Conservative surgical and drug therapies for adenomyosis Medicine

Adenomyosis is a benign invasion/infiltration of endometrial glands and stroma in the uterine myometrium. The optimal choice of adenomyosis treatment remains a subject of discussion. For patients with adenomyosis without fertility requirements, hysterectomy can be performed by laparotomy or laparoscopic surgery to eliminate symptoms. However, this is an inadequate option for women who want to preserve fertility or avoid more extensive surgery. To summarize the medicine and conservative surgery treatment for adenomyosis. An extensive literature search was performed using PubMed, Web of Science, Embase, Ovid Medline, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure (CNKI) without language restriction. The search terms were as follows: adenomyomas, adenomyosis, conservative therapy; combined therapy; medicine; surgery. The search included all titles and abstracts assessing conservative treatment for adenomyosis including medical and surgical therapy. All published papers were analyzed if considered relevant. Increasing current conservative treatments will not only improve the quality of life of the patients but also preserve fertility. Therefore, conservative treatment is extremely important for patients with fertility requirements or a strong desire to retain the uterus. Conservative treatment for adenomyosis may become a future trend in the field of gynecology.     

An accumulation of insulin-like growth factor I (IGF-I) in human myometrium and uterine leiomyomas in various stages of tumour growth

It is commonly thought that uterine leiomyomas result from hyperstimulation of myometrium by ovarian hormones. Some observations suggest that cytokines and growth factors are intermediate elements through which the ovarian hormones may exert their growth-stimulatory effects on leiomyomas. Human myometrium and uterine leiomyomas of various weights were homogenised and extracted with 1 M acetic acid or with 0.05 M Tris/HCl, pH 7.6. The extracts were assayed for IGF-I using the ELISA technique. It was found that 0.05 M Tris/HCl extracts contained several times more IGF-I than the 1 M acetic acid extracts. Nanogram amounts of IGF-I were found in both control myometrium and in leiomyomas. It was found that the amounts of IGF-I extracted from leiomyomas were distinctly higher in comparison to control myometrium and they increased as a function of tumour growth. Polyacrylamide gel electrophoresis, followed by Western immunoblotting, demonstrated that IGF-I in acidic and alkaline extracts exists as stable complexes, probably with extracellular matrix components. No free IGF-I was detected. Furthermore, it was found that some components of both the acidic and alkaline extracts were able to bind exogenous (125)I-labeled IGF-I. It is suggested that IGF-I plays an important role both in myometrium biology and in the growth of uterine leiomyomas.     

高强度聚焦超声治疗子宫腺肌病的免疫学状态改变及影像学评估研究

摘要 目的：探讨高强度聚焦超声（HIFU）治疗子宫腺肌病（AM）的免疫学状态改变及影像学评估。方法：选择2020年12月-2021年12月于石家庄市人民医院收治的186例AM患者,HIFU消融术治疗前后行血清补体C3、C4、辅助性T细胞17与调节性T细胞比值（Th17/Treg）检测和磁共振成像（MRI）检查。比较AM患者治疗前后超声特征以及MRI测量参数、血清补体C3、C4、Th17/Treg水平的差异;采用Spearman相关性分析治疗后血清补体C3、C4、Th17/Treg水平与消融率、无灌注区MRI参数的相关性。结果：AM患者HIFU治疗前超声显示子宫壁肌层回声不均匀,肌层血流信号丰富,病灶血运丰富;MRI表现为子宫不均一性体积增大,子宫壁明显增厚,与子宫结合带分界不清,信号不均匀,动态增强扫描病灶表现为不均匀强化,强化程度均略低于附近的正常子宫内肌层。AM患者HIFU治疗后VAS评分显著低于治疗前（P<0.05）;超声显示子宫肌层回声不均匀,肌层血运明显减少,MRI显示子宫壁增厚程度减轻,信号不均匀,增强扫描表现为中央无强化的灌注区,周边结节状或不规则形强化即为残余病灶,消融率为90%左右。HIFU治疗后血清补体C3、C4水平、残余病灶ADC值、MSI值显著升高（P<0.05）,而HIFU治疗后Th17/Treg、无灌注区ADC值、MSI值显著下降（P<0.05）。HIFU治疗后血清补体C3、C4水平与消融率、无灌注区ADC值以及MSI值存在显著负相关（P<0.05）,而Th17/Treg与消融率、无灌注区ADC值以及MSI值存在显著正相关（P<0.05）。结论：HIFU治疗AM患者后的免疫学状态改变以及MRI评估有助于预测AM患者的预后,并指导临床医师对AM患者后续治疗方案的选择提供客观真实的依据。     

