A comparison of oestrogen receptor and progesterone receptor expression in endometrial polyps and endometrium of premenopausal women

Assessment of Long- and Short-Term Outcomes of Hysteroscopic Polypectomy in Patients with Uterine Polyps

Background

Polyps are a common diagnosis in women of different ages. They can cause a variety of symptoms from bleeding to infertility and can even be the progenitor for malignancies.

Materials and Methods

This was a retrospective cohort study conducted in Isfahan. A total of 1004 patients were included in this study. After hysteroscopic polypectomy, patients had their information regarding the complications and recurrence recorded.

Results

Symptoms improved in 639 (63.8%). Recurrence of polyps was seen in 143 (14.2%) patients. A total of 170 had a successful pregnancy, with 110 of them spontaneous. Using scissors had lower recurrence compared to graspers. Eight cases had complications during the treatment, two of which were major.

Conclusion

Hysteroscopic polypectomy is the treatment of choice for uterine polyps. We show hysteroscopic polypectomy to have a high success rate and a low complications rate, with polypectomies done using scissors to have lower risk of complications or recurrence compared to graspers.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Copper in Gynecological Diseases

Copper (Cu) is an essential micronutrient for the correct development of eukaryotic organisms. This metal plays a key role in many cellular and physiological activities, including enzymatic activity, oxygen transport, and cell signaling. Although the redox activity of Cu is crucial for enzymatic reactions, this property also makes it potentially toxic when found at high levels. Due to this dual action of Cu, highly regulated mechanisms are necessary to prevent both the deficiency and the accumulation of this metal since its dyshomeostasis may favor the development of multiple diseases, such as Menkes' and Wilson's diseases, neurodegenerative diseases, diabetes mellitus, and cancer. As the relationship between Cu and cancer has been the most studied, we analyze how this metal can affect three fundamental processes for tumor progression: cell proliferation, angiogenesis, and metastasis. Gynecological diseases are characterized by high prevalence, morbidity, and mortality, depending on the case, and mainly include benign and malignant tumors. The cellular processes that promote their progression are affected by Cu, and the mechanisms that occur may be similar. We analyze the crosstalk between Cu deregulation and gynecological diseases, focusing on therapeutic strategies derived from this metal.

Impact of estrogen and progesterone receptor expression on the incidence of endometrial polyps

Aim: We studied the association of estrogen receptor (ER) and progesterone receptor (PR) with endometrial polyp (EP) formation. Methods: A total of 129 EP patients and an equal number of disease-free women were evaluated for ER and PR expression in endometrial tissues. Correlation with EP incidence was analyzed, as well as diagnostic value via receiver operating characteristic curve. Results: ER expression was higher and PR was lower in patients than in controls (p < 0.01). ER levels positively correlated with EP incidence, and PR negatively (p < 0.01). Receiver operating characteristic curves gave ER an area under the curve of 0.6168 (95% CI: 0.5479-0.6856; p < 0.0001) and PR 0.739 (95% CI: 0.6776-0.8003; p < 0.0001). Conclusion: Imbalance in ER and PR expression associates with EPs formation, offering clinical insights into EP pathology.

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

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

Retrospective analysis of the endometrial preparation protocols for frozen-thawed embryo transfers in women with endometrial polyps

We aimed to explore the clinical effects of the endometrial preparation protocol for frozen-thawed embryo transfer (FET) in women with endometrial polyps. This retrospective study was performed at the Reproductive Medicine Centre of the First Affiliated Hospital of Sun Yat-sen University between January 2015 and May 2018 involving women diagnosed with endometrial polyps by hysteroscopy. The freeze-all strategy was performed in controlled ovarian stimulation cycles followed by FET cycles. Endometrial preparation protocols included: (i) gonadotropin-releasing hormone agonist-hormone replacement therapy (GnRHa-HRT); (ii) hormone replacement therapy (HRT); (iii) natural cycle (NC); and (iv) ovulation induction (OI). Recurrence rate of polyps and clinical results were compared among the four groups. If polyp recurrence was found in ultrasound scans during the FET cycles, the embryo transfers were cancelled. The recurrence rate of polyps was lower in the GnRHa-HRT protocol [2.13% (2/94)] than in the other three protocols [6.15% (26/423), 6.7% (28/418), and 4% (1/25) in the HRT, NC, and OI, respectively; p = 0.038], showing statistically significant difference. Pregnancy, early pregnancy loss, and live birth rates among the four protocols were similar (p = 0.922, p = 0.171, and p = 0.072, respectively). The GnRHa-HRT protocol used for FET in women with endometrial polyps could reduce the recurrence rate of the polyps. In addition, we found that it did not decrease pregnancy or live birth rates.

