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Kestelyn E, Van Nuil JI, Umulisa MM, Umutoni G, Uwingabire A, De Baetselier I, Uwineza M, Agaba S, Crucitti T, Delvaux T, van de Wijgert JHHM. High adherence to intermittent and continuous use of a contraceptive vaginal ring among women in a randomized controlled trial in Kigali, Rwanda. Front Glob Womens Health 2024; 5:1278981. [PMID: 38680542 PMCID: PMC11047128 DOI: 10.3389/fgwh.2024.1278981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/20/2024] [Indexed: 05/01/2024] Open
Abstract
Background The introduction of female-initiated drug-delivery methods, including vaginal rings, have proven to be a promising avenue to address sexually transmitted infections and unintended pregnancies, which disproportionally affects women and girls in sub-Saharan Africa. Efficient uptake of existing and new technologies such as vaginal rings requires in depth understanding of product adherence. This remains a major challenge as data on adherence to vaginal rings from African countries is limited. In this study, we explored adherence of contraceptive vaginal ring (NuvaRing®) use in Kigali, Rwanda using a mixed methods approach. Methods We collected quantitative and qualitative data at multiple time points from women participating in a clinical trial exploring the safety and acceptability of either intermittent or continuous use of the NuvaRing®. Various adherence categories were used including monthly and cumulative adherence measurement. The quantitative data were analysed using R and the qualitative data were analysed using a deductive, content-analytical approach based on categories related to the quantitative adherence measures. All data were compared and triangulated. Results Data from 120 enrolled participants showed that self-reported adherence was high at every study visit in both study groups. At first study visit 80% of the intermittent ring users and 79.7% of the continuous ring users reported perfect adherence (assessed as "the ring was never out"). Reporting of ring expulsions and removals were highest (28.3%) at the beginning of the trial. Self-reported perfect ring adherence increased during the study and reports of ring expulsions and removals declined as familiarity with this contraceptive method increased. The percentage of women with perfect cumulative adherence was non-significantly higher in the intermittent (61.7%) than in the continuous use group (54.3%). The low rate of discrepant adherence data after triangulation (6%) is in line with the perception of the participants as adherent throughout the study. Conclusions Self-reported adherence in both study groups was high with removals and expulsions being within the expected product range. Comprehensive adherence data triangulation allowed for a deeper understanding of context-driven behaviour that shaped adherence patterns and challenges. Our data categorisation and triangulation approach has shown potential for implementation in future vaginal ring studies aiming to better understand and measure adherence.
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Affiliation(s)
- Evelyne Kestelyn
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Jennifer Ilo Van Nuil
- Rinda Ubuzima, Kigali, Rwanda
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Irith De Baetselier
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Tania Crucitti
- Experimental Bacteriology Unit, Institut Pasteur Madagascar, Antananarivo, Madagascar
| | - Thérèse Delvaux
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Janneke H. H. M. van de Wijgert
- Rinda Ubuzima, Kigali, Rwanda
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Pedro NA, Mira NP. A molecular view on the interference established between vaginal Lactobacilli and pathogenic Candida species: Challenges and opportunities for the development of new therapies. Microbiol Res 2024; 281:127628. [PMID: 38246122 DOI: 10.1016/j.micres.2024.127628] [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: 10/23/2023] [Revised: 01/03/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
Vaginal infectious diseases caused by viruses and bacteria have been linked to the occurrence of dysbiosis, that is, a reduction in the abundance of the normally dominating vaginal Lactobacillus species. Mucosal infections in the vagina and/or vulva caused by Candida species, usually known as vulvovaginal candidiasis (or VVC), are among the leading causes of diseases in the vaginal tract. The existence of a clear link between the occurrence of dysbiosis and the development of VVC is still unclear, although multiple observations point in that direction. Based on the idea that vaginal health is linked to a microbiota dominated by lactobacilli, several probiotics have been used in management of VVC, either alone or in combination with antifungals, having obtained different degrees of success. In most cases, the undertaken trials resorted to lactobacilli species other than those indigenous to the vaginal tract, although in vitro these vaginal species were shown to reduce growth, viability and virulence of Candida. In this paper we overview the role of lactobacilli and Candida in the vaginal micro- and myco-biomes, while discussing the results obtained in what concerns the establishment of interference mechanisms in vivo and the environmental factors that could determine that. We also overview the molecular mechanisms by which lactobacilli species have been shown to inhibit pathophysiology of Candida, including the description of the genes and pathways determining their ability to thrive in the presence of each other. In a time where concerns are increasing with the emergence of antifungal resistance and the slow pace of discovery of new antifungals, a thorough understanding of the molecular mechanisms underneath the anti-Candida effect prompted by vaginal lactobacilli is of utmost importance to assure a knowledge-based design of what can be a new generation of pharmaceuticals, eventually focusing therapeutic targets other than the usual ones.
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Affiliation(s)
- Nuno A Pedro
- iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico - Department of Bioengineering, Universidade de Lisboa, 1049-001 Lisboa, Portugal; Associate Laboratory i4HB-Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal
| | - Nuno P Mira
- iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico - Department of Bioengineering, Universidade de Lisboa, 1049-001 Lisboa, Portugal; Associate Laboratory i4HB-Institute for Health and Bioeconomy at Instituto Superior Técnico, Universidade de Lisboa, Av. Rovisco Pais, 1049-001 Lisboa, Portugal.
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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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Tolley EE, Hanif H, Thurman A, Brache V, Doncel GF. Preferred product attributes of a multipurpose vaginal ring: Findings from a phase 1 trial. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1148134. [PMID: 37064825 PMCID: PMC10097978 DOI: 10.3389/frph.2023.1148134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/09/2023] [Indexed: 04/01/2023] Open
Abstract
IntroductionMost women face multiple and co-occurring risks from unwanted pregnancy, human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) at some point during their lifetime. While a range of contraceptive methods exist and options for HIV prevention are increasing, to date, only male and female condoms provide multipurpose protection from both pregnancy and disease.MethodsFrom September 2017 to December 2018, 60 women from the United States and the Dominican Republic, randomized 1:1 to continuous or interrupted use and 4:1 to active vs. placebo ring, participated in a Phase I trial to assess the safety and tolerability of a three-month multipurpose intravaginal ring (IVR) containing the antiviral tenofovir and the contraceptive levonorgestrel. This study examines survey responses from all participants and qualitative data from a subset of 17 women to assess acceptability of and preferences for IVR characteristics.ResultsOverall, women liked the concept of a multipurpose IVR and found it easy to insert and remove. Initial concerns about the size or thickness of the ring generally disappeared with use experience. Women weighed trade-offs between the ease of continuous use for a longer duration against concerns about hygiene and discoloration of the ring when left in place during menses. Whether randomized to continuous or interrupted use, most women found ring attributes (size, thickness, flexibility) very acceptable. They provided recommendations via survey and qualitative interviews for ring modifications that would further increase acceptability. Insights into women's use experiences also suggest the need for clear counseling messages and introduction strategies that can facilitate women's choice and use of prevention methods.DiscussionStudy findings suggest that a multipurpose IVR would make a valuable contribution to women's sexual and reproductive health options, and that both continuous and interrupted use strategies may be preferred.
