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Armstrong-Buisseret L, Brittain C, Kai J, David M, Anstey Watkins J, Ozolins M, Jackson L, Abdali Z, Hepburn T, Griffiths F, Montgomery A, Daniels J, Manley A, Dean G, Ross JDC. Lactic acid gel versus metronidazole for recurrent bacterial vaginosis in women aged 16 years and over: the VITA RCT. Health Technol Assess 2022; 26:1-170. [DOI: 10.3310/zzkh4176] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background
Bacterial vaginosis is a common and distressing condition associated with serious comorbidities. Antibiotic treatment is usually clinically effective in the short term, but recurrence is common and side effects can occur.
Objectives
The objective is to assess whether or not intravaginal lactic acid gel is clinically effective and cost-effective for treating recurrent bacterial vaginosis compared with oral metronidazole (Flagyl, Sanofi).
Design
This was an open-label, multicentre, parallel-arm, randomised (1 : 1) controlled trial.
Setting
This took place in one general practice and 19 sexual health centres in the UK.
Participants
Women aged ≥ 16 years with bacterial vaginosis symptoms and one or more episode(s) within the past 2 years took part.
Interventions
The interventions were 5 ml of intravaginal lactic acid gel taken once daily for 7 days (intervention) or 400-mg oral metronidazole tablets taken twice daily for 7 days (control).
Main outcome measures
The primary outcome was the resolution of bacterial vaginosis symptoms 14 days after randomisation. The secondary outcomes were time to first recurrence of symptoms; number of recurrences and treatment courses over 6 months; microbiological resolution on microscopy of vaginal smears at week 2; time to resolution of symptoms; tolerability, adherence and acceptability of the treatment; prevalence of concurrent sexually transmitted infections; quality of life; and cost-effectiveness.
Results
Recruitment stopped prior to reaching the target of 1900 participants on recommendation from the Data Monitoring Committee and Trial Steering Committee after a planned review of the results indicated that the research question had been answered. Overall, 518 participants were randomised and primary outcome data were available for 409 participants (79%; 204 in the metronidazole arm, 205 in the lactic acid gel arm). Participant-reported symptom resolution at week 2 was higher with metronidazole (143/204; 70%) than with lactic acid gel (97/205; 47%) (adjusted risk difference –23.2%, 95% confidence interval –32.3% to –14.0%). Recurrence in 6 months in a subset of participants who had initial resolution and were available for follow-up was similar across arms (metronidazole arm: 51/72, 71%; lactic acid gel arm: 32/46, 70%). A higher incidence of some side effects was reported with metronidazole than with lactic acid gel (nausea 32% vs. 8%; taste changes 18% vs. 1%; diarrhoea 20% vs. 6%, respectively). At week 2, the average cost per participant with resolved symptoms was £86.94 (metronidazole), compared with £147.00 (lactic acid gel). Some participants preferred using lactic acid gel even if they perceived it to be less effective than metronidazole.
Limitations
Loss to follow-up for collection of the primary outcome data was 21% and was similar in both arms. There is a risk of bias owing to missing outcome data at 3 and 6 months post treatment.
Conclusions
A higher initial response was seen with metronidazole than with lactic acid gel, but subsequent treatment failure was common with both. Lactic acid gel was less cost-effective than metronidazole. In general, women disliked taking repeated courses of metronidazole and preferred lactic acid gel, even when they were aware that it was less likely to provide symptom resolution. In the absence of effective curative therapy, further evaluation of non-antibiotic treatments to control the symptoms of recurrent bacterial vaginosis is required to improve quality of life for these patients. Further microbiological analysis of vaginal samples would be useful to identify additional factors affecting response to treatment.
