Sandra Fyfe

To inform a high-level National Institutes of Health (NIH) meeting, Juliana Grant, MD, MPH, founder of the consulting company Public Health Nerds, LLC, in Seattle, Washington, and colleagues conducted a narrative review that was published in the journal 

 The authors’ goal was to find knowledge gaps and key considerations for pregnant women with STIs to inform future research needed for the creation of guidelines for screening and treatment in low- and middle-income countries. The authors said that prior to the review, current evidence was insufficient to develop global guidelines.

Grant and colleagues said that in many countries, STIs such as trichomoniasis, chlamydia, and gonorrhea are common in pregnant women, and are linked to poor neonatal and maternal outcomes such as preterm labor and birth, low birthweight, pregnancy loss, and neonatal/perinatal mortality. However, no global standard STI screening and treatment guidelines exist. “Syndromic STI management is frequently used in pregnant women in low- and middle-income countries, yet its low specificity and sensitivity lead to both overtreatment and undertreatment,” the authors said.

Study authors searched PubMed literature and clinical trial registry searches through January 20, 2020. They also reviewed the World Health Organization (WHO) and other agency guidelines and collected expert opinions. Results were limited to full-text English, and the authors noted that literature searches were not done systematically because this was not a systematic review; articles and studies were not evaluated with standard criteria.

Grant and colleagues reported that adverse maternal-child outcomes ranged widely and had variable definitions. They did not find any randomized, controlled trials of etiologic screenings or targeted treatment. They only found limited evidence from observational studies. In addition, they reported mixed results from trials of presumptive STI treatment. The authors identified subgroups of pregnant women that could benefit from specific recommendations. They also noted that harm evidence was limited, and that STI prevalence and testing infrastructure availability and high/low accuracy of tests influenced cost-effectiveness. They also said that high patient acceptability was suggested by preliminary data.

“Preliminary data on harms, acceptability, and feasibility and the availability of emerging test technologies suggest that etiologic STI screening deserves further evaluation as a potential tool to improve maternal and neonatal health outcomes worldwide,” the authors wrote.

One important subgroup of women who could benefit from guidelines were pregnant women with HIV, who have higher rates of STIs, the authors said. Another high priority subgroup included pregnant women living in regions with endemic malaria and/or places that intermittently use preventative treatment for malaria.

Study senior author Jeffrey D Klausner, MD, MPH, professor of preventive medicine at the Division of Disease Prevention, Policy and Global Health in the Department of Preventive Medicine at the University of Southern California Keck School of Medicine in Los Angeles, California discussed the review in an interview with 

®. He said the most important takeaway for providers was the importance of full STI screening for pregnant women, including consideration of emergent infections. He said this was especially the case due to STIs such as 

, which is not routinely screened for, and for which there is little research on how it impacts pregnancy.

“STIs in pregnancy are under-recognized and under-researched, even in the United States,” he explained. While the US has routine screening for pregnant women for HIV, gonorrhea, chlamydia, syphilis, and hepatitis B, Klausner said there needs to be wider screening for STIs worldwide. “There are only 13 countries that routinely screen pregnant women for gonorrhea, and 14 for chlamydia,” he said. “These easily treatable infections are known to cause adverse pregnancy outcomes like prematurity, low birth weight, stillbirth, newborn sepsis, and blindness.” He said the gap is in implementation of testing, and the goal of the review was to figure out how to raise awareness and increase STI screening. Klausner noted that congenital syphilis is at a 20-year high in the US, highlighting the urgency of screening and treatment implementation for pregnant women. He said the pandemic is further impacting screening with women avoiding in person healthcare visits, resulting in an increase of STIs due to delays in testing and treatment. He advocated for at-home STI testing for pregnant women, but added that the costs are often not covered by insurance, which causes this option to be underutilized.

To assist patients, Klausner said “practicing providers need to regularly monitor their own practice and make sure pregnant patients are fully screened for the 5 recommended STIs (syphilis, gonorrhea, chlamydia, hepatitis B, and HIV). Results should be handled in a timely manner, and both women and their partners should be treated and retested. Providers need quality assurance programs in their practices,” to ensure optimal positive pregnancy outcomes.

