Endometriosis: advances and controversies in classification, pathogenesis, diagnosis, and treatment

The short- and mid-term efficacy and safety of elagolix in the management of pain associated with endometriosis: A systematic review and meta-analysis

BACKGROUND

Elagolix, an approved non-peptide GnRH antagonist, shows promise in relieving endometriosis-related pain, but its short- and mid-term efficacy and potential side effects are still under investigation.

OBJECTIVE

The aim is to provide data for therapeutic applications by methodically evaluating elagolix's safety and effectiveness in treating endometriosis-related pain.

METHODS

Databases such as PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and others were thoroughly searched. The search time was from the establishment date to September 2023. The study included randomized controlled trials (RCTs) that compared the efficacy of elagolix versus placebo in treating endometriosis-associated pain. After data extraction and literature scanning, quality assessment was carried out using Quality evaluation was carried out using the bias risk assessment tool suggested by the Cochrane Reviewers' Handbook 5.1.0 after literature screening and data extraction. Stata 15.0 was used to do the meta-analysis.

RESULTS

In total, five RCTs involving 2056 patients were included in the analysis. The meta-analysis demonstrated a significant superiority of elagolix over placebo in the management of endometriosis-related pain, specifically in endometriosis pain [WMD=-0.77, 95% CI (-1.00, -0.53), P<0.001], as well as in non-menstrual pelvic pain, daily assessment of dysmenorrhea (DYS), and dyspareunia (DYSP), all of which are associated with endometriosis. Regarding safety, no discernible variation was observed in the incidence of serious adverse responses between the elagolix and placebo groups [RR=0.90, 95% CI (0.58, 1.40), P=0.643]. Conversely, the elagolix group exhibited a significantly higher incidence rate of general adverse responses [RR = 1.34, 95% CI (1.18, 1.52), P<0.001] compared to the control group.

CONCLUSIONS

The efficacy of elagolix in reducing pain in premenopausal women with endometriosis has been demonstrated over the short- to mid-term. However, careful monitoring for potential adverse effects is essential throughout the treatment duration.

Decreased expression of KLF6 in ectopic endometrial stromal cells contributes to endometriosis progression by targeting CTNNB1

Despite decades of research, endometriosis remains a mysterious gynecological disease with unknown etiology and pathogenesis. Krüppel-like Factor 6 (KLF6), a transcription factor, has a wide expression profile and regulates a variety of biological processes. Here, we investigated the expression and function of KLF6 and its possible regulatory mechanisms in endometriosis. To determine the function of KLF6, knockdown and overexpression experiments were performed in eutopic endometrial stromal cells (EU-ESCs) and ectopic endometrial stromal cells (EC-ESCs), respectively. Cell viability, apoptosis, migration, invasion, and angiogenesis assays were conducted in ESCs. ChIP-sequencing and mRNA-sequencing were performed to investigate the functional mechanism of KLF6 in regulating ESCs. We found that KLF6 was highly expressed in eutopic endometrium of endometriosis patients, compared with ectopic endometrium. Similarly, the same was true in EU-ESCs, which was compared with EC-ESCs. Overexpression of KLF6 significantly suppressed EC-ESC proliferation, migration and invasion and induced cell apoptosis, while knockdown of KLF6 resulted in the opposite effects on EU-ESCs. Overexpression of KLF6 significantly inhibited EC-ESC angiogenesis. Mechanistically, the results of ChIP sequencing and mRNA sequencing revealed that CTNNB1 may be a transcriptional target regulated by KLF6. Reintroduction of KLF6 reversed the effects of KLF6 knockdown on EU-ESCs. KLF6 inhibited the proliferation, migration and angiogenesis of EC-ESCs by inhibiting the expression of CTNNB1. Our findings provided a new perspective on the role of KLF6 in endometriosis progression and inspire potential targeted therapeutic strategies.

Endometriosis: A Comprehensive Analysis of the Pathophysiology, Treatment, and Nutritional Aspects, and Its Repercussions on the Quality of Life of Patients

Endometriosis is a chronic proinflammatory pathology characterized by the growth of tissue similar to the endometrium outside the uterus, affecting approximately 5 to 15% of women worldwide. Suffering from endometriosis entails a complex pathophysiological process, significantly impacting the quality of life and reproductive function of affected women; therefore, it must be addressed in a personalized and comprehensive manner, as its management requires a multidisciplinary approach. This article aims to conduct a comprehensive literature review of endometriosis, not only as a pathophysiological condition but also as a significant factor impacting the social, nutritional, and mental well-being of those who experience it. Emphasis is placed on the importance of understanding and assessing the impact of the pathology to provide a better and more comprehensive approach, integrating various alternatives and strategic treatments for the factors involved in its development. The aim is to provide a complete overview of endometriosis, from its pathophysiology to its impact on the quality of life of patients, as well as a review of current treatment options, both pharmacological and alternative, in order to broaden the perspective on the pathology to improve the care of patients with this disease.

Establishment of a diagnostic model of endometriosis based on disulfidptosis-related genes

OBJECTIVES

We aimed to establish a diagnostic model of endometriosis (EM) based on disulfidptosis-related genes (DRGs).

MATERIALS AND METHODS

The mRNA expression data of EM were downloaded from the gene expression omnibus database and subjected to differential analysis, and co-expression analysis was performed based on 10 disulfidptosis genes to acquire DRGs. The differentially expressed DRGs were subjected to biofunctional analysis. Lasso analysis and support vector machine-recursive feature elimination (SVM-RFE) analysis were employed to extract the intersection of feature genes as biomarkers, and the diagnostic values of biomarkers for EM were evaluated based on receiver operating characteristic curves. The correlations between biomarkers and the immune microenvironment were assessed by Pearson analysis of biomarkers and immune cell infiltration levels.

RESULTS

Transforming growth factor β stimulated protein clone 22 domain family member 4 (TSC22D4), and F-box/SPRY domain-containing protein 1 (FBXO45) worked as the diagnostic classifiers in EM, with an obvious decrease in FBXO45 expression and an evident increase in TSC22D4 expression. The areas under the curves of FBXO45 and TSC22D4 were 0.752 and 0.706, respectively, and the area of FBXO45 combined with TSC22D4 reached 0.865, suggesting that TSC22D4 and FBXO45 had high predictive values. The diagnostic markers were closely correlated with immune cell infiltration.

CONCLUSION

The diagnostic markers constructed based on disulfidptosis are good predictors for EM, which have close correlations with EM.

The impact of vitamin D treatment on pregnancy rate among endometriosis patients: a systematic review and meta-analysis

Background

Vitamin D supplementation is supposed to have an important role in the management of several endometriosis-related aspects, offering potential relief to affected individuals. Herein, the authors aim to evaluate the impact of vitamin D on pregnancy rates and clinical symptoms in women with endometriosis.

Methods

The authors extensively searched PubMed, Cochrane Library, EMBASE, Ovid MEDLINE, and CINAHL from their inception to 20 July 2023.

Results

Three randomized controlled trials involving 167 patients were included in this meta-analysis. The findings demonstrated that vitamin D supplementation exhibits efficacy in alleviating dysmenorrhea associated with endometriosis, as evidenced by a meta-analysis showing a significant reduction in dysmenorrhea (mean difference -1.41, 95% CI -2.61 to -0.22, P = 0.02). However, the impact on dyspareunia was inconclusive, with a non-significant mean difference of -0.2 (95% CI -1.62 to 1.22, P = 0.78). In contrast, dyschezia significantly decreased with vitamin D supplementation (mean difference -1.10, 95% CI -2.22 to 0.02, P = 0.05 However, the meta-analysis did not show a significant effect of vitamin D on chronic pelvic pain associated with endometriosis.

Conclusion

While antioxidant vitamin D supplementation demonstrates general effectiveness in alleviating endometriosis symptoms, such as dysmenorrhea, dyspareunia, and dyschezia, the existing literature lacks direct investigations into the specific impact of vitamin D on enhancing pregnancy rates among endometriosis patients. This observation prompts various hypotheses, suggesting that the positive effects of vitamin D supplementation on endometriosis-related symptoms may indirectly contribute to improved pregnancy outcomes and enhanced fertility.

Diagnostic Value and Molecular Function of MicroRNAs in Endometrial Diseases: A Systematic Review

The human endometrium experiences significant cyclic morphological and biochemical changes throughout the menstrual cycle to prepare for embryo implantation. These processes are meticulously regulated by ovarian steroids and various locally expressed genes, encompassing inflammatory reactions, apoptosis, cell proliferation, angiogenesis, differentiation (tissue formation), and tissue remodeling. MicroRNAs (miRNAs) have been recognized as crucial regulators of gene expression, with their altered expression being linked to the onset and progression of various disorders, including cancer. This review examines the expression of miRNAs in the endometrium and their potential regulatory roles under pathological conditions such as endometriosis, recurrent implantation failure and endometrial cancer. Given miRNAs' critical role in maintaining gene expression stability, understanding the regulatory mechanisms of endometrial miRNAs and identifying their specific target genes could pave the way for developing preventive and therapeutic strategies targeting specific genes associated with these reproductive disorders.

