Adenomyosis demonstrates increased expression of the basic fibroblast growth factor receptor/ligand system compared with autologous endometrium

Efficacy and safety of elagolix with add-back therapy in women with uterine fibroids and coexisting adenomyosis

Objective

To determine if coexisting adenomyosis limits the efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy in reducing heavy menstrual bleeding in women with uterine fibroids.

Design

Pooled analysis of two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids [UF]-1 and UF-2).

Setting

A total of 153 gynecological clinical care settings in the United States and Canada.

Patients

Premenopausal women (18-51 years) with >80 mL of menstrual blood loss (MBL)/cycle and uterine fibroids with and without coexisting adenomyosis diagnosed by ultrasound and/or magnetic resonance imaging at baseline.

Interventions

Participants were randomized 1:1:2 to placebo, elagolix 300 mg twice daily alone, or elagolix 300 mg twice daily with estradiol 1 mg/norethindrone acetate 0.5 mg once daily.

Main Outcome Measures

The primary endpoint was the proportion of women who had <80 mL of MBL during the final month and ≥50% reduction in MBL from baseline to the final month. Adverse events were monitored.

Results

Of 786 women treated across the two trials, 16% (126 women) had coexisting adenomyosis. Among this subset, a significantly greater proportion of women who received elagolix with add-back therapy (77.1% [95% confidence interval, 66.2, 88.0]) met both primary endpoint criteria compared with women who received placebo (12.2% [95% confidence interval, 1.0, 23.4]). Adverse events most frequently reported in the elagolix with add-back adenomyosis subset were hot flushes (18.3%), nausea (11.7%), and night sweats (8.3%).

Conclusions

Elagolix with add-back therapy significantly reduced heavy menstrual bleeding in women with uterine fibroids and coexisting adenomyosis, suggesting that elagolix efficacy was not adversely affected by the presence of adenomyosis (Elaris UF-1 and UF-2 Clinical-Trials.gov numbers, NCT02654054 and NCT02691494).

[The second generation endometrial ablation (NovaSure) improves efficacy of levonorgestrel-releasing intrauterine system in management of adenomyosis]

OBJECTIVE

To determine the efficacy of second generation endometrial ablation (NovaSure) combined with levonorgestrel-releasing intrauterine system (Mirena) in the treatment of adenomyosis.

METHODS

Clinical data of patients with adenomyosis admitted in Women's Hospital, Zhejiang University School of Medicine from January 2015 to December 2018 were retrospectively analyzed. Among 66 patients, 44 received Mirena placement only (control group) and 22 received Mirena placement and NovaSure treatment (study group). The menstruation blood loss, dysmenorrhea score, uterine size, expulsion rate of Mirena and the patients' satisfaction rate were assessed in two groups.

RESULTS

There was a significant reduction in menstruation blood loss (P<0.05) and significant improvement in dysmenorrhea (P<0.05) after the treatment in both groups. The patients in study group had more marked improvement in menstruation blood loss than those in control group (P<0.05). The patients' satisfaction was higher and the expulsion rate of Mirena was lower in study group than that in control group (all P<0.05). The score of dysmenorrhea and the size of uterine had no significant difference between two groups (all P>0.05).

CONCLUSIONS

NovaSure can improve the efficacy of Mirena in treatment of adenomyosis.

Potential mechanisms of an antiadenomyosis chinese herbal formula shaoyao-gancao decoction in primary cell culture model

Background. Shaoyao-Gancao Decoction (SGD), a well-known traditional Chinese medicine prescription, has been widely used to treat adenomyosis, dysmenorrhea, abdominal pain, and inflammation in Asia. However, the mechanism underlying the effectiveness of SGD in the treatment of adenomyosis still remains elusive. The present study aimed to investigate the bioactivity of SGD and its underlying molecular mechanisms using cultured human adenomyosis-derived cells. Methods. Human adenomyosis-derived cells were treated with SGD and its major constituents (paeoniflorin and liquiritin) in vitro. Effects of SGD, paeoniflorin, and liquiritin on cell proliferation and apoptosis were examined by MTT assay and flow cytometry analyses. The effects of SGD, paeoniflorin, and liquiritin on the production of PGE₂ and PGF_2α were assayed using ELISA. ER-α and OTR mRNA expression levels were also evaluated by real-time qRT-PCR. Results. SGD, paeoniflorin, and liquiritin inhibited proliferation and induced apoptosis of human adenomyosis-derived cells in a dose-dependent manner. SGD and paeoniflorin significantly reduced the PGE₂ and PGF_2α production. Furthermore, they remarkably decreased the mRNA levels of ER-α and OTR. Conclusions. The results of this study provide possible mechanisms for the bioactivity of SGD for treating adenomyosis and contribute to the ethnopharmacological knowledge about this prescription.

