Endometriosis is a chronic systemic disease: clinical challenges and novel innovations

Therapeutic effects and mechanisms of alcohol extracts from Polygala fallax Hemsl on endometriosis in rats

Endometriosis is a chronic estrogen-dependent inflammatory disease that significantly affects women's health. Polygala fallax Hemsl. (PFH), a traditional Zhuang medicine, has been frequently used for gynecological disorders. This study investigated the therapeutic effects and mechanisms of the alcohol extract of Polygala fallax Hemsl. (ae-PFH) in a rat model of endometriosis, as well as its potential for combination therapy. SD rats were divided into seven groups: control, model, PFH, mifepristone, PFH combined with mifepristone, exosomes, and PFH combined with exosomes. After 21 days of treatment, body weight, organ coefficients, and histopathological changes in uterine and ovarian tissues were analyzed. UPLC-Q-Exactive Orbitrap-MS identified active components in ae-PFH and serum samples, followed by molecular docking with key disease target proteins. Serum levels of inflammatory cytokines and hormones were measured using ELISA, while protein and mRNA expression of key regulatory factors were assessed via Western blot and q-PCR. Ae-PFH reduced lesion size and suppressed inflammation, angiogenesis, and pain by inhibitied the PI3K/AKT pathway. Additionally, in combination therapy, ae-PFH significantly enhanced therapeutic effects of mifepristone or exosomes derived from umbilical cord mesenchymal stem cells. These findings indicated that ae-PFH presentd a promising medical method for the treatment of endometriosis, exhibiting innovative potentiality for combination therapy.

Hypoxic endometrial epithelial cell-derived microRNAs effectively regulate the regenerative properties of mesenchymal stromal cells

Endometrial thickness plays an important role in successful embryo implantation and normal pregnancy achievement. However, a thin endometrial layer (≤ 7 mm) may have a significant effect on microenvironment tolerance, which is further related to successful embryo implantation or conception, either naturally or after assisted reproductive technology. Moreover, this microenvironment tolerance shift induces hypoxic damage to endometrial epithelial cells (EECs), which results in altered signaling biomolecule secretion, including exosome content. In the context of endometrium regeneration, mesenchymal stromal cells (MSCs) and umbilical cord (UC)-derived stem cells have been applied in clinical trials with promising results. It has been recently shown that exosomes derived from hypoxic damaged EECs directly contribute to the increased migratory and regenerative abilities of UCs and MSCs. Specifically, microRNAs in exosomes secreted by the hypoxic damaged EECs, such as miR-214-5p and miR-21-5p, play a crucial role in the migratory capacity and differentiation ability of MSCs to EECs mediated through the signal transducer and activator of transcription 3 (STAT3) signaling pathway. Taking into consideration the above information, UC-MSCs may be considered as a modern intervention for endometrial regeneration.

Multiomic insight into the involvement of cell aging related genes in the pathogenesis of endometriosis

Endometriosis significantly impacts women's health and fertility, with cell aging playing a crucial role in its development. This study utilized a multi-omic summary Mendelian randomization (SMR) analysis, integrating genome-wide association studies (GWAS), expression quantitative trait loci (eQTLs), methylation quantitative trait loci (mQTLs), and protein quantitative trait loci (pQTLs). The goal was to identify genes that exhibit causal associations between cell aging and endometriosis. Validation was conducted using the FinnGen R10 and UK Biobank cohorts. The SMR and HEIDI tests evaluated the genetic variants linked to both cell aging and endometriosis risk. Colocalization analysis revealed shared genetic variants, uncovering significant associations between the two conditions. A total of 196 CpG sites in 78 genes, alongside 18 eQTL-associated genes and 7 pQTL-associated proteins, were identified. Notably, the MAP3K5 gene displayed contrasting methylation patterns linked to endometriosis risk. In validation cohorts, the THRB gene and ENG protein were confirmed as risk factors. The findings suggest a causal mechanism where specific methylation patterns downregulate the MAP3K5 gene, heightening endometriosis risk, highlighting it and associated pathways as potential therapeutic targets.

Effect of letrozole cotreatment in progestin-primed ovarian stimulation on IVF/ICSI outcomes in POSEIDON group 3 and 4 poor responders: a retrospective cohort study

BACKGROUND

For poor ovarian response patients, obtaining higher number of transferable and high-quality embryos is crucial and progestin-primed ovarian stimulation protocol is becoming widespread and constantly improving in this population. Letrozole has shown promise in numerous protocols and individuals. This study aims to evaluate the effect of the early addition of letrozole in progestin-primed ovarian stimulation protocol among expected poor ovarian response patients.

METHODS

This retrospective cohort study was performed in POSEIDON group 3 and 4 patients who underwent in vitro fertilization or intracytoplasmic sperm injection with their first progestin-primed ovarian stimulation protocol from January 1, 2018 to December 31, 2021. Totally 557 patients were enrolled in this research with 189 ovarian stimulation cycles for POSEIDON group 3 patients and 368 ovarian stimulation cycles for POSEIDON group 4 patients. The primary outcome of this study was the cumulative live birth rate and cumulative clinical pregnancy rate, and the second outcomes included the laboratory outcomes and pregnancy outcomes, maternal and neonatal complications also were encompassed.

RESULTS

In this study, progestin-primed ovarian stimulation protocol combined with letrozole (study group) was associated with a significantly higher number of oocytes for retrieval and maturation [3.0 (2.0, 5.0) vs. 2.0 (1.3, 4.0), P < 0.001; 3.0 (2.0, 5.0) vs. 2.0 (1.0, 3.8), P < 0.001] as well as 2PN embryos [2.0 (1.0, 3.0) vs. 2.0 (1.0, 3.0), P = 0.026] among POSEIDON group 4 patients. In POSEIDON group 3 patients, the letrozole cotreatment did not show an advantage in these indicators. There was no significant difference in both cumulative live birth rate and cumulative clinical pregnancy rate between the study and control group in POSEIDON group 3 and 4 patients. Multivariate logistic regression model showed that significant favorable effects of the number of available embryos on cumulative live birth rate in all included patients.

CONCLUSIONS

These findings indicate that advanced-aged poor ovarian response patients may benefit more from using letrozole as an advantageous adjuvant agent in the progestin-primed ovarian stimulation protocol to obtain more oocytes and embryos in clinical practice. Trial registration This trial was retrospectively registered.

Identification and validation of a novel machine learning model for predicting severe pelvic endometriosis: A retrospective study

This study aimed to explore potential risk factors for severe endometriosis and to develop a model to predict the risk of severe endometriosis. A total of 308 patients with endometriosis were analyzed. Least absolute shrinkage and selection operator (LASSO) was performed to identify the potential risk factors for severe endometriosis. Then, we used seven machine learning (ML) algorithms to construct the predictive models. Finally, SHapley Additive exPlanations (SHAP) interpretation was performed to evaluate the contributions of each factor to risk prediction. About 59.2% (183/308) of patients were diagnosed with severe endometriosis. The random forest (RF) model performed best in discriminative ability among the seven ML models, achieving an area under the curve (AUC) of 0.744. After reducing features according to feature importance rank, an explainable final RF model was established with six features. From the SHAP map, we found that the negative sliding sign had the greatest impact on the diagnostic performance of the RF model. This study provided a personalized risk assessment for the development of severe endometriosis, which may enable early identification of high-risk patients, facilitating timely intervention and optimized treatment strategies.

Phosphatase and tensin homolog deficiency induces M2 macrophage polarization by promoting glycolytic activity in endometrial stromal cells

Endometriosis is a common gynecological disorder, whose pathogenesis remains incompletely understood. Macrophages, a key type of immune cell, are pivotal in the context of endometriosis. This study seeks to explore the interactions between endometriotic cells and macrophages. Quantitative real-time PCR (qRT-PCR) and Western blot experiments were employed to detect phosphatase and tensin homolog (PTEN) expression. Glucose consumption, lactate production, extracellular acidification rate, and oxygen consumption rate levels were used to assess cellular glycolytic capacity. The interaction between conditioned media from ectopic endometrial stromal cells (EESCs) and macrophages was investigated through co-culture experiments. The expression of M2 macrophage marker proteins and inflammatory factors was detected via qRT-PCR, immunofluorescence staining, and enzyme-linked immunosorbent assay. Cellular functions were evaluated using Cell Counting Kit-8, 5-Ethynyl-2'-deoxyuridine (EdU), and wound healing assays. We found that PTEN deficiency promoted the glycolytic activity of EESCs. Simultaneously, it significantly promoted the macrophages' polarization toward the M2 phenotype, demonstrated by increased expression of M2 markers (differentiation 206 (CD206), CD163, and (C-C motif) ligand 22 (CCL22)). Further studies revealed that PTEN-deficient EESCs increased the level of CCL2 via promoting glycolytic activity, which was reversed by glycolytic inhibitor. Moreover, lactate and conditioned media from overexpressed CCL2 EESCs facilitated M2 polarization of macrophages, while 2-deoxy-d-glucose reversed the promoting effect. Furthermore, lactate-facilitated macrophages promoted the proliferation and migration abilities of EESCs. PTEN deficiency induces M2 macrophage polarization by promoting glycolytic activity in EESCs, which deepens the knowledge of the pathophysiology of endometriosis and provides novel insights into its treatment.