The "Road" to Malignant Transformation from Endometriosis to Endometriosis-Associated Ovarian Cancers (EAOCs): An mTOR-Centred Review

Ovarian cancer is an umbrella term covering a number of distinct subtypes. Endometrioid and clear-cell ovarian carcinoma are endometriosis-associated ovarian cancers (EAOCs) frequently arising from ectopic endometrium in the ovary. The mechanistic target of rapamycin (mTOR) is a crucial regulator of cellular homeostasis and is dysregulated in both endometriosis and endometriosis-associated ovarian cancer, potentially favouring carcinogenesis across a spectrum from benign disease with cancer-like characteristics, through an atypical phase, to frank malignancy. In this review, we focus on mTOR dysregulation in endometriosis and EAOCs, investigating cancer driver gene mutations and their potential interaction with the mTOR pathway. Additionally, we explore the complex pathogenesis of transformation, considering environmental, hormonal, and epigenetic factors. We then discuss postmenopausal endometriosis pathogenesis and propensity for malignant transformation. Finally, we summarize the current advancements in mTOR-targeted therapeutics for endometriosis and EAOCs.

Research progress of indocyanine green fluorescence technology in gynecological applications

Indocyanine green is a near-infrared fluorescent dye which is widely used in various fields of surgery and gynecology. It is currently mainly used to detect various malignant tumors, sentinel lymph nodes, endometriosis lesions, ureter or intestinal occlusion, vaginal perfusion, uterine arterial blood perfusion, pelvic nerve, uterine niche, lymphatic edema, metastatic lesion shadow, and so on, providing new methods for decision-making during surgery. This article elaborates the application progress of indocyanine green fluorescence technology in gynecology.

HIF-1α regulates DcR3 to promote the development of endometriosis

OBJECTIVE

The aim of this study was to investigate the expression and clinical significance of HIF-1α and DcR3 in endometriosis by analysing clinical case data. Tissue samples were collected for tissue chip analysis and staining, and human endometrial stromal cells were isolated and cultured for cell experiments. Additionally, experiments were conducted on collected peritoneal fluid to explore the association and role of HIF-1α and DcR3 in endometriosis.

STUDY DESIGN

Patients who visited the Department of Obstetrics and Gynaecology at Central Hospital in Fengxian District, Shanghai, from January 2018 to December 2021 were recruited for this controlled study. Clinical data and tissue chip staining results were collected for multiple regression analysis on the clinical significance of HIF-1α and DcR3. Endometrial tissue, ovarian cysts, and pelvic fluid were collected, and human endometrial stromal cells were cultured. The impact of HIF-1α on DcR3 in different oxygen environments and its role in endometriosis were investigated through PCR, Western blotting, enzyme-linked immunosorbent assay, as well as adhesion and migration assays.

RESULTS

In patients with endometriosis, the expression of DcR3 and HIF-1α was found to be upregulated and correlated in ectopic endometrium. The expression of DcR3 served as an indicator of the severity of endometriosis. Hypoxia induced the expression of DcR3, which was regulated by HIF-1α and promoted migration and adhesion.

CONCLUSION

DcR3 can be used as a clinical indicator to assess the severity of endometriosis. The hypoxic environment in endometriosis enhances disease progression by regulating DcR3 through HIF-1α.

Endometriosis in Menopausal Women-A New Age Is Coming? Literature Review

Endometriosis is a chronic inflammatory disease, characterized by the presence of ectopic endometrial tissue, that leads to dysmenorrhea, painful intercourse and infertility. The shift in paradigm from the previous belief that endometriosis exclusively impacts women of reproductive age has brought attention to the condition in both premenarchal and postmenopausal women. Currently, 2-4% of postmenopausal women have endometriosis. Many women experience menopausal symptoms during the peri- and postmenopausal periods and require extensive investigations and monitoring in order to avoid the recurrence of endometriosis symptoms or the risk of malignant transformation when treatment with menopausal hormones is elected. Our goal was to compile and present a clear and concise overview of the existing literature on postmenopausal endometriosis, offering an up-to-date and precise summary of the available information.

Correlation of Glycolysis-immune-related Genes in the Follicular Microenvironment of Endometriosis Patients with ART Outcomes

Endometriosis (EMT) -related infertility has been a challenge for clinical research. Many studies have confirmed that abnormal alterations in the immune microenvironment and glycolysis are instrumental in causing EMT-related infertility. Recently, our research team identified several key glycolysis-immune-related genes in the endometrial cells of EMT patients. This study aimed to further investigate the expression patterns of pyruvate dehydrogenase kinase 3 (PDK3), glypican-3 (GPC3), and alcohol dehydrogenase 6 (ADH6), which are related to glycolysis and immunity, in the follicular microenvironment of infertile patients with EMT using enzyme-linked immunosorbent assay (ELISA) and quantitative real-time polymerase chain reaction (qRT-PCR) assays. According to the results, compared to the patients with tubal factor infertility, the concentrations of PDK3 and GPC3 were considerably increased in the follicular environment of EMT patients, while ADH6 expression was significantly reduced. The number of oocytes retrieved, the transferable embryo rate, and the cumulative clinical pregnancy rate of EMT patients were significantly reduced, and there was a correlation with the level of PDK3, GPC3, and ADH6 in Follicular Fluid (FF). The area under the receiver operating characteristic (ROC) curve for predicting clinical pregnancy in infertile patients with EMT for PDK3, GPC3, ADH6, and their combination was 0.732, 0.705, 0.855, and 0.879, respectively (P < 0.05). In conclusion, our research indicates that glycolysis-immune-related genes may contribute to infertility in EMT patients through immune infiltration, and disruption of mitochondrial and oocyte functions. The combined detection of PDK3, GPC3, and ADH6 in FF helps to predict clinical pregnancy outcomes in infertile patients with EMT.

Expression of HIF-1α, Ki67, SMA and E-cadherin in endometriosis, endometrial and ovarian carcinoma

INTRODUCTION

Endometriosis is a benign gynecological condition that shares many characteristics with cancer cells, including immune evasion, survival, adhesion, invasion, and angiogenesis. The simultaneous investigation of tissue hypoxia, EMT, and proliferative index in endometriosis, endometrial, and ovarian carcinomas may provide new insight into the evolution and progression of gynecological neoplasms.

Galectin-3 promotes fibrosis in ovarian endometriosis

Objective

This study aimed to investigate the potential role of galectin-3 (Gal-3) in the pathogenesis of fibrotic alterations in ovarian endometriosis (OVE).

Methods

In this study, we collected the ectopic endometrial tissues and eutopic endometrial tissues from 31 OVE patients treated by laparoscopy, and the eutopic endometrial tissues from 23 non-OVE patients with leiomyoma or other benign diseases were used as control. Hematoxylin and eosin (H&E) and Masson's trichrome staining were utilized for histopathological assessment. The primary normal endometrial stromal cells (NESC), ectopic endometrial stromal cells (ECSC), and eutopic endometrial stromal cells (EUSC) were isolated. Gal-3 overexpression plasmids (Gal-OE) and short hairpin RNA targeting Gal-3 (Gal-3-shRNA) were transfected into the immortalized human endometriotic cell line 12Z, respectively. RT-qPCR, Western blot analysis, and immunohistochemistry were used to detect the mRNA and protein expression levels of Gal-3, type I collagen (COL-1), connective tissue growth factor (CTGF) and α-smooth muscle actin (α-SMA), respectively.

Results

H&E and Masson staining showed that ovarian ectopic endometrium exhibited glandular hyperplasia, high columnar glandular epithelium, apical plasma secretion, more subnuclear vacuoles, and obvious fibrosis, compared with normal endometrium. The mRNA and protein levels of Gal-3 , CTGF, α-SMA, and COL-1 were all upregulated in the ectopic endometrial tissues of OVE patients compared to the eutopic endometrial tissues from OVE patients and non-OVE patients. Moreover, ECSC expressed higher levels of Gal-3, CTGF, α-SMA, and COL-1 than EUSC and NESC. Follow-up investigations demonstrated that the Gal-3 overexpression substantially increased fibrosis-related markers including CTGF, α-SMA, and COL-1 within the 12Z cell line. Conversely, Gal-3 knockdown showed the opposite effects.

