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Shi L, Xu S, Zhu Q, Wei Y. Chitosan-coated miconazole as an effective anti-inflammatory agent for the treatment of postoperative infections in obstetrics and vaginal yeast infection control on in vitro evaluations. Microb Pathog 2023; 184:106312. [PMID: 37652266 DOI: 10.1016/j.micpath.2023.106312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/07/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
People with immune deficiency are at risk of developing infections caused by several bacterial and fungal species. In this work, chitosan-coated miconazole was developed by a simple sol-gel method. Miconazole is considered an effective drug to treat vaginal infection-causing bacteria and fungi. The coating of chitosan with miconazole nitrate showed the highest drug loading efficiency (62.43%) and mean particle size (2 μm). FTIR spectroscopic analysis confirmed the entrapment of miconazole nitrate into chitosan polymer. The antifungal result demonstrated that MN@CS microgel possessed notable anti-Aspergillus fumigatus and Candida albicans activity in lower doses. Antibacterial activity results revealed excellent bacterial growth inhibition of MN@CS microgel towards human skin infectious pathogens Escherichia coli and Staphylococcus aureus. The biocompatibility studies of In vitro cell viability and Artemia salina lethality assay suggested that MN@CS microgel is more biosafe and suitable for human external applications. In the future, it will be an efficient anti-inflammatory agent for the treatment of vaginal infections.
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Affiliation(s)
- Lixia Shi
- Department of Obstetrics, JiNan Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Shan Xu
- Department of Obstetrics, JiNan Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Qing Zhu
- Department of Obstetrics, JiNan Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China
| | - Yongqing Wei
- Department of Obstetrics, JiNan Central Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, PR China.
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2
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Balle C, Happel AU, Heffron R, Jaspan HB. Contraceptive effects on the cervicovaginal microbiome: Recent evidence including randomized trials. Am J Reprod Immunol 2023; 90:e13785. [PMID: 37881121 PMCID: PMC10696626 DOI: 10.1111/aji.13785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/24/2023] [Accepted: 09/28/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Until recently, most data regarding the effects of non-barrier contraceptives on the mucosal microbiome have derived from observational studies, which are potentially biased due to behavioral confounders that may mask their true biological effects. METHOD OF STUDY This narrative review summarises recent evidence of the effect of contraceptives on the cervicovaginal microbiome, emphasising data obtained through randomized trials. RESULTS Good quality data describe that initiation of long-acting progestin-only contraceptives, including levonorgestrel (LNG)-implant and the injectables depot-medroxyprogesterone acetate (DMPA-IM) and norethisterone enanthate (NET-EN) do not alter the mucosal microbial environment. Likewise, no strong evidence exists that the use of oral contraceptive pills (OCPs) is associated with alterations of the vaginal microbiome or increased risk of bacterial sexually transmitted infections (STIs). Limited data on the effect of intravaginal rings (IVRs) on the mucosal environment exist and show conflicting effects on the vaginal microbiota. Copper intrauterine device (Cu-IUD) initiation has been associated with bacterial vaginosis (BV) acquisition, including in a randomized trial. LNG-IUDs may have similar affects but need to be evaluated further. CONCLUSION Different synthetic hormones have divergent effects on the microbiome and therefore novel hormonal methods need to be rigorously evaluated. Furthermore, the addition of antiretrovirals into multipurpose technologies may alter the effects of the hormonal component. There is thus a critical need to improve our understanding of the biological effects of contraceptive hormones and delivery methods with different pharmacokinetic and chemical properties on the mucosal microbiome in rigorous trials, to inform the development of novel contraceptives and improve individual family planning guidance.
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Affiliation(s)
- Christina Balle
- Division of Immunology, Department of Pathology, University of Cape Town, South Africa
| | - Anna-Ursula Happel
- Division of Immunology, Department of Pathology, University of Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
| | - Renee Heffron
- University of Washington Department of Global Health, Seattle, WA, USA
| | - Heather B. Jaspan
- Division of Immunology, Department of Pathology, University of Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
- University of Washington Department of Global Health, Seattle, WA, USA
- Seattle Children’s Research Institute, Department of Pediatrics, University of Washington, Seattle, WA, USA
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3
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Genital microbiota of women using a 90 day tenofovir or tenofovir and levonorgestrel intravaginal ring in a placebo controlled randomized safety trial in Kenya. Sci Rep 2022; 12:12040. [PMID: 35835755 PMCID: PMC9283538 DOI: 10.1038/s41598-022-13475-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/25/2022] [Indexed: 11/09/2022] Open
Abstract
In a phase-IIa trial, we investigated the influence of 90 days continuous-delivery tenofovir (TFV) intravaginal rings (IVRs) with/without levonorgestrel (LNG) on the genital microbiota of Kenyan women. Eligible women (n = 27; 18-34 years; negative for HIV, sexually transmitted infections, and Amsel-bacterial vaginosis) were randomized 2:2:1 to use of IVRs containing TFV, TFV/LNG, or placebo. Using vaginal wall and IVR swabs at IVR insertion and removal, the genital microbial composition was determined using 16S rRNA gene sequencing. The presence of Candida spp. was determined using qPCR. The vaginal total bacterial burden appeared to decrease with TFV and TFV/LNG IVR use (log100.57 and log100.27 decrease respectively; p > 0.05). The TFV/LNG IVR was more 'stabilizing': 50% of the participants' microbiota community state types remained unchanged and 50% shifted towards higher Lactobacillus abundance. Specifically, TFV/LNG IVR use was accompanied by increased abundances of Lactobacillus gasseri/hominis/johnsonii/taiwanensis (16.3-fold) and L. fermentum/reuteri/vaginalis (7.0-fold; all p < 0.01). A significant shift in the overall microbial α-diversity or β-diversity was not observed for either IVR, and IVR use did not influence Candida spp. prevalence. TFV/LNG and TFV IVRs did not adversely affect the genital microbiota and are safe to use. Our findings support further studies assessing their efficacy in preventing HIV/HSV-2 and unintended pregnancies.
