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Maybin J, Watters M, Rowley B, Walker C, Sharp G, Alvergne A. COVID-19 and abnormal uterine bleeding: potential associations and mechanisms. Clin Sci (Lond) 2024; 138:153-171. [PMID: 38372528 PMCID: PMC10876417 DOI: 10.1042/cs20220280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/20/2024]
Abstract
The impact of COVID-19 on menstruation has received a high level of public and media interest. Despite this, uncertainty exists about the advice that women and people who menstruate should receive in relation to the expected impact of SARS-CoV-2 infection, long COVID or COVID-19 vaccination on menstruation. Furthermore, the mechanisms leading to these reported menstrual changes are poorly understood. This review evaluates the published literature on COVID-19 and its impact on menstrual bleeding, discussing the strengths and limitations of these studies. We present evidence consistent with SARS-CoV-2 infection and long COVID having an association with changes in menstrual bleeding parameters and that the impact of COVID vaccination on menstruation appears less significant. An overview of menstrual physiology and known causes of abnormal uterine bleeding (AUB) is provided before discussing potential mechanisms which may underpin the menstrual disturbance reported with COVID-19, highlighting areas for future scientific study. Finally, consideration is given to the effect that menstruation may have on COVID-19, including the impact of the ovarian sex hormones on acute COVID-19 severity and susceptibility and reported variation in long COVID symptoms across the menstrual cycle. Understanding the current evidence and addressing gaps in our knowledge in this area are essential to inform public health policy, direct the treatment of menstrual disturbance and facilitate development of new therapies, which may reduce the severity of COVID-19 and improve quality of life for those experiencing long COVID.
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Affiliation(s)
- Jacqueline A. Maybin
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, U.K
| | - Marianne Watters
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, U.K
| | - Bethan Rowley
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, U.K
| | - Catherine A. Walker
- Centre for Reproductive Health, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, U.K
| | | | - Alexandra Alvergne
- ISEM, Univ Montpellier, CNRS, IRD, Montpellier, France
- School of Anthropology and Museum Ethnography, Oxford, U.K
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2
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Salcedo AC, Yun J, Carter C, Hart E. Therapeutic Carbohydrate Restriction as a Metabolic Modality for the Prevention and Treatment of Abnormal Uterine Bleeding. Nutrients 2023; 15:3760. [PMID: 37686792 PMCID: PMC10490487 DOI: 10.3390/nu15173760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/21/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Therapeutic carbohydrate restriction diets have been becoming increasingly popular over the years, resulting in dramatic weight loss and an improvement in metabolic disorders. Obesity, insulin resistance, and diabetes are the risk factors for many gynecologic morbidities such as uterine leiomyoma, endometrial polyps, and polycystic ovarian syndrome. There is evidence suggesting that the pathogenesis of cardiovascular disease is similar to that seen in many causes of abnormal uterine bleeding. We aim to explain how cardiovascular disease risk factor reduction with the use of therapeutic carbohydrate restriction may prevent and potentially treat these gynecologic disorders.
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Affiliation(s)
- Andrea C. Salcedo
- Department of Gynecology and Obstetrics, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
| | - Jane Yun
- Department of Gynecology and Obstetrics, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
| | - Cody Carter
- Department of Pathology and Human Anatomy, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
| | - Elaine Hart
- Department of Gynecology and Obstetrics, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
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3
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Akram Z, Mahjabeen I, Irshad F, Ahmed MW, Rehman S, Rizwan M, Shafqat A, Kiran A, Saeed A. Expression deregulation of matrix metalloproteinases and vasoconstriction related genes in Pakistani females with abnormal uterine bleeding. BMC Womens Health 2022; 22:543. [PMID: 36564776 PMCID: PMC9784108 DOI: 10.1186/s12905-022-02132-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Abnormal uterine bleeding (AUB) is irregular menstrual bleeding which has great impact on female health and life style. Various genetic factors are involved in etiology and pathology of AUB. Present study was designed to explore the association of PTGFR, MMP9, MMP2, TGFB3 and VEGFB with AUB. METHODS Blood samples of 212 females with AUB were collected along with age-matched healthy control. Expression variation of targeted genes was evaluated using qPCR. Present study cohort was divided into different groups based on demographic parameters and all targeted genes were correlated with study demographics. RESULTS Expression of targeted genes was significantly (P < 0.001) downregulated in females with AUB compared to control. Reduced (P < 0.01) expression of targeted genes was observed in all age groups (21-30, 31-40, 41-50 year) of AUB patients compared to respective control. Expression of VEGFB increased (P < 0.05) in AUB females with > 9 days bleeding compared to AUB patient had < 9 days bleeding. AUB women with miscarriage history showed upregulation in MMP2, TGFB3 (P < 0.05), and downregulation in MMP9 and VEGFB (P < 0.05) expression compared to AUB group with no miscarriage history. Expression of MMP2 increased (P < 0.05) in AUB females with > 60 kg body weigh compared to AUB patient with < 60 kg weight. CONCLUSION Present study open a new window for diagnosis of AUB at early stages and suggested a possible involvement of PTGFR, MMP9, MMP2, TGFB3 and VEGFB as candidate biomarkers in AUB.