Intra-ovarian injection of autologous menstrual blood-derived-mesenchymal stromal cells: a safe and promising method to improve pregnancy rate in poor ovarian responders

BACKGROUND

Poor ovarian response (POR) significantly reduces the success rates of fertility treatments. This study investigates the long-term efficacy and potential complications associated with autologous menstrual blood-derived mesenchymal stromal cells (MenSCs) therapy in improving fertility outcomes for women with POR.

OBJECTIVE

To evaluate the long-term efficacy and potential complications associated with MenSC therapy in improving fertility outcomes for women with POR.

METHODS

This longitudinal, single-center retrospective observational study included 105 POR patients who received autologous MenSC injections from August 2018 to September 2021. Participants were monitored for at least 3 years, and demographic, menstrual, and fertility data were collected. Potential complications were also assessed during this period. Statistical analyses were performed to determine pregnancy rates and possible complications.

RESULTS

The average age of participants at the time of injection was 37.91 years. During the follow-up period, 36.19% of women became pregnant, with a live birth rate of 30.48% per treatment cycle. The treatment showed no significant difference in pregnancy rates between women with regular and irregular menstrual cycles. The spontaneous pregnancy rate was also notably higher within the first three months post-injection. No significant complications such as endometriosis, ovarian malignancies, or autoimmune disorders were observed. Only one case of an ovarian cyst, which resolved without intervention, was reported. MenSC treatment did not increase the risk of congenital anomalies or infant mortality.

CONCLUSION

Intra-ovarian injection of MenSCs is a safe and promising method for improving pregnancy outcomes in women with POR.

Imaging of endometriosis-related infertility

Endometriosis is a common cause of subfertility and infertility through myriad mechanisms. Imaging of endometriosis is critical for its diagnosis, characterization, and treatment. Understanding its imaging appearance, surgical management, and implications for assisted reproductive therapy is essential to providing the most clinically relevant and impactful reports in endometriosis patients. This manuscript will review imaging techniques used to diagnose and characterize endometriosis-related infertility. We will describe relevant imaging findings by anatomic site and review the impact of surgery and ART on its appearance.

Gut microbiome in patients with early-stage and late-stage endometriosis

BACKGROUND

Endometriosis is a chronic inflammatory gynecological disease. Previous studies have explored relationships between endometriosis and the microbiota, but none have focused on differences in gut microbiota between early-stage and late-stage endometriosis patients or their connections to dysmenorrhea symptoms. This study compared gut microbiota compositions between early-stage and late-stage endometriosis patients using amplicon sequencing and further analyzed their dysmenorrhea symptoms.

METHODS

To minimize seasonal and dietary impacts, we recruited Guangdong residents hospitalized for surgery at Zhujiang Hospital. Participants underwent preoperative screening based on enrollment criteria and fecal samples were collected. Endometriosis was classified according to the American Society for Reproductive Medicine (ASRM) staging system based on surgincal and pathological findings. Stage I-II cases were designated as early-stage endometriosis, and Stage III-IV as late-stage endometriosis.

RESULTS

A total of 112 patient fecal samples were collected, with 75 (median age, 32 years [range, 18-49 years]) meeting the enrollment criteria, including 39 early-stage (32 Stage I and 7 Stage II) and 36 late-stage (16 Stage III and 20 Stage IV) patients. The gut microbiota structure and functions in early-stage patients significantly differed from those in late-stage cases. Dysmenorrhea was associated with specific microbial traits. Late-stage patients with dysmenorrhea displayed distinctly different gut profiles compared to other endometriosis groups. Bartonella, Snodgrassella, and other taxa were enriched in late-stage cases, while Bacteroides, and Prevotella were decreased.

CONCLUSION

The gut microbial community structure in early-stage endometriosis patients significantly differs from that in late-stage cases, with late-stage patients experiencing dysmenorrhea displaying particularly distinct gut profiles. Predicted functional analysis indicated suppressed steroid biosynthesis pathways in the gut of late-stage endometriosis patients. In conclusion, it is plausible that the multiple effects of steroids on the lower gastrointestinal tract may involve microbiota alterations, suggesting the need for further investigations.

Ovarian Endometriosis Accelerates Premature Ovarian Failure and Contributes to Osteoporosis and Cognitive Decline in Aging Mice

Ovarian endometriosis (OEM) is a chronic inflammatory condition that impairs ovarian function. While its effects on ovarian reserve are well established, the long-term consequences of OEM on ovarian dysfunction, premature ovarian failure (POF), and systemic health, particularly in the context of accelerated aging, remain insufficiently studied. In this study, we employed an OEM mouse model and bulk RNA sequencing to investigate the underlying mechanisms. Our results show that OEM accelerates primordial follicle depletion and upregulates mTOR signaling pathway gene expression, along with mechanical stress and paracrine signaling via the Hippo and Myc pathways. OEM also induces irregular estrus and ovarian fibrosis in aging mice, decreases serum AMH levels, and increases FSH levels. Systemically, elevated serum IgG levels contribute to osteoporosis and cognitive decline, both linked to ovarian dysfunction and POF in OEM. These findings elucidate the mechanisms driving premature ovarian reserve depletion in OEM and highlight its broader systemic effects. This study emphasizes the importance of monitoring ovarian health and ectopic tissue to safeguard ovarian reserves and mitigate long-term risks such as osteoporosis and cognitive decline.

A "novel" MRI sequence for improving conspicuity and detection of hemorrhagic foci in pelvic endometriosis: Technical note

There is a growing need to develop new MRI sequences to identify and characterize hemorrhagic foci within endometriosis lesions. These foci are pivotal, as they represent a significant component of the disease's pathophysiology and have been associated with increased inflammation and angiogenesis. However, their detection within a dense, mixed background of fibrotic tissue is challenging using conventional T1W sequences, even with fat suppression. In this technical report, we propose a T1W 3D-FSE sequence specifically optimized to enhance the detection of hemorrhagic foci in endometriosis. Future clinical validation holds promise for increasing MRI accuracy, ultimately impacting patient management, outcomes, and quality of life.

Bowel Endometriosis: Systematic Approach to Diagnosis with US and MRI

Endometriosis involving the bowel is a severe form of the disease, and the bowel is the most common site of extragenital endometriosis. Surface lesions of the bowel are considered peritoneal disease. Bowel endometriosis (BE) is defined as endometriotic tissue infiltrating the muscularis propria layer of the bowel wall. BE is estimated to affect up to 37% of patients with known deep endometriosis, highlighting its coexistence with genital endometriosis. The rectosigmoid colon is the most common segment of the bowel involved, followed by the distal small bowel. US and MRI are the most common imaging modalities used to detect BE. Depending on which bowel segment is imaged, endometriosis protocols for transvaginal US after bowel preparation with a transabdominal component and MRI and MR enterography are most commonly used. The authors provide a systematic approach to the diagnosis of BE using these imaging modalities. Imaging protocols and techniques for optimization of visualization of the bowel are discussed, the normal bowel wall anatomy with both imaging modalities is described, and the varying degrees of bowel wall involvement in endometriosis are illustrated. The imaging features of infiltration of endometriosis in the bowel muscularis propria are described in detail, along with key imaging findings to be conveyed to surgical colleagues to optimize surgical treatment and decrease complications, thereby improving overall patient outcomes. ©RSNA, 2025 Supplemental material is available for this article.

Endometriosis and adenomyosis unveiled through single-cell glasses

Single-cell technologies are expanding our understanding of endometriosis and adenomyosis, which are sister disorders of the uterine endometrium that contain similar complements of lesion cell types but in different locations-outside and inside the uterus, respectively. Both diseases cause significant morbidity and impaired quality of life among those affected, and current therapies mitigate most of the symptoms although with highly variable efficacy, duration of effect, and frequent intolerable side effects. Thus, there is a pressing need for transformative approaches and to develop individualized therapies for the variety of presentations of endometriosis and adenomyosis symptoms and the heterogeneity of lesion types, both histologically and architecturally. Single-cell technologies are transforming the understanding of human physiology and pathophysiology in the reproductive system and beyond. This manuscript reviews the clinical characteristics of endometriosis and adenomyosis and the recent studies focused on eutopic endometrium and ectopic lesions at single-cell resolution, the myriad of cell types and subtypes, cell-cell communications, signaling pathways, applications for novel drug discovery and therapeutic approaches, and challenges and opportunities that accompany this type of research. Key take-home messages from the studies reviewed herein include the following: We conclude the review with an eye to the future-what Alice might see beyond the single-cell looking glass that connects endometrium and endometrial disorders with the trillions of cells of other tissues and organs in health and disease throughout the human body and the opportunities for novel diagnostic modalities and drug discovery for endometriosis, adenomyosis, and related uterine and inflammatory conditions.

Cyclooxygenase 2 overexpression suppresses Smad3 and augments ERK1/2 signaling activated by TGFβ1 in endometrial stromal cells: A novel insight into endometriosis pathogenesis

RESEARCH QUESTION

To investigate the underlying mechanisms driving the opposing effects of transforming growth factor-beta 1 (TGFβ1) on the proliferation of control (CESCs) and ectopic (EESCs) endometrial stromal cells.

DESIGN

Cell proliferation assays (CCK-8 and colony formation) were employed to assess the effects of TGFβ1 on CESC and EESC proliferation. An immortalized human endometrial stromal cell line (HESC) was used to elucidate the mechanisms behind cytostatic effect of TGFβ1 and the potential role of cyclooxygenase (COX)-2 in mediating the modulation of TGFβ1 signaling.

