1
|
Schutte SC, Ghosh D, Moset Zupan A, Warwar R, Dawson MR. Differential Response to Mechanical Cues in Uterine Fibroid Versus Paired Myometrial Cells. Reprod Sci 2023; 30:3305-3314. [PMID: 37253935 DOI: 10.1007/s43032-023-01267-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/08/2023] [Indexed: 06/01/2023]
Abstract
Uterine leiomyomas, or fibroids, are common, benign tumors for which hysterectomy is the only definitive treatment. The extracellular matrix of fibroids is disorganized and stiffer than the surrounding myometrial tissue. To understand how stiffness affects fibroid cells, patient-matched fibroid and myometrial cells were cultured on substrates with stiffnesses varying from 0.2 to 150 kPa. Fibroid cells grew more slowly than myometrial cells overall, and only the myometrial cells altered their growth rate in response to stiffness. In both cell types, cell proliferation decreased with inhibition of PI3K and increased with inhibition of IGF-1. The cellular area was greater for the fibroid cells. The only significant effect of stiffness on the cell area was between the 0.2 and 64 kPa substrates, and this was true for both cell types. To investigate intracellular stiffness, intracellular particle tracking microrheology was used. Fibroid cells exhibited a more than 100-fold increase in elastic modulus at a frequency of 1 Hz in response to the addition of external stress, while myometrial cells showed little change in elastic modulus. Overall, the responses of both cells followed similar trends in response to stiffness and inhibitors, although the response was attenuated in the fibroid cells. The changes that were demonstrated by the change in intracellular stiffness with response to compression suggest that other mechanical forces may provide insight into differences in the two cell types.
Collapse
Affiliation(s)
- S C Schutte
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA.
| | - D Ghosh
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI, USA
| | - A Moset Zupan
- Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - R Warwar
- Department of Obstetrics and Gynecology, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - M R Dawson
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI, USA.
| |
Collapse
|
2
|
Islam MS, Parish M, Brennan JT, Winer BL, Segars JH. Targeting fibrotic signaling pathways by EGCG as a therapeutic strategy for uterine fibroids. Sci Rep 2023; 13:8492. [PMID: 37231028 DOI: 10.1038/s41598-023-35212-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/15/2023] [Indexed: 05/27/2023] Open
Abstract
Fibrosis is characterized by excessive accumulation of extracellular matrix, which is a key feature of uterine fibroids. Our prior research supports the tenet that inhibition of fibrotic processes may restrict fibroid growth. Epigallocatechin gallate (EGCG), a green tea compound with powerful antioxidant properties, is an investigational drug for uterine fibroids. An early phase clinical trial showed that EGCG was effective in reducing fibroid size and its associated symptoms; however, its mechanism of action(s) has not been completely elucidated. Here, we probed effects of EGCG on key signaling pathways involved in fibroid cell fibrosis. Viability of myometrial and fibroid cells was not greatly affected by EGCG treatment (1-200 µM). Cyclin D1, a protein involved in cell cycle progression, was increased in fibroid cells and was significantly reduced by EGCG. EGCG treatment significantly reduced mRNA or protein levels of key fibrotic proteins, including fibronectin (FN1), collagen (COL1A1), plasminogen activator inhibitor-1 (PAI-1), connective tissue growth factor (CTGF), and actin alpha 2, smooth muscle (ACTA2) in fibroid cells, suggesting antifibrotic effects. EGCG treatment altered the activation of YAP, β-catenin, JNK and AKT, but not Smad 2/3 signaling pathways involved in mediating fibrotic process. Finally, we conducted a comparative study to evaluate the ability of EGCG to regulate fibrosis with synthetic inhibitors. We observed that EGCG displayed greater efficacy than ICG-001 (β-catenin), SP600125 (JNK) and MK-2206 (AKT) inhibitors, and its effects were equivalent to verteporfin (YAP) or SB525334 (Smad) for regulating expression of key fibrotic mediators. These data indicate that EGCG exhibits anti-fibrotic effects in fibroid cells. These results provide insight into mechanisms behind the observed clinical efficacy of EGCG against uterine fibroids.
Collapse
Affiliation(s)
- Md Soriful Islam
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA.
| | - Maclaine Parish
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - Joshua T Brennan
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - Briana L Winer
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA
| | - James H Segars
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins Medicine, 720 Rutland Ave, Ross Building, Room 624, Baltimore, MD, 21205, USA.
| |
Collapse
|
3
|
Xie N, Xiao C, Shu Q, Cheng B, Wang Z, Xue R, Wen Z, Wang J, Shi H, Fan D, Liu N, Xu F. Cell response to mechanical microenvironment cues via Rho signaling: From mechanobiology to mechanomedicine. Acta Biomater 2023; 159:1-20. [PMID: 36717048 DOI: 10.1016/j.actbio.2023.01.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 01/30/2023]
Abstract
Mechanical cues in the cell microenvironment such as those from extracellular matrix properties, stretching, compression and shear stress, play a critical role in maintaining homeostasis. Upon sensing mechanical stimuli, cells can translate these external forces into intracellular biochemical signals to regulate their cellular behaviors, but the specific mechanisms of mechanotransduction at the molecular level remain elusive. As a subfamily of the Ras superfamily, Rho GTPases have been recognized as key intracellular mechanotransduction mediators that can regulate multiple cell activities such as proliferation, migration and differentiation as well as biological processes such as cytoskeletal dynamics, metabolism, and organ development. However, the upstream mechanosensors for Rho proteins and downstream effectors that respond to Rho signal activation have not been well illustrated. Moreover, Rho-mediated mechanical signals in previous studies are highly context-dependent. In this review, we systematically summarize the types of mechanical cues in the cell microenvironment and provide recent advances on the roles of the Rho-based mechanotransduction in various cell activities, physiological processes and diseases. Comprehensive insights into the mechanical roles of Rho GTPase partners would open a new paradigm of mechanomedicine for a variety of diseases. STATEMENT OF SIGNIFICANCE: In this review, we highlight the critical role of Rho GTPases as signal mediators to respond to physical cues in microenvironment. This article will add a distinct contribution to this set of knowledge by intensively addressing the relationship between Rho signaling and mechanobiology/mechanotransduction/mechanomedcine. This topic has not been discussed by the journal, nor has it yet been developed by the field. The comprehensive picture that will develop, from molecular mechanisms and engineering methods to disease treatment strategies, represents an important and distinct contribution to the field. We hope that this review would help researchers in various fields, especially clinicians, oncologists and bioengineers, who study Rho signal pathway and mechanobiology/mechanotransduction, understand the critical role of Rho GTPase in mechanotransduction.
