Lower genital tract infections in women: comparison of clinical and epidemiologic findings with microbiology

Hormonal contraception is associated with a reduced risk of bacterial vaginosis: a systematic review and meta-analysis

Objective

To examine the association between hormonal contraception (HC) and bacterial vaginosis (BV) by systematic review and meta-analysis.

Methods

Medline, Web of Science and Embase databases were searched to 24/1/13 and duplicate references removed. Inclusion criteria 1) >20 BV cases; 2) accepted BV diagnostic method; 3) measure of HC-use either as combined oestrogen-progesterone HC (combined), progesterone-only contraception (POC) or unspecified HC (u-HC); 4) ≥10% of women using HC; 5) analysis of the association between BV and HC-use presented; 6) appropriate control group. Data extracted included: type of HC, BV diagnostic method and outcome (prevalent, incident, recurrent), and geographical and clinic-setting. Meta-analyses were conducted to calculate pooled effect sizes (ES), stratified by HC-type and BV outcome. This systematic review is registered with PROSPERO (CRD42013003699).

Results

Of 1713 unique references identified, 502 full-text articles were assessed for eligibility and 55 studies met inclusion criteria. Hormonal contraceptive use was associated with a significant reduction in the odds of prevalent BV (pooled effect size by random-effects [reES] = 0.68, 95%CI0.63–0.73), and in the relative risk (RR) of incident (reES = 0.82, 95%CI:0.72–0.92), and recurrent (reES = 0.69, 95%CI:0.59–0.91) BV. When stratified by HC-type, combined-HC and POC were both associated with decreased prevalence of BV and risk of incident BV. In the pooled analysis of the effect of HC-use on the composite outcome of prevalent/incident/recurrent BV, HC-use was associated with a reduced risk of any BV (reES = 0.78, 95%CI:0.74–0.82).

Conclusion

HC-use was associated with a significantly reduced risk of BV. This negative association was robust and present regardless of HC-type and evident across all three BV outcome measures. When stratified by HC-type, combined-HC and POC were both individually associated with a reduction in the prevalence and incidence of BV. This meta-analysis provides compelling evidence that HC-use influences a woman’s risk of BV, with important implications for clinicians and researchers in the field.

The association between oral contraceptives, depot-medroxyprogesterone acetate, and trichomoniasis

BACKGROUND

Hormonal contraception use by women may increase the risk of acquiring certain sexually transmitted infections. We explored the effect of hormonal contraceptive use, specifically oral contraception (OC), and depot-medroxyprogesterone acetate (DMPA) on Trichomonas vaginalis infections in women.

METHODS

We examined data from a prospective case-control study of women with trichomoniasis and noninfected female patients recruited from 3 public sexually transmitted disease clinics. Women with positive wet mount microscopy or T. vaginalis culture results were classified as having trichomoniasis. Participants underwent physical examinations, sexually transmitted infections testing and completed questionnaires which included information about demographics, sexual behavior, douching and contraceptive use. We assessed the association between hormonal contraceptives and trichomoniasis using bivariable and multivariable analysis and estimated exposure odds ratios (ORs) and adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

We identified 427 women with trichomoniasis and 144 uninfected women who had information reported about contraception use. Compared with nonhormonal contraceptive use, OC use was negatively associated with trichomoniasis in bivariable analysis (OR: 0.5; 95% CI: 0.3-0.8). This association was no longer statistically significant after adjusting for demographic variables, douching and condom use (aOR: 0.9; 95% CI: 0.5-1.6). Use of DMPA, compared with nonhormonal contraceptive use, was not associated with trichomoniasis in bivariable or multivariable analyses (OR: 1.0, 95% CI: 0.5-2.1; aOR = 1.4, 95% CI: 0.6-3.4, respectively).

CONCLUSIONS

Although OC use appeared to have a protective effect in the bivariable analysis, the hormonal contraceptives OC and DMPA were not associated with T. vaginalis infection after adjustment for other factors.

