Danazol but not gonadotropin-releasing hormone agonists suppresses autoantibodies in endometriosis

Peritoneal autoantibody profiling identifies p53 as an autoantibody target in endometriosis

OBJECTIVE

To map the peritoneal autoantibody (AAb) landscape in women with endometriosis.

DESIGN

Case-control laboratory study.

SETTING

Academic medical and research units.

PATIENT(S)

Women who presented with or without endometriosis.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Using native-conformation and citrullinated modified protein arrays, proteome-wide analysis of AAbs against 1,623 proteins were profiled in peritoneal fluids (PFs) of 25 women with endometriosis and 25 women without endometriosis.

RESULT(S)

In women with endometriosis, the median number of AAbs detected was 4, including AAbs that targeted autoantigens involved in implantation, B-cell activation/development, and aberrant migration and mitogenicity. Forty-six percent of women with endometriosis have ≥5 peritoneal AAbs. Conversely, in women without endometriosis, the median number of detected AAbs was 1. Autoantibodies recognizing tumor suppressor protein p53 were the most commonly detected AAbs, being present in 35% of women with endometriosis, and p53 AAb was associated with a monocyte/macrophage-like PF cytokine signature. Further investigation of the global reactivity of AAbs against citrullinated PF antigens by peptidylarginine deiminase enzymes 1, 2, and 6 revealed anticitrullinated p53 as the only AAb target elevated and citrullinated by all 3 peptidylarginine deiminase isotypes. Furthermore, unsupervised hierarchical clustering and integrative pathway analysis revealed that 60% of women with endometriosis-associated infertility were positive for AAbs, which are involved in platelet-derived growth factor, transforming growth factor-β, RAC1/PAK1/p38/MMP2 signaling, LAT2/NTAL/LAB-mediated calcium mobilization, and integrin-mediated cell adhesion.

CONCLUSION(S)

Together, our data identify peritoneal autoimmunity in a significant subset of women with endometriosis, with implications on infertility and disease pathophysiology. In these patients, p53 was identified as the most frequent PF AAb target, which was present in both the native and citrullinated forms.

Gonadotropin-releasing hormone analogues for endometriosis

BACKGROUND

Endometriosis is a common gynaecological condition affecting 6 to 11% of reproductive-age women and may cause dyspareunia, dysmenorrhoea, and infertility. One treatment strategy is medical therapy with gonadotrophin-releasing hormone analogues (GnRHas) to reduce pain due to endometriosis. One of the adverse effects of GnRHas is a decreased bone mineral density. In addition to assessing the effect on pain, quality of life, most troublesome symptom and patients' satisfaction, the current review also evaluated the effect on bone mineral density and risk of adverse effects in women with endometriosis who use GnRHas versus other treatment options.

OBJECTIVES

To assess the effectiveness and safety of GnRH analogues (GnRHas) in the treatment of painful symptoms associated with endometriosis and to determine the effects of GnRHas on bone mineral density of women with endometriosis.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO and the trial registries in May 2022 together with reference checking and contact with study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) which compared GnRHas with other hormonal treatment options, including analgesics, danazol, intra-uterine progestogens, oral or injectable progestogens, gestrinone and also GnRHas compared with no treatment or placebo. Trials comparing GnRHas versus GnRHas in conjunction with add-back therapy (hormonal or non-hormonal) or calcium-regulation agents were also included in this review.  DATA COLLECTION AND ANALYSIS: We used standard methodology as recommended by Cochrane. Primary outcomes are relief of overall pain and the objective measurement of bone mineral density. Secondary outcomes include adverse effects, quality of life, improvement in the most troublesome symptoms and patient satisfaction.  Due to high risk of bias associated with some of the studies, primary analyses of all review outcomes were restricted to studies at low risk of selection bias. Sensitivity analysis including all studies was then performed.

MAIN RESULTS

Seventy-two studies involving 7355 patients were included. The evidence was very low to low quality: the main limitations of all studies were serious risk of bias due to poor reporting of study methods, and serious imprecision.  Trials comparing GnRHas versus no treatment  We did not identify any studies. Trials comparing GnRHas versus placebo There may be a decrease in overall pain, reported as pelvic pain scores (RR 2.14; 95% CI 1.41 to 3.24, 1 RCT, n = 87, low-certainty evidence), dysmenorrhoea scores (RR 2.25; 95% CI 1.59 to 3.16, 1 RCT, n = 85, low-certainty evidence), dyspareunia scores (RR 2.21; 95% CI 1.39 to 3.54, 1 RCT, n = 59, low-certainty evidence), and pelvic tenderness scores (RR 2.28; 95% CI 1.48 to 3.50, 1 RCT, n = 85, low-certainty evidence) after three months of treatment. We are uncertain of the effect for pelvic induration, based on the results found after three months of treatment (RR 1.07; 95% CI 0.64 to 1.79, 1 RCT, n = 81, low-certainty evidence). Besides, treatment with GnRHas may be associated with a greater incidence of hot flushes at three months of treatment (RR 3.08; 95% CI 1.89 to 5.01, 1 RCT, n = 100, low-certainty evidence). Trials comparing GnRHas versus danazol For overall pain, for women treated with either GnRHas or danazol, a subdivision was made between pelvic tenderness, partly resolved and completely resolved. We are uncertain about the effect on relief of overall pain, when a subdivision was made for overall pain (MD -0.30; 95% CI -1.66 to 1.06, 1 RCT, n = 41, very low-certainty evidence), pelvic pain (MD 0.20; 95% CI -0.26 to 0.66, 1 RCT, n = 41, very low-certainty evidence), dysmenorrhoea (MD 0.10; 95% CI -0.49 to 0.69, 1 RCT, n = 41, very low-certainty evidence), dyspareunia (MD -0.20; 95% CI -0.77 to 0.37, 1 RCT, n = 41, very low-certainty evidence), pelvic induration (MD -0.10; 95% CI -0.59 to 0.39, 1 RCT, n = 41, very low-certainty evidence), and pelvic tenderness (MD -0.20; 95% CI -0.78 to 0.38, 1 RCT, n = 41, very low-certainty evidence) after three months of treatment. For pelvic pain (MD 0.50; 95% CI 0.10 to 0.90, 1 RCT, n = 41, very low-certainty evidence) and pelvic induration (MD 0.70; 95% CI 0.21 to 1.19, 1 RCT, n = 41, very low-certainty evidence), the complaints may decrease slightly after treatment with GnRHas, compared to danazol, for six months of treatment. Trials comparing GnRHas versus analgesics  We did not identify any studies. Trials comparing GnRHas versus intra-uterine progestogens We did not identify any low risk of bias studies. Trials comparing GnRHas versus GnRHas in conjunction with calcium-regulating agents There may be a slight decrease in bone mineral density (BMD) after 12 months treatment with GnRHas, compared to GnRHas in conjunction with calcium-regulating agents for anterior-posterior spine (MD -7.00; 95% CI -7.53 to -6.47, 1 RCT, n = 41, very low-certainty evidence) and lateral spine (MD -12.40; 95% CI -13.31 to -11.49, 1 RCT, n = 41, very low-certainty evidence).  AUTHORS' CONCLUSIONS: For relief of overall pain, there may be a slight decrease in favour of treatment with GnRHas compared to placebo or oral or injectable progestogens. We are uncertain about the effect when comparing GnRHas with danazol, intra-uterine progestogens or gestrinone. For BMD, there may be a slight decrease when women are treated with GnRHas, compared to gestrinone. There was a bigger decrease of BMD in favour of GnRHas, compared to GnRHas in conjunction with calcium-regulating agents. However, there may be a slight increase in adverse effects when women are treated with GnRHas, compared to placebo or gestrinone. Due to a very low to low certainty of the evidence, a wide range of outcome measures and a wide range of outcome measurement instruments, the results should be interpreted with caution.

