Sjögren and Gynecologic Considerations

Vaginal Infections and Sexual Dysfunction in Women With Primary Sjögren's Syndrome

Sjögren's syndrome is an autoimmune disorder characterized by glandular and extra-glandular manifestations. It is called primary Sjögren's syndrome (pSS) in absence of another connective tissue disease. The hallmark symptoms of pSS are dry eyes and dry mouth due to the decreased lacrimal and salivary gland functions. However, other tissue and organs may also be involved which precede such as xerotrachea in upper airway, atrophic gastritis and pancreatitis in gastrointestinal tract, and dryness in vaginal mucosa.

Regarding to the genital involvement in pSS, vaginal dryness and resultant vaginal discomfort, and pain are reported as the common complaints. The transudate released by vaginal mucosa is the main resource of vaginal secretions.The human microbiome was reported to have a potential impact in etiopathogenesis of certain autoimmune disorders. The previous research revealed significant alterations in the gut, eye, and oral flora of the pSS patients. The disturbed oral flora due to immunodeficiency and reduced salivary flow was also reported to make the SS patients to prone to bacterial infections and recurrent oral candidiasis. Vaginitis has been defined as a spectrum of symptoms suggesting vulvovaginal discomfort such as itching, burning, irritation, and abnormal discharge. Even the vaginitis is an evidence of disturbance in vaginal flora, previous prospective research on vaginal microbiome of pSS patients either excluded the cases with vaginitis or not mentioned from the presence of vaginitis in women with pSS. To the best of our knowledge, there has not been any study yet to define the characteristics of vaginal flora through the presence of clinical signs and symptoms in women with pSS. To gain more insight into the clinical context of the gynecologic complaints, sexual dysfunction, and presence of vaginitis in pSS, the current study aims to identify the associations between these issues and pSS related disease parameters.

Study Overview

• Status: Completed
• Conditions: Sexual Dysfunction; Vaginitis; Primary Sjögren Syndrome; Vaginitis Candida
• Intervention / Treatment: Other: Visual analogue scale (VAS) for dyspareunia; Other: Visual analogue scale (VAS) for vaginal dryness; Other: The European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI); Other: The European League Against Rheumatism Sjögren's Syndrome Patient Reported Index (ESSPRI)

Detailed Description

Sjögren's syndrome is an autoimmune disorder characterized by glandular and extra-glandular manifestations. In the absence of another connective tissue disease, it is called primary Sjögren's syndrome (pSS). The hallmark symptoms of pSS are dry eyes and dry mouth due to the decreased lacrimal and salivary gland functions. However, other tissue and organs may also be affected including the vaginal mucosa. Regarding to the genital involvement in pSS, vaginal dryness and resultant vaginal discomfort, and pain are reported as the common complaints. The transudate released by vaginal mucosa is the main resource of vaginal secretions.The human microbiome was reported to have a potential impact in etiopathogenesis of certain autoimmune disorders. The previous research revealed significant alterations in the gut, eye, and oral flora of the pSS patients. The disturbed oral flora due to immunodeficiency and reduced salivary flow was also reported to make the SS patients to prone to bacterial infections and recurrent oral candidiasis. Vaginitis has been defined as a spectrum of symptoms suggesting vulvovaginal discomfort such as itching, burning, irritation, and abnormal discharge. Even the vaginitis is an evidence of disturbance in vaginal flora, previous prospective research on vaginal microbiome of pSS patients either excluded the cases with vaginitis or not mentioned from the presence of vaginitis in women with pSS. To the best of our knowledge, there has not been any study yet to define the characteristics of vaginal flora through the presence of clinical signs and symptoms in women with pSS. To gain more insight into the clinical context of the gynecologic complaints, sexual dysfunction, and presence of vaginitis in pSS, the current study aims to identify the associations between these issues and pSS related disease parameters. In this prospective cohort study, we planned to include sexually active 118 women at reproductive age who had the symptoms of itching, burning, irritation, and abnormal discharge. Women with pSS (study group, n=49) will be compared with women who had not any other disease or complaint rather than vaginal discharge (control group, n=69). Besides the physical examination and gynecological evaluation including sterile speculum examination enabling swab sampling for vaginal discharge and PAP smear; the Visual analogue scales (VAS) for dyspareunia, and vaginal dryness and The European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI), and Sjögren's Syndrome Patient Reported Index (ESSPRI) Sjögren's syndrome disease activity will be also performed. Correlation and regression analyses will be also performed for pSS related parameters.

