Different HLA-DR expression in endometriotic and adenomyotic lesions: correlation with transvaginal ultrasonography findings.

OBJECTIVE: Human leukocyte antigen-DR (HLA-DR) has been implicated in eutopic and ectopic glandular epithelial cells in endometriosis. We investigated the expression of HLA-DR in endometriotic and adenomyotic tissues within the stromal and glandular cells. Moreover, we correlate the HLA-DR expression according the transvaginal ultrasonography findings. METHODS: We studied operative and pathologic reports of 113 women who underwent laparoscopic or laparotomy treatment of endometrioma or adenomyosis. Tissues from 51 women with endometrioma and 62 women with adenomyosis were retrospectively evaluated. The distribution and intensity of the HLA-DR immunostaining was assessed using electron microscopy. Pathologic finding of the uterine junction zone and the size of endometrioma were evaluated with the laparoscopic results and the ultrasound findings. RESULTS: In adenomyosis tissues, the percentage of HLA-DR cells expression was significantly higher in stromal cells (83.9%) compared to glandular cells (25.8%), (p<0.001). The number of HLA-DR-positive endometriotic glandular cells was significantly higher than the total glandular adenomyotic cells (p<0.005). HLA-DR-positive cells was significantly different between stromal (p<0.016) and glandular cells (p<0.044) in each side of endometrioma. Finally, HLA-DR-positive percentage cells were significantly more frequent in the secretory phase than the proliferative in stromal and glandular cells in both groups. CONCLUSION: HLA-DR antigen expression in endometrium and adenomyotic tissues. However, HLA-DR expression is distributed preferentially in glandular epithelial cells in endometrioma and in the adenomyotic stroma. In both groups the HLA-DR expression was significantly higher in the secretory phase than the proliferative or glandular and stroma cells. Larger perspective studies are needed to establish the expression of HLA antigens in immune reactions which occur in adenomyosis and endometriosis.

Constitutive or induced elevated levels of L-carnitine correlate with the cytokine and cellular profile of endometriosis.

During the past decade, accumulated evidence indicates an association between endometriosis and an alteration of humoral and cell-mediated immunity. While the role of L-carnitine in the regulation of energy metabolism is well established, it is only recently that L-carnitine has been recognized to modify the immune response in mice after in vitro or in vivo treatment. The present study has examined whether administration of L-carnitine to young female mice alters the percentage of immune cells in peritoneal exudates and the uterus as well as the levels of IFN-gamma, TNF-alpha, IL-2, IL-4, IL-6, VEGF, GM-CSF and IGF-I in blood serum, peritoneal fluid and supernatants of uterine cultured cells as tested by immunofluorescence or ELISA techniques, respectively, leading to a pathological disorder resembling human endometriosis. The results showed that, except from infertility, L-carnitine treatment resulted in a significant increase of macrophages and to a lesser degree an increase of T-cells, while elevated levels of IFN-gamma and TNF-alpha were detected in both serum and peritoneal fluid compared to controls. Although levels of L-carnitine measured in mouse serum samples using a radioisotopic method showed an increase as compared to controls, levels of acyl-L-carnitine measured in the murine peritoneal fluid samples showed a decrease similar to that measured in peritoneal fluid samples from patients with endometriosis in stage IV of the disease. These results indicate that L-carnitine administration to female mice alters the cellular and growth factor profile in the uterus and peritoneum towards a phenotypical pathology similar to that of clinical endometriosis.

Serum concentrations of growth factors in women with and without endometriosis: the action of anti-endometriosis medicines.