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Affiliation(s)
- Zertashia Akram
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Ishrat Mahjabeen
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Faiza Irshad
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Malik Waqar Ahmed
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Sadaf Rehman
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Muhammad Rizwan
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Amna Shafqat
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Aniqa Kiran
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
| | - Asma Saeed
- grid.418920.60000 0004 0607 0704Cancer Genetics and Epigenetics Lab, Department of Biosciences, COMSATS University Islamabad, Islamabad, Pakistan
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Vannuccini S, Jain V, Critchley H, Petraglia F. From menarche to menopause, heavy menstrual bleeding is the underrated compass in reproductive health. Fertil Steril 2022; 118:625-636. [PMID: 36075746 DOI: 10.1016/j.fertnstert.2022.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/14/2022] [Accepted: 07/19/2022] [Indexed: 01/13/2023]
Abstract
Menstruation is defined as monthly uterine bleeding, regarded as a sign of reproductive health. When characterized by excessive bleeding (heavy menstrual bleeding [HMB]), it may act as a useful clinical marker for diagnosis of reproductive diseases. Endometrial and myometrial mechanisms underlying abnormal uterine bleeding (AUB), which includes HMB, have hormonal, cellular, and molecular aspects. Structural and nonstructural causes of AUB, presenting with HMB as the major symptom, result in iron depletion and consequent anemia. Heavy menstrual bleeding can be considered as a single entity to identify the possible underlying causes, which may be different to some extent to those of AUB, as a whole. Furthermore, the difficulties in defining HMB through objective methods do not allow the current epidemiological scenario on the prevalence of the symptom among reproductive-age women to be outlined. Moreover, the introduction of new diagnostic methods, including imaging technologies, entails a revision of the available figures on HMB in different age groups from menarche to menopause. In addition, a proper diagnostic algorithm for HMB should be implemented to adapt recommendations for clinical investigation when HMB is present.
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Affiliation(s)
- Silvia Vannuccini
- Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Varsha Jain
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, Scotland
| | - Hilary Critchley
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, Scotland
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.
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5
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Salcedo AC, Shehata H, Berry A, Riba C. Insulin resistance and other risk factors of cardiovascular disease amongst women with abnormal uterine bleeding. JOURNAL OF INSULIN RESISTANCE 2022. [DOI: 10.4102/jir.v5i1.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Jain V, Chodankar RR, Maybin JA, Critchley HOD. Uterine bleeding: how understanding endometrial physiology underpins menstrual health. Nat Rev Endocrinol 2022; 18:290-308. [PMID: 35136207 PMCID: PMC9098793 DOI: 10.1038/s41574-021-00629-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 12/16/2022]
Abstract
Menstruation is a physiological process that is typically uncomplicated. However, up to one third of women globally will be affected by abnormal uterine bleeding (AUB) at some point in their reproductive years. Menstruation (that is, endometrial shedding) is a fine balance between proliferation, decidualization, inflammation, hypoxia, apoptosis, haemostasis, vasoconstriction and, finally, repair and regeneration. An imbalance in any one of these processes can lead to the abnormal endometrial phenotype of AUB. Poor menstrual health has a negative impact on a person's physical, mental, social, emotional and financial well-being. On a global scale, iron deficiency and iron deficiency anaemia are closely linked with AUB, and are often under-reported and under-recognized. The International Federation of Gynecology and Obstetrics have produced standardized terminology and a classification system for the causes of AUB. This standardization will facilitate future research endeavours, diagnosis and clinical management. In a field where no new medications have been developed for over 20 years, emerging technologies are paving the way for a deeper understanding of the biology of the endometrium in health and disease, as well as opening up novel diagnostic and management avenues.
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Affiliation(s)
- Varsha Jain
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Rohan R Chodankar
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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7
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Endometrial macrophages in health and disease. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2022; 367:183-208. [PMID: 35461658 DOI: 10.1016/bs.ircmb.2022.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Macrophages are present in the endometrium throughout the menstrual cycle and are most abundant during menstruation. Endometrial macrophages contribute to tissue remodeling during establishment of pregnancy and are thought to play key roles in mediating tissue breakdown and repair during menstruation. Despite these important roles, the phenotype and function of endometrial macrophages remains poorly understood. In this review, we summarize approaches used to characterize endometrial macrophage phenotype, current understanding of the functional role of macrophages in normal endometrial physiology as well as the putative contribution of macrophage dysfunction to women's reproductive health disorders.