Conclusion

Gal-3 promotes fibrosis in OVE, positioning it as a prospective therapeutic target for mitigating fibrosis in endometriosis.

Regulatory mechanism of GPER in the invasion and migration of ectopic endometrial stromal cells in endometriosis

Endometriosis (EMS) is a chronic inflammatory disorder of high incidence that causes serious reproductive consequences. High estrogen production is a consistently observed endocrine feature of EMS. The present study aims to probe the molecular mechanism of G protein-coupled estrogen receptor 1 (GPER) in the invasion and migration of ectopic endometrial stromal cells (Ect-ESCs) and provides a new rationale for EMS treatment. Eutopic and ectopic endometrial tissues were collected from 41 EMS patients, and primary ESCs were separated. GPER, miR-16-5p, and miR-103a-3p levels in cells and tissues were determined by qRT-PCR or Western blot assay. Cell viability, proliferation, invasion, and migration were evaluated by CCK-8, colony formation, and Transwell assays. The upstream miRNAs of GPER were predicted by databases, and dual-luciferase assay was performed to validate the binding of miR-16-5p and miR-103a-3p to GPER 3'UTR. GPER was highly expressed in EMS tissues and Ect-ESCs. Inhibition of GPER mitigated the proliferation, invasion, and migration of Ect-ESCs. GPER was regulated by miR-16-5p and miR-103a-3p. Overexpression of miR-16-5p and miR-103a-3p negatively regulated GPER expression and inhibited the invasion and migration of Ect-ESC. In conclusion, GPER promoted the invasion and migration of Ect-ESCs, which can be reversed by upstream miR-16-5p and miR-103a-3p.

New insights about endometriosis-associated ovarian cancer: pathogenesis, risk factors, prediction and diagnosis and treatment

Previous studies have shown that the risk of malignant transformation of endometriosis in premenopausal women is approximately 1%, significantly impacting the overall well-being and quality of life of affected women. Presently, the diagnostic gold standard for endometriosis-associated ovarian cancer (EAOC) continues to be invasive laparoscopy followed by histological examination. However, the application of this technique is limited due to its high cost, highlighting the importance of identifying a non-invasive diagnostic approach. Therefore, there is a critical need to explore non-invasive diagnostic methods to improve diagnostic precision and optimize clinical outcomes for patients. This review presents a comprehensive survey of the current progress in comprehending the pathogenesis of malignant transformation in endometriosis. Furthermore, it examines the most recent research discoveries concerning the diagnosis of EAOC and emphasizes potential targets for therapeutic intervention. The ultimate objective is to improve prevention, early detection, precise diagnosis, and treatment approaches, thereby optimizing the clinical outcomes for patients.

The feasibility of an anti-inflammatory diet in endometriosis: barriers and facilitators perceived by endometriosis patients

RESEARCH QUESTION

What is the feasibility of an anti-inflammatory diet in women diagnosed with endometriosis?

DESIGN

Qualitative study using semi-structured focus groups and individual interviews among patients with endometriosis. Transcripts of the focus groups and interviews were thematically analysed using ATLAS.ti 9. To identify and structure the ideas and views from the focus groups and interviews, two behavioural change models were used. The Capability Opportunity Motivation Behaviour (COM-B) model and domains of the Theoretical Domains Framework (TDF) helped to identify factors that make adherence to an anti-inflammatory diet more or less feasible for women with endometriosis.

RESULTS

The study population consisted of 23 patients with endometriosis. Numerous perceived barriers and facilitators were identified from all COM-B components and 13 out of 15 TDF domains. Knowledge and social influences were the most prominent TDF domains. Key barriers were eating with others; disbelief in a patients' own capability regarding specific dietary guidelines; concerns about taste; lack of knowledge on how to follow the diet; lack of noticeable beneficial effect; and lack of intention to follow the diet to full extent. Key facilitators were receiving social support; general confidence in a participant's own capabilities; knowing how and why to follow the diet; noticing beneficial effect; and belief that the diet would alleviate symptoms.

CONCLUSION

Provision of knowledge, stimulating social support and enhancing self-efficacy should be emphasized. Overall, an anti-inflammatory diet in endometriosis patients, especially when identified barriers and facilitators are addressed in an intervention, is feasible.

Elucidating the role of Brain-Derived Neurotrophic Factor (BDNF) and its receptor Tyrosine Receptor Kinase B (TrkB) in the development and symptoms of endometriosis

Endometriosis (EMs) is a common disease among women of reproductive age, and as of now, the clinical understanding of the etiology of this disease remains unclear. The occurrence of EMs has a profound impact on the reproductive health of women, making early diagnosis and treatment of this disease a pressing challenge in clinical practice. Recent studies have found that Brain-Derived Neurotrophic Factor (BDNF), in combination with its high-affinity receptor Tyrosine Receptor Kinase B (TrkB), participates in the development of EMs and the appearance of clinically relevant symptoms by activating the Mitogen-Activated Protein Kinase (MAPK) pathway, the Phosphatidylinositol 3-Kinase/Protein Kinase B (PI3K/AKT) pathway, and the Phospholipase C-gamma (PLCγ) signaling pathway, or by interacting with other factors. In order to gain a deeper understanding of the pathogenesis related to EMs, this article reviews the roles of BDNF and TrkB in EMs, particularly in terms of aberrant apoptosis and autophagy, cell invasion, proliferation, angiogenesis, oxidative stress, and inflammatory reactions, as well as their relationship with the symptoms associated with EMs.

Endometriosis Predictive Models Based on Self-Assessment Questionnaire, Evidence from Clinical Examination or Imaging Findings: A Narrative Review

OBJECTIVE

The aim of this narrative review is to evaluate existing questionnaires on predictive models for endometriosis. These symptom-based models have the potential to serve as screening tools for adult women to detect endometriosis.

DATA SOURCES

A comprehensive search of PubMed and Embase databases was conducted to identify studies on endometriosis screening.

SELECTION OF STUDIES

The search targeted predictive models for endometriosis localisation, bowel involvement, need for bowel surgery and fertility. Due to the heterogeneity identified, a systematic review was not possible. A total of 23 studies were identified.

DATA EXTRACTION AND SYNTHESIS

Among these studies, twelve included measures for general endometriosis, two targeted specific sites, four focused on deep infiltrating endometriosis (DIE), and three addressed the need for endometriosis-related bowel surgery. Many measures combined clinical, imaging and laboratory tests with patient questionnaires. Validation of these models as screening tools was lacking in all studies, as the focus was on diagnosis rather than screening.

CONCLUSION

This review did not identify any fully validated, symptom-based questionnaires for endometriosis screening in adult women. Substantial validation work remains to establish the efficacy of such tools.

Association between pathological positivity rate of endometriosis, demographics, and concomitant gynecological conditions

Background

To date, there remains a paucity of present-day literature on the topic of demographics and the biopsy-proven pathological positivity rate of endometriosis.

Objective

The goal of this study was to explore the association between patients' demographics and other concomitant gynecological conditions or procedures and the pathological positivity rate of excision of endometriosis.

Design

Retrospective cohort study.

Methods

All women >18 years old who underwent laparoscopic surgery for endometriosis at a tertiary care hospital from October 2011 to October 2020. Women were classified into two groups: (1) Study group: women with >80% pathological positivity rate of endometriosis and (2) Control group: women with <80% pathological positivity rate.

Results

A total of 401 women were included in the analysis. No difference was noted in the 80% pathological positivity rate based on body mass index [BMI; 68.7% in normal BMI versus 80% in underweight, versus 74.5% in overweight, and 74.1% in obese patients (p = 0.72)]. The percentage of patients reaching 80% pathological positivity of endometriosis was lower in women who had undergone previous laparoscopy for endometriosis compared to surgery naïve women (66.5% versus 76.5%, p = 0.03). In addition, a higher percentage of women who underwent concomitant hysterectomy (83.5% versus 68.8% for non-hysterectomy, p = 0.005) or bilateral oophorectomy (92.7% versus 70.0% for non-oophorectomy, p = 0.002) reached 80% pathological positivity. Women with an associated diagnosis of fibroids (79.7% versus 70.5%) or adenomyosis (76.4% versus 71.7%) were more likely to reach 80% pathological positivity compared to women without any other coexisting pathology; however, the observed differences were not statistically significant. After applying a log-binomial regression model, compared to White non-Hispanics, Hispanic patients were 30% less likely to reach 80% positivity (RR: 0.70, 95% CI: 0.49-1.02), although not statistically significant.

Conclusion

No significant racial difference was found when comparing the rates of 80% pathological positivity of suspected endometriosis lesions among groups. Endometriosis pathological positivity rate was unaffected by patients' BMI and the presence of concomitant pathologies. In addition, prior laparoscopic surgery for endometriosis might cause tissue changes that result in a decrease in the observed pathological positivity rate of endometriosis lesions during subsequent surgeries.

