological plausibility for a link between hormonal contraception anf HIV acquisition is provided by evidence of a hypo-oestrogenic state induced by progestogen contraception with vaginal mucosal thinning, and evidence of effects on the humoral and cellular immune systems. Thirdly, some but not other large observational studies have found an increase in HIV acquisition among women using hormonal contraception.

OBJECTIVES

To determine, from the best available evidence, the effect of hormonal contraception on HIV acquisition.

SEARCH METHODS

We used the Cochrane Fertility Regulation Group trials search strategy.

SELECTION CRITERIA

Published, unpublished and ongoing trials with random allocation, comparing hormonal with non-hormonal methods, other hormonal methods or no contraception in women at risk of HIV acquisition.

DATA COLLECTION AND ANALYSIS

Data will be extracted from eligible trials onto a data extraction sheet and analysed using routine Cochrane Collaboration methodology,

MAIN RESULTS

One ongoing randomised trial was identified, with no data available to date.

AUTHORS' CONCLUSIONS

There is currently no robust evidence from randomized trials on the possible effect of hormonal contraception on HIV acquisition. High quality trials in this area are needed to inform counselling of individual woman and public health policy.

Prevalence and treatment outcome of cervicitis of unknown etiology

BACKGROUND

Mucopurulent cervicitis (MPC) is a clinical syndrome characterized by mucopurulent discharge from the cervix and other signs of inflammation. This was a phase III, multicenter study designed to evaluate the effectiveness of placebo versus empiric antibiotic treatment for clinical cure of MPC of unknown etiology at 2-month follow-up. Unfortunately, enrollment was terminated because of low accrual of women with cervicitis of unknown etiology, but important prevalence and outcome data were obtained.

METHODS

Five hundred seventy-seven women were screened for MPC. Women with MPC were randomized to the treatment or placebo arm of the study, and the 2 arms were evaluated based on the etiology, clinical cure rates, adverse events (AEs), and rates of pelvic inflammatory disease.

RESULTS

One hundred thirty-one (23% [131/577]) screened women were found to have MPC. Eighty-seven were enrolled and randomized. After excluding women with sexually transmitted infections and other exclusions, 61% (53/87) had cervicitis of unknown etiology. The overall clinical failure rate was 30% (10/33), and the clinical cure rate was only 24% (8/33). Rates were not significantly different between the arms. There were 24 gastrointestinal AEs in the treatment arm compared with 1 AE in the placebo arm.

CONCLUSIONS

More than half of the cases of MPC were of unknown etiology. Clinical cure rates for the placebo and treatment arms were extremely low, with most women concluding the study with a partial response. Gastrointestinal AEs were higher in the treatment arm.

Uterine cervical ectopy during reproductive age: cytological and microbiological findings

Cervical ectopy is common in adolescents, pregnant women, and those taking high doses of estrogen-containing contraceptives. The majority of cases have spontaneous reversion, but some cases can be persistent. Studies suggested that the adequacy of a Pap smear could be affected and there is an increased risk cervical infections. This study is a cross-sectional study conducted from December 2009 to February 2011 with 457 women with cervical ectopy and 736 without ectopy. Cervical samples were collected in vials for analysis by ThinPrep cytology (Hologic, Marlborough, MA). The Mann-Whitney test and Fisher's exact test (95% CI) were applied. The study was approved by the ethics committee of the Federal University of Ceará. The mean ages of the study group and control group were 28.7 (±14.8) and 33.6 (±7.5) years old, respectively (P < 0.0001). Negative diagnosis for malignancy and intraepithelial lesion was present in 399 (87%) cases and 705 (96%) in the study and control groups, respectively (P < 0.0001). Shift in the flora suggestive of bacterial vaginosis (BV) was observed more frequently in the study group: 74 (16.2%) than in the control group: 86(11.7%) (P = 0.017). The differences among the other morphotypes showed no significance. The smears were atypical in 12.7% (58/457) of the patients from the study group and in 4.2% (31/736) in the control group (P < 0.001; RR = 3 [2.033-4.712]). The association between ectopy and inflammatory cytology, the presence of the shift in the flora suggestive of BV and cytological atypia is evident.