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4
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Thurman AR, Ravel J, Gajer P, Marzinke MA, Ouattara LA, Jacot T, Peet MM, Clark MR, Doncel GF. Vaginal Microbiota and Mucosal Pharmacokinetics of Tenofovir in Healthy Women Using a 90-Day Tenofovir/Levonorgestrel Vaginal Ring. Front Cell Infect Microbiol 2022; 12:799501. [PMID: 35350436 PMCID: PMC8957918 DOI: 10.3389/fcimb.2022.799501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/09/2022] [Indexed: 01/04/2023] Open
Abstract
Background A relationship between the vaginal microbiota and tenofovir (TFV) concentrations and activity after topical administration has been previously reported. Objective CONRAD A15-138 was a randomized, placebo-controlled Phase I study aimed at characterizing the safety, pharmacokinetics (PK), and pharmacodynamics (PD) of TFV and levonorgestrel (LNG) administered through a vaginal ring (IVR) for 90 days. Herein, we describe changes from baseline in the vaginal microbiota with IVR use and the impact of the vaginal microbiota on mucosal TFV PK. Methods The study screened 68 participants and randomized 47 (37 TFV/LNG, 10 placebo), assessing the vaginal microbiota by sequencing the V3–V4 regions of 16S rRNA genes prior to IVR insertion and monthly for 3 months. Concentrations of TFV in vaginal fluid (VF), and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue, and modeled PD against HIV-1 in vitro were measured before and after treatment. Results There were no clinically significant changes in relative abundance of vaginal bacterial phylotypes from pre-insertion baseline at any month among active and placebo IVR users. There were no significant changes in community state type (CST) with IVR use. Participants with diverse, anaerobic CST IVA/B microbiota had higher in vivo release of TFV from the IVR compared to women with Lactobacillus-dominated (LbD) microbiota, who had expected in vivo TFV release rates. Median VF TFV concentrations were significantly higher among women with CST IVA/B microbiota in months 1 (3,135 ng/mg VF) and 2 (3,800 ng/mg). Women with LbD microbiota had significantly higher median VF TFV concentration (1,423 ng/mg) and median TFV (103 ng/mg) and TFV-DP (5,877 fmol/mg) tissue concentrations versus women with CST IVA/B microbiota at month 3. All women demonstrated a significant increase from pre-insertion baseline of in vitro HIV-1 inhibition by VF (p values <0.05). PD differences in tissue according to CST, however, were not statistically significant. Conclusion TFV/LNG IVR use did not change the vaginal microbiota nor increase the incidence of CST IVA/B. Vaginal microbiota, and in particular CST IVA/B, possibly through increased vaginal pH, impacted in vivo TFV release and cervicovaginal (CV) PK, but both PK and PD data suggest CV protection against HIV-1. Clinical Trial Registration ClinicalTrials.gov (#NCT03279120)
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Affiliation(s)
- Andrea R. Thurman
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
- *Correspondence: Andrea R. Thurman,
| | - Jacques Ravel
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Pawel Gajer
- Institute for Genome Sciences and Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Mark A. Marzinke
- Departments of Pathology and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Louise A. Ouattara
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Terry Jacot
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - M. Melissa Peet
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Meredith R. Clark
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Gustavo F. Doncel
- Department of Obstetrics and Gynecology, CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States
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5
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Austin MN, Meyn LA, Avolia HA, Petrina MA, Cosentino LA, Alphonse C, Chen BA, Bunge K, Noguchi L, Beigi R, Squires K, Hillier SL. Impact of Dapivirine and Placebo Vaginal Rings on the Microbiota of Adolescent, Lactating, and Postmenopausal Females. J Infect Dis 2021; 225:2208-2218. [PMID: 34865071 DOI: 10.1093/infdis/jiab590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A 25 mg dapivirine vaginal ring has been demonstrated to reduce risk of HIV acquisition in nonpregnant adult women. In this secondary analysis of studies conducted in US adolescent, lactating, and postmenopausal females, vaginal microbiota was assessed prior to and after ring use, and between dapivirine and placebo ring users. METHODS Vaginal fluid swabs were collected before and after product use for the evaluation of microbiota using Nugent's criteria, quantitative culture, and qPCR. RESULTS Vaginal ring use did not impact bacterial vaginosis prevalence among the three populations and was associated with minimal shifts in microbiota. Adolescents in both arms demonstrated an increased prevalence of Lactobacillus crispatus and a decrease in quantity of Megasphaera lornae. Postmenopausal active and placebo ring users demonstrated an increased prevalence of lactobacilli and non-albicans yeast while dapivirine ring users demonstrated an increased prevalence of Candida albicans, and increased quantity of Group B Streptococcus (GBS) and non-albicans yeasts. Prevotella species were increased in lactating women while P. timonensis increased in prevalence and concentration among adolescent and postmenopausal women and P. bivia increased in prevalence among adolescent dapivirine ring users. CONCLUSIONS Dapivirine vaginal ring use was associated with minimal changes in the vaginal microbiota that are likely not clinically significant.
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Affiliation(s)
| | - Leslie A Meyn
- Magee-Womens Research Institute, Pittsburgh, PA, USA, 15213.,University of Pittsburgh, Pittsburgh, PA, USA, 15260
| | | | | | | | - Calins Alphonse
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA, 98109
| | - Beatrice A Chen
- Magee-Womens Research Institute, Pittsburgh, PA, USA, 15213.,University of Pittsburgh, Pittsburgh, PA, USA, 15260
| | | | - Lisa Noguchi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, 21287
| | - Richard Beigi
- University of Pittsburgh, Pittsburgh, PA, USA, 15260
| | | | - Sharon L Hillier
- Magee-Womens Research Institute, Pittsburgh, PA, USA, 15213.,University of Pittsburgh, Pittsburgh, PA, USA, 15260
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6
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Vaginal microbiome: normalcy vs dysbiosis. Arch Microbiol 2021; 203:3793-3802. [PMID: 34120200 DOI: 10.1007/s00203-021-02414-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 12/12/2022]
Abstract
It has been long understood that the vaginal microflora is crucial in maintaining a normal physiological environment for the host and its involvement is deemed indispensable for reproductive success. A global concept of normalcy vs. dysbiosis of vaginal microbiome is debatable as women of different races have a unique vaginal microflora with regional variations. Vaginal microflora is a dynamic microenvironment affected by gestational status, menstrual cycle, sexual activity, age, and contraceptive use. Normal vaginal flora is dominated by lactobacilli especially in women of European descent vs. African American women. These microbes confer the host vagina protection from potentially pathogenic microbes that may lead to urinary tract infections and sexually transmitted diseases. Changes in the vaginal microbiota including reduced lactobacilli abundance and increased facultative and anaerobic organism populations result in bacterial vaginosis, that predisposes the host to several conditions like low birth weight and increased risk of contracting bacterial infections. On the other hand, the vaginal microbiome is also reshaped during pregnancy, with less microbial diversity with a dominance of Lactobacillus species. However, an altered vaginal microbiota with low lactobacilli abundance especially during pregnancy may result in induction of excessive inflammation and pre-term labor. Since the vaginal microbiome plays an important role during embryo implantation, it is not surprising that bacterial vaginosis is more common in infertile women and associated with reduced rates of conception. Probiotic has great success in treating bacterial vaginosis and restoring the normal microbiome in recent. This report, reviewed the relationships between the vaginal microbiome and women's reproductive health.
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7
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Carson L, Merkatz R, Martinelli E, Boyd P, Variano B, Sallent T, Malcolm RK. The Vaginal Microbiota, Bacterial Biofilms and Polymeric Drug-Releasing Vaginal Rings. Pharmaceutics 2021; 13:pharmaceutics13050751. [PMID: 34069590 PMCID: PMC8161251 DOI: 10.3390/pharmaceutics13050751] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/14/2021] [Accepted: 05/18/2021] [Indexed: 12/26/2022] Open
Abstract
The diversity and dynamics of the microbial species populating the human vagina are increasingly understood to play a pivotal role in vaginal health. However, our knowledge about the potential interactions between the vaginal microbiota and vaginally administered drug delivery systems is still rather limited. Several drug-releasing vaginal ring products are currently marketed for hormonal contraception and estrogen replacement therapy, and many others are in preclinical and clinical development for these and other clinical indications. As with all implantable polymeric devices, drug-releasing vaginal rings are subject to surface bacterial adherence and biofilm formation, mostly associated with endogenous microorganisms present in the vagina. Despite more than 50 years since the vaginal ring concept was first described, there has been only limited study and reporting around bacterial adherence and biofilm formation on rings. With increasing interest in the vaginal microbiome and vaginal ring technology, this timely review article provides an overview of: (i) the vaginal microbiota, (ii) biofilm formation in the human vagina and its potential role in vaginal dysbiosis, (iii) mechanistic aspects of biofilm formation on polymeric surfaces, (iv) polymeric materials used in the manufacture of vaginal rings, (v) surface morphology characteristics of rings, (vi) biomass accumulation and biofilm formation on vaginal rings, and (vii) regulatory considerations.
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Affiliation(s)
- Louise Carson
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Elena Martinelli
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Teresa Sallent
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA; (R.M.); (E.M.); (B.V.); (T.S.)
| | - Robert Karl Malcolm
- School of Pharmacy, Queen’s University Belfast, Belfast BT9 7BL, UK; (L.C.); (P.B.)
