The Vaginal Microbiome: II. Vaginal Dysbiotic Conditions.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "dysbiosis," "bacterial vaginosis," "cytolytic vaginosis," "desquamative inflammatory vaginitis," and "aerobic vaginitis." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The second article in this series focuses on vaginal dysbiotic conditions. Dysbiosis is a term describing imbalances in bacterial communities. Given that lactobacillus-dominated microbiota are thought to be the most optimal, vaginal dysbiosis is usually considered as lactobacilli-depleted VMB. Bacterial vaginosis (BV), the most common vaginal dysbiotic condition, is a polymicrobial disorder, considered the leading cause for vaginal discharge in women worldwide. In addition, we review the VMB in other vaginal conditions associated with lactobacilli depletion: desquamative inflammatory vaginitis and aerobic vaginitis. We also discuss the controversial diagnosis of cytolytic vaginosis, related with lactobacilli overgrowth. CONCLUSIONS: Bacterial vaginosis displays complex microbiology. The heterogeneity and diversity within the genus Gardnerella may impact the progression of BV. Bacterial biofilms may contribute to the etiology and persistence of BV, and various bacteria may affect its clinical presentation and pathogenicity. Lack of lactobacilli is not always accompanied by an overgrowth of anaerobes.

The Vaginal Microbiome: I. Research Development, Lexicon, Defining "Normal" and the Dynamics Throughout Women's Lives.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome, written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the current findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A database search of PubMed was performed, using the search terms "vaginal microbiome" (VMB) with "research," "normal," "neonate," "puberty," "adolescent," "menopause," and "ethnicities," as well as "human microbiome project." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: In the last 2 decades, many studies applying molecular techniques were performed, intending to characterize the vaginal microbiota. These studies advanced our understanding of how vaginal health is defined. The first article in this series focuses on the advancement of VMB research, technical definitions, the definition of "normal" VMB, and the dynamics of VMB throughout women's lives. CONCLUSIONS: Understanding how microorganisms inhabiting the vagina interact with each other and with the host is important for a more complete understanding of vaginal health. The clinical application of microbial community sequencing is in its beginning, and its interpretation regarding practical clinical aspects is yet to be determined.

The Vaginal Microbiome: IV. The Role of Vaginal Microbiome in Reproduction and in Gynecologic Cancers.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "reproduction," "infertility," "fertility," "miscarriages," "pregnancy" "cervical cancer," "endometrial cancer," and "ovarian cancer." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The fourth article of this series focuses on 2 distinct areas: the role of VMB in various aspects of human reproduction and, in sharp contrast, the association between the VMB and gynecologic malignancies. Several of the negative pregnancy outcomes have been associated with an altered VMB. Dysbiosis is remarkably linked with poor pregnancy outcomes from preconception to delivery. The associations between the microbiome and gynecologic cancers are described. CONCLUSIONS: The development of the microbiome research, enabled by molecular-based techniques, has dramatically increased the detection of microorganisms and the understanding of bacterial communities that are relevant to maternal-fetal medicine in health and disease, as well as in gynecological malignancies. Proving causation in cancer is difficult because of the complex interactive nature of potential causative factors. Certain elements of the microbiota have been shown to provoke inflammatory reactions, whereas others produce anti-inflammatory reactions; this balance might be impaired with a change in microbial variety.

The Vaginal Microbiome: V. Therapeutic Modalities of Vaginal Microbiome Engineering and Research Challenges.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "treatment," "diagnosis," and "research." Full article texts were reviewed. Reference lists were screened for additional articles. RESULTS: The currently available approaches for treating vaginitis or attempting to modulate the VMB are often insufficient. It has traditionally relied on the use of antibiotics, antiseptics, and antifungals. The fifth and last article of this series discusses the new and/or alternative therapeutic modalities. It addresses the role of probiotics, prebiotics and symbiotics, activated charcoal, biofilm disrupting agents, acidifying agents, phage therapy, and the concept of vaginal microbiome transplant. The challenges facing the research of VMB, including the clinical impact of microbiome manipulation, classification, and new diagnostic approaches are discussed. CONCLUSIONS: Microbiome research has grown dramatically in recent years, motivated by innovations in technology and decrease in analysis costs. This research has yielded huge insight into the nature of microbial communities, their interactions, and effects with their hosts and other microbes. Further understanding of the bacterial, fungal, phage, and viral microbiomes in combination with host genetics, immunologic status, and environmental factors is needed to better understand and provide personalized medical diagnostics and interventions to improve women's health.