Grant JS, Chico RM, Lee AC, et al. Sexually transmitted infections in pregnancy: a narrative review of the global research gaps, challenges, and opportunities. 

. 2020;47(12):779-789. doi:10.1097/OLQ.0000000000001258.

Articles

A narrative review identified gaps in knowledge and considerations for informing sexually transmitted infection (STI) screening guidelines and treatment to improve the health of pregnant women and children.

More Research and Screening for STIs Needed to Improve Worldwide Maternal and Neonatal Health

Genitourinary Syndrome of Menopause (GSM), a condition caused by declining hormones, especially the decline of estrogen, results in progressive but treatable vulvovaginal and urinary symptoms. However, it is often overlooked by providers.

GSM represents a collection of symptoms that can cause a decrease in the quality of lives and relationships of menopausal women. However, symptoms are treatable and with better provider awareness, patient education, evaluation, and treatment, women can have a sense of restored wellbeing, according to a review published in the journal 

Nancy Phillips, MD, associate professor at the department of obstetrics, gynecology, and reproductive sciences and director of the Center for Vulvovaginal Health at Rutgers Robert Wood Johnson Medical School in New Brunswick, New Jersey, along with colleagues collected data through searches of vulvovaginal atrophy and GSM from PubMed, Google Scholar, and OVID. They also looked at US Society Guidelines to write a narrative review of GSM.

GSM’s symptoms include, but are not limited to, urinary symptoms of urgency, dysuria, recurrent urinary tract infection, and vulvovaginal symptoms of dryness, burning, irritation, and dyspareunia. Symptoms can be very disruptive in women’s lives and affect their sense of physical and emotional wellbeing. Phillips and colleagues reported that the symptoms are usually progressive and do not resolve spontaneously on their own. 

They added that symptoms require a clinical diagnosis from a provider.

The authors said that telemedicine may play an important role in diagnosis, treatment initiation, and follow-up, and that a variety of treatments are available. These include local therapy with hormones (estrogen or dehydroepiandrosterone), oral selective estrogen receptor agonists, moisturizers, and lubricants. 

Clinical follow-up treatment is necessary, and evaluation is needed if symptoms change, worsen, or do not improve.Good clinical judgement is needed because telemedicine treatment guidelines of GSM are not yet developed. The review said that laser or radiofrequency procedures that are currently being used are still being studied for safety and efficacy, as is the influence and effect of the vaginal microbiome and its manipulation for GSM treatment possibilities.

, Phillips presents a sample roleplaying interaction between doctor and patient on how to start the discussion about GSM with women who may be suffering from symptoms. Communication with patients is essential to address the problem and offer treatment options for women, especially since Phillips explains in the video that women will tend to not bring up symptoms during visits with their provider.

®, Phillips said that despite GSM’s negative effects on a patient’s life and relationship quality, the symptoms are often not discussed, evaluated, or treated as part of routine care. She said multiple effective treatments with and without hormones are available. “Relief of symptoms is possible for most women with guided clinical management,” Phillips explained. “From a clinical perspective, increasing awareness and encouraging dialogue between women and healthcare providers is key. Screening and early intervention, even in peri- or early-menopausal woman with minimal symptoms should be undertaken. However, treatment can be initiated at any age that symptoms become apparent.”

 that better long-term safety data of hormone therapies in breast cancer survivors and at-risk women is needed. In addition, “laser and radiofrequency procedures for the treatments of GSM also need better safety and outcome data before their role can be clarified,” she said, and added that “investigation of the vaginal microbiome and how it relates to vulvovaginal health and disease are just beginning, and clinical applications from this research are yet to be seen.”

Phillips NA, Bachmann GA. The genitourinary syndrome of menopause [published online ahead of print, 2021 Feb 1]. 

. 2021; doi:10.1097/GME.0000000000001728.

Genitourinary Syndrome of Menopause is often overlooked by providers.

Genitourinary Syndrome of Menopause is Overlooked and Undertreated 

Vaginal microbiota in prepubescent girls with vulvovaginitis consists of different and less diverse flora than prepubescent girls without vulvovaginitis, according to a study published in the 

European Journal of Clinical Microbiology & Infectious Diseases.

