A randomized trial of double vs single-dose etonogestrel implant to overcome the interaction with efavirenz-based antiretroviral therapy

BACKGROUND

Concomitant use of efavirenz-based antiretroviral therapy and a standard-dose etonogestrel contraceptive implant led to 82% lower etonogestrel exposure when compared with women who do not receive antiretroviral therapy. The clinical impact of this reduced exposure is supported by retrospective cohort evaluations that demonstrated higher rates of unintended pregnancies when contraceptive implants were combined with efavirenz. We hypothesized that placement of 2 etonogestrel implants in those taking efavirenz-based antiretroviral therapy could increase etonogestrel exposure and improve measures of contraceptive efficacy.

OBJECTIVE

This study compared the rate of ovulation and etonogestrel pharmacokinetics among women on efavirenz-based antiretroviral therapy who received 2 etonogestrel implants (136 mg; double implant group) in comparison with those who received 1 etonogestrel implant (68 mg; control group).

STUDY DESIGN

This randomized, open-label study enrolled Ugandan women with regular menstrual periods who were receiving efavirenz-based antiretroviral therapy for the treatment of HIV. Participants were randomized 1:1 to the double implant or control group, and the etonogestrel implant(s) were placed in the same arm at enrollment. All participants used a copper intrauterine device to prevent pregnancy. Ovulation was evaluated by weekly serum progesterone concentrations measured over 4 consecutive weeks at months 3 (weeks 9-12), 6 (weeks 21-24), and 12 (weeks 45-48). Progesterone concentrations >3 ng/mL were interpreted as ovulation. The ovulation rate in each group was compared using Fisher's exact tests for each month and generalized estimating equations over 48 weeks. Plasma was collected at day 3 and weeks 1, 4, 12, 24, 36, and 48 after implant placement and analyzed using a validated liquid chromatography-triple quadrupole mass spectrometry method for etonogestrel. Etonogestrel concentrations were summarized as median (interquartile range) and compared between groups by geometric mean ratio with 90% confidence intervals.

RESULTS

All participants (n=72) were cisgender Ugandan women with a median age of 31 years (interquartile range, 29-36), and 36 participants were enrolled in each study group. Two participants in the control group discontinued the trial; 1 at week 1 because of undetected pregnancy at entry and another at week 45 because of clinically significant depression. There were 47 ovulations over 104 person-months (45%) in 25 of 34 participants in the control group, and 2 ovulations over 108 person-months (2%) in 2 of 36 participants in the double implant group (month 3: 11 [31%] vs 0 [0%]; month 6: 17 [49%] vs 0 [0%]; month 12: 19 [56%] vs 2 [6%], respectively; all P<.001). The odds of ovulation were reduced by 97.7% (95% confidence interval, 90.1-99.5) in the double implant group over 48 weeks. At each time point, etonogestrel concentration was more than 2-fold higher in the double implant group than in the controls (geometric mean ratio, 2.30-2.83) with a geometric mean ratio of 2.83 (90% confidence interval, 1.89-3.35) at week 48. There were no differences in the adverse events between groups and no participant discontinued because of adverse events.

CONCLUSION

Over 48 weeks of combined use, placing 2 etonogestrel implants suppressed ovulation and increased plasma etonogestrel exposure when compared with 1 etonogestrel implant among women on efavirenz-based antiretroviral therapy. Doubling the dose of etonogestrel during efavirenz-based antiretroviral therapy could improve contraceptive effectiveness.

Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry

OBJECTIVE

The aim of the study was to compare 12-month subjective and objective outcomes between 3 approaches to apical pelvic organ prolapse (POP) surgery in patients presenting with uterovaginal or posthysterectomy vaginal prolapse enrolled in the Pelvic Floor Disorders Registry for Research.

STUDY DESIGN

This was an analysis of a multicenter, prospective registry that collected both patient- and physician-reported data for up to 3 years after conservative (pessary) and surgical treatment for POP. Twelve-month subjective and anatomic outcomes for patients who underwent surgical treatment were extracted from the registry for analysis. Pelvic organ prolapse recurrence was defined as a composite outcome and compared between the 3 apical surgery groups (native tissue repair, sacrocolpopexy, colpocleisis) as well as the 2 reconstructive surgery groups (native tissue repair and sacrocolpopexy).

RESULTS

A total of 1,153 women were enrolled in the registry and 777 (67%) opted for surgical treatment, of whom 641 underwent apical repair and were included in this analysis (404 native tissue repair, 187 sacrocolpopexy, and 50 colpocleisis). The overall incidence of recurrence was as follows: subjective 6.5%, anatomic 4.7%, retreatment 7.2%, and composite 13.6%. The incidence of recurrence was not different between the 3 surgical groups. When baseline patient characteristics were controlled for, composite POP recurrence between the native tissue and sacrocolpopexy groups remained statistically nonsignificant. Concurrent perineorrhaphy with any type of apical POP surgery was associated with a lower risk of recurrence (adjusted odds ratio, 0.43; 95% confidence interval, 0.25-0.74; P = 0.002) and prior hysterectomy was associated with a higher risk (adjusted odds ratio, 1.77, 95% confidence interval, 1.04-3.03; P = 0.036).

CONCLUSION

Pelvic Floor Disorders Registry for Research participants undergoing native tissue apical POP repair, sacrocolpopexy, and colpocleisis surgery had similar rates of POP recurrence 12 months after surgery.

Impact of Dapivirine and Placebo Vaginal Rings on the Microbiota of Adolescent, Lactating, and Postmenopausal Females

BACKGROUND

A 25 mg dapivirine vaginal ring has been demonstrated to reduce risk of HIV acquisition in nonpregnant adult women. In this secondary analysis of studies conducted in US adolescent, lactating, and postmenopausal females, vaginal microbiota was assessed prior to and after ring use, and between dapivirine and placebo ring users.

METHODS

Vaginal fluid swabs were collected before and after product use for the evaluation of microbiota using Nugent's criteria, quantitative culture, and qPCR.

RESULTS

Vaginal ring use did not impact bacterial vaginosis prevalence among the three populations and was associated with minimal shifts in microbiota. Adolescents in both arms demonstrated an increased prevalence of Lactobacillus crispatus and a decrease in quantity of Megasphaera lornae. Postmenopausal active and placebo ring users demonstrated an increased prevalence of lactobacilli and non-albicans yeast while dapivirine ring users demonstrated an increased prevalence of Candida albicans, and increased quantity of Group B Streptococcus (GBS) and non-albicans yeasts. Prevotella species were increased in lactating women while P. timonensis increased in prevalence and concentration among adolescent and postmenopausal women and P. bivia increased in prevalence among adolescent dapivirine ring users.

CONCLUSIONS

Dapivirine vaginal ring use was associated with minimal changes in the vaginal microbiota that are likely not clinically significant.

Diagnosis and Treatment of Vaginal Discharge Syndromes in Community Practice Settings

Background

Although vaginal symptoms are common, diagnosis of bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and Trichomonas vaginalis (TV) is not standardized. Diagnostic approaches and appropriateness of treatment were evaluated for women with symptoms of vaginitis who were seeking care at community practice sites.

Methods

Three hundred three symptomatic women, across 8 University of Pittsburgh Medical Center–affiliated clinics, were evaluated per standard office-based practice. Four of 5 vaginal swabs (1 cryopreserved) were collected for a US Food and Drug Administration–authorized nucleic acid amplification test (NAAT) for vaginitis/vaginosis diagnosis; Nugent scoring (BV); yeast culture (VVC); and a second NAAT (for TV). Two hundred ninety women had evaluable samples. Medical record extraction facilitated verification of treatments prescribed within 7 days of the index visit and return visit frequency within 90 days.

Results

Women had a mean age of 29.4 ± 6.5 years, 90% were not pregnant, 79% were of white race, and 38% reported vaginitis treatment within the past month. Point-of-care tests, including vaginal pH (15%), potassium hydroxide/whiff (21%), and wet mount microscopy (17%), were rarely performed. Of the 170 women having a laboratory-diagnosed cause of vaginitis, 81 (47%) received 1 or more inappropriate prescriptions. Of the 120 women without BV, TV, or VVC, 41 (34%) were prescribed antibiotics and/or antifungals. Among women without infectious vaginitis, return visits for vaginitis symptoms were more common among women treated empirically compared to those not receiving treatment (9/41 vs 5/79, P = .02).

Conclusions

Within a community practice setting, 42% of women having vaginitis symptoms received inappropriate treatment. Women without infections who received empiric treatment were more likely have recurrent visits within 90 days.

Clinical Trials Registration

NCT03151928.

