Prevalence of human papillomavirus genotypes, and mucosal IgA anti-viral responses in women with cervical ectopy

Altered Vaginal Microbiota Composition Correlates With Human Papillomavirus and Mucosal Immune Responses in Women With Symptomatic Cervical Ectopy

Cervical ectopy is a benign condition of the lower genital tract that is frequently detected in women of reproductive age. Although cervical ectopy is regarded as a physiological condition, some women experience symptoms such as leucorrhoea, persistent bleeding and recurrent vaginal infections that require medical intervention. Cervical ectopy has not been linked to cervical cancer, but it is thought to facilitate the acquisition of sexually transmitted diseases (STDs), like Human Papillomavirus (HPV) infection, as it provides a favorable microenvironment for virus infection and dissemination. We and others have described the presence of oncogenic HPV types in women with symptomatic cervical ectopy. The relevance of this finding and the impact of symptomatic cervical ectopy on the cervicovaginal microenvironment (vaginal microbiota, immune and inflammatory responses) are currently unknown. To shed some light into the interplay between HPV, the vaginal microbiota and mucosal immune and inflammatory responses in the context of this condition, we enrolled 156 women with symptomatic cervical ectopy and determined the presence of HPV using a type-specific multiplex genotyping assay. Overall, HPV was detected in 54.48% women, oncogenic HPV types were found in more than 90% of HPV-positive cases. The most prevalent HPV types were HPV16 (29.4%), HPV31 (21.17%) and HPV18 (15.29%). Next, we evaluated the vaginal microbial composition and diversity by 16S rDNA sequencing, and quantified levels of cytokines and chemokines by flow cytometry using bead-based multiplex assays in a sub-cohort of 63 women. IL-21 and CXCL9 were significantly upregulated in HPV-positive women (p=0.0002 and p=0.013, respectively). Women with symptomatic cervical ectopy and HPV infection had increased diversity (p<0.001), and their vaginal microbiota was enriched in bacterial vaginosis-associated anaerobes (Sneathia, Shuttleworthia, Prevotella, and Atopobium) and depleted in Lactobacillus spp. Furthermore, the vaginal microbiota of women with symptomatic cervical ectopy and HPV infection correlated with vaginal inflammation (IL-1β, rho=0.56, p=0.0004) and increased mucosal homeostatic response (IL-22, rho=0.60, p=0.0001). Taken together, our results suggest that HPV infection and dysbiotic vaginal communities could favor a vaginal microenvironment that might delay the recovery of the cervical epithelium in women with symptomatic cervical ectopy and favor STDs acquisition.

Association of Sexually Transmitted Diseases With Cervical Ectopy: A Systematic Review

OBJECTIVE

The aim of this study was to review the available literature to explore evidence indicating an association between cervical ectopy and sexually transmitted diseases, which could help in the decision to treat or not to treat this condition.

METHODS

A review of the literature was conducted using the PubMed, EMBASE and clinicaltrials.gov databases on ectopy of the cervix using the terms "ectopy OR ectropium AND cervix" filtered only by language, without limit of date. A total of 71 studies were found in the initial selection, of which 56 were deleted by title, abstract, or full text. The remaining 15 articles were analyzed in this study.

RESULTS

Cervical ectopy showed a positive association with human papillomavirus, human immunodeficiency virus, bacterial vaginosis, cervical epithelial atypia, postcoital bleeding, and desquamative inflammatory vaginitis. High-quality studies reported no association between ectopy and chlamydia infection. It was also not associated with gonococcal infection and herpes simplex.

CONCLUSIONS

Cervical ectopy shows a probable association with increased acquisition of some sexually transmitted diseases. Additional studies are required to confirm the possible beneficial effects of treatment and to evaluate the possible complications of these treatments.

