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Escudero-Lara A, Cabañero D, Maldonado R. Contribution of CD4+ cells in the emotional alterations induced by endometriosis in mice. Front Behav Neurosci 2022; 16:946975. [PMID: 36311856 PMCID: PMC9596757 DOI: 10.3389/fnbeh.2022.946975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Endometriosis is a disease defined by the presence of endometrial tissue in extrauterine locations. This chronic condition is frequently associated with pain and emotional disorders and has been related with altered immune function. However, the specific involvement of immune cells in pain and behavioral symptoms of endometriosis has not been yet elucidated. Here, we implement a mouse model of non-surgical endometriosis in which immunocompetent mice develop abdomino-pelvic hypersensitivity, cognitive deficits, anxiety and depressive-like behaviors. This behavioral phenotype correlates with expression of inflammatory markers in the brain, including the immune cell marker CD4. Depletion of CD4 + cells decreases the anxiety-like behavior of mice subjected to the endometriosis model, whereas abdomino-pelvic hypersensitivity, depressive-like behavior and cognitive deficits remain unaltered. The present data reveal the involvement of the immune response characterized by CD4 + white blood cells in the anxiety-like behavior induced by endometriosis in mice. This model, which recapitulates the symptoms of human endometriosis, may be a useful tool to study the immune mechanisms involved in pain and behavioral alterations associated to endometriosis.
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Affiliation(s)
- Alejandra Escudero-Lara
- Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - David Cabañero
- Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- David Cabañero,
| | - Rafael Maldonado
- Laboratory of Neuropharmacology, Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- *Correspondence: Rafael Maldonado,
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Tal A, Tal R, Pluchino N, Taylor HS. Endometrial cells contribute to preexisting endometriosis lesions in a mouse model of retrograde menstruation†. Biol Reprod 2020; 100:1453-1460. [PMID: 30869747 DOI: 10.1093/biolre/ioz039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/11/2019] [Accepted: 03/12/2019] [Indexed: 12/14/2022] Open
Abstract
Endometriosis is characterized by extrauterine growth of endometrial tissue accompanied by adverse clinical manifestations including chronic pelvic pain and infertility. Retrograde menstruation, the efflux of endometrium into the peritoneal cavity during menstruation, is believed to contribute to implantation of endometrial tissue and formation of endometriotic lesions at ectopic sites. While it is established through various rodent and nonhuman primate models that endometrial tissue fragments, as well as nondissociated stroma and glands, are capable of seeding endometriosis in a manner mimicking retrograde menstruation, the ability of single endometrial cells to participate in endometriotic processes has not been evaluated due to their failure to establish macroscopic endometriosis. We designed a model by which this capacity can be assessed by examining the integration of individual uterine cells into existing endometriosis lesions in mice. Endometriosis was induced in C57BL/6J female mice followed by intraperitoneal injection of GFP-labeled single uterine cells. We found that freshly introduced uterine cells can successfully integrate and contribute to various cell populations within the lesion. Strikingly, these cells also appeared to contribute to neo-angiogenesis and inflammatory processes within the lesion, which are commonly thought of as host-driven phenomena. Our findings underscore the potential of individual uterine cells to continuously expand lesions and participate in the progression of endometriosis. This model of retrograde menstruation may therefore be used to study processes involved in the pathophysiology of endometriosis.