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

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

An epidemiological survey of vulvovaginal candidiasis in Italy

Eight Italian hospital or University gynecology clinics participated in a prospective survey of patients with culture-confirmed symptomatic vulvovaginal candidiasis (VVC) (October 1999 to March 2001). Of 1138 patients recruited in the study, 931 were evaluable. A recent history of VVC was documented in 43.5% patients (358/823) with a mean number of 2.9+/-2.7 episodes per patient (N=302). A total of 77 patients (10.0%) had a history of recurrent VVC (four and more episodes in a 12-month period). The most frequent associated factors were related to life style: synthetic fabric underwear, vaginal douching and bike, training bike and motorbike (about 1/3 each). Oral contraception was found in 20.8% patients, recent antibiotic use in 15.9% patients, current pregnancy concerned 10.3% patients while 3.4% patients were taking hormonal replacement therapy. Diabetes, corticosteroids or HIV were rarely encountered. Yeast was documented by direct microscopy in 78.3% patients (448/572). A positive culture was obtained in 98.3% patients (909/925). Candida albicans was the predominant species (77.1%), followed by Candida glabrata (14.6%) and Candida krusei (4.0%). With the exception of one center with a lower proportion of C. albicans, this latter represented between 75 and 85% of the isolates. Overall, this study confirmed the preponderant role played by C. albicans in either sporadic and recurrent VVC.

Colposcopic and Cytologic Findings Among Women with Abnormal Vaginal Flora

OBJECTIVE

The purpose of our study was to evaluate the association of abnormal vaginal flora with pathological colposcopic and cytological findings.

MATERIALS AND METHODS

A total of 100 women of reproductive age were examined. Pregnant women were excluded. Each patient completed a self-administered questionnaire regarding sexual history and vaginal symptoms. All participants underwent a gynecological examination and colposcopy. Pap smear of the cervix and samples of vaginal discharge for microbiological analysis were obtained before the colposcopic examination. Statistical analysis was performed using Fisher exact test, chi test, and multifactorial analysis of variance.

RESULTS

Results of colposcopic examination were normal in more than 70% of all examined women, except in women with bacterial vaginosis where < 30% had normal results. Of all the women examined only 1 did not have normal (class II) Pap smear results.

CONCLUSIONS

Our study indicates that women with abnormal vaginal flora more often have pathological colposcopic findings, such as leukoplakia, vaginal hyperemia, and chronic cervicitis.

A clinical study on the association of Trichomonas vaginalis and Mycoplasma hominis infections in women attending a sexually transmitted disease (STD) outpatient clinic

Swabs from the posterior vaginal fornix were obtained from 804 consecutive female patients visiting a large Dutch sexually transmitted diseases (STD) outpatient clinic. A detailed clinical history was obtained and complaints concerning the lower genital tract, such as vaginal discharge or vulval and vaginal irritation, were recorded. Patients were examined and the presence of non-physiological vaginal secretions was established by speculum examination. The swabs were monitored for bacterial vaginosis (BV) or Candida albicans infection. PCR diagnosis of Chlamydia trachomatis and Trichomonas vaginalis was performed as well. Four groups of patients (n=14-21) with BV or single infections caused by one of these three pathogens and a control group with no pathogens were selected and Mycoplasma hominis PCR was performed additionally. At clinical presentation, controls and single-infected patient groups were comparable with regard to complaints of the lower genital tract and sexual risk behavior defined as having prior STDs and/or admitted prostitution. Only in the T. vaginalis-positive group significantly more women reporting sexual risk behavior were found than in controls. In agreement with former in vitro observations, an in vivo association between the PCR-detected presence of M. hominis and T. vaginalis was established. In 79% of all samples positive for T. vaginalis, M. hominis could be detected, as compared to only 6% in control samples (P=0.0004). However, since single infections by either of the two pathogens were regularly observed, there does not seem to be an exclusive association between the species, as the bacterium is also more frequently found in cases of BV (P=0.026). Co-infection of M. hominis with C. albicans (11%) or C. trachomatis (0%) did not differ significantly from controls (6%). M. hominis did not associate with complaints of the lower genital tract. However, if all groups were combined there appears to be a very significant association between the presence of M. hominis and sexual risk behavior (P=0.0004). M. hominis and sexual risk behavior were more closely associated than M. hominis and T. vaginalis. No indications were found for an enhanced pathogenicity by either of the symbionts.