Infection and vaccine-induced HPV-specific antibodies in cervicovaginal secretions. A review of the literature

Background

Human papillomavirus (HPV) infects and propagates in the cervical mucosal epithelium. Hence, in addition to assessing systemic immunity, the accurate measurement of cervical immunity is important to evaluate local immune responses to HPV infection and vaccination. This review discusses studies that investigated the presence of infection and vaccine-induced HPV-specific antibodies in cervicovaginal secretions (CVS).

Methods

We searched the two main health sciences databases, PubMed and the ISI Web of Science, from the earliest dates available to March 2019. From the eligible publications, information was extracted regarding: (i) study design, (ii) the reported HPV-specific antibody concentrations in CVS (and the associated serum levels, when provided), (iii) the CVS collection method, and (iv) the immunoassays used.

Results

The systematic search and selection process yielded 44 articles. The evidence of HPV-specific antibodies in CVS after natural infection (26/44) and HPV vaccination (18/44) is discussed. Many studies indicate that HPV-specific antibody detection in CVS is variable but feasible with a variety of collection methods and immunoassays. Most CVS samples were collected by cervicovaginal washing or wicks, and antibody presence was mostly determined by VLP-based ELISAs. The moderate to strong correlation between vaccine-induced antibody levels in serum and in CVS indicates that HPV vaccines generate antibodies that transudate through the cervical mucosal epithelium.

Conclusion

Although HPV-specific antibodies have lower titres in CVS than in serum samples, studies have shown that their detection in CVS is feasible. Nevertheless, the high variability of published observations and the lack of a strictly uniform, well-validated method for the collection, isolation and quantification of antibodies indicates a need for specific methods to improve and standardize the detection of HPV-specific antibodies in CVS.

Cryotherapy as a Method for Relieving Symptoms of Cervical Ectopy: A Randomized Clinical Trial

Objectives

Benign cervical ectopy (CE) may cause chronic or recurrent symptoms leading to women repeatedly being referred to gynecology clinics. We aimed to present a safe and effective method for relieving symptoms of CE.

Methods

This double-blind clinical trial was conducted among 164 women with CE who complained of persistent or recurrent symptoms of cervicitis in the last six months. Patient’s demographic data, medical history, symptoms, and vaginal examination results were recorded. Normal co-test or Pap smear was required to enter the study. Participants were divided into two groups; the intervention group received cryotherapy and the control group underwent cryo-placebo (inserted the probe without true cryotherapy). The outcomes including improvement of symptoms and CE were monitored one, three, and six months later.

Results

The prevalence of symptoms in the two groups were not significantly different (p > 0.050). Symptom improvement was significantly higher with cryotherapy: vaginal discharge (p = 0.006), itching (p < 0.001), dyspareunia (p = 0.005), post-coital bleeding (p = 0.023), and pelvic pain (p = 0.009). If the symptoms did not disappear, their severity was lower after cryotherapy, comparatively (p < 0.050). Examination showed more improvement of CE following cryotherapy (p < 0.001). Cryotherapy showed no remarkable side effects and was associated with more satisfaction (p < 0.001).

Conclusions

Cryotherapy is a safe, effective, fast-acting, and cost-benefit therapy that can be considered for the treatment of symptomatic CE.

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.

Evaluation of antibody level against Fusobacterium nucleatum in the serological diagnosis of colorectal cancer

Fusobacterium nucleatum (F. nucleatum, Fn) is associated with the colorectal cancer (CRC). Fn-infection could induce significant levels of serum Fn-specific antibodies in human and mice. The objective of this study was to identify Fn-infection that elicit a humoral response in patients with CRC and evaluate the diagnostic performance of serum anti-Fn antibodies. In this work, we showed the mean absorbance value of anti-Fn-IgA and -IgG in the CRC group were significantly higher than those in the benign colon disease group and healthy control group (P < 0.001). The sensitivity and specificity of ELISA for the detection of anti-Fn-IgA were 36.43% and 92.71% based on the optimal cut-off. The combination of anti-Fn-IgA and carcino-embryonic antigen (CEA) was better for diagnosing CRC (Sen: 53.10%, Spe: 96.41%; AUC = 0.848). Furthermore, combining anti-Fn-IgA with CEA and carbohydrate antigen 19-9 (CA19-9) (Sen: 40.00%, Spe: 94.22%; AUC = 0.743) had the better ability to classify CRC patients with stages I-II. These results suggested that Fn-infection elicited high level of serum anti-Fn antibodies in CRC patients, and serum anti-Fn-IgA level may be a potential diagnosing biomarker for CRC. Serum anti-Fn-IgA in combination with CEA and CA19-9 increases the sensitivity of detecting early CRC.

