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Molecular Targets for Nonhormonal Treatment Based on a Multistep Process of Adenomyosis Development. Reprod Sci 2023; 30:743-760. [PMID: 35838920 DOI: 10.1007/s43032-022-01036-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/09/2022] [Indexed: 10/17/2022]
Abstract
Adenomyosis is an estrogen-dependent gynecologic disease characterized by the presence of endometrial tissue within the myometrium. Adenomyosis presents with abnormal uterine bleeding, pelvic pains, and infertility. This review aimed to investigate the major estrogen downstream effectors involved in the process of adenomyosis development and their potential use for nonhormonal treatment. A literature search was performed for preclinical and clinical studies published between January 2010 and November 2021 in the PubMed and Google Scholar databases using a combination of specific terms. Adenomyosis presents with a wide spectrum of clinical manifestations from asymptomatic to severe through a complex process involving a series of molecular changes associated with inflammation, invasion, angiogenesis, and fibrosis. Adenomyosis may develop through a multistep process, including the acquisition of (epi)genetic mutations, tissue injury caused at the endometrial-myometrial interface, inside-to-outside invasion (from the endometrial side into the uterine wall), or outside-to-inside invasion (from the serosal side into the uterine wall), and epithelial-mesenchymal transition, tissue repair or remodeling in the myometrium. These processes can be regulated by increased estrogen biosynthesis and progesterone resistance. The expression of estrogen downstream effectors associated with persistent inflammation, fragile and more permeable vessel formation, and tissue injury and remodeling may be correlated with dysmenorrhea, heavy menstrual bleeding, and infertility, respectively. Key estrogen downstream targets (e.g., WNT/β-catenin, transforming growth factor-β, and nuclear factor-κB) may serve as hub genes. We reviewed the molecular mechanisms underlying the development of adenomyosis and summarized potential nonhormonal therapies.
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Zhai J, Vannuccini S, Petraglia F, Giudice LC. Adenomyosis: Mechanisms and Pathogenesis. Semin Reprod Med 2020; 38:129-143. [PMID: 33032339 DOI: 10.1055/s-0040-1716687] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Adenomyosis is a common disorder of the uterus, and is associated with an enlarged uterus, heavy menstrual bleeding (HMB), pelvic pain, and infertility. It is characterized by endometrial epithelial cells and stromal fibroblasts abnormally found in the myometrium where they elicit hyperplasia and hypertrophy of surrounding smooth muscle cells. While both the mechanistic processes and the pathogenesis of adenomyosis are uncertain, several theories have been put forward addressing how this disease develops. These include intrinsic or induced (1) microtrauma of the endometrial-myometrial interface; (2) enhanced invasion of endometrium into myometrium; (3) metaplasia of stem cells in myometrium; (4) infiltration of endometrial cells in retrograde menstrual effluent into the uterine wall from the serosal side; (5) induction of adenomyotic lesions by aberrant local steroid and pituitary hormones; and (6) abnormal uterine development in response to genetic and epigenetic modifications. Dysmenorrhea, HMB, and infertility are likely results of inflammation, neurogenesis, angiogenesis, and contractile abnormalities in the endometrial and myometrial components. Elucidating mechanisms underlying the pathogenesis of adenomyosis raise possibilities to develop targeted therapies to ameliorate symptoms beyond the current agents that are largely ineffective. Herein, we address these possible etiologies and data that support underlying mechanisms.
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Affiliation(s)
- Junyu Zhai
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Sciences, University of California, San Francisco, San Francisco, California.,Center for Reproductive Medicine, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.,Shanghai Key Laboratory for Assisted Reproduction and Reproductive Genetics, Shanghai, People's Republic of China
| | - Silvia Vannuccini
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy.,Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Felice Petraglia
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Linda C Giudice
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Reproductive Sciences, University of California, San Francisco, San Francisco, California
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Rižner TL. The Important Roles of Steroid Sulfatase and Sulfotransferases in Gynecological Diseases. Front Pharmacol 2016; 7:30. [PMID: 26924986 PMCID: PMC4757672 DOI: 10.3389/fphar.2016.00030] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/03/2016] [Indexed: 01/08/2023] Open
Abstract
Gynecological diseases such as endometriosis, adenomyosis and uterine fibroids, and gynecological cancers including endometrial cancer and ovarian cancer, affect a large proportion of women. These diseases are estrogen dependent, and their progression often depends on local estrogen formation. In peripheral tissues, estrogens can be formed from the inactive precursors dehydroepiandrosterone sulfate and estrone sulfate. Sulfatase and sulfotransferases have pivotal roles in these processes, where sulfatase hydrolyzes estrone sulfate to estrone, and dehydroepiandrosterone sulfate to dehydroepiandrosterone, and sulfotransferases catalyze the reverse reactions. Further activation of estrone to the most potent estrogen, estradiol, is catalyzed by 17-ketosteroid reductases, while estradiol can also be formed from dehydroepiandrosterone by the sequential actions of 3β-hydroxysteroid dehydrogenase-Δ4-isomerase, aromatase, and 17-ketosteroid reductase. This review introduces the sulfatase and sulfotransferase enzymes, in terms of their structures and reaction mechanisms, and the regulation and different transcripts of their genes, together with the importance of their currently known single nucleotide polymorphisms. Data on expression of sulfatase and sulfotransferases in gynecological diseases are also reviewed. There are often unchanged mRNA and protein levels in diseased tissue, with higher sulfatase activities in cancerous endometrium, ovarian cancer cell lines, and adenomyosis. This can be indicative of a disturbed balance between the sulfatase and sulfotransferases enzymes, defining the potential for sulfatase as a drug target for treatment of gynecological diseases. Finally, clinical trials with sulfatase inhibitors are discussed, where two inhibitors have already concluded phase II trials, although so far with no convincing clinical outcomes for patients with endometrial cancer and endometriosis.