- Correspondence:
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8
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Bastianelli C, Farris M, Bianchi P, Benagiano G. The effect of different contraceptive methods on the vaginal microbiome. Expert Rev Clin Pharmacol 2021; 14:821-836. [PMID: 33863265 DOI: 10.1080/17512433.2021.1917373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Following a historical overview, the effect of different contraceptive methods on vaginal microbiome has been reviewed and summarized.Areas covered: Effects of combined hormonal contraceptives (oral or vaginal) and of progestin only (injectable and implantable), intrauterine devices/systems (copper- or levonorgestrel-releasing), on vaginal microbiome. In addition, mention is made of vaginal rings releasing antiviral drugs and lactic acid.Expert opinion: The vaginal microbiota (VM) is unique in that it is normally dominated by Lactobacillus species providing a degree of protection against infections; this however may vary, depending on the species and strains of Lactobacillus. Bacterial Vaginosis represents the most common dysbiosis of the VM and its prevalence can be influenced by use of contraception. Available evidence indicates that, under the influence of oral or systemically administered female sex hormones, there is apromotion of vaginal eubiosis, with aprevalence of ahealthy VM in which Lactobacilli predominate.
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Affiliation(s)
- Carlo Bastianelli
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy
| | - Manuela Farris
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy.,Italian Association for Demographic Education, AIED, Rome, Italy
| | - Paola Bianchi
- Department of Medico-Surgical Sciences and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Giuseppe Benagiano
- Department of Maternal & Child Health, Gynecology and Urology, Sapienza, University of Rome, Rome, Italy
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Farr A, Effendy I, Tirri BF, Hof H, Mayser P, Petricevic L, Ruhnke M, Schaller M, Schäfer APA, Willinger B, Mendling W. Vulvovaginal Candidosis (Excluding Mucocutaneous Candidosis): Guideline of the German (DGGG), Austrian (OEGGG) and Swiss (SGGG) Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry Number 015/072, September 2020). Geburtshilfe Frauenheilkd 2021; 81:398-421. [PMID: 33867561 DOI: 10.1055/a-1345-8793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/23/2020] [Indexed: 01/10/2023] Open
Abstract
Aim The aim of this official guideline, published and coordinated by the German (DGGG), Austrian (OEGGG) and Swiss (SGGG) Societies of Gynecology and Obstetrics in collaboration with the DMykG, DDG and AGII societies, was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnosis, treatment and management of women with vulvovaginal candidosis. Methods This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the above-mentioned societies. Recommendations This guideline gives recommendations for the diagnosis, management, counseling, prophylaxis and screening of vulvovaginal candidosis.
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Affiliation(s)
- Alex Farr
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Isaak Effendy
- Hautklinik, Klinikum der Stadt Bielefeld, Bielefeld, Germany
| | | | - Herbert Hof
- MVZ Labor Limbach und Kollegen, Heidelberg, Germany
| | - Peter Mayser
- Facharzt für Haut- und Geschlechtskrankheiten, Biebertal, Germany
| | - Ljubomir Petricevic
- Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Austria
| | - Markus Ruhnke
- Klinik für Hämatologie, Onkologie und Palliativmedizin, Helios Klinikum Aue, Aue, Germany
| | - Martin Schaller
- Hautklinik, Zentrum für Dermato-Onkologie, Universität Tübingen, Tübingen, Germany
| | | | - Birgit Willinger
- Abteilung für Klinische Mikrobiologie, Medizinische Universität Wien, Wien, Austria
| | - Werner Mendling
- Deutsches Zentrum für Infektionen in Gynäkologie und Geburtshilfe, Wuppertal, Germany
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10
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Farr A, Effendy I, Frey Tirri B, Hof H, Mayser P, Petricevic L, Ruhnke M, Schaller M, Schaefer APA, Sustr V, Willinger B, Mendling W. Guideline: Vulvovaginal candidosis (AWMF 015/072, level S2k). Mycoses 2021; 64:583-602. [PMID: 33529414 PMCID: PMC8248160 DOI: 10.1111/myc.13248] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
Approximately 70-75% of women will have vulvovaginal candidosis (VVC) at least once in their lifetime. In premenopausal, pregnant, asymptomatic and healthy women and women with acute VVC, Candida albicans is the predominant species. The diagnosis of VVC should be based on clinical symptoms and microscopic detection of pseudohyphae. Symptoms alone do not allow reliable differentiation of the causes of vaginitis. In recurrent or complicated cases, diagnostics should involve fungal culture with species identification. Serological determination of antibody titres has no role in VVC. Before the induction of therapy, VVC should always be medically confirmed. Acute VVC can be treated with local imidazoles, polyenes or ciclopirox olamine, using vaginal tablets, ovules or creams. Triazoles can also be prescribed orally, together with antifungal creams, for the treatment of the vulva. Commonly available antimycotics are generally well tolerated, and the different regimens show similarly good results. Antiseptics are potentially effective but act against the physiological vaginal flora. Neither a woman with asymptomatic colonisation nor an asymptomatic sexual partner should be treated. Women with chronic recurrent Candida albicans vulvovaginitis should undergo dose-reducing maintenance therapy with oral triazoles. Unnecessary antimycotic therapies should always be avoided, and non-albicans vaginitis should be treated with alternative antifungal agents. In the last 6 weeks of pregnancy, women should receive antifungal treatment to reduce the risk of vertical transmission, oral thrush and diaper dermatitis of the newborn. Local treatment is preferred during pregnancy.
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Affiliation(s)
- Alex Farr
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Isaak Effendy
- Klinikum Bielefeld Rosenhohe, Department of Dermatology and Allergology, Bielefeld, Germany
| | | | - Herbert Hof
- Labor Dr. Limbach und Kollegen, Heidelberg, Germany
| | - Peter Mayser
- Facharzt für Dermatologie und Allergologie, Biebertal, Germany
| | - Ljubomir Petricevic
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Markus Ruhnke
- Department of Hematology, Oncology and Palliative Medicine, Helios Hospital Aue, Aue, Germany
| | - Martin Schaller
- Department of Dermatology, University Hospital Tuebingen, Tuebingen, Germany
| | | | - Valentina Sustr
- Division of Obstetrics and Feto-Maternal Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Birgit Willinger
- Department of Laboratory Medicine, Division of Clinical Microbiology, Medical University of Vienna, Vienna, Austria
| | - Werner Mendling
- Deutsches Zentrum fuer Infektionen in Gynaekologie und Geburtshilfe, Wuppertal, Germany
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11
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Balle C, Konstantinus IN, Jaumdally SZ, Havyarimana E, Lennard K, Esra R, Barnabas SL, Happel AU, Moodie Z, Gill K, Pidwell T, Karaoz U, Brodie E, Maseko V, Gamieldien H, Bosinger SE, Myer L, Bekker LG, Passmore JAS, Jaspan HB. Hormonal contraception alters vaginal microbiota and cytokines in South African adolescents in a randomized trial. Nat Commun 2020; 11:5578. [PMID: 33149114 PMCID: PMC7643181 DOI: 10.1038/s41467-020-19382-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Young women in sub-Saharan Africa are disproportionally affected by HIV infection and unintended pregnancies. However, hormonal contraceptive (HC) use may influence HIV risk through changes in genital tract microbiota and inflammatory cytokines. To investigate this, 130 HIV negative adolescent females aged 15-19 years were enrolled into a substudy of UChoose, an open-label randomized crossover study (NCT02404038), comparing acceptability and contraceptive product preference as a proxy for HIV prevention delivery methods. Participants were randomized to injectable norethisterone enanthate (Net-En), combined oral contraceptives (COC) or etonorgesterol/ethinyl estradiol combined contraceptive vaginal ring (CCVR) for 16 weeks, then crossed over to another HC for 16 weeks. Cervicovaginal samples were collected at baseline, crossover and exit for characterization of the microbiota and measurement of cytokine levels; primary endpoints were cervical T cell activation, vaginal microbial diversity and cytokine concentrations. Adolescents randomized to COCs had lower vaginal microbial diversity and relative abundance of HIV risk-associated taxa compared to Net-En or CCVR. Cervicovaginal inflammatory cytokine concentrations were significantly higher in adolescents randomized to CCVR compared to COC and Net-En. This suggests that COC use may induce an optimal vaginal ecosystem by decreasing bacterial diversity and inflammatory taxa, while CCVR use is associated with genital inflammation.
