Pathogenesis of endometriosis

The role of probiotics in women's health: An update narrative review

Probiotics, live microorganisms that confer health benefits to the host when administered in adequate amounts, have gained considerable attention for their potential role in maintaining women's health. This overview summarizes key clinical findings on the beneficial effects of probiotics in various aspects of women's health. Probiotics, particularly Lactobacillus species, contribute to vaginal health by promoting a balanced vaginal microbiome to prevent infections and maintain an acidic environment. In gynecologic conditions, probiotics show potential in preventing and managing bacterial vaginosis, vulvovaginal candidiasis, and sexually transmitted infections. Probiotic supplementation has also been associated with improvements in metabolic parameters and menstrual irregularities in polycystic ovary syndrome patients. During pregnancy, probiotics may be helpful in reducing the risk of gestational diabetes, maternal group B streptococcal colonization, obstetric anemia, and postpartum mastitis. In recent years, the potential role of probiotics in the prevention and management of gynecologic cancer has gained attention. Further research is needed to better understand the specific mechanisms and determine the optimal Lactobacillus strains and dosages regimens for gynecologic cancer prevention and therapy. In conclusion, probiotics offer a non-invasive and cost-effective approach to support women's health and prevent obstetric and gynecologic complications.

Biological aspects in controlling angiogenesis: current progress

All living beings continue their life by receiving energy and by excreting waste products. In animals, the arteries are the pathways of these transfers to the cells. Angiogenesis, the formation of the arteries by the development of pre-existed parental blood vessels, is a phenomenon that occurs naturally during puberty due to certain physiological processes such as menstruation, wound healing, or the adaptation of athletes' bodies during exercise. Nonetheless, the same life-giving process also occurs frequently in some patients and, conversely, occurs slowly in some physiological problems, such as cancer and diabetes, so inhibiting angiogenesis has been considered to be one of the important strategies to fight these diseases. Accordingly, in tissue engineering and regenerative medicine, the highly controlled process of angiogenesis is very important in tissue repairing. Excessive angiogenesis can promote tumor progression and lack of enough angiogensis can hinder tissue repair. Thereby, both excessive and deficient angiogenesis can be problematic, this review article introduces and describes the types of factors involved in controlling angiogenesis. Considering all of the existing strategies, we will try to lay out the latest knowledge that deals with stimulating/inhibiting the angiogenesis. At the end of the article, owing to the early-reviewed mechanical aspects that overshadow angiogenesis, the strategies of angiogenesis in tissue engineering will be discussed.

Inguinal endometriosis with a disappearing mass preoperatively: A case report

Introduction

Endometriosis is a common gynecological disease that affects approximately 10% of reproductive-age women. Inguinal endometriosis is uncommon, affecting only 0.6% of all patients with endometriosis. We present a case of inguinal endometriosis with a disappearing mass preoperatively.

Presentation of case

A 44-year-old woman presented with a palpable mass and pain in her left inguinal region. Computed tomography showed a 20-mm mass near the pubic tubercle. After 2 months of observation, the mass became impalpable and could not be confirmed by computed tomography; however, the inguinal pain did not improve regardless of menstrual cycles. Resection of the inguinal mass and the entire extraperitoneal portion of the uterine round ligament was performed. Histopathological examination revealed endometrial glands and stroma with CD10-positive cells, which confirmed inguinal endometriosis diagnosis. Erythrophagocytic macrophages indicated endometriosis-related hematoma absorption. Her symptoms disappeared after surgery, and no postoperative complications occurred.

Discussion

For treating inguinal endometriosis, the complete removal of the mass and the entire extraperitoneal portion of the round ligament by an anterior approach is necessary to prevent postoperative residual symptoms and recurrence. However, the preoperative diagnosis of inguinal endometriosis remains a challenge and is frequently discovered incidentally by intraoperative findings and pathological examination.

Conclusion

Clinicians should have a high suspicion of inguinal endometriosis and improved diagnostic precision to select the appropriate surgical approach. Regardless of menstrual variability, the feature of a decreased mass size caused by endometriosis-related hematoma absorption can serve as a preoperative diagnostic clue.

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Endometriosis affects approximately 10% of reproductive-age women.

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Inguinal endometriosis is uncommon and difficult to diagnose.

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Surgery is the first choice for symptom relief of inguinal endometriosis.

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Diagnostic precision improvement for inguinal endometriosis before surgery is crucial.

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The feature of decreased mass size can serve as a preoperative diagnostic clue.

Endometriosis: Epidemiology, Classification, Pathogenesis, Treatment and Genetics (Review of Literature)

Endometriosis is a “mysterious” disease and its exact cause has not yet been established. Among the etiological factors, congenital, environmental, epigenetic, autoimmune and allergic factors are listed. It is believed that the primary mechanism of the formation of endometriosis foci is retrograde menstruation, i.e., the passage of menstrual blood through the fallopian tubes into the peritoneal cavity and implantation of exfoliated endometrial cells. However, since this mechanism is also observed in healthy women, other factors must also be involved in the formation of endometriosis foci. Endometriosis is in many women the cause of infertility, chronic pain and the deterioration of the quality of life. It also represents a significant financial burden on health systems. The article presents a review of the literature on endometriosis—a disease affecting women throughout the world.

Skin endometriosis: A case report and review of the literature

Skin endometriosis is a rare disease with variable clinical and histopathological characteristics that depend on hormonal stimuli. The skin is not a common location, as most cases of endometriosis involve pelvic sites, such as the ovaries, peritoneum and bowel. However, the most common extrapelvic site affected is the abdominal wall and this location of the disease is frequently associated with obstetric and gynecologic surgery. Here we report a case of skin endometriosis emerged as a painful subcutaneous nodule located near to the left side of an obstetrical surgery procedure scar. The patient affected was a woman in her reproductive age, with a history of right ovary endometriotic cyst laparoscopically removed and histologically confirmed as a primary endometriosis. Dermatologists should be aware of this condition in any woman with a painful lump located in the proximity of a pelvic surgery-induced scar. Its non-specific clinical appearance may confuse the clinician and may delay the diagnosis and management.