The incidence of actinomyces-like organisms in Papanicolaou-stained smears of copper- and levonorgestrel-releasing intrauterine devices

Actinomyces-like organisms (ALOs) are a common finding in Papanicolaou-stained cervico-vaginal smears (PAP smears) of women using an intrauterine device (IUD). The incidence of ALOs positive PAP smears depends on the type of IUD. Pelvic actinomycosis is a severe disease that may require hysterectomy and salpingo-oophorectomy. In a retrospective study we compared the incidence of ALOs positive PAP smears in users of the new levonorgestrel-releasing intrauterine device (LNG-IUD) (n = 52) with the incidence in Multiload Copper IUD (ML375) users (n = 104). All IUDs had been inserted from 1996-1998. Women with a follow-up period of more than 9 months were included into the final analysis (LNG-IUD: n = 34; ML375: n = 65). The incidence of ALOs in LNG-IUD users (2.9%) was significantly lower than in ML375 users (20%). Clinical consequences of ALOs positive PAP smears are discussed controversially. The low incidence in the LNG-IUD users probably leads to less IUD-removals, reinsertions and less pelvic-inflammatory-diseases.

Bacterial vaginosis in pregnancy

Bacterial vaginosis is a clinical condition caused by replacement of the normal hydrogen peroxide producing Lactobacillus sp. in the vagina with high concentrations of characteristic sets of aerobic and anaerobic bacteria. Bacterial vaginosis is the most prevalent cause of vaginal discharge or malodor, although 50 percent of women who meet the criteria for this condition are asymptomatic. Bacterial vaginosis is reported in 10 to 41 percent of women, and new evidence has shown association with maternal and fetal morbidity. Studies have shown that spontaneous abortion, preterm labor, premature birth, preterm premature rupture of the membranes, amniotic fluid infection, postpartum endometritis, and postcesarean wound infections are increased because of infection with bacterial vaginosis during pregnancy. Clinical trials demonstrated important reductions in many of these adverse events with appropriate screening and antimicrobial treatment protocols. New low-cost, diagnostic, point-of-care screening tools are available for rapid screening of patients, affording the physician the opportunity to potentially make a dramatic clinical and cost impact in preventing preterm birth and the costly sequelae of prematurity. Practicing physicians need to be aware of current guidelines for screening and treating pregnant patients for bacterial vaginosis. The authors recommend that all pregnant women be screened and treated with the Centers for Disease Control and Prevention (CDC-P) recommended oral regimens early in pregnancy. Each treated women should be evaluated for "test of cure" 1 month after treatment. Mothers likely to benefit from "screen and treat" approaches include 1) those with the highest concentrations of genital anaerobes and mycoplasmas, 2) women with prior preterm birth or who have low body mass (BMI < 19.8 kg/m2), 3) those with evidence of endometritis before pregnancy, and 4) those who are treated with oral agents effective for both presumed intrauterine mycoplasmas and other bacterial vaginosis flora (i.e., oral clindamycin or erythromycin and metronidazole).

Symptoms and signs in single and mixed genital infections

OBJECTIVE

To compare symptoms and signs in women with single and mixed genital infections.

METHODS

The study population comprised 996 apparently healthy women. Gynecological symptoms and signs were looked for and diagnostics for the most prevalent gynecological infections were made.

RESULTS

When co-infections were excluded, chlamydial infections, bacterial vaginosis and cervical human papillomavirus infections were associated with a fishy malodor; for the two former conditions an easily bleeding ectopy was also found. Vaginal candidosis showed characteristic symptoms and signs. Genital warts were associated with dysuria, general and lower abdominal pain. Out of 494 women with a genital infection, 112 (22.7%) had a mixed infection, which in some cases influenced symptoms and signs.

CONCLUSION

Many women who consider themselves gynecologically healthy, may nevertheless harbor one or more infectious agents. The need to exclude multiple infections is obvious. Positive predictive values were for specific symptoms and signs were generally low.

Contraceptive use in women with bacterial vaginosis

The aim of the study was to investigate if bacterial vaginosis (BV) is associated with use of specific contraceptives. Women at family planning and youth clinics (n = 956), among whom 131 had BV, were subjects for structured in-depth interviews including current and previous contraceptive use. Variables measuring sexual risk-taking were ascertained. Current users of contraceptives were compared with non-users. Both oral contraceptive (OC) and condom use showed a significant protective effect against BV, adjusted for possible confounders (odds ratios were 0.4 and 0.3, respectively). Intrauterine device use (IUD) showed no association with BV. Women with BV had less often used any contraceptives, including condom, at their sexual debut than the women in the comparison group. In this study, OC and condom use seemed to exert a protective effect against BV, whereas no effect for IUD use was found.

Detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction in introital specimens from pregnant women

OBJECTIVE

We analyzed whether specimens obtained from the vaginal introitus were comparable to endocervical and posterior vaginal vault specimens for detection of Chlamydia trachomatis and Trichomonas vaginalis by polymerase chain reaction.

STUDY DESIGN

Introital and endocervical specimens were obtained from 300 women at the first prenatal visit. Specimens from the posterior vaginal vault were also obtained from 219 of these patients. All samples were tested for C. trachomatis and T. vaginalis by polymerase chain reaction.

RESULTS

C. trachomatis was identified in the endocervices of 36 women (12.0%); all but one of these women and none of the endocervical-negative women were positive for this organism in the introitus. T. vaginalis was detected in 22 women (10.0%); all but one were also introitus positive for this organism. Compared with endocervical and vaginal polymerase chain reaction, introital testing had a 100% specificity and a 97.2% and 95.5% sensitivity for detecting C. trachomatis and T. vaginalis, respectively.

CONCLUSION

Polymerase chain reaction analysis of vaginal introital specimens is highly sensitive and specific in detecting C. trachomatis and T. vaginalis in pregnant women and thus provides an alternative to speculum examination in screening for these pathogens.

Clinical and microscopic diagnosis of vaginal yeast infection: a prospective analysis

STUDY OBJECTIVES

To evaluate the accuracy of clinical findings and direct microscopy in the diagnosis of yeast vaginitis.

DESIGN

Prospective.

SETTING

Urban teaching hospital emergency department and walk-in clinic.

PARTICIPANTS

Seventy-one consecutive nonmenstruating women with a presenting complaint of vaginal discharge, itching, or pain.

INTERVENTIONS

Trained emergency physicians and nurse practitioners, blinded to culture results, collected clinical information, examined vaginal secretions, and obtained yeast cultures. Treatment was based on clinical impression and not altered by the study. Associations between clinical and laboratory parameters and yeast culture results were evaluated.

RESULTS

Twenty-three patients (32.4%) had positive yeast cultures. Accepted risk factors were seen in patients with and without culture-positive yeast vaginitis. Clinical criteria for yeast vaginitis--including pruritus, caseous discharge, perineal edema or erythema, and patient self-diagnosis--were more common in women with yeast vaginitis but were seen with other causes of vaginitis. Watery discharge and amine odor (negative "whiff" test) were good predictors of an alternative diagnosis, but, again, accuracy was poor. Gram stain showing yeast was the most accurate laboratory method of diagnosis. Saline microscopy, potassium hydroxide, and methylene blue were all equal and only moderately accurate, with a significant proportion of false-negative and false-positive results.

CONCLUSION

Standard criteria for diagnosis of monilial vaginitis are relatively unreliable. Gram stain, absence of watery discharge, and patient self-diagnosis of "another yeast infection" are the best independent predictors of a positive culture.

Chlamydia trachomatis and oral contraceptive use: a quantitative review

OBJECTIVES

Chlamydia trachomatis is now recognised as a major sexually transmitted disease; oral contraceptive use is rapidly increasing particularly in developing countries. There are thus important public health implications of the many reports that isolation of C trachomatis is more frequent among users of oral contraceptives. The aim of this analysis was to assess the strength and consistency of this association by summarising published studies between 1972 and 1990.

DESIGN

Studies identified were grouped according to whether they were prospective or case-control studies. Data were extracted and pooled estimates of the unadjusted odds ratios were made for all studies, as well as for sub-groups defined by an index of study quality, background prevalence of C trachomatis, and the contraceptive comparison being made.

LOCATION

Studies in the analysis were mainly conducted in Europe and North America; the meta-analysis was done at the Harvard School of Public Health, Boston, MA, USA.