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Affiliation(s)
- Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Iyaloo N Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shameem Z Jaumdally
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Enock Havyarimana
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Katie Lennard
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, South Africa
| | - Rachel Esra
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaun L Barnabas
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Zoe Moodie
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Tanya Pidwell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Ulas Karaoz
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA
| | - Eoin Brodie
- Earth and Environmental Science, Lawrence Berkeley National Laboratories, Berkeley, CA, 94720, USA.,University of California, Berkeley, CA, USA
| | - Venessa Maseko
- National Institute for Communicable Diseases, Sandringham, Johannesburg, South Africa
| | - Hoyam Gamieldien
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Steven E Bosinger
- Department of Pathology & Laboratory Medicine, Emory University School of Medicine; Division of Microbiology and Immunology, Yerkes National Primate Research Center, Atlanta, GA, USA
| | - Landon Myer
- Division of Epidemiology, Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - Jo-Ann S Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Cape Town, South Africa
| | - Heather B Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa. .,Seattle Children's Research Institute, Seattle, WA, USA. .,University of Washington Department of Pediatrics and Global Health, Seattle, WA, USA.
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12
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Balle C, Gill K, Konstantinus IN, Jaumdally SZ, Lennard K, Esra R, Happel AU, Barnabas SL, Gamieldien H, Pidwell T, Maseko V, Lesosky M, Myer L, Passmore JAS, Bekker LG, Jaspan HB. Hormonal contraception and risk of STIs and bacterial vaginosis in South African adolescents: secondary analysis of a randomised trial. Sex Transm Infect 2020; 97:112-117. [PMID: 32989170 DOI: 10.1136/sextrans-2020-054483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Young women in sub-Saharan Africa are at high risk of STIs and unintended pregnancies, yet hormonal contraceptive (HC) use may affect STI risk. We compared the influence of three HCs on the incidence and prevalence of STIs and bacterial vaginosis (BV) in South African adolescents. METHODS One hundred and thirty adolescents between 15 and 19 years were randomised to the injectable norethisterone enanthate (Net-En), combined oral contraceptives (COC) (Triphasil or Nordette) or a combined contraceptive vaginal ring (CCVR; NuvaRing) for 16 weeks (clinicaltrials.gov/NCT02404038). Vaginal samples were collected at baseline and 16 weeks post contraceptive initiation for STI and BV testing. RESULTS In an intention-to-treat analysis, no significant differences in BV prevalence were found between study arms. The overall incidence of any STI at follow-up was high: 16.2% in the COC arm; 25.7% in the Net-En arm; and 37.1% in the CCVR arm. The incidence rate (IR) of any STI was similar between Net-En (IR 0.74 (95% CI 0.34 to 1.41)) and the oestrogen-containing contraceptives (IR 0.78 (95% CI 0.47 to 1.22)). A lower IR of Chlamydia trachomatis (incidence rate ratio (IRR) 0.68 (95% CI 0.19 to 1.99)) and Neisseria gonorrhoeae (IRR 0.25 (95% CI 0.01 to 1.35)) but a higher IR of Mycoplasma genitalium (IRR 16.0 (95% CI 2.96 to 400)), was observed in the Net-En arm compared with the oestrogen-containing contraceptives, although the overall incidence of M. genitalium was low (4.7%). In an exploratory analysis, the risk of any STI and N. gonorrhoeae was lower in the COC arm compared with CCVR. A per-protocol analysis yielded similar results. CONCLUSION Our results suggest that use of Net-En may be associated with increased risk of M. genitalium compared with oestrogen-containing contraceptives but not with overall STI risk. COC use may decrease STI risk relative to CCVR.
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Affiliation(s)
- Christina Balle
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Katherine Gill
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Iyaloo N Konstantinus
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Shameem Z Jaumdally
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Katie Lennard
- Department of Integrative Biomedical Sciences, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Rachel Esra
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Anna-Ursula Happel
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Shaun L Barnabas
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.,Family Clinical Research Centre, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Hoyam Gamieldien
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Tanya Pidwell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Venessa Maseko
- National Institute for Communicable Diseases, Johannesburg, Gauteng, South Africa
| | - Maia Lesosky
- Division of Epidemiology, Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Landon Myer
- Division of Epidemiology, Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Jo-Ann S Passmore
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa.,National Health Laboratory Service, Johannesburg, Gauteng, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Heather B Jaspan
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, Western Cape, South Africa .,Center for Global Infectious Disease Research, Seattle Children's Research Institute, Seattle, Washington, DC, USA.,Pediatrics and Global Health, University of Washington, Seattle, WA, USA
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13
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Long-Lasting, Patient-Controlled, Procedure-Free Contraception: A Review of Annovera with a Pharmacist Perspective. PHARMACY 2020; 8:pharmacy8030156. [PMID: 32872116 PMCID: PMC7558341 DOI: 10.3390/pharmacy8030156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 11/22/2022] Open
Abstract
Annovera (segesterone acetate and ethinyl estradiol vaginal system) is a US Food and Drug Administration FDA-approved long-lasting, reversible contraceptive that is fully administered by the user and does not require a procedure for insertion or removal. The vaginal system is in the shape of a ring and contains low doses of a novel progestin, egesterone acetate, and ethinyl estradiol. It is made of silicone and is fully pliable and flexible. The vaginal system is reusable for 13 cycles, using a 21 days in/7 days out regimen, providing women with the ability to control their fertility. Particularly now during the COVID-19 pandemic when access to contraception has been further reduced, patients may benefit from a method that is both long-lasting and patient-controlled.
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14
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Boyd P, Merkatz R, Variano B, Malcolm RK. The ins and outs of drug-releasing vaginal rings: a literature review of expulsions and removals. Expert Opin Drug Deliv 2020; 17:1519-1540. [DOI: 10.1080/17425247.2020.1798927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Peter Boyd
- School of Pharmacy, Queen’s University Belfast, Belfast, UK
| | - Ruth Merkatz
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
| | - Bruce Variano
- Population Council, One Dag Hammarskjold Plaza, New York, NY, USA
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15
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Micks EA, Jensen JT. A technology evaluation of Annovera: a segesterone acetate and ethinyl estradiol vaginal ring used to prevent pregnancy for up to one year. Expert Opin Drug Deliv 2020; 17:743-752. [PMID: 32410464 DOI: 10.1080/17425247.2020.1764529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The segesterone acetate and ethinyl estradiol contraceptive vaginal ring (SA/EE CVR) was FDA-approved in August 2018 and is now available in the U.S. The CVR is placed vaginally for 21 days followed by a 7-day ring-free interval, when withdrawal bleeding typically occurs. One ring can be used for up to a year (13 cycles). AREAS COVERED This review summarizes this novel method of contraception, including the delivery system and the hormonal components. We describe the potential market, how it is used, the pharmacokinetic properties of the device, and results of clinical trials including efficacy, bleeding profile, acceptability, and safety. EXPERT OPINION The SA/EE CVR represents the first long-lasting user-controlled hormonal contraceptive device. The bleeding pattern is highly favorable and consistent over the entire year and is associated with very low discontinuation. Efficacy and safety are similar to other methods of combined hormonal contraceptives. Unscheduled ring removals increase the risk of failure. Further studies are needed to evaluate continuous use of the ring for greater than 21 days, and potential non-contraceptive benefits of the ring such as reduced menstrual bleeding.
