Vaginal infections are among the most frequent reproductive health complaints of women worldwide. Treatments or preventive measures that can improve vaginal health and reduce the frequency of minor infections may also lower the impact and risk of more serious and potentially life-threatening infections. Through our work in this area, we seek to improve our knowledge of the vaginal environment and its interaction with pathogens, to produce and re-interpret epidemiological evidence, and to identify avenues for improving women’s reproductive health.
Untangling the Relationships between Medical Abortion, Antibiotics, and Clostridial Infection
Although very rare, obstetric-gynecologic infections with two species of Clostridia bacteria (Clostridium sordellii and Clostridium perfringens) have resulted in a toxic shock-like syndrome with a high fatality rate. Cases of fatal pelvic clostridial infections have followed miscarriages, full-term deliveries, stillbirths, abortions, and cervical procedures. Between 2003 and 2009, 8 deaths occurred in the U.S. after medical abortion. Although no causal relationship has been established between the abortion medications and the development of clostridial infection, concerns over the deaths prompted changes in the way medical abortion is provided including in some places use of routine antibiotics. The occurrence of these infections continues to fuel misinformation spread by anti-abortion activists.
In partnership with the University of Washington, the Centers for Disease Control and Prevention (CDC), Vanderbilt University, and RM Alden Research Laboratory, Gynuity Health Projects conducted a body of work to help fill the information gap on C. sordellii and C. perfringens, medical abortion, and antibiotic use. Some of our key findings include:
- Presence of clostridia bacteria is rare and transient in the vagina and rectum
- Presence of the bacteria very rarely results in infection, and risk of infection is not increased due to medical abortion
- Of ten antibiotics tested on strains of clostridia, the most resistance was found to doxycycline
- In a pilot study, a single dose of misoprostol administered vaginally or buccally did not impair the immune system, suggesting that vaginal use does not increase susceptibility to reproductive tract infections
- The majority of women do not adhere to commonly prescribed preventive antibiotic regimens following medical abortion, and those who do report substantial levels of side effects.
Woman-controlled Estrogen Products
Natural fluctuations in hormones during the menstrual cycle result in a thickened vaginal epithelium in the follicular phase that thins during the progesterone-dominant luteal phase. The thinner epithelium is a less effective barrier and could possibly render the reproductive tract more vulnerable to pathogens. In a randomized controlled trial in the US, Gynuity Health Projects investigated the delivery of an estrogen gel to the vaginal mucosa as a means of thickening the vaginal epithelium to enhance natural protections against pathogens and maintenance of beneficial vaginal flora. In a world that still has no effective, widely available woman-controlled means of preventing STIs, including HIV, this innovative approach may contribute to efforts that enable women to protect their reproductive health.
Partnerships for Policy and Practice
Providing Evidence on Zika Infection and to U.S. Health Care Workers
In response to the emerging Zika public health crisis, Gynuity organized and sponsored the opening plenary session of the 2016 North American Forum on Family Planning, entitled Zika virus: Technical updates and current controversies in the care of reproductive age women. The session reviewed recommendations for prevention, testing and surveillance of Zika virus in the U.S. It also featured an overview of current evidence for fetal effects and pregnancy outcomes associated with Zika exposure in utero. All of the presentations underscored the importance of access to comprehensive health services, including contraception and abortion, in the midst of this public health emergency. Speakers included: Deborah Kaplan, DrPh, MPH, R-PA, Assistant Commissioner, Bureau of Maternal, Infant and Reproductive Health at the New York City Department of Health and Mental Hygiene; R. Phillips Heine, MD, Professor of Obstetrics & Gynecology and Pediatrics and Director of the Division of Maternal-Fetal Medicine at Duke University; and, Laura Gil Urbano, MD of Orientame Foundation in Colombia. The session was moderated by Monica Dragoman, MD, Medical Associate at Gynuity Health Projects.
Relationship of Hormonal Contraceptive use to HIV Transmission
Concern about a possible association between hormonal contraceptive (HC) use and increased risk of HIV infection has been mounting in recent years. A series of laboratory, clinical and epidemiological studies have contributed to a growing body of evidence that suggests such an association may exist. As of now, however, the association remains speculative, and a causal relationship between HC use and changes in HIV risk has not been established. Given the enormity of the AIDS epidemic, especially among women, and the popularity of HC use in many settings, any evidence that HC use may increase the risk of HIV transmission or contribute to disease progression could be expected to have significant impact on policy and program discussions as well as individual women’s decision making.
In response to this potential problem, Gynuity convened a meeting of top experts in the field in May 2005. The meeting’s purpose was to review existing evidence and reach consensus on implications for reproductive health and HIV programs and future research. The participants concluded that there is evidence suggestive of increased HIV susceptibility with hormonal contraceptive use among female sex workers. However, no basis exists for women in the general population to change their contraceptive behavior. Gynuity continues to be involved in global efforts to explore and advise on this topic to advance women-centered recommendations.
Communications for Impact
Translation of critical evidence for diverse audiences
Gynuity develops informational and educational materials in multiple languages for use by a range of audiences. In this topic area we have published articles reporting results of clinical research, and created Frequently Asked Questions and Issue Briefs that synthesize evidence for use by policymakers, program implementers, organizations and health facilities that serve providers, families and women.
- Infectious Disease Program Brief
- FAQ on Hormonal Contraception and HIV
- Issue Brief on Hormonal Contraception and HIV
- Outlook Newsletter on Hormonal Contraception and HIV
- Relationship of Hormonal Contraception to HIV
- What happens when we routinely give doxycycline to medical abortion patients?
- DMPA and HIV: do we need a trial?
- Vaginal and Rectal Clostridium sordellii and Clostridium perfringens Presence Among Women in the US
- 800μg misoprostol and mucosal and systemic immune activation or the cervicovaginal microbiome
- FAQs on Fatal Infection and Medical Abortion - Summary
- FAQs on Fatal Infection and Medical Abortion - Technical Version