RESULTS

The pooled estimated unadjusted odds ratio for 29 case-control studies examined was 1.93 (95% CI, 1.77-2.11), indicating an almost twofold increased risk of chlamydial infection for oral contraceptive users. Neither study quality nor prevalence of C trachomatis modified this risk. When compared to the use of barrier contraceptives, however, the risk of infection for women using oral contraceptives increased to 2.91 (95% CI, 1.86-4.55). The pooled estimated protective effect of barrier methods in these studies was 0.34 (95% CI, 0.22-0.54).

CONCLUSIONS

Cross-study comparisons of the relationship between oral contraceptive use and chlamydial infection are limited by the design and analysis of many component studies which did not control for confounding factors such as sexual behaviour and age. The almost twofold risk of increased chlamydial infection for oral contraceptive users, supported by the findings of two prospective studies, however, points to the importance of considering the risks and benefits of oral contraceptive use in women who are likely to be exposed to C trachomatis and other STDs. The protective effect of barrier methods emphasizes the continued need for promoting barrier methods of contraception.

Bacterial vaginosis: current review with indications for asymptomatic therapy

Bacterial vaginosis is a definable clinical entity whose exact origin is unknown. A shift in normal vaginal flora from aerobic, predominantly but not exclusively lactobacilli, to a predominantly anaerobic flora characterizes the condition. More than one half of all women with bacterial vaginosis have no symptoms. The condition is not entirely benign. The potentially pathogenic bacteria present in the vagina in large numbers place these women at risk for postoperative morbidity and adverse obstetric outcome. Sexual transmission has not been proved, but therapeutic cures sometimes require that patient and partner be treated simultaneously. Recommended therapy is with metronidazole or clindamycin and must be given for 7 days for maximal effectiveness. Recurrence of disease can be a problem.

Bacterial vaginosis

Bacterial vaginosis (BV) is the most common of the vaginitides affecting women of reproductive age. It appears to be due to an alteration in the vaginal ecology by which Lactobacillus spp., the predominant organisms in the healthy vagina, are replaced by a mixed flora including Prevotella bivia, Prevotella disiens, Porphyromonas spp., Mobiluncus spp., and Peptostreptococcus spp. All of these organisms except Mobiluncus spp. are also members of the endogenous vaginal flora. While evidence from treatment trials does not support the notion that BV is sexually transmitted, recent studies have shown an increased risk associated with multiple sexual partners. It has also been suggested that the pathogenesis of BV may be similar to that of urinary tract infections, with the rectum serving as a reservoir for some BV-associated flora. The organisms associated with BV have also been recognized as agents of female upper genital tract infection, including pelvic inflammatory disease, and the syndrome BV has been associated with adverse outcome of pregnancy, including premature rupture of membranes, chorioamnionitis, and fetal loss; postpartum endometritis; cuff cellulitis; and urinary tract infections. The mechanisms by which the BV-associated flora causes the signs of BV are not well understood, but a role for H2O2-producing Lactobacillus spp. in protecting against colonization by catalase-negative anaerobic bacteria has been recognized. These and other aspects of BV are reviewed.

Evaluation of the significance of Mycoplasma hominis and Ureaplasma urealyticum in female genital tract infection--a retrospective case note study

Routine screening for sexually transmitted diseases in new patients attending the Genitourinary Clinic in Stoke-on-Trent includes a culture for Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU). A retrospective study was carried out on 400 female patients to ascertain whether there were any significant differences between the group positive for MH and UU and the negative control group. The positive group were found to be younger on average, but to have similar sexual histories to the negative control group. An association was found between the presence of genital mycoplasmas and Gardnerella vaginalis. An odourous vaginal discharge was more common in the positive group. Erythromycin was ineffective in eradicating the organisms in 62.5% of patients with MH, and 70% of those with UU. Continuing work is required to identify those women in whom the presence of MH or UU could have pathogenic effects. Treatment regimens for this group of women need to be carefully reassessed, in the light of increasing antibiotic resistance.

Comparative in vitro activities of pristinamycin and other antimicrobial agents against genital pathogens

The MICs of pristinamycin for genital pathogens were compared with those of ampicillin, tetracycline, erythromycin, and ciprofloxacin. Pristinamycin was active against all the strains studied. Because of this activity and its lack of toxicity, pristinamycin might be a valuable therapeutic agent for treating major sexually transmitted diseases.