Endometriosis origin from primordial germ cells

The rising tide raises all ships

It is easy to feel as if you are alone in academia, especially if you face challenges that not everyone does, or can, understand. Community is essential in facing these challenges, and we each have a role to play in creating a more equitable research community. Here, I discuss the importance of community, finding your village and being part of the academic support system.

Reproductive outcome in 326 women with unicornuate uterus

OBJECTIVES

To study the reproductive outcomes of women with a unicornuate uterus and compare them to those of women with no congenital uterine anomaly.

METHODS

This was a single-center, retrospective cohort study. Cases were women aged at least 16 years who were diagnosed with a unicornuate uterus on transvaginal/transrectal ultrasound between January 2008 and September 2021. Controls were women with no congenital uterine anomaly matched 1:1 by age and body mass index. The primary outcome was live-birth rate. Secondary outcomes were pregnancy loss (miscarriage, ectopic pregnancy, termination of pregnancy), preterm delivery, mode of delivery and concomitant gynecological abnormalities (endometriosis, adenomyosis, fibroids).

RESULTS

Included in the study were 326 cases and 326 controls. Women with a unicornuate uterus had a significantly lower live-birth rate (184/388 (47.4%) vs 229/396 (57.8%); P = 0.004) and higher rates of overall miscarriage (178/424 (42.0%) vs 155/465 (33.3%); adjusted odds ratio (aOR), 2.21 (95% CI, 1.42-3.42), P < 0.001), ectopic pregnancy (26/424 (6.1%) vs 11/465 (2.4%); aOR, 2.52 (95% CI, 1.22-5.22), P = 0.01), preterm delivery (45/184 (24.5%) vs 17/229 (7.4%); aOR, 3.04 (95% CI, 1.52-5.97), P = 0.001) and Cesarean delivery (116/184 (63.0%) vs 70/229 (30.6%); aOR, 2.54 (95% CI, 1.67-3.88), P < 0.001). Rudimentary-horn pregnancies accounted for 7/26 (26.9%) ectopic pregnancies in the study group. Women with a unicornuate uterus were more likely to have endometriosis (17.5% vs 10.7%; P = 0.018) and adenomyosis (26.7% vs 15.6%; P = 0.001), but were not more likely to have fibroids compared with controls. Women with a functional rudimentary horn were more likely to have pelvic endometriosis compared to those without (odds ratio, 2.4 (95% CI, 1.4-4.1), P = 0.002).

CONCLUSIONS

Pregnant women with a unicornuate uterus should be classified as high risk. Removal of a functional rudimentary horn should be discussed with the patient to prevent a rudimentary-horn ectopic pregnancy. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Early Gonadal Development and Sex Determination in Mammal

Sex determination is crucial for the transmission of genetic information through generations. In mammal, this process is primarily regulated by an antagonistic network of sex-related genes beginning in embryonic development and continuing throughout life. Nonetheless, abnormal expression of these sex-related genes will lead to reproductive organ and germline abnormalities, resulting in disorders of sex development (DSD) and infertility. On the other hand, it is possible to predetermine the sex of animal offspring by artificially regulating sex-related gene expression, a recent research hotspot. In this paper, we reviewed recent research that has improved our understanding of the mechanisms underlying the development of the gonad and primordial germ cells (PGCs), progenitors of the germline, to provide new directions for the treatment of DSD and infertility, both of which involve manipulating the sex ratio of livestock offspring.

New Understanding of Diagnosis, Treatment and Prevention of Endometriosis

For 100 years, pelvic endometriosis has been considered to originate from the implantation of endometrial cells following retrograde menstruation or metaplasia. Since some observations, such as the clonal aspect, the biochemical variability of lesions and endometriosis in women without endometrium, the genetic-epigenetic (G-E) theory describes that endometriosis only begins after a series of cumulative G-E cellular changes. This explains that the endometriotic may originate from any pluripotent cell apart from the endometrium, that 'endometrium-like cells' can harbour important G-E differences, and that the risk is higher in predisposed women with more inherited incidents. A consequence is a high risk after puberty which decreases progressively thereafter. Considering a 10-year delay between initiation and performing a laparoscopy, this was observed in the United Arab Emirates, Belgium, France and USA. The subsequent growth varies with the G-E changes and the environment but is self-limiting probably because of the immunologic reaction and fibrosis. That each lesion has a different set of G-E incidents explains the variability of pain and the response to hormonal treatment. New lesions may develop, but recurrences after surgical excision are rare. The fibrosis around endometriosis belongs to the body and does not need to be removed. This suggests conservative excision or minimal bowel without safety margins and superficial treatment of ovarian endometriosis. This G-E concept also suggests prevention by decreasing oxidative stress from retrograde menstruation or the peritoneal microbiome. This suggests the prevention of vaginal infections and changes in the gastrointestinal microbiota through food intake and exercise. In conclusion, a higher risk of initiating endometriosis during adolescence was observed in UAE, France, Belgium and USA. This new understanding and the limited growth opens perspectives for earlier diagnosis and better treatment.