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Affiliation(s)
- Aya Tal
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Reshef Tal
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nicola Pluchino
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
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3
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O DF, Roskams T, Van den Eynde K, Vanhie A, Peterse DP, Meuleman C, Tomassetti C, Peeraer K, D'Hooghe TM, Fassbender A. The Presence of Endometrial Cells in Peritoneal Fluid of Women With and Without Endometriosis. Reprod Sci 2016; 24:242-251. [PMID: 27324432 DOI: 10.1177/1933719116653677] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To reinforce Sampson's theory of retrograde menstruation in the pathogenesis of endometriosis, proof should be provided that during menstruation endometrial cells are present in peritoneal fluid (PF). We hypothesize that the prevalence of PF samples containing endometrial cells is higher in patients with endometriosis than in controls without endometriosis during menstruation. We selected from our biobank PF samples of 17 reproductive-age women with (n = 9) or without (n = 8) endometriosis who had received a diagnostic laparoscopy for investigation of pain/infertility. Peritoneal fluid had been collected during laparoscopy in the menstrual phase of the cycle, centrifuged, and the resulting pellet was stored at -80°C. About 5-μm sections of frozen PF pellets were stained using the Dako Envision Flex system with primary antibodies against epithelial cell adhesion molecule (Ep-CAM; endometrial epithelial cells), CD10 (endometrial stromal cells), prekeratin (epithelial/mesothelial cells), vimentin (endometrial/mesothelial/immune cells), calretinin (mesothelial cells), and CD68 (macrophages). The PF cells positive for Ep-CAM were detected in 5 of 9 patients with endometriosis and 6 of 8 controls ( P = .62). CD10 stained positively in 6 of the 9 patients with endometriosis and 3 of the 8 controls ( P = .35). Calretinin and prekeratin staining showed the presence of mesothelial cells in all pellets. Vimentin stained approximately 100% of the PF cells. CD68+ macrophages represented >50% of cells in all pellets. The prevalence of PF samples containing endometrial epithelial and stromal cells was not higher in patients with endometriosis than in controls without endometriosis during menstruation. Our findings question the relevance of endometrial cells in PF for the pathogenesis of endometriosis and support the importance of other mechanisms such as immune dysfunction and/or endometrial stem cells.
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Affiliation(s)
- Dorien F O
- 1 Department of Development and Regeneration, Organ systems, KU Leuven, Leuven, Belgium.,2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Tania Roskams
- 3 Department of Imaging and Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Kathleen Van den Eynde
- 3 Department of Imaging and Pathology, KU Leuven and University Hospitals Leuven, Leuven, Belgium
| | - Arne Vanhie
- 1 Department of Development and Regeneration, Organ systems, KU Leuven, Leuven, Belgium.,2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Daniëlle P Peterse
- 1 Department of Development and Regeneration, Organ systems, KU Leuven, Leuven, Belgium.,2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Christel Meuleman
- 2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Carla Tomassetti
- 2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Karen Peeraer
- 2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
| | - Thomas M D'Hooghe
- 1 Department of Development and Regeneration, Organ systems, KU Leuven, Leuven, Belgium
| | - Amelie Fassbender
- 1 Department of Development and Regeneration, Organ systems, KU Leuven, Leuven, Belgium.,2 Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
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4
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Stilley JAW, Birt JA, Sharpe-Timms KL. Cellular and molecular basis for endometriosis-associated infertility. Cell Tissue Res 2013; 349:849-62. [PMID: 22298022 PMCID: PMC3429772 DOI: 10.1007/s00441-011-1309-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/06/2011] [Indexed: 11/28/2022]
Abstract
Endometriosis is a gynecological disease characterized by the presence of endometrial glandular epithelial and stromal cells growing in the extra-uterine environment. The disease afflicts 10%–15% of menstruating women causing debilitating pain and infertility. Endometriosis appears to affect every part of a woman’s reproductive system including ovarian function, oocyte quality, embryo development and implantation, uterine function and the endocrine system choreographing the reproductive process and results in infertility or spontaneous pregnancy loss. Current treatments are laden with menopausal-like side effects and many cause cessation or chemical alteration of the reproductive cycle, neither of which is conducive to achieving a pregnancy. However, despite the prevalence, physical and psychological tolls and health care costs, a cure for endometriosis has not yet been found. We hypothesize that endometriosis causes infertility via multifaceted mechanisms that are intricately interwoven thereby contributing to our lack of understanding of this disease process. Identifying and understanding the cellular and molecular mechanisms responsible for endometriosis-associated infertility might help unravel the confounding multiplicities of infertility and provide insights into novel therapeutic approaches and potentially curative treatments for endometriosis.