Endometriosis is a common gynecologic syndrome of unknown etiology and pathogenesis. Growth factors and inflammatory mediators produced by peritoneal leukocytes have recently been postulated to participate in the pathogenesis of endometriosis. Angiogenic factors released from peritoneal macrophages may also play a role in the development of this disease. In the present study, we investigate the soluble levels of vascular endothelial growth factor (VEGF), epidermal growth factor-receptor (EGF-R), granulocyte/macrophage-colony stimulating factor (GM-CSF), Insulin-like growth factor-1 (IGF-1) and interferon-gamma (IFN-gamma) in the serum of 28 women with and 20 without endometriosis. We also compared these levels before, during and after treatment with danazol and leuprorelin acetate depot, the two therapeutic regiments of choice concerning this disease. We found that only sVEGF levels were higher in women with endometriosis in comparison to controls (P < 0.001) while sEGF-R is not present. GM-CSF, IGF-1 and IFN-gamma soluble levels are not affected in either healthy or endometriotic subjects. The 6-month treatment with danazol decreased sVEGF levels (P < 0.02) and increased sEGF-R levels (P < 0.001). These observations support the view that VEGF may be associated with the disease process and that danazol may bring sVEGF levels to a normal threshold. However, future studies will be focused on the anti-angiogenic control of the action of VEGF in patients with endometriosis.

Low-penetrance genes are associated with increased susceptibility to endometriosis.

OBJECTIVE: To investigate whether genetic polymorphisms of CYP1A1, GSTM1, and GSTT1 are associated with endometriosis. DESIGN: Genetic polymorphism analysis. SETTING: University department. PATIENT(S): A family with four women in two generations who had endometriosis and one member with suspected endometriosis in the third generation were compared with a group of fertile women. INTERVENTION(S): Laparoscopic examination. MAIN OUTCOME MEASURE(S): Blood specimens were obtained from fertile females and available affected female family members. Multiplex polymerase chain reaction (PCR) and restriction fragment length polymorphism PCR was done to determine each participant's genotype. RESULT(S): All affected family members had genotype CYP1A1 wt/m1 and GSTM1 null deletion. The frequency of this genotype in 54 fertile women was 13%. A 17-year-old family member with suspected endometriosis had the same genotype. One affected member was also a carrier of a GSTT1 null deletion. This combination was not found in any of the fertile participants. The most frequent genotypes in the sample were CYP1A1 wt/wt, with GSTM1 null deletion and at least one functional allele of GSTT1, and CYP1A1 wt/wt, with at least one functional allele of GSTM1 and GSTT1 (33% and 31%, respectively). CONCLUSION(S): The combination of CYP1A1 m1 polymorphism and GSTM1 null deletion is closely associated with penetration of the endometriosis phenotype, whereas GSTT1 null deletion may add to the penetration of this trait.

Soluble ICAM-1 levels in the serum of endometriotic patients appear to be independent of medical treatment.

Adhesion molecules regulate the interaction of cells with the extracellular matrix and/or other cells. The intercellular adhesion molecule-1 (ICAM-1; CD54) is a member of the immunoglobulin superfamily and expressed by several cell types, including leukocytes and endothelial cells. A circulating form of the usually membrane-bound molecule was identified and characterized in normal human serum and in sera from patients with endometriosis. In the present study, we established the serum-soluble ICAM-1 (sICAM-1) levels in patients with endometriosis. We also studied the effect of danazol and leuprorelin acetate depot on the levels of sICAM-1. Thirty-eight women, 18-45 years of age, with regular menses and documented pelvic endometriosis were recruited from a University Hospital setting. Twenty-two women with endometriosis were randomly divided into two groups. Danazol (600 mg) were given every day for 6 months, and 3.75 mg of leuprorelin acetate depot every 28 days for 6 months. Serum sICAM-1 concentrations were measured before, during and after treatment, and its quantitative determination was performed by an ELISA technique using a specific immunoassay. We found that (1) sICAM-1 levels were higher in women with endometriosis in comparison to healthy subjects; (2) the 6 month treatment with danazol or leuprorelin acetate depot increased sICAM-1 levels (P<0.001); (3) 3 months after termination of both treatments, sICAM-1 levels were unchanged. Although the mechanism leading to the increase of sICAM-1 needs to be further clarified, any benefits of medical treatment of endometriosis such as danazol or leuprorelin appear to be independent of changes in ICAM-1 serum levels.