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Affiliation(s)
- Elizabeth A Micks
- Department of Obstetrics and Gynecology, University of Washington , Seattle, WA, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University , Portland, OR, USA
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16
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Lewis AL, Gilbert NM. Roles of the vagina and the vaginal microbiota in urinary tract infection: evidence from clinical correlations and experimental models. GMS INFECTIOUS DISEASES 2020; 8:Doc02. [PMID: 32373427 PMCID: PMC7186798 DOI: 10.3205/id000046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Mounting evidence indicates that the vagina can harbor uropathogenic bacteria. Here, we consider three roles played by the vagina and its bacterial inhabitants in urinary tract infection (UTI) and urinary health. First, the vagina can serve as a reservoir for Escherichia coli, the most common cause of UTI, and other recognized uropathogens. Second, several vaginal bacterial species are frequently detected upon urine culture but are underappreciated as uropathogens, and other vaginal species are likely under-reported because of their fastidious nature. Third, some vaginal bacteria that are not widely viewed as uropathogens can transit briefly in the urinary tract, cause injury or immunomodulation, and shift the balance of host-pathogen interactions to influence the outcomes of uropathogenesis. This chapter describes the current literature in these three areas and summarizes the impact of the vaginal microbiota on susceptibility to UTI and other urologic conditions.
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Affiliation(s)
- Amanda L. Lewis
- Washington University School of Medicine, Department of Molecular Microbiology, St. Louis, United States
| | - Nicole M. Gilbert
- Washington University School of Medicine, Department of Obstetrics and Gynecology, St. Louis, United States
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17
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Hormonal Contraception and Vaginal Infections Among Couples Who Are Human Immunodeficiency Virus Serodiscordant in Lusaka, Zambia. Obstet Gynecol 2020; 134:573-580. [PMID: 31403592 DOI: 10.1097/aog.0000000000003404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine the relationship between hormonal contraception and vaginal infections with bacterial vaginosis, vaginal candidiasis, or trichomoniasis. METHODS Couples who were human immunodeficiency virus (HIV) serodiscordant in Zambia were enrolled in a longitudinal cohort study. From 1994 to 2002, both partners were seen quarterly and received physical exams including genital examinations. Separate rates for three outcome infections of interest (bacterial vaginosis, vaginal candidiasis, and trichomoniasis) were calculated. Bivariate associations between baseline and time-varying covariates and outcome infections of interest were evaluated using unadjusted Anderson-Gill survival models. Adjusted hazard ratios (aHRs) were generated using multivariable Anderson-Gill survival models that included demographic and clinical factors associated with both hormonal contraceptive use and each infection of interest. RESULTS There were 1,558 cases of bacterial vaginosis, 1,529 cases of vaginal candidiasis, and 574 cases of trichomoniasis over 2,143 person-years of observation. Depot medroxyprogesterone acetate (DMPA) users had significantly lower rates of trichomoniasis and bacterial vaginosis. In adjusted models, DMPA was protective for bacterial vaginosis (aHR=0.72; 95% CI 0.54-0.95), candidiasis (aHR 0.75, 95% CI 0.57-1.00) and trichomoniasis (aHR=0.43, 95% CI 0.25-0.74). Oral contraceptive pills were protective for candidiasis (aHR=0.79, 95% CI 0.65-0.97). CONCLUSION We confirm that DMPA use was associated with reduced rates of the three most common causes of vaginitis, and oral contraceptive pill use was associated with reduced rates of candidiasis among women in couples who were HIV discordant.
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18
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Nelson AL. Comprehensive overview of the recently FDA-approved contraceptive vaginal ring releasing segesterone acetate and ethinylestradiol: A new year-long, patient controlled, reversible birth control method. Expert Rev Clin Pharmacol 2019; 12:953-963. [DOI: 10.1080/17512433.2019.1669448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anita L. Nelson
- Obstetrics & Gynecology, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
- Obstetrics & Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
- Obstetrics & Gynecology, University Southern California, Los Angeles, CA, USA
- Research Division, Essential Access Health, Los Angeles, CA, USA
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19
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Thurman AR, Schwartz JL, Ravel J, Gajer P, Marzinke MA, Yousefieh N, Anderson SM, Doncel GF. Vaginal microbiota and mucosal pharmacokinetics of tenofovir in healthy women using tenofovir and tenofovir/levonorgestrel vaginal rings. PLoS One 2019; 14:e0217229. [PMID: 31107913 PMCID: PMC6527208 DOI: 10.1371/journal.pone.0217229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 05/05/2019] [Indexed: 12/25/2022] Open
Abstract
Recent data support that the vaginal microbiota may alter mucosal pharmacokinetics (PK) of topically delivered microbicides. Our team developed an intravaginal ring (IVR) that delivers tenofovir (TFV) (8–10 mg/day) alone or with levonorgestrel (LNG) (20 ug/day). We evaluated the effect of IVRs on the vaginal microbiota, and describe how the vaginal microbiota impacts mucosal PK of TFV. CONRAD A13-128 was a randomized, placebo controlled phase I study. We randomized 51 women to TFV, TFV/LNG or placebo IVR. We assessed the vaginal microbiota by sequencing the V3-V4 regions of 16S rRNA genes prior to IVR insertion and after approximately 15 days of use. We measured the concentration of TFV in the cervicovaginal (CV) aspirate, and TFV and TFV-diphosphate (TFV-DP) in vaginal tissue at the end of IVR use. The change in relative or absolute abundance of vaginal bacterial phylotypes was similar among active and placebo IVR users (all q values >0.13). TFV concentrations in CV aspirate and vaginal tissue, and TFV-DP concentrations in vaginal tissue were not significantly different among users with community state type (CST) 4 versus those with Lactobacillus dominated microbiota (all p values >0.07). The proportions of participants with CV aspirate concentrations of TFV >200,000 ng/mL and those with tissue TFV-DP concentrations >1,000 fmol/mg were similar among women with anaerobe versus Lactobacillus dominated microbiota (p = 0.43, 0.95 respectively). There were no significant correlations between the CV aspirate concentration of TFV and the relative abundances of Gardnerella vaginalis or Prevotella species. Tissue concentrations of TFV-DP did not correlate with any the relative abundances of any species, including Gardnerella vaginalis. In conclusion, active IVRs did not differ from the placebo IVR on the effect on the vaginal microbiota. Local TFV and TFV-DP concentrations were high and similar among IVR users with Lactobacillus dominated microbiota versus CST IV vaginal microbiota. Trial registration: ClinicalTrials.gov NCT02235662.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
- * E-mail:
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Pawel Gajer
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Clinical Pharmacology Analytical Laboratory, Baltimore, MD, United States of America
| | - Nazita Yousefieh
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Sharon M. Anderson
- CONRAD, Eastern Virginia Medical School, Norfolk, VA, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Arlington, VA, United States of America
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20
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Gemzell-Danielsson K, Sitruk-Ware R, Creinin MD, Thomas M, Barnhart KT, Creasy G, Sussman H, Alami M, Burke AE, Weisberg E, Fraser I, Miranda MJ, Gilliam M, Liu J, Carr BR, Plagianos M, Roberts K, Blithe D. Segesterone acetate/ethinyl estradiol 12-month contraceptive vaginal system safety evaluation. Contraception 2019; 99:323-328. [PMID: 30831102 DOI: 10.1016/j.contraception.2019.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate safety outcomes from clinical studies of a 12-month contraceptive vaginal system (CVS) releasing an average of segesterone acetate (SA) 150 mcg and ethinyl estradiol (EE) 13 mcg daily. STUDY DESIGN We integrated clinical safety data from nine studies in which women used the CVS for 21 consecutive days and removed it for 7 days of each 28-day cycle. Four studies used the final manufactured CVS, including a 1-year pharmacokinetic study, two 1-year phase 3 trials and a second-year treatment extension study. We assessed safety by evaluating adverse events women reported in a daily diary. We also included data from focused safety studies evaluating endometrial biopsies, vaginal microbiology and liver proteins from one of the phase 3 studies. RESULTS The combined studies included 3052 women; 2308 women [mean age 26.7±5.1 years; mean body mass index (BMI) 24.1±3.7 kg/m2] received the final manufactured CVS, of whom 999 (43.3%) completed 13 cycles of use. Women using the final CVS most commonly reported adverse events of headache (n=601, 26%), nausea (n=420, 18%), vaginal discharge/vulvovaginal mycotic infection (n=242, 10%) and abdominal pain (n=225, 10%). Few (<1.5%) women discontinued for these complaints. Four (0.2%) women experienced venous thromboembolism (VTE), three of whom had risk factors for thrombosis [Factor V Leiden mutation (n=1); BMI>29 kg/m2 (n=2)]. During 21,482 treatment cycles in the phase 3 studies evaluable for expulsion, women reported partial expulsions in 4259 (19.5%) cycles and complete expulsions in 1509 (7%) cycles, most frequently in the initial cycle [499/2050 (24.3%) and 190/2050 (9.3%), respectively]. Safety-focused studies revealed no safety concerns. CONCLUSION The 1-year SA/EE CVS has an acceptable safety profile. Additional studies are warranted in obese women at higher risk of VTE. IMPLICATIONS This 1-year contraceptive vaginal system represents a new long-term, user-controlled and procedure-free option with a safety profile similar to other combination hormonal contraceptives. The same precautions currently used for combination hormonal contraceptive prescriptions apply to this new contraceptive vaginal system.