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.

Cervical human papillomavirus infection and persistence: a clinic-based study in the countryside from South Brazil

Human papillomavirus (HPV) infection is common in sexually active women and viral persistence may cause intraepithelial lesions and eventually progress to cervical cancer (CC). The present study aimed to investigate epidemiological factors related to HPV infection and to evaluate viral persistence and CC precursor lesions frequencies in women from a city in the countryside of South Brazil. Three hundred women were recruited from a primary public health care clinic. The patients were interviewed and underwent sampling with cervical brushes for HPV-DNA detection/typing by a PCR-based assay and cytological analysis by Pap smear test. HPV was detected in 47 (15.7%) women. HPV infection was significantly associated with young age (<30 years) and low socio-economic status. Seventeen (5.7%) women presented cytological abnormalities, three of them with precursor CC intraepithelial lesions. A subgroup of 79 women had been previously analyzed and thirteen (16.4%) were persistently infected, two with precursor CC intraepithelial lesions and high-risk HPV types infection (both of them without cervical abnormalities in the first exam). In conclusion, HPV infection was associated with young age (<30 years) and low family income; viral persistence was low (16.4%) but related to CC precursor lesions; and HPV-DNA high risk types detection would help to screen CC in the population.

Efficacy and safety of focused ultrasound versus microwave therapy for cervical ectopy: a meta-analysis

OBJECTIVES

To assess the efficacy and safety of focused ultrasound therapy (FU) and microwave therapy (MW) for cervical ectopy (CE).

METHODS

We searched PubMed, EMbase, the Cochrane Library, Chinese Biomedical Literature Database (CBM), Chinese Scientific Journals Database (VIP), China Academic Journals Full-text Database (CNKI), and WanFang Data for randomized controlled trials (RCTs) comparing FU with MW for women with symptomatic CE from inception to 30 August 2014. Two review authors (Tang XL and Gao Z) independently screened for eligible studies according to the inclusion and exclusion criteria, extracted data and assessed risk of bias of included RCTs. Then, meta-analysis was performed using the RevMan 5.2 software. Funnel plots were used to evaluate publication bias.

RESULTS

A total of 33 RCTs with 11,759 participants were included. All studies had high risk of bias. The results of meta-analysis indicated that compared to MW, FU significantly reduced the risk of vaginal bleeding (RR = 0.09, 95%CI 0.05 to 0.17, P < 0.00001) and vaginal discharge (RR = 0.10, 95%CI 0.04 to 0.24, P < 0.00001), increased the cure rate (RR = 1.10, 95%CI 1.05 to 1.15, P < 0.0001) and the total effectiveness rate (RR = 1.04, 95%CI 1.02 to 1.06, P = 0.0005), and decreased the recurrence rate (RR = 0.13, 95%CI 0.02 to 1.00, P = 0.05); however, this last difference was not statistically significant.

CONCLUSION

Current available evidence suggests that FU is safer and more effective than MW for treating CE. However, some limitations will reduce the reliability of our results. Further well-designed clinical trials are needed to provide further clarification.