Altered hormonal responsiveness of proliferation and apoptosis during myometrial maturation and the development of uterine leiomyomas in the rat

Uterine leiomyomas are responsive to the ovarian steroids, estrogen and progesterone; however, a mechanistic understanding of the role of these hormones in the development of this common gynecologic lesion remains to be elucidated. We have used the Eker rat uterine leiomyoma model to investigate how ovarian hormones regulate or promote the growth of these tumors. Proliferative and apoptotic rates were quantitated in normal uterine tissues and leiomyomas in response to endogenous ovarian steroids. In 2- to 4-mo-old animals, cell proliferation in the normal uterus corresponded with high serum levels of steroid hormones during the estrous cycle, and apoptosis occurred in the rat uterus in all cell types following sharp, cyclical declines in serum hormone levels. It is interesting that the responsiveness of uterine mesenchymal cells changed between 4 and 6 mo of age, with significant decreases in both proliferative and apoptotic rates observed in myometrial and stromal cells of cycling animals. Leiomyomas displayed much higher levels of proliferation than did age-matched myometrium; however, their apoptotic index was significantly decreased in comparison with normal myometrium. This disregulation between proliferative and apoptotic responses, which were tightly regulated during ovarian cycling in the normal myometrium, may contribute to the disruption of tissue homeostasis and underlie neoplastic growth of these tumors.     

Expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak in human uterine leiomyomas and myometrium during the menstrual cycle and after menopause

To investigate the expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak proteins in human uterine leiomyomas and homologous myometrium during the menstrual cycle and after menopause.The expression of Bcl-2, Bcl-x, Mcl-1, Bax and Bak in leiomyomas (n=24) and myometrial samples (n=22) from women with leiomyomas was measured by immunohistochemistry and Western blot. Measured by immunohistochemistry, a significant difference between leiomyomas and myometrium was observed only for the Bax protein, in tissues obtained from women in the secretory phase of the menstrual cycle. The Bcl-2 staining was more abundant in leiomyomas than in myometrium only in tissues obtained in the proliferative phase of the cycle. Bcl-2 was more abundant in leiomyomas from women of fertile age than in leiomyomas from menopausal women. No significant differences were observed for the Bcl-x or Bak proteins, whereas the Mcl-1 protein was significantly less abundant in secretory phase leiomyomas than in leiomyomas from menopausal women. Western blot analysis based on pools of tissue extracts from the different groups essentially confirmed the data obtained by immunohistochemistry. Bcl-2 family proteins are expressed in leiomyomas and myometrium in different phases related to and influenced by gonadal steroids. These proteins are suggested to interact with each other in the regulation of programmed cell death, apoptosis, but their specific role in growth control of uterine leiomyomas remains to be investigated.     