Gonadotrophin-releasing hormone analogues for pain associated with endometriosis

EDITORIAL NOTE

See https://pubmed.ncbi.nlm.nih.gov/37341141/ for a more recent review that covers this topic and has superseded this review.

BACKGROUND

Endometriosis is a common gynaecological condition, characterised by the presence of endometrial tissue in sites other than the uterine cavity (excluding adenomyosis) that frequently presents with pain. The gonadotrophin-releasing hormone analogues (GnRHas) comprise one intervention that has been offered for pain relief in pre-menopausal women. GnRHas can be administered intranasally, by subcutaneous, or intramuscular injection. They are thought to result in down regulation of the pituitary and induce a hypogonadotrophic hypogonadal state.

OBJECTIVES

To determine the effectiveness and safety of GnRHas in the treatment of the painful symptoms associated with endometriosis.

SEARCH STRATEGY

Electronic searches of the Cochrane Menstrual Disorders and Subfertility Group specialist register, CENTRAL, MEDLINE, EMBASE, PSYCInfo and CINAHL were conducted in April 2010 to identify relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

RCTs of GnRHas as treatment for pain associated with endometriosis versus no treatment, placebo, danazol, intra-uterine progestagens, or other GnRHas were included. Trials using add-back therapy, oral contraceptives, surgical intervention, GnRH antagonists or complementary therapies were excluded.

DATA COLLECTION AND ANALYSIS

Quality assessment and data extraction were performed independently by two reviewers. The primary outcome was pain relief. Relative risk was used as the measure of effect for dichotomous data. For continuous data, mean differences or standardised mean differences were used.

MAIN RESULTS

Forty one trials (n=4935 women) were included. The evidence suggested that GnRHas were more effective at symptom relief than no treatment/placebo. There was no statistically significant difference between GnRHas and danazol for dysmenorrhoea RR 0.98 (95%CI 0.92 to 1.04; P = 0.53). This equates to 3 fewer women per 1000 (95%CI 12 to 6) with symptomatic pain relief in the GnRHa group. More adverse events were reported in the GnRHa group. There was a benefit in overall resolution for GnRHas RR1.10 (95%CI 1.01 to 1.21, P=0.03) compared with danazol. There was no statistically significant difference in overall pain between GnRHas and levonorgestrel SMD -0.25 (95%CI -0.60 to 0.10, P=0.46). Evidence was limited on optimal dosage or duration of treatment for GnRHas. No route of administration appeared superior to another.

AUTHORS' CONCLUSIONS

GnRHas appear to be more effective at relieving pain associated with endometriosis than no treatment/placebo. There was no evidence of a difference in pain relief between GnRHas and danazol although more adverse events reported in the GnRHa groups. There was no evidence of a difference in pain relief between GnRHas and levonorgestrel and no studies compared GnRHas with analgesics.

Peripheral biomarkers of endometriosis: a systematic review

BACKGROUND

Endometriosis is estimated to affect 1 in 10 women during the reproductive years. There is often delay in making the diagnosis, mainly due to the non-specific nature of the associated symptoms and the need to verify the disease surgically. A biomarker that is simple to measure could help clinicians to diagnose (or at least exclude) endometriosis; it might also allow the effects of treatment to be monitored. If effective, such a marker or panel of markers could prevent unnecessary diagnostic procedures and/or recognize treatment failure at an early stage.

METHODS

We used QUADAS (Quality Assessment of Diagnostic Accuracy Studies) criteria to perform a systematic review of the literature over the last 25 years to assess critically the clinical value of all proposed biomarkers for endometriosis in serum, plasma and urine.

RESULTS

We identified over 100 putative biomarkers in publications that met the selection criteria. We were unable to identify a single biomarker or panel of biomarkers that have unequivocally been shown to be clinically useful.

CONCLUSIONS

Peripheral biomarkers show promise as diagnostic aids, but further research is necessary before they can be recommended in routine clinical care. Panels of markers may allow increased sensitivity and specificity of any diagnostic test.

Paracrine regulation of endometriotic tissue

Endometriosis is a chronic estrogen-dependent gynecological disease, characterized by pelvic pain and infertility, defined as the presence of endometrial glands and stroma within the pelvic peritoneum and other extrauterine sites. In the peritoneal cavity endometrial cells adhere, proliferate and induce an inflammatory response. Despite a long history of clinical and experimental research, the pathogenesis of endometriosis is still controversial. Abnormal immunological activation, the endocrine milieu and the peritoneal environment all dramatically affect endometriotic tissue function. Recent studies suggest that the peritoneal fluid of women with endometriosis contains an increased number of activated macrophages and other immune cells that secrete various local products, such as growth factors and cytokines, which exert a paracrine action on endometriotic cells. Since the peculiar biological characteristics of eutopic endometrium from women with endometriosis differ from endometrium of normal subjects, an important role in the pathogenesis of this complex disease has been suggested. All of these factors contribute to enhanced proliferative and angiogenic activity and a number of functional and structural changes, resulting in the particular behavior of this tissue.

Endometriosis as a model for inflammation–hormone interactions in ovarian and breast cancers

Chronic inflammation has been implicated in a variety of cancers. In this review, we consider associations between endometriosis and cancers both local (ovarian) and distant (breast). We review the epidemiological data linking endometriosis to ovarian and breast cancers. We then consider evidence for a role for sex steroid hormones and for inflammation in the aetiology of each of these cancers. Finally, we consider that endometriosis may promote alterations in sex steroid hormones and inflammatory mediators. A possible explanation for the association between endometriosis and these reproductive cancers may then be local and systemic enhancement of aberrant inflammatory and hormonal mediators. If this hypothesis is true, endometriosis may need to be considered as a risk factor for ovarian and breast cancers, triggering increasingly intensive surveillance. Moreover, treatments for endometriosis may require consideration of the impact on long-term cancer risk.

Endometriosis and Systemic Lupus Erythematosus: A Comparative Evaluation of Clinical Manifestations and Serological Autoimmune Phenomena

PROBLEM

In view of evidences suggesting association between endometriosis (EM) and systemic lupus erythematosus (SLE), we have performed a comparative evaluation of clinical and humoral immunologic abnormalities in both diseases.

METHOD OF STUDY

Forty-five women (18-40 years) with histologically confirmed pelvic EM, 21 healthy-women and 15 female SLE-patients (18-40 years) without surgically confirmed EM were prospectively evaluated. Immunologic investigations were performed by blinded researchers.

RESULTS

None of the EM-patients fulfilled criteria for SLE. However, EM-patients presented higher frequencies of arthralgia (62%) and generalized myalgia (18%) superior than normal-controls (24%, P = 0.004/0%, P = 0.048) but comparable with SLE-patients (33%, P = 0.052/27%, P = 0.5). Similarly to SLE (7%), 9% of EM-patients presented fibromyalgia. Antinuclear antibodies (ANA) were detected in 18% of EM-sera, as compared with healthy-women (0%, P = 0.014) and SLE-patients (93%, P = 0.0005). In contrast with SLE, antibodies to dsDNA, Sm and U1RNP were negative in EM-sera. Anti-Ro and anticardiolipin antibodies were more often in SLE (40%, 33%) than in EM-patients (2%, P < 0.001/9%, P = 0.04). Elevated immune-complexes and low total complement were more frequent in SLE (40%, 13%) compared with EM-sera (7%, P = 0.005/0%, P = 0.01).

