[Current aspects on the treatment of endometriosis]

The aim of pharmacological treatment of endometriosis is to reduce estrogen levels, which may be achieved using gestagens or GnRH-agonists. The effects of the different hormones are mainly the same, while side effects differ. If the GnRH-agonist dose is modified, or if a low dose of estrogen and/or gestagen is given in addition, the hypo-estrogenic side effects of GnRH-agonists can be reduced. Surgical treatment can often be performed in conjunction with diagnostic laparoscopy. Supplementary hormonal treatment may postpone recurrence. Because endometriosis is in many women a chronically recurring disorder, continuity in the doctor-patient relationship is essential.

Current drug therapy recommendations for the treatment of endometriosis

The principal symptoms and signs of endometriosis are tissue lesions and pelvic pain. These occur to varying degrees, with a chronic pattern and a tendency for deterioration with time. Patients with endometriosis often also have fertility problems, but the relationship between this and the signs and symptoms of the disease is inconsequent; the basic pathophysiology is not exactly known. Although an immunological defect resulting in an inflammatory reaction around discharged menstrual debris in the pelvic cavity has been shown, no treatments based on this process are available. Estrogen often plays an important role in the progression of lesions and pain. Therefore, the aim of treatment usually has been to downregulate the ovaries and/or given antiestrogenic drugs as an alternative to surgical removal. As complete downregulation of the ovaries and hypoestrogenaemia does not seem to be crucial, achievement of amenorrhoea seems to be sufficient. This means that women may continue to have circulating estrogen levels so that severe hypoestrogenic adverse effects such as bone demineralisation, dry vagina, psychiatric symptoms or anabolic/androgenic effects of gestagens can be avoided. However, as both symptoms and the dependence of hormones may vary between and within women, the treatment needs to be individualised. There are a number of available treatments for endometriosis on the market and it is important for the doctor to know how to reach the therapeutic window of these treatments for each woman. It is also important to inform the patient about the different possibilities so that the treatment with the least impact on her quality of life can be chosen. When the therapeutic window has been identified, the treatment may then either be continued for a long period of time or be repeated when needed.

Divergent effects of weight reduction and oral anticonception treatment on adrenergic lipolysis regulation in obese women with the polycystic ovary syndrome

The influence of weight reduction and female sex hormones on the regulation of lipolysis was investigated in isolated abdominal sc adipocytes from 20 obese hyperandrogenic women with polycystic ovary syndrome (PCOS). Nine PCOS women were reinvestigated after 8-12 weeks of weight reduction therapy (WR) with a very low calorie diet, inducing a mean loss of 8 +/- 3 kg, and 8 PCOS women were reinvestigated after 12 weeks of treatment with combined oral contraceptives (OC), containing ethinyl estradiol and norethisterone; the remaining 3 subjects were drop-outs. Both WR and OC normalized hyperandrogenicity. WR caused a 50% reduction of basal lipolysis rate and a 5- to 7-fold increased noradrenaline and terbutaline sensitivity (P < 0.02); the latter could be ascribed to a 2-fold increased beta2-adrenoceptor density (P < 0.02) as determined with radioligand binding. There was no change with regard to dobutamine (beta1-adrenoceptor sensitivity) or clonidine, (alpha2-adrenoceptor sensitivity) or to beta1-adrenoceptor density. OC treatment did not influence the basal lipolysis rate or beta2- or alpha2-adrenoceptor sensitivity, but lowered the beta1-adrenoceptor sensitivity 7-fold (P < 0.03) without a reduction in beta1-adrenoceptor density. The OC treatment effect was not observed when forskolin and dibutyryl cAMP, acting on adenylate cyclase or protein kinase A, respectively, were used, suggesting a partial uncoupling of beta1-adrenoceptors. WR therapy, but not OC therapy, caused, in addition to changes in lipolysis function, improved in vivo insulin sensitivity and lower plasma noradrenaline levels. These findings suggest that factors other than hyperandrogenicity modulate lipolysis regulation in obese subjects with PCOS. Disturbances in sympathetic pathways could be of pathogenic importance.

Tenascin is differentially expressed in endometrium and endometriosis

Endometriosis is characterized by the presence of functional endometrial tissue outside the uterine cavity, most commonly on the ovary and peritoneum. The aetiology of endometriosis is not understood, although the adhesion of endometrial cells to the extracellular matrix (ECM) would be expected to play a central role in its pathogenesis. The expression of ECM molecules in endometrium and in endometriosis has been investigated using immunohistochemistry and western blotting techniques. The ECM components collagen IV, laminin, vitronectin, and fibronectin had a similar pattern of expression throughout the menstrual cycle in endometrium and endometriosis. Expression of tenascin was elevated in the stroma of the functionalis region of the endometrium during the proliferative stage of the menstrual cycle and in endometriosis. Tenascin expression in endometriosis was not modulated according to the stage of the menstrual cycle. It is concluded that expression of tenascin is strictly regulated in endometrium and may be important in endometrial regeneration and in the pathogenesis of endometriosis.

Fibrinolytic factors in endometriotic tissue, endometrium, peritoneal fluid, and plasma from women with endometriosis and in endometrium and peritoneal fluid from healthy women

OBJECTIVE

To determine whether there is a difference in fibrinolytic compounds in endometriotic tissue, endometrium, peritoneal fluid (PF), and plasma from women with endometriosis and in endometrium and PF from healthy women.

DESIGN

Prospective study.

SETTING

Two university clinics.

PATIENT(S)

Regularly menstruating women with and without endometriosis.

INTERVENTION(S)

Tissue samples, PF, and blood were collected at surgery performed for clinical reasons.

MAIN OUTCOME MEASURE(S)

The antigen concentrations of plasminogen activators and plasminogen activator inhibitors (PAls) in tissue homogenates, PF, and plasma were assayed by ELISA.

RESULT(S)

The concentrations of urokinase plasminogen activator (u-PA) and PAI-1 were higher in endometrium from women with endometriosis than in endometrium from controls and even higher in endometriotic tissue than in endometrium from both groups. In PF, the concentration of PAI-2 was higher in women with endometriosis than in controls.

CONCLUSION(S)

The high concentrations of u-PA and PAI-1 in endometrium from women with endometriosis might facilitate implantation of endometrial cells and the high concentration in endometriotic tissue might contribute to their invasive growth. The inflammatory reaction may contribute to the high concentration of PAI-2.

