COX-2 inhibitors and their role in gynecology

Epigenetic Dysregulation in Endometriosis: Implications for Pathophysiology and Therapeutics

Endometriosis is a prevalent gynecological condition associated with pelvic pain and infertility. Despite more than a century of research, the etiology of endometriosis still eludes scientific consensus. This lack of clarity has resulted in suboptimal prevention, diagnosis, and treatment options. Evidence of genetic contributors to endometriosis is interesting but limited; however, significant progress has been made in recent years in identifying an epigenetic role in the pathogenesis of endometriosis through clinical studies, in vitro cell culture experiments, and in vivo animal models. The predominant findings include endometriosis-related differential expression of DNA methyltransferases and demethylases, histone deacetylases, methyltransferases, and demethylases, and regulators of chromatin architecture. There is also an emerging role for miRNAs in controlling epigenetic regulators in the endometrium and endometriosis. Changes in these epigenetic regulators result in differential chromatin organization and DNA methylation, with consequences for gene expression independent of a genetic sequence. Epigenetically altered expression of genes related to steroid hormone production and signaling, immune regulation, and endometrial cell identity and function have all been identified and appear to play into the pathophysiological mechanisms of endometriosis and resulting infertility. This review summarizes and critically discusses early seminal findings, the ever-growing recent evidence of epigenetic contributions to the pathophysiology of endometriosis, and implications for proposed epigenetically targeted therapeutics.

Causal effects of genetically predicted endometriosis on breast cancer: a two-sample Mendelian randomization study

This study used a Mendelian randomization (MR) approach to investigate the causal relationship between genetically predicted endometriosis (EMS) and breast cancer risk. A total of 122,977 cases and 105,974 controls were included in the analysis, with gene-level summary data obtained from the Breast Cancer Association Consortium (BCAC). An inverse variance-weighting approach was applied to assess the causal relationship between EMS and breast cancer risk, and weighted median and MR-Egger regression methods were used to evaluate pleiotropy. Results showed a causal relationship between EMS and a decreased risk of overall breast cancer (odds ratio [OR] 0.95; 95% CI 0.90-0.99, p = 0.02). Furthermore, EMS was associated with a lower risk for estrogen receptor (ER)-positive breast cancer in a subgroup analysis based on immunohistochemistry type (OR 0.91; 95% CI 0.86-0.97, p = 0.005). However, there was no causal association between ER-negative breast cancer and survival (OR 1.00; 95% CI 0.94-1.06, p = 0.89). Pleiotropy was not observed. These findings provide evidence of a relationship between EMS and reduced breast cancer risk in invasive breast cancer overall and specific tissue types, and support the results of a previous observational study. Further research is needed to elucidate the mechanisms underlying this association.

The Contractile Response to Oxytocin in Non-pregnant Rat Uteri Is Modified After the First Pregnancy

During pregnancy, the uterus undergoes several modifications under the influence of hormonal and mechanical stimuli. We hypothesize that while most of these modifications are reverted during involution, some of the physiological properties of the uterus are permanently altered. To investigate this hypothesis, we conducted motility experiments to evaluate the contractility response of uterine tissue samples from non-pregnant virgin and proven breeder female rats to oxytocin (10-10 to 10-5 M). We found that the virgin tissue contracts more robustly than proven breeder tissue in the absence of oxytocin, yet with oxytocin, proven breeder samples displayed a significantly higher increase in activity. These results could depend on a more elevated expression of oxytocin receptor and/or on an alteration in the intracellular pathways affected by the activation of the oxytocin receptors. Here, we explored the impact of some structures involved in the management of intracellular calcium on the dose response to oxytocin recorded from virgin and proven breeder uterine strips. Specifically, we replicated the dose response experiments in low extracellular calcium (10 μM), in the presence of the intracellular calcium channel blocker ruthenium red (10 μM), and in the presence of the sarcoplasmic-endoplasmic reticulum calcium ATP-ase pump inhibitor, cyclopiazonic acid (10 μM). The results of these experiments suggest that also the expression of proteins that control intracellular calcium availability is affected by the experience of pregnancy. Molecular biology experiments will give us more detail on the magnitude of these expression changes.

Promising therapeutic targets of endometriosis obtained from microRNA studies

Endometriosis is a benign tumor that affect 6-10% women of reproductive age. To date, it is suggested that the aberrant microRNA (miRNA) expressions play important roles in the pathogenesis of endometriosis. Reviewing the literature, we found nine overexpressed miRNAs, which were thoroughly investigated in the context of endometriotic tissues and cells. Most of the overexpressed miRNAs induced endometriosis-specific characteristics including inhibition of apoptosis and decidualization, upregulation of fibrogenesis, invasion, migration, cell proliferation, attachment to extracellular matrix, inflammation, and angiogenesis in the endometriotic cells. Then, we found that the downstream target molecules of these miRNAs, such as early growth response protein-1, extracellular signal-regulated kinase, matrix metallopeptidase 1, signal transducer and activator of transcription 3, cyclooxygenase-2, phosphoinositide 3-kinase, AKT, mammalian target of rapamycin, and vascular endothelial growth factor-A are promising for the therapeutic targets of endometriosis. Recent findings suggest that complex molecular mechanisms leading to development and progression of endometriosis by miRNAs may exist in endometriosis. The meticulous balance between tumorigenic miRNAs and tumoristatic miRNAs may destine the natural course and response to the surgical, medical, and hormonal treatments of this disease. Further investigations into endometriosis-associated miRNAs may elucidate the pathogenesis of endometriosis and help to develop novel therapeutics.

Comprehensive management of adults with chronic migraine: Clinical practice guidelines in Mexico

Introduction:

Migraine is a polygenic multifactorial disorder with a neuronal initiation of a cascade of neurochemical processes leading to incapacitating headaches. Headaches are generally unilateral, throbbing, 4–72 h in duration, and associated with nausea, vomiting, photophobia, and sonophobia. Chronic migraine (CM) is the presence of a headache at least 15 days per month for ≥3 months and has a high global impact on health and economy, and therapeutic guidelines are lacking.

Methods:

Using the Grading of Recommendations, Assessment, Development, and Evaluations system, we conducted a search in MEDLINE and Cochrane to investigate the current evidence and generate recommendations of clinical practice on the identification of risk factors and treatment of CM in adults.

Results:

We recommend avoiding overmedication of non-steroidal anti-inflammatory drugs (NSAIDs); ergotamine; caffeine; opioids; barbiturates; and initiating individualized prophylactic treatment with topiramate eptinezumab, galcanezumab, erenumab, fremanezumab, or botulinum toxin. We highlight the necessity of managing comorbidities initially. In the acute management, we recommend NSAIDs, triptans, lasmiditan, and gepants alone or with metoclopramide if nausea or vomiting. Non-pharmacological measures include neurostimulation.

Conclusions:

We have identified the risk factors and treatments available for the management of CM based on a grading system, which facilitates selection for individualized management.

Thyme (Thymus vulgaris [Lamiaceae]) Leaves Inhibit Contraction of the Nonpregnant Mouse Uterus

Dysmenorrhea is painful menstrual periods, which affects 25% of women within reproductive age and has a prevalence of 67.2-90.0%. Current treatment has several adverse effects and can be ineffective once the pain is initiated. Thymus vulgaris traditionally used for pain management was investigated in this study for its activity on uterine contraction in the nonpregnant uterus, as a parameter for dysmenorrhea. The dried leaves of T. vulgaris were macerated in water, and the resulting aqueous extract was investigated on the isolated mouse uterus. Parameters investigated included spontaneous contractions, oxytocin-induced contractions, and high potassium chloride (KCl; 80 mM)-induced tonic contractions. Mass spectrometric analysis of the thyme extract was also performed using liquid chromatography-high-resolution Fourier Transform mass spectrometry. Thyme extract inhibited the amplitude and frequency of spontaneous and oxytocin-induced uterine contractions. It also inhibited KCl-induced tonic contractions. The activities observed suggest that T. vulgaris inhibits uterine contractions through blockade of extracellular voltage-gated calcium channels. Secondary metabolites detected included compounds belonging to chlorogenic phytochemical class and flavonoids, which are known to have activities on extracellular calcium blockade. This study has shown that aqueous T. vulgaris extract, also known as thyme, inhibits contractions of the nonpregnant uterus and can be a lead plant in the drug discovery process for the management of dysmenorrhea.

