Endometrial-myometrial Interface Research Articles

Meclizine improves endometrial repair and reduces simulated menstrual bleeding in mice with induced adenomyosis

BackgroundAdenomyosis is one of the structural causes of abnormal uterine bleeding, which often presents as heavy menstrual bleeding (HMB). Mostly due to poor understanding of its pathophysiology, medical management of adenomyosis-induced HMB is still a challenge. We have previously reported that glycolysis is crucial to endometrial repair following menstruation and that suppressed glycolysis can cause HMB. Objective(s)To test the hypothesis that meclizine, a drug with excellent safety profile, alleviates HMB in mice with induced adenomyosis using a simulated menstruation model. Study DesignAdenomyosis was induced in 36 female C57BL/6 mice using endometrial-myometrial interface disruption. Three months after induction, the mice were randomly divided into three groups: low- and high-dose meclizine, and controls. Treatment with meclizine or vehicle started shortly before the simulated menstruation procedure and ended before progesterone withdrawal. The amount of blood loss was quantitated and uterine tissue was harvested for histological evaluation of the grade of endometrial repair. We performed immunohistochemistry analysis of 4 proteins critically involved in glycolysis, namely glucose transporter 1 (Glut1), hexokinase 2 (Hk2), 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3 (Pfkfb3) and pyruvate kinase 2 (Pkm2). The extent of tissue fibrosis in both ectopic and eutopic endometrium was evaluated using Masson trichrome staining. ResultsIn mice with induced adenomyosis, meclizine accelerated endometrial repair in a dose-dependent manner and reduced the amount of menstrual bleeding. Meclizine administration raised endometrial immunoexpression of Hk2 and Pfkfb3 but not of Glut1 or Pkm2.The extent of endometrial fibrosis was reduced following the meclizine administration. Remarkably, these favorable changes were accompanied with suppression of lesional progression, as evidenced by the dose-dependent reduction in the extent of fibrosis (a surrogate for lesional progression). Conclusion(s)These encouraging results, taken together, suggest that glycolysis may be a promising therapeutic target and that meclizine may hold a therapeutic potential as a non-hormonal treatment for adenomyosis-induced HMB without exacerbating the disease.

Diagnostic Role of Cell-Free miRNAs in Identifying Placenta Accreta Spectrum during First-Trimester Screening.

Placenta accreta spectrum (PAS) is a severe complication of pregnancy associated with excessive invasion of cytotrophoblast cells at the sites of the endometrial-myometrial interface and the myometrium itself in cases of adherent (creta) and invasive (increta and percreta) forms, respectively. This leads to a high risk of massive blood loss, maternal hysterectomy, and preterm birth. Despite advancements in ultrasound protocols and found associations of alpha-fetoprotein, PAPP-A, hCG, PLGF, sFlt-1, IL-8, and IL-33 peripheral blood levels with PAS, there is a high need for an additional non-invasive test to improve the diagnostic accuracy and to select the real PAS from the suspected ones in the first-trimester screening. miRNA signatures of placental tissue, myometrium, and blood plasma from women with PAS in the third trimester of pregnancy, as well as miRNA profiles in exosomes from the blood serum of women in the first trimester with physiologically progressing pregnancy, complicated by PAS or pre-eclampsia, were obtained using deep sequencing. Two logistic regression models were constructed, both featuring statistically significant parameters related to the levels of miR-26a-5p, miR-17-5p, and miR-101-3p, quantified by real-time PCR in native blood serum. These models demonstrated 100% sensitivity in detecting PAS during the first pregnancy screening. These miRNAs were identified as specific markers for PAS, showing significant differences in their blood serum levels during the first trimester in the PAS group compared to those in physiological pregnancies, early- or late-onset pre-eclampsia groups. Furthermore, these miRNAs exhibited differential expression in the PAS placenta and/or myometrium in the third trimester and, according to data from the literature, control angiogenesis. Significant correlations were found between extracellular hsa-miR-101-3p and nuchal translucency thickness, hsa-miR-17-5p and uterine artery pulsatility index, and hsa-miR-26a-5p and hsa-miR-17-5p with PLGF. The developed test system for early non-invasive PAS diagnosis based on the blood serum level of extracellular miR-26a-5p, miR-17-5p, and miR-101-3p can serve as an auxiliary method for first-trimester screening of pregnant women, subject to validation with independent test samples.