CONCLUSIONS

Our data indicate differences of ANA antigenic specificity and complement consumption between EM and SLE. The high prevalence of generalized musculoskeletal complaints in EM justifies a multidisciplinary approach.

Pelvic pain caused by intraperitoneal Enterobius vermicularis (threadworm) ova with an associated systemic autoimmune reaction

AIM

The aim of this paper, based on a case study was two-fold; firstly to review the sites and gynecologic complications of ectopic Enterobius vermicularis and secondly study the autoimmune accompaniments of parasitic infestations.

METHODS

A case of intraperitoneal ectopic Enterobius vermicularis, with accompanying autoimmune signs and symptoms, is presented and its response to surgical and medical treatment described. A medical literature search was carried out into the subject of ectopic Enterobius vermicularis, particularly from the gynecologic perspective along with a study of autoimmune activation associated with parasitic infestation.

RESULTS

Pelvic pain was found to be caused by chronic inflammation from ectopic Enterobius vermicularis. This was treated both surgically and medically, with the surgical treatment proving to be inadequate but with a good response to immune modification. In the literature ectopic Enterobius vermicularis was found to be treatable surgically.

CONCLUSION

Ectopic Enterobius vermicularis was found to create symptomatic inflammatory lesions that could be treated surgically and an associated autoimmune response treatable by immune modification.

Potential involvement of the immune system in the development of endometriosis

This article presents an overview of immunological factors and their role in the development of endometriosis, with emphasis on inflammatory cytokines, growth and adhesion factors. Although retrograde menstruation is a common phenomenon among women of reproductive age, not all women who have retrograde menstruation develop endometriosis. The development of endometriosis is hypothesised to be a complex process, which may be facilitated by several factors, including the quantity and quality of endometrial cells in peritoneal fluid (PF), increased inflammatory activity in PF, increased endometrial-peritoneal adhesion and angiogenesis, reduced immune surveillance and clearance of endometrial cells, and increased production of autoantibodies against endometrial cells. Potential biomarkers like cytokines and autoantibodies upregulated during development of endometriosis may be useful in the development of a non-surgical diagnostic tool. Although endometriosis can be treated using hormonal suppression, there is need for non-hormonal drugs, which can inhibit the development of endometriosis and alleviate pain or infertility without inhibition of ovulation. New molecules that modulate immune function in endometriosis should be the targets for future research.

Endometriosis and ovarian cancer: thoughts on shared pathophysiology

BACKGROUND

Endometriosis appears to predispose to ovarian cancer. How this may occur has been little discussed.

STUDY DESIGN

This article reviews the English language literature for in vitro, animal, clinical, and epidemiologic studies linking the two conditions.

RESULTS

Pathology case series consistently report endometrioid and clear cell types of ovarian cancer arising from endometriotic foci. Epidemiologic studies have been consistent with this association. There are also marked similarities between the proposed etiology of ovarian cancer and the observed pathophysiology of endometriosis. Specifically, both are characterized by immune alterations. Both conditions are promoted by estrogen excess and by progesterone deficit. Finally, steroid hormones interacting with the immune system may stimulate both endometriosis and ovarian cancer. I propose that the biology common to endometriosis and ovarian cancer represents not just a parallelism, but instead a causal pathway: aberrant immune function, fed by and feeding on estrogens, unbalanced by progesterone, may create a positive feed-forward loop that enhances the growth and invasiveness of endometriosis and promotes its malignant transformation.

CONCLUSIONS

The same pathophysiology may orchestrate the progression of endometriosis and its transformation to endometroid and clear cell ovarian neoplasias. This notion of a unifying biology suggests a directed approach to future research and identifies possible chemoprevention strategies for women with endometriosis.

Immunology and Endometriosis

PROBLEM

Accumulating data suggests that aberrant immune responses during retrograde menstruation may be involved in the development of endometriosis.

METHOD OF STUDY

The role of immunology in the etiology of endometriosis is reviewed and summarized from the available literature.

RESULTS

Immunologic factors may affect a woman's susceptibility to implantation of exfoliated endometrial cells. Immune alterations include increased number and activation of peritoneal macrophages, decreased T cell reactivity and natural killer cell cytotoxicity, increased circulating antibodies, and changes in the cytokine network.

CONCLUSION

There is substantial evidence that immunologic factors play a role in the pathogenesis of endometriosis and endometriosis-associated infertility. Decreased natural killer cell cytotoxicity leads to an increased likelihood of implantation of endometriotic tissue. In addition, macrophages and a complex network of locally produced cytokines modulate the growth and inflammatory behavior of ectopic endometrial implants.

Low molecular weight heparin in immunological recurrent abortion--the incredible cure

The most compelling association between pregnancy loss and autoimmune phenomena has been with the presence of antiphospholipid antibodies (APA)--lupus anticoagulant and anticardiolipin antibody. The 'antiphospholipid antibody syndrome' has been described in women with a history of recurrent pregnancy loss or thrombosis with positive APA or lupus anticoagulant on two occasions. Although several treatments have been advocated, heparin and aspirin treatment is emerging as the treatment of choice for the APA syndrome associated with recurrent pregnancy loss. The rationale for prescribing aspirin in cases of recurrent reproductive failure associated with APA seropositivity is that aspirin may counter APA-mediated hypercoagulability in the choriodecidual space, a situation which if left unaddressed would traumatize the trophoblast and compromise feto-maternal exchange. Heparin on the other hand, through preventing APA from interfering with syncytialization of the early cytotrophoblast and by countering APA interference with phospholipid-decidual reactions that are vital to early implantation, might potentially promote both early implantation and subsequent placentation.

The immunological "Wars of the Roses": disagreements amongst reproductive immunologists

The relevance of abnormal autoimmune function to reproductive function in the female has over recent years become an increasingly controversial and contentious issue. Opposing views have led to a polarization of opinions which, at times, resulted in publications of rather vocal opinions by individuals as well as societal committees. This communication is an attempt to reconcile these, at times diametrically opposing opinions, in a concept of (auto)immune-driven reproduction failure, which could explain and unify these opposing opinions and, thus, hopefully end the ongoing "immunological wars of the roses".

Treating endometriosis as an autoimmune disease

OBJECTIVE

To review the literature on the role of autoimmunity in the etiology of endometriosis, compare the similarities in the pathophysiologies between endometriosis and autoimmune diseases, and discuss the use of immunomodulators currently used to treat autoimmune diseases as potential therapies for endometriosis.

DESIGN

The literature on endometriosis and other autoimmune diseases was reviewed, and summary data are presented.

RESULTS

Endometriosis shares many similarities with autoimmune diseases such as rheumatoid arthritis, Crohn's disease, and psoriasis. These similarities include elevated levels of cytokines, decreased cell apoptosis, and T- and B-cell abnormalities. Because the use of immunomodulators and inflammatory modulators has proven to be an effective means of medical management for these autoimmune diseases, similar therapies may prove useful in treating endometriosis.

CONCLUSION(S)

Although substantial evidence indicates that endometriosis at least shares many similarities with autoimmune diseases, endometriosis is primarily treated by using compounds that induce a hypoestrogenic environment. A review of the literature combined with the shortcomings of current means of medical management for endometriosis support the postulate that treatment of endometriosis with immunomodulators and inflammatory modulators is warranted.

Spz1, a novel bHLH-Zip protein, is specifically expressed in testis

We isolated a novel bHLH-Zip gene designated Spz1 from a mouse testis cDNA library. Spz1 is expressed specifically in the testis and epididymis. Immunofluorescence staining detected Spz1 protein in the nuclei of LFG6 Leydig cells. The ability of Spz1 protein to bind to the bHLH consensus-binding site, the E-box, was confirmed by EMSA, and a 9-bp asymmetric target site was identified by random selection and PCR amplification. Hormonal regulation of Spz1 was investigated and downregulation of Spz1 expression by testosterone and retinoic acid was found. This nuclear transcription factor may play a crucial role in spermatogenesis by regulating cell proliferation or differentiation through binding to specific DNA sequences like other bHLH-Zip molecules.

