Maria A. Neonaki

Serum concentrations of growth factors in women with and without endometriosis: the action of anti-endometriosis medicines

Endometriosis is a common gynecologic syndrome of unknown etiology and pathogenesis. Growth factors and inflammatory mediators produced by peritoneal leukocytes have recently been postulated to participate in the pathogenesis of endometriosis. Angiogenic factors released from peritoneal macrophages may also play a role in the development of this disease. In the present study, we investigate the soluble levels of vascular endothelial growth factor (VEGF), epidermal growth factor-receptor (EGF-R), granulocyte/macrophage-colony stimulating factor (GM-CSF), Insulin-like growth factor-1 (IGF-1) and interferon-gamma (IFN-gamma) in the serum of 28 women with and 20 without endometriosis. We also compared these levels before, during and after treatment with danazol and leuprorelin acetate depot, the two therapeutic regiments of choice concerning this disease. We found that only sVEGF levels were higher in women with endometriosis in comparison to controls (P < 0.001) while sEGF-R is not present. GM-CSF, IGF-1 and IFN-gamma soluble levels are not affected in either healthy or endometriotic subjects. The 6-month treatment with danazol decreased sVEGF levels (P < 0.02) and increased sEGF-R levels (P < 0.001). These observations support the view that VEGF may be associated with the disease process and that danazol may bring sVEGF levels to a normal threshold. However, future studies will be focused on the anti-angiogenic control of the action of VEGF in patients with endometriosis.

Detection of interleukin-6, interleukin-8, and interleukin-11 in plasma from women with spontaneous abortion

OBJECTIVE To investigate the role of IL-6, IL-8, and IL-11 in the immune-regulatory mechanisms involved in the spontaneous abortion of the first trimester of pregnancy. STUDY DESIGN Plasma levels of IL-6, IL-8, and IL-11 were determined in 68 women who had a spontaneous abortion of unknown aetiology during the first trimester of pregnancy. They were compared with the corresponding levels of 73 age-matched pregnant women who had an uneventful pregnancy, and 52 age-matched non-pregnant women. All enrolled women presented without any severe disease, syndrome or recent infection. Cytokine levels were measured by a sensitive sandwich enzyme-linked immunoassay. RESULTS The women with spontaneous abortion had significantly decreased plasma levels of IL-6, IL-8 and IL-11 compared to those with normal pregnancies (P<0.05). The non-pregnant women had no detectable cytokine levels. CONCLUSIONS The reduced plasma levels of IL-6, IL-8 and IL-11 in women with spontaneous abortion may be related to the underlying aetiopathogenetic mechanisms, however, there is no sufficient evidence for their use as predictive markers of pregnancy outcome.

Soluble ICAM-1 levels in the serum of endometriotic patients appear to be independent of medical treatment

Adhesion molecules regulate the interaction of cells with the extracellular matrix and/or other cells. The intercellular adhesion molecule-1 (ICAM-1; CD54) is a member of the immunoglobulin superfamily and expressed by several cell types, including leukocytes and endothelial cells. A circulating form of the usually membrane-bound molecule was identified and characterized in normal human serum and in sera from patients with endometriosis. In the present study, we established the serum-soluble ICAM-1 (sICAM-1) levels in patients with endometriosis. We also studied the effect of danazol and leuprorelin acetate depot on the levels of sICAM-1. Thirty-eight women, 18-45 years of age, with regular menses and documented pelvic endometriosis were recruited from a University Hospital setting. Twenty-two women with endometriosis were randomly divided into two groups. Danazol (600 mg) were given every day for 6 months, and 3.75 mg of leuprorelin acetate depot every 28 days for 6 months. Serum sICAM-1 concentrations were measured before, during and after treatment, and its quantitative determination was performed by an ELISA technique using a specific immunoassay. We found that (1) sICAM-1 levels were higher in women with endometriosis in comparison to healthy subjects; (2) the 6 month treatment with danazol or leuprorelin acetate depot increased sICAM-1 levels (P<0.001); (3) 3 months after termination of both treatments, sICAM-1 levels were unchanged. Although the mechanism leading to the increase of sICAM-1 needs to be further clarified, any benefits of medical treatment of endometriosis such as danazol or leuprorelin appear to be independent of changes in ICAM-1 serum levels.

