Functional uterine bleeding; etiologic factors and therapy

Endometrial hyperplasia and irregular shedding of the endometrium comprise the largest group of known causes of functional uterine bleeding.Most patients with functional uterine bleeding have a normal endometrial pattern. In a series of patients with functional uterine bleeding, it was noted that 69.7 per cent of endometrial specimens reported as normal showed evidence of hyalinized tissue which included endometrial glands. Tissue of this type was noted in only 3.5 per cent of curetted specimens from patients without functional uterine bleeding. Diagnostic uterine curettage is the initial step in the management of functional uterine bleeding. Hysterectomy and radiation castration are seldom necessary in the management of functional uterine bleeding and are indicated only under specific circumstances.     

Ultrasound characteristics of uterine myoma before and after uterine artery embolization

The diagnosis and treatment of uterine leiomyoma are topical problems of modern gynecology and radiodiagnosis. Organ-saving treatments for uterine myoma, one of which is uterine artery embolization, are gaining wide acceptance now. The objective of the study was to increase the informative value of ultrasound study to predict the uterine myoma after uterine artery embolization. One hundred uterine myoma patients aged 20 to 52 years were examined. Small pelvic Doppler ultrasonography was carried out in all the patients. The reduction of myomatous nodules was estimated after uterine artery embolization. The decrease in uterine myoma sizes was found to be due to the reduction in their vascularization and the occurrence of ischemia with degeneration in the myoma. Ultrasonography was found to be most accessible and informative in the prognostic and postoperative evaluation of the efficiency of X-ray endovascular treatment for uterine myoma.     

Uterine activity, sperm transport, and the role of boar stimuli around insemination in sows

This paper describes changes in spontaneous myometrial activity around estrus, factors that affect myometrial activity, and the possible role of uterine contractions in the process of (artificial) insemination, sperm transport and fertilization. Myometrial activity in the sow increases during estrus. The activity is myogenic in origin, but several factors have been shown to affect myometrial activity. Natural mating stimulates uterine contractions through several mechanisms. The presence of a boar, rather than the act of mating, induces central oxytocin release in the sow and thus increases uterine activity. Estrogens in the ejaculate of a boar can trigger prostaglandin release by the endometrium and thus increase uterine activity. Tactile stimulation of the genital tract (cervix) or tactile stimulation of the back and flanks of the sow during artificial insemination does not cause a release of oxytocin. There is hardly any evidence for the effects of these latter stimuli on uterine activity, and if they are present at all, the effects are very small. Evidence for the effects of synthetic boar odor on oxytocin release and/or uterine activity is inconsistent. The mere presence of a boar during insemination, in contrast, clearly stimulates uterine activity through the release of oxytocin. Hormonal stimulation (intrauterine) of uterine activity with estrogens, prostaglandins, or oxytocins before, during or after insemination generally improves fertilization rate, especially in situations with reduced fertility. Therefore, uterine contractions are believed to play an important role in the transport of sperm cells to the oviducts after insemination. Whether uterine contractions are absolutely necessary for sperm transport through the uterine horns, however, is not clear. Intensive stimulation of uterine contractions using hormones can also reduce the fertilization rate, probably by increasing the reflux of sperm cells during insemination. In this respect, the presence of a boar during AI seems more adequate, as only sows with a low level of uterine activity show an increase in uterine activity in response to this stimulus.     

Role of polyamines in regulation of uterine blood flow of ovariectomized rats.

Polyamines have been shown to relax several types of smooth muscle including vasculature. In the estrogen-treated uterus, uterine blood flow and polyamine levels in the uterus are increased. The relaxant effect of polyamines on blood vessels suggest that polyamines may act on uterine vasculature to cause uterine hyperemia. In this study, we examined the roles of polyamines in regulating uterine blood flow. Ovariectomized rats were administered with polyamines or estrogen. The uterine blood flow was then measured by employing radioactive microspheres. The direct injection of polyamines into systemic circulation caused a 3-fold increase in uterine blood flow within 30 seconds. The polyamine-induced uterine hyperemia was counteracted by increasing extracellular calcium concentration. When rats were treated with estradiol, uterine blood flow increased. However, the treatment with alpha-difluromethylornithine, a polyamine synthesis inhibitor, did not attenuate the estrogen-induced uterine blood flow. Our results suggest that polyamines may affect uterine blood flow via antagonizing the entry of extracellular calcium. However, the detailed mechanisms via which polyamines involved in estrogenic stimulation of uterine hyperemia may require further studies.     