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8
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Watters M, Martínez-Aguilar R, Maybin JA. The Menstrual Endometrium: From Physiology to Future Treatments. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 3:794352. [PMID: 36304053 PMCID: PMC9580798 DOI: 10.3389/frph.2021.794352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/20/2021] [Indexed: 01/12/2023] Open
Abstract
Abnormal uterine bleeding (AUB) is experienced by up to a third of women of reproductive age. It can cause anaemia and often results in decreased quality of life. A range of medical and surgical treatments are available but are associated with side effects and variable effectiveness. To improve the lives of those suffering from menstrual disorders, delineation of endometrial physiology is required. This allows an increased understanding of how this physiology may be disturbed, leading to uterine pathologies. In this way, more specific preventative and therapeutic strategies may be developed to personalise management of this common symptom. In this review, the impact of AUB globally is outlined, alongside the urgent clinical need for improved medical treatments. Current knowledge of endometrial physiology at menstruation is discussed, focusing on endocrine regulation of menstruation and local endometrial inflammation, tissue breakdown, hypoxia and endometrial repair. The contribution of the specialised endometrial vasculature and coagulation system during menstruation is highlighted. What is known regarding aberrations in endometrial physiology that result in AUB is discussed, with a focus on endometrial disorders (AUB-E) and adenomyosis (AUB-A). Gaps in existing knowledge and areas for future research are signposted throughout, with a focus on potential translational benefits for those experiencing abnormal uterine bleeding. Personalisation of treatment strategies for menstrual disorders is then examined, considering genetic, environmental and demographic characteristics of individuals to optimise their clinical management. Finally, an ideal model of future management of AUB is proposed. This would involve targeted diagnosis of specific endometrial aberrations in individuals, in the context of holistic medicine and with due consideration of personal circumstances and preferences.
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Affiliation(s)
- Marianne Watters
- Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | | | - Jacqueline A. Maybin
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, United Kingdom
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9
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Kaygusuz I, Semerci Gündüz N. Investigation of vascular endothelial growth factor (VEGF) polymorphism in patients with idiopathic heavy menstrual bleeding. Arch Gynecol Obstet 2021; 305:109-116. [DOI: 10.1007/s00404-021-06225-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022]
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10
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Critchley HOD, Maybin JA, Armstrong GM, Williams ARW. Physiology of the Endometrium and Regulation of Menstruation. Physiol Rev 2020; 100:1149-1179. [DOI: 10.1152/physrev.00031.2019] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The physiological functions of the uterine endometrium (uterine lining) are preparation for implantation, maintenance of pregnancy if implantation occurs, and menstruation in the absence of pregnancy. The endometrium thus plays a pivotal role in reproduction and continuation of our species. Menstruation is a steroid-regulated event, and there are alternatives for a progesterone-primed endometrium, i.e., pregnancy or menstruation. Progesterone withdrawal is the trigger for menstruation. The menstruating endometrium is a physiological example of an injured or “wounded” surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair. Progress in our understanding of endometrial pathophysiology has been facilitated by modern cellular and molecular discovery tools, along with animal models of simulated menses. Abnormal uterine bleeding (AUB), including heavy menstrual bleeding (HMB), imposes a massive burden on society, affecting one in four women of reproductive age. Understanding structural and nonstructural causes underpinning AUB is essential to optimize and provide precision in patient management. This is facilitated by careful classification of causes of bleeding. We highlight the crucial need for understanding mechanisms underpinning menstruation and its aberrations. The endometrium is a prime target tissue for selective progesterone receptor modulators (SPRMs). This class of compounds has therapeutic potential for the clinical unmet need of HMB. SPRMs reduce menstrual bleeding by mechanisms still largely unknown. Human menstruation remains a taboo topic, and many questions concerning endometrial physiology that pertain to menstrual bleeding are yet to be answered.