Collapse
Affiliation(s)
- Ning Xie
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Cailan Xiao
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Qiuai Shu
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Bo Cheng
- Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Ziwei Wang
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Runxin Xue
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Zhang Wen
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Jinhai Wang
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Haitao Shi
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an Shaanxi 710049, China.
| | - Na Liu
- Department of Gastroenterology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China.
| | - Feng Xu
- Bioinspired Engineering and Biomechanics Center (BEBC), Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China; The Key Laboratory of Biomedical Information Engineering of Ministry of Education, School of Life Science and Technology, Xi'an Jiaotong University, Xi'an, Shaanxi 710049, China.
| |
Collapse
|
4
|
Wright D, Britten J, Malik M, Catherino WH. Relugolix and elagolix directly inhibit leiomyoma extracellular matrix production in 2-dimesnional and 3-dimensional cell cultures. F&S SCIENCE 2022; 3:299-308. [PMID: 35977805 DOI: 10.1016/j.xfss.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To determine the effect relugolix and elagolix have on the production of extracellular matrix (ECM) proteins in human leiomyoma cells. DESIGN Laboratory study. SETTING University hospital. PATIENT(S) OR ANIMALS None. January 5, 2022 Cell culture, protein analysis, immunohistochemistry. MAIN OUTCOME MEASURE(S) Production of GnRHR, COL1A1, FN1, VCAN, p-ERK, & ERK in treated/untreated leiomyoma cells. RESULTS 100 nM relugolix resulted in decreased production of COL1A1 at 24 (1.78 0.06-fold; P < .05) and 48 hours (1.92 0.14-fold; P < .05). Elagolix treatment resulted in a decrease in COL1A1 production at 24 but not 48 hours. In 2D and 3D, 100 nM relugolix resulted in decreased production of FN1 at 24 (1.7 ± 0.07-fold; P < .05) and 48 hours (1.8 ± 0.07-fold; P < .05); 100 nM elagolix resulted in decreased production of FN1 at 24 (1.7 ± 0.14-fold; P < .05) and 48 hours (2.0 ± 0.09-fold; P < .05). For cells treated with relugolix 100 nM resulted in decreased VCAN production by 48 hours (0.66 ± 0.07-fold; P < .05). Contrary to our 3D data, 2D elagolix-treated cells demonstrated a decrease in VCAN production that was identified only at 24 hours. For GnRHR, no significant difference between the drugs was seen at 24 hours; at 48 hours production was only significantly decreased for relugolix (P < .05). Comparing both drugs, there was a significant difference in the concentration of p-ERK to ERK at 24 hours (P < .05); there was no difference by 48 hours. CONCLUSIONS Our findings demonstrated that treatment with either drug can 1) decrease ECM protein production and 2) inhibit the MAPK pathway.
Collapse
Affiliation(s)
- Danielle Wright
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Minnie Malik
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - William H Catherino
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| |
Collapse
|
5
|
Yang Q, Ciebiera M, Bariani MV, Ali M, Elkafas H, Boyer TG, Al-Hendy A. Comprehensive Review of Uterine Fibroids: Developmental Origin, Pathogenesis, and Treatment. Endocr Rev 2022; 43:678-719. [PMID: 34741454 PMCID: PMC9277653 DOI: 10.1210/endrev/bnab039] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Indexed: 11/24/2022]
Abstract
Uterine fibroids are benign monoclonal neoplasms of the myometrium, representing the most common tumors in women worldwide. To date, no long-term or noninvasive treatment option exists for hormone-dependent uterine fibroids, due to the limited knowledge about the molecular mechanisms underlying the initiation and development of uterine fibroids. This paper comprehensively summarizes the recent research advances on uterine fibroids, focusing on risk factors, development origin, pathogenetic mechanisms, and treatment options. Additionally, we describe the current treatment interventions for uterine fibroids. Finally, future perspectives on uterine fibroids studies are summarized. Deeper mechanistic insights into tumor etiology and the complexity of uterine fibroids can contribute to the progress of newer targeted therapies.
Collapse
Affiliation(s)
- Qiwei Yang
- Qiwei Yang, Ph.D. Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, M167, Billings, Chicago, IL 60637, USA.
| | - Michal Ciebiera
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, ul. Cegłowska 80, 01-809, Warsaw, Poland
| | | | - Mohamed Ali
- Clinical Pharmacy Department, Faculty of Pharmacy, Ain Shams University, Cairo 11566, Egypt
| | - Hoda Elkafas
- Department of Anesthesiology, University of Illinois at Chicago, Chicago, IL 60612, USA
- Department of Pharmacology and Toxicology, Egyptian Drug Authority, formerly National Organization for Drug Control and Research, Cairo 35521, Egypt
| | - Thomas G Boyer
- Department of Molecular Medicine, Institute of Biotechnology, University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229-3900, USA
| | - Ayman Al-Hendy
- Correspondence: Ayman Al-Hendy, MD, Ph.D. Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Ave, N112, Peck Pavilion, Chicago, IL 60637. USA.
| |
Collapse
|
6
|
Britten JL, Malik M, Pekny C, DeAngelis A, Catherino WH. Three-dimensional human leiomyoma xenografts induce angiogenesis by inducing hypoxia inducible factor-1 alpha. F&S SCIENCE 2021; 2:219-227. [PMID: 35559755 DOI: 10.1016/j.xfss.2020.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/28/2020] [Accepted: 09/28/2020] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To characterize the method by which angiogenesis occurred in three-dimensional (3D) leiomyoma xenografts, and to assess the impact of hypoxia on two-dimensional (2D) and 3D myometrial and leiomyoma cells and leiomyoma xenografts in vivo. DESIGN Laboratory study. SETTING Academic research. PATIENT(S) Cell cultures from patient-matched myometrial and leiomyoma tissues. INTERVENTION(S) In vivo 3D leiomyoma xenografts from ovariectomized mice treated with gonadal hormones; myometrial and leiomyoma cells in 2D and 3D growth formats exposed to 1% oxygen. MAIN OUTCOME MEASURE(S) Protein expression. RESULT(S) Blood vessels in the xenograft estradiol group are identified with anti-mouse/anti-rat CD31/PECAM-1 antibody. Hormone-stimulated 3D leiomyoma xenografts stain positively for adrenomedullin (ADM). Myometrial cells exposed to 1% oxygen demonstrated an increase in hypoxia-inducible factor (HIF)-1α at 6 hours and a marked increase at 24 hours. Under normoxic conditions, leiomyoma cells at 6 hours show increased expression of HIF-1α, which is further increased at 24 hours. Leiomyoma cells under hypoxia demonstrated a 1.14-fold decrease in HIF-1α expression at 6 hours and no change at 24 hours. Hypoxic myometrium decreased the proangiogenic protein ADM expression at 6 hours and showed a >1.5-fold increase at 24 hours. Normoxic leiomyoma decrease ADM at 24 hours and showed a >1.5-fold increase at 24 hours of hypoxia. CONCLUSION(S) Hypoxia-induced HIF-1α expression facilitates angiogenesis in 3D xenografts in vivo by increasing the expression of the proangiogenic protein ADM. Angiogenesis contributes to the viability and extended survival of these xenografts. Furthermore, 2D myometrial and leiomyoma cells increase HIF-1α and ADM expression in vitro under hypoxic conditions.