Wu Xiaoming, MD, of the Department of Pediatric Gynecology at Beijing Children’s Hospital at Capital Medical University’s National Center for Children’s Health in China, and colleagues conducted the study. They noted that vulvovaginitis causes significant anxiety in children and their parents and that it is the most common gynecological disease in prepubescent girls.

 Vulvovaginitis causes inflammation of the vulva and vagina.

The authors said that behavioral issues, in addition to anatomic and physiological factors for girls this age, can cause changes in vaginal microbiota. “Disorders involving vaginal flora usually cause infectious clinical syndromes with irritating symptoms, such as vaginal discharge, external genital organ erythema, soreness, itch, irritation, dysuria, and bleeding,” the authors noted.

Researchers collected samples from 10 girls with vulvovaginitis and 16 healthy girls aged 3 to 9 years. They examined 24 vaginal samples and 16 fecal samples collected between February 2020 and April 2020 at the National Center for Children’s Health in Beijing. Girls in the study did not have secondary sexual characteristics. Patients excluded from the study included those with a history of sexual abuse and those with other vaginal infections.

One trained pediatric gynecologist collected all the samples with a sterile swab and put the samples on dry ice and into a − 80 °C freezer within 30 minutes. No additives were used until the samples were analyzed.

Researchers collected samples from 10 girls with vulvovaginitis and 16 healthy girls aged 3 to 9 years.

Researchers categorized the samples into 3 groups: healthy fecal swabs (HF), healthy vaginal swabs (HV), and vulvovaginitis swabs (VVS). Researchers used the NovaSeq 6000 SP500 platform to determine vaginal microbiota by sequencing the V3-V4 region of the 

 gene.1 The authors also analyzed intestinal microbiota of healthy girls to compare results.

 were prevalent in healthy girls. Healthy girls also had more vaginal microbiota diversity. “The dominant taxa in the HF group were 

, which were not the main vaginal bacteria in children with vulvovaginitis,” the authors said.

Girls with vulvovaginitis had lower vaginal microbiota diversity, with 

Porphyromonas, Ezakiella, Peptoniphilus, Campylobacter, Anaerococcus, Dialister, Haemophilus, and Granulicatella 

prevalent. “Compared with the HVS group, some of the top 30 bacteria (

“Lactobacillus deficiency and high bacterial diversity were characteristics of the vaginal microbiome in healthy prepubertal girls; this is inconsistent with that in reproductive-age women,” the authors wrote, noting that the differences in microbiota were not fecal in origin.

 The study adds evidence that vulvovaginitis is caused by a disturbance in the vaginal microbiome. Because this microbiome has not been well defined in prepubescent girls, the purpose of this study was to document microbiota.

“Measures of alpha diversity indicated that the diversity of the vaginal microbiome in healthy prepubertal girls was high; vulvovaginitis-associated dysbiosis is generally characterized by loss of diversity and the presence of pathogens with high levels of abundance,” Xiaoming and colleagues concluded.

Xiaoming W, Jing L, Yuchen P, Huili L, Miao Z, Jing S. Characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis. 

 Published online January 16, 2021. doi:10.1007/s10096-021-04152-2

Different and less diverse microbiota

The large, multi-center retrospective study reports that TL-NSRH has benefits for early and locally advanced cervical cancer patients over OA-NSRH. While TL-NSRH has been thought to be a promising procedure for cervical cancer patients, clinical, surgical, oncological, and functional outcomes have not been previously examined in depth.

Marcello Ceccaroni, MD, PhD, of the department of obstetrics and gynecology and gynecologic oncology and minimally-invasive pelvic surgery at the International School of Surgical Anatomy, and director of gynecology and obstetrics at the IRCCS Sacro Cuore Don Calabria Hospital in Verona, Italy, conducted the research along with colleagues. They emphasized post-surgical pelvic function outcomes.

Radical hysterectomy is a difficult procedure, and often leads to postoperative complications for patients, the authors said. Laparoscopic surgery improves short-term outcomes by decreasing pain and post-operative complications. It also enhances recovery. However, authors noted concern that laparoscopic surgery has its flaws: “recent publications…particularly the 

 [LACC] trial have raised serious concerns regarding the oncological safety of endoscopic surgery in cervical cancer, describing a significant and alarming increase in the rate of recurrence.” From a technical standpoint, TL-NSRH is a challenging procedure, which increases risk.