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Affiliation(s)
- Hilary O. D. Critchley
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Jacqueline A. Maybin
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Gregory M. Armstrong
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
| | - Alistair R. W. Williams
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, United Kingdom
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11
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Maybin JA, Boswell L, Young VJ, Duncan WC, Critchley HOD. Reduced Transforming Growth Factor-β Activity in the Endometrium of Women With Heavy Menstrual Bleeding. J Clin Endocrinol Metab 2017; 102:1299-1308. [PMID: 28324043 PMCID: PMC5460733 DOI: 10.1210/jc.2016-3437] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/28/2016] [Indexed: 12/31/2022]
Abstract
Context Heavy menstrual bleeding (HMB) is common and incapacitating. Aberrant menstrual endometrial repair may result in HMB. The transforming growth factor (TGF)-β superfamily contributes to tissue repair, but its role in HMB is unknown. Objective We hypothesized that TGF-β1 is important for endometrial repair, and women with HMB have aberrant TGF-β1 activity at menses. Participants/Setting Endometrial biopsies were collected from women, and menstrual blood loss objectively measured [HMB >80 mL/cycle; normal menstrual bleeding (NMB) <80 mL]. Design Immunohistochemistry and reverse transcription polymerase chain reaction examined endometrial TGF-β1 ligand, receptors, and downstream SMADs in women with NMB and HMB. The function and regulation of TGF-β1 were examined using cell culture. Results TGFB1 mRNA was maximal immediately prior to menses, but no differences detected between women with NMB and HMB at any cycle stage. Histoscoring of TGFB1 revealed reduced staining in the stroma during menses in women with HMB (P < 0.05). There were no significant differences in TGFBR1/2 or TGFBR1/2 immunostaining. Cortisol increased activation of TGFB1 in the supernatant of human endometrial stromal cells (HES; P < 0.05) via thrombospondin-1. Endometrial SMAD2 and SMAD3 were lower in women with HMB during menstruation (P < 0.05), and decreased phosphorylated SMAD2/3 immunostaining was seen in glandular epithelial cells during the late secretory phase (P < 0.05). Wound scratch assays revealed increased repair in HES cells treated with TGF-β1 versus control (P < 0.05). Conclusions Women with HMB had decreased TGF-β1 and SMADs perimenstrually. Cortisol activated latent TGF-β1 to enhance endometrial stromal cell repair. Decreased TGF-β1 activity may hinder repair of the denuded menstrual endometrium, resulting in HMB.
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Affiliation(s)
- Jacqueline A Maybin
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - Lyndsey Boswell
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - Vicky J Young
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - William C Duncan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - Hilary O D Critchley
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
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12
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Elkilani OA, Soliman MA. Angiogenesis mediators in women with idiopathic heavy menstrual bleeding. Int J Gynaecol Obstet 2016; 136:280-284. [PMID: 28099683 DOI: 10.1002/ijgo.12068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/04/2016] [Accepted: 11/23/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the relationship between stromal cell-derived factor 1 (SDF-1) and mature endothelial cells in patients with heavy menstrual bleeding (HMB). METHODS In a prospective observational study, women with idiopathic HMB and control individuals attending Menoufia University Hospital, Egypt, between August 2015 and January 2016 were enrolled. The inclusion criteria were a regular menstrual cycle, a normal coagulation study, and no anomalous ultrasonographic or hysteroscopic findings. Blood samples were collected during different phases of the menstrual cycle (day 5, ovulation, day 24) for measurement of the SDF-1 plasma level (by enzyme-linked immunosorbent assay) and for quantification of mature endothelial cells (by flow cytometry). RESULTS Overall, 20 women with HMB and 10 control individuals were enrolled. The SDF-1 level was significantly lower in the HMB group than in the control group during all phases of the menstrual cycle (P≤0.05 for all). The percentage of mature endothelial cells was significantly higher in the HMB group than among controls (P<0.001 for all). The SDF-1 level and the percentage of endothelial cells were negatively correlated throughout the cycle (P<0.001 for all). CONCLUSION Some mediators of angiogenesis, such as SDF-1 and endothelial cells, are disturbed in women with idiopathic HMB.
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Affiliation(s)
- Osama A Elkilani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Mohamed A Soliman
- Department of Clinical Pathology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
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13
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Aberrant bone marrow vascularization patterns in untreated patients with Gaucher disease type 1. Blood Cells Mol Dis 2016; 68:54-59. [PMID: 27836528 DOI: 10.1016/j.bcmd.2016.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 10/19/2016] [Indexed: 01/03/2023]
Abstract
Bone marrow (BM) in subjects with Gaucher disease (GD) displays accumulation of Gaucher cells (GC), i.e. glucocerebroside-laden macrophages. Following the assumption that macrophage proliferation and perturbation in GD modulates local inflammation-associated phenomena including angiogenesis, BM biopsies from 11 untreated GD patients and 36 controls were investigated for morphology and angiogenesis-associated features. These included microvascular density, (MVD), vessel structure and pericyte coverage, expression of VEGF-A and angiopoietins (ANGPT1 and 2). In GD BM, cellularity was higher, and GC clustered in cohesive but poorly demarcated areas, leaving irregular islands with normal hematopoiesis. MVD was 2.6-fold higher in GD marrows than in controls (p<0.001). In GC-rich areas, MVD was 1.4-fold higher (p=0.026), and vessel architecture was abnormal compared with GC-poor areas. MVD correlated with BM cellularity, particularly in GC-rich areas. Moreover, 30±17% of GD BM vessels were pericyte-coated, significantly fewer than in controls (48±16%; p<0.001). Expression of ANGPT1 and 2 was significantly higher in GD BM vessel walls than in controls (7.2- and 13.2-fold higher), whereas VEGF expression was 20-fold lower (p<0.05 for all). Thus, human GD BM shows increased angiogenesis with defective pericyte coating and skewed VEGF/ANGPT1 and 2 balances, presumably related to local accumulation of GC.