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Affiliation(s)
- Julie A W Stilley
- Division of Reproductive and Perinatal Research, Department of Obstetrics, Gynecology and Women's Health, The University of Missouri School of Medicine, Columbia, 65212, USA
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Carvalho L, Podgaec S, Bellodi-Privato M, Falcone T, Abrão MS. Role of Eutopic Endometrium in Pelvic Endometriosis. J Minim Invasive Gynecol 2011; 18:419-27. [DOI: 10.1016/j.jmig.2011.03.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 02/27/2011] [Accepted: 03/03/2011] [Indexed: 11/15/2022]
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Wölfler MM, Meinhold-Heerlein IM, Söhngen L, Rath W, Knüchel R, Neulen J, Maass N, Henkel C. Two-dimensional gel electrophoresis in peritoneal fluid samples identifies differential protein regulation in patients suffering from peritoneal or ovarian endometriosis. Fertil Steril 2011; 95:2764-8. [PMID: 21497343 DOI: 10.1016/j.fertnstert.2011.03.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 03/06/2011] [Accepted: 03/21/2011] [Indexed: 11/27/2022]
Abstract
Endometriosis is determined by local and systemic proinflammatory dysregulation and therefore differential protein expression in peritoneal fluid (PF). Of highest interest is lesion formation and the establishment and persistence of endometriosis. In this study we analyzed well-characterized PF samples of patients with ovarian or peritoneal endometriosis and compared them to control samples. We found 11 proteins differentially regulated, of which some might play a key role in the pathogenesis of endometriosis.
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Affiliation(s)
- Monika M Wölfler
- Department of Obstetrics and Gynecology, Medical Faculty of RWTH Aachen University, Aachen, Germany.
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Sharpe-Timms KL, Nabli H, Zimmer RL, Birt JA, Davis JW. Inflammatory cytokines differentially up-regulate human endometrial haptoglobin production in women with endometriosis. Hum Reprod 2010; 25:1241-50. [PMID: 20176595 PMCID: PMC2902841 DOI: 10.1093/humrep/deq032] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 01/08/2010] [Accepted: 01/25/2010] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Evidence suggests that eutopic endometrium from women with endometriosis (US-E) has intrinsic functional anomalies compared with women without endometriosis (US-C). We hypothesized that differences in endometrial haptoglobin (eHp) mRNA and protein levels exist between eutopic endometrium from US-E and US-C and that inflammatory mediators may be involved. METHODS Endometrial stromal cells and tissue explants from US-E (n = 18) and US-C (n = 18) were cultured (24 h/48 h for cells/explants) with interleukin (IL)-1alpha, -1beta, -6, -8 or tumor necrosis factor-alpha (TNF-alpha) at 0-100 ng/ml. eHp protein in media and mRNA levels were quantified by enzyme-linked immunosorbent assay and quantitative PCR. RESULTS In eutopic endometrial stromal cells from US-E, IL-1beta, IL-6 and TNF-alpha (10 ng/ml) increased eHp mRNA levels (P = 0.002, P < 0.001 and P < 0.001, respectively) and eHp protein (P = 0.023, 0.031 and 0.006, respectively) versus control. In endometrial tissues from US-E, IL-1beta, IL-6 and TNF-alpha increased eHp mRNA (P < 0.001, P = 0.017 and P < 0.001, respectively) and eHp protein (P < 0.001, P = 0.007 and 0.039, respectively) versus control. IL-1alpha and IL-8 had small or no effects on isolated endometrial cells or tissues. In US-C, IL-1beta, IL-8 and TNF-alpha each reduced eHp mRNA in endometrial stromal cells (all P < 0.001) versus control; IL-1alpha and IL-6 had no effect. eHp mRNA increased in endometrial tissues from US-C in response to IL-1beta (P = 0.008), IL-6 (P = 0.015) and TNF-alpha (P = 0.031) versus control; IL-1alpha or IL-8 had no effect. CONCLUSIONS Endometrium from US-E differentially responds to specific inflammatory cytokines by production of eHp. We propose that up-regulation of endometrial eHp by inflammatory mediators disrupts normal endometrial function and may facilitate the pathogenesis of endometriosis.
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Affiliation(s)
- K L Sharpe-Timms
- Department of Obstetrics, Gynecology and Women's Health, The University of Missouri-Columbia, 1 Hospital Drive, N 625 HSC, Columbia, MO 65212, USA.
