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.     

B 超引导下子宫内膜消融术治疗更年期功血51 例临床分析

目的:探讨在B超引导下子宫内膜消融术治疗更年期功血的效果。方法:扩张宫颈至6.5号,吸宫,在B超监视下由子宫右前壁始向外刮凝,依次顺时针方向刮凝宫腔2周。结果:治愈31例(60.8%),有效19例(37.3%),好转1例(1.9%),无效0例。结论:电凝刀子宫内膜消融术与其他更年期功血治疗方法相比,消融的范围及深度由B超监视,安全性高,创伤小,不开刀,恢复快,并且治愈率高,更容易在临床上推广。     

体外受精-胚胎移植412个周期分析

IVF-ET(in vitro fertilization and embryo transfer)的临床妊娠率受多种因素的影响:妇女年龄,子宫内膜厚度,促性腺激素(Gonadtropin,Gn)的用量,移植胚胎数以及胚胎质量。回顾性分析本生殖中心2000年9月到2002年7月的IVF/ICSI(intra cytoplasmic sperm injection)共412个周期。并将所有周期按照年龄分成3组,随年龄的增长3组的妊娠率分别是42.31％、33.70％、28％;子宫内膜的厚度与临床妊娠率无显著性相关;促性腺激素的用量与临床妊娠率呈负相关(P<0.05);移植胚胎数及优质胚胎数与临床妊娠率呈显著性正相关(P<0.05)。     

Uterine growth-promoting effects of relaxin: a morphometric and histological analysis

The hormone relaxin has been implicated in the regulation of several processes in the reproductive tract during pregnancy and parturition. This study investigated the uterine effects of relaxin in immature and mature ovariectomized, estrogen-primed rats using morphometric and histochemical analysis. Rats were sprayed at 30 or 70 days of age and given estrogen (5 micrograms) 7 days later. After a week, they received an injection of porcine relaxin (100 micrograms) and were killed 6 h later; controls received vehicle alone. Histological sections were obtained from 7 levels of each uterine horn, and the volumes of endometrium and myometrium were calculated by use of a Zeiss Videoplan Computer Image Analyzer. In immature animals, relaxin treatment doubled uterine weights during the treatment period, and cross sections from relaxin-treated animals exhibited significant increases in the areas of both the myometrium and endometrium, 150% and 130% respectively. Mature animals were less responsive to relaxin although they also exhibited significant increases in uterine weight (31%), myometrial volume (29%), and endometrial volume (22%). With the use of Masson's Trichrome stain for collagen, we observed that relaxin alters the connective tissue framework of both endometrium and myometrium; control uterine collagen appears highly organized and dense with compact collagen fibers, whereas the collagen of relaxin-treated uteri is loosely arranged and disorganized with widely separated collagen fibers. Relaxin-stimulated uteri exhibited significantly greater vascularization, as evidenced by the size of arteries and veins in the vascular region between the circular and longitudinal muscle layers. Increased vascularization and uterine blood flow may be one mechanism involved in relaxin's uterotropic effect and is being investigated further.(ABSTRACT TRUNCATED AT 250 WORDS)     

Abdominal pregnancies in farm rabbits

Abdominal pregnancy is defined as the implantation and development of a fertilized ovum or a embryo in the peritoneal cavity. Although this has been reported in several species, it is considered as a low incidence process. It is classified as a primary abdominal pregnancy, if there is no evidence of uterine rupture, with presumed regurgitation of early embryos from the uterine tube and as a secondary abdominal pregnancy, when there is evidence of uterine rupture. During a necropsy study of 550 adult fertile female New Zealand white rabbits (Oryctolagus cuniculus) from two rabbit farms in Valencia (Spain), the main causes of elimination were studied. Twenty-eight abdominal pregnancies were diagnosed. Seven animals showed no lesions in their reproductive tract. The remaining twenty one animals showed acute or chronic lesions in the reproductive tract. The classification as a primary or secondary condition is discussed. It may be concluded therefore that extrauterine pregnancies would not be such an unusual finding in rabbits, and that this premise should be considered in the diagnostic approach when assessing rabbit doe pathology. New husbandry systems in rabbits such as artificial insemination are factors to be considered.     

