Evolution of medical treatment for endometriosis: back to the roots?

Diagnostic and therapeutic approaches for endometriosis: a patent landscape

OBJECTIVE

The aim of this review is to analyze the patent filings and to systematize the main technological trends in patent protection for the diagnosis and therapeutics for endometriosis. Patent literature has also been explored to identify active inventors and applicants in this field.

METHODOLOGY

Patent search was carried out in the freely accessible patent search databases namely, patentscope using various combinations of the keywords "Endometriosis OR Adenomyosis" AND "Diagnostic OR Therapeutics" were used along with wildcard search queries in the "Title", "Abstract" and "Descriptions" fields.

RESULTS

A patent search revealed 144 patents describing inventions for diagnostic and therapeutic purposes of endometriosis. These patents include 26 patent applications in the diagnostic utility and 116 patent applications under the therapeutic approaches. Out of these 116 patent applications, 43 describe traditional medicines for endometriosis. Two patent applications describe inventions that can fall into both categories.

CONCLUSION

Efforts are being made to improve current diagnostic instruments. Hormonal alteration methods is the most common field of invention, followed by surgical interventions for therapeutics. A general trend of increase in patent application filings has been observed with a slight decrease in recent years.

Ethanol extract of basil (Ocimum Basilicum L.) leaves inhibits endometriosis growth in a mouse model by modulating vascular endothelial growth factor (VEGF) expression

The objective of this study was to examine the effect of administering an ethanol extract obtained from basil leaves on the expression of vascular endothelial growth factor (VEGF) and the severity of endometriosis lesions in a mouse model. A total of 28 female mice, aged 2-3 months and weighing 20-30 grams, were randomly divided into four groups: the control group (C), treatment group 1 (T1) receiving a dose of basil leaf ethanol extract (0.21 mg/g-BW), treatment group 2 (T2) receiving a higher dose (0.42 mg/g BW), and treatment group 3 (T3) receiving the highest dose (0.84 mg/g-BW). Each group underwent a 14-day treatment period, and tissue samples were collected on the 29th day. An immunohistochemical examination was conducted to assess the expression of VEGF and evaluate the severity of endometriosis lesions. The statistical analysis of VEGF expression revealed a significant difference (p=0.026; p<0.05), with the most pronounced effects observed when administering basil leaf ethanol extract at doses of 0.21 mg/g-BW and 0.42 mg/g-BW. Although not statistically significant (p=0.271; p<0.05), a reduction in the severity of endometriosis lesions was observed following the administration of basil leaf ethanol extract at doses of 0.21 mg/g-BW and 0.42 mg/g-BW. Administering basil leaf ethanol extract at doses of 0.21 mg/g-BW and 0.42 mg/g-BW effectively decreased VEGF expression and limited the severity of endometriosis lesions.

Frankincense ameliorates endometriosis via inducing apoptosis and reducing adhesion

Background

Frankincense, a resin derived from trees of the Boswellia genus, has been used as an incense and a type of herbal medicine for treating inflammatory diseases such arthritis, chronic bowel illness, and asthma. While endometriosis is a well-known inflammatory gynecological illness caused by the ectopic attachment and development of uterine tissue over the menstrual cycle, the impact of frankincense on this illness is poorly understood. The purpose of this study was to explore the effects of frankincense on endometriosis.

Methods

We used a network pharmacological assessment, in vitro and in vivo investigations with a human endometriotic cell line as well as a syngeneic uterine transfer mouse model. High-performance liquid chromatographic analysis was used to compare water-extracted frankincense (Fr) to its reference compounds and validate the sample.

Results

A network pharmacological analysis suggested a positive effect of Fr on endometriosis. Fr relieved endometriosis by reducing ectopic endometrial adherence and development, according to both in vivo and in vitro models. We suggested that the ER stress/p53-apoptosis and chemokine-migration/adhesion pathways underlie Fr's anti-endometriotic action using RNA sequencing and bioinformatic analysis.

Conclusion

This study revealed the potential effect of Fr on endometriosis using an experimental investigation. Fr may have the potential to be an effective and safe treatment for endometriosis.

Regulation of Apoptosis and Oxidative Stress by Oral Boswellia Serrata Gum Resin Extract in a Rat Model of Endometriosis

Endometriosis (EMS) is a gynecological disease characterized by inflammation, oxidative stress, and apoptosis dysregulation. This study aims to evaluate the effect of Boswellia serrata gum resin extract (BS) on the endometriotic lesions in a rat model of endometriosis. We divided female rats into three groups, including Sham, EMS, EMS + BS. In the EMS and EMS + BS groups, pathology was induced and after 7 days by the abdominal high-frequency ultrasound (hfUS) analysis the presence of the endometriotic lesions was confirmed. Subsequently, the EMS + BS group was administered with BS (100 mg/Kg) daily for another 7 days. At the end of the experiment, the hfUS analysis was repeated and the animals were sacrificed to evaluate the size and histoarchitecture of the endometriotic implants. Pelvic ultrasound showed increased size of the endometriotic lesions in the Endo group, while BS administration reduced the lesion size. The macroscopic analysis confirmed the reduced area and volume of the endometriotic lesions of the EMS + BS group. The histological analysis showed reduced characteristic of ectopic stroma and glands in the animals treated with BS. Western blot analyses were conducted to evaluate the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway. BS increases the expression of Nfr2 in the nucleus and the expression of its downstream antioxidant proteins NQO-1 and HO-1. Moreover, it reduced lipid peroxidation and increased glutathione (GSH) levels, and glutathione peroxidase (GPx) and superoxide dismutase (SOD) activities. BS administration also restored the impaired apoptotic pathway in the lesions by reducing Bcl-2 expression and increasing Bax and cleaved caspase 9 levels. The BS apoptotic effect was also confirmed by the cleavage of PARP, another specific marker of apoptosis, and by the TUNEL assay. Our results show that BS administration resulted in an effective and coordinated suppression of Endo owing to its antioxidant and antiapoptotic activities.

Efficacy and Safety of Chinese Herbal Medicine for Endometriosis Associated Pain

Endometriosis is a chronic, estrogen-dependent condition that causes dysmenorrhea and pelvic pain. Chinese herbal medicine (CHM) has been used for endometriosis for many years in Asian populations. This is a retrospective study in a territory teaching hospital of the China Academy of Chinese Medical Sciences in Beijing, China to compare the short- and long-term effectiveness and safety of CHM for endometriosis associated pain (EAP) before and after CHM treatment. A total of 338 out of 1143 women confirmed with endometriosis by ultrasonogram or surgery within three months received a CHM decoction twice a day for at least 3 and up to 24 months. All data were collected by a Structured Medical Records of Endometriosis (SMRE) in every clinic visit covering the whole treatment period. Pain score, evaluated by Numeric Rating Scale, was significantly decreased from 3rd to 12th month in women with moderate or severe pain. Frequency and severity rating of menstrual symptoms, evaluated by Cox Menstrual Symptom Scale, were significantly decreased in women with any pain level. Psychological changes rated by Self-rating Anxiety Scale (SAS) were significantly lower in 3, 6, 12, and 24 months of treatment, but those by Self-rating Depression Scale (SDS) was significantly decreased in six months of treatment. There was no severe adverse event but only minor side-effects. In conclusion, our study showed that CHM relieved EAP and related symptoms with minimal side-effects after treatment. A large-scale randomized and placebo-controlled trial could be designed to confirm the efficacy and safety.

Exploring Compounds to be used as Cosmetic Agents that Activate Peroxisome Proliferator-Activated Receptor Alpha

OBJECTIVE

The human epidermis is formed by the proliferation and differentiation of keratinocytes adjacent to the basement membrane. The outermost layer, the stratum corneum, is equipped with a barrier function that prevents water evaporation, and intercellular lipids play an important role in this barrier function. When the barrier is functioning normally, evaporation is prevented; however, when barrier function is impaired, moisture evaporates, resulting in dry and rough skin. Therefore, maintenance of normal barrier function is critical for maintaining normal skin function. Peroxisome proliferator-activated receptor α (PPARα) is mainly involved in lipid metabolism in the liver but is also expressed in the epidermis and is involved in inducing keratinocyte differentiation, promoting lipid production, maintaining barrier function, and suppressing skin inflammation. Hence, compounds that activate PPARα are expected to control skin function. Therefore, we identified PPARα activators from among extracts of natural resources that have been approved for use in humans and analyzed the effects of these extracts on skin function.

METHODS

First, extracts of 474 natural resources were screened using a PPARα activator screening cell line independently constructed in our laboratory. Next, reporter assays were performed using the Gal4-chimera system to evaluate whether these extracts act as ligands for PPARα. We then analyzed their effect on primary normal human epidermal keratinocyte cells by using real-time RT-PCR. Finally, we evaluated PPARα activation effect by the combination of these extracts.