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Affiliation(s)
- Elizabeth E. Tolley
- FHI 360, Global Health and Population Research, Durham, NC, United States
- Correspondence: Elizabeth E. Tolley
| | - Homaira Hanif
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
| | - Andrea Thurman
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
| | | | - Gustavo F. Doncel
- CONRAD and Eastern Virginia Medical School, Norfolk, VA, United States
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Brown BP, Feng C, Tanko RF, Jaumdally SZ, Bunjun R, Dabee S, Happel AU, Gasper M, Nyangahu DD, Onono M, Nair G, Palanee-Phillips T, Scoville CW, Heller K, Baeten JM, Bosinger SE, Burgener A, Passmore JAS, Heffron R, Jaspan HB. Copper intrauterine device increases vaginal concentrations of inflammatory anaerobes and depletes lactobacilli compared to hormonal options in a randomized trial. Nat Commun 2023; 14:499. [PMID: 36717556 PMCID: PMC9886933 DOI: 10.1038/s41467-023-36002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 01/12/2023] [Indexed: 02/01/2023] Open
Abstract
Effective contraceptives are a global health imperative for reproductive-aged women. However, there remains a lack of rigorous data regarding the effects of contraceptive options on vaginal bacteria and inflammation. Among 218 women enrolled into a substudy of the ECHO Trial (NCT02550067), we evaluate the effect of injectable intramuscular depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel implant (LNG), and a copper intrauterine device (Cu-IUD) on the vaginal environment after one and six consecutive months of use, using 16S rRNA gene sequencing and multiplex cytokine assays. Primary endpoints include incident BV occurrence, bacterial diversity, and bacterial and cytokine concentrations. Secondary endpoints are bacterial and cytokine concentrations associated with later HIV seroconversion. Participants randomized to Cu-IUD exhibit elevated bacterial diversity, increased cytokine concentrations, and decreased relative abundance of lactobacilli after one and six months of use, relative to enrollment and other contraceptive options. Total bacterial loads of women using Cu-IUD increase 5.5 fold after six months, predominantly driven by increases in the concentrations of several inflammatory anaerobes. Furthermore, growth of L. crispatus (MV-1A-US) is inhibited by Cu2+ ions below biologically relevant concentrations, in vitro. Our work illustrates deleterious effects on the vaginal environment induced by Cu-IUD initiation, which may adversely impact sexual and reproductive health.
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Affiliation(s)
- Bryan P Brown
- Seattle Children's Research Institute, Seattle, USA.
- University of Washington, Seattle, USA.
| | - Colin Feng
- Seattle Children's Research Institute, Seattle, USA
| | - Ramla F Tanko
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- The Medical Research Centre, Institute of Medical Research and Medicinal Plant Studies (IMPM), Ministry of Scientific Research and Innovation, Yaoundé, Cameroon
| | - Shameem Z Jaumdally
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Rubina Bunjun
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Smritee Dabee
- Seattle Children's Research Institute, Seattle, USA
- University of Washington, Seattle, USA
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna-Ursula Happel
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Melanie Gasper
- Seattle Children's Research Institute, Seattle, USA
- University of Washington, Seattle, USA
| | - Donald D Nyangahu
- Seattle Children's Research Institute, Seattle, USA
- University of Washington, Seattle, USA
| | | | | | | | | | | | - Jared M Baeten
- University of Washington, Seattle, USA
- Gilead Sciences, Inc, Seattle, USA
| | - Steven E Bosinger
- Yerkes National Primate Research Center, Atlanta, USA
- Emory University, Atlanta, USA
| | - Adam Burgener
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, USA
- University of Manitoba, Winnipeg, Canada
- Karolinska Institute, Stockholm, Sweden
| | - Jo-Ann S Passmore
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Cape Town, South Africa
| | - Renee Heffron
- University of Washington, Seattle, USA
- University of Alabama, Birmingham, USA
| | - Heather B Jaspan
- Seattle Children's Research Institute, Seattle, USA.
- University of Washington, Seattle, USA.
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Tuddenham S, Gajer P, Burke AE, Murphy C, Klein SL, Stennett CA, Wilgus B, Ravel J, Ghanem KG, Brotman RM. Lactobacillus-dominance and rapid stabilization of vaginal microbiota in combined oral contraceptive pill users examined through a longitudinal cohort study with frequent vaginal sampling over two years. EBioMedicine 2023; 87:104407. [PMID: 36529102 PMCID: PMC9792759 DOI: 10.1016/j.ebiom.2022.104407] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Bacterial vaginosis (BV), a condition in which vaginal Lactobacillus spp. are in low abundance, is associated with vulvovaginal symptoms, obstetric outcomes and urogenital infections. Recurrent BV is difficult to manage, and emerging data indicate a reduced risk of BV with the use of hormonal contraception (HC). Despite widespread use, little longitudinal data is available on whether, and in what timeframe, combined oral contraceptive pills (COCs) may act to affect vaginal microbiota stability and Lactobacillus dominance. METHODS We compared the vaginal microbiota of reproductive-age cisgender women during intervals on combined estrogen and progestin COCs with non-use intervals in a 2-year observational study. Vaginal microbiota were characterized by 16S rRNA gene amplicon sequencing. FINDINGS COC users were more likely to have Lactobacillus-dominated microbiota and more stable microbiota over time. Stability increased and then plateaued four weeks after COC initiation. The associations between COCs and Lactobacillus spp. dominance, and microbiota stability, were statistically significant for White, but not African American women; however sample size was limited for African American participants. Findings were similar for other forms of HC and when excluding samples collected during menses. INTERPRETATION Our study provides a methodologic framework to evaluate observational longitudinal microbiota data with exposure crossovers. We found COCs are associated with vaginal microbiota stability and a Lactobacillus-dominated state. COCs appear to impact stability within a month of initiation. Our findings have clinical implications for how soon benefits can be expected in (at least White) patients initiating COCs, and support the need for larger prospective trials to verify our results in ethnically diverse populations. FUNDING R01-AI089878.
