A call for more transparency of registered clinical trials on endometriosis

Emerging bioengineering breakthroughs in precision diagnosis and therapy for endometriosis and adenomyosis

Endometriosis and adenomyosis are debilitating gynecological conditions that severely affect the quality of life of women. Traditional diagnostic and treatment methods, including laparoscopic surgery and hormonal therapy, face significant limitations such as incomplete lesion detection, high recurrence rates, and adverse side effects. Emerging bioengineering technologies offer promising solutions for precise diagnosis and therapy of these diseases. Advances in biomarker detection through electrochemical immunosensors, including specific molecular markers like cytokines and growth factors, have improved their early diagnosis. Innovative imaging techniques, such as near-infrared fluorescence imaging, magnetic resonance imaging, and photoacoustic imaging, enhance lesion visualization and surgical precision. In therapeutic applications, bioengineered drug delivery systems enable targeted therapy by modifying drug carriers with ligands targeting highly expressed receptors in endometriotic lesions. Such strategies could improve drug accumulation at target sites and reduce damage to healthy tissues. Integrating external energy (including lasers, focused ultrasound, and magnetic fields) with nanoplatforms offers key benefits for treating endometriosis and adenomyosis, allowing precise delivery of energy-responsive molecules to lesions and minimizing damage to healthy tissues. Additionally, novel approaches, such as immunotherapy, gene therapy, ferroptosis induction, and synthetic lethal activation, offer new avenues for effective treatment of endometriosis and adenomyosis. Significantly, this paper discusses the advantages of precision diagnosis and treatment of endometriosis in preserving the fertility of women of reproductive age. This review highlights the potential of bioengineering breakthroughs to transform the diagnosis and management of endometriosis and adenomyosis, emphasizing their role in advancing precision medicine and improving women's health.

Unveiling the therapeutic mechanisms of taraxasterol from dandelion in endometriosis: Network pharmacology and cellular insights

AIMS

Endometriosis is a chronic inflammatory disease. The current treatment options in clinical practice mainly include hormonal therapy and surgical intervention. However, hormonal therapy is associated with serious side effects, and surgical treatment often leads to a high recurrence rate. Dandelion, a commonly used traditional Chinese medicine, has played a significant role in the treatment of endometriosis due to its notable efficacy and minimal side effects as a component of compound formulations. The purpose of this study is to investigate the molecular mechanisms of Taraxasterol, the main component of dandelion, in the treatment of endometriosis.

MATERIALS AND METHODS

This study employed network pharmacology to screen potential targets associated with Taraxasterol in the treatment of endometriosis. Subsequently, molecular docking was performed to preliminarily validate the core targets. Furthermore, GO and KEGG enrichment analyses were conducted to identify potential signaling pathways related to the treatment. The mechanisms underlying the therapeutic effects of Taraxasterol on endometriosis were further validated through in vitro cell experiments, including Western blotting, colony formation assays, scratch assays, and CCK-8 assays.

RESULTS

A total of 148 potential targets of Taraxasterol were selected through screening on a prediction website, along with 1180 disease targets and 71 overlapping targets. Subsequently, the overlapping targets were imported into the STRING database to construct a protein-protein interaction (PPI) network, which was visualized using Cytoscape 3.7. Ten key targets were identified from the network, and preliminary validation was performed through molecular docking of these ten targets. Additionally, GO and KEGG analyses were conducted on the overlapping targets, resulting in the identification of the top 10 enriched GO terms and the top 20 KEGG pathways, which were subsequently visualized. Finally, cellular experiments demonstrated that taraxasterol inhibits the proliferation and migration of ectopic endometrial cells through the PI3K/Akt/mTOR pathway, while promoting apoptosis.

CONCLUSIONS

Our study investigated the potential mechanisms underlying the therapeutic effects of Taraxacum officinale (dandelion) on endometriosis. Through network pharmacology and in vitro cellular experiments, we revealed that Taraxasterol, a bioactive compound present in dandelion, can inhibit the proliferation and migration of endometrial ectopic cells and promote apoptosis through the PI3K/Akt/mTOR pathway.