Serum concentrations of heavy metals in women with endometrial polyps

Endometrial polyps are one of the common reasons of abnormal uterine bleeding in women. Industrialisation, urbanisation and increased air pollution cause increased heavy metal exposure. Heavy metals that have oestrogenic effects in human body are named as metalloestrogens. The aim of this study was to investigate the serum metalloestrogen levels such as copper (Cu), zinc (Zn), aluminium (Al), lead (Pb), nickel (Ni) and Cu/Zn ratio and their possible relationship with the occurrence of endometrial polyps. Eighty women with abnormal uterine bleeding were divided into two groups: 40 women diagnosed with endometrial polyp (study group) and 40 women without endometrial polyp (control group). Ages, body mass indices, smoking behaviours, drinking water choices, chronic diseases and intrauterine device histories were noted for all patients. Blood levels of Cu, Zn, Al, Pb, Ni and Cu/Zn ratio were analysed by inductively coupled plasma-mass spectrometry method for both groups. No statistically significant differences were observed in terms of serum median levels of Cu and Pb between the study and the control groups. The serum median levels of Zn, Ni and Al were found to be statistically lower in the study group when compared with the control group. The Cu/Zn ratio was statistically higher in the study group. High Cu/Zn ratio, as a biomarker of oxidative stress, suggests the role of oxidative stress in etiopathogenesis of endometrial polyps.IMPACT STATEMENTWhat is already known on this subject? Studies demonstrate that oestrogen and progesterone play an important role in pathogenesis of endometrial polyps. Inorganic heavy metal ions that bind and activate oestrogen receptors are referred to as 'metalloestrogens'. Apart from toxic effects, metalloestrogens have been linked to the aetiology of oestrogen-dependent diseases such as breast and endometrium cancer and endometriosis. However, serum levels of heavy metals were not investigated in a large group of endometrial polyp patients.What do the results of this study add? This is the first study investigating the serum levels of heavy metals in a large group of endometrial polyp patients. We did not observe any increased serum levels of heavy metals in endometrial polyp patients. Our results might suggest that oestrogenic heavy metal exposure has no role in the appearance of endometrial polyps. However, increased Cu/Zn ratio due to low serum levels zinc suggests oxidative stress might play a role in endometrial polyps.What are the implications of these findings for clinical practice and/or further research? Further research of heavy metals in endometrial polyps with simultaneous blood and tissue samples could show the precise effect of environmental exposure of metalloestrogens in aetiopathogenesis of endometrial polyps.

Abnormal expression of estrogen receptor is associated with thin endometrium

This study was conducted to investigate the association of estrogen receptor (ER) and progesterone receptor (PR) expressions with thin endometrium. Patients with endometrial thickness of less than 7 mm were classified as the study group, while the control group was comprised of patients with endometrial thickness of 7 to 14 mm. The expressions of ER and PR were detected with semi-quantitative immunohistochemical analysis, and the differences were compared between the two groups. The expression of ER was significantly decreased (p < .05) in the stromal cells of thin endometrium during both proliferative and secretory phases as compared to those of normal endometrium. Likewise, ER expression was found to be lower in the glandular cells of thin endometrium than those of normal endometrium during proliferative phase. However, no significant differences were observed for the expression of PR in both glandular and stromal cells between the two groups. Thin endometrium was associated with reduced expression of ER in stromal cells both during proliferative and secretory phase, but in glandular epithelial cells only during proliferative phase.