The Vaginal Microbiome: III. The Vaginal Microbiome in Various Urogenital Disorders.

OBJECTIVE: This series of articles, titled The Vaginal Microbiome (VMB), written on behalf of the International Society for the Study of Vulvovaginal Disease, aims to summarize the recent findings and understanding of the vaginal bacterial microbiota, mainly regarding areas relevant to clinicians specializing in vulvovaginal disorders. MATERIALS AND METHODS: A search of PubMed database was performed, using the search terms "vaginal microbiome" with "Candida," "vaginitis," "urinary microbiome," "recurrent urinary tract infections," "sexually transmitted infections," "human immunodeficiency virus," "human papillomavirus," "nonspecific vaginitis," "vulvodynia," and "vulvovaginal symptoms." Full article texts were reviewed. Reference lists were screened for additional articles. The third article in this series describes VMB in various urogenital disorders. RESULTS: Variable patterns of the VMB are found in patients with vulvovaginal candidiasis, challenging the idea of a protective role of lactobacilli. Highly similar strains of health-associated commensal bacteria are shared in both the bladder and vagina of the same individual and may provide protection against urinary tract infections. Dysbiotic VMB increases the risk of urinary tract infection. Loss of vaginal lactic acid-producing bacteria combined with elevated pH, increase the risk for sexually transmitted infections, although the exact protective mechanisms of the VMB against sexually transmitted infections are still unknown. CONCLUSIONS: The VMB may constitute a biological barrier to pathogenic microorganisms. When the predominance of lactobacilli community is disrupted, there is an increased risk for the acquisition of various vaginal pathogents. Longitudinal studies are needed to describe the association between the host, bacterial, and fungal components of the VMB.

Diagnosing Sexual Dysfunction in Men and Women: Sexual History Taking and the Role of Symptom Scales and Questionnaires.

INTRODUCTION: A detailed sexual history is the cornerstone for all sexual problem assessments and sexual dysfunction diagnoses. Diagnostic evaluation is based on an in-depth sexual history, including sexual and gender identity and orientation, sexual activity and function, current level of sexual function, overall health and comorbidities, partner relationship and interpersonal factors, and the role of cultural and personal expectations and attitudes. AIM: To propose key steps in the diagnostic evaluation of sexual dysfunctions, with special focus on the use of symptom scales and questionnaires. METHODS: Critical assessment of the current literature by the International Consultation on Sexual Medicine committee. MAIN OUTCOME MEASURES: A revised algorithm for the management of sexual dysfunctions, level of evidence, and recommendation for scales and questionnaires. RESULTS: The International Consultation on Sexual Medicine proposes an updated algorithm for diagnostic evaluation of sexual dysfunction in men and women, with specific recommendations for sexual history taking and diagnostic evaluation. Standardized scales, checklists, and validated questionnaires are additional adjuncts that should be used routinely in sexual problem evaluation. Scales developed for specific patient groups are included. Results of this evaluation are presented with recommendations for clinical and research uses. CONCLUSION: Defined principles, an algorithm and a range of scales may provide coherent and evidence based management for sexual dysfunctions.

Self-reported pelvic organ prolapse surgery, prevalence, and nonobstetric risk factors: findings from the Nord Trøndelag Health Study.