Applications of nanomaterials in endometriosis treatment

Endometriosis is a common disease of the reproductive system in women of childbearing age with an unclear pathogenesis. Endometriosis mainly manifests as dysmenorrhea, abdominal pain, and infertility. Currently, medical therapy and surgical treatment are usually used for endometriosis treatment. However, due to the high recurrence rate and many complications, it has greatly affected patients' quality of life. Nanotechnology is a new technology that mainly investigates the characteristics and applications of nanomaterials. To date, nanotechnology has received widespread attention in the field of biomedicine. Nanomaterials can not only be used as drugs to treat endometriosis directly, but also enhance the therapeutic effect of endometriosis by delivering drugs, siRNA, antibodies, vesicles, etc. This review comprehensively discusses nanomaterial-based therapies for endometriosis treatment, such as nanomaterial-based gene therapy, photothermal therapy, immunotherapy, and magnetic hyperthermia, which provides a theoretical reference for the clinical application of nanotechnology in the treatment of endometriosis.

Tetramethylpyrazine Retards the Progression and Fibrogenesis of Endometriosis

The development of more efficacious, non-hormonal therapeutics for endometriosis is still an unmet medical need begging to be fulfilled. Growing evidence indicates that endometriotic lesions are wounds undergoing repeated tissue injury and repair, and, as such, platelets play an important role in lesional progression. Tetramethylpyrazine (TMP), a compound derived from a herb that has been used for thousands of years to combat “blood stasis” in traditional Chinese medicine, is a prescription drug in China for the treatment of cerebrovascular disorders. We tested the hypothesis that TMP can decelerate lesional progression through arresting epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), and fibrogenesis. We found in our in vitro experiments that TMP treatment suppresses platelet-induced EMT, FMT, cellular contractility, and collagen production in a concentration-dependent manner. We also showed that in a mouse model of endometriosis, treatment with TMP significantly reduced lesion weight and the extent of lesional fibrosis and improved hyperalgesia, mostly likely through the reduction of lesional aggregation of platelets and the lesional expression of markers of EMT, FMT, and fibrogenesis. In light of our results and in view of its excellent safety profiles, TMP appears to be a promising drug candidate for treating endometriosis.

Endometriosis: current challenges in modeling a multifactorial disease of unknown etiology

Endometriosis is a chronic inflammatory hormone-dependent condition associated with pelvic pain and infertility, characterized by the growth of ectopic endometrium outside the uterus. Given its still unknown etiology, treatments usually aim at diminishing pain and/or achieving pregnancy. Despite some progress in defining mode-of-action for drug development, the lack of reliable animal models indicates that novel approaches are required. The difficulties inherent to modeling endometriosis are related to its multifactorial nature, a condition that hinders the recreation of its pathology and the identification of clinically relevant metrics to assess drug efficacy. In this review, we report and comment endometriosis models and how they have led to new therapies. We envision a roadmap for endometriosis research, integrating Artificial Intelligence, three-dimensional cultures and organ-on-chip models as ways to achieve better understanding of physiopathological features and better tailored effective treatments.

SULFATION PATHWAYS: Contribution of intracrine oestrogens to the aetiology of endometriosis

Endometriosis is an incurable hormone-dependent inflammatory disease that causes chronic pelvic pain and infertility characterized by implantation and growth of endometrial tissue outside the uterine cavity. Symptoms have a major impact on the quality of life of patients resulting in socioeconomic, physical and psychological burdens. Although the immune system and environmental factors may play a role in the aetiology of endometriosis, oestrogen dependency is still considered a hallmark of the disorder. The impact of oestrogens such as oestrone and particularly, oestradiol, on the endometrium or endometriotic lesions may be mediated by steroids originating from ovarian steroidogenesis or local intra-tissue production (intracrinology) dependent upon the expression and activity of enzymes that regulate oestrogen biosynthesis and metabolism. Two key pathways have been implicated: while there is contradictory data on the participation of the aromatase enzyme (encoded by CYP19A1), there is increasing evidence that the steroid sulphatase pathway plays a role in both the aetiology and pathology of endometriosis. In this review, we consider the evidence related to the pathways leading to oestrogen accumulation in endometriotic lesions and how this might inform the development of new therapeutic strategies to treat endometriosis without causing the undesirable side effects of current regimes that suppress ovarian hormone production.