Outcome of IVF in patients with endometriosis in comparison with tubal-factor infertility

PURPOSE

The aim of this retrospective study was to compare the outcome of in vitro fertilization and embryo transfer in women with endometriosis and a control group with tubal-factor infertility.

METHODS

Forty-eight patients with endometriosis underwent 65 cycles of in vitro fertilization and embryo transfer at Huddinge University Hospital. The matched control group with tubal-factor infertility consisted of 98 cycles in 98 patients. These groups were retrospectively analyzed regarding stimulation, fertilization, embryo development, implantation, and pregnancy outcome.

RESULTS

The fertilization rate was significantly lower in women with endometriosis, but the cleavage, implantation, and pregnancy rates did not differ.

CONCLUSIONS

Our results show that women with endometriosis have a lower fertilization rate compared with women with tubal-factor infertility. However, once the oocyte is fertilized, it seems that the preembryo has a normal chance of implantation, leading to similar pregnancy rates.

Template-dependent initiation of Sindbis virus RNA replication in vitro

Recent insights into the early events in Sindbis virus RNA replication suggest a requirement for either the P123 or P23 polyprotein, as well as mature nsP4, the RNA-dependent RNA polymerase, for initiation of minus-strand RNA synthesis. Based on this observation, we have succeeded in reconstituting an in vitro system for template-dependent initiation of SIN RNA replication. Extracts were isolated from cells infected with vaccinia virus recombinants expressing various SIN proteins and assayed by the addition of exogenous template RNAs. Extracts from cells expressing P123C>S, a protease-defective P123 polyprotein, and nsP4 synthesized a genome-length minus-sense RNA product. Replicase activity was dependent upon addition of exogenous RNA and was specific for alphavirus plus-strand RNA templates. RNA synthesis was also obtained by coexpression of nsP1, P23C>S, and nsP4. However, extracts from cells expressing nsP4 and P123, a cleavage-competent P123 polyprotein, had much less replicase activity. In addition, a P123 polyprotein containing a mutation in the nsP2 protease which increased the efficiency of processing exhibited very little, if any, replicase activity. These results provide further evidence that processing of the polyprotein inactivates the minus-strand initiation complex. Finally, RNA synthesis was detected when soluble nsP4 was added to a membrane fraction containing P123C>S, thus providing a functional assay for purification of the nsP4 RNA polymerase.

Effects of triptorelin versus placebo on the symptoms of endometriosis

OBJECTIVE

To compare the effect of a GnRH-agonist, triptorelin, versus placebo on the symptoms of endometriosis.

DESIGN

A prospective, randomized, double-blind study of 6 months of treatment followed by 12 months of follow-up.

SETTING

Departments of Obstetrics and Gynecology at two universities and one general hospital.

PATIENT(S)

Forty-nine women with symptoms of laparoscopically verified endometriosis.

INTERVENTION(S)

Triptorelin depot or placebo was given every 4 weeks. Clinical evaluation, including the Duration Intensity Behavior Scale and Visual Analogue Scale for pain, was performed before the injections and up to 12 months after treatment. A control laparoscopy was performed 4-6 weeks after the last injection.

MAIN OUTCOME MEASURE(S)

Quantitation of pain.

RESULT(S)

Twenty-four patients had active treatment and 25 received placebo. Pain symptoms according to both scales were significantly more reduced after 2 months of triptorelin treatment compared to placebo. The extent of endometriotic lesions was reduced 50% during triptorelin treatment and increased 17% during placebo. The average area of endometriotic lesions was reduced 45% during triptorelin treatment but was unchanged during placebo. Side effects, mainly hot flushes, were experienced by 80% of the actively treated group but also by 33% of patients in the placebo group. Because of recurrent symptoms, only five patients could be observed for 12 months after completion of treatment.

CONCLUSION(S)

Triptorelin reduces endometriotic lesions and pain to a significantly higher degree than placebo.

Concentrations of prostaglandin F2alpha in follicular fluid from women with endometriosis

Previous data have indicated that prostaglandins (PG) play an important role in the ovulation process and significant quantities have been found in follicular fluid. The synthesis of PG is influenced by ovarian steroids as well as inflammatory processes. Increased PG has been shown in peritoneal fluid from women with endometriosis. The aim of this study was to see whether PGF2alpha concentration in follicular fluid varies according to the presence or absence of remaining endometriotic lesions in the pelvis of women with endometriosis. Follicular fluid was collected at visual puncture of the follicles at laparoscopy of 26 women with diagnosed endometriosis. Visible lesions were found in 10 women and in 16 women no lesions could be seen macroscopically. PGF2alpha was determined using radioimmunoassay. The results showed no significant difference in the concentrations of PGF2alpha between women with visible and not macroscopically visible endometriotic lesions and there was no significantly linear correlation with endometriotic lesions in the follicle punctured. These data are in accordance with clinical results showing that fertility rate does not increase in endometriotic women even if the lesions disappear after treatment.

A double-blind randomized study of the treatment of endometriosis with nafarelin or nafarelin plus norethisterone

The objective of this study was to compare the efficacy of nafarelin 200 micrograms (Group A), nafarelin 400 micrograms (Group B) and the combination of nafarelin 200 micrograms and norethisterone 1.2 mg (Group C) daily, in treating symptoms of endometriosis, American Fertility Society score and adverse events during 6 months of treatment. A prospective, randomized, double-blind parallel group study was performed in two centers and 49 women with endometriosis diagnosed laparoscopically were included. The patients were seen monthly for physical examination and records were taken for bleeding pattern, symptom score and adverse events. A control laparoscopy was performed at the end of 6 months of treatment. All patients were followed 6 months after treatment. At 3 and 6 months the pelvic examination total score had decreased significantly in all three groups. The total endometriosis score was significantly reduced in Groups B and C. After 2 months the total symptom score showed a significant decrease in Groups B and C. The frequency of hot flushes during the first month of treatment was lowest in Group C, but during the rest of treatment there were no differences between the groups. Best bleeding control was obtained in Group C. We conclude that nafarelin 200 micrograms daily has as good an effect on endometriosis symptoms as nafarelin 400 micrograms daily, and the addition of norethisterone 1.2 mg results in fewer hot flushes and better bleeding control.