Trial registration
Current Controlled Trials ISRCTN14161293.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Clare Brittain
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Joe Kai
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Miruna David
- Clinical Microbiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mara Ozolins
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zainab Abdali
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Alan Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alice Manley
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jonathan DC Ross
- Department of Genitourinary Medicine, Whittall Street Clinic, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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2
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Sarmento ACA, Kamilos MF, Costa APF, Vieira-Baptista P, Eleutério J, Gonçalves AK. Use of Moisturizers and Lubricants for Vulvovaginal Atrophy. FRONTIERS IN REPRODUCTIVE HEALTH 2021; 3:781353. [PMID: 36303977 PMCID: PMC9580673 DOI: 10.3389/frph.2021.781353] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/07/2021] [Indexed: 11/13/2022] Open
Abstract
The estrogen decrease in postmenopausal women results in functional and anatomical changes in the genitourinary tract. The most prevalent and bothersome symptoms are vaginal dryness, dyspareunia, and reduced lubrication, which can significantly affect the quality of life of these women, principally those who are sexually active. Hormonal therapy with local estrogens is generally considered the “gold standard.” However, there are cases in which there are clinical concerns about its use or women opt for non-hormonal options. Thus, safe and effective non-hormonal options are needed to improve symptoms in these women. Moisturizers and lubricants are first-line therapy for breast cancer survivors.
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Affiliation(s)
- Ayane Cristine Alves Sarmento
- Health Sciences Postgraduate Program, Federal University of Rio Grande Do Norte (UFRN), Natal, Brazil
- *Correspondence: Ayane Cristine Alves Sarmento
| | | | - Ana Paula Ferreira Costa
- Health Sciences Postgraduate Program, Federal University of Rio Grande Do Norte (UFRN), Natal, Brazil
| | - Pedro Vieira-Baptista
- Lower Genital Tract Unit, Centro Hospitalar de São João, Porto, Portugal
- Hospital Lusíadas Porto, Porto, Portugal
| | - José Eleutério
- Department of Obstetrics and Gynecology, Federal University of Ceará, Fortaleza, Brazil
| | - Ana Katherine Gonçalves
- Health Sciences Postgraduate Program, Federal University of Rio Grande Do Norte (UFRN), Natal, Brazil
- Department of Obstetrics and Gynaecology, Federal University of Rio Grande Do Norte (UFRN), Natal, Brazil
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Tomás M, Palmeira-de-Oliveira A, Simões S, Martinez-de-Oliveira J, Palmeira-de-Oliveira R. Bacterial vaginosis: Standard treatments and alternative strategies. Int J Pharm 2020; 587:119659. [PMID: 32687973 DOI: 10.1016/j.ijpharm.2020.119659] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/24/2020] [Accepted: 07/13/2020] [Indexed: 12/23/2022]
Abstract
Bacterial vaginosis (BV) affects many women and has a high influence on their self-esteem, being associated with huge discomfort and changes in the routines, especially the sexual life. International guidelines recommend the administration of metronidazole, clindamycin or tinidazole orally or intravaginally as the standard treatment. However, the treatment with these antibiotics is associated with high levels of failure and recurrence rates. These may be associated with antibiotic resistance, the inability to eradicate the polymicrobial biofilms, and failure to reestablish acidic pH and the lactobacillus-dominated commensal flora. Therefore, it is emergent to study alternative strategies to replace or to be combined with standard therapies in order to prevent and treat BV more efficiently. Alternative strategies may include antimicrobial substances (other antimicrobials, antiseptics and natural compounds) or substances that aim to reestablish the physiologic vaginal environment (probiotics, prebiotics and acidifying agents) while improving the local immunity response. Besides, the development of formulation strategies and new dosage forms and drug delivery systems can improve treatment efficacy and overcome some limitations associated with conventional products.
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Affiliation(s)
- Mariana Tomás
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal; Labfit-HPRD Health Products Research and Development, Lda Edifício UBIMedical, Estrada Municipal 506, 6200-281 Covilhã, Portugal
| | - Sérgio Simões
- CNC-Center for Neurosciences and Cell Biology, University of Coimbra, 3004-531 Coimbra, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal
| | - Rita Palmeira-de-Oliveira
- CICS-UBI, Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Avenida, Infante D. Henrique, 6200-506 Covilhã, Portugal; CNC-Center for Neurosciences and Cell Biology, University of Coimbra, 3004-531 Coimbra, Portugal.