A Randomized Controlled Trial of Ceftriaxone and Doxycycline, With or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease

BACKGROUND

Anaerobic organisms are important pathogens in acute pelvic inflammatory disease (PID). The currently recommended PID regimen of a single dose of ceftriaxone and doxycycline for 14 days has limited anaerobic activity. The need for broader anaerobic coverage is unknown and concerns have been raised about metronidazole tolerability.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial comparing ceftriaxone 250 mg intramuscular single dose and doxycycline for 14 days, with or without 14 days of metronidazole in women with acute PID. The primary outcome was clinical improvement at 3 days following enrollment. Additional outcomes at 30 days following treatment were the presence of anaerobic organisms in the endometrium, clinical cure (absence of fever and reduction in tenderness), adherence, and tolerability.

RESULTS

We enrolled 233 women (116 to metronidazole and 117 to placebo). Clinical improvement at 3 days was similar between the 2 groups. At 30 days following treatment, anaerobic organisms were less frequently recovered from the endometrium in women treated with metronidazole than placebo (8% vs 21%, P < .05) and cervical Mycoplasma genitalium was reduced (4% vs 14%, P < .05). Pelvic tenderness was also less common among women receiving metronidazole (9% vs 20%, P < .05). Adverse events and adherence were similar in each treatment group.

CONCLUSIONS

In women treated for acute PID, the addition of metronidazole to ceftriaxone and doxycycline was well tolerated and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline. Metronidazole should be routinely added to ceftriaxone and doxycycline for the treatment of women with acute PID.

CLINICAL TRIALS REGISTRATION

NCT01160640.

Effect of injectable progestin-only contraceptives, depot medroxyprogesterone acetate and norethisterone enanthate, on cytokine production during T-cell activation

PROBLEM

There is paucity of human data about the effects of depot medroxyprogesterone (DMPA) and norethisterone enanthate (Net-En) use on systemic immune function, which may have implications for reproductive tract infection susceptibility and transmissibility. We sought to evaluate the impact of injectable contraceptive use on T-cell responsiveness using T cells exposed in vivo and tested ex vivo.

METHODS

Peripheral blood mononuclear cells were obtained from healthy, HIV-negative women after 30, 90 and 180 days of DMPA, norethisterone enanthate (Net-En) or copper intrauterine device (Cu-IUD) contraceptive use. Cells were stimulated ex vivo with phorbol myristate acetate and ionomycin, stained and analysed using flow cytometry. Mixed-effects linear models were used to evaluate change in proportions of T cells producing IFN-γ, TNF-α, IL-4 and IL-13.

RESULTS

Compared with baseline, decreased proportions of IFN-γ-producing CD4+ and CD8+ T cells (p = .003, p = .006, respectively) and TNF-α-producing CD4+ and CD8+ T cells (p = .039, p = .034, respectively) were observed after 180 days of DMPA use. Decreased IL-4-producing CD4+ and CD8+ T cells (p = .045 and p = .024, respectively) were noted after 180 days of Net-En use. Decreased IL-4-producing CD4+ T cells were observed after 30 days (p = .035) and not after 180 days of DMPA use (p = .49). There were no changes in proportion of T cells producing IL-13 in DMPA users, nor any changes in IFN-γ, TNF-α and IL-13 in Net-En and Cu-IUD users.

CONCLUSION

In vivo exposure of CD4+ and CD8+ T cells to typical pharmacologic concentrations of DMPA does not cause broad suppression to stimuli; however, depletion of specific cytokine-producing T cells may occur after prolonged DMPA use.

Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study

Background

Hepatitis C virus (HCV) infection is increasing among pregnant women because of the opioid epidemic, yet there are no interventions to reduce perinatal HCV transmission or to treat HCV during pregnancy. Physiological changes in pregnancy alter the pharmacokinetics of some medications; thus, our aim was to compare the pharmacokinetic parameters of ledipasvir 90 mg plus sofosbuvir 400 mg during pregnancy with non-pregnant women.

Methods

This was an open-label, phase 1 study of pregnant women with genotype 1 HCV infection and their infants. A reference group of women who had participated in pharmacokinetic studies of ledipasvir–sofosbuvir during phase 2 and 3 trials was used. Participants were enrolled at Magee-Womens Hospital (Pittsburgh, PA, USA) between 23 and 24 weeks’ gestation and had a 12-week course of oral ledipasvir–sofosbuvir (daily 90 mg ledipasvir plus 400 mg sofosbuvir). Three 12-h intensive pharmacokinetic visits were done at 25–26, 29–30, and 33–34 weeks’ gestation and individual pharmacokinetics were summarised by geometric mean across the three visits. The primary outcome, analysed in all participants without suspected dosing errors, was the ledipasvir–sofosbuvir area under the concentration–time curve of the dosing interval (AUC_tau) during pregnancy compared with the reference group by geometric mean ratio. This study is registered with ClinicalTrials.gov, NCT02683005.

Findings

From Oct 1, 2016, to Sept 30, 2018, 29 pregnant women were screened and nine (31%) were enrolled. Eight (89%) women were included in the primary analysis. Ledipasvir and sofosbuvir exposures were similar in the pregnant women versus the non-pregnant reference group (geometric mean ratio of AUC_tau ledipasvir 89·3% [90% CI 68·7–116·1]; sofosbuvir 91·1% [78·0–106·3]).

Interpretation

Ledipasvir–sofosbuvir was safe and effective without clinically meaningful differences in drug exposure among pregnant versus non-pregnant women.

Funding

National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health/Office of Research on Women’s Health, and Gilead Sciences.

Zim CHIC: A cohort study of immune changes in the female genital tract associated with initiation and use of contraceptives

Problem

Contraceptive hormones are systemically active, potent, and likely to invoke biological responses other than known fertility regulation impacts. We hypothesized that initiation of depot medroxyprogesterone acetate (DMPA) would increase genital HIV‐target‐cells and soluble immune mediators compared with baseline and initiation of other contraceptive methods.

Method of Study

We collected cervical cytobrushes and cervicovaginal fluid from healthy Zimbabwean women aged 18‐34 to assess immune cell populations, cytokines, and innate anti‐HIV activity at baseline and after 30, 90, and 180 days use of DMPA (n = 38), norethisterone enanthate (n = 41), medroxyprogesterone acetate/estradiol cypionate (n = 36), levonorgestrel implant (n = 43), etonogestrel implant (n = 47), or copper intrauterine device (Cu‐IUD) (n = 45). Cells were quantified by flow cytometry, cytokines were detected by multiplex assays, and innate anti‐HIV activity was assessed by in vitro HIV challenge.

Results

Compared to baseline, the number of cervical HIV target cells (#CD4 cells P < .04 and #CD11c cells P < .04), the concentration of the inflammatory cytokine IL‐1β (P < .01), and the innate in vitro anti‐HIV activity (P < .001) significantly decreased following DMPA initiation. In Cu‐IUD users, genital HIV target cells increased (#CD4 cells P < .001, #CD4CCR5 cells P = .02, #CD4CD69 cells P < .001, #CD8CD69 P = .01, and #CD11c cells P = .003) at day 30 and resolved by day 180. IFN‐γ (P < .001), IL‐1β (P < .001), IL‐6 (P < .001), IL‐8 (P < .001), IL‐10 (P < .01), and RANTES (P < .001) were also significantly increased at day 30. Minimal alterations were observed following initiation of subdermal implantable contraceptives.

Conclusions

This head‐to‐head study compared six contraceptives and found increased HIV target cells and cervical inflammation temporally associated with Cu‐IUD initiation. Use of hormonal contraception, including DMPA, did not increase cervical HIV target cells or inflammation.

Clinical Trial Number: NCT02038335

Optimization of processing female genital tissue samples for lymphocyte analysis by flow cytometry

PROBLEM

A variety of methods have been used to process cervical cytobrush and genital tissue for flow cytometric evaluation of immune cell populations. We sought to optimize genital tract specimen processing and to determine if blood could be used as a model for assessment of tissue processing methods.

METHOD OF STUDY

Cervical cytobrushes, PBMCs, and genital tissue samples (cervical and endometrial biopsies) were subjected to varying processing conditions to characterize the effects on cell yields, lymphocyte viability, and surface receptors. We exposed PBMC and tissue specimens to varied collagenase types, concentrations, and exposure durations and cytobrushes to immediate vs delayed processing with/without vortexing.

