Transmissible diseases are re-emerging as a global problem, with Sexually Transmitted Diseases (STDs) becoming endemic. Chlamydia trachomatis is the leading cause of bacterially-acquired STD worldwide, with the Australian cost of infection estimated at $90 - $160 million annually. Studies using animal models of genital tract Chlamydia infection suggested that the hormonal status of the genital tract epithelium at the time of exposure may influence the outcome of infection. Oral contraceptive use also increased the risk of contracting chlamydial infections compared to women not using contraception. Generally it was suggested that the outcome of chlamydial infection is determined in part by the hormonal status of the epithelium at the time of exposure. Using the human endolmetrial cell line ECC-1 this study investigated the effects of C. trachomatis serovar D infection, in conjunction with the female sex hormones, 17β-estradiol and progesterone, on chlamydial gene expression. While previous studies have examined the host response, this is the first study to examine C.trachomatis gene expression under different hormonal conditions. We have highlighted a basic model of C. trachomatis gene regulation in the presence of steroid hormones by identifying 60 genes that were regulated by addition of estradiol and/or progesterone. In addition, the third chapter of this thesis discussed and compared the significance of the current findings in the context of data from other research groups to improve our understanding of the molecular basis of chlamydial persistence under hormonal different conditions. In addition, this study analysed the effects of these female sex hormones and C. trachomatis Serovar D infection, on host susceptibility and bacterial growth. Our results clearly demonstrated that addition of steroid hormones not only had a great impact on the level of infectivity of epithelial cells with C.trachomatis serovar D, but also the morphology of chlamydial inclusions was affected by hormone supplementation.

Objectives: To study recovery after hysterectomy under Enhanced Recovery After Surgery (ERAS) care, and in relation to different operation techniques. Materials and Methods: An observational study was conducted comparing 85 patients undergoing hysterectomy with ERAS care to 120 patients immediately before establishing ERAS. In a prospective cohort study of 121 consecutive patients undergoing hysterectomy, the outcome was compared for patients with malignant versus benign indications. The main outcome measure was length of stay (LOS). A randomised controlled trial (RCT) of 20 women scheduled for hysterectomy compared robot-assisted laparoscopic with abdominal hysterectomy in terms of the development of insulin resistance, inflammatory reactions, and clinical recovery, and examined the relation to hormonal status. All studies were conducted in 2011--2015, at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden. Results: Implementation of a structured ERAS protocol significantly reduced LOS compared to non-ERAS care. The effect was similar between patients with malignant and benign indications for surgery. No difference in complications was found. There was no difference in development of insulin resistance between robotic and abdominal technique, but clinical outcomes and inflammatory responses significantly favoured robot-assisted hysterectomy. Female sex hormone status was associated with the development of insulin resistance. Conclusions: Recovery after hysterectomy can be influenced. ERAS care seems to be effective and safe. Clinical outcome can also be influenced by operational technique. Hysterectomy triggers a stress reaction in both the metabolic and the inflammatory system. It remains unclear why the reduced inflammatory reaction and favourable clinical outcome in robotic surgery were not mirrored by less insulin resistance. This could not be explained by female sex hormone status.