Collapse
Affiliation(s)
- Joy L Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Carissa Pekny
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anthony DeAngelis
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Eunice Kennedy Shriver National Institute of Child Health and Human Development, Program in Reproductive Endocrinology and Gynecology, National Institutes of Health, Bethesda, Maryland
| | - William H Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Eunice Kennedy Shriver National Institute of Child Health and Human Development, Program in Reproductive Endocrinology and Gynecology, National Institutes of Health, Bethesda, Maryland.
| |
Collapse
|
7
|
Cordeiro Mitchell CN, Islam MS, Afrin S, Brennan J, Psoter KJ, Segars JH. Mechanical stiffness augments ligand-dependent progesterone receptor B activation via MEK 1/2 and Rho/ROCK-dependent signaling pathways in uterine fibroid cells. Fertil Steril 2021; 116:255-265. [PMID: 33676751 DOI: 10.1016/j.fertnstert.2020.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To test whether mechanical substrate stiffness would influence progesterone receptor B (PRB) signaling in fibroid cells. Uterine fibroids feature an excessive extracellular matrix, increased stiffness, and altered mechanical signaling. Fibroid growth is stimulated by progestins and opposed by anti-progestins, but a functional interaction between progesterone action and mechanical signaling has not been evaluated. DESIGN Laboratory studies. SETTING Translational science laboratory. PATIENT(S)/ANIMAL(S) Human fibroid cell lines and patient-matched fibroid and myometrial cell lines. INTERVENTION(S) Progesterone receptor B-dependent reporter assays and messenger RNA quantitation in cells cultured on stiff polystyrene plates (3GPa) or soft silicone plates (930KPa). Pharmacologic inhibitors of extracellular signal-related protein kinase (ERK) kinase 1/2 (MEK 1/2; PD98059), p38 mitogen-activated protein kinase (SB202190), receptor tyrosine kinases (RTKs; nintedanib), RhoA (A13), and Rho-associated coiled-coil kinase (ROCK; Y27632). MAIN OUTCOME MEASURE(S) Progesterone-responsive reporter activation. RESULT(S) Fibroid cells exhibited higher PRB-dependent reporter activity with progesterone (P4) in cells cultured on stiff vs. soft plates. Mechanically induced PRB activation with P4 was decreased 62% by PD98059, 78% by nintedanib, 38% by A13, and 50% by Y27632. Overexpression of the Rho-guanine nucleotide exchange factor (Rho-GEF), AKAP13, significantly increased PRB-dependent reporter activity. Collagen 1 messenger RNA levels were higher in fibroid cells grown on stiff vs. soft plates with P4. CONCLUSION(S) Cells cultured on mechanically stiff substrates had enhanced PRB activation via a mechanism that required MEK 1/2 and AKAP13/RhoA/ROCK signaling pathways. These studies provide a framework to explore the mechanisms by which mechanical stiffness affects progesterone receptor activation.
Collapse
Affiliation(s)
- Christina N Cordeiro Mitchell
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology & Infertility, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Md Soriful Islam
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Sadia Afrin
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Joshua Brennan
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Kevin J Psoter
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - James H Segars
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology & Infertility, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women's Health Research, Johns Hopkins Medicine, Baltimore, Maryland.
| |
Collapse
|
8
|
Leppert PC, Al-Hendy A, Baird DD, Bulun S, Catherino W, Dixon D, Ducharme M, Harmon QE, Jayes FL, Paul E, Perucho AM, Segars J, Simón C, Stewart EA, Teixeira J, Tinelli A, Tschumperlin D, Zota AR. Summary of the Proceedings of the Basic Science of Uterine Fibroids Meeting: New Developments February 28, 2020. F&S SCIENCE 2021; 2:88-100. [PMID: 34124698 PMCID: PMC8192074 DOI: 10.1016/j.xfss.2020.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Scientists from multiple basic disciplines and an international group of physician-scientists from the field of obstetrics and gynecology presented recent studies and discussed new and evolving theories of uterine fibroid etiology, growth and development at The Basic Science of the Uterine Fibroids meeting, sponsored by the Campion Fund and the National Institute of Environmental Health Sciences. The purpose was to share up-to date knowledge and to stimulate new concepts regarding the basic molecular biology and pathophysiology of uterine fibroids, and to promote future collaborations. The meeting was held at the National Institute of Environmental Health Sciences in North Carolina on February 28, 2020. Speakers reviewed recent advances in cellular and molecular processes that contribute to fibroid growth and new opportunities for treatment. At the conclusion of the conference, attendees identified important new directions for future research.