The possible anti-inflammatory role of circulating human leukocyte antigen levels in women with endometriosis after treatment with danazol and leuprorelin acetate depot.

BACKGROUND: Endometriosis is defined as an inflammatory condition of the female reproductive tract, a state often associated with infertility and miscarriage. Many exogenously administered factors (treatments) control the disease via as yet unknown pathways. Possible candidate molecules involved in these mechanisms could be the serum-soluble human leukocyte antigens (sHIA) that have been detected in a variety of human body fluids and that are associated with several diseases. AIMS: We here examine how danazol and leuprorelin acetate depot treatments exert their anti-inflammatory action. It is plausible that subtle alterations mediated by these treatments and in relation to sHLA may explain the pathophysiology of endometriosis and provide insights towards new therapeutic protocols. METHODS: Indirect enzyme-linked immunosorbent assay (ELISA), using specific monoclonal antibodies, determined serum-soluble class-I and class-II HLA levels. ELISA readings from treated women were compared with normal healthy subjects. RESULTS: Serum-soluble class-I and class-II HLA levels are statistically significantly lower (P < 0.001) in women with endometriosis than in the control groups. However, danazol but not leuprorelin acetate depot administration augments soluble HLA class I and class II (P < 0.01 and P < 0.001, respectively) to normal levels during the treatment period, an increase that may account for the anti-inflammatory effect and the remission observed. CONCLUSIONS: It is shown that one of the underlying causes of endometriosis may be the lack of both circulating class-I and class-II antigen levels. Danazol administration acts via an induced release of these antigens, whose presence correlates with the degree of the inflammatory alleviation obtained. We thus provide evidence that the inflammatory state of the disease appears to be associated with soluble HLA levels because, 3 months after ceasing therapy, the circulating antigens in the serum return to the same levels that correspond to the pathological condition.

The role of estrogen replacement therapy in Alzheimer's disease.

Multiple factors appear to contribute to the expression of Alzheimer's disease (AD). About 30% of cases of dementia of the Alzheimer's type (DAT) can be attributed to genetic factors. These observations raise the possibility of identifying multiple interventions that may modify the disease process and, therefore, the clinical expression of the dementia. Prominent among factors that may contribute to dementia and, specifically, to dementia of the Alzheimer's type is cerebral vascular disease. Estrogen is a potent factor that not only prevents vascular disease but also improves blood flow in diseased vessels, including blood flow in regions of the brain affected by AD. Estrogen also has direct effects on neuronal function that may play an important role not only in the preservation of neurons but in the repair of neurons damaged by the disease process. These effects of estrogen on the CNS suggest that the hormone may be effective not only in the prevention of dementia but also in its treatment. Given the distressingly high prevalence of AD among older women and the exorbitant social and economic costs associated with this disorder, a true risk reduction on the order of one-third to one-half, as suggested by several recent analytical studies, would be of tremendous public health importance.

Microsatellite DNA assays reveal an allelic imbalance in p16(Ink4), GALT, p53, and APOA2 loci in patients with endometriosis.

OBJECTIVE: To detect allelic imbalance on specific genetic loci occurring in endometriosis. DESIGN: Microsatellite analysis. SETTING: Paraffin-embedded tissues histologically confirmed as endometriotic or normal endometrium. PATIENT(S): Premenopausal women undergoing laparoscopy for suspected endometriosis. INTERVENTION(S): Laparoscopic excision of specimens. MAIN OUTCOME MEASURE(S): Allelic imbalance and alterations of intensity of microsatellite alleles. RESULT(S): Five of 17 microsatellite DNA markers (29.4%) showed allelic imbalance. Eight samples (36.4%) showed allelic imbalance in at least one locus. Loci 9p21, 1q21, and 17p13.1 exhibited imbalance in 27.3%, 4.5%, and 4.5%, respectively. A 3-fold increase of the fractional allelic loss was observed from disease stage II to III and IV, whereas only 1.3-fold was found between patients of 41-50 and 20-40 years. CONCLUSION(S): We found that loss of heterozygosity on p16(Ink4), GALT, and p53, as well as on APOA2, a region frequently lost in ovarian cancer, occurs in endometriosis, even in stage II of the disease. The occurrence of such genomic alterations may represent important events in the development of endometriosis. The 9p21 locus may contain a gene associated with the pathogenesis of the disease, and therefore its loss may be a prognostic marker of the disease.