RESULTS

This study demonstrated that TGFβ1 inhibited the proliferation of CESCs and HESCs while significantly promoting the proliferation of EESCs. In both CESCs and HESCs, TGFβ1-induced growth arrest was primarily mediated by cell cycle arrest rather than apoptosis. Mechanistically, TGFβ1 activated both Smad3 and ERK1/2 signaling pathways, with Smad3 acting to inhibit proliferation and ERK1/2 to promote it. Notably, overexpression of COX-2 in HESCs abolished the cytostatic effect of TGFβ1 by enhancing ERK1/2 signaling and decreasing Smad3 protein levels and its nuclear translocation. Similar effects were observed following prostaglandin E2 (PGE2) treatment. In contrast, inhibition of COX-2 activity in EESCs resulted in increased Smad3 expression, reduced ERK1/2 activation, and a restoration of the cytostatic effect of TGFβ1.

CONCLUSION

COX-2 modulates the effects of TGFβ1 on endometrial stromal cells by altering the balance between the Smad3 and ERK1/2 signaling pathways, thereby converting TGFβ1 from a growth inhibitor to a proliferation stimulator.

Precision surgery for endometriosis: preventing chronic pelvic pain in patients with higher pre-operative pain scores and in patients of advanced age

OBJECTIVE

Symptom relief can be achieved for many patients with endometriosis by tailored individual treatment. However, therapy resistance is observed in some patients. This study surveyed patient-reported long-term outcomes after laparoscopic endometriosis surgery and evaluated potential pre-operative predictors for insufficient symptom control.

METHODS

This retrospective study included patients with complete surgical endometriosis resection treated between 2013-2016 at the Department of Gynaecology and Reproductive Medicine, Jena University Hospital. Our 2020 survey gathered socio-demographic, reproductive, symptom-related, and subjective general condition data from 122 patients. Overall pain intensity was assessed using a numeric rating scale (NRS) from zero (no pain) to 100 (highest imaginable pain). Clinical records provided additional information.

RESULTS

Median time between surgery and interview was 6 years. Postoperatively, the proportion of patients reporting symptoms was considerably reduced (menstrual pain 32.0% vs. 85.2%, chronic pelvic pain [CPP] 40.2% vs. 67.2%, dyspareunia 34.4% vs. 59.8%, hypermenorrhea 17.2% vs. 49.2%; p < 0.001). The majority of respondents (70%) reported improved subjective general condition. Mean NRS Score significantly decreased from 77.2 to 26.6 (p < 0.001). Among pre-operatively infertile women, 45.2% reported successful pregnancies. However, 20-30% of patients did not respond to therapy in one of the analyzed domains. Multivariate logistic regression identified CPP as a strong predictor for failure in permanent pain reduction (OR 5.544, 95% CI 1.338-22.965, p = 0.018) and risk for reoperation (OR 5.191, 95% CI 1.100-24.501, p = 0.038). Higher pre-operative NRS scores and increasing age were associated with better long-term pain relief.

CONCLUSION

Patients with higher pre-operative pain scores and patients of advanced age benefit significantly from precision surgery, experiencing sustained symptom relief and improved subjective general condition. However, younger patients with CPP and moderate pre-operative pain intensity showed a higher risk for therapy resistance and require multimodal treatment strategies.

Observational and Genetic Analyses of Traumatic Experiences and Endometriosis

Importance

Although psychological traumas have been associated with endometriosis, limited information is available regarding the role of trauma type and genetic predisposition.

Objective

To examine the relationship between traumatic experiences and endometriosis using observational and genetically informed analyses.

Design, Setting, and Participants

For this case-control study, the analyses were performed between May 13, 2023, and September 30, 2024. Genotypic and phenotypic information was combined from UK Biobank individual-level data (up to 8276 patients with endometriosis and 240 117 female controls) with genome-wide information available from a large meta-analysis (European ancestry: 21 779 patients and 449 087 female controls; East Asian ancestry: 1713 patients and 1581 female controls) and the FinnGen cohort (16 588 patients and 111 583 female controls of European descent).

Main Outcomes and Measures

Phenotypic associations via multiple regression; latent-class analysis (LCA) to investigate the co-occurrence patterns of different traumatic experiences in endometriosis cases and controls; genetic correlation and polygenic risk scoring (PRS) analyses to assess pleiotropy linking traumatic events to endometriosis.

Results

Up to 8276 women with endometriosis (mean [SD] age, 53.2 [13.0] years) and 240 117 female controls (mean [SD] age, 56.5 [9.6] years) were investigated in the study. Women with endometriosis were more likely to report childhood and adulthood traumatic experiences and stressful events (eg, contact trauma odds ratio [OR], 1.28; 95% CI, 1.02-1.26). Our LCA highlighted the association of endometriosis with emotional and physical trauma (225 [8%] vs 3948 [5%]; P < 2.2 × 10-16) and sexual trauma (414 [5%] vs 3158 [4%]; P = 2.9 × 10-3). Unaffected women (controls) were more likely assigned to the "no trauma" latent class (563 [20%] vs 18 949 [24%]; P = 7.4 × 10-14). Our genetic correlation (rg) analyses linked endometriosis to multiple trauma-related outcomes, including posttraumatic stress disorder (meta-analysis rg = 0.31, P = 7.1 × 10-16; FinnGen rg = 0.26, P = 4.7 × 10-15) and childhood maltreatment (meta-analysis rg = 0.23, P = 1.3 × 10-6; FinnGen rg = 0.16, P = 1 × 10-4). Endometriosis PRS was associated with increased odds of the disease (β = 0.31, P < 2.2 × 10-16), but no interaction was observed with different types of trauma events.

Conclusions and Relevance

The present study comprehensively investigated the impact of childhood and adulthood traumatic experiences and stressful events on endometriosis. In particular, our findings highlight the potential association between contact traumas and endometriosis, which appears to be independent of the disease genetic predisposition.

Soluble adhesion molecules in serum and peritoneal fluid are associated with pelvic pain in endometriosis

OBJECTIVE

To investigate the association between soluble adhesion molecules (sE-cadherin, sE-selectin, sICAM-1, sVCAM-1) in serum and peritoneal fluid and pelvic pain in infertile women with endometriosis.

METHODS

This observational study included 86 infertile women undergoing diagnostic laparoscopy, 43 of whom were diagnosed with endometriosis. Pain intensity was evaluated using the visual analog scale (VAS). Levels of soluble adhesion molecules in serum and peritoneal fluid were quantified using ELISA. Statistical analysis included the Mann-Whitney U test for group comparisons, Spearman's rank correlation for associations with VAS scores, and receiver operating characteristic (ROC) curve analysis for diagnostic performance.

RESULTS

Serum sE-selectin levels were significantly higher in women with pelvic pain (P = 0.022) and correlated with VAS scores (r = 0.271, P = 0.012). Peritoneal sE-selectin and sICAM-1 levels were elevated in women with pelvic pain (P = 0.044 and P = 0.029, respectively) and showed positive correlations with VAS scores (r = 0.246, P = 0.022 and r = 0.310, P = 0.004, respectively). Comparing endometriosis and control groups, peritoneal sE-selectin and sICAM-1 levels were significantly higher in endometriosis cases with pelvic pain (P = 0.003 and P < 0.001, respectively). ROC analysis revealed the potential diagnostic value of serum sE-selectin (AUC = 0.698, P = 0.002), serum sICAM-1 (AUC = 0.721, P < 0.001), and serum sVCAM-1 (AUC = 0.750, P < 0.001) in distinguishing endometriosis from non-endometriosis cases.

CONCLUSION

Elevated levels of sE-selectin and sICAM-1 in serum and peritoneal fluid are associated with pelvic pain in women with endometriosis, suggesting their role in pain pathogenesis and potential as biomarkers for pain severity and disease diagnosis. Further research is warranted to explore the underlying mechanisms and validate these findings in larger cohorts.

Mitochondrial Involvement in the Pathogenesis of Endometriosis and its Potential as Therapeutic Targets

Endometriosis is an estrogen-dependent benign disease characterized by the development of endometrial tissue outside the uterus. This intricate ailment markedly affects a patient's well-being and lacks a definitive cure. Endometriotic cells enhance their viability by modulating genetic and epigenetic characteristics, with mitochondria being important organelles in determining cellular metabolic pathways. Mitochondrial malfunction is associated with various human disorders, and the disruption of mitochondrial adaptation mechanisms may help develop new therapies for endometriosis. This article examines the significance of mitochondrial balance in the etiology and advancement of endometriosis and introduces several potential drugs targeting mitochondria for its treatment.

Two possible entities of endometriosis-associated ovarian cancer: correlated or incidental?

OBJECTIVE

This study aimed to describe 2 types of endometriosis-associated ovarian cancer: those with transitional elements (atypical endometriosis and borderline tumors) termed endometriosis-correlated or incidental benign endometriosis vs ovarian cancer cases not associated with endometriosis.

METHODS

This was a prospective, observational, monocentric study conducted from November 2021 to December 2023. Patients with ovarian cancer eligible for surgery were enrolled and classified into endometriosis-correlated ovarian carcinoma, endometriosis-incidental ovarian carcinoma, or ovarian carcinoma without endometriosis groups based on the presence or not of endometriosis and transitional lesions. Clinical, sonographic, surgical and pathological data and progression-free survival were recorded. Logistic regression models for accurate patient classification were developed from pre-surgical variables.