Some aspects of immunology of the bovine uterus related to treatments for endometritis

Endometritis in breeding cattle occurs during the postpartum period, and is associated primarily with contamination of the reproductive tract involving Arcanobacter pyogenes (formerly Actinomyces pyogenes) together with Gram-negative anaerobes. Polymorphonuclear inflammatory cells (PMNs) contribute partly to the defense mechanisms against micro-organisms contaminating the vagina and uterine lumen, whose phagocytic activity depends on bacterial opsonisation by humoral antibodies; significant numbers of lymphocytes are also present. Whilst leukocyte numbers in the uterine lumen are relatively high during metoestrus and dioestrus compared to other phases of the oestrous cycle, their functional activity is unaffected. Humoral antibody concentrations in the reproductive tract are stimulated following exposure to local antigen, and the response is site dependent; of the several different classes of immunoglobulins, IgG predominates in the uterus and IgA the vagina. Only a portion of the total IgG1 found on the uterine lumen is synthesised locally in the endometrium, the remainder and all of the IgG2 is derived from the local uterine blood supply. Generally, concentrations of immunosuppressant proteins present in the uterine lumen increase under progesterone dominance, and these inhibit lymphocyte proliferation, making the uterus more susceptible to infection. The relationship between uterine susceptibility to micro-organism contamination and the luteal phase of the oestrous cycle is still unclear. Intrauterine infusion of immunomodulators such as E. coli lipopolysaccharides (LPS) or oyster glycogen, in healthy cows and those with endometritis, stimulates leukocytes to migrate into the uterine lumen. At a dosage rate of 100 microg, lipopolysaccharides are not absorbed by the healthy endometrium and do not alter the oestrous cycle length. It is unknown, whether a similar dose can be absorbed through an inflamed endometrium in naturally occurring cases of endometritis to cause systemic illness. Currently, prostaglandin F2alpha is recommended for treating endometritis in both cycling and non-cycling cows, but its mode of action in non-cycling cows is not fully understood. The efficacy of endometritis treatment using an intrauterine infusion of an immunomodulator in cases occurring naturally has not been determined on a large scale.     

DNA content and the endometrial cellular mitotic activity in the phase of menstrual bleeding

Endometrium obtained during menses from 46 healthy women in reproductive age was investigated morphologically and cytospectrophotometrically in order to solve the problem on the source of the cells reepithelizing the uterine mucous membrane after desquamation. It was stated that desquamation takes place not in the whole functional layer of endometrium, some mucous fragments, covered with persisting luminal epithelium, are always preserved. During endometrial regeneration the cells of the luminal and glandular epithelia and those of endometrial stroma are predominantly diploid. The amount of premitotic cells in population is so small that they cannot secure any intensive cellular proliferation. Mitogenesis in endometrium is stimulated only after a complete restoration of the epithelial layer. It is suggested that persisting luminal epithelium is the source of cells for reepithelization; they migrate towards endometrial "wounds" and repair defects in the uterine mucosa during the regeneration phase.     

Hysterographic appearance and uterine histology at different stages of the reproductive cycle and after progestagen treatment in the domestic cat

The aims of this study were to characterize the hysterographic and histological features of the uteri and to perform immunohistochemistry with proliferating cell nuclear antigen (PCNA) in the cat endometrium at various stages of the reproductive cycle and after treatment with exogenous progestagen. Seventy-four female domestic cats submitted for routine ovariohysterectomy were categorized into six groups: inactive (n=20), follicular (n=9), luteal (n=18), and postpartum (n=12) stages of the reproductive cycle; cats given medroxyprogesterone acetate for estrus prevention (MPA group) (n=12); and cats with uterine pathological lesions (n=3). Hysterography was performed and the relation of the uterine and luminal shape in the hysterogram with the stage of the reproductive cycle as well as with any pathological conditions of the uterus was evaluated. The uteri and ovaries were thereafter surgically removed and sectioned for histological examination. The PCNA was used to demonstrate the expression of endometrial epithelial cell growth. The hysterographic appearance was found to differ between the six groups of cats. A straight uterine cavity was characteristic for cats in the inactive stage, whereas a wavy uterine cavity was characteristic for cats in the follicular stage. In the luteal stage, the luminal cavity of the uteri differed in shape with increasing progesterone concentration from straight to irregular wavy or coiled. The coil shaped uterine lumen seen in the MPA treated and pathological groups was considered also to be an expression of a progestagenic effect. Waviness and coiling of the uterine lumen was related to a proliferation of the endometrial glands, whereas irregular filling defects were indicative of endometrial cystic changes. This study is the first to demonstrate the expression of PCNA in the cat endometrium although no differences were found between the six groups of cats. The hysterographic appearance was found to differ according to stage of the reproductive cycle and pathological conditions. Thus, a normative hysterogram is now available for diagnosing the reproductive stage and uterine changes in cats developing endometrial hyperplasia with and without cystic changes.     

Transcervical resection of endometrium in women with menorrhagia.

