Hormonal therapy potentiates the effect of surgery on gene expression profile of peripheral blood mononuclear cells in patients affected by endometriosis.

BACKGROUND: Combined oral contraceptives (COCs) represent a common pharmacological approach for endometriosis. They have been demonstrated to mitigate painful symptoms in patients and are considered the first line therapy for symptomatic disease. The goal of this study was to evaluate whether the presence of pelvic endometriotic lesions can exert a systemic effect on PBMC gene expression and to investigate whether hormonal treatment may restore a normal gene expression profile. METHODS: Forty women, with endometriosis at stage III-IV, were enrolled in the study. After surgery, 20, randomly chosen, were treated with COC for six months and 20 did not receive hormonal therapy. Blood samples were obtained few days before surgery and six months after surgery. Gene expression profile of PBMC was studied by microarray. Gene expression levels before surgery and post-surgery, in presence and absence of COC, were compared. RESULTS: Nine genes previously reported to be overexpressed by endometriosis, were confirmed to be significantly downregulated after surgery. COC treatment lead to a greater down-regulation of these genes and to a significant down-regulation of 3 additional genes. 145 genes resulted downregulated and 28 upregulated by comparing gene expression before surgery with that 6 months after surgery in the presence of COC therapy. CONCLUSIONS: Results support the concept that a systemic chronic inflammatory status is among the mechanisms underlying endometriosis. Moreover, they shed light into the mechanisms of action of COCs and strength the rationale for their use to improve quality of life of women affected by the disease.

Recurrent atypical polypoid adenomyoma and pregnancy: A new conservative approach with levonorgestrel-releasing intrauterine system.

•Levonorgestrel IUD was effective in treatment of recurrent APA.•No side effects were reported.•No impairments on a subsequent pregnancy were reported.

Adenomyosis: What the Patient Needs.

A panel of experts in the field of endometriosis expressed their opinions on management options in a 28-year-old patient, attempting pregnancy for 1 year, with severe cyclic pelvic pain and with clinical examination and imaging techniques suggestive of adenomyosis. Many questions this paradigmatic patient may pose to the clinician are addressed, and all clinical scenarios are discussed. A decision algorithm derived from this discussion is also proposed.

Surgical excision of ovarian endometriomas: Does it truly impair ovarian reserve? Long term anti-Müllerian hormone (AMH) changes after surgery.

AIM: The long-term effects of laparoscopic cystectomy on ovarian reserve in patients with unilateral and bilateral ovarian endometriomas were evaluated. METHODS: A total of 22 patients undergoing laparoscopic cystectomy for unilateral endometrioma (n = 10) and bilateral endometriomas (n = 12) were included in the study. RESULT(S): Serum anti-Müllerian hormone (AMH) levels significantly decreased from the baseline value (3.98 ± 3.27 ng/mL) one (1.67 ± 1.56 ng/mL), three (2.01 ± 1.70 ng/mL), and six months (2.43 ± 2.39 ng/mL) postoperatively. There was no difference between preoperative and 12 month postoperative AMH levels (4.01 ± 3.39 ng/mL) (P > 0.05). Patients with bilateral endometriomas had a significantly higher rate of decline in AMH levels 12 months after surgery than patients with monolateral endometriomas (P = 0.035), but in both groups there was no difference in AMH levels at one and 12 months postoperatively (P > 0.05). CONCLUSION(S): AMH levels temporarily decreased after laparoscopic cystectomy for ovarian endometriomas, with complete recovery of preoperative AMH values at 12 months postoperatively. This pattern was equal in patients with bilateral and unilateral ovarian involvement. Patients with bilateral cysts have higher rates of decline of AMH levels compared to patients with unilateral affection.

Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity.