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Affiliation(s)
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Michael Thomas
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, USA
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George Creasy
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Heather Sussman
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Mohcine Alami
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Bayview Medical Center, Baltimore, MD, USA
| | - Edith Weisberg
- Family Planning NSW, and University of Sydney, Sydney, Australia
| | - Ian Fraser
- University of New South Wales; Family Planning NSW, and University of Sydney, Sydney, Australia
| | | | - Melissa Gilliam
- Department of Obstetrics, Gynecology and Pediatrics, University of Chicago, Chicago, IL, USA
| | - James Liu
- Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, OH, USA
| | | | - Marlena Plagianos
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Kevin Roberts
- Center for Biomedical Research, Population Council, New York, NY, USA
| | - Diana Blithe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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21
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Deese J, Pradhan S, Goetz H, Morrison C. Contraceptive use and the risk of sexually transmitted infection: systematic review and current perspectives. Open Access J Contracept 2018; 9:91-112. [PMID: 30519127 PMCID: PMC6239113 DOI: 10.2147/oajc.s135439] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose Evidence on the association between contraceptive use and risk of sexually transmitted infections (STIs) and bacterial vaginosis (BV) is lacking, with few prospective studies. We systematically reviewed the last 10 years' evidence on the association between contraception and STI/BV, building on the most recent systematic reviews published in 2006 and 2009. Methods We searched the MEDLINE and POPLINE databases for peer-reviewed articles p ublished between January 1, 2008 and January 31, 2018 reporting prospective studies that assessed the association between contraceptive use and incident STI and/or incident or recurrent BV. Results We identified 33 articles that evaluated combined oral contraceptives (COC), depot medroxyprogesterone acetate (DMPA), the copper intrauterine device (Cu-IUD), the levonorgestrel intrauterine system (LNG-IUS) and other methods. The strength of the evidence for many specific contraceptive method/STI associations is limited by few prospective studies with comparably defined exposures and outcomes. Available data suggest no association of COCs and Neisseria gonorrhoeae, Trichomonas vaginalis, HSV-2 or syphilis, and mixed evidence on the association with HPV, Chlamydia trachomatis, and BV. For DMPA, none of the studies identified found an association with N. gonorrhoeae or syphilis, and data on C. trachomatis, T. vaginalis, HPV and BV were mixed. Two large studies showed a highly clinically significant increased risk of HSV-2 infection with DMPA use. Data on the effect of Cu-IUD and the LNG-IUS on the acquisition of C. trachomatis, N. gonorrhoeae and T. vaginalis are sparse, and data on HPV and BV are mixed. Conclusion Few data are available from prospective studies, including randomized trials, to draw strong conclusions about the relationships between contraceptive methods and specific STIs. The overall evidence on the association between contraceptive use and STI/BV risk is limited by the lack of any randomized trials, few published prospective studies designed to analyze these associations, wide variability in exposure definitions and comparator groups, potential for confounding due to inaccurate sexual behavior data, differential confounder adjustment and differences in study populations and sizes. Despite these limitations, new evidence is supportive of a significantly increased risk of HSV-2 infection among DMPA users which warrants additional research to better understand this association.
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Affiliation(s)
- Jennifer Deese
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Subarna Pradhan
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Hannah Goetz
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
| | - Charles Morrison
- Global Health, Population and Nutrition, FHI 360, Durham, NC, USA,
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22
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Wessels JM, Felker AM, Dupont HA, Kaushic C. The relationship between sex hormones, the vaginal microbiome and immunity in HIV-1 susceptibility in women. Dis Model Mech 2018; 11:dmm035147. [PMID: 30154116 PMCID: PMC6177003 DOI: 10.1242/dmm.035147] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The role of sex hormones in regulating immune responses in the female genital tract has been recognized for decades. More recently, it has become increasingly clear that sex hormones regulate susceptibility to sexually transmitted infections through direct and indirect mechanisms involving inflammation and immune responses. The reproductive cycle can influence simian/human immunodeficiency virus (SHIV) infections in primates and HIV-1 infection in ex vivo cervical tissues from women. Exogenous hormones, such as those found in hormonal contraceptives, have come under intense scrutiny because of the increased susceptibility to sexually transmitted infections seen in women using medroxyprogesterone acetate, a synthetic progestin-based contraceptive. Recent meta-analyses concluded that medroxyprogesterone acetate enhanced HIV-1 susceptibility in women by 40%. In contrast, estradiol-containing hormonal contraceptives were not associated with increased susceptibility and some studies reported a protective effect of estrogen on HIV/SIV infection, although the underlying mechanisms remain incompletely understood. Recent studies describe a key role for the vaginal microbiota in determining susceptibility to sexually transmitted infections, including HIV-1. While Lactobacillus spp.-dominated vaginal microbiota is associated with decreased susceptibility, complex microbiota, such as those seen in bacterial vaginosis, correlates with increased susceptibility to HIV-1. Interestingly, sex hormones are inherently linked to microbiota regulation in the vaginal tract. Estrogen has been postulated to play a key role in establishing a Lactobacillus-dominated microenvironment, whereas medroxyprogesterone acetate is linked to hypo-estrogenic effects. The aim of this Review is to contribute to a better understanding of the sex-hormone-microbiome-immunity axis, which can provide key information on the determinants of HIV-1 susceptibility in the female genital tract and, consequently, inform HIV-1 prevention strategies.