Effect of hormonal agents on monocyte chemotactic protein-1 expression by endometrial epithelial cells of women with endometriosis

OBJECTIVE

To assess whether hormonal agents used in the medical treatment of endometriosis, such as danazol and GnRH agonist, exert direct regulatory action on monocyte chemotactic protein-1 (MCP-1) expression by endometrial epithelial cells.

DESIGN

Primary cultures of epithelial cells isolated from human endometrium were exposed to different concentrations of cytokines and steroid hormone analogs. Expression of MCP-1 was analyzed at the levels of protein and messenger RNA.

SETTING

Gynecology clinic and laboratory of endocrinology of reproduction.

PATIENT(S)

Women presenting for infertility or pelvic pain in whom endometriosis was diagnosed by using laparoscopy.

INTERVENTION(S)

Endometrial tissue biopsy performed at laparoscopy.

MAIN OUTCOME MEASURE(S)

Secretion of MCP-1 protein was measured by using enzyme-linked immunosorbent assay, and mRNA steady-state levels were measured by performing Northern blot analysis.

RESULT(S)

Buserelin acetate, a GnRH agonist (0.1-10 ng/mL), had no significant effect on MCP-1 expression, whereas danazol (10(-7)-10(-5) M), a testosterone analog, and dexamethasone, an anti-inflammatory glucocorticoid hormone (10(-12)-10(-6)M), showed a direct and a dose-dependent inhibitory effect on MCP-1 expression. This effect occurred at the level of protein and mRNA.

CONCLUSION(S)

The findings of the study may affect understanding of the mechanisms by which hormonal treatments act on endometriosis and influence its clinical manifestations.

Peritoneal and peripheral B-1-cell populations in patients with endometriosis

OBJECTIVE

The purpose of this study was to investigate the frequency of B-1 cells in the peritoneal cavity and peripheral blood of patients with endometriosis.

MATERIALS AND METHODS

We examined 31 patients with endometriosis and 14 normal nonpregnant women. Peripheral blood cells and peritoneal exudate cells (PECs) were stained with FITC or PE-labeled anti-CD5/CD19 monoclonal antibodies. Immunofluorescence analysis was performed using a flow cytometer. The significance of differences between the patient and control groups was determined by the non-parametric Mann-Whitney test.

RESULTS

There was no significant difference in the percentages of B-1 cells in the peripheral blood of women with and without endometriosis (median, 22.7%; range, 4.7-92.3% vs median, 20.05%; range, 11.1-12.6%, respectively). Endometriosis patients with antinuclear antibodies (ANAs) demonstrated significantly elevated B-1 cells compared to both endometriosis patients without ANAs and normal controls (p < 0.005 and p < 0.05, respectively). Endometriosis patients demonstrated significantly higher B-1 cell populations (B-1 cells/total B-cell ratio) in PECs than did non-endometriosis patients (p < 0.05).

CONCLUSIONS

The peripheral B-1-cell population in patients with endometriosis is related to ANA production. B-1 cells might play important roles in the development of endometriosis through autoantibody production.

Environmental endocrine modulators and human health: an assessment of the biological evidence

Recently, a great deal of attention and interest has been directed toward the hypothesis that exposure, particularly in utero exposure, to certain environmental chemicals might be capable of causing a spectrum of adverse effects as a result of endocrine modulation. In particular, the hypothesis has focused on the idea that certain organochlorine and other compounds acting as weak estrogens have the capability, either alone or in combination, to produce a variety of adverse effects, including breast, testicular and prostate cancer, adverse effects on male reproductive tract, endometriosis, fertility problems, alterations of sexual behavior, learning disability or delay, and adverse effects on immune and thyroid function. While hormones are potent modulators of biochemical and physiological function, the implication that exposure to environmental hormones (e.g., xenoestrogens) has this capability is uncertain. While it is reasonable to hypothesize that exposure to estrogen-like compounds, whatever their source, could adversely affect human health, biological plausibility alone is an insufficient basis for concluding that environmental endocrine modulators have adversely affected humans. Diethylstilbestrol (DES) is a potent, synthetic estrogen administered under a variety of dosing protocols to millions of women in the belief (now known to be mistaken) that it would prevent miscarriage. As a result of this use, substantial in utero exposure to large numbers of male and female offspring occurred. Numerous studies have been conducted on the health consequences of in utero DES exposure among the adult offspring of these women. There are also extensive animal data on the effects of DES and there is a high degree of concordance between effects observed in animals and humans. The extensive human data in DES-exposed cohorts provide a useful basis for assessing the biological plausibility that potential adverse effects might occur following in utero exposure to compounds identified as environmental estrogens. The effects observed in both animals and humans following in utero exposure to sufficient doses of DES are consistent with basic principles of dose response as well as the possibility of maternal dose levels below which potential non-cancer effects may not occur. Significant differences in estrogenic potency between DES and chemicals identified to date as environmental estrogens, as well as an even larger number of naturally occurring dietary phytoestrogens, must be taken into account when inferring potential effects from in utero exposure to any of these substances. The antiestrogenic properties of many of these same exogenous compounds might also diminish net estrogenic effects. Based on the extensive data on DES-exposed cohorts, it appears unlikely that in utero exposure to usual levels of environmental estrogenic substances, from whatever source, would be sufficient to produce many of the effects (i.e., endometriosis, adverse effects on the male reproductive tract, male and female fertility problems, alterations of sexual behavior, learning problems, immune system effects or thyroid effects) hypothesized as potentially resulting from exposure to chemicals identified to date as environmental estrogens.

The immunotherapy during in vitro fertilization and embryo transfer cycles in infertile patients with endometriosis

OBJECTIVE

To investigate if the immunotherapy with corticosteroids would improve the pregnancy rate in infertile patients with endometriosis who undergo in vitro fertilization and embryo transfer (IVF-ET).

METHODS

Forty-two infertile patients with endometriosis plus tubal factor and 87 pure tubal infertility patients who underwent IVF-ET in our unit were allocated randomly to the corticosteroid treatment group and the control group.

RESULTS

The prevalence of autoantibodies (antinuclear antibody, lupus anticoagulant, anticardiolipin antibody, rheumatoid factor) was elevated significantly in patients with endometriosis plus tubal factor compared with pure tubal infertility patients (38.1% vs 2.3%). Twenty-one patients with endometriosis plus tubal factor underwent 54 cycles of IVF-ET, receiving corticosteroids. Forty-three patients with pure tubal factor underwent 81 cycles of IVF-ET, receiving corticosteroids. Twenty-one patients with endometriosis plus tubal factor who underwent 57 cycles of IVF-ET and 44 patients with pure tubal factor who underwent 84 cycles of IVF-ET served as controls, not receiving corticosteroids. In patients with endometriosis plus tubal factor, there was a significantly higher clinical pregnancy rate per cycle in the treatment group, with 42.6% (23/54) compared with 22.8% (13/57) in the control group but no differences between 2 groups in spontaneous abortion rate (21.7% vs 15.4%) and multiple pregnancy rate (17.4% vs 15.4%). In patients with pure tubal infertility, there were no significant differences between the treatment group and control group in clinical pregnancy rate (40.7% vs 34.5%), spontaneous abortion rate (12.1% vs 10.3%) or multiple pregnancy rate (18.2% vs 10.3%). In the endometriosis plus tubal infertility group with autoantibodies, the clinical pregnancy rate per cycle was significantly higher in the treatment group at 40.9% compared with 14.8% in the control group. In endometriosis plus tubal infertility group without autoantibodies, there was no significant difference between 2 groups with respect to the clinical pregnancy rate per cycle (43.8% vs 30.0%).