STUDY OBJECTIVE: To evaluate the integrity of the endoscopic bag after transvaginal in-bag morcellation of uteri that need to be removed by vaginal morcellation during total laparoscopic hysterectomy (TLH). DESIGN: Prospective pilot study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Twelve patients with uteri that needed to be removed and who required vaginal morcellation underwent TLH from September 2014 to February 2015, without suspected or confirmed malignancy. INTERVENTIONS: After transvaginal in-bag morcellation of uteri at the end of TLH, careful visual inspection of the endoscopic pouch, using diluted methylene blue, was carried out, highlighting any minimal bag damage. MEASUREMENTS AND MAIN RESULTS: No gross rupture was encountered after morcellation; however, 4 minimal ruptures were recognized (33%) after filling up the bag with diluted methylene blue. CONCLUSIONS: Minimal lesions of the bag may occur after transvaginal morcellation of uteri that need to be removed by vaginal morcellation; this may potentially affect the spread of cancer cells into the abdominal cavity.

How to Manage Bowel Endometriosis: The ETIC Approach.

A panel of experts in the field of endometriosis expressed their opinions on management options in a 35-year-old patient desiring pregnancy with a history of previous surgery for endometrioma and bowel obstruction symptoms. Many questions that this paradigmatic patient may pose to the clinician are addressed, and various clinical scenarios are discussed. A decision algorithm derived from this discussion is proposed as well.

An Italian association study and meta-analysis with previous GWAS confirm WNT4, CDKN2BAS and FN1 as the first identified susceptibility loci for endometriosis.

BACKGROUND: Although endometriosis may benefit from primary prevention measures, the epidemiological risk factors identified are equivocal. Two genome-wide association studies (GWAS) have been conducted for endometriosis in two different ethnic populations but results are still to be replicated consistently and across various ethnicities. To confirm the association of GWAS-derived susceptibility loci, we conducted a replication Italian case-control study and a meta-analysis. METHODS: An independent set of 305 laparoscopically-proven endometriosis patients and 2710 controls were recruited. Four SNPs-CDKN2BAS rs1333049, rs7521902 close to WNT4, rs12700667 in an inter-genic region on 7p15.2 and fibronectin 1 rs1250248-were selected for this association study. RESULTS: Rs1333049 risk allele G frequency resulted significantly higher in endometriosis patients compared with controls (OR 1.32, 95% CI 1.11 to 1.57), confirming the role of this locus also in the Caucasian population. The meta-analysis showed that rs7521902 was associated with endometriosis at a genome-wide significance (p(meta)=2.23×10(-9)) while for rs1250248, a genome-wide significant p(meta) value of 3.89×10(-9) was detected only in association with severe forms. An epistatic interaction between rs7521902 and rs1250248 (OR 1.56, p=1.19×10(-2)) was found especially in presence of ovarian disease (OR=2.15, p=3.12×10(-4)). CONCLUSIONS: We confirm WNT4, CDKN2BAS and FN1 as the first identified common loci for endometriosis.

Interferon-inducible genes, TNF-related apoptosis-inducing ligand (TRAIL) and interferon inducible protein 27 (IFI27) are negatively regulated in leiomyomas: implications for a role of the interferon pathway in leiomyoma development.

Uterine leiomyomas are the most common tumors in the human female pelvis and the leading indication for pelvic surgery. Lack of understanding of the molecular pathogenesis of leiomyoma has put severe limitations on the availability of alternative treatments. Using an oligonucleotide micro-array-based hybridisation analysis we observed a group of genes with a broad range of functional activity differentially expressed in smooth muscle cells (SMC) derived from leiomyomas when compared to matched myometrial cells. Among them, two IFNα inducible genes, TRAIL and IFI27, were underexpressed in leiomyoma vs. myometrial cells. Expression levels of TRAIL and IFI27 were also measured in myometrial and leiomyoma cells by real-time quantitative PCR in basal condition and after IFNα stimulation. In both cell types, the transcription of the two genes resulted induced by IFNα but the IFI27 transcription stimulation was weaker in leiomyoma than myometrial cells whereas the TRAIL transcription stimulation resulted stronger in leiomyoma respect myometrial cells. Based on this finding and on previous observations we have hypothesized that a reduced response to IFNα stimulation might be involved in leiomyoma formation and growth.

Gene expression profiling of peripheral blood mononuclear cells in endometriosis identifies genes altered in non-gynaecologic chronic inflammatory diseases.