Recurrent vulvovaginal candidosis among young women in south eastern Nigeria: the role of lifestyle and health-care practices

This work was carried out to study the association between lifestyle, health-care practices and incidence of recurrent vulvovaginal candidosis (RVVC) among young women in south eastern Nigeria. It was a multicentre case-control study of 176 women aged between 20 and 35 years recruited from the designated health facilities. Lifestyle and health-care practice structured questionnaires were used to survey the participants. Clinical examination was performed and vaginal swabs were taken from participants for microscopy, culture and sensitivity. The germ tube test was performed for identification of Candida albicans. The results of this study showed that frequent douching with water or other fluids (odds ratio [OR](adjusted) = 2.41, 95% confidence interval [CI] = 1.25-4.66, P = 0.000), wearing tight nylon/synthetic underwear (OR(adjusted) = 4.76, 95% CI = 2.28-9.95, P = 0.000), alternative medical treatment for repeated or recalcitrant cases (OR(adjusted) = 4.84, 95% CI = 2.94-15.91, P = 0.000), were significantly associated with higher odds for RVVC and self-diagnosis and use of over-the-counter antifungal medications (OR(adjusted) = 4.61, 95% CI = 2.29-9.32, P = 0.000) were associated with RVVC. Results of the fungal cultures showed that C. albicans and non-C. albicans were isolated from 83.7% and 16.3% of participants, respectively. Our results supported the association between some of the hypothesized risk factors and the occurrence of RVVC.

Correlation of leukorrhea and Trichomonas vaginalis infection

Trichomonas vaginalis is a common sexually transmitted infection (STI) causing vaginitis. Microscopy has poor sensitivity but is used for diagnosis of trichomoniasis in resource-poor settings. We aimed to provide a more reliable diagnosis of trichomoniasis by investigating an association with leukorrhea. Women presenting for evaluation of vaginal discharge, STI exposure, or preventative gynecologic examination were evaluated for Trichomonas infection. Vaginal pH was determined and microscopy was performed by the provider, who recorded the number of polymorphonuclear leukocytes (PMNLs) per epithelial cell and the presence of clue cells, yeast, and/or motile trichomonads. Leukorrhea was defined as greater than one PMNL per epithelial cell. Culture and a nucleic acid amplification test (NAAT) were used to detect T. vaginalis. Patients were evaluated for Chlamydia trachomatis and Neisseria gonorrhoeae using NAATs and bacterial vaginosis using Gram stains. Two hundred ninety-four women were enrolled, and 16% were found to have Trichomonas (46/294). Trichomonas infection was more common in parous non-Hispanic, black women, who reported low rates of contraceptive use (33% versus 17%; P = 0.02) and a STI history (85% versus 55%; P = 0.002). These women were more likely to report vaginal discharge (76% versus 59%; P = 0.02) and have an elevated vaginal pH (87% versus 48%; P < 0.001) and gonorrhea infection (15% versus 4%; P = 0.002). Leukorrhea was associated with a 4-fold-increased risk of Trichomonas infection. Leukorrhea on microscopy was associated with Trichomonas vaginitis. Patients with leukorrhea should be evaluated with more-sensitive tests for T. vaginalis, preferably NAATs, if microscopy is negative.