Collapse
Affiliation(s)
- Phyllis C. Leppert
- Campion Fund of the Phyllis and Mark Leppert Foundation for Fertility Research, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Illinois
| | - Donna D. Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
| | - Serdar Bulun
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Il
| | - William Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Darlene Dixon
- National Toxicology Program, National Institutes of Environmental Health Sciences, National Institutes of Health. Research Triangle Park, NC
| | - Merrick Ducharme
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Quaker E. Harmon
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
| | - Friederike L. Jayes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC
| | - Emmanuel Paul
- Grand Rapids Research Center, Michigan State University, Grand Rapids, MI
| | | | - James Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD
| | - Carlos Simón
- IgenomixFoundation, INCLIVA Health Research Institute, Valencia, Spain
- Department of Obstetrics and Gynecology, Valencia University, Valencia
- Harvard University, Boston MA
| | - Elizabeth A. Stewart
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Mayo Clinic
| | - Jose Teixeira
- Grand Rapids Research Center, Michigan State University, Grand Rapids, MI
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, Vitto Fazzi Hospital, Lecce, Italy
| | - Daniel Tschumperlin
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Ami R. Zota
- Department of Environmental and Occupational Health, George Washington University, Milken School of Public Health
| |
Collapse
|
9
|
Afrin S, Islam MS, Patzkowsky K, Malik M, Catherino WH, Segars JH, Borahay MA. Simvastatin ameliorates altered mechanotransduction in uterine leiomyoma cells. Am J Obstet Gynecol 2020; 223:733.e1-733.e14. [PMID: 32417359 DOI: 10.1016/j.ajog.2020.05.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 04/18/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Uterine leiomyomas, the most common tumors of the female reproductive system, are characterized by excessive deposition of disordered stiff extracellular matrix and fundamental alteration in the mechanical signaling pathways. Specifically, these alterations affect the normal dynamic state of responsiveness to mechanical cues in the extracellular environment. These mechanical cues are converted through integrins, cell membrane receptors, to biochemical signals including cytoskeletal signaling pathways to maintain mechanical homeostasis. Leiomyoma cells overexpress β1 integrin and other downstream mechanical signaling proteins. We previously reported that simvastatin, an antihyperlipidemic drug, has antileiomyoma effects through cellular, animal model, and epidemiologic studies. OBJECTIVE This study aimed to examine the hypothesis that simvastatin might influence altered mechanotransduction in leiomyoma cells. STUDY DESIGN This is a laboratory-based experimental study. Primary leiomyoma cells were isolated from 5 patients who underwent hysterectomy at the Department of Gynecology and Obstetrics of the Johns Hopkins University Hospital. Primary and immortalized human uterine leiomyoma cells were treated with simvastatin at increasing concentrations (0.001, 0.01, 0.1, and 1 μM, or control) for 48 hours. Protein and mRNA levels of β1 integrin and extracellular matrix components involved in mechanical signaling were quantified by quantitative real-time polymerase chain reaction, western blotting, and immunofluorescence. In addition, we examined the effect of simvastatin on the activity of Ras homolog family member A using pull-down assay and gel contraction. RESULTS We found that simvastatin significantly reduced the protein expression of β1 integrin by 44% and type I collagen by 60% compared with untreated leiomyoma cells. Simvastatin-treated cells reduced phosphorylation of focal adhesion kinase down to 26%-60% of control, whereas it increased total focal adhesion kinase protein expression. Using a Ras homolog family member A pull-down activation assay, we observed reduced levels of active Ras homolog family member A in simvastatin-treated cells by 45%-85% compared with control. Consistent with impaired Ras homolog family member A activation, simvastatin treatment reduced tumor gel contraction where gel area was 122%-153% larger than control. Furthermore, simvastatin treatment led to reduced levels of mechanical signaling proteins involved in β1 integrin downstream signaling, such as A-kinase anchor protein 13, Rho-associated protein kinase 1, myosin light-chain kinase, and cyclin D1. CONCLUSION The results of this study suggest a possible therapeutic role of simvastatin in restoring the altered state of mechanotransduction signaling in leiomyoma. Collectively, these findings are aligned with previous epidemiologic studies and other reports and support the need for clinical trials.
Collapse
|
10
|
O’Connor BB, Pope BD, Peters MM, Ris-Stalpers C, Parker KK. The role of extracellular matrix in normal and pathological pregnancy: Future applications of microphysiological systems in reproductive medicine. Exp Biol Med (Maywood) 2020; 245:1163-1174. [PMID: 32640894 PMCID: PMC7400725 DOI: 10.1177/1535370220938741] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPACT STATEMENT Extracellular matrix in the womb regulates the initiation, progression, and completion of a healthy pregnancy. The composition and physical properties of extracellular matrix in the uterus and at the maternal-fetal interface are remodeled at each gestational stage, while maladaptive matrix remodeling results in obstetric disease. As in vitro models of uterine and placental tissues, including micro-and milli-scale versions of these organs on chips, are developed to overcome the inherent limitations of studying human development in vivo, we can isolate the influence of cellular and extracellular components in healthy and pathological pregnancies. By understanding and recreating key aspects of the extracellular microenvironment at the maternal-fetal interface, we can engineer microphysiological systems to improve assisted reproduction, obstetric disease treatment, and prenatal drug safety.
Collapse
Affiliation(s)
- Blakely B O’Connor
- Disease Biophysics Group, Wyss Institute for Biologically Inspired Engineering; Harvard John A. Paulson School of Engineering and Applied Sciences; Harvard University, Cambridge, MA 02138, USA
| | - Benjamin D Pope
- Disease Biophysics Group, Wyss Institute for Biologically Inspired Engineering; Harvard John A. Paulson School of Engineering and Applied Sciences; Harvard University, Cambridge, MA 02138, USA
| | - Michael M Peters
- Disease Biophysics Group, Wyss Institute for Biologically Inspired Engineering; Harvard John A. Paulson School of Engineering and Applied Sciences; Harvard University, Cambridge, MA 02138, USA
| | - Carrie Ris-Stalpers
- Department of Gynecology and Obstetrics, Academic Reproduction and Development, Amsterdam UMC, University of Amsterdam, Amsterdam 1105, The Netherlands
| | - Kevin K Parker
- Disease Biophysics Group, Wyss Institute for Biologically Inspired Engineering; Harvard John A. Paulson School of Engineering and Applied Sciences; Harvard University, Cambridge, MA 02138, USA
| |
Collapse
|
11
|
Malik M, Britten J, Catherino WH. Development and Validation of Hormonal Impact of a Mouse Xenograft Model for Human Uterine Leiomyoma. Reprod Sci 2020; 27:1304-1317. [PMID: 32016804 DOI: 10.1007/s43032-019-00123-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
Multiple in vivo animal models for uterine leiomyoma do not adequately represent human disease based on etiology, molecular phenotype, or limited fixed life span. Our objective was to develop a xenograft model with sustained growth, by transplanting a well-established actively growing three-dimensional (3D) cell culture of human leiomyoma and myometrium in NOD/SCID ovariectomized female mice. We demonstrated continued growth to at least 12 weeks and the overexpression of extracellular matrix (ECM). Further, we confirmed maintenance of hormonal response that is comparable to human disease in situ. Leiomyoma xenografts under hormonal treatment demonstrated 8 to12-fold increase of volume over the xenografts not treated with hormones. Estradiol-treated xenografts were more cellular as compared to progesterone or combination milieu, at the end of 8-week time frame. There was also a non-statistically significant 2-4 mm3 increase in volume between 8-week and 12-week xenografts with higher matrix to cell ratio in 12-week xenografts compared to the 8-week and placebo xenografts. Increased expression of ECM proteins, fibronectin, versican, and collagens, indicated an actively growing cell matrix formation in the xenografts. In conclusion, we have developed and validated a xenograft in vivo model for uterine leiomyoma that shares the genomic and proteomic characteristics with the human surgical specimens of origin and recapitulates the most important features of the human tumors, the aberrant ECM expression that defines the leiomyoma phenotype and gonadal hormone regulation. Using this model, we demonstrated that combination of estradiol and progesterone resulted in increased cellularity and ECM production leading to growth of the xenograft tumors.