INTRODUCTION: The aim of this study was to assess prevalence and risk factors of self-reported pelvic organ prolapse (POP) surgery in a Nordic county. METHODS: We assessed cross-sectional data collection from participants in the Nord-Trøndelag Health Study in 2006-2008. All women in the county ≥30 years were eligible, of whom 20,285 (50.3 %) responded by completing questionnaires and attending screening stations. Outcome measures were self-reported POP surgery, age at survey, sociodemographic factors, and information on selected risk factors for POP: self-reported smoking, chronic obstructive pulmonary disease (COPD), asthma, constipation a decade prior, and measured body mass index (BMI). Descriptive statistics, Kaplan-Meier estimates, and multivariate logistic regression were used. Statistical significance was defined as p ≤ 0.01. RESULTS: POP surgery was reported by 1,123 (5.3 %) of all women: 0.7 % < age 40, 3.1 % between age 40 and 59, and 10.8 % age >60. Cumulative incidence by age 85 was 14.6 %; mean age at surgery was 51.6 [standard deviation 14.7]. After adjustment for sociodemographic and lifestyle factors, odds ratios (OR) with 99 % confidence intervals (CI) for reporting the need for POP surgery were marked constipation 1.83 (1.30-2.56), BMI categories above normal 1.58-1.64 (1.10-2.25), COPD 1.51 (1.06-2.16), occupation involving lifting compared with sitting 1.40 (0.98-2.01), and asthma 1.25 (0.98-1.59). Cigarette smoking was not significantly associated. CONCLUSION: Prevalence of self-reported POP surgery was high and increased with age. Constipation reported a decade prior, above-normal BMI, and COPD were significant nonobstetric risk factors.

Sexual function in the late postmenopause: a decade of follow-up in a population-based cohort of Australian women.

INTRODUCTION: There is a paucity of longitudinal studies assessing sexual function of women in the late postmenopause. AIM: This study aims to describe sexual function of women in the late postmenopause and to investigate change from early postmenopause. METHODS: Cross-sectional analysis of 2012/13 and longitudinal analysis from 2002/04 of the population based, Australian cohort of the Women's Healthy Ageing Project, applying validated instruments: Short Personal Experience Questionnaire (SPEQ), Female Sexual Distress Scale (FSDS), Hospital Anxiety and Depression Scale, Geriatric Depression Scale, and California Verbal Learning Test. MAIN OUTCOME MEASURES: Sexual activity, SPEQ, and FSDS. RESULTS: Two hundred thirty women responded (follow-up rate 53%), mean age was 70 years (range 64-77), 49.8% were sexually active. FSDS scores showed more distress for sexually active women (8.3 vs. 3.2, P<0.001). For 23 (23%) sexually active and for five (7%) inactive women, the diagnosis of female sexual dysfunction could be made. After adjustment, available partner (odds ratio [OR] 4.31, P<0.001), no history of depression (OR 0.49, P=0.036), moderate compared with no alcohol consumption (OR 2.43, P=0.019), and better cognitive function score (OR1.09, P=0.050) were significantly predictive for sexual activity. Compared with early postmenopause, 18% more women had ceased sexual activity. For women maintaining their sexual activity through to late postmenopause (n=82), SPEQ and FSDS scores had not changed significantly, but frequency of sexual activity had decreased (P=0.003) and partner difficulties had increased (P=0.043). [Correction added on 10 July 2014, after first online publication: Mean age of respondents was added.] CONCLUSIONS: In late postmenopause, half of the women were sexually active. Most important predictors were partner availability and no history of depression. However, being sexually active or having a partner were associated with higher levels of sexual distress. Compared with early postmenopause, sexual function scores had declined overall but were stable for women maintaining sexual activity. Further research into causes of sexual distress and reasons for sexual inactivity at this reproductive stage is warranted.

What predicts improvement of sexual function after pelvic floor surgery? A follow-up study.

OBJECTIVE: To analyze factors predictive for changes in sexual function after pelvic floor surgery and explore differences between stress urinary incontinence (SUI) and pelvic organ prolapse (POP) surgery. DESIGN: Prospective observational study. SETTING: St Olav Hospital, Trondheim University Hospital, Norway. SAMPLE: Of 346 mailed questionnaires for women scheduled for SUI and POP surgery, 65 questionnaires were available for analysis together with examination findings before and 1 year after surgery. METHODS: Postal questionnaires including Prolapse and Incontinence Sexual Function Questionnaire (PISQ 12), Hopkins Symptom Checklist 5 for psychological distress, questions from the validated Body Image Questionnaire, a general health question, questions addressing goals for improvement after surgery, clinical findings based on the Pelvic Organ Prolapse Quantification System and Brief Sexual Function Index for partners. Uni- and multivariate linear regressions adjusting for age were performed. MAIN OUTCOME MEASURES: Change in PISQ 12 score at follow-up. RESULTS: Sexual function significantly improved in the total group (p = 0.000). After stratification into SUI and POP surgery, improvement only remained significant after SUI surgery (p = 0.001). Improvement for the total group was predicted by good health or coital incontinence, whereas psychological distress or the goal of improved defecation predicted deterioration. For women undergoing SUI surgery, increasing age, parity or the goal of improving sexuality or body image predicted improvement, while for women undergoing POP surgery, menopausal status or anterior colporrhaphy predicted improvement. CONCLUSION: Significantly improved sexuality was observed after pelvic floor surgery. Predictive factors for change differed for women undergoing SUI surgery and and those undergoing POP surgery.