Isolation and characterization mesenchymal stem cells from red panda (Ailurus fulgens styani) endometrium

Endometrial mesenchymal stem cells (eMSCs) are undifferentiated endometrial cells with self-renewal, multidirectional differentiation and high proliferation potential. Nowadays, eMSCs have been found in a few species, but it has never been reported in endangered wild animals, especially the red panda. In this study, we successfully isolated and characterized the eMSCs derived from red panda. Red panda eMSCs were fibroblast-like, had a strong proliferative potential and a stable chromosome number. Pluripotency genes including Klf4, Sox2 and Thy1 were highly expressed in eMSCs. Besides, cultured eMSCs were positive for MSC markers CD44, CD49f and CD105 and negative for endothelial cell marker CD31 and haematopoietic cell marker CD34. Moreover, no reference RNA-seq was used to analyse the eMSCs transcriptional expression profile and key pathways. Compared with skin fibroblast cell group, 9104 differentially expressed genes (DEGs) were identified, among which are 5034 genes upregulated, 4070 genes downregulated and the top 20 enrichment pathways of DEGs in Gene Ontology (GO) and the Kyoto Encyclopedia of Genes Genomes (KEGG) mainly associated with G-protein coupled receptor signalling pathway, carbohydrate derivative binding, nucleoside binding, ribosome biogenesis, cell cycle, DNA replication, Ras signalling pathway and purine metabolism. Among the DEGs, some representative genes about promoting MSCs differentiation and proliferation were upregulated and promoting fibroblasts proliferation were downregulated in eMSCs group. Red panda eMSCs also had multiple differentiation ability and could differentiate into adipocytes, chondrocytes and hepatocytes. In conclusion, we, for the first time, isolated and characterized the red panda eMSCs with ability of multiplication and multilineage differentiation in vitro. The new multipotential stem cell could be beneficial not only for the germ plasm resources conservation of red panda, but also for basic or pre-clinical studies in the future.

Germany Endometriosis Pattern Changes; Prevalence and Therapy over 2010 and 2019 Years: A Retrospective Cross-Sectional Study

BACKGROUND

The aim of this study was to investigate whether the prevalence and the therapy patterns of endometriosis differ in 2010 and 2019.

MATERIALS AND METHODS

This retrospective cross-sectional study was based on the data from the IQVIA Disease Analyzer database and included women with at least one visit to one of the 136 private gynecologist practices in Germany in 2010 or 2019. The prevalence of endometriosis as well as prevalence of each endometriosis therapy such as Dienogest, other Progestins than Dienogest, and Gonadotropin-Releasing Hormones, was calculated in both years.

RESULTS

The present study included 346,249 women documented in 2010 and 343,486 women documented in 2019. The prevalence of endometriosis increased from 0.53% in 2010 to 0.66% in 2019 (P<0.001). The proportion of endometriosis patients treated with Dienogest increased significantly between 2010 and 2019 (18.1 vs. 35.0%). The proportion of women prescribed other Progestins than Dienogest has not significantly changed between 2010 and 2019 (8.4 vs. 8.3%). Gonadotropin-releasing hormones were prescribed only rarely in both 2010 and 2019, with a significant decrease in prescriptions between these two years (3.7 vs. 2.0%).

CONCLUSION

There were significant changes in the prevalence and medical therapeutic patterns of endometriosis in 2010 versus 2019 reflecting changes in therapy guidelines and possibly in diagnostic methods.