Endometrial polyps: Pathogenesis, sequelae and treatment

Endometrial polyps are overgrowths of endometrial glands that typically protrude into the uterine cavity. Endometrial polyps are benign in nature and affect both reproductive age and postmenopausal women. Although endometrial polyps are relatively common and may be accompanied by abnormally heavy bleeding at menstruation. In asymptomatic women, endometrial polyps may regress spontaneously, in symptomatic women endometrial polyps can be treated safely and efficiently with hysteroscopic excision.

Post hysteroscopic progesterone hormone therapy in the treatment of endometrial polyps

OBJECTIVE

To find out the clinical effects of post hysteroscopic progesterone hormone therapy in the treatment of endometrial polyps in terms of clinical outcome and the expression of endometrial Vascular Endothelial Growth Factor (VEGF).

METHODS

Ninety-eight patients who were confirmed as endometrial polyp in the hospital from April 2014 and December 2016 were selected and divided into treatment group and a control group using random number table, 49 in each group. Patients in both groups were given hysteroscopic operation. Patients in the treatment group were treated by progesterone hormone drugs after hysteroscopic operation, while patients in the control group were not given progesterone hormone. The changes of menstrual blood volume, menstrual cycle and expression of VEGF were compared between the two groups after treatment, and the recurrence condition, thickness of endometrium and hemoglobin were followed up one year after treatment.

RESULTS

The pictorial blood loss assessment chart (PBAC) scores of patients in the two groups had no significant difference before treatment (P>0.05); but the score of the treatment group was much lower than that of the control group. The improvement rate of menstrual cycle of the treatment group was much higher than that of the control group, and the difference had statistical significance (P<0.05). Compared to before treatment, the serum VEGF level of the patients in both groups had a remarkable decline in the 1st, 3rd and 6th month after treatment, and the difference had statistical significance (P<0.05). The difference of the serum VEGF level between the two groups in the 1st and 3rd month after treatment had no statistical significance (P>0.05). The serum VEGF level of the treatment group was notably lower than that of the control group six months after treatment, and the difference had statistical significance (P<0.05). The follow-up results demonstrated that the treatment group had smaller thickness of endometrium and higher level of hemoglobin compared to the control group, and the recurrence rate of the treatment group was lower than that of the control group (P<0.05).

CONCLUSION

Post hysteroscopic progesterone hormone therapy has favorable clinical effect in treating endometrial polyps as it can effectively prevent the recurrence of endometrial polyps, relieve the level of hemoglobin and reduce endometrial thickness.

ART and uterine pathology: how relevant is the maternal side for implantation?

BACKGROUND

Assisted reproduction technology (ART) has become a standard treatment for infertile couples. Increased success rates obtained over the years have resulted primarily from improved embryo quality, but implantation rates still remain lower than expected. The uterus, an important player in implantation, has been frequently neglected. While a number of uterine pathologies have been associated with decreased natural fertility, less information exists regarding the impact of these pathologies in ART. This report reviews the evidence to help clinicians advise ART patients.

METHODS

An electronic search of PubMed and EMBASE was performed to identify articles in the English, French or Spanish language published until May 2014 which addressed uterine pathology and ART. Data from natural conception were used only in the absence of data from ART. Studies were classified in decreasing categories: RCTs, prospective controlled trials, prospective non-controlled trials, retrospective studies and experimental studies. Studies included in lower categories were only used if insufficient evidence was available. Pooled data were obtained from systematic reviews with meta-analyses when available. The summary of the evidence for the different outcomes and the degree of the recommendation for interventions were based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) statement recommendations.

RESULTS

There is strong evidence that surrogacy is effective for uterine agenesia. For the remaining pathologies, however, there is very little evidence that the established treatments improve outcomes, or that these pathologies have a negative effect on ART. In the presence of an apparently normal uterus, assessing endometrial receptivity (ER) is the goal; however diagnostic tests are still under development.

CONCLUSIONS

The real effect of different uterine/endometrial integrity pathologies on ART is not known. Moreover, currently proposed treatments are not based on solid evidence, and little can be done to assess ER in normal or abnormal conditions. No strong recommendations can be given based on the published experience, bringing an urgent need for well-designed studies. In this context, we propose algorithms to study the uterus in ART.

