The Impact of Hormonal Replacement Treatment in Postmenopausal Women with Uterine Fibroids: A State-of-the-Art Review of the Literature

Establishment of Murine Pregnancy Requires the Promyelocytic Leukemia Zinc Finger Transcription Factor

Using an established human primary cell culture model, we previously demonstrated that the promyelocytic leukemia zinc finger (PLZF) transcription factor is a direct target of the progesterone receptor (PGR) and is essential for progestin-dependent decidualization of human endometrial stromal cells (HESCs). These in vitro findings were supported by immunohistochemical analysis of human endometrial tissue biopsies, which showed that the strongest immunoreactivity for endometrial PLZF is detected during the progesterone (P4)-dominant secretory phase of the menstrual cycle. While these human studies provided critical clinical support for the important role of PLZF in P4-dependent HESC decidualization, functional validation in vivo was not possible due to the absence of suitable animal models. To address this deficiency, we recently generated a conditional knockout mouse model in which PLZF is ablated in PGR-positive cells of the mouse (Plzf d/d). The Plzf d/d female was phenotypically analyzed using immunoblotting, real-time PCR, and immunohistochemistry. Reproductive function was tested using the timed natural pregnancy model as well as the artificial decidual response assay. Even though ovarian activity is not affected, female Plzf d/d mice exhibit an infertility phenotype due to an inability of the embryo to implant into the Plzf d/d endometrium. Initial cellular and molecular phenotyping investigations reveal that the Plzf d/d endometrium is unable to develop a transient receptive state, which is reflected at the molecular level by a blunted response to P4 exposure with a concomitant unopposed response to 17-β estradiol. In addition to a defect in P4-dependent receptivity, the Plzf d/d endometrium fails to undergo decidualization in response to an artificial decidual stimulus, providing the in vivo validation for our earlier HESC culture findings. Collectively, our new Plzf d/d mouse model underscores the physiological importance of the PLZF transcription factor not only in endometrial stromal cell decidualization but also uterine receptivity, two uterine cellular processes that are indispensable for the establishment of pregnancy.

Sex hormones and immune system: Menopausal hormone therapy in the context of COVID-19 pandemic

The fatal outcomes of COVID-19 are related to the high reactivity of the innate wing of immunity. Estrogens could exert anti-inflammatory effects during SARS-CoV-2 infection at different stages: from increasing the antiviral resistance of individual cells to counteracting the pro-inflammatory cytokine production. A complex relationship between sex hormones and immune system implies that menopausal hormone therapy (MHT) has pleiotropic effects on immunity in peri- and postmenopausal patients. The definite immunological benefits of perimenopausal MHT confirm the important role of estrogens in regulation of immune functionalities. In this review, we attempt to explore how sex hormones and MHT affect immunological parameters of the organism at different level (in vitro, in vivo) and what mechanisms are involved in their protective response to the new coronavirus infection. The correlation of sex steroid levels with severity and lethality of the disease indicates the potential of using hormone therapy to modulate the immune response and increase the resilience to adverse outcomes. The overall success of MHT is based on decades of experience in clinical trials. According to the current standards, MHT should not be discontinued in COVID-19 with the exception of critical cases.

Menopausal hormone therapy in women with benign gynaecological conditions and cancer

The efficacy of menopausal hormone therapy for bothersome menopausal symptoms is well established. However, there are a range of benign and malignant gynaecological conditions that pose a challenge in managing menopausal symptoms. Their hormone-dependent nature either raises concerns about symptom recurrence or malignant disease progression making decisions about menopausal hormone therapy complex for both clinicians and patients. It appears there is a small potential for symptom recurrence with menopausal hormone therapy use in menopausal women with a history of severe endometriosis. Malignant transformation of previous endometriotic lesions is likely to be rare but is not adequately understood. In this setting, combined hormone therapy is preferred, including in woman post-hysterectomy. Uterine fibroids are not a contraindication to menopausal hormone therapy use but women with large fibroids at menopause should have regular follow-up of their fibroids. Generally, menopausal hormone therapy is considered appropriate for women with cervical cancer and most ovarian cancers except for low grade serous tumours. Endometrial cancer requires an individualised discussion. The overall quality of data in this area is poor but suggests women with a low risk of recurrence may consider hormonal therapy, balancing symptom impact with prognosis.

Macrophages and Immune Responses in Uterine Fibroids

Uterine fibroids represent the most common benign tumors of the uterus. They are considered a typical fibrotic disorder. In fact, the extracellular matrix (ECM) proteins—above all, collagen 1A1, fibronectin and versican—are upregulated in this pathology. The uterine fibroids etiology has not yet been clarified, and this represents an important matter about their resolution. A model has been proposed according to which the formation of an altered ECM could be the result of an excessive wound healing, in turn driven by a dysregulated inflammation process. A lot of molecules act in the complex inflammatory response. Macrophages have a great flexibility since they can assume different phenotypes leading to the tissue repair process. The dysregulation of macrophage proliferation, accumulation and infiltration could lead to an uncontrolled tissue repair and to the consequent pathological fibrosis. In addition, molecules such as monocyte chemoattractant protein-1 (MCP-1), granulocyte macrophage-colony-stimulating factor (GM-CSF), transforming growth factor-beta (TGF-β), activin A and tumor necrosis factor-alfa (TNF-α) were demonstrated to play an important role in the macrophage action within the uncontrolled tissue repair that contributes to the pathological fibrosis that represents a typical feature of the uterine fibroids.

Neither soyfoods nor isoflavones warrant classification as endocrine disruptors: a technical review of the observational and clinical data

Soybeans are a rich source of isoflavones, which are classified as phytoestrogens. Despite numerous proposed benefits, isoflavones are often classified as endocrine disruptors, based primarily on animal studies. However, there are ample human data regarding the health effects of isoflavones. We conducted a technical review, systematically searching Medline, EMBASE, and the Cochrane Library (from inception through January 2021). We included clinical studies, observational studies, and systematic reviews and meta-analyses (SRMA) that examined the relationship between soy and/or isoflavone intake and endocrine-related endpoints. 417 reports (229 observational studies, 157 clinical studies and 32 SRMAs) met our eligibility criteria. The available evidence indicates that isoflavone intake does not adversely affect thyroid function. Adverse effects are also not seen on breast or endometrial tissue or estrogen levels in women, or testosterone or estrogen levels, or sperm or semen parameters in men. Although menstrual cycle length may be slightly increased, ovulation is not prevented. Limited insight could be gained about possible impacts of in utero isoflavone exposure, but the existing data are reassuring. Adverse effects of isoflavone intake were not identified in children, but limited research has been conducted. After extensive review, the evidence does not support classifying isoflavones as endocrine disruptors.

Uterine Fibroids and Progestogen Treatment: Lack of Evidence of Its Efficacy: A Review

BACKGROUND

The objective of this review is to determine the evidence or, conversely, the absence of evidence regarding the effectiveness of progestogens in treating premenopausal women with uterine fibroids. In particular, the goal is to address recurring questions as to whether they are effective or not for managing symptoms commonly attributed to fibroids.

METHODS

A review of the most relevant papers (n = 63) on the efficacy of progesterone and progestogens as medical therapy for uterine fibroids.

RESULTS

Having reviewed the most significant papers on the relationship between uterine fibroids and progesterone/progestogens, it is clear that there is biochemical, histological and clinical evidence that progesterone and progestogens play a critical role in the pathogenesis of myomas.

CONCLUSION

Since progesterone is already implicated in the pathogenesis of this entity, using progestogens to manage fibroids is like constantly adding fuel to the fire, rendering this treatment ineffective.