RESULTS

Of the 170 patients included, 83 (48.82%) had ovarian carcinoma without endometriosis, 39 (22.94%) had endometriosis-incidental ovarian carcinoma, and 48 (28.24%) had endometriosis-correlated ovarian carcinoma. Patients with endometriosis-incidental ovarian carcinoma and endometriosis-correlated ovarian carcinoma were diagnosed at younger ages (p = .002) and had lower post-menopausal rates than patients with ovarian carcinoma without endometriosis (p = .011). Patients with endometriosis-correlated ovarian carcinoma had fewer pregnancies (p < .001) and higher CA-19.9 levels (p = .002) presented with unilateral and multilocular solid lesions than patients with ovarian carcinoma without endometriosis (p < .001). Patients with endometriosis-incidental ovarian carcinoma showed intermediate lesion morphology. Endometriosis-correlated ovarian carcinoma was mostly diagnosed at early Federation of Gynecology and Obstetrics stages (range; I-II) compared with endometriosis-incidental ovarian carcinoma and ovarian carcinoma without endometriosis (p < .001), had less extensive disease (p < .001), and a higher likelihood of complete cytoreduction (p = .035). Endometriosis-correlated ovarian carcinoma was more likely to include clear cell, endometrioid, and mesonephric-like adenocarcinomas, whereas serous histotype predominated in the other groups (p < .001). Logistic regression models accurately identified patients with endometriosis-correlated ovarian carcinoma vs patients with endometriosis-incidental ovarian carcinoma (area under the curve [AUC] = 0.926) and ovarian carcinoma without endometriosis (AUC = 0.968) but could not reliably differentiate endometriosis-incidental ovarian carcinoma from ovarian carcinoma without endometriosis (AUC = 0.668). The 2-year progression-free survival rates were 91% in endometriosis-incidental ovarian carcinoma, 80% in endometriosis-correlated ovarian carcinoma, and 59% in ovarian carcinoma without endometriosis (p = .024).

CONCLUSIONS

Our study indicates that ovarian cancer associated with endometriosis consists of 2 clinical entities, with endometriosis-incidental ovarian carcinoma emerging as a bridging group between endometriosis-correlated ovarian carcinoma and ovarian carcinoma without endometriosis.

Transcription factor addictions: exploring the potential Achilles' Heel of endometriosis

A considerable number of women of reproductive age suffer from endometriosis worldwide. There is a significant physical, mental, and financial burden on patients affected by this condition in terms of pelvic pain, either continuously or intermittently, dysmenorrhea, infertility, and a higher risk of certain types of cancer. Several treatments available in clinical settings for endometriosis management do not provide adequate efficacy and have undesirable side effects. Transcription factors (TFs) are crucial regulators of key biological processes involved in endometriosis. Here, we elaborated on the research progress regarding the crucial roles of TFs in endometriosis, emphasizing their implications for clinical outcomes and critical therapeutic contributions. By delving into their involvement in key processes, such as cell proliferation and apoptosis, we revealed the multifaceted role of key TFs in disease progression. We aimed to provide a systemic understanding of TFs regulation in endometriosis pathogenesis, establishing a foundation for innovative treatment approaches.

A new perspective on endometriosis: Integrating eQTL mendelian randomization with transcriptomics and single-cell data analyses

Endometriosis is caused by the migration of endometrial cells to locations outside the uterine lining. Despite the increasing prevalence of endometriosis, there has been limited research on genetic effects, and its molecular mechanisms remain unclear. This study aimed to investigate the mechanisms underlying the development of endometriosis and to identify new genetic targets for endometriosis by integrating data from gene chips, single-cell mapping, and genome-wide association study databases. Using the Gene Expression Omnibus database, we downloaded data on normal endometrium, eutopic endometrium, and ectopic lesion tissues to explore the differentially expressed genes (DEGs) between normal and eutopic endometrium, and between eutopic and ectopic endometrium. Assessment of the relationships between DEGs and endometriosis involved differential expression, expression quantitative trait loci (eQTL), and Mendelian randomization (MR) analyses. Two single-cell atlas datasets were then analyzed to explore the mechanisms underlying disease development and progression. Intersection of MR results with DEGs between normal and eutopic endometrium highlighted 28 candidate biomarker genes (17 upregulated and 11 downregulated). Similarly, we identified two additional candidate biomarker genes by intersecting the DEGs between eutopic and ectopic endometrium with MR results. Among these 30 candidates, further filtering using single-cell datasets revealed that the histamine N-methyltransferase (HNMT), coiled-coil domain containing 28 A (CCDC28A), fatty acid desaturase 1 (FADS1) and mahogunin ring finger 1 (MGRN1) genes were differentially expressed between the normal and eutopic groups, consistent with transcriptomic and MR results. Our findings suggested that eutopic endometrium exhibits epithelial-mesenchymal transition (EMT). Cell communication analysis focused on ciliated epithelial cells expressing CDH1 and KRT23 revealed that, in the eutopic endometrium, ciliated epithelial cells are strongly correlated and interact with natural killer cells, T cells, and B cells. We identified four novel biomarker genes and found evidence for EMT in the eutopic endometrium. The mechanism of endometriosis progression may be closely related to EMT and changes in the immune microenvironment triggered by damage to ciliated epithelial cells.

Analysis of clinical factors in endometriosis of the abdominal wall

BACKGROUND

The abdominal wall is one of the rare sites of endometriosis, and its clinical incidence is increasing year by year with the increasing cesarean section rate nowadays.

METHODS

A retrospective analysis was made on patients with abdominal wall endometriosis who attended Changzhou Second Hospital of Nanjing Medical University from January 2013 to December 2022. They were grouped by depth of infiltration of lesion and direction of incision, and the differences between the groups were compared.

RESULTS

A total of 228 patients aged 32.7 ± 4.2 with abdominal wall endometriosis were included in this study, including 210 cases with a history of abdominal transverse incision surgery, 16 cases with a history of vertical incision surgery, 1 case with a history of uterine fibroids surgery, and 1 case with primary abdominal endometriosis, and 178 cases with the primary symptom of cyclic pain. The patients were classified as solitary and complex ones according to the number of lesions. Both groups were statistically significant for BMI, number of caesarean sections, operation time, bleeding, and postoperative hospital stay (p < 0.05). According to the depth of infiltration, the patients were divided into fascial, rectus abdominis, and peritoneal types, with differences in latency time, CA125, maximum diameter of the lesion, operation time, bleeding, and postoperative hospital stay (p < 0.05). The direction of incision for caesarean section had no significant effect on the development of endometriosis in the abdominal wall or whether the lesions were multiple (p > 0.05). On imaging, magnetic resonance imaging was more accurate for lesion typing.

CONCLUSION

AWE should be diagnosed early and treated surgically. The clinical manifestations of the same type are different, and CA125 testing and abdominal wall ultrasound can be used preoperatively for lesion typing. Nuclear magnetic resonance (NMR) may be used to improve preoperative preparations for difficult diagnosis or typing.

Mechanism of FBXW7 mRNA degradation mediated by circSMAD2 through METTL3-METTL14 m6A axis affects proliferation and invasion of endometrial stromal cells

This study investigates the role of circSMAD2 in ectopic endometrium of endometriosis (EMS) patients, focusing on its upregulation of FBXW7 m6A level by mediating the formation of the METTL3/METTL14 complex. Ectopic endometria from EMS patients and healthy individuals were compared for the expression levels of FBXW7 and YTHDF2, as well as total m6A levels. Results showed elevated FBXW7 and reduced YTHDF2 expressions in EMS ectopic endometria, along with decreased m6A levels. YTHDF2 was found to bind to FBXW7 mRNA, leading to its degradation and suppression of FBXW7 expression. CircSMAD2 interacted with METTL3/METTL14 complex in human endometrial stromal cells, increasing FBXW7 m6A level without affecting complex expression levels. Overexpression of YTHDF2 or circSMAD2 inhibited cell proliferation, migration, and invasion, effects partly reversed by FBXW7 overexpression. Reduced circSMAD2 expression in EMS resulted in decreased METTL3/METTL14 complex formation and FBXW7 m6A levels, while decreased YTHDF2 expression in EMS led to higher FBXW7 expression, promoting cell proliferation and invasion. This study sheds light on the regulatory mechanism of circSMAD2 in EMS pathogenesis. DATA AVAILABILITY: The datasets used or analyzed during the current study are available from the corresponding author on reasonable request.

SCM-198 Inhibits EMS Development by Reversing Decreased Proportions of IFN-γ+T Cells and CCR5+T Cells

Endometriosis is a common gynecological disease that causes severe pain and infertility. However, the available treatments for EMS are limited. SCM-198, a synthetic form of leonurine, possesses various abilities, including anti-inflammatory, immunomodulatory, antioxidant, anti-fibrotic, and anti-proliferative effects. Previous studies have shown that SCM-198 can inhibit the growth of ectopic lesions, but the specific mechanism remains unknown. The results of our studies indicate that SCM-198 significantly suppresses the endometriotic growth of EMS mice. Enrichment analysis of RNA-seq indicates that SCM-198 is involved in T cell differentiation, activation, cytokine production, stimulation of chemotaxis, and migration. Flow cytometry reveals that SCM-198 reverses the decreased proportions of IFN-γ + T cells and CCR5 + T cells in ectopic lesions. RNA-seq analysis shows that SCM-198 enhances the expression of CCL5 in the ectopic lesions, and western blot is conducted to verify this conclusion both in vivo and in vitro. These findings demonstrate that SCM-198 reverses the decreased proportions of IFN-γ + T cells and CCR5 + T cells, alleviating the growth of mouse ectopic lesions, and the changes in CCR5 + T cells are likely due to the reduced expression of CCL5.