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Affiliation(s)
- Susan Tuddenham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Pawel Gajer
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine Murphy
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christina A Stennett
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Barbara Wilgus
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khalil G Ghanem
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca M Brotman
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, USA; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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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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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] [Key Words] [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
| | - 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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9
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Ratten LK, Plummer EL, Bradshaw CS, Fairley CK, Murray GL, Garland SM, Bateson D, Tachedjian G, Masson L, Vodstrcil LA. The Effect of Exogenous Sex Steroids on the Vaginal Microbiota: A Systematic Review. Front Cell Infect Microbiol 2021; 11:732423. [PMID: 34869054 PMCID: PMC8633117 DOI: 10.3389/fcimb.2021.732423] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/13/2021] [Indexed: 12/12/2022] Open
Abstract
Background Exogenous sex steroids within hormonal contraception and menopausal hormone therapy (MHT) have been used for family planning and management of menopausal symptoms, without consideration of their effects on the vaginal microbiota. This is largely because their use predates our understanding of the importance of the vaginal microbiome on human health. We conducted a systematic review (PROSPERO: CRD42018107730) to determine the influence of exogenous sex steroids, stratified by oestrogen-containing or progestin-only types of contraception, and MHT on the vaginal microbiome, as measured by molecular methods. Methods Embase, PubMed and Medline were searched for relevant literature published through to December 1st 2020. Eligible studies reported on the effect of specific exogenous sex steroids on the vaginal microbiome using a molecular method. Data regarding the ‘positive’, ‘negative’ or ‘neutral’ effect of each type of contraceptive or MHT on the vaginal microbiome was extracted and summarised. A positive effect reflected sex steroid exposure that was associated with increased abundance of lactobacilli, a change to, or maintenance of, an optimal vaginal microbiota composition, or a decrease in bacterial diversity (specifically reflecting a low-diversity optimal microbiota state), relative to the control group. An exogenous sex steroid was designated as having a negative effect on the vaginal microbiome if it resulted in opposing effects (i.e. loss of lactobacilli, a non-optimal microbiota state). When no significant change was found, this was considered neutral/inconclusive. Results We identified 29 manuscripts reporting on the effect of exogenous sex steroids on the vaginal microbiome; 25 investigating hormonal contraceptives, and 4 investigating MHT. Oestrogen-containing contraception, particularly reflecting the combined oestrogen and progestin-containing contraceptive pill, had a positive effect on the composition of the vaginal microbiota. Progestin-only contraception, particularly reflecting depo-medroxyprogesterone acetate, had mixed effects on the microbiota. Among post-menopausal women using MHT, exogenous oestrogen applied topically was associated with increased prevalence of lactobacilli. Conclusion Our findings suggest that oestrogen-containing compounds may promote an optimal vaginal microbiota, which could have clinical applications. The impact of progestin-only contraceptives on the vaginal microbiota is less clear; more data is needed to determine how progestin-only contraceptives contribute to adverse reproductive and sexual health outcomes.
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Affiliation(s)
- Larissa K Ratten
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - Erica L Plummer
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia
| | - Gerald L Murray
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, VIC, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Suzanne M Garland
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, VIC, Australia.,Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, VIC, Australia.,Infection and Immunity, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Deborah Bateson
- Family Planning NSW, Sydney, NSW, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gilda Tachedjian
- Life Sciences Discipline, Burnet Institute, Melbourne, VIC, Australia.,Department of Microbiology, Monash University, Clayton, VIC, Australia.,Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Lindi Masson
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Life Sciences Discipline, Burnet Institute, Melbourne, VIC, Australia.,Institute of Infectious Disease and Molecular Medicine and Department of Pathology, University of Cape Town, Cape Town, South Africa.,Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Lenka A Vodstrcil
- Central Clinical School, Monash University, Carlton, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Carlton, VIC, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia
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10
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Graham ME, Herbert WG, Song SD, Raman HN, Zhu JE, Gonzalez PE, Walther-António MRS, Tetel MJ. Gut and vaginal microbiomes on steroids: implications for women's health. Trends Endocrinol Metab 2021; 32:554-565. [PMID: 34049772 PMCID: PMC8282721 DOI: 10.1016/j.tem.2021.04.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 04/17/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
This review discusses the interactions of steroids with the gut and vaginal microbiomes within each life phase of adult women and the implications for women's health. Each phase of a woman's life is characterized by distinct hormonal states which drive overall physiology of both host and commensal microbes. These host-microbiome interactions underlie disease pathology in disorders that affect women across their lifetime, including bacterial vaginosis, gestational diabetes, polycystic ovary syndrome (PCOS), anxiety, depression, and obesity. Although many associations between host health and microbiome composition are well defined, the mechanistic role of the microbiome in women's health outcomes is largely unknown. This review addresses potential mechanisms by which the microbiota influences women's health and highlights gaps in current knowledge.
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Affiliation(s)
- Madeline E Graham
- Neuroscience Department, Wellesley College, Wellesley, MA 02481, USA
| | - William G Herbert
- Department of Surgery, Department of Obstetrics and Gynecology, and Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA; Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN 55905, USA
| | - Stephanie D Song
- Department of Surgery, Department of Obstetrics and Gynecology, and Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Harshini N Raman
- Neuroscience Department, Wellesley College, Wellesley, MA 02481, USA
| | - Jade E Zhu
- Neuroscience Department, Wellesley College, Wellesley, MA 02481, USA
| | | | - Marina R S Walther-António
- Department of Surgery, Department of Obstetrics and Gynecology, and Microbiome Program, Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Marc J Tetel
- Neuroscience Department, Wellesley College, Wellesley, MA 02481, USA.