Long-term therapy with dienogest or other oral cyclic estrogen-progestogen can reduce the need for ovarian endometrioma surgery

BACKGROUND

Almost 10% of women in reproductive age are diagnosed with ovarian endometriomas and can experience symptoms and infertility disorders. Ovarian endometriomas can be treated with medical or surgical therapy.

OBJECTIVE

To assess whether long-term therapy with dienogest or oral cyclic estrogen-progestogens is effective in reducing the size of ovarian endometriomas, alleviating associated symptoms, and reducing the requirement for surgery.

DESIGN

Prospective non-interventional cohort study.

METHODS

We enrolled childbearing women diagnosed with ovarian endometriomas. We collected demographic, clinical, and surgical data, including the evaluation of ovarian endometrioma-associated symptoms and pain using the visual analog scale. We grouped the women according to treatment regimen into dienogest, estrogen-progestogens, and no-treatment. Patient's assessment was performed at baseline and after 12 months evaluating the largest ovarian endometrioma diameter (in millimeters) and the associated symptoms. Furthermore, we analyzed the impact of hormonal treatment in a sub-group of women fulfilling at baseline the criteria for a first-line surgical approach (ovarian endometrioma > 30 mm with visual analog scale > 8 or ovarian endometrioma > 40 mm before assisted reproductive treatments or any ovarian endometrioma(s) > 60 mm).

RESULTS

We enrolled 142 patients: 62, 38, and 42 in dienogest, estrogen-progestogens, and no-treatment groups, respectively. No significant differences were found regarding baseline characteristics. After 12 months, the mean largest ovarian endometrioma diameter increased in the no-treatment group (31.1 versus 33.8; p < 0.01), while a significant reduction was registered in the dienogest (35.1 versus 25.8; p < 0.01) and estrogen-progestogens (28.4 versus 16.7; p < 0.01) groups; no significant difference in ovarian endometrioma diameter reduction between these two latter groups was noted (p = 0.18). Ovarian endometrioma-associated symptoms and pain improved in dienogest and estrogen-progestogens groups, with a significantly greater effect for dienogest than for estrogen-progestogens for dysmenorrhea (74% versus 59%; p < 0.01). In the sub-group of women eligible for first-line surgery at baseline, long-term treatment with dienogest and estrogen-progestogens reduced surgical eligibility by 30%.

CONCLUSIONS

Decreased mean largest ovarian endometriomas'diameter after 12 months and reduction of the need for surgical treatment by 30% were observed in dienogest and estrogen-progestogens groups. Long-term treatment with dienogest had a greater effect in alleviating dysmenorrhea and pain.

The Antigen-Processing Pathway via Major Histocompatibility Complex I as a New Perspective in the Diagnosis and Treatment of Endometriosis

Endometriosis is a debilitating gynecological disease defined as the presence of endometrium-like epithelium and/or stroma outside the uterine cavity. The most commonly affected sites are the pelvic peritoneum, ovaries, uterosacral ligaments, and the rectovaginal septum. The aberrant tissue responds to hormonal stimulation, undergoing cyclical growth and shedding similar to appropriately located endometrial tissue in the uterus. Common symptoms of endometriosis are painful periods and ovulation, severe pelvic cramping, heavy bleeding, pain during sex, urination and bowel pain, bleeding, and pain between periods. Numerous theories have been proposed to explain the pathogenesis of endometriosis. Sampson's theory of retrograde menstruation is considered to be the most accepted. This theory assumes that endometriosis occurs due to the retrograde flow of endometrial cells through the fallopian tubes during menstruation. However, it has been shown that this process takes place in 90% of women, while endometriosis is diagnosed in only 10% of them. This means that there must be a mechanism that blocks the immune system from removing endometrial cells and interferes with its function, leading to implantation of the ectopic endometrium and the formation of lesions. In this review, we consider the contribution of components of the Major Histocompatibility Complex (MHC)-I-mediated antigen-processing pathway, such as the ERAP, TAP, LMP, LNPEP, and tapasin, to the susceptibility, onset, and severity of endometriosis. These elements can induce significant changes in MHC-I-bound peptidomes that may influence the response of immune cells to ectopic endometrial cells.

Regeneration and anti-inflammatory effects of stem cells and their extracellular vesicles in gynecological diseases

There are many gynecological diseases, among which breast cancer (BC), cervical cancer (CC), endometriosis (EMs), and polycystic ovary syndrome (PCOS) are common and difficult to cure. Stem cells (SCs) are a focus of regenerative medicine. They are commonly used to treat organ damage and difficult diseases because of their potential for self-renewal and multidirectional differentiation. SCs are also commonly used for difficult-to-treat gynecological diseases because of their strong directional differentiation ability with unlimited possibilities, their tendency to adhere to the diseased tissue site, and their use as carriers for drug delivery. SCs can produce exosomes in a paracrine manner. Exosomes can be produced in large quantities and have the advantage of easy storage. Their safety and efficacy are superior to those of SCs, which have considerable potential in gynecological treatment, such as inhibiting endometrial senescence, promoting vascular reconstruction, and improving anti-inflammatory and immune functions. In this paper, we review the mechanisms of the regenerative and anti-inflammatory capacity of SCs and exosomes in incurable gynecological diseases and the current progress in their application in genetic engineering to provide a foundation for further research.

Identifying Immune Cell Infiltration and Hub Genes Related to M2 Macrophages in Endometriosis by Bioinformatics Analysis

Endometriosis (EM) is a chronic, estrogen-dependent inflammatory disease. Presently, the pathophysiology of EM is still unclear, and numerous studies have established that the immune system plays a major role in the pathophysiology of EM. Six microarray datasets were downloaded from the GEO public database. A total of 151 endometrial samples (72 ectopic endometria and 79 controls) were included in this study. CIBERSORT and ssGSEA were applied to calculate the immune infiltration of EM and control samples. Moreover, we validated four different correlation analyses to explore immune microenvironment of EM and finally identified M2 macrophage-related hub genes and further conducted the specific immunologic signaling pathway analysis by GSEA. The logistic regression model was investigated by ROC and further validated by two external datasets. From the results of the two immune infiltration assays, we concluded that M2 macrophages, regulatory T cells (Tregs), M1 macrophages, activated B cells, T follicular helper cells, activated dendritic cells, and resting NK cells have a significant difference between control and EM tissues. Through multidimensional correlation analysis, we found that macrophages play an important central role in cell-to-cell interactions, especially M2 macrophages. Four immune-related hub genes, namely FN1, CCL2, ESR1, and OCLN, are closely related to M2 macrophages and play a crucial role in the occurrence and immune microenvironment of endometriosis. The combined AUC of ROC prediction model in test and validation sets were 0.9815 and 0.8206, respectively. We conclude that M2 macrophages play a central role in the immune-infiltrating microenvironment of EM.

The deviations of CD4 + T cells during peripheral blood and peritoneal fluid of endometriosis: a systematic review and meta-analysis

OBJECTIVE

To assess whether endometriosis (EMs) was related to systematic and/or local deviations of cluster of differentiation (CD)4 + T cells.

METHODS

Until November 2022, we enrolled a total of 1363 EMs and 1564 healthy women from 32 studies who met the inclusion criteria.

RESULTS

After systematically retrieving the literature, we identified 1086 citations and 32 case-control studies were enrolled. Cumulative results suggested that there were insignificant deviations of CD4 + T cells during peripheral blood (PB) between EMs and healthy women (RR: - 0.83, I2 = 99%, p = 0.65), also no statistically significant difference was found between mild and severe EMs (RR: 3.19, I2 = 94%, p = 0.19). We also found insignificant deviations of CD4 + /CD8 + during PB between EMs and healthy women (RR: 0.09, I2 = 99%, p = 0.39), and between mild and severe EMs (RR: - 0.16, I2 = 99%, p = 0.29). The results might suggest that there was no significant correlation between EMs and systematic deviations of CD4 + T cells. When it came to local deviation during peritoneal fluid (PF), the polled results suggested that the frequency of CD4 + T cells during EMs was significantly lower than healthy women (RR: - 5.38, I2 = 93%, p = 0.01), and the ratio of CD4 + /CD8 + during EMs was significantly lower than healthy women (RR: - 0.13, I2 = 0%, p < 0.0001). However, there were insignificant deviations of CD4 + during PF between mild and severe EMs (RR: 1.65, I2 = 53%, p = 0.15), also there was an insignificant difference of CD4 + /CD8 + between mild and severe EMs (RR: - 0.09, I2 = 14%, p = 0.19). EMs might be closely related to local deviations of CD4 + T cells.