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Armstrong-Buisseret L, Brittain C, David M, Dean G, Griffiths F, Hepburn T, Jackson L, Kai J, Montgomery A, Roberts T, Thandi S, Ross JDC. Metronidazole versus lactic acid for treating bacterial vaginosis (VITA): protocol for a randomised controlled trial to assess the clinical and cost effectiveness of topical lactic acid gel for treating second and subsequent episodes of bacterial vaginosis. Trials 2019; 20:648. [PMID: 31775859 PMCID: PMC6880606 DOI: 10.1186/s13063-019-3731-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
Background Bacterial vaginosis (BV) affects 30–50% of women at some time in their lives and is an embarrassing and distressing condition which can be associated with potentially serious comorbidities. Current antibiotic treatments such as metronidazole are effective but can result in side effects, and recurrence is common. This trial aims to investigate whether lactic acid gel is clinically effective and cost effective in the treatment of recurrent BV compared with metronidazole. Methods VITA is an open-label, multicentre, parallel group randomised controlled trial for women with a clinical diagnosis of BV and at least one previous BV episode in the past 2 years. Participants will be randomised 1:1 to intravaginal lactic acid gel 5 ml once daily for 7 days or oral metronidazole tablets 400 mg twice daily for 7 days. All participants will be followed up for 6 months to assess health status and healthcare costs. A subgroup will be interviewed to further explore adherence, tolerability and acceptability of treatment. The estimated sample size is 1900 participants to detect a 6% absolute increase in response rate to 86% in those receiving lactic acid gel. The primary outcome is participant-reported resolution of BV at Week 2. Discussion Results from this trial will help inform UK treatment guidelines for BV and may provide an alternative effective treatment for recurrent episodes of this condition which avoids repeated exposure to antibiotics. Trial registration ISRCTN, ISRCTN14161293. Registered on 8 September 2017.
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Affiliation(s)
- Lindsay Armstrong-Buisseret
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Clare Brittain
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Miruna David
- Clinical Microbiology, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Gillian Dean
- Elton John Research Centre, Sussex House, 1 Abbey Road, Brighton, BN2 1ES, UK
| | - Frances Griffiths
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Louise Jackson
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Joe Kai
- School of Medicine, Tower Building, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Alan Montgomery
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Tracy Roberts
- Health Economics Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Sukhwinder Thandi
- Nottingham Clinical Trials Unit (NCTU), Building 42, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Jonathan D C Ross
- Department of GU Medicine, University Hospitals Birmingham NHS Foundation Trust, Whittall Street Clinic, Whittall Street, Birmingham, B4 6DH, UK.
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Melis GB, Piras B, Marotto MF, Neri M, Corda V, Vallerino V, Saba A, Lello S, Pilloni M, Zedda P, Paoletti AM, Mais V. The stimulation of the vaginal immune system with short-term administration of a vaginal gel containing fraction of Propionibacterium acnes, hyaluronic acid and polycarbophil is efficacious in vaginal infections dependent on disorders in the vaginal ecosystem. Gynecol Endocrinol 2018; 34:880-883. [PMID: 29648469 DOI: 10.1080/09513590.2018.1460345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
The vaginal immune system (VIS) is the first defense against antigens recognized as foreign. Substances capable of locally activating the VIS could be a valid strategy to treat vulvo-vaginal infections (VVI), caused by changes in the vaginal ecosystem, such as bacterial vaginosis (BV), vulvo-vaginal candidiasis (CA), and mixed vaginitis (MV). Bacterial lysates, obtained by crushing bacterial cultures, exert immuno-modulatory activities. The parietal fraction from Propionibacterium acnes is a patent of Depofarma (MoglianoVeneto, Italy). The preparation that associates such fraction to hyaluronic acid and polycarbophil is a registered trademark, commercially available in Italy as vaginal gel, Immunovag®. The study aimed to evaluate whether a 5-day-treatment with Immunovag® improves the symptoms and signs of VVI, in 60 women with Gardnerella vaginalis (GV), 154 with CA, 95 with MV, diagnosed with vulvar vaginal swab (VVS), and in 283 with BV, diagnosed with the Amsel criteria. At the end of the treatment (visit 2), the symptoms and signs of VVI disappeared in a significant number of subjects (χ2p < .02 vs pre-treatment) in all VVI groups, and their intensity was significantly (p < .0002) reduced in the subjects in which they were still present. Immunovag® represents a valid treatment of VVI induced by changes in the vaginal ecosystem.