CONCLUSIONS

This study suggests that immunotherapy with corticosteroids could improve the clinical pregnancy rate in endometriosis patients undergoing IVF-ET and may be more effective in patients with positive autoantibodies.

Elevated serum lipoprotein(a) levels in young women with endometriosis

Elevated serum lipoprotein(a) [Lp(a)] levels increase the risk of cardiovascular disease if levels of low-density lipoproteins (LDLs) are also high. The biological function of Lp(a) is unknown, but plasma levels may be elevated in inflammatory disease. Endometriosis is a common gynecologic disorder in which endometrial tissue is found outside of the lining of the uterine cavity. There is an immune component to this condition whereby the number of peritoneal macrophages is increased and the level of prostanoids and cytokines in peritoneal fluid is elevated. In the present study, we measured serum lipid, lipoprotein, and apolipoprotein levels in 29 women with endometriosis and in 29 matched healthy controls. Fasting serum triglyceride and apolipoprotein (apo) Al levels were higher in women with endometriosis (+28.1%, P < .001, and +12.3%, P < .01, respectively), but there were no significant differences in LDL or high-density lipoprotein (HDL) cholesterol levels. Serum Lp(a) levels were fivefold higher (P < .01) in the patients (median, 15.0 mg/dL; range, 0.05 to 60.0) than in controls (median, 3.1 mg/dL; range, 0.05 to 57.2). The distribution of apo(a) isoforms was similar in the two groups, but in women with endometriosis the individual apo(a) isoforms tended to be associated with higher serum Lp(a) levels. Endometriosis may represent a relatively common condition in which to investigate the role of Lp(a) in human metabolism.

Pathogenesis of endometriosis

This article reviews the pathogenesis of endometriosis, which involves retrograde dissemination of endometrium and/or development in situ by metaplasia, and there is evidence suggesting that genetic and hormonal factors may play a role. There is also substantial evidence that immunologic factors, namely peritoneal macrophages, T cells, natural killer cells, and soluble products secreted by these cells, are involved in the pathogenesis of endometriosis.

Enhanced interleukin-4 expression in patients with endometriosis

OBJECTIVE

To investigate the expression of cytokines by T-helper cells type 1 (interleukin [IL]-2 and interferon-gamma [IFN-gamma]) and type 2 (IL-4 and IL-10) in peripheral blood monocytes and peritoneal fluid (PF) cells from patients with endometriosis.

DESIGN

Peripheral blood (PB) monocytes and PF cells from patients with endometriosis were isolated and the expression of cytokines investigated.

SETTING

Institute for the treatment of endometriosis and research institute in university-based medical center.

PATIENT(S)

The study included 7 women with normal pelvic structure, 36 patients with endometriosis, and 7 women with pelvic adhesion but without apparent endometriotic lesion. The existence and severity of endometriosis was determined by laparoscopic examination.

INTERVENTION(S)

All patients received laparoscopic operation to identify the existence and stages of endometriosis. Danazol (200 mg, twice daily) was prescribed for those with endometriosis.

MAIN OUTCOME MEASURE(S)

Transcription of cytokines were directly analyzed using the reverse transcriptase-polymerase chain reaction method. The concentrations of cytokines in peritoneal fluids and sera were analyzed by the ELISA.

RESULT(S)

Levels of IL-4 messenger RNA (mRNA) and protein in the PB and peritoneal cells of patients with endometriosis were higher than those of normal patients, whereas levels of IFN-gamma mRNA and protein were suppressed. There were no significant changes in the mRNA or protein levels of IL-2 or IL-10 in both peritoneal fluids and sera. The level of IL-4 was reduced to normal after combined treatment with laparoscopic surgery and danazol. The secretion of IFN-gamma was elevated after treatment.

CONCLUSION(S)

Cytokine secretion by T-helper cells type 1 and type 2 is altered in women with endometriosis, suggesting that these T-helper subsets play a role in the immunologic responses to endometriosis.

Autoimmunity and reproduction

OBJECTIVE

To review the association between autoimmunity and reproductive failure.

DESIGN

A MEDLINE search done from 1965 to 1996. More than 300 original and review articles were evaluated, from which the most relevant were selected.

RESULT(S)

Autoimmune processes now are accepted widely as one of the possible mechanisms of many human diseases. The presence of autoimmune disorders has been associated repeatedly with reproductive failure. On the other hand, reproductive failure may be the first manifestation of autoimmune disorders.

CONCLUSION(S)

When abnormal autoantibody levels are present in women with reproductive failure, the reproductive failure alone should be considered as one of the possible clinical expressions of autoimmune disorders. Two relevant questions of whether these patients should be treated for autoimmunity remain unsolved. A prospective, placebo-controlled trial is necessary to evaluate the importance of any treatment.

Successful glucocorticoid treatment for patients with abnormal autoimmunity on in vitro fertilization and embryo transfer

PURPOSE

To analyze the effects of glucocorticoid treatment for patients with abnormal autoimmunity on IVF-ET outcomes, low-dose predonisolone or dexamethasone was administered in 51 IVF-ET cycles of 41 patients with positive antinuclear antibody (ANA), anti-DNA antibody, and/or lupus anticoagulant (LAC). Rates of clinical pregnancy and implantation in these patients were compared with those in 48 cycles without corticosteroid therapy. Autoantibody-negative patients were also treated with IVF-ET combined with (29 cycles) or without (57 cycles) glucocorticoid administration, and the pregnancy and implantation rates were investigated.

RESULTS

Without glucocorticoid treatment, the pregnancy rate per cycle and implantation rate per embryo in antibody-positive patients were 10.4 and 3.8%, respectively. Significant increases in pregnancy (35.3%) and implantation (13.2%) rates were observed with corticosteroid treatment. In antibody-negative patients, the rates of pregnancy and implantation showed no significant differences with versus without the glucocorticoid administration.

CONCLUSIONS

Our results indicate that because autoimmune abnormalities may be at least one cause of implantation failure following IVF-ET, the combined use of low-dose corticosteroid can be effective for autoantibody-positive women.

Effect of danazol on the immunocompetent cells in the eutopic endometrium in patients with endometriosis: a multicenter cooperative study

OBJECTIVE

To assess the effects of danazol on immunocompetent cells, human leukocyte antigen (HLA) expression, and adhesion molecules in the eutopic endometrium of patients with endometriosis.

DESIGN

Antigens were localized immunohistochemically in the endometria, before treatment and during treatment (2 months later).

PARTICIPANTS

Ten patients with laparoscopically proven endometriosis who consented to participate in this study were treated with 400 mg/d of danazol for 4 months. Forty-two infertile patients without endometriosis or adenomyosis served as controls.

RESULTS

Immunohistochemical analysis revealed significantly increased expression of the T cell subsets, macrophages, adhesion molecules, and HLA antigens in eutopic endometrium in patients with endometriosis compared with the infertile group. Treatment with danazol reduced the number of cells in T cell subsets, adhesion molecules, or HLA antigen expression, especially of gamma delta T cells, to 39.5% of the pretreatment value in patients with endometriosis.

CONCLUSIONS

Danazol had an immunomodulatory effect on the autoimmune response in endometrium associated with endometriosis.