As an alternative to hysterectomy 16 women with menorrhagia were treated with hysteroscopic transcervical resection of the endometrium with an unmodified urological resectoscope. Twelve patients requested total resection of the endometrial lining with the intention of producing amenorrhoea, and four chose partial resection and hypomenorrhoea. Surgery was completed successfully in 15; the remaining woman, who had an acutely retroflexed uterus, sustained a uterine perforation during insertion of the rigid hysteroscope. There were no important postoperative complications, and 13 patients were discharged from hospital the day after operation. Follow up for up to six months showed beneficial effects on the duration of menses and the subjective assessment of menstrual blood loss and pain in the treated women, six of them becoming amenorrhoeic after total resection. Hysteroscopy at three months in 13 patients showed fibrosis confined to the upper half of the uterine cavity. Endouterine biopsy specimens showed the presence of microscopic deposits of normal endometrium in 10 women. Although these results are preliminary, transcervical resection of the endometrium may have an important role in managing this common complaint.     

The uterine length in women with Turner syndrome reflects the postmenarcheal daily estrogen dose

AIM: To evaluate the effects of estrogen substitution on the uterine development in patients with Turner syndrome. METHOD: 57 women, aged 18.1-41.5 years, were treated with estrogen from puberty induction. RESULTS: In 21 women (37%), the uterus developed to >65 mm in length. The daily estrogen dose correlated with both uterine length (r = 0.29; p < 0.05) and Tanner breast stage (r = 0.44; p < 0.001). A negative correlation between age at artificial menarche and uterine length was found (r = -0.29; p < 0.05). The endometrium thickness was greater in women with an uterus length >65 mm (p < 0.05). In 50% of the women (18 were evaluated), an adult-shaped uterus developed. Previous growth hormone therapy (n = 32) had no impact on the uterus length. CONCLUSIONS: The uterine development was suboptimal in most patients. Further investigation is needed to optimize estrogen therapy for uterine development in patients with Turner syndrome.     

Effect of the bovine viral diarrhea (BVD) virus on the endometrium of the rabbit

The objective of this study was to determine the effect of BVD virus on the rabbit's endometrium. Six New Zealand White does (3-4 kg bwt) were used. Blood samples were obtained before treatment and euthanasia for determination of estrogen and progesterone. Does were anesthetized and both uterine horns identified through a midventral incision. Each horn was doubly-ligated at both cervical and ovarian ends. The right uterine horn (control) was injected with 1ml Eagle's MEM and the left (treated) with 1ml BVD virus (Singer strain, 10(3) CCID(50/ml)). Two does each were euthanized at 48h, 72h and 144h post-inoculation (PI) and uterine samples obtained for viral assay and light microscopic examination. Serum hormonal levels showed that all does were in the estrogenic phase before treatment and euthanasia. Viral isolation was negative for all samples taken. On each day examined, there were no histopathologic lesions in the control uterine horn. However, in the treated horn at 48h PI there was evidence of a purulent endometritis. At 72h and 144h PI there was mononuclear cell infiltration of the stratum compactum, but no other obvious lesions. A common feature in both treated and control uterine horns was mitosis of both endometrial and glandular epithelia. Results of this study suggest that BVD virus can induce histopathologic lesions of the rabbit's endometrium, the most obvious effect being at 48h PI.     

Cholinesterase Activities in Uterus of Normal and Fenchlorphos Treated Blue Foxes (Alopex Lagopus) during Various Reproductive States

The uterine acetylcholinesterase and total cholinesterase (acetylcholinesterase plus butyrylcholinesterase) activities in normal and fenchlorphos treated blue fox vixens were determined during various reproductive states. AChE and Total-ChE of non-medicated vixens in oestrus were about one half of those in anoestrus. In pregnant uteri (luteal phase) the activities were 25 % and 30% compared to anoestrus. In vixens given 100 mg/kg fenchlorphos for 3 weeks during anoestrus, the remaining activity of AChE in uterus were in average 37%. Pregnant and non-pregnant vixens in the luteal phase medicated prior to mating and during time of implantation, displayed AChE activities which were only moderabely reduced (remaining activities 83% and 72% compared to medicated animals in anoestrus: remaining activity 37%). Plasma ChE-activity increased during pregnancy in the controls while enzyme activity was strongly reduced in animals given 100 mg/kg fenchlorphos daily through the whole pregnancy. It was concluded that the previous reported embryotoxic effect of fenchlorphos in the blue fox did not seem to be directed towards the moderate inhibition of the uterine cholinesterases.     

