Paola Penacchioni

Prevalence of Bacterial Vaginosis and Vaginal Flora Changes in Peri- and Postmenopausal Women

ABSTRACT Our aim was to evaluate the prevalence of bacterial vaginosis and decrease in lactobacillus colonization in women 40 years old or older in relation to menopausal status by evaluation of Gram-stained smears. A total of 1,486 smears from Italian Caucasian women aged 40 to 79 years were examined. Women were classified as follows: fertile (regular cycles) (n = 328), perimenopausal (irregular cycles) (n = 237), and postmenopausal (n = 921), including 331 women on estroprogestinic hormone replacement therapy (HRT). The prevalences of bacterial vaginosis (assessed as a Nugent score of ≥7) in fertile (9.8%) and perimenopausal (11.0%) women were not statistically different, whereas the prevalence was significantly lower overall in postmenopausal women (6.0%) (P = 0.02). Specifically, 6.3% of postmenopausal women without HRT and 5.4% of postmenopausal women with HRT were positive for bacterial vaginosis. The Nugent score system was not adequate for evaluating the normal and intermediate vaginal flora in women over the age of 40 years. High numbers of peri- and postmenopausal women had no lactobacilli and no bacterial-vaginosis-associated microorganisms. This nonpathological absence of lactobacilli in women with a Nugent score of 4 was scored as 4∗, and this group was considered separately from the intermediate flora group. A score of 4∗ was obtained for 2.1% of fertile women, 11.4% of perimenopausal women, 44.1% of postmenopausal women without HRT, and 6.9% of postmenopausal women with HRT. The physiological reduction in lactobacillus colonization of the vagina in postmenopausal women does not cause an increase in bacterial-vaginosis prevalence. Reversion of lactobacillus flora to premenopausal levels due to HRT does not increase the prevalence of bacterial vaginosis in postmenopausal women.

Bleeding patterns in recent postmenopausal outpatients with uterine myomas: comparison between two regimens of HRT

OBJECTIVES To evaluate and to compare the bleeding patterns obtained with two regimens of hormone replacement therapy given to early postmenopausal women with asymptomatic uterine leiomyomas. METHODS In this randomised prospective 1-year study 50 early postmenopausal women with one to four asymptomatic uterine leiomyomas were enrolled into two study-groups to take two regimens of hormone replacement therapy for 12 28-day cycles: (A) Tibolone, 2.5 mg/day; (B) conjugated equine estrogens (CEE), 0.625 mg/day plus medroxyprogesterone acetate (MPA), 5 mg/day. The bleeding patterns and the changes in uterine volume of the 47 outpatients who completed the study were evaluated and compared. RESULTS Amenorrhea incidence was higher in group A (75.0% of the cycles) than in group B (65.6% of the cycles), while irregular bleeding and irregular spotting incidences were higher in group B (29.7 and 4.7% of the cycles, respectively) compared to group A (22.6 and 2.4% of the cycles, respectively). The mean bleeding and spotting lengths were not statistically different between patients in group A and those in group B. Finally, at the end of the study period transvaginal ultrasonography showed no significant change in leiomyoma size. CONCLUSIONS The results demonstrate that, in early postmenopausal patients with asymptomatic uterine leiomyomas, Tibolone treatment seems to be preferable compared to CEE-MPA continuous combined treatment in relation to the lesser occurrence of irregular bleeding. Furthermore, neither Tibolone nor CEE-MPA therapy, at the doses used here, promote fibroid growth.

Bone effects of transdermal hormone replacement therapy in postmenopausal women as evaluated by means of ultrasound : An open one-year prospective study

OBJECTIVES To evaluate the effectiveness of transdermal oestrogen replacement therapy plus medrogestone (HRT) in postmenopausal bone loss prevention by means of US. METHODS We enrolled 112 healthy postmenopausal women in an open, prospective study. These women, after a gynaecological evaluation and an US assessment of the skeletal status, were advised to take cyclic sequential oestrogen/progestagen therapy: 50 microg/day of transdermal 17beta-oestradiol (Rotta Research Laboratorium) plus 5 mg/day of medrogestone, for 12 days per cycle (Wyeth-Ayerst). After 1 year we recalled these women: only 32 of them were taking HRT, while 49 had declined HRT without taking alternative therapies. The remaining women were excluded from the study as they were either unavailable for the check-up or they were taking prohibited therapies. We used DBM Sonic 1200 (Igea, Italy) to assess US parameter changes at phalanxes at enrollment and after 1 year. This device enabled us to evaluate US transmission velocity (AD-SoS) and US attenuation pattern (UBPS). In a previous study we had evaluated the intra- and inter-observer reproducibility of AD-SoS measurements (0.4 and 1.0% respectively). Using the same data we evaluated the intra- and inter-observer precision of UBPS. RESULTS The UBPS intra-operator reproducibilities were 5.3% and 6.1% (for the 1st and the 2nd operator, respectively), while inter-observer precision was 8.8%. Both AD-SoS and UBPS significantly decreased in the non-user group(-0.7%, P < 0.001 and -14.3%, P < 0.001 respectively). In the user group AD-SoS showed a significant increase (+0.7%, P < 0.01), while a slight but significant decrease was observed for UBPS (-2.8%, P < 0.05). CONCLUSIONS Our findings show that the effectiveness of transdermal HRT in slowing or even arresting postmenopausal bone loss can be monitored by quantitative US studies. The trend difference observed between AD-SoS and UBPS with and without therapy is at least partially explained by a different response to HRT with regard to bone density as well as structure.