Endometriosis

Pelvic endometriosis is a complex syndrome characterized by an estrogen-dependent chronic inflammatory process that affects primarily pelvic tissues, including the ovaries. It is caused when shed endometrial tissue travels retrograde into the lower abdominal cavity. Endometriosis is the most common cause of chronic pelvic pain in women and is associated with infertility. The underlying pathologic mechanisms in the intracavitary endometrium and extrauterine endometriotic tissue involve defectively programmed endometrial mesenchymal progenitor/stem cells. Although endometriotic stromal cells, which compose the bulk of endometriotic lesions, do not carry somatic mutations, they demonstrate specific epigenetic abnormalities that alter expression of key transcription factors. For example, GATA-binding factor-6 overexpression transforms an endometrial stromal cell to an endometriotic phenotype, and steroidogenic factor-1 overexpression causes excessive production of estrogen, which drives inflammation via pathologically high levels of estrogen receptor-β. Progesterone receptor deficiency causes progesterone resistance. Populations of endometrial and endometriotic epithelial cells also harbor multiple cancer driver mutations, such as KRAS, which may be associated with the establishment of pelvic endometriosis or ovarian cancer. It is not known how interactions between epigenomically defective stromal cells and the mutated genes in epithelial cells contribute to the pathogenesis of endometriosis. Endometriosis-associated pelvic pain is managed by suppression of ovulatory menses and estrogen production, cyclooxygenase inhibitors, and surgical removal of pelvic lesions, and in vitro fertilization is frequently used to overcome infertility. Although novel targeted treatments are becoming available, as endometriosis pathophysiology is better understood, preventive approaches such as long-term ovulation suppression may play a critical role in the future.

Pharmacokinetic-pharmacodynamic modeling to study the anti-dysmenorrhea effect of Guizhi Fuling capsule on primary dysmenorrhea rats

BACKGROUND

Primary dysmenorrhea (PDM) is one of the most common gynaecological disorders among women, which seriously affects women's life quality due to its high incidence rate. Guizhi Fuling capsule (GZFLC), a well-known traditional Chinese medical prescription, has been widely used to treat gynecological blood stasis syndromes such as PDM. However, its mechanisms of action and combination were still unknown.

PURPOSE

The aim of this study was to develop a pharmacokinetic-pharmacodynamic (PK-PD) model to assess time-concentration-effect relationships for anti-dysmenorrhea effect of GZFLC and provide better understanding for mechanisms of action and combination of GZFLC.

STUDY DESIGN AND METHODS

The PDM rats model was induced by oxytocin exposure following estradiol benzoate pretreatment. Gallic acid (GA), amygdalin (AMY), albiflorin (ALB), prunasin (PA) and cinnamic acid (CA) were evaluated as bioactive ingredients for investigating PK processes. GA, AMY, ALB and PA exhibited appropriate PK parameters and were selected as the PK markers to map the anti-dysmenorrhea effect of GZFLC. A PK-PD model was established on the basis of GA, AMY, ALB and PA plasma concentrations vs. the values of two ratios (PGE₂/PGF_2α and 6-Keto-PGF_1α/TXB₂), by a two-compartment PK model with a simple E_max model to explain the time delay between the drug plasma concentrations of PK markers and the anti-dysmenorrhea effect.

RESULTS

The PDM rat model has been successfully established. Compared with the normal treated group, the bioactive ingredients in PDM treated group exhibited significant changing trends of PK behaviors, such as better absorption and distribution, slower elimination and delays in reaching the maximum concentration (T_max). The analysis of PK-PD parameters indicated that the active metabolites and prototypes of bioactive ingredients in GZFLC were inclined to regulate the activity of prostacyclin synthetase and thromboxane synthetase to control the production of TXA₂ and PGI₂ so as to treat PDM. As the main effective medicinal materials for the treatment of PDM in GZFLC prescription Persicae Semen, Moutan Cortex and Paeonia lactiflora Pall, Persicae Semen played the most important role, while the role of Paeonia lactiflora Pall was the weakest.

CONCLUSION

The PK-PD model results provided scientific basis for clarifying compatibility mechanisms of GZFLC prescription and a better understanding for biosynthetic mechanisms of four prostaglandins (PGE₂, PGF_2α, 6-Keto-PGF_1α and TXB₂) in the treatment of PDM by GZFLC. Investigations on the relationship between the effects and the bioactive ingredients are of benefit to explore the mechanisms of action and combination for traditional Chinese medical prescriptions (TCP) and facilitate the development of future clinical applications of TCP.

Human Parturition: Nothing More Than a Delayed Menstruation

Humans are one of the few mammalian viviparous species in which pregnancy is extended beyond the luteal phase, the phase during which progesterone is synthesized by the maternal ovary. Instead, it is the fetal placenta that produces progesterone throughout the latter 2 trimesters of human pregnancy. The placenta is developmentally crucial for reproductive success and is the most conspicuous anatomical novelty of placental mammals. However, before it can exert its dual functions as both an endocrine organ and an organ capable of facilitating gas and nutrient exchange, enormous changes must take place within the uterus to not only tolerate the presence of this hemiallogeneic tissue but to also accommodate and support placental development. The most dramatic of these changes is endometrial decidualization, the origin of which coincides in evolutionary history with invasive placentation. This article builds on the observation that the physiological changes that occur during the nonpregnant secretory phase of the uterine cycle in women are remarkably similar to that seen during pregnancy. The fundamental characteristics of human pregnancy (including endometrial decidualization followed several months later by intrauterine inflammation, uterine contractions, and discharge of the decidual lining from the uterine cavity) are present already in the nonpregnant menstrual cycle and are thus independent of the fetus. We hypothesize that many of the physiological defects that lead to complications during pregnancy and parturition are detectable already during spontaneous decidualization in the nonpregnant state and at the onset of menstruation, and can thus be determined before the onset of pregnancy.

Selective Estrogen-Receptor Modulators and Aromatase Inhibitors: Promising New Medical Therapies for Endometriosis?

Endometriosis is an estrogen-dependent disease and estrogen-related pathways are imbalanced in women with endometriosis. One of the key enzymes in estrogen synthesis is aromatase. Inhibiting this pathway at several points is a promising idea for the treatment of endometriosis. The third generation of aromatase inhibitors is becoming more potent in efficacy, with fewer side effects than previous generations, but cotreatment with other hormones is needed to inhibit ovarian stimulation. Other components that promote estrogen synthesis such as COX-2 can also be potentially targeted. Selective estrogen-receptor modulators could also be interesting in view of their tissue-specific effect. However, all these new drugs are still in an early phase of development. At present, it is too early to conclude that aromatase inhibitors, COX-2 inhibitors or selective estrogen-receptor modulators really present any added value compared with the existing drugs that can be used to achieve hormonal suppression in the medical treatment of endometriosis.