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Affiliation(s)
- Tea Lanišnik Rižner
- Faculty of Medicine, Institute of Biochemistry, University of Ljubljana Ljubljana, Slovenia
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Colette S, Defrère S, Van Kerk O, Van Langendonckt A, Dolmans MM, Donnez J. Differential expression of steroidogenic enzymes according to endometriosis type. Fertil Steril 2013; 100:1642-9. [DOI: 10.1016/j.fertnstert.2013.08.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 07/31/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
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The pathophysiology of uterine adenomyosis: an update. Fertil Steril 2012; 98:572-9. [PMID: 22819188 DOI: 10.1016/j.fertnstert.2012.06.044] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/16/2012] [Accepted: 06/22/2012] [Indexed: 01/10/2023]
Abstract
The diagnosis of adenomyosis using noninvasive techniques such as vaginal ultrasounds and magnetic resonance has clear clinical applications and has renewed the interest in the pathogenesis of uterine adenomyosis. However, the research remains hampered by the lack of consensus on the classification of lesions. Magnetic resonance imaging and transvaginal ultrasound have comparable diagnostic accuracy. Minimal interventional biopsy techniques have recently been introduced. This article reviews human and animal studies and provides an update on the pathophysiology of adenomyosis. Recent views on the pathogenesis and links with endometriosis are discussed.
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Colette S, Defrere S, Lousse JC, Van Langendonckt A, Gotteland JP, Loumaye E, Donnez J. Inhibition of steroid sulfatase decreases endometriosis in an in vivo murine model. Hum Reprod 2011; 26:1362-70. [DOI: 10.1093/humrep/der079] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pasqualini JR, Chetrite GS. Recent advances on the action of estrogens and progestogens in normal and pathological human endometrium. Horm Mol Biol Clin Investig 2010; 2:155-75. [DOI: 10.1515/hmbci.2010.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 04/07/2010] [Indexed: 01/25/2023]
Abstract
AbstractHormonal control in the development of the normal endometrium is of the utmost importance. It is well established that the two main hormones involved in this process are estradiol and progesterone, which are also implicated in the pathological conditions concerning endometriosis and endometrial carcinoma. There are two types of endometrial carcinoma: type I which represents 80%–90% is hormone-dependent, whereas the remainder is type II and is hormone-independent. The endometrial tissue contains all the enzymatic systems in the formation and transformation of the various hormones, including aromatases, sulfatases, sulfotransferases, hydroxysteroid dehydrogenases, hydroxylases, and glucuronidases. It is interesting to note that increased sulfatase activity is correlated with severity of endometriosis. An increased sulfatase/sulfotransferase ratio represents a poor prognosis in patients with endometrial carcinoma. Treatment with hormone replacement therapy (estrogens+progestogens), as well as with tibolone, is most effective in protecting this tissue by climacteric alterations, owing to the significant decrease of ovarian hormones. In conclusion, enzymatic control can open appealing perspectives to protect this organ from possible pathological alterations.
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Abstract
Like endometriosis and uterine myomas, adenomyosis presents the typical characteristics of oestrogen-dependent diseases. The medical treatment of adenomyosis is based on the hormonal dependency of the disease and its strongly debated similarities with endometriosis. Infact, despite the evident differences between the two conditions, the therapies that treat endometriosis effectively have also been successful for the treatment of adenomyosis. Although the two diseases have distinct epidemiological features, they have the same 'target tissue' for hormonal therapy, namely ectopic endometrium. Recognized approaches are systemic hormonal treatments, which are generally used for endometriosis and are capable of suppressing the oestrogenic induction of the disease, and local hormonal treatment that targets the ectopic endometrium directly. Gonadotropin-releasing hormone agonists, danazol and intrauterine levonorgestrel- or danazol-releasing devices have been used in the treatment of adenomyosis. Despite the solid rational basis for its hormonal treatment, few studies have been performed on medical therapy for adenomyosis.