BACKGROUND: Pelvic inflammatory phenomena have been suggested as critical players in the natural history of endometriosis. However, to what extent these events could affect the systemic immunologic status remains to be clarified. Here, we compared the gene expression profile in peripheral blood mononuclear cells from endometriosis patients in the severe diseased stage with the profile after a conventional surgical treatment for removal of endometriotic lesions and adhesions. METHODS: Microarray analysis included four patients suffering from severe endometriosis in which blood samples were obtained few days before the surgical intervention and again 6 months later. Real-time quantitative PCR analyses on a larger population were performed for some genes up-regulated in the diseased stage in a case-control approach. RESULTS: Among the 17,665 probe signals detected in the microarray, n = 26 genes resulted up-regulated and n = 15 were down-regulated in the diseased stage. Five genes up-regulated in diseased stage (FBJ Murine osteosarcoma viral oncogene homolog gene, dual specificity phosphatase 1, pre-B-cell colony enhancing factor 1, adrenomedullin and S100 calcium binding protein P) were exactly those shown as up-regulated in peripheral leukocytes of psoriasis patients in a very similar study design (diseased versus 'cured' stage), with a 5.2 × 10(-11) hypergeometric probability that this event could occur by chance. CONCLUSIONS: Endometriosis induces the expression of genes in peripheral leukocytes already identified in non-gynaecologic chronic inflammatory diseases, thus revealing the disease as a local affliction with relevant consequences at the systemic level. Although the commonality of gene expression with other inflammatory diseases prevents the use of these genes as non-invasive diagnostic markers, from a clinical standpoint, the idea that the surgical intervention may reduce the expression of peripheral leukocyte genes represents a novel finding.

Histologic analysis of specimens from laparoscopic endometrioma excision performed by different surgeons: does the surgeon matter?

OBJECTIVE: To evaluate whether the amount of ovarian tissue inadvertently removed along with the endometrioma cyst wall at laparoscopy differs in relation to the operating surgeon's level of expertise. DESIGN: Multicenter, prospective trial. SETTING: Four tertiary care university hospitals. PATIENT(S): Fifty patients, aged 25 to 40 years, with monolateral ovarian endometriomas who underwent laparoscopic excision. INTERVENTION(S): Operation with the stripping technique by surgeons with specific expertise in endometriosis surgery in four centers (groups A, B, C, and D) and by residents with average training in laparoscopic surgery (group E). MAIN OUTCOME MEASURE(S): Histologic examination for the evaluation of the mean thickness of the cyst wall from each specimen, and the mean thickness and morphologic characteristics of any ovarian tissue removed. RESULT(S): No statistically significant differences were present in the rate of presence of ovarian tissue in the endometrioma wall specimens from the different groups (44%, 45%, 55%, 56%, and 60% in groups A, B, C, D, and E, respectively). For groups A+B+C+D versus group E, a statistically significant difference was found in the mean thickness of the tissue specimens (1.51 mm vs. 1.91 mm, respectively) and in the mean thickness of ovarian tissue inadvertently excised (0.49 mm vs. 0.97 mm, respectively). CONCLUSION(S): Level of expertise in endometriosis surgery is inversely correlated with inadvertent removal of healthy ovarian tissue along with the endometrioma capsule.

Endocannabinoid system regulates migration of endometrial stromal cells via cannabinoid receptor 1 through the activation of PI3K and ERK1/2 pathways.