Predicting Cyclooxygenase Inhibition by Three-Dimensional Pharmacophoric Profiling. Part I: Model Generation, Validation and Applicability in Ethnopharmacology

3D pharmacophore modeling has evolved as an established and state-of-the-art method for performing in-silico predictions of biological activity. Using one single model is limited to single binding modes, while the combination of several models bears a broader application scope. We demonstrate the generation of a complete and predictive 3D model set for cyclooxygenase 1 and 2 inhibitors, along with a selection and validation protocol optimized for parallel virtual screening. This model set was applied to explain the cyclooxygenase activity of an ethnopharmacologically known mixture of natural products, the Thai traditional medicine "Prasaplai". Results show that rationalizing natural product activity by modern in-silico approaches is promising and can be tremendously useful in the identification of the mechanisms of action for known biological effects of complex herbal remedies.

Importance of cervical length in dysmenorrhoea aetiology

The objective of this prospective case-control study was to determine whether uterine corpus and cervical length measurements have a role in dysmenorrhoea aetiology in virgins. Patients with severe primary dysmenorrhoea with visual analog scale scores of ≥7 composed the dysmenorrhoea group (n = 51), while the control group (n = 51) was of women with painless menstrual cycles or with mild pain. Longitudinal and transverse axes of the uterine cervix and uterine corpus were measured. Correlation between severity of dysmenorrhoea and uterine cervix and corpus axes was calculated. Longitudinal and transverse axes of uterine cervix as well as uterine cervix volume were significantly higher in the dysmenorrhoea group compared to the controls. There was a significant positive correlation between severity of dysmenorrhoea and the length of cervical longitudinal and transverse axes and uterine cervical volume. Our findings reveal longer cervical length and greater cervical volume in young virgin patients with dysmenorrhoea and severe pain compared to those with no or less pain.

Neonatal exposure to estradiol-17β modulates tumour necrosis factor alpha and cyclooxygenase-2 expression in brain and also in ovaries of adult female rats

The sexually dimorphic organization in perinatal rat brain is influenced by steroid hormones. Exposure to high levels of estrogen or endocrine-disrupting compounds during perinatal period may perturb this process, resulting in compromised reproductive physiology and behavior as observed in adult In our recent observation neonatal exposure of the female rats to estradiol-17β resulted in down-regulation of TNF-α, up-regulation of COX-2 and increase in SDN-POA size in pre-optic area in the adulthood. It is known that the control of reproductive performance in female involves a complex interplay of the hypothalamus, pituitary, and ovary. The present study was undertaken to understand the possible molecular mechanism involved in changes observed in the ovarian morphology and expression of selected genes in the ovary. Administration of estradiol-17β (100 μg) on day 2 and 3 after birth revealed up-regulation of ER-α, ER-β, COX-2 and down-regulation of TNF-α expression. Also the decrease in the ovarian weight, altered ovarian morphology and changes in the 2D protein profiles were also seen. This is apparently the first report documenting that neonatal estradiol exposure modulates TNF-α and COX-2 expression in the ovary as seen during adult stage. Our results permit us to suggest that cues originating from the modified brain structure due to neonatal exposure of estradiol-17β remodel the ovary at the molecular level in such a way that there is a disharmony in the reproductive function during adulthood and these changes are perennial and can lead to infertility and changes of reproductive behavior.

Evidence-based anesthesia for major gynecologic surgery

Studies on enhanced recovery after gynecological surgery are limited but seem to report outcome benefits similar to those reported after colorectal surgery. Regional anesthesia is recommended in enhanced recovery protocols. Effective regional anesthetic techniques in gynecologic surgery include spinal anesthesia, epidural analgesia, transversus abdominis plane blocks, local anesthetic wound infusions and intraperitoneal instillation catheters. Non-opioid analgesics including pregabalin, gabapentin, NSAIDs, COX-2 inhibitors, and paracetamol reduce opioid consumption after surgery. This population is at high risk for PONV, thus, a multimodal anti-emetic strategy must be employed, including strategies to reduce the baseline risk of PONV in conjunction with combination antiemetic therapy.

Medical treatments for endometriosis-associated pelvic pain

The main sequelae of endometriosis are represented by infertility and chronic pelvic pain. Chronic pelvic pain causes disability and distress with a very high economic impact. In the last decades, an impressive amount of pharmacological agents have been tested for the treatment of endometriosis-associated pelvic pain. However, only a few of these have been introduced into clinical practice. Following the results of the controlled studies available, to date, the first-line treatment for endometriosis associated pain is still represented by oral contraceptives used continuously. Progestins represent an acceptable alternative. In women with rectovaginal lesions or colorectal endometriosis, norethisterone acetate at low dosage should be preferred. GnRH analogues may be used as second-line treatment, but significant side effects should be taken into account. Nonsteroidal anti-inflammatory drugs are widely used, but there is inconclusive evidence for their efficacy in relieving endometriosis-associated pelvic pain. Other agents such as GnRH antagonist, aromatase inhibitors, immunomodulators, selective progesterone receptor modulators, and histone deacetylase inhibitors seem to be very promising, but there is not enough evidence to support their introduction into routine clinical practice. Some other agents, such as peroxisome proliferator activated receptors-γ ligands, antiangiogenic agents, and melatonin have been proven to be efficacious in animal studies, but they have not yet been tested in clinical studies.

Development of pro-apoptotic peptides as potential therapy for peritoneal endometriosis

Endometriosis is a common gynaecological disease associated with pelvic pain and infertility. Current treatments include oral contraceptives combined with nonsteroidal anti-inflammatory drugs or surgery to remove lesions, all of which provide a temporary but not complete cure. Here we identify an endometriosis-targeting peptide that is internalized by cells, designated z13, using phage display. As most endometriosis occurs on organ surfaces facing the peritoneum, we subtracted a phage display library with female mouse peritoneum tissue and selected phage clones by binding to human endometrial epithelial cells. Proteomics analysis revealed the z13 receptor as the cyclic nucleotide-gated channel β3, a sorting pathway protein. We then linked z13 with an apoptosis-inducing peptide and with an endosome-escaping peptide. When these peptides were co-administered into the peritoneum of baboons with endometriosis, cells in lesions selectively underwent apoptosis with no effect on neighbouring organs. Thus, this study presents a strategy that could be useful to treat peritoneal endometriosis in humans.

Regression of experimentally induced endometriosis with a new selective cyclooxygenase-2 enzyme inhibitor

BACKGROUND

Cyclooxygenase-2 (COX-2) levels increase in women with endometriosis. COX-2, via increasing prostaglandin E2, contributes to an increase in vascular endothelial growth factor. In this way, COX-2 may contribute to the progression and continuity of endometriosis. We investigated the effect of dexketoprofen trometamol, a new selective COX-2 enzyme inhibitor, on experimentally induced endometriotic cysts.

METHODS

Experimental endometriotic cysts were created in 60 adult female Wistar albino rats. The rats were randomized to 2 equal groups, a control (group Con) and a dexketoprofen (group Dex) group. Six weeks later, cyst volumes were measured as in vivo (volume 1). Following volume 1 measurement, for 4 weeks group Con received 0.1 ml distilled water; group Dex received 0.375 mg dexketoprofen trometamol/0.1 ml distilled water, intramuscularly, twice a day. At the end of administration, the cyst volumes were remeasured (volume 2), and the cysts totally excised and weighed. Glandular (GT) and stromal tissues (ST) and natural killer (NK) cell contents in the cyst wall were scored.

RESULTS

NK cell content and volume 1 were not different between the 2 groups. Volume 2, cyst weight, and GT and ST contents in group Dex were significantly lower than those in group Con.

CONCLUSION

Dexketoprofen trometamol significantly reduced the development of experimentally induced endometriotic cysts both macroscopically and microscopically.

Augmented epithelial multidrug resistance-associated protein 4 expression in peritoneal endometriosis: regulation by lipoxin A(4)

OBJECTIVE

To compare the expression of the prostaglandin (PG) E(2) transporter multidrug resistance-associated protein 4 (MRP4) in eutopic and ectopic endometrial tissue from endometriosis patients with that of control subjects and to examine whether MRP4 is regulated by the antiinflammatory lipid lipoxin A(4) (LXA(4)) in endometriotic epithelial cells.