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Affiliation(s)
- Luigi Fedele
- Fondazione Policlinico, Mangiagalli e Regina Elena, Clinica Ostetrica e Ginecologica II, Università di Milano, Istituto Luigi Mangiagalli, Via della Commenda 12, 20122 Milano, Italy.
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Abstract
Adenomyosis of the uterus is a common condition amongst women in their reproductive years. It is defined as the presence of heterotopic endometrial glands and stroma in the myometrium with adjacent smooth muscle hyperplasia. The common presenting symptoms are painful and heavy periods and infertility, although many women are asymptomatic. Adenomyosis is thought to affect 1% of women and is typically diagnosed in the 4th and 5th decades of life. The aetiology is unclear, and until recently a diagnosis was made only after invasive and destructive surgery. With the advent of improved imaging of the pelvic organs, and in particular magnetic resonance imaging, the diagnosis of adenomyosis is being made more frequently. Unfortunately, because the disease has been infrequently diagnosed prior to hysterectomy, there are few well-designed studies of medical or surgical management. Management with hormonal treatment that aims to reduce the proliferation of endometrial cells is promising, but there is a paucity of well-designed studies to guide treatment. Hysterectomy or use of the levonorgestrel intrauterine system (LNG-IUS) remains the mainstay of treatment.
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Affiliation(s)
- Cynthia Farquhar
- Department of Obstetrics and Gynaecology, National Womens' Health at Auckland, City Hospital, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Kitawaki J. Adenomyosis: the pathophysiology of an oestrogen-dependent disease. Best Pract Res Clin Obstet Gynaecol 2006; 20:493-502. [PMID: 16564227 DOI: 10.1016/j.bpobgyn.2006.01.010] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Adenomyosis uteri is a common gynaecological disorder that is characterized by the presence of ectopic endometrial glands and stroma in the myometrium. Although adenomyosis and endometriosis are different diseases, both of them grow and regress in an oestrogen-dependent fashion. Polymorphisms in the oestrogen receptor alpha gene are associated with a risk of adenomyosis. Adenomyotic tissue contains steroid receptors as well as aromatase and sulphatase enzymes. Together with the circulating oestrogen, locally produced oestrogens stimulate the growth of tissue mediated by the oestrogen receptors. Oestrogen metabolism, including the expression pattern of aromatase and the regulation of 17beta-hydroxysteroid dehydrogenase type 2 is altered in the eutopic endometrium of women with endometriosis, adenomyosis, and/or leiomyomas compared to that in the eutopic endometrium of women without disease. In addition to the conventional hormonal treatment with gonadotropin-releasing hormone agonists and danazol, the use of steroid-releasing intrauterine devices may be applicable to clinics.
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Affiliation(s)
- Jo Kitawaki
- Department of Obstetrics and Gynecology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kamigyo-ku, Kyoto 602-8566, Japan.
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Wéry O, Thille A, Gaspard U, van den Brûle F. [Adenomyosis: update on a frequent but difficult diagnosis]. ACTA ACUST UNITED AC 2006; 34:633-48. [PMID: 16270001 DOI: 10.1016/s0368-2315(05)82896-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.
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Affiliation(s)
- O Wéry
- Service de Gynécologie, CHU Sart-Tilman
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Deffieux X, Fernandez H. Évolutions physiopathologiques, diagnostiques et thérapeutiques dans la prise en charge de l’adénomyose : revue de la littérature. ACTA ACUST UNITED AC 2004; 33:703-12. [PMID: 15687941 DOI: 10.1016/s0368-2315(04)96631-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Adenomyosis is a relatively frequent disease of unknown origin, which is difficult to diagnose. Appropriate treatment for women who want to preserve or improve their fertility remains to be defined. METHODS This review summarized the reports found on Medline database about pathophysiology, diagnosis and management of adenomyosis. RESULTS Many pathophysiological factors may be involved in the occurrence of adenomyosis: immunological factors, estrogen sulfatase activity, tenascin which is a fibronectin inhibitor and angiogenesis and growth factors such as EGF, VEGF and GM-CSF. Endovaginal ultrasonography seems to be as effective as MRI for the diagnosis of adenomyosis. GnRH agonist decreases symptoms and uterine volume; however, the symptoms reappear after discontinuation of agonist therapy, and side effects limit their prolonged use. Progesterone receptor modulators, anti-progestative and danazol or levonorgestrel-releasing intra-uterine system have been used as therapeutic modalities for adenomyosis, but the lack of controlled studies make their efficacy difficult to quantify. Some women with superficial adenomyosis may theoretically benefit from hysteroscopic myometrial or endometrial resection, but these procedures would be limited to women not wishing to conceive. Laparoscopic myometrial electrocoagulation or excision has proven to be effective but pregnancy following these techniques poses special problems, particularly the increased risk of uterine rupture. CONCLUSION Transvaginal ultrasonography can successfully diagnose adenomyosis. Medical and conservative surgical treatments are already available.
