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Gök F, Ekin S, Karaman E, Erten R, Yıldız D, Bakır A. Total Sialic Acid, Antioxidant Enzyme Activities, Trace Elements, and Vitamin Status Before and After Surgery in Women with Uterine Myoma and Endometrial Cancer. Reprod Sci 2023; 30:2743-2757. [PMID: 37069473 DOI: 10.1007/s43032-023-01241-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
The objective of present study was to examine endometrial tissue Be, As, Cr, Mo, Sr, Ti, Tl, Cu, Co, Se, Zn, Mn, Fe, Cd, Pb, Mg, P, erythrocytes CAT, SOD, GSH-Px, GSH, MDA, serum retinol, cholecalciferol, phylloquinone, TSA, LSA, TOS, and TAS status and to evaluate the relationships between the variables. The study had 110 participants; of these, 50 were women with uterine myoma (UM), 10 were women with endometrial cancer (EC), and 50 were healthy female subjects. In the study, vitamin analyses by HPLC and element analyses were determined using ICP-OES method. It was observed that EC group was significantly lower than healthy group in terms of levels of cholecalciferol (p < 0.05), phylloquinone (p < 0.01), GSH (p < 0.05), Fe (p < 0.05), and had a significant rise in Mg/Fe (p < 0.01) and Zn/Fe (p < 0.05) in preoperative period. UM group had significantly lower retinol (p < 0.05), phylloquinone (p < 0.001), GSH-Px (p < 0.01), GSH (p < 0.01), Cr (p < 0.01), Cu (p < 0.05), Mg (p < 0.01), and Zn (p < 0.01) levels than control group in preoperative period and significantly higher levels of MDA (p < 0.01), TSA (p < 0.01), and LSA (p < 0.01) than control group. It was found that significant associations were observed between Cu-CA 15-3 (r = 0.558, p = 0.016), Mn-CA 15-3 (r = 0.511, p = 0.030), P-CA 15-3(r = - 0.502, p = 0.034) and with UM, also between GSH-CA-125 (r = - 0.825, p = 0.022) and with EC group. The results of correlation analysis observed that concentrations of Cu, Mn, P, and GSH together with CA 15-3 and CA-125 levels might be important for monitoring patients with UM and EC before surgery.
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Affiliation(s)
- Fazilet Gök
- Department of Chemistry, Division of Biochemistry, Institute of Natural and Applied Sciences, Van Yuzuncu Yil University, Van, Turkey
| | - Suat Ekin
- Department of Chemistry, Division of Biochemistry, Science Faculty, Van Yuzuncu Yil University, Van, Turkey.
| | - Erbil Karaman
- Department of Gynecology and Obstetrics, Division of Gynecological Oncology, Van Yuzuncu Yil University, Van, Turkey
| | - Remzi Erten
- Department of Medical Pathology, Van Yuzuncu Yil University, Van, Turkey
| | - Damla Yıldız
- Department of Chemistry, Division of Biochemistry, Institute of Natural and Applied Sciences, Van Yuzuncu Yil University, Van, Turkey
| | - Ahmet Bakır
- Department of Chemistry, Division of Biochemistry, Institute of Natural and Applied Sciences, Van Yuzuncu Yil University, Van, Turkey
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Guo X, Li N, Wang H, Su W, Song Q, Liang Q, Liang M, Sun C, Li Y, Lowe S, Bentley R, Song EJ, Zhou Q, Ding X, Sun Y. Combined exposure to multiple metals on cardiovascular disease in NHANES under five statistical models. ENVIRONMENTAL RESEARCH 2022; 215:114435. [PMID: 36174761 DOI: 10.1016/j.envres.2022.114435] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/13/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND It is well-documented that heavy metals are associated with cardiovascular disease (CVD). However, there is few studies exploring effect of metal mixture on CVD. Therefore, the primary objective of present study was to investigate the joint effect of heavy metals on CVD and to identify the most influential metals in the mixture. METHODS Original data for study subjects were obtained from the National Health and Nutrition Examination Survey. In this study, adults with complete data on 12 kinds of urinary metals (antimony, arsenic, barium, cadmium, cobalt, cesium, molybdenum, mercury, lead, thallium, tungsten, and uranium), cardiovascular disease, and core covariates were enrolled. We applied five different statistical strategies to examine the CVD risk with metal exposure, including multivariate logistic regression, adaptive elastic net combined with Environmental Risk Score, Quantile g-computation, Weighted Quantile Sum regression, and