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The Interplay Between Immune System and Microbiota in Gynecological Diseases: a Narrative Review

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The Interplay Between Immune System and Microbiota in Gynecological Diseases: a Narrative Review European Review for Medical and Pharmacological Sciences 2020; 24: 5676-5690 The interplay between immune system and microbiota in gynecological diseases: a narrative review P. V IL L A1,2, C. CIPOLLA1, S. D’IPPOLITO1, I.D. AMAR2, M. SHACHOR2, F. INGRAVALLE3, F. SCALDAFERRI4,5, P. PUCA5, N. DI SIMONE1,2, G. SCAMBIA1,2 1Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy 2Istituto di Ostetricia e Ginecologia, Università Cattolica del Sacro Cuore, Rome, Italy 3Scuola di Specializzazione in Igiene e Medicina Preventiva, Università di Tor Vergata, Rome, Italy 4Centro Malattie Apparato Digerente, Dipartimento Scienze Gastroenterologiche, Endocrino-Metaboliche e Nefro-Urologiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy 5Istituto di Patologia Speciale Medica, Università Cattolica del Sacro Cuore, Rome, Italy Abstract. – OBJECTIVE: The vaginal micro- tion. A decreased concentration of Lactobacil- biome is a dynamic environment, depending on li seems to be playing a role in preterm labor as the results of a complex interplay between mi- well as the increased levels of pro-inflammato- crobiota and the host. In physiological condi- ry cytokines. Finally, the disequilibrium in the tions, Lactobacillus species are the most rep- Th1/Th2 immune adaptive response, with a shift resented, regulating glycogen metabolism in from Th2 to Th1, appears to be playing a role in order to maintain normal pH. Vaginal flora has miscarriage. been divided into five subtypes. Pattern rec- CONCLUSIONS: The interplay between micro- ognition receptors are present on both squa- biota and the host closely involves the immune mous epithelial cells lining the vagina and co- system. In particular, the vaginal microbiota is lumnar cells lining the upper female genital classically characterized by Lactobacilli even if tract. They respond directly to bacterial prod- vaginal microbiome of asymptomatic woman of uct expressed by vaginal microbiome. The va- reproductive age includes multiple aerobic and gina contains different immune related cells facultative or obligate anaerobic species. The and receptors which can recognize and react role of microbiota and immune system in deter- with the microbial environment. Altered micro- mining gynecological and obstetric events has biota and altered interplay between microbiota been studied throughout recent years reaching and immune system underlie several gyneco- new advancements. Therefore, additional stud- logic diseases. ies are needed to better comprehend the com- MATERIALS AND METHODS: In this re- plexity of the issue. view, literature data related to vaginal microbi- ota, vaginal inflammation, immune system and Key Words: menopause, preterm labor and miscarriage, Vaginal microbiota, Immune system, Lactobacil- were summarized. Relevant publications were li, Menopause, Inflammation; miscarriage, Preterm la- retrieved from: PubMed, Medline, Scopus and bor. Web of Science. RESULTS: The vaginal microbiome and the re- lationship with immune system has been ana- lyzed in different gynecologic conditions. Meno- Introduction pause is associated to estrogen loss which causes vaginal atrophy, reduced abundance of The vaginal microbiome is a dynamic environ- Lactobacilli and increased amount of other bac- ment, depending on the results of a complex in- terial species. Estrogens influence vaginal im- terplay between microbiota (the core of microbial munity through known and unknown mecha- nisms. In bacterial vaginosis (BV), due to many communities) and the host. Several modifying bacterial species, there has been found an in- factors are thought to impact the microbiome hibition of the chemotaxis and cytokine secre- throughout life. The first contact with microbiota 5676 Corresponding Author: Paola Villa, MD; e-mail: [email protected] The interplay between immune system and microbiota in gynecological diseases may begin during late gestation, with the largest • Bacterial density, which refers to the degree of exposure at the time of delivery. Over time, the bacterial distribution. It reflects the total bio- abundance and diversity of the infant microbiome mass of the vaginal flora6. increase with life, stabilize around the time that • Flora diversity, which represents the total num- the infant begins to eat solid foods, and persist ber of bacterial species in the vaginal flora. throughout adulthood. Several modifying factors This reflects the vaginal flora variety7. are thought to have an influential role in shaping • Vaginal H2O2 is mainly produced by Lactoba- the identity and abundance of the infant microbio- cilli, such as