DESIGN

Molecular analysis in human samples and a cell line.

SETTING

Two university hospitals and a private clinic.

PATIENT(S)

A total of 59 endometriosis patients and 32 age- and body mass index-matched control subjects undergoing laparoscopy or hysterectomy.

INTERVENTION(S)

Normal, eutopic, and ectopic endometrial biopsies as well as peritoneal fluid were obtained during surgery performed during the proliferative phase of the menstrual cycle. 12Z endometriotic epithelial cells were used for in vitro mechanistic studies.

MAIN OUTCOME MEASURE(S)

Tissue MRP4 mRNA levels were quantified by quantitative reverse-transcription polymerase chain reaction (qRT-PCR), and localization was analyzed with the use of immunohistochemistry. Cellular MRP4 mRNA and protein were quantified by qRT-PCR and Western blot, respectively. PGE(2) was measured in peritoneal fluid and cell supernatants using an enzyme immunoassay (EIA).

RESULT(S)

MRP4 was expressed in eutopic and ectopic endometrium, where it was overexpressed in peritoneal lesions and localized in the cytoplasm of glandular epithelial cells. LXA(4) attenuated MRP4 mRNA and protein levels in endometriotic epithelial cells in a dose-dependent manner, while not affecting the expression of enzymes involved in PGE(2) metabolism. Investigations employing receptor antagonists and small interfering RNA revealed that this occurred through estrogen receptor α. Accordingly, LXA(4) treatment inhibited extracellular PGE(2) release.

CONCLUSION(S)

We report for the first time that MRP4 is expressed in human endometrium, elevated in peritoneal endometriosis, and modulated by LXA(4) in endometriotic epithelial cells.

Progesterone action in endometrial cancer, endometriosis, uterine fibroids, and breast cancer

Progesterone receptor (PR) mediates the actions of the ovarian steroid progesterone, which together with estradiol regulates gonadotropin secretion, prepares the endometrium for implantation, maintains pregnancy, and differentiates breast tissue. Separation of estrogen and progesterone actions in hormone-responsive tissues remains a challenge. Pathologies of the uterus and breast, including endometrial cancer, endometriosis, uterine fibroids, and breast cancer, are highly associated with estrogen, considered to be the mitogenic factor. Emerging evidence supports distinct roles of progesterone and its influence on the pathogenesis of these diseases. Progesterone antagonizes estrogen-driven growth in the endometrium, and insufficient progesterone action strikingly increases the risk of endometrial cancer. In endometriosis, eutopic and ectopic tissues do not respond sufficiently to progesterone and are considered to be progesterone-resistant, which contributes to proliferation and survival. In uterine fibroids, progesterone promotes growth by increasing proliferation, cellular hypertrophy, and deposition of extracellular matrix. In normal mammary tissue and breast cancer, progesterone is pro-proliferative and carcinogenic. A key difference between these tissues that could explain the diverse effects of progesterone is the paracrine interactions of PR-expressing stroma and epithelium. Normal endometrium is a mucosa containing large quantities of distinct stromal cells with abundant PR, which influences epithelial cell proliferation and differentiation and protects against carcinogenic transformation. In contrast, the primary target cells of progesterone in the breast and fibroids are the mammary epithelial cells and the leiomyoma cells, which lack specifically organized stromal components with significant PR expression. This review provides a unifying perspective for the diverse effects of progesterone across human tissues and diseases.

Anastrozole and celecoxib for endometriosis treatment, good to keep them apart?

Endometriosis is a benign gynecological disease. Cyclooxygenase-2 (COX-2) and aromatase proteins have been shown to be overexpressed in eutopic endometrium from women suffering from this disease compared to disease-free women. Furthermore, inhibition of these molecules individually was demonstrated to have antiproliferative and proapoptotic effects both in vitro and in vivo in several models. In this study, the effect of combining celecoxib, a selective COX-2 inhibitor, and anastrozole, an aromatase inhibitor, on the implantation and growth of endometriotic like lesions in a murine model of endometriosis was evaluated. Endometriosis was surgically induced in female BALB/c mice. After 28 days of treatment with celecoxib, anastrozole, or their combination, animals were killed and lesions were counted, measured, excised, and fixed. Immunohistochemistry for proliferating cell nuclear antigen and CD34 was performed for assessment of cell proliferation and vascularization. TUNEL technique was performed for apoptosis evaluation. Celecoxib was the only treatment to significantly reduce the number of lesions established per mouse, their size and vascularized area. In addition, cell proliferation was significantly diminished and apoptosis was significantly enhanced by both individual treatments. When the therapies were combined, they reversed their effects. These results confirm that celecoxib and anastrozole separately decrease endometriotic growth, but when combined they might have antagonizing effects.

Morinda citrifolia (Noni) as an Anti-Inflammatory Treatment in Women with Primary Dysmenorrhoea: A Randomised Double-Blind Placebo-Controlled Trial

Introduction. Noni (Morinda citrifolia) has been used for many years as an anti-inflammatory agent. We tested the efficacy of Noni in women with dysmenorrhea. Method. We did a prospective randomized double-blind placebo-controlled trial in 100 university students of 18 years and older over three menstrual cycles. Patients were invited to participate and randomly assigned to receive 400 mg Noni capsules or placebo. They were assessed for baseline demographic variables such as age, parity, and BMI. They were also assessed before and after treatment, for pain, menstrual blood loss, and laboratory variables: ESR, hemoglobin, and packed cell volume. Results. Of the 1027 women screened, 100 eligible women were randomized. Of the women completing the study, 42 women were randomized to Noni and 38 to placebo. There were no significant differences in any of the variables at randomization. There were also no significant differences in mean bleeding score or pain score at randomization. Both bleeding and pain scores gradually improved in both groups as the women were observed over three menstrual cycles; however, the improvement was not significantly different in the Noni group when compared to the controls. Conclusion. Noni did not show a reduction in menstrual pain or bleeding when compared to placebo.

Cyclooxygenase-2 ( COX -2) gene-765G/C polymorphism and advanced-stage endometriosis in Korean women

PROBLEM

We investigated the association of COX -2 gene-765G/C polymorphism and risk of advanced-stage endometriosis in Korean women.

METHOD OF STUDY

This study consisted of 268 women with advanced-stage endometriosis and 242 control women without endometriosis in Korea. Subjects were genotyped for the -765G/C polymorphism of the COX -2 gene by RFLP-PCR analysis.

RESULTS

There were significant differences in the genotype distributions of the -765G/C polymorphism between patients with advanced-stage endometriosis and control subjects. The C allele for -765G/C was associated with significantly lower risk of advanced-stage endometriosis (OR, 0.14; 95% CI, 0.06-0.30).

CONCLUSIONS

We have demonstrated a significant genetic association between the -765G/C polymorphism and advanced-stage endometriosis in Korean women. The -765C allele may be protective against the development of the disease in Korean women.

Predicting cyclooxygenase inhibition by three-dimensional pharmacophoric profiling. Part II: Identification of enzyme inhibitors from Prasaplai, a Thai traditional medicine

Prasaplai is a medicinal plant mixture that is used in Thailand to treat primary dysmenorrhea, which is characterized by painful uterine contractility caused by a significant increase of prostaglandin release. Cyclooxygenase (COX) represents a key enzyme in the formation of prostaglandins. Former studies revealed that extracts of Prasaplai inhibit COX-1 and COX-2. In this study, a comprehensive literature survey for known constituents of Prasaplai was performed. A multiconformational 3D database was created comprising 683 molecules. Virtual parallel screening using six validated pharmacophore models for COX inhibitors was performed resulting in a hit list of 166 compounds. 46 Prasaplai components with already determined COX activity were used for the external validation of this set of COX pharmacophore models. 57% of these components were classified correctly by the pharmacophore models. These findings confirm that the virtual approach provides a helpful tool (i) to unravel which molecular compounds might be responsible for the COX-inhibitory activity of Prasaplai and (ii) for the fast identification of novel COX inhibitors.