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14
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Maybin JA, Critchley HOD. Menstrual physiology: implications for endometrial pathology and beyond. Hum Reprod Update 2015; 21:748-61. [PMID: 26253932 PMCID: PMC4594618 DOI: 10.1093/humupd/dmv038] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/08/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Each month the endometrium becomes inflamed, and the luminal portion is shed during menstruation. The subsequent repair is remarkable, allowing implantation to occur if fertilization takes place. Aberrations in menstrual physiology can lead to common gynaecological conditions, such as heavy or prolonged bleeding. Increased knowledge of the processes involved in menstrual physiology may also have translational benefits at other tissue sites. METHODS Pubmed and Cochrane databases were searched for all original and review articles published in English until April 2015. Search terms included ‘endometrium’, ‘menstruation’, ‘endometrial repair’, ‘endometrial regeneration’ ‘angiogenesis’, ‘inflammation’ and ‘heavy menstrual bleeding’ or ‘menorrhagia’. RESULTS Menstruation occurs naturally in very few species. Human menstruation is thought to occur as a consequence of preimplantation decidualization, conferring embryo selectivity and the ability to adapt to optimize function. We highlight how current and future study of endometrial inflammation, vascular changes and repair/regeneration will allow us to identify new therapeutic targets for common gynaecological disorders. In addition, we describe how increased knowledge of this endometrial physiology will have many translational applications at other tissue sites. We highlight the clinical applications of what we know, the key questions that remain and the scientific and medical possibilities for the future. CONCLUSIONS The study of menstruation, in both normal and abnormal scenarios, is essential for the production of novel, acceptable medical treatments for common gynaecological complaints. Furthermore, collaboration and communication with specialists in other fields could significantly advance the therapeutic potential of this dynamic tissue.
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Affiliation(s)
- Jacqueline A Maybin
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Hilary O D Critchley
- MRC Centre for Reproductive Health, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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Andersson E, Zetterberg E, Vedin I, Hultenby K, Palmblad J, Mints M. Low pericyte coverage of endometrial microvessels in heavy menstrual bleeding correlates with the microvessel expression of VEGF-A. Int J Mol Med 2014; 35:433-8. [PMID: 25504455 DOI: 10.3892/ijmm.2014.2035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 12/10/2014] [Indexed: 11/06/2022] Open
Abstract
A prospective clinical study was carried out to investigate whether endometrial microvessels in patients with idiopathic heavy menstrual bleeding (HMB) of endometrial origin (HMB-E) are fragile due to low pericyte coverage. Idiopathic HMB-E is characterized by large endothelial cell gaps related to the microvascular overexpression of vascular endothelial growth factor (VEGF)-A and VEGF receptors 1-3. A total of 10 women with a normal menstrual cycle and a history of HMB of <5 years, and 17 healthy women with a normal menstrual cycle were recruited from the Karolinska University Hospital. Blood samples were obtained for hormone analysis and coagulation tests. Endometrial biopsies were collected in the proliferative or in the secretory phase. Pericyte coverage was assessed using immunohistochemical staining for smooth muscle actin-α (SMAα) and by image analysis (microvascular density) of endometrial biopsies from 10 patients with HMB-E and 17 healthy ovulating women (control subjects). Previously published data on endothelial cell gap size and the expression of VEGF receptors were used. Although microvascular density did not differ between the patients with HMB-E and the control subjects, the number of SMAα-positive microvessels in the proliferative phase was significantly (P=0.005) lower in the patients with HMB-E than in the control subjects. Moreover, the number of SMAα-positive microvessels in the control subjects was significantly fewer in the secretory (P=0.04) than in the proliferative phase, whereas this number did not differ among the patients with HMB-E regardless of phase. A significant negative correlation was observed between the number of VEGF-A-positive microvessels and microvessels with pericyte coverage (r=0.8; P=0.04). Finally, the endothelial cell layer was significantly thicker in the patients with HMB-E than in the control subjects. Thus, the upregulation of VEGF-A in idiopathic HMB-E is associated with a low pericyte coverage during the proliferative phase of intense angiogenesis, which may confer vessel fragility, possibly leading to excessive blood loss.