Effect of Endometriosis on Disease-Specific Quality of Life

OBJECTIVE

To evaluate disease-specific quality of life (QOL) in women with endometriosis and assess concurrent validity of the Endometriosis Impact Questionnaire (EIQ).

DESIGN

Observational, cross-sectional design.

SETTING

Online survey.

PARTICIPANTS

Women ages 18 to 49 years who self-reported a diagnosis of endometriosis.

MEASUREMENT

Disease-specific QOL was measured with the EIQ and the Endometriosis Health Profile-5 (EHP-5). Health-related QOL was measured with two WHOQOL-BREF questions.

RESULTS

There were 413 participants with complete data included in the analysis. Mean (SD) age at participation was 33.9 (7.1) years and at diagnosis was 28.9 (7.0) years. Responses to the EIQ demonstrated that endometriosis had the greatest effect on QOL through physical-psychosocial symptoms and fertility problems. Lifestyle behaviors related to alcohol and tobacco use were the least affected. Scores on the EHP-5 demonstrated similar results, with social support, self-image, and feelings of control being most impacted. Health-related QOL was also found to be impaired. Participants rated their overall QOL as neither poor nor good and their overall satisfaction with their health as dissatisfied. Concurrent validity for the EIQ was acceptable. Women who reported worse disease-specific QOL on the EIQ also had worse disease-specific QOL on the EHP-5 (p ˂ .01) and worse health-related QOL on the WHOQOL-BREF questions (p ˂ .01).

CONCLUSION

Endometriosis significantly impairs disease-specific QOL in addition to general health-related QOL. The EIQ is a valid measure of disease-specific QOL and can be used to assess the impact of endometriosis on the multiple dimensions of women's lives. It is recommended that providers use this tool to obtain a more in-depth understanding of the effect on QOL and tailor patient-specific care that targets the multidimensions of endometriosis.

Assessing healthcare needs in endometriosis: a scoping review

OBJECTIVE

Women with endometriosis still have to seek the legitimacy of their disease from the medical community and often feel unheard. This scoping review aims to map the scientific literature to describe barriers and facilitators in the endometriosis management from both patients' and healthcare professionals' (HCPs') perspectives.

METHODS AND MEASURES

We searched the literature published between 2012 and 2023 in the Web of Science, PsychInfo, PubMed, CINAHL, Embase, and Cochrane Library databases. A total of 52 eligible studies were identified.

RESULTS

We observed several barriers in the endometriosis management: the perception of patients as challenging and psychosomatic; lack of awareness and medical knowledge; persistent taboos and biases; challenging communication about pain, pregnancy, and infertility; lack of empathy from HCPs; and barriers in diagnostic tools and healthcare accessibility. Key facilitators were HCPs and community awareness; taking patients' symptoms seriously; compassionate communication about fertility and pain; shared decision-making, encouraging patients to seek evidence-based information; and multidisciplinary support.

CONCLUSION

We were able to identify concrete barriers and facilitators to successful endometriosis management. Future research is now required to identify optimal ways to implement this evidence, and research the extent to which it applies to more diverse populations in non-Western setting, and to explore the impact of HCP demographic characteristics.

Focal 68Ga-FAPI-04 Uptake in Endometriosis at the Rectouterine Pouch

Endometriosis is a benign condition characterized by chronic inflammation and fibrosis. We report the findings of endometriosis at the rectouterine pouch on 68Ga-FAPI-04 PET/CT scan in a 25-year-old woman. The finding was initially thought as peritoneal metastasis from her newly diagnosed gastric cancer. However, subsequent pathologic examination confirmed that it was endometriosis.

FOXA2 loss results in an increase of endometriosis development and LIF reveals a therapeutic effect for endometriosis

Endometriosis, characterized by the growth of uterine-like tissue outside the uterus, causes chronic pain and infertility. Current diagnostic and therapeutic strategies have notable limitations, including delayed diagnosis and adverse effects. The transcription factor forkhead box A2 (FOXA2), which is exclusively expressed in the uterine glandular epithelium, regulates key genes involved in endometrial proliferation, differentiation, fertility, and hormone response. While FOXA2 expression is reduced in the endometrial tissue of women with endometriosis, its pathophysiological role in the disease is not well understood. In this study, we report that endometriosis significantly reduced FOXA2 expression in the eutopic endometrium of mice with endometriosis compared to sham controls, accompanied by decreased expression of its downstream gene, CXCL15. To evaluate the effect of FOXA2 loss in endometriosis, we surgically induced endometriosis by transplanting control Rosa26mTmG/+ or Pgrcre/+Foxa2f/fRosa26mTmG/+ (Foxa2d/dRosa26mTmG/+) endometrial tissue into the peritoneal cavity of mice. The number and weight of ectopic lesions were significantly increased in the mice with Foxa2d/dRosa26mTmG/+ ectopic lesions compared to controls. Furthermore, progesterone receptor expression was significantly reduced in the endometrial epithelium from mice with Foxa2d/dRosa26mTmG/+ ectopic lesions compared to mice with control ectopic lesions. Importantly, treatment with leukemia inhibitory factor (LIF), a cytokine regulated by FOXA2, significantly reduced ectopic lesion formation in Foxa2d/dRosa26mTmG/+ endometriosis mice compared to vehicle-treated mice. This study demonstrates that FOXA2 loss results in an increase in endometriosis incidence and that treatment with LIF offers a novel promising therapeutic approach for endometriosis.

Nanomicelle curcumin improves oxidative stress, inflammatory markers, and assisted reproductive techniques outcomes in endometriosis cases: a randomized clinical trial

We studied the effect nanomicelle curcumin on oxidative stress markers, pro-inflammatory cytokines, and assisted reproductive techniques (ART) outcomes in endometriosis cases. This randomized controlled trial was conducted on 50 women with endometriosis at the age of 25-35 candidate for ART referred to Roya Infertility Center in Qom, Iran, 2022. The participants were allocated to intervention (n = 25) and control (n = 25) groups by the blocked randomization method. Nanomicelle curcumin with a dose of 120 mg per day was given to the intervention group twice a day for 10 weeks, and the placebo with the same dose was given to the control group. Follicular fluid (FF) samples were collected from women with endometriosis stage III/IV undergoing ART. Antioxidant enzyme (MDA, SOD, CAT, and TAC) and pro-inflammatory cytokines (IL-8 and TNF-a) were tested. ART results such as (number of oocyte received, high-quality embryo, and pregnancy outcomes) were compared between two groups. Increased serum levels of TAC, CAT, and SOD were observed after nanomicelle curcumin treatment. Furthermore, FF levels of MDA, IL-8, and TNF-a reduced significantly after treatment in nanomicelle curcumin. Nanomicelle curcumin supplementation led to an improved number of oocytes retrieved, number of mature (MII) oocytes, fertilization, cleavage, and high-quality embryos. Nanomicelle curcumin treatment can modulate stress oxidative and inflammation in endometriosis-induced infertile patients. ART outcomes also improved after nanomicelle curcumin therapy. Our results suggest that nanomicelle curcumin can be a therapeutic target for infertile patients with endometriosis.

Endometriosis and Infertility: Gynecological Examination Practical Guide

Endometriosis, a prevalent gynecological condition affecting 10-15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women.

Update on the pathogenesis of endometriosis-related infertility based on contemporary evidence

Endometriosis, the most prevalent cause of infertility, is associated with anatomical distortion leading to adhesions and fibrosis, as well as endocrine abnormalities and immune disorders. This review discusses the mechanisms underlying endometriosis-related infertility. Firstly, alterations in the hypothalamic-pituitary-ovarian axis lead to the secretion of gonadotropins and steroid hormones, with adverse effects on ovulation and implantation, leading to fertility decline. Secondly, dysregulation of the hypothalamic-pituitary-adrenal axis induces elevated serum cortisol and prolactin levels in patients with endometriosis, accounting for its regulation of stress, depression, and anxiety. Abnormal interactions between endometrial cells and the immune system change the local microenvironment, resulting in epithelial-mesenchymal transition and inflammation. Activated epithelial cells, stromal cells, and immunocytes produce various chemokines, cytokines, or autoantibodies, creating an unfavorable environment for embryo implantation. These findings suggest that alterations in the immune spectrum play a crucial role in endometriosis-related infertility. Thirdly, oxidative stress has adverse effects on the ovarian reserve and subsequent embryonic development, predicting another promising strategy for endometriosis-related infertility. An unbalanced redox state, including impaired mitochondrial function, dysregulated lipid metabolism, and iron-induced oxidative stress, generates a pro-oxidative microenvironment, which negatively impacts oocyte quality and sperm and embryo viability. Thus, an updated understanding of the mechanisms involved in this disease will help to develop effective strategies to manage endometriosis-related infertility.