Detection of antineutrophil cytoplasmic antibodies in primary sclerosing cholangitis: a comparison of the alkaline phosphatase and immunofluorescent techniques

BACKGROUND

The reported prevalence of antineutrophil cytoplasmic antibodies (ANCA) in primary sclerosing cholangitis (PSC) varies considerably (26-85%). Part of this may reflect methodological differences but part may reflect the differences in the patient groups analysed. To resolve this issue we compared the sensitivity and specificity of the immunoalkaline phosphatase (IALP) and immunofluorescence (IF) techniques in four different populations.

METHOD

Sera from four centres were tested blind on alcohol-fixed neutrophils using both techniques.

PATIENTS

USA: 14 PSC, 14 primary biliary cirrhosis (PBC); Sweden: 32 PSC, 3 autoimmune hepatitis (AIH), 14 PBC, 11 chronic liver disease; Norway: 32 PSC, 14 AIH, 13 PBC, 1 hepatitis C. Italy: 8 PSC, 14 PBC, 8 viral hepatitis. Thirty-six normal healthy volunteers from Oxford, together with positive and negative controls, were also tested.

RESULTS

The healthy controls were all ANCA negative. The diagnostic sensitivity and specificity, respectively, of ANCA for PSC using the IALP technique for the different test sera were: USA 71% and 93%, Sweden 66% and 96%, Norway 69% and 46%, Italy 50% and 95%. The diagnostic sensitivity and specificity, respectively, of the IF technique on the same sera were: USA 50% and 86%, Sweden 56% and 86%, Norway 47% and 61%, Italy 50% and 91%. Overall, combining all four groups, detection of ANCA using the IALP technique gave a diagnostic sensitivity of 66% with a specificity of 74% for PSC. In contrast, the IF technique gave an overall diagnostic of only 51% (P = 0.044, compared with IALP) with a specificity of 73%. Although overall the IALP technique was more sensitive than IF, the differences in sensitivity and specificity between the two techniques did not reach statistical significance for any individual group. Furthermore, the small differences in sensitivity between the four groups using either technique were not significant. However, the IALP technique had greater specificity in the US, Swedish and Italian groups compared with the Norwegian group (P < 0.05) whereas no statistically significant differences in specificity were noted between the groups using the IF technique.

CONCLUSION

This study shows that the IALP method of ANCA detection is at least as sensitive as IF for the serological diagnosis of PSC. Indeed, combining data from all four centres, the IALP technique was significantly more sensitive than IF. We therefore recommend the use of the IALP technique, which is also easier to interpret and does not require the use of a specialist fluorescent microscope. The lack of a wide variation in sensitivity between IALP and IF for any individual patient group reported in this study suggests that the previously reported regional differences in ANCA prevalence in PSC of between 26% and 85% may be patient, related, rather than due to ethnic or methodological differences in ANCA detection, perhaps reflecting possible disease heterogeneity within PSC, or case selection bias. Further studies are needed to investigate this intriguing possibility. Such differences, if confirmed, will need to be taken into account when assessing the use of ANCA as a serological marker of PSC.

Quantitative enzyme immunoassay and semiquantitative immunohistochemistry of oestrogen and progesterone receptors in endometriotic tissue and endometrium

BACKGROUND

The capacity of different tissues to respond to steroids has been evaluated mainly according to the concentrations of oestrogen (ER) and progesterone (PR) receptors, which may be assayed either in tissue homogenates or histochemically. These two principles have been used in different studies of endometriotic tissue, giving somewhat different results, probably because the tissue is heterogeneously mixed with fibrotic tissue and blood cells to various degrees.

AIMS

To compare a quantitative and a qualitative, semiquantitative immunocytochemical assay for ER and PR in a heterogenous tissue (endometriotic) and a similar but more homogenous tissue (endometrium).

METHODS

ER and PR concentrations were measured using enzyme immunoassay (EIA) and immunocytochemistry (ICA) in the same tissue samples (endometriotic tissue from 31 women and endometrium from 19 of the same women).

RESULTS

There was a significant correlation between PR concentration (using EIA) and semiquantitation of PR using PRICA in endometrial epithelium (p = 0.028). The correlation between the two techniques for ER concentration was not significant. In endometriotic tissue no correlation was found between the two techniques for ER or PR.

CONCLUSIONS

These data show that in heterogeneous tissues like endometriotic tissue different techniques for measuring steroid receptors may produce substantially different results. The two techniques (EIA and ICA) are complementary and a combination of the two techniques might aid in determining optimal treatment.

Impaired adipocyte lipolysis in nonobese women with the polycystic ovary syndrome: a possible link to insulin resistance?

The polycystic ovary syndrome (PCOS) is the most common hyperandrogenic disorder among women and is characterized by metabolic and cardiovascular aberrations similar to those seen in the so-called insulin resistance syndrome. The regulation of lipolysis was investigated in isolated abdominal sc adipocytes from 10 nonobese women with PCOS and in 11 age- and body mass index-matched healthy women. Eight PCOS women were reinvestigated after 3 months of treatment with combined oral contraceptives containing ethinyl estradiol and norethisterone, which normalized hyperandrogenicity. The PCOS women showed a marked resistance to the lipolytic effect of noradrenaline due to defects at two different levels in the lipolytic cascade: first, a 7-fold reduction in sensitivity to the beta 2-selective agonist terbutaline (P < 0.005), which could be ascribed to a 50% lower beta 2-adrenoceptor density (P < 0.02) as determined with radioligand binding; there was no difference with regard to dobutamine (beta 1) or clonidine (alpha 2-sensitivity) or beta 1-adrenoceptor density; second, the maximum lipolytic response was also 35% lower (P < 0.02) in the PCOS women compared to that in the healthy women. This was seen with all beta-adrenergic agonists and the postreceptor-acting agents forskolin (activating adenylyl cyclase) and dibutyryl cAMP (activating protein kinase). Neither beta 2-adrenoceptor sensitivity or density nor the reduced lipolytic responsiveness was restored by 3 months of oral contraceptives treatment. The results indicate the existence of a marked impairment of catecholamine-induced lipolysis in nonobese PCOS women displaying early features of the insulin resistance syndrome due to multiple lipolysis defects as a lower beta 2-adrenoceptor density and reduced function of the protein kinase, hormone-sensitive lipase complex. These lipolysis defects are identical to those observed in the insulin resistance (metabolic) syndrome and could be a primary pathogenic mechanism for the development of these disorders.