OBJECTIVE: To evaluate the effects of the cannabinoid system on the regulation of endometrial stromal cell (ESCs) dynamic behavior. DESIGN: ESC migration, electrical signal generated by K(+) channels, and cytoskeletal-actin dynamics were evaluated in response to treatment with the synthetic endocannabinoid methanandamide. Selective agonists and antagonists were used to identify both the receptor and the biochemical pathways involved. SETTING: Molecular research institution. PATIENT(S): Endometrial tissues were obtained from 40 reproductive-age women undergoing laparoscopy for benign pathologies. INTERVENTIONS: ESCs were treated with methanadamide and with selective agonist (ACEA) and antagonist (AM251) of the cannabinoid receptor 1. MAIN OUTCOME MEASURES: Cellular migration was evaluated by means of chemotaxis experiments in a Boyden chamber. Electric signal generated by K(+) channels was evaluated by patch clamp experiments Cellular morphology and cytoskeletal-actin dynamics were evaluated by immunofluorescence. RESULT(S): Methanandamide enhanced ESC migration via cannabinoid receptor I (CNR1) through the activation of PI3K/Akt and ERK1/2 pathways. The increased ESC migration was associated with cytoskeleton reorganization identified by the dissolution of F-actin stress fibers and the presence of stress fiber arcs and with increased electrical signal generated by K(+) channels. CONCLUSION(S): In physiologic conditions, the cannabinoid system has a central role in regulating endometrial cell migration. The involvement of ERK1/2 and PI3-K/Akt pathways points to a potential role of endocannabinoids in some pathologic conditions characterized by enhanced endometrial cell invasiveness.

Endometrial stromal progesterone receptor-A/progesterone receptor-B ratio: no difference between women with and without endometriosis.

The aim of the present study was to investigate whether alterations of the P receptor-A/P receptor-B ratio could be considered an etiopathogenetic factor for endometriosis. We failed to observe statistically significant differences in both P receptor-A/P receptor-B messenger RNA and protein ratio between endometrial stromal cells derived from women with and without endometriosis.

Endometrial stromal cells from women with endometriosis reveal peculiar migratory behavior in response to ovarian steroids.

OBJECTIVE: To evaluate differences in endometrial stromal cell (ESC) migration between patients with and without endometriosis. DESIGN: Differences in ESC migration, cellular morphology, and cytoskeletal-actin dynamics were evaluated in response to platelet-derived growth factor-BB (PDGF-BB) and steroid hormones (17beta-estradiol and progesterone). SETTING: Medical school research laboratory. PATIENT(S): Endometrial biopsy samples obtained from 43 women: 23 as controls (endometriosis excluded by laparoscopy), 20 with severe or moderate endometriosis (diagnosed by laparoscopy). INTERVENTION(S): ESCs were treated with and without PDGF-BB, 17beta-estradiol, and progesterone. MAIN OUTCOME MEASURE(S): Cellular migration was evaluated by means of chemotaxis experiments in a Boyden chamber. Cellular morphology and cytoskeletal-actin dynamics were evaluated by immunofluorescence. RESULT(S): Progesterone stimulated the migratory behavior of ESCs derived from women with endometriosis, while 17beta-estradiol could stimulate motility of ESCs derived from both controls and women with endometriosis, with a greater effect observed in the latter group. No difference in ESC migratory behavior after PDGF-BB treatment was observed between women with and without the disease. Also, PDGF-BB and steroid hormones could modify the organization of actin cytoskeletal structures. CONCLUSION(S): Ovarian steroids differently affect the migration of ESCs derived from women with and without endometriosis. This effect is likely to involve cytoskeletal reorganization. Nongenomic signaling pathways induced by steroid hormones might have a role in this phenomenon.

Plasminogen activator inhibitor-1 4G/5G polymorphism and susceptibility to endometriosis in the Italian population.

OBJECTIVES: Some controversy exists for the potential association of the plasminogen activator inhibitor-1 (PAI-1) gene polymorphism 4G/5G and susceptibility to endometriosis. To clarify this issue, we have examined the prevalence of this polymorphism in a case-control study in the Italian population. STUDY DESIGN: The PAI-1 4G/5G polymorphism was evaluated in n=368 reproductive year aged Caucasian women who underwent gynaecological laparoscopy for chronic pelvic pain, infertility, ovarian cysts and myomas. A second group of controls included n=329 normal subjects. RESULTS: The 697 women enrolled were divided as follows: the endometriosis group (n=204), the gynaecological control group (n=164) and the general population control group (n=329). No statistical significant differences emerged between endometriosis patients and gynaecological controls with regard to the allele frequencies and co-dominant and dominant models of genotype distribution. A borderline statistical difference was only observed for the recessive model of inheritance in which, contrary to previous findings, the PAI-1 4G/4G genotype seems to be less linked to the disease development. CONCLUSION: The findings reported herein do not support the previously reported data indicating a greater susceptibility to endometriosis in patients harbouring the PAI-1 4G/5G and 4G/4G genotypes and exclude a significant role of polymorphism in endometriosis development.

