Hormonal contraception is associated with a reduced risk of bacterial vaginosis: a systematic review and meta-analysis

Lenka A Vodstrcil, Jane S Hocking, Matthew Law, Sandra Walker, Sepehr N Tabrizi, Christopher K Fairley, Catriona S Bradshaw, Lenka A Vodstrcil, Jane S Hocking, Matthew Law, Sandra Walker, Sepehr N Tabrizi, Christopher K Fairley, Catriona S Bradshaw

Abstract

Objective: To examine the association between hormonal contraception (HC) and bacterial vaginosis (BV) by systematic review and meta-analysis.

Methods: Medline, Web of Science and Embase databases were searched to 24/1/13 and duplicate references removed. Inclusion criteria 1) >20 BV cases; 2) accepted BV diagnostic method; 3) measure of HC-use either as combined oestrogen-progesterone HC (combined), progesterone-only contraception (POC) or unspecified HC (u-HC); 4) ≥ 10% of women using HC; 5) analysis of the association between BV and HC-use presented; 6) appropriate control group. Data extracted included: type of HC, BV diagnostic method and outcome (prevalent, incident, recurrent), and geographical and clinic-setting. Meta-analyses were conducted to calculate pooled effect sizes (ES), stratified by HC-type and BV outcome. This systematic review is registered with PROSPERO (CRD42013003699).

Results: Of 1713 unique references identified, 502 full-text articles were assessed for eligibility and 55 studies met inclusion criteria. Hormonal contraceptive use was associated with a significant reduction in the odds of prevalent BV (pooled effect size by random-effects [reES] = 0.68, 95%CI0.63-0.73), and in the relative risk (RR) of incident (reES = 0.82, 95%CI:0.72-0.92), and recurrent (reES = 0.69, 95%CI:0.59-0.91) BV. When stratified by HC-type, combined-HC and POC were both associated with decreased prevalence of BV and risk of incident BV. In the pooled analysis of the effect of HC-use on the composite outcome of prevalent/incident/recurrent BV, HC-use was associated with a reduced risk of any BV (reES = 0.78, 95%CI:0.74-0.82).

Conclusion: HC-use was associated with a significantly reduced risk of BV. This negative association was robust and present regardless of HC-type and evident across all three BV outcome measures. When stratified by HC-type, combined-HC and POC were both individually associated with a reduction in the prevalence and incidence of BV. This meta-analysis provides compelling evidence that HC-use influences a woman's risk of BV, with important implications for clinicians and researchers in the field.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. Flowchart demonstrating selection of studies…
Figure 1. Flowchart demonstrating selection of studies for the systematic review and meta-analysis of the association between hormonal contraceptive (HC) use and bacterial vaginosis (BV).
Figure 2. Meta-analysis of the association between…
Figure 2. Meta-analysis of the association between hormonal contraceptive (HC) type and prevalent BV.
Key: ES = effects size, CI = confidence interval, combined HC-use = combined oestrogen- and progesterone-containing methods of HC, POC-use = progesterone only containing methods of HC.
Figure 3. Meta-analysis of the association between…
Figure 3. Meta-analysis of the association between hormonal contraceptive (HC) type and incident BV.
Key: ES = effects size, CI = confidence interval, combined HC-use = combined oestrogen- and progesterone-containing methods of HC, POC-use = progesterone only containing methods of HC.
Figure 4. Meta-analysis of the association between…
Figure 4. Meta-analysis of the association between specified and unspecified hormonal contraceptive (HC) use and BV outcome, stratified by prevalent, incident or recurrent BV.
Key: ES = effects size, CI = confidence interval, combined = combined oestrogen- and progesterone-containing methods of HC, POC = progesterone only containing methods of HC, u-HC = unspecified HC.
Figure 5. Funnel plots demonstrating the potential…
Figure 5. Funnel plots demonstrating the potential presence of publication bias in studies reporting A) prevalent BV, B) incident BV and C) the composite outcome of any BV.
Key: OR = odds ratio, RR = risk ratio.

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