The relationship between uterine pathogen growth density and ovarian function in the postpartum dairy cow

In cattle, the first postpartum dominant follicle grows slower and produces less oestradiol in animals with high numbers of bacteria contaminating the uterine lumen. However, only bacteria that are uterine pathogens are correlated with severe clinical disease and an increased inflammatory response. It is unknown whether the effect on the ovary in relation to uterine bacterial contamination is associated with the presence of recognised uterine pathogens. Therefore, the present study examined the relationship between pathogenic bacteria in the postpartum uterine lumen, follicle growth and function and the formation of a competent corpus luteum. In addition, peripheral plasma concentrations of immune mediators were quantified. Swabs were collected from the uterine lumen of cattle on day 7 postpartum. Bacteria were cultured and identified and bacterial growth was scored semi-quantitatively. Animals were categorized into high or low recognized uterine pathogen contamination groups based on the number of colonies. Ovarian structures were monitored by daily transrectal ultrasonography and blood samples were collected. In animals with high numbers of uterine pathogens on day 7 postpartum, the diameter of the first postpartum dominant follicle was smaller and plasma oestradiol concentrations were lower. In addition, these animals had smaller corpora lutea, which produced less progesterone. Furthermore, animals with a high day 7 uterine pathogen growth density had higher peripheral concentrations of acute phase proteins. Thus, contamination of the uterus with recognized uterine pathogens is associated with ovarian dysfunction during the postpartum period. Furthermore, infection results in an increase in the production of inflammatory mediators.     

Mucus and the mare: how little we know

Uterine infections are a major cause of infertility, but the role of mucus in equine uterine defense is not well understood. Mucociliary currents play an important role in protecting mucous membranes, including the upper and lower respiratory tracts of mammals, and are required for feeding and oxygenation of many aquatic invertebrates. Although phagocytosis has long been considered the first line of uterine defense in the mare, there are concerns about its efficacy in the uterine lumen. Additional local defenses, such as mucociliary currents, have therefore been proposed. The uterine epithelium exhibits alternating mucus-secreting and ciliated cells supporting a mucopolysaccharide blanket, features shared with mucociliary membranes throughout the animal kingdom. Gross uterine anatomy, such as continuity of uterine and cervical folds, may indicate adaptations to mucociliary clearance. In addition, ciliated cells obtained in uterine lavages often display motility. Disruptions of mucociliary clearance play major roles in pathogenesis of mucosal infections in humans, including pneumonia, chronic sinusitis, and otitis media. Establishing drainage is a major goal of therapy in treatment of chronic sinusitis, hastening return of mucociliary function. Similar disruptions may occur in equine uterine infections, associated with accumulations of uterine fluid, loss of endometrial folds, and cervical trauma. Possible clinical implications of mucociliary clearance in the mare are discussed, however the role of mucociliary clearance in the mare remains speculative.     

Increase in uterine peroxidase activity in the rat uterus during oestrogen hyperaemia.

The administration of oestrogen results in increased arterial blood flow in all mammalian species studied to date, but its mechanism of action has not been elucidated. Because an interval of 30-60 min is observed between oestrogen injection and uterine hyperaemia, it has been suggested that a vasoactive intermediate is involved and recent evidence suggests that catechol oestrogens are the vasoactive oestrogen intermediates. Uterine peroxidase catalyses the conversion of oestrogens to their catechol forms and thus may play an important role in oestrogen-induced uterine hyperaemia. The present studies evaluated the time course and dose-response effects of oestrogen on uterine peroxidase activity and related these to changes in uterine blood volume, an index of uterine hyperaemia in immature rats. These data demonstrated that the minimal effective hyperaemic dose of oestradiol also increased (P less than 0.05) uterine peroxidase activity. The oestradiol-induced increase in uterine peroxidase activity preceded significant increases in uterine blood volume (1 h versus 2 h, respectively). These data are consistent with a role for peroxidase-mediated conversion of oestradiol to catechol oestradiol in facilitating uterine hyperaemia in rats.     