Vacuum births and barriers to its use: An observational study in governmental hospitals in Sierra Leone.

OBJECTIVES: Assisted vaginal births (AVD) can prevent unnecessary caesarean sections (CS). The number of CS is increasing rapidly in sub-Saharan Africa; these are still associated with high perioperative mortality rates. The aim of this study is to define the proportion of AVD in governmental hospitals in Sierra Leone and examine barriers to its use. DESIGN: Retrospective observational study of AVD between September 2016 and August 2017. SETTING: A representative selection of Sierra Leonean governmental hospitals (n=11). PARTICIPANT AND INTERVENTION: (a) Data were collected from labour ward records. (b) Health workers involved in labour management were questioned. PRIMARY AND SECONDARY OUTCOME MEASURES: (a) Number of spontaneous, assisted vaginal and caesarean births. (b) Potential barriers to use vacuum-assisted births. RESULTS: (a) Total annual numbers of registered births, AVD and CS were 16 833, 631 (3.7%) and 4642 (27.6%). The proportion of vacuum births ranged from 0.0% to 5.1% across facilities. The proportion of CS ranged from 6.5% to 33.4%. (b) The most frequently reported reasons for limited vacuum use were lack of equipment (25/72; 35%) and insufficient training (18/72; 25%). CONCLUSIONS: The proportion of AVD was particularly low in district facilities, and according to healthcare workers this was mostly due to lack of equipment and insufficient training. Implementing relevant training programmes on the use of vacuum devices and increasing the availability of working devices may increase the proportion of vacuum births in government hospitals in Sierra Leone. This could reduce the number of unnecessary CS.

ISIDOG Consensus Guidelines on COVID-19 Vaccination for Women before, during and after Pregnancy.

INTRODUCTION: Sars-CoV-2 infection poses particular problems in pregnancy, as the infection more frequently causes severe complications than in unaffected pregnant women or nonpregnant women with SARS-CoV-2 infection. Now that vaccination is available and rapidly being implemented worldwide, the question arises whether pregnant women should be vaccinated, and if so, whether they should receive priority. METHODS: Available scientific data and available guidelines about vaccination against SARS-CoV-2 were collected by the Guideline Committee of the International Society of Infectious Diseases in Obstetrics and Gynecology (ISIDOG) and were analyzed, discussed and summarized as guidelines for healthcare workers caring for pregnant women. Concluding statements were graded according to the Oxford evidence-based medicine grading system. RESULTS: There is evidence to consider pregnancy as a risk factor for serious complications of COVID-19 infection, even in the absence of additional risk factors, such as hypertension, diabetes and obesity which increase these risks even more in pregnancy. Currently available data slightly favor mRNA-based vaccines above vector-based vaccines during pregnancy and breastfeeding, until more safety data become available. CONCLUSION: ISIDOG advises policy makers and societies to prioritize pregnant women to receive vaccination against SARS-CoV-2 and favor the mRNA vaccines until further safety information becomes available.

ISIDOG Recommendations Concerning COVID-19 and Pregnancy.

Providing guidelines to health care workers during a period of rapidly evolving viral pandemic infections is not an easy task, but it is extremely necessary in order to coordinate appropriate action so that all patients will get the best possible care given the circumstances they are in. With these International Society of Infectious Disease in Obstetrics and Gynecology (ISIDOG) guidelines we aim to provide detailed information on how to diagnose and manage pregnant women living in a pandemic of COVID-19. Pregnant women need to be considered as a high-risk population for COVID-19 infection, and if suspected or proven to be infected with the virus, they require special care in order to improve their survival rate and the well-being of their babies. Both protection of healthcare workers in such specific care situations and maximal protection of mother and child are envisioned.

