Endometriosis: still an enigma

Role of endocrine status and cell type in adhesion of human endometrial cells to the peritoneum in nude mice

OBJECTIVE

To investigate the role of different cellular types (epithelial and stromal endometrial cells and peritoneal cells) in the ectopic implantation of endometrium and to evaluate the importance of endocrine environment on the adhesion of endometrial cells to the peritoneum.

DESIGN

Experimental prospective study.

SETTING

University hospital, department of cell biology.

ANIMAL(S)

One hundred one nude mice.

INTERVENTION(S)

Monolayer culture of human epithelial and stromal endometrial cells obtained from patients undergoing hysterectomy or laparoscopy for benign disease. Intraperitoneal injection of cells into nude mice.

MAIN OUTCOME MEASURE(S)

Two weeks after cell injection, adhesion of endometrial cells was evaluated by histological and immunohistochemical examination.

RESULT(S)

Mixed cultures of stromal and epithelial cells, but not purified epithelial or stromal cells alone, adhered to the mouse peritoneum and led to endometriotic-like nodules. Pretreatment of cells with estrogen alone or with estrogen and progestin resulted in a higher percentage of animals developing endometriotic-like nodules, whereas treatment with progestin alone did not affect endometriotic implantation.

CONCLUSION(S)

Our data indicate that the success of endometrial cell implantation is dependent on the cooperativeness between stromal and epithelial endometrial cells, as well as on the endocrine environment of endometrial cells, but not that of recipient animals. The results emphasize the role of both endometrial cell types for ectopic implantation.

Magnetic resonance imaging with gadolinium-diethylenetriamine pentaacetic acid is useful in assessment of tubal patency in a patient with iodine-induced hypothyroidism

A 32-year-old woman presented for evaluation of primary infertility. Because she had a history of iodine-induced hypothyroidism, conventional hysterosalpingography was contraindicated. Tubal patency was assessed by magnetic resonance imaging (MRI) after infusion of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA). Visualization of the contrast medium in the peritoneal cavity revealed tubal patency. Our case indicates that MRI with gadolinium-diethylenetriamine pentaacetic acid is a safe, simple, and easy way to confirm that at least one tube is patent when a patient is at risk for hysterosalpingography. To our knowledge, this is the first report that tubal patency was diagnosed on MRI.

Environmental endocrine modulators and human health: an assessment of the biological evidence

Recently, a great deal of attention and interest has been directed toward the hypothesis that exposure, particularly in utero exposure, to certain environmental chemicals might be capable of causing a spectrum of adverse effects as a result of endocrine modulation. In particular, the hypothesis has focused on the idea that certain organochlorine and other compounds acting as weak estrogens have the capability, either alone or in combination, to produce a variety of adverse effects, including breast, testicular and prostate cancer, adverse effects on male reproductive tract, endometriosis, fertility problems, alterations of sexual behavior, learning disability or delay, and adverse effects on immune and thyroid function. While hormones are potent modulators of biochemical and physiological function, the implication that exposure to environmental hormones (e.g., xenoestrogens) has this capability is uncertain. While it is reasonable to hypothesize that exposure to estrogen-like compounds, whatever their source, could adversely affect human health, biological plausibility alone is an insufficient basis for concluding that environmental endocrine modulators have adversely affected humans. Diethylstilbestrol (DES) is a potent, synthetic estrogen administered under a variety of dosing protocols to millions of women in the belief (now known to be mistaken) that it would prevent miscarriage. As a result of this use, substantial in utero exposure to large numbers of male and female offspring occurred. Numerous studies have been conducted on the health consequences of in utero DES exposure among the adult offspring of these women. There are also extensive animal data on the effects of DES and there is a high degree of concordance between effects observed in animals and humans. The extensive human data in DES-exposed cohorts provide a useful basis for assessing the biological plausibility that potential adverse effects might occur following in utero exposure to compounds identified as environmental estrogens. The effects observed in both animals and humans following in utero exposure to sufficient doses of DES are consistent with basic principles of dose response as well as the possibility of maternal dose levels below which potential non-cancer effects may not occur. Significant differences in estrogenic potency between DES and chemicals identified to date as environmental estrogens, as well as an even larger number of naturally occurring dietary phytoestrogens, must be taken into account when inferring potential effects from in utero exposure to any of these substances. The antiestrogenic properties of many of these same exogenous compounds might also diminish net estrogenic effects. Based on the extensive data on DES-exposed cohorts, it appears unlikely that in utero exposure to usual levels of environmental estrogenic substances, from whatever source, would be sufficient to produce many of the effects (i.e., endometriosis, adverse effects on the male reproductive tract, male and female fertility problems, alterations of sexual behavior, learning problems, immune system effects or thyroid effects) hypothesized as potentially resulting from exposure to chemicals identified to date as environmental estrogens.

Follow-up report on a randomized controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal to moderate endometriosis

OBJECTIVE

To assess the longer term efficacy of laparoscopic laser surgery in the treatment of painful pelvic endometriosis and to observe the natural history of the disease at second-look laparoscopy in a control group.

DESIGN

One-year follow-up of a prospective, randomized, double-blind controlled trial.

SETTING

A referral center for the laparoscopic laser treatment of endometriosis.

PATIENT(S)

Sixty-three patients with pelvic pain and minimal to moderate endometriosis.

INTERVENTION(S)

After the 6-month follow-up visit, the randomization code was broken, and follow-up was continued to 1 year. Symptomatic patients were offered second-look laser laparoscopy.

MAIN OUTCOME MEASURE(S)

Continued symptom relief at 1 year after treatment and findings at second-look laparoscopy in symptomatic controls.

RESULT(S)

Symptom relief continued at 1 year in 90% of those who initially responded. All symptomatic controls had a second-look procedure, with 7 (29%) showing disease progression, 7 (29%) showing disease regression, and 10 (42%) having static disease.