Dysregulation of uterine signaling pathways in progesterone receptor-cre knockout of dicer

Epithelial-stromal interactions in the uterus are required for normal uterine functions such as pregnancy, and multiple signaling pathways are essential for this process. Although Dicer and microRNA (miRNA) have been implicated in several reproductive processes, the specific roles of Dicer and miRNA in uterine development are not known. To address the roles of miRNA in the regulation of key uterine pathways, we generated a conditional knockout of Dicer in the postnatal uterine epithelium and stroma using progesterone receptor-Cre. These Dicer conditional knockout females are sterile with small uteri, which demonstrate significant defects, including absence of glandular epithelium and enhanced stromal apoptosis, beginning at approximately postnatal d 15, with coincident expression of Cre and deletion of Dicer. Specific miRNA (miR-181c, -200b, -101, let-7d) were down-regulated and corresponding predicted proapoptotic target genes (Bcl2l11, Aldh1a3) were up-regulated, reflecting the apoptotic phenomenon. Although these mice had normal serum hormone levels, critical uterine signaling pathways, including progesterone-responsive genes, Indian hedgehog signaling, and the Wnt/β-catenin canonical pathway, were dysregulated at the mRNA level. Importantly, uterine stromal cell proliferation in response to progesterone was absent, whereas uterine epithelial cell proliferation in response to estradiol was maintained in adult uteri. These data implicate Dicer and appropriate miRNA expression as essential players in the regulation of multiple uterine signaling pathways required for uterine development and appropriate function.     

Mice-lacking LMP2, immuno-proteasome subunit,as an animal model of spontaneous uterine leiomyosarcoma

Uterine tumors are the most common type of gynecologic neoplasm. Uterine leiomyosarcoma (LMS) is rare, accounting for 2% to 5% of tumors of the uterine body. Uterine LMS develops more often in the muscle tissue layer of the uterine body than in the uterine cervix. The development of gynecologic tumors is often correlated with female hormone secretion; however, the development of uterine LMS is not substantially correlated with hormonal conditions, and the risk factors are not yet known. Radiographic evaluation combined with PET/CT can be useless in the diagnosis and surveillance of uterine LMS. Importantly, a diagnostic biomarker, which distinguishes malignant LMS and benign tumor leiomyoma (LMA) is yet to be established. Accordingly, it is necessary to analyze risk factors associated with uterine LMS in order to establish a method of treatment. LMP2-deficient mice spontaneously develop uterine LMS, with a disease prevalence of ~40% by 14 months of age. It is therefore of interest whether human uterine LMS shows a loss of LMP2 expression. We found LMP2 expression is absent in human LMS, but present in human LMA. Therefore, defective LMP2 expression may be one of the risk factors for LMS. LMP2 is potentially a diagnostic biomarker for uterine LMS, and gene therapy with LMP2-encording DNA may be a new therapeutic approach.     

Uterine and chorioallantoic angiogenesis and changes in the uterine epithelium during gestation in the viviparous lizard,niveoscincus conventryi (squamata: scincidae)

We used immunofluorescent confocal microscopy and scanning electron microscopy to quantify uterine vascularity and to describe uterine surface morphology during gestation in pregnant females of the lecithotrophic lizard Niveoscincus coventryi. As uterine angiogenesis and epithelial cell morphology are thought to be under progesterone control, we studied the effect of a progesterone receptor antagonist (mifepristone) on uterine and chorioallantoic microvasculature and features of the uterine epithelial surfaces. Although intussuceptive angiogenesis was observed in both, uterine and chorioallantoic, vascular beds during gestation, the only significant increases were in the diameters of the uterine vessels. An ellipsoid vessel‐dense area grows in the mesometrial hemisphere of the developing conceptus, which parallels the expansion of the allantois to form the chorioallantoic placenta. Uterine surface topography changed during gestation. In particular, uterine blood vessels bulge over the luminal surface to form marked ridges on the uterine embryonic hemisphere, especially during the last stage of pregnancy, and ciliated cells are maintained in the embryonic and abembryonic hemispheres but disappear in both the mesometrial and antimesometrial poles. This distinct regionalization of uterine ridges and ciliated cells in the uterine surface and in the shape of the epithelial component of the chorion might be related to the function of both chorioallantoic and yolk sac placentae during gestation. There was no significant difference between females treated with or without mifepristone, which may be related to the partial function of mifepristone as a progestin antagonist and/or with the function and time of action of progesterone in the uterus during gestation in N. coventryi. Differences in the pattern of angiogenesis and uterine surface morphology during gestation among squamates may be related to the functional diversity of the uterine component of the different placentae and probably reflect its diverse evolutionary history. J. Morphol., 2011. © 2011 Wiley Periodicals, Inc.     