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Affiliation(s)
- Gian Benedetto Melis
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Bruno Piras
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Maria Francesca Marotto
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Manuela Neri
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valentina Corda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valerio Vallerino
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Alessandra Saba
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Stefano Lello
- c Department of Health Protection for Women and Children , Gemelli Polyclinic Foundation, Rome , Italy
| | - Monica Pilloni
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Pierina Zedda
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Anna Maria Paoletti
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
| | - Valerio Mais
- a Department of Surgical Sciences , University of Cagliari , Cagliari , CA , Italy
- b Department of Obstetrics and Gynecology , University Hospital of Cagliari (AOUCA) , Cagliari , CA , Italy
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Multifunctional Tannic Acid/Silver Nanoparticle-Based Mucoadhesive Hydrogel for Improved Local Treatment of HSV Infection: In Vitro and In Vivo Studies. Int J Mol Sci 2018; 19:ijms19020387. [PMID: 29382085 PMCID: PMC5855609 DOI: 10.3390/ijms19020387] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 12/31/2022] Open
Abstract
Mucoadhesive gelling systems with tannic acid modified silver nanoparticles were developed for effective treatment of herpes virus infections. To increase nanoparticle residence time after local application, semi solid formulations designed from generally regarded as safe (GRAS) excipients were investigated for their rheological and mechanical properties followed with ex vivo mucoadhesive behavior to the porcine vaginal mucosa. Particular effort was made to evaluate the activity of nanoparticle-based hydrogels toward herpes simplex virus (HSV) type 1 and 2 infection in vitro in immortal human keratinocyte cell line and in vivo using murine model of HSV-2 genital infection. The effect of infectivity was determined by real time quantitative polymerase chain reaction, plaque assay, inactivation, attachment, penetration and cell-to-cell assessments. All analyzed nanoparticle-based hydrogels exhibited pseudoplastic and thixotropic properties. Viscosity and mechanical measurements of hydrogels were found to correlate with the mucoadhesive properties. The results confirmed the ability of nanoparticle-based hydrogels to affect viral attachment, impede penetration and cell-to-cell transmission, although profound differences in the activity evoked by tested preparations toward HSV-1 and HSV-2 were noted. In addition, these findings demonstrated the in vivo potential of tannic acid modified silver nanoparticle-based hydrogels for vaginal treatment of HSV-2 genital infection.
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Caramella CM, Rossi S, Ferrari F, Bonferoni MC, Sandri G. Mucoadhesive and thermogelling systems for vaginal drug delivery. Adv Drug Deliv Rev 2015; 92:39-52. [PMID: 25683694 DOI: 10.1016/j.addr.2015.02.001] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 01/29/2015] [Accepted: 02/06/2015] [Indexed: 11/28/2022]
Abstract
This review focuses on two formulation approaches, mucoadhesion and thermogelling, intended for prolonging residence time on vaginal mucosa of medical devices or drug delivery systems, thus improving their efficacy. The review, after a brief description of the vaginal environment and, in particular, of the vaginal secretions that strongly affect in vivo performance of vaginal formulations, deals with the above delivery systems. As for mucoadhesive systems, conventional formulations (gels, tablets, suppositories and emulsions) and novel drug delivery systems (micro-, nano-particles) intended for vaginal administration to achieve either local or systemic effect are reviewed. As for thermogelling systems, poly(ethylene oxide-propylene oxide-ethylene oxide) copolymer-based and chitosan-based formulations are discussed as thermogelling systems. The methods employed for functional characterization of both mucoadhesive and thermogelling drug delivery systems are also briefly described.