L. Crispatus, L. Gasseri, L. Jen- ta throughout life. senii and L. Acidophilus. Thus, as these Lac- Lactobacillus species are the most represented1 tobacilli are often the predominant bacteria in non-pregnant woman reaching the concentra- in healthy women, H2O2 levels may reflect the tion of 107 to 108 CFU/g of vaginal fluid, together function of Lactobacilli8. with Lactobacillus Crispatus, Lactobacillus • Enzymatic activity, such us leukocyte esterase Iners, Lactobacillus Jensenii, and Lactobacillus activity indicates the presence of inflammation Gasseri2. in the vagina. Sialidase is a specific marker of Lactobacilli regulate the glycogen metaboli- BV, whereas β-glucuronidase and coagulase sm, converting glycogen from vaginal epithelial activity may represent bacterial vaginitis9,10. cells into glucose and lactic acid to maintain the typical acidic vaginal pH (pH ≤ 4.5, range Patients with the following features are consi- 3.8-4.4). Hence, creating an unfavorable envi- dered to have a normal micro-ecological status: ronment for the growth of pathogens or other “un-healthy” bacteria3. Lactobacilli may also • pH values ranging from 3.8 to 4.5; prevent the adherence of pathogenic microorga- • Bacterial density degree II to III; nisms to vaginal epithelial cells through ‘com- • Flora diversity degree II to III; petitive exclusion’ and ‘bacterial interference’3. • Gram-positive rods as predominant flora; In addition, Lactobacilli produce various me- • Nugent and AV score ≤3; tabolites, such as bacteriocins and H2O2, which • Absence of pathogens and negative specific en- may help to stimulate the immune response du- zymes. ring vaginal infections. Lactobacilli reduce lo- cal production of interleukin (IL)-1β, IL-6, and Gajer et al4 and Srinivasan et al11 showed that IL-8 and increase anti-inflammatory cytokines, the diversity, the composition, and the relative such as IL-2 and IL-173. In addition to Lacto- abundance of vaginal microbial species chan- bacilli, the vaginal core microbiota account also ge dramatically, during different periods of life. for other multiple aerobic or facultative aerobic Ravel et al14 have demonstrated that reproducti- species as well as obligate anaerobic species. ve-aged women can be grouped into five diffe- In healthy women, the transition from puber- rent categories referred to as Community State ty to menopause as well as transient hormonal Types (CSTs). Four of these CSTs are dominated changes, such as pregnancy and menstruation are by Lactobacilli, namely, L. Crispatus (CST-I), L. characterized by major changes in vaginal mi- Iners (CST-III), L. Gasseri (CST-II) or L. Jen- crobiome. Furthermore, external factors, such as senii (CST-V). One category, CST-IV, does not antibiotic usage, sexually transmitted infections, contain a significant number of Lactobacillus, but and vaginal irrigation can affect vaginal flora is composed of a polymicrobial mixture of stri- composition as well4. In particular, estrogens play ct and facultative anaerobes including species of a central role. The estrogen environment helps in the genera Gardnerella, Atopobium, Mobiluncus, the maintenance of the right balance among diffe- Prevotella and other species in the order of Clo- rent vaginal bacterial communities. Indeed, it has stridiales12-15. been showed that the hormone replacement the- CST IV was recently divided into two subtypes, rapy (HRT) in menopause relieves the symptoms termed CST IV-A and CST IV-B; by Gajer et al4 of vulvovaginal atrophy and supports the enrich- CST IV-A is characterized by various species of ment of vaginal microbiota5. anaerobic bacteria belonging to the genera Anae- Vaginal infections are the most common cause rococcus, Peptoniphilus, Prevotella, and Strepto- of abnormal functional status. Thus, while eva- coccus. However, CST IV-B has higher propor- luating these infections, several characteristics tions of the genera Atopobium and Megasphaera, should be considered: among others (Figure 1). Species-specific diffe- 5677 P. Villa, C. Cipolla, S. D’Ippolito, I.D. Amar, M. Shachor, et al. Figure 1. Microbiome composition is not equally expressed over the female reproductive tract. Components of the female reproductive system and their respective microbiome population; the uterus appears to be mostly occupied by Lactobacillus spp, the uterine cervix is predominated by non-Lactobacillus spp, and the vagina is normally predominated by Lactobacillus spp of the Community State Types (CST) I,II, III and V. CST-IV is mainly composed by a polymicrobial mixture of anaerobes. Therefore, a vaginal predominance of CST-IV can manifest clinically as bacterial vaginosis. It was demonstrated that the innate immune response is largely driven by vaginal bacterial community states, with CST-IV potentially having a greater pro-inflammatory response than CST-I
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