RESULTS

We identified 36 extracts having the effect of activating PPARα. In particular, #419, a Typha angustifolia spike extract, showed concentration-dependent transcriptional activation through PPARα-LBD and was considered to be likely to contain a compound that is a ligand of PPARα. #419 increased the expression of PPARα target genes as well as genes related to skin function in primary cultured human epidermal keratinocytes. Finally, the use of #419 in combination with nine extracts increased PPAR activity more than twice as much as #419 alone treatment.

CONCLUSIONS

These results showed that the reporter cell line could be useful for discovering extracts of natural resources and that the identified Typha angustifolia spike extract could be used in cosmetics that activate PPARα, which expected to improve skin function.

Polyphenols as a Diet Therapy Concept for Endometriosis-Current Opinion and Future Perspectives

Endometriosis represents an often painful, estrogen-dependent gynecological disorder, defined by the existence of endometrial glands and stroma exterior to the uterine cavity. The disease provides a wide range of symptoms and affects women’s quality of life and reproductive functions. Despite research efforts and extensive investigations, this disease’s pathogenesis and molecular basis remain unclear. Conventional endometriosis treatment implies surgical resection, hormonal therapies, and treatment with nonsteroidal anti-inflammatory drugs, but their efficacy is currently limited due to many side effects. Therefore, exploring complementary and alternative therapy strategies, minimizing the current treatments’ adverse effects, is needed. Plants are sources of bioactive compounds that demonstrate broad-spectrum health-promoting effects and interact with molecular targets associated with endometriosis, such as cell proliferation, apoptosis, invasiveness, inflammation, oxidative stress, and angiogenesis. Anti-endometriotic properties are exhibited mainly by polyphenols, which can exert a potent phytoestrogen effect, modulating estrogen activity. The available evidence derived from preclinical research and several clinical studies indicates that natural biologically active compounds represent promising candidates for developing novel strategies in endometriosis management. The purpose of this review is to provide a comprehensive overview of polyphenols and their properties valuable for natural treatment strategy by interacting with different cellular and molecular targets involved in endometriosis progression.

Plants as source of new therapies for endometriosis: a review of preclinical and clinical studies

BACKGROUND

Given the disadvantages and limitations of current endometriosis therapy, there is a progressive increase in studies focusing on plant-derived agents as a natural treatment option with the intention of achieving high efficiency, avoiding adverse effects and preserving the chance for successful pregnancy. The heterogeneity of these studies in terms of evaluated agents, applied approaches and outcomes illustrates the need for an up-to-date summary and critical view on this rapidly growing field in endometriosis research.

OBJECTIVE AND RATIONALE

This review provides a comprehensive overview of plant-derived agents and natural treatment strategies that are under preclinical or clinical investigation and critically evaluates their potential for future endometriosis therapy.

SEARCH METHODS

An English language PubMed literature search was performed using variations of the terms 'endometriosis', 'natural therapy', 'herb/herbal', 'plant', 'flavonoid', 'polyphenol', 'phytochemical', 'bioactive', 'Kampo' and 'Chinese medicine'. It included both animal and human studies. Moreover, the Clinicaltrials.gov database was searched with the term 'endometriosis' for clinical trials on plant-derived agents. No restriction was set for the publication date.

OUTCOMES

Natural therapies can be assigned to three categories: (i) herbal extracts, (ii) specific plant-derived bioactive compounds and (iii) Chinese herbal medicine (CHM). Agents of the first category have been shown to exert anti-proliferative, anti-inflammatory, anti-angiogenic and anti-oxidant effects on endometrial cells and endometriotic lesions. However, the existing evidence supporting their use in endometriosis therapy is quite limited. The most studied specific plant-derived bioactive compounds are resveratrol, epigallocatechin-3-gallate, curcumin, puerarin, ginsenosides, xanthohumol, 4-hydroxybenzyl alcohol, quercetin, apigenin, carnosic acid, rosmarinic acid, wogonin, baicalein, parthenolide, andrographolide and cannabinoids, with solid evidence about their inhibitory activity in experimental endometriosis models. Their mechanisms of action include pleiotropic effects on known signalling effectors: oestrogen receptor-α, cyclooxygenase-2, interleukin-1 and -6, tumour necrosis factor-α, intercellular adhesion molecule-1, vascular endothelial growth factor, nuclear factor-kappa B, matrix metalloproteinases as well as reactive oxygen species (ROS) and apoptosis-related proteins. Numerous studies suggest that treatment with CHM is a good choice for endometriosis management. Even under clinical conditions, this approach has already been shown to decrease the size of endometriotic lesions, alleviate chronic pelvic pain and reduce postoperative recurrence rates.

WIDER IMPLICATIONS

The necessity to manage endometriosis as a chronic disease highlights the importance of identifying novel and affordable long-term safety therapeutics. For this purpose, natural plant-derived agents represent promising candidates. Many of these agents exhibit a pleiotropic action profile, which simultaneously inhibits fundamental processes in the pathogenesis of endometriosis, such as proliferation, inflammation, ROS formation and angiogenesis. Hence, their inclusion into multimodal treatment concepts may essentially contribute to increase the therapeutic efficiency and reduce the side effects of future endometriosis therapy.

Contribution of salidroside to the relieve of symptom and sign in the early acute stage of osteoarthritis in rat model

ETHNOPHARMACOLOGICAL RELEVANCE

The genus Rhodiola has been used to treat cough, hemoptysis, fever, pain, bruise and other symptoms which are related to injury and inflammation over a thousand years in traditional Tibetan medicine. Salidroside (p-hydroxyphenethyl-β-D-glucoside) is one of the most potent bioactive ingredients of the genus Rhodiola.

AIM OF STUDY

The present study aimed to explore whether salidroside could alleviate the clinical symptom and sign in the early acute stage of osteoarthritis (OA) in monosodium iodoacetate (MIA) rat model, and its underlying mechanisms.

MATERIALS AND METHODS

Osteoarthritis (OA) was induced in rat knees by intra-articular injection of MIA; simultaneously salidroside was administered by intravenous injection. Pain behaviors were evaluated by knee-bend test, hind limb weight-bearing asymmetry and hind paw mechanical withdrawal threshold. The joint swelling was determined by the difference of knee joint diameter. Inflammatory exudates in synovial fluid were evaluated by leukocyte counting and protein content. Cytokines, chemokines, reactive oxygen species (ROS) and reactive nitrogen species (RNS) markers were determined by Enzyme-linked immunosorbent assay (ELISA) and colorimetric assay in synovial fluid. Pro-inflammatory gene expressions in synovial tissue were detected by quantitative real time RT-PCR (qRT-PCR). Nuclear factor kappa-B (NF-κB) DNA binding assay and western blot were used to determine NF-κB activation and ROS marker protein expression in synovial tissue. Glycosaminoglycan (GAG) content in the cartilage was measured by dimethylmethylene blue method. Hematoxylin and eosin (H&E), Safranin O-fast green and a modified Mankin grading system were used to evaluate the histology of articular cartilage.

RESULTS

Salidroside could alleviate pain and joint swelling in the early acute stage of OA in rat model, reduced the number of leukocytes, total protein content, proinflammatory mediators and ROS/RNS markers in synovial fluid, down regulated the expression of proinflammatory genes in synovium, inhibited the activation of NF- κ B and oxidative stress response in synovium, promoted the synthesis of cartilage GAG, prevented the loss of proteoglycan and chondrocyte degeneration.

CONCLUSIONS

Salidroside effectively alleviates acute symptom and sign of OA in rat model by its anti-inflammatory and antioxidant affects to inhibit synovial inflammation, which provides a new strategy to prevent the onset and progression of OA.

Interleukin-1β inhibits estrogen receptor-α, progesterone receptors A and B and biomarkers of human endometrial stromal cell differentiation: implications for endometriosis

Human blastocyst nidation in the uterus and successful pregnancy require coordinated endometrial expression of estrogen receptor (ER)-α, progesterone receptors (PR)-A and -B and the gap junction protein, connexin (Cx)43. Our prior work established that inflammation associated with conditions of reduced fecundity, particularly endometriosis, can perturb eutopic decidual function. In the current studies, we have modeled endometrial decidualization in primary human endometrial stromal cell cultures derived from normal controls (NESC) and from the eutopic endometria of women with endometriosis (EESC) to test the hypothesis that a proinflammatory cytokine, interleukin (IL)-1β, can disrupt stromal cell differentiation. The cells were grown under a standard protocol with hormones (10 nM 17β-estradiol, 100 nM progesterone and 0.5 mM dibutyryl cAMP) for up to 7 days in the absence or presence of IL-1β. Time-course experiments showed that IL-1β compromised decidual function in both NESC and EESC, which was accompanied by rapid phosphorylation of ER-α, PR and Cx43 and their cellular depletion. Inhibition of the extracellular signal-regulated kinase (ERK)1/2 pathway by a selective pharmacological blocker (PD98059) or siRNA interference, or the addition of hormones themselves, blocked the phosphorylation of ERK mediators; increased the production of steroid receptors, Cx43, prolactin, insulin-like growth factor binding protein-1 (IGFBP)-1 and vascular endothelial growth factor (VEGF) and accelerated the differentiation. The results indicate that inhibition of IL-1β can enhance decidualization in NESC and EESC in vitro. Strategies to interfere with this pathway might be implemented as an in vivo approach to enhance fertility in women with endometriosis and, potentially, other inflammatory pathologies.

