Impact of the menstrual cycle and ethinyl estradiol/etonogestrel contraceptive vaginal ring on granulysin and other mucosal immune mediators

Abstract

Problem: Changes in sex hormones during the menstrual cycle and contraceptive vaginal ring (CVR) use influence immunity within the female genital tract, but the magnitude of these effects and their anatomical location are unclear. Method of Study:In a prospective study, 29 women were assessed at three-time points: follicular phase, luteal phase, and one month after initiation of the ethinyl estradiol/etonogestrel CVR (NuvaRing®, Merck). We performed microarrays on endocervical cytobrushes and measured immune mediators in cervicovaginal fluid, adjusting for bacterial vaginosis and the presence of blood. We compared these results to public gene expression data from the fallopian tubes, endometrium, endo-and ectocervix, and vagina.Results: Immune-related gene expression in the endocervix and immune mediators in cervicovaginal fluid increased during CVR use versus both menstrual phases, and in the follicular versus luteal phase. The antimicrobial protein granulysin was high during CVR use, intermediate in the follicular phase, and nearly absent from the luteal phase.Re-analysis of public gene expression data confirmed increased immune-related gene expression in the endocervix during the follicular phase. However, in the fallopian tube, endometrium, and vagina, the follicular phase showed immunosuppression. Conclusions: Immune-related genes in the cervicovaginal tract were highest during CVR use, intermediate in the follicular phase, and lowest in the luteal phase. Granulysin is a potential biomarker of menstrual phase: Frequently detected in follicular samples, but rare in luteal. Lastly, immunological differences between the follicular and luteal phases vary throughout the female genital tract.

The cervical transcriptome changes during the menstrual cycle but does not predict the window of implantation

“…Since the expression levels of the most common endometrial receptivity genes also did not differ between the LH + 2 and LH + 7 samples, cervical cells' transcriptomics is probably unsuitable for receptivity testing. The lack of transcriptomic differences between the cervical cells collected from the follicular and luteal phase was also reported in a previous microarray study (22), which coincides our results. Our results demonstrated that the transcriptome of cervical cells is relatively uniform throughout the menstrual cycle; however, more changes occur in the latesecretory phase, when the best time for embryo implantation is already passed.…”

“…During the sample collection with a cervical brush, mainly superficial cells are obtained, and the most hormone sensitive glandular cells in cervical crypts are not collected, which likely explains the differences between our and previous results. Endocervical tissue (7,8) studies have reported significant gene-expression changes between proliferative and secretory phase samples, but no similar menstrual cyclerelated changes were seen in brush-derived cervical cells (22). Like endometrial tissue, endocervical tissue contains estrogen and progesterone receptors that make it susceptible to progesterone action during the menstrual cycle (23).…”

Systems Analysis Reveals Contraceptive-Induced Alteration of Cervicovaginal Gene Expression in a Randomized Trial

“…These results affirm data from the same cohort in which we observed that CCVR users had significantly elevated inflammatory- and Th17-related cytokine concentrations in cervicovaginal fluid (CVF) compared to COC and Net-En users and relative to baseline levels ( 5 , 9 ). Similarly, in a small prospective study of US women initiating CCVR (NuvaRing ® , Merck), the endocervical expression of immune-related genes increased after 1 month of CCVR use compared to both the follicular and luteal phase of the menstrual cycle prior to CCVR initiation ( 71 ). We further observed that CCVR users had lower levels of transcriptional responses indicative of epithelial differentiation and keratinization relative to those assigned to Net-En or COC.…”

“…We further observed that CCVR users had lower levels of transcriptional responses indicative of epithelial differentiation and keratinization relative to those assigned to Net-En or COC. While there is limited data on the effects of CCVRs on cervical gene expression, some studies have identified increased levels of genital matrix metalloproteinase (MMPs) and reduced levels of MMP tissue inhibitors (TIMPs) with CCVR initiation ( 71 ), suggestive of mucosal barrier repair or remodeling ( 18 ). Whether CCVR use mediates the disruption of epithelial barrier or whether this occurs up- or downstream of the CCVR-mediated increase in inflammation and dysbiosis observed in this cohort is yet to be determined.…”