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Affiliation(s)
- Carla M Caramella
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Silvia Rossi
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy
| | - Franca Ferrari
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy
| | | | - Giuseppina Sandri
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy
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Palmeira-de-Oliveira R, Palmeira-de-Oliveira A, Martinez-de-Oliveira J. New strategies for local treatment of vaginal infections. Adv Drug Deliv Rev 2015; 92:105-22. [PMID: 26144995 DOI: 10.1016/j.addr.2015.06.008] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 06/15/2015] [Accepted: 06/24/2015] [Indexed: 01/07/2023]
Abstract
Vaginal infections are extremely prevalent, particularly among women of reproductive age. Although they do not result in high mortality rates, these infections are associated with high levels of anxiety and reduction of quality of life. In most cases, topical treatment of vaginal infections has been shown to be at least as effective as oral treatment, resulting in higher local drug concentrations, with fewer drug interactions and adverse effects. Furthermore, the emergence of microbial resistance to chemotherapeutics and the difficulties in managing infection recurrences sustain the need for more effective local treatments. However, conventional dosage forms have been associated with low retention in the vagina and discomfort. Formulation strategies such as the development of bioadhesive, thermogelling systems and microtechnological or nanotechnological approaches have been proposed to improve delivery of traditional drugs, and other treatment modalities such as new drugs, plant extracts, and probiotics are being studied. This article reviews the recent strategies studied to improve the treatment and prevention of the commonest vaginal infections-namely, vaginal bacteriosis, aerobic vaginitis, vulvovaginal candidosis, and trichomoniasis-through the intravaginal route.
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Cunha AR, Machado RM, Palmeira-de-Oliveira A, Martinez-de-Oliveira J, das Neves J, Palmeira-de-Oliveira R. Characterization of commercially available vaginal lubricants: a safety perspective. Pharmaceutics 2014; 6:530-42. [PMID: 25247884 PMCID: PMC4190534 DOI: 10.3390/pharmaceutics6030530] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 09/05/2014] [Accepted: 09/09/2014] [Indexed: 12/21/2022] Open
Abstract
Vaginal lubricants are widely used by women to help solve intercourse difficulties or as enhancers, but recent reports raise questions about their safety. Twelve commercially available gel products were tested for pH value, pH buffering capacity, osmolality and cytotoxicity relevant to vaginal delivery. Obtained data were analyzed in light of the recent Advisory Note by the World Health Organization (WHO) for personal lubricants to be concomitantly used with condoms. Results showed that most products do not comply with pH and osmolality recommended standards, thus posing a potential hazard. Four products presented values of osmolality around three-times higher than the maximum acceptable limit of 1200 mOsm/kg. In vitro cell testing further identified substantial cytotoxicity even at 1:100 dilutions for three products, contrasting with no significant effect of up to at least a 1:5 dilution of a Universal Placebo gel. However, no direct correlation between these last results and pH or osmolality was found, thus suggesting that the individual toxicity of specific formulation components plays an important role in the outcome of a particular product. Although further assessment is required, these results highlight potential safety issues related to the formulation of commercially available vaginal lubricants.
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Affiliation(s)
- Ana Raquel Cunha
- CICS-UBI: Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; E-Mails: (A.R.C.); (R.M.M.); (A.P.-d.-O.); (J.M.-d.-O.)
| | - Rita M. Machado
- CICS-UBI: Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; E-Mails: (A.R.C.); (R.M.M.); (A.P.-d.-O.); (J.M.-d.-O.)
- Labfit–Health Products Research and Development (HPRD), Lda, 6200-506 Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- CICS-UBI: Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; E-Mails: (A.R.C.); (R.M.M.); (A.P.-d.-O.); (J.M.-d.-O.)