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Affiliation(s)
- Emil Andersson
- Department of Women's and Children's Health, Karolinska Institutet at Karolinska University Hospital Solna, S-17176 Stockholm, Sweden
| | - Eva Zetterberg
- Departments of Medicine and Hematology, Karolinska Institutet and Karolinska University Hospital Huddinge, S-14186 Stockholm, Sweden
| | - Inger Vedin
- Department of Coagulation, Skånes University Hospital, S-21428 Malmö, Sweden
| | - Kjell Hultenby
- Department of Laboratory Medicine, Karolinska Institutet, S-14186 Stockholm, Sweden
| | - Jan Palmblad
- Department of Coagulation, Skånes University Hospital, S-21428 Malmö, Sweden
| | - Miriam Mints
- Department of Women's and Children's Health, Karolinska Institutet at Karolinska University Hospital Solna, S-17176 Stockholm, Sweden
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Elsheikh E, Andersson E, Sylven C, Ericzon BG, Palmblad J, Mints M. Plasma levels of stromal cell-derived factor-1 (CXCL12) and circulating endothelial progenitor cells in women with idiopathic heavy menstrual bleeding. Hum Reprod 2013; 29:49-56. [DOI: 10.1093/humrep/det402] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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17
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Abstract
The endometrium has a complex and dynamic blood and lymphatic vasculature which undergoes regular cycles of growth and breakdown. While we now have a detailed picture of the endometrial blood vasculature, our understanding of the lymphatic vasculature in the endometrium is limited. Recent studies have illustrated that the endometrium contains a population of lymphatic vessels with restricted distribution in the functional layer relative to the basal layer. The mechanisms responsible for this restricted distribution and the consequences for endometrial function are not known. This review will summarise our current understanding of endometrial lymphatics, including the mechanisms regulating their growth and function. The potential contribution of lymphatic vessels and lymphangiogenic growth factors to various endometrial disorders will be discussed.
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Affiliation(s)
- Jane E Girling
- Gynaecology Research Centre, Department of Obstetrics and Gynaecology, The University of Melbourne, The Royal Women's Hospital, Cnr Flemington Rd and Grattan St, Parkville, VIC, Australia.
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Abstract
The ovarian steroid hormones progesterone and estradiol are well established regulators of human endometrial function. However, more recent evidence suggests that androgens and locally generated steroids, such as the glucocorticoids, also have a significant impact on endometrial breakdown and repair. The temporal and spatial pattern of steroid receptor presence in endometrial cells has a significant impact on the endometrial response to steroids. Furthermore, regulation of steroid receptor function by modulatory proteins further refines local responses. This review focuses on steroid regulation of endometrial function during the luteo-follicular transition with a focus on menstruation and endometrial repair.
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Affiliation(s)
- Jacqueline A Maybin
- MRC Centre for Reproductive Health, The University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
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19
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Abstract
The human endometrium is exposed to repeated inflammation every month, culminating in tissue breakdown and menstruation. Subsequently, the endometrium has a remarkable capacity for efficient repair and remodeling to enable implantation if fertilization takes place. Endometrial function is known to be governed by the ovarian hormones estradiol and progesterone. This review paper focuses on hormonal control of the cyclical tissue injury and repair that takes place in the local endometrial environment at the time of menstruation. Progesterone levels decline premenstrually as the corpus luteum regresses in the absence of pregnancy, and estradiol levels increase during the postmenstrual phase. The functional impact of these significant changes is discussed, including their immediate and downstream effects. Finally, we examine the contribution of aberrant endometrial function to the presentation of heavy menstrual bleeding and identify potential therapeutic targets for the treatment of this common gynecological problem.
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Affiliation(s)
- Jacqueline A Maybin
- The University of Edinburgh's Centre for Reproductive Biology, The Queen's Medical Research Institute, Edinburgh, UK
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Maybin JA, Critchley HOD, Jabbour HN. Inflammatory pathways in endometrial disorders. Mol Cell Endocrinol 2011; 335:42-51. [PMID: 20723578 DOI: 10.1016/j.mce.2010.08.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Revised: 08/11/2010] [Accepted: 08/11/2010] [Indexed: 01/19/2023]
Abstract
Complex interactions between the endocrine and immune systems govern the key endometrial events of implantation and menstruation. In contrast to other tissue sites, cyclical endometrial inflammation is physiological. However, dysregulation of this inflammatory response can lead to endometrial disorders. This review examines the inflammatory processes occurring in the normal endometrium during menstruation and implantation, highlighting recent advances in our understanding and gaps in current knowledge. Subsequently, the role of inflammatory pathways in the pathology of various common endometrial conditions is discussed, including heavy menstrual bleeding, dysmenorrhoea (painful periods), uterine fibroids, endometriosis and recurrent miscarriage.