Deregulation of the serum- and glucocorticoid-inducible kinase SGK1 in the endometrium causes reproductive failure

Infertility and recurrent pregnancy loss (RPL) are prevalent but distinct causes of reproductive failure that often remain unexplained despite extensive investigations. Analysis of midsecretory endometrial samples revealed that SGK1, a kinase involved in epithelial ion transport and cell survival, is upregulated in unexplained infertility, most prominently in the luminal epithelium, but downregulated in the endometrium of women suffering from RPL. To determine the functional importance of these observations, we first expressed a constitutively active SGK1 mutant in the luminal epithelium of the mouse uterus. This prevented expression of certain endometrial receptivity genes, perturbed uterine fluid handling and abolished embryo implantation. By contrast, implantation was unhindered in Sgk1-/- mice, but pregnancy was often complicated by bleeding at the decidual-placental interface and fetal growth retardation and subsequent demise. Compared to wild-type mice, Sgk1-/- mice had gross impairment of pregnancy-dependent induction of genes involved in oxidative stress defenses. Relative SGK1 deficiency was also a hallmark of decidualizing stromal cells from human subjects with RPL and sensitized these cells to oxidative cell death. Thus, depending on the cellular compartment, deregulated SGK1 activity in cycling endometrium interferes with embryo implantation, leading to infertility, or predisposes to pregnancy complications by rendering the feto-maternal interface vulnerable to oxidative damage.     

Aquaporin-2 expression in human endometrium correlates with serum ovarian steroid hormones

The aim of the present study was to examine the expression of aquaporin-2 (AQP2), a member of the water channel family aquaporins (AQPs), in human uterine endometrium and its modulation of ovarian steroid hormone at the proliferative and secretory phases. Western blot, immunohistochemistry, and RT-PCR were employed in the present study. Western blot revealed a 29-kDa band that represented AQP2 in human endometrium. The expression of AQP2 in endometrium was confirmed by RT-PCR and immunohistochemical results. The immunohistochemical analysis demonstrated that AQP2 was prominent in luminal and glandular epithelial cells of endometrium. The levels of endometrial AQP2 expression changed during the menstrual cycle and were higher in the secretory endometrium than in the proliferative endometrium. A significantly high level of AQP2 was detected at the mid-secretory phase. There was a positive correlation between the levels of the endometrial AQP2 expression and the concentrations of the serum 17beta-estradiol (E2) or/and progesterone (P4). These data for the first time corroborate that AQP2 is expressed in human endometrium and that the expression of AQP2 in human endometrium might be regulated by E2 or/and P4. The changed expression of AQP2 at different phases of the menstrual cycle may be essential to reproductive physiology in human. The high level of endometrial AQP2 expression was observed at the mid-secretory phase, the time of embryo implantation, suggesting that AQP2 might play physiological roles in the uterine receptivity.     

Coexpression and estrogen-mediated regulation of TRPV6 and PMCA1 in the human endometrium during the menstrual cycle

Maintenance of calcium balance in the uterus is essential for many of its functions, including embryo implantation. The plasma membrane Ca²⁺‐pumping ATPase proteins are encoded by four genes designated PMCA1‐4, and PMCA1 is expressed in the uterus of rats during the estrous cycle. Although transient receptor potential cation channel subfamily V, member 6 (TRPV6), has been detected in the human placenta, pancreas and the prostate gland, expression patterns of uterine TRPV6 and PMCA1 and their potential roles in the human endometrium remain to be elucidated. In the present study, the expression patterns of TRPV6 and PMCA1 were examined to predict their potential roles in the human endometrium during the menstrual cycle. Human classified endometrial tissues (total n = 40) were separated into three groups according to menstrual cycle phase: menstrual, proliferative (early‐, mid‐, late), and secretory phase (early‐, mid‐, late). The expression of TRPV6 and PMCA1 mRNA and protein in the uterine endometrium during the menstrual cycle increased by 1.5‐ to 1.8‐fold at the proliferative phase (early‐, mid‐, and late‐) in comparison to the other phases. Estrogen treatment caused a significant increase in TRPV6 and PMCA1 mRNA expression. Immunohistochemical analysis of the distribution of TRPV6 and PMCA1 in the uterus revealed that both proteins are abundantly expressed in the cytoplasm of endometrial and glandular epithelial cells during menstrual phases. Taken together, these results suggest that uterine expression of TRPV6 and PMCA1 may be involved in human reproductive function. Mol. Reprod. Dev. 78:274–282, 2011. © 2011 Wiley‐Liss, Inc.     