• Study Type: Observational
• Enrollment (Actual): 118

Contacts and Locations

Study Locations

• Turkey
  • Ankara, Turkey, 06100
    • Ankara City Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 20 years to 50 years (Adult)
• Accepts Healthy Volunteers: N/A
• Genders Eligible for Study: Female

• Sampling Method: Non-Probability Sample

Study Population

This study is designed as a prospective cohort study, to include sexually active 118 women at reproductive age who had the symptoms of itching, burning, irritation, and abnormal discharge. Women with pSS (study group, n=49) will be compared with women who had not any other disease or complaint rather than vaginal discharge (control group, n=69). All the participants will be recruited from sexually active women with single sexual partner.

Description

Inclusion Criteria:

• All participants are recruited from women who consecutively applied to outpatient clinic.
• Normally menstruating women at reproductive age (without menopause) for all participants.
• Regular sexual activity with single sexual partner for all participants.
• Receiving only hydroxychloroquine sulfate treatment for women with pSS.
• Presence of the symptoms of vaginitis for all participants.
• Without any known disease including autoimmune disorders for women in control group.

Exclusion Criteria:

• Women with the pelvic anatomical structural abnormalities
• History of any type of cancer including gynecological cancers, chemotherapy, and/or radiotherapy,
• Endometriosis, chronic cervicitis, menopause, pregnancy, lactation, use of hormonal contraceptive medication, use of vaginal estrogen, pre-malign or malign cytology at Papanicolaou (PAP) smear, having intrauterine device,
• Smoking,
• Chronic diseases (diabetes mellitus, psychiatric disorders,
• Multiple sexual partners, sexually transmitted infections including gonorrhea, chlamydia, genital herpes, and/or mycoplasma, mixed vaginal infections,
• Urinary tract infection in last three months,
• Antibiotic medication at last one month,
• Administration of drugs which may lead vaginal dryness including antihistaminics, antidepressants, and anti-hypertensives,
• Treatment with glucocorticoids, biologic disease modifying anti-rheumatic drugs, or immune-suppressive agents at last three months
• Women who had sexual partners with any sexual dysfunction

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
pSS group (Study group); Women with the diagnosis of pSS for at least 3 years.; At reproductive age (without menopause).; Receiving only hydroxychloroquine sulfate treatment.; Presence of the symptoms of vaginitis.	Other: Visual analogue scale (VAS) for dyspareunia; Dyspareunia scores between 0 to 10 points; Other: Visual analogue scale (VAS) for vaginal dryness; Vaginal dryness scores between 0 to 10 points; Other: The European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI); Sjögren's Syndrome Disease Activity Index scores between 0 to 3 points; Other: The European League Against Rheumatism Sjögren's Syndrome Patient Reported Index (ESSPRI); Sjögren's Syndrome Patient Reported Index scores between 0 to 10 points
Women without pSS (Control group); Women without any known disease.; At reproductive age (without menopause).; Presence of the symptoms of vaginitis.	Other: Visual analogue scale (VAS) for dyspareunia; Dyspareunia scores between 0 to 10 points; Other: Visual analogue scale (VAS) for vaginal dryness; Vaginal dryness scores between 0 to 10 points; Other: The European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI); Sjögren's Syndrome Disease Activity Index scores between 0 to 3 points; Other: The European League Against Rheumatism Sjögren's Syndrome Patient Reported Index (ESSPRI); Sjögren's Syndrome Patient Reported Index scores between 0 to 10 points