Premenopause-Dependent Changes

The authors retrospectively evaluated 1,773 climacteric outpatients in order to establish: (a) criteria able to distinguish different conditions in the transitional phase before menopause (advanced fertile age and premenopause) and (b) premenopause-related changes during the transition from one to the other of several clinical and laboratory parameters. Results showed an increase in gonadotropin plasma levels, a decrease in estrogen plasma levels and a greater frequency of women complaining of hot flushes in premenopause compared to advanced fertile age, as an expression of the progressive decline of ovarian function. Premenopause-related changes were a decrease in thyroid function and an increase in the body mass index, the beginning of bone loss, an increase in glucose, total cholesterol and triglyceride serum levels and a greater frequency of women complaining of hypertension and urinary stress incontinence. An increase in total proteins, uric acid and aminotransferase serum levels was also noted.

Correlation of Innate Immune Response with IgA against Gardnerella vaginalis Cytolysin in Women with Bacterial Vaginosis

SABINA CAUCI,a SECONDO GUASCHINO,b DOMENICO DE ALOYSIO,c SILVIA DRIUSSI,a,d DAVIDE DE SANTO,b PAOLA PENACCHIONI,c ALINE BELLONI,a PAOLO LANZAFAME,e AND FRANCO QUADRIFOGLIOa aDepartment of Biomedical Sciences and Technologies, School of Medicine, University of Udine, Udine, Italy bObstetric and Gynecologic Unit, Department of Reproductive and Development Sciences, IRCCS Burlo Garofolo Hospital, School of Medicine, University of Trieste, Trieste, Italy cDepartment of Obstetrics and Gynecology, Sant’Orsola Hospital, School of Medicine, University of Bologna, Bologna, Italy dAzienda Servizi Sanitari N. 4 Medio Friuli, Udine, Italy eMicrobiology Unit, Santa Maria della Misericordia Hospital, Udine, Italy

BLEEDING PATTERNS AND COMPLIANCE WITH CEE PLUS MPA CONTINUOUS SEQUENTIAL OR COMBINED REGIMENS IN POSTMENOPAUSAL WOMEN

Transvaginal sonography (TVS) should be performed in order to evaluate endometrial thickness. Endometrial biopsy, if possible under hysteroscopic control, is required whenever endometrial thickness is above 4 mm. Usually, in these cases, pathologic features are found (polyp, hyperplasia, adenocarcinoma). When endometrial thickness is below 4 mm, bleeding and/or spotting (BS) is usually due to altered vascular integrity in the atrophic endometrium.

Individualization of Hormone Replacement Therapy

Hormone replacement therapy (HRT) [1–3] may be viewed in several ways. As symptomatic relief for a large variety of complaints (perimenopausal cycle disorders, hot flushes and sweating, urogenital atrophy, lack of well-being, depressive mood, joint-muscle complaints, skin, mouth and eye epithelial atrophy), HRT should be started in perimenopause and continued whenever complaints persist after HRT is stopped. HRT may also be considered as primary prevention which may be a) extended to all women without contraindications and who are willing to take HRT or b) administered to selected women at high risk for estrogen deficiency-dependent diseases (risk indicators of CHD, osteopenia, bilateral oophorectomy, premature ovarian failure). HRT may be started at any moment after menopause, preferably in recent postmenopause, and continued long-term. HRT can be viewed as secondary prevention for women affected by osteoporosis, CHD, and possibly Alzheimer’s disease.In this case, HRT may be started at any moment after menopause, but usually in late postmenopause. There is no consensus as to which choice should be adopted because each one has its drawbacks: symptomatic therapy does not account for preventive issues; primary prevention requires long-term compliance and probably increases breast cancer risk; and secondary prevention may not be effective in improving survival and, more importantly, quality of life.