Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Chronic endometritis multiplies the recurrence risk of endometrial polyps after transcervical resection of endometrial polyps: a prospective study

BACKGROUND

To investigate the impact of chronic endometritis (CE) on the recurrence of endometrial polyps (EPs) in premenopausal women after transcervical resection of endometrial polyps (TCRP).

METHODS

This prospective study enrolled 507 women who underwent TCRP between January 1, 2022 and December 31, 2022. The patients were divided into a CE group (n = 133) and non-CE group (n = 374) based on the expression of CD138 in the endometrium. The EP recurrence rate at 1 year after TCRP was compared between the CE and non-CE groups and between groups with mild CE and severe CE. The impact of CD138 expression by resected EPs on EP recurrence also was investigated.

RESULTS

The EP recurrence rate at 1 year post-TCRP was higher in the CE group than in the non-CE group (25.6% vs. 10.4%) and also higher in the severe CE group than in the mild CE group (34.5% vs. 18.7%). Additionally, the EP recurrence rate was higher among patients with CD138-expressing EPs than among those with EPs lacking CD138 expression (30.5% vs. 6.5%). The odds ratio (OR) for EP recurrence in the CE cohort compared with the non-CE cohort was 3.10 (95% confidence interval [CI] 1.84-5.23) after adjustment for EP number and precautions against EP recurrence. The ORs for EP recurrence in patients with mild CE and severe CE were 2.21 (95%CI 1.11-4.40) and 4.32 (95%CI 2.26-8.26), respectively. Similarly, the OR for EP recurrence in cases with CD138-expressing EPs relative to cases with EPs lacking CD138 expression was 6.22 (95%CI 3.59-10.80) after adjustment for EP number and precautions against EP recurrence.

CONCLUSIONS

CE multiplied the recurrence rate of EPs in premenopausal women after TCRP, and this effect positively correlated with CE severity. CD138 expression by EPs also was associated with a higher risk for EP recurrence.

Endometrial microbiota alteration in female patients with endometrial polyps based on 16S rRNA gene sequencing analysis

Introduction

The potential role of the endometrial microbiota in the pathogenesis of endometrial polyps (EPs) warrants further investigation, given the current landscape of limited and inconclusive research findings. We aimed to explore the microecological characteristics of the uterine cavity in patients with EPs and investigate the potential of endometrial microbiota species as novel biomarkers for identifying EPs.

Methods

Endometrial samples were collected from 225 patients who underwent hysteroscopies, of whom 167 had EPs, whereas 58 had non- hyperproliferative endometrium status. The endometrial microbiota was assessed using 16S rRNA gene sequencing. We characterized the endometrial microbiota and identified microbial biomarkers for predicting EPs.

Results

The endometrial microbial diversity and composition were significantly different between the EP and control groups. Predictive functional analyses of the endometrial microbiota demonstrated significant alterations in pathways involved in sphingolipid metabolism, steroid hormone biosynthesis, and apoptosis between the two groups. Moreover, a classification model based on endometrial microbial ASV-based biomarkers along with the presence of abnormal uterine bleeding symptoms achieved powerful classification potential in identifying EPs in both the discovery and validation cohorts.

Conclusion

Our study indicates a potential association between altered endometrial microbiota and EPs. Endometrial microbiota-based biomarkers may prove valuable for the diagnosis of EPs.

Clinical trial registration

Chinese Clinical Trial Registry (ChiCTR2100052746).

Case report: septic shock after endometrial polypectomy with tissue removal system