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Vaginal candidiasis	Culture of swab sampling from vaginal fluid at Sabouraud dextrose agar plates incubated in CO2 for evaluation of candida	20 minutes
Acute vaginitis	Laboratory assessment of vaginal swab sampling from vaginal fluid for bacterial vaginosis	10 minutes
Visual analogue scale for dyspareunia	The severity of symptoms scored between 0 (no symptoms) to 10 (worst symptoms) points.	20 minutes
Visual analogue scale for vaginal dryness	The severity of symptoms scored between 0 (no symptoms) to 10 (worst symptoms) points.	20 minutes
The European League Against Rheumatism Sjögren's Syndrome Disease Activity Index (ESSDAI)	The severity of clinical signs regarding Sjögren's Syndrome disease activity, scored between 0 (no symptoms) to 3 (worst symptoms) points.	20 minutes
The European League Against Rheumatism Sjögren's Syndrome Patient Reported Index (ESSPRI)	he severity of patient reported symptoms regarding Sjögren's Syndrome, scored between 0 (no symptoms) to 10 (worst symptoms) points.	20 minutes

Collaborators and Investigators

• Sponsor: Ankara City Hospital Bilkent

Publications and helpful links

General Publications

• Mariette X, Criswell LA. Primary Sjogren's Syndrome. N Engl J Med. 2018 Mar 8;378(10):931-939. doi: 10.1056/NEJMcp1702514. No abstract available.
• Priori R, Minniti A, Derme M, Antonazzo B, Brancatisano F, Ghirini S, Valesini G, Framarino-dei-Malatesta M. Quality of Sexual Life in Women with Primary Sjogren Syndrome. J Rheumatol. 2015 Aug;42(8):1427-31. doi: 10.3899/jrheum.141475. Epub 2015 Jul 1.
• Mulherin DM, Sheeran TP, Kumararatne DS, Speculand B, Luesley D, Situnayake RD. Sjogren's syndrome in women presenting with chronic dyspareunia. Br J Obstet Gynaecol. 1997 Sep;104(9):1019-23. doi: 10.1111/j.1471-0528.1997.tb12060.x.
• Brito-Zeron P, Baldini C, Bootsma H, Bowman SJ, Jonsson R, Mariette X, Sivils K, Theander E, Tzioufas A, Ramos-Casals M. Sjogren syndrome. Nat Rev Dis Primers. 2016 Jul 7;2:16047. doi: 10.1038/nrdp.2016.47.
• ACOG Committee on Practice Bulletins--Gynecology. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. Obstet Gynecol. 2006 May;107(5):1195-1206. doi: 10.1097/00006250-200605000-00049.

Study record dates

Study Major Dates

• Study Start (Actual): March 1, 2021
• Primary Completion (Actual): October 15, 2022
• Study Completion (Actual): November 10, 2022

Study Registration Dates

• First Submitted: January 2, 2023
• First Submitted That Met QC Criteria: January 3, 2023
• First Posted (Estimate): January 4, 2023

Study Record Updates

• Last Update Posted (Estimate): January 4, 2023
• Last Update Submitted That Met QC Criteria: January 3, 2023
• Last Verified: January 1, 2023

More Information

Terms related to this study

• Keywords: Dyspareunia; Sjögren's Syndrome; Sexual dysfunction; Vaginal candidiasis; Acute vaginitis; Gynecological complaints
• Additional Relevant MeSH Terms: Pathologic Processes; Immune System Diseases; Autoimmune Diseases; Eye Diseases; Disease; Joint Diseases; Musculoskeletal Diseases; Rheumatic Diseases; Connective Tissue Diseases; Arthritis; Stomatognathic Diseases; Mouth Diseases; Lacrimal Apparatus Diseases; Vaginal Diseases; Arthritis, Rheumatoid; Xerostomia; Salivary Gland Diseases; Dry Eye Syndromes; Syndrome; Vaginitis; Sjogren's Syndrome
• Other Study ID Numbers: E1-20-1290

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: No
• IPD Plan Description: The research data is not shared unless it is needed.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No