- Labfit–Health Products Research and Development (HPRD), Lda, 6200-506 Covilhã, Portugal
| | - José Martinez-de-Oliveira
- CICS-UBI: Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; E-Mails: (A.R.C.); (R.M.M.); (A.P.-d.-O.); (J.M.-d.-O.)
- Child and Women Health Department, Centro Hospitalar Cova da Beira, 6200-251 Covilhã, Portugal
| | - José das Neves
- INEB–Instituto de Engenharia Biomédica, University of Porto, 4150-180 Porto, Portugal
- CESPU, Instituto de Investigação e Formação Avançada em Ciências e Tecnologias da Saúde, 4585-116 Gandra PRD, Portugal
| | - Rita Palmeira-de-Oliveira
- CICS-UBI: Health Sciences Research Center, Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; E-Mails: (A.R.C.); (R.M.M.); (A.P.-d.-O.); (J.M.-d.-O.)
- Labfit–Health Products Research and Development (HPRD), Lda, 6200-506 Covilhã, Portugal
- Pharmacy Department, Centro Hospitalar Cova da Beira, 6200-251 Covilhã, Portugal
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10
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Africa CWJ, Nel J, Stemmet M. Anaerobes and bacterial vaginosis in pregnancy: virulence factors contributing to vaginal colonisation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:6979-7000. [PMID: 25014248 PMCID: PMC4113856 DOI: 10.3390/ijerph110706979] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/25/2014] [Accepted: 06/30/2014] [Indexed: 12/21/2022]
Abstract
The aetiology and pathogenesis of bacterial vaginosis (BV) is unclear but it appears to be associated with factors that disrupt the normal acidity of the vagina thus altering the equilibrium between the normal vaginal microbiota. BV has serious implications for female morbidity, including reports of pelvic inflammatory disease, adverse pregnancy outcomes, increased susceptibility to sexually transmitted infections and infertility. This paper reviewed new available information regarding possible factors contributing to the establishment of the BV vaginal biofilm, examined the proposed role of anaerobic microbial species recently detected by new culture-independent methods and discusses developments related to the effects of BV on human pregnancy. The literature search included Pubmed (NLM), LISTA (EBSCO), and Web of Science. Because of the complexity and diversity of population groups, diagnosis and methodology used, no meta-analysis was performed. Several anaerobic microbial species previously missed in the laboratory diagnosis of BV have been revealed while taking cognisance of newly proposed theories of infection, thereby improving our understanding and knowledge of the complex aetiology and pathogenesis of BV and its perceived role in adverse pregnancy outcomes.
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Affiliation(s)
- Charlene W J Africa
- Department of Medical Biosciences, University of the Western Cape, Private Bag X17, Bellville 7535, Cape Town, South Africa.
| | - Janske Nel
- Department of Medical Biosciences, University of the Western Cape, Private Bag X17, Bellville 7535, Cape Town, South Africa.
| | - Megan Stemmet
- Department of Medical Biosciences, University of the Western Cape, Private Bag X17, Bellville 7535, Cape Town, South Africa.
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Donders GGG, Zodzika J, Rezeberga D. Treatment of bacterial vaginosis: what we have and what we miss. Expert Opin Pharmacother 2014; 15:645-57. [PMID: 24579850 DOI: 10.1517/14656566.2014.881800] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The disturbing, foul-smelling discharge of bacterial vaginosis (BV) is a nuisance to women. Treatment possibilities for BV are limited and only achieve complete cure in 65 to 85% of cases. In most women, the condition relapses within weeks to months after treatment. AREAS COVERED In search of new therapeutic actions to cure, prevent or delay recurrences of BV, PubMed and web of science were searched for papers with i) decent study layout, ii) proper statistics, iii) comparison group (placebo or standard treatment) and iv) language English, French, Dutch or German. The following keywords were used: bacterial vaginosis and treatment or management or therapy or prophylaxis or prevention. Results were grouped in treatment categories and were discussed. EXPERT OPINION Clindamycin and metronidazole are the standard drugs for BV. As other antibiotic and acidifying treatments are progressively being studied, like tinidazole, rifaximin, nitrofuran, dequalinium chloride, vitamin C and lactic acid, more options have become available for switching therapy, combining therapies and long-term prophylactic use to prevent recurrences. Further studies are needed. Also, adjuvant therapy with probiotics may have a significant role in improving efficacy and in preventing recurrences. However, it is unlikely that probiotics will replace antibiotherapy.