Fibroblast growth factors (FGF) in human myometrium and uterine leiomyomas in various stages of tumour growth

We previously described that the growth of human uterine leiomyomas was associated with a significant remodelling of the extracellular matrix of these tumours. Significant weight-related increase of collagen and heparan sulphate contents was detected. The latter was known as a component, which bound some peptide growth factors, mainly FGFs, therefore it was decided to evaluate the amounts of acidic FGF (aFGF) and basic FGF (bFGF) in human myometrium and in leiomyomas of various weight and FGF-binding to tissue components. It was found that myometrium and uterine leiomyomas contain picogram amount of aFGF and nanogram amounts of bFGF. No free aFGF was found. Slight amounts of free bFGF were detected both in myometrium and in the tumours. The aFGF and most of bFGF existed in a form of complex with a high molecular component(s). These complexes were very stable and they did not dissociate in denaturation conditions. In comparison to myometrium the tumours contained several times more FGFs and their amounts distinctly increased during the tumour growth. The expression of FGF-receptor I (FGF RI) in the tumours was more distinct in comparison to myometrium. The extracts from myometrium did not bind exogenous 125I-bFGF. In contrast to that the tumours of different weights contained at least two high molecular weight FGF-binding components. One of them (150 kDa) corresponded to FGF-receptor. The other one (190-200 kDa) might be a heparan sulphate-proteoglycan. It seems that aFGF and bFGF play an important role in transformation of normal myometrium into leiomyoma and further growth of this tumour. The action of FGFs on tumour cells enhances biosynthesis of collagen and sulphated glycosaminoglycans, especially heparan sulphate which binds FGFs in the vicinity of cells and facilitates their interaction with membrane receptors. The effect of these processes may be further stimulation of tumour growth and remodelling of tumour extracellular matrix.     

Identification of a uterine elastase in the pregnant rat uterus

During development of the pregnant rat uterus there is a several fold increase in elastin content. Using Verhoeff's elastic fiber stain, we have shown that a significant proportion of these elastin fibers are in the extracellular matrix of the myometrium. They do not appear as an organized structure but rather in a variety of partially extended, random configurations. An elastase was identified in both the pregnant and the postpartum uterus. Partial characterization of the enzyme indicated that it is a serine protease with a molecular weight around 24,500 and a pH optimum of 8.5. In addition to the enzyme, relatively high levels on an elastase inhibitor were found in the uterine extracts. The inhibitor did not inhibit trypsin, indicating that it was not alpha-1-antiprotease. The data suggest that the elastase and inhibitor are uterine tissue derived and perhaps important in the normal remodeling process of uterine connective tissue.     

Neutral metalloendopeptidase associated with the smooth muscle cells of pregnant rat uterus

The pregnant rat uterus contains a membrane-bound metalloendopeptidase that is biochemically and immunologically similar to kidney enkephalinase (E.C.3.4.24.11). The uterus enzyme readily cleaved specific neutral endopeptidase substrates and oxytocin as well as the synthetic elastase substrate, Suc(Ala)3-pNA, yet did not digest native elastin. Using specific inhibitors, the uterus endopeptidase was identified as a metallopeptidase and not a serine protease, having an absolute requirement for zinc and perhaps calcium for maximal activity. The uterus endopeptidase cross-reacted with polyclonal antiserum to kidney microvillar endopeptidase and a monoclonal antibody to common acute lymphocytic leukemia antigen. Immunohistochemical localization of the enzyme in a 17 day pregnant uterus indicated that the enzyme was localized on the smooth muscle bundles of the myometrium and the endometrial epithelium. Total enzyme activity was 25 times higher in the late-term pregnant uterus (17th day of pregnancy) than in the nonpregnant uterus. Enzyme levels dropped rapidly prior to parturition and within 4 days after delivery the enzyme activity had returned to control levels. Inhibition of NEP in uterine strips with phosphoramidon resulted in a marked potentiation of oxytocin-induced contractions. Our results suggest that the uterine endopeptidase may have an important role in regulating uterine smooth muscle cell contraction during the later stages of pregnancy through its action on oxytocin and perhaps other biologically active peptides.     