The possible anti-inflammatory role of circulating human leukocyte antigen levels in women with endometriosis after treatment with danazol and leuprorelin acetate depot

BACKGROUND: Endometriosis is defined as an inflammatory condition of the female reproductive tract, a state often associated with infertility and miscarriage. Many exogenously administered factors (treatments) control the disease via as yet unknown pathways. Possible candidate molecules involved in these mechanisms could be the serum-soluble human leukocyte antigens (sHIA) that have been detected in a variety of human body fluids and that are associated with several diseases. AIMS: We here examine how danazol and leuprorelin acetate depot treatments exert their anti-inflammatory action. It is plausible that subtle alterations mediated by these treatments and in relation to sHLA may explain the pathophysiology of endometriosis and provide insights towards new therapeutic protocols. METHODS: Indirect enzyme-linked immunosorbent assay (ELISA), using specific monoclonal antibodies, determined serum-soluble class-I and class-II HLA levels. ELISA readings from treated women were compared with normal healthy subjects. RESULTS: Serum-soluble class-I and class-II HLA levels are statistically significantly lower (P < 0.001) in women with endometriosis than in the control groups. However, danazol but not leuprorelin acetate depot administration augments soluble HLA class I and class II (P < 0.01 and P < 0.001, respectively) to normal levels during the treatment period, an increase that may account for the anti-inflammatory effect and the remission observed. CONCLUSIONS: It is shown that one of the underlying causes of endometriosis may be the lack of both circulating class-I and class-II antigen levels. Danazol administration acts via an induced release of these antigens, whose presence correlates with the degree of the inflammatory alleviation obtained. We thus provide evidence that the inflammatory state of the disease appears to be associated with soluble HLA levels because, 3 months after ceasing therapy, the circulating antigens in the serum return to the same levels that correspond to the pathological condition.

Factors that may predispose to rupture of tubal ectopic pregnancy

OBJECTIVE The purpose of our study was to evaluate factors that may predispose to rupture of tubal ectopic pregnancy. The study included 99 cases of ectopic pregnancies that were treated during the 5-year period 1992-1996. RESULTS It was found that: (1) tubal rupture is encountered more often in women with no history of ectopic pregnancy and in those who have full-term pregnancy, suggesting that ectopic pregnancy is less suspected in these women; (2) tubal rupture is encountered less often in lower age ectopic pregnancy; and (3) serum beta-hCG level does not predict tubal rupture. CONCLUSIONS Rupture of the tube is more often observed in women with a history of ectopic pregnancy and in women with full-term pregnancy. Such observations suggest that ectopic pregnancy is less suspect in these cases.

Arguments for a left lateral predisposition of endometrioma

OBJECTIVE To analyze a hypothesis regarding the pathogenesis of endometriosis. DESIGN Retrospective study. SETTING Two academic endometriosis referral centers. PATIENT(S) We evaluated operative and pathologic reports of 251 women who underwent laparoscopic or laparotomy treatment of endometrioma from August 1996 to February of 2002 at Yale University School of Medicine and at the University of Crete Department of Obstetrics and Gynecology. INTERVENTION(S) Laparascopic examination. MAIN OUTCOME MEASURE(S) Statistical methods included chi(2) and Mann-Whitney U tests measuring incidence of right- vs. left-sided endometria. RESULT(S) One hundred seventy patients from Yale University and 81 Greek patients participated in this study. Endometrioma was significantly more frequent in the left ovary (139 of 206 [67.4%]) than in the right ovary (67 of 206 [32.6%]; odds ratio [OR] = 4.3; 95% confidence interval [CI) 2.9-6.5; chi(2) = 48.9) and significantly different from the expected proportion of 50% (chi(2) = 25.2). When bilateral endometriomas were included, 62.1% (184 of 296) were left-sided and 37.15 (112 of 296) were right-sided (OR = 17.5; 95% CI 1.9-3.8; chi(2) = 34.1). Dilated ovarian veins in were found in 22 (68.7%) of 32 Greek cases with endometrioma. All 20 women with left endometrioma had left ovarian vein dilated. CONCLUSION(S) We suggest a new mechanical theory of implication, the female varicocele theory, which could play an important role in the development of ovarian endometriosis or endometriomas.

Expression of serum human leukocyte antigen and growth factor levels in a Greek family with familial endometriosis.

Objective: An increased incidence of endometriosis in the first-degree relatives of patients with endometriosis has been reported, suggesting a familial predisposition and possible genetic influence. In this study, we present a family with four members who have histologically proven endometriosis (mother and three daughters) in two generations and one member with suspected endometriosis in the third generation. The aim of this study was to investigate the presence of serum-soluble class I and class II human leukocyte antigen (sHLA) levels, because they have been shown to be reduced in women with endometriosis. We also studied the levels of vascular endothelial growth factor (VEGF) and epidermal growth factor-receptor (EGF-Rc) whose function in angiogenesis implies an active role in endometriosis. Methods: Apart from the family members under study, the control groups consisted of 38 women with endometriosis and 30 without any pelvic disease. All the soluble factors under investigation were measured by an enzyme-linked immunosorbent assay technique using a specific immunoassay. Results: All the affected family members and the 38 women with endometriosis had very low levels of serum-soluble class I and class II HLA levels compared with healthy subjects. The circulating levels of VEGF were higher in the endometriosis group than the healthy control group, a pattern in accordance with the family members. On the contrary, EGF-Rc was negative in controls and women with endometriosis, with the exception of certain family members in specific stage of endometriosis. Conclusion: We studied the association of endometriosis with circulating levels of human leukocyte antigens and VEGF in two generations of a single family (mother and three daughters). These markers were expressed distinctly in women with familial endometriosis.