Although women constitute more than half of the estimated 34-40 million people living with HIV/AIDS worldwide, little is known about the early events of HIV-1 infection in the female genital tract (FGT). Genital epithelial cells (GECs) line the FGT and act as intrinsic barriers providing mechanical protection against foreign microbes. GECs are also sentient and are capable of sensing and immunologically responding to various types of pathogens including sexually transmitted infections (STIs). These responses play a central role in preventing disease and also help mobilize both innate and adaptive immune cells against invading threats. While it is well understood that GECs exert important physical and immunological protective roles in the FGT, little is known regarding the role of GECs and GEC inflammatory responses in HIV infection. It is estimated that 40% of all new HIV infections are established each year in the FGT. Our understanding of the early events following HIV transmission in the FGT remains particularly elusive in the context of endogenous or exogenous factors found in the genital microenvironment that may influence susceptibility to HIV-1. Inflammation is known to play a critical role in increasing HIV susceptibility, replication as well as initiating and maintaining chronic immune activation, a hallmark of disease progression. Among the key factors in the FGT that are known to or that could influence inflammation are sexually transmitted co-infections and female sex hormones. The work summarized in this thesis examines how GEC innate immune responses to co-infecting microbes or female sex hormones impact HIV infection and replication in the FGT. Our results show that GEC innate immune response against herpes simplex virus type 2 (HSV-2), a common HIV co-infecting agent, consists of elevated proinflammatory cytokines and chemokines in addition to biologically active interferon-β. Furthermore, our results show that these responses require potent viral HSV-2 replication and that proinflammatory cytokine and chemokine responses are enhanced in the absence of the HSV-2 virus host shutoff protein. Based on this work, we decided to investigate whether GEC inflammatory responses to common STIs played a role in regulating HIV replication in T-cells. We found that HIV co-infecting microbes, specifically HSV-1, HSV-2 and Neisseria gonorrhoeae, directly induced HIV replication in T-cells, and caused primary GECs to upregulate inflammatory responses that indirectly increased HIV replication in T-cells. Next we examined a translational aspect of the aforementioned studies by examining whether blocking inflammatory pathways, using the broad anti-inflammatory compound curcumin, could provide prophylactic or therapeutic protection against HIV. We found that curcumin pre-treatment a) protected the genital epithelial barrier against HIV-1-mediated disruption and inflammation, b) prevented the gp120-mediated upregulation of chemokines by GECs that recruit HIV target cells to the FGT, c) blocked GEC innate inflammatory responses to co-infecting microbes and indirect activation of the HIV promoter in T-cells, d) decreased HIV amplification in chronically infected T-cells and e) blocked HSV-2 viral replication in GECs by a mechanism that likely involves NFκB. Lastly, it has long been speculated that female sex hormones can regulate inflammatory responses, and numerous lines of evidence suggest that they may also regulate susceptibility to HIV-1. Thus, we investigated how female sex hormones and the hormonal contraceptive medroxyprogesterone acetate (MPA), used by more than 100 million women worldwide, regulated HIV infection and replication in GECs and whether inflammation played an important role in this regulation. Our results showed that progesterone and in particular MPA increased uptake of HIV-1 and transcytosis, but not replication, across GECs – in the absence of a proinflammatory milieu - and that this enhanced transcytosis resulted in increased infection of HIV target cells. These results demonstrate that sex hormones and co-infection both play an important role in regulating HIV-1 infection and replication in the FGT. Furthermore, our results suggest that anti-inflammatory compounds such as curcumin may offer paradigm shifting prophylactic or therapeutic strategies against HIV-1 infection and future research should investigate its potential benefit in vivo. / Thesis / Doctor of Philosophy (Medical Science)

Lesão pulmonar aguda é caracterizada por infiltrado de neutrófilos no pulmão, edema, lesão alveolar difusa e alteração da reatividade das vias aéreas. Evidências clínicas e experimentais sugerem que os hormônios sexuais femininos (HSF) modulam a inflamação. Nesse estudo camundongos fêmeas C57BL/6 foram ovariectomizados (OVx) ou falsamente operados, com ovários mantidos (Sham). Após 7 dias foi realizada instilação nasal de LPS (ou salina como controle). Após 4 ou 24 h os experimentos foram conduzidos. Os resultados obtidos 24 h após o LPS mostram aumento de neutrófilos, IL-1b e de óxido nítrico (NO) e redução de IL-10 no pulmão dos animais OVx em relação aos Sham. Também foi observada redução da reatividade traqueal e da resistência e elastância pulmonar dos animais OVx. O tratamento dos animais OVx com 17b-estradiol ou progesterona antes do LPS reverteram esses efeitos. Os dados mostram que 4 h após o LPS a OVx não altera a inflamação e a reatividade das vias aéreas. Pode-se concluir nesse modelo experimental que os HSF exerçam papel de proteção ao organismo. / Acute lung injury is characterized by lung neutrophil infiltration, edema, diffuse alveolar damage and changes in airway reactivity. Clinical and experimental evidences suggest that the female sex hormones (FSH) modulate the inflammation. In this study, female mice C57BL/6 were ovariectomized (OVx) or not (Sham). After 7 days, LPS or saline (as control) were intranasally instillated. After 4 or 24 h the experiments were carried. We observed, 24 h after LPS, increase in neutrophil, IL-1b and nitric oxide (NO) and reduction of IL-10 in the lungs of OVx compared to Sham. We also noted reduced tracheal reactivity and lung resistance and elastance in OVx animals. Treatment of OVx with 17b-estradiol or progesterone before LPS reversed these effects. The data show that 4 h after LPS, the OVx does not promote inflammation and airway reactivity. We can conclude that in our experimental model, FSH exert protective role.