Bayesian kernel machine regression. RESULTS Higher levels of cadmium, tungsten, cobalt, and antimony were significantly associated with Increased risk of CVD when covariates were adjusted for multivariate logistic regression. The results from multi-pollutant strategies all indicated that metal mixture was positively associated with the risk of CVD. Based on the results of multiple statistical strategies, it was determined that cadmium, tungsten, cobalt, and antimony exhibited the strongest positive correlations, whereas barium, lead, molybdenum, and thallium were most associated with negative correlations. CONCLUSION Overall, our study demonstrates that exposure to heavy metal mixture is linked to a higher risk of CVD. Meanwhile, this association may be driven primarily by cadmium, tungsten, cobalt, and antimony. Further prospective studies are warranted to validate or refute our primary findings as well as to identify other important heavy metals linked with CVD.
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Affiliation(s)
- Xianwei Guo
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Ning Li
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Hao Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Wanying Su
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Qiuxia Song
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Qiwei Liang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Mingming Liang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Chenyu Sun
- AMITA Health Saint Joseph Hospital Chicago, 2900 N. Lake Shore Drive, Chicago, IL, 60657, USA
| | - Yaru Li
- Internal Medicine, Swedish Hospital, 5140 N California Ave, Chicago, IL, 60625, USA
| | - Scott Lowe
- College of Osteopathic Medicine, Kansas City University, 1750 Independence Ave, Kansas City, MO, 64106, USA
| | - Rachel Bentley
- College of Osteopathic Medicine, Kansas City University, 1750 Independence Ave, Kansas City, MO, 64106, USA
| | - Evelyn J Song
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Qin Zhou
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Xiuxiu Ding
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China
| | - Yehuan Sun
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, PR China; Chaohu Hospital, Anhui Medical University, Hefei, 238006, Anhui, PR China.
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Aendo P, Mingkhwan R, Senachai K, Santativongchai P, Thiendedsakul P, Tulayakul P. Health significant alarms of toxic carcinogenic risk consumption of blood meal metals contamination in poultry at a gold mining neighborhood, northern Thailand. ENVIRONMENTAL GEOCHEMISTRY AND HEALTH 2022; 44:783-797. [PMID: 34057663 DOI: 10.1007/s10653-021-00971-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 05/06/2021] [Indexed: 06/12/2023]
Abstract
The proposes of this study were to compare THg (total mercury), Pb(Lead), Cd(Cadmium), and Mn (Manganese) contamination in poultry blood between polluted areas (≤ 25 km) and unpolluted areas (> 25 km) adjacent to the largest gold mining in northern Thailand. The THg level in the free-grazing duck in polluted areas was significantly higher than unpolluted area. Both THg and Pb levels in free-grazing duck were also highest in polluted areas. In contrast, the level of (Mn) in chicken blood was the highest in polluted areas. Cadmium in farmed duck from polluted areas was significantly higher than unpolluted areas. The target hazard quotient (THQ) and hazard index (HI) of Hg, Pb, Cd, and Mn in all age groups in both areas did not exceed 1, meaning there is no possibility of the non-carcinogenic toxicity. Whereas, the incremental lifetime cancer risk (ILCR) of both Pb and Cd exceeded 1 × 10-4 in all age groups and these were particularly higher in the polluted area and considered to yield significant health effects of increasing the cancer risk. The ILCR in descending order for Pb and Cd was 13-18 years old = 18-35 years old > 6-13 years old = 35-65 years old > 3-6 years old > 65 up years old, respectively. The results revealed that the human cancer risk related to consuming poultry blood contaminated with both Pb and Cd in all age groups must be of concern, especially 13-18 and 18-35 years, it must be recommended to avoid raising animals in contaminated areas, especially free-grazing duck.