Progesterone receptor ligands for the treatment of endometriosis: the mechanisms behind therapeutic success and failure

BACKGROUND

Despite intense research, it remains intriguing why hormonal therapies in general and progestins in particular sometimes fail in endometriosis.

OBJECTIVE AND RATIONALE

We review here the action mechanisms of progesterone receptor ligands in endometriosis, identify critical differences between the effects of progestins on normal endometrium and endometriosis and envisage pathways to escape drug resistance and improve the therapeutic response of endometriotic lesions to such treatments.

SEARCH METHODS

We performed a systematic Pubmed search covering articles published since 1958 about the use of progestins, estro-progestins and selective progesterone receptor modulators, to treat endometriosis and its related symptoms. Two reviewers screened the titles and abstracts to select articles for full-text assessment.

OUTCOMES

Progesterone receptor signalling leads to down-regulation of estrogen receptors and restrains local estradiol production through interference with aromatase and 17 beta-hydroxysteroid dehydrogenase type 1. Progestins inhibit cell proliferation, inflammation, neovascularisation and neurogenesis in endometriosis. However, progesterone receptor expression is reduced and disrupted in endometriotic lesions, with predominance of the less active isoform (PRA) over the full-length, active isoform (PRB), due to epigenetic abnormalities affecting the PGR gene transcription. Oxidative stress is another mechanism involved in progesterone resistance in endometriosis. Among the molecular targets of progesterone in the normal endometrium that resist progestin action in endometriotic cells are the nuclear transcription factor FOXO1, matrix metalloproteinases, the transmembrane gap junction protein connexin 43 and paracrine regulators of estradiol metabolism. Compared to other phenotypes, deep endometriosis appears to be more resistant to size regression upon medical treatments. Individual genetic characteristics can affect the bioavailability and pharmacodynamics of hormonal drugs used to treat endometriosis and, hence, explain part of the variability in the therapeutic response.

WIDER IMPLICATIONS

Medical treatment of endometriosis needs urgent innovation, which should start by deeper understanding of the disease core features and diverse phenotypes and idiosyncrasies, while moving from pure hormonal treatments to drug combinations or novel molecules capable of restoring the various homeostatic mechanisms disrupted by endometriotic lesions.

Potential use of ellagic acid for endometriosis treatment: its effect on a human endometrial cell cycle, adhesion and migration

EA treatment decreases cell adhesion and migration of endometrial cells and alters the progression of an endometrial stromal cell line cycle.

Novel Drug Targets with Traditional Herbal Medicines for Overcoming Endometriosis

Endometriosis is a disease in which the lining of the endometrium is found outside of the uterus. Recent medical treatments for endometriosis have adverse effects, limiting their long-term use. Furthermore, the recurrence of the disease after the cessation of therapy is quite common, and most patients need to continue treatment to maintain a hypoestrogenic environment till conception. Notwithstanding recent advances in computational and chemical practices, traditional medicines are considered the most consistent sources for the discovery of new drugs. Numerous medicinal plants and plantderived compounds have been tested against gynecological disorders, mainly endometriosis. This review aimed to describe the pharmacological activity profile of the medicinal plants and their active ingredients and draw attention to the discovery of multitargeted drug molecules for rational therapy.

Calligonum comosum (Escanbil) extract exerts anti-angiogenic, anti-proliferative and anti-inflammatory effects on endometriotic lesions

ETHNOPHARMACOLOGICAL RELEVANCE

Calligonum comosum is a desert plant that is applied in traditional folkloric medicine for the treatment of abnormally heavy or prolonged menstruation and menstrual cramps. Moreover, it has been suggested for the treatment of infertility-causing conditions. Its bioactive chemical constituents inhibit multiple processes, such as angiogenesis, inflammation and invasive tissue growth, which may be beneficial in the therapy of endometriosis.

AIM OF THE STUDY

We investigated the effects of Calligonum comosum on the development of endometriotic lesions.

MATERIALS AND METHODS

We evaluated the anti-angiogenic activity of Calligonum comosum ethyl acetate fraction (CCEAF) in different in vitro angiogenesis assays. Moreover, we surgically induced endometriotic lesions in BALB/c mice, which received 50 mg/kg Calligonum comosum total extract (CCTE) or vehicle (control) over 4 weeks. The growth, cyst formation, vascularization and immune cell infiltration of the lesions were assessed with high-resolution ultrasound imaging, caliper measurements, histology and immunohistochemistry.

RESULTS

CCEAF doses of up to 10 μg/mL did not impair the viability of human dermal microvascular endothelial cells (HDMEC), but dose-dependently suppressed their migration, tube formation and sprouting, indicating a substantial anti-angiogenic effect of CCEAF. Furthermore, CCTE significantly inhibited the growth and cyst formation of developing murine endometriotic lesions when compared to vehicle-treated controls. This was associated with a reduced vascularization, cell proliferation and immune cell infiltration.

CONCLUSIONS

Our findings show that Calligonum comosum targets multiple, fundamental processes in the pathogenesis of endometriosis, which may be beneficial for the treatment of this common gynecological disorder.

Understanding the Role of Gui-Zhi-Fu-Ling-Capsules (Chinese Medicine) for Treatment of Endometriosis in the Rat Model: Using NMR Based Metabolomics

The objective of this study is to identify the changes of metabolites in the rat endometriosis models treated with Gui-Zhi-Fu-Ling-capsules (GZFLC), a classic Chinese medicinal formula, and to explore the effects of GZFLC on the serum levels of transforming growth factor-β1 (TGF-β1) and the mRNA expression levels of vascular endothelial growth factor (VEGF) and glucose transporter 4 (GLUT-4) in the endometriotic tissues. Forty female Wistar rats were randomly divided into the sham-operation group (Normal group), Model group, Danazol group, and GZFLC group. The serum levels of TGF-β1 were measured using enzyme-linked immune-sorbent assay (ELISA). The mRNA expression levels of VEGF and GLUT-4 in the endometriotic tissue of the rat endometriosis models were measured using real-time quantitative PCR. The metabolites in urine were detected by ¹H NMR method. Eight identified metabolites of the NMR resonance were involved in the glycolysis metabolism. Among the 8 metabolites, Lactate, Acetate, TMA, and Formate were downregulated with GZFLC. Citrate, TMAO, Taurine, and Hippurate were unregulated with GZFLC. The serum levels of TGF-β1 in the Danazol and GZFLC groups were significantly higher than those of Normal group and significantly lower than the Model group. GZFLC treatment significantly decreased the GLUT-4 and VEGF mRNA expression levels in the endometriotic tissues of the endometriosis rats (P < 0.05). GZFLC significantly decreased the GLUT-4 mRNA expression levels in rats of GZFLC group compared with Danazol group. It is through regulating the metabolites changes of glycolysis or gluconeogenesis that GZFLC significantly affected the expression levels of TGF-β1, GLUT-4, and VEGF of the model rats with endometriosis.

The use of home remedies and complementary health approaches in endometriosis

RESEARCH QUESTION

Conventional treatments are often associated with adverse effects and endometriosis pain symptoms may reoccur despite treatment. Consequently, many women use complementary health approaches (CHA) and home remedies (HR) to relieve their pain. The aim of this study was to examine the frequency and the subjectively perceived efficacy of CHA/HR use by women affected by endometriosis.

DESIGN

Retrospective evaluation using medical charts and a questionnaire. Women recruited in hospitals and in self-help groups were asked about the use of 'topical heat', 'repose/relaxation', 'movement/massages', 'homeopathy/phytotherapy', 'acupuncture/traditional Chinese medicine (TCM)' and 'kinesiology/physiotherapy'.

RESULTS

From a total of 574 women with a confirmed diagnosis of endometriosis, 359 (62.5%) applied some form of CHA/HR. Women suffering from fatiguing disease symptoms more often selected alternative therapies (odds ratio [OR] 3.14, 95% confidence interval [CI] 1.39-7.11, P = 0.006) compared with women without these characteristics. Furthermore, women dissatisfied with healthcare provided by their treating physician, more frequently (OR 2.30, 95% CI 1.19-4.45, P = 0.013) chose the aforementioned alternative strategies.