Understanding adenomyosis: a case control study

OBJECTIVE

To elucidate the clinical profile of adenomyosis by comparison with uterine leiomyomas.

DESIGN

Retrospective case-control study.

SETTING

Academic medical center.

PATIENT(S)

The study comprised 76 women undergoing hysterectomy with adenomyosis and 152 women with uterine leiomyomas but no adenomyosis.

INTERVENTION(S)

Retrospective medical record review of hospital and ambulatory records.

MAIN OUTCOME MEASURE(S)

Comparison of women undergoing hysterectomy with a sole pathologic finding of adenomyosis and women with leiomyomas alone.

RESULT(S)

Adenomyosis was independently associated with younger age (41.1 years vs. 44.3 years), history of depression (57.1% vs. 24.7%), dysmenorrhea (65.7% vs. 42.3%), and pelvic pain (52.9% vs. 21.1%) in a multivariable unconditional logistic regression analysis compared with women with leiomyomas, where women from both groups had gynecologic symptoms. Furthermore, in a second multivariate model where all subjects had uteri weighing>150 g, women with adenomyosis were more likely to have a history of depression (52.6% vs. 22.2%) and endometriosis (26.3% vs. 2.8%) compared with women with leiomyomas.

CONCLUSION(S)

Women undergoing hysterectomy with a histologic diagnosis of adenomyosis have a distinct symptomatology and medical history compared with women with leiomyomas. Better understanding of this disease is required to improve diagnosis and management.

Understanding cellular leiomyomas: a case-control study

OBJECTIVE

Reports exist in which cellular leiomyomas (CLs) appear to have clinical characteristics or genetic profiles similar to leiomyosarcomas. This study aimed to determine whether most CLs differ clinically from typical uterine leiomyomas (ULs).

STUDY DESIGN

A case-control study was conducted with women who underwent surgical procedures between January 1989 and December 2008 and who were diagnosed with a CL (n = 99). Control subjects, who were matched in a 2:1 ratio, were women with a diagnosis of UL (n = 198). Hospital and ambulatory records were reviewed.

RESULTS

In multivariable logistic regression analyses, women with CLs were more likely to have surgery for the indication of enlarging leiomyoma and less likely to have concomitant endometriosis or adenomyosis. Uteri that contained CLs were also more likely to have larger and fewer leiomyomas when compared with control subjects.

CONCLUSION

CLs have a distinct clinical phenotype compared with ULs and have some characteristics in common with leiomyosarcomas.

Association between genetic polymorphisms in fibroblast growth factor (FGF)1 and FGF2 and risk of endometriosis and adenomyosis in Chinese women

BACKGROUND

Angiogenesis appears to be an important event in the pathophysiology of endometriosis (EM) and adenomyosis. Two angiogenic factors, fibroblast growth factor (FGF) 1 and 2, play a central role in the initiation of angiogenesis. We investigated whether FGF1 -1385A/G and FGF2 754C/G polymorphisms are associated with a risk of developing EM and adenomyosis.

METHODS

Genotypes were analyzed by the PCR-restriction fragment length polymorphism method in two groups of women, of Han ethnicity in north China, aged 16-55 years: (1) 421 EM patients and 421 controls; (2) 269 adenomyosis patients and 269 controls.

RESULTS

There was no difference in genotype distribution of the FGF1 -1385A/G polymorphism between adenomyosis cases and controls (P > 0.05), but the frequency of the A allele in EM patients was lower than that in controls (P = 0.013). Genotype and allele frequencies of the FGF2 754C/C polymorphism were significantly different in both EM and adenomyosis cases versus control groups. Compared with C/C homozygotes, the G allele (C/G + G/G) was associated with a decreased susceptibility to developing EM [odds ratio (OR) = 0.575, 95% confidence interval (CI) = 0.387-0.854] and adenomyosis (OR = 0.577, 95% CI = 0.367-0.906). Combined genotype analysis of both polymorphisms also showed differences between cases versus controls (all P < 0.001).