Spontaneous decidual reactions and menstruation in the black mastiff bat, Molossus ater

Uterine function was assessed histologically in nonpregnant Molossus ater removed from a laboratory breeding colony. During the luteal phase of the cycle, bilateral decidual reactions were found to develop spontaneously in the absence of either embryos or experimental manipulation of the uterus. These included the formation of early decidual giant cells, closure of the uterine lumina, and morphological changes in the endometrial blood vessels. Some endothelial cell hypertrophy was noted in much of the decidua, but this was most pronounced in vessels associated with an unusual vascular tuft that formed in the endometrium surrounding the cranial end of the uterine lumen. These latter vessels also developed very prominent basal laminae. In pregnant bats, this tuft played a central role in the morphogenesis of the definitive discoidal chorioallantoic placenta. At the end of nonpregnant cycles, the decidua became necrotic and was sloughed off with associated bleeding. As in menstruating catarrhine primates, the endometrium of M. ater is vascularized by spiral arterioles and populated by distinctive granulocytes containing large, acidophilic granules. Increased coiling of these arterioles did not appear to be an essential element in the mechanism of mensturation in this species. M. ater is a monotocous, seasonal breeder, with a relatively long gestation period. Although it has a bicornuate uterus, ovulation and implantation appear to occur only on the right side of the tract. The ability to menstruate probably affords this bat an efficient mechanism for eliminating a highly differentiated endometrium from the usual implantation site in the event of a reproductive failure. In the wild, this may provide M. ater with another chance to establish a pregnancy at a still opportune time during the same breeding season.     

Aberrant expression of retinol-binding protein, osteopontin and fibroblast growth factor 7 in the porcine uterine endometrium of pregnant recipients carrying embryos produced by somatic cell nuclear transfer

The technique of somatic cell nuclear transfer (NT) is a useful tool to produce cloned animals for various purposes, but the efficiency to generate cloned animals using this technique is still very low. To improve the low efficiency in production of cloned pigs it is critical to understand the reprogramming process during development of cloned embryos, but it is also essential to understand the uterine function interacting with the transferred cloned embryos during implantation and placentation. Thus, to understand the uterine responsiveness to NT cloned embryos during pregnancy, we investigated expression of retinol-binding protein (RBP), osteopontin (OPN) and fibroblast growth factor 7 (FGF7), which play important roles in implantation and/or maintenance of pregnancy as a transport protein, an extracellular matrix protein and a growth factor, respectively, in the uterine endometrium in pigs. The uterine tissue samples were obtained by C-section from pigs with NT cloned normal (NT-normal) embryos and NT cloned abnormal (NT-abnormal) embryos and pigs with non-NT (Non-NT) embryos at term. Immunoblot analysis showed that expression of RBP and FGF7 decreased in the uterine endometrium of recipient gilts carrying NT embryos than in the endometrium of gilts carrying Non-NT embryos. Levels of OPN protein of 70 and 45kDa were not different in between the uterine endometrium of gilts carrying Non-NT and NT-normal embryos, but in the uterine endometrium of gilts carrying NT-abnormal embryos 70 and 45kDa OPN proteins increased compared to those in the endometrium of gilts carrying Non-NT embryos. Immunohistochemistry results showed that RBP expression was lower in the endometrial glandular epithelial cells, while OPN expression was higher in the endometrial luminal epithelial cells of the uterus of gilts carrying NT embryos than in the uterus of gilts carrying Non-NT embryos. Results of this study showed that maternal uterine genes were aberrantly expressed in the uterine endometrium of gilts carrying NT cloned embryos in varying degrees depending on the normality of the developing embryos. These results indicate that abnormal maternal-fetal interactions of the uterus carrying the developing NT cloned embryos may cause problems in development of cloned embryos.     

Changes in the development of uterine pinopodes in steroid hormone supplemented cycles

The endometrium acquires the ability to implant a hatched blastocyst only within a specific time termed the receptive phase. Ovarian steroid hormones are essential for structural and functional changes that prepare the endometrium to be receptive. Pinopodes have been suggested to be markers of uterine receptivity. The aim of this study was to compare the pinopode expression and serum levels of ovarian steroid hormones in the mid-luteal phase of the natural cycle and in a "mock" cycle in the same subject. Sequentional endometrial biopsies within 48 hours were obtained from women in the mid-luteal phase (ovulation +5, ovulation +7) of the natural cycle and in the "mock" cycle (progesterone supplementation +5 and +7). Biopsies were examined under a scanning electron microscope for pinopode detection. The expression of pinopodes was similar in both cycles, where pinopodes covered about 5 % of the endometrial surface. The developmental stages were also similar with a slight increase of fully developed pinopodes in both samples in the "mock" cycles. Our findings suggest that hormonal preparation of the endometrium do not change the timing of pinopode expression.