Three-year follow-up of [CA-125, CA 19-9, CA 15-3, SIL-2R, IL-6, IL-la, TNF-a, sCD8 and sCD4] levels in a woman with severe endometriosis.

A 37-year old woman presented with severe endometriosis and the patient underwent a conservative operation. We investigated the effect of treatment with danazol on the levels of CA-125, CA-19-9, CA 15-3, SIL-2R, IL-6, IL-1a, TNE-a, SCD8 and SCD4 in this woman. Our findings suggest that severe endometriosis is a condition which induces a rise of tumor markers and cytokine levels that are suppressed on danazol treatment.

Loss of heterozygosity in adenomyosis on hMSH2, hMLH1, p16Ink4 and GALT loci.

Adenomyosis is a gynecological condition in which tissue histologically similar to that in endometrium is found within the myometrium in the uterus. Although, lesions of both adenomyosis and endometriosis are identical to their sources with respect to structure and function, they are generally regarded as separate and distinct nosologic processes. In this study, we used 17 microsatellite markers, in four tetraplex and one single PCR assay, to determine the incidence of loss of heterozygosity (LOH) in 31 cases of adenomyosis. The markers used are located close to tumor suppressor genes, DNA repair genes, and genes which are thought to be involved in endometriosis. Moreover, the markers were involved in regions frequently lost in ovarian cancer, on chromosomal arms 1p, 1q, 2p, 2q, 3p, 9p, 9q, 17p and 17q. Nine samples (29.0%) showed LOH in at least one locus. Loci 2p22.3-p16.1, 3p24.2-p22 and 9p21 exhibited imbalance (19.4%, 9.7% and 6.5% respectively). This is the first report, that LOH occurs in adenomyosis. The regional chromosomal losses were detectable early during the development of this condition. In addition, hMSH2, hMLH1, p16Ink4 and GALT genes were associated for the first time with adenomyosis and its pathogenesis.

Increase in serum leptin concentrations among women with endometriosis during danazol and leuprolide depot treatments.

OBJECTIVE: This study was undertaken to evaluate serum leptin concentrations in women with endometriosis during treatment with danazol and with leuprolide depot. STUDY DESIGN: Twenty patients aged 18 to 42 years with regular menses and documented pelvic endometriosis were recruited from a university hospital setting. Treatment was 200 mg danazol 3 times daily for 6 months or 3.75 mg leuprolide depot every 28 days for 6 months. Serum leptin concentrations were measured before, during, and after treatment. A single blood sample was taken from each of 10 control women without endometriosis for comparison. Serum leptin level was measured with a radioimmunoassay kit with human leptin, and analysis of variance and paired t tests were used for statistical analysis. RESULTS: Serum leptin levels were almost the same among women with endometriosis as in the control group. Leptin levels were higher among women with endometriosis during treatment with danazol and leuprolide(P <.001). Three months after treatment, leptin values remained moderately higher than before treatment. CONCLUSION: Danazol and leuprolide increased serum leptin levels. The mechanism of leptin increase is unclear. Further studies are needed to determine whether an adipogonadal axis exists.

A randomized comparison of danazol and leuprolide acetate suppression of serum-soluble CD23 levels in endometriosis.

