Nickel Allergy Is a Risk Factor for Endometriosis: An 11-Year Population-Based Nested Case-Control Study

Holistic approaches to living well with endometriosis

Endometriosis is a common chronic non curable neuro-inflammatory condition, which can cause endometriosis-related pelvic pain (ERPP). Sufferers may struggle with side effects and/or risks from conventional medical and surgical treatments, or not get pain relief. Increasing numbers of endometriosis patients wish to explore holistic management with fewer side effects, however it is important that medical professionals maintain an evidence-based practice for recommended treatments. We present up-to-date evidence of holistic strategies used for managing ERPP including nutrition, body and mind therapies, acupuncture, traditional Chinese medicine (TCM) and the use of adjunct devices such as phallus length reducers and transcutaneous electrical nerve stimulation (TENS).

Recent findings

Nutrition: Gluten-free, low-nickel and high intake of omega-3 polyunsaturated fatty acids diets improve ERPP. Low FODMAP (fermentable oligo-, di-, monosaccharides and polyols), plant-based diet and antioxidant vitamin supplementation is helpful including those with concurrent irritable bowel syndrome. Body and Mind: Cognitive behaviour therapy (CBT) is beneficial in postoperative pain reduction, whilst mindfulness has been shown to reduce pain scores and dyschezia. Progressive muscle relaxation therapy and regular yoga sessions improve ERPP and Quality of life. Acupuncture: Acupuncture and moxibustion show improved pain scores compared to conventional therapies alone. Adjunct devices: TENS improves deep dyspareunia and reduces the number of days pain is experienced.

Summary

Holistic management strategies for ERPP should be incorporated into routine counselling when discussing conservative, medical and or surgical treatments for endometriosis. The growing evidence presented for the use of holistic management strategies gives hope to those patients who cannot have, or don't respond to conventional approaches and as an adjunct alongside standard treatments. These findings should be incorporated into the routine counselling when seeing patients in the gynaecology outpatient setting presenting with chronic pelvic pain.

Diet in Prevention and Treatment of Endometriosis: Current State of Knowledge

PURPOSE OF REVIEW

Endometriosis (EM) is a chronic gynecological disease that affects about 10% of women worldwide. It is characterized by the implantation of endometrial cells at ectopic sites. The most common symptom of EM is painful menstruation, which can often lead to chronic pelvic pain that significantly worsens the quality of life. Because some disease-related processes, such as inflammation, hormonal activity, menstrual cycle, or prostaglandin metabolism, can be modified by diet, nutrition may have a significant impact on development and treatment of EM. The purpose of this article was to overview the current knowledge regarding the dietary management of endometriosis.

RECENT FINDINGS

The attention of researchers has so far concentrated mainly on the role of nutrition in the risk of developing EM, while less attention has been paid to examining the use of diet in the treatment of the disease. Current studies focus primarily on various dietary components that have antiproliferative, anti-inflammatory, antioxidant, analgesic, and estrogen-lowering properties. Exploring different ways of coping with endometriosis can make a significant contribution to improving the quality of life of women at risk or diagnosed with EM.

How Can Selected Dietary Ingredients Influence the Development and Progression of Endometriosis?

Endometriosis is a chronic, hormone-dependent disease characterized by the presence of endometrial tissue in ectopic locations. Since the treatment options for this disease are still limited, and the cure rate is unsatisfactory, the search for ways to treat symptoms and modify the course of the disease is of key importance in improving the quality of life of patients with endometriosis. So far, the literature has shown that nutrition can influence endometriosis through hormonal modification and altering the inflammatory or oxidative response. Since the importance of nutrition in this disease is still a subject of scientific research, we aimed to summarize the current knowledge on the role of dietary modifications in endometriosis. Our review showed that nutrients with anti-inflammatory and antioxidant properties, including most vitamins and several trace elements, may influence the pathogenesis of endometriosis and can be considered as the nutrients preventing the development of endometriosis. However, despite the many discoveries described in this review, further interdisciplinary research on this topic seems to be extremely important, as in the future, it may result in the development of personalized therapies supporting the treatment of endometriosis.

Associations between endometriosis and allergy-related diseases as well as different specific immunoglobulin E allergy: A cross-sectional study

AIM

To explore the associations between endometriosis and different kinds of allergy-related diseases as well as different specific immunoglobulin E (IgE) allergy.

METHODS

This cross-sectional study included 1332 female participants ≥20 years and divided them into the endometriosis group (n = 97) and the nonendometriosis group (n = 1235). The confounders were obtained by comparing the differences of variables in groups. Univariate and multivariate logistic regression analyses were performed to analyze the associations between endometriosis and allergy-related diseases as well as different specific IgE allergy. Subgroup analysis were performed in age, body mass index (BMI), and pregnancy history.