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Affiliation(s)
- Jacqueline A Maybin
- University of Edinburgh Centre for Reproductive Biology, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
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Agarwal U, El Sheikh S, Kulkarni A, Baff D, Kadir RA. Von Willebrand factor expression in endometrial endothelial cells in women with menorrhagia. Fertil Steril 2010; 94:2335-7. [DOI: 10.1016/j.fertnstert.2010.02.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Revised: 02/23/2010] [Accepted: 02/23/2010] [Indexed: 11/28/2022]
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Girling JE, Rogers PAW. Regulation of endometrial vascular remodelling: role of the vascular endothelial growth factor family and the angiopoietin–TIE signalling system. Reproduction 2009; 138:883-93. [DOI: 10.1530/rep-09-0147] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Angiogenesis, lymphangiogenesis and vascular maturation occur on a regular, physiological basis in human endometrium. These processes form part of a continuum of vascular remodelling involving numerous regulatory factors. Key factors include vascular endothelial growth factor (VEGF)A, VEGFC and VEGFD, and their associated receptors VEGFR1, VEGFR2 and VEGFR3. A second group of vascular regulatory proteins belongs to the angiopoietin (ANG)–TIE system. Although members of the VEGF family and the ANG–TIE system are represented in the endometrium, our understanding of how these different molecules interact to regulate remodelling of the blood and lymphatic vasculature present in the endometrium is still limited. A review of the current information is provided.
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Alvarez Gonzalez ML, Frankenne F, Galant C, Marbaix E, Foidart JM, Nisolle M, Béliard A. Mixed origin of neovascularization of human endometrial grafts in immunodeficient mouse models. Hum Reprod 2009; 24:2217-24. [PMID: 19508999 DOI: 10.1093/humrep/dep203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In vivo mouse models have been developed to study the physiology of normal and pathologic endometrium. Although angiogenesis is known to play an important role in endometrial physiology and pathology, the origin of neovasculature in xenografts remains controversial. The aim of this study was to assess the origin of the neovasculature of endometrial grafts in different mouse models. METHODS Human proliferative endometrium (n = 19 women) was grafted s.c. in two immunodeficient mouse strains: nude (n = 8) and severely compromised immunodeficient (SCID; n = 20). Mice were also treated with estradiol, progesterone or levonorgestrel. Fluorescence in-situ hybridization using a centromeric human chromosome X probe, immunohistochemistry (von Willebrand factor and collagen IV) and lectin perfusion were performed to identify the origin of the vessels. RESULTS More than 90% of vessels within xenografts were of human origin 4 weeks after implantation. Some vessels (9.67 +/- 2.01%) were successively stained by human or mouse specific markers, suggesting the presence of chimeric vessels exhibiting a succession of human and murine portions. No difference in staining was observed between the two strains of mouse or different hormone treatments. Furthermore, erythrocytes were found inside human vessels, confirming their functionality. CONCLUSION This article shows that human endometrial grafts retain their own vessels, which connect to the murine vasculature coming from the host tissue and become functional.
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Affiliation(s)
- M-L Alvarez Gonzalez
- Laboratory of Tumor and Development Biology, GIGA-Research, University de Liège, Tour de Pathologie (B23), Sart-Tilman, B-4000 Liège, Belgium
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Mints M, Blomgren B, Palmblad J. Expression of angiopoietins 1, 2 and their common receptor tie-2 in relation to the size of endothelial lining gaps and expression of VEGF and VEGF receptors in idiopathic menorrhagia. Fertil Steril 2009; 94:701-7. [PMID: 19406397 DOI: 10.1016/j.fertnstert.2009.03.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Revised: 03/04/2009] [Accepted: 03/09/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate whether idiopathic menorrhagia (IM) is associated with alterations of the vascular expression of angiopoietin-1, angiopoietin-2, and tie-2 receptor. DESIGN Prospective clinical study. SETTING University Hospital, Department of Gynecology. PATIENT(S) Twenty-four patients with IM and 18 women with eumenorrhea. INTERVENTION(S) Endometrial samples underwent immunohistochemical staining for CD34, angiopoetin-1, angiopoietin-2, tie-2, and smooth muscle actin-alpha. Previously published data on gap size and expression of vascular endothelial growth factor family members were used. MAIN OUTCOME MEASURE(S) Differences in immunostaining for these markers by computer-assisted stereological analysis. RESULT(S) There was significantly more angiopoetin-1 positive vessels in IM in the secretory phase, but not of angiopoetin-2 and tie-2, compared with controls. Densities of angiopoetin-1 positive vessels correlated significantly to those of angiopoetin-2 and vascular endothelial growth factor receptor 3. Smooth muscle actin-alpha positive pericytes covered the gaps. Double staining for CD34 and tie-2 receptor was partly identical, but gaps were covered by tie-2 stain. CONCLUSION(S) The discrete deregulation observed of the angiopoetin-1 expression before menstruation might affect vascular integrity, thereby contributing to the excessive blood loss in IM.