Intrauterine oxytocin system

At term, uterine epithelial cells express oxytocin (OT) as well as the OT receptor (OTR). Like other epithelial cells, uterine epithelial cells are polarized and sort secretory and membrane components to the apical or the basolateral cell surface. We have studied the subcellular localization of OT-like immunoreactivity (OT-IR) and OTR-IR in rat uterine epithelium by immuno-gold labelling of ultrathin frozen sections. Our observations indicate that OT and OTR are both distributed preferentially to the apical surface of rat uterine epithelial cells. OT-IR showed a 6-fold apical versus basolateral preference and was localized in apical secretory vesicles, suggesting that uterine OT is released by apical exocytosis. OTR-IR was localized to the apical surface with a 9-fold apical versus basolateral preference and was found specifically in association with apical microvilli. The present findings represent the first example of a G protein-coupled receptor that is preferentially localized on the microvillar compartment and support the concept of an autocrine uterine OT system at the apical side of the uterine epithelium.     

Implantation-associated proteinase in mouse uterine fluid

Proteinase activity was detected in mouse uterine fluid by means of a new casein-substrate assay. The activity was found to be generally low in diestrous and proestrous stages of the estrous cycle and was more variable in proestrous. During pregnancy, activity was very low on day 1 (counting the plug date as day 0). By day 3, proteinase activity (expressed as Pronase equivalents/mg protein of uterine fluid) increased more than 100-fold, and then declined on day 4. Peak activity thus coincides with initiation of embryo implantation, which occurs on day 3 of pregnancy in the strain tested. The results provide direct biochemical support for previous indirect bioassay indications of the presence in uterine fluid of a proteolytic factor of uterine origin. The quantitative changes observed here are also consistent with previous bioassay observations and with the hypothesis that the uterine proteinase may mediate initial attachment of the blastocyst to the uterine wall. These and other data are used to formulate a 2-stage hypothesis of implantation, according to which uterine and trophoblast proteinases act sequentially to cause attachment and invasion, respectively.     

Secretory proteins in the reproductive tract of the snapping turtle, Chelhydra serpentina

SDS-polyacrylamide gel electrophoresis was used to separate the secretory proteins produced by the epithelial and endometrial glands of the uterine tube and uterus in the snapping turtle Chelydra serpentina. The proteins were analyzed throughout the phases of the reproductive cycle from May to August, including preovulatory, ovulatory, postovulatory or luteal, and vitellogenic phases. The pattern of secretory proteins is quite uniform along the length of the uterine tube, and the same is true of the uterus, but the patterns for uterine tube and uterus are clearly different. We identify 13 major proteins in C. serpentina egg albumen. Bands co-migrating with 11 of these are found in the uterine tube, but at most 4 are found in the uterus, suggesting that the majority of the albumen proteins are most likely secreted in the uterine tube, not in the uterus. Although some of the egg albumen proteins are present in the uterine tube only at the time of ovulation, most of the bands corresponding to albumen proteins are present throughout the breeding season even though the snapping turtle is a monoclutch species. These results suggest that the glandular secretory phase in the uterine tube is active and quite homogeneous in function regardless of location or phase of the reproductive cycle.     

The Eker rat: establishing a genetic paradigm linking renal cell carcinoma and uterine leiomyoma