CONCLUSION(S)

The benefits of laser laparoscopy for painful pelvic endometriosis are continued in the majority of patients at 1 year. Untreated painful endometriosis will progress or remain static in the majority of patients but will spontaneously improve in others.

Health and fertility outcomes among women surgically treated for endometriosis

STUDY OBJECTIVE

To assess health and fertility status among women after surgical treatment of endometriosis.

DESIGN

Prospective study.

SETTING

Community-based gynecologic specialty practice.

PATIENTS

Two hundred ninety women with newly diagnosed endometriosis.

MEASUREMENTS AND MAIN RESULTS

Medical records of all women were abstracted at baseline; self-administered questionnaires were used to collect follow-up data. Most women (68-79%) reported some or great improvement in symptomology after surgical treatment. One hundred twenty-four (53%) of 232 women reported one or more pregnancies, two-thirds of which resulted in live births. Secondary sex ratios were below 1 (range 0.92-0.50), reflecting a female excess. Logistic regression analysis identified previous live birth as the only significant predictor of pregnancy after surgery; advancing maternal age significantly decreased the likelihood of a live birth.

CONCLUSIONS

Overall, these women reported improvement in symptoms at follow-up. Operative and clinical findings were not significant predictors of pregnancy likelihood. Prior live birth conferred more than a twofold increase in pregnancy likelihood, whereas advancing age decreased the likelihood. Reasons for reversed sex ratios are unknown but warrant further study.

Localization of laminin, fibronectin, E-cadherin, and integrins in endometrium and endometriosis

OBJECTIVE

To compare the localization of adhesion proteins (laminin and fibronectin) and their receptors of the integrin family in endometriosis and endometrium.

DESIGN

An immunohistochemical study.

SETTING

University Hospital, Department of Gynecology and Department of Cell Biology.

PATIENT(S)

Eighteen endometriosis patients undergoing laparoscopy for pain or infertility and nine control patients undergoing laparoscopy for sterilization or hysterectomy.

MAIN OUTCOME MEASURE(S)

The expression of adhesion glycoproteins (laminin and fibronectin), their receptors alpha 1 beta 1, alpha 2 beta 1, alpha 3 beta 1, alpha 5 beta 1, and alpha 6 beta 1, and E-cadherin was determined by immunohistochemistry on frozen sections.

RESULT(S)

The distribution of both adhesive glycoproteins, laminin and fibronectin, and their receptors was identical in endometriosis and endometrium. Fibronectin receptors (alpha 4 beta 1, alpha 5 beta 1) displayed distinct expression patterns in endometrium and endometriosis. No endometrial glands showed positive staining for the alpha 5 chain, whereas this integrin subunit was detected in almost all endometriotic lesions. The integrin alpha 4 chain was present in all endometriotic glands but was absent from endometrial glands in the proliferative phase of the cycle.

CONCLUSION(S)

No difference in cell adhesion molecule localization nor receptors was observed between endometriotic and endometrial samples, except for fibronectin receptors. Their expression persisted around endometriotic glands but not in endometrium. These results suggest that fibronectin receptors could play a role in the persistence of endometriotic lesions, despite menstruation in corresponding eutopic endometrium.

Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis

OBJECTIVE

To assess the efficacy of laser laparoscopic surgery in the treatment of pain associated with minimal, mild, and moderate endometriosis.

DESIGN

A prospective, randomized, double-blind, and controlled clinical study.

SETTING

Royal Surrey County Hospital, Guildford, United Kingdom, a referral center for the laser laparoscopic treatment of endometriosis.

PATIENTS

Sixty-three patients with pain (dysmenorrhoea, pelvic pain, or dyspareunia) and minimal to moderate endometriosis.

INTERVENTIONS

The patients were randomized at the time of laparoscopy to laser ablation of endometriotic deposits and laparoscopic uterine nerve ablation or expectant management. Pain symptoms were recorded subjectively and by visual analogue scale. The women were unaware of the treatment allocated as was the nurse who assessed them at 3 and 6 months after surgery.

MAIN OUTCOME MEASURE

Improvement or resolution of pain symptoms assessed subjectively and by visual analogue score.

RESULTS

Laser laparoscopy results in statistically significant pain relief compared with expectant management at 6 months after surgery. Sixty-two and a half percent of the lasered patients reported improvement or resolution of symptoms compared with 22.6% in the expectant group. Results were poorest for minimal disease and, if patients with mild and moderate disease only are included, 73.7% of patients achieved pain relief. There were no operative or laser complications.

CONCLUSIONS

Laser laparoscopy is a safe, simple, and effective treatment in alleviating pain symptoms in women with stages I, II, and III endometriosis.

Expression of integrin adhesion molecules in endometrium and endometriosis

OBJECTIVE

To compare the expression of cell adhesion molecules by endometrium and endometriosis.

DESIGN

A comparative study of integrin expression, determined immunohistochemically, in eutopic and ectopic endometrium biopsied synchronously from patients with endometriosis diagnosed at laparoscopy or laparotomy.

SETTING

University Departments of Obstetrics and Gynaecology, and Pathology, Southampton; Department of Obstetrics and Gynaecology, Newcastle upon Tyne.

SAMPLES

Eighteen paired samples of endometria and endometriosis.

RESULTS

A wide distribution of collagen-laminin receptor proteins was demonstrated. alpha 1 integrin expression was limited to secretory endometrium. beta 3 expression was only demonstrated on proliferative endometrium.

CONCLUSIONS

Expressions of the integrin proteins differed between the various elements of the endometrium. Cyclical changes in integrin expression also were demonstrated. No difference in cell adhesion molecule expression was seen when comparing endometrial and endometriosis samples.