Collapse
Affiliation(s)
- Minnie Malik
- Department of Obstetrics and Gynecology, Building A, Room 3082, Uniformed Services University of the Health Sciences, Bethesda, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Joy Britten
- Department of Obstetrics and Gynecology, Building A, Room 3082, Uniformed Services University of the Health Sciences, Bethesda, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - William H Catherino
- Department of Obstetrics and Gynecology, Building A, Room 3082, Uniformed Services University of the Health Sciences, Bethesda, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.
| |
Collapse
|
12
|
Sato S, Maekawa R, Tamura I, Shirafuta Y, Shinagawa M, Asada H, Taketani T, Tamura H, Sugino N. SATB2 and NGR1: potential upstream regulatory factors in uterine leiomyomas. J Assist Reprod Genet 2019; 36:2385-2397. [PMID: 31728810 DOI: 10.1007/s10815-019-01582-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/06/2019] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We attempted to identify the genes involved in the pathogenesis of uterine leiomyomas, under a hypothesis that the aberrant expression of upstream regulatory genes caused by aberrant DNA methylation is involved in the onset and development of uterine leiomyomas. METHODS To find such genes, we compared genome-wide mRNA expression and DNA methylation in uterine leiomyomas and adjacent normal myometrium. Analysis of the data by Ingenuity Pathway Analysis software identified SATB2 which is known to be an epigenetic regulator, and NRG1 as candidate upstream regulatory genes. To infer the functions of these genes, human uterine smooth muscle cell lines overexpressing SATB2 or NRG1 genes were established (SATB2 or NRG1 lines), and their transcriptomes and pathways were analyzed. RESULTS SATB2 and NRG1 were confirmed to be hypermethylated and upregulated in most uterine leiomyoma specimens (nine to 11 of the 11 cases). Among the established cell lines, morphological changes from spindle-like forms to fibroblast-like forms with elongated protrusions were observed in only the SATB2 line. Pathway analysis revealed that WNT/β-catenin and TGF-β signaling pathways which are related to the pathogenesis of uterine leiomyomas were activated in both SATB2 and NRG1 lines. In addition, signaling of growth factors including VEGF, PDGF, and IGF1, and retinoic acid signaling were activated in the SATB2 and NRG1 lines, respectively. CONCLUSIONS These results indicate that SATB2 and NRG1 overexpression induced many of the signaling pathways that are considered to be involved in the pathogenesis of uterine leiomyomas, suggesting that these genes have roles as upstream regulatory factors.
Collapse
Affiliation(s)
- Shun Sato
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Ryo Maekawa
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Isao Tamura
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Yuichiro Shirafuta
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Masahiro Shinagawa
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Hiromi Asada
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Toshiaki Taketani
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Hiroshi Tamura
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan
| | - Norihiro Sugino
- Department of Obstetrics and Gynecology, Yamaguchi University Graduate School of Medicine, Minamikogushi, 1-1-1, Ube, 755-8505, Japan.
| |
Collapse
|
13
|
Ng SSM, Jorge S, Malik M, Britten J, Su SC, Armstrong CR, Brennan JT, Chang S, Baig KM, Driggers PH, Segars JH. A-Kinase Anchoring Protein 13 (AKAP13) Augments Progesterone Signaling in Uterine Fibroid Cells. J Clin Endocrinol Metab 2019; 104:970-980. [PMID: 30239831 PMCID: PMC6365770 DOI: 10.1210/jc.2018-01216] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/10/2018] [Indexed: 01/11/2023]
Abstract
CONTEXT Uterine leiomyomata (fibroids) are prevalent sex hormone‒dependent tumors with an altered response to mechanical stress. Ulipristal acetate, a selective progesterone receptor (PR) modulator, significantly reduces fibroid size in patients. However, PR signaling in fibroids and its relationship to mechanical signaling are incompletely understood. OBJECTIVE Our prior studies revealed that A-kinase anchoring protein 13 (AKAP13) was overexpressed in fibroids and contributed to altered mechanotransduction in fibroids. Because AKAP13 augmented nuclear receptor signaling in other tissues, we sought to determine whether AKAP13 might influence PR signaling in fibroids. METHODS AND RESULTS Fibroid samples from patients treated with ulipristal acetate or placebo were examined for AKAP13 expression by using immunohistochemistry. In immortalized uterine fibroid cell lines and COS-7 cells, we observed that AKAP13 increased ligand-dependent PR activation of luciferase reporters and endogenous progesterone-responsive genes for PR-B but not PR-A. Inhibition of ERK reduced activation of PR-dependent signaling by AKAP13, but inhibition of p38 MAPK had no effect. In addition, glutathione S-transferase‒binding assays revealed that AKAP13 was bound to PR-B through its carboxyl terminus. CONCLUSION These data suggest an intersection of mechanical signaling and PR signaling involving AKAP13 through ERK. Further elucidation of the integration of mechanical and hormonal signaling pathways in fibroids may provide insight into fibroid development and suggest new therapeutic strategies for treatment.
Collapse
Affiliation(s)
- Sinnie Sin Man Ng
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Soledad Jorge
- Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington
| | - Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Szu-Chi Su
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Charles R Armstrong
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Joshua T Brennan
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - Sydney Chang
- Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of OBGYN and Reproductive Science, Mount Sinai School of Medicine, New York, New York
| | - Kimberlyn Maravet Baig
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
- Section on Reproductive Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Paul H Driggers
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
| | - James H Segars
- Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Baltimore, Maryland
- Correspondence and Reprint Requests: James H. Segars, MD, Department of Gynecology and Obstetrics, Division of Reproductive Sciences & Women’s Health Research, Johns Hopkins Medicine, Ross Building 624, 720 Rutland Avenue, Baltimore, Maryland 21205. E-mail address:
| |
Collapse
|
14
|
Britten JL, Malik M, Lewis TD, Catherino WH. Ulipristal Acetate Mediates Decreased Proteoglycan Expression Through Regulation of Nuclear Factor of Activated T-Cells (NFAT5). Reprod Sci 2018; 26:184-197. [PMID: 30567472 DOI: 10.1177/1933719118816836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Nuclear factor of activated T-cells (NFAT5) is a tissue specific, osmoadaptive transcription factor essential for the control of hydration homeostasis in mammalian cells. Nuclear factor of activated T-cells regulates osmolyte transporters aldo-keto reductase family 1 member B1 (AKR1B1) and solute carrier family 5 member 3 (SLC5A3) to maintain fluid equilibrium in cells. The osmotic potential of the extracellular matrix of leiomyomas is attributed to the role of proteoglycans. In leiomyoma cells, NFAT5 is overexpressed compared to myometrial cells. The selective progesterone receptor modulator, ulipristal acetate, has been reported to decrease the size of leiomyomas in clinical trials. When treated with ulipristal acetate, both patient leiomyoma tissue and leiomyoma cells grown in 3-dimensional cultures show a decrease in the expression of NFAT5 protein, solute transporters AKR1B1 and SLC5A3, and results in an associated decline in the expression of proteoglycans, versican, aggrecan, and brevican. In summary, ulipristal acetate induces changes in leiomyoma cell osmoregulation which result in a decrease in proteoglycan expression.