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Bokor A, Debrock S, Drijkoningen M, Goossens W, Fülöp V, D'Hooghe T. Quantity and quality of retrograde menstruation: a case control study. Reprod Biol Endocrinol 2009; 7:123. [PMID: 19878540 PMCID: PMC2789082 DOI: 10.1186/1477-7827-7-123] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 10/30/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to test the hypothesis that menstruation is associated with a higher concentration of endometrial cells in peritoneal fluid(PF) and with increased white and red blood cell concentration in PF when compared to nonmenstrual phases of the cycle. METHODS PF was obtained at laparoscopy from 107 women with endometriosis (n = 59) and controls with a normal pelvis (n = 48) during the luteal (n = 46), follicular (n = 38) or menstrual (n = 23) phase of the cycle. Endometriosis was classified according to the classification of the American Society for Reproductive Medicine (rAFS into minimal (n = 25), mild(n = 20), moderate(n = 6) and severe(n = 8) disease. Cell counts (leucocytes, erythrocytes, thrombocytes) were determined on a cell counter. In a subset of 32 patients (13 controls and 19 women with endometriosis), PF was fixed, processed and thinlayers were prepared and stained with Papanicolaou method and with immunocytochemistry using monoclonal antibodies against cytokeratin 7(CK 7), CK 8/18, Ber-Ep4, vimentin, calretinin and CD68. Ber-Ep4 is a marker for cells with epithelial origin (in some cases for mesothelial cells as well). CD68 is specific for cells from monocyte/macrophage lineage; CK7 and CK8/18 are markers for both endometrial epithelial and mesothelial cells, whereas calretinin and vimentin are markers for both endometrial stromal and mesothelial cells. RESULTS In comparison with the nonmenstrual phase of the cycle, analysis of PF during menstruation showed an increased concentration of leucocytes (3.3 x 109/L vs 0.8 x 109/L, P = 0.03), erythrocytes (0.3 x 1012/L vs 0.02 x 1012/L, P = 0.006), hematocrit (0.03 L/L vs 0.003 L/L, P = 0.01) and hemoglobin (0.8 g/dL vs 0.1 g/dL, P = 0.01). Mesothelial cells stained positively with CK7, CK8/18, vimentin, and calretinin. Cells positive for Ber-Ep4 were not observed, except in 2 patients with endometriosis investigated during menses. In all patients 50-98% of single cells were strongly positive for both vimentin and CD68. CONCLUSION When compared to nonmenstrual phases of the cycle, menstruation is associated with an increased concentration of red and white blood cells in PF. However, the presence of EM cells that are detectable by immunohistochemistry in PF is low during all phases of the cycle, including menstruation.
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Affiliation(s)
- Attila Bokor
- Leuven University Fertility Center, UZ Gasthuisberg, KULeuven, Belgium
| | - Sophie Debrock
- Leuven University Fertility Center, UZ Gasthuisberg, KULeuven, Belgium
| | | | | | | | - Thomas D'Hooghe
- Leuven University Fertility Center, UZ Gasthuisberg, KULeuven, Belgium
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9
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Nabli H, Tuller E, Sharpe-Timms KL. Haptoglobin expression in endometrioid adenocarcinoma of the uterus. Reprod Sci 2009; 17:47-55. [PMID: 19801537 DOI: 10.1177/1933719109346331] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Elevated serum haptoglobin (Hp) concentrations have been reported in patients with malignant diseases. We have shown that Hp is produced by and localizes only in the stroma and not the epithelium of endometriotic lesions, which share many characteristics of carcinoma. Furthermore, Hp mRNA and protein are found exclusively in the stroma of eutopic endometrium from women with endometriosis and not those without endometriosis. We hypothesized that characteristic patterns of Hp gene expression and protein localization in endometrioid adenocarcinoma of the uterus may provide insight into the clinical utility of Hp as a tumor marker or alternative therapeutic approach. METHODS Biopsies of endometrioid adenocarcinoma tumors of the uterus and their adjacent nonaffected endometrium were collected. Normal endometrium was collected from healthy women. Haptoglobin messenger RNA (mRNA) levels were quantified by quantitative polymerase chain reaction (Q-PCR). Haptoglobin protein cell-specific localization was identified by immunohistochemistry. RESULTS Haptoglobin mRNA levels were significantly greater (P < .005) in endometrioid adenocarcinoma and adjacent nonaffected endometrial tissues than normal endometrium. No correlation was found between Hp levels and cancer stage (P = .673) or grade (P = .739). Haptoglobin protein localized in both stromal and glandular epithelial cells of endometrioid adenocarcinoma and their adjacent nonaffected tissue but not in control endometrium. CONCLUSIONS Our results have identified, for the first time, unique patterns of Hp mRNA expression and protein localization in the stromal and glandular epithelial cells of endometrioid adenocarcinoma of the uterus. We propose that this unique pattern of endometrioid adenocarcinoma Hp expression may be developed as a novel diagnostic marker. Modulation of Hp, with its immunomodulatory and angiogenic properties, may generate novel methods of prevention or treatment for endometrial cancer.