A asma traz remodelamento das vias aéreas por deposição de colágeno, hiperplasia mucoide, hipertrofia celular lisa e hipertrofia epitelial além de afetar a reatividade das vias aéreas. Camundongos C57Bl/6 ovariectomizadas (OVx) foram sensibilizadas e desafiadas com OVA por inalação 3 vezes por semana durante 3 ou 7 semanas. Passadas 120h pós desafio avaliou-se: reatividade traqueal, histologia, MMPs 2 e 9 e mecânica pulmonar. O grupo OVx alérgico teve a reatividade traqueal à MCh e a quantificação de muco, colágeno e músculo liso reduzida em comparação ao grupo controle (sham OVx). O tratamento com estrógeno aumentou MMP2 e o tratamento com progesterona aumentou MMP9. A mecânica ventilatória não diferiu entre os grupos. Nossos dados sugerem que o remodelamento brônquico pode ser modulado por HSFs. / Asthma is characterized by remodeling and increased airway responsiveness. Remodeling is recognized by sub-epithelial fibrosis, bronchial glands hypertrophy and goblet cell hyperplasia. We investigated role of HSF in airway remodeling and in tracheal responsiveness in a model of chronic lung inflammation. Mice were ovariectomized (OVx), sensitized and OVA challenged. Elapsed 120h of the last challenge, histological assessment and contractile response of trachea to methacholine (MCh) was performed. Total lung resistance (R) and elastance (E) were measured under mechanical ventilation. Control group consisted of Sham OVx allergic mice. Airway remodeling were significantly lower of OVx mice compared with Sham OVx allergic counterparts. OVx allergic mice showed lower tracheal responsiveness than Sham OVx. R and E were the same between groups.

Lesão pulmonar aguda é caracterizada por infiltrado de neutrófilos no pulmão, edema, lesão alveolar difusa e alteração da reatividade das vias aéreas. Evidências clínicas e experimentais sugerem que os hormônios sexuais femininos (HSF) modulam a inflamação. Nesse estudo camundongos fêmeas C57BL/6 foram ovariectomizados (OVx) ou falsamente operados, com ovários mantidos (Sham). Após 7 dias foi realizada instilação nasal de LPS (ou salina como controle). Após 4 ou 24 h os experimentos foram conduzidos. Os resultados obtidos 24 h após o LPS mostram aumento de neutrófilos, IL-1b e de óxido nítrico (NO) e redução de IL-10 no pulmão dos animais OVx em relação aos Sham. Também foi observada redução da reatividade traqueal e da resistência e elastância pulmonar dos animais OVx. O tratamento dos animais OVx com 17b-estradiol ou progesterona antes do LPS reverteram esses efeitos. Os dados mostram que 4 h após o LPS a OVx não altera a inflamação e a reatividade das vias aéreas. Pode-se concluir nesse modelo experimental que os HSF exerçam papel de proteção ao organismo. / Acute lung injury is characterized by lung neutrophil infiltration, edema, diffuse alveolar damage and changes in airway reactivity. Clinical and experimental evidences suggest that the female sex hormones (FSH) modulate the inflammation. In this study, female mice C57BL/6 were ovariectomized (OVx) or not (Sham). After 7 days, LPS or saline (as control) were intranasally instillated. After 4 or 24 h the experiments were carried. We observed, 24 h after LPS, increase in neutrophil, IL-1b and nitric oxide (NO) and reduction of IL-10 in the lungs of OVx compared to Sham. We also noted reduced tracheal reactivity and lung resistance and elastance in OVx animals. Treatment of OVx with 17b-estradiol or progesterone before LPS reversed these effects. The data show that 4 h after LPS, the OVx does not promote inflammation and airway reactivity. We can conclude that in our experimental model, FSH exert protective role.

