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Hey-Cunningham AJ, Riaz A, Fromm PD, Kupresanin F, Markham R, McGuire HM. Circulating and Endometrial Regulatory T Cell and Related Populations in Endometriosis and Infertility: Endometriosis Is Associated with Blunting of Endometrial Cyclical Effects and Reduced Proportions in Moderate-Severe Disease. Reprod Sci 2021; 29:229-242. [PMID: 34160778 DOI: 10.1007/s43032-021-00658-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/09/2021] [Indexed: 12/30/2022]
Abstract
Evidence to date supports regulatory T cell (Treg) alterations in endometriosis; however, the relationship remains unclear, and Tregs have not previously been investigated with respect to infertility in endometriosis. This prospective cross-sectional cohort study details circulating and endometrial tissue-specific disturbances in Tregs and broader gated populations in women of reproductive age with and without endometriosis (n = 57 and 29, respectively) using flow cytometry and immunohistochemistry. Participants were characterised by menstrual cycle phase, r-ASRM endometriosis disease stage and fertility status.In the endometrium of women with endometriosis, endometrial Tregs and CD4+ lymphocyte proportions did not change between the proliferative and secretory phases, while in women without the disease, they significantly decreased (p = 0.045 and p = 0.039, respectively). In women with endometriosis, endometrial Tregs were lower than in women without endometriosis overall (p = 0.050 as a proportion of all CD45+ immune cells). We have shown for the first time that proportions of CD4+ lymphocytes (p = 0.021), overall lymphocytes (p = 0.034) and non-granulocytes (p = 0.027) were significantly decreased in the endometrium of women with moderate-severe (r-ASRM stages III and IV) compared to minimal-mild (r-ASRM stages I and II) endometriosis. During the secretory phase, circulating Treg proportions were significantly increased in infertile compared to fertile women (p = 0.049). This study confirms differences in endometrial Tregs in women with endometriosis, with blunting of normal menstrual cyclical variations, reduced proportions during the proliferative phase and disease stage-specific relationships.
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Affiliation(s)
- A J Hey-Cunningham
- The University of Sydney Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - A Riaz
- The University of Sydney Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - P D Fromm
- Dendritic Cell Research Group, ANZAC Research Institute, The University of Sydney, Sydney, NSW, 2139, Australia
| | - F Kupresanin
- Dendritic Cell Research Group, ANZAC Research Institute, The University of Sydney, Sydney, NSW, 2139, Australia
| | - R Markham
- The University of Sydney Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - H M McGuire
- Ramaciotti Facility for Human Systems Biology and Discipline of Pathology, Charles Perkins Centre, The University of Sydney, Sydney, NSW, 2006, Australia.
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Ersoy B, Hey-Cunningham AJ, Lindsay L, Varol N, Markham R. Altered immune environment in peritoneal endometriotic lesions: relationship to lesion appearance. F&S SCIENCE 2021; 2:207-218. [PMID: 35559754 DOI: 10.1016/j.xfss.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To study the localization of and quantify different immune cell populations in red, black, and white peritoneal endometriotic lesions and compare immune cell densities between lesions and the surrounding tissue. DESIGN Cross-sectional study. SETTING Teaching hospital, university research laboratory. PATIENT(S) Participants undergoing laparoscopic excision of endometriosis were recruited from gynecological operating theaters at Royal Prince Alfred Hospital, Sydney (n = 28). INTERVENTION(S) Immunohistochemical staining for and quantification of dendritic cells (mature and immature), T cells (effector, cytotoxic, and regulatory), B cells, and macrophages in endometriotic peritoneal lesions and the surrounding tissue. MAIN OUTCOME MEASURE(S) Immune cell densities and aggregates were quantified. RESULT(S) Red and black lesions are significantly more likely to be surrounded by immune cell aggregates than white lesions (P=.036). In the tissue surrounding the peritoneal endometriotic lesions, there was a consistent pattern of greater and more variable density of immune cell populations for red lesions than black or white lesions and a range of significant positive correlations between densities of different immune populations (all P≤.004; not observed within the lesion stroma). CONCLUSION(S) There is a greater presence of immune cells in the tissue surrounding earlier/red and black lesions than older scarred white lesions, particularly in the form of immune cell aggregates, indicating an immunologic response in close proximity to the adjacent lesion. The relationship between densities of immune populations in the tissue surrounding the lesions suggests complementary recruitment and local interactions between cells. Categorizing immune cell populations in proximity to peritoneal endometriotic lesions may improve the understanding of lesion persistence and transition to older white appearances. Early (red) peritoneal endometriotic lesions are surrounded by a greater density of immune cells, including immune aggregates, than later (black or white) lesions. These immune cells may support lesion persistence.