Psychological Morbidity in Endometriosis: A Couple's Study

Endometriosis is a chronic gynecological disease that impacts more than 176 million women worldwide, having a strong impact on psychological morbidity. This study aimed to evaluate the contribution of psychological morbidity, in women with endometriosis, taking into consideration the duration of the couple’s relationship and the duration of the disease and also examined whether women’s sexual satisfaction had an impact on their psychological morbidity (actor effect) and on their sexual partners’ psychological morbidity (partner effect) and vice versa. Participants were 105 women and their partners, who answered the Hospital Anxiety and Depression Scale (HADS); Couple Satisfaction Index (CSI-4) and the Global Measure of Sexual Satisfaction (GMSEX). The results revealed a direct effect between the perception of symptom severity, marital satisfaction, and women’s psychological morbidity. Sexual activity and the presence of infertility had an indirect effect on the relationship between sexual satisfaction, diagnosis duration, and psychological morbidity, respectively. Finally, women’s sexual satisfaction had a direct effect on their own and their partner’s marital satisfaction that predicted less psychological morbidity, in both. Thus, a multidisciplinary intervention focused on the couple’s sexual and marital relationship is needed to promote psychological well-being in this population.

Endometriosis stem cell sources and potential therapeutic targets: literature review and bioinformatics analysis

The stem cell origin theory of endometriosis (EMS) is a significant area of new research but the sources of this have yet to be adequately summarized. Existing treatments for EMS are commonly associated with a high recurrence rate; consequently, there is an urgent need to develop new therapeutic measures for the future treatment of this disease from the view of stem cells and gene therapy. Recently, we described the evidence for the potential sources of EMS stem cells and other key molecules participating in the establishment of lesions, and predict the miRNAs that target these key genes via bioinformatics analysis for further research. This review highlights the origin of EMS stem cells and potential therapy targets.

Familial risk for endometriosis and its interaction with smoking, age at menarche and body mass index: a population-based cohort study among siblings

OBJECTIVE

To quantify familial risk of endometriosis among full siblings and examine interactions between family history and smoking, age at menarche or body mass index (BMI).

DESIGN, SETTING AND POPULATION

Population-based nationwide cohort study.

METHODS

Using data from the Korean National Health Insurance and Screening Programme databases on kinship, healthcare utilisation, lifestyle and anthropometrics, we identified 2 109 288 women with full siblings and their environmental risk factors from 2002 to 2018. Familial risks were estimated using Cox proportional-hazards models, represented as incidence risk ratios (IRR) with 95% CI. Interaction between family history and smoking, age at menarche or BMI were assessed on an additive scale.

MAIN OUTCOME MEASURES

IRR of endometriosis among women with and without affected siblings.

RESULTS

From 19 195 women with affected siblings, 1126 developed endometriosis with an incidence of 35.45/10 000 person-years. Familial risk of endometriosis with versus without affected siblings was increased to IRR 2.75 (95% CI 2.25-3.36), and the highest risk was with affected twins (IRR 6.98; 95% CI 4.19-11.62). Women with both a family history and either smoking, early menarche or low BMI had a significantly higher risk of endometriosis compared with the general population and can be regarded as a high-risk group, the IRRs were 4.28 (95% CI 2.43-7.55), 3.47 (95% CI 2.82-4.26) and 3.09 (95% CI 2.68-3.56), respectively. Substantial effect modification of the associations was noted by smoking and early menarche, as their combined risk with family history exceeded the sum of their individual risks, which was also statistically significant.

CONCLUSION

Genetic factors are the primary contributor to the familial aggregation of endometriosis. Significant gene-environment interaction exists between family history and smoking or early menarche.

The role of mitogen-activated protein kinase signaling pathway in endometriosis

AIM

Endometriosis is an estrogen-dependent chronic inflammatory condition which causes pain, infertility, and predisposition for ovarian cancer. Endometriosis generates a unique microenvironment for survivability of endometriotic lesions which includes cell proliferation, differentiation, migration, and apoptosis. For these cellular activities, cascading activations of intracellular kinases are needed. Many kinase signaling pathways, IKKβ/NK-κB pathway, PI3K/AKT/mTOR, and the mitogen-activated protein kinase (MAPK) pathways (ERK1/2, p38, and JNK), are activated in endometriosis. In this review, we focus on the role of MAPK pathways in endometriosis.

METHODS

To identify the role of MAP Kinase signaling pathway in endometriosis we searched the Pubmed database using the search terms in various combinations "endometriosis," "endometrium," "ovary," "MAPK pathway," "ERK pathway," "p38 pathway," "JNK pathway," "estrogen," and "progesterone."