A selective cyclooxygenase-2 inhibitor suppresses the growth of endometriosis with an antiangiogenic effect in a rat model

OBJECTIVE

To analyze the antiangiogenic effects of the selective cyclooxygenase-2 (COX-2) inhibitor parecoxib on the growth of endometrial implants in a rat model of peritoneal endometriosis.

DESIGN

Pharmacologic interventions in an experimental model of peritoneal endometriosis.

SETTING

Research laboratory in the Federal University of Rio de Janeiro.

ANIMAL(S)

Twenty female Sprague-Dawley rats with experimentally induced endometriosis.

INTERVENTION(S)

After implantation and establishment of autologous endometrium onto the peritoneum abdominal wall, rats were randomized into groups and treated with parecoxib or the vehicle by IM injection for 30 days.

MAIN OUTCOME MEASURE(S)

Vascular density, the expression of vascular endothelial growth factor (VEGF) and its receptor Flk-1, the distribution of activated macrophages, the expression of COX-2, and the prostaglandin concentration in the endometriotic lesions treated with parecoxib were analyzed.

RESULT(S)

The treatment significantly decreased the implant size, and histologic examination indicated mostly atrophy and regression. A reduction in microvessel density and in the number of macrophages, associated with decreased expression of VEGF and Flk-1, also were observed. The treatment group showed a low concentration of prostaglandin E(2).

CONCLUSION(S)

These results suggest that the use of COX-2 selective inhibitors could be effective to suppress the establishment and growth of endometriosis, partially through their antiangiogenic activity.

Dysmenorrhea

Primary dysmenorrhea is commonly a straightforward diagnosis that can be made accurately with an attentive history. In young women who have classic symptoms and no specific indication, a pelvic examination is often unnecessary in the initial evaluation. The opportunity for primary care practitioners to support women in unearthing the best approach to this chronic recurrent discomfort to minimize adverse life impact is significant and valuable. Identification of patients who are incapacitated by their symptoms or have symptoms that represent underlying pathology is a critical component of a careful history. The wide range of treatments available for primary dysmenorrhea virtually ensures that all females troubled by the symptoms can find relief with safe and inexpensive treatments while limiting negative side effects.

Effects of adlay hull extracts on uterine contraction and Ca2+ mobilization in the rat

Dysmenorrhea is directly related to elevated PGF(2alpha) levels. It is treated with nonsteroid antiinflammatory drugs (NSAIDs) in Western medicine. Since NSAIDs produce many side effects, Chinese medicinal therapy is considered as a feasible alternative medicine. Adlay (Coix lachryma-jobi L. var. ma-yuen Stapf.) has been used as a traditional Chinese medicine for treating dysmenorrhea. However, the relationship between smooth muscle contraction and adlay extracts remains veiled. Therefore, we investigated this relationship in the rat uterus by measuring uterine contraction activity and recording the intrauterine pressure. We studied the in vivo and in vitro effects of the methanolic extracts of adlay hull (AHM) on uterine smooth muscle contraction. The extracts were fractionated using four different solvents: water, 1-butanol, ethyl acetate, and n-hexane; the four respective fractions were AHM-Wa, AHM-Bu, AHM-EA, and AHM-Hex. AHM-EA and its subfractions (175 microg/ml) inhibited uterine contractions induced by PGF(2alpha), the Ca(2+) channel activator Bay K 8644, and high K(+) in a concentration-dependent manner in vitro. AHM-EA also inhibited PGF(2alpha)-induced uterine contractions in vivo; furthermore, 375 microg/ml of AHM-EA inhibited the Ca(2+)-dependent uterine contractions. Thus 375 microg/ml of AHM-EA consistently suppressed the increases in intracellular Ca(2+) concentrations induced by PGF(2alpha) and high K(+). We also demonstrated that naringenin and quercetin are the major pure chemical components of AHM-EA that inhibit PGF(2alpha)-induced uterine contractions. Thus AHM-EA probably inhibited uterine contraction by blocking external Ca(2+) influx, leading to a decrease in intracellular Ca(2+) concentration. Thus adlay hull may be considered as a feasible alternative therapeutic agent for dysmenorrhea.

Celecoxib versus magnesium sulfate to arrest preterm labor: randomized trial

AIM

The effectiveness of the management of preterm birth remains an important health care issue, especially when considering that more than two thirds of singleton neonatal death occurs in preterm labor. The purpose of this study was to compare oral celecoxib with intravenous magnesium sulfate as tocolytic.

METHODS

This was a randomized study of patients who were between 24 and 34 weeks of gestation with preterm labor. One hundred and four pregnant women with preterm labor were randomly assigned to receive celecoxib 100 mg b.i.d. for 48 h or intravenous magnesium sulfate (MgSO4) for maximum of 48 h. Outcome variables included delay of delivery for 48 h and the incidence of side-effects. Data was analyzed using the Student t-test and the chi(2) test.

RESULTS

There was no difference between the groups over the course of the study in demographic characteristics, cervical examination and amniotic fluid index. Labor was arrested for 48 h was in 42 (81%) and 45 (87%) of the patients in the celecoxib and magnesium sulfate groups, respectively (p-0.298). There were no severe maternal or neonatal complications in either group.

CONCLUSION

Celecoxib is as effective as magnesium sulfate for primary tocolysis.

Targeting mast cells in endometriosis with janus kinase 3 inhibitor, JANEX-1

Endometriosis (EMS) is a chronic inflammatory disease of multifactorial etiology characterized by implantation and growth of endometrial glands and stroma outside the uterine cavity. EMS is a significant public health issue as it affects 15-20% of women in their reproductive age. Clinical symptoms may include pelvic pain, dysmenorrhea, dyspareunia, pelvic/abdominal masses, and infertility. Symptomatic treatments such as surgical resection and/or hormonal suppression of ovarian function and analgesics are not as effective as desired. Consequently, there is an enormous unmet need to develop effective medical therapy capable of preventing the occurrence and recurrence of EMS without undesirable side-effects. EMS-associated intra-abdominal bleeding episodes, local inflammation, adhesions, and i.p. immunologic dysfunction leads to pelvic nociception and pelvic pain. Increasing evidence supports the involvement of allergic-type inflammation in EMS. Invasion of mast cells, degranulation, and proliferation of interstitial component are observed in endometriotic lesions. Presence of activated and degranulating mast cells within the nerve structures can contribute to the development of pain and hyperalgesia by direct effects on primary nociceptive neurons. Therefore, treatments targeting endometrial mast cells may prove effective in preventing or alleviating EMS-associated symptoms. The Janus kinase 3 (JAK3) is abundantly expressed in mast cells and is required for the full expression of high-affinity IgE receptor-mediated mast cell inflammatory sequelae. JANEX-1/WHI-P131 is a rationally designed novel JAK3 inhibitor with potent anti-inflammatory activity in several cellular and in vivo animal models of inflammation, including mouse models of peritonitis, colitis, cellulitis, sunburn, and airway inflammation with favorable toxicity and pharmacokinetic profile. We hypothesize that JAK3 inhibitors, especially JANEX-1, may prove useful to prevent or alleviate the symptoms of EMS.