Cancer risk after a hospital discharge diagnosis of endometriosis

OBJECTIVES

Our goal was to determine the risk of cancer after hospitalization for endometriosis.

STUDY DESIGN

Records of 20,686 women hospitalized with endometriosis during the period 1969 to 1983, as identified through the nationwide Swedish Inpatient Register, were linked against the National Swedish Cancer Registry through 1989 to identify all subsequent diagnoses of cancer. The study subjects were followed up for a mean of 11.4 years, with the cohort contributing 216,851 woman years of follow-up. Standardized incidence ratios were computed by the use of age- and period-specific incidence rates derived from the Swedish population. Because of the high proportion of subjects with gynecologic operations (55.6%), evaluation of the risk of gynecologic cancers involved truncation of person years at the time of any such operation.

RESULTS

The overall cancer risk was 1.2 (95% confidence interval 1.1 to 1.3). Significant excesses were observed for breast cancer (standardized incidence ratio = 1.3, 95% confidence interval 1.1 to 1.4), ovarian cancer (1.9, 1.3 to 2.8), and hematopoietic malignancies (1.4, 1.0 to 1.8); this latter excess was largely driven by an excess risk of non-Hodgkin's lymphoma (1.8, 1.2 to 2.6). The risk of ovarian cancer was particularly elevated among subjects with a long-standing history of ovarian endometriosis (4.2, 2.0 to 7.7). Cervical cancer risk was slightly reduced (0.7, 0.4 to 1.3) whereas no association was observed for cancer of the endometrium (1.1, 0.6 to 1.9).

CONCLUSIONS

These findings suggest that further attention be given to the risk of breast, ovarian and hematopoietic cancers among women with endometriosis and to exploring possible hormonal and immunologic reasons for the excess risks.

Altered susceptibility to tumor necrosis factor alpha-induced apoptosis of mouse cells expressing polyomavirus middle and small T antigens

Infection with some virus types induces susceptibility to the cytotoxic effect of tumor necrosis factor alpha (TNF-alpha). To investigate whether expression of polyomavirus proteins has this effect on cells, the TNF-alpha sensitivity of C127 and L929 mouse cells transfected with viral DNA was analyzed. Expression of all three polyomavirus early proteins, the tumor (T) antigens, had no apparent effect. In contrast, middle T antigen by itself induced hypersensitivity to TNF-alpha. This effect was reversed by retransfection of the cells with DNA encoding small T antigen. Expression of this polypeptide also decreased the sensitivity of bovine papillomavirus type 1-transformed cells to TNF-alpha, showing that the protective function of the polyomavirus small T antigen was not strictly linked to a middle-T-antigen-induced event. Mouse and human TNF-alpha had the same effect on normal and transformed mouse cells, suggesting that this effect was mediated by TNF receptor 1. Consistent with this conclusion, all cell clones used in the experiments expressed TNF receptor 1 at similar levels, while we failed to detect TNF receptor 2. The amount of receptor on the cells was not influenced by binding of the ligand. Addition of TNF-alpha at cytotoxic concentrations to cells expressing middle T antigen by itself resulted in significant fragmentation of chromosomal DNA after only a few hours, indicating induction of apoptosis. Addition of the cytokine to these cells also leads to release of arachidonic acid, showing that phospholipase A2 was activated. However, production of arachidonic acid did not appear to significantly precede loss of cell viability.

Integrins alpha 3 and alpha 6 are differentially expressed in endometrium and endometriosis

The expression of integrin subunits has been investigated in the stroma and epithelium of eutopic and ectopic endometrial tissues, using immunohistochemistry and fluorescently activated cell-sorting techniques. Integrin subunits exhibited tissue-specific expression in both eutopic and ectopic endometrium. Integrin alpha 3 subunit was up-regulated in ectopic endometrium compared with the eutopic counterpart, whereas alpha 6 integrin subunit was down-regulated in the ectopic tissues. Cycle stage-dependent expression of alpha v and beta 3, observed in eutopic endometrium, was absent in the ectopic counterpart. It is concluded that the development and regeneration of the endometrium involve complex integrin-ligand interactions and that regulation of specific adhesive events is lost in endometriosis.

Flow cytometric DNA analysis in endometriotic tissue compared to normal uterine endometrium

Endometriotic tissue sometimes shows an invasive pattern. but the growth regulation of the tissue is insufficiently characterized. In a research programme on factors regulating endometriotic growth, the DNA ploidy status and S-phase fraction (SPF) were studied. Fresh-frozen endometriotic tissue from 14 women and endometrium from 11 of them were studied using flow cytometry. A clear diploid pattern was seen in most cases of endometriotic (8/14) and endometrial (8/11) samples. In the remaining cases the G0/G1 peak was broad and skewed, which might indicate a near-diploid cell population. To clarify this, a second group was studied, consisting of 29 formalin-fixed endometriotic samples from 22 women and endometrium from five of them. All these samples were diploid, with one having a broad G0/G1 peak. No convincing difference in SPF between endometrium and endometriotic tissue was found, as the calculations had to be handled with caution because of debris in many samples. Although the study of fresh-frozen samples gave some indications of differences in DNA ploidy status, flow of cytometric DNA analysis of formalin fixed samples of endometriosis showed a diploid DNA pattern in all samples. In conclusion, DNA flow cytometry did not show a convincing aneuploid DNA pattern in endometriotic tissue.

A comparison of cathepsin D levels in endometriotic tissue and in uterine endometrium

OBJECTIVE

To assay the cathepsin D level in endometriotic tissue, to study the difference to uterine endometrium and the correlation to localization.

DESIGN

Prospective consecutive study on endometriotic tissue and endometrium.

SETTING

University clinic.

PATIENTS

Thirty-five women undergoing laparotomy for clinical indications.

INTERVENTIONS

Samples of endometriotic tissue and uterine endometrium were obtained simultaneously from the same woman at laparotomy, fresh frozen, and assayed using an immunoradiometric method.

MAIN OUTCOME MEASURE

The cathepsin D level in endometrium and endometriotic tissue expressed in pmol/mg DNA.