CONCLUSIONS

Our study shows for the first time that the FGF2 754C/G polymorphism may be associated with a risk of developing EM and adenomyosis in north Chinese women. Carriers of the G allele in the FGF2 gene appear to be protected from these gynecological diseases. Further studies in other populations, and of other candidate genes, are now warranted.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

Expression of Apoptosis-Related Proteins in Adenomyotic Uteri Treated with Danazol and GnRH Agonists

The biologic properties of adenomyosis and the effects of therapeutic agents on adenomyosis were evaluated with immunohistochemistry, terminal deoxy-nucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) method, transmission electron microscopy, and analysis of genomic abnormality. In the adenomyotic endometrium, estrogen receptor (ER) expression was more intense than in the eutopic endometrium during the secretory phase, and bcl-2 was constantly expressed throughout the menstrual cycle. The expression of ER and bcl-2 was weaker in the adenomyotic endometrium treated with danazol than in that treated with gonadotro-pin-releasing hormone agonist (GnRHa), whereas bcl-2 phosphorylated on serine-87 was more intensely expressed in danazol-treated adenomyotic endometrium than in the GnRHa-treated one. The number of TUNEL-positive cells increased in the adenomyotic endometrium treated with danazol or GnRHa. Ultrastructurally, most of the adenomyotic endometrial cells treated with danazol underwent postapoptotic necrosis and formed a cluster of dead cells. In contrast, cells treated with GnRHa underwent typical apoptosis and were sparsely distributed in the adenomyotic endometrium. Analysis of several cancer-related genes showed no microsatellite instability or loss of heterozygosity in adenomyotic tissues. Therefore, we conclude that the occurrence of adenomyosis is correlated to bcl-2 expression regulated by estrogen and ER rather than genetic mutation.

Developmental and hormonal regulated gene expression of fibroblast growth factor 2 (FGF-2) and its receptors in porcine endometrium

This study examined the mRNA levels of the fibroblast growth factor 2 (FGF-2) and two of its receptors, FGFR1IIIc and FGFR2IIIc, at days 12 and 20 of the ovarian cycle (DC 12 and DC 20), days 1 and 12 of pregnancy (DP 1 and DP 12) as well as the influence of progesterone (P) and estradiolbenzoate (EB) on their expression in the endometrium of ovariectomized (ovx) gilts by real-time PCR. Proteins of FGF-2 and FGFR1 were immunolocalized. FGF-2 and FGFR2IIIc mRNAs were always found with a 5- to 30-fold higher absolute concentration compared to FGFR1IIIc. The latter transcript significantly declined between DP 1 and DP 12, whereas FGF-2 and FGFR2IIIc showed no significant changes at that time. FGF-2 transcription was greater at DC 20 than at DC 12, but significantly most transcripts were found in ovx gilts. EB induced a significant suppression of FGF-2 mRNA, an effect which was antagonized by P and even prevented by P+EB. FGFR1IIIc mRNA was significantly increased at DC 20, that of FGFR2IIIc at DC 12 displaying a 10 times higher absolute mRNA amount. Suppression of FGFR1IIIc mRNA by P was abolished by EB while P+EB attenuated this effect. FGFR2IIIc transcripts were equally restrained by P or EB while a combination of both slightly reduced such declines. Localization of FGF-2 and FGFR1 proteins in stromal, glandular and vascular compartments was effected by sex steroids. Both proteins were strongly expressed at DP 12 but not at DP 1. Summarized, differential temporal and spatial localization of FGF-2 and FGFR1 after response to sex steroids support a complex regulation of this ligand receptor system important for proliferation and differentiation of uterine cells including angiogenic processes. While FGFR1IIIc is presumed to be promoted by estradiol FGFR2IIIc appears to be dominated by progesterone implicating different biological importance for a functional endometrium.

Adenomyosis

Adenomyosis is characterized as ectopic endometrial tissues within the myometrium in the uterus. The etiology and pathogenetic mechanism(s) responsible for adenomyosis are poorly understood. Definite diagnosis is made on hysterectomy specimens, although attempts are made at securing preoperative diagnosis by magnetic resonance imaging and myometrial biopsies. Definite treatment of symptomatic women is hysterectomy.