#260 : Spatial Analysis of Adenomyosis Reveals the Inflammatory Feature of Immune Cells and Provide Insights into the Ciliated Cell in Ectopic Endometrium

Adenomyosis is a prevalent and non-cancerous uterine disease which can significantly impaired the fertility of reproductive-age women. However, the etiology, as well as the cellular and molecular mechanism underlying adenomyosis remain largely unknown. Here, we utilized cutting-edge spatial and single-cell RNA sequencing technologies to create a comprehensive transcriptional atlas of adenomyosis pathology. Our spatial profiling clearly distinguished gland, mesenchyma and myometrium regions, recapitulating spatial transcriptome structural characteristics of uterus. Moreover, we analyzed the expression profiles of 69,115 single cells and integrated them with spatial data. The analysis of immune cells showed a distinct immune inflammatory microenvironment in the eutopic and ectopic endometrial glands of adenomyosis. Notably, we discovered an increased number of DNAH9+ ciliated cells in ectopic endometrial glands, indicating their potential role in the formation of ectopic endometrium. These findings provide cellular evidence to support the invagination theory and offer a new vision on the pathophysiology and clinical intervention of adenomyosis. Background and Aims: Adenomyosis is characterized by the presence of endometrial glands and stroma-like tissue within the myometrium 1 , resulting in abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain and infertility 2 . Around 35% of reproductive-age women suffer from adenomyosis worldwide 3 , 4 . Highly variable symptoms make diagnosis challenging and commonly result in misdiagnosis. Furthermore, due to the advance of diagnostic imaging techniques such as transvaginal ultrasound scan (TVUS) and magnetic resonance imaging (MRI), there is an increasing trend of incidence rate, especially the remarkably increased proportion of young women diagnosed 4 . Although several hypotheses have been proposed to explain the pathogenesis of adenomyosis, including invagination of the endometrium into the myometrium, trauma to the endometrial-myometrial interface, and the stem cell potential of de novo ectopic tissue5, none of the these theories can fully account for all the phenotypes 6 . This ambiguous understanding of underlying pathophysiologic mechanisms hinders the development of effective early intervention strategies, emphasizing the need for further research into the biological mechanisms involved. Common symptoms of adenomyosis, such as dysmenorrhea and irregular uterine bleeding, suggest dysfunction of the endometrium, despite the absence of significant morphological change between in situ endometrium (eutopic) and the ectopic endometrial gland found within adenomyoma. Recently studies utilizing single-cell RNA sequencing (scRNA-seq) have reported functional differences within limited partial regions, offering some insight into cellular heterogeneity 7 , 8 . It is important to note that these studies have been limited in scope, either focusing on a small number of patients or lacking investigation into the spatial distribution of specific disease regions. As a result, our understanding of adenomyosis at a high-resolution level remains incomplete. Advancements in scRNA-seq and spatial transcriptomics techniques provide powerful tools to investigate rare subpopulations, cellular interactions and tissue architecture 9 , 10 , 11 , 12 . These cutting-edge technologies have the potential to enhance our understanding of adenomyosis. Method: Herein, we simultaneously combined scRNA-seq and spatial transcriptome (Geo-seq) 13 data to gain a global understanding of cell types and niches in the entire layer of adenomyosis uterus tissue. By allocating cell types to different adenomyosis niches, determining molecular mediators of intercellular interactions, and pinpointing the cellular and spatial sources of niche factors, our data shed new light on the invagination of eutopic endometrium and tissue architecture of adenomyosis. This multi-dimensional molecular profiling provides a foundation for further exploration of adenomyosis pathophysiology, enabling a better understanding of the cellular and molecular mechanisms involved. Ultimately, this study has the potential to facilitate early clinical diagnosis and medication intervention for adenomyosis. Results: Our spatial profiling clearly distinguished gland, mesenchyma and myometrium regions, recapitulating spatial transcriptome structural characteristics of uterus. Moreover, we analyzed the expression profiles of 69,115 single cells and integrated them with spatial data. The analysis of immune cells showed a distinct immune inflammatory microenvironment in the eutopic and ectopic endometrial glands of adenomyosis. Notably, we discovered an increased number of DNAH9+ ciliated cells in ectopic endometrial glands, indicating their potential role in the formation of ectopic endometrium. Conclusion: These findings provide cellular evidence to support the invagination theory and offer a new vision on the pathophysiology and clinical intervention of adenomyosis.