RESULTS

According to the current literature, MAPK signaling pathway has various roles in generating microenvironment and survival of endometriosis. Abnormal MAPK activation in migration, implantation, growth, invasion into the pelvic structures, proliferation, and apoptosis leads to the form of endometriosis and to worsen the condition in patients with endometriosis.

CONCLUSION

To further investigations on the effective and long-term endometriosis treatment, MAPK signaling pathways may be targeted. Molecular mechanism of MAPK signaling pathway in endometriosis should be more deeply understood and clinical trials should be more commonly performed for possible new endometriosis treatments to improve fertility and rescue endometriosis irreversibly.

Endometriosis and the Fallopian Tubes: Theories of Origin and Clinical Implications

Endometriosis is a common, oestrogen driven chronic condition, where endometrium-like epithelial and stromal cells exist in ectopic sites. At present, no curative treatments are available and the existing evidence for disease progression is conflicting. The pathogenesis is still unknown and evidently complex, as mechanisms of initiation may depend on the anatomical distribution of endometriotic lesions. However, amongst the numerous theories and plethora of mechanisms, contributions of the fallopian tubes (FT) to endometriosis are rarely discussed. The FT are implicated in all endometriosis associated symptomatology and clinical consequences; they may contribute to the origin of endometriotic tissue, determine the sites for ectopic lesion establishment and act as conduits for the spread of proinflammatory media. Here, we examine the available evidence for the contribution of the human FT to the origin, pathogenesis and symptoms/clinical consequences of endometriosis. We also examine the broader topic linking endometriosis and the FT epithelium to the genesis of ovarian epithelial cancers. Further studies elucidating the distinct functional and phenotypical characteristics of FT mucosa may allow the development of novel treatment strategies for endometriosis that are potentially curative.

Management of women affected by endometriosis: Are we stepping forward?

Endometriosis is an estrogen-dependent chronic disease defined by the presence of endometrial-like tissue, glands and stroma in ectopic areas. Among all the pathogenic theories proposed to explain the origin of the disease, a pivotal role for immune, hormonal, and epigenetic disbalances have been hypothesized. Endometriosis affects up to 10%–15% of women in reproductive age and represents one of the most common gynecological causes of severe pelvic pain. The main symptoms reported by patients are dysmenorrhea and deep dyspareunia. Although the histological confirmation has been commonly considered mandatory, to date the possibility offered by the improvement in imagining techniques allows to make a proper diagnosis of the disease in most of the cases. Medical therapy represents only a symptomatic treatment and not the definitive solution. The aim of the hormonal therapy is to abolish the menstrual flow using progestin, oral contraceptives, and gonadotropin-releasing hormone agonists to reduce pelvic pain. Surgical treatment consisting of laparoscopy has the goal of abolishing pain and may be conservative or radical in nature depending on the patients’ desire of spontaneous conception in the future. Radical surgery seems to be associated with a higher percentage of pain relief as well as higher recurrence rates. Due to the worldwide acceptance and the ongoing evolution of minimally invasive surgery to treat both benign and malignant diseases, future investigations may be conducted to consider this approach to save the function of all the organs involved by the disease and to reduce post-operative discomfort and psychological impact.

Effects of psychological care in patients with endometriosis: A systematic review protocol

BACKGROUND

This systematic review will be proposed for investigating the effects of psychological care (PC) in patients with endometriosis.

METHODS

We will search the following 7 electronic databases from inception to the present: MEDLINE, EMBASE, SinoMed, Web of Science, Cochrane Library, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. We will include randomized controlled trials for evaluating the effects of PC in patients with endometriosis. Cochrane risk of bias tool will be used to evaluate the methodological quality for each included study. Two authors will independently carry out the study selection, data extraction, and methodological quality evaluation. Any disagreements will be solved by a third author through discussion.

RESULTS

This proposed systematic review will use high-quality evidence-based medicine to evaluate the efficacy and safety of PC for endometriosis. The primary outcomes include depression and anxiety. The secondary outcomes consist of pain intensity, health-related quality of life, and adverse events.

CONCLUSION

The findings of this study will provide convincing evidence to determine whether PC therapy is an effective and safe intervention for patients with endometriosis.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD42019123292.