CONCLUSION

As conventional therapies may not be sufficiently effective, women's needs should be closely examined, and individual treatment options should be discussed and initiated by clinicians to provide the best comprehensive treatment possible for endometriosis.

Laparoscopic Neuronavigation for Deep Lateral Pelvic Endometriosis: Clinical and Surgical Implications

STUDY OBJECTIVE

To evaluate the clinical presentation and surgical outcome in patients with deep lateral pelvic endometriosis (dLPE).

DESIGN

A retrospective multicentric study (Canadian Task Force classification II-2).

SETTING

University tertiary referral centers.

PATIENTS

One hundred forty-eight women with deep infiltrating endometriosis (DIE).

INTERVENTIONS

Laparoscopic excision of DIE. Disease distribution was classified as follows: central pelvic endometriosis (CPE) when DIE involved 1 of the following anatomic sites: cervix, vagina, uterosacral ligaments, rectum, bladder, or pelvic peritoneum; superficial lateral pelvic endometriosis when parametria, ureters, or hypogastric plexus were involved; and dLPE in the presence of sacral plexus and/or sciatic nerve infiltration.

MEASUREMENTS AND MAIN RESULTS

All patients showed CPE. LPE was detected in 116 cases (78.4%); among these, we observed dLPE in 41 patients (35.3%). dLPE occurred in 40% of women with CPE and in 72.7% of patients with hypogastric plexus involvement. Thirty women with dLPE (73.2%) received gastrointestinal or urologic resection in addition to gynecologic procedures compared with 40 patients (57.1%) without dLPE (p = .001). No differences were observed in terms of perioperative complications according to the presence of dLPE. According to univariate/multivariate analysis, chronic pelvic pain was the only predictor of dLPE (odds ratio = 3.041, p = .003). The median preoperative visual analog scale for dysmenorrhea (median = 8, range, 0-10) and dyspareunia (median = 5; range, 0-10) dropped to 0 after surgery. The median follow-up was 36 months (range, 6-66 months) with a recurrence rate of 8.8%.

CONCLUSIONS

dLPE is not a rare event in women with DIE. Complete laparoscopic removal of endometriosis seems to ensure benefit in terms of recurrence rate without increased surgical morbidities.

Effects of acupuncture for the treatment of endometriosis-related pain: A systematic review and meta-analysis

BACKGROUND

Endometriosis is a multifactorial, oestrogen-dependent, inflammatory, gynaecological condition that can result in long-lasting visceral pelvic pain and infertility. Acupuncture could be an effective treatment for endometriosis and may relieve pain. Our aim in the present study was to determine the effectiveness of acupuncture as a treatment for endometriosis-related pain.

METHODS

In December 2016, six databases were searched for randomised controlled trials that determined the effectiveness of acupuncture in the treatment of endometriosis-related pain. Ultimately, 10 studies involving 589 patients were included. The main outcomes assessed were variation in pain level, variation in peripheral blood CA-125 level, and clinical effective rate. All analyses were performed using comprehensive meta-analysis statistical software.

RESULTS

Of the 10 studies included, only one pilot study used a placebo control and assessed blinding; the rest used various controls (medications and herbs), which were impossible to blind. The sample sizes were small in all studies, ranging from 8 to 36 patients per arm. The mean difference (MD) in pain reduction (pre- minus post-interventional pain level-measured on a 0-10-point scale) between the acupuncture and control groups was 1.36 (95% confidence intervals [CI] = 1.01-1.72, P<0.0001). Acupuncture had a positive effect on peripheral blood CA-125 levels, as compared with the control groups (MD = 5.9, 95% CI = 1.56-10.25, P = 0.008). Similarly, the effect of acupuncture on clinical effective rate was positive, as compared with the control groups (odds ratio = 2.07; 95% CI = 1.24-3.44, P = 0.005).

CONCLUSIONS

Few randomised, blinded clinical trials have addressed the efficacy of acupuncture in treating endometriosis-related pain. Nonetheless, the current literature suggests that acupuncture reduces pain and serum CA-125 levels, regardless of the control intervention used. To confirm these findings, additional, blinded studies with proper controls and adequate sample sizes are needed.

Effect of Hua Yu Xiao Zheng decoction on the expression levels of vascular endothelial growth factor and angiopoietin-2 in rats with endometriosis

The aims of the present study were to investigate the effects of a traditional Chinese medicine, Hua Yu Xiao Zheng (HYXZ) decoction, on surgically induced endometriosis in a rat model and to determine the possible underlying regulatory mechanisms. A total of 108 female Sprague-Dawley rats were divided into the control group (n=12) and endometriosis group (EM group; n=96), in which endometriosis was surgically induced in model rats by autotransplantation of endometrial tissues and 72 rats survived. After 3 weeks, the EM model rats were randomly divided into four subgroups (n=18), including the untreated model group, and three groups administered 7, 14 or 21 g/kg HYXZ decoction. Following 28 days of treatment, the associated proteins and genes of ectopic endometrial tissues were analyzed using immunohistochemistry, western blotting and quantitative polymerase chain reaction to investigate the underlying mechanisms. Compared with the model group, the size of the endometriotic implants decreased significantly in the HYXZ-treated groups. Furthermore, the expression levels of vascular endothelial growth factor (VEGF) and angiopoietin-2 (Ang-2) were significantly decreased in HYXZ-treated groups compared with the model group. These results indicate that HYXZ affected the inhibition of angiogenesis and decreased the endometriotic implant volumes and histopathological scores. The effectiveness of HYXZ may be partially attributed to the decrease of VEGF and Ang-2 expression levels in the ectopic endometrium.

Cyclic Perimenstrual Pain and Discomfort and Australian Women's Associated Use of Complementary and Alternative Medicine: A Longitudinal Study

OBJECTIVE

To examine the longitudinal change in Australian women's prevalence of cyclic perimenstrual pain and discomfort and the association between their symptoms and use of complementary and alternative medicine (CAM).

METHOD

Data on endometriosis, premenstrual syndrome (PMS), irregular periods, heavy periods, and severe period pain were collected over a 7-year period from the Australian Longitudinal Study on Women's Health, for women aged 28 to 33 years in 2006, and at 3-year follow-ups. Changes in symptoms and patterns of CAM practitioner and therapy/product use associated with these symptoms were analyzed using longitudinal regression modeling.

RESULTS

Over the 7-year period, prevalence rates of PMS and heavy periods increased, while prevalence rates of endometriosis, irregular periods, and severe period pain remained stable. The most common use of CAM longitudinally associated with the perimenstrual symptoms was use of vitamins/minerals, yoga/meditation, massage therapy, herbal medicine, and aromatherapy. Excluding consultation with a naturopath/herbalist, over the 7-year survey women's use of all other CAM practitioners increased as did their use of vitamin/minerals, yoga/meditation, and Chinese medicines, while aromatherapy use declined.

CONCLUSION

Only the prevalence of PMS and heavy periods increased with aging in this sample of women. While overall use of CAM practitioner and self-prescribed products/therapies increased over time, CAM was chosen by women mainly to treat endometriosis and PMS. The extent to which this use reflects treatment efficacy is uncertain.

Wenshen Xiaozheng Tang induces apoptosis and inhibits migration of ectopic endometriotic stromal cells

ETHNOPHARMACOLOGICAL RELEVANCE

Wenshen Xiaozheng Tang (WXT), a traditional Chinese medicine prescription, exerted a good therapeutic effect on endometriosis. However, the underlying mechanism is unclear. In the present study, we sought to evaluate the effect of WXT on the proliferation and migration of ectopic endometriotic stromal cells and explore the potential molecular mechanism.

MATERIALS AND METHODS

Primary stromal cells derived from ectopic endometriotic lesions of patients with endometriosis were isolated and cultured. The inhibition effect of WXT on cell proliferation was determined by MTT. Apoptosis of ectopic endometriotic cells treated with WXT was analyzed with Annexin V-FITC/7-AAD staining. The activation of caspases was detected by western blot analysis. The influence of WXT on migration of ectopic endometriotic cells was measured by scratch wound healing assay and Transwell assay. The DNA binding activity of NF-κB and the expression of nuclear p65 protein were determined by electrophoretic mobility shift assay and western blot analysis, respectively. The impact of WXT on the expression of NF-κB regulated gene products involved in apoptosis and migration was determined by western blot analysis.