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Affiliation(s)
- X Deffieux
- Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, 157, rue de la Porte-de-Trivaux, 92141 Clamart Cedex
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Maitoko K, Sasaki H. Gonadotropin-releasing hormone agonist inhibits estrone sulfatase expression of cystic endometriosis in the ovary. Fertil Steril 2004; 82:322-6. [PMID: 15302278 DOI: 10.1016/j.fertnstert.2003.12.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 12/18/2003] [Accepted: 12/18/2003] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To clarify the inhibitory effect of GnRH agonist on estrone (E(1)) sulfatase expression. DESIGN Retrospective immunohistochemical study. SETTING The Jikei University Hospital, Tokyo, Japan. PATIENT(S) Thirty-three women who had undergone cystectomy of the ovary or oophorectomy and were proved histopathologically to have cystic endometriosis in the ovary. INTERVENTION(S) Fifteen of the 33 patients were treated with GnRH agonists monthly for 2-6 months before surgery. The other 18 patients did not receive any hormonal therapy. Tissue sections were immunostained with an anti-E(1) sulfatase monoclonal antibody (KM1049) originating from human placenta. MAIN OUTCOME MEASURE(S) Microscopic evaluation to assess the presence and localization of E(1) sulfatase and to describe any variations in its expression with or without treatment with GnRH agonist. RESULT(S) Immunostaining showed that E(1) sulfatase was localized only on the glandular epithelial cells of cystic endometriosis in the ovary. The immunostaining with anti-E(1) sulfatase proved that GnRH agonist inhibited E(1) sulfatase expression in the cystic endometriosis in the ovary. CONCLUSION(S) Gonadotropin-releasing hormone agonist inhibits E(1) sulfatase expression in cystic endometriosis in the ovary.
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Affiliation(s)
- Kazuhiro Maitoko
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, 3-25-8 Nihonbashi, Minato-ku, Tokyo 105-8461, Japan
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Tanaka K, Kubushiro K, Iwamori Y, Okairi Y, Kiguchi K, Ishiwata I, Tsukazaki K, Nozawa S, Iwamori M. Estrogen sulfotransferase and sulfatase: Roles in the regulation of estrogen activity in human uterine endometrial carcinomas. Cancer Sci 2003; 94:871-6. [PMID: 14556660 PMCID: PMC11160014 DOI: 10.1111/j.1349-7006.2003.tb01369.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Revised: 08/08/2003] [Accepted: 08/11/2003] [Indexed: 11/27/2022] Open
Abstract
The regulation of estrogen activity through the formation and cleavage of sulfoconjugates of estrogens is known to be related to the progression and metastasis of estrogen-dependent breast carcinomas, but the involvement of sulfoconjugates in the steroid stimulation of endometrial functions and the progression of endometrial adenocarcinomas is not clearly understood yet. Estrogen sulfotransferase (EST) in the uterine endometria during the follicular phase was more active than during the luteal phase, but estrogen sulfate (ES) sulfatase exhibited lower activity during the follicular phase than during the luteal phase. However, ES sulfatase activities in cancerous tissues were lower than those in normal endometria and endometrial adenocarcinoma-derived cells, among which the activity was exceedingly high in Ishikawa cells, suggesting that ES sulfatase in Ishikawa cells contributes to the estrogen-dependent growth of these cells. EST activities higher than that in Ishikawa cells were found in only 3 of 24 cancerous tissues. Reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of the EST and ES sulfatase genes in carcinoma-derived cells demonstrated the extensive expression of both genes in Ishikawa cells. The isolated EST gene was transfected into Ishikawa cells with a mammalian expression vector to establish cell clones with enhanced EST activity, and the estrogen-dependent cell growth of the resultant cell clones was found to be abolished, due to the enhanced sulfoconjugation of estrogen. Since ES sulfatase activity in cancerous tissues was significantly lower than that in Ishikawa cells, it might be not involved in the enhancement of estrogen activity associated with the pathogenesis of endometrial adenocarcinoma tissues.
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Affiliation(s)
- Kyoko Tanaka
- Department of Obstetrics and Gynecology, School of Medicine, Keio University, Shinjuku-ku, Tokyo 160-8582, Japan
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