As an emerging surgical technology, tissue removal systems have been widely used in the treatment of endometrial polyps due to its characteristics of less endometrial damage, shorter learning curve and clearer vision of the operative field. There are few cases in the literature reporting serious complications after endometrial polypectomy using tissue removal systems. As known, septic shock is a rare complication following hysteroscopic polypectomy. Now, we present the case of a 23-year-old woman who developed septic shock after polypectomy with tissue removal system. The patient had a history of recurrent vaginitis for more than half a year. Due to endometrial polyps, she was admitted to our hospital and scheduled to undergo hysteroscopic endometrial polypectomy. Three hours after the endometrial polypectomy using the tissue removal system, the patient had shock symptoms such as increased body temperature, decreased blood pressure and increased heart rate. Then, the patient was successfully treated and discharged after anti-infection and anti-shock treatments. The purpose of this case report is to remind clinicians to consider the possibility of serious infection and comprehensively evaluate the risk of infection before choosing hysteroscopic devices for endometrial polyps, especially for patients who choose the mechanical hysteroscopic tissue removal systems. Furthermore, the mechanical hysteroscopic tissue removal systems should be used with caution in patients with previous recurrent vaginitis.

Serum Essential Trace Element Status in Women and the Risk of Endometrial Diseases: a Case-Control Study : Serum Essential Trace Element Status in Women and the Risk of Endometrial Diseases: a Case-Control Study

Endometrial diseases, including uterine fibroids, polyps, intrauterine adhesion, endometritis, etc., are the major causes of infertility among women. However, the association between essential trace element status in women and the risk of endometrial disease is limited and unclear. This study aimed to investigate this association using a case-control study design; a total of 302 women patients with endometrial diseases and 302 healthy women were included. Compared to women in the control group, serum selenium (Se) (p = 0.024) and zinc (Zn) (p = 0.017) levels were significantly lower, while copper (Cu) (p = 0.004) and molybdenum (Mo) (p = 0.005) levels were significantly higher among women with endometrial diseases. In addition, compared to women in the first quartile of the copper/zinc (Cu/Zn) ratio value group, the adjusted ORs (95% CIs) of endometrial diseases were 1.50 (1.05, 2.14), 1.68 (1.18, 2.39), and 1.47 (1.02, 2.10), respectively, in the second, third, and fourth quartile of the Cu/Zn ratio value group (p trend = 0.047). In addition, the results from restricted cubic splines showed that the dose-response relationships of serum levels of these essential elements with the risk of endometrial diseases were nonlinear for Se, Cu, and Zn and relatively linear for Mo and Cu/Zn ratio. The present study showed serum levels of Zn and Se among women with endometrial diseases were significantly lower compared to that among healthy women, while serum levels of Cu and Mo were significantly higher, in addition, the serum Cu/Zn ratio value was also significantly and positively associated with the risk of endometrial diseases.

Cyclic processes in the uterine tubes, endometrium, myometrium, and cervix: pathways and perturbations

This review leads the 2023 Call for Papers in MHR: 'Cyclical function of the female reproductive tract' and will outline the complex and fascinating changes that take place in the reproductive tract during the menstrual cycle. We will also explore associated reproductive tract abnormalities that impact or are impacted by the menstrual cycle. Between menarche and menopause, women and people who menstruate living in high-income countries can expect to experience ∼450 menstrual cycles. The primary function of the menstrual cycle is to prepare the reproductive system for pregnancy in the event of fertilization. In the absence of pregnancy, ovarian hormone levels fall, triggering the end of the menstrual cycle and onset of menstruation. We have chosen to exclude the ovaries and focus on the other structures that make up the reproductive tract: uterine tubes, endometrium, myometrium, and cervix, which also functionally change in response to fluctuations in ovarian hormone production across the menstrual cycle. This inaugural paper for the 2023 MHR special collection will discuss our current understanding of the normal physiological processes involved in uterine cyclicity (limited specifically to the uterine tubes, endometrium, myometrium, and cervix) in humans, and other mammals where relevant. We will emphasize where knowledge gaps exist and highlight the impact that reproductive tract and uterine cycle perturbations have on health and fertility.

Pituitary suppression with GnRH agonists before ART may be insufficient to treat women with severe adenomyosis

RESEARCH QUESTION

Does aromatase inhibitor improve IVF outcomes by reducing local oestrogen production in patients with adenomyosis undergoing long-term gonadotrophin-releasing hormone agonist (GnRHa) treatment?