Collapse
Affiliation(s)
- Joy L Britten
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Minnie Malik
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Terrence D Lewis
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,2 Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| | - William H Catherino
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,2 Program in Reproductive Endocrinology and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| |
Collapse
|
15
|
Jamaluddin MFB, Nahar P, Tanwar PS. Proteomic Characterization of the Extracellular Matrix of Human Uterine Fibroids. Endocrinology 2018; 159:2656-2669. [PMID: 29788081 DOI: 10.1210/en.2018-00151] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/08/2018] [Indexed: 01/04/2023]
Abstract
Uterine leiomyomas (fibroids) are the most common benign tumors that are associated with increased production of extracellular matrix (ECM). Excessive ECM deposition plays a major role in the enlargement and stiffness of these tumors and contributes to clinical symptoms, such as abnormal bleeding and abdominal pain. However, no study so far has explored the global composition of the ECM of fibroids and normal myometrium. In this study, we performed a systematic ECM enrichment procedure and comparative proteomic analyses to profile the ECM composition of genetically annotated different-sized fibroids (small, medium, and large) and adjacent normal myometrium (ANM). Our matrisome analysis identified a combined total of 108, 126, 126, and 130 unique ECM and ECM-associated proteins with a confidence corresponding to a false discovery rate <1% in ANM and in small, medium, and large fibroids, respectively. The majority of fibroid ECM proteins belong to the core matrisome that includes glycoproteins, collagens, and proteoglycans. Considering that the small-sized fibroids represent the initial stages of leiomyogenesis, we highlighted some of the most abundant and important upregulated ECM proteins in small fibroids (i.e., POSTN, TNC, COL3A1, COL24A1, and ASPN). Furthermore, we revealed 30 unique ECM proteins that exist only in fibroids but that are not present in ANM regardless of MED12 mutation. We propose that some of the proteins identified represent potential novel ECM drug targets that may change the paradigm of fibroid treatment.
Collapse
Affiliation(s)
- M Fairuz B Jamaluddin
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - Pravin Nahar
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- Department of Maternity and Gynecology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Pradeep S Tanwar
- School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| |
Collapse
|
16
|
Jamaluddin MFB, Nagendra PB, Nahar P, Oldmeadow C, Tanwar PS. Proteomic Analysis Identifies Tenascin-C Expression Is Upregulated in Uterine Fibroids. Reprod Sci 2018; 26:476-486. [PMID: 29730954 DOI: 10.1177/1933719118773420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Uterine leiomyomas (fibroids) are the most common gynecological tumors, which are enriched in the extracellular matrix (ECM). Fibroids are leading cause of abnormal uterine bleeding and hysterectomy. One of the major questions yet to be answered is the overproduction of specific ECM components in human uterine fibroids, particularly in relation to mutations in the driver gene mediator complex subunit 12 ( MED12). Surgical specimens from 14 patients with uterine leiomyoma having fibroids and corresponding adjacent normal myometrium (ANM) were utilized to analyze genetic and proteomic expression patterns in the tissue samples. MED12 mutations in the fibroids were screened by Sanger sequencing. iTRAQ was used to label the peptides in small-, medium-, and large-sized fibroid samples of annotated MED12 mutation from the same patient. The mixtures of the peptides were fractionated by hydrophilic interaction liquid chromatography (HILIC) and analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) to identify the differential expression proteins. Using isobaric tagged-based quantitative mass spectrometry on 3 selected patients, ECM-related protein tenascin-C (TNC) was observed significantly upregulated (>1.5-fold) with a confidence corresponding to false discovery rate (FDR) <1% in small-, medium-, and large-sized fibroid samples regardless of MED12 mutation status. The TNC was validated on additional patient samples using Western blotting (WB) and immunohistochemistry (IHC) and confirmed significant overexpression of this protein in fibroids compared to matched ANM. Proteomic analyses have identified the increased ECM protein expression, TNC, as a hallmark of uterine fibroids regardless of MED12 mutations. Further functional studies focusing on the upregulated ECM proteins in leiomyogenesis will lead to the identification of novel ECM drug targets for fibroid treatment.
Collapse
Affiliation(s)
- M Fairuz B Jamaluddin
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - Prathima B Nagendra
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| | - Pravin Nahar
- 2 School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia.,3 Department of Maternity and Gynaecology, John Hunter Hospital, New South Wales, Australia
| | - Christopher Oldmeadow
- 4 Clinical Research Design, Information Technology and Statistical Support (CReDITSS) Unit, Hunter Medical Research Institute, New South Wales, Australia
| | - Pradeep S Tanwar
- 1 School of Biomedical Sciences and Pharmacy, University of Newcastle, Callaghan, New South Wales, Australia
| |
Collapse
|
17
|
Cox J, Malik M, Britten J, Lewis T, Catherino WH. Ulipristal Acetate and Extracellular Matrix Production in Human Leiomyomas In Vivo: A Laboratory Analysis of a Randomized Placebo Controlled Trial. Reprod Sci 2017; 25:198-206. [PMID: 28929861 DOI: 10.1177/1933719117728802] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In a prior randomized controlled study, patients treated with ulipristal acetate (UPA) or placebo for 3 months had a decrease in leiomyoma size. A total of 10 patients' tissue samples (5 placebo and 5 treated with 10 mg/d UPA) that underwent hysterectomy and tissue preservation were identified from this study. Quantitative real-time reverse transcriptase polymerase chain reaction and Western blotting were used to assess fold gene and protein expression of extracellular membrane (ECM) proteins: collagen 1A (COL1A), fibronectin (FN1), and versican (VCAN) of the samples. Confirmatory immunohistochemical analysis was performed. Changes in total matrix collagen were examined using Masson trichrome staining. Multiplex measurement of the matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases was performed. Compared to placebo-treated surgical specimens, 80% of the treated specimens showed decrease in VCAN protein, 60% showed decrease in FN1, but no consistent alteration in COL1A. This effect was also supported by immunohistochemistry where leiomyoma surgical specimens demonstrated decreased amount of FN1 and VCAN on UPA treatment. Increased MMP2 and decreased MMP9 in treated patient leiomyomas indicate both degradation of the matrix and inhibition of the pathway involved in matrix production. Treatment with UPA decreased fibroid volume in placebo-controlled, randomized trials. Treatment with UPA decreased gene expression and protein production in leiomyoma tissue, suggesting both an impact on water content and ECM protein concentration as a mechanism of ulipristal-mediated decrease in leiomyoma size.