口服他莫昔芬法建立ICR小鼠子宫腺肌病模型

目的使用口服他莫昔芬法建立ICR小鼠子宫腺肌病模型,并检测其病灶特征、动情周期、血管生成、子宫炎症等变化,以介绍和评价这一动物模型。方法新生ICR小鼠（15只）连续4 d滴喂他莫昔芬,并与同龄对照小鼠（15只）分别于42、85-95、135-145日龄处死,使用苏木素-伊红染色检测子宫病理改变;阴道脱落细胞法检测动情周期变化;免疫组化补体31（CD31）染色计算子宫微血管的密度、直径及所占面积比;逆转录-聚合酶链反应（RT-PCR）检测子宫缓激肽受体、神经激肽受体的基因表达。结果使用口服他莫昔芬法建立ICR小鼠子宫腺肌病模型的造模率为100%,且疾病严重程度随病程进展。部分给药小鼠可出现动情周期紊乱。85-95及135-145日龄给药小鼠子宫肌层微血管密度和面积比均高于对照小鼠（P〈0.05）。135-145日龄给药小鼠子宫缓激肽受体、神经激肽受体的基因表达较对照组明显升高（P〈0.05）。结论口服他莫昔芬法可方便、高效的建立腺肌病小鼠模型,出现腺肌病相关的血管生成、炎症状态、疼痛相关受体表达增高等特征,是研究腺肌病发生、发展的良好模型。     

Environmental estrogens differentially engage the histone methyltransferase EZH2 to increase risk of uterine tumorigenesis

Environmental exposures during sensitive windows of development can reprogram normal physiologic responses and alter disease susceptibility later in life in a process known as developmental reprogramming. For example, exposure to the xenoestrogen diethylstilbestrol during reproductive tract development can reprogram estrogen-responsive gene expression in the myometrium, resulting in hyperresponsiveness to hormone in the adult uterus and promotion of hormone-dependent uterine leiomyoma. We show here that the environmental estrogens genistein, a soy phytoestrogen, and the plasticizer bisphenol A, differ in their pattern of developmental reprogramming and promotion of tumorigenesis (leiomyomas) in the uterus. Whereas both genistein and bisphenol A induce genomic estrogen receptor (ER) signaling in the developing uterus, only genistein induced phosphoinositide 3-kinase (PI3K)/AKT nongenomic ER signaling to the histone methyltransferase enhancer of zeste homolog 2 (EZH2). As a result, this pregenomic signaling phosphorylates and represses EZH2 and reduces levels of H3K27me3 repressive mark in chromatin. Furthermore, only genistein caused estrogen-responsive genes in the adult myometrium to become hyperresponsive to hormone; estrogen-responsive genes were repressed in bisphenol A-exposed uteri. Importantly, this pattern of EZH2 engagement to decrease versus increase H3K27 methylation correlated with the effect of these xenoestrogens on tumorigenesis. Developmental reprogramming by genistein promoted development of uterine leiomyomas, increasing tumor incidence and multiplicity, whereas bisphenol A did not. These data show that environmental estrogens have distinct nongenomic effects in the developing uterus that determines their ability to engage the epigenetic regulator EZH2, decrease levels of the repressive epigenetic histone H3K27 methyl mark in chromatin during developmental reprogramming, and promote uterine tumorigenesis.     

Increase of DNA synthesis in uterine adenomyosis in mice with ectopic pituitary isograft.

Ectopic pituitary isografts (EPI) have been found to induce a high incidence of uterine adenomyosis in SHN mice. All the SHN mice given EPI in the right uterus at 40 days of age developed uterine adenomyosis, and more than 80% of mice showed the genesis of subserosal nodules, an advanced state of adenomyosis, 65 days after EPI. Activities of both thymidylate synthetase and thymidine kinase, i.e. DNA-synthesizing enzymes in de novo and salvage pathways of pyrimidine metabolism, respectively, were significantly increased in EPI-induced uterine adenomyosis to approximately 2-fold those in normal control uteri. Bromodeoxyuridine-immunoreactive cells were regarded as the cells in S phase, and the number in the endometrial epithelium and stroma in EPI-induced uterine adenomyosis was more than 1.5-fold that in normal control uteri. EPI may affect the genesis of uterine adenomyosis generally, but not locally, because there were no differences between the right uterus with EPI and the left without EPI in the incidence of adenomyosis, histology or DNA-synthesizing enzyme activities.     