Therapeutic effects of focused ultrasound in 4014 patients with symptomatic cervical ectopy

This study aimed to explore the therapeutic effect of focused ultrasound (FU) therapy in patients with symptomatic cervical ectopy. 4677 patients with symptomatic cervical ectopy were enrolled and treated with FU. Three months after treatment, we analyzed the therapeutic effects and the adverse reactions in 4014 cases with complete records. All influential factors were also analyzed with logistic regression analysis. For the treatment of symptomatic cervical ectopy, the effective rate of FU was 99.8%, and the cure rate was 72.52%. Bleeding that either reached or exceeded normal menstrual volume occurred in 12 cases. Logistic regression analysis showed that the degree of illness, vaginal cleanliness, economic level, occupation, age and artificial abortion frequency were all influential factors. Focused ultrasound is a promising new therapeutic option for the treatment of symptomatic cervical ectopy. Additionally, it can be widely used for a variety of patients.

Innate and adaptive anti-HIV immune responses in the female reproductive tract

The mucosal surface of the female reproductive tract (FRT) is the primary site of transmission for a plethora of sexually transmitted infections, including human immunodeficiency virus (HIV), that represent a significant burden upon womens' health worldwide. However, fundamental aspects of innate and adaptive immune protection against HIV infection in the FRT are poorly understood. The FRT immune system is regulated by the cyclical changes of the sex hormones estradiol and progesterone across the menstrual cycle, which as we have hypothesized, leads to the creation of a window of vulnerability during the secretory stage of the menstrual cycle, when the risk of HIV transmission is increased. The goal of this review is to summarize the multiple levels of protection against HIV infection in the FRT, the contribution of different cell types including epithelial cells, macrophages, T cells, and dendritic cells to this, and their regulation by estradiol and progesterone. Understanding the unique immune environment in the FRT will allow for the potential development of novel therapeutic interventions such as vaccines and microbicides that may reduce or prevent HIV transmission in women.

Incidence and correlates of Chlamydia trachomatis infection in a high-risk cohort of Kenyan women

BACKGROUND

In Africa, data on Chlamydia trachomatis infection are scarce because reliable diagnosis is costly and not widely available. Our objective was to evaluate the incidence and correlates of C. trachomatis infection among high-risk Kenyan women.

METHODS

We conducted prospective cohort analyses using data from a cohort of women who reported transactional sex. C. trachomatis testing was performed using the Gen-Probe Aptima GC/CT Detection System. We used Andersen-Gill proportional hazards modeling to evaluate correlates of C. trachomatis.

RESULTS

Between August 2006 and December 2010, 865 women contributed 2011 person-years of observation. Sixty-four women experienced 101 episodes of C. trachomatis infection (incidence rate, 5.0/100 person-years). There was a large difference in incidence by age group: those younger than 25 years had an incidence of 27.6 per 100 person-years (95% confidence interval [CI], 16.3-46.5), those 25 to 34 years old had an incidence of 8.4 per 100 person-years (95% CI, 6.4-11.0), and those 35 years and older had an incidence of 2.6 per 100 person-years (95% CI, 1.8-3.6). In multivariate analyses, younger age (<25 and 25-34 years vs. ≥35 years; hazard ratio [HR], 8.5 [95% CI, 4.1-17.7] and 2.9 [95% CI, 1.7-5.0], respectively), depot medroxyprogesterone acetate use (HR, 1.8; 95% CI, 1.1-3.0), and recent Neisseria gonorrhoeae infection (HR, 3.3; 95% CI, 1.5-7.4) were significantly associated with increased risk of acquiring C. trachomatis infection.

CONCLUSIONS

The high incidence of C. trachomatis among younger high-risk women suggests the need for screening as an important public health intervention for this population.

Hormonal contraceptive use and female-to-male HIV transmission: a systematic review of the epidemiologic evidence

OBJECTIVE

To systematically review epidemiologic evidence assessing whether hormonal contraception alters the risk of HIV transmission from an HIV-positive woman to an HIV-negative male partner.

DESIGN

Systematic review.

METHODS

We included articles published or in press through December 15, 2011. We assessed studies with direct evidence on hormonal contraception use and HIV transmission, and summarized studies with indirect evidence related to genital or plasma viral load.