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Affiliation(s)
- Paweena Aendo
- Graduate Student, Animal Health and Biomedical Science, Faculty of Veterinary Medicine, Kasetsart University, Bangkok, 10900, Thailand
| | - Rachaneekorn Mingkhwan
- Department of Social and Environmental Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | | | - Pitchaya Santativongchai
- Bio-Veterinary Sciences (International Program), Faculty of Veterinary Medicine, Kasetsart University, Bangkok, 10900, Thailand
| | - Piriyaporn Thiendedsakul
- Faculty of Veterinary Medicine, Animal Health and Biomedical Science, Kasetsart University, Bangkok, 10900, Thailand
| | - Phitsanu Tulayakul
- Department of Veterinary Public Health, Faculty of Veterinary Medicine, Kasetsart University Kamphaeng Saen Campus, Nakhon Pathom, 73140, Thailand.
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Cadmium-Related Effects on Cellular Immunity Comprises Altered Metabolism in Earthworm Coelomocytes. Int J Mol Sci 2020; 21:ijms21020599. [PMID: 31963425 PMCID: PMC7013597 DOI: 10.3390/ijms21020599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
The heavy metal cadmium (Cd) is known to modulate the immune system, challenging soil-dwelling organisms where environmental Cd pollution is high. Since earthworms lack adaptive immunity, we determined Cd-related effects on coelomocytes, the cellular part of innate immunity, which is also the site of detoxification processes. A proteomics approach revealed a set of immunity-related proteins as well as gene products involved in energy metabolism changing in earthworms in response to Cd exposure. Based on these results, we conducted extracellular flux measurements of oxygen and acidification to reveal the effect of Cd on coelomocyte metabolism. We observed a significantly changing oxygen consumption rate, extracellular acidification, as well as metabolic potential, which can be defined as the response to an induced energy demand. Acute changes in intracellular calcium levels were also observed, indicating impaired coelomocyte activation. Lysosomes, the cell protein recycling center, and mitochondrial parameters did not change. Taken together, we were able to characterize coelomocyte metabolism to reveal a potential link to an impaired immune system upon Cd exposure.
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Seifalinezhad A, Bahreini M, Hassani Matin MM, Tavassoli SH. Feasibility Study on Discrimination of Neo-plastic and Non-Neoplastic Gastric Tissues Using Spark Discharge Assisted Laser Induced Breakdown Spectroscopy. J Lasers Med Sci 2018; 10:64-69. [PMID: 31360371 DOI: 10.15171/jlms.2019.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction: The present work is a novel in vitro study that evaluated the possibility of diagnosing neoplastic from nonneoplastic gastric tissues using spark discharge assisted laser induced breakdown spectroscopy (SD-LIBS) method. Methods: In these experiments, the low energy laser pulses ablated a tiny amount of tissue surface leading to plasma formation. Then, a spark discharge was applied to plasma in order to intensify the plasma radiation. Light emission from plasma was recorded as spectra which were analyzed. Gastric tissues of 5 people were studied through this method. Results: The SD-LIBS technique had the potential to discriminate normal and cancerous tissues based on the significant differences in the intensities of some particular elements. The comparison of normalized calcium (Ca) and magnesium (Mg) peaks of neoplastic and nonneoplastic gastric tissues could be viewed as a practical measure for tissue discrimination since Ca and Mg peaks in spectra of neoplastic were noticeably higher than nonneoplastic. Conclusion: Considering the identification of gastric cancer, the applied method in these experiments seems quite fast, noninvasive and cost-effective with respect to other conventional methods. The significant increment of specific Ca and Mg lines of neoplastic gastric tissues in comparison to the nonneoplastic ones can be considered as valuable information that might bring about tissue classification. The number of samples in this work, however, was not sufficient for a decisive conclusion and further researches is needed to generalize this idea.