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Affiliation(s)
- Gilbert G G Donders
- Femicare, Clinical Research center for Women, Tienen and Departments of Obstetrics and Gynaecology , Tienen , Belgium
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Wang L, Cui Y, Zhang L, Wang C, Jiang Y, Shi W. Influence of gender equity awareness on women's reproductive healthcare in rural areas of midwest China. Int J Gynaecol Obstet 2013; 123:155-9. [PMID: 23992624 DOI: 10.1016/j.ijgo.2013.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/27/2013] [Accepted: 08/06/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the impact of married women's gender equity awareness on use of reproductive healthcare services in rural China. METHODS The questionnaire-based study recruited 1500 married women who were aged 15-49years, had at least 1 pregnancy, and were living in rural Gansu, Qinghai, Shanxi, or Xinjiang, China, between October and December 2010. "Gender equity awareness" was quantified by responses to 7 statements, graded in accordance with a system scoring the strength of overall belief (≥19, strong; 15-18, moderate; and ≤14, weak). RESULTS Only 383 women (26.3%) demonstrated high gender equity awareness. The percentage of women who received consistent prenatal care was highest in the group scoring 15 points or more (P<0.001); the percentage of women with hospital delivery and gynecologic examination (P<0.001) was highest in the group scoring 19 points or more; and the percentage of women with reproductive tract infections was highest in the group with the lowest scores (P<0.001). CONCLUSION Women's gender equity awareness is not strong in rural midwest China. There was a positive correlation between gender equity awareness and use of reproductive healthcare services. There should be an emphasis on various activities to educate women so that they can fully access reproductive healthcare.
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Affiliation(s)
- Lei Wang
- National Management Center for 12320 Health Hotline, Chinese Center for Disease Control and Prevention, Beijing, China
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13
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Furneri P, Corsello S, Masellis G, Salvatori M, Cammarata E, Roccasalva L, Mangiafico A, Tempera G. Econazole-Polycarbophil, a New Delivery System for Topical Therapy: Microbiological and Clinical Results on Vaginal Candidiasis. J Chemother 2013; 20:336-40. [DOI: 10.1179/joc.2008.20.3.336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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14
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Impact of vaginal ascorbic acid on abnormal vaginal microflora. Arch Gynecol Obstet 2013; 288:1039-44. [DOI: 10.1007/s00404-013-2876-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
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Verstraelen H, Verhelst R. Bacterial vaginosis: an update on diagnosis and treatment. Expert Rev Anti Infect Ther 2010; 7:1109-24. [PMID: 19883331 DOI: 10.1586/eri.09.87] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bacterial vaginosis is the most common cause of vaginal complaints. Bacterial vaginosis is further associated with a sizeable burden of infectious complications. Diagnosis relies on standardized clinical criteria or on scoring bacterial cell morphotypes on a Gram-stained vaginal smear. A few point-of-care tests have not gained footage in clinical practice, but molecular diagnosis is now pending. Treatment remains cumbersome and clinicians are currently rather poorly armed to treat bacterial vaginosis in the long run. As an adjuvant to standard treatment with antibiotics, alternative treatments with antiseptics and disinfectants, vaginal-acidifying and -buffering agents, and probiotics hold some promise for long-term prevention.
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Affiliation(s)
- Hans Verstraelen
- Department of Obstetrics & Gynaecology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium.