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Affiliation(s)
- Burcu Ersoy
- Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Alison J Hey-Cunningham
- Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Laura Lindsay
- Discipline of Anatomy and Histology, School of Medical Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Nesrin Varol
- Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Robert Markham
- Obstetrics, Gynaecology and Neonatology, Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Jerman LF, Anderson L, Markham R, Hey-Cunningham AJ. The Lymphatic System in Endometriosis: a Pilot Study of Endometrial-Like Cells and Immune Cell Populations in Lymph Nodes Associated with Deep Infiltrating Bowel Lesions. Reprod Sci 2020; 27:977-987. [PMID: 32077078 DOI: 10.1007/s43032-020-00171-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 02/04/2019] [Indexed: 10/25/2022]
Abstract
In endometriosis, the lymphatic and immune systems are implicated in disease establishment and progression. The objective of this pilot study was to examine endometrial-like, and for the first time, immune cell populations in lymph nodes associated with deep infiltrating endometriosis (DIE) bowel lesions. Premenopausal women undergoing excision of endometriosis and/or hysterectomy were included. DIE bowel lesion-associated (n = 10) and other pelvic (n = 15) lymph nodes were studied. Samples were immunohistochemically stained for endometrial-like cells (CD10), T cells (CD3, CD4, CD8, and FoxP3), dendritic cells (DC; DC-Lamp and DC-Sign), B cells (CD20, CD79 and plasma), macrophages (CD68), and natural killer cells (NK; CD57). Cell abundance (percentage positive area) and antigen expression (optical density; OD) were quantified. Endometrial-like cells and each immune cell population were present in all studied nodes. The DIE bowel lesion-associated nodes showed features of immune activation, with T cell proliferation (CD3+ area p = 0.007, CD4+ area p = 0.015 compared with other pelvic nodes); and a mixture of helper and regulatory T cells, B cells, DCs, macrophages, and plasma cells present in the paracortex. In DIE bowel lesion-associated compared with other pelvic nodes, CD10+ endometrial-like cells were reduced (percentage positive area p < 0.001, OD p = 0.004). This study provides new insight into lymphatic and immune system involvement in advanced endometriosis. In particular, we have shown evidence of immune activation in DIE lesion-associated nodes. This was despite lower endometrial-like cell numbers compared with other pelvic nodes. The observations contribute to a developing understanding of the local immune response to advanced disease.
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Affiliation(s)
- Laila F Jerman
- The University of Sydney Obstetrics, Gynaecology and Neonatology; Central Clinical School; Faculty of Medicine and Health, Medical Foundation Building K25, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Lyndal Anderson
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, NSW, 2050, Australia.,The University of Sydney Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Robert Markham
- The University of Sydney Obstetrics, Gynaecology and Neonatology; Central Clinical School; Faculty of Medicine and Health, Medical Foundation Building K25, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Alison J Hey-Cunningham
- The University of Sydney Obstetrics, Gynaecology and Neonatology; Central Clinical School; Faculty of Medicine and Health, Medical Foundation Building K25, The University of Sydney, Sydney, NSW, 2006, Australia.
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Maharajaa SPK, Asally R, Markham R, Manconi F. Endometriotic lesions. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2019. [DOI: 10.1177/2284026519838748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Endometriosis is a complex gynaecological condition affecting women of reproductive age. It is characterised by the presence of lesions containing endometrial glands and stroma outside the uterus. The disease is typically associated with pelvic pain (including dysmenorrhoea and dyspareunia), infertility and bowel-related symptoms. Endometriotic lesions have a highly variable presentation and most commonly occur in the abdominal cavity. These lesions are broadly classified into peritoneal, ovarian and deep infiltrating endometriosis. There have been observations of increased density of nerve fibres and neurological molecules in the endometriotic lesions compared to the uninvolved peritoneum of women without endometriosis and the presence of unmyelinated nerve fibres were higher near the glands. The lesion sites are characterised by a range of immunological alterations, and specific immune cell populations have also been known to synthesise and secrete neurogenic factors. Endometriotic lesions are capable of producing prostaglandins which are direct generators of pain and are capable of inducing inflammation. Diagnosing the disease involves direct visualisation of the lesions through a laparoscopic or laparotomy, which is followed by histopathological examination of biopsied or excised lesions. The staging of endometriosis due to its complexity is highly variable as presentation and gaps in knowledge pose a great challenge in the classification of the disease. The medical management of endometriosis aims at providing adequate analgesia and suppression of the activity of the lesion. A better understanding of endometriotic lesion relationships between innervations and specific clinical characteristics may elucidate aspects of pain mechanisms and infertility in endometriosis and facilitate the development of novel therapeutic approaches.