MEIS1-mediated Apoptosis via TNFR1 in Endometriosis

Abnormal apoptosis both maintains endometrial cell growth and induces endometrial pathogenesis. The etiology of endometriosis is unclear and no treatment is curative. Therefore, the aim herein was to identify genes involved in the pathogenesis of endometriosis. Using the data from our previous results and RNA sequencing data of normal endometrial tissue and ovarian endometrioma (OMA) tissue, along with Gene Expression Omnibus (GEO) dataset on endometriosis, we identified an apoptotic-related gene, meis homeobox I (MEIS1). Normal endometrium, eutopic endometrium and ectopic endometriotic tissues were used to detect MEIS1. Primary normal endometrial and eutopic endometrial stromal cells were isolated and cultured for exploring the function of MEIS1 and related pathways. A mouse endometriosis model was used to verify the therapeutic effects of MEIS1. The mRNA and protein of MEIS1 in tissues from patients with endometriosis were decreased. Overexpression of MEIS1 induced the apoptosis of primary eutopic endometrium stromal cells by regulating TNFR1. Using Cell Counting Kit 8 (CCK8) assay and EdU assay, we found that knockdown of MEIS1 promoted the proliferation of primary normal endometrium stromal cells. We also observe that upregulated MEIS1 may lead to caspase pathway activation, promoting endometrial cell apoptosis. Furthermore, MEIS1 lentivirus inhibited endometriotic lesion formation and induced apoptosis in the mouse endometriosis model. These cumulative findings suggest that MEIS1 may mediate apoptosis by initiating TNFR1 in endometrial cells via the caspase pathway.

Weighing up GnRH agonist therapy for endometriosis: outcomes and the treatment paradigm

INTRODUCTION

Endometriosis is a chronic inflammatory estrogen-dependent disease affecting 10% of women worldwide leading to chronic pelvic pain and infertility which may be treated clinically or surgically.

AREAS COVERED

Current literature was reviewed using the keywords 'gonadotropin releasing hormone agonists (GnRHa),' 'endometriosis,' 'infertility' and 'chronic pelvic pain.' Relevant papers prioritizing randomized controlled clinical trials (RCT), systematic reviews, meta-analyses, as well as international guidelines were evaluated.

EXPERT OPINION

Available options for relieving endometriosis-associated pain include GnRHa, progestagens, and combined oral contraceptives, all of which block menstruation to control symptoms without curing the disease. GnRHa administration decreases pain and symptom recurrence after surgical treatment, but side effects and costs limit its use. Published studies to test its effectiveness in easing endometriosis-associated pain are heterogeneous, consider different outcomes with no long-term results. Drug choice should be individualized considering the side-effect profile, tolerability, costs, risks, and benefits as one size does not fit all. As we wait for the development of an ideal pharmacological agents, GnRHa with an add-back regimen remains a second-line option to alleviate the painful symptoms in women with endometriosis. Endometriosis management should consider the systemic nature of the disease and the complexity involved in the pathogenesis of symptoms.

Metformin reverses infertility in a mouse model of endometriosis: unveiling disease pathways and implications for future clinical approaches

RESEARCH QUESTION

Does metformin reverse endometriosis-associated infertility?

DESIGN

Endometriosis was induced by transplanting uterus fragments from B6CBAF1 mice into recipients of the same strain. The mice were divided into groups: endometriosis (End, n = 24), sham-operated (Sham, n = 12), endometriosis with metformin (0.5mg/ml) orally administered for 3 months (EndMet, n = 21) and sham-operated metformin-treated (ShamMet, n = 16). Implant growth was monitored using ultrasonography. Fibrosis was computer-assisted quantified in Masson's trichrome-stained sections of eutopic (EuEnd) and ectopic (EcEnd) endometrium. PCNA, CYP17a1, F4/80 and galectin-3 were analysed by immunofluorescence and western blotting, and NFkB, GPX-1 and HO-1 only by western blotting. Statistical significance was set at P <0.05.

RESULTS

The endometriosis model was successfully established. The End groups showed lower fertility rates than sham-operated mice (P = 0.0034), whereas metformin treatment increased the number of fetuses per pregnant mouse (P = 0.0295), restoring fertility to control levels; it also slowed implant growth and vascularization. Metformin also restored PCNA expression and fibrosis levels to those of non-treated EuSham mice. PCNA expression decreased in pregnant mice (P <0.0178). Metformin diminished CYP17a1 expression in EcEnd versus EuEnd non-treated tissues and conversely up-regulated F4/80 in EuEnd tissue (P <0.0170), and galectin-3, NFkB and the antioxidant enzymes HO-1 and GPX-1 in EcEnd tissue (P <0.0293), in non-mated mice.

CONCLUSIONS

These results indicate that application of metformin can alleviate oxidative stress and mitigate fibrosis in endometriosis lesions in a murine model of endometriosis, which highlights metformin's potential as a pharmacological intervention for improving infertility in endometriosis.

The effect of endometriosis on oocyte quality: mechanisms, diagnosis and treatment

Endometriosis significantly impacts the physical and mental health of women of reproductive age. While some patients can achieve pregnancy through surgery or in vitro fertilization (IVF), many still struggle with IVF failure due to poor oocyte quality. This presents a major clinical challenge that requires immediate attention. The causes of oocyte quality decline in endometriosis patients are diverse and have not yet been definitively identified. Furthermore, effective diagnostic mechanisms and therapeutic strategies remain elusive. To provide possible clinical solutions to improve pregnancy rates in patients with endometriosis, this review evaluates the current literature on the impact of endometriosis on oocyte quality, the possible mechanisms and management strategies of endometriosis leading to poor oocyte quality.

Barriers to Diagnosis and Innovations in Care for Endometriosis

An estimated 190 million women are affected by endometriosis worldwide yet delays in diagnosis and treatment and validation of patient symptoms remain significant barriers to care. While a lack of data and gaps in research are central to understanding and addressing this disease, researchers are developing some promising innovations. In this column, I review prevalence and symptoms, barriers to diagnosis, and new innovations in care for endometriosis and the implications for research, practice, and policy. I conclude with information from professional organizations and the need for updated clinical guidelines.

Pain Phenotypes in Endometriosis: A Population-Based Study Using Latent Class Analysis

OBJECTIVE

To identify pain phenotypes in patients with endometriosis and investigate their associations with demographics, clinical characteristics, comorbidities and pain-related quality of life (QoL).

DESIGN

Cross-sectional, single-centre, population-based study.

SETTING

Referral university centre in Quebec City, Canada.

POPULATION

Patients diagnosed with endometriosis were enrolled consecutively between January 2020 and April 2024.

METHODS

Latent class analysis was used to identify pain phenotypes. A three-step approach of latent class analysis, involving logistic regression models, was applied to assess the associations between pain phenotypes and demographics, clinical characteristics, comorbidities and pain-related QoL.

MAIN OUTCOME MEASURES

Pain phenotypes; demographic, clinical and comorbidity predictors of phenotype membership; association between QoL and pain phenotypes.

RESULTS

A total of 352 patients were included. Two pain phenotypes were identified with distinct clinical presentations: one (54% of the participants) with more severe and frequent pain symptoms and poorer QoL and the other (46% of the participants) with mild and less frequent pain symptoms. The high pain phenotype was associated with previous treatment failure, painkiller use, familial history of endometriosis, low annual family income and comorbidities, including painful bladder, fibromyalgia, migraines, lower back pain, irritable bowel syndrome, anxiety and depression or mood disorders. The presence of endometrioma was associated with the low pain phenotype. Phenotype membership was associated with distinct QoL profiles (p < 0.001). The mean QoL score was higher in the high pain phenotype (59; 95% CI, 56-62) than in the low pain phenotype (33; 95% CI, 29-37).

CONCLUSION

Patients with endometriosis can be categorised into two distinct phenotypes that correlate with QoL and patient characteristics. Validation in other populations is necessary and could aid the development of specialised or personalised interventions.

Endometriosis and adenomyosis research priorities in India and Sri Lanka: a call for regional collaboration

Endometriosis and adenomyosis are major gynaecological conditions affecting women of reproductive age-group, particularly in low- and middle-income countries. This Health Policy outlined research priorities for India and Sri Lanka, derived from a structured debate during the 'Future Directions in Endometriosis and Adenomyosis Research' workshop. Researchers from both countries emphasise the need for nationally representative data, improved diagnostic tools, and comprehensive care models. Shared priorities include developing patient registries and improving healthcare access. India focuses on multidisciplinary care centres, advanced diagnostic research, and public education, while Sri Lanka highlights integrating traditional medicine and assessing economic impacts. Both countries prioritise non-invasive diagnostics to address diagnostic delays and healthcare limitations. Establishing patient registries and consortiums for large-scale studies could inform healthcare strategies. Collaborative research among Asian countries could generate tailored regional solutions. Coupled with a strong political will, and adequate funding, the initiative can potentially improve diagnosis, treatment, and quality of life for affected women.

The NLRP3 activation-related signature predicts the diagnosis and indicates immune characteristics in endometriosis

Endometriosis (EMS) is a prevalent gynecological disease that leads to chronic pelvic pain and infertility in women of reproductive age. However, the underlying pathogenic genes and effective treatment for EMS remain unclear. Therefore, this study aims to identify key genes influencing the diagnosis and treatment of EMS. The GSE7307 dataset, comprising 18 EMS and 23 control samples, was obtained from the GEO database. Fourteen differential genes related to NOD-like receptor protein 3 (NLRP3) activation and EMS were extracted from endometrial samples in GSE7307 through differential analysis. GO and KEGG analyses revealed that these genes were primarily involved in the production and regulation of the cytokine IL-1β and the NOD-like receptor signaling pathway. Random Forest (RF) and support vector machine recursive feature elimination algorithms were employed to select four diagnostic markers related to NLRP3 activation (NLRP3, IL-1β, LY96, and PDIA3) for constructing the EMS diagnostic model. These markers were validated using western blotting and tested in GSE7305 and GSE23339 datasets. The AUC values demonstrated the model's robust diagnostic performance. Additionally, the infiltration of immune cells in the samples and the correlation between different immune factors and diagnostic markers were explored. These results suggest that the four diagnostic markers may also play a crucial role in EMS immunity. Finally, the DrugBank database indicated that niclosamide could be effective for NLRP3-targeted therapy. In conclusion, we identified four key diagnostic genes for EMS, and niclosamide emerged as a potential drug for NLRP3-targeted therapy in EMS.