Evaluation of peritoneal endometriosis treatment using intralesional acetylsalicylic acid injection in rabbits

PURPOSE

To investigate the efficacy of intralesional 20% aspirin injection for treatment of experimental peritoneal endometriosis.

METHODS

Peritoneal endometriosis was experimentally induced in forty adult nulligravid female rabbits. On day 30 post-endometriosis induction, rabbits were randomly divided to assess early (10 days) and late (20 days) effects of intralesional injection of physiological saline solution (control groups) in comparison to intralesional injection of 20% bicarbonate aspirin solution (experimental groups) as follows: control group 1 (10 days, n=10); control group 2 (20 days, n=10); experimental group 3 (10 days, n=10); experimental group 4 (20 days, n=10). Resected tissues, including endometriosis foci, were qualitatively (general morphology and signs of inflammatory cells infiltrate, necrosis and apoptosis) and quantitatively (remaining endometriosis area) assessed by histopathological analysis.

RESULTS

Extensive necrosis, hemorrhage, apoptosis, and fibrosis were observed in the experimental groups 3 and 4. Groups 1 and 2 presented typical endometrial tissue cysts, respectively. Groups 3 and 4 showed sparse endometrial tissue foci and no endometrial tissue, respectively. Quantitative analysis revealed that aspirin-treated groups 3 and 4 had significantly (p<0.05) smaller remaining endometriosis area, compared to control groups 1 and 2.

CONCLUSION

Intralesional 20% aspirin injection caused total destruction of peritoneal endometriosis foci in rabbits.

Clinical trials in allied medical fields: A cross-sectional analysis of World Health Organization International Clinical Trial Registry Platform

BACKGROUND

Clinical trials are mandatory for evidence-based practice. Hardly, any data are available regarding the number of clinical trials and their methodological quality that are conducted in allied fields of medicine.

OBJECTIVE

The present study was envisaged to assess methodological quality of trials in allied medical fields.

MATERIALS AND METHODS

Registered clinical trials in World Health Organization International Clinical Trials Registry Platform (http://apps.who.int/trialsearch/AdvSearch.aspx) in the following fields were extracted: Acupuncture; Ayurveda; biofeedback; complementary and alternate medicine; herbal; homeopathy; massage; naturopathy; Reiki; Siddha; Unani; and yoga. The eligible studies were assessed for the following key details: Type of sponsors; health condition in which the trial has been conducted; recruitment status; study design; if randomization was present, method of randomization and allocation concealment; single or multi-centric; retrospective or prospective registration; and publication status in case of completed studies.

RESULTS

A total of 276 clinical trials were registered majority of which have been proposed to be conducted in the field of oncology and psychiatry. Most of the clinical trials were done in single centers (87.75%), and almost all the clinical trials were investigator-initiated with pharmaceutical company sponsored studies contributing to a maximum extent of 24.5%. A large majority of the study designs were interventional where almost 85% of the studies were randomized controlled trials. However, an appropriate method of randomization was mentioned only in 27.4%, and the rate of allocation concealment was found to be just 5.5%. Only 1-2% of the completed studies were published, and the average rate of retrospective registration was found to be 23.6% in various fields.

CONCLUSION

The number of clinical trials done in allied fields of medicine other than the allopathic system has lowered down, and furthermore focus is required regarding the methodological quality of these trials and more support from various organizations.