Aquaporin-1 Increases in the Rat Myometrium During Early Pregnancy

Immunofluorescence and immunogold techniques were used to determine the presence and distribution of aquaporin-1 (AQP1) within the rat uterus. Uterine tissue from non-pregnant (proestrus) as well as pregnant (days 1, 3, 6 and 7) rats were used. It was found that this water channel was present in the myometrium of the pregnant rat uterus with the intensity of AQP1 immunoreactivity increasing from day 1 to day 6 of pregnancy. In particular, an increase was also observed in mesometrial as compared to antimesometrial myometrium. Immunolocalization at the electron microscope level indicated that AQP1 was localized to the plasma membrane of smooth muscle cells found within the inner circular layer. It is suggested that AQP1 plays a role in stromal oedema, uterine closure and orientation of the blastocyst.     

Distribution of vitamin A, retinol-binding protein, cellular retinoic acid-binding protein I, and retinoid X receptor beta in the porcine uterus during early gestation.

Retinol and retinol-binding protein (RBP), among the major secretory products of the uterine endometrium in the uterine fluid of pigs, are assumed to be of importance for early embryonic development. While uterine RBP has been widely characterized, little information is available on the metabolism of vitamin A itself or other specific binding proteins or nuclear receptors in the uterus of pigs. In the present study, the content and distribution of vitamin A in uterine tissue of pigs during early gestation (Days 14-30) were examined macroscopically and microscopically via autofluorescence and HPLC. In addition, the distribution of specific proteins involved in vitamin A metabolism at the cellular and nuclear level was investigated. Macroscopically, the yellowish-greenish autofluorescence characteristic of vitamin A was observed in uterine endometrium. Microscopy showed that the autofluorescence was associated with glandular and surface epithelium of the endometrium. In these structures, immunoreactive RBP was localized, as was cellular retinoic acid-binding protein I. Retinoid X receptor beta was observed in the nucleus of myometrium and endometrium. The intensity of fluorescence decreased with the progress of gestation. This decrease was paralleled by a decrease in vitamin A content of endometrium and myometrium. In general, vitamin A concentration in the endometrium was higher than in the myometrium (P < 0.01). In the myometrium, if present at all, vitamin A was found almost exclusively as retinyl esters. In the endometrium, the dominant fraction was retinol, representing more than 90% of total vitamin A. These results show for the first time that the yellowish-greenish autofluorescence in the pig uterus can be attributed to vitamin A. Differences in the form of vitamin A present in endometrium and myometrium might point to differences in metabolism. In the myometrium, vitamin A might be stored, and in the endometrium, vitamin A is present primarily as retinol-the form in which it is secreted into the uterine fluid.     

Expression of the calcium-activated potassium channel in upper and lower segment human myometrium during pregnancy and parturition

Background  

Large conductance calcium-activated potassium channel (BKCa) plays an important role in the control of uterine contractility during pregnancy. The change from uterine quiescence to enhanced contractile activity may be associated with the spatial and temporal expression of BKCa within myometrium. The objectives of this study were to examine the expression of BKCa alpha- and beta-subunit in upper segment (US) and lower segment (LS) regions of uterus, and to investigate for the possibly differential expression of these proteins in US and LS myometrium obtained from three functional states: (1) non-pregnant (NP); (2) term pregnant not in labour (TNL) and (3) term pregnant in labour (TL).     

Identification of differentially expressed genes in human uterine leiomyomas using differential display

INTRODUCTIONUterine leiomyomas (ULs) have been consideredto be of uniceIIular origin[l1. It is one of the mostcommon benign tumors, occurring in 20% to 30% ofwomen[2], accounting for significant morbidity andusually need major surgery[3] which might causesome side effects afterwards[4]. Therefore, to de-velop certain drug treatments instead has been thehope of these patients for a long time. Using alter-native approaches fOr studying patients sufferingfrom leiomyoma in various ethnic gr…