Endometrioma excision and ovarian reserve: a dangerous relation.

Endometrioma is one of the most frequent pathologies in gynecologic surgery. Laparoscopic cyst excision is considered the best treatment in terms of lower recurrence and improved fertility. However, it was recently questioned whether the excision of the endometrioma could decrease the function of the operated ovary and if it could affect the subsequent fertility. Even if a consistent amount of ovarian tissue is unintentionally removed together with the capsule of the cyst, resulting in does not show the follicular pattern observed in working ovaries. Currently, no definitive data clarify whether the damage to the ovarian reserve, observed in patient with endometrioma, is related to the surgical procedure, to the previous presence of the cyst, or both. Electrosurgial coagulation during hemostasis could play an important role in terms of damage to ovarian stroma and vascularization. Particular attention must be paid in presence of bilateral endometriotic cysts. In fact, an increase in premature ovarian failure rate was reported when both the ovaries are involved in surgery. Incase of assisted reproductive techniques, no clear evidence indicates which is the best approach for concomitant endometriotic cyst. On the base of these considerations endometriomas Should be treated only in case of pain, infertility, and in asymptomatic patients if the cyst diameter is greater than 4 cm.

Progesterone receptor +331G/A polymorphism in endometriosis and deep-infiltrating endometriosis.

In this study, we sought to examine the association between P receptor +331G/A polymorphism and endometriosis. We excluded any relationship between endometriosis in general and the P receptor +331G/A polymorphism but found a significant association with deep-infiltrating endometriosis, supporting a potential role of this variant in the P receptor-dependent invasive behavior of endometrial cells.

The vascular endothelial growth factor +405G>C polymorphism in endometriosis.

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent stimulus of angiogenesis potentially contributing to the pathogenesis of endometriosis. The aim of this study was to investigate the potential association between the single nucleotide polymorphism +405G>C of the VEGF gene with the risk of endometriosis, for the first time in the Caucasian population. METHODS: The polymorphism +405G>C of the VEGF gene was examined in n = 203 Italian women affected by endometriosis and in n = 140 women without laparoscopic evidence of the disease. All the women were genotyped by PCR-restriction fragment length polymorphism from venous blood samples. We then performed a meta-analysis including results from the present study and from the two previously published studies on this topic. RESULTS: The distribution of the three different genotypes significantly differed between women with and without the disease (P = 0.03). The odds ratio (95% confidence interval) for endometriosis in women carrying the C allele was 1.8 (1.2-2.8). The Breslow-Day test revealed statistically significant heterogeneity among the studies performed so far thus indicating inconsistency among studies and excluding the possibility of obtaining a common estimation of the effect. CONCLUSIONS: Results obtained herein are in keeping with those obtained previously and support a role for the +405G>C VEGF polymorphism in endometriosis development, although a further, larger study is required to confirm our findings. However, this effect may depend on the population studied. Ethnicity and the characteristics of endometriosis are likely to influence this association.

Genetics of endometriosis: current status and prospects.

Family and twin studies have shown that heritability accounts for endometriosis development to an extent similar to other complex genetic diseases. Both linkage analysis and association studies have been performed to identify genetic determinants for the disease. Results from the linkage scan of 1,176 families collected thanks to a joint effort between an Australian and a UK group supported significant linkage to a novel susceptibility locus on chromosome 10q26. Although gene variants with effects on the disease predisposition have been proposed to exist and several candidates have been put forward, their effects have not been or are yet to be confirmed. The main categories of candidate genes studied have been those involved in detoxification processes, sex steroid biosynthesis and action, immune system regulation. Genetic studies on endometriosis face numerous challenges as the disease has several manifestations and different forms. Moreover, strong gene-environmental interactions might definitively influence approaches to identify genetic variants involved. Genome-wide association studies that survey most of the genome for causal genetic variants provide the potential for future progress.