The expression of cyclooxygenase-2 and vascular endothelial growth factor in the endometrium during the peri-implantation period in women with and without polyps

OBJECTIVE

This prospective study was designed to determine whether the expression of cyclooxygenase-2 (COX-2) and vascular endothelial growth factor (VEGF) in the endometrial tissue obtained from the peri-implantation period of women with endometrial polyp (EP) differs from that of control subjects without a polyp.

METHODS

Endometrial samples were collected from 30 patients with EP and 30 control subjects without EP, in the mid-secretory phase. The expression of COX-2 and VEGF in the endometrium was examined with the use of immunohistochemistry.

RESULTS

COX-2 and VEGF were predominantly expressed in endometrial glands. The expression of COX-2 and VEGF in the endometrium obtained from women with EP was lower than that of control subjects.

CONCLUSION

The reduced expression of COX-2 and VEGF in the endometrium of women with EP may account for the association between EP and infertility.

Predictive diagnosis of endometrial hyperplasia and personalized therapeutic strategy in women of fertile age

Introduction

Endometrial hyperplasia has a high risk for malignant transformation and relapses; existing mini-invasive treatments may lead to irrevocable endometrium destruction. The aims were to analyze receptor systems in endometrial hyperplasia, to evaluate the capabilities of ultrasonography, sonoelastography for diagnosis and treatment control, and to develop treatment algorithm.

Materials and methods

We included 313 women (20–45 years), assessed into the following: group 1 (n = 112) with glandular cystic hyperplasia, group 2 (n = 98) endometrial polyps, and group 3 (n = 103) atypical hyperplasia; and 82 controls who have undergone hysteroscopy before in vitro fertilization in tubal origin infertility were also included. Patients underwent clinical examination, transvaginal ultrasound, immunohistochemical study, and hormonal therapy/hysteroresectoscopy.

Results

In patients with glandular hyperplasia, we registered increase of endometrium estrogen receptors (75.6% in the epithelium and 30.9% in the stroma; in controls, 43.3% and 29.6%, respectively); in polyps, there was a significant estrogen receptor increase in the stroma (48.2% vs 29.6% in controls), and in atypical hyperplasia, progesterone receptors significantly increased in the stroma. Ki-67 increased (40% to 50%) in the epithelium without changes in the stroma. Ultrasound has a sensitivity of 96% and a specificity of 85% for early detection of endometrial pathology and prediction outcome of intervention, and sonoelastography has a sensitivity of 91% and a specificity of 83% for polyp diagnosis. Personalized treatment was effective in 88.8%, relapse was diagnosed in 11.2% after 6 months, and conservative treatment of atypical hyperplasia was effective in 45%: in 25.8%, ablative hysteroresectoscopy was performed, while in 22.6% with comorbidities, hystero/oophorectomies were performed.

Conclusions

The evaluation of receptor status with ultrasound data in patients with endometrial hyperplasia allows for a clear definition of the treatment policy, avoidance of relapse, treatment optimization, and observation of such patients.

Cellular immune environment in endometrial polyps

STUDY OBJECTIVE

To investigate the immune environment of endometrial polyps (EPs).

DESIGN

Prospective case-control study.

SETTING

Teaching hospital and university research laboratory.

PATIENT(S)

Reproductive-age women undergoing hysteroscopy dilation and curettage for benign indications. Samples were collected from women with (n = 23) and without (n = 40) EPs.

INTERVENTION(S)

Endometrial samples were immunohistochemically stained with antibodies against mast cells (MCs) and regulatory T cells (Tregs).

MAIN OUTCOME MEASURE(S)

Tryptase+, chymase+, and c-Kit+ MCs and Foxp3+ Tregs were quantified in EPs and polyp-adjacent, polyp-distant, and control endometrium.

RESULT(S)

Densities of all MC types were highly significantly increased in EPs compared with adjacent, distant, and control endometrium. Chymase+ and c-Kit+ MCs were increased in density in adjacent compared with control endometrium. c-Kit+ MCs were also increased in distant compared with control endometrium. Foxp3+ Treg density was increased in EPs compared with distant and control endometrium and decreased in distant compared with control endometrium.

