Intrauterine Adhesions in Response to Pelvic Inflammatory Disease Due to Change in Vaginal Microecology [Letter]

I have read the paper by Sidi Dun, Chunying liu, and Na Li on “Changes of vaginal microecology of women with intrauterine adhesions: A case control study.” This study provides up-to-date information regarding how the changes in vaginal microecology cause change in pH of the vagina and provide a favorable environment for the growth of exogenous and endogenous pathogens, causing ascending infection and pelvic inflammatory disease, and if chronic endometritis persists for long then it is likely to form intrauterine adhesions. 1 , 2 This study aimed to assess the microbial ecology of the vagina. The researchers did this study by case control method and investigated the changes in vaginal pH, growth of pathogens, and disturbance in normal flora. In the case control group, the researchers consider those patients who presented to hospital for diagnosis and treatment with clinical symptoms such as decreased menstrual flow, amenorrhea, and infertility as their major concern, and hysteroscopy is done to exclude intrauterine adhesions. But the question arises here that these symptoms themselves present a possibility of reproductive disease which can be the predisposing factor for intrauterine adhesions because these clinical features are secondary to some diseases because study excludes genital tract malformations. 3 This study also excludes other reproductive diseases such as endometrial polyps, fibroids, and adenomyosis also in exclusion criteria previous diagnosed or treated Intrauterine adhesions by hysteroscopy, which clearly show the case control group can be manifested as some other reproductive disease. The authors mentioned in their study all the risk factors but still confusion presents there is all risk factors associated with intrauterine adhesions should be excluded like history of myomectomy due to any previous reproductive disease, history of genital tuberculosis and mainly the history of surgical management of postpartum hemorrhage and abortion because it can sometimes manifest as intrauterine adhesions with normal vaginal microecology. For the study on vaginal microecology, the investigation indicators included were the bacterial flora density, 4–6 bacterial floral diversity, dominant bacterial species, fungi and trichomonas in vagina, also for vaginal pH, hydrogen peroxide, leukocyte esterase (LE), sialidase (SNA), 3 glucuronidase (GUS), and acetylglucosaminidase (NAG) detection kits were used. I appreciate all authors for the detailed vaginal microecology examination and for the results on exclusive vaginal microecology based and other risk factors that contribute in formation of intrauterine adhesions.