RESULTS

PBMCs and tissues exposed to varying enzymatic digestion conditions demonstrated stability of some cell surface receptors, including CD3⁺ , CD4⁺ , and CD8⁺ , while others, including CCR6⁺ , were cleaved when exposed to any concentration of collagenase B, or ≥0.25 mg/mL of collagenase D. We observed increased CD69 expression (marker of cell activation) after exposure to collagenase B. Neither a 2-hour delay in cytobrush processing nor vortexing at a setting of 50% for 30 seconds had significant impacts on viability or quantities of genital immune cells of interest.

CONCLUSION

Although tissue digestion with collagenase D was sufficient to recover and analyze cells from endometrial biopsy specimens, cervical biopsy specimens required a limited exposure to collagenase B at 1 mg/mL to optimize cell yield and viability for cytometric analysis. PBMCs can be used as a model to assess the impact of tissue processing on co-receptor expression and to optimize methods prior to study implementation.

Depot medroxyprogesterone acetate and norethisterone enanthate differentially impact T-cell responses and expression of immunosuppressive markers

PROBLEM

Injectable contraceptive use may impact immune cell responsiveness and susceptibility to infection. We measured responsiveness of T-cells from women before and after initiating depot medroxyprogesterone acetate (DMPA) or norethisterone enanthate (Net-En).

METHOD OF STUDY

Peripheral blood mononuclear cells collected from women aged 18-34 years prior to, at steady state, and nadir concentrations after initiating DMPA (n = 30) or Net-En (n = 36) and from women initiating copper intrauterine device (CU-IUD; n = 32) were stimulated with phorbol myristate acetate and analyzed using flow cytometry. We evaluated percentage change in T-cells expressing programmed cell death-1 (PD-1) and cytotoxic T-lymphocyte associated protein-4 (CTLA-4).

RESULTS

Compared to baseline, there were decreased numbers of CD4+CTLA4+ (P < .001) and CD8+CTLA4+ (P < .01) T-cells following ex vivo stimulation challenge at steady state DMPA concentrations and no differences at nadir concentrations (P = .781 and P = .463, respectively). In Net-En users, no differences in CD4+CTLA4+ T-cells at steady state (P = .087) and nadir concentrations (P = .217) were observed. DMPA users had fewer CD4+PD-1+ (P < .001) and CD8+PD-1+ (P < .001) T-cells at nadir concentrations. Number of CD4+PD-1+ and CD8+PD-1+ T-cells decreased at steady state concentration (P = .002 and P = .001, respectively) and at nadir concentrations after Net-En initiation (P < .001 and P < .001). In CU-IUD users, there were no changes in number of CD4+CTLA4+ (P = .426) and CD8+CTLA4+ (P = .169) and no changes in CD4+PD-1+ (P = .083) and CD8+PD-1+ (P = .936) compared to baseline.

CONCLUSION

Activation of T-cells in response to ex vivo stimulation is suppressed at steady state DMPA concentration and resolves at nadir concentration, suggesting DMPA immunosuppressive effects may be transient.

FAME-04: A Phase 1 trial to assess the safety, acceptability, pharmacokinetics and pharmacodynamics of film and gel formulations of tenofovir

INTRODUCTION

Fast-dissolving vaginal film formulations release antiretroviral drugs directly into vaginal fluid and may be as efficient at drug delivery yet more acceptable to women than gels. In this Phase 1 vaginal film study, the safety, acceptability, pharmacokinetics and pharmacodynamics of two doses of tenofovir (TFV) film and TFV 1% gel were compared to corresponding placebo formulations.

METHODS

Seventy-eight healthy HIV negative women were randomized to self-insert daily vaginal film (10 mg TFV, 40 mg TFV or placebo) or 4 mL of vaginal gel (TFV 1% [40 mg] or placebo) for seven days. Grade 2 and higher adverse events (AEs) related to study product were compared across study arms using Fisher's exact test. Plasma TFV concentrations were measured before and 2 hours after last product use. Paired cervical and vaginal tissue biopsies obtained 2 hours after the last dose were measured to determine tenofovir diphosphate (TFV-DP) concentrations and exposed to HIV in an ex vivo challenge assay. Acceptability was assessed through questionnaire.

RESULTS

There was only one grade 2 or higher related AE, the primary endpoint; it occurred in the placebo gel arm. AEs occurred in 90% of participants; the majority (91%) were grade 1. AEs were similar across study arms. TFV concentrations in plasma and TFV-DP concentrations in cervical and vaginal tissues were comparable between 40 mg TFV film and the TFV gel groups. There was a significant relationship between reduced viral replication and TFV-DP concentrations in cervical tissues. Film users were less likely to report product leakage than gel users (66% vs. 100%, p < 0.001).

CONCLUSIONS

Films were safe and well tolerated. Furthermore, films delivered TFV to mucosal tissues at concentrations similar to gel and were sufficient to block HIV infection of genital tissue ex vivo.

Long-Acting Reversible Contraceptive Uptake before and after the Affordable Care Act Contraceptive Mandate in Women Undergoing First Trimester Surgical Abortion

OBJECTIVE

To compare long-acting reversible contraceptive (LARC) uptake before and after the Affordable Care Act (ACA) contraceptive mandate among women undergoing a first trimester surgical abortion.

STUDY DESIGN

We conducted a retrospective chart review of 867 women undergoing a first trimester surgical abortion at an academic gynecology practice between December 2010 and December 2014 (excluding August to December 2012) to evaluate intrauterine device and contraceptive implant uptake before and after the ACA contraceptive mandate.

RESULTS

Before the ACA contraceptive mandate, 79% of privately insured women (213 of 271) had full LARC coverage (no out-of-pocket costs) compared with 92% (298 of 324) after the mandate (p < .001). We found no difference in postabortal LARC uptake before and after the ACA in women with private insurance, Medicaid, or overall. Among all women, 46% chose a postabortal LARC method before the mandate as compared with 48% after the mandate (p = .63). Among privately insured women, 45% used a postabortal LARC method before the mandate as compared with 50% after the mandate (p = .25). One-half of privately insured women (268 of 534) with full or partial LARC coverage used a postabortal LARC method compared with 32% of privately insured women (18 of 56) with no LARC coverage after implementation of the ACA contraceptive mandate (p = .01).

CONCLUSIONS

Despite the significant increase in full coverage of LARC among privately insured women, there was no change in postabortal LARC use after the ACA. However, privately insured women with full or partial LARC coverage were more likely to use a postabortal LARC method compared with privately insured women with no LARC coverage after the implementation of the ACA contraceptive mandate.

Impact of contraceptive initiation on vaginal microbiota

BACKGROUND

Data evaluating the impact of contraceptives on the vaginal microbiome are limited and inconsistent.

OBJECTIVE

We hypothesized that women initiating copper intrauterine device use would have increased bacterial vaginosis and bacterial vaginosis-associated microbes with use compared to women initiating and using hormonal contraceptive methods.

STUDY DESIGN

Vaginal swabs (N = 1047 from 266 participants seeking contraception) for Nugent score determination of bacterial vaginosis and quantitative polymerase chain reaction analyses for assessment of specific microbiota were collected from asymptomatic, healthy women aged 18-35 years in Harare, Zimbabwe, who were confirmed to be free of nonstudy hormones by mass spectrometry at each visit. Contraception was initiated with an injectable (depot medroxyprogesterone acetate [n = 41], norethisterone enanthate [n = 44], or medroxyprogesterone acetate and ethinyl estradiol [n = 40]), implant (levonorgestrel [n = 45] or etonogestrel [n = 48]), or copper intrauterine device (n = 48) and repeat vaginal swabs were collected after 30, 90, and 180 days of continuous use. Self-reported condom use was similar across all arms at baseline. Quantitative polymerase chain reaction was used to detect Lactobacillus crispatus, L jensenii, L gasseri/johnsonii group, L vaginalis, L iners, Gardnerella vaginalis, Atopobium vaginae, and Megasphaera-like bacterium phylotype I from swabs. Modified Poisson regression and mixed effects linear models were used to compare marginal prevalence and mean difference in quantity (expressed as gene copies/swab) prior to and during contraceptive use.

RESULTS

Bacterial vaginosis prevalence increased in women initiating copper intrauterine devices from 27% at baseline, 35% at 30 days, 40% at 90 days, and 49% at 180 days (P = .005 compared to marginal prevalence at enrollment). Women initiating hormonal methods had no change in bacterial vaginosis prevalence over 180 days. The mean increase in Nugent score was 1.2 (95% confidence interval, 0.5-2.0; P = .001) in women using copper intrauterine devices. Although the frequency and density of beneficial lactobacilli did not change among intrauterine device users over 6 months, there was an increase in the log concentration of G vaginalis (4.7, 5.2, 5.8, 5.9; P = .046) and A vaginae (3.0, 3.8, 4.6, 5.1; P = .002) between baseline and 30, 90, and 180 days after initiation. Among other contraceptive groups, women using depot medroxyprogesterone acetate had decreased L iners (mean decrease log concentration = 0.8; 95% confidence interval, 0.3-1.5; P = .004) and there were no significant changes in beneficial Lactobacillus species over 180 days regardless of contraceptive method used.