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11
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Lagenaur LA, Hemmerling A, Chiu C, Miller S, Lee PP, Cohen CR, Parks TP. Connecting the Dots: Translating the Vaginal Microbiome Into a Drug. J Infect Dis 2021; 223:S296-S306. [PMID: 33330916 PMCID: PMC8502429 DOI: 10.1093/infdis/jiaa676] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
A Lactobacillus-dominated vaginal microbiota (VMB) has been associated with health and considered an important host defense mechanism against urogenital infections. Conversely, depletion of lactobacilli and increased microbial diversity, amplifies the risk of adverse gynecologic and obstetric outcomes. A common clinical condition that exemplifies dysbiosis is bacterial vaginosis (BV). BV is currently treated with antibiotics, but frequently recurs, due in part to persistent dysbiosis and failure of lactobacilli to repopulate the vagina. New treatment options are needed to address BV. The VMB is relatively simple and optimally dominated by one or several species of Lactobacillus. Lactobacillus crispatus is strongly associated with vaginal health and depleted in dysbiosis. Replenishing the dysbiotic VMB with protective L. crispatus CTV-05 is a promising approach to prevent recurrent infections and improve women's health. Here we discuss confirmation of this approach with the microbiome-based biologic drug, LACTIN-V (L. crispatus CTV-05), focusing on prevention of BV recurrence.
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Affiliation(s)
| | - Anke Hemmerling
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
| | - Charles Chiu
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Steve Miller
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Craig R Cohen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
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12
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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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13
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Ruiz-Perez D, Coudray MS, Colbert B, Krupp K, Kumari H, Stebliankin V, Mathee K, Cook RL, Schwebke J, Narasimhan G, Madhivanan P. Effect of metronidazole on vaginal microbiota associated with asymptomatic bacterial vaginosis. Access Microbiol 2021; 3:000226. [PMID: 34151180 PMCID: PMC8209634 DOI: 10.1099/acmi.0.000226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/17/2021] [Indexed: 01/10/2023] Open
Abstract
Vaginal dysbiosis-induced by an overgrowth of anaerobic bacteria is referred to as bacterial vaginosis (BV). The dysbiosis is associated with an increased risk for acquisition of sexually transmitted infections. Women with symptomatic BV are treated with oral metronidazole (MET), but its effectiveness remains to be elucidated. This study used whole-genome sequencing (WGS) to determine the changes in the microbiota among women treated with MET. WGS was conducted on DNA obtained from 20 vaginal swabs collected at four time points over 12 months from five randomly selected African American (AA) women. The baseline visit included all women who were diagnosed with asymptomatic BV and were untreated. All subjects were tested subsequently once every 2 months and received a course of MET for each BV episode during the 12 months. The BV status was classified according to Nugent scores (NSs) of vaginal smears. The microbial and resistome profiles were analysed along with the sociodemographic metadata. Despite treatment, none of the five participants reverted to normal vaginal flora - two were consistently positive for BV, and the rest experienced episodic cases of BV. WGS analyses showed Gardnerella spp. as the most abundant organism. After treatment with MET, there was an observed decline of Lactobacillus and Prevotella species. One participant had a healthy vaginal microbiota based on NS at one follow-up time point. Resistance genes including tetM and lscA were detected. Though limited in subjects, this study shows specific microbiota changes with treatment, presence of many resistant genes in their microbiota, and recurrence and persistence of BV despite MET treatment. Thus, MET may not be an effective treatment option for asymptomatic BV, and whole metagenome sequence would better inform the choice of antibiotics.
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Affiliation(s)
- Daniel Ruiz-Perez
- Bioinformatics Research Group (BioRG), Knight Foundation School of Computing and Information Sciences, College of Engineering and Computing, Florida International University (FIU), Miami, FL, USA
| | - Makella S Coudray
- Department of Epidemiology, Stempel College of Public Health, FIU, Miami, FL, USA.,Present address: Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, FL 32827, USA
| | - Brett Colbert
- Department of Biological Sciences, College of Arts, Sciences and Education, FIU, Miami, FL, USA.,Present address: Miller School of Medicine, University of Miami, Miami, FL 33136, USA
| | - Karl Krupp
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
| | - Hansi Kumari
- Department of Human and Molecular Genetics, Herbert Wertheim College of Medicine, FIU, Miami, FL, USA
| | - Vitalii Stebliankin
- Bioinformatics Research Group (BioRG), Knight Foundation School of Computing and Information Sciences, College of Engineering and Computing, Florida International University (FIU), Miami, FL, USA
| | - Kalai Mathee
- Department of Human and Molecular Genetics, Herbert Wertheim College of Medicine, FIU, Miami, FL, USA.,Biomolecular Sciences Institute, FIU, Miami, FL, USA
| | - Robert L Cook
- Department of Epidemiology, College of Public Health and Health Professions, University of Florida (UF), Gainesville, FL 32611, USA.,Department of Medicine, Division of General Internal Medicine, UF, Gainesville, FL 32611, USA
| | - Jane Schwebke
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Giri Narasimhan
- Bioinformatics Research Group (BioRG), Knight Foundation School of Computing and Information Sciences, College of Engineering and Computing, Florida International University (FIU), Miami, FL, USA.,Biomolecular Sciences Institute, FIU, Miami, FL, USA
| | - Purnima Madhivanan
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.,Division of Infectious Diseases, College of Medicine, University of Arizona (UA), Tucson, AZ, USA.,Department of Family & Community Medicine, UA, Tucson, AZ, USA.,Public Health Research Institute of India, Mysore, Karnataka, India
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14
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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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15
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Di Pierro F, Criscuolo AA, Dei Giudici A, Senatori R, Sesti F, Ciotti M, Piccione E. Oral administration of Lactobacillus crispatus M247 to papillomavirus-infected women: results of a preliminary, uncontrolled, open trial. Minerva Obstet Gynecol 2021; 73:621-631. [PMID: 33876901 DOI: 10.23736/s2724-606x.21.04752-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vaginal microbiotas can be clustered into five different possible categories (CST I to V), according to their bacterial dominance. In CST I, the dominance of Lactobacillus crispatus seems to correlate with better vaginal health and with a lower incidence of sine causa infertility, preterm delivery, bacterial vaginosis, and viral (including human papillomavirus; HPV) infection. According to the same method of classifying the vaginal microbiome, CST IV (non-Lactobacillusdominated) demonstrates a higher incidence of disorders. METHODS In an open, non-controlled study, we enrolled 35 HPV-positive women who mostly (N=24) demonstrated CST IV status, with the other individuals categorized as having either CST III (N=10) or CST II (N=1) microbiotas. RESULTS After 90 days of oral treatment with a probiotic (L. crispatus M247) we observed a reduction of approximately 70% in HPV positivity and a significant change in CST status with 94% of women now classified as CST I. CONCLUSIONS Despite the limitations of our study, it is the first demonstration that it is possible to intervene orally with an L. crispatus probiotic to bring about a change in CST status and, in parallel, increased HPV clearance.