RESULTS

WXT inhibited the proliferation of ectopic endometriotic cells in a time- and dose-dependent manner. In addition, WXT treatment resulted in significant induction of apoptosis through the activation of caspases and inhibition of migration in ectopic endometriotic cells. WXT notably suppressed constitutive NF-κB-DNA-binding activity as well as TNF-α induced nuclear translocation of NF-κB p65 subunit in ectopic endometriotic cells. Moreover, WXT diminished the expression of NF-κB regulated gene products involved in apoptosis and migration, including c-IAP1, c-IAP2, XIAP, survivin, Mcl-1, COX-2 and MMP-9.

CONCLUSIONS

Our results indicate that WXT induces apoptosis and inhibits migration of ectopic endometriotic stromal cells.

Effects of steroid hormone on estrogen sulfotransferase and on steroid sulfatase expression in endometriosis tissue and stromal cells

Endometriosis is an estrogen-dependent disease that afflicts about 10% of women in their reproductive age, causing severe pain and infertility. The potential roles of female steroid hormones in modulating key estrogen-metabolizing enzymes, steroid sulfatase (STS) and estrogen sulfotransferase (SULT1E1), were investigated. The expression of STS and SULT1E1 mRNA in biopsy samples (n=78) of superficial and deep endometriotic lesions, eutopic endometrium of women with endometriosis and endometrium from control patients were compared according to the menstrual cycle phase. Increased STS gene expression was detected in superficial and deep-infiltrating lesions and a reduced SULT1E1 expression was also observed in the eutopic endometrium relative to the superficial lesions. Additionally, a significantly positive correlation was detected between STS and SULT1E1 mRNA expression levels in biopsy specimens collected from the endometriosis patients, and not in control individuals. The actions of female steroid hormones on SULT1E1 and STS expression were evidenced in endometriosis, revealed by increased expression levels in the luteal phase of the cycle. There was an increased STS expression in primary eutopic and ectopic endometrial stromal cells treated with estradiol and progesterone (representative of the luteal phase, n=3). Although an increased STS mRNA expression was observed in hormone-induced endometrial stromal cells in vitro, no difference could be detected between the hormone treatment groups in estradiol formation from estradiol sulfate measured by LC-MS-MS. Interestingly, a greater expression of STS was observed in stromal cells from eutopic endometrium with an agreement in estradiol formation originated from estradiol sulfate. The differential regulation of STS and SULT1E1 could provide insights for novel studies of the therapeutic use of STS inhibitors.

Is acupuncture effective in the treatment of pain in endometriosis?

Introduction

Endometriosis is a multifactorial, estrogen-dependent, inflammatory gynecological condition – often with long-lasting visceral pelvic pain of different origin, and infertility among women. Current management options for patients’ are often inadequate, with side effects for many for whom acupuncture techniques could be an alternative. Earlier studies have discussed the efficacy of acupuncture, but not its methodological aspects.

Objectives

To summarize the documented clinical effects of acupuncture on rated visceral pelvic endometriosis-related pain, and associated variables among individuals, within and between studied groups, and to discuss the methodological treatment aspects.

Methods

Published full text clinical studies, case reports, and observational studies with abstracts written in English were searched by using the keywords “Acupuncture and Endometriosis” in databases such as PubMed, Web of Science, and CINAHL. The reporting guidelines, Standards for Reporting Interventions in Clinical Trials of Acupuncture was used for the methodological report.

Results

Three studies were found including 99 women, 13–40 years old, with diagnosed endometriosis. The studies were different in research design, needle stimulation techniques, and evaluation instruments. Methodological similarities were seven to12 needle insertions per subject/session, and 15–25 minutes of needle retention time. The needles were placed in lower back/pelvic-abdominal area, in the shank, feet, and hands. Treatment numbers varied from nine to 16 and patients received one to two treatments per week. Similarity in reported treatment effects in the quoted studies, irrespective of research design or treatment technique, was reported decrease of rated pain intensity.

Discussion

Meta-analysis is the standard procedure for the evaluation of evidence of treatment effects, ie, on a group level, usually without analysis of the individual responses even with obvious spread in the results leading to lack of guidance for treatment of the individual patient. By conceptualizing pain as subjective, the individual aspect should serve as the basis for the analysis to allow clinical recommendations. From a physiological and a western medical perspective, acupuncture can be regarded as a type of sensory stimulation that induces changes in the function of the central nervous system that partly can explain the decrease of perceived pain in response to acupuncture treatment irrespective of the technique.

Conclusion

Endometriosis is often painful, although with various origin, where standard treatments may be insufficient or involve side effects. Based on the reported studies, acupuncture could be tried as a complement as it is an overall safe treatment. In the future, studies designed for evaluating effectiveness between treatment strategies rather than efficacy design would be preferred as the analyses of treatment effects in the individual patients.

The oil-resin of the tropical rainforest tree Copaifera langsdorffii reduces cell viability, changes cell morphology and induces cell death in human endometriotic stromal cultures

OBJECTIVES

The hormonal treatment for endometriosis frequently fails to completely eradicate endometriotic implants. A new therapeutic treatment is needed. This study investigates the in-vitro effect of Copaifera langsdorffii oil-resin on human eutopic and ectopic endometrium stromal cell cultures (EuESCs and EctESCs).

METHODS

A nanocomposite system containing the copaiba oil-resin (NanoCOR) was developed and acute toxicity test was performed. Endometrial stromal cells (ESCs) from non-endometriotics controls (CESCs), EuESCs and EctESCs were isolated and treated with different concentrations of NanoCOR, at different time intervals to evaluate its effect on cell morphology, proliferation, viability, necrosis and apoptosis induction.

KEY FINDINGS

When treated with 50 μg/ml of NanoCOR, the morphology of EctESCs changed, as the actin microfilaments were disorganized, disassembled or disrupted. Moreover, at 24 h of treatment with NanoCOR, the EctESCs viability was inhibited, and a significant number of these cells underwent apoptosis. In EuESCs, these effects were observed only at 48 h. Finally, the treatment of EctESCs with NanoCOR increased the lactate dehydrogenase release into the extracellular medium more than in EuESCs.

CONCLUSIONS

Our data indicate that NanoCOR has a greater impact on the behaviour of human endometriotic stromal cells than on the eutopic endometrium stromal cells, supporting the idea that NanoCOR should be further investigated as a novel and valuable alternative to treat endometriosis.

Effect of GuiXiong Xiaoyi Wan in Treatment of Endometriosis on Rats

Objective. To evaluate the effect of GuiXiong Xiaoyi Wan (GXXYW) on the development of endometriosis in a rat model. Methods. Sprague-Dawley rats with surgically induced endometriosis were randomly treated with low-dose GXXYW, high-dose GXXYW, or vehicle (negative control) for 28 days. Immunohistochemistry was used to assess cell proliferation in the lesions. The terminal deoxynucleotidyl transferase- (TdT-) mediated dUTP biotin nick end labelling (TUNEL) method was performed to analyse the apoptosis induced by GuiXiong Xiaoyi Wan. The percentages of CD3+ lymphocytes, CD4+ lymphocytes, and CD8+ lymphocytes in the spleens of the rats were evaluated using flow cytometric analysis. Results. Treatment with GXXYW significantly decreased the lesion size, inhibited cell proliferation, and induced apoptosis in endometriotic tissue. The spleens of GXXYW-treated rats also demonstrated a significant increase in the percentage of CD4+ lymphocytes and a significant decrease in the percentage of CD8+ lymphocytes. Conclusions. These results suggest that, in a rat model, GXXYW may be effective in the suppression of the growth of endometriosis, possibly through the inhibition of cell proliferation, the induction of apoptosis of endometriotic cells, and the regulation of the immune system.

Ethnomedicine of menstruation in rural Dominica, West Indies

ETHNOPHARMACOLOGICAL RELEVANCE

In Dominica, women offer dysmenorrhea, delayed menses, and menorrhagia as prevalent menstrual troubles. Dominican humoral theory considers menstruation to be "hot" such that menstrual problems are caused by the introduction of too much "cold" in the body. These conditions can be painful and may require herbal medicine. Our method finds the most culturally salient plants for these conditions-those which are of common knowledge across the population. We hypothesize that cultural agreement on ethnobotanical treatments (1) reflects their perceived ethnophysiological efficacy, and that (2) salient plants contain bioactive compounds appropriate for the menstrual conditions for which Dominicans employ the plants.

MATERIALS AND METHODS

Qualitative data on local explanatory models and treatment of menstrual conditions were collected using participant-observation, focus groups, and informal key informant interviews. Quantitative ethnobotanical data come from freelist (or "free-list") tasks, conducted with 54 adults.