RESULTS

: One study provided direct evidence on oral contraceptive pills (OCPs) or injectable contraception and female-to-male HIV transmission; both injectables [Cox-adjusted hazard ratio (adjHR) 1.95, 95% confidence interval (CI) 1.06-3.58; marginal structural model (MSM) adjusted odds ratio (adjOR) 3.01, 95% CI 1.47-6.16] and OCPs (Cox adjHR 2.09, 95% CI 0.75-5.84; MSM adjOR 2.35, 95% CI 0.79-6.95) generated elevated point estimates, but only estimates for injectables were significant. Findings from 11 indirect studies assessing various hormonal contraception methods and viral genital shedding or setpoint were mixed, and seven of eight studies indicated no adverse effect of various hormonal contraception methods on plasma viral load.

CONCLUSION

The only direct study on OCPs or injectable contraception and female-to-male HIV transmission suggests increased risk with the use of injectables. Given the potential for confounding in observational data, the paucity of direct evidence on this subject, and mixed indirect evidence, additional evidence is needed.

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.

Genital immunology and HIV susceptibility in young women

Women account for a substantial majority of HIV infections in endemic regions, where women are also infected at a much younger age than men. Part of this epidemiological skewing is due to socio-cultural factors, but it is clear that biological factors enhance the susceptibility of women--particularly young women--to HIV acquisition after sexual exposure. These factors, including important differences in mucosal immunology at the site of genital HIV exposure, are the focus of this concise review. Compared to heterosexual men, women have an increased surface area of mucosal HIV exposure, increased mucosal expression of the HIV co-receptor CCR5 and a greater probability of virus exposure on the rectal mucosa. Differences that are specific to young women include a pro-inflammatory immune environment and a proportionate increase in single-cell, columnar genital epithelium. These important biological reasons for enhanced HIV susceptibility in young women highlight the need for targeted HIV prevention within this vulnerable population.

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.

Mycoplasma genitalium infection in women attending a sexually transmitted infection clinic: diagnostic specimen type, coinfections, and predictors

In female sexually transmitted infection clinic attendees, Mycoplasma genitalium was more frequently detected using vaginal (53/73) versus endocervical (43/73) specimens. In women without other sexually transmitted infections, M. genitalium detection (N = 44) was associated with age ≤22 years (odds ratio, 2.53; P = 0.006) and clinical evidence of cervicitis (odds ratio, 2.11; P = 0.03).

Using platelet-rich plasma for the treatment of symptomatic cervical ectopy

OBJECTIVE

To evaluate the effectiveness of autologous platelet-rich plasma (PRP) applications in the treatment of benign cervical ectopy.

METHODS

Symptomatic women with benign cervical ectopy (n=120) were randomized to a PRP or a laser group. In the PRP group, PRP was applied twice on the cervical erosion with a 1-week interval. In the laser group, an Nd-YAG laser was used once for tissue vaporization.

RESULTS

The complete cure rates were 93.7% for the PRP and 92.4% for the laser group (P>0.05). The mean time to re-epithelialization was significantly shorter in the PRP (6.41 ± 2.05 weeks) than in the laser group (8.28 ± 1.72 weeks) (P<0.01). The rate of adverse treatment effects (i.e. vaginal discharge or vaginal bleeding) was much lower in the PRP than that in the laser group (P<0.01) and the effects were milder. Eleven patients in the PRP group had mild or moderate vaginal bleeding after treatment but none had heavy bleeding. Of 25 patients with vaginal bleeding in the laser group, 2 had heavy bleeding necessitating tamponade.

CONCLUSION

Autologous PRP applications appear promising for the treatment of cervical ectopy in symptomatic women, as they generate a shorter tissue healing time and milder adverse effects than laser treatment.

Postpartum sexually transmitted disease: refining our understanding of the population at risk

BACKGROUND

Scant literature exists on sexually transmitted disease (STD) risk specific to pregnancy and postpartum. The objective of this prospective study is to examine risk factors for incident postpartum STDs among young mothers (ages, 14-25).