Killer cell immunoglobulin-like receptors (KIR) and human leukocyte antigen-C (HLA-C) allorecognition patterns in women with endometriosis

Endometriosis shares similarities with several autoimmune diseases. The human leukocyte antigen (HLA)-C genotype is associated with several human autoimmune diseases. HLA-C is a ligand of killer cell immunoglobulin receptors (KIRs) and is an essential regulator of natural killer cell activity, which is associated with endometriosis progression. Polymorphisms in HLA-C and KIR affect the activity of NK cells and susceptibility to several diseases. Therefore, we attempted to investigate an association between HLA-C genotype and KIR polymorphism and the occurrence of endometriosis. We tested the association of certain KIR and HLA-C combinations and the development of endometriosis by characterizing both KIR and HLA-C genes in 147 women with endometriosis and 117 controls. The HLA-C genotypes and KIR polymorphisms were analyzed via DNA-based method for higher-resolution genotyping. We found that the occurrence of HLA-C*03:03*01 was increased in endometriosis than in control groups. Analysis of various KIR haplotypes revealed differences between the endometriosis and control cohorts. The number of KIR centromeric A/A haplotypes was increased in the endometriosis group than controls. Moreover, the endometriosis cohort was characterized by reduced number of KIR2DS2-positive individuals in the Han Chinese population. Our current findings suggest that the KIR and HLA-C genotypes are associated with the pathogenesis of endometriosis.

Apoptotic functions of microRNAs in pathogenesis, diagnosis, and treatment of endometriosis

MicroRNAs or miRNAs are a component of the non-coding RNAs family which is engaged in many cellular functions such as cell proliferation, apoptosis, gene expression, signaling pathways, angiogenesis, and etc. Endometriosis is a malignant gynecologic disorder occurring in women before menopausal age. Pathogenesis of this illness is still a discussion subject between the scientists but in our knowledge, microRNAs can be one of the possible involved factors. The purpose of this paper is to investigate the role of apoptotic activities of miRNAs in endometriosis. Accumulative evidence has demonstrated the role of cell proliferation, apoptosis, and invasion in the progression of these diseases. In this review, we looked into the specific role of apoptosis and its related genes and pathways in endometriosis and tied to present an explanation of how miRNAs can affect endometriosis by their apoptotic activities. What we found is that a great extent of miRNAs is involved in this illness and they are responsible for repressing apoptosis and progression of the disease. As a result, miRNAs have two different usages in endometriosis: biomarkers and potential therapeutic targets. In this review we gathered a great amount of evidence to inquire into the role of micro RNAs in inducing apoptosis and how this mechanism can be exerted for therapeutic purposes for endometriosis.

Increased α2-6 sialylation of endometrial cells contributes to the development of endometriosis

Endometriosis is a disease characterized by implants of endometrial tissue outside the uterine cavity and is strongly associated with infertility. Focal adhesion of endometrial tissue to the peritoneum is an indication of incipient endometriosis. In this study, we examined the effect of various cytokines that are known to be involved in the pathology of endometriosis on endometrial cell adhesion. Among the investigated cytokines, transforming growth factor-β1 (TGF-β1) increased adhesion of endometrial cells to the mesothelium through induction of α2-6 sialylation. The expression levels of β-galactoside α2-6 sialyltransferase (ST6Gal) 1 and ST6Gal2 were increased through activation of TGF-βRI/SMAD2/3 signaling in endometrial cells. In addition, we discovered that terminal sialic acid glycan epitopes of endometrial cells engage with sialic acid-binding immunoglobulin-like lectin-9 expressed on mesothelial cell surfaces. Interestingly, in an in vivo mouse endometriosis model, inhibition of endogenous sialic acid binding by a NeuAcα2-6Galβ1-4GlcNAc injection diminished TGF-β1-induced formation of endometriosis lesions. Based on these results, we suggest that increased sialylation of endometrial cells by TGF-β1 promotes the attachment of endometrium to the peritoneum, encouraging endometriosis outbreaks.

A growth factor involved in cell differentiation and proliferation contributes to the development of endometriosis by stimulating a protein modification mechanism that increases the adhesiveness of cells lining the uterus. Endometriosis results when these cells, known as endometrial cells, start growing outside the uterus causing pelvic pain, heavy periods and, in some cases, infertility. Ki-Tae Ha at Pusan National University, Yangsan, South Korea, and colleagues found that transforming growth factor-β1 signaling promoted the addition of sialic acid sugar units onto endometrial cell surface proteins. This modification enhanced the adhesion of endometrial cells to mesothelial cells, which line other internal organs, and the formation of endometriosis lesions in mice. Preventing sialic acid binding to its mesothelial cell receptor reduced lesion formation. The findings reveal a new molecular mechanism underlying endometriosis and a potential treatment strategy.

Retroperitoneal Endometriotic Cyst Infiltrated in the Iliopsoas Incidentally Found in a Patient with Acute Back Pain

We describe a rare case of retroperitoneal endometriotic cyst infiltrated in the iliopsoas incidentally found in a patient with acute back pain. Endometriosis at the pelvic peritoneum, including the Douglas pouch, has been reported often; there are few reports of cystic endometriosis in the retroperitoneal cavity. Today there are various theories regarding how endometriosis occurs. By pathological findings and lesion sites of the present case, we concluded that the endometrial tissues in the menstrual blood might metastasize lymphatically and implant and form the retroperitoneal cyst.

Serum galectin-9 as a noninvasive biomarker for the detection of endometriosis and pelvic pain or infertility-related gynecologic disorders

OBJECTIVE

To investigate the usefulness of soluble galectin-9 (Gal-9) in the noninvasive laboratory diagnosis of endometriosis and various gynecologic disorders.

DESIGN

Prospective case-control study.

SETTING

University medical centers.

PATIENT(S)

A total of 135 women of reproductive age were involved in the study, 77 endometriosis patients, 28 gynecologic controls, and 30 healthy women.

INTERVENTION(S)

Diagnostic laparoscopy and collection of tissue biopsies, peritoneal cells, and native peripheral blood from different case groups of gynecology patients and healthy women.

MAIN OUTCOME MEASURE(S)

The expression of mRNA and serum concentration of Gal-9.