RESULTS

Mean salience values calculated from freelisted data reveal that the same four plants, Cinnamomum verum (synonym Cinnamomum zeylanicum) (Lauraceae), Mentha suaveolens (Lamiaceae), Pimenta racemosa (Myrtaceae) and Sphagneticola trilobata (synonym Wedelia trilobata) (Asteraceae) are used to treat dysmenorrhea and delayed menses. The only remedy reported for menorrhagia, Sphagneticola trilobata (Asteraceae), is also a treatment for dysmenorrhea and delayed menses. The Dominican humoral system views menstruation as a "hot" condition, yet these "bush medicines" are also "hot." Dominicans do not view menstruation as a problem, rather, they reckon that excess "cold" in a woman׳s menstruating body impedes menstrual function to cause problems thus requiring "hot" plants to alleviate their symptoms. A literature review revealed that all four plants contain analgesic, anti-nociceptive, and anti-inflammatory properties. Additionally, Mentha suaveolens is muscle-relaxing and anti-spasmodic, Cinnamomum verum has a mild anti-coagulant, and Sphagneticola trilobata has wound healing, anti-stress, and sedative properties.

CONCLUSIONS

In Dominican menstrual problems there is correspondence between cultural consensus, bioactivity, and humoral theory. Examining the ethnophysiology of menstruation and its complications provides evidence for the expectations of actions and effectiveness of locally culturally salient medicinal plants.

The traditional Chinese medicine prescription pattern of patients with primary dysmenorrhea in Taiwan: a large-scale cross sectional survey

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine (TCM), when given for symptom relief, has gained widespread popularity among women with primary dysmenorrhea (PD). The aim of this study was to analyze the utilization of TCM among PD women in Taiwan.

METHODS

The use, service frequency and Chinese herbal products prescribed for PD women were evaluated using a cross sectional survey of 23,118 beneficiaries who were recruited from the National Health Insurance Research Database. The logistic regression method was employed to estimate the odds ratios (ORs) for utilization of TCM.

RESULTS

Overall, 53.4% (N=12,349) of PD women utilized TCM and 92.2% of them sought TCM with the intention of treating their menstruation-related pain symptoms. PD women who do not take prescription painkillers (aOR=35.75, 95% CI:33.20-38.49) were more likely to seek TCM treatment than those who took pain medication (aOR=1.00). There were a total of 213,249 TCM visits due to PD, of which more than 99% were treated with Chinese herbal products (CHPs). Dang-gui-shao-yao-san (Tangkuei and Peony Powder) was the most frequently prescribed formula for treating PD.

CONCLUSION

Primary dysmenorrhea women tended to use Chinese herbal products to deal with pain-related symptoms, rather than use acupuncture. Dang-gui-shao-yao-san, which containing both sedative and anti-inflammatory agents, is the most commonly prescribed Chinese herbal formula for the treatment of PD. A well designed, double-blind, randomized, placebo-controlled study to further evaluate the efficacy of Dang-gui-shao-yao-san as a treatment women with primary dysmenorrhea is warranted.

The traditional Chinese medicine prescription patterns for migraine patients in Taiwan: a population-based study

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine (TCM), when given for symptom relief, has gained widespread popularity among migraine patients. The aim of this study is to analyze the utilization of TCM among migraine patients in Taiwan.

MATERIALS AND METHODS

The usage, frequency of service, and the Chinese herbal products prescribed for migraine were evaluated using a representative sample of one million subjects selected at random from the 22 million beneficiaries of the National Health Insurance scheme of Taiwan.

RESULTS

Overall, 89.3% (N=12,827) migraine patients utilized TCM and 24.2% of them sought TCM with the intention of treating their migraine-related symptoms. Migraine patients who are living in urban area and those with an episodic migraine pattern (<15 days/month) (aOR=3.18, 95% CI: 2.75-3.67) were more likely to be TCM users than those living in a rural area and those who suffered from chronic migraine (≥15 days/month) (aOR=1.00). Overall, 81.2% of TCM visits involved the prescription of a Chinese herbal remedy or remedies and Chuan-Xiong-Cha-Tiao-San, Jia-Wei-Xiao-Yao-San, Ge-Gen-Tang, Xue-Fu-Zhu-Yu-Tang, Ban-Xia-Bai-Zhu-Tian-Ma-Tang, Qing-Shang-Juan-Tong-Tang, Xiao-Chai-Hu-Tang, Tian-Ma-Gou-Teng-Yin, Bu-Zhong-Yi-Qi-Tang, and Tian-Wang-Bu-Xin-Dan were the ten most frequently prescribed formula for treating migraine based on syndrome differentiation.

CONCLUSIONS

Chuan-Xiong-Cha-Tiao-San, which contains sedative and anti-inflammatory agents, is the most commonly prescribed Chinese herbal formula for the treatment of migraine-related phenomena.

Parthenolide reduces cell proliferation and prostaglandin E2 [corrected] in human endometriotic stromal cells and inhibits development of endometriosis in the murine model

OBJECTIVE

To evaluate the effects of parthenolide on human endometriotic cells and murine endometriotic lesions.

DESIGN

Experimental study.

SETTING

University hospital and laboratory of animal science.

PATIENT(S) AND ANIMAL(S)

Twenty women with ovarian endometrioma and 30 mice.

INTERVENTION(S)

Ectopic endometrial tissue from the endometrioma was collected.

MAIN OUTCOME MEASURE(S)

Human endometriotic stromal cells (ESCs) were pretreated with parthenolide and exposed to tumor necrosis factor (TNF)-α. Interleukin 8 (IL-8) and COX-2 gene expressions were evaluated by real-time reverse transcription-polymerase chain reaction. Interleukin-8 protein, prostaglandin E₂ (PGE₂) level, and intranuclear p65 protein concentration were determined by ELISA. Cell proliferation was assessed by 5-bromo-2'-deoxyuridine-ELISA. Phosphorylation of signaling pathways in ESCs was evaluated by Western blotting. Gene expression and proliferative activity in murine endometriosis-like lesions were assessed by real-time reverse transcription-polymerase chain reaction and Ki67 staining, respectively.

RESULT(S)

With parthenolide pretreatment, TNF-α-induced IL-8 gene and protein expression in ESCs were diminished. Tumor necrosis factor α-induced COX-2 expression and PGE2 synthesis were also inhibited. Adding parthenolide repressed TNF-α-induced 5-bromo-2'-deoxyuridine incorporation and IκB phosphorylation in ESCs. As in vivo experiments, administering parthenolide reduced the number, surface area, and weight, the level of Vegf, Il-6, Mcp-1, and Lif gene expression, and the percentage of Ki67-positive cells in murine endometriosis-like lesions.

CONCLUSION(S)

Parthenolide repressed the development of endometriosis by suppressing the inflammatory peritoneal environment through the nuclear factor κB pathway.

Western herbal medicine, epigenetics, and endometriosis

Endometriosis is an enigmatic disease characterized by the presence and growth of endometrial-like tissue outside the uterine cavity. The etiology of endometriosis is poorly understood, yet recent evidence suggests that epigenetic aberrations and heritable changes in the genome may be the key to understanding how to approach this disease. Difficulty in long-term management of endometriosis symptoms and unpredictability of treatment outcome necessitate research into other treatment modalities, such as Western herbal medicine. This article reviews commonly used herbs in the treatment of endometriosis, the effects of phytochemical constituents on endometrial cells, and the impact on the epigenome.

Therapeutic potential of Wenshen Xiaozheng tang, a traditional Chinese medicine prescription, for treating endometriosis

The objective of this study is to investigate the effect of Wenshen Xiaozheng Tang (WXT) on the development of endometriosis in a rat model. Sprague-Dawley rats in which endometriotic implants were induced were divided randomly into 3 groups. The rats in the low-dose and high-dose WXT groups were administered WXT 8.57 and 17.14 g/kg/d, respectively. The rats in the control groups received an equal volume of dissolvent, as did the sham-operated rats. After treatment for 4 weeks, WXT significantly decreased the mean lesion size as well as the peritoneal fluid and serum levels of tumor necrosis factor α and interleukin 1β. Cyclooxygenase-2, matrix metalloproteinase 9, plasminogen activator inhibitor 1, and intercellular adhesion molecule 1 messenger RNA (mRNA) levels were downregulated, and the mRNA expression of tissue inhibitor of metalloproteinase 1 was upregulated in the endometriotic lesions of WXT versus control group. Our data suggested that WXT may suppress the development of endometriosis by inhibiting the production of proinflammatory cytokines and regulating the expression of invasion-related genes in the endometriotic lesions.

Natural therapies assessment for the treatment of endometriosis

STUDY QUESTION

Can resveratrol and epigallocatechin-3-gallate (EGCG) inhibit the growth and survival of endometriotic-like lesions in vivo in a BALB/c model of endometriosis, and in vitro in primary cultures of human endometrial epithelial cells (EECs)?