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Affiliation(s)
- Miriam Mints
- Department of Clinical Science, Division of Obstetrics and Gynaecology, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Robb AO, Mills NL, Smith IBJ, Short A, Tura-Ceide O, Barclay GR, Blomberg A, Critchley HOD, Newby DE, Denison FC. Influence of menstrual cycle on circulating endothelial progenitor cells. Hum Reprod 2008; 24:619-25. [PMID: 19088108 DOI: 10.1093/humrep/den411] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Endothelial progenitor cells (EPCs) are circulating mononuclear cells that participate in angiogenesis. The aim of this study was to determine the influence of the menstrual cycle on the number and function of EPCs, and to investigate their relationship with circulating concentrations of sex steroids and inflammatory mediators. METHODS Ten healthy nulliparous, premenopausal, non-smoking women with regular menses were studied over a single menstrual cycle. Venepuncture was performed in the menstrual, follicular, peri-ovulatory and luteal phases. EPCs were quantified by flow cytometry (CD133(+)CD34(+)KDR(+) phenotype) and the colony-forming unit (CFU-EPC) functional assay. Circulating concentrations of estradiol, progesterone and inflammatory mediators (TNF-alpha, IL-6, sICAM-1 and VEGF) were measured by immunoassays. RESULTS The numbers of CD133(+)CD34(+)KDR(+) cells were higher in the follicular phase (0.99 +/- 0.3 x 10(6) cells/l) compared with the peri-ovulatory phase (0.29 +/- 0.1 x 10(6) cells/l; P < 0.05). In contrast, the numbers of CFU-EPCs did not vary over the menstrual cycle. There were no correlations between EPCs and concentrations of either circulating sex steroids or inflammatory mediators. CONCLUSIONS CD133(+)CD34(+)KDR(+) cells but not CFU-EPCs vary during the menstrual cycle. Our findings suggest a potential role for circulating EPCs in the normal cycle of physiological angiogenesis and repair of the uterine endometrium that is independent of circulating sex steroids or inflammatory mediators.
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Affiliation(s)
- A O Robb
- Centre for Reproductive Biology, University of Edinburgh, Edinburgh EH16 4TJ, UK
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Mints M, Luksha L, Kublickiene K. Altered responsiveness of small uterine arteries in women with idiopathic menorrhagia. Am J Obstet Gynecol 2008; 199:646.e1-5. [PMID: 18667186 DOI: 10.1016/j.ajog.2008.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2007] [Revised: 03/18/2008] [Accepted: 06/03/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study was undertaken to study vascular reactivity of small myometrial arteries in women with idiopathic menorrhagia. STUDY DESIGN Small myometrial arteries were isolated from 6 patients with idiopathic menorrhagia and 4 controls. The contractile responses to thromboxane mimetic (U46619) and endothelin-1 were assessed before and after incubation with N(w)-nitro-L arginine methyl ester alone or in combination with indomethacin (Indo). Endothelium-dependent dilation to bradykinin and basal tension were compared before and after incubation with N(w)-nitro-L arginine methyl ester alone, or with N(w)-nitro-L arginine methyl ester in combination with indomethacin. RESULTS Constriction to endothelin-1 was enhanced in idiopathic menorrhagia arteries (P < .05). Idiopathic menorrhagia arteries demonstrated enhanced basal tension after incubation with N(w)-nitro-L arginine methyl ester, which was further exaggerated by indomethacin. NOS inhibition had no effect on basal tension in controls, but basal tension was enhanced after inhibition of cyclooxygenase-derived products (P < .05). Bradykinin-mediated dilation was significantly increased in idiopathic menorrhagia (P < .05). CONCLUSION The presence of functional alterations in small myometrial arteries could contribute to idiopathic menorrhagia.
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Affiliation(s)
- Miriam Mints
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention, and Technology CLINTEC, Karolinska University Hospital-Huddinge, Karolinska Institutet, Stockholm, Sweden
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