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Affiliation(s)
- Aida Seifalinezhad
- Laser and Plasma Research Institute, Shahid Beheshti University, G. C., Tehran, Iran
| | - Maryam Bahreini
- Laser Application in Medical Sciences Research Center (LAMSRC), Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Hazrat-e Masoumeh University, Qom, Iran
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Wang X, Dong F, Wang F, Yan S, Chen X, Tozawa H, Ushijima T, Kapron CM, Wada Y, Liu J. Low dose cadmium upregulates the expression of von Willebrand factor in endothelial cells. Toxicol Lett 2018; 290:46-54. [PMID: 29571895 DOI: 10.1016/j.toxlet.2018.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 03/01/2018] [Accepted: 03/18/2018] [Indexed: 11/17/2022]
Abstract
Cadmium (Cd) is a persistent and widespread environmental pollutant of continuing worldwide concern. Previous studies have suggested that Cd exposure increases the risk of cardiovascular diseases, such as atherosclerosis and hypertension. However, the underlying mechanisms are poorly understood. In this study, we observed that low dose Cd treatment induced von Willebrand factor (vWF) expression in vascular endothelial cells in mouse lung and kidney tissues. In vitro analysis showed that 1 μM Cd specifically upregulated vWF mRNA and protein expression in human umbilical vein endothelial cells (HUVECs), indicating that Cd targets vascular endothelial cells even at relatively low concentrations. Further study demonstrated that nuclear factor kappa B (NF-κB) and GATA3, two established transcription regulators of the vWF gene, were not altered in the presence of Cd. However, ETS-related gene (ERG) was significantly induced by 1 μM Cd. When ERG was knocked down by siRNA, Cd induced upregulation of vWF was totally blocked. Chromatin immunoprecipitation (ChIP) assay showed that Cd increases the binding of ERG on the -56 ETS motif on the human vWF promoter. These results indicated that ERG mediated the increased expression of vWF by Cd. Since vWF is a key regulator for vascular homeostasis, our findings may provide a novel mechanism for understanding low dose Cd induced development of vascular diseases.
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Affiliation(s)
- Xia Wang
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, Shandong, 250014, China
| | - Fengyun Dong
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, Shandong, 250014, China
| | - Fufang Wang
- Department of Geriatrics, Qilu Hospital of Shandong University, 107 Wenhua Xi Road, Jinan, Shandong, China; Key laboratory of Cardiovascular Proteomics of Shandong Province, 107 Wenhua Xi Road, Jinan, Shandong, China
| | - Suhua Yan
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, Shandong, 250014 China
| | - Xiaocui Chen
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, Shandong, 250014, China
| | - Hideto Tozawa
- The Research Center for Advanced Science and Technology, and Isotope Science Center, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8904, Japan
| | - Toshiyuki Ushijima
- The Research Center for Advanced Science and Technology, and Isotope Science Center, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8904, Japan
| | - Carolyn M Kapron
- Department of Biology, Trent University, Peterborough, Ontario, K9L 0G2, Canada
| | - Youichiro Wada
- The Research Center for Advanced Science and Technology, and Isotope Science Center, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo 153-8904, Japan
| | - Ju Liu
- Laboratory of Microvascular Medicine, Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, 16766 Jingshi Road, Jinan, Shandong, 250014, China.