10587 Fibroid Location Affects Peak Stresses and Strains at the Endometrial-Myometrial Interface: A Finite Element Analysis

10587 Fibroid Location Affects Peak Stresses and Strains at the Endometrial-Myometrial Interface: A Finite Element Analysis

MiR-141-3p Regulates the Proliferation and Apoptosis of Endometrial-Myometrial Interface Smooth Muscle Cells in Adenomyosis Via JAK2/STAT3 Pathway.

Adenomyosis (ADS) is a common benign gynecological disease. Abnormal proliferation at the endometrial-myometrial interface (EMI) plays a crucial role in the occurrence and progression of ADS. miR-141-3p is associated with cell proliferation and apoptosis. However, the specific mechanism of miR-141-3p in the etiology of ADS is still unknown. In this study, we explored the effects of miR-141-3p on the proliferation and apoptosis of ADS EMI smooth muscle cells (SMCs). We collected EMI tissues for the primary culture of SMCs from 25 patients diagnosed with ADS and 20 without ADS. Real-time quantitative polymerase chain reaction and western blot were used to measure the mRNA and protein expression levels of miR-141-3p, JAK2, STAT3, phospho-JAK2, and phospho-STAT3 in ADS EMI SMCs. The cell counting kit 8 assay and flow cytometry analysis were used to evaluate the proliferation and apoptosis of EMI SMCs. The miR-141-3p mimic/inhibitor was used to increase or decrease the expression level of miR-141-3p. We added WP1066 to block the phosphorylation of JAK2/STAT3 pathway components. The miR-141-3p levels were decreased, while JAK2 and STAT3 levels were increased in ADS EMI SMCs. miR-141-3p overexpression significantly inhibited the proliferation and enhanced the apoptosis of EMI SMCs, whereas a decrease in miR-141-3p expression level was connected to the opposite results. Meanwhile, inactivated JAK2/STAT3 pathway decreased proliferation and enhanced apoptosis of EMI SMCs after WP1066 treatment. Furthermore, rescue experiments confirmed that the JAK2/STAT3 pathway was the downstream pathway of miR-141-3p and reduced the effect of miR-141-3p on the proliferation and apoptosis of EMI SMCs. These results demonstrate that miR-141-3p regulates the proliferation and apoptosis of ADS EMI SMCs by modulating the JAK2/STAT3 pathway.

Reduced endometrial expression of histone deacetylase 3 in women with adenomyosis who complained of heavy menstrual bleeding

What role, if any, does histone deacetylase 3 (HDAC3) play in adenomyosis-associated heavy menstrual bleeding (HMB)? Seventy-two women with adenomyosis-associated HMB were recruited. Of these, 37 women reported moderate/heavy bleeding (MHB) and the remaining 35 women reported excessive bleeding (EXB). The stiffness of adenomyotic lesions and neighbouring endometrial-myometrial interface (EMI) was measured by transvaginal elastosonography, and full-thickness uterine tissue columns were processed for Masson trichrome staining and immunohistochemistry analyses. The protein expression levels of HDAC3 in endometrial cells cultured on substrates of different stiffnesses, and the protein concentrations of nuclear factor-κB (NF-κB) p65 subunit with HDAC3 suppression were evaluated. Mouse experiments were performed to assess the effect of adenomyosis on Hdac3 expression, endometrial repair and bleeding, and to evaluate the effect of HDAC3 inhibition on endometrial repair. Compared with controls, the endometrial staining of HDAC3 was significantly lower in women with adenomyosis-associated HMB, concomitant with a greater extent of fibrosis. The stiffness of lesions and neighbouring EMI was significantly higher in the EXB group compared with the MHB group, as was the extent of fibrosis in lesions, their neighboring EMI and endometrium. Expression of HDAC3 was reduced significantly when endometrial epithelial cells were cultured in stiff substrates. Suppression of HDAC3 abrogated the activation and signalling of NF-κB. Mice with induced adenomyosis exhibited reduced Hdac3 staining and elevated fibrosis in endometrium, concomitant with disrupted endometrial repair and more bleeding. Hdac3 inhibition resulted in botched inflammation and increased bleeding. Lesional fibrosis results in reduced endometrial HDAC3 expression and subsequent disruption in NF-κB signalling and inflammation, leading to adenomyosis-associated HMB.