DESIGN

Four patients with severe adenomyosis who failed to improve after long-term treatment (≥3 months) with depot GnRHa received treatment with an aromatase inhibitor for 21 days. Blood oestradiol concentrations were monitored after GnRHa treatment both before and after treatment with an aromatase inhibitor. Women received a transfer of IVF autologous or donor oocytes. Pregnancy and ongoing pregnancy rates were the primary outcomes. Blood oestradiol concentration after treatment with an aromatase inhibitor was a secondary outcome.

RESULTS

Patients with severe adenomyosis presented with hyperestrogenism due to local production from the lesions even after long-term treatment with GnRHa. Treatment with an aromatase inhibitor reduced hyperestrogenism and improved clinical outcomes in adenomyosis patients who have experienced previous embryo transfer failures.

CONCLUSION

Women with severe adenomyosis would benefit from letrozole or a combination of GnRHa plus letrozole before receipt of treatment with assisted reproductive technology. For women with severe adenomyosis, GnRHa treatment alone may be insufficient to suppress oestrogen production by adenomyotic lesions. Thus, it should be mandatory to test for oestradiol concentrations in patients with severe adenomyosis who have received long-term GnRHa treatment. Also, GnRHa may not always be the sole strategy for medical management of adenomyotic lesions. Letrozole is safe and can improve IVF outcomes for patients with adenomyosis.

Optimal waiting period for frozen embryo transfer after hysteroscopic polypectomy: A propensity score matching analysis

OBJECTIVE

To evaluate the optimal waiting period for frozen-thawed embryo transfer (FET) after hysteroscopic polypectomy (HSC-P).

DESIGN

Retrospective cohort.

SETTING

University-affiliated hospital.

PATIENTS

All patients included in this research underwent hysteroscopy before the first FET cycle after whole embryo freezing. A total of 206 patients had undergone HSC-P, and 3681 patients without endometrial polyps were defined as the controls.

INTERVENTIONS

HSC-P.

MAIN OUTCOME MEASURES

The HSC-P group was divided into three subgroups based on the time interval between HSC-P and the start of an FET cycle. Subgroup 1 consisted of patients who underwent FET after their next menses, subgroup 2 after two menstrual cycles, and subgroup 3 after three or more menstrual cycles. Demographics, baseline in vitro fertilization (IVF) characteristics, and pregnancy outcomes, especially perinatal outcomes after FET were compared among the groups.

RESULTS

There were 137 patients in subgroup 1, 40 in subgroup 2, and 29 in subgroup 3. There were no differences in the baseline characteristics of the three groups. IVF-related data and FET-related data, such as endometrial thickness and ET no. Of embryoes, were similar among the three subgroups. The three subgroups showed no significant differences in implantation rate, biochemical pregnancy rate, abortion rate, clinical pregnancy rate or live birth rate. Besides, There was no significant difference in perinatal outcomes including very preterm delivery, preterm delivery, low birth weight, macrosomia, small for gestational age, large for gestational age, birth weight(g), birth-height(cm)and Apgar Scores.

CONCLUSIONS

Compared with FET after their next menses, FET after two or more menstrual cycles after HSC-P does not necessarily produce superior outcomes.

Integrating Network Pharmacology and Experimental Validation Deciphers the Mechanism of Guizhi Fuling Wan against Adenomyosis

Aim

This study aimed to predict the key targets and endocrine mechanisms of Guizhi Fuling Wan (GZFLW) in treating adenomyosis (AM) through network pharmacology, molecular docking, and animal experiment verification.

Methods

The related ingredients and targets of GZFLW in treating AM were screened out using TCMSP, BATMAN-TCM, SwissTargetPrediction, and PubChem Database. Then, the protein-protein interaction (PPI) analysis and the network of compound-hub targets were constructed. At the same time, the key targets were uploaded to the Metascape Database for KEGG pathway enrichment analysis. After that, the molecular docking technology of the main active components and hub targets was performed. Furthermore, animal experiments were used to verify the results of network pharmacology analysis.