Collapse
Affiliation(s)
- Jeris Cox
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,2 Fort Belvoir Community Hospital, Fort Belvoir, VA, USA
| | - Minnie Malik
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Joy Britten
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Terrence Lewis
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,3 Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| | - William H Catherino
- 1 Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.,3 Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| |
Collapse
|
18
|
Loss of stiffness in collagen-rich uterine fibroids after digestion with purified collagenase Clostridium histolyticum. Am J Obstet Gynecol 2016; 215:596.e1-596.e8. [PMID: 27177523 DOI: 10.1016/j.ajog.2016.05.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/19/2016] [Accepted: 05/03/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Uterine fibroids are a significant health problem. These common benign tumors occur in 70-80% of women before age 50 years and often cause bleeding and pain and can interfere considerably with daily life. Current treatment options are limited. Fibroids contain substantial amounts of altered and disordered collagens, which contribute to their bulk. Targeting these collagens directly presents a novel treatment approach. OBJECTIVES We sought to test the hypothesis that a highly purified collagenase Clostridium histolyticum will digest interstitial collagen in uterine fibroids and reduce their stiffness and thereby evaluate the feasibility that this collagenase C histolyticum can be developed into an alternative treatment for fibroids. A secondary objective was to describe the collagen content of the fibroid tissue. STUDY DESIGN Fibroid tissue cubes (1 cm3; n = 154) were cut from 17 uterine fibroids that were obtained from 7 consented subjects undergoing scheduled hysterectomies. Tissue cubes were injected with diluent, placebo, or highly purified collagenase C histolyticum (0.05, 0.1, or 0.2 mg/cube) and incubated at 37°C for 24, 48, 72, or 96 hours. At each time point, 6 noninjected control cubes were also evaluated. Tissue cubes were photographed before and after incubation. Myometrial samples (n = 21) were also evaluated. Stiffness was quantified through rheometry by measuring complex shear moduli of the tissues. Percent fibrosis was determined by computerized analysis of Masson-trichrome-stained slides. Digestion of collagen fibrils was confirmed by transmission electron microscopy. RESULTS Fibrosis in untreated fibroids ranged from 37% to 77%, reflecting the collagen-rich nature of these tumors. After treatment with collagenase for 96 hours, fibrosis ranged from 5.3% to 2.4%. Transmission electron microscopy confirmed complete digestion of collagen fibrils. Tissue stiffness was reduced with all 3 doses of collagenase treatment and at all 4 time points. Longer incubation times with collagenase caused greater reduction in stiffness, and treated cubes lost their cuboidal shape and had gelatinous/liquefied centers. At 96 hours the stiffness in tissues treated with the lowest dose was reduced to 966 ± 106 Pascal compared with the diluent-treated control at the same time (5323 ± 903 Pascal; P < .0001; by analysis of variance with Tukey-Kramer). CONCLUSION Uterine fibroids have a high content of collagen that can be effectively digested by highly purified collagenase C histolyticum, resulting in reduced tissue stiffness. Loss of stiffness may decrease bulk symptoms in vivo and possibly lead to shrinkage of fibroids through changed mechanotransduction, leading ultimately to reduced fibroid symptoms of pain and bleeding. Clinical trials are necessary to evaluate the safety and efficacy of collagenase C histolyticum including the rate of regrowth of fibroids. The data of this study provide a strong rationale for using this purified collagenase in clinical trials as a local treatment for women with fibroids.
Collapse
|
19
|
Abstract
Reproductive biologists are well-versed in many types of biochemical signaling, and indeed, there are almost innumerable examples in reproduction, including steroid and peptide hormone signaling, receptor-ligand and secondary messenger-mediated signaling, signaling regulated by membrane channels, and many others. Among reproductive scientists, a perhaps lesser-known but comparably important mode of signaling is mechanotransduction: the concept that cells can sense and respond to externally applied or internally generated mechanical forces. Given the cell shape changes and tissue morphogenesis events that are components of many phenomena in reproductive function, it should be no surprise that mechanotransduction has major impacts in reproductive health and pathophysiology. The conference on "Mechanotransduction in the Reproductive Tract" was a valuable launch pad to bring this hot issue in development, cell biology, biophysics, and tissue regeneration to the realm of reproductive biology. The goal of the meeting was to stimulate interest and increased mechanotransduction research in the reproductive field by presenting a broad spectrum of responses impacted by this process. The meeting highlighted the importance of convening expert investigators, students, fellows, and young investigators from a number of research areas resulting in cross-fertilization of ideas and suggested new avenues for study. The conference included talks on tissue engineering, stem cells, and several areas of reproductive biology, from uterus and cervix to the gametes. Specific reproductive health-relevant areas, including uterine fibroids, gestation and parturition, and breast tissue morphogenesis, received particular attention.
Collapse
Affiliation(s)
- Janice P Evans
- a Department of Biochemistry and Molecular Biology , Bloomberg School of Public Health, Johns Hopkins University , Baltimore , MD , USA
| | - Phyllis C Leppert
- b Department of Obstetrics and Gynecology , Duke University School of Medicine , Durham , NC , USA.,c The Campion Fund , Durham , NC , USA
| |
Collapse
|
20
|
Investigating the effects of the Rho-kinase enzyme inhibitors AS1892802 and fasudil hydrochloride on the contractions of isolated pregnant rat myometrium. Eur J Obstet Gynecol Reprod Biol 2016; 202:45-50. [PMID: 27160814 DOI: 10.1016/j.ejogrb.2016.04.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 04/23/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Rho-kinases (ROCKs), are one of the dynamic structures of the actin cytoskeleton and they mediate different biological processes, including regulation of calcium sensitivity of smooth muscle contraction. The activation of Rho A/ROCK system is thought to be effective on the termination time of the pregnancy process. The aim of this study, was to investigate in vitro effects of the ROCK enzyme inhibitors, clinically available fasudil hydrochloride, and a new promising inhibitor AS1892802, on the contractions of isolated pregnant rat myometrium. STUDY DESIGN Term pregnant Wistar albino rats (n=12), weighing 200-220g, were used in this study. Myometrial tissues obtained from rats were dissected into four full-thickness longitudinal muscle strips and then myometrial tension was recorded isometrically. The inhibitory effects of cumulative concentrations of AS1892802 and of fasudil hydrochloride in the presence and absence of ODQ (guanylate cyclase inhibitor), l-NAME (nitric oxide synthase inhibitor) and l-NNA (endothelial nitric oxide synthase inhibitor) on oxytocin-induced myometrial contractions were measured, and values for -log10EC50 (pD2) and mean maximal inhibition (Emax) were compared. RESULTS Both ROCK inhibitors, AS1892802 and fasudil hydrochloride starting from the concentrations of 10(-6)M reached statistical significance on contraction amplitude and frequency of myometrial strips (p<0.05). The inhibition of the amplitude and frequency of myometrial contractions was antagonized with ODQ (10(-5)M; only amplitude), l-NAME (3×10(-5)M) and l-NNA (10(-5)M) (p<0.05). CONCLUSION These results suggest that fasudil hydrochloride and AS1892802 may contribute to the development of new tocolytic drugs. We conclude that AS1892802 and fasudil hydrochloride perform this inhibitory effect partially through ROCK inhibition and the NO/cGMP pathway.