Renal Cell Carcinoma (RCC) and uterine leiomyoma (often referred to as fibroids) are tumors arising from tubular epithelium and myometrial compartments of the kidney and uterus, respectively. These tumors have a very different clinical presentation, with RCC being one of the less common cancers, having a very poor prognosis, and occurring predominantly in men, whereas uterine leiomyoma are the most common tumor of women and are benign. Although they are distinct histologically, with RCC arising from epithelial cells and leiomyoma arising from smooth muscle cells, they share a common embryological origin. Renal tubular epithelial cells arise during nephrogenesis as a result of the mesenchymal-epithelial transition of condensed mesenchyme induced by the developing ureteric bud, and have a shared mesenchymal lineage with smooth muscle cells of the uterus. In addition to a common embryological origin, RCC and leiomyoma have been demonstrated to share a common genetic etiology. The Eker rat model was the first demonstration of a specific genetic linkage between RCC and uterine leiomyoma. Eker rats carry a germline defect in the rat homologue of the tuberous sclerosis complex 2 (TSC-2) tumor suppressor gene and develop spontaneous RCC and uterine leiomyoma with a high frequency. TSC patients are also at risk for RCC, and sporadic human uterine leiomyomas exhibit loss of function of the TSC-2 gene product, tuberin. Individuals with the inherited cancer syndrome hereditary leiomyomatosis and renal cell cancer (HLRCC) that have germline defects in the fumarate hydratase (FH) gene develop papillary RCC and uterine and skin leiomyomas. Benign cutaneous lesions and uterine leiomyoma also arise in German Shepherd dogs with germline mutations in the Birt-Hogg-Dube (BHD) gene, and these animals develop RCC and uterine leiomyoma with a high frequency. Identification of the tumor suppressor genes involved in these diseases, TSC, FH and BHD, and the elucidation of the function of their protein products, tuberin, fumarate hydratase and folliculin, respectively, opens new avenues for understanding the pathogenesis of both RCC and uterine leiomyoma.     

Storage and Release of Spermatozoa from the Pre-Uterine Tube Reservoir

In mammals, after coitus a small number of spermatozoa enter the uterine tube and following attachment to uterine tube epithelium are arrested in a non-capacitated state until peri-ovulatory signalling induces their detachment. Whilst awaiting release low numbers of spermatozoa continually detach from the epithelium and the uterine tube reservoir risks depletion. There is evidence of attachment of spermatozoa to uterine epithelium in several species which might form a potential pre-uterine tube reservoir. In this study we demonstrate that: (1) dog spermatozoa attach to uterine epithelium and maintain flagellar activity, (2) in non-capacitating conditions spermatozoa progressively detach with a variety of motility characteristics, (3) attachment is not influenced by epithelial changes occurring around ovulation, (4) attachment to uterine epithelium slows capacitation, (5) capacitated spermatozoa have reduced ability to attach to uterine epithelium, (6) under capacitating conditions increased numbers of spermatozoa detach and exhibit transitional and hyperactive motility which differ to those seen in non-capacitating conditions, (7) detachment of spermatozoa and motility changes can be induced by post-ovulation but not pre-ovulation uterine tube flush fluid and by components of follicular fluid and solubilised zona pellucida, (8) prolonged culture does not change the nature of the progressive detachment seen in non-capacitating conditions nor the potential for increased detachment in capacitating conditions. We postulate that in some species binding of spermatozoa to uterine epithelium is an important component of the transport of spermatozoa. Before ovulation low numbers of spermatozoa continually detach, including those which are non-capacitated with fast forward progressive motility allowing the re-population of the uterine tube, whilst around the time of ovulation, signalling from as-yet unknown factors associated with follicular fluid, oocytes and uterine tube secretion promotes the detachment of large numbers of capacitated spermatozoa with hyperactive motility that may contribute to the fertilising pool.     

Unique sensitivity to alpha-galactosylceramide of NKT cells in the uterus

It was previously reported that NKT cells, which are mainly present in the liver of mice, are also present in the uterus and that these uterine NKT cells are associated with abortion under overactivated conditions. In this study, we further examined their phenotypic and functional properties. In parallel with the progression of pregnancy, the number of uterine lymphocytes increased. This increase accompanied an increase in the number of TCRalphabeta(+) T cells and NKT cells in the uterus, although the number of NKT cells decreased at late pregnancy. Approximately one-third of the TCRalphabeta(+) cells were NKT cells at the early pregnant stage, while this ratio decreased toward late pregnancy. These uterine NKT cells were found to respond to alpha-galactosylceramide (alpha-GalCer) differently in comparison with liver NKT cells. In contrast to the apoptotic response of liver NKT cells on day 1 after alpha-GalCer injection, uterine NKT cells expanded prominently without such apoptosis. The majority of liver NKT cells were CD4(+). In contrast, almost all of the uterine NKT cells were double negative CD4(-)8(-). However, similar to liver NKT cells, uterine NKT cells used an invariant chain of Valpha14Jalpha281 gene for TCRalpha. The resistance against apoptosis might be due to the high expression of bcl-2 on uterine NKT cells after alpha-GalCer activation. Other evidence was that macrophages which existed in the pregnant uterus carried an activation marker, CD69, and could potentially produce many cytokines by their activation. The present results suggest that uterine NKT cells and surrounding macrophages are quite different in function from those in the liver.     