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Affiliation(s)
- Francesco Di Pierro
- Scientific Department, Velleja Research, Milan, Italy - .,Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
| | - Anna A. Criscuolo
- Section of Gynecology, Academic Department of Biomedicine and Prevention and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Anna Dei Giudici
- Section of Gynecology, Academic Department of Biomedicine and Prevention and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Roberto Senatori
- SICPCV (Italian Society of Colposcopy and Cervico-Vaginal Pathology) board, Rome, Italy
| | - Francesco Sesti
- Section of Gynecology, Academic Department of Biomedicine and Prevention and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Marco Ciotti
- Section of Gynecology, Academic Department of Biomedicine and Prevention and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
| | - Emilio Piccione
- Section of Gynecology, Academic Department of Biomedicine and Prevention and Clinical Department of Surgery, Tor Vergata University Hospital, Rome, Italy
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16
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Gould FG, Carey MP, Plummer EL, Murray GL, Danielewski JA, Tabrizi SN, Garland SM. Bacterial biofilm formation on vaginal ring pessaries used for pelvic organ prolapse. Int Urogynecol J 2021; 33:287-295. [PMID: 33660005 DOI: 10.1007/s00192-021-04717-x] [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] [Received: 11/15/2020] [Accepted: 02/01/2021] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to characterize the bacterial biofilm on vaginal ring pessaries used to treat pelvic organ prolapse and investigate the relationship between biofilm phenotype and patient symptoms and clinical signs that are suggestive of inflammation. METHODS This was a cross-sectional observational study of 40 women wearing a ring-shaped pessary continuously for at least 12 weeks. Participants underwent a clinical examination, and the pessary was removed. Clinical signs were recorded. A swab from the pessary surface and a high vaginal swab were collected from each woman. Participants completed a questionnaire on symptoms. Pessary biofilm presence and phenotype were determined by scanning electron microscopy (SEM). Vaginal and pessary bacterial composition was determined by 16S rRNA gene sequencing. The relationship between biofilm phenotype and symptoms and clinical signs was assessed using logistic regression. RESULTS SEM confirmed biofilm formation on all 40 pessaries. Microbiota data were available for 25 pessary swabs. The pessary biofilm microbiota was composed of bacteria typically found in the vagina and was categorized into Lactobacillus-dominated (n = 10/25 pessaries, 40%) communities and Lactobacillus-deficient communities with high relative abundance of anaerobic/facultative anaerobes (n = 15/25 pessaries, 60%). While increasing age was associated with presence of a Lactobacillus-deficient pessary biofilm (odds ratio = 3.60, 95% CI [1.16-11.22], p = 0.04), no associations between biofilm microbiota composition and symptoms or clinical signs were observed. CONCLUSIONS Lactobacillus-deficient biofilms commonly form on pessaries following long-term use. However, the contribution of biofilm phenotype to symptoms and clinical signs remains to be determined.
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Affiliation(s)
- Felicity G Gould
- Pelvic Floor Unit, The Royal Women's Hospital, 20 Flemington Rd, Parkville, 3051, Australia.
| | - Marcus P Carey
- Pelvic Floor Unit, The Royal Women's Hospital, 20 Flemington Rd, Parkville, 3051, Australia
| | - Erica L Plummer
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Parkville, Australia
| | - Gerald L Murray
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Parkville, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, 3052, Australia
| | - Jennifer A Danielewski
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Parkville, Australia
| | - Sepehr N Tabrizi
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, 3052, Australia
| | - Suzanne M Garland
- Centre for Women's Infectious Diseases Research, The Royal Women's Hospital, Parkville, Australia.,Infection & Immunity Theme, Murdoch Children's Research Institute, Parkville, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, 3052, Australia
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17
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Farr Zuend C, Noël-Romas L, Hoger S, McCorriser S, Westmacott G, Marrazzo J, Hillier SL, Dezzutti C, Squires K, Bunge KE, Burgener A. Influence of dapivirine vaginal ring use on cervicovaginal immunity and functional microbiome in adolescent girls. AIDS 2021; 35:369-380. [PMID: 33181534 PMCID: PMC7924934 DOI: 10.1097/qad.0000000000002751] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/15/2020] [Accepted: 04/21/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The antiretroviral-based dapivirine vaginal ring reduced HIV risk among women in phase III clinical trials. However, limited data exists on the impact of dapivirine on the vaginal microenvironment in adolescents. DESIGN A comprehensive metaproteomics approach was used to assess host proteome and microbiome changes in cervicovaginal mucus with dapivirine ring use in adolescents enrolled in the MTN-023/IPM 030 (MTN-023) trial. METHODS Participants were randomized 3 : 1 to use dapivirine or placebo vaginal rings monthly for 6 months. Cervicovaginal samples from a subset of 35 participants (8 placebo, 27 dapivirine) were analyzed. RESULTS Mass spectrometry analysis identified 405 human and 2467 bacterial proteins belonging to 15 unique genera. The host proteome belonged to many functional pathways primarily related to inflammation. When stratified by study treatment arm, 18 (4.4%) and 28 (6.9%) human proteins were differentially abundant (adjusted P < 0.05) between baseline and follow-up in the placebo and dapivirine arms, respectively. The vaginal microbiome was predominantly composed of Lactobacillus, Gardnerella, and Prevotella. Although bacterial taxa did not differ by arm or change significantly, Lactobacillus crispatus increased (P < 0.001) and Lactobacillus iners decreased (P < 0.001) during the 6-month follow-up. There were no significant differences in bacterial functions by arm or time in the trial. Protected vaginal sex significantly associated with decreased neutrophil inflammatory biomarkers and may be associated with changes in bacterial taxa and metabolism. CONCLUSION Condom use may associate with differences to inflammation and bacterial function but dapivirine ring use does not, thereby supporting the mucosal safety profile of this vaginal ring for adolescents.
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Affiliation(s)
- Christina Farr Zuend
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
| | - Laura Noël-Romas
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Sarah Hoger
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
| | - Stuart McCorriser
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Garrett Westmacott
- Mass Spectrometry and Proteomics Core Facility, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Jeanne Marrazzo
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Sharon L. Hillier
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Charlene Dezzutti
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Kathleen Squires
- Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Katherine E. Bunge
- University of Pittsburgh School of Medicine
- Magee-Women's Research Institute, Pittsburgh
| | - Adam Burgener
- Center for Global health and Diseases, Case Western Reserve University, Cleveland, Ohio, USA
- Departments of Obstetrics and Gynecology and Medical Microbiology, University of Manitoba
- Department of Medicine Solna, Center for Molecular Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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18
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Tuddenham S, Ravel J, Marrazzo JM. Protection and Risk: Male and Female Genital Microbiota and Sexually Transmitted Infections. J Infect Dis 2021; 223:S222-S235. [PMID: 33576776 DOI: 10.1093/infdis/jiaa762] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Unique compositional and functional features of the cervicovaginal microbiota have been associated with protection against and risk for sexually transmitted infections (STI). In men, our knowledge of the interaction between the penile microbiota and STI is less developed. The current state of our understanding of these microbiota and their role in select STIs is briefly reviewed, along with strategies that leverage existing findings to manipulate genital microbiota and optimize protection against STIs. Finally, we focus on major research gaps and present a framework for future studies.