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Affiliation(s)
- Sri PK Maharajaa
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Razan Asally
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Robert Markham
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
| | - Frank Manconi
- Discipline of Obstetrics, Gynaecology and Neonatology, The University of Sydney, Camperdown, NSW, Australia
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Tarjanne S, Ng CH, Manconi F, Arola J, Mentula M, Maneck B, Fraser IS, Heikinheimo O. Use of hormonal therapy is associated with reduced nerve fiber density in deep infiltrating, rectovaginal endometriosis. Acta Obstet Gynecol Scand 2015; 94:693-700. [DOI: 10.1111/aogs.12652] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 04/05/2015] [Indexed: 01/16/2023]
Affiliation(s)
- Satu Tarjanne
- Department of Obstetrics and Gynecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Cecilia H.M. Ng
- Department of Obstetrics, Gynecology and Neonatology; Queen Elizabeth II Research Institute for Mothers and Infants; University of Sydney; Sydney New South Wales Australia
| | - Frank Manconi
- Department of Obstetrics, Gynecology and Neonatology; Queen Elizabeth II Research Institute for Mothers and Infants; University of Sydney; Sydney New South Wales Australia
| | - Johanna Arola
- Department of Pathology; Haartman Institute; University of Helsinki and HUSLAB; Helsinki Finland
| | - Maarit Mentula
- Department of Obstetrics and Gynecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Bharvi Maneck
- Department of Obstetrics, Gynecology and Neonatology; Queen Elizabeth II Research Institute for Mothers and Infants; University of Sydney; Sydney New South Wales Australia
| | - Ian S. Fraser
- Department of Obstetrics, Gynecology and Neonatology; Queen Elizabeth II Research Institute for Mothers and Infants; University of Sydney; Sydney New South Wales Australia
| | - Oskari Heikinheimo
- Department of Obstetrics and Gynecology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Jerman LF, Hey-Cunningham AJ. The Role of the Lymphatic System in Endometriosis: A Comprehensive Review of the Literature1. Biol Reprod 2015; 92:64. [DOI: 10.1095/biolreprod.114.124313] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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An Investigation of the Relationship between Pelvic Pain and Density of Nerve Fibers in Peritoneal Lesions of Endometriosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2014. [DOI: 10.5301/je.5000185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose Endometriosis is a gynecological disease often characterized by severe pelvic pain, including perimenstrual and intermenstrual pain and dyspareunia. Sensory nerve fibers within peritoneal lesions have previously been shown to contribute to generation of pain in endometriosis; however, their association with different types of pelvic pain is currently uncertain. Methods Peritoneal endometriotic lesions (n = 30) were sectioned and stained immunohistochemically with protein gene product 9.5 (PGP 9.5; pan-neuronal marker), neuropeptide Y (NPY; sympathetic), vasoactive intestinal polypeptide (VIP; parasympathetic), substance P (SP; sensory) and nerve growth factor (NGF) to identify nerve fibers and neurotrophin levels. Densities were assessed within stroma of the lesions and in the adjacent peritoneum. Pelvic pain scores were obtained using a visual analogue scale (VAS), and correlation analysis was performed. Results Increased density of nerve fibers was observed within the stroma of lesions. NGF expression was significantly increased in glandular epithelium, compared with stromal regions (p = 0.026) and correlated inversely with menstrual pain scores (p = 0.05). Sympathetic nerve fiber density (NPY) in stroma showed a significant positive correlation with intensity of menstrual pain (p = 0.04). Parasympathetic nerve fiber density (VIP) also showed a strong trend toward a positive correlation with menstrual pain intensity (p = 0.056). Conclusions There is increased neurogenesis in the stromal region. Innervation of lesions correlates to intensity of menstrual pain. NGF in glandular epithelium may promote growth of nerve fibers into the core of lesions; however, the inverse correlation between NGF expression in glandular epithelium and menstrual pain indicates that mechanisms of pain generation in endometriosis are complex.
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