CONCLUSION

There was no obvious correlation between EMs and systematic deviations of CD4 + T cells, EMs might be closely related to local deviations of CD4 + T cells. Further study on the functional deviations and subpopulation distribution of CD4 + T cells is urgently needed.

Photodynamic therapy for treatment of recurrent hemoptysis secondary to pulmonary endometriosis: a case report

Pulmonary endometriosis (PEM) is rare, and drug therapy remains the primary treatment. However, patients with PEM frequently experience recurrent hemoptysis that is refractory to pharmacological intervention. We herein describe a patient with PEM who developed recurrent hemoptysis and was successfully treated with photodynamic therapy (PDT) after drug withdrawal. The patient was admitted to our hospital because of recurrent hemoptysis despite repeated drug treatments for more than 1 year. Given that PDT targets specific tissues and destroys vascular endothelial cells through the cytotoxic effect produced by the photodynamic reaction of the photosensitizer, we considered that it may effectively control hemoptysis secondary to vascular morphological changes in PEM. Therefore, we performed PDT in this case, and the patient's recurrent hemoptysis regressed. Approximately 2 years following PDT, the patient had recovered well and reported no discomfort. We recommend consideration of PDT as a treatment option for patients with PEM who develop recurrent hemoptysis after drug withdrawal. Notably, the patient's lung lesions should be superficial and limited, and no contraindications should be present.

Endometriosis Grade 4 in In Vitro Fertilisation and Its Management: A Case Report

Endometriosis is a condition in which tissue that lines the uterus grows outside the uterus. Patients with endometriosis often experience pelvic pain with menstrual periods and sometimes also infertility. Sometimes it is mistaken for pelvic inflammatory disease or ovarian cysts. This condition is a contraindication for pregnancy. This is a case report of a 37-year-old female who came to in vitro fertilisation (IVF) with a history of infertility of 14 years and was diagnosed with Grade 4 endometriosis on diagnostic ultrasonography-guided hysterolaparoscopy. After many trials of intrauterine insemination she was advised to go for IVF, and that not by obtaining her own ovum. The donor's egg and male partner's sperm were used for the IVF. The fertilised zygote was then implanted in the patient's uterus.

Biomarkers of endometriosis

Endometriosis is one of the most severe female reproductive disorders, affecting 6-10% of women between 18 and 35. It is a gynaecological condition where endometrial tissue develops and settles outside the uterus. The aetiology of endometriosis is primarily influenced by genetic, epigenetic, and non-genetic variables, making it highly challenging to create a therapeutic therapy explicitly targeting the ectopic tissue. The delay in the treatment is due to the limitations in the diagnostic approaches, which are restricted to invasive techniques such as laparoscopy or laparotomy. This accords to 70% of the women being diagnosed at later stages. By understanding the subject, several treatment medications have been produced to lessen the disease's symptoms. Nevertheless, endometriosis cannot be permanently cured. A viable or persuasive standard screening test for endometriosis must be utilized in a clinical context. A helpful assessment method for the early identification of endometriosis could be biomarkers. A major research priority is the identification of a biomarker that is sensitive and specific enough for detecting endometriosis. The present article has reviewed studies published on the expression of biomarkers of endometriosis. It outlines various biomarkers from different sample types, such as serum/plasma and urine, in addition to tissue. This would provide a non-invasive approach to diagnosing the disease at the initial stages without any harmful repercussions. Future high-throughput advances in science and technology are anticipated to result in the creation of a potent remedy for endometriosis. To achieve successful outcomes, it is necessary to research the discussed biomarkers that demonstrate substantial results extensively.

Autologous Platelet-Rich Plasma (PRP) Efficacy on Endometrial Thickness and Infertility: A Single-Centre Experience from Romania

(1) Background: During IVF (in vitro fertilization), a proper endometrium thickness is one of the most difficult parameters to achieve and one of the most important prognostic factors of the success rate. One major problem is the high cancelation percentage in frozen embryo transfer cycles. The focus on the adjuvant methods for improving endometrium thickness is an on-going subject of interest. (2) Methods: This prospective single-arm self-control study was conducted in an IVF centre in Oradea, Romania. The patients were divided into two groups. The control group included 51 patients with at least one attempt to transfer a good-quality blastocyst, but the endometrial thickness did not surpass 7 mm under standard endometrial preparation protocol with oestradiol and with adjuvant therapy (other than PRP, such as aspirin, vitamin C, and vitamin E), and the study group included the same 51 patients that had the embryo transfer performed under the same standard endometrial preparation protocol with oestradiol preparation protocol and intrauterine PRP infusion. (3) Results: In our study, the PRP treatment had a positive impact on the parameters that were followed for the evaluation of the success rate of the embryo transfer procedure. The endometrial thickness (an increase in endometrial thickness by 0.6 mm after PRP treatment with p = 0.0001) and the clinical pregnancy rate (having a MD ± SD of 0 ± 0.38 before PRP treatment and with an increase to 0.5 ± 0.1 after the PRP treatment, p = 0.0004) were statistically significant (4) Conclusions: PRP has a positive effect in promoting endometrial proliferation, improving embryo implantation rate and clinical pregnancy rate for women with thin endometrium.

Insight into the Potential Mechanisms of Endocrine Disruption by Dietary Phytoestrogens in the Context of the Etiopathogenesis of Endometriosis

Phytoestrogens (PEs) are estrogen-like nonsteroidal compounds derived from plants (e.g., nuts, seeds, fruits, and vegetables) and fungi that are structurally similar to 17β-estradiol. PEs bind to all types of estrogen receptors, including ERα and ERβ receptors, nuclear receptors, and a membrane-bound estrogen receptor known as the G protein-coupled estrogen receptor (GPER). As endocrine-disrupting chemicals (EDCs) with pro- or antiestrogenic properties, PEs can potentially disrupt the hormonal regulation of homeostasis, resulting in developmental and reproductive abnormalities. However, a lack of PEs in the diet does not result in the development of deficiency symptoms. To properly assess the benefits and risks associated with the use of a PE-rich diet, it is necessary to distinguish between endocrine disruption (endocrine-mediated adverse effects) and nonspecific effects on the endocrine system. Endometriosis is an estrogen-dependent disease of unknown etiopathogenesis, in which tissue similar to the lining of the uterus (the endometrium) grows outside of the uterus with subsequent complications being manifested as a result of local inflammatory reactions. Endometriosis affects 10-15% of women of reproductive age and is associated with chronic pelvic pain, dysmenorrhea, dyspareunia, and infertility. In this review, the endocrine-disruptive actions of PEs are reviewed in the context of endometriosis to determine whether a PE-rich diet has a positive or negative effect on the risk and course of endometriosis.

Proteomics in the study of female fertility: an update

INTRODUCTION

Female fertility has been a field of interest for the scientific community throughout the years. The contribution of proteomics in the study of female fertility as well as female infertility and in vitro fertilization (IVF) has been significant. Proteomics is a recently developed field, extensively applied to the identification and quantification of proteins, which could be used as potential biomarkers in a diagnostic, prognostic, or predictive manner in a variety of medical conditions.

AREAS COVERED

The present review focuses on proteomic studies of the oocyte and endometrial environment as well as on conditions related to infertility, such as polycystic ovarian syndrome, endometriosis, obesity, and unexplained infertility. Moreover, this review presents studies that have been done in an effort to search for fertility biomarkers in individuals following the IVF procedure.

EXPERT OPINION

The comprehension of the molecular pathways behind female fertility and infertility could contribute to the diagnosis, prognosis, and prediction of infertility. Moreover, the identification of proteomic biomarkers for IVF cycles could predict the possible outcome of an IVF cycle, prevent an unsuccessful IVF, and monitor the IVF cycle in a personalized manner, leading to increased success rates. [Figure: see text].

Leveraging electronic health record data for endometriosis research

Endometriosis is a chronic, complex disease for which there are vast disparities in diagnosis and treatment between sociodemographic groups. Clinical presentation of endometriosis can vary from asymptomatic disease-often identified during (in)fertility consultations-to dysmenorrhea and debilitating pelvic pain. Because of this complexity, delayed diagnosis (mean time to diagnosis is 1.7-3.6 years) and misdiagnosis is common. Early and accurate diagnosis of endometriosis remains a research priority for patient advocates and healthcare providers. Electronic health records (EHRs) have been widely adopted as a data source in biomedical research. However, they remain a largely untapped source of data for endometriosis research. EHRs capture diverse, real-world patient populations and care trajectories and can be used to learn patterns of underlying risk factors for endometriosis which, in turn, can be used to inform screening guidelines to help clinicians efficiently and effectively recognize and diagnose the disease in all patient populations reducing inequities in care. Here, we provide an overview of the advantages and limitations of using EHR data to study endometriosis. We describe the prevalence of endometriosis observed in diverse populations from multiple healthcare institutions, examples of variables that can be extracted from EHRs to enhance the accuracy of endometriosis prediction, and opportunities to leverage longitudinal EHR data to improve our understanding of long-term health consequences for all patients.