Clinical pharmacology of celecoxib, a COX-2 selective inhibitor

NSAIDs are extensively used worldwide; nonetheless, they are associated with adverse gastrointestinal (GI) effects. COX-2 inhibitors (coxibs) have been developed to reduce pain and inflammation without associated GI and bleeding risks. Celecoxib was the first COX-2 inhibitor introduced on the market, and it still remains so, whereas rofecoxib and valdecoxib were withdrawn due to excess cardiovascular (CV) risk. There is consequently a concern that CV toxicity reflects a class effect of all COX-2 inhibitors. Celecoxib possesses anti-inflammatory and analgesic properties, and the evidence for CV risk is rather small and comparable to that of other traditional NSAIDs in short-term treatments (of < 4 weeks). It could be suggested that the use of low doses of celecoxib (100 mg b.i.d.) in short-treatment, especially in patients with previous experience of GI events and the recommendation of avoiding use of celecoxib in patients with CV history or risk, contribute in the decision-making process of prescribing COX-2 or NSAIDs.

TOCOLYTIC EFFECT OF PARECOXIB, A NEW PARENTERAL CYCLO-OXYGENASE-2-SPECIFIC INHIBITOR, ON THE SPONTANEOUS AND PROSTAGLANDIN-INDUCED CONTRACTIONS OF RAT ISOLATED MYOMETRIUM

1. The present study was undertaken to elucidate the effects of parecoxib, a novel cyclo-oxygenase (COX)-2 inhibitor, on spontaneous and prostaglandin-induced contractions of uterine smooth muscle. 2. Non-pregnant adult Wistar rats were decapitated and dissected to isolate myometrial strips. The tissue was mounted in 5 mL organ baths filled with Krebs' solution that was maintained at 37 degrees C and bubbled continuously with a mixture of 95% O(2)-5% CO(2) to give pH 7.4. Contractions were recorded through transducers for isometric tension recording. The dose-dependent effects of parecoxib on contractility were quantified by changes in the mean amplitude, frequency and area under the contractile curve (AUC; percentage of control conditions) of the isometric tension recordings, averaged over 5 min intervals. Statistical analyses were performed using ANOVA. 3. Application of parecoxib (50-900 micromol/L) caused dose-dependent decreases in mean amplitude, mean frequency and mean AUC of both spontaneous and prostaglandin-induced contractions. Mean percentage inhibition of the AUC of spontaneous contractions was found to be 29, 56, 74 and 84% in the presence of 50, 150, 300 and 600 micromol/L parecoxib, resepctively (n = 8). In the case of prostaglandin (PG) F(2alpha)-induced contractions, 100, 300, 600 and 900 micromol/L parecoxib resulted in a 27, 43, 61 and 73% inhibition, respectively (n = 9). Moreover, pretreatment with parecoxib (600 micromol/L) reduced the responsiveness and maximum contractility to PGF(2alpha) compared with non-treated strips. 4. The data from the present study indicate, for the first time, that parecoxib inhibits spontaneous and prostaglandin-induced contractions of rat myometrium in vitro. These results raise the possibility that parecoxib may be of therapeutic use in the management of preterm labour and dysmenorrhoea.

Konservative Therapie der Endometriose

Endometriosis is the second most frequent benign disease of the female of reproductive age. In spite of extensive research, the etiology of this disease is still largely enigmatic. A causal therapy has not been found yet. Several drug therapy approaches are available but none offers a permanent cure of endometriosis. In addition, the range of side effects of the particular drug therapies has to be considered individually. The treatment of patients with endometriosis cannot be standardized but has to differentiate the individual factors and life circumstances of the patients.

Impact of pregnancy on primary dysmenorrhea

OBJECTIVE

Because it has been observed that dysmenorrhea can improve after childbirth, this investigation was intended to quantify the impact of both gestational length and mode of delivery on primary dysmenorrhea.

METHODS

This is an 8-year prospective observational study. Patients with a history of dysmenorrhea who later gave birth were evaluated for improvement on the severity of dysmenorrhea, with use of visual analogue scale (VAS), and Likert-type scale.

RESULT

Final analysis involved 3694 patients. Women who had spontaneous delivery would have significantly more improvement than women with cesarean delivery per VAS (term delivery, 51 vs. 33, P<0.001; preterm delivery, 17 vs. 10, P<0.001). For first delivery, patients in the spontaneous delivery subgroup were the most likely to have improvement in severity of dysmenorrhea. For second delivery, only patients in the spontaneous delivery subgroup had statistically significant improvement.

CONCLUSION

Both length of gestation and mode of delivery have an impact on primary dysmenorrhea. The most significant improvement occurred after the first delivery.

The association between somatization and perceived ability: roles in dysmenorrhea among Israeli Arab adolescents

OBJECTIVE

The aim of this study was to investigate whether somatization and attitudes toward menstruation predict the incidence of pain intensity and dysmenorrhea among Israeli Arab adolescent females.

METHODS

Participants were 160 Israeli Arab adolescents, including 50 Muslims, 50 Christians, and 60 Druze. A 20-item questionnaire was used to assess attitudes regarding menstruation. The short version of the Brief Symptom Inventory was used to measure the level of somatization.

RESULTS

Factor analysis of the Attitudes Toward Menstruation Instrument revealed two significant composites: perceived ability and impurity during menstruation. High levels of somatization predicted pain intensity and low levels of perceived ability predicted the prevalence of dysmenorrhea. Although the Israeli Muslim adolescents revealed higher levels of somatization as compared with their Christian and Druze counterparts and the Druze revealed the lowest levels of perceived ability compared with the other subgroups, no significant role for ethnicity and impurity was found. No differences were found between groups in scores of menstrual pain and prevalence of dysmenorrhea. Higher levels of somatization and lower levels of perceived ability, as well as a greater portion of Muslim and Druze and higher levels of religiosity, were found among rural residents.

CONCLUSIONS

The role of cultural variables and personality traits in the complexity of dysmenorrhea as a socio-bio-psychological phenomenon is proposed in light of contemporary interactive models. It is suggested that within the Israeli Arab minorities the impact of cultural background on health affects more the perceptual and cognitive levels and are not generalized to overt behavior and morbidity such as dysmenorrhea.

COX-2 overexpression in peritoneal lesions is correlated with nonmenstrual chronic pelvic pain

OBJECTIVE

To investigate cyclooxygenase (COX-2) expression within different endometriotic lesions and to assess whether these expression patterns correlate with clinical characteristics.

DESIGN

Retrospective cross-sectional study.

SETTING

University Hospital.

PATIENTS

Seventy patients with histologically confirmed exclusively peritoneal (n=20), ovarian (n=19) or deep-infiltrating (n=31) endometriosis and a detailed medical history.

INTERVENTION

Immunohistochemical analysis for COX-2 was performed on 108 endometriotic lesions.

MEASUREMENTS AND MAIN RESULTS

COX-2 intensity, percentage of stained glandular endometriotic cells, and correlation of COX-2 expression with clinicopathological parameters. Semiquantitative COX-2 expression did not differ between distinct morphological types of endometriosis and showed no association with the menstrual cycle. Patients with peritoneal-only endometriosis suffering from moderate or severe chronic pelvic pain showed significantly more frequent COX-2 overexpression than asymptomatic patients or patients with minimal symptoms. In patients with exclusively ovarian or deep-infiltrating endometriosis no association between COX-2 expression and clinical parameters, such as chronic pelvic pain, dysmenorrhoea, dyspareunia, sterility, lower urinary tract symptoms or gastrointestinal symptoms was observed.

CONCLUSION

Peritoneal endometriotic lesions with increased COX-2 expression have a special relevance for the development of chronic, nonmenstruation-associated, pelvic pain in endometriotic patients. These patients may benefit from therapy with COX-2 inhibitors.

Aromatase inhibitors and cyclooxygenase-2 (COX-2) inhibitors in endometriosis: New questions—old answers?