Collapse
|
21
|
Patel A, Malik M, Britten J, Cox J, Catherino WH. Mifepristone inhibits extracellular matrix formation in uterine leiomyoma. Fertil Steril 2016; 105:1102-10. [PMID: 26776909 DOI: 10.1016/j.fertnstert.2015.12.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 12/07/2015] [Accepted: 12/16/2015] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To characterize the efficacy of mifepristone treatment on extracellular matrix (ECM) production in leiomyomas. DESIGN Laboratory study. SETTING University research laboratory. PATIENT(S) None. INTERVENTION(S) Treatment of human immortalized two-dimensional (2D) and three-dimensional (3D) leiomyoma and myometrial cells with mifepristone and the progestin promegestone (R5020). MAIN OUTCOME MEASURE(S) Expression of COL1A1, fibronectin, versican variant V0, and dermatopontin in treated leiomyoma cells by Western blot analysis and confirmatory immunohistochemistry staining of treated 3D cultures. RESULT(S) Treatment with progestin stimulated production of COL1A1, fibronectin, versican, and dermatopontin. Mifepristone treatment inhibited protein production of these genes, most notably with versican expression. Combination treatment with both the agonist and antagonist further inhibited protein expression of these genes. Immunohistochemistry performed on 3D cultures demonstrated generalized inhibition of ECM protein concentration. CONCLUSION(S) Our study demonstrated that the progesterone agonist R5020 directly stimulated extracellular matrix components COL1A1, fibronectin, versican, and dermatopontin production in human leiomyoma cells. Progesterone antagonist mifepristone decreased protein production of these genes to levels comparable with untreated leiomyoma cells.
Collapse
Affiliation(s)
- Amrita Patel
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeris Cox
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - William H Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
| |
Collapse
|
22
|
Malik M, Britten J, Catherino W. A 3D Culture System of Human Immortalized Myometrial Cells. Bio Protoc 2016. [DOI: 10.21769/bioprotoc.1970] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
|
23
|
Malik M, Britten J, Cox J, Patel A, Catherino WH. Gonadotropin-releasing hormone analogues inhibit leiomyoma extracellular matrix despite presence of gonadal hormones. Fertil Steril 2015; 105:214-24. [PMID: 26409322 DOI: 10.1016/j.fertnstert.2015.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/19/2015] [Accepted: 09/03/2015] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To determine the effect of GnRH analogues (GnRH-a) leuprolide acetate (LA) and cetrorelix acetate on gonadal hormone-regulated expression of extracellular matrix in uterine leiomyoma three-dimensional (3D) cultures. DESIGN Laboratory study. SETTING University research laboratory. PATIENT(S) Women undergoing hysterectomy for symptomatic leiomyomas. INTERVENTION(S) The 3D cell cultures, protein analysis, Western blot, immunohistochemistry. MAIN OUTCOME MEASURE(S) Expression of extracellular matrix proteins, collagen 1, fibronectin, and versican in leiomyoma cells 3D cultures exposed to E2, P, LA, cetrorelix acetate, and combinations for 24- and 72-hour time points. RESULT(S) The 3D leiomyoma cultures exposed to E2 for 24 hours demonstrated an increased expression of collagen-1 and fibronectin, which was maintained for up to 72 hours, a time point at which versican was up-regulated significantly. Although P up-regulated collagen-1 protein (1.29 ± 0.04) within 24 hours of exposure, significant increase in all extracellular matrix (ECM) proteins was observed when the gonadal hormones were used concomitantly. Significant decrease in the amount of ECM proteins was observed on use of GnRH-a, LA and cetrorelix, with 24-hour exposure. Both the compounds also significantly decreased ECM protein concentration despite the presence of E2 or both gonadal hormones. CONCLUSION(S) This study demonstrates that GnRH-a directly affect the gonadal hormone-regulated collagen-1, fibronectin, and versican production in their presence. These findings suggest that localized therapy with GnRH-a may inhibit leiomyoma growth even in the presence of endogenous gonadal hormone exposure, thereby providing a mechanism to eliminate the hypoestrogenic side effects associated with GnRH-a therapy.
Collapse
Affiliation(s)
- Minnie Malik
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joy Britten
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeris Cox
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Amrita Patel
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - William H Catherino
- Department of Obstetrics and Gynecology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.
| |
Collapse
|
24
|
Thorne JT, Segal TR, Chang S, Jorge S, Segars JH, Leppert PC. Dynamic reciprocity between cells and their microenvironment in reproduction. Biol Reprod 2014; 92:25. [PMID: 25411389 DOI: 10.1095/biolreprod.114.121368] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Dynamic reciprocity (DR) refers to the ongoing, bidirectional interaction between cells and their microenvironment, specifically the extracellular matrix (ECM). The continuous remodeling of the ECM exerts mechanical force on cells and modifies biochemical mediators near the cell membrane, thereby initiating cell-signaling cascades that produce changes in gene expression and cell behavior. Cellular changes, in turn, affect the composition and organization of ECM components. These continuous interactions are the fundamental principle behind DR, and its critical role throughout development and adult tissue homeostasis has been extensively investigated. While DR in the mammary gland has been well described, we provide direct evidence that similar dynamic interactions occur in other areas of reproductive biology as well. In order to establish the importance of DR in the adaptive functioning of the female reproductive tract, we present our most current understanding of DR in reproductive tissues, exploring the mammary gland, ovary, and uterus. In addition to explaining normal physiological function, investigating DR may shed new light into pathologic processes that occur in these tissues and provide an exciting opportunity for novel therapeutic intervention.
Collapse
Affiliation(s)
- Jeffrey T Thorne
- Department of Obstetrics & Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Thalia R Segal
- Department of Obstetrics & Gynecology, North Shore - Long Island Jewish Hospital, Manhasset, New York
| | - Sydney Chang
- Unit of Reproductive Endocrinology and Infertility, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| | - Soledad Jorge
- Unit of Reproductive Endocrinology and Infertility, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland Yale University School of Medicine, New Haven, Connecticut
| | - James H Segars
- Unit of Reproductive Endocrinology and Infertility, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland
| | - Phyllis C Leppert
- Department of Obstetrics & Gynecology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|