The value of pre-operative outpatient flexible sigmoidoscopy in patients with deep infiltrating endometriosis

BACKGROUND

Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management.

OBJECTIVES

We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE.

MATERIALS AND METHODS

A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team.

MAIN OUTCOME MEASURES

The primary outcome measure was the incidence of luminal disease.

RESULTS

102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%.

CONCLUSIONS

Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning.

WHAT IS NEW?

This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Primary spontaneous inguinal endometriosis: Two cases with emphasis on the diagnostic approach

OBJECTIVE

While endometriosis is common, inguinal endometriosis with hernia is rarely observed, making its preoperative diagnosis challenging.

CASE REPORT

We report two cases of inguinal endometriosis with different presentations and focus on tailored surgical treatment. The two patients in our series presented with painful swelling in the right groin area. Surgery and pathological examination confirmed the diagnosis of endometriosis in both cases. Herniorrhaphy and excision of the extraperitoneal round ligament were performed in one patient with concomitant inguinal endometriosis and indirect inguinal hernia.

CONCLUSION

We highlight the importance of the preoperative evaluation of concomitant pelvic endometriosis, round ligament involvement, and endometriosis within the inguinal hernia sac. Inguinal endometriosis with or without hernia should be considered even in reproductive-aged women without a previous medical and surgical history. Postoperative hormonal therapy, including dienogest, can be considered to prevent disease recurrence.

Endometriosis and the Temporomandibular Joint-Preliminary Observations

(1) Background: The complete picture of the disease is not fully recognized and extends far beyond the pelvis. The disease's impacts lead to systemic inflammation, in turn resulting in sensitization to pain. The aim of this study was to check whether statistical correlations exist in women with endometriosis with regard to their experience of pain: headache, pelvic pain, temporomandibular joint pain, along with teeth clenching and the treatment of the disease. We constructed contingency tables, followed by Pearson's chi-square test and Cramer's V coefficient values. (2) Methods: A survey was conducted among 128 women aged 33.43 ± 5.79 with a diagnosis of endometriosis (disease duration 6.40 ± 5.88 years). (3) Results: There was a correlation between the occurrence of pain on the right and left sides of the pelvis and pain on the right and left sides of the temporomandibular joint, p-value = 0.0397, V = 0.2350, and between the presence of pelvic pain and the treatment of endometriosis, p-value = 0.0104, V = 0.3709, and between the presence of pain outside the pelvis and the treatment of endometriosis, p-value = 0.0311, V = 0.4549. There was a highly significant correlation between teeth clenching and temporomandibular joint pain, p-value = 0.0005, V = 0.3695. (4) Conclusions: The study revealed a correlation between pelvic endometriosis symptoms and symptoms in the temporomandibular joint.

COX Isozymes and Non-Uniform Neoangiogenesis: What is their role in Endometriosis?

This literature review compared the efficacy in of NSAIDs with a placebo in pain relief and disease regression of endometriosis. Despite the poor evidence found, the results showed that NSAIDs were more effective in pain relief with regressive effects on the endometriotic lesions compared to placebo. We postulate herein that COX-2 is chiefly responsible for pain whilst COX-1 is responsible mainly for the establishment of endometriotic lesions. Hence, there must be a temporal difference in the activation of the two isozymes. We differentiated between two pathways in the conversion of arachidonic acid to prostaglandins by the COX isozymes referred to as 'direct' and indirect', supporting our initial theory. Finally, we postulate that there are two stages of neoangiogenesis in the formation of endometriotic lesions; 'founding' that first establishes blood supply and 'maintenance' that upkeeps it This is fertile ground for further research in a niche that needs more literature. Its aspects may be diversely explored. The theories we propose offer information for a more targeted treatment of endometriosis.

Assessment of BMP7, SMAD4, and CDH1 Expression Profile and Regulatory miRNA-542-3p in Eutopic and Ectopic Endometrium of Women with Endometriosis

Alterations in the expression of numerous genes and the miRNAs that are recognized as their regulators in the endometrial cells of women with endometriosis may disrupt the intracellular signaling pathways associated with epithelial–mesenchymal transition (EMT). So far, the functional role of BMP7 in endometrial physiology has been confirmed, especially in the context of fertility, but the role of the activation of a specific mechanism operating through the BMP–SMAD–CDH1 axis in the formation of endometrial lesions remains unexplored. The aim of this study was to evaluate the expression profile of miR-542-3p and the EMT markers (BMP7, SMAD4, CDH1) in matched eutopic endometrium (EUE) and ectopic endometrium (ECE) samples from women with endometriosis in relation to healthy women. The levels of expression of the studied genes and miRNA in peripheral blood mononuclear cells (PBMCs) obtained from women diagnosed with endometriosis and those without the disease were also evaluated. Fifty-four patients (n = 54: with endometriosis—n = 29 and without endometriosis—n = 25) were included in the study. A comparative analysis of the relative mean expression values (RQ) of the studied mRNA and miRNA assessed by RT-qPCR demonstrated downregulation of BMP7, SMAD4, and CDH1 expression in ectopic lesions and upregulation in the eutopic endometrium compared with the control group. In the eutopic tissue of women with endometriosis, miR-542-3p expression was similar to that of the control but significantly lower than in endometrial lesions. We also confirmed a trend towards a negative correlation between miR-542-3p and BMP7 in ectopic tissue, and in PBMC, a significant negative correlation of miR-542-3p with further BMP signaling genes, i.e., SMAD4 and CDH1, was observed. These results indicate that the miRNA selected by us may be a potential negative regulator of BMP7-SMAD4-CDH1 signaling associated with EMT. The different patterns of BMP7, SMAD4, and CDH1 gene expression in ECE, EUE, and the control endometrium observed by us suggests the loss of the endometrial epithelium phenotype in women with endometriosis and demonstrates their involvement in the pathogenesis and pathomechanism of this disease.

Appendiceal Endometriosis Presenting As Chronic Appendicitis: A Case Report

The origin of endometriosis has multiple theories, with controversy over which may demonstrate the prominent pathophysiology. The most common extra-pelvic organ system affected by endometriosis is the gastrointestinal tract. Gastrointestinal endometriosis (GE) accounts for 3 to 37% of all endometriosis cases, and appendiceal endometriosis is present in around 3% of GE cases, therefore constituting less than 1% of all endometriosis cases. In this report, we present a 24-year-old female with a past medical history significant for endometriosis status post two excisional laparoscopies who presented with eight months' duration of right lower quadrant pain, constant and stabbing, with rebound tenderness. Appendectomy and histopathology demonstrated focal endometriosis, diffuse serosal fibrovascular adhesions involving the appendiceal serosa/subserosa, as well as a dilated lumen filled with hemorrhagic content. When the appendix is not considered in endometriosis pathology, patients are at increased risk for unresolved pain and further laparoscopic procedures. Prophylactic appendectomy appears to be a worthwhile consideration in patients with chronic pelvic pain, given the high frequency of appendiceal pathology.

Aberrant epigenetic regulation of estrogen and progesterone signaling at the level of endometrial/endometriotic tissue in the pathomechanism of endometriosis

Endometriosis is a term referring to a condition whereby the endometrial tissue is found outside the uterine cavity. This progressive and debilitating condition affects up to 15% of women of reproductive age. Due to the fact that endometriosis cells may express estrogen receptors (ERα, Erβ, GPER) and progesterone (P4) receptors (PR-A, PR-B), their growth, cyclic proliferation, and breakdown are similar to the processes occurring in the endometrium. The underlying etiology and pathogenesis of endometriosis are still not fully explained. The retrograde transport of viable menstrual endometrial cells with the retained ability to attach within the pelvic cavity, proliferate, differentiate and invade into the surrounding tissue explains the most widely accepted implantation theory. Endometrial stromal cells (EnSCs) with clonogenic potential constitute the most abundant population of cells within endometrium that resemble the properties of mesenchymal stem cells (MSCs). Accordingly, formation of the endometriotic foci in endometriosis may be due to a kind of EnSCs dysfunction. Increasing evidence indicates the underestimated role of epigenetic mechanisms in the pathogenesis of endometriosis. Hormone-mediated epigenetic modifications of the genome in EnSCs or even MSCs were attributed an important role in the etiopathogenesis of endometriosis. The roles of excess estrogen exposure and P4 resistance were also found to be crucial in the development of epigenetic homeostasis failure. Therefore, the aim of this review was to consolidate the current knowledge regarding the epigenetic background of EnSCs and MSCs and the changed properties due to estrogen/P4 imbalances in the context of the etiopathogenesis of endometriosis.