A asma traz remodelamento das vias aéreas por deposição de colágeno, hiperplasia mucoide, hipertrofia celular lisa e hipertrofia epitelial além de afetar a reatividade das vias aéreas. Camundongos C57Bl/6 ovariectomizadas (OVx) foram sensibilizadas e desafiadas com OVA por inalação 3 vezes por semana durante 3 ou 7 semanas. Passadas 120h pós desafio avaliou-se: reatividade traqueal, histologia, MMPs 2 e 9 e mecânica pulmonar. O grupo OVx alérgico teve a reatividade traqueal à MCh e a quantificação de muco, colágeno e músculo liso reduzida em comparação ao grupo controle (sham OVx). O tratamento com estrógeno aumentou MMP2 e o tratamento com progesterona aumentou MMP9. A mecânica ventilatória não diferiu entre os grupos. Nossos dados sugerem que o remodelamento brônquico pode ser modulado por HSFs. / Asthma is characterized by remodeling and increased airway responsiveness. Remodeling is recognized by sub-epithelial fibrosis, bronchial glands hypertrophy and goblet cell hyperplasia. We investigated role of HSF in airway remodeling and in tracheal responsiveness in a model of chronic lung inflammation. Mice were ovariectomized (OVx), sensitized and OVA challenged. Elapsed 120h of the last challenge, histological assessment and contractile response of trachea to methacholine (MCh) was performed. Total lung resistance (R) and elastance (E) were measured under mechanical ventilation. Control group consisted of Sham OVx allergic mice. Airway remodeling were significantly lower of OVx mice compared with Sham OVx allergic counterparts. OVx allergic mice showed lower tracheal responsiveness than Sham OVx. R and E were the same between groups.

Recent Findings: Recent data support previous work indicating that estrogen enhances chlamydial development via multiple mechanisms. Progesterone negatively impacts Chlamydia infections also through multiple mechanisms, particularly by altering the immune response. Conflicting data exist regarding the effect of synthetic hormones, such as those found in hormonal contraceptives, on chlamydial infections. Summary: Numerous studies over the years have indicated that female sex hormones affect C. trachomatis infection. However, we still do not have a clear understanding of how these hormones alter Chlamydia disease transmission and progression. The studies reviewed here indicate that there are many variables that determine the outcome of Chlamydia/hormone interactions, including (1) the specific hormone, (2) hormone concentration, (3) cell type or area of the genital tract, (4) hormone responsiveness of cell lines, and (5) animal models.

The female genital tract represents the first line of defence against HIV. Biological factors such as female sex hormones, and the vaginal microbiota are known to affect HIV susceptibility at this site. The female sex hormone estradiol is known to play a protective role, whereas the progestin based contraceptive medroxyprogesterone acetate increases HIV susceptibility HIV. In addition, a Lactobacilli dominant vaginal microbiota is generally protective against HIV. Therefore, in this study, we aimed to elucidate the effects of female sex hormones, and Lactobacilli on the innate immune response of vaginal epithelial cells. / Thesis / Master of Science (MSc)

Mulheres asmáticas na pós-menopausa podem apresentar piora dos sintomas, portanto neste trabalho investigamos o papel dos hormônios sexuais femininos (HSF) sobre a inflamação alérgica pulmonar. A re-exposição ao antígeno exacerbou a inflamação alérgica pulmonar e a liberação de mediadores no pulmão dos animais alérgicos ovariectomizados (OVx). O valor da reatividade traqueal foi semelhante ao observado nos animais alérgicos Sham/OVx. O tratamento com estrógeno exacerbou a inflamação pulmonar, mas atenuou a reatividade das vias aéreas. O tratamento com progesterona não alterou o número de células do lavado broncoalveolar e atenuou a reatividade das vias aéreas, apesar acentuar a produção de muco e de colágeno. O tratamento com estrógeno em associação com a progesterona atenuou a inflamação pulmonar aos valores encontrados nos animais alérgicos Sham/OVx. Nossos estudos apontam para uma possível dissociação entre os efeitos moduladores dos HSF sobre a resposta inflamatória, notadamente no recrutamento celular e as alterações de mecânica respiratória. / Asthmatic postmenopausal women may experience worsening of symptoms, so in this work we investigated the role of female sex hormones (HSF) on pulmonary allergic inflammation. The re-exposure to antigen exacerbated allergic lung inflammation and release of mediators in the lungs of ovariectomized allergic mice (OVX ) . The value of tracheal reactivity was similar to that observed in allergic Sham/OVx . Treatment with estrogen exacerbated pulmonary inflammation but attenuated airways reactivity. Treatment with progesterone did not alter the number of cells in bronchoalveolar lavage and attenuated airways reactivity, although enhance mucus production and collagen. Treatment with estrogen in combination with progesterone attenuated lung inflammation to the values found in allergic animals Sham/OVx. Our studies point to a possible dissociation between the modulatory effects of HSF on the inflammatory response, especially on cell recruitment and alterations in respiratory mechanic.