Results

A total of 55 active ingredients of GZFLW and 44 overlapping targets of GZFLW in treating AM were obtained. After screening, 25 hub targets were collected, including ESR1, EGF, and EGFR. Then, the KEGG pathway enrichment analysis results indicated that the endocrine therapeutic mechanism of GZFLW against AM is mainly associated with the estrogen signaling pathway, endocrine resistance, and an EGFR tyrosine kinase signaling pathway. Then, molecular docking showed that the significant compounds of GZFLW had a strong binding ability with ERα and EGFR. More importantly, the animal experiments confirmed that the GZFLW could downregulate the abnormal infiltration of the endometrial epithelium into the myometrium and had no interference with the normal sexual cycle. This effect may be directly related to intervening the local estrogen signaling pathway of the endometrial myometrial interface (EMI). It may also be associated with the myometrium cells' estrogen resistance via GPER/EGFR signaling pathway.

Conclusion

The endocrine mechanism of GZFLW in treating AM was explored based on network pharmacology, molecular docking, and animal experiments, which provided a theoretical basis for the clinical application of GZFLW.

Uterine Artery Embolization with Small-Sized Particles for the Treatment of Symptomatic Adenomyosis: A 42-Month Clinical Follow-Up

Purpose

To assess the long-term outcome of performing uterine artery embolization (UAE) using small particles in women with symptomatic adenomyosis (AD).

Methods

Twenty-seven consecutive women (median age 42 years, range 29–53 years) with AD, in eight cases AD combined with fibroids, who underwent UAE between February 2015 and January 2019, were retrospectively analyzed. The embolization was performed using small-sized polyvinyl alcohol particles (100 μm and 300 μm). The patients completed the Uterine Fibroid Symptom and Quality of Life questionnaire at baseline and at a 42-month follow-up (range 24–71). The junction zone (JZ) thickness and uterine volume were also calculated at baseline and at a three-month follow-up.

Results

The total symptom severity score (SSS) decreased from a median of 59 (range 34–78) at baseline to a median of 9 (range 3–47) at the end of this study; the health-related quality of life score (HRQOL) increased from a median of 38 (range 23–49) at baseline to a median of 84 (range 46–97) at 42 months. Twenty of the 27 patients were asymptomatic. The clinical response of the remaining seven women was little improvement in their symptoms, and one of the seven women underwent a hysterectomy at 35 months. Twenty-six of the 27 (96%) patients had a preserved uterus at the 42-month follow-up. There was no difference after UAE in SSS, HRQOL, junction zone (JZ) thickness, and uterus volume between patients with pure AD and those with AD combined with fibroids (p = 0.729, 0.710, 0.973, and > 0.99). There was no difference in the JZ thickness and uterus volume at baseline between the asymptomatic women and the women with an insufficient response (p = 0.854 and 0.253), and there were no major complications afterwards.

Conclusion

From the long-term follow-ups, it could be seen that UAE using small particles is safe and effective in treating AD, especially in preserving the uterus. There is no relationship between the clinical outcomes and the initial presence of AD, with or without fibroids, and the JZ thickness at baseline does not seem to be a predictor for the long-term outcome of UAE.

Upregulated Talin1 synergistically boosts β-estradiol-induced proliferation and pro-angiogenesis of eutopic and ectopic endometrial stromal cells in adenomyosis