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Affiliation(s)
- Susan Tuddenham
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jeanne M Marrazzo
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
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19
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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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20
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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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21
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Daily Vaginal Microbiota Fluctuations Associated with Natural Hormonal Cycle, Contraceptives, Diet, and Exercise. mSphere 2020; 5:5/4/e00593-20. [PMID: 32641429 PMCID: PMC7343982 DOI: 10.1128/msphere.00593-20] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The vaginal microbiome is a critical component of women’s sexual and reproductive health, with variations in microbial composition, particularly the loss of Lactobacillus species, being implicated in gynecologic and obstetric diseases. Given that the vaginal microbiome is so crucial, why do vaginal microbial profiles vary strikingly from person to person and even change over time within the same person? In the present study, which tracked the daily vaginal microbiomes of young healthy women through different lifestyles, we found that use of a locally released progestin contraceptive, a vegetarian diet, and intense exercise appear to lead to vaginal microbiome alterations and loss of Lactobacillus species. The impact of these vaginal microbiome changes on immediate and long-term health remain to be investigated. The microorganisms of the vaginal tract are critical for vaginal and reproductive health. However, the regulation of these microorganisms is not well understood. Therefore, we investigated whether different factors regulate the vaginal microbiota of healthy college-aged women (n = 26) with high temporal resolution by collecting daily self-administered vaginal swabs and using 16S rRNA sequencing for bacterial identification. As expected, vaginal microbiota clustered into five predefined community state types. Vaginal microbial diversity, stability, and Lactobacillus abundances were associated with the menstrual cycle and hormonal contraceptive use. Vaginal microbial diversity, as measured using the Shannon index, increased during menses (P < 0.001), while Lactobacillus abundances decreased (P = 0.01). The covariance of these microbial measures with previously established estradiol levels suggests that estrogens can regulate vaginal microbiota. Moreover, the use of hormonal contraceptives may alter the temporal dynamics of the vaginal microbiota and decrease Lactobacillus abundances, depending on hormonal content and release method. Interestingly, intrasample diversity was greater in participants on a vegetarian diet (P = 0.004) and among participants who exercised more (P = 0.04). These findings indicate that ovarian hormones, diet, and exercise can regulate vaginal microbial composition and stability and may impact vaginal and reproductive health. IMPORTANCE The vaginal microbiome is a critical component of women’s sexual and reproductive health, with variations in microbial composition, particularly the loss of Lactobacillus species, being implicated in gynecologic and obstetric diseases. Given that the vaginal microbiome is so crucial, why do vaginal microbial profiles vary strikingly from person to person and even change over time within the same person? In the present study, which tracked the daily vaginal microbiomes of young healthy women through different lifestyles, we found that use of a locally released progestin contraceptive, a vegetarian diet, and intense exercise appear to lead to vaginal microbiome alterations and loss of Lactobacillus species. The impact of these vaginal microbiome changes on immediate and long-term health remain to be investigated.
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22
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Francis SC, Crucitti T, Smekens T, Hansen CH, Andreasen A, Jespers V, Hardy L, Irani J, Changalucha J, Baisley K, Hayes R, Watson-Jones D, Buvé A. The Vaginal Microbiota Among Adolescent Girls in Tanzania Around the Time of Sexual Debut. Front Cell Infect Microbiol 2020; 10:305. [PMID: 32670894 PMCID: PMC7330010 DOI: 10.3389/fcimb.2020.00305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/20/2020] [Indexed: 12/28/2022] Open
Abstract
The aetiology of bacterial vaginosis (BV) is not well-understood, and prevalence appears to be higher among women living in sub-Saharan Africa. A recent conceptual model implicates three main bacteria (Gardnerella vaginalis; Atopobium vaginae; and Prevotella bivia), sexual activity, sialidase activity, and biofilm formation in the pathogenesis of BV. We describe the vaginal microbiota, presence of the putative sialidase A gene of G. vaginalis, and biofilm among 386 adolescent girls aged 17 and 18 years in a cross-sectional study in Mwanza, Tanzania around the time of expected sexual debut. Vaginal swabs were collected and tested by quantitative polymerase chain reaction (qPCR) for five Lactobacillus species, G. vaginalis, A. vaginae, P. bivia, the sialidase A gene of G. vaginalis, and by fluorescence in situ hybridisation (FISH) for evidence of G. vaginalis and A. vaginae biofilm. We conducted a risk factor analysis of G. vaginalis, A. vaginae and P. bivia, and explored the associations between biofilm, the presence of the sialidase A gene, and non-optimal vaginal microbiota (Nugent 4-7). L. crispatus and L. iners were detected in 69 and 82% of girls, respectively. The prevalence of L. crispatus was higher than previously reported in earlier studies among East and Southern African women. G. vaginalis, A. vaginae, P. bivia were independently associated with reported penile-vaginal sex. Samples with all three BV-associated bacteria made up the highest proportion of samples with Nugent-BV compared to samples with each bacterium alone or together in pairs. Of the 238 girls with G. vaginalis, 63% had the sialidase A gene detected, though there was no difference by reported sexual activity (p = 0.197). Of the 191 girls with results for sialidase A gene and FISH, there was strong evidence for an increased presence of sialidase A gene among those with evidence of a biofilm (p < 0.001). There was a strong association between biofilm and non-optimal microbiota (aOR67.00; 95% CI 26.72-190.53). These results support several of the steps outlined in the conceptual model, although the role of sexual activity is less clear. We recommend longitudinal studies to better understand changes in vaginal microbiota and biofilm formation around the time of sexual debut.