Global, regional, and national prevalence and disability-adjusted life-years for endometriosis in 204 countries and territories, 1990-2019: Findings from a global burden of disease study

Introduction

This study aimed to analyze the worldwide, regional burden of endometriosis and its trends from 1990 to 2019, utilizing the latest data from Global Burden of Disease (GBD) 2019. GBD 2019 is a global database tool for comprehensive analysis and an important result of long-term collaboration among governments worldwide.

Methods

We utilized the Global Health Data Exchange Query tool to analyze endometriosis in prevalence numbers, age-standardized prevalence rates (ASPR), and disability-adjusted life-years (DALYs) from 1990 to 2019 in 204 countries and regions. Additionally, this study investigated the impacts of period, age, and cohort on the prevalence and DALYs of endometriosis from the global perspective and in the five sociodemographic index (SDI) regions.

Results

Among the 21 regions, the most significant reduction in the prevalence of endometriosis between 1990 and 2019 occurred in Central Latin America. In 204 countries, the most pronounced decline was observed in Guatemala. At the SDI level, with the increase of SDI, the ASPR of endometriosis in all regions worldwide showed an overall decreasing trend. The prevalence of endometriosis peaked between the ages of 25 and 29.

Discussion

The findings of this study reflect the temporal and spatial tendency of the burden of endometriosis during the study period, and provide a reference for health agencies around the world to formulate policies on endometriosis, so as to reduce the harm of endometriosis to women worldwide.

Association between endometriosis and working life among Danish women

STUDY QUESTION

What is the association between endometriosis and working life (lost), workforce participation, and productivity?

SUMMARY ANSWER

Women with endometriosis experienced more working years lost due to disability pension and to a smaller degree sick leave, they were less frequently working or enrolled in education, had more sick days, were less productive, and had lower work ability.

WHAT IS KNOWN ALREADY

Endometriosis is associated with negative consequences on working life; however, previous studies are based on self-reported data or smaller samples of women. To the best of our knowledge, no previous studies have quantified the average reduction in working hours during the entire span of working life using population-based registers.

STUDY DESIGN, SIZE, DURATION

This study included two Danish data sources. In the register-based cohort study (main analysis), a total of 2 650 554 women aged 18-65 years were followed for a total of 42.8 million person-years from 1992 to 2021. In the questionnaire-based cross-sectional study (Supplementary Analysis), 35 490 women aged 26-51 years were invited to participate and 7298 women completed the questionnaire.

PARTICIPANTS/MATERIALS, SETTING, METHODS

For the main analysis, 42 741 (1.6%) were diagnosed with endometriosis. We estimated working years lost decomposed into disability pension, voluntary early retirement, or death for women with endometriosis and the general female population. For the supplementary analysis, 270 (4.0%) reported to have endometriosis. We analysed these recent questionnaire data on women's health to further investigate working life and productivity among women with and without endometriosis.

MAIN RESULTS AND THE ROLE OF CHANCE

Based on the main analysis, women with endometriosis lost on average an additional 0.26 years (95% CI: 0.17-0.37) of working life compared to the general female population. This was due to sick leave and especially disability pension. For the supplementary analysis, the participation rate was 20.6%. Women with endometriosis reported to be less frequently working or enrolled in education (74.1% (95% CI 68.4%-79.2%) with endometriosis, 82.7% (95% CI 81.8%-83.7%) without) and had more sick days (4-28 sick days last 4 weeks: 16.2% (95% CI 11.6%-21.8%) with endometriosis, 7.9% (95% CI 7.2%-8.7%) without). In addition, they reported lower productivity and work ability.

LIMITATIONS, REASONS FOR CAUTION

Endometriosis is underdiagnosed in the register data as only hospital diagnoses are registered and diagnoses from private practicing gynaecologists and general practitioners are missing. In addition, sick leave might be underestimated as shorter periods of sick leave are not included in the registers. Questionnaire data were self-reported including endometriosis and participants might be a selected group of women.

WIDER IMPLICATIONS OF THE FINDINGS

This study is in line with previous studies on endometriosis and its impact on working life. In addition, to the best of our knowledge, no previous study has quantified the average reduction in working years over the entire working life. However, the findings might only be generalizable to a Danish or Nordic context as these countries have welfare systems with economic security during unemployment, periods with illness, or reduced ability to work.

STUDY FUNDING/COMPETING INTEREST(S)

This study is supported by a grant from the project 'Finding Endometriosis using Machine Learning' (FEMaLe/101017562), which has received funding from The European Union's Horizon 2020 research and innovation programme. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Role of soluble neural cell adhesion molecule, soluble IL-2 receptor ɑ, and IL-2 in pelvic pain severity and their association with endometriosis in infertile women

INTRODUCTION

Pelvic pain, often associated with endometriosis, significantly affects women's quality of life. This study explored the soluble neural cell adhesion molecules (sNCAM), soluble interleukin 2 receptor α (sIL-2Rα), and IL-2 levels in the serum and peritoneal fluid of infertile women with pelvic pain.

METHODS

We enrolled 86 infertile women aged 24 to 41 years undergoing diagnostic laparoscopy: 44 women with endometriosis and 42 women who acted as controls. Pain intensity was assessed using the visual analog scale. The soluble molecules were measured using enzyme-linked immunosorbent assay.

RESULTS

Serum and peritoneal sNCAM, sIL-2Rα, and IL-2 levels were statistically significantly higher in women with pelvic pain. Both serum and peritoneal sNCAM levels correlated with visual analog scale scores, indicating a relationship between these markers and pain severity. Elevated peritoneal sIL-2Rα levels were also associated with pelvic pain. Receiver operating characteristic curve analysis showed the potential of serum sNCAM in distinguishing between mild and moderate to severe pain.

DISCUSSION

Elevated levels of sNCAM, sIL-2Rα, and IL-2 in serum and peritoneal fluid correlate with pelvic pain severity in infertile women, suggesting their involvement in disease pathogenesis and potential as objective biomarkers for pain assessment in endometriosis. Further research is needed to validate these findings for clinical use.

A novel mechanism of FTO modulating the progression of endometriosis through mediating the m6A methylation of GEF-H1 in a YTHDF1-dependent manner

BACKGROUND

Endometriosis (EMs) is a condition characterized by the growth of endometrial tissue outside the uterine cavity. Although this condition is benign, it has cancer-like features. N6-methyladenosine (m6A) is a common RNA modification involved in diverse biological processes, but its role in EMs remains unclear.

METHODS

A human endometrial stromal cell line (HESCs), primary eutopic endometrial stromal cells (Eu-ESCs), primary ectopic endometrial stromal cells (Ec-ESCs), and clinical samples were used in this study. A colorimetric assay was used to measure methylation levels in clinical and mouse EMs samples. Functional assays (CCK-8, EdU, Transwell, and wound healing) were used to evaluate phenotypic changes. m6A immunoprecipitation sequencing (MeRIP-seq) identified downstream targets. Mechanistic studies were conducted via qRT‒PCR, Western blot, RNA immunoprecipitation (RIP), dual-luciferase reporter, and RNA stability assays.

RESULTS

We detected aberrantly low levels of m6A within endometriotic lesions, which was attributed to increased expression of the m6A eraser fat mass and obesity-associated protein (FTO). Notably, estrogen and inflammatory factors, which are recognized as pathogenic agents in EMs amplify FTO expression while suppressing m6A levels. In vitro experiments demonstrated that overexpression of FTO in endometrial stromal cells leads to a reduction in m6A levels and concomitantly promotes their proliferation, migration, and invasion. Furthermore, both genetic deletion of Fto and chemical inhibition of FTO impeded the growth of ectopic endometrial lesions in vivo. By utilizing m6A-seq, we identified GEF-H1 (a Rho guanine nucleotide exchange factor) as a pivotal downstream target of FTO. Specifically, diminished m6A methylation at a certain site within the 3'UTR of GEF-H1 promotes its expression in a YTH N6-methyladenosine RNA-binding protein F1 (YTHDF1)-dependent manner, thereby activating the RhoA pathway. Subsequent experiments revealed that GEF-H1 mediates the effects of FTO in promoting migration and invasion.

CONCLUSIONS

This study revealed that FTO decreases the m6A level of GEF-H1, thereby increasing its stability, which in turn activates the GEF-H1-RhoA pathway to promote the migration and invasion of endometrial stromal cells, thereby inducing EMs. Our findings suggest potential therapeutic avenues for targeting FTO to alleviate EMs progression.