RESULTS

The cathepsin D level was significantly higher in endometriotic tissue than in endometrium both in follicular and luteal phase. The highest values in endometriotic tissue were found in luteal phase, in ovarian lesions, and in primary lesions. In endometrium, but not in endometriotic tissue, there was a positive correlation between cathepsin D level and serum E2 level.

CONCLUSION

The level of the proteolytic enzyme cathepsin D is significantly higher in endometriotic tissue than in endometrium, which might be of importance for implantation and the invasive growth of endometriotic tissue.

Apoptosis of Spodoptera frugiperda cells induced by okadaic acid is abrogated by baculovirus infection

Okadaic at low concentrations specifically inhibits protein phosphatase 2A. Treatment of cells with this inhibitor leads to growth arrest and cell injury within 1 to 2 days. After testing several different types of cells we found that mouse 3T6 cells and insect Sf9 cells responded to okadaic acid by apoptosis, as defined by changes in morphology and degradation of chromatin to fragments of nucleosome size. Infection of insect cells by baculovirus prevented the okadaic acid-induced apoptosis. Analysis of phosphoprotein synthesis by polyacrylamide gel electrophoresis showed that okadaic acid treatment resulted in hyperphosphorylation of some cellular proteins, including histone H1. Concomitant baculovirus infection of the cells did not change the overall phosphorylation pattern, but appeared to mitigate the okadaic acid-induced hyperphosphorylation of histone H1.

Oestrogen and progesterone receptors in endometriotic tissue and endometrium: comparison of different cycle phases and ages

The levels of oestrogen and progesterone receptors were analysed in 62 endometriotic tissue samples obtained at laparotomy of 58 women and in samples of endometrium obtained simultaneously from 49 of the women. Both ligand techniques and enzyme immunoassays were used for the assays. The steroid receptor levels were significantly lower in endometriotic tissue than in endometrium, both in cytosol and nuclear fractions. The differences were most pronounced in follicular phase. In endometrium the oestrogen and progesterone receptor levels varied during the menstrual cycle, being highest in follicular phase. In endometriotic tissue, the oestrogen receptor level remained low throughout the cycle. The progesterone receptor level, determined by immunoassay, increased during the menstrual cycle, being higher in luteal than in follicular phase. This cycle phase pattern was found neither in the nuclear progesterone receptor level nor when the cytosol was assayed with the ligand technique. In contrast to endometrium, there were no correlations between patients' age and steroid receptor levels in endometriotic tissue. The results show that oestrogen and progesterone receptors in endometriotic tissue have a different pattern during the menstrual cycle than endometrium and that the progesterone receptors synthesized are not all biologically active. These results strengthen previous data indicating differences in the hormonal regulation of the two tissue types.

Immunohistochemical analysis of oestrogen and progesterone receptors in endometriotic tissue and endometrium

The objective of the study was to compare the localization and staining intensity of oestrogen and progesterone receptors in endometrium and endometriotic tissue. Using monoclonal antibodies towards oestrogen and progesterone receptors, analysis was performed in 63 endometriotic samples from 40 women and compared to endometrium obtained simultaneously from 25 of the women. Using a staining index, 'total immuno-staining score', calculated from the staining intensity multiplied by the fraction of positive cells, the receptor content was estimated semiquantitatively. The scores for both oestrogen and progesterone receptors were lower in endometriotic epithelial cells than in endometrial epithelial cells, but the differences reached statistical significance only for the progesterone receptor. No difference was found for stromal cells. There was a significant correlation between oestrogen receptor score in endometriotic tissue and in endometrium, but not for progesterone receptor score. In endometrium and vaginal and peritoneal endometriosis, the progesterone receptor score showed similar values, higher than those in ovarian endometriosis. The data from this large immunohistochemical study support previous results of quantitative steroid receptor analyses, indicating that the regulation of steroid effects, especially those of progesterone, differs between endometriotic and endometrial tissue.

Different types of extragenital endometriosis: a review

Endometriotic growth may appear in any structure in the body. As well as affecting the internal genitalia, lesions are not uncommon in the bowel, urinary tract and thorax and reports of a number of cases at rarer sites have been published. This review is based on more than 1000 publications on the subject, that allows an overview of the appearance of the disease in different organs.

Estrogen and progesterone receptors in endometriotic tissue and endometrium: comparison according to localization and recurrence

OBJECTIVE

To study the hormonal regulation of primary and recurrent endometriosis by comparing the levels of estrogen receptors (ER) and progesterone receptors (PR) with the levels in uterine endometrium obtained simultaneously.

DESIGN

Tissue samples collected at routine operations.

SETTING

One university clinic.

PATIENTS

A total of 69 endometriotic samples were obtained from 61 women, and endometrium was obtained from 54 of the women. Seventeen of the patients (26%) had a recurrent disease; the others (n = 49) were operated on for the first time.

MAIN OUTCOME MEASURES

Samples from recurrences constituted 18% (6/34) of the endometriomas, 37% (10/27) of the biopsies from ovarian lesions, and 4 of 5 biopsies from peritoneal endometriosis. In primary endometriotic lesions, both ER and PR were significantly lower than in endometrium. In recurrent lesions, ER levels in cytosol were significantly lower than in endometrium, but there was no difference concerning PR. In endometriotic tissue, the PR level was significantly higher in recurrent than in primary tissue, but there was no difference concerning ER. The ER level was significantly lower in ovarian but not in peritoneal endometriosis, compared with endometrium. No difference was seen concerning PR.

CONCLUSION

This study shows differences in ER and PR levels in primary and recurrent endometriosis and indicates a different hormonal regulation of the two stages of the disease.