CONCLUSION

Copper intrauterine device use may increase colonization by bacterial vaginosis-associated microbiota, resulting in increased prevalence of bacterial vaginosis. Use of most hormonal contraception does not alter vaginal microbiota.

Hepatitis C Virus Screening Among Children Exposed During Pregnancy

OBJECTIVES

Because of the opioid epidemic, hepatitis C virus (HCV) infection is increasing among pregnant women, resulting in an increased risk of perinatal transmission and HCV infection among children. Our primary objectives in this study were to determine the prevalence of HCV among pregnant women and the frequency of pediatric HCV screening.

METHODS

A population-based, retrospective cohort of pregnant women who delivered between 2006 and 2014 was identified and classified as HCV infected or HCV uninfected by billing codes. Infant records linked to the HCV-infected pregnant women were identified and queried for HCV tests and the receipt of well-child services, which were defined as the presence of hemoglobin and/or lead testing at or after 9 months of age.

RESULTS

Between 2006 and 2014, 1043 (1.2%) HCV-infected pregnant women delivered, and the HCV prevalence increased by 60%. HCV-infected women were more likely to be <30 years of age (67% vs 53%; P < .001), white (93% vs 72%; P < .001), insured by Medicaid (77% vs 29%; P < .001), and have opiate use disorder (68% vs 1%; P < .001) than HCV-uninfected women. Infants born to HCV-infected women were more likely to be preterm (<37 weeks' gestation; 22% vs 10%; P < .001) and of low birth weight (<2500 g; 23% vs 8%; P < .001). Among 1025 HCV-exposed infants with available pediatric records, 323 (31%) received well-child services, and among these, only 96 (30%) were screened for HCV.

CONCLUSIONS

Despite the increased HCV prevalence among pregnant women and the risk of perinatal HCV transmission, HCV-exposed infants are not adequately screened, and many pediatric HCV infections remain undetected.

Examining intendedness among pregnancies ending in spontaneous abortion

OBJECTIVES

Spontaneous abortion (SAB) affects over 1 million US women each year, yet little is known about the intendedness of these pregnancies. We examined prevalence and correlates of unintended and unwanted pregnancies ending in SAB.

STUDY DESIGN

We used nationally-representative cross-sectional data of US women aged 15-44 from the 2011-2013 National Survey of Family Growth to examine pregnancies ending in SAB. We used modified Poisson regression models to evaluate associations between demographic and pregnancy characteristics with unintended and unwanted pregnancy.

RESULTS

Among 1351 pregnancies ending in SAB, 44.5% were unintended (i.e. unwanted or occurring sooner than desired). Younger women with SAB were more likely to report unintended pregnancies than women 30-44 years, and women 15-19 years reported unintended pregnancy most often [adjusted relative risk (aRR)=3.0; 95% confidence interval (CI): 2.2-4.1]. Unintended pregnancy was two times more likely among unmarried than married women [never married: aRR=2.2; 95% CI: 1.7-2.7; previously married: aRR=2.2; 95% CI: 1.7-3.0]. Other factors associated with unintended pregnancy were multiparity compared to nulliparity [aRR=2.6; 95% CI: 1.7-4.1 for ≥3 children; aRR=1.8; 95% CI: 1.3-2.5 for 2 children] and inter-pregnancy interval ≤12 months compared to >12 months [aRR=1.4; 95% CI: 1.2-1.7]. We found similar associations with unwanted pregnancies ending in SAB (15.3% of pregnancies). Neither race/ethnicity nor socioeconomic indicators were independently associated with unintended or unwanted pregnancy ending in SAB.

CONCLUSIONS

Many pregnancies ending in spontaneous abortion are unintended and/or unwanted. Women with pregnancy loss, like all reproductive-aged women, should receive comprehensive counseling about reproductive planning and contraception.

IMPLICATIONS

Similar to all pregnancies, nearly half of pregnancies ending in spontaneous abortion are unintended and/or unwanted, suggesting that many women experiencing spontaneous abortion may benefit from a review of family planning desires and the provision of reproductive planning counseling and effective contraception to prevent future undesired pregnancy.

Preferred Physical Characteristics of Vaginal Film Microbicides for HIV Prevention in Pittsburgh Women

Unprotected heterosexual intercourse is the leading cause of HIV acquisition in women. Due to the complex nature of correct and consistent condom use by both men and women, developing alternative female-controlled HIV prevention options is a global health priority. Vaginal films containing antiretroviral drugs are a potential delivery system for the prevention of HIV acquisition through sexual contact. In this study, we explored women's preferences regarding physical characteristics of microbicide vaginal films through questionnaires and focus groups. Eighty-four sexually active, ethnically diverse women 18-30 years of age from Pittsburgh, Pennsylvania, participated in the study. Women visually and manually examined a variety of vaginal films, as well as three other vaginal products undergoing evaluation for HIV prevention: tablet, ring, and gel. Means and standard deviations or frequencies and 95 % confidence intervals were calculated for questionnaire data. Focus groups were audio-recorded, transcribed verbatim, and coded for content analysis. Women most frequently preferred vaginal films to be smooth and thin (63 %), translucent (48 %), and 2″ × 2″ square size (36 %). Driving these preferences were five major themes: ease and accuracy of use, desire for efficacy, discretion, intravaginal comfort and minimal impact, and minimizing disruption of sexual mood/activities. Women's preferences for various microbicide vaginal film physical attributes represented a balance of multiple values. In general, women desired a comfortable, efficacious, easy to use, and minimally intrusive product.

Bacterial species colonizing the vagina of healthy women are not associated with race

The vaginal microbiota of 36 white versus 25 black asymptomatic women were compared using both cultivation-dependent and -independent identification. Significant differences by race were found in colonization and density of bacterial species. However, exclusion of 12 women with bacterial vaginosis by Nugent criteria resulted in no significant differences by race.

The Effects of Hormones and Vaginal Microflora on the Glycome of the Female Genital Tract: Cervical-Vaginal Fluid

In this study, we characterized the glycome of cervical-vaginal fluid, collected with a Catamenial cup. We quantified: glycosidase levels; sialic acid and high mannose specific lectin binding; mucins, MUC1, MUC4, MUC5AC, MUC7; and albumin in the samples collected. These data were analyzed in the context of hormonal status (day of menstrual cycle, hormonal contraception use) and role, if any, of the type of the vaginal microflora present. When the Nugent score was used to stratify the subjects by microflora as normal, intermediate, or bacterial vaginosis, several important differences were observed. The activities of four of six glycosidases in the samples from women with bacterial vaginosis were significantly increased when compared to normal or intermediate women: sialidase, P = <0.001; α-galactosidase, P = 0.006; β-galactosidase, P = 0.005; α-glucosidase, P = 0.056. Sialic acid binding sites as measured by two lectins, Maackia amurensis and Sambucus nigra binding, were significantly lower in women with BV compared to women with normal and intermediate scores (P = <0.0001 and 0.008 respectively). High mannose binding sites, a measure of innate immunity were also significantly lower in women with BV (P = <0.001). Additionally, we observed significant increases in MUC1, MUC4, MUC5AC, and MUC7 concentrations in women with BV (P = <0.001, 0.001, <0.001, 0.02 respectively). Among normal women we found that the membrane bound mucin MUC4 and the secreted MUC5AC were decreased in postmenopausal women (P = 0.02 and 0.07 respectively), while MUC7 (secreted) was decreased in women using levonorgestrel-containing IUDs (P = 0.02). The number of sialic acid binding sites was lower in the postmenopausal group (P = 0.04), but the number of high mannose binding sites, measured with Griffithsin, was not significantly different among the 6 hormonal groups. The glycosidase levels in the cervical-vaginal mucus were rather low in the groups, with exception of α-glucosidase activity that was much lower in the postmenopausal group (P<0.001). These studies present compelling evidence that the vaginal ecosystem responds to the presence of different vaginal microorganisms. These effects were so influential that it required us to remove subjects with BV for data interpretation of the impact of hormones. We also suggest that certain changes occurring in vaginal/cervical proteins are due to bacteria or their products. Therefore, the quantitation of vaginal mucins and lectin binding offers a new method to monitor bacteria-host interactions in the female reproductive tract. The data suggest that some of the changes in these components are the result of host processing, such as the increases in mucin content, while the microflora is responsible for the increases in glycosidases and the decreases in lectin binding. The methods should be considered a valid marker for insult to the female genital tract.