Ultrasound Elastography for the Diagnosis of Endometriosis and Adenomyosis: A Systematic Review with Meta-analysis

Elastography is capable of measuring tissue mechanical properties and elasticity. It is used to help diagnose various diseases, although its use in pelvic endometriosis remains to be established. A systematic review and meta-analysis were conducted to assess transvaginal ultrasound elastography for the diagnosis of different manifestations of endometriosis and adenomyosis. PRISMA guidelines were used for a Medline, PubMed, Embase, BVS/Bireme, Scopus, Cochrane Library and Escudos database search. Studies indexed until March 2021 that evaluated elastography compared with histopathological results (gold standard), ultrasound or magnetic resonance imaging for diagnosis of pelvic endometriosis and adenomyosis were eligible. The Rayyan platform was used to select studies. Sensitivity (S), specificity (Ps), positive and negative predictive values and receiver operating characteristic curves were calculated for elastographic diagnosis of endometriosis. A meta-analysis using Review Manager 5 and Open Meta Analyst was performed. Bias risk in the studies was analyzed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. This systematic review was prospectively registered in the PROSPERO database: CRD42021244555. Among the 163 identified citations, 10 studies were eligible for review (5 for diagnosis of adenomyosis, 2 for endometrioma, 3 for deep intestinal endometriosis and rectovaginal septum [deep pelvic endometriosis], N = 744 women). In deep pelvic endometriosis, lesions diagnosed by elastography were found to correlate with histopathology results. Increased "stiffness" (elastography) was associated with a higher fibrotic component, with S = 78%-100% and Ps = 100%, according to the authors. On elastography, endometriomas were stiffer than hemorrhagic cysts (S = 82%, Ps = 79%) and malignant tumors (S = 86%, Ps = 100%). For these lesions, a meta-analysis could not be performed because the small number of studies and insufficient data. In adenomyosis, meta-analysis and receiver operating characteristic curve analysis revealed that elastography had good sensitivity and specificity. Studies indicated a low bias risk by QUADAS-2. Elastography had high sensitivity and specificity for deep pelvic endometriosis diagnosis, and its findings correlated with histopathology results. For adenomyosis, the meta-analysis confirmed the sensitivity and specificity results of the studies. Given these results, elastography may be a promising imaging test, contributing to non-invasive diagnosis of endometriosis and adenomyosis.

Peripheral blood subpopulations of Bregs producing IL-35 in women with endometriosis

PROBLEM

Interleukin 35 (IL-35) is involved in the pathogenesis of endometriosis by suppressing immunoreaction and promoting endometrial cell proliferation. It may also be an essential cytokine in forming the immunosuppressive functions of regulatory B lymphocytes (Bregs). The involvement of Bregs in the pathogenesis of endometriosis has not been previously investigated. In this study, we determined the frequencies of different Breg subpopulations, namely, B10, immature B-cells, and plasmablasts, and their abilities to produce IL-35 in women with endometriosis compared to healthy women.

METHODS

The frequencies of different subpopulations of Bregs producing IL-35 were measured in the peripheral blood of women with endometriosis (total pool), women with deep infiltration endometriosis (DIE), women with ovarian endometriosis, and healthy women as a control by flow cytometry.

RESULTS

We observed a decrease in the percentage of B10 cells and plasmablasts in women with endometriosis and an increase in the percentage of these Breg populations producing IL-35 in the same experimental group. Interestingly, we also revealed that women with DIE had increased percentages of B10 cells and plasmablasts producing IL-35.

CONCLUSION

Taken together, our findings are the first to reveal the frequencies of different subpopulations of Bregs producing IL-35 in women with endometriosis. The results suggest that IL-35 expression in B lymphocytes could be used as a peripheral marker of endometriosis; however, further studies are needed.

Impacts of endometrioma on ovarian aging from basic science to clinical management

Endometriosis is a common reproductive disorder characterized by the presence of endometrial implants outside of the uterus. It affects ~1 in 10 women of reproductive age. Endometriosis in the ovary, also known as endometrioma (OMA), is the most frequent implantation site and the leading cause of reproductive failure in affected women. Ovarian aging is one of the characteristic features of OMA, however its underlying mechanism yet to be determined. Accumulated evidence has shown that pelvic and local microenvironments in women with OMA are manifested, causing detrimental effects on ovarian development and functions. Whilst clinical associations of OMA with poor ovarian reserve, premature ovarian insufficiency, and early menopause have been reported. Moreover, surgical ablation, fenestration, and cystectomy of OMA can further damage the normal ovarian reservoir, and trigger hyperactivation of primordial follicles, subsequently resulting in the undesired deterioration of ovarian functions. Nevertheless, there is no effective treatment to delay or restore ovarian aging. This review comprehensively summarised the pathogenesis and study hypothesis of ovarian aging caused by OMA in order to propose potential therapeutic targets and interventions for future studies.

Telocytes and endometriosis

Endometriosis involving the presence and growth of glands and stroma outside the uterine cavity is a common, inflammatory, benign gynecologic disease. Nevertheless, no single theory can exactly account for the pathogenesis of endometriosis. Telocytes, a kind of novel mesenchymal cells, have been suggested to be crucial in promoting angiogenesis and increasing the activity of endometrial interstitial cells and inflammatory cells. Given above roles, telocytes may be considered as the possible pathogenesis of endometriosis. We reviewed the current literature on telocytes. The following aspects were considered: (A) the telocytes' typical characteristics, function, and morphological changes in endometriosis; (B) the potential role of telocytes in endometriosis by impacting the inflammation, invasion, and angiogenesis; (C) telocytes as the potential treatment options for endometriosis.

Sexual Activity during Menstruation as A Risk Factor for Endometriosis: A Systematic Review and Meta-Analysis

Up to now, limited studies have been done to evaluate the effect of sexual activity during menstruation on the endometriosis. However, due to the menstrual-related symptoms of endometriosis, this study aimed to systematically review the published articles on the association between sexual activity through menstruation and endometriosis. This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). This study examined all published observational studies on the association between sexual activity during menstruation and endometriosis, on the basis of the PICOS from conception until September 2021. The Newcastle-Ottawa Quality Assessment Scale was used to evaluate the quality of the articles. Also, Meta-analysis was conducted using Review Manager (RevMan 5.3). Out of the 1,905 retrieved articles of related databases, four studies comprised a total of 3641 patients (2251 cases and 1390 controls), which fulfilled the inclusion criteria, and equally encompassed high (2/4) and low (2/4) methodological quality, were reviewed. The results of all pooled studies showed that the probability of having sexual activity during menstruation is approximately two times higher in the women with endometriosis compared to women without endometriosis [odds ratio (OR)=1.80, 95% confidence interval (CI): 1.12 to 2.90, P=0.02, I2=78%, Tau=0.17, Chi2=13.72, P=0.003]. In this review, the sexual activity during menstruation was found to be an influencing factor for endometriosis. Due to the importance and complexity of endometriosis and the dearth of evidence on this topic, further studies with more robust designs are recommended.

In Vitro Inhibitory Effects of Maqian Essential Oil against Ectopic Endometrial Stromal Cells and LPS-Induced Endometrial Epithelial Cells

Previous studies revealed that MQEO (Maqian fruits essential oil), which is extracted from the fruit of Maqian (Zanthoxylum myriacanthum var. Pubescens), had a good anti-inflammatory effect, but the effect on endometriosis in vitro remains unknown. In the present study, the inhibitory effects of MQEO against the EESCs (ectopic endometrial stromal cells) were investigated. Cells were treated with a concentration gradient (from 0.025 % to 0.15 %) of MQEO for 24 h and cell viability was detected by CCK-8. In addition, apoptotic rates were investigated using flow cytometry. The effect of MQEO on cell migration was determined by wound-healing and transwell assay. The expression of apoptosis-associated and cell adhesion-related proteins was assessed by western blotting. The transcriptional levels of IL-1, IL-6 and TNF-α were determined by Real-time qPCR. RNA-seq was used to identify the DEGs (differentially expressed genes) in MQEO-pretreated EESCs. We found that the MQEO condition dosage-dependently reduced the cell viability of EESCs. Based on flow cytometry results, the number of apoptotic cells increased significantly with dosage. The wound-healing and transwell results showed that MQEO group exhibited a significantly decreased cell motility and migration ability in comparison with the normal group. Western blotting results showed that MQEO down-regulated the expression of Bcl-2, ICAM-1 (intercellular adhesion molecule 1) and CD44, but up-regulated the cleaved caspase-3 expression in EESCs. What's more, MQEO also inhibited the LPS-induced inflammation in human EECs (endometrial epithelial cells). RNA-seq revealed that 221 DEGs were up-regulated genes and 284 DEGs were down-regulated in MQEO-pretreated EESCs. Our data uncovered the beneficial effects of MQEO in endometriosis and provided new insights into the mechanism of the effect of MQEO on EESCs, suggesting MQEO could be a promising new therapeutic agent for endometriosis.