For the study, 301 consecutive patients who had class C1-NSRH plus bilateral pelvic + para-aortic lymphadenectomy for stage IA2–IIB cervical cancer were enrolled at gynecologic oncologic centers in the Italian cities of Negrar, Varese, Bologna, and Avellino. Patients were divided into two groups: TL-NSRH (170) and OA-NSRH (131) and given preoperative questionnaires to gather data about rectal, urinary, and sexual function. The authors reported no differences in demographics or pathological characteristics between the 2 groups. They noted a trend for fewer adenocarcinomas and a higher cancer stage in the OA-NSRH group. “No difference was noted in terms of the proportion of patients who underwent neoadjuvant chemotherapy,” the authors said.

After surgery, patients completed another questionnaire to assess their quality of life, including sexual function and psychological status. In addition, the authors used the Kaplan-Meyer method to determine oncological outcomes.

Ceccaroni and colleagues reported that patients in the OA-NSRH group had a higher chance of experiencing urinary incontinence. They added that this group also experienced urinary retention after a 12-month follow-up. Five patients in this group (5.5%) had complete urinary retention after more than 24 months of follow-up. The study authors said no patients who had the laparoscopic procedure experienced complete urinary retention.

Anal incontinence was uncommon, and rates between the two groups were comparable, the authors said. Rates of constipation were also similar through a 2 -year follow-up but were more common in the OA-NSRH group.

Seventy-one patients (41.7%) who were sexually active prior to the procedure completed a sexual activity questionnaire in the TL-NSRH group and 65 (49.6%) completed it in the OA-NSRH group at the 12-month follow-up. Of these patients, 87.3% (62) in the TL-NSRH group and 87.7% (57) in the OA-NSRH group recovered the ability to be sexually active. “Forty-eight (77.4%) and 39 (68.4%) of the women who recovered sexual activity after surgery considered their sexual life as ‘satisfactory’ in 2 groups, respectively (p=0.30),” the authors noted.

The authors reported a median follow-up time of 30 months in the TL-NSRH group (6-88) and 39 months in the OA-NSRH group (8-85). Twenty patients in the TL-NSRH group (11.8%) had disease recurrence, while 11 patients (8.4%) had recurrence in the OA-NSRH group. “The first relapse of disease was in the pelvis in 14 patients (70%) and at distant sites in 6 (30%) patients in the TL-NSRH. In the OA-NSRH group the first location of recurrence was the pelvis in 7 (63.6%) cases and distant sites in 4 (36.4%) cases,” the authors said.

Fourteen patients in the laparoscopic group died (8.2%), while 9 patients in the open abdominal group died (6.9%). The authors reported that 3 deaths in the TL-NSRH group were unrelated to cervical cancer.

Ceccaroni and colleagues concluded that the risks of laparoscopic surgery due to technical difficulty were worthwhile. They noted the large amount of data that indicates a low rate of pelvic dysfunction, and said that, “preservation of the neural autonomic fibers has actually a positive effect on patients' post-operative well being and quality of life.” The authors reported that pelvic dysfunction is lower with laparoscopic surgery, and that “oncological outcomes and the survival rates of TL-NSRH well compare with the available series of non-nerve-sparing laparoscopic procedures.”

Ceccaroni M, Roviglione G, Malzoni M, et al. Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer

. 2021;32(1):e10. doi:10.3802/jgo.2021.32.e10. Accessed 4 January 2020.

Total laparoscopic nerve-sparing radical hysterectomy (TL-NSRH) has advantages over open abdominal nerve-sparing radical hysterectomy (OA-NSRH), according to research published in the Journal of Gynecologic Oncology.

Sandra Fyfe

Articles

More Research and Screening for STIs Needed to Improve Worldwide Maternal and Neonatal Health

Genitourinary Syndrome of Menopause is Overlooked and Undertreated

Different and less diverse microbiota

Total laparoscopic nerve-sparing radical hysterectomy versus open abdominal nerve-sparing radical hysterectomy