SUMMARY ANSWER

Resveratrol and EGCG exerted a potent inhibitory effect on the development of endometriosis in a BALB/c murine model and on the survival of EECs.

WHAT IS KNOWN ALREADY

Endometriosis is a common condition associated with infertility and pelvic pain in women of reproductive age. Resveratrol and EGCG are two polyphenols with anticarcinogenic and antioxidant properties that have been proposed as natural therapies to treat endometriosis.

STUDY DESIGN, SIZE, DURATION

Fifty-six 2-month-old female BALB/c mice underwent surgical induction of endometriosis. Treatments with resveratrol or EGCG started 15 days post-surgery and continued for 4 weeks. Human biopsies were taken with a metal Novak curette from the posterior uterine wall from 16 patients with untreated endometriosis and 15 controls who underwent diagnostic laparoscopy for infertility.

MATERIALS, SETTING, METHODS

After the treatments, animals were sacrificed and lesions were counted, measured, excised and fixed. Immunohistochemistry for proliferating cell nuclear antigen and CD34 was performed for cell proliferation and vascularization assessment in the lesions. The terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick-end labeling (TUNEL) technique was performed for apoptosis evaluation. Peritoneal fluid was collected to analyze vascular endothelial growth factor levels. Human EECs were purified from proliferative-phase endometrial biopsies and cultured. The effect of both polyphenols on cell proliferation was determined by a colorimetric assay using the CellTiter 96®AQueous One Solution Cell Proliferation Assay kit and on apoptosis by the TUNEL technique, using an In Situ Cell Death Detection Kit with Fluorescein.

MAIN RESULTS

In the mouse model, both treatments significantly reduced the mean number (P < 0.05 versus control) and the volume of established lesions (P < 0.05 versus control). Treatments consistently statistically significantly diminished cell proliferation (resveratrol P < 0.01 and EGCG P < 0.05, versus control), reduced vascular density (resveratrol P < 0.01 and EGCG P < 0.001, versus control) and increased apoptosis within the lesions (resveratrol P < 0.01 and EGCG P < 0.05, versus control). Both compounds induced reduction in human EEC proliferation (P < 0.05 versus basal) and increased apoptosis (P < 0.05 versus basal) in primary cultures.

LIMITATIONS

In vitro studies were only carried out in epithelial cells from human eutopic endometrium.

WIDER IMPLICATIONS OF THE FINDINGS

The present findings are promising and will assist the development of novel natural treatments for endometriosis.

STUDY FUNDING

This study was supported by ANPCYT (PICT 6384 BID 1201 OC-AR) and CONICET (PIP 5471), Argentina. None of the authors has any conflict of interest to declare.

The traditional chinese medicine prescription pattern of endometriosis patients in taiwan: a population-based study

Background. Traditional Chinese medicine (TCM), when given for symptom relief, has gained widespread popularity among women with endometriosis. The aim of this study was to analyze the utilization of TCM among women with endometriosis in Taiwan. Methods. The usage, frequency of service, and the Chinese herbal products prescribed for endometriosis, among endometriosis patients, were evaluated using a randomly sampled cohort of 1,000,000 beneficiaries recruited from the National Health Insurance Research Database. Results. Overall, 90.8% (N = 12, 788) of reproductive age women with endometriosis utilized TCM and 25.2% of them sought TCM with the intention of treating their endometriosis-related symptoms. Apart from the usage of either analgesics or more than one type of medical treatment, the odds of using TCM and Western medicine were similar in all types of conventional endometriosis treatment. However, endometriosis patients suffering from symptoms associated with endometriosis were more likely to seek TCM treatment than those with no symptoms. There were 21,056 TCM visits due to endometriosis and its related symptoms, of which more than 98% were treated with Chinese herbal products (CHPs). Conclusion. Gui-Zhi-Fu-Ling-Wan (Cinnamon Twig and Poria Pill) containing sedative and anti-inflammatory agents is the most commonly prescribed Chinese herbal formula mainly for the treatment of endometriosis-related symptomatic discomfort and the effects of these TCMs should be taken into account by healthcare providers.

Proteomic identification of neurotrophins in the eutopic endometrium of women with endometriosis

OBJECTIVE

To evaluate neurotrophin (NT) expression in the endometrium of women with and without endometriosis.

DESIGN

Prospective, cross-sectional, translational study.

SETTING

Academic hospital.

PATIENT(S)

Thirty-three reproductive-age women undergoing laparoscopy for infertility, pelvic pain, intramural fibroids, or tubal ligation.

INTERVENTION(S)

Endometrial biopsies, protein microarrays, reverse transcriptase-polymerase chain reaction, ELISAs, and Western blotting.

MAIN OUTCOME MEASURE(S)

Neurotrophin proteins and mRNAs in eutopic endometrial biopsies.

RESULT(S)

Among seven neurotrophic proteins detected on the antibody microarrays, reverse transcriptase-polymerase chain reaction analysis confirmed nerve growth factor, NT-4/5, and brain-derived neurotrophic factor mRNAs in endometrial tissue. Quantitative ELISAs revealed that NT-4/5 (806 ± 701 vs. 256 ± 190 pg/100 mg protein) and brain-derived neurotrophic factor (121 ± 97 vs. 14 ± 11 ng/100 mg protein) concentrations were significantly higher in women with endometriosis. Nerve growth factor (100 ± 74 vs. 93 ± 83 pg/100 mg protein) levels did not differ between cases and controls.

CONCLUSION(S)

Neurotrophins are synthesized in situ within the endometrium. NT-4/5 and brain-derived neurotrophic factor proteins were more concentrated in biopsies from endometriosis cases than controls, whereas nerve growth factor levels were similar. We hypothesize that the local production of NTs induces sensory innervation of endometrium of women with endometriosis. These NTs represent novel targets for the diagnosis and treatment of endometriosis.

Contraceptive effect of Uncaria tomentosa (cat's claw) in rats with experimental endometriosis

PURPOSE

Evaluate the histological changes in parenchyma's epithelial layer of the uterus and ovarian of rats with induced endometriosis, treated with Uncaria tomentosa extract.

METHODS

29 rats with experimental endometriosis, were selected and divided in three groups: The uncaria group received 32 mg/ml of Uncaria tomentosa extract, 1 ml administered daily and the placebo group received 1 ml of saline 0.9% per day, during for 14 days (both groups); the leuprolide group received leuprolide acetate 1mg/kg body weight applied single subcutaneous dose. In the 15th day of treatment the uterine horn and ovaries were removed for histopathological analysis.

RESULTS

The uncaria group presented nine samples (90%) with immature ovarian follicles, whereas the placebo group did not present any case and in the leuprolide group there were eight rats (88%) with the same change. The placebo group showed mature corpus luteum in all animals, occurring less frequent in uncaria (10%) and leuprolide (22%) groups. The uterine epithelium showed weak proliferative in nine (90%) samples of the uncaria group, in two (20%) animals in the placebo group and seven (77.8%) rats in the leuprolide group.

CONCLUSIONS

The findings suggest that Uncaria tomentosa has contraceptive effect.

New trends for the medical treatment of endometriosis

INTRODUCTION

Endometriosis is a benign sex hormone-dependent gynecological disease, characterized by the presence and growth of endometrial tissue outside the uterus; it affects 10% of women of reproductive age and is associated with infertility and pain. Treatment of endometriosis involves conservative or radical surgery, or medical therapies. The goals for endometriosis treatment may be the relief of pain and/or a successful pregnancy achievement in infertile patients. Treatment must be individualized with a multidisciplinary approach. The classical treatments carry adverse side effects and in some cases a negative impact on quality of life. New agents promise a distinct perspective in endometriosis treatment.

AREAS COVERED

The aim of this paper is to systematically review the literature evidence of new medical treatments for endometriosis, defined as pharmacological treatments not yet commonly available and currently under investigation.

EXPERT OPINION

These new medical therapies would be used associated with surgical treatment and, in the future, will render possible the association of hormone therapy with non-hormonal treatment for endometriosis.