Estrogen and progesterone receptors in vessel walls. Biochemical and immunochemical assays

The purpose of the present investigation was to examine the estrogen and progesterone receptor status in arterial and vein walls in women and men. Biopsies from uterine arteries and veins were obtained from 14 fertile and six post menopausal women. Biopsies from saphenous veins were obtained from eight fertile women, 12 post menopausal women and 12 men. Comparative receptor assays were performed with ligand technique and monoclonal antibodies. Immunohistochemical localization of estrogen and progesterone receptors was performed using monoclonal antibodies. The ligand technique revealed estrogen and progesterone receptors in low frequency in the uterine vessels but the monoclonal antibodies showed low receptor level in all arterial and vein samples. There was no statistical difference between fertile and post menopausal women. In the few nuclear fractions examined, both estrogen and progesterone receptors were measurable. Estrogen receptors were found in all peripheral vein samples from fertile women but not in all samples from post menopausal women and men. Progesterone receptors were detected in almost all samples of peripheral veins. There were significant differences with higher levels of estrogen receptors in cytosol and nuclear fraction and of progesterone receptors in nuclear fraction, all assayed with monoclonal antibodies, in uterine veins from fertile women compared to peripheral veins from fertile women, post menopausal women and men, respectively. These data indicate that the hormonal regulation of peripheral vein walls is different than that of the uterine vessel.

Identification of binding sites on the regulatory A subunit of protein phosphatase 2A for the catalytic C subunit and for tumor antigens of simian virus 40 and polyomavirus

Protein phosphatase 2A is composed of three subunits: the catalytic subunit C and two regulatory subunits, A and B. The A subunit consists of 15 nonidentical repeats and has a rodlike shape. It is associated with the B and C subunits as well as with the simian virus 40 small T, polyomavirus small T, and polyomavirus medium T tumor antigens. We determined the binding sites on subunit A for subunit C and tumor antigens by site-directed mutagenesis of A. Twenty-four N- and C-terminal truncations and internal deletions of A were assayed by coimmunoprecipitation for their ability to bind C and tumor antigens. It was found that C binds to repeats 11 to 15 at the C terminus of A, whereas T antigens bind to overlapping but distinct regions of the N terminus. Simian virus 40 small T binds to repeats 3 to 6, and polyomavirus small T and medium T bind to repeats 2 to 8. The data suggest cooperativity between C and T antigens in binding to A. This is most apparent for medium T antigen, which can only bind to those A subunit molecules that provide the entire binding region for the C subunit. We infer from our results that B also binds to N-terminal repeats. A model of the small T/medium T/B-A-C complexes is presented.

Extragenital endometriosis. A review

Extragenital endometriosis is common and may be found in any tissue. The most pronounced symptoms are pain and local bleeding that usually (at least initially) are cyclical and more pronounced at the time of menstruation. The lesions often infiltrate neighbouring organs, and cause considerable fibrosis together with increasing symptoms. The patients have often had pain for many years, have been investigated at different clinics, and been given conflicting diagnoses, often of mental instability, before the correct diagnosis is finally made. The disease is difficult to diagnose clinically, and must be verified histologically. Often the endometriosis responds to treatment with hormones to inactivate the ovaries, but, sometimes the lesions are resistant, or respond too slowly, to drugs, and local excision is required. A gynaecologist should be called if the diagnosis is made at laparotomy or laparoscopy, to establish the extension of the endometriotic lesion and should be consulted about complementary investigations and hormonal treatment.

Islet cell antibody reactivity with human fetal pancreatic islets

To evaluate the possibility of autoimmune processes against pancreatic islets in fetal life, we tested islet cell antibody (ICA) reactivity with 14 fetal pancreata obtained after abortion at the 15th up to the 19th week of gestation. Pancreatic islets positive for a monoclonal proinsulin antibody but non-reactive with ICA negative control serum were found in 9/14 pancreata and all (9/9) of them showed a positive reaction with the ICA standard. It is concluded that ICA reactivity may be detected in fetal human pancreata. Further studies on fetal islet cell antibody reactivity in the development of insulin dependent diabetes mellitus (IDDM) are warranted.

No transplacental passage of standard heparin or an enzymatically depolymerized low molecular weight heparin

In 21 women who had an abortion by hysterotomy between the 15th and 23rd week of pregnancy, the possibility that unfragmented heparin or low molecular weight heparin (LMWH) passed the placental barrier to the foetus was studied. Laboratory analyses included amidolytic assays of factor Xa inhibitory activity (XaI), antithrombin III (ATIII) and a direct measurement of heparin-like substances in plasma with a competitive binding assay. The ATIII concentration in foetal plasma was about 20% of that in normal human plasma and varied considerably between individuals (2-27%). The XaI activity did not differ between the two treated groups, but the mean XaI activity of the combined groups differed from zero (P less than 0.05). If the XaI activity was corrected for the ATIII concentration, the heparin activities no longer differed significantly from zero. As the concentration of heparin-like substances were above the detection limit (0.35 microgram/ml) in 6/16 analysable samples of foetal plasma, a further 15 women who had not received any heparin were included as controls. In 12/14 analysable foetal plasmas heparin-like substances in concentrations above 0.35 micrograms/ml could be detected. Determination of heparin activity in foetal plasma is thus difficult due to the influence of endogenous ATIII on heparin assays. In conclusion, this study did not demonstrate any evidence for the passage of heparin or LMWH across the placental barrier. No differences were detected whether unfragmented heparin or LMWH had been given to the mothers. Our results also indicate the presence of an endogenous glycosaminoglycan in foetal plasma.

Loss of DNA-binding and new transcriptional trans-activation function in polyomavirus large T-antigen with mutation of zinc finger motif

A putative zinc finger in polyomavirus large T-antigen was investigated. We were unable to demonstrate unequivocally a requirement for zinc in specific DNA-binding using the chelating agent 1, 10-phenanthroline. An involvement of the putative zinc finger in specific DNA-binding was nevertheless suggested by the properties of a mutant protein with a cys----ser replacement in the finger motif. Probably as a result of the defective DNA-binding, the mutant protein had lost its activity in initiation of viral DNA-replication and in negative regulation of viral early transcription. However, the trans-activation of the viral late promoter was normal. The analysis also revealed a previously unrecognized activity of large T-antigen. The mutant protein trans-activated the viral early promoter. In the wild-type protein this activity is probably concealed by the separate, negative regulatory function.

Late symptoms after pregnancy-related deep vein thrombosis

Thromboembolism during pregnancy is a rare complication with a potential fatal outcome. Very little is known about long-term effects and therefore 104 women with thrombosis during pregnancy or puerperium were identified and their subjective complaints were assessed in a questionnaire. All had their thrombosis diagnosed by objective methods and the median follow-up time was 11 years. In spite of anticoagulant treatment only 22% were without complaints; 4% had ulceration, all occurring in the group with thrombosis during pregnancy. Significantly more women who had had their thrombosis during pregnancy used compression bandages than those who had their thrombosis during puerperium. The severity of the symptoms increased with the increasing number of thromboses. Anticoagulant therapy of the acute episode does not appear to alter the degree of long-term handicap in the lower limbs.