Text Messaging to Improve Preventive Health Attitudes and Behaviors During Pregnancy: A Prospective Cohort Analysis

OBJECTIVE

To delineate the effects of text messages sent to pregnant women to promote preventive health beliefs and behaviors.

STUDY DESIGN

A prospective cohort analysis was performed among women who participated in a randomized, controlled trial aimed at improving preventive health. Participants (158 pregnant women enrolled from 2010-2012) received 12 weekly text messages encouraging preventive health behaviors (tobacco cessation, condom use for disease prevention, nutrition optimization, seat belt use, breastfeeding). Pre- and postintervention surveys assessed preventive health beliefs and practices.

RESULTS

At follow-up, participants agreed that receiving text messages changed their beliefs about targeted preventive health behaviors: smoking (50%), sexually transmitted disease prevention (72%), prenatal vitamins (83%), seat belt use (68%), nutritious foods (84%), and breastfeeding (68%). Many participants reported more frequent engagement in target behaviors at follow-up than at baseline: decreased tobacco use (among 41% of smokers), more consistent condom use (among 7% of sexually active participants), more prenatal vitamin intake (32%), more frequent seatbelt use (32%), more frequent healthy food intake (41%), and intention to breastfeed longer (21%).

CONCLUSION

Pregnant women receiving text messages promoting preventive health reported improvements in targeted beliefs and behaviors, suggesting that text messaging may be used for health promotion during pregnancy.

The effect of menopause on the innate antiviral activity of cervicovaginal lavage

OBJECTIVE

Reproductive hormones are known to impact innate mucosal immune function of the lower genital tract. Our objectives were to determine the effect of hormonal status on intrinsic antiviral (herpes simplex virus [HSV]-1, HSV-2, and human immunodeficiency virus [HIV]-1) activity of cervicovaginal lavage (CVL).

STUDY DESIGN

CVL was collected from 165 asymptomatic women including postmenopausal women (n = 29); women not on contraception in days 1-14 (n = 26) or days 15-28 (n = 27) of the menstrual cycle; and women using the levonorgestrel intrauterine device (n = 28), depot medroxyprogesterone acetate (n = 28), or combined oral contraceptives (n = 27). The anti-HSV-1/-2 and the anti-HIV-1 activity of the CVL were measured using plaque assays and the Jurkat-Tat-CCR5 assay, respectively.

RESULTS

CVL from all of the groups had modest antiviral activity. Anti-HIV-1 activity was decreased in CVL from postmenopausal women when compared to premenopausal women (11% vs 34%, P = .002). However, there was no difference in anti-HIV-1 activity among premenopausal women regardless of phase of menstrual cycle or contraceptive use. Anti-HIV-1 activity was associated with the protein content of the CVL (r = 0.44, P < .001). There was no difference in anti-HSV-1 or -2 activity by hormonal group.

CONCLUSION

Menopause is associated with decreased innate HIV-1 activity in the lower genital tract, suggesting that factors in the vaginal fluid could play a role in increased susceptibility of HIV-1 infection in postmenopausal women. Hormonal contraceptive use, menopause, and phase of menstrual cycle did not have a measurable impact on the intrinsic anti-HSV-1 or -2 activity.

The effects of reproductive hormones on the physical properties of cervicovaginal fluid

OBJECTIVE

The purpose of this study was to determine the impact of contraception, menopause, and vaginal flora on the physical and biochemical properties of cervicovaginal fluid (CVF).

STUDY DESIGN

Vaginal swabs, CVF, and cervicovaginal lavage (CVL) were collected from a total of 165 healthy asymptomatic women including: postmenopausal women (n = 29), women in the proliferative (n = 26) or follicular (n = 27) phase, and women using the levonogestrel intrauterine device (n = 28), depomedroxyprogesterone acetate (n = 28) or combined oral contraceptives (n = 27). Vaginal smears were evaluated using the Nugent score. The osmolality, viscosity, density, and pH of CVL samples were measured.

RESULTS

CVL from postmenopausal women and women with abnormal vaginal flora was less viscous and had higher pH than premenopausal women and women with normal flora, respectively. Women using hormonal contraceptives had more viscous CVL as compared with premenopausal women not using hormonal contraceptives, but this increase in viscosity was mitigated in the presence of bacterial vaginosis. Women using depomedroxyprogesterone acetate had less total protein in the CVL as compared with women using the levonogestrel intrauterine device, and had similar protein content when compared with postmenopausal women.

CONCLUSION

The differences in CVL protein content between depomedroxyprogesterone acetate and levonogestrel intrauterine device suggest that type of progesterone and route of delivery impact the vaginal environment. Contraceptive hormone users had more viscous CVL than women not using contraceptives. However, the presence of bacterial vaginosis impacted both the pH and viscosity (regardless of hormonal contraceptive use), demonstrating that vaginal flora has a greater impact on the physical properties of CVF than reproductive hormones.

Perceptions and acceptance of immunization during pregnancy

OBJECTIVE

To estimate patients' perceptions of the need, safety and acceptability of vaccination during pregnancy.

STUDY DESIGN

An office-based survey was offered to patients presenting for obstetric and gynecologic care from December 2007 to July 2008 at an academic women's hospital. The anonymous questionnaire assessed demographics, medical and vaccination history, interest in receiving vaccines, and beliefs about vaccination safety. Data were evaluated using descriptive statistics and chi2 analyses.

RESULTS

A total of 1,436 completed surveys were available for analysis, including 573 from pregnant women. Pregnant women were less likely than non-pregnant women to report perceived risks from vaccine-preventable illness (22.8% vs. 34.5%, p < 0.001) and to believe that their doctor thinks they should get vaccines (42.6% vs. 49.7%, p < 0.027). Nearly two-thirds (61%) reported concern about possible vaccine effects on their pregnancy. However, the overwhelming majority (89%) of pregnant women surveyed reported willingness to accept vaccination during pregnancy if recommended by their obstetrician.

CONCLUSION

Despite concerns about vaccine safety and a low perceived need for immunization, most pregnant respondents endorse acceptance of vaccination when recommended by their obstetrician. These findings suggest that obstetric providers should maximize opportunities for uptake of appropriate immunizations during pregnancy.

Mifepristone and misoprostol for early pregnancy failure: a cohort analysis

OBJECTIVE

We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting.

STUDY DESIGN

A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success.

RESULTS

Treatment success occurred in 99 (80%; 95% confidence interval, 72-87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75-89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12).

CONCLUSION

Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.

Universal prenatal HIV screening: are we there yet?

The objectives of this study were to determine the prevalence of and factors associated with prenatal HIV screening and the availability of HIV test results in medical records in Pittsburgh, PA, USA. Three hundred postpartum women were surveyed about demographics and prenatal care provider(s) and practice setting and were asked to recall prenatal HIV screening and reasons for accepting or declining a HIV test. Medical records were reviewed for documentation of HIV results. Overall, 65% of women reported screening. White race, higher annual household income and fewer lifetime sexual partners were independently associated with decreased likelihood of prenatal HIV screening. Provider presentation of screening as standard practice and provider encouragement were associated with prenatal HIV screening. Only 38% of medical records contained HIV results at the time of labour. Universal and routine offering of prenatal HIV screening as standard practice, in conjunction with encouragement from health-care providers, may increase patient acceptability and the uptake of prenatal HIV screening.

Vaccine eligibility and acceptance among ambulatory obstetric and gynecologic patients

OBJECTIVE

To assess vaccine eligibility and factors associated with vaccine acceptance among ambulatory obstetric and gynecologic patients.

METHODS

An anonymous office-based survey was administered to women seeking ambulatory obstetric and gynecologic care at a large women's hospital from December 2007 to July 2008. Information collected included: demographics, medical and vaccination history, interest in receiving vaccines and attitudes towards vaccine providers. Vaccine eligibility was based on age and/or self-reported risk factors in accord with the 2007-2008 Center for Disease Control and Prevention (CDC) adult immunization schedule. Vaccine eligibility was examined using descriptive statistics, and demographic characteristics were compared using chi-squared analysis. A multivariable logistic regression model was developed to assess factors associated with participants' willingness to accept vaccines from their obstetrician-gynecologist.

RESULTS

A total of 1441 women completed the survey. The majority of participants (87%) would accept vaccines if recommended by their obstetrician-gynecologist. The primary factors associated with vaccine acceptance were having less than a high school education, being privately insured, currently being pregnant, reporting a history of vaccinations and previously receiving vaccinations from an obstetrician-gynecologist. A significant portion of participants were eligible for the hepatitis B, influenza and HPV vaccines (≥ 50% for each). The type of vaccine did not influence willingness to accept vaccines from an obstetrician-gynecologist.