The medical treatment of endometriosis needs to be optimized. Therapeutic management strategies for endometriosis-associated pain or recurrent disease are primarily aimed at downregulating ovarian function or antagonizing the effect of estrogen in ectopic endometrial implants. In this context, basic research is providing important results for the development of new, specific treatment modalities. Aromatase overexpression has recently been detected in endometriotic tissue. Aromatase (p450arom) is responsible for converting C19 androgens into estrogen in several types of human tissue. Aromatase activity causes local estrogen biosynthesis, which, in turn, stimulates prostaglandin E2 production by upregulating cyclooxygenase-2 (COX-2). Thus, a positive feedback cycle develops between the two systems. Another abnormality in endometriosis, the deficient 17beta-hydroxysteroiddehydrogenase type II (17beta-HSD-Type-II) expression, impairs the inactivation of estradiol to estrone. In contrast to the eutopic endometrium, these molecular aberrations increase the amount of local estradiol and prostaglandin E2 in endometriosis. In several human cell lines, prostaglandin and estrogen concentrations are associated with proliferation, migration, angiogenesis, apoptosis resistance and even invasiveness. Consequently, aromatase and COX-2 are thought to be promising new therapeutic targets. Thus, specific aromatase inhibitors (e.g. Letrozol/Femara, Anastrozol/Arimidex or Exemestan/Aromasin) or selective COX-2 inhibitors (e.g. Celecoxib/Celebrex, Rofecoxib/Vioxx, Valdecoxib/Bextra) are of great interest and should be studied in clinical trials in premenopausal woman with endometriosis to expand the spectrum of currently available treatment options.

Menorrhagia, mechanisms and targeted therapies

PURPOSE OF REVIEW

Efficient treatment options for the increasing complaint of heavy menstrual bleeding are required to avoid the morbidity associated with major surgery. This review summarizes recent developments in the nonsurgical approach to treating menorrhagia.

RECENT FINDINGS

Even though the mechanism of menstruation has still not been fully elucidated, there have been promising developments in the attempt to reduce menstrual blood loss. The levonorgestrel-releasing intrauterine system has proven very efficient, and there is a frameless device suitable for enlarged uterine cavities. The side effect of breakthrough bleeding has been the main reason for discontinuing treatment. Recent studies have investigated options of concomitant therapy with antiprogestogens to counter this effect. Another group of novel compounds are selective progesterone receptor modulators, which thus far have been shown to reduce menstrual bleeding without the unwanted effect of unscheduled bleeding episodes.

SUMMARY

As menorrhagia is largely a subjective complaint, it is important for successful therapy to be based on an informed patient's choice. Currently, lack of evidence-based practice, poor compliance and unpleasant side effects limit the success of medical therapies contributing to the amount of major surgery performed for this indication. If concomitant therapies succeeded in minimizing the episodes of breakthrough bleeding with the levonorgestrel-releasing intrauterine system, its recommendation as a first choice treatment may be confounded. Further research is needed into efficiency and safety of selective progesterone receptor modulators, which appear to have great potential in reducing menstrual blood loss.

Comparison of developmental toxicity of selective and non-selective cyclooxygenase-2 inhibitors in CRL:(WI)WUBR Wistar rats – DFU and piroxicam study

BACKGROUND

Cyclooxygenase (COX) inhibitors are one of the most often ingested drugs during pregnancy. Unlike general toxicity data, their prenatal toxic effects were not extensively studied before. The aim of the experiment was to evaluate the developmental toxicity of the non-selective (piroxicam) and selective (DFU; 5,5-dimethyl-3-(3-fluorophenyl)-4-(4-methylsulphonyl) phenyl-2(5H)-furanon) COX-2 inhibitors.

METHODS

Drugs were separately, orally once daily dosed to pregnant rats from day 8 to 21 (GD1=plug day). Doses were set at 0.3, 3.0 and 30.0mg/kg for piroxicam and 0.2, 2.0 and 20.0mg/kg for DFU. Fetuses were delivered on GD 21 and routinely examined. Comprehensive clinical and developmental measurements were done. The pooled statistical analysis for ventricular septal (VSD) and midline (MD) defects was performed for rat fetuses exposed to piroxicam, selective and non-selective COX-2 inhibitor based on present and historic data.

RESULTS

Maternal toxicity, intrauterine growth retardation, and increase of external and skeletal variations were found in rats treated with the highest dose of piroxicam. Decrease of fetal length was the only signs of the DFU developmental toxicity observed in pups exposed to the highest compound dose. Lack of teratogenicity was found in piroxicam and DFU-exposed groups. Prenatal exposure to non-selective COX inhibitors increases the risk of VSD and MD when compared to historic control but not with selective COX-2 inhibitors.

CONCLUSION

Both selective and non-selective COX-2 inhibitors were toxic for rats fetuses when administered in the highest dose. Unlike DFU, piroxicam was also highly toxic to the dams. Prenatal exposure to selective COX-2 inhibitors does not increase the risk of ventricular septal and midline defects in rat when compared to non-selective drugs and historic control.

Effect of the menstrual cycle and oral contraceptives on cyclooxygenase-2 expression in the endometrium

OBJECTIVE

To compare the expression of cyclooxygenase-2 (COX-2) and proliferation markers (Ki-67) in the endometrium of patients with ovulatory cycles with those in the endometrium of patients using oral contraceptives.

PATIENTS AND METHODS

Endometrial biopsies from 104 premenopausal patients with regular ovulatory cycles (n=90) or using an oral contraceptive (n=14) were selected for this study. Using immunohistochemical methods, both COX-2 (Novocastra clone 4H12) and Ki-67 (Dako clone MIB-1) expression were determined in the endometrium during the various phases of the menstrual cycle or following the use of oral contraceptives.

RESULTS

COX-2 expression in the glandular epithelium was maximal during menstruation, the late proliferative phase and the early luteal phase, and minimal during the late luteal phase. However, in the surface epithelium, COX-2 expression remained strongly positive throughout the luteal phase. Ki-67 positivity increased during the proliferative phase and diminished during the luteal phase in the glands. In contraceptive users, both Ki-67 and COX-2 expression in the endometrium was low.

CONCLUSION

The increased expression of COX-2 during menstruation and at mid-cycle is eliminated by the continuous use of oral contraceptives. This may be the rationale for their therapeutic action in the treatment of dysmenorrhea and bleeding.

Correlation of cyclooxygenase-2 (COX-2) and aromatase expression in human endometrial cancer: tissue microarray analysis

OBJECTIVE

The objective of this study was to compare the prevalence of cyclooxygenase-2 (COX-2), aromatase, and hormone receptor immunohistochemical (IHC) expression to well defined clinical-pathologic prognostic factors in a large group of surgically staged endometrial cancer patients.

STUDY DESIGN

A tissue microarray (TMA) was constructed from 336 separate specimens of endometrial cancer. IHC was performed for estrogen (ER) and progesterone (PR) receptor, COX-2, COX-1, and aromatase.

RESULTS

The majority of tumors expressed COX-2 (59%) and aromatase (65%). COX-2 staining significantly correlated with aromatase expression ( P < .014) but did not correlate with ER and PR. COX-2 expression was correlated with worsening histologic grade ( P < .026) and approached statistical significance for deep myometrial invasion ( P < .055). After applying multivariate analysis, no single IHC or combination of IHCs correlated with intrauterine poor prognostic factors or advanced stage. Only myometrial invasion >50% (OR 6.98, P < .001) and nonendometrioid histology (OR 4.933, P < .001) were predictive of advanced stage after multivariate analysis.

CONCLUSION

COX-2 and aromatase are expressed in the majority of endometrial cancer patients. COX-2 expression was not associated with the great majority of surgical-pathologic prognostic factors. COX-2 expression did significantly correlate with aromatase expression, suggesting that intratumoral production of estrogen in endometrial cancer may be an important mechanism in tumorigenesis.

Nonsteroidal antiinflammatory drugs differentially suppress endometriosis in a murine model

OBJECTIVE

To determine whether nonsteroidal antiinflammatory drugs (NSAIDs) affect the establishment and progression of endometriotic lesions in a murine model.