Recurrent thromboembolism in pregnancy and puerperium. Is there a need for thromboprophylaxis?

By sending a questionnaire (response rate 93%) to 321 women with a history of venous thromboembolism and previous coagulation tests, 72 patients were identified who had a total of 87 pregnancies after the thromboembolic episode. The main aim of the study was to analyze the influence of prophylaxis during pregnancy and delivery on the development of further thromboembolic complications. During pregnancy there was no difference in frequency of thromboses between the group given prophylaxis (n = 20) and the group not receiving it (n = 67). At delivery the frequency of thrombosis was 5.3% among the 57 women given prophylaxis and 11.1% among the 30 without prophylaxis, a difference that is not significant. The implication of these findings is discussed both concerning the indications for giving prophylaxis and concerning the problem of designing relevant prophylactic trials.

Metabolism of estrone sulfate in endometriotic tissue and in uterine endometrium in proliferative and secretory cycle phase

The metabolism of [3H]estrone sulfate (E1S) into [3H]estrone (E1) and [3H]estradiol-17 beta (E2) was studied in samples of endometriotic tissue and uterine endometrium obtained simultaneously from 13 patients, 7 in the proliferative and 5 in the secretory cycle phase, and 1 menstruating. E1S was efficiently converted into E1 and E2 by both types of tissue. Total hydrolysis (formation of E1 + E2), as well as the specific formation of E2, was higher in uterine endometrium than in endometriotic tissue, especially in the proliferative phase. Cycle phase associated variations in E2 formation occurred in both tissues, but were statistically significant only for uterine endometrium. E2 formation and total hydrolysis were correlated in endometriotic tissue, but not in uterine endometrium, indicating certain differences in the regulation of estrogen metabolism.

Vascular injuries during gynecologic surgery

Iatrogenic vascular injuries are common in the civilian western world. The frequency seen following gynecologic surgery is not known and a questionnaire was therefore sent to all gynecologic clinics in Sweden undertaking surgery, to establish the frequency during a 5-year period and to analyse the types of injury. Case reports in the literature were also analysed. The frequencies per 10,000 operations were: after laparoscopy, 0.93, after laparotomy, 0.76 and after major vaginal surgery, 0.33. All laparoscopic injuries were localized to the iliac arteries, caused bleeding, and were treated with arterial suture without complications or late sequelae. Injuries during laparotomy were most frequently venous and all patients had hemorrhage as the main symptom. In one case the external iliac vein was ligated, with immediate postoperative swelling, and in another case the external iliac artery was ligated, after which the patient developed postoperative ischemia. The internal iliac veins were ligated, and the other vessels reconstructed. There was no mortality, but a high rate of morbidity, also with late sequelae.

Endometriosis in the uterosacral ligament giving orthopedic symptoms through compression of the sciatic nerve and surgically treated via an extraperitoneal approach keeping the pelvic organs intact

Sciatic pain in a young woman was not relieved by orthopedic treatment. The gynecologist found a large hard tumor-like mass in the uterosacral ligament extending to the pelvic wall. Cytologic examination of fine needle aspirate indicated an endometriotic lesion. The large tumor-like mass was extirpated by an extraperitoneal technique and the pain disappeared.

Glycogen and acid and neutral polysaccharides in endometriotic tissue and in uterine endometrium: a comparative histochemical study

A comparative histochemical study was performed on endometriotic tissue and uterine endometrium obtained simultaneously from the same patient. No difference in the amount and distribution of glycogen and acid and neutral polysaccharides was found in the samples from the 26 women studied.

Late venous function in the leg after deep venous thrombosis occurring in relation to pregnancy

The frequency of deep venous insufficiency was investigated in 23 patients 3-10 years (mean 7 years) after they had developed an objectively diagnosed deep venous thrombosis (DVT) during pregnancy or the first week after delivery. Investigations included clinical examination, listing of symptoms and plethysmography, venous pressure and Doppler ultrasound. At follow-up there were clinical signs or symptoms of venous insufficiency in 35% of the legs with earlier DVT but in none of the non-thrombosed contralateral legs. Objective evidence of venous insufficiency was present in 15 (65%) of the legs with earlier DVT and in only five (22%) of the non-thrombosed legs. The differences between thrombosed and non-thrombosed legs are statistically significant. There was no correlation between objectively measured venous insufficiency and extent of the DVT. It is concluded that a DVT during pregnancy often leads to venous insufficiency and the risk seems to be higher than after DVT occurring in other groups of patients.

Colonization of broilers with Campylobacter in conventional broiler-chicken flocks

Eight of 16 conventional broiler-chicken flocks examined contained Campylobacter. All isolates were identified as C. jejuni except from 1 flock were C. coli was isolated. One herd consisting of 6 different houses where Campylobacter regularly has been isolated was continuously examined. It was not possible to isolate Campylobacter from newly hatched chickens or from environmental samples and cloacal swabs during the 2 first weeks of growth.

Characterization and localization of specific oestrogen binding in the human thymus

Clinical and experimental observations suggest that oestrogens may influence immune reactivity. The oestrogen-binding properties of the human thymus were studied by the use of an aqueous two-phase separation technique. A specific, high-affinity and low-capacity binding was found in 9 out of 10 thymic tissue samples obtained from children and adults of both sexes, their ages ranging from 1 to 42 years. The association constant (+/- SD) for the oestradiol binding in human thymus was 3.7 +/- 1.4 X 10(9) M-1 and was in the same range as the receptor binding in the human uterus. The steroid specificity was found to differ from the classical oestrogen receptor. The concentration of oestrogen-binding sites (+/- SD) was 182 +/- 181 fmol/mg protein and was higher than the receptor concentration of the uterus. According to histochemical analyses the binding is located in the reticulo-epithelial stroma rather than the thymocytes. Data suggest that the human thymus is a target organ for oestrogens which may influence lymphocyte function during therapy.