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Risk factors for reproductive tract infections among married women in rural areas of Anhui Province, China. Eur J Obstet Gynecol Reprod Biol 2009; 147:187-91. [DOI: 10.1016/j.ejogrb.2009.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 08/17/2009] [Accepted: 08/20/2009] [Indexed: 11/22/2022]
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17
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Değim İT, Tuğcu-Demiröz F, Tamer-İlbasmış S, Acartürk F. Development of Controlled Release Sildenafil Formulations for Vaginal Administration. Drug Deliv 2008; 15:259-65. [DOI: 10.1080/10717540802006781] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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18
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Melvin L, Glasier A, Elton R, Cameron ST. pH-balanced tampons: do they effectively control vaginal pH? BJOG 2008; 115:639-45. [DOI: 10.1111/j.1471-0528.2008.01666.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Neves JD, Santos B, Teixeira B, Dias G, Cunha T, Brochado J. Vaginal drug administration in the hospital setting. Am J Health Syst Pharm 2008; 65:254-9. [DOI: 10.2146/ajhp070093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- José das Neves
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Porto, Portugal, and Compounding Pharmacist and Clinical Pharmacist, Pharmacy Department, Santo António General Hospital (HGSA), Porto
| | - Bárbara Santos
- Abel Salazar Institute of Biomedical Sciences, Porto, and Clinical Pharmacist, Pharmacy Department, HGSA
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Makhlof A, Werle M, Takeuchi H. Mucoadhesive drug carriers and polymers for effective drug delivery. J Drug Deliv Sci Technol 2008. [DOI: 10.1016/s1773-2247(08)50075-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Wu JP, Fielding SL, Fiscella K. The effect of polycarbophil gel (Replens™) on bacterial vaginosis: A pilot study. Eur J Obstet Gynecol Reprod Biol 2007; 130:132-6. [PMID: 16464528 DOI: 10.1016/j.ejogrb.2006.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 12/06/2005] [Accepted: 01/06/2006] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine if use of intravaginal polycarbophil gel (Replens) for 1 month will: (1) lower vaginal pH; (2) improve signs of bacterial vaginosis (BV). STUDY DESIGN Seventeen women with BV self-administered polycarbophil gel every third day for 4 weeks in an open-label, prospective pilot study. Primary outcome measures included vaginal pH, presence of amines and Nugent scores. RESULTS At week 4, there was improvement in Nugent scores, vaginal odor and clue cell count (p<0.05). Eleven women converted from amine positive to negative (73+/-20%). There was no significant change in vaginal pH. CONCLUSIONS Polycarbophil gel is associated with improved signs of BV, although not vaginal pH.
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Affiliation(s)
- Justine P Wu
- University of Rochester, Highland Hospital, Department of Family Medicine Research Programs, 1381 South Avenue, Rochester, NY 14620, USA.
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The management of women of reproductive age attending non-genitourinary medicine settings complaining of vaginal discharge. ACTA ACUST UNITED AC 2006; 32:33-42; quiz 42. [PMID: 16492336 DOI: 10.1783/147118906775275172] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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23
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das Neves J, Bahia MF. Gels as vaginal drug delivery systems. Int J Pharm 2006; 318:1-14. [PMID: 16621366 DOI: 10.1016/j.ijpharm.2006.03.012] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2005] [Revised: 03/10/2006] [Accepted: 03/10/2006] [Indexed: 10/24/2022]
Abstract
The vagina has been used as a mucosal drug delivery route for a long time. Its single characteristics can be either limitative or advantageous when drug delivery is considered. Gels are semi-solid, three-dimensional, polymeric matrices comprising small amounts of solid, dispersed in relatively large amounts of liquid, yet possessing more solid-like character. These systems have been used and are receiving a great deal of interest as vaginal drug delivery systems. Gels are versatile and have been used as delivery systems for microbicides, contraceptives, labour inducers, and other substances. Although somewhat neglected in clinical studies, pharmaceutical characterization of vaginal gels is an important step in order to optimize safety, efficacy and acceptability. Indeed, the simple formulation of a gel can lead to different performances of systems containing the same amount of active substances. Therefore, this paper discusses and summarizes current use and research of vaginal drug delivery systems based in gels.
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Affiliation(s)
- J das Neves
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Porto, Rua Aníbal Cunha, 164, 4050-030 Porto, Portugal.
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