Construction organoid model of ovarian endometriosis and the function of estrogen and progesterone in the model

Endometriosis is a refractory estrogen-dependent gynecological disease in which ovarian endometriosis(OE) is the most common, and the main cell components are endometrial epithelial cells and stromal cells. However, constructing ectopic endometrial epithelial cell models in basic studies is still challenging. In this study, we explored the feasibility and influencing factors of constructing and validating eutopic and ectopic endometrial organoid models of OE as in-vitro models. Eutopic and ectopic endometrial tissues of OE patients were selected to establish organoids. Morphologically, the organoids showed a three-dimensional glandular structure with vacuoles or cystic irregularities, and the histological features of the epithelial organoids in endometriosis were well preserved. Immunofluorescence showed positive expression of epithelial markers and estrogen/progesterone receptors. Genetic identification revealed a 100% match between endometriosis epithelial organoids and endometrial tissue, indicating a common origin. The effects of estrogen and progesterone on the proliferation and secretion of organoids differed with the change in concentration. The successful construction of ectopic endometrial organoids provides a new in vitro model for drug intervention and mechanism study of ovarian endometriosis.

Exploring Microbial Signatures in Endometrial Tissues with Endometriosis

OBJECTIVE

The endometrial microbiota exerts a crucial role in maintaining the health of the female reproductive system. As such, in this study, we have examined the composition of the microbiota in endometrium tissues with and without endometriosis, with the objective of identifying key species that may potentially contribute to the progression of endometriosis.

METHODS

We obtained endometrial tissues from 43 women diagnosed as either having endometriosis or not. Subsequently, we utilized a diverse array of techniques, including fluorescence in situ hybridization (FISH), immunohistochemistry (utilizing anti-LPS and anti-LTA antibodies), transmission electron microscopy (TEM), and 16S rRNA sequencing, to undertake a comprehensive examination of the presence of microorganisms in the endometrium and their potential role in endometriosis.

RESULTS

Our findings consistently indicated the existence of bacteria in both normal endometrium tissues and those affected by endometriosis. By employing the fluorescent co-staining technique, we observed the colocalization of macrophages and bacteria in both tissue types. Notably, we discovered a significant increase in microbial diversity in endometrial tissue from women with endometriosis compared to normal endometrial tissues. Additionally, we identified 13 species that were more abundant in the normal group, such as Acinetobacter guillouiae. In contrast, seven species were prominent in the endometriosis group, with Faecalibacterium prausnitzii being a notable one. Finally, our results suggest that Faecalibacterium prausnitzii may play an essential role in the progression of endometriosis.

CONCLUSION

We carried out a comprehensive analysis of the endometrial microbial landscape in endometriosis tissue and revealed that Faecalibacterium prausnitzii is a pivotal species that may potentially play a crucial role in the pathogenesis of endometriosis.

Unveiling the Mechanisms of Pain in Endometriosis: Comprehensive Analysis of Inflammatory Sensitization and Therapeutic Potential

Endometriosis is a complicated, estrogen-dependent gynecological condition with a high morbidity rate. Pain, as the most common clinical symptom of endometriosis, severely affects women's physical and mental health and exacerbates socioeconomic burden. However, the specific mechanisms behind the occurrence of endometriosis-related pain remain unclear. It is currently believed that the occurrence of endometriosis pain is related to various factors, such as immune abnormalities, endocrine disorders, the brain-gut axis, angiogenesis, and mechanical stimulation. These factors induce systemic chronic inflammation, which stimulates the nerves and subsequently alters neural plasticity, leading to nociceptive sensitization and thereby causing chronic pain. In this paper, we compile and review the articles published on the study of nociceptive sensitization and endometriosis pain mechanisms. Starting from the factors influencing the chronic pain associated with endometriosis, we explain the relationship between these factors and chronic inflammation and further elaborate on the potential mechanisms by which chronic inflammation induces nociceptive sensitization. We aim to reveal the possible mechanisms of endometriosis pain, as well as nociceptive sensitization, and offer potential new targets for the treatment of endometriosis pain.

Decoding immune tolerance in infertility: Exploring immune pathways and non-coding RNAs as pioneering biomarkers and therapeutic targets

Infertility, impacting a significant number of couples, is characterized by the failure to conceive after one year of consistent, unprotected sexual intercourse. It is multifactorial, with etiological contributors including ovulatory dysfunction, male reproductive anomalies, and tubal patency issues. Approximately 15% of infertility cases are classified as "unexplained," highlighting the complexity of this condition. Lifestyle determinants such as obesity and smoking further complicate reproductive outcomes, while infertility can also indicate underlying chronic health conditions. A specialized category, immune infertility, arises from a breakdown of immunological tolerance, an essential aspect for conception and the maintenance of pregnancy. The role of various immunological components, including immune cells, cytokines, chemokines, factors like HLA-G, etc., is pivotal in this context. Moreover, non-coding RNAs (ncRNAs) have emerged as critical regulators of immune tolerance within the reproductive axis. This review synthesizes the complex immunological pathways vital for successful implantation and the early stages of pregnancy alongside the regulatory roles of ncRNAs in these processes. Offering an integrated view of molecular and immunological interactions associated with infertility seeks to enhance our understanding of potential strategies to facilitate successful conception and sustain early pregnancy.

The Improved-EFI Score: A Multi-Omics-Based Novel Efficacy Predictive Tool for Predicting the Natural Fertility of Endometriosis Patients

Objective

Infertility caused by endometriosis (EM) directly affects the possibility of pregnancy in women of gestational age. This study aims to establish a prediction model to accurately predict the natural pregnancy outcome of patients with EM, providing valuable information for clinical decision-making.

Methods

We retrospectively selected a total of 496 patients who underwent their first laparoscopic surgery for infertility at the Obstetrics and Gynecology Department of Jingzhou Central Hospital from January 2016 to June 2023. An improved endometriosis fertility index (EFI) predictive model was created based on ultrasound radiomics and urinary proteomics gathered during the patient's initial admission, using two machine learning algorithms. The predictive model was evaluated for C-index, calibration, and clinical applicability through receiver working characteristic curve, decision curve analysis.

Results

The improved EFI prediction model nomogram, based on five ultrasound radiomics parameters and three urine proteomics, had AUC values of 0.921 (95% CI: 0.864-0.978) and 0.909 (95% CI: 0.852-0.966) in the training and validation sets, respectively, while the traditional EFI prediction model had AUC values of 0.889 (95% CI: 0.832-0.946) and 0.873 (95% CI: 0.816-0.930) in the training and validation sets, respectively. Additionally, the nomogram exhibited better discrimination ability and achieved an overall better benefit against threshold probability than the EFI model and decision tree in the decision curve analysis (DCA).

Conclusion

The combined ultrasound radiomics-urine proteomics model was better able to predict natural pregnancy-associated patients with EM compared to the classical EFI score. This can help clinicians better predict an individual patient's risk of natural pregnancy following a first-ever laparoscopic surgery and facilitate earlier diagnosis and treatment.

Perturbations of the endometrial immune microenvironment in endometriosis and adenomyosis: their impact on reproduction and pregnancy

The impact of endometriosis and adenomyosis on reproduction and pregnancy is significant, with both conditions linked to increased rates of infertility, poor ovarian function in women with endometriosis, and elevated pregnancy complications in those with adenomyosis. However, the underlying mechanisms remain largely unclear. Both conditions share a similar pathophysiological process characterized by the growth of ectopic endometrium, which may originate from the eutopic endometrium. Notably, surgical removal of ectopic lesions does not appear to significantly improve reproductive and pregnancy outcomes, further underscoring the importance of eutopic endometrium in these adverse effects. Emerging evidence indicates substantial differences in endometrial NK cells, macrophages, and T cells, leading to inflammatory responses in women with endometriosis and adenomyosis. These alterations may contribute not only to disease progression but also to defective endometrial receptivity, insufficient angiogenesis remodeling, impaired maternal-fetal immune tolerance, and poor placentation, thereby influencing embryo implantation and pregnancy maintenance. This provides an immunological perspective to explain the higher rates of infertility and pregnancy complications observed in affected women. Therefore, we systematically review the alterations in endometrial immune cells in women with endometriosis and adenomyosis compared to healthy controls, exploring the potential impacts of these changes on reproduction and pregnancy. This review aims to lay the groundwork for future studies on the immunopathogenesis associated with endometriosis and adenomyosis-related reproductive failure and pregnancy complications, shedding lights on the development of immunotherapeutic strategies to mitigate these adverse impacts in affected women.

Reprogramming peritoneal macrophages with outer membrane vesicle-coated PLGA nanoparticles for endometriosis prevention

Endometriosis is a chronic inflammatory disease that primarily affects women of reproductive age. The current hormonal treatments are unsuitable for women who wish to conceive, highlighting the need for non-hormonal therapeutic alternatives. In this study, we engineered outer membrane vesicle (OMV)-coated poly (lactic-co-glycolic acid) (PLGA) nanoparticles (OMV-NPs) as a potential therapy for endometriosis. These OMV-NPs were internalized by macrophages more efficiently than bacterial OMVs and preserved the immunostimulatory properties of OMVs. In vivo administration of OMV-NPs in mice achieved prolonged retention in the peritoneal cavity, with effective uptake by nearly 80 % of the peritoneal macrophages. Notably, treatment with OMV-NPs reprogrammed macrophages toward the M1 phenotype, resulting in a significant decrease in the M2 to M1 ratio within the peritoneal cavity and in endometriotic lesions. This shift from M2 to M1 was associated with reduced TGF-β1 production and suppressed myofibroblast activation, which led to substantial inhibition of endometriosis progression. Furthermore, immunohistochemical imaging of paired eutopic and ectopic endometrial tissues from endometriosis patients revealed a positive correlation between M2-polarized macrophages and fibrosis. This finding suggests that reprogramming macrophages with OMV-NPs could be a promising therapeutic approach for endometriosis.