METHODS

Pregnant women were enrolled at <24 weeks gestation (N = 848). Data were collected via in-depth interviews and STD testing conducted in the second and third trimesters and at 6 and 12 months postpartum. Prevalence and incidence of STD diagnosis in pregnancy and postpartum is described. Logistic and linear regression are used to identify risk factors for postpartum infection.

RESULTS

Forty-four percent of enrolled women never had an STD, 29% had a history of an STD before pregnancy, 28% got an STD during pregnancy, and 27% were diagnosed with an STD postpartum. Incidence of postpartum infection was higher for women who contracted an STD in pregnancy (43%) compared with those with a prior STD (24%) or no STD (19%). In multivariate analysis, STD in pregnancy, having less than high school education, having a new sexual partner, and black race were risk factors for incident postpartum STD.

CONCLUSION

Prenatal providers should be aware of the significant risk of incident infection among women diagnosed with STDs in pregnancy. Elevated postpartum incidence among those with an STD in pregnancy supports a shift toward more frequent and targeted postpartum STD screening, with implications for clinical care, future research, and interventions.

Bridging the gap between preclinical and clinical microbicide trials: blind evaluation of candidate gels in murine models of efficacy and safety

Background

Despite significant protection in preclinical studies, cellulose sulfate (CS) failed to protect women against HIV-1/2 and was associated with a trend toward increased HIV-1 acquisition in one of the clinical trials. These results highlight the need for preclinical tests more predictive of clinical outcomes. The objective of this study was to test coded vaginal gels, including CS, in murine models of safety and efficacy to determine the models' utility for evaluating future products.

Methods

Four coded formulations, including 6% CS, 2% PRO 2000 and two placebo gels, were administered intravaginally to medroxyprogesterone-treated mice and their ability to prevent genital herpes (efficacy) or to alter the susceptibility to low dose HSV challenge (safety) was determined. Nonoyxnol-9 served as a positive toxicity control.

Results

CS and PRO 2000 significantly protected mice from genital herpes following infection with a laboratory or clinical isolate of HSV-2 introduced in buffer (p<0.001). However, protection was reduced when virus was introduced in seminal plasma. Moreover, mice were significantly more susceptible to infection with low doses of HSV-2 when challenged 12 h after the 7th daily dose of CS or nonoxynol-9 (p<0.05). The increased susceptibility was associated with alterations in epithelial architecture.

Conclusions

CS prevented genital herpes when present at the time of viral challenge, but increased the rate of infection when gel was applied daily for 7 days with a vaginal wash prior to viral inoculation. The findings presumably reflect altered epithelial architecture, which may have contributed to the trend towards increased HIV observed clinically.

Oral contraceptive and progestin-only use correlates to tissue tumor marker expression in women with cervical intraepithelial neoplasia

BACKGROUND

The study was conducted to investigate correlations between combined oral contraceptive (COC), any progestin-only contraceptive, medicated intrauterine device (MID) or systemic progestin-only (Syst-P) use and tumor marker expression in cervical intraepithelial neoplasia compared to nonusers.

STUDY DESIGN

One-hundred ninety-five women of fertile age with cervical biopsies ranging histologically from normal epithelium to carcinoma in situ were recruited consecutively. Combined oral contraceptive, Syst-P and MID users were investigated according to the expression of 11 tumor markers.

RESULTS

Overexpression of cyclooxygenase-2 (Cox-2) was observed in COC users, while interleukin 10 was underexpressed. When users of progestogen-only contraceptives were analyzed, there was a lower expression of cytokeratin 10 and interleukin 10. When only MID users were analyzed, a high expression of p53 was found. Expression of Cox-2, p53 and retinoblastoma protein differed between COC and MID users.

CONCLUSION

The study showed molecular alterations, which, in general, have not been studied previously in COC users and have never been studied in progestogen-only users. These biological events might be involved in epidemiological correlations found between hormonal contraceptive use and cervical neoplasms.

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.