RESULT(S)

Semiquantitative reverse transcription-polymerase chain reaction analysis and serum soluble Gal-9 ELISA were performed on three different cohorts of patients: those with endometriosis, those with benign gynecologic disorders, and healthy controls. Differences in the Gal-9 concentrations between the investigated groups and the stability of Gal-9 in the serum and diagnostic characteristics of Gal-9 ELISA were determined by statistical evaluation and receiver operating characteristic (ROC) curve analysis. Significantly elevated Gal-9 levels were found in both minimal-mild (I-II) and moderate-severe (III-IV) stages of endometriosis in comparison with healthy controls. At a cutoff of 132 pg/mL, ROC analysis revealed an excellent diagnostic value of Gal-9 ELISA in endometriosis (area under the curve = 0.973) with a sensitivity of 94% and specificity of 93.75%, indicating better diagnostic potential than that of other endometriosis biomarkers. Furthermore, various pelvic pain or infertility-associated benign gynecologic conditions were also associated with increased serum Gal-9 levels.

CONCLUSION(S)

Our results suggest that Gal-9 could be a promising noninvasive biomarker of endometriosis and a predictor of various infertility or pelvic pain-related gynecologic disorders.

Surgical outcomes of laparoscopic endometriosis surgery: a 6 year experience

OBJECTIVES

The aim of the present study was to review 6 year experience on the surgical outcomes of laparoscopic endometriosis surgery.

METHODS

A cohort study was performed in Shiraz University of Medical Sciences using data from medical records of 1315 cases of patients with endometriosis undergoing laparoscopic surgery with follow-up of 6 to 72 months.

RESULTS

This study concerned a cohort of 1315 patients diagnosed with endometriosis operated between April 2010 and April 2016, 1086 (82.5%) of whom were in stage III and IV; 968 (73.61%) had endometrioma (regardless of having deep infiltrative endometriosis [DIE] or peritoneal involvement) and 347 (26.39%) of patients had either DIE or peritoneal involvement without endometrioma. Regarding the patients, unilateral endometrioma was statistically significant in the left ovary (p = .002). One hundred and thirty-three (10.7%) rectal wall, 7 (0.32%) sigmoid colon, 4 (0.18%) vagina, 125 (5.6%) ureter and 33 (1.52) bladder involvements were detected. Prior to operation, the pain VAS score was 8.23 ± 2.03, which decreased to 4.46 ± 2.47 in 93.07% of patients. Fifty-three patients (6.56%) needed reoperation. Sixty-six (33.1%) infertile women had spontaneous pregnancy and 15 (25%) became pregnant using intrauterine insemination (IUI) or assisted reproductive technique (ART) post-operatively.

CONCLUSION

Surgical treatment of endometriosis seems to be an effective treatment. DIE can be present in the absence of endometrioma. The rate of left endometrioma is higher due to the pressure effect of the sigmoid colon. Nonetheless, if an expert surgeon performs this procedure, not only the rate of post-operative complications, but also the possibility of recurrence would decrease.

Immunohistochemical Expression of p53, MDM2, and p21Wafi Oncoproteins in Endometriomas But Not Adenomyosis

OBJECTIVE

p53, MDM2, and p21Waf1 are oncoproteins that regulate the cell cycle. The purpose of this study was to examine the distribution of p53, MDM2, and p21Waf1 oncoprotein expression in endometriomas and in adenomyosis.

METHODS

Tissue samples from 25 women with pathologically confirmed endometriomas and 31 women with pathologically confirmed adenomyosis were analyzed. Expression of p53, MDM2, and p21Waf1 oncoproteins was assessed by immunohistochemical nuclear staining.

RESULTS

p53, MDM2, and p21Waf1 expression were detected in 20%, 60%, and 80% of endometrioma tissue samples, respectively. All endometrioma tissue samples expressing p53 also tested positive for both MDM2 and p21Waf1. MDM2 expression was significantly higher in the proliferative than in the secretory phase of the cycle. In contrast, all 31 adenomyosis tissue samples were negative for p53, MDM2, and p21Waf1 expression.

CONCLUSION

The expression of p53, MDM2, and p21Waf1 suggests a role for these oncoproteins in the regulation of endometrioma cell growth, but not in adenomyosis.

Animal Models in Endometriosis Research

The initiation of endometriosis in women is difficult to investigate, because there is usually a delay of several years from the onset of lesion development to the clinical diagnosis. Animal models of endometriosis, on the other hand, provide an important contribution to the investigation of the disease pathogenesis and the efficacy of therapeutic intervention strategies.

Common chromosomal imbalances and stemness-related protein expression markers in endometriotic lesions from different anatomical sites: the potential role of stem cells

BACKGROUND

Endometriosis is a multifactorial gynecological disease characterized by the presence of functional endometrium-like tissue in ectopic sites. Several studies have focused on elucidating the immunological, endocrine, environmental and genetic factors involved in endometriosis. However, its pathogenesis is still unclear.

METHODS

High-resolution comparative genomic hybridization was applied to screen for genomic imbalances in laser microdissected stromal and epithelial cells from 20 endometriotic lesions and three samples of eutopic endometrium derived from eight patients. The expression of seven stemness-related markers (CD9, CD13, CD24, CD34, CD133, CD117/c-Kit and Oct-4) in endometrial tissue samples was evaluated by immunohistochemistry.

RESULTS

Samples of eutopic endometrium showed normal genomic profiles. In ectopic tissues, an average of 68 genomic imbalances was detected per sample. DNA losses were more frequently detected and involved mainly 3p, 5q, 7p, 9p, 11q, 16q, 18q and 19q. Many of the genomic imbalances detected were common to endometriotic stroma and epithelia and also among different endometriotic sites from the same patient. These findings suggested a clonal origin of the endometriotic cells and the putative involvement of stem cells. Positive immunostaining for CD9, CD34, c-Kit and Oct-4 markers was detected in isolated epithelial and/or stromal cells in eutopic and ectopic endometrium in the majority of cases.

CONCLUSIONS

The presence of shared genomic alterations in stromal and epithelial cells from different anatomical sites of the same patient and the expression of stemness-related markers suggested that endometriosis arises as a clonal proliferation with the putative involvement of stem cells.

Hypoxia-induced microRNA-20a expression increases ERK phosphorylation and angiogenic gene expression in endometriotic stromal cells

CONTEXT

Aberrant activation of MAPK has been implicated to play important roles in pathological processes of endometriosis. However, how MAPK are constitutively activated in endometriotic tissues remains largely unknown. microRNA are small noncoding RNA that regulate the stability or translational efficiency of target mRNA by interacting with the 3' untranslated region. Thus, miRNA are thought to be modulators of the transcriptional response, fine-tuning gene expression.

OBJECTIVE

The aim of this study was to evaluate the functional roles of microRNA-20a (miR20a) in MAPK activation and the pathogenesis of endometriosis.

DESIGN

miR20a expression was analyzed in nonpaired (endometrium = 17; endometriosis = 37) and paired (n = 12) endometriotic tissues by quantitative RT-PCR. Overexpression of miR20a in eutopic endometrial stromal cells or inhibition of miR20a in ectopic endometriotic stromal cells was used to evaluate its impact on ERK phosphorylation and subsequently angiogenesis- and proliferation-related gene expression.

RESULTS

Levels of miR20a were up-regulated in endometriotic stromal cells. Elevation of miR20a was up-regulated by hypoxia inducible factor-1α. The up-regulation of miR20a causes the down-regulation of dual-specificity phosphatase-2, which leads to prolonged ERK phosphorylation and an increase in the expression of several angiogenic genes. Furthermore, the up-regulation of miR20a enhances the prostaglandin E(2)-induced expression of fibroblast growth factor-9, a potent mitogen that stimulates both endothelial and endometrial cell proliferation.

CONCLUSION

Our findings provide the novel mechanism that not only functionally links together hypoxic stress, miR20a expression, aberrant ERK phosphorylation, and angiogenesis but also demonstrates that miR20a is an important modulator in the development of endometriosis.

Pleural endometriosis in an aged rhesus macaque (Macaca mulatta): a histopathologic and immunohistochemical study

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity and is one of the most common reproductive abnormalities encountered in women as well as Old World primates. The majority of endometriosis cases in Old World primates occur within the abdominal cavity, with spread to extraabdominal sites considered to be a rare event. A 19-year-old multiparous female rhesus macaque (Macaca mulatta) presented to necropsy for difficulty breathing and weight loss. Grossly, the animal had marked abdominal endometriosis and severe hemoabdomen and hemothorax, the latter of which was accompanied by marked pleural fibrosis. Histologic examination confirmed the abdominal endometriosis and also revealed numerous uterine glands and stroma embedded within the pleural fibrosis. Rafts of endometrial tissue were present within pulmonary lymphatics and the tracheobronchial lymph nodes. Immunohistochemically, all ectopic endometrial tissue had varying degrees of positive immunoreactivity to cytokeratin, vimentin, progesterone and estrogen receptors, and calretinin but was negative for desmin and carcinoembryonic antigen. Pleural endometriosis is an extremely rare manifestation of endometriosis in nonhuman primates. This case report emphasizes lymphatic spread as a likely mechanism for extrauterine endometriosis.

Extracts of Salvia miltiorrhiza Bunge on the cytokines of rat endometriosis models

Endometriosis is a common mysterious and fascinating gynaecological condition with diverse clinical manifestations, highly variable and unpredictable clinical course with decreased quality of life. Clinically, Salvia miltiorrhiza Bunge (SMB, Chinese Danshen) has been applied to treat endometriosis and get satisfactory results. The present study was aimed to explore the effects of the extracts of SMB (ESMB) on the serum levels of cancer antigen 125 (CA-125) and the levels of interleukin (IL)-13, IL-18 and tumor necrosis factor-alpha (TNF-alpha) in the peritoneal fluids of rat endometriosis models. Three extraction methods for SMB were compared, which are the sample extracted with conventional method, the sample extracted with espresso coffee machine and the commercial condensed powder of natural products. We determined tanshinone IIA, salvianolic acid B and danshensu in the ESMB of different extraction methods. Forty female Sprague-Dawley (SD) rats were randomly divided into ESMB group, Danazol (positive control) group, model group and the sham-operation group (Sham group). After all the treatment ended, the serum levels of CA125 and the levels of IL-13, IL-18 and TNF-alpha in the peritoneal fluids of rat endometriosis models were measured using enzyme-linked immune-sorbent assay (ELISA) as directed by the manufacturer. The extraction efficiency of the ESMB samples extracted with coffee machine ranged from 600µm to 710µm was the highest. The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly lower than those of the Model group (P<0.05). The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of Danazol group and ESMB group were significantly higher than those of Sham group, respectively (P<0.05), and no marked difference existed between them (P>0.05). The levels of IL-13 in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly higher than those of the Model group (P<0.05). The levels of IL-13 in the peritoneal fluids of ESMB group and Danazol group were significantly lower than those of Sham group (P<0.05), and there was no marked difference between ESMB group and Sham group (P>0.05). ESMB shows promises in treating endometriosis by markedly decreasing the serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids and significantly increasing the levels of IL-13 in the peritoneal fluids.

Correlation of angiogenic cytokines-leptin and IL-8 in stage, type and presentation of endometriosis

Pelvic endometriosis is a chronic inflammatory disease with an immunological background. Yet there is paucity of contemporary research exploring both the angiogenic cytokines, leptin and IL-8 for a possible role in its pathophysiology.

OBJECTIVE

To compare levels of both leptin and IL-8 in peritoneal fluid (PF) in women with endometriosis vs. fertile controls and correlate with disease stage, type and symptoms.

MATERIALS AND METHODS

PF from 58 women with endometriosis and 28 women undergoing tubal ligation was collected at laparoscopy and leptin and IL-8 levels were measured using ELISA. Results showed significantly higher levels of both cytokines in women with endometriosis. Significantly higher leptin and IL-8 levels were demonstrated in patients with early peritoneal (ASRM stage I and II) and advancing disease (ASRM stage III and IV), respectively. Levels of leptin/IL-8 were significantly lower in patients with endometrioma (4.8 ng/mL/32 pg/mL) vs. implants (13.0 ng/mL/68 pg/mL). There was no correlation of infertility or chronic pelvic pain with these levels.

CONCLUSION

Both leptin and IL-8 levels are raised in PF of women with endometriosis reflecting inflammation and dysregulated immunomodulation. Higher levels of leptin were seen in early stages; IL-8 seems to stimulate the disease in a dose-dependent manner.

A systematic review: endometriosis presenting with ascites

BACKGROUND

The present review aims to increase the awareness of the gynecologists by analyzing all the case reports which refer to endometriosis presenting either with only ascites or with massive ascites with pleural effusion.

METHODS

To conduct the present review, the CENTRAL (in the Cochrane Library, current issue), MEDLINE (Silver Platter, from 1950 to 2010), and EMBASE (from 1950 to 2010) electronic databases were searched. As a result, all the publications based on the keywords relating to the review topic were acquired.

RESULTS

Since the description of first case in 1954, endometriosis-related ascites was reported to occur in a total of 63 women who were aged between 19 and 51 years. Approximately 63.0% of the recruited women for whom ethnicity was specified were of African origin (29 out of 46). Of the 50 subjects with known obstetric history, 41 (82.0%) were nulliparous. Abdominal distention, anorexia/weight loss, abdominal pain, and menometrorrhagia were the most frequently encountered clinical symptoms, whereas pelvic mass was the most common physical finding. The serum concentrations of CA 125 were between 20 and 3,504 IU/ml for 19 women whose CA 125 levels were determined. Pleural effusion was also present in 38.1% of the reviewed subjects (24 out of 63). The clinical features of the women with endometriosis-related ascites and pleural effusion were similar to those of the women who had only endometriosis-related ascites.

CONCLUSION

Endometriosis-related ascites and/or pleural effusion refers to extensive disease with a high risk for recurrence which usually affects non-Caucasian, nulliparous women of reproductive age and leads to clinical symptoms resembling those of an ovarian malignancy. Therefore, clinicians should consider endometriosis in differential diagnosis of pelvic masses and also include endometriosis in diagnostic workup of ascites or pleural effusion.

Mapping of susceptibility locus for endometriosis within the HLA region using microsatellite markers in Japanese women

Endometriosis is a female disorder characterized by the presence of uterine endometrial tissue in ectopic loci. Previous studies reported a higher prevalence of particular human leukocyte antigen (HLA) in endometriosis. In order to confirm the association between endometriosis and the HLA region, 15 polymorphic microsatellite markers distributed in the HLA class II to class III region were subjected to association analysis by polymerase chain reaction (PCR)-based DNA typing of 89 patients and 136 healthy controls. Statistical analysis of the allelic frequency at each microsatellite locus showed that there were no statistically significant differences in the allele frequency distributions between the cases and controls. This finding suggests that the etiology of endometriosis does not involve the HLA class II genomic region and a portion of class III genomic region in the Japanese population.

Inflammatory cytokines differentially up-regulate human endometrial haptoglobin production in women with endometriosis

BACKGROUND

Evidence suggests that eutopic endometrium from women with endometriosis (US-E) has intrinsic functional anomalies compared with women without endometriosis (US-C). We hypothesized that differences in endometrial haptoglobin (eHp) mRNA and protein levels exist between eutopic endometrium from US-E and US-C and that inflammatory mediators may be involved.

METHODS

Endometrial stromal cells and tissue explants from US-E (n = 18) and US-C (n = 18) were cultured (24 h/48 h for cells/explants) with interleukin (IL)-1alpha, -1beta, -6, -8 or tumor necrosis factor-alpha (TNF-alpha) at 0-100 ng/ml. eHp protein in media and mRNA levels were quantified by enzyme-linked immunosorbent assay and quantitative PCR.

RESULTS

In eutopic endometrial stromal cells from US-E, IL-1beta, IL-6 and TNF-alpha (10 ng/ml) increased eHp mRNA levels (P = 0.002, P < 0.001 and P < 0.001, respectively) and eHp protein (P = 0.023, 0.031 and 0.006, respectively) versus control. In endometrial tissues from US-E, IL-1beta, IL-6 and TNF-alpha increased eHp mRNA (P < 0.001, P = 0.017 and P < 0.001, respectively) and eHp protein (P < 0.001, P = 0.007 and 0.039, respectively) versus control. IL-1alpha and IL-8 had small or no effects on isolated endometrial cells or tissues. In US-C, IL-1beta, IL-8 and TNF-alpha each reduced eHp mRNA in endometrial stromal cells (all P < 0.001) versus control; IL-1alpha and IL-6 had no effect. eHp mRNA increased in endometrial tissues from US-C in response to IL-1beta (P = 0.008), IL-6 (P = 0.015) and TNF-alpha (P = 0.031) versus control; IL-1alpha or IL-8 had no effect.

CONCLUSIONS

Endometrium from US-E differentially responds to specific inflammatory cytokines by production of eHp. We propose that up-regulation of endometrial eHp by inflammatory mediators disrupts normal endometrial function and may facilitate the pathogenesis of endometriosis.

Cyclooxygenase-2 regulates survival, migration, and invasion of human endometriotic cells through multiple mechanisms

Endometriosis is a debilitating disease characterized by the presence of functional endometrial glandular epithelium and stroma outside the uterine cavity that affects up to 20% of women of child-bearing age. Cyclooxygenase-2 (COX-2), a rate-limiting enzyme in the biosynthesis of prostaglandin E(2) (PGE(2)), is highly expressed in endometriotic tissues and results in increased concentrations of peritoneal PGE(2) in women. In this study, we determined the expression of COX-2 protein in ectopic and eutopic endometria in humans and the role of COX-2 in endometriotic cell survival, migration, and invasion in humans. Our results indicate that COX-2 protein is abundantly expressed in ectopic endometria compared with eutopic endometria. Comparatively, expression of COX-2 protein is higher in eutopic endometria from women with endometriosis compared with women without endometriosis. Inhibition of COX-2 decreases survival, migration, and invasion of endometriotic cells that are associated with decreased production of PGE(2). Cell growth inhibitory effects of COX-2 inhibition/silencing are mediated through nuclear poly (ADP-ribose) polymerase-mediated apoptosis. Cell motility and invasion inhibitory effects of COX-2 inhibition/silencing are mediated through matrix metalloproteinase-2 and -9 activities. Interestingly, effects of COX-2 inhibition is more profound in endometriotic epithelial than in stromal cells. Furthermore, inhibition of COX-2 affects invasion rather than migration of endometriotic epithelial and stromal cells. It is the first evidence showing that inhibition of COX-2 decreases endometriotic epithelial and stromal cell survival, migration, and invasion in humans. Our results support the emerging concept that COX-2/PGE(2) promotes the pathophysiology and pathogenesis of endometriosis in humans.

Abnormal interleukin 1 receptor types I and II gene expression in eutopic and ectopic endometrial tissues of women with endometriosis

Interleukin-1 (IL1) is believed to play a central role in the immuno-inflammatory process associated with endometriosis. IL1 triggers cell activation via its receptor type I (IL1R1), but its receptor type II (IL1R2) is known instead as a scavenger that buffers the cytokine's effects. Our previous studies have shown increased expression of IL1R1 in active endometriotic implants compared to normal and endometriosis women-derived endometrial tissues, and a simultaneous decrease in IL1R2 expression at the protein level. In the present study, in situ hybridization demonstrated a noticeable decrease in IL1R2 mRNA hybridization score in eutopic and matched ectopic endometrial tissues of women with endometriosis compared to normal women in the stroma (P<0.001 and P<0.001, respectively) and the epithelium (P<0.01 and P<0.05, respectively), whereas IL1R1 mRNA hybridization score was higher only in the ectopic implants, with a statistically significant difference in the stroma (P<0.05). This was corroborated by RT-PCR analysis of IL1R1 and IL1R2 mRNAs in ectopic (P<0.05 and P<0.05, respectively) and matched eutopic (P=0.22 and P<0.05, respectively) endometrial tissues from women with endometriosis compared to endometrial tissues from normal women. The decrease in IL1R2 mRNA levels in eutopic endometrial tissue of endometriosis women, and the concomitant increase in IL1R1 mRNA levels in ectopic implants, reveal a profound defect in IL1R 1 and IL1R2 gene expression which may accentuate the capability of this tissue to respond to IL1 and favor its ectopic growth.

Imbalance in the expression of the activating type I and the inhibitory type II interleukin 1 receptors in endometriosis

BACKGROUND

The ectopic establishment and progression of endometrial tissue is dependent upon its interaction with and responsiveness to the stimuli present in its new environment. Immune cell-derived cytokines, such as interleukin 1 (IL1), may alone or in concert with estrogens enhance the capability of ectopic endometrial cells to implant and develop into the host tissue. The objective of this study was to further evaluate the expression and significance of IL1 receptor type I (IL1R1), the signalling receptor that mediates cell activation by IL1, and IL1 receptor type II (IL1R2), a potent and specific down-regulator of IL1 action, in normal compared to endometriotic/endometrial tissues.

METHODS

Techniques included immunohistochemistry, immunofluorescent staining, ELISA, western blotting and endometriotic cell culture transfection.

RESULTS

Our study showed an imbalance in the expression of IL1R1 and IL1R2 in eutopic, and particularly in ectopic, endometrial tissues of women with endometriosis. Actually, a decreased IL1R2 expression is predominant in the eutopic and ectopic endometrium of women with endometriosis when compared with normal women, whereas a concomitant increase in IL1R1 expression occurs in ectopic endometrial tissue in comparison to eutopic endometrial tissue of normal or endometriotic women, particularly in the initial and most active implants. Transfection of endometriotic cells with a cDNA coding for IL1R2 resulted in a significant decrease in IL1-induced secretion of vascular endothelial cell growth factor and monocyte chemotactic protein 1.

CONCLUSIONS

IL1R1/IL1R2 imbalance may amplify endometrial cell responsiveness to IL1 and represent a key mechanism underlying the ability of these cells to implant and develop into host tissues.

Endométriomes de la paroi abdominale : apport de l’imagerie

Endometrioma of the abdominal wall is a not well-recognized disease and usually develops after pelvic surgery. The most common presentation is a mass of the abdominal wall associated with pain during menstruation. We report six cases of parietal endometriomas studied with ultrasonography, CT, and in one case with MRI. Our results are compared with recent findings in the literature. The purpose of this study was to describe the clinical and imaging findings in abdominal wall endometriomas that can help reach a presurgical diagnosis.

Immunohistochemical analysis of an ectopic endometriosis in the uterine round ligament

A rare case of the inguinal endometriosis was reported with immunohistochemical analysis. A 28-year-old woman had a thumb-sized tumor in the right groin for two years with a gradual increase in size and pain. An operation revealed an elastic hard tumor with an unclear margin and adhesion to the uterine round ligament. The histology showed irregular proliferation of the endometrial glands and stroma. The glandular epithelium stained weakly positive against CD125 antibody and the stromal matrix stained strongly positive against CD10 antibody. The nucleus in both the epithelial and stromal cells stained strongly positive against progesterone and estrogen receptor antibodies, and the cytoplasm in both types of cells stained moderately positive against COX-2 (cyclooxygenase-2) antibody. In conclusion, the combination of estrogen or progesterone receptor antibody for the nucleus and CD10 or COX-2 antibody for the cytoplasm could enhance the accuracy of diagnosis for ectopic endometriosis.

Haptoglobin expression by shed endometrial tissue fragments found in peritoneal fluid

OBJECTIVE

To confirm the endometrial glandular epithelial and stromal cells in tissue fragments recovered from peritoneal fluid and to quantify haptoglobin expression.

DESIGN

Prospective, randomized study.

SETTING

University of Missouri-Columbia School of Medicine and Health Care System.

SUBJECT(S)

Women undergoing laparoscopic surgery for diagnosis or treatment of endometriosis or for laparoscopic tubal cautery for desired sterilization.

INTERVENTION(S)

Aspiration of peritoneal fluid at laparoscopic surgery.

MAIN OUTCOME MEASURE(S)

Histological confirmation of endometrial glandular epithelial and stromal cells and evaluation of haptoglobin gene expression and protein localization in shed endometrial tissue fragments recovered from peritoneal fluid.

RESULT(S)

More visible tissue fragments were found in the peritoneal fluid from women with endometriosis (n = 28/65) than from that of women without endometriosis (n = 5/34). Of these tissues, endometrial glands and stroma were histologically confirmed in about half of women with endometriosis (n = 13/28) and without endometriosis (n = 3/5). Retrogradely shed endometrial tissues recovered from peritoneal fluid robustly express haptoglobin.

CONCLUSION(S)

Haptoglobin expression by retrogradely shed endometrial tissues in peritoneal fluid supports a mechanism whereby these purported precursors of endometriotic lesions escape immune destruction. Low recovery of histologically confirmed endometrial tissue fragments from peritoneal fluid reveals the potential difficulties for using these tissues for studies modeling the pathogenesis of endometriosis.

Endométriose avec ascite et épanchement pleural : à propos d'un cas

Massive ascites associated with pelvic endometriosis is an uncommon combination. Pleural effusion may rarely occur. Fourteen cases are reported in the literature. We report the case of a black nulligravida woman followed for a primary infertility. Endometriosis was suspected in presence of increasing dysmenorrhea, cystic adnexal masse, umbilical nodes and ascites. The diagnosis was confirmed at exploratory laparoscopy. The patient had been followed for assisted procreation for six years and had undergone a conservative laparoscopic surgery never described. After several ascites recurrences, the pathology was resolved by Gonadotropin-releasing hormone agonist therapy. But a right pleural effusion with ascites occurred following a bad therapeutic observance. This complication reveals an early pregnancy never reported for this exceptional pathology. A conservative management allowed this unique case of well outcoming pregnancy. The possible pathogenesis of ascites and pleural effusion are explored and recommendations for diagnosis and treatment options are discussed.

A selective estrogen receptor-β agonist causes lesion regression in an experimentally induced model of endometriosis

BACKGROUND

Endometriosis is a common gynaecological problem of uncertain aetiology. It affects primarily young, reproductive-aged women and can result in chronic pelvic pain and infertility. Current approved therapies have significant side-effects and hysterectomy is employed as a final solution. ERB-041 is a selective estrogen receptor-beta (ERbeta) agonist that has anti-inflammatory activity in preclinical models of arthritis and inflammatory bowel disease, but is inactive in many preclinical models of classic estrogen activity. Because endometriosis is now thought to be, at least in part, an inflammatory disease, we evaluated ERB-041's activity in an experimentally induced model of endometriosis.

METHODS

Athymic nude mice (ovariectomized or intact) were implanted with tissue fragments of normal human endometrium. After establishment of lesions for 11-14 days, mice were treated with ERB-041 for 15-17 days. Upon euthanasia, the number of lesions, their size and location were noted. Five lesions were recovered for RNA analysis.

RESULTS

Across six studies, ERB-041 caused complete lesion regression in 40-75% of the mice studied. The compound appeared to be equally effective in gonad-intact as in ovariectomized mice, and analysed recovered lesions expressed ERalpha but not ERbeta mRNA.

CONCLUSIONS

ERB-041 and possibly other ERbeta selective agonists may be a useful new approach to treating endometriosis.

Susceptibility to ovarian endometriosis in Polish population is not associated with HLA-DRB1 alleles

BACKGROUND

Endometriosis is associated with inflammatory autoimmune reactions; however, aetiopathogenesis of the disease is still poorly understood. While autoimmune disorders are often associated with particular HLA alleles, the possible involvement of HLA in the aetiopathogenesis of endometriosis is still a subject of controversy. The aim of the study was to examine the distribution of HLA-DRB1 alleles in women with endometriosis. To ensure homogeneity of the studied group, only women with ovarian endometrial cysts were included.

METHODS

The study included 65 Polish patients of Caucasian origin in whom ovarian endometriosis had been confirmed by laparoscopic and histopathological examinations. HLA-DRB1 alleles were typed using a reverse slot blot method. A frequency of particular HLA-DRB1 alleles in patients was compared with that of a control group of 700 unrelated ethnically matched individuals as well as 193 age-matched women without endometriosis.

RESULTS

No statistically significant differences were found in the distribution of HLA-DRB1 alleles in patients with ovarian endometriosis as compared with control populations.

CONCLUSIONS

The results of the present study show that ovarian endometriosis is not associated with particular HLA-DRB1 allele(s). This may suggest that aetiology of this form of endometriosis may be not primarily associated with class II HLA-mediated autoimmune reactions.

Tumor necrosis factor alpha secretion by peritoneal macrophages in patients with endometriosis

INTRODUCTION

As a cytotoxic product of activated monocytes, macrophages, and lymphocytes, tumor necrosis factor alpha (TNF-alpha)--together with other cytokines and growth factors--is an important component in the immune response of the human organism. In addition, TNF-alpha plays a central role in neoangiogenesis. Because of its cytotoxicity with regard to several tumor cells and its motility-hindering effect on human sperm, TNF-alpha is considered to be a significant pelvic mediator of female sterility.

OBJECTIVE

The goal of our study was to determine as to whether or not an increased TNF-alpha secretion by peritoneal macrophages (PM) can be measured in female patients with endometriosis compared with healthy subjects, and if TNF-alpha secretion can be correlated with the activity of endometriosis.

METHODS

During infertility work-up, 100 female patients underwent a diagnostic laparoscopy. In accordance with the rAFS classification as well as from the macroscopic aspect of the degree of activity of the endometriosis, the patients were divided as follows: an endometriosis-free control group with a completely normal pelvic status (n=35) and three groups with increasing stages of endometriosis (n=65). In the control group (Group 1), the TNF-alpha concentrations (median values with minimum / maximum) were 6.2 pg/ml (1.9/10.2), in Group 2 with rAFS stage I/II less active endometriosis 56.33 pg/ml (39.5/71.2), in Group 3 with rAFS stage I/II but highly active endometriosis 81.41 pg/ml (68.4/98.7), while in Group 4 with rAFS stage III/IV 200,15 pg/ml (182.6/226.8), respectively.

CONCLUSION

In conclusion, we were able to show that the TNF-alpha secretion of PM was significantly higher in patients with proven endometriosis compared to the control group. These results were found to be statistically significant and were in accordance with the histological findings. Thus, due to its immunomodulating potential, TNF-alpha may be a marker of both activity and stage of endometriosis.

In vitro effect of gonadotropin-releasing hormone agonist on natural killer cell cytolysis in women with and without endometriosis

OBJECTIVE

The purpose of this study was to assess the in vitro effect of gonadotropin-releasing hormone agonist on natural killer cell activity in women with and without endometriosis and to ascertain whether gonadotropin-releasing hormone agonist effects on natural killer cell activity are direct or mediated solely through the hypoestrogenic state that they produce in vivo.

STUDY DESIGN

With use of a chromium 51 release microcytotoxicity assay with K562 target cells, natural killer cell activity was measured after the incubation of mononuclear cells with leuprolide acetate that was obtained from 16 patients with endometriosis and 11 control subjects.

RESULTS

The cytotoxicity of natural killer cells that were obtained from patients with endometriosis was reduced significantly (P<.001) with leuprolide. Natural killer cell cytotoxicity from control patients was also significantly decreased (P=.005) with gonadotropin-releasing hormone agonist. Natural killer cell cytotoxicity was significantly lower in patients with endometriosis than in control patients (P=.029).

CONCLUSION

These findings suggest a direct immunomodulatory role of gonadotropin-releasing hormone agonist on natural killer cell activity and confirm previous findings that patients with endometriosis have reduced natural killer cell cytotoxicity.

Altered expression of interleukin-18 in the peritoneal fluid of women with endometriosis

OBJECTIVE

Peritoneal fluid (PF) inflammatory factors may participate in the pathogenesis of endometriosis. The aim of this study was to investigate PF interleukin (IL)-18 levels in women with and without endometriosis.

DESIGN

Controlled clinical study.

SETTING

Women undergoing laparoscopy at a university hospital.

PATIENT(S)

Fifty women with previously untreated endometriosis, 8 women on GnRH agonists for endometriosis, and 18 control women with normal pelvic anatomy who were undergoing tubal ligation.

INTERVENTION(S)

Peritoneal fluid IL-18 levels as measured by ELISA.

MAIN OUTCOME MEASURE(S)

Peritoneal fluid IL-18 levels.

RESULT(S)

Peritoneal fluid IL-18 levels were significantly higher in women with previously untreated endometriosis (mean +/- SEM, 91.1 +/- 6.5 pg/mL) than in control women (59.4 +/- 2.0 pg/mL). Interestingly, women with superficial (100.0 +/- 10.2 pg/mL) and deep peritoneal implants (94.0 +/- 10.8 pg/mL) had significantly higher PF IL-18 levels than did women with endometriomas (57.8 +/- 1.8 pg/mL). Similarly, women with stage I-II endometriosis (97.3 +/- 8.0 pg/mL), but not women with stage III-IV endometriosis (74.9 +/- 9.9 pg/mL), had significantly higher PF IL-18 levels than did control women. Peritoneal fluid IL-18 levels were significantly higher in the luteal phase than in the follicular phase but did not discriminate between women with pelvic pain or infertility.

CONCLUSION(S)

Peritoneal fluid IL-18 is elevated in women with peritoneal, minimal- to mild-stage endometriosis.

An improved mouse model for endometriosis allows noninvasive assessment of lesion implantation and development

OBJECTIVE

To test whether fragments of human endometrium transduced with the green fluorescent protein (GFP) cDNA and transplanted into nude mice can be noninvasively visualized.

DESIGN

A murine experimental model for human endometriosis.

SETTING

A biotechnology company.

ANIMAL(S)

Ovariectomized nude mice.

INTERVENTION(S)

Whole fragments of human endometrium were transduced in vitro by adenoviral infection with the GFP cDNA before transplantation into nude mice. Animals were noninvasively and repeatedly imaged before lesion collection.

MAIN OUTCOME MEASURE(S)

Fluorescence of GFP-expressing human endometrial fragments was evaluated before transplantation into animals. Development of endometriotic lesions was monitored through direct visualization of fluorescent tissue in the living animal or through conventional dissection.

RESULT(S)

GFP gene transfer into whole endometrial fragments can be performed, and a high proportion of cells express the reporter gene. Fluorescent endometrial fragments implant in nude mice and form endometriotic-like lesions, which can be directly visualized through the skin of living mice using a simple imaging device.

CONCLUSION(S)

This improved mouse model allows noninvasive and dynamic studies of lesion implantation and development to be conducted. In addition to helping better understand the pathophysiology of the disease, this model represents a valuable preclinical tool for testing the efficacy of new drugs targeting endometriosis, which should ultimately accelerate their development phase.

Transactivation of steroidogenic acute regulatory protein in human endometriotic stromalcells is mediated by the prostaglandin EP2 receptor

Steroidogenic acute regulatory protein (StAR) regulates the first committed step in the biosynthesis of steroids, and thus aberrant expression of StAR in endometriotic implants plays a critical role in the etiology of endometriosis. However, the mechanism responsible for abnormal expression of StAR in ectopic endometriotic tissues remains unknown. In the present study, we demonstrate that prostaglandin (PG) E(2) stimulates StAR protein expression at the cellular and molecular levels. PGE(2) caused a rapid increase in StAR expression that involves activation of the EP2 receptor-coupled protein kinase A pathway. Activation of EP2 receptor-induced phosphorylation of ERK and cAMP response element binding protein (CREB). However, activation of ERK did not involve in CREB phosphorylation or concomitantly StAR expression. Phosphorylation of CREB induced by PGE(2) increased the recruitment of CREB binding protein and thus histone H3 acetylation. Chromatin immunoprecipitation experiments showed that acetylated histone H3 bound to the proximal region of the StAR promoter was increased after 30 min treatment with PGE(2), and this was mirrored by an increase in nascent StAR RNA transcription. Treatment with the histone deacetylase inhibitor, tricostatin A, enhanced PGE(2)-induced nascent StAR RNA transcription. We conclude that increased histone H3 acetylation involving the EP2 receptor, protein kinase A, CREB, and CREB binding protein is responsible for PGE(2)-induced StAR gene activation in endometriotic stromal cells. Our current report may provide new insights in understanding mechanism of abnormally local production of estrogen and the etiology of endometriosis.