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Affiliation(s)
- Jocelyn M Wessels
- McMaster Immunology Research Centre, Department of Pathology and Molecular Medicine, Michael G. DeGroote Centre for Learning and Discovery, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | - Allison M Felker
- McMaster Immunology Research Centre, Department of Pathology and Molecular Medicine, Michael G. DeGroote Centre for Learning and Discovery, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | - Haley A Dupont
- McMaster Immunology Research Centre, Department of Pathology and Molecular Medicine, Michael G. DeGroote Centre for Learning and Discovery, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | - Charu Kaushic
- McMaster Immunology Research Centre, Department of Pathology and Molecular Medicine, Michael G. DeGroote Centre for Learning and Discovery, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario L8S 4L8, Canada
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23
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Crucitti T, Hardy L, van de Wijgert J, Agaba S, Buyze J, Kestelyn E, Delvaux T, Mwambarangwe L, De Baetselier I, Jespers V. Contraceptive rings promote vaginal lactobacilli in a high bacterial vaginosis prevalence population: A randomised, open-label longitudinal study in Rwandan women. PLoS One 2018; 13:e0201003. [PMID: 30036385 PMCID: PMC6056036 DOI: 10.1371/journal.pone.0201003] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 07/04/2018] [Indexed: 12/12/2022] Open
Abstract
Background Hormonal contraception has been associated with a reduced risk of vaginal dysbiosis, which in turn has been associated with reduced prevalence of sexually transmitted infections (STIs), including HIV. Vaginal rings are used or developed as delivery systems for contraceptive hormones and antimicrobial drugs for STI and HIV prevention or treatment. We hypothesized that a contraceptive vaginal ring (CVR) containing oestrogen enhances a lactobacilli-dominated vaginal microbial community despite biomass accumulation on the CVR’s surface. Methods We enrolled 120 women for 12 weeks in an open-label NuvaRing® study at Rinda Ubuzima, Kigali, Rwanda. Vaginal and ring microbiota were assessed at baseline and each ring removal visit by Gram stain Nugent scoring (vaginal only), quantitative PCR for Lactobacillus species, Gardnerella vaginalis and Atopobium vaginae, and fluorescent in situ hybridization to visualize cell-adherent bacteria. Ring biomass was measured by crystal violet staining. Results Bacterial vaginosis (BV) prevalence was 48% at baseline. The mean Nugent score decreased significantly with ring use. The presence and mean log10 concentrations of Lactobacillus species in vaginal secretions increased significantly whereas those of G. vaginalis and presence of A. vaginae decreased significantly. Biomass accumulated on the CVRs with a species composition mirroring the vaginal microbiota. This ring biomass composition and optical density after crystal violet staining did not change significantly over time. Conclusions NuvaRing® promoted lactobacilli-dominated vaginal microbial communities in a population with high baseline BV prevalence despite the fact that biomass accumulated on the rings.
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Affiliation(s)
- Tania Crucitti
- Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | | | | | | | | | - Evelyne Kestelyn
- University of Liverpool, Liverpool, United Kingdom
- Rinda Ubuzima, Kigali, Rwanda
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24
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Thurman AR, Schwartz JL, Brache V, Clark MR, McCormick T, Chandra N, Marzinke MA, Stanczyk FZ, Dezzutti CS, Hillier SL, Herold BC, Fichorova R, Asin SN, Rollenhagen C, Weiner D, Kiser P, Doncel GF. Randomized, placebo controlled phase I trial of safety, pharmacokinetics, pharmacodynamics and acceptability of tenofovir and tenofovir plus levonorgestrel vaginal rings in women. PLoS One 2018; 13:e0199778. [PMID: 29953547 PMCID: PMC6023238 DOI: 10.1371/journal.pone.0199778] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/07/2018] [Indexed: 01/28/2023] Open
Abstract
To prevent the global health burdens of human immunodeficiency virus [HIV] and unintended/mistimed pregnancies, we developed an intravaginal ring [IVR] that delivers tenofovir [TFV] at ~10mg/day alone or with levonorgestrel [LNG] at ~20μg/day for 90 days. We present safety, pharmacokinetics, pharmacodynamics, acceptability and drug release data in healthy women. CONRAD A13-128 was a randomized, placebo controlled phase I study. We screened 86 women; 51 were randomized to TFV, TFV/LNG or placebo IVR [2:2:1] and 50 completed all visits, using the IVR for approximately 15 days. We assessed safety by adverse events, colposcopy, vaginal microbiota, epithelial integrity, mucosal histology and immune cell numbers and phenotype, cervicovaginal [CV] cytokines and antimicrobial proteins and changes in systemic laboratory measurements, and LNG and TFV pharmacokinetics in multiple compartments. TFV pharmacodynamic activity was measured by evaluating CV fluid [CVF] and tissue for antiviral activity using in vitro models. LNG pharmacodynamic assessments were timed based on peak urinary luteinizing hormone levels. All IVRs were safe with no significant colposcopic, mucosal, immune and microbiota changes and were acceptable. Among TFV containing IVR users, median and mean CV aspirate TFV concentrations remained above 100,000 ng/mL 4 hours post IVR insertion and mean TFV-diphosphate [DP] concentrations in vaginal tissue remained above 1,000 fmol/mg even 3 days post IVR removal. CVF of women using TFV-containing IVRs completely inhibited [94-100%] HIV infection in vitro. TFV/LNG IVR users had mean serum LNG concentrations exceeding 300 pg/mL within 1 hour, remaining high throughout IVR use. All LNG IVR users had a cervical mucus Insler score <10 and the majority [95%] were anovulatory or had abnormal cervical mucus sperm penetration. Estimated in vivo TFV and LNG release rates were within expected ranges. All IVRs were safe with the active ones delivering sustained high concentrations of TFV locally. LNG caused changes in cervical mucus, sperm penetration, and ovulation compatible with contraceptive efficacy. The TFV and TFV/LNG rings are ready for expanded 90 day clinical testing. Trial registration ClinicalTrials.gov #NCT02235662.
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Affiliation(s)
- Andrea Ries Thurman
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Jill L. Schwartz
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | | | - Meredith R. Clark
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Timothy McCormick
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
| | - Neelima Chandra
- CONRAD, Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | - Mark A. Marzinke
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Frank Z. Stanczyk
- University of Southern California Keck School of Medicine, Los Angeles, California, United States of America
| | - Charlene S. Dezzutti
- University of Pittsburgh, Department of Obstetrics, Gynecology & Reproductive Sciences, Department of Infectious Diseases & Microbiology, Graduate School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - Sharon L. Hillier
- University of Pittsburgh School of Medicine, Departments of Obstetrics, Gynecology and Reproductive Sciences and Microbiology and Molecular Genetics, Pittsburgh, Pennsylvania, United States of America
| | - Betsy C. Herold
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | - Raina Fichorova
- Laboratory of Genital Tract Biology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Susana N. Asin
- V.A. Medical Center, White River Junction, VT and Geisel School of Medicine at Dartmouth, New Hampshire
| | - Christiane Rollenhagen
- V.A. Medical Center, White River Junction, VT and Geisel School of Medicine at Dartmouth, New Hampshire
| | - Debra Weiner
- FHI360, Durham, North Carolina, United States of America
| | - Patrick Kiser
- Northwestern University, Evanston, Illinois, United States of America
| | - Gustavo F. Doncel
- CONRAD, Eastern Virginia Medical School, Arlington, Virginia, United States of America
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25
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Abstract
Over the last century, there has been a dramatic change in the nature of therapeutic, biologically active molecules available to treat disease. Therapies have evolved from extracted natural products towards rationally designed biomolecules, including small molecules, engineered proteins and nucleic acids. The use of potent drugs which target specific organs, cells or biochemical pathways, necessitates new tools which can enable controlled delivery and dosing of these therapeutics to their biological targets. Here, we review the miniaturisation of drug delivery systems from the macro to nano-scale, focussing on controlled dosing and controlled targeting as two key parameters in drug delivery device design. We describe how the miniaturisation of these devices enables the move from repeated, systemic dosing, to on-demand, targeted delivery of therapeutic drugs and highlight areas of focus for the future.