Danazol distribution in plasma and cell membranes as related to altered cell properties: implications for mechanism

Concentrations of danazol in patient plasma and red blood cells (RBC) were assayed over a 6-month period in 75 patients on danazol therapy using a high-pressure liquid chromatography (HPLC) method more reliable than previous radioimmunoassay (RIA) methods. It was found that plasma danazol rose regularly for 15 days after the beginning of treatment, reaching a steady state plateau of 175 +/- 76 ng/ml in 20 patients on normal dose, and less for lower dose schedules. After stopping danazol, concentrations declined to near zero in a similar time frame. RBC concentrations on a packed volume basis were similar to plasma levels. However, the membrane ghosts of RBC contained about 50% of the total RBC danazol, implying about 100-fold higher concentration in membranes than in plasma. Similar distributions were obtained in vitro with both RBC and platelets, and were confirmed by 14-C-labeled danazol. These findings tend to support the hypothesis that the benefits of danazol in immune disorders may be attributable in part to its intercalation in the lipid bilayer of the plasma membrane, altering antigen/receptor expression to modulate immune reactions. This hypothesis was first suggested when it was observed that the RBC of patients on danazol therapy showed morphological changes and increased resistance to osmotic lysis. It was later shown that danazol in vitro reduces binding of autoantibodies, and protects against complement-mediated lysis, suggesting direct action of danazol on the membranes. This hypothesis is discussed, and danazol's effect in protecting against complement-mediated lysis is described.

Immune dysfunction--a potential target for treatment in endometriosis

The treatment approach towards endometriosis has been traditionally either surgical or hormonal in nature. Since endometriosis is, to a large extent, a microscopic disease, a surgical approach cannot be expected to eradicate the disease. Treatment is, therefore, generally attempted by hormonal manipulation, an approach based on the known oestrogen sensitivity of endometriosis. Hormonal manipulation can only temporarily affect endometriosis, and quite clearly does not address the underlying aetiology and/or pathophysiology of the disease. Since neither is, at present, well understood, one can only speculate as to the treatment approach that would, in fact, affect the pathophysiology of the condition. Endometriosis has, in recent years, been characterized by a large number of immunological abnormalities in the host. It is, therefore, very tempting to speculate that an immunological defect represents the basic abnormality which later leads to the occurrence of the disease. This assumption is supported by the observation that those immunological defects are already present in the mildest forms of the disease. In fact, if one believes that many cases of unexplained infertility represent undiagnosed microscopic endometriosis, then evidence suggests that this precursor stage of the disease is basically characterized by an identical immunological profile to that of endometriosis. An immunological aetiology and/or pathophysiology of endometriosis should lead to an immunological treatment approach toward the disease. Specifically, a number of non-specific immunomodulators, presently utilized in a variety of medical conditions with immunological aetiologies, would seem to represent promising new therapeutic strategies to conquer endometriosis at its roots. A new treatment approach to endometriosis appears urgently needed since, at least with regard to the effects of endometriosis on fertility and pregnancy loss, present approaches have proven ineffective.

Changes in bone mineral content following hormone treatment for endometriosis

The effects of danazol and buserelin on the bone mineral content (BMC) of 19 Japanese women with endometriosis were studied. Subjects received 24-week courses of oral danazol (400 mg/day) or intranasal buserelin (900 micrograms/day). Trabecular BMC of the 3rd lumbar vertebra (L3) was monitored by computerized tomography scans pretreatment, at the end of treatment and 6 months post-treatment. In the buserelin group there was a significant decrease in BMC (10-25.4%, P < 0.01) which was not fully reversed 6 months after therapy, and increased parameters of bone resorption. In the danazol group, there was a slight gain in BMC despite a decrease in serum estrogen. Danazol and buserelin have similar success in the treatment of endometriosis, but the decrease in BMC at L3 suggests that cumulative bone loss may follow repeated buserelin therapy.

Immunological aspects of endometriosis

During the past decade, evidence has accumulated indicating an association between endometriosis and changes in humoral and cell-mediated immunity. However, it is not clear whether immune changes are the sequelae or play a role in the etiopathogenesis of the disease. The latter concept is supported by the observation that exposure of rhesus monkeys to radiation or immunotoxicants leads several years later to an increase in frequency and severity of endometriosis. Studies from our laboratories support the theory that endometrial cells misplaced during menses can implant in ectopic locations only in women with genetically or environmentally altered cell-mediated immune function. Development of endometriosis may then prompt a humoral response in some women, which results in the production of autoantibodies to endometrial cells or cell-derived antigens. These autoantibodies may cross-react with the uterine endometrium, interfere with implantation, and cause infertility or early spontaneous abortions. We recently observed that the presence of autoantibodies in endometriosis was associated with significantly lower in vitro fertilization/embryo transfer pregnancy rates. Interestingly, in about 30% of women with unexplained infertility, immune changes characteristic of endometriosis were also present, suggesting a subclinical form of this disease. We conclude that: (1) women with unexplained infertility should have studies of the immune function to rule out subclinical form of endometriosis; (2) evaluation of infertility in women with endometriosis should include an assessment of autoantibody status; and (3) treatment methods involving autoantibody suppression should be considered in women with endometriosis positive for autoantibodies.

Leukocyte subpopulation changes in rats with autotransplanted endometrium and the effect of danazol

PROBLEM

This study examines immune cell populations in rats with autotransplanted endometrium and determines the effect of danazol on leukocyte subsets.

METHODS

As an experimental model of endometriosis, an autologous endometrial segment was implanted in the rat peritoneum. We used flow cytometry to analyze lymphocyte subsets in the peripheral blood (PB) and peritoneal fluid (PF) of the following groups of rats: no treatment, sham operation, endometrial implantation, endometrial implantation treated with danazol, and normal rats treated with danazol.

RESULTS

The natural killer (NK) cell population was decreased in both the PB and PF of rats with autotransplanted endometrium. Moreover, NK cells increased in a dose-dependent manner following danazol administration. Surgery itself increased the number of peritoneal macrophages as compared with the untreated group. This elevation was suppressed partially by endometrium-implantation and was attenuated by subsequent administration of danazol in a dose-dependent fashion.

CONCLUSIONS

These data suggest that ectopic endometrial cells may release immunosuppressive factors. This is the first documentation that rats with autotransplanted endometrium show the same immunologic changes as humans with endometriosis, and establishes the utility of this model for the study of endometriosis.

The effect of endometriosis, its stage and activity, and of autoantibodies on in vitro fertilization and embryo transfer success rates

OBJECTIVES

To analyze IVF cycle parameters, including pregnancy rates (PR), in women with and without endometriosis and to evaluate the effect of the stage and activity of endometriosis and of autoantibodies.

DESIGN

A retrospective analysis of 237 consecutive IVF cycles (193 patients), 119 in women with and 118 without endometriosis. The endometriosis group was further subdivided according to the stage and activity of the disease and autoantibody positivity.

SETTING

Hospital-based and freestanding IVF programs with the same IVF team.

PATIENTS

One hundred ninety-three women of reproductive age undergoing IVF; 84 had prior diagnosis of endometriosis, and 109 had other indications for IVF. Within the endometriosis group, 40 did and 44 did not have evidence of active disease. Autoantibodies were measured in 50 patients.

INTERVENTIONS

The IVF protocol was standard with GnRH agonist administered from the midluteal phase of the preceding cycle. Variables included the method of ET and the use of corticosteroids.

MAIN OUTCOME MEASURES

Number of follicles produced, number of eggs retrieved, fertilization rates, number of embryos transferred, and PR per transfer.