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Affiliation(s)
- Suzanna Carter Francis
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tania Crucitti
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Tom Smekens
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Christian Holm Hansen
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.,MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Aura Andreasen
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Vicky Jespers
- Belgian Health Care Knowledge Centre, Brussels, Belgium
| | - Liselotte Hardy
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Julia Irani
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania
| | | | - Kathy Baisley
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Hayes
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Deborah Watson-Jones
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza, Tanzania.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Buvé
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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23
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Barriga Pooley P, Von Hoveling A, Galán G, López Berroa J. Analysis and new contraception frontiers with combined vaginal rings. Gynecol Endocrinol 2020; 36:475-478. [PMID: 32091277 DOI: 10.1080/09513590.2020.1729730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Combined vaginal rings (ethinylestradiol (EE)/desogestrel), indicated for contraception, are highly effective, comparable to other combined hormonal contraceptives, such as pills. In addition to this benefit, vaginal rings are easy to use, with a probable lower risk of forgetting, due to their non-daily, monthly schedule. Besides, for users with poor gastric tolerance to oral formulations, they represent a method with safety and comparable extraconceptive benefits. The latest generation rings have a novel polymeric structure, do not need special storage methods and do not generate accelerated initial release of EE, reducing the early increased systemic exposure to the synthetic steroids they contain. This review describes main aspects related to its use, efficacy, and safety for contraceptive purposes.
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Affiliation(s)
- Patricio Barriga Pooley
- Women's Healthcare Service (Obstetrics and Gynecology Department), School of Medicine Finis Terrae and San Sebastian Universities, Santiago, Chile
| | | | - Guillermo Galán
- Centro de Capacitación e Investigaciones Clínicas, Santiago, Chile
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24
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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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25
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Abdelsalam NA, Ramadan AT, ElRakaiby MT, Aziz RK. Toxicomicrobiomics: The Human Microbiome vs. Pharmaceutical, Dietary, and Environmental Xenobiotics. Front Pharmacol 2020; 11:390. [PMID: 32372951 PMCID: PMC7179069 DOI: 10.3389/fphar.2020.00390] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
The harmful impact of xenobiotics on the environment and human health is being more widely recognized; yet, inter- and intraindividual genetic variations among humans modulate the extent of harm, mostly through modulating the outcome of xenobiotic metabolism and detoxification. As the Human Genome Project revealed that host genetic, epigenetic, and regulatory variations could not sufficiently explain the complexity of interindividual variability in xenobiotics metabolism, its sequel, the Human Microbiome Project, is investigating how this variability may be influenced by human-associated microbial communities. Xenobiotic-microbiome relationships are mutual and dynamic. Not only does the human microbiome have a direct metabolizing potential on xenobiotics, but it can also influence the expression of the host metabolizing genes and the activity of host enzymes. On the other hand, xenobiotics may alter the microbiome composition, leading to a state of dysbiosis, which is linked to multiple diseases and adverse health outcomes, including increased toxicity of some xenobiotics. Toxicomicrobiomics studies these mutual influences between the ever-changing microbiome cloud and xenobiotics of various origins, with emphasis on their fate and toxicity, as well the various classes of microbial xenobiotic-modifying enzymes. This review article discusses classic and recent findings in toxicomicrobiomics, with examples of interactions between gut, skin, urogenital, and oral microbiomes with pharmaceutical, food-derived, and environmental xenobiotics. The current state and future prospects of toxicomicrobiomic research are discussed, and the tools and strategies for performing such studies are thoroughly and critically compared.
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Affiliation(s)
| | - Ahmed Tarek Ramadan
- The Center for Genome and Microbiome Research, Cairo University, Cairo, Egypt
| | - Marwa Tarek ElRakaiby
- The Center for Genome and Microbiome Research, Cairo University, Cairo, Egypt.,Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Ramy Karam Aziz
- The Center for Genome and Microbiome Research, Cairo University, Cairo, Egypt.,Department of Microbiology and Immunology, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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26
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Grandi G, Timò A, Sammarini M, Del Savio MC, Facchinetti F. Surface roughness of different contraceptive vaginal rings: evaluation by scanning electron microscope (SEM). EUR J CONTRACEP REPR 2020; 25:60-64. [PMID: 31922428 DOI: 10.1080/13625187.2019.1709964] [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: 12/27/2022]
Abstract
Objective: The aim of the study was to evaluate whether the compositions of the ethylene vinyl acetate (EVA) membrane of two different contraceptive vaginal rings could influence the surface roughness, which is associated with the possible accumulation of vaginal biomass on the rings during use.Methods: We measured and compared the surface roughness of unused vaginal rings, NuvaRing and Ornibel, using a scanning electron microscope (SEM) and dedicated software that can convert SEM images into 3D models. Average roughness (Ra), average quadratic roughness (Rq) and mean height of the irregularities at 10 points (Rz) were calculated.Results: Different thicknesses of the EVA membranes between the two rings were noted. No significant differences were found between the two rings in the three evaluated values of surface roughness (NuvaRing vs Ornibel, respectively: Ra, 1.53 ± 0.14 vs 1.61 ± 0.14 µm, p = 0.141; Rq, 2.03 ± 0.25 vs 2.07 ± 0.16 µm, p = 0.688; Rz, 11.4 ± 3.1 vs 11.4 ± 2.4 µm, p = 0.987).Conclusion: The different composition of the vaginal rings' EVA membrane is not associated with different surface roughness. Ornibel is equivalent to NuvaRing in terms of surface roughness, despite the different composition of the membrane polymers.