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Affiliation(s)
- Derfogail Delcassian
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,b Department of Anaesthesiology , Boston Children's Hospital, Harvard Medical School , Boston , MA , USA.,c Division of Regenerative Medicine and Cellular Therapies, School of Pharmacy , University of Nottingham , Nottingham , UK
| | - Asha K Patel
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,d Division of Cancer and Stem Cells, School of Medicine, and Division of Advanced Materials and Healthcare Technologies, School of Pharmacy , University of Nottingham , Nottingham , UK
| | - Abel B Cortinas
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,e Department of Chemical Engineering , Massachusetts Institute of Technology , Cambridge , MA , USA
| | - Robert Langer
- a David H. Koch Institute for Integrative Cancer Research , Massachusetts Institute of Technology , Cambridge , MA , USA.,e Department of Chemical Engineering , Massachusetts Institute of Technology , Cambridge , MA , USA.,f Institute for Medical Engineering and Science , Massachusetts Institute of Technology , Cambridge , MA , USA.,g Media Lab , Massachusetts Institute of Technology , Cambridge , MA , USA
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26
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Stifani BM, Plagianos M, Vieira CS, Merkatz RB. Factors associated with nonadherence to instructions for using the Nestorone®/ethinyl estradiol contraceptive vaginal ring. Contraception 2017; 97:415-421. [PMID: 29269252 DOI: 10.1016/j.contraception.2017.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/08/2017] [Accepted: 12/08/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES We sought to identify factors associated with nonadherence to instructions for using a novel contraceptive providing 1 year of protection. STUDY DESIGN Data from a multicountry Phase 3 trial of the Nestorone® (segesterone acetate)/ethinyl estradiol (NES/EE) contraceptive vaginal ring (CVR) were analyzed. Participants were instructed to use the CVR over 13 cycles and follow a 21/7 regimen. Their reports of CVR removals >2 h outside scheduled removal periods served as a proxy for nonadherence. We used multivariate logistic regression to determine factors associated with such use. RESULTS Of 905 participants, 120 (13%) reported CVR removals >2 h. Removals for washing [odds ratio (OR) 3.96, 95% confidence interval (CI) 2.50-6.27] or sexual intercourse (OR 3.19, 95% CI 2.03-4.99), and finding CVR insertion difficult (OR 2.80, 95% CI 1.36-5.80) were factors associated with removals >2 h. Lower educational attainment also predicted ring removal >2 h (OR 3.23, 95% CI 1.55-6.75). Women residing in Europe or Australia were less likely to remove the ring for >2 h compared with women in the United States (OR 0.44, 95% CI 0.24-0.83 and OR 0.13, 95% CI 0.02-0.98, respectively). Participants who reported removals >2 h were more likely to discontinue CVR use (OR 1.93, 95% CI 1.24-2.95), report dissatisfaction (OR 2.20, 95% CI 1.32-3.69) and become pregnant during the study (OR 4.07, 95% CI 1.58-10.50). CONCLUSIONS Removing the CVR for washing and removing it before intercourse are factors associated with nonadherence to ring use. These are important topics for counseling women who are considering or using vaginal rings, including the NES/EE CVR. IMPLICATIONS Findings from this study may be useful in guiding counseling for current and prospective vaginal ring users. Anticipatory guidance should focus on how the ring feels in the vagina and during sex. Asking about ring removals may help identify women who are at increased risk for having an unplanned pregnancy.
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Affiliation(s)
- Bianca M Stifani
- Department of Obstetrics, Gynecology and Women's Health of Albert Einstein College of Medicine/Montefiore Medical Center, 1300 Morris Park Avenue, Bronx, NY, 10461, USA; Population Council, 1230 York Avenue, New York, NY, 10065, USA
| | | | - Carolina Sales Vieira
- Population Council, 1230 York Avenue, New York, NY, 10065, USA; Department of Gynecology and Obstetrics, Ribeirao Preto Medical School, University of São Paulo. Avenida Bandeirantes, 3900-Campus Universitário-Monte Alegre, CEP: 14049-900, Ribeirão Preto, SP, Brazil
| | - Ruth B Merkatz
- Population Council, 1230 York Avenue, New York, NY, 10065, USA.
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27
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Hardy L, Jespers V, De Baetselier I, Buyze J, Mwambarangwe L, Musengamana V, van de Wijgert J, Crucitti T. Association of vaginal dysbiosis and biofilm with contraceptive vaginal ring biomass in African women. PLoS One 2017; 12:e0178324. [PMID: 28594946 PMCID: PMC5464551 DOI: 10.1371/journal.pone.0178324] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 05/08/2017] [Indexed: 11/29/2022] Open
Abstract
We investigated the presence, density and bacterial composition of contraceptive vaginal ring biomass and its association with the vaginal microbiome. Of 415 rings worn by 120 Rwandese women for three weeks, the biomass density was assessed with crystal violet and the bacterial composition of biomass eluates was assessed with quantitative polymerase chain reaction (qPCR). The biomass was visualised after fluorescence in situ hybridisation (FISH) and with scanning electron microscopy (SEM). The vaginal microbiome was assessed with Nugent scoring and vaginal biofilm was visualised after FISH. All vaginal rings were covered with biomass (mean optical density (OD) of 3.36; standard deviation (SD) 0.64). Lactobacilli were present on 93% of the rings, Gardnerella vaginalis on 57%, and Atopobium vaginae on 37%. The ring biomass density was associated with the concentration of A. vaginae (OD +0.03; 95% confidence interval (CI) 0.01–0.05 for one log increase; p = 0.002) and of G. vaginalis (OD +0.03; (95% CI 0.01–0.05; p = 0.013). The density also correlated with Nugent score: rings worn by women with a BV Nugent score (mean OD +0.26), and intermediate score (mean OD +0.09) had a denser biomass compared to rings worn by participants with a normal score (p = 0.002). Furthermore, presence of vaginal biofilm containing G. vaginalis (p = 0.001) and A. vaginae (p = 0.005) correlated with a denser ring biomass (mean OD +0.24 and +0.22 respectively). With SEM we observed either a loose network of elongated bacteria or a dense biofilm. We found a correlation between vaginal dysbiosis and the density and composition of the ring biomass, and further research is needed to determine if these relationships are causal. As multipurpose vaginal rings to prevent pregnancy, HIV, and other sexually transmitted diseases are being developed, the potential impact of ring biomass on the vaginal microbiota and the release of active pharmaceutical ingredients should be researched in depth.
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Affiliation(s)
- Liselotte Hardy
- HIV and Sexual Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Vicky Jespers
- HIV and Sexual Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Irith De Baetselier
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jozefien Buyze
- Clinical Trials Unit, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Janneke van de Wijgert
- Rinda Ubuzima, Kigali, Rwanda
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Tania Crucitti
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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28
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Blithe DL. Pipeline for contraceptive development. Fertil Steril 2016; 106:1295-1302. [PMID: 27523300 PMCID: PMC5159203 DOI: 10.1016/j.fertnstert.2016.07.1115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/14/2016] [Accepted: 07/21/2016] [Indexed: 11/16/2022]
Abstract
The high rates of unplanned pregnancy reflect an unmet need for effective contraceptive methods for women, especially for individuals with health risks such as obesity, diabetes, hypertension, and other conditions that may contraindicate use of an estrogen-containing product. Improvements in safety, user convenience, acceptability, and availability of products remain important goals of the contraceptive development program. Another important goal is to minimize the impact of the products on the environment. Development of new methods for male contraception has the potential to address many of these issues of safety for women who have contraindications to effective contraceptive methods but want to protect against pregnancy. It would also address a huge unmet need for men who want to control their fertility. Products under development for men would not introduce ecotoxic hormones into the water system.
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Affiliation(s)
- Diana L Blithe
- Contraception Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
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