Changing Vaginal Microbiome Triggers and Relieves Atrophy

Kate Johnson

October 11, 2013

DALLAS — Postmenopausal vulvovaginal atrophy is associated with age-related changes in the vaginal microbiome, with a shift from Lactobacillus-dominated strains in premenopause to a predominance of anaerobic organisms, new research shows.

"We have not yet identified specific interventions, but we are interested in pursuing personalized selections of probiotics and prebiotics for a given woman," said lead investigator Rebecca Brotman, PhD, from the Institute for Genome Sciences at the University of Maryland in Baltimore.

"We have been advocating probiotics or prebiotics to improve vaginal health for almost 30 years," said Gregor Reid, PhD, from the Canadian Research and Development Centre for Probiotics, the Lawson Health Research Institute, and the Schulich School of Medicine at the University of Western Ontario in London, Ontario, Canada.

"I 100% support the conclusions of this work. It is nice to see confirmation of work we published in 2011, with an aberrant microbiota associated with some cases of vulvovaginal atrophy," Dr. Reid told Medscape Medical News (PLoS One, 2011;6:e26602).

We are interested in pursuing personalized selections of probiotics and prebiotics for a given woman. Dr. Rebecca Brotman

Dr. Brotman presented the study results here at the North American Menopause Society (NAMS) 2013 Annual Meeting. They were published online September 30 in Menopause.

The study involved 90 women randomly selected from a larger prospective study assessing human papillomavirus in perimenopause (J Low Genit Tract Dis, 2013;17:38-47).

The substudy cohort was evenly split between pre-, peri-, and postmenopaual women.

Vaginal samples from the baseline visit were examined in a cross-sectional analysis. In addition, an interview-based questionnaire and pelvic examination at baseline assessed vaginal symptoms and atrophy, including signs of vaginal pallor, dryness, rugosity, blanching of tissue, friability, and petechiae.

The 87 women for whom there were complete data were grouped into 6 previously described bacterial community state types (CSTs) on the basis of their dominant microbiota. There were 4 Lactobacillus-dominated types: Lactobacillus crispatus (CST I), Lactobacillus gasseri (CST II), Lactobacillus iners (CST III), and Lactobacillus jensenii (CST V). A fifth CST was characterized by lower proportions of Lactobacillus and higher proportions of anaerobic organisms.

This last CST was divided into 2 groups. CST IV-A was characterized by the presence of Anaerococcus, Peptoniphilus, Prevotella, and Streptococcus; and CST IV-B was characterized by higher proportions Atopobium and Megasphaera.

The study found that "there was significant association between menopause stage and community state type and atrophy and community state type," Dr. Brotman reported.

Although Lactobacillus dominated the vaginal microbiota in each stage of the menopausal transition, levels of the organism were significantly lower in postmenopausal women than in pre- or perimenopausal women (54% vs 83%), she said.

Among postmenopausal women, 29% were classified as CST IV-A, 25% were classified as CST I (L crispatus–dominated), and 18% were classified as CST III (L iners–dominated). In contrast, 46% of premenopausal women were dominated by L crispatus (CST I), and 38% of perimenopausal women were dominated by L iners (CST III).

Compared with women with no atrophy, the odds of the vaginal microbiome of women with mild to moderate atrophy being classified as CST IV-A was 25 times greater than the odds of being classified as CST I, she explained. The greater abundance of Anaerococcus, Peptoniphilus, and Prevotella "could be playing a putative role in the clinical presentation of vulvovaginal atrophy."

Additionally, the transition to CST IV-A may begin with perimenopausal women who are often dominated by L iners, she said. "L iners is not your typical lactobacilli. There are some strains that are not as protective and are less efficient at maintaining a stable microenvironment."

Although the loss of Lactobacillus is associated with atrophy, "if we were able to reseed with Lactobacillus, I don't know what the independent effect would be," she said. "I'm not a clinician, but my suspicion is that it might be helpful for mild to moderate cases but not for more severe cases. One of the things that we've been advocating is what we call the rational selection of probiotics — a personalized approach to maintain the microbiome that is both species- and temporal-specific — because we know that the vaginal microbiome is not stable over time. It's very dynamic."

Previous work by Dr. Reid has shown a transition away from a lactobacilli-dominated microbiota in postmenopausal women, with "an inverse correlation between Lactobacillus ratio and dryness."

It seems incomprehensible to me that the management of extremely common problems in women's health has changed little in 30 years... Dr. Gregor Reid

"It seems incomprehensible to me that the management of extremely common problems in women's health has changed little in 30 years, and the adverse quality of life of so many women seems unimportant to a portion of the medical research, regulatory, and pharmaceutical communities," he told Medscape Medical News. "It seems to need a revolution to change things, starting from funding this type of research to making new interventions available."

This study was funded by grants from the National Institutes of Health. Dr. Brotman has disclosed no relevant financial relationships. Dr. Reid reports that he formed, but has since sold, a company that developed a Lactobacillus-based supplement proven to prevent urinary tract infections and bacterial vaginosis that is approved for oral use in North America and elsewhere and for vaginal use in Croatia; and he receives grants for educational activities from Wyeth-Ayerst Canada.

North American Menopause Society (NAMS) 2013 Annual Meeting: Abstract S2. Presented October 10, 2013.


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