Extracts of Salvia miltiorrhiza Bunge on the cytokines of rat endometriosis models

Endometriosis is a common mysterious and fascinating gynaecological condition with diverse clinical manifestations, highly variable and unpredictable clinical course with decreased quality of life. Clinically, Salvia miltiorrhiza Bunge (SMB, Chinese Danshen) has been applied to treat endometriosis and get satisfactory results. The present study was aimed to explore the effects of the extracts of SMB (ESMB) on the serum levels of cancer antigen 125 (CA-125) and the levels of interleukin (IL)-13, IL-18 and tumor necrosis factor-alpha (TNF-alpha) in the peritoneal fluids of rat endometriosis models. Three extraction methods for SMB were compared, which are the sample extracted with conventional method, the sample extracted with espresso coffee machine and the commercial condensed powder of natural products. We determined tanshinone IIA, salvianolic acid B and danshensu in the ESMB of different extraction methods. Forty female Sprague-Dawley (SD) rats were randomly divided into ESMB group, Danazol (positive control) group, model group and the sham-operation group (Sham group). After all the treatment ended, the serum levels of CA125 and the levels of IL-13, IL-18 and TNF-alpha in the peritoneal fluids of rat endometriosis models were measured using enzyme-linked immune-sorbent assay (ELISA) as directed by the manufacturer. The extraction efficiency of the ESMB samples extracted with coffee machine ranged from 600µm to 710µm was the highest. The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly lower than those of the Model group (P<0.05). The serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids of Danazol group and ESMB group were significantly higher than those of Sham group, respectively (P<0.05), and no marked difference existed between them (P>0.05). The levels of IL-13 in the peritoneal fluids of ESMB group, Danazol group and Sham group were significantly higher than those of the Model group (P<0.05). The levels of IL-13 in the peritoneal fluids of ESMB group and Danazol group were significantly lower than those of Sham group (P<0.05), and there was no marked difference between ESMB group and Sham group (P>0.05). ESMB shows promises in treating endometriosis by markedly decreasing the serum levels of CA-125 and the levels of IL-18 and TNF-alpha in the peritoneal fluids and significantly increasing the levels of IL-13 in the peritoneal fluids.

MiR-199a attenuates endometrial stromal cell invasiveness through suppression of the IKKβ/NF-κB pathway and reduced interleukin-8 expression

MicroRNAs have recently been identified as regulators that modulate target gene expression and are suggested to be involved in the development and progression of endometriosis. This study was undertaken to analyze the expression level of microRNA-199a (miR-199a) in paired ovarian endometrioma and eutopic endometrium from women with endometriosis, and to investigate the contribution of miR-199a to the invasive capability of endometrial stromal cells (ESCs). Cell adhesion, migration and Matrigel invasion assays were carried out to measure the invasiveness of ESCs. Bioinformatics prediction, reporter gene assay, PCR, western blotting and ELISA were performed to identify miR-199a targets and related signaling pathways. The results showed that the expression level of miR-199a was lower in the eutopic endometrium from women with endometriosis, and even lower in the paired ovarian endometrioma, compared with the expression in normal controls. Moreover, ectopic expression of miR-199a attenuated ESC adhesion, migration and invasiveness. MiR-199a targeted and inhibited IkappaB kinase beta (IKKβ) in ESCs. Accompanied by IKKβ reduction, miR-199a suppressed nuclear factor-kappa B (NF-κB) pathway activation and interleukin-8 (IL-8) production in ESCs. All these findings suggest that miR-199a, down-regulated in endometriosis, attenuates the invasive capability of ESCs in vitro partly through IKK/NF-κB pathway suppression and reduced IL-8 expression. In conclusion, miR-199a could be involved in the pathogenesis of endometriosis.

Chronic pelvic pain and endometriosis: translational evidence of the relationship and implications

BACKGROUND

Many clinicians and patients believe that endometriosis-associated pain is due to the lesions. Yet causality remains an enigma, because pain symptoms attributed to endometriosis occur in women without endometriosis and because pain symptoms and severity correlate poorly with lesion characteristics. Most research and reviews focus on the lesions, not the pain. This review starts with the recognition that the experience of pain is determined by the central nervous system (CNS) and focuses on the pain symptoms.

METHODS

Comprehensive searches of Pubmed, Medline and Embase were conducted for current basic and clinical research on chronic pelvic pain and endometriosis. The information was mutually interpreted by a basic scientist and a clinical researcher, both in the field of endometriosis. The goal was to develop new ways to conceptualize how endometriosis contributes to pain symptoms in the context of current treatments and the reproductive tract.

RESULTS

Endometriotic lesions can develop their own nerve supply, thereby creating a direct and two-way interaction between lesions and the CNS. This engagement provides a mechanism by which the dynamic and hormonally responsive nervous system is brought directly into play to produce a variety of individual differences in pain that can, in some women, become independent of the disease itself.

CONCLUSIONS

Major advances in improving understanding and alleviating pain in endometriosis will likely occur if the focus changes from lesions to pain. In turn, how endometriosis affects the CNS would be best examined in the context of mechanisms underlying other chronic pain conditions.

Involvement of the nuclear factor-κB pathway in the pathogenesis of endometriosis

OBJECTIVE

To evaluate the role of nuclear factor-κB (NF-κB) in the pathogenesis of endometriosis.

DESIGN

A literature search was conducted in PubMed to identify all relevant citations.

RESULT(S)

Our findings highlight the important role of NF-κB in the pathophysiology of endometriosis. In vitro and in vivo studies show that NF-κB-mediated gene transcription promotes inflammation, invasion, angiogenesis, and cell proliferation and inhibits apoptosis of endometriotic cells. Constitutive activation of NF-κB has been demonstrated in endometriotic lesions and peritoneal macrophages of endometriosis patients. Agents blocking NF-κB are effective inhibitors of endometriosis development and some drugs with known NF-κB inhibitory properties have proved efficient at reducing endometriosis-associated symptoms in women. Iron overload activates NF-κB in macrophages. NF-κB activation in macrophages and ectopic endometrial cells stimulates synthesis of proinflammatory cytokines, generating a positive feedback loop in the NF-κB pathway and promoting endometriotic lesion establishment, maintenance and development.

CONCLUSION(S)

NF-κB transcriptional activity modulates key cell processes contributing to the initiation and progression of endometriosis. Because endometriosis is a multifactorial disease, inhibiting NF-κB appears to be a promising strategy for future therapies targeting different cell functions involved in endometriosis development, such as cell adhesion, invasion, angiogenesis, inflammation, proliferation, and apoptosis. Upcoming research will elucidate these hypotheses.

Female reproductive disorders: the roles of endocrine-disrupting compounds and developmental timing

OBJECTIVE

To evaluate the possible role of endocrine-disrupting compounds (EDCs) on female reproductive disorders emphasizing developmental plasticity and the complexity of endocrine-dependent ontogeny of reproductive organs. Declining conception rates and the high incidence of female reproductive disruptions warrant evaluation of the impact of EDCs on female reproductive health.

DESIGN

Publications related to the contribution of EDCs to disorders of the ovary (aneuploidy, polycystic ovary syndrome, and altered cyclicity), uterus (endometriosis, uterine fibroids, fetal growth restriction, and pregnancy loss), breast (breast cancer, reduced duration of lactation), and pubertal timing were identified, reviewed, and summarized at a workshop.

CONCLUSION(S)

The data reviewed illustrate that EDCs contribute to numerous human female reproductive disorders and emphasize the sensitivity of early life-stage exposures. Many research gaps are identified that limit full understanding of the contribution of EDCs to female reproductive problems. Moreover, there is an urgent need to reduce the incidence of these reproductive disorders, which can be addressed by correlative studies on early life exposure and adult reproductive dysfunction together with tools to assess the specific exposures and methods to block their effects. This review of the EDC literature as it relates to female health provides an important platform on which women's health can be improved.

Is There a Role for Acupuncture in Endometriosis Pain, Or ‘endometrialgia’?

Endometriosis is a common cause of pelvic pain in women, many of whom suffer a progression of symptoms over their menstrual life. Symptoms may include combinations of abnormal visceral sensations and emotional distress. Endometriosis pain, or ‘endometrialgia’ often has a negative influence on the ability to work, on family relationships and sense of worth.

Endometrialgia is often considered to be a homogeneous sensory entity, mediated by a specialised high threshold sensory system, which extends from the periphery through the spinal cord, brain stem and thalamus to the cerebral cortex. However, multiple mechanisms have been detected in the nervous system responsible for the pain including peripheral sensitisation, phenotypic switches, central sensitisation, ectopic excitability, structural reorganisation, decreased inhibition and increased facilitation, all of which may contribute to the pain.

Although the causes of endometrialgia can differ (eg inflammatory, neuropathic and functional), they share some characteristics. Endometrialgia may be evoked by a low intensity, normally innocuous stimulus (allodynia), or it may be an exaggerated and prolonged response to a noxious stimulus (hyperalgesia). The pain may also be spontaneous in the absence of any apparent peripheral stimulus.

Oestrogens and prostaglandins probably play key modulatory roles in endometriosis and endometrialgia. Consequently many of the current medical treatments for the condition include oral drugs, like non-steroid anti-inflammatory drugs, contraceptives, progestogens, androgenic agents, gonadotrophin releasing hormone analogues, as well as laparoscopic surgical excision of the endometriosis lesions. However, management of pain in women with endometriosis is currently inadequate for many. Possibly acupuncture and cognitive therapy may be used as an adjunct.