Genital inflammatory status and the innate immune response to contraceptive initiation

Abstract

Problem: Data on the effects of contraceptives on female genital tract (FGT) immune mediators are inconsistent, possibly in part due to pre-existing conditions that influence immune mediator changes in response to contraceptive initiation.

Methods: This study included 161 South African women randomised to injectable depot medroxyprogesterone acetate (DMPA-IM), copper intrauterine device (IUD), or levonorgestrel (LNG) implant in the Evidence for Contraceptive Options and HIV Outcomes (ECHO) trial. We measured thirteen cytokines and antimicrobial peptides previously associated with HIV acquisition in vaginal swabs using Luminex and ELISA, before, and at 1 and 3 months after contraceptive initiation. Women were grouped according to an overall baseline inflammatory profile. We evaluated modification of the relationships between contraceptives and immune mediators by baseline inflammation, demographic, and clinical factors.

Results: Overall, LNG implant and copper IUD initiation were associated with increases in inflammatory cytokines, while no changes were observed following DMPA-IM initiation. However, when stratifying by baseline inflammatory profile, women with low baseline inflammation in all groups experienced significant increases in inflammatory cytokines, while those with a high baseline inflammatory profile experienced no change or decreases in inflammatory cytokines.

Conclusion: We conclude that pre-contraceptive initiation immune profile modifies the effect of contraceptives on the FGT innate immune response.

Keywords: contraception; copper; cytokines; female; inflammation; intrauterine devices; levonorgestrel; medroxyprogesterone acetate.

FIGURE 1

(A‐K). Changes in genital immune mediator concentrations (pg/ml) over time. Boxplots representing mean immune mediator concentrations at baseline, 1 month (m1) and 3 months (m3) following contraceptive initiation in women using (A), copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), LNG implant (n = 58). Error bars indicate the ranges. Each coloured line represents one woman and immune mediator changes over time. The colour of the lines is based on the contraceptive methods used (blue, copper IUD; pink, DMPA‐IM; green, LNG implant). Samples were run in duplicate. Wilcoxon signed rank test was used for comparisons and P‐values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons

FIGURE 1

(A‐K). Changes in genital immune mediator concentrations (pg/ml) over time. Boxplots representing mean immune mediator concentrations at baseline, 1 month (m1) and 3 months (m3) following contraceptive initiation in women using (A), copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), LNG implant (n = 58). Error bars indicate the ranges. Each coloured line represents one woman and immune mediator changes over time. The colour of the lines is based on the contraceptive methods used (blue, copper IUD; pink, DMPA‐IM; green, LNG implant). Samples were run in duplicate. Wilcoxon signed rank test was used for comparisons and P‐values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons

FIGURE 1

(A‐K). Changes in genital immune mediator concentrations (pg/ml) over time. Boxplots representing mean immune mediator concentrations at baseline, 1 month (m1) and 3 months (m3) following contraceptive initiation in women using (A), copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), LNG implant (n = 58). Error bars indicate the ranges. Each coloured line represents one woman and immune mediator changes over time. The colour of the lines is based on the contraceptive methods used (blue, copper IUD; pink, DMPA‐IM; green, LNG implant). Samples were run in duplicate. Wilcoxon signed rank test was used for comparisons and P‐values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons

FIGURE 2

(A‐K). Fold changes of genital immune mediator concentrations relative to baseline. Bar graphs representing the fold change of immune mediator concentrations at 1‐month (M1) and 3 months (M3) following contraceptive initiation in women using (A), the copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), the LNG implant (n = 58) in women with high (pink) and low (blue) baseline inflammation. Women were grouped into high (pink) and low (blue) baseline inflammation using overall factor scores at baseline. Samples were run in duplicate. The immune mediators TNF‐α, IL‐8, MIP‐1α, IL‐6, IP‐10, IL‐1β and MIP‐3α were included in the factor analysis. All pro‐inflammatory cytokines and chemokines were loaded onto the same factor and scores were generated to represent overall level of inflammation. Error bars indicate the 95% confidence intervals. Mann‐Whitney U test was used for comparisons and P values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons

FIGURE 2

(A‐K). Fold changes of genital immune mediator concentrations relative to baseline. Bar graphs representing the fold change of immune mediator concentrations at 1‐month (M1) and 3 months (M3) following contraceptive initiation in women using (A), the copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), the LNG implant (n = 58) in women with high (pink) and low (blue) baseline inflammation. Women were grouped into high (pink) and low (blue) baseline inflammation using overall factor scores at baseline. Samples were run in duplicate. The immune mediators TNF‐α, IL‐8, MIP‐1α, IL‐6, IP‐10, IL‐1β and MIP‐3α were included in the factor analysis. All pro‐inflammatory cytokines and chemokines were loaded onto the same factor and scores were generated to represent overall level of inflammation. Error bars indicate the 95% confidence intervals. Mann‐Whitney U test was used for comparisons and P values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons

FIGURE 2

(A‐K). Fold changes of genital immune mediator concentrations relative to baseline. Bar graphs representing the fold change of immune mediator concentrations at 1‐month (M1) and 3 months (M3) following contraceptive initiation in women using (A), the copper IUD (n = 51), (B), DMPA‐IM (n = 52) and (C), the LNG implant (n = 58) in women with high (pink) and low (blue) baseline inflammation. Women were grouped into high (pink) and low (blue) baseline inflammation using overall factor scores at baseline. Samples were run in duplicate. The immune mediators TNF‐α, IL‐8, MIP‐1α, IL‐6, IP‐10, IL‐1β and MIP‐3α were included in the factor analysis. All pro‐inflammatory cytokines and chemokines were loaded onto the same factor and scores were generated to represent overall level of inflammation. Error bars indicate the 95% confidence intervals. Mann‐Whitney U test was used for comparisons and P values were adjusted for multiple comparisons using a false discovery rate step‐down procedure. Abbreviations: IUD, intrauterine device; DMPA‐IM, 150 mg intramuscular depot medroxyprogesterone acetate; LNG, levonorgestrel; M1, 1‐month post contraceptive initiation; M3, 3 months post contraceptive initiation; TNF‐α, tumour necrosis factor‐alpha; IL, interleukin; MIP, macrophage inflammatory protein; IP‐10, interferon‐γ inducible protein‐10; IFN‐α, interferon‐alpha, SLPI, secretory leukocyte protease inhibitor; HBD, human beta defensin. * Indicates P < .05 after adjusting for multiple comparisons