Human uterine endometrium and endometriotic tissue transplanted into nude mice. Morphologic effects of various steroid hormones

In a study of the morphologic effects of various steroid hormones on human uterine endometrium and endometriotic tissue, specimens from 6 women were transplanted subcutaneously into 24 nude mice. In each case, specimens collected simultaneously were transplanted to 4 mice, endometrium to one lateral abdominal wall and endometriotic tissue to the other. All mice were given polyestradiol phosphate subcutaneously the first day after operation. After a 2-week interval, of each 4 mice, 1 mouse was given polyestradiol phosphate, 1 medroxyprogesterone acetate, 1 danazol, and 1 no further injections. This treatment continued for 8 weeks, after which the mice were killed and the grafts extirpated. Histologic changes in the grafts varied according to the treatment schedule but were very similar in both types of tissue. Our findings suggest that histologic differences between endometrium and endometriotic tissue seen under natural conditions may, at least partly, be due to variations in environmental factors.

Human endometrium transplanted into nude mice. Histologic effects of various steroid hormones

In a histologic study of human endometrium transplanted into nude mice, eutopic endometrium from each of 8 women was transplanted subcutaneously to 4 nude mice, 1 of which was treated with polyestradiol phosphate, 1 with MPA, 1 with danazol, and 1 of which was left untreated as a control. Grafts were removed after varying intervals of up to 57 days. Residual histologically evaluable endometrial tissue was found in 32 of the 96 grafts (33%). None of the extirpated grafts had the same histologic pattern as the eutopic endometrium. Besides confirming that human endometrium can be transplanted into nude mice, our findings suggest that grafts react histologically in the same way as eutopic human endometrium to hormone treatment. The specific stroma seems to be crucial to a graft's capacity to respond to hormonal stimuli, and its replacement by fibrous tissue was accompanied by glandular epithelial changes very similar to those seen in human endometriotic lesions.

Binding of estrogen and progesterone to human endometrium in the different phases of the menstrual cycle. A histochemical study

Specific estrogen and progesterone binding in human endometrium was studied histochemically using fluorochrome-labeled steroids (estradiol-17 beta-BSA-FITC and progesterone-BSA-TMRITC), endometrial samples from 36 women being investigated. The binding pattern was similar with both reagents. The relationship between the bindings to glands and to stroma, however, varied with the menstrual phase of the tissue. The specific fluorescence was more intense in the epithelial structures in the proliferative phase. In the secretory phase, the fluorescence from stromal cells was as intense as, or more intense than, that from the glands. The localization of the fluorophores in the glandular epithelial cells also varied by menstrual phase. In the proliferative phase, the fluorescence was most intense in the basal part or the whole cytoplasm of the glandular epithelial cells, while in the secretory phase the fluorescence was most intense in the apical and sometimes also in the basal part of the epithelial cells.

Histochemical demonstration of estrogen and progesterone binding in endometriotic tissue and in uterine endometrium: A comparative study

Estrogen and progesterone binding to endometriotic and endometrial tissue was studied histochemically using estradiol and progesterone fluorochrome derivatives (E2-bovine serum albumin-fluorescein isothiocyanate and progesterone-bovine serum albumin-tetramethylrhodamine isothiocyanate). Thirty endometriotic samples from 21 women were studied, together with endometrial specimens obtained simultaneously from 14 of the women. In 77% of the endometriotic samples binding of the estrogen conjugate was indicated by specific fluorescence in more than half of the epithelial cell population, and in 20% in less than half. The corresponding figures for the progesterone conjugate binding were 75 and 18%, respectively. Blocking studies indicated a reasonable degree of ligand specificity. In endometrial tissue the corresponding figures were 64 and 29%, respectively, for binding of the estrogen conjugate and 54 and 38%, respectively, for binding of the progesterone conjugate. In 7 of 13 cases where evaluable samples of both tissues had been obtained, the relative proportion of fluorescent cells, with either reagent, was similar in the two tissue types. Our results suggest that the cytoplasm of epithelial cells in endometriotic tissue and in uterine endometrium contains specific binding sites for both estrogen and progesterone. The binding pattern of the two conjugates in endometriotic tissue was unrelated to the menstrual phase.

Histochemical localization of estrogen and progesterone receptors: evaluation of a method

A histochemical method for the detection of estrogen (ER) and progesterone (PR) receptors in human endometrium, using estrogen and progesterone derivatives linked to fluorochrome-labeled bovine serum albumin (E2-BSA-fluorescein isothiocyanate (FITC) and progesterone-BSA-tetramethylrhodamine isothiocyanate (TMRITC], has been evaluated. The fluorochrome-labeled steroids were bound to the cytoplasm--preferably in glandular epithelial cells but to a lesser extent also to stromal cells. The steroid specificity of the observed binding was studied by preincubating the sections with a series of unlabled steroids and nonsteroidal, hormonally active compounds (estradiol-17 beta, diethylstilbestrol, tamoxifen, 5 alpha-dihydrotestosterone and R 1881 for ER and ORG 2058, R 5020, dexamethasone, cortisol and 5 alpha-dihydrotestosterone for PR). The inhibition studies indicated that E2-BSA-FITC and progesterone-BSA-TMRITC bind to ER and PR in human endometrium with a reasonable degree of specificity. The method was reproducible and various procedural steps were tested, showing satisfactory technical stability. The method is applicable to small tissue samples, and is a valuable complement to quantitative biochemical receptor assays, as it localizes the receptors in tissue slices.

Human endometrium and endometriotic tissue obtained simultaneously: a comparative histological study

A comparative study on the histological appearance of endometrium and endometriotic tissue obtained simultaneously has been performed. In all, 47 endometriotic samples from 28 patients were examined. In 15 cases, samples from more than one endometriotic lesion were included. The endometriotic tissue had developed a distinctive menstrual phase pattern in 23 patients (82%). In 16 of these patients (70%), the phase pattern was found to be synchronous (+/- 3 days) in the two tissue types. In seven cases (30%), it varied inconsistently as compared with the endometrial phase. In the remaining five cases (18%), no menstrual phase pattern was found in the endometriotic specimens in spite of a well-defined phase in the endometrium. When biopsy specimens from different endometriotic lesions in the same patient showed a menstrual phase pattern, the phase did not differ significantly among the specimens. Although a menstrual phase pattern could be recognized in the endometriotic tissue samples in most cases, a considerable variability in glandular and epithelial cell morphology was frequently found.