CONCLUSION

A majority of women appear eligible for, and will accept, vaccinations regardless of specific vaccine, if recommended by their obstetrician-gynecologist. These findings justify ongoing efforts to expand immunization services offered by obstetrician-gynecologists.

Prophylactic bilateral oophorectomy or removal of remaining ovary at the time of hysterectomy in the United States, 1979-2004

OBJECTIVE

The purpose of this study was to describe national rates and trends of prophylactic bilateral oophorectomy or remaining oophorectomy (BO/RO) at hysterectomy in women without specific gynecologic disease.

STUDY DESIGN

Data from the National Hospital Discharge Survey were analyzed for 1979-2004. Hysterectomies were divided into 2 groups: (1) hysterectomy with BO/RO and (2) hysterectomy alone (> or =1 ovary remaining). Age-adjusted rates (AARs) were calculated with 2000 US census data.

RESULTS

Approximately 3,686,000 hysterectomies with BO/RO were performed from 1979-2004. AARs of hysterectomy with BO/RO decreased during this period; the AARs in women > or =50 years old increased. The number of hysterectomies alone was 5,461,100, and AARs of hysterectomy alone decreased significantly from 2.9 per 1000 women in from 1979-1981 to 1.1 per 1000 women in 2001 (P < .001). The proportion of women who underwent hysterectomy with BO/RO increased from 29% in 1979 to 45% in 2004.

CONCLUSION

Although AARs of prophylactic BO/RO decreased from 1979-2004, the actual proportion of BO/RO at hysterectomy increased.

Vaginal colonization by probiotic Lactobacillus crispatus CTV-05 is decreased by sexual activity and endogenous Lactobacilli

BACKGROUND

Two potencies of gelatin capsules containing Lactobacillus crispatus CTV-05 were evaluated for safety and vaginal colonization in 90 young women.

METHODS

Sexually active females aged 14-21 years were randomized to receive either 10(6)- or 10(8)-cfu CTV-05 capsules inserted intravaginally twice daily for 3 days. At enrollment and at 4 weekly follow-up visits, behavioral and demographic information and quantitative vaginal cultures were collected. Lactobacillus species were identified by DNA hybridization, and the CTV-05 strain was discerned using repetitive-sequence polymerase chain reaction DNA fingerprinting.

RESULTS

Of the 90 participants, 87 returned for at least 2 follow-up visits. Of 40 participants who lacked L. crispatus colonization at enrollment, 36 (90%) were successfully colonized by CTV-05 at 1 or more follow-up visits, whereas only 24 (51%) of 47 participants colonized by L. crispatus at enrollment were positive for CTV-05 at follow-up (P < .001). Compared with sexually abstinent participants, females engaging in sexual intercourse with the use of condoms (odds ratio [OR], 6.3 [95% confidence interval {CI}, 1.3-29.4]; P = .02) or having unprotected sex (OR, 75.5 [95% CI, 6.9-820.6]; P < .001) during the first week were less likely to become colonized by CTV-05.

CONCLUSIONS

These data suggest that the factors that predict failure to become colonized by probiotic lactobacilli include exposure to semen, vaginal intercourse, and the presence of lactobacilli of the same species at enrollment.

Acceptance of a pandemic avian influenza vaccine in pregnancy

OBJECTIVE

To evaluate acceptance of a pandemic avian influenza vaccine among obstetric patients and nonphysician obstetric office personnel.

STUDY DESIGN

Two separate office-based questionnaires were administered to patients and nonphysician personnel. Questions included demographics, vaccine beliefs and acceptance of a potential pandemic avian influenza vaccine in pregnancy.

RESULTS

Questionnaires were completed by 394 of 600 (65.7%) eligible patients and 101 of 134 (75.3%) eligible office personnel. Only 15.4% of the patients stated they would definitely accept a pandemic influenza vaccine in pregnancy despite most (68%) reporting they would first consult their obstetrician for information. Fifty percent of the office personnel would not recommend a pandemic influenza vaccine to pregnant women and 40% reported unwillingness to accept the same vaccine if they were pregnant.

CONCLUSION

Barriers exist that may hinder mass vaccination efforts among the pregnant population during the next influenza pandemic. Preemptive educational efforts may assist in the acceptance of a pandemic vaccine among pregnant women and enable obstetricians to better provide disease prevention during the next influenza pandemic.

The amount and activity of active matrix metalloproteinase 13 is suppressed by estradiol and progesterone in human pelvic floor fibroblasts

As a key degrader of fibrillar collagens, matrix metalloproteinase 13 (MMP13), may contribute to the progression of pelvic organ prolapse. Here we aimed to define the regulation of MMP13 by estradiol and progesterone in the vaginal supportive tissues. Fibroblasts cultured from the arcus tendineous fasciae pelvis of three pre- and three postmenopausal women with prolapse were treated with 17-beta-estradiol (E2), progesterone (P4), E2 + P4, or E2 + ICI 182,780 (ICI). Collagenase inhibitor I (CI) and MG-132 were employed to investigate the mechanism of MMP13 degradation into inactive fragments (fragmentation) by hormones. The regulation of MMP13 in vivo was assessed by comparing tissues of ovariectomized (ovx) vs. sham-operated rats. Expression of MMP13 (proenzyme and active and fragment forms) was quantitated by Western immunoblotting, and MMP13 enzymatic activity was measured using a substrate degradation assay. The amount of cellular active MMP13 and MMP13 proteolytic activity decreased in the presence of hormones. The decrease was paralleled by increased proenzyme and fragment forms. MG-132, not CI, suppressed cellular MMP13 fragmentation. Active MMP13 increased in rats following ovx and was suppressed by E2 + P4 supplementation. Active MMP13 is suppressed in vivo and in vitro by estradiol and progesterone, suggesting a protective effect against vaginal supportive tissue deterioration.

Hormones restore biomechanical properties of the vagina and supportive tissues after surgical menopause in young rats

OBJECTIVE

The objective of the study was to determine the impact of hormones on the biomechanical properties of the vagina and its supportive tissues following surgical menopause in young vs middle-aged rats.

STUDY DESIGN

Long-Evans rats (4-month virgin [n = 34], 4-month parous [n = 36], and 9-month parous [n = 34]), underwent ovariectomy (OVX) or sham surgery. OVX animals received hormones (estrogen [E2] or estrogen plus progesterone [E2 plus P4]), placebo, or a matrix metalloproteinase inhibitor (chemically modified tetracycline-8 [CMT-8]). Animals were euthanized after 8 weeks and the biomechanical properties of the vagina and supportive tissues determined. Data were analyzed using a 1-way analysis of variance and posthoc tests.

RESULTS

OVX induced a rapid decline in the biomechanical properties of pelvic tissues in young but not middle-aged rats. Supplementation with E2, E2 plus P4, or CMT-8 restored tissues of young rats to control levels with no effect on middle-aged tissues. Parity did not have an impact on tissue behavior.

CONCLUSION

OVX has a differential effect on the tissues of young vs middle-aged rats.

Cervicovaginal colposcopic lesions associated with 5 nonoxynol-9 vaginal spermicide formulations

OBJECTIVE

This study was undertaken to compare the colposcopic appearance of the cervicovaginal epithelium with spermicide use vs condom use in a low-risk population.

STUDY DESIGN

This was an ancillary study of a trial comparing the efficacy of 5 nonoxynol-9 spermicides. A cohort of women who used condoms without spermicide served as a control group. Colposcopic examinations were performed during product use to identify genital lesions.

RESULTS

One hundred fifty-one participants had 1 or more follow-up examinations. At baseline, study groups differed only by the prevalence of baseline lesions. New lesions were identified at 49% of follow-up visits. Controlling for the presence of a baseline lesion, compared with condom use none of the spermicides were associated with an increase in new lesions (overall odds ratio, 0.8; 95% CI, 0.4-1.6; P = .5); and lesions characterized by epithelial disruption were less frequent with spermicide use (overall odds ratio, 0.3; 95% CI, 0.1-0.6; P < .001).

CONCLUSION

In a low-risk population, women who used nonoxynol-9 spermicides were less likely to have lesions with epithelial disruption, and equally likely to have any new lesion compared with condom use.

Hormonal contraceptive use modulates the local inflammatory response to bacterial vaginosis

OBJECTIVES

To compare cervical concentrations of numerous cytokines/chemokines in women with bacterial vaginosis (BV) compared with the levels detected after BV resolution and determine if hormonal contraceptive use modulates the local inflammatory response to BV.

METHODS

Cervical secretions from 81 women with BV at enrollment and normal flora at one-month follow-up were analysed for 10 different cytokines/chemokines using multiplexed fluorescent bead-based immunoassays.

RESULTS

BV was associated with significantly higher concentrations of IL-1 beta, tumour necrosis factor (TNF), interferon-gamma, IL-2, IL-4, and IL-10 compared with the levels detected in the presence of normal vaginal flora. Analysis of results stratified by contraceptive practice demonstrated significantly lower levels of numerous cytokines among women with BV using hormonal contraceptives compared with those women with BV not using hormonal contraceptives. Hormonal contraceptive use was also associated with a statistically significant lesser change in TNF levels between the two study visits compared with the amount of change detected between visits among women who denied their use.

CONCLUSIONS

Despite increases in the levels of both pro and anti-inflammatory cytokines in the lower genital tract of women with BV, the overall balance of these two types of molecules was maintained. The character of this local inflammatory response may help explain the typical absence of overt signs of inflammation among women with BV. In addition, hormonal contraceptive use was associated with significantly lower levels of the pro-inflammatory molecules TNF, interferon-gamma, and granulocyte macrophage colony-stimulating factor in women with BV, but did not significantly reduce the levels of IL-10, a key anti-inflammatory cytokine. These results suggest the possibility of an association between hormonal contraceptive use and altered genital tract immunity.

Cytokines, pregnancy, and bacterial vaginosis: comparison of levels of cervical cytokines in pregnant and nonpregnant women with bacterial vaginosis

BACKGROUND

Pregnancy has been considered to be a time of relative immune compromise. Lower-genital-tract immune response appears to be influenced by pregnancy. The objective of this study was to compare, in pregnant versus nonpregnant women, endocervical proinflammatory-cytokine expression in response to bacterial vaginosis.

METHODS

Endocervical levels of interleukin (IL)-1 beta , IL-6, and IL-8 in 99 pregnant and 99 nonpregnant women, all with bacterial vaginosis and without concurrent sexually transmitted infections, were assessed by ELISA. Vaginal flora was characterized on the basis of quantitative vaginal cultures.

RESULTS

Women in the 2 groups differed with respect to smoking status and microbiological constituents responsible for bacterial vaginosis. When the data were stratified by these potential confounders, the levels of all 3 proinflammatory endocervical cytokines were significantly higher in pregnant women than in nonpregnant women.

CONCLUSIONS

The proinflammatory cytokine milieu in the cervix is enhanced in pregnant women with bacterial vaginosis, compared with that in nonpregnant women. The notion of pregnancy as an immune-compromised state may be anatomically compartment specific.

Mifepristone and misoprostol administered simultaneously versus 24 hours apart for abortion: a randomized controlled trial

OBJECTIVE

Mifepristone and oral misoprostol are typically used for medical abortion in women up to 49 days of gestation, with a 36- to 48-hour interval between the medications. Alternative routes of misoprostol administration allow for use beyond 49 days of gestation. We designed this randomized, noninferiority trial to compare the efficacy, adverse effects, and acceptability of misoprostol 800 mcg vaginally administered simultaneously with, or 24 hours after, mifepristone 200 mg orally for abortion in women up to 63 days of gestation.

METHODS

The 1,128 participants swallowed mifepristone 200 mg and were then randomized to self-administer misoprostol intravaginally immediately in the office (group 1) or 24 hours later at home (group 2). Subjects returned for an evaluation, including transvaginal ultrasonography, 7+/-1 days after initiating treatment. Women who had not aborted were offered a second dose of misoprostol and returned for another evaluation in approximately 1 week. A phone contact was also attempted approximately 5 weeks after treatment. Treatment was considered a failure if a suction aspiration was performed for any indication.

RESULTS

The complete abortion rate for group 1 (95.1%, 95% confidence interval [CI] 93.0-96.8%) was statistically noninferior to that for group 2 (96.9%, 95% CI 95.1-98.2%) (P=.003). The abortion rates between groups did not significantly differ by gestational age. Adverse effects were mostly similar, although nausea, diarrhea, and warmth or chills were significantly more common in group 1.

CONCLUSION

Mifepristone 200 mg and misoprostol 800 mcg vaginally used simultaneously is as effective for abortion as compared with regimens using a 24-hour dosing interval.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00269568

LEVEL OF EVIDENCE

I.

Regulation of MMP-1 by sex steroid hormones in fibroblasts derived from the female pelvic floor

OBJECTIVE

The aim of this study was to investigate the effect of sex steroid hormones on the overall expression profile of cellular matrix metalloproteinase-1 (MMP-1) in fibroblasts that are derived from arcus tendineus fasciae pelvis.

STUDY DESIGN

Arcus tendineus fasciae pelvis fibroblasts that originated from a premenopausal woman and a postmenopausal woman who was undergoing a prolapse repair were treated with physiologic concentrations of 17-beta-estradiol (E2), progesterone, E2 plus progesterone, and E2 plus ICI 182,780. Cellular expressions of the latent, active, and fragment forms of MMP-1 were analyzed quantitatively by Western immunoblotting.

RESULTS

The latent and fragment forms of MMP-1 were increased by E2, progesterone, and E2 plus progesterone. The active form of MMP-1 was not changed by either E2 or progesterone alone but was decreased significantly when both hormones were added together. ICI 182,780 inhibited the stimulatory effect of E2.

CONCLUSION

Fragmentation is a site of regulation of MMP-1 expression by hormones. Only E2 combined with progesterone decreased the active form of MMP-1, which suggests that both hormones are necessary to maintain the integrity of female pelvic floor.

Adaptations of the rat vagina in pregnancy to accommodate delivery

OBJECTIVE

To characterize ultrastructural changes in the rat vagina in pregnancy, delivery, and postpartum, focusing on collagen architecture and smooth muscle cell morphology.

METHODS

The vagina of four virgin, four midpregnant, four late pregnant, four immediate, and four late post-vaginal-delivery rats were examined by transmission electron microscopy. Images were classified into one of four categories based on collagen fibril area fraction, with group 1 containing the highest number of collagen fibers per unit area and group 4 containing the lowest. Smooth muscle cells were characterized into three cell types ("synthetic," "intermediate," and "contractile") based on the volume fraction of cytoplasm occupied by organelles compared with myofibrils.

RESULTS

Quantitative analysis demonstrated that 76% of collagen fibers in virgin rats were categorized as group 1 or 2 compared with 49% in midpregnant, 40% in late pregnant, and 23% in immediate postpartum animals (P=0.006). Late postpartum tissue seemed similar to virgin tissue (77%). Midpregnant (37%), late-pregnant (34%) and immediate postpartum animals (43%) contained a higher proportion of synthetic smooth muscle cells compared with virgins (20%) and late postpartum animals (21%) (P=.02). Contractile smooth muscle cells predominated in virgin (64%) and late postpartum animals (70%) compared with midpregnant (42%), late pregnant (50%) and immediate postpartum (50%, P=.05).

CONCLUSION

In pregnancy, collagen fiber area decreased while smooth muscle cells transformed from a contractile to a synthetic phenotype. The late postpartum period returned to prepregnant levels for both collagen and smooth muscle cell morphologies. It is likely that these changes represent adaptations to minimize trauma to the vagina during passage of the fetus.

The Associations Between Pelvic Inflammatory Disease, Trichomonas vaginalis Infection, and Positive Herpes Simplex Virus Type 2 Serology

OBJECTIVE

Roles for Chlamydia trachomatis and Neisseria gonorrhoeae infections in pelvic inflammatory disease pathogenesis are well delineated; however, the etiologic contributions of herpes simplex virus type 2 (HSV-2) and Trichomonas vaginalis have been underexplored.

GOAL

The goal of this study was to investigate the association between acute and plasma cell endometritis, fallopian tube obstruction, HSV-2 serology, and T. vaginalis infection.

STUDY DESIGN

The authors conducted a cross-sectional secondary analysis of 736 women at risk for bacterial sexually transmitted diseases that used endometrial biopsy data obtained at enrollment as well as hysterosalpingography results obtained 12 weeks after enrollment.

RESULTS

Women diagnosed with T. vaginalis at enrollment were more likely to have histologic evidence of acute endometritis. Both plasma cell and acute endometritis were significantly more common among women with positive serology HSV-2; furthermore, women coinfected with HSV-2 and C. trachomatis, N. gonorrhoeae, T. vaginalis, or bacterial vaginosis were much more likely to be diagnosed with acute endometritis than were women infected with HSV-2 or one of these pathogens alone. Among women with available HSV-2 serology and hysterosalpingogram results, HSV-2 was the only genital tract pathogen infection associated with fallopian tube obstruction.

CONCLUSIONS

Our analyses demonstrate that T. vaginalis infection and positive HSV-2 serology are associated with endometritis. Further work will be needed to determine the specific roles these pathogens may play in pelvic inflammatory disease pathogenesis.

Susceptibility of vaginal bacteria to metronidazole and tinidazole

In vitro antimicrobial susceptibility testing was performed on 470 vaginal isolates from women with bacterial vaginosis and three species of Lactobacillus, to metronidazole and tinidazole using the agar dilution method. There was no significant difference observed in the inhibitory activity of either drug to any of the isolates tested.

Comparison of autologous rectus fascia and cadaveric fascia in pubovaginal sling continence outcomes

OBJECTIVE

The purpose of this study was to compare autologous versus cadaveric grafts in pubovaginal slings.

STUDY DESIGN

Women who had pubovaginal slings from 1994 to 2003 completed history, questionnaires, prolapse staging, and cough stress testing. Failure was defined by recurrent urinary incontinence symptoms and reoperation for stress incontinence. Group differences were evaluated using Student t test or chi-square test. The log-rank test was used to evaluate time to failure between the groups.

RESULTS

Of 303 women enrolled, 153 had autologous and 150 had cadaveric grafts. Regular urine leakage (39.6% vs 28.3%, P = .04) and reoperation for stress incontinence (12.7% vs 3.3%, P = .003) occurred more in the cadaveric versus autologous group, respectively. Adjusting for differing follow-up times, the cadaveric versus autologous group experienced higher rates of urinary incontinence (16 vs 5 per 100 women-years, P < .0001) and higher rates of reoperation (4 vs 1 per 100 women-years, P < .0003).

CONCLUSION

Autologous grafts used in pubovaginal slings have superior continence outcomes compared with cadaveric fascia.

Remodeling of vaginal connective tissue in patients with prolapse

OBJECTIVE

As pelvic organ prolapse progresses, the morphology of the vagina dramatically changes. The objective of this study was to determine whether these changes observed clinically correlate with histologic and biochemical evidence of tissue remodeling

METHODS

After informed consent, full-thickness biopsies of the vaginal apex were obtained at the time of surgery from 77 women. The tissue of 15 premenopausal women with less than stage II prolapse (controls) was compared with that of 62 women with prolapse divided according to their menopausal status. All specimens were examined histologically. Scanning confocal microscopic analysis of fluorescent micrographs was used to quantitate collagen subtypes I, III, and V. Collagen fiber orientation was analyzed by scanning electron microscopy. Gelatin zymography was used to quantitate the expression of the proenzyme and active forms of matrix metalloproteinases (MMP) -2 and -9. Median values were compared using Mann-Whitney U or Kruskal-Wallis tests, where appropriate

RESULTS

Vaginal collagen fibers are arranged in a whorled pattern, with collagen III as the predominant fibrillar collagen. The amount of total collagen in the vagina was increased in women with prolapse relative to women without prolapse (P = .054) primarily due to increased expression of collagen III (P = .031). There was no difference in the expression of proMMP-2, active MMP-2, or proMMP-9; however, active MMP-9 was increased in patients with prolapse (P = .030) CONCLUSION: The increase in collagen III and active MMP-9 expression in the vaginal tissues of patients with prolapse suggests that this tissue is actively remodeling under the biomechanical stresses associated with prolapse.

LEVEL OF EVIDENCE

II-2.

Effects of long-term use of nonoxynol-9 on vaginal flora

OBJECTIVE

Products containing nonoxynol-9 have been used as spermicidal contraceptives for many years, but limited data have been published describing the long-term effects of nonoxynol-9 use on the vaginal microbial ecosystem. This longitudinal study was conducted to examine the effects of nonoxynol-9 on the vaginal ecology.

METHODS

Vaginal swabs were obtained from 235 women enrolled in a randomized clinical trial before initiation of use of 1 of 5 different formulations of nonoxynol-9 for contraception, and up to 3 more samples were gathered over 7 months of use. The swab samples were evaluated in a single laboratory. The prevalence of several constituents of the normal vaginal flora was evaluated. The associations between nonoxynol-9 dosage, formulation, average product use per week, and number of sex acts per week were calculated.

RESULTS

The changes in prevalence of vaginal microbes after nonoxynol-9 use were minimal for each of the different nonoxynol-9 formulations. However, when both nonoxynol-9 concentration and number of product uses are taken into account, nonoxynol-9 did have dose-dependant effects on the increased prevalence of anaerobic gram-negative rods (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.1-5.3), H2O2-negative lactobacilli (OR 2.0, 95% CI 1.0-4.1), and bacterial vaginosis (OR 2.3, 95% CI 1.1-4.7).

CONCLUSION

This study demonstrated that most nonoxynol-9 users experienced minimal disruptions in their vaginal ecology. There were no differences between the different formulations evaluated with respect to changes in vaginal microflora. However, independent of the nonoxynol-9 formulation, there was a dose-dependent effect with increased exposure to nonoxynol-9 on the risk of bacterial vaginosis and its associated flora.

LEVEL OF EVIDENCE

II-2.

Microbiologic response to treatment of bacterial vaginosis with topical clindamycin or metronidazole

To compare the frequencies, concentrations, and antimicrobial susceptibilities of vaginal microbes isolated from women with bacterial vaginosis (BV) before and after therapy, 119 nonpregnant women aged 18 to 45 with clinical and Gram stain evidence of BV were randomized to receive intravaginal clindamycin or metronidazole. Vaginal swabs were collected at baseline and 7 to 12 days, 35 to 45 days, and 70 to 90 days following therapy for quantitative vaginal culture. For the 99 women completing all four visits, statistical analyses were performed comparing differences in vaginal microflora between the two treatment arms and between visits in the same treatment group. Antimicrobial susceptibility testing using the agar dilution method was performed for anaerobic gram-negative rods. Although both therapies resulted in decreased colonization by Gardnerella vaginalis and Mycoplasma hominis, only metronidazole treatment resulted in a significant decrease in the frequency and concentration of Prevotella bivia and black-pigmented Prevotella species. Of the 865 anaerobic gram-negative rods evaluated for susceptibility, only 3 (0.3%) were resistant to metronidazole, whereas clindamycin resistance increased significantly for P. bivia and black-pigmented anaerobic gram-negative rods persisting following clindamycin therapy. Clindamycin-resistant subpopulations of P. bivia and black-pigmented Prevotella species emerged 7 to 12 days after therapy even among women colonized initially by clindamycin-susceptible strains. These resistant subpopulations persisted at high frequencies (42 to 50%) 70 to 90 days following therapy. The two topical agents for treatment of BV have differing microbiologic effects on the vaginal microflora. The emergence of clindamycin-resistant anaerobic gram-negative rods following therapy is of concern.

Genital tract shedding of herpes simplex virus type 2 in women: effects of hormonal contraception, bacterial vaginosis, and vaginal group B Streptococcus colonization

BACKGROUND

Genital infections due to herpes simplex virus type 2 (HSV-2) are characterized by frequent reactivation and shedding of the virus and by the attendant risk of transmission to sexual partners. We investigated the effects of vaginal coinfections and hormonal contraceptive use on genital tract shedding of HSV-2 in women.

METHODS

A total of 330 HSV-2-seropositive women were followed every 4 months for a year. At each visit, one vaginal swab specimen was obtained for detection of HSV-2 by polymerase chain reaction, a second vaginal swab specimen was obtained for detection of group B Streptococcus (GBS) organisms and yeast by culture, and a vaginal smear was obtained for the diagnosis of bacterial vaginosis by Gram staining.

RESULTS

HSV-2 DNA was detected in 88 (9%) of 956 vaginal swab specimens. Independent predictors of genital tract shedding of HSV-2 were HSV-2 seroconversion during the previous 4 months (adjusted odds ratio [aOR], 3.0; 95% confidence interval [CI], 1.3-6.8), bacterial vaginosis (aOR, 2.3; 95% CI, 1.3-4.0), high-density vaginal GBS colonization (aOR, 2.2; 95% CI, 1.3-3.8), and use of hormonal contraceptives (aOR, 1.8; 95% CI, 1.1-2.8).

CONCLUSIONS

The present study identifies hormonal contraceptive use, bacterial vaginosis, and high-density vaginal GBS colonization as risk factors for genital tract shedding of HSV-2 in women. Because hormonal contraceptives are used by millions of women worldwide and because bacterial vaginosis and vaginal GBS colonization are common vaginal conditions, even modest associations with HSV-2 shedding would result in substantial attributable risks for transmission of the virus.