Bioinformatics identification and validation of biomarkers and infiltrating immune cells in endometriosis

Background

Endometriosis (EM) is a common gynecological disorder that often leads to irregular menstruation and infertility. The pathogenesis of EM remains unclear and delays in diagnosis are common. Thus, it is urgent to explore potential biomarkers and underlying molecular mechanisms for EM diagnosis and therapies.

Methods

Three EM-related datasets (GSE11691, GSE25628, and GSE86534) were downloaded from the Gene Expression Omnibus (GEO) which were integrated into a combined dataset after removing batch effect. Differentially expressed immune cell-related genes were obtained by CIBERSORT, WGCNA, and the identification of differentially expressed genes. Random forest model (RF), support vector machine model (SVM), and generalized linear model (GLM) were then constructed and the biomarkers for EM were determined. A nomogram evaluating the risk of disease was constructed and the validity was assessed by the calibration curve, DCA curve, and clinical impact curve. Single-gene Gene Set Enrichment Analysis (GSEA)was performed to explore the molecular mechanisms of biomarkers. The ceRNA regulatory network of biomarkers was created by Cytoscape and potential target drugs were obtained in the DGIdb database (Drug-Gene Interaction database).The expression levels of biomarkers from clinical samples was quantified by RT-qPCR.

Results

The ratio of eight immune cells was significantly different between the eutopic and ectopic endometrium samples. A total of eight differentially expressed immune cell-related genes were investigated. The SVM model was a relatively suitable model for the prediction of EM and five genes (CXCL12, PDGFRL, AGTR1, PTGER3, and S1PR1) were selected from the model as biomarkers. The calibration curve, DCA curve, and clinical impact curve indicated that the nomogram based on the five biomarkers had a robust ability to predict disease. Single gene GSEA result suggested that all five biomarkers were involved in labyrinthine layer morphogenesis and transmembrane transport-related biological processes in EM. A ceRNA regulatory network containing 184 nodes and 251 edges was constructed. Seven drugs targeting CXCL12, 49 drugs targeting AGTR1, 16 drugs targeting PTGER3, and 21 drugs targeting S1PR1 were extracted as potential drugs for EM therapy. Finally, the expression of PDGFRL and S1PR1 in clinical samples was validated by RT-qPCR, which was consistent with the result of public database.

Conclusions

In summary, we identified five biomarkers (CXCL12, PDGFRL, AGTR1, PTGER3, and S1PR1) and constructed diagnostic model, furthermore predicted the potential therapeutic drugs for EM. Collectively, these findings provide new insights into EM diagnosis and treatment.

Persistent dysregulation of genes in the development of endometriosis

BACKGROUND

Endometriosis is a chronic condition that affects women of child-bearing age. Since the etiology and pathogenesis of endometriosis have not been fully elucidated, it is important to investigate the mechanisms that lead to the deterioration of endometriosis.

METHODS

In this study, the transcriptome data of patients with normal, mild, and severe endometriosis were examined using the GSE51981 dataset obtained from the Gene Expression Omnibus database. Short Time Series Expression Miner (STEM) was used to screen the genes with continuous expression disorder in the development process, and the core genes were identified by constructing a protein-protein interaction network. The molecular mechanisms of endometriosis were examined using enrichment analysis. Finally, the transcription factors that regulate the core genes were predicted and the comprehensive mechanisms involved in the development of endometriosis were examined.

RESULTS

A total of 3,472 differentially expressed genes were identified from the normal, mild, and severe endometriosis samples. These were allocated into 12 modules and HRAS, HSP90AA1, TGFB1, TP53, and UBC were selected as the core genes. Enrichment analysis showed that the genes in modules 6, 7, and 9 were significantly related to oxygen levels, metallic processes, and hormone levels, respectively. Transcription factor prediction analysis showed that TP53 regulates HRAS to participate in immune related signaling pathways. Drug prediction analysis identified 792 drugs that interact with the targeted core genes.

CONCLUSIONS

This study explored the molecular mechanisms involved in the development of endometriosis and identified potential biomarkers of endometriosis. This data may provide novel targets and research directions for the diagnosis and treatment of endometriosis.

Association between RNAm-Based COVID-19 Vaccines and Permanency of Menstrual Cycle Alterations in Spanish Women: A Cross-Sectional Study

Introduction: The purpose of this study was to delve more deeply into the medium and long-term relation between mRNA-based vaccines and changes in menstrual pain, cycle length, and amount of bleeding in Spanish women. Material and Methods: A total of 746 women (63% between 18−30 and 37% between 31−45 years old) participated in the study. A numerical rating scale was used for recording pain intensity, a pictorial chart for menstrual bleeding, and data from menstrual cycle duration, type of vaccine, number of doses and time from vaccination. Results: Sixty-five per cent of the women perceived changes in their menstrual cycle after receiving the vaccines, irrespective of type of vaccine or number of doses; all p values were >0.05. Most of them (n = 316 out of 484) reported more than one alteration in their menstrual cycle. Almost half of the participants had been vaccinated over 5 months (45%), 3−4 months (15%) 2−3 months (26%), and one month or less (13%) before. The percentage of women that reported alterations remained strongly constant across time, p > 0.05, ranging from 64 to 65%. Conclusions: Reported alterations in Spanish women after COVID vaccination remained more than 5 months after the last dose.

PEG2-Induced Pyroptosis Regulates the Expression of HMGB1 and Promotes hEM15A Migration in Endometriosis

Endometriosis (EMS) is a common gynecological disease. Prostaglandin E2 (PGE2), which induces chronic pelvic inflammation and cell pyroptosis, a form of programmed cell death based on inflammasome activation, are involved in EMS, but the extent of their involvement and roles remain unclear. The present study aimed to evaluate PGE2-induced pyroptosis in EMS and the influence of PGE2 in EMS progression. Using western blotting, it was found that the expressions of PGE2 and pyroptosis-related proteins (NLRP3, cleaved caspase-1, interleukin (IL)-1β and IL-18) were higher in EMS tissues than in normal endometrial tissues. The levels of PGE2, IL-1β, and IL-18 in the serum of patients with EMS and cell culture fluids were also detected. Using the transwell assay, we verified that PGE2 promoted hEM15A migration via the NLRP3/caspase-1 pyroptotic pathway, and PGE2-induced pyroptosis upregulated the expressions of high mobility group box 1 (HMGB1), E-cadherin, and vimentin. Immunohistochemistry analysis confirmed that PGE2-induced pyroptosis contributed to EMS invasion. These results suggest that PGE2-induced pyroptosis affects the progression of EMS by changing the migration ability of pyroptotic cells and upregulating the expression of HMGB1, E-cadherin, and vimentin. Our findings provide crucial evidence for new treatment pathways and use of anti-inflammatory drugs in EMS.

StackPR is a new computational approach for large-scale identification of progesterone receptor antagonists using the stacking strategy

Progesterone receptors (PRs) are implicated in various cancers since their presence/absence can determine clinical outcomes. The overstimulation of progesterone can facilitate oncogenesis and thus, its modulation through PR inhibition is urgently needed. To address this issue, a novel stacked ensemble learning approach (termed StackPR) is presented for fast, accurate, and large-scale identification of PR antagonists using only SMILES notation without the need for 3D structural information. We employed six popular machine learning (ML) algorithms (i.e., logistic regression, partial least squares, k-nearest neighbor, support vector machine, extremely randomized trees, and random forest) coupled with twelve conventional molecular descriptors to create 72 baseline models. Then, a genetic algorithm in conjunction with the self-assessment-report approach was utilized to determine m out of the 72 baseline models as means of developing the final meta-predictor using the stacking strategy and tenfold cross-validation test. Experimental results on the independent test dataset show that StackPR achieved impressive predictive performance with an accuracy of 0.966 and Matthew’s coefficient correlation of 0.925. In addition, analysis based on the SHapley Additive exPlanation algorithm and molecular docking indicates that aliphatic hydrocarbons and nitrogen-containing substructures were the most important features for having PR antagonist activity. Finally, we implemented an online webserver using StackPR, which is freely accessible at http://pmlabstack.pythonanywhere.com/StackPR. StackPR is anticipated to be a powerful computational tool for the large-scale identification of unknown PR antagonist candidates for follow-up experimental validation.