Single-Cell Profiling Uncovers the Roles of Endometrial Fibrosis and Microenvironmental Changes in Adenomyosis.

Adenomyosis (AM) is a common benign uterine disorder that has deleterious effects on women's health. However, the pathogenesis of AM is not clearly understood. We aimed to investigate the pathophysiological changes and molecular mechanism in AM. Single-cell RNA sequencing (scRNA-seq) was employed to construct a transcriptomic atlas of various cell subsets from the ectopic endometrium (EC) and eutopic endometrium (EM) of one AM patient and evaluate differential expression. The Cell Ranger software pipeline (version 4.0.0) was applied to conduct sample demultiplexing, barcode processing and mapping reads to the reference genome (human GRCh38). Different cell types were classified with markers with the "FindAllMarkers" function, and differential gene expression analysis was performed with Seurat software in R. The findings were confirmed by Reverse Transcription Real-Time PCR using samples from three AM patients. We identified nine cell types: endothelial cells, epithelial cells, myoepithelial cells, smooth muscle cells, fibroblasts, lymphocytes, mast cells, macrophages and unknown cells. A number of differentially expressed genes, including CLO4A1, MMP1, TPM2 and CXCL8, were identified from all cell types. Functional enrichment showed that aberrant gene expression in fibroblasts and immune cells was related to fibrosis-associated terms, such as extracellular matrix dysregulation, focal adhesion and the PI3K-Akt signaling pathway. We also identified fibroblast subtypes and determined a potential developmental trajectory related to AM. In addition, we identified increased cell-cell communication patterns in EC, highlighting the imbalanced microenvironment in AM progression. Our results support the theory of endometrial-myometrial interface disruption for AM, and repeated tissue injury and repair could lead to increased fibrosis in the endometrium. Therefore, the present study reveals the association between fibrosis, the microenvironment, and AM pathogenesis. This study provides insight into the molecular mechanisms regulating AM progression.

Effect of dual trigger with chorionic gonadotropin hormone and follicle-stimulating hormone on endometrial thickness in infertile women who had superovulation with an aromatase inhibitor

Beginning in October 2020 and ending in April 2021, researchers from Al-Nahrain University's High Institute for Infertility Diagnosis and Assisted Reproductive Technologies compared the success rates of two different methods of diagnosing and treating infertility. The major purpose of the research was to assess the impact of a combined trigger (follicle-stimulating hormone [FSH] and human chorionic gonadotropin [hCG]) on endometrial receptivity (endometrial thickness, endometrial pattern, sub-endometrial blood flow). A total of 100 females took part in the study. All patients gave their informed written consent, and the study was approved by the Al-Nahrain University Ethics Committee. Procedure Time To confirm ovulation, measure and analyze the endometrial pattern, and examine the sub-endometrial blood flow, a vaginal ultrasound was done 36 to 48 hours following trigger ovulation. All four hormones (FSH, LH, Progesterone, and E2) were tested in the blood at the same time to determine whether a couple was fertile, a complete medical history, and physical examination whereas performed on each member of the pair. An ultrasound vaginal probe was used to do the transvaginal examination. Patients were placed in the dorsal lithotomy position with an empty bladder for early follicular US (CD 2-3) to assess the number of antral follicles, measure endometrial thickness, and rule out ovarian cysts or other pathology. A second ultrasound was performed during the middle of the cycle (CD9-14) to determine whether a mature follicle had been found. A multiplanar image of the uterus was acquired after an ultrasound scan was swept across the mid-sagittal plane. Endometrial thickness in the median longitudinal plane of the uterus was calculated as the largest distance from one basal endometrial interface via the endometrial canal to the opposite endometrial-myometrial interface of the anterior-posterior uterine wall. A statistically significant difference was found between Group A's average E2 concentration of 69.62 pg/mL and Groups B and C's concentrations of 53.32 and 36.65 pg/mL. (P 0.001). In group C, there was a statistically significant difference in E2 levels on the day of the trigger and the day of the IUI (P = 0.036). On the day of IUI compared to the day of trigger, no statistically significant differences were seen between the study groups for any of the other hormonal indicators (P > 0.05). There were no significant differences (P > 0.05) in any of the baseline clinical measures between the research groups. All clinical indicators were comparable across groups (P > 0.05). There were no statistically significant differences (P > 0.05) between the research groups on any other clinical indicators. When comparing groups, A, B, and C on the decline in RI between the trigger and IUI days, group A significantly outperformed the others (P = 0.003). There was no statistically significant difference (P > 0.05) in any of the other clinical parameters between the IUI and trigger groups on the day of IUI.

The Role of Platelets in the Pathogenesis and Pathophysiology of Adenomyosis.

Widely viewed as an enigmatic disease, adenomyosis is a common gynecological disease with bewildering pathogenesis and pathophysiology. One defining hallmark of adenomyotic lesions is cyclic bleeding as in eutopic endometrium, yet bleeding is a quintessential trademark of tissue injury, which is invariably followed by tissue repair. Consequently, adenomyotic lesions resemble wounds. Following each bleeding episode, adenomyotic lesions undergo tissue repair, and, as such, platelets are the first responder that heralds the subsequent tissue repair. This repeated tissue injury and repair (ReTIAR) would elicit several key molecular events crucial for lesional progression, eventually leading to lesional fibrosis. Platelets interact with adenomyotic cells and actively participate in these events, promoting the lesional progression and fibrogenesis. Lesional fibrosis may also be propagated into their neighboring endometrial-myometrial interface and then to eutopic endometrium, impairing endometrial repair and causing heavy menstrual bleeding. Moreover, lesional progression may result in hyperinnervation and an enlarged uterus. In this review, the role of platelets in the pathogenesis, progression, and pathophysiology is reviewed, along with the therapeutic implication. In addition, I shall demonstrate how the notion of ReTIAR provides a much needed framework to tether to and piece together many seemingly unrelated findings and how it helps to make useful predictions.

Altered Expression of Interleukin-18 System mRNA at the Level of Endometrial Myometrial Interface in Women with Adenomyosis.

Adenomyosis is a uterine pathology characterized by a deep invasion of endometrial glands and stroma, disrupting the endometrial-myometrial interface (EMI). Interleukin-18 (IL-18) system is a dominant cytokine involved in the menstrual cycle of human endometrium. IL-18 may play a defensive role against maternal immune response in the uterine cavity. The present study was designed to determine IL-18-mediated immune response at the level of EMI. We uncovered that mRNA of IL-18 system, including IL-18, IL-18 receptor (IL-18R), and its antagonist, IL-18 binding protein (IL-18BP), expressed in eutopic, ectopic endometrium, and corresponding myometrium in patients with adenomyosis. IL-18 system was demonstrated in paired tissue samples by immunochemistry and immunofluorescence study. According to RT-PCR with CT value quantification and 2-∆∆Ct method, a significant down-regulation of IL-18BP in corresponding myometrium in comparison to eutopic endometrium (p < 0.05) indicates that the IL-18 system acts as a local immune modulator at the level of EMI and regulating cytokine networks in the pathogenesis of adenomyosis. Furthermore, an increased IL-18 antagonist to agonist ratio was noted in ectopic endometrium compared with corresponding myometrium. We suggest that altered IL-18 system expression contributes to immunological dysfunction and junctional zone disturbance in women with adenomyosis.

Cracking the enigma of adenomyosis: an update on its pathogenesis and pathophysiology.

Traditionally viewed as enigmatic and elusive, adenomyosis is a fairly common gynecological disease but is under-recognized and under-researched. This review summarizes the latest development on the pathogenesis and pathophysiology of adenomyosis, which have important implications for imaging diagnosis of the disease and for the development of non-hormonal therapeutics. Traditionally considered as an enigmatic disease, adenomyosis is a uterine disease that affects many women of reproductive age and is a contributing factor for pelvic pain, heavy menstrual bleeding (HMB), and subfertility. In this review, the new development in the pathogenesis and pathophysiology of adenomyosis has been summarized, along with their clinical implications. After reviewing the progress in our understanding of the pathogenesis and describing the prevailing theories, in conjunction with their deficiencies, a new hypothesis, called endometrial-myometrial interface disruption (EMID), which is backed by extensive epidemiologic data and demonstrated by a mouse model, is reviewed, along with recent data implicating the role of Schwann cells in the EMI area in the genesis of adenomyosis. Additionally, the natural history of adenomyotic lesions is elaborated and underscores that, in essence, adenomyotic lesions are fundamentally wounds undergoing repeated tissue injury and repair (ReTIAR), which progress to fibrosis through epithelial-mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation, and smooth muscle metaplasia. Increasing lesional fibrosis propagates into the neighboring EMI and endometrium. The increased endometrial fibrosis, with ensuing greater tissue stiffness, results in attenuated prostaglandin E2, hypoxia signaling and glycolysis, impairing endometrial repair and causing HMB. Compared with adenomyosis-associated HMB, the mechanisms underlying adenomyosis-associated pain are less understood but presumably involve increased uterine contractility, hyperinnervation, increased lesional production of pain mediators, and central sensitization. Viewed through the prism of ReTIAR, a new imaging technique can be used to diagnose adenomyosis more accurately and informatively and possibly help to choose the best treatment modality.

RNA-seq reveals co-dysregulated circular RNAs in the adenomyosis eutopic endometrium and endometrial–myometrial interface

BackgroundUterine adenomyosis is associated with chronic pelvic pain, abnormal uterine bleeding, and infertility. The pathogenesis of adenomyosis is still unclear. Circular RNAs (circRNAs) have been implicated in several benign diseases and malignant tumors. We aimed to explore the co-dysregulated circular RNA profile in the eutopic endometrium and endometrial–myometrial interface (EMI) of adenomyosis.MethodsTotal RNA was extracted from the eutopic endometrium and EMI of 5 patients with adenomyosis and 3 patients without adenomyosis. Next-generation sequencing was performed to identify the circRNA expression profile of the two tissue types. Bioinformatics analysis was performed to predict circRNA-binding miRNAs and miRNA-binding mRNAs and construct ceRNA networks, and functional enrichment analysis was performed to predict the biological functions of circRNAs.ResultsAmong the adenomyosis patients, 760 circRNAs were significantly upregulated and 119 circRNAs were significantly downregulated in the EMI of adenomyosis, while 47 circRNAs were significantly upregulated and 17 circRNAs were significantly downregulated in the eutopic endometrium of adenomyosis. We identified hsa_circ_0002144 and hsa_circ_0005806 as co-upregulated and hsa_circ_0079536 and hsa_circ_0024766 as co-downregulated in the eutopic endometrium and EMI. Bioinformatics analysis was performed to construct a ceRNA network of codifferentially expressed circRNAs. The MAPK signaling pathway is the most important signaling pathway involved in the function of the ceRNA network.ConclusionsCo-dysregulated circRNAs were present in the eutopic endometrium and EMI of adenomyosis. MiRNA binding sites were observed for all of these circRNAs and found to regulate gene expression. Co-dysregulated circRNAs may induce the eutopic endometrial invagination process through the MAPK signaling pathway and promote the progression of adenomyosis.

Molecular Targets for Nonhormonal Treatment Based on a Multistep Process of Adenomyosis Development.

Adenomyosis is an estrogen-dependent gynecologic disease characterized by the presence of endometrial tissue within the myometrium. Adenomyosis presents with abnormal uterine bleeding, pelvic pains, and infertility. This review aimed to investigate the major estrogen downstream effectors involved in the process of adenomyosis development and their potential use for nonhormonal treatment. A literature search was performed for preclinical and clinical studies published between January 2010 and November 2021 in the PubMed and Google Scholar databases using a combination of specific terms. Adenomyosis presents with a wide spectrum of clinical manifestations from asymptomatic to severe through a complex process involving a series of molecular changes associated with inflammation, invasion, angiogenesis, and fibrosis. Adenomyosis may develop through a multistep process, including the acquisition of (epi)genetic mutations, tissue injury caused at the endometrial-myometrial interface, inside-to-outside invasion (from the endometrial side into the uterine wall), or outside-to-inside invasion (from the serosal side into the uterine wall), and epithelial-mesenchymal transition, tissue repair or remodeling in the myometrium. These processes can be regulated by increased estrogen biosynthesis and progesterone resistance. The expression of estrogen downstream effectors associated with persistent inflammation, fragile and more permeable vessel formation, and tissue injury and remodeling may be correlated with dysmenorrhea, heavy menstrual bleeding, and infertility, respectively. Key estrogen downstream targets (e.g., WNT/β-catenin, transforming growth factor-β, and nuclear factor-κB) may serve as hub genes. We reviewed the molecular mechanisms underlying the development of adenomyosis and summarized potential nonhormonal therapies.

Perioperative Suppression of Schwann Cell Dedifferentiation Reduces the Risk of Adenomyosis Resulting from Endometrial-Myometrial Interface Disruption in Mice.

We have recently demonstrated that endometrial–myometrial interface (EMI) disruption (EMID) can cause adenomyosis in mice, providing experimental evidence for the well-documented epidemiological finding that iatrogenic uterine procedures increase the risk of adenomyosis. To further elucidate its underlying mechanisms, we designed this study to test the hypothesis that Schwann cells (SCs) dedifferentiating after EMID facilitate the genesis of adenomyosis, but the suppression of SC dedifferentiation perioperatively reduces the risk. We treated mice perioperatively with either mitogen-activated protein kinase kinase (MEK)/extracellular-signal regulated protein kinase (ERK) or c-Jun N-terminal kinase (JNK) inhibitors or a vehicle 4 h before and 24 h, 48 h and 72 h after the EMID procedure. We found that EMID resulted in progressive SCs dedifferentiation, concomitant with an increased abundance of epithelial cells in the myometrium and a subsequent epithelial–mesenchymal transition (EMT). This EMID-induced change was abrogated significantly with perioperative administration of JNK or MEK/ERK inhibitors. Consistently, perioperative administration of a JNK or a MEK/ERK inhibitor reduced the incidence by nearly 33.5% and 14.3%, respectively, in conjunction with reduced myometrial infiltration of adenomyosis and alleviation of adenomyosis-associated hyperalgesia. Both treatments significantly decelerated the establishment of adenomyosis and progression of EMT, fibroblast-to-myofibroblast trans-differentiation and fibrogenesis in adenomyotic lesions. Thus, we provide the first piece of evidence strongly implicating the involvement of SCs in the pathogenesis of adenomyosis induced by EMID.

Comparison of One-Stage and Two-Stage Intraoperative Uterine Artery Embolization during Cesarean Delivery for Placenta Accreta: Report of Two Clinical Cases at a Tertiary Referral Medical Center.

Placenta accreta spectrum (PAS) described the anchoring placental villi attached or penetrating into/through the myometrium. PAS is clinically important because of the unpredictable bleeding amount when manually removing the defective decidualization at the endometrial-myometrial interface. Therefore, a multidisciplinary strategy for cesarean delivery with PAS is crucial. Postoperative embolization after cesarean hysterectomy in a hybrid suite was studied by many scientists. In this study, we demonstrated two cases of intraoperative embolization without hysterectomy in a hybrid operating room for cesarean delivery with placenta accreta. Our results show that intraoperative uterine artery embolization with a hybrid suite is a time-preserving and safe method for cesarean delivery with PAS owing to avoiding the risk of morbidity and mortality during patient transfer.

Unveiling the Pathogenesis of Adenomyosis through Animal Models.

Background: Adenomyosis is a common gynecological disorder traditionally viewed as “elusive”. Several excellent review papers have been published fairly recently on its pathogenesis, and several theories have been proposed. However, the falsifiability, explanatory power, and predictivity of these theories are often overlooked. Since adenomyosis can occur spontaneously in rodents and many other species, the animal models may help us unveil the pathogenesis of adenomyosis. This review critically tallies experimentally induced models published so far, with a particular focus on their relevance to epidemiological findings, their possible mechanisms of action, and their explanatory and predictive power. Methods: PubMed was exhaustively searched using the phrase “adenomyosis and animal model”, “adenomyosis and experimental model”, “adenomyosis and mouse”, and “adenomyosis and rat”, and the resultant papers were retrieved, carefully read, and the resultant information distilled. All the retrieved papers were then reviewed in a narrative manner. Results: Among all published animal models of adenomyosis, the mouse model of adenomyosis induced by endometrial–myometrial interface disruption (EMID) seems to satisfy the requirements of falsifiability and has the predictive capability and also Hill’s causality criteria. Other theories only partially satisfy Hill’s criteria of causality. In particular, animal models of adenomyosis induced by hyperestrogenism, hyperprolactinemia, or long-term exposure to progestogens without much epidemiological documentation and adenomyosis is usually not the exclusive uterine pathology consequent to those induction procedures. Regardless, uterine disruption appears to be a necessary but not sufficient condition for causing adenomyosis. Conclusions: EMID is, however, unlikely the sole cause for adenomyosis. Future studies, including animal studies, are warranted to understand how and why in utero and/or prenatal exposure to elevated levels of estrogen or estrogenic compounds increases the risk of developing adenomyosis in adulthood, to elucidate whether prolactin plays any role in its pathogenesis, and to identify sufficient condition(s) that cause adenomyosis.

A case series on abnormal placenta accreta spectrum in a rural tertiary care centre

Placenta accreta spectrum (PAS) is a potentially life-threatening obstetric condition that requires a multidisciplinary approach to management. The main complication of PAS is due to it’s massive obstetric haemorrhage which leads to maternal morbidity and mortality. The incidence of placenta accreta spectrum increases day by day due to an alarming increase in caesarean section rates. Depending on the range of invasiveness, The Placenta accreta spectrum is classified as placenta accreta, placenta increta and placenta percreta. The etiology of placenta accreta spectrum is that a defect of the endometrial–myometrial interface leading to failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. In recent times, prenatal ultrasound scanning with gray scale imaging and color Doppler imaging seems to be an excellent tool for screening of PAS.We report here a series of 5 cases of Placenta Accreta who reported to hospital as Bleeding P/v or USG scan report showing Abnormal Placental invasion or Placental Position. Patients reported were posted for Emergency LSCS under definitive indications but underwent Peripartum hysterectomy. The Ultrasound findings were subsequently confirmed at surgery and proven on histopathological examination. Peripartum hysterectomy remains the life saving procedure over conservative methods for PPH secondary to Abnormal Placental invasion.

How does the extent of fibrosis in adenomyosis lesions contribute to heavy menstrual bleeding?

PurposeTo investigate how the extent of fibrosis in adenomyosis lesions contributes to heavy menstrual bleeding (HMB).MethodsWe recruited 57 women with histologically confirmed adenomyosis, 29 of whom reported moderate/heavy bleeding (MHB) (menstrual blood loss (MBL) ≥20 but <100 mL) and the remaining 28, excessive MBL (EXB; ≥100 mL). Lesional stiffness was measured by transvaginal elastosonography. Full‐thickness uterine tissue columns containing the lesion and its neighboring endometrial‐myometrial interface (EMI) and endometrial tissues were evaluated for tissue fibrosis and immunohistochemical analysis of HIF‐1α, COX‐2, EP2, and EP4.ResultsThe lesional stiffness in the EXB group was significantly higher than that of MHB, and consistently, the extent of lesional fibrosis and the extent of tissue fibrosis in both EMI and eutopic endometrium were also significantly higher. In adenomyotic lesions and their neighboring EMI and eutopic endometrial tissues, the immunostaining of HIF‐1α, COX‐2, EP2, and EP4 was significantly reduced. The extent of fibrosis and the immunostaining levels of HIF‐1α, COX‐2, EP2, and EP4 were negatively correlated in all tissues.ConclusionsLesional fