Sandra Fyfe

Anh Thi Chau Nguyen, PhD, of the department of microbiology at Hue University of Medicine and Pharmacy in Hue, Vietnam and colleagues conducted the study, which was published in the journal 

Symptoms of AV, which can vary in severity and can last for a long time, include yellow or yellow-green pus-like discharge, redness of the vaginal opening and the vagina, a rotten odor, painful intercourse. Severe cases can include ecchymotic bleeding points and erosions, researchers said.

The hallmark of AV is the existence of facultative and aerobic bacteria such as 

and coagulase-negative staphylococci. “AV is described as a depletion of the 

 microbiota and an increase in aerobic bacteria derived mainly from the gastrointestinal tract, accompanied by inflammatory markers and deficient epithelial maturation,” the authors wrote.

Researchers performed a cross-sectional descriptive study that examined 323 pregnant women during routine prenatal care visits at Hue University Hospital in Hue, Vietnam between July 2018 and January 2019. Study participants had a mean age of 28.3 years, and researchers said most of the women had secondary or above levels of education. Most were employed as public servants or were housewives. Almost all study participants were married, with only 0.6% reporting their status as single. None of the women had fetuses with abnormalities.

Women who had been treated for reproductive infections or who had used antibiotics within the last week for some other type of infection, a previous diagnosis of a ruptured membrane, or douching before or during the collection of the specimen were excluded from the study. Women who experienced antepartum hemorrhaging were also not included.

Nguyen and colleagues examined vaginal specimens obtained during the third trimester using 2 sterile cotton swabs to collect vaginal fluid. One swab was analyzed using Gram-stained slide smear, and the second was frozen in cryotube for culturing at a lab in Estonia. Researchers used the Donders scoring system and cultured the swabs for predominant bacteria identification. The authors followed the women’s pregnancies to term and recorded outcomes for both infants and mothers.

Over 15% of the women had AV in the third trimester, researchers reported. Eighty-four percent had light AV, while 16% had moderate AV. Of positive samples, 

 were the most common microorganisms. Third trimester AV correlated with an increased risk of puerperal sepsis (OR 8.65, 95% CI: 1.41—53.16, p=0.020) and researchers said there was an increased risk of neonatal infections, although this was not statistically significant.

“Previous studies have revealed that AV can be related to different pregnancy complications like chorioamnionitis, fetal infection, premature birth,” researchers said, in addition to premature rupture of membranes, preterm premature rupture of membranes, and neonatal infections. Nguyen and colleagues said that less data is available regarding postpartum infections and that complications of AV are similar to bacterial vaginosis.

Of women in the study, 6% had puerperal sepsis, and the authors emphasized that women with AV have a 9-fold risk of postpartum infection. Nguyen and colleagues stressed that postpartum infections worldwide are 1 of the top 5 causes of maternal death, and cause 10 to 15% of deaths in the postpartum period. 75,000 maternal deaths yearly are attributed to puerperal sepsis, the authors explained. 

“AV in pregnant women is significantly associated with an increased risk of postpartum infections and therefore needs to be diagnosed and treated before delivery,” Nguyen and colleagues concluded.

Lubna Mohammed, MBBS, Internal Medicine at the California Institute of Behavioral Neurosciences & Psychology, who was not associated with the study, told 

 that the most important takeaway from this study for providers in practice is the importance of diagnosing AV before delivery as it is related to a higher risk of developing puerperal sepsis and other complications.

“For next steps, researchers should study the prevalence of AV in pregnant women belonging to all demographical populations so that a vigilant eye can be kept to diagnose and treat it, as the current study only concentrates on the Vietnamese population,” she said in the interview.

Mohammed added that even though the third trimester of pregnancy starts at 28 weeks, most of the samples in this study were collected after 37 weeks. “Diagnosing AV from the beginning of the third trimester can be considered by ob-gyn provider audience and the outcome of early diagnosis can be studied,” she said.

Nguyen ATC, Le Nguyen NT, Hoang TTA, et al. Aerobic vaginitis in the third trimester and its impact on pregnancy outcomes. 

. 2022;22(1):432. Published 2022 May 24. doi:10.1186/s12884-022-04761-5

Articles

Aerobic vaginitis (AV) in pregnant Vietnamese women correlated with a higher risk of puerperal sepsis and negative pregnancy outcomes.

Pregnancy outcomes affected by aerobic vaginitis

Diseases like psoriasis cause systemic inflammation, which is not an optimal environment for a developing fetus. Inflammation can result in APOs. Cæcilie Bachdal Johansen, MD, of the department of dermatology and venereology and the department of clinical pharmacology at Bispebjerg and Frederiksberg Hospital in Copenhagen, Denmark, and colleagues conducted a study to see what APOs are linked with psoriasis. They also wanted to investigate if psoriasis disease severity resulted in differences in APOs.

In Denmark, residents are given a 10-digit number to identify them across healthcare registries. Johansen and colleagues used this nationwide registry to conduct a case-controlled study that collected data from 1973-2017. APOs (42,041 study participants/8.56%) were examined; diagnoses included stillbirth, intrauterine fetal death, EP, and spontaneous abortion in women with psoriasis. These were compared to 449,233 (91.44%) single live birth controls. Of these, 6426 (1.31%) pregnant people had psoriasis. For this group, 6225 (96.87%) had mild psoriasis and 201 (3.13%) had moderate-to-severe psoriasis.

Psoriasis severity was defined based on psoriasis treatment any time before the index date via hierarchical approach, with moderate-to-severe overruling mild psoriasis,” researchers reported.

 Moderate-to-severe psoriasis was considered when pregnant people were treated with any systemic antipsoriatic drugs: acitretin, adalimumab, brodalumab, certolizumab pegol, cyclosporin, etanercept, guselkumab, infliximab, ixekizumab, methotrexate, secukinumab, and ustekinumab.

Researchers used adjusted logistic regression models for statistical analysis. Of all APOs, EP was the only statistically associated adverse outcome linked to psoriasis (odds ratio, 1.34; 95% CI, 1.06-1.68), Johansen and colleagues reported. The authors said this was highest for pregnant people with moderate to severe psoriasis (odds ratio, 2.77; 95% CI, 1.13-6.76). “The absolute risk of EP was 2.48% higher for women with moderate-to-severe psoriasis compared with women without psoriasis (3.98% vs 1.50%),” they wrote.1 While rare, EP is a life-threatening emergency that requires surgery, so providers should be aware of this increased risk due to psoriasis, researchers noted. The authors said there could be a number of reasons for this increase, but more data is needed to provide evidence. “Although embryo implantation and tolerance of pregnancy are extremely complex processes and not yet fully understood, the preexisting inflammatory load in women with severe psoriasis and psoriatic arthritis (PsA) may facilitate a microenvironment in the fallopian tubes permissive of embryo implantation, resulting in an increased risk of EP,” Johansen and colleagues said.1 They added that this idea may be reinforced “by psoriasis’ shared immunologic pathway with IBD, which also is associated with an increased risk of EP.”

Women with psoriasis have more risk factors for APOs than women without the diagnosis, researchers reported. These include lower fertility rates, obesity, thyroid disease, smoking, preconception hypertension, gestational hypertension, diabetes, inflammatory bowel diseases, rheumatoid arthritis, low socioeconomic status, and use of nonsteroidal anti-inflammatory drugs.

Johansen and colleagues stressed that EP is a major cause of maternal mortality and morbidity in the first trimester of pregnancy, so providers should be on the lookout for this complication in women with psoriasis, particularly those with moderate to severe form of the disease. Patients should be instructed to go to the ED for lower abdominal pain for an emergency gynecological evaluation, unplanned lack of menstrual bleeding, and concurrent light vaginal bleeding. Finally, researchers said more studies are needed to address the causal relationship between psoriasis and EP.

This article was published by our sister publication Dermatology Times.

Johansen CB, Egeberg A, Jimenez-Solem E, Skov L, Thomsen SF. Psoriasis and adverse pregnancy outcomes: A nationwide case-control study in 491,274 women in Denmark. 

. 2022;7:146-155. Published 2022 Apr 19. doi:10.1016/j.jdin.2022.03.009

A study published in JAAD International examined the association between psoriasis and adverse pregnancy outcomes (APOs) and found that providers should be on the lookout for ectopic pregnancies (EP) in this population.

Researchers investigate psoriasis and adverse pregnancy outcomes

Worldwide, 1 in 10 women suffer from endometriosis and often find it difficult to control their symptoms, which include painful intercourse, constipation, dysmenorrhea, and persistent pelvic pain.

Symptom management has been more challenging during the COVID-19 pandemic, due to limited access to healthcare. Mike Armour, PhD, of the NICM Health Research Institute at Western Sydney University in Penrith, New South Wales, Australia and colleagues set out to examine how frequently women used cannabis over a period of 12 weeks to manage their endometriosis symptoms during the pandemic in a survey-based study.

Researchers recruited women between the ages of 18-55 with the condition using social media to access some of the largest endometriosis support and advocacy groups worldwide. These included Nancy’s Nook, Endometriosis Australia, Endometriosis NZ, the World Endometriosis Organization, the Centre for Endometriosis Research, Endometriosis Ireland, and The Endometriosis Network Canada, for a total pool of about 95,000 women.

 The authors ensured that surveys could only be taken once per IP address to prevent multiple submissions from an individual.

The anonymous, cross-sectional, online survey was designed by a team that included cannabis, endometriosis, and menstrual health academics and gynecologists. Researchers collected demographic information, endometriosis symptoms, diagnosis method, and current management approaches, in addition to current and previous cannabis use and method of consumption.

Armour and colleagues received 1635 responses worldwide, and reported the average age of respondents was 30 (mean 25 years).

 Twenty percent of respondents said they had previously used cannabis. Pre-pandemic, 61% of women said they used cannabis at least once a day, with 51% using inhaled forms. Sixty-five percent of users reported they stopped using cannabis because of the pandemic. The authors said cannabis use increased among current users during the pandemic.

Fifty-one percent of respondents (846) said they consumed cannabis in the past 3 months; of these, 55% (465) reported using it for symptomatic management. “Legal access was associated both with a greater likelihood of using cannabis and greater disclosure to health care professionals,” the authors said.

Stress/anxiety was the most common reason (59%) participants reported using cannabis, followed by symptomatic management due to difficulty accessing medical care (48%) the authors reported. They also noted that the way women consumed cannabis changed during the pandemic, with increases in edibles and oil consumption (40% and 25.2% respectively) and a 39.5% decrease in inhalation methods. Survey respondents said the decline in inhaled use was due to respiratory health concerns during the COVID-19 pandemic.

One of the barriers to consumption was cost; this included both the cost of the product and the expense of obtaining a medical prescription in places where cannabis is not legal for recreational consumption. “Lack of public (Medicare-like) insurance reimbursement and limited private health insurance coverage push the out-of-pocket costs associated with cannabis medicines onto patient households, a burden not every patient/family can bear, regardless of its reported effectiveness in the management of endometriosis,” the authors wrote. They said this creates barriers for women who would use it to alleviate their symptoms.

Armour and colleagues noted several weaknesses of the study: there was no proof of diagnosis, selection bias may have occurred due to nonresponse in social media groups, and study participants may have experienced recall bias. Study strengths noted by researchers included international reach of the survey, the size of the sample, and the ability to report anonymously encouraged study participants to disclose information.

“Use of cannabis for symptom relief was common, with over half of respondents having used cannabis for symptom management in the 12 weeks preceding survey completion,” the authors said.

Armour M, Sinclair J, Cheng J, et al. Endometriosis and Cannabis Consumption During the COVID-19 Pandemic: An International Cross-Sectional Survey [published online ahead of print, 2022 Jan 21]. 

. 2022;10.1089/can.2021.0162. doi:10.1089/can.2021.0162

A study published in Cannabis and Cannabinoid Research found that women often used cannabis to manage endometriosis symptoms during the COVID-19 pandemic.

Cannabis consumption and endometriosis management during the COVID-19 pandemic

Elke Hunsche, PhD, of Global Market Access and Health Economics and Outcomes Research at Myovant Sciences GmbHIn in Basal, Switzerland and colleagues conducted the substudy. Thirty women with heavy menstrual bleeding (HMB) who participated in the phase 3, randomized, double-blind, placebo-controlled 

 trials were selected for the substudy. Liberty 1 and 2 were performed to evaluate the safety and efficacy of relugolix. Women chosen for the substudy were from the US trials sites, fluent in English, and reported improvement on a 5-point global assessment scale at week 12 for their symptoms.

Researchers conducted interviews via telephone (26 women/86.7%) or web-based video conferencing (4 women, 13.3%) that were scheduled between 3 and 14 days after the final week of the study visit (week 24).

 Women participating were between 35-51 years of age (mean 43 years). Over 86% of women reported attending college or higher education. Twenty-one women were Black or African American.

Hunsche and colleagues used a semi-structured format of open-ended questions followed up with targeted probes to gather data about women’s experiences with UF before and after participating in the Liberty 1 and 2 trials. Researchers asked women to describe the onset, frequency, severity, and duration of their UF symptoms and impact, and to consider and their lifetime experience with the disease.

More than 90% of women reported HMB as the most frequent symptom (n=30, 100.0%).

 The impact of open-ended questions is clear. Researchers said, “one woman characterized HMB as 'no matter how many sanitary towels you put in, when the blood comes out, it drains down to your feet because it pours.' 

 Pain was the second most commonly reported symptom (n=28, 93.3%), according to study authors. One woman described her pain as "a stabbing pain. I could be walking—just walking around a store and literally be broke down, like something literally is trying to rip out of me—or it’s a sharp, stabbing pain." the authors wrote.

 The passing of blood clots was also frequently reported (n=28, 93.3%).

 that the data found that UF symptoms had a negative impact on almost every aspect of women’s lives. They affected activities of daily life, work-school attendance and productivity, emotional wellbeing, sleep quality and social activities, and placed a burden on women both physically, emotionally, and financially, she said.

Hunsche explained that the most important takeaway from the research is that it “emphasizes the importance of care providers discussing with women which symptoms of uterine fibroids have a significant impact on their daily lives, so that treatments can be tailored to individual needs.” 

In addition, she said that the interview approach differs from traditional patient questionnaires by giving women the chance to freely share their experiences of UF symptomatic burden and impact has on women’s daily lives. “This allows greater opportunity to identify symptoms and impacts that are perhaps discussed less frequently in the clinical setting,” she said.

For next steps to be taken, Hunsche told 

 that “further research should be conducted in a population of women with UF not experiencing heavy menstrual bleeding, as well as in countries other than the US, to assess the burden of UF in a broader population.” She said additional research could explore the development of a short questionnaire for assessing the most bothersome symptoms and impacts of UF for regular use in clinical practice.

Hunsche said she and her colleagues have conducted a similar interview study to assess the symptomatic burden and impact of endometriosis-associated pain, the results of which will be published soon. “This study provides insights on the experience and perspectives of endometriosis – a disease reported in up to 15% of premenopausal women – as described by women in their own words,” Hunsche said.

Hunsche and Rakov are employed by Myovant Sciences and are shareholders of the company. McCain was an employee and a shareholder of Myovant Sciences at the time of writing. Witherspoon is employed by Endpoint Outcomes, who was compensated by Myovant Sciences to conduct this research. Scippa was an employee of Endpoint Outcomes at the time this research was conducted.

Hunsche E, Rakov V, Scippa K, Witherspoon B, McKain L. The Burden of Uterine Fibroids from the Perspective of US Women Participating in Open-Ended Interviews

 2022 Mar 4;3(1):286-296. doi: 10.1089/whr.2021.0086. PMID: 35415708; PMCID: PMC8994433.

A study published in Women’s Health Reports offers deeper knowledge of women’s lived experience with fibroids in their own words, and confirms the burden of the disease.

Open-ended interviews shed light on US women’s perspective of fibroid burden

 infections are among the most common reasons patients visit their providers. What increases the likelihood of these infections? In a 10-year, lab-based cohort study, researchers examined how seasonal variations and changes in diet, clothing, exposure to the sun, and temperature play a role in 

Gilbert G G Donders, MD, PhD, of Femicare, Clinical Research for Women in Tienen, Belgium, and also the departments of obstetrics and gynecology at both Regional Hospital Heilig Hart (also in Tienen), and University Hospital in Antwerpen, Belgium, and colleagues conducted the study. Researchers examined 12,941 vaginal cultures from vulvovaginitis clinic patients from the Department of the Regional Hospital Heilig Hart in Tienen, Belgium from September 2007 to August 2017. Seventy percent of the women were from the area local to the hospital and 30% were from more rural areas, Donders and colleagues reported. Five percent were from non-European countries. “At this consultation, mainly patients presenting with recurrent vulvovaginal symptoms, with vague and undetermined symptoms, or for follow up during treatment regimens were seen,” researchers reported.1

Swab samples were collected from the upper lateral vaginal vault using a speculum and immediately placed into a liquid Amies preservation medium, then transported to a lab and examined for 

Researchers comparedthe presence of albicans and non-albicans species monthly to look for seasonal variation in the winter and summer using Chi-square and chi-square for trend analysis.

Donders and colleagues reported that in 2019, 16% of samples were positive with albicans versus non-albicans species only varying between 1-2% per month and no large differences on a monthly basis.1 For the 10-year period, researchers said June was the month with the highest number of infections (19.0%, p = 0.008) and December had the lowest number (14.5%, p = 0.04).1 Summer had the most number at 15.5% from June, July, and August, while the winter months of December, January, and February had 14%.1

“Change in temperature, dietary habits, and bodily adaptations due to increased amount of sunlight were discussed as potential pathophysiological mechanisms to explain the excess of Candida in summertime. Further confirmatory research would be beneficial. Women at risk for Candida vulvovaginitis should pay more attention to living habits in summertime to avoid recurrences,” Donders and colleagues reported.1

® Donders said caring for women with recurrent 

 vaginitis is very difficult. “Very often, physicians and other health care providers don’t know how to handle the disease and start to provide personal advice,” he said. This can include changing underwear, avoiding soap use on the genitals, refraining from bathing, and changing their diet, Donders explained. “Unfortunately, most of these ‘don’t do’s’ only accumulate and make a woman’s life miserable. They seldomly solve or improve the problem of recurrent vulvovaginitis,” Donders said.

 that there is vast experience in taking care of patients lasting over several decades, with a large quantity of lab test results and clinical data. “This allowed us to study in more detail several host factors such as the influence of genetic predisposition, concomitant skin disease, glucose metabolism, and multiple site colonization with candida in women with recurrent vulvovaginal candidiasis,” he said. He added that the nature of the infecting organism and symptom severity may differ from person to person. The organism can also give closer insight into the development of both antimycotic resistance of

 albicans towards more non-albicans Candida infections in women taking antimycotic regularly.

“We had the clinical impression that Candida vaginitis presented more often during summertime, and less in wintertime, but this has never been studied before to our knowledge,” Donders explained to 

“We studied the seasonal influence on an undeniable standard: the number and proportion of positive vaginal cultures per month, over a period of 10 years.” He said this showed a peak of 

 vaginitis is present in June-July and a dip in winter. “Being able to use a large database from a single lab, using an unchanged technique over that period of time, we were able to find a difference in rates in winter versus summertime and speculated about the hypothetical reasons for this. We could also determine that non-albicans strains were not the cause of the differences found,” Donder said.

Donders GGG, Ruban K, Donders F, Reybrouck R. Lab-Based Retrospective 10-Year Analysis Shows Seasonal Variation of Vaginal Candida Infection Rates in Belgium. 

. 2022;11(3):574. Published 2022 Jan 24. doi:10.3390/jcm11030574

The research published in the Journal of Clinical Medicine found women were more likely to have infections in the summer.

Belgian study finds seasonal variance in Candida infections

Vered H Eisenberg, MD, MHA, senior obstetrician-gynecologist at Sheba Medical Center in the Sackler Faculty of Medicine at Tel Aviv University in Israel and colleagues conducted the retrospective, case-controlled study.

 Researchers reviewed case records from a computerized database of a nationwide Israeli healthcare plan containing 2.1 million members. This is approximately 25% of the country’s population and reflects its demographics. Researchers cited another study where data sources are fully described.

From this database, researchers examined 6,146 women between the ages of 15-55 years (mean age ± SD: 40.4 ± 8.0) as of December 31st, 2015 that had been enrolled in the health care plan for a full year and had been diagnosed by a PCP or other specialist with endometriosis between 1998-2015. “While the results of imaging and surgical evaluation were not used for validating the diagnosis, more than 90% had a previous record of a pelvic/gynecological US examination,” the authors said. Endometriosis patients were compared with 24,572 controls who had not been diagnosed with the condition. They were matched 1:4 based on age in 5-year groupings, and on where participants resided.

Eisenberg and colleagues reported that women with endometriosis (WWE) were more likely to be of higher socioeconomic status (SES) and have lower body mass index (BMI) than controls. They also said those with endometriosis were more likely to live in the Central region of Israel and less likely to live in areas with mainly Arab or orthodox Haredi populations.

Researchers reported that after adjusting for BMI and SES, study participants with endometriosis were significantly more likely to experience infertility, with 36.9% of women being affected. The highest lifetime infertility rates in women with endometriosis were in those aged 40-44, according to the authors.

In addition to infertility, WWE were more likely to have chronic comorbidities, including chronic kidney disease, diabetes, cancer, hypertension, and cardiovascular disease.

 Researchers also noted a higher incidence of irritable bowel disease and appendicitis, “conditions with potentially overlapping abdominal pain symptoms, where the distinction between comorbidity and misdiagnosis is often challenging.”

WWE were much more likely to have seen a PCP or gynecologist within the past year than controls Eisenberg and colleagues said; nearly 20% had at least 5 gynecological visits, which researchers said was 1.5 times as many as the control group. The endometriosis group also had higher rates of hospitalizations and ED visits, with double the chance of controls being hospitalized once, and triple the chance of being hospitalized at least twice.

They were also more likely to have imaging procedures such as MRI and ultrasound, and to also have more lab tests for complete blood count, luteinizing hormone, and follicle-stimulating hormone tests. “Overall, 42.2% of women with endometriosis had a pelvic/genital US, of which only 3.1% underwent a dedicated endometriosis US.,” researchers said. 

The endometriosis group was also more likely to undergo CA-125 and CA-15.3 testing for ovarian and breast cancer respectively. The additional healthcare needed by endometriosis patients adds up: “Overall, endometriosis was associated with an excess in total per-person direct medical costs across all age groups and with an age-adjusted OR of 1.75 (95% CI 1.69–1.85),” researchers reported.

WWE were more likely to use oral contraceptives (23.6% versus 15.6% in the control group) for the past twelve months and had an even higher rate of lifetime use at 71% versus 53.2% in controls.1 “Women aged 25–29 had the highest rates of oral contraceptive use in 2015: 86.4% and 73.4% among endometriosis patients and controls, respectively,” Eisenberg and colleagues said. They reported a similar, low rate of IUD insertion for both groups. Gonadotropin use was triple in the endometriosis group compared to controls. Pain medication use, such as narcotics like tramadol, was also higher in the endometriosis group, as was antidepressant use (11.8 versus 8.6% in controls).

Researchers noted that young women between 15–19 years old with endometriosis had a much higher rate of oral contraceptive use (76.9% vs. 9.6%), PCP visits (57.7% vs. 14.4%), and gynecological visits (57.7% vs. 14.4%). Women aged 20-24 also had an increase in PCP visits (92.8% vs. 83.1%), gynecological visits (76.6% vs. 54.8%), and oral contraceptives (83.8% vs. 56.7%). Researchers said pain medication and contraceptive use in this younger age group also had higher use than in the age-matched control group.

“Women with a diagnosis of endometriosis have a significantly higher burden of infertility and chronic comorbidities, increased healthcare resource utilization, and excess costs, particularly younger patients whose healthcare needs may differ widely from those of otherwise healthy women,” Eisenberg and colleagues concluded.

Eisenberg VH, Decter DH, Chodick G, Shalev V, Weil C. Burden of Endometriosis: Infertility, Comorbidities, and Healthcare Resource Utilization

 2022;11(4):1133. Published 2022 Feb 21. doi:10.3390/jcm11041133

Eisenberg VH, Weil C, Chodick G, Shalev V. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members. 

. 2018;125(1):55-62. doi:10.1111/1471-0528.14711

A study published in the Journal of Clinical Medicine highlights the high burden of endometriosis, including infertility, comorbidities, health care usage, and medical costs.