CONCLUSION(S)

This study provides novel insights into localized disturbances in the cellular immune environment within EPs consistent with EPs being inflammatory lesions associated with MC overactivity. Tregs are likely to be recruited to EPs in an attempt to suppress the inflammatory process due to the greatly increased presence of MCs. These immunologic disturbances are likely to be involved in the causation of abnormal bleeding and infertility in premenopausal women with EPs, and their role in the pathophysiology requires further research.

Endometrial polyps and subfertility

Endometrial polyps are a relatively common finding in infertility patients. They can distort the endometrial cavity, may have a detrimental effect on endometrial receptivity and increase the risk of implantation failure. Although treatment seems to be safe and easy, this may not always be the case if endometrial polyps are diagnosed after starting an in vitro fertilization cycle. This paper reviews the medical literature to provide an evidence-based approach for management of endometrial polyps in subfertile women.

Is endometrial polyp formation associated with increased expression of vascular endothelial growth factor and transforming growth factor-beta1?

OBJECTIVE

Endometrial polyp is a common cause of abnormal uterine bleeding, but the etiology and pathogenesis remain unclear. Vascular endothelial growth factor (VEGF) is angiogenic, related to thick walled vessels and transforming growth factor-beta1 (TGF-β1) is related to fibrotic tissue, which are characteristics of endometrial polyps. The primary objective of this study was to find out if endometrial polyp formation is associated with increased expression of VEGF or TGF-β1, or both. A secondary objective is to determine if the changes are related to steroid receptor expression.

STUDY DESIGN

This prospective study compared VEGF and TGF-β1 expression of endometrial polyps and adjacent endometrial tissue in 70 premenopausal women. The comparison of results was separately made for endometrium specimens obtained in the proliferative and secretory phases. The results were correlated with the steroid receptors (estrogen receptor and progesterone receptor) expression.

RESULTS

The score of VEGF in glandular cells of endometrial polyps was significantly higher than the score in adjacent endometrium, both in the proliferative phase (P<0.001) and the secretory phase (P=0.03); the score of VEGF in stromal cells of endometrial polyps was significantly higher than the score in adjacent endometrium only in proliferative phase (P=0.006). The score of TGF-β1 in glandular cells of endometrial polyps was significantly higher than the score in adjacent endometrium in proliferative phase (P=0.02); whereas the score of TGF-β1 in stromal cells of endometrial polyps was significantly higher than the score in adjacent endometrium, both in the proliferative phase (P=0.006) and the secretory phase (P=0.008). There was a significant correlation between the expression of steroid receptors and VEGF and TGF-β1 (Spearman's correlation P<0.001 and P<0.05, respectively).

CONCLUSIONS

There was increased expression of TGF-β1 and VEGF in polyps compared to adjacent normal endometrial tissue. It suggested that these cytokines might play a role in endometrial polyp formation. In addition, there was a significant correlation between steroid receptor expression and VEGF and TGF-β1 expression.

Implantation failure: molecular mechanisms and clinical treatment

BACKGROUND

Implantation is a complex initial step in the establishment of a successful pregnancy. Although embryo quality is an important determinant of implantation, temporally coordinated differentiation of endometrial cells to attain uterine receptivity and a synchronized dialog between maternal and embryonic tissues are crucial. The exact mechanism of implantation failure is still poorly understood.

METHODS

This review summarizes the current knowledge about the proposed mechanisms of implantation failure in gynecological diseases, the evaluation of endometrial receptivity and the treatment methods to improve implantation.

RESULTS

The absence or suppression of molecules essential for endometrial receptivity results in decreased implantation rates in animal models and gynecological diseases, including endometriosis, hydrosalpinx, leiomyoma and polycystic ovarian syndrome. The mechanisms are diverse and include abnormal cytokine and hormonal signaling as well as epigenetic alterations.

CONCLUSIONS

Optimizing endometrial receptivity in fertility treatment will improve success rates. Evaluation of implantation markers may help to predict pregnancy outcome and detect occult implantation deficiency. Treating the underlying gynecological disease with medical or surgical interventions is the optimal current therapy. Manipulating the expression of key endometrial genes with gene or stem cell-based therapies may some day be used to further improve implantation rates.