Detection of systemic and mucosal HPV-specific IgG and IgA antibodies in adolescent girls one and two years after HPV vaccination

The bivalent HPV16/18 vaccine induces high antibody concentrations in serum while data about antibody responses in the cervix are limited. In this study, we investigated pre- and post-vaccination antibody responses against seven high-risk HPV types by detection of IgG and IgA HPV-specific antibodies in cervical secretion samples (CVS) and serum. From an HPV vaccine monitoring study CVS and serum samples were available (pre-vaccination (n = 297), one year (n = 211) and two years (n = 141) post-dose-one vaccination) from girls aged 14-16 y. The girls were vaccinated with the bivalent HPV vaccine at months 0, 1 and 6. CVS was self-sampled using a tampon. Samples were tested for HPV-specific antibodies (HPV16/18/31/33/45/52/58) by a VLP-based multiplex immunoassay. Post-vaccination, IgG and IgA antibody levels for HPV16/18 were detectable in CVS and amounted to 2% and 1% of the IgG and IgA antibody levels observed in serum, respectively. The antibody levels remained constant between one and two years after vaccination. The correlation between CVS and serum was similar for IgG and IgA vaccine-derived antibody levels for HPV16 (rs = 0.58, rs = 0.54) and HPV18 (rs = 0.50, rs = 0.55). Vaccine-derived IgG antibody levels against cross-reactive HPV types in CVS and in serum were highest for HPV45. No IgA cross-reactive antibody responses could be detected in CVS. Post-vaccination, HPV16/18 IgG and IgA antibodies are not only detectable in serum but also in CVS. The correlation of HPV16/18 IgG antibody levels between serum and CVS suggests that vaccine induced HPV antibodies transudate and/or exudate from the systemic circulation to the cervical mucosa to provide protection against HPV infections.

Active squamous metaplasia of the cervical epithelium is associated with subsequent acquisition of human papillomavirus 16 infection among healthy young women

BACKGROUND

Vulnerability of younger women to human papillomavirus 16 (HPV16) infection has been attributed to the predominance of ectocervical columnar epithelia in this age group. However, squamous metaplastic tissue may be more influential. We examined the extent of ectopy and metaplastic activity as risks for HPV16 acquisition in a prospective cohort.

METHODS

Participants were HPV16 negative at the first two visits. Follow-up occurred every 4 months. Ectopy was quantitatively measured on colpophotographs. We calculated metaplastic rate as the difference in ectopy between visits. Cox proportional hazards models were constructed, adjusting for several covariates.

RESULTS

Analyses included 198 women (mean baseline age 17 years) for 1734 visits. Mean follow-up was 4.4 years. Incident HPV16 was detected in 36 (18%) women. Metaplastic rate between the two visits before HPV16 detection was significantly associated with incident infection (hazard ratio [HR], 1.17; confidence interval [CI], 1.02-1.33; P = .02). However, ectopy was not significant, whether measured before or concurrent to HPV16 detection (HR range, 0.99-1.00; CI range, .97-1.02; P range, .47-.65).

CONCLUSIONS

Dynamic metaplasia rather than the sheer extent of ectopy appears to increase risk for incident HPV16 in healthy young women. This in vivo observation is consistent with the HPV life cycle, during which host cell replication and differentiation supports viral replication.

Youth-specific considerations in the development of preexposure prophylaxis, microbicide, and vaccine research trials

Preventing HIV infection in adolescents and young adults will require a multimodal targeted approach, including individual-directed behavioral risk reduction, community-level structural change, and biomedical interventions to prevent sexual transmission. Trials testing biomedical interventions to prevent HIV transmission will require special attention in this population due to the unique psychosocial and physiologic characteristics that differentiate them from older populations. For example, microbicide research will need to consider acceptability, dosing requirements, and coinfection rates that are unique to this population. Preexposure prophylaxis studies also will need to consider potential unique psychosocial issues such as sexual disinhibition and acceptability as well as unique pharmacokinetic parameters of antiretroviral agents. Vaccine trials also face unique issues with this population, including attitudes toward vaccines, risks related to false-positive HIV tests related to vaccine, and different immune responses based on more robust immunity. In this article, we will discuss issues around implementing each of these biomedical prevention modalities in trials among adolescents and young adults to help to guide future successful research targeting this population.