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Affiliation(s)
- Giovanni Grandi
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Alex Timò
- Department for Quality and Regulatory Affairs, JDentalCare srl, Modena, Italy
| | - Margaret Sammarini
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Chiara Del Savio
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
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27
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Marcotte H, Larsson PG, Andersen KK, Zuo F, Mikkelsen LS, Brandsborg E, Gray G, Laher F, Otwombe K. An exploratory pilot study evaluating the supplementation of standard antibiotic therapy with probiotic lactobacilli in south African women with bacterial vaginosis. BMC Infect Dis 2019; 19:824. [PMID: 31533663 PMCID: PMC6751625 DOI: 10.1186/s12879-019-4425-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022] Open
Abstract
Background To reduce acquisition and relapse of bacterial vaginosis (BV), lactobacilli must be maintained in the vaginal microbiome. Probiotic lactobacilli may aid this purpose. We investigated whether vaginal probiotics (containing Lactobacillus rhamnosus DSM 14870 and Lactobacillus gasseri DSM 14869) would result in vaginal colonisation with lactobacilli in women with and without BV. Methods This prospective, partially randomised, exploratory pilot study was conducted in Soweto, South Africa. Thirty-nine sexually-active, HIV negative women were enrolled from October 2014 to May 2016 into three arms. Women who did not have BV (Group 1, n = 13) self-administered probiotic capsules vaginally once daily for 30 days, then once a week until Day 190. Women diagnosed with BV were randomized into Group 2 (n = 12) or Group 3 (n = 14) and treated with the triple oral antibiotic combination for vaginal discharge syndrome per South African guidelines (cefixime 400 mg stat, doxycycline 100 mg BD for 7 days and metronidazole 2 g stat). Immediately after antibiotic treatment, women in Group 2 self-administered probiotic capsules vaginally once daily for 30 days then vaginally once a week until Day 190. Women in Group 3 were not given lactobacilli. Results During the study, L. rhamnosus DSM 14870 or L. gasseri DSM 14869, were isolated in 5/13 (38.5%) women in Group 1 compared to 10/12 (83.3%) women in Group 2 (p = 0.041). The 1-month and 6-month BV cure rates were similar (P > 0.05) between Group 2 (42 and 25%) compared to Group 3 (36 and 25%). In Group 2, no correlation was observed between the frequency of isolation of the two Lactobacillus strains and the 1-month or 6-month cure rate. Conclusions Supplementation with vaginal probiotic capsules resulted in colonisation of the vagina by the Lactobacillus strains (L. rhamnosus DSM 14870 and L. gasseri DSM 14869) contained in the capsules. We observed low initial cure rates of BV after a stat dose of metronidazole and that the probiotic did not improve BV cure rates or alleviate recurrence which could be due to treatment failure or very limited power of the study. Trial registration Registered at the Pan African Clinical Trial Registry (www.pactr.org) on April 13, 2018 (retrospectively registered). Trial identification number: PACTR201804003327269. Electronic supplementary material The online version of this article (10.1186/s12879-019-4425-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Harold Marcotte
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden.
| | - Per Göran Larsson
- Department of Obstetrics and Gynaecology Kärnsjukhuset, Skaraborg Hospital, 54185, Skövde, Sweden.,Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183, Linköping, Sweden
| | - Kasper Krogh Andersen
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden
| | - Fanglei Zuo
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, 14186, Stockholm, Sweden
| | | | | | - Glenda Gray
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 1862, South Africa
| | - Fatima Laher
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 1862, South Africa
| | - Kennedy Otwombe
- Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 1862, South Africa
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28
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Sailer M, Colli E, Regidor PA. In vitro evaluation of microbial adhesion to a contraceptive vaginal ring with a new polymer composition. EUR J CONTRACEP REPR 2019; 24:188-191. [PMID: 30977415 DOI: 10.1080/13625187.2019.1595575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The aim of the study was to evaluate in vitro the amount of Candida albicans and Lactobacillus acidophilus adhering to the surface of Ornibel, a contraceptive vaginal ring with a new polymer composition, in comparison with NuvaRing. Methods: Ornibel and NuvaRing were tested for adhesion of microorganisms in vitro. The vaginal rings were aseptically sectioned into 1 cm segments. Suspensions of C. albicans (1-2 × 107 colony-forming units [CFU]/ml) and L. acidophilus (1-2 × 108 CFU/ml) were prepared and incubated either in monoculture or as co-culture with the ring segments. After incubation, adherent C. albicans and L. acidophilus were quantified by plate counting. Results: In monoculture, the measured amount of adhesion of C. albicans on the ring surface was significantly lower with Ornibel compared with NuvaRing (p = 6.77 × 10-5), while the adherence of L. acidophilus did not differ between the two rings. Similarly, when co-incubated with C. albicans, the number of adhering L. acidophilus microorganisms was significantly lower with Ornibel compared with NuvaRing (p = .018) . This reduction also resulted in significantly lower levels of adhering L. acidophilus in co-culture compared with L. acidophilus when incubated alone (p = .003). Conclusion: The study demonstrates that the adherence of C. albicans, as well as that of L. acidophilus when co-cultured with C. albicans, is lower with the Ornibel vaginal ring compared with NuvaRing. These in vitro findings warrant future human trials using molecular techniques to assess the vaginal microbiota composition and to establish whether Ornibel can support vaginal health.
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29
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Bayigga L, Kateete DP, Anderson DJ, Sekikubo M, Nakanjako D. Diversity of vaginal microbiota in sub-Saharan Africa and its effects on HIV transmission and prevention. Am J Obstet Gynecol 2019; 220:155-166. [PMID: 30321529 PMCID: PMC10715630 DOI: 10.1016/j.ajog.2018.10.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/27/2018] [Accepted: 10/07/2018] [Indexed: 01/23/2023]
Abstract
The vaginal microbial community ("microbiota") is a key component of the reproductive health of women, providing protection against urogenital infections. In sub-Saharan Africa, there is a high prevalence of bacterial vaginosis, a condition defined by bacterial overgrowth and a shift away from a Lactobacillus-dominated profile toward increased percentages of strict anaerobic species. Bacterial vaginosis is associated with an increased risk of HIV acquisition and transmission, as well as an increased risk of acquiring other sexually transmitted infections, preterm births, and pelvic inflammatory disease. Vaginal microbiota, rich in taxa of strict anaerobic species, disrupts the mucosal epithelial barrier through secretion of metabolites and enzymes that mediate inflammation. Advancements in next-generation sequencing technologies such as whole-genome sequencing have led to deeper profiling of the vaginal microbiome and further study of its potential role in HIV pathogenesis and treatment. Until recently data on the composition of the vaginal microbiome in sub-Saharan Africa have been limited; however, a number of studies have been published that highlight the critical role of vaginal microbiota in disease and health in African women. This article reviews these recent findings and identifies gaps in knowledge about variations in female genital commensal bacteria that could provide vital information to improve the effectiveness of interventions to prevent HIV and other sexually transmitted infections. In addition, we review the effects of pregnancy, contraception, and sexual practices on vaginal microbiome and the potential of vaginal microbiota on HIV transmission and prevention. A better understanding of the role of vaginal microbiota in host susceptibility to HIV infection and its prevention among African women could inform the development of novel local and systemic interventions to minimize new HIV infections among high-risk women.
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Affiliation(s)
- Lois Bayigga
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - David P Kateete
- Department of Immunology and Molecular Biology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Deborah J Anderson
- Departments of Obstetrics and Gynecology, Microbiology, and Medicine, Boston University School of Medicine, Boston, MA
| | - Musa Sekikubo
- Department of Obstetrics and Gynecology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Damalie Nakanjako
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
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