Effects of Hysterectomy on Sexual Function.

Hysterectomy remains the most common major gynecological surgery. Postoperative sexual function is a concern for many women and their partners. In this respect, a beneficial effect of hysterectomy for benign disease independent of surgical techniques or removal of the cervix has been demonstrated in the past decade by the majority of studies. For about 20 % of women, deteriorated sexual function has been reported and current research is attempting to identify mechanisms and predictive factors explaining these postoperative changes. Alternative treatments of benign uterine disorders or uterus preserving surgery for genital prolapse appeared to have similar outcomes in terms of sexual function. Concomitant oophorectomy had negative effects on sexual function and long-term health, particularly in premenopausal women. This may not be reversed by estrogen replacement. Hysterectomy performed for malignancy had a detrimental effect on sexual function. Individualized risk assessment and information should be aimed at during preoperative decision making.

Male sexual function and pelvic floor surgery of their female partner: A one-year follow-up study.

OBJECTIVE: The aim of this study was to examine if sexual function of male partners changed after surgery for pelvic floor disorders and to explore associated factors. STUDY DESIGN: This was an observational follow-up study at the Gynecological Department at the St Olavs University Hospital, Trondheim. The sample consisted of 35 male partners of women scheduled for pelvic organ prolapse or stress urinary incontinence surgery. Self-administered questionnaires, containing validated instruments as well as exploratory questions, were sent to women and their partners before and one year after pelvic floor surgery. Vaginal dimensions were measured in all women according to the Pelvic Organ Prolapse Quantification System, both before and after the surgery. MAIN OUTCOME MEASURES: The Brief Sexual Function Instrument and the presence of erectile dysfunction. RESULTS: One year after pelvic floor surgery, scores for sexual drive, erection and overall satisfaction from the Brief Sexual Function Instrument were unchanged; the ejaculation score (range 0-4) had mildly improved from a range of 4 (median 4) to a range of 3.5 (median 4), (p = 0.014). The proportion of men with erectile dysfunction was unchanged, while the proportion of men reporting vaginal wind had significantly decreased (p = 0.016). None of the baseline factors, subjective experiences or vaginal dimensions at baseline or follow-up were associated with the improved ejaculation score; only a reduction in the proportion of men reporting their partners with dyspareunia (ns) was significantly correlated (Spearman's rho 0.42, p = 0.019). CONCLUSION: Sexual function of male partners was unchanged or mildly improved after pelvic floor surgery.

Sexual experience of partners after hysterectomy, comparing subtotal with total abdominal hysterectomy.

BACKGROUND: There is a lack of knowledge about partners' sexual experience after hysterectomy. The aim of this study was to explore potential differences in the experience of sexual intercourse by the partner, related to the operation method (subtotal versus total abdominal hysterectomy). METHOD: Of all patients having undergone abdominal hysterectomy for benign indications at St Olav Hospital, Trondheim between February 2001 and March 2003, Norway, 120 patients (60 total, 60 subtotal abdominal hysterectomy) were identified. Each patient and partner received a postal questionnaire addressing sexuality in connection with the operation. RESULTS: Of the 240 questionnaires, 111 were returned, a response rate of 46%. Among partners of women having undergone total hysterectomy, proportionally more noticed during sexual intercourse that the uterus had been removed (12%) compared to partners of women having undergone subtotal hysterectomy (4%); this was not significant and all of these partners experienced this as positive. Sexual satisfaction was improved or unchanged in most women and their partners, regardless of operation type. Partners who reported poor satisfaction before the operation were significantly more likely to report poor satisfaction after the operation. A high proportion of partners in both hysterectomy groups had not discussed sexuality in relation to the surgery either before or after the operation (subtotal: 44%; total: 24%; not significant). CONCLUSION: The majority of women and their partners reported no negative impact on sexual satisfaction after abdominal hysterectomy, regardless if subtotal or total. The only predictor of negative sexual experience of partners after hysterectomy was negative sexual experience before hysterectomy.