Adenomyosis (ADS) is an estrogen-dependent gynecological disease with unspecified etiopathogenesis. Local hyperestrogenism may serve a key role in contributing to the origin of ADS. Talin1 is mostly identified to be overexpressed and involved in the progression of numerous human carcinomas through mediating cell proliferation, adhesion and motility. Whether Talin1 exerts an oncogenic role in the pathogenesis of ADS and puts an extra impact on the efficacy of estrogen, no relevant data are available yet. Here we demonstrated that the adenomyotic eutopic and ectopic endometrial stromal cells (ADS_Eu_ESC and ADS_Ec_ESC) treated with β-estradiol (β-E₂) presented stronger proliferative and pro-angiogenetic capacities, accompanied by increased expression of PCNA, Ki67, VEGFB and ANGPTL4 proteins. Meanwhile, these promoting effects were partially abrogated by Fulvestrant (ICI 182780, an estrogen-receptor antagonist). Aberrantly upregulation of Talin1 mRNA and protein level was observed in ADS endometrial specimens and stromal cells. Through performing functional experiments in vitro, we further determined that merely overexpression of Talin1 (OV-Talin1) also enhanced ADS stromal cell proliferation and pro-angiogenesis, while the most pronounced facilitating effects were found in the co-intervention group of OV-Talin1 plus β-E₂ treatment. Results from the xenograft nude mice model showed that the hypodermic endometrial lesions from co-intervention group had the highest mean weight and volume, compared with that of individual OV-Talin1 or β-E₂ treatment. The expression levels of PCNA, Ki67, VEGFB and ANGPTL4 in the lesions were correspondingly elevated the most in the co-intervention group. Our findings unveiled that overexpressed Talin1 might cooperate withβ-E₂ in stimulating ADS endometrial stromal cell proliferation and neovascularization, synergistically promoting the growth and survival of ectopic lesions. These results may be beneficial to provide a new insight for clarifying the pathogenesis of ADS.

Adjuvant therapy in conservative surgery for adenomyosis

OBJECTIVE

To investigate the significance of perioperative levonorgestrel-releasing intrauterine system (LNG-IUS) and/or gonadotropin-releasing hormone agonists (GnRHa) as adjuvant therapy in preventing recurrences or progression of diseases.

METHODS

Medical records were collected from patients diagnosed with adenomyosis who underwent uterus-sparing surgeries from March 1, 2012 to December 31, 2018. The associations of perioperative adjuvant therapy with recurrence of disease and symptoms were analyzed with the Kaplan-Meier method and proportional hazards models with hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

A total of 322 eligible patients were included, of whom 173 (58.1%) received perioperative adjuvant therapy. Perioperative adjuvant therapy (HR 0.44, 95% CI 0.22-0.91, P = 0.022) and perioperative GnRHa therapy (HR 0.48, 95% CI 0.24-0.99, P = 0.042) significantly reduced disease recurrence. No patient using perioperative LNG-IUS therapy experienced recurrence. In the multivariate analysis, increased age (>35 years at surgery) was the only risk factor for disease recurrence (HR 2.35, 95% CI 1.01-5.45, P = 0.047).

CONCLUSION

Perioperative adjuvant therapy with GnRHa and/or the LNG-IUS can significantly reduce disease recurrence or progression for adenomyosis patients undergoing uterus-sparing surgery. Older patients are more likely to experience disease recurrence.

TGF-β1 role in uterine leiomyoma and endometrial polyp: an insight to drug-based treatment instead of surgical techniques

Objective

Considering the high prevalence of leiomyoma and endometrial polyps, investigating the contributing factors and determining the pathophysiology of these lesions are essential. Target therapy is now an acceptable method for the treatment of some diseases. We aimed to determine the expression of transforming growth factor (TGF)-β1 in endometrial polyps and leiomyomas to discover a drug-based method to overcome surgical treatments.

Methods

In this cross-sectional study, 55 patients with leiomyoma and 55 patients with polyps were included. Prepared slides from leiomyoma and adjacent myometrium or polyp lesions and adjacent endometrium were obtained and investigated for TGF-β1. Then, data were collected and analyzed using SPSS version 22.

Results

The mean age of participants was 40.6±5.8 years. Based on their reports, 88.2% (n=97) of patients in the study population had abnormal uterine bleeding with similar distributions among both groups. In contrast, 63.5% of the leiomyoma group did not express TGF-β1. However, in normal myometrium, 23.6% had the highest degree of TGF-β1 expression. Polyp tissue did not show staining for TGF-β1 in any patients. Additionally, 89.1% of non-polypoid endometrium did not express TGF-β1. Normal tissue had a significantly greater amount of TGF-β1 compared to leiomyoma and endometrial polyps.

Conclusion

TGF-β1 is expressed more prominently in normal myometrium with mostly high-intensity features compared to leiomyoma. Additionally, polyps showed no staining for TGF-β1, while normal endometrium showed a low-density staining pattern.