RESULTS

After adjusting for confounders, increased risk of allergy (odd ratios [OR] = 2.13, 95% confidence interval [CI]: 1.31-3.47), hay fever (OR = 2.31, 95%CI: 1.32-4.06), and dog-specific IgE (OR = 2.13, 95%CI: 1.03-4.41) were observed in females with endometriosis. Among females aged between 30 and 39 years, the risk of allergy (OR = 3.51, 95%CI: 1.07-11.56), hay fever (OR = 3.26, 95%CI: 1.08-9.83), and dog-specific IgE (OR = 4.39, 95%CI: 1.02-18.88) was increased in patients with endometriosis compared with those without. In terms of females aged 40 to 49 years, the risk of hay fever was increased in patients with endometriosis. For females with BMI of 25-30 kg/m² , the risk of allergy was increased in patients with endometriosis. Increased risk of allergy, hay fever, and dog-specific IgE was observed in females with a history of pregnancy.

CONCLUSION

Endometriosis was associated with higher risk of allergy, hay fever, and dog dander. Special care should be provided for patients with endometriosis for the potential risk of allergy.

Transition metallo-curcumin complexes: a new hope for endometriosis?

Endometriosis is a debilitating gynecological disorder in women of reproductive age. Laparoscopy, a minimally invasive surgical procedure, provides a definitive diagnosis of the disease. Current treatments, including hormonal therapy and pain medication, are often associated with undesirable side effects limiting their long-term usage. This calls for exploring newer diagnostic and therapeutic options with minimal side effects. Curcumin is an established anti-endometriotic agent with inherent fluorescent properties; however, poor bioavailability limits its clinical utility. To address this shortcoming, various transition metals were conjugated with curcumin to improve its stability, specificity and pharmacological properties. The chemical stability, hemocompatibility and ability of the synthesized metallo-curcumin complexes (MCCs) to ameliorate endometriotic lesions were investigated. While all of the MCCs exhibited low hemolytic activity, their chemical and biological activities were largely dependent on the nature of the metal ion conjugated to the curcumin molecule. Copper-curcumin and nickel-curcumin complexes demonstrated superior therapeutic efficacy evidenced by enhanced antioxidant activity, selective cytotoxicity and increased accumulation in endometriotic cells mediated by an energy-dependent active transport process.

Correlation between Endometriosis and Selected Allergic and Autoimmune Diseases and Eating Habits

Background and Objectives: Endometriosis is a hormone-dependent chronic inflammatory disease with serious reproductive and general health consequences. It is viewed as a multifactorial problem, consisting of matters related to altered immunity and genetics. In this study, we determined the correlation between endometriosis and allergic and autoimmune diseases in patients at reproductive age. Materials and Methods: Online surveys distributed through websites related to gynecological problems. The questionnaire was composed of 63 single and multiple-choice questions concerning the course of endometriosis, diet, and allergic and autoimmune diseases. The obtained data were assessed using statistical tests. Results: 501 female patients (mean age 31.1 SD = 6.8) were included in the study. The control group (n = 155) consisted of healthy females, whereas the study group (n = 346) consisted of female patients with endometriosis; each group was subdivided according to allergy status. There were statistically significant differences between groups for the following: positive family history of endometriosis (p = 0.0002), onset of allergic symptoms (p = 0.0003), frequency and duration of abdominal pain (p = 0.00625), and defecation disorders (p = 0.0006). Asthma was less common in the study group (p = 0.00611). The group of patients with endometriosis and allergies had a high median of consumption of red meat (p = 0.0143), fish (p = 0.0016), and dairy products (p = 0.0001). Conclusions: Endometriosis did not affect autoimmune diseases and their courses. Patients with diagnosed endometriosis presented allergy symptoms much earlier than the healthy patients. The consumption of dietary products such as soya products, red meat, and alcohol had an influence on the occurrence of endometriosis.