Diagnostic role of inhibin B in resistant ovary syndrome associated with secondary amenorrhea

To report two rare cases of gonadotropin-resistant ovary syndrome associated with secondary amenorrhea and normal levels of inhibin B. Case report. Two university teaching hospitals. Two women presenting with secondary amenorrhea and infertility. The control group for the inhibin B levels consisted of 30 cycling women of reproductive age. Medical history, physical examination, laboratory data, histologic findings, and IVF results. Diagnosis and treatment of resistant ovary syndrome. Case 1 was a 25-year-old woman with secondary amenorrhea and primary infertility. She had high serum levels of FSH and LH, low E(2) levels, and normal inhibin B levels (62 pg/mL). Karyotype was 46,XX, and ovarian biopsy showed primordial follicles with oocytes. Administration of GnRH analogue with hMG for 15 days did not affect E(2) levels. She had a successful pregnancy with IVF using donor oocytes. Case 2 was a 24-year-old woman with secondary amenorrhea. She had elevated serum levels of FSH and LH, low E(2) levels, and normal inhibin B levels (57 pg/mL). Karyotype was 46,XX and ovarian biopsy showed primordial follicles. Administration of GnRH analogue with hMG for 12 days did not affect E(2) levels. Both women were given estrogen-progestin replacement therapy. Inhibin B has a diagnostic role in women with gonadotropin-resistant ovary syndrome associated with secondary amenorrhea. A review of the literature confirms the uniqueness of the diagnostic role of inhibin B in these cases.

Pulmonary endometriosis in a patient with unicornuate uterus and noncommunicating rudimentary horn

OBJECTIVE To report a rare case of a patient with catamenial hemoptysis, secondary infertility, and endometriosis associated with a unicornuate uterus and noncommunicating rudimentary horn. DESIGN Case report. SETTING University hospital. PATIENT(S) A 29-year-old woman who developed progressive catamenial hemoptysis and secondary infertility was evaluated at the University Hospital of Crete. INTERVENTION(S) The complete history, laboratory data, laparoscopic findings, and chest magnetic resonance image of this patient were analyzed. A GnRH agonist, leuprolide acetate, was successfully administered. MAIN OUTCOME MEASURE(S) Diagnosis and appropriate treatment of pulmonary endometriosis in a patient with rudimentary uterine horn. RESULT(S) Treatment with a GnRH agonist achieved suppression of both menstruation and hemoptysis. After 6 months of normal menstrual activity, the symptoms reappeared. The patient was again treated with leuprolide acetate (3.75 mg/mo IM) for 6 months and remained asymptomatic. In fact, the patient became pregnant after cessation of therapy. Finally, the patient was treated successfully with removal of the rudimentary uterine horn during cesarean section. Three-year follow-up showed disappearance of the chest symptoms. CONCLUSION(S) Pulmonary endometriosis and unicornuate uteri are rare. To our knowledge, this is the first case of catamenial hemoptysis with a congenital müllerian anomaly. We describe successful management using a combination of GnRH agonist and surgical resection of the rudimentary uterine horn.

The anti-inflammatory action of danazol and leuprorelin acetate depot on endometriosis is CRH independent

Corticotropin-releasing hormone (CRH) is a hypothalamic neuropeptide involved in the neuroendocrine response to stress, also playing a role in cell mediated immune functions. The aim of this study was to determine the circulating in the serum CRH levels in women with endometriosis and investigate the effect of the routinely 6-month administered treatment of danazol or leuprorelin acetate depot on these hormonal levels. Serum CRH levels were not significantly different in women with endometriosis and in the control group. The 6-month danazol or leuprorelin treatment had no effect on the levels of CRH. Three months after danazol treatment CRH levels were significantly lower (p < 0.005) than those before treatment. In contrast, after treatment with leuprorelin, CRH levels were significantly higher (p < 0.001). Our results suggest that endometriosis is not associated with CRH and that danazol as well as leuprorelin acetate depot have no effect on these levels during the treatment-specific period. However, they both showed significant fluctuations after the administration of these compounds ceased.