OBJECTIVE: To determine the effects of treatment with danazol and leuprolide acetate depot on serum-soluble CD23 concentrations in women with endometriosis. METHODS: This randomized trial involved 20 women 18-42 years old with regular menses and known pelvic endometriosis who were recruited from a university hospital between 1993 and 1998. Ten women took 200 mg of danazol three times daily for 6 months, and the remaining ten were given 3.75 mg of leuprolide acetate depot every 28 days for 6 months. Blood-soluble CD23 levels were measured before treatment, during the last 15 days of the 6-month treatment course, and 3 months after treatment. Only one blood sample was taken from ten women without endometriosis, between the 5th and 7th days of their menstrual cycles. For statistical analysis, we used independent and paired t tests with the Pearson correlation coefficient. RESULTS: Soluble CD23 levels were significantly higher in women with endometriosis before treatment than in ten normal controls. Levels decreased significantly during treatment with either danazol or leuprolide acetate. Three months after treatment, soluble CD23 values remained lower than before treatment. There was no correlation between soluble CD23 concentrations and severity of endometriosis. CONCLUSION: Our findings suggest that endometriosis increases soluble CD23 levels, which can be suppressed with either danazol or leuprolide acetate injection.

Hyperinsulinemia does not influence androgens/estrogens ratio in patients with polycystic ovarian syndrome.

OBJECTIVE: The ratio of androgens to estrogens in patients with polycystic ovarian syndrome (PCOS) and controls was evaluated in order to investigate whether hyperinsulinemia might induce hyperandrogenemia by decreasing androgen catabolism. STUDY DESIGN: Forty women were divided into four groups according to the presence of PCOS, insulin resistance, and normal or abnormal body mass index (BMI); each group consisted of 10 women. Group I comprised patients with PCOS, insulin resistance, and abnormal BMI. Group II consisted of patients with PCOS, without insulin resistance, and with normal BMI. Group III consisted of healthy women (controls) with abnormal BMI. Group IV consisted of healthy women with normal BMI. RESULTS: We found that: (1) the mean fasting insulin levels of groups II, III, and IV were significantly lower than those of group I (P < .001); (2) serum testosterone levels were significantly lower in groups III and IV than in group I and II; (3) there were no significant differences in serum estradiol and estrone levels between women of all groups; (4) women of groups III and IV had significantly lower ratios of testosterone to estradiol at time 0 compared to patients of groups I and II. CONCLUSION: Our results support the view that since hyperinsulinemia induces hyperandrogenism, the increase of androgens should not be attributed to the decrease of androgen catabolism.

Delayed interval delivery and survival of the two fetuses after second trimester loss of one triplet.

Due to the implementation of assisted reproduction techniques, the incidence of multiple pregnancies associated with fetal and neonatal complications has significantly increased. A woman in the 24th week of a triplet pregnancy came to the hospital because of premature rupture of membranes of one amniotic sack and she had a miscarriage of one of the fetuses the same day. After confirmation of the viability of the two fetuses, she was kept under observation with antibiotic therapy only. The woman gave live birth to these remaining fetuses in her 32nd week of pregnancy. The outcome of this case demonstrates that watchful expectancy may be a feasible alternative to invasive intervention. The aim of this report is to add to the currently very limited literature of an expectant (conservative) policy with regard to pregnancy outcome after the early loss of a fetus from a multiple pregnancy.

Vulvovaginitis during childhood and adolescence.

STUDY OBJECTIVE: To evaluate cases of vulvovaginitis treated in our institutions. DESIGN: Follow-up of 1,778 cases of vulvovaginitis to investigate the prevalence of various pathogens involved in the disease. SETTING: Divisions of pediatric and adolescent gynecology, university hospitals of Crete and Athens, Greece. PARTICIPANTS: Girls 1-18 years old seen at the clinics of the above institutions. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Vaginal culture, cytology, and vaginoscopy. RESULTS: Vulvovaginitis was encountered in 61.8% of the gynecological problems seen during childhood and adolescence. Infections were usually located in both the vulva and the vagina (56.9%). The main symptoms were vaginal discharge (53%), erythema (33%), and pruritus (27%). Candida spp (23.0%), beta-hemolytic Streptococci group B (15.0%), and Enterococci spp (10.0%) were the most frequent pathogens involved in the disease. CONCLUSIONS: Vulvovaginitis is a common disease during childhood and adolescence. Effective treatment, reassurance, and appropriate consultation based on the prevention of relapses are the most important steps for the management of the disease.