Dienogest and the Risk of Reoperation in Endometriosis

Background: This retrospective cohort study aimed to determine whether there is a difference in reoperation rates between patients who used dienogest (DNG) and patients who did not use DNG. Methods: Using Health Insurance Review and Assessment Service (HIRA) data generated between 1 January 2010 and 30 June 2018, we identified women with an endometriosis diagnosis code who used GnRH agonists after gynecological surgery. Among them, women prescribed DNG were selected as the DNG group, and those who did not receive DNG were selected as the control group. A survival analysis of the reoperation between the two groups was performed. Results: DNG and control groups were extracted from 9735 people each. The reoperation rates were 0.4% and 0.6% in the DNG and control groups, respectively, without adjusting. In the Cox proportional risk analysis, DNG use increased the reoperation rate {hazard ratio (HR), 1.599; 95% confidence interval (CI), 1.005–2.545}. The site of endometriosis and the number of GnRH agonist injections were not associated with reoperation (HR, 1.008; 95% CI, 0.739–1.374; HR, 1.062; 95% CI, 0.690–1.635). In the subgroup survival analysis, according to the period between the last GnRH agonist injection and the first DNG dose, DNG did not increase the reoperation rates up to 9 months (~3 months: HR, 0.968; 95% CI, 0.551–1.699; 4~6 months: HR, 1.094; 95% CI, 0.58–2.063; 7~9 months: HR, 2.419; 95% CI, 0.735–7.962), but DNG increased the reoperation rate from 10 months onwards (10~12 months: HR, 3.826; 95% CI, 1.164–12.579 and ~13 months: HR, 8.436; 95% CI, 4.722–15.072). Conclusions: Women who used DNG had a higher endometriosis reoperation rate than women who did not use DNG. However, the initiation of DNG treatment within nine months after the last GnRH agonist injection did not affect the endometriosis reoperation rate.

Update of the risk assessment of nickel in food and drinking water

The European Commission asked EFSA to update its previous Opinion on nickel in food and drinking water, taking into account new occurrence data, the updated benchmark dose (BMD) Guidance and newly available scientific information. More than 47,000 analytical results on the occurrence of nickel were used for calculating chronic and acute dietary exposure. An increased incidence of post-implantation loss in rats was identified as the critical effect for the risk characterisation of chronic oral exposure and a BMDL 10 of 1.3 mg Ni/kg body weight (bw) per day was selected as the reference point for the establishment of a tolerable daily intake (TDI) of 13 μg/kg bw. Eczematous flare-up reactions in the skin elicited in nickel-sensitised humans, a condition known as systemic contact dermatitis, was identified as the critical effect for the risk characterisation of acute oral exposure. A BMDL could not be derived, and therefore, the lowest-observed-adverse-effect-level of 4.3 μg Ni/kg bw was selected as the reference point. The margin of exposure (MOE) approach was applied and an MOE of 30 or higher was considered as being indicative of a low health concern. The mean lower bound (LB)/upper bound (UB) chronic dietary exposure was below or at the level of the TDI. The 95th percentile LB/UB chronic dietary exposure was below the TDI in adolescents and in all adult age groups, but generally exceeded the TDI in toddlers and in other children, as well as in infants in some surveys. This may raise a health concern in these young age groups. The MOE values for the mean UB acute dietary exposure and for the 95th percentile UB raises a health concern for nickel-sensitised individuals. The MOE values for an acute scenario regarding consumption of a glass of water on an empty stomach do not raise a health concern.

Irritable Bowel Syndrome-Like Disorders in Endometriosis: Prevalence of Nickel Sensitivity and Effects of a Low-Nickel Diet. An Open-Label Pilot Study

Alimentary nickel (Ni) may result in allergic contact mucositis (ACM), whose prevalence is >30% and may present with IBS-like and extra-intestinal symptoms. These symptoms are also frequent in endometriosis, and Ni allergic contact dermatitis has already been observed in endometriosis. Therefore, intestinal and extra-intestinal symptoms in endometriosis may depend on a Ni ACM, and a low-Ni diet could improve symptoms. We studied the prevalence of Ni ACM in endometriosis and focused on the effects of a low-Ni diet on gastrointestinal, extra-intestinal, and gynecological symptoms. We recruited 84 women with endometriosis, symptomatic for gastrointestinal disorders. Thirty-one out of 84 patients completed the study. They underwent Ni oral mucosa patch test (omPT), questionnaire for intestinal/extra-intestinal/gynecological symptoms, and a low-Ni diet. Clinical evaluation was performed at baseline (T0) and after three months (T1). Twenty-eight out 31 (90.3%) patients showed Ni omPT positive results, with Ni ACM diagnosis, whereas three out of 31 (9.7%) patients showed negative Ni omPT. After three months of low-Ni diet, all gastrointestinal, extra-intestinal and gynecological symptoms showed a statistically significant reduction. Ni ACM has a high prevalence in endometriosis and a low-Ni diet may be recommended in this condition to reduce gastrointestinal, extra-intestinal and gynecological symptoms.