Practices and Attitudes Concerning Endometriosis Among Nurses Specializing in Gynecology

Endometriosis is a chronic disease affecting approximately 10% of fertile women. These women often have negative health care experiences. This study adds new knowledge about endometriosis care in a hospital setting and nurses' attitudes toward the disease. To explore how the personal attitudes of gynecological nurses, their specialized knowledge, and their clinical experiences influenced the way they conceptualized and cared for women with endometriosis, participant observations and semistructured interviews were conducted. Categorization of patients into certain kinds, with more or less legitimate needs, provided an important framework for practice. Specialized knowledge qualified the nurses' views of their patients and seemed to be conducive to sustained patient involvement. However, the organization of care based solely on medical specialization restricted a holistic approach. An important goal is, therefore, to investigate patients' perspectives of health and illness and to create participatory relationships with patients, regardless of their diagnosis.

Endometriosis: pathogenesis and treatment

Endometriosis is defined as the presence of endometrial-type mucosa outside the uterine cavity. Of the proposed pathogenic theories (retrograde menstruation, coelomic metaplasia and Müllerian remnants), none explain all the different types of endometriosis. According to the most convincing model, the retrograde menstruation hypothesis, endometrial fragments reaching the pelvis via transtubal retrograde flow, implant onto the peritoneum and abdominal organs, proliferate and cause chronic inflammation with formation of adhesions. The number and amount of menstrual flows together with genetic and environmental factors determines the degree of phenotypic expression of the disease. Endometriosis is estrogen-dependent, manifests during reproductive years and is associated with pain and infertility. Dysmenorrhoea, deep dyspareunia, dyschezia and dysuria are the most frequently reported symptoms. Standard diagnosis is carried out by direct visualization and histologic examination of lesions. Pain can be treated by excising peritoneal implants, deep nodules and ovarian cysts, or inducing lesion suppression by abolishing ovulation and menstruation through hormonal manipulation with progestins, oral contraceptives and gonadotropin-releasing hormone agonists. Medical therapy is symptomatic, not cytoreductive; surgery is associated with high recurrence rates. Although lesion eradication is considered a fertility-enhancing procedure, the benefit on reproductive performance is moderate. Assisted reproductive technologies constitute a valid alternative. Endometriosis is associated with a 50% increase in the risk of epithelial ovarian cancer, but preventive interventions are feasible.

Surgery Versus Pharmacological Treatment for Endometriosis

The two major consequences of endometriosis are pain and infertility. Despite numerous studies and proposed guidelines, some aspects of the treatment for these complications are still under debate or lack convincing evidence that favors one approach over the other. Future studies will hopefully present new evidence in regard to the optimal treatment for each indication and suggest innovative pharmacotherapy following improved understanding of the pathophysiology of endometriosis. Until then, individualization of the treatment according to the specific indication, taking into consideration the benefits versus the risks for the patient and the tolerability profile, remains the most appropriate approach.

Review of lipiodol treatment for infertility - an innovative treatment for endometriosis-related infertility?

A lipiodol hysterosalpingogram was the routine test for tubal patency as recently as the 1970s. Observational studies, then randomised controlled trials, provided evidence of a fertility enhancing effect of lipiodol. It has been found to improve fertility for women with normal tubal patency, particularly where the woman has a history of endometriosis. Previous successful treatment for infertility with lipiodol is a marker of further successful treatment for infertility in a repeat procedure. Whilst lipiodol is probably effective at flushing debris that could hinder fertility from fallopian tubes, it also exerts immunobiological effects in pelvic peritoneum and on the endometrium that could be responsible for fertility enhancement. Effects of lipiodol on the endometrium that might be important at the time of the implantation window are a reduced expression of osteopontin and an increased number of uterine natural killer cells postlipiodol. The effect of lipiodol uterine bathing for women with endometriosis, repeat in vitro fertilisation (IVF) implantation failure and other reproductive disorders merits further investigation. Lipiodol presents a new, simple, low invasive, inexpensive treatment option for endometriosis-related infertility and might have wider applications.

An overview of the current status of clinical trials on endometriosis: issues and concerns

OBJECTIVE

To examine and compare differences, if any, between industry- and nonindustry-sponsored clinical trials on endometriosis and to evaluate the effect of prior published positive preclinical results, or lack thereof, on trial status.