Placental Type Interactions and Evolutionary Trends of Development of Uterus in Cestodes

In Proteocephalus thymalli and P. torulosus, a contact of the placental type in uterus was shown to be formed at two different levels. At the first level an interaction occurs between outgrowths of uterine epithelium and thin capsule of embryos closely adjacent to uterine wall. The next level is formation of contact between neighboring egg capsules, which allows distributing nutrients among fetuses present in the uterine cavity. Placental interactions in Clestobothrium acheilognathi are limited in time and space. First, a relatively small number of eggs are involved in interaction of the placental type in the uterine sac, while uterine duct is filled with freely lying eggs. Second, the closest contact is observed in eggs with non-sclerosed egg shell. One of the main evolutionary tendencies in cestodes has been shown to be a modification of uterus for formation of close interrelations with embryonic membranes in the course of transition from the extrauterine to the intrauterine type of embryonic development. Uterus in parasites with a polylecital type of the egg is suggested to serve to the greater extent as a reservoir, whereas in cestodes with oligolecital eggs, uterus performs its direct function—supply of developing embryos with nutrients. As a result, modifications of uterine epithelium are formed: from the appearance of the placental type interactions formed repeatedly in phylogenetically distant groups of cestodes to formation of branched outgrowths separating the uterine space into units or disintegration to actively functioning uterine capsules.     

The structure and formation of the egg-shell of Syphacia obvelata Rudolphi (Nematoda: Oxyurida)

The egg of Syphacia obvelata is a flattened elipsoid. The egg-shell consists of 5 layers: external uterine layer, internal uterine layer, vitelline layer, chitinous layer and lipid layer. An operculum is present at one pole of the egg. The opercular groove consists of a break in the uterine layers and the modification of the chitinous layer by the deposition of lipoprotein material. On the curved side of the egg the uterine layers are modified to form alternate ridges and depressions. Discrete spaces are present in the internal uterine layer between the ridges. These are open to the exterior via pores in the external uterine layer. The structure of the uterine layers is quite different on the flattened side of the egg. The morphology of the reproductive system and the formation of the egg-shell is described. It is suggested that the complex structure of the uterine layers of oxyurids forms by a self-assembly process.     

Dynamic changes to claudins in the uterine epithelial cells of the marsupial Sminthopsis crassicaudata (Dasyuridae) during pregnancy

The fluid that surrounds the embryo in the uterus contains important nourishing factors and secretions. To maintain the distinct microenvironment in the uterine lumen, the tight junctions between uterine epithelial cells are remodeled to decrease paracellular movement of molecules and solutes. Modifications to tight junctions between uterine epithelial cells is a common feature of pregnancy in eutherian mammals, regardless of placental type. Here we used immunofluorescence microscopy and western blot analysis to describe distributional changes to tight junctional proteins, claudin‐1, ‐3, ‐4, and ‐5, in the uterine epithelial cells of a marsupial species, Sminthopsis crassicaudata. Immunofluorescence microscopy revealed claudin‐1, ‐3, and ‐5 in the tight junctions of the uterine epithelium of S. crassicaudata during pregnancy. These specific claudins are associated with restricting passive movement of fluid between epithelial cells in eutherians. Hence, their function during pregnancy in S. crassicaudata may be to maintain the uterine luminal content surrounding developing embryos. Claudin‐4 disappears from all uterine regions of S. crassicaudata at the time of implantation, in contrast with the distribution of this claudin in some eutherian mammals. We conclude that like eutherian mammals, distributional changes to claudins in the uterine epithelial cells of S. crassicaudata are necessary to support pregnancy. However, the combination of individual claudin isoforms in the tight junctions of the uterine epithelium of S. crassicaudata differs from that of eutherian mammals. Our findings suggest that the precise permeability of the paracellular pathway of the uterine epithelium is species‐specific.