HORMONAL THERAPY IN WOMEN OF REPRODUCTIVE AGE WITH ENDOMETRIOSIS: AN UPDATE

Medical therapy of endometriosis is under continuous reevaluation. Hereby we updated the drugs currently available or under investigation for the hormonal treatment of endometriosis.

Pathogenesis of endometriosis: the genetic/epigenetic theory

OBJECTIVE

To study the pathophysiology of endometriosis.

DESIGN

Overview of observations on endometriosis.

SETTING

Not applicable.

PATIENT(S)

None.

INTERVENTIONS(S)

None.

MAIN OUTCOME MEASURE(S)

The hypothesis is compatible with all observations.

RESULT(S)

Endometriosis, endometrium-like tissue outside the uterus, has a variable macroscopic appearance and a poorly understood natural history. It is a hereditary and heterogeneous disease with many biochemical changes in the lesions, which are clonal in origin. It is associated with pain, infertility, adenomyosis, and changes in the junctional zone, placentation, immunology, plasma, peritoneal fluid, and chronic inflammation of the peritoneal cavity. The Sampson hypothesis of implanted endometrial cells following retrograde menstruation, angiogenic spread, lymphogenic spread, or the metaplasia theory cannot explain all observations if metaplasia is defined as cells with reversible changes and an abnormal behavior/morphology due to the abnormal environment. We propose a polygenetic/polyepigenetic mechanism. The set of genetic and epigenetic incidents transmitted at birth could explain the hereditary aspects, the predisposition, and the endometriosis-associated changes in the endometrium, immunology, and placentation. To develop typical, cystic ovarian or deep endometriosis lesions, a variable series of additional transmissible genetic and epigenetic incidents are required to occur in a cell which may vary from endometrial to stem cells. Subtle lesions are viewed as endometrium in a different environment until additional incidents occur. Typical cystic ovarian or deep endometriosis lesions are heterogeneous and represent three different diseases.

CONCLUSION(S)

The genetic epigenetic theory is compatible with all observations on endometriosis. Implications for treatment and prevention are discussed.

[Ectopic tissue of the female genital tract]

Ectopias of female genital tissues are a common event in routine pathology. Mostly they derive from paramesonephric tissues displaced during embryonal development or later. However, gonadal-, mesonephric-, or mesothelial-derived tissues may also appear in unusual localizations in and outside the female genital tract. They may be the source of benign and malignant tumors or tumor-like lesions. This review aims to provide an overview of possible tissue ectopias and to improve the developmental understanding of tumorous diseases of the female genital tract. Ectopias of primarily extragenital tissues in the female genital tract are also reviewed.

Role of Ovarian Suspension in Preventing Postsurgical Ovarian Adhesions in Patients with Stage III-IV Pelvic Endometriosis: A Systematic Review

Endometriosis is a benign complex gynecologic condition with high morbidity that affects women of reproductive age. Pelvic adhesion formation represents a serious clinical challenge in the management of patients with endometriosis. Several interventions aimed at reducing postoperative ovarian adhesion formation have been proposed in recent years. Here we summarize the published evidence on the efficacy of ovarian suspension in preventing postoperative ovarian adhesion formation in women undergoing laparoscopic surgery for stage III-IV endometriosis. The research was conducted using electronic databases. A review of the abstracts of all references retrieved from the search was conducted. Selection criteria for the systematic review included all randomized controlled trials (RCTs) and nonrandomized studies (NRSs) of premenopausal women diagnosed with stage III-IV pelvic endometriosis who underwent ovarian suspension or no ovarian suspension (control group). The RCTs were eligible for meta-analysis. Eight studies, 2 RCTs and 6 NRSs, were included in the systematic review. In all 8 studies, ovarian suspension was performed during surgery for stage III-IV endometriosis. The site of the suspension was the anterior abdominal wall in 76.8% of the cases. Five studies reported the use of polypropylene as suture for the suspension. Removal of the suspension suture in the postoperative period was reported in 6 studies. Pooled data from a meta-analysis of the RCTs show that women who underwent ovarian suspension had a significantly lower incidence of postoperative adhesion formation, particularly of moderate to severe adhesions. Ovarian suspension may reduce the rate and severity of postoperative adhesions formation in women undergoing laparoscopy for the treatment of stage III-IV endometriosis; however, RCTs with larger sample sizes are needed.