RESULTS

There was no difference between groups in the response to stimulation, number of oocytes retrieved, number fertilized, and number cleaved. The overall PR was 27% per transfer; it was similar in women with and without endometriosis (29% and 25%, respectively). There was also no difference in PR according to the stage or activity of the disease. However, PR in autoantibody-positive and -negative patients were significantly different (22.9% and 45.7%, respectively). Among autoantibody-positive patients treated with corticosteroids, 8 of 10 conceived.

CONCLUSIONS

This study confirms previous reports that IVF success rates are comparable in women with and without endometriosis regardless of the activity and stage of the disease. However, our study also indicates that autoantibodies may affect adversely implantation of embryos and that this effect can be overcome by administration of corticosteroids.

Gestrinone inhibits macrophage function and mitogen-stimulated lymphocyte proliferation in vitro

Clinical and experimental evidence supports the hypothesis that some steroidal drugs with androgenic effects might influence the immune system. The present study investigated whether gestrinone is able to affect macrophage and lymphocyte activity in vitro. Macrophage function was determined by phagocytosis of fluorescent microspheres, whilst lymphocyte proliferation was assessed by cell counting. Macrophage phagocytosis was evaluated after an overnight incubation in the presence or absence of gestrinone at serial dilutions; lymphocyte proliferation was detected in basal conditions and after stimulation with Concanavalin A (Con A) in the presence or absence of gestrinone. The results of this study showed that gestrinone significantly inhibited macrophage phagocytosis at the concentrations of 10(-8), 3 x 10(-8) and 10(-7) M. Furthermore, a significant suppression of lymphocyte blastogenesis was observed when lymphocytes were incubated with gestrinone at the concentration of 10(-7) M for 6 days. The biological significance of gestrinone as an inhibitor of immune functions under experimentally defined conditions is discussed in relation to its potential mechanism for fertility enhancement.

Autoantibody profiles and immunoglobulin levels as predictors of in vitro fertilization success

OBJECTIVE

Our aim was to determine the predictive value of autoantibody and immunoglobulin determinations as indicators of the success of in vitro fertilization.

STUDY DESIGN

This was a blinded study in which laboratory evaluations were performed on coded samples obtained from another institution. Codes were broken and data were analyzed after results of all laboratory tests had been reported out. One hundred five infertility patients who had undergone in vitro fertilization were randomly chosen. Among those, 46 were considered low responders (six or fewer oocytes were retrieved) and 59 as high responders (13 to 30 oocytes were retrieved). Total immunoglobulin G, M, and A levels and 15 autoantibody levels (6 antiphospholipids, 5 antihistones, and 4 antipolynucleotides) were determined separately for immunoglobulin G, immunoglobulin M, and immunoglobulin A isotypes.

RESULTS

High and low responders demonstrated an unusual incidence of autoantibody (25% and 30%, respectively) and immunoglobulin (46% and 48%, respectively) abnormalities. They did not differ from each other, however, in either immunoglobulin or autoantibody parameters. Autoantibody and immunoglobulin abnormalities alone or in combination did not predict pregnancy success (24% vs 16%), incidence of chemical pregnancies (15% vs 24%), or clinical pregnancy loss (9% vs 11%) when such women were compared with those without either abnormality. However, the occurrence of hypergammaglobulinemias, in contrast to hypogammaglobulinemias, was associated with a significant decrease in the clinical pregnancy rate (6% vs 24%, p = 0.05).

CONCLUSIONS

Neither autoantibody abnormalities nor total immunoglobulin abnormalities allow differentiation between high and low responders in in vitro fertilization cycles. The presence of autoantibody and total immunoglobulin abnormalities also does not predict low clinical pregnancy rates. Within a group of women with immunoglobulin abnormalities, those with hypergammaglobulinemias appear, however, at significant risk for low pregnancy rates with in vitro fertilization. This observation suggests that high total immunoglobulin levels may serve as a marker for an as yet to be determined immunologic factor that adversely affects the chance of conception. The evaluation of total immunoglobulin levels may be indicated as part of a routine infertility workup.

Immunosuppressive effect of danazol on lymphocyte-mediated cytotoxicity toward human endometrial stromal cells

The influence of danazol on the expression of lymphocyte-mediated cytotoxicity toward the stromal component of the endometrium was examined. Stromal cells were isolated from endometrial biopsy specimens of nine women without endometrial pathology and 12 patients with endometriosis. A cytotoxicity assay by 51Cr release was performed to determine the effect of danazol on natural killer lymphocyte lytic activity. A significant suppression of spontaneous cytotoxicity against stromal cell targets of both study subjects was observed when effectors were pretreated for 48 h with danazol at a concentration of 5 x 10(-6) mol/l. The time-course of the danazol effect indicated that drug activity was detectable as early as 24 h after the addition of the drug and increase up to 72 h. These findings confirm that danazol may influence the immune system at many levels. In particular, they demonstrate that the drug is also able to inhibit the natural immunity toward the stromal component of the endometrium.

Endometriosis: the host response

There is abundant evidence of altered immune function in endometriosis. The task that remains is to attempt a synthesis from the accumulated data, to try to make some sense of the observed phenomena and to fit them into a conceptual framework; this might permit the formulation and testing of hypotheses. Evidently, eutopic endometrium does not engender an immune response in normal subjects, otherwise the endometrium would be subject to autoimmune destruction. It has also been established that the overwhelming majority of women regurgitate menstrual debris into the peritoneal cavity. Why does this lead to endometriosis in some, but not in others? There are several possible explanations. The uterus might act as a privileged site, i.e. be exempt from immune effector mechanisms. This would certainly be conducive to the reproductive goal, the survival of the fetal allograft. Endometrium would then not enjoy the immunologic tolerance of most other tissues, and upon leaving the uterus and entering an immunocompetent environment would be subject to immune attack. In normal subjects, this could consist of elimination of menstrual debris without further sequelae. An altered response, characterized by the production of antibody that could mask receptors for cytotoxic or phagocytic effector cells, would permit persistence of ectopic endometrium. The alternative to this hypothesis is that the uterus is not a privileged site, and that the organism is normally tolerant to endometrial antigens. Menstrual debris would be eliminated intraperitoneally without loss of tolerance due to the presence of homeostatic mechanisms including suppressor T cells and suppressive cytokines. In endometriosis, this tolerance breaks down, as is the case in several autoimmune disorders, causing a chronic inflammatory response with the release of toxic factors and, eventually, peritoneal scarring. Finally, the role of cell adhesion molecules, including the integrins, is only just being explored. The behaviour of these molecules in ectopic endometrium differs from that in eutopic endometrium, and it remains to be seen whether regurgitated endometrial debris from normal subjects is different from that of endometriosis sufferers. It seems that this will be an area of intense investigation in the immediate future.

Markers for endometriosis

Screening for endometriosis is subject to general rules. The two most important conditions, i.e. the disorder should be well-defined and serious, and there must be an effective way to treat or prevent it through screening, are not satisfied for endometriosis. Given the lack of understanding of the pathogenesis of this disease and the disreputable evidence of treatment effectiveness, other criteria for worthwhile screening programmes, such as prevalence, cost effectiveness and screening test performance, cannot be evaluated. Markers may be applied in the diagnostic process in the individual patient, although it should be realized that the best results will be obtained in patients with advanced disease, in whom routine pelvic examination will establish the diagnosis on purely clinical grounds anyway. The development of appropriate tissue markers may in the future shed more light on the intricate mechanisms involved in the pathogenesis of endometriosis.