DESIGN

Pharmacologic intervention in a surgically induced murine model of abdominal/peritoneal endometriosis.

SETTING

Animal research facility.

PATIENT(S)

Eight-week-old, female C57BL/6 mice.

INTERVENTION(S)

After implantation of autologous endometrium, mice were randomized into groups and treated with one of several NSAIDs or the vehicle-matched control for 4 weeks.

MAIN OUTCOME MEASURE(S)

Establishment, growth, and total burden of endometriotic lesions.

RESULT(S)

The NSAIDs differentially inhibited lesion establishment and growth, resulting in significantly reduced disease burden. Compared with controls (5.7 +/- 2.3 mm(2)), lesion burden was reduced by celecoxib (1.3 +/- 1.2 mm(2)), indomethacin (1.4 +/- 1.4 mm(2)), naproxen (2.7 +/- 1.2 mm(2)), sulindac (3.1 +/- 1.5 mm(2)), rofecoxib (3.4 +/- 3.0 mm(2)), and ibuprofen (4.1 +/- 1.4 mm(2)). In contrast, aspirin (5.9 +/- 1.2 mm(2)) had no statistically significant effect. Uninterrupted estrus cycling was confirmed by vaginal exams and smears in celecoxib-treated mice.

CONCLUSION(S)

Chronic administration of certain NSAIDs limits the progression of endometriosis in this murine model. The data suggest that NSAID selection in the treatment of endometriosis should be extended beyond pain management to maximize the inhibitory effect on disease burden.

Stress and dysmenorrhoea: a population based prospective study

BACKGROUND

Dysmenorrhoea is the most common gynaecological disorder in women of reproductive age. Despite the association between stress and pregnancy outcomes, few studies have examined the possible link between stress and dysmenorrhoea.

AIMS AND METHODS

Using a population based cohort of Chinese women, the independent effect of women's perceived stress in the preceding menstrual cycle on the incidence of dysmenorrhoea in the subsequent cycle was investigated prospectively. The analysis included 1160 prospectively observed menstrual cycles from 388 healthy, nulliparous, newly married women who intended to conceive. The perception of stress and the occurrence of dysmenorrhoea in each menstrual cycle were determined from daily diaries recorded by the women.

RESULTS

After adjustment for important covariates, the risk of dysmenorrhoea was more than twice as great among women with high stress compared to those with low stress in the preceding cycle (OR = 2.4; 95% CI 1.4 to 4.3). The risk of dysmenorrhoea was greatest among women with both high stress and a history of dysmenorrhoea compared to women with low stress and no history of dysmenorrhoea (OR = 10.4, 95% CI 4.9 to 22.3). Stress in the follicular phase of the preceding cycles had a stronger association with dysmenorrhoea than stress in the luteal phase of the preceding cycles.

CONCLUSION

This study shows a significant association between stress and the incidence of dysmenorrhoea, which is even stronger among women with a history of dysmenorrhoea.

Gastrointestinal and hepatic toxicity of selective and non-selective cyclooxygenase-2 inhibitors in pregnant and non-pregnant rats

The aim of the study was to evaluate the toxicity of non-selective (tolmetin, ibuprofen and piroxicam) and selective (DFU) cyclooxygenase-2 inhibitors on pregnant and non-pregnant rats. The drugs were administered orally once (DFU, piroxicam) or three times (tolmetin, ibuprofen) a day from days 8 through 21 of gestation experiment in three doses. The initial dose was similar to the human antiinflammatory one and set as 8.5 mg/kg (tolmetin, ibuprofen), 0.3 mg/kg (piroxicam) and 0.2 mg/kg (DFU). The middle dose was increased 10 times and the highest one 100 times the initial dose. The highest dose for ibuprofen was set at 200mg/kg due to high mortality. On gestation/experimental day 21 animals were sacrificed, blood was collected and abdominal organs were taken for pathological examination. Activity of alanine and asparate aminotransferases and levels of total protein and urea were determined. Stomach, small and large intestines, and liver were grossly and histologically examined. Dose-dependent mortality, signs of gastrointestinal toxicity, and significant changes of biochemical parameters were found in groups exposed to non-selective COX inhibitors in both pregnant and non-pregnant rats. Mild regressive structural hepatic changes were observed. Significant decrease of protein level in non-pregnant rats treated with high DFU dose, and occasionally observed gastrointestinal changes were the only changes noted in groups exposed to the selective COX-2 inhibitor. Tolerability of non-selective COX inhibitors was lower in both pregnant and non-pregnant groups when compared with DFU. Insignificant mortality and histological changes were noted between pregnant and non-pregnant groups.

Developmental toxicity evaluation of ibuprofen and tolmetin administered in triple daily doses to Wistar CRL:(WI)WUBR rats

BACKGROUND

Ibuprofen and tolmetin are popular non-steroidal anti-inflammatory drugs. Previous animal studies taken with single daily doses showed their good prenatal tolerability. However, since both cyclooxygenase (COX) inhibitors have a short half-life, the current report presents drug developmental effects after triple daily doses administration, as they are used in human.

METHODS

Drugs were separately, orally dosed to pregnant rats triple daily 8 hr apart from day 8 to 21 (GD=1-plug day). The total daily doses were set at 25.5, 255.0, and 600.0 mg/kg for ibuprofen and 25.5, 255.0, and 2550.0 mg/kg for tolmetin. Fetuses were delivered on GD 21 and routinely examined. Comprehensive clinical and developmental measurements were done.

RESULTS

Maternal toxicity and intrauterine growth retardation were found in groups exposed to the highest doses of both drugs. An increase of external variations was reported in groups exposed to the middle and highest dose of ibuprofen and to the highest dose of tolmetin. Skeletal variations were significantly different only in litters treated with the highest doses of the drugs. Pooled statistical analysis showed a higher incidence of midline and ventricular septal (VSD) defect in rat fetuses exposed to COX inhibitors when compared with historical control data. For ibuprofen, the influence on VSD was similar to aspirin.

CONCLUSION

Both COX inhibitors were toxic to dams in the highest doses evaluated, which caused a significantly greater incidence of intrauterine growth retardation and developmental variations.

Regression of endometrial explants in rats treated with the cyclooxygenase-2 inhibitor rofecoxib

OBJECTIVE

To investigate the effects of cyclooxygenase-2 (COX-2) inhibitor rofecoxib on endometrial explants and on peritoneal vascular endothelial growth factor (VEGF) levels in the rat endometriosis model.

DESIGN

Prospective, placebo-controlled study.

SETTING

Laboratory at Dokuz Eylül University.

ANIMAL(S)

Twenty-six rats with experimentally induced endometriosis.

INTERVENTION(S)

Rats were treated for 3 weeks with oral rofecoxib (3 mg/kg per day; n = 9); single subcutaneous injection of depot leuprolide acetate (1 mg/kg; n = 9); or vehicle (control; n = 8).

MAIN OUTCOME MEASURE(S)

Change in explant area and histologic examination by semiquantitative analysis of endometriotic explants and measurement of peritoneal VEGF levels.

RESULT(S)

Three weeks of treatment with rofecoxib statistically significantly decreased the implant size (62.4%) compared with control (16.6%), and this effect was comparable with the decrease in leuprolide (64.3%). Histologic examination of the explants indicated mostly atrophy and regression in treatment groups, and semiquantitative analysis showed statistically significantly lower scores in rats treated with rofecoxib and leuprolide compared with controls. Both rofecoxib and leuprolide statistically significantly decreased VEGF levels compared with controls.

CONCLUSION(S)

Rofecoxib causes regression and atrophy of the endometriotic lesions and is as effective as a GnRH agonist with an accompanying decrease in the VEGF levels.