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Affiliation(s)
- Henda Nabli
- Division of Reproductive and Perinatal Research, The Department of Obstetrics and Gynecology and Women's Health, The University of Missouri-Columbia, Columbia, Missouri 65212, USA
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Berbic M, Schulke L, Markham R, Tokushige N, Russell P, Fraser IS. Macrophage expression in endometrium of women with and without endometriosis. Hum Reprod 2009; 24:325-32. [DOI: 10.1093/humrep/den393] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Eyster KM, Klinkova O, Kennedy V, Hansen KA. Whole genome deoxyribonucleic acid microarray analysis of gene expression in ectopic versus eutopic endometrium. Fertil Steril 2007; 88:1505-33. [PMID: 17462640 DOI: 10.1016/j.fertnstert.2007.01.056] [Citation(s) in RCA: 121] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2006] [Revised: 01/11/2007] [Accepted: 01/11/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To use DNA microarrays to identify differentially expressed genes in eutopic endometrium compared with ectopic endometrium. DESIGN Prospective, cross-sectional, observational study. SETTING University Medical Center and Research Laboratory. PATIENT(S) Eleven women with endometriosis. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Differential gene expression. RESULT(S) Seven hundred seventeen of the 53,000 probes on the whole human DNA microarrays were changed by twofold or greater in ectopic versus eutopic endometrium. Families of genes that were expressed differentially include genes that code for proteins associated with the immune system and inflammatory pathways, cell adhesion, cell-cell junctions, the extracellular matrix and its remodeling, cytoskeletal proteins, and signal transduction pathway components, among others. CONCLUSION(S) The altered immune environment may allow survival of endometriotic cells that enter the abdominal cavity. Alterations of cell adhesion-associated genes may contribute to the adhesive and invasive properties of ectopic endometrium, and changes in signal transduction pathways support a change in the communication among cells of the endometrial explant compared with eutopic endometrium. These families of differentially expressed genes provide multiple opportunities for the development and testing of new hypotheses regarding endometriosis.
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Affiliation(s)
- Kathleen M Eyster
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, South Dakota 57069, USA.
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Sharpe-Timms KL. Defining endometrial cells: the need for improved identification at ectopic sites and characterization in eutopic sites for developing novel methods of management for endometriosis. Fertil Steril 2005; 84:35-7; discussion 38-9. [PMID: 16009152 DOI: 10.1016/j.fertnstert.2005.01.123] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2005] [Revised: 01/11/2005] [Accepted: 01/11/2005] [Indexed: 11/22/2022]
Abstract
Endometriosis is classically defined as ectopic growth of endometrial glands and stroma. Currently, histologic confirmation of laparoscopic findings is paramount for diagnosis of endometriosis and evidence is evolving suggesting that the pathogenesis of endometriosis is related to endometrial anomalies.
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Affiliation(s)
- Kathy L Sharpe-Timms
- Division of Reproductive and Perinatal Research, Department of Obstetrics, Gynecology and Women's Health, University of Missouri-Columbia, Columbia, Missouri 65212, USA.
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