DESIGN

Cross-sectional study of clinical trials on endometriosis that evaluate drugs/biologicals registered at ClinicalTrials.gov as of July 3, 2013.

SETTING

University-affiliated hospital.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Trial status, size, phase, and duration; use of comparator groups; drug classes, number of arms, targeting conditions; and presence or absence of prior positive preclinical results before the launch of the trial.

RESULT(S)

Eighty trials were identified. The trials sponsored by industry and non-industry have distinct features, differing in trial status, phase, comparator, drug classes, number of arms, trial size, and duration. The phase II/III trials are predominantly industry supported, but these trials frequently use placebo as the comparator. Trials launched without prior published preclinical results do not seem to fare well, although the presence of such studies is no guarantee for success.

CONCLUSION(S)

Questions as to whether the drug on trial is truly superior to the best available drug or of its cost-benefit profile are overlooked in most cases. There seems to be a deluge of "me-too" drugs with equivocal superiority over existing drugs and cost-benefit profiles. Because clinical trials are time-consuming, no blockbuster drug for endometriosis seems to be on the horizon yet.

Lack of transparency of clinical trials on endometriosis

OBJECTIVE

To estimate patterns of publication of clinical trials of endometriosis registered in ClinicalTrials.gov and their associated characteristics.

METHODS

Information on interventional clinical trials on endometriosis that were registered at ClinicalTrials.gov and updated as having been completed by October 25, 2012, was retrieved and the publication status and time to publication in Medline-indexed journals were ascertained by searching PubMed and by sending e-mail inquiries to the principal investigators listed by the registry.

RESULTS

Seventy-one interventional trials of endometriosis, testing various drugs and biologicals, were identified. Among them, 49.3% (35/71) were completed by October 25, 2012, 21.1% were either stopped or inactive in the past 2 years, and the remaining 29.6% were ongoing. Among the 35 completed trials, 25 (71.4%) were sponsored by industry and results were published for only 11 (31.4%; five industry-sponsored, and six nonindustry-sponsored). Trials sponsored by industry were nearly four times less likely to publish their results than nonindustry-sponsored trials, even though these trials typically had larger sample sizes and were completed faster. Compared with the publication rate of 20% found 4 years ago, the current rate has increased only marginally but still lies significantly below the reported 66.3% surveyed recently among 546 completed nonendometriosis trials registered at ClinicalTrials.gov (P<.001).

CONCLUSION

Despite mounting pressure on more transparency of clinical trials, the current state of transparency or lack thereof of clinical trials on endometriosis is worrisome and does not benefit the trial sponsor or the public. Thus, we again call for more transparency for endometriosis trials.

Treatment with bazedoxifene, a selective estrogen receptor modulator, causes regression of endometriosis in a mouse model

Endometriosis is a common estrogen-dependent disorder. Medical treatments currently consist of progestins or GnRH agonists; however, neither is fully effective and both entail significant side effects. Selective estrogen receptor (ER) modulators (SERM) have tissue-selective actions, acting as an ER agonist in some tissues and ER antagonist in others. The SERM bazedoxifene (BZA) effectively antagonizes estrogen-induced uterine endometrial stimulation without countering estrogenic effects in bone or central nervous system. These properties make it an attractive candidate for use in the treatment of endometriosis. Experimental endometriosis was created in reproductive-age CD-1 mice. After 8 wk, 10 animals received i.p. injections of BZA (3 mg/kg·d) for 8 wk, whereas 10 received vehicle control. Mice were killed, and implant size was assessed. The mean size of the implants after treatment was 60 mm(2) in the control group and 21 mm(2) in the BZA treatment group (P = 0.03). Quantitative PCR and immunohistochemical analysis were used to determine the effect on endometrial gene expression. PCNA, ERα, and LIF mRNA and protein expression were significantly decreased in endometrium of the treated group. Caspase 3 mRNA expression was increased. Expression of PR and Hoxa10 were not significantly altered by treatment. There was no evidence of ovarian enlargement or cyst formation. Decreased PCNA and ER expression demonstrated that the regression of endometriosis likely involved decreased estrogen-mediated cell proliferation. BZA may be an effective novel agent for the treatment of endometriosis due to greater endometrial-specific estrogen antagonism compared with other SERM.