Endometriosis: medical therapy

The management of women with endometriosis is complex and necessitates individualization of patient care. The most commonly used medical therapies are danazol, GnRH agonists, medroxyprogesterone acetate and gestrinone. Studies to date have shown these drugs to have equal efficacy in terms of reduction in laparoscopic score and relief of symptoms. However, their side-effects make them unsuitable for long-term use. The addition of low dose hormone replacement therapy to GnRH agonist regimens may allow prolonged use but the current cost of these agents is high. Low dose oral contraceptive pills deserve further investigation. The role of medical treatment for women with endometriosis and infertility is controversial. There is no place for hormonal therapy in such women with stage I or II disease. When expectant management fails, gamete intrafallopian transfer offers excellent results. For those with stage III or IV disease, surgery is preferable with adjunctive medical therapy in selected cases. If pregnancy does not ensue, in vitro fertilization and embryo transfer are the next line of management, and results are optimized by prior medical therapy and aspiration of endometriomas. Major advances have been made in the medical management of endometriosis. However, current treatment strategies are ineffective in eliminating the disease in most women. New approaches are required in both basic and clinical research in order to finally eradicate this often devastating disease.

Hormone treatment related bone mineral content changes in Japanese women with endometriosis

The effects of a GnRH agonist and danazol on bone mineral content (BMC) in Japanese women with endometriosis were investigated. Nineteen women with laparoscopically confirmed endometriosis were treated with buserelin (900 micrograms/d administered intranasally, 10 cases) or with danazol (400 mg/d p.o., 9 cases) for 6 months. Trabecular BMC of the 3rd lumbar vertebra was measured using quantitative computerized tomography before treatment, at the end of treatment and 6 months after treatment by the same radiologist who was not informed about the drug used. Serum estradiol and the biochemical parameters of bone metabolism were also measured. A significant decrease in BMC (10% on average; maximum 25.4%) was observed at the end of treatment with buserelin (p < 0.01) and this loss was only partially recovered 6 months after treatment. In the danazol group, however, a slight gain in BMC was observed. Buserelin suppressed serum estrogen levels much more than danazol did. Parameters of bone resorption tended to increase in the buserelin group. Because treatment with buserelin, but not with danazol, was always associated with a significant decrease in BMC at L3, repeated usage of buserelin may lead to cumulative bone loss in patients with endometriosis.

Inflammatory reaction in endometriotic tissue: an immunohistochemical study

A panel of monoclonal antibodies specific for macrophage subtypes appearing in early (27E10), down-regulatory (RM3/1) and late (25F9) stages of inflammation had been applied to 20 endometriotic implants of 14 women. Of those patients 9 were in the follicular phase of the cycle, two on danazol, one on LHRH-analogue (buserelin) and another two on oral contraceptives. Beside the macrophage subsets, antibodies against T4, T8 lymphocytes as well as proliferating cells (EN7/44 and Ki67) were examined. In all specimens immunologically competent cells could be detected to a varying degree and within the same implant different stages of inflammation were discernible. Endometriosis presented with signs of early inflammation indicated by 27E10+ macrophages and CD4+ lymphocytes (15 specimens) and with down-regulatory, late inflammatory reactions as shown by RM3/1+, 25F9+ macrophages and CD8+ lymphocytes (19 biopsies). Additionally, in 14 specimens cells of the EN7/44+ and Ki67+ type was detected. These preliminary results showed no significant correlation to either extension of endometriotic implants or adhesions or concomitant therapy and clearly indicate, that there is an immunological dynamic process within the lesion itself in addition to that one of the peritoneal fluid.

What do we really know about autoantibody abnormalities and reproductive failure: a critical review

CONDENSATION

The diagnosis and treatment of autoantibody-associated forms of reproductive failure is critically reviewed.

OBJECTIVE

To critically evaluate the published literature in reference to autoantibody-associated forms of reproductive failure.

LOCATION

Medical School-affiliated private Infertility Center.

MATERIALS

A review of over 200 published papers reflecting on the topic.

RESULTS

Autoantibody associated reproductive failure, characterized by a decrease in fecundity and an increase in the risk of pregnancy loss, appears established. Autoantibody abnormalities, as routinely detected by standard laboratory assays, are, however, neither immunologically nor biologically specific since cross reactivities between autoantibodies are frequent and a specific autoantibody may cause a biological effect in one but not in another affected individual.

CONCLUSIONS

The evaluation of autoantibody abnormalities in all cases of suspected autoimmune-associated reproductive failure is valuable and will improve clinical care of affected patients. Clinicians need, however, to recognize the limitations of autoantibody testing and have to adjust their clinical management to the degree and quality of autoantibody evaluation available to them in their community.

Effects of danazol at the immunologic level in patients with adenomyosis, with special reference to autoantibodies: a multi-center cooperative study

OBJECTIVE

We attempted to evaluate the effects of danazol on autoantibodies, in particular, to phospholipids, and on the immune system in patients with adenomyosis.

STUDY DESIGN

Forty-two patients with adenomyosis who had high titers of autoantibodies were randomly chosen, and they received 400 mg/day of danazol for 4 months (n = 22) or underwent hysterectomy (n = 20).

RESULTS

Among the six autoantibodies we investigated, the incidence of antiphosphatidylinositol immunoglobulin G was the highest (42.9%), followed by antiphosphatidylglycerol immunoglobulin G (38.1%). The autoantibody titers decreased with time and were comparable to the control values 16 weeks after treatment in both groups. Total serum levels of immunoglobulin G and M were high before treatment, but immunoglobulin M levels decreased significantly in week 8 during treatment with danazol, whereas C4 levels increased and C3 levels decreased with danazol.

CONCLUSION

Danazol has an inhibitory effect on the autoimmunologic response associated with adenomyosis.

The fetus as an allograft: immunobiologic role of human trophoblasts for fetal survival

OBJECTIVE

The hypothesis of this study is that trophoblasts contribute to the survival of the mammalian fetal allograft.

STUDY DESIGN

Immunologic and molecular biologic studies were performed with human trophoblasts or trophoblastic tumor cells to investigate the expression of class I human leukocyte antigens, the susceptibility to natural killer and lymphokine-activated cells, the ontogeny of Fc gamma-receptors, and the production of immunosuppressive factors.

RESULTS

Heterogeneous expression of class I human leukocyte antigens on trophoblasts was regulated at transcriptional level. Trophoblasts showed low susceptibility to natural killer and lymphokine-activated cells. Trophoblasts expressed natural killer cell-type Fc gamma-receptor III, which mediates phagocytosis. The trophoblast-derived immunosuppressive factor was very similar to transforming growth factor-beta.

CONCLUSION

The trophoblasts, which ultimately form the fetoplacental interface, constitute a major immune barrier for the survival of the allogenic conceptus.

Comparison of cytokine levels and embryo toxicity in peritoneal fluid in infertile women with untreated or treated endometriosis

OBJECTIVE

Our aim was to examine the relationship between the levels of cytokines in peritoneal fluid and its embryo toxicity.

STUDY DESIGN

The levels of interleukin-1 and tumor necrosis factor were measured in peritoneal fluid from infertile women who did not have endometriosis (n = 21), who had untreated endometriosis (n = 19), and who had undergone medical treatment for endometriosis (n = 10). Embryo toxicity was investigated in mouse two-cell embryos cocultured with the oviducts in culture media that contained various concentrations of peritoneal fluid.

RESULTS

The levels of cytokines were significantly higher in the peritoneal fluid from women who had untreated endometriosis than in women who did not have endometriosis, but they were extremely low in women who had undergone medical treatment with either danazol or buserelin. The peritoneal fluid from women who had untreated endometriosis adversely affected the cleavage of mouse two-cell embryos. After medical treatment the embryo toxicity of the peritoneal fluid was almost undetectable.

CONCLUSION

These results offer some theoretic bases in support of medical treatment to improve reproductive performance in infertile women who have endometriosis.