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Activity of MPF and expression of its related genes in mouse MI oocytes exposed to cadmium. Food Chem Toxicol 2017; 112:332-341. [PMID: 29287790 DOI: 10.1016/j.fct.2017.12.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 12/05/2017] [Accepted: 12/22/2017] [Indexed: 11/20/2022]
Abstract
Research has revealed that cadmium can disrupt ovarian function; however, few reports have focused on MI oocytes meiotic progression, especially the activity of maturation promoting factor (MPF) and its related genes (Cdk1, Ccnb1, and Cdc25b) expression. In this study, GV oocytes cultured in vitro for 0, 6, and 9 hours with five groups (control and doses of 0.05, 0.5, 2.5, and 5 μM Cd). At the same dose of cadmium but different exposure time: compared with 0h, Periodic changes in MPF activity were changed and continuously increased over time. The mRNA and protein expression of each MPF-related gene in different cadmium dose groups were changed compared with that of 0h. At the same exposure time but different dose of cadmium: compared with control group, MPF activity, mRNA and protein expressions of each MPF-related gene in all the cadmium exposure groups were increased at 9h after exposure. Cadmium maintains the high MPF activity in mouse MI oocytes during its meiotic process and disturbs the periodic change of MPF activity; meanwhile, cadmium exposure promotes the syntheses of MPF-related gene, which may be one of the molecular mechanisms for the maintenance of high MPF activity, and ultimately prevents the meiotic progression in oocytes.
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Wei R, De Vivo I, Huang S, Zhu X, Risch H, Moore JH, Yu H, Garmire LX. Meta-dimensional data integration identifies critical pathways for susceptibility, tumorigenesis and progression of endometrial cancer. Oncotarget 2016; 7:55249-55263. [PMID: 27409342 PMCID: PMC5342415 DOI: 10.18632/oncotarget.10509] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 05/02/2016] [Indexed: 11/25/2022] Open
Abstract
Endometrial Cancer (EC) is one of the most common female cancers. Genome-wide association studies (GWAS) have been investigated to identify genetic polymorphisms that are predictive of EC risks. Here we utilized a meta-dimensional integrative approach to seek genetically susceptible pathways that may be associated with tumorigenesis and progression of EC. We analyzed GWAS data obtained from Connecticut Endometrial Cancer Study (CECS) and identified the top 20 EC susceptible pathways. To further verify the significance of top 20 EC susceptible pathways, we conducted pathway-level multi-omics analyses using EC exome-Seq, RNA-Seq and survival data, all based on The Cancer Genome Atlas (TCGA) samples. We measured the overall consistent rankings of these pathways in all four data types. Some well-studied pathways, such as p53 signaling and cell cycle pathways, show consistently high rankings across different analyses. Additionally, other cell signaling pathways (e.g. IGF-1/mTOR, rac-1 and IL-5 pathway), genetic information processing pathway (e.g. homologous recombination) and metabolism pathway (e.g. sphingolipid metabolism) are also highly associated with EC risks, diagnosis and prognosis. In conclusion, the meta-dimensional integration of EC cohorts has suggested some common pathways that may be associated from predisposition, tumorigenesis to progression.
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Affiliation(s)
- Runmin Wei
- Molecular Biosciences and Bioengineering Graduate Program, University of Hawaii at Manoa, Honolulu, HI, USA
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | | | - Sijia Huang
- Molecular Biosciences and Bioengineering Graduate Program, University of Hawaii at Manoa, Honolulu, HI, USA
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Xun Zhu
- Molecular Biosciences and Bioengineering Graduate Program, University of Hawaii at Manoa, Honolulu, HI, USA
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Harvey Risch
- Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Jason H. Moore
- Institute for Biomedical Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Herbert Yu
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
| | - Lana X. Garmire
- Molecular Biosciences and Bioengineering Graduate Program, University of Hawaii at Manoa, Honolulu, HI, USA
- Epidemiology Program, University of Hawaii Cancer Center, Honolulu, HI, USA
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Kim TH, Lee HH. Uterine leiomyoma research. KOSIN MEDICAL JOURNAL 2015. [DOI: 10.7180/kmj.2015.30.1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Uterine leiomyoma is the most common type of benign tumor in women of reproductive age. This disease is rare before menarche, and its incidence decreases after menopause. Uterine leiomyoma is known to be related to hormonal changes, but the precise underlying mechanism has yet to be determined. Although it is a benign disease, the most common form of management involves surgical intervention. Uterine leiomyoma is also related to infertility and obstetric complications. Here, we present a review of the literature regarding uterine leiomyoma and discuss management of this disease.
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