Generalized hyperalgesia in women with endometriosis and its resolution following a successful surgery

Although pains of various kinds top the list of complaints from women with endometriosis and are the most debilitating of the disease, little is known about the mechanism/mechanisms of endometriosis-associated pains. To test the hypothesis that women with endometriosis have generalized hyperalgesia which may be alleviated by a successful surgery, we recruited 100 patients with surgically and histologically confirmed endometriosis and 70 women without, and tested their responses to pain stimulations. Before the surgery, all patients rated their dysmenorrhea severity by Visual Analog scale (VAS) and went through an ischemic pain test (IPT) and an electrical pain test (EPT). The controls were also administrated with IPT/EPT. Three and 6 months after surgery, all patients were administrated with IPT/EPT and rated their severity of dysmenorrhea. We found that patients with endometriosis had significantly higher IPT VAS scores and lower EPT pain threshold than controls, but after surgery their IPT scores and EPT pain threshold were significantly and progressively improved, along with their dysmenorrhea severity. Thus, we conclude that women with endometriosis have generalized hyperalgesia, which was alleviated by surgery. Consequently, central sensitization may be a possible mechanism underlying various forms of pain associated with endometriosis, and its recognition should have important implications for the development of novel therapeutics and better clinical management of endometriosis.

Legislation for trial registration and data transparency

Public confidence in clinical trials has been eroded by data suppression, misrepresentation and manipulation. Although various attempts have been made to achieve universal trial registration- e.g., Declaration of Helsinki, WHO clinical Trial Registry Platform (WHO ICTRP), the International Committee of Medical Journal Editors requirement- they have not succeeded, probably because they lack the enough power of enforcement.Legislation appears to be the most efficient and effective means to ensure that all researchers register their trials and disseminate their data accurately and in a timely manner. We propose that a global network be established. This could be accomplished in two steps. The first step is to legislate about trial registration and data transparency, such as USA's FDAAA Act 2007; and the second step to establish a global network to ensure uniform, international consistency in policy and enforcement of trial registration and data transparency.

Legislation for trial registration and data transparency

Public confidence in clinical trials has been eroded by data suppression, misrepresentation and manipulation. Although various attempts have been made to achieve universal trial registration- e.g., Declaration of Helsinki, WHO clinical Trial Registry Platform (WHO ICTRP), the International Committee of Medical Journal Editors requirement- they have not succeeded, probably because they lack the enough power of enforcement.Legislation appears to be the most efficient and effective means to ensure that all researchers register their trials and disseminate their data accurately and in a timely manner. We propose that a global network be established. This could be accomplished in two steps. The first step is to legislate about trial registration and data transparency, such as USA's FDAAA Act 2007; and the second step to establish a global network to ensure uniform, international consistency in policy and enforcement of trial registration and data transparency.

A dose-ranging study to determine the efficacy and safety of 1, 2, and 4mg of dienogest daily for endometriosis

OBJECTIVES

To compare the efficacy and safety of dienogest at doses of 1, 2, and 4mg/day orally in the treatment of endometriosis.

METHODS

An open-label, randomized, multicenter, 24-week comparative trial in women with histologically confirmed endometriosis. Efficacy was assessed by second-look laparoscopy and patient-reported symptoms. Statistical tests included chi(2) and Wilcoxon signed rank tests.

RESULTS

Dienogest reduced mean revised American Fertility Society scores from 11.4 to 3.6 (n=29; P<0.001) in the 2-mg group and from 9.7 to 3.9 (n=35; P<0.001) in the 4-mg group. Dienogest at 2 and 4mg/day was associated with symptom improvements in substantial proportions of women. Both dienogest doses were generally well tolerated, with low rates of treatment discontinuation due to adverse events. The 1-mg dose arm was discontinued owing to insufficient bleeding control.

CONCLUSION

Dienogest at 2mg once a day is recommended as the optimal dose in future studies of endometriosis.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)