Nickel allergy in lipid transfer protein sensitized patients: Prevalence and clinical features

Nickel (Ni), the main responsible for allergic contact dermatitis worldwide, is also involved in systemic condition called "Systemic Nickel Sulfate Allergy Syndrome (SNAS)." Likewise, IgE-mediated reactivity to Lipid Transfer Protein (LTP) represents the main cause of primary food allergy in adults of Mediterranean countries. We evaluated the prevalence of SNAS in LTP allergic patients and investigated patients' clinical features with double sensitization (LTP and Ni). A retrospective, single-center, observational study was conducted performing a complete allergological work-up including: (1) skin prick tests; (2) serum specific IgE for plant food allergens and rPru p3 (LTP); (3) patch test with 5% Ni sulfate in petrolatum. We enrolled 140 LTP allergic patients of which 36 patients (25.7% of sample) showed additional positivity to Ni patch test. Patients with double sensitization were more frequently females and reported fewer cutaneous symptoms. Higher values of sIgE for peach, apple, peanut, walnut, grain, corn, and garlic were found in LTP allergic patients, while higher values for hazelnut in the other subgroup. The prevalence of SNAS in the LTP allergic population is clinically relevant. Moreover, the clinical and immunological profiles of patients with double sensitization were different from patients monosensitized to LTP.

Knockdown of vascular cell adhesion molecule 1 impedes transforming growth factor beta 1-mediated proliferation, migration, and invasion of endometriotic cyst stromal cells

PURPOSE

Endometriosis is one of the most common, difficult, and complicated gynecological disorders. Vascular cell adhesion molecule 1 (VCAM-1) has been reported to be aberrantly expressed in patients with endometriosis. However, the exact role and mechanism of VCAM-1 in endometriosis remains unclear.

METHODS

The expression of transforming growth factor beta 1 (TGF-β1) and VCAM-1 was determined by quantitative real-time polymerase chain reaction and western blotting. Human endometriotic cells were cultured and their responsiveness to TGF-β1 was evaluated by Cell Counting Kit-8, 5-ethynyl-2'-deoxyuridine, and transwell migration and invasion assays.

RESULTS

The levels of TGF-β1 and VCAM-1 mRNA were upregulated in the endometriotic tissues. Knockdown of TGF-β1 in endometriotic cyst stromal cells caused a marked inhibition of cell proliferation, migration, and invasion. Treatment of endometriotic cyst stromal cells with TGF-β1 resulted in an obvious promotion of cell proliferation, migration, and invasion, and strikingly increased the protein expression of VCAM-1. Silencing of Smad3 abated TGF-β1-stimulated VCAM-1 expression. Furthermore, the promoting effects of TGF-β1 on the proliferation, migration, and invasion of endometriotic cyst stromal cells were blocked by silencing of VCAM-1.

CONCLUSION

Knockdown of VCAM-1 impedes TGF-β1-mediated proliferation, migration, and invasion of endometrial cells, thereby indicating that VCAM-1 may serve as a therapeutic target for endometriosis.

Suppressive regulatory T cells and latent transforming growth factor-β-expressing macrophages are altered in the peritoneal fluid of patients with endometriosis

BACKGROUND

Endometriosis is a known cause of infertility. Differences in immune tolerance caused by regulatory T cells (Tregs) and transforming growth factor-β (TGF-β) are thought to be involved in the pathology of endometriosis. Evidence has indicated that Tregs can be separated into three functionally and phenotypically distinct subpopulations and that activated TGF-β is released from latency-associated peptide (LAP) on the surfaces of specific cells. The aim of this study was to examine differences in Treg subpopulations and LAP in the peripheral blood (PB) and peritoneal fluid (PF) of patients with and without endometriosis.

METHODS

PB and PF were collected from 28 women with laparoscopically and histopathologically diagnosed endometriosis and 20 disease-free women who were subjected to laparoscopic surgery. Three subpopulations of CD4⁺ T lymphocytes (CD45RA⁺FoxP3^low resting Tregs, CD45RA^-FoxP3^high effector Tregs, and CD45RA^-FoxP3^low non-Tregs) and CD11b⁺ mononuclear cells expressing LAP were analyzed by flow cytometry using specific monoclonal antibodies.

RESULTS

Proportions of suppressive Tregs (resting and effector Tregs) were significantly higher in the PF samples of patients with endometriosis than in those of control women (P = 0.02 and P < 0.01, respectively) but did not differ between the PB samples of patients and controls. The percentage of CD11b⁺LAP⁺ macrophages was significantly lower in PF samples of patients with endometriosis than in those of controls (P < 0.01) but was not altered in the PB samples.

CONCLUSION

Proportions of suppressive Tregs and LAP⁺ macrophages are altered locally in the PF of endometriosis patients.

Nickel-resistant bacteria isolated in human microbiome

Nickel-resistant bacteria have been isolated so far only in contaminated soils and wastewaters polluted with different industrial sources. The aim of our study was to determine if nickel-resistant bacteria could also be isolated from human samples. In this brief communication, we describe how we were able to isolate human bacterial strains that grew without oxygen and in the presence of high concentrations of nickel. The identification was made by phenotypic and genetic techniques. The bacterial sequences have been deposited in the NCBI database repository. Our finding shows that there are several different heavy-metal-tolerant bacteria in humans that should be considered for further studies.