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Shafrir AL, Mu F, Eliassen AH, Thombre Kulkarni M, Terry KL, Hankinson SE, Missmer SA. Endogenous Steroid Hormone Concentrations and Risk of Endometriosis in Nurses' Health Study II. Am J Epidemiol 2023; 192:573-586. [PMID: 36562714 PMCID: PMC10404067 DOI: 10.1093/aje/kwac219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/14/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
Few studies have assessed the association between endogenous steroid hormone levels and a subsequent diagnosis of endometriosis. We prospectively evaluated premenopausal plasma sex hormone levels and the risk of laparoscopically confirmed endometriosis in a nested case-control study within Nurses' Health Study II. Between blood collection (1996-1999) and 2009, we ascertained 446 women with incident endometriosis and matched them to 878 controls through risk-set sampling. We conducted multivariable conditional logistic regression accounting for matching and confounders to estimate relative risks (RRs) and 95% confidence intervals (CIs). Women with greater early follicular-phase total or free estradiol levels had a nonlinear increased risk of endometriosis (early follicular total estradiol: second quartile vs. first, RR = 2.23 (95% CI: 1.44, 3.47); third quartile, RR = 1.83 (95% CI: 1.16, 2.88); fourth quartile, RR = 1.68 (95% CI: 1.05, 2.68); early follicular free estradiol: second quartile vs. first, RR = 1.63 (95% CI: 1.05, 2.54); third quartile, RR = 2.02 (95% CI: 1.31, 3.12); fourth quartile, RR = 1.04 (95% CI: 0.66, 1.65)). Free testosterone assessed in quartile categories was not associated with endometriosis, although a threshold effect was observed, with a positive association among women in the top 2% of free testosterone levels. Levels of mid-luteal-phase total and free estradiol, follicular and luteal estrone, total testosterone, progesterone, and sex hormone binding globulin were not associated with endometriosis risk. These results support the role of sex steroids in endometriosis etiology, although the relationships suggest complex threshold effects.
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Affiliation(s)
- Amy L Shafrir
- Correspondence to Dr. Amy Shafrir, Division of Adolescent/Young Adult Medicine, Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, 1 Autumn Street, 5th Floor, Boston, MA 02115 (e-mail: )
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Hager M, Wenzl R, Riesenhuber S, Marschalek J, Kuessel L, Mayrhofer D, Ristl R, Kurz C, Ott J. The Prevalence of Incidental Endometriosis in Women Undergoing Laparoscopic Ovarian Drilling for Clomiphene-Resistant Polycystic Ovary Syndrome: A Retrospective Cohort Study and Meta-Analysis. J Clin Med 2019; 8:jcm8081210. [PMID: 31416144 PMCID: PMC6722764 DOI: 10.3390/jcm8081210] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022] Open
Abstract
To evaluate the incidence of endometriosis in polycystic ovary syndrome (PCOS) patients who did not present with any endometriosis symptoms and underwent laparoscopic ovarian drilling (LOD) for clomiphene citrate (CC) resistance, 225 and 630 women with CC-resistant PCOS without classic endometriosis symptoms were included in a retrospective study and a meta-analysis, respectively. All women underwent LOD. The main outcome parameter was the prevalence of incidental endometriosis. Laparoscopy revealed endometriosis in 38/225 (16.9%) women (revised American Fertility Society (rAFS) stage I: 33/38, 86.8%; rAFS stage II: 5/38, 13.2%). When women with CC-resistant PCOS without endometriosis were compared, lower body mass index (BMI) and lower 25-hydroxy-vitamin D levels were associated with the presence of endometriosis at laparoscopy (odds ratios (OR): 0.872, 95% confidence intervals (95%CI): 0.792–0.960; p = 0.005 and OR: 0.980, 95%CI: 0.962–0.999; p = 0.036; respectively). The inclusion criteria for the meta-analysis were fulfilled by 4/230 reports about LOD. After correction for study heterogeneity, the pooled prevalence of incidental endometriosis was 7.7% in women with CC-resistant PCOS. In conclusion, the rate of incidental endometriosis in women with CC-resistant PCOS might reflect the prevalence of asymptomatic endometriosis. All cases were affected by minimal or mild disease. Since the literature lacks reports on associated clinical outcomes, the relevance of this entity in such patients should be the subject of further studies.
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Affiliation(s)
- Marlene Hager
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - René Wenzl
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Oncology and General Gynecology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Sonja Riesenhuber
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Julian Marschalek
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Lorenz Kuessel
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Oncology and General Gynecology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Daniel Mayrhofer
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Robin Ristl
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Christine Kurz
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Johannes Ott
- Department of Obstetrics and Gynecology, Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria.
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Ono YJ, Tanabe A, Nakamura Y, Yamamoto H, Hayashi A, Tanaka T, Sasaki H, Hayashi M, Terai Y, Ohmichi M. A low-testosterone state associated with endometrioma leads to the apoptosis of granulosa cells. PLoS One 2014; 9:e115618. [PMID: 25536335 PMCID: PMC4275210 DOI: 10.1371/journal.pone.0115618] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 11/27/2014] [Indexed: 01/15/2023] Open
Abstract
Although endometriosis is suspected to be a cause of premature ovarian insufficiency (POI), the mechanism(s) underlying this process have not been elucidated. Recently, androgens were shown to promote oocyte maturation and to play a role in folliculogenesis. In addition, several reports have documented low testosterone levels in the follicular fluid obtained from endometriosis patients. We therefore examined whether the low levels of serum testosterone are associated with the apoptosis of granulosa cells in follicles obtained from endometriosis patients. Serum samples were collected from 46 patients with endometriosis and from 62 patients without endometriosis who received assisted reproductive therapy. Specimens of the ovaries obtained from 10 patients with endometrioma were collected using laparoscopy. The mean serum testosterone concentration in the patients with endometriosis was significantly lower than that observed in the patients without endometriosis. Furthermore, high expression of a pro-apoptotic Bcl-2 member, BimEL, in the follicles was found to be associated with a low serum testosterone level. We clarified the underlying mechanisms using a basic approach employing human immortalized granulosa cells derived from a primary human granulosa cell tumor, the COV434 cell line. The in vitro examination demonstrated that testosterone inhibited apoptosis induced by sex steroids depletion via the PI3K/Akt-FoxO3a pathway in the COV434 cells. In conclusion, we elucidated the mechanism underlying the anti-apoptotic effects of testosterone on granulosa cells, and found that a low-testosterone status is a potentially important step in the development of premature ovarian insufficiency in patients with endometriosis.
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Affiliation(s)
- Yoshihiro J. Ono
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Akiko Tanabe
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
- * E-mail:
| | - Yoko Nakamura
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Hikaru Yamamoto
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Atsushi Hayashi
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Tomohito Tanaka
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Hiroshi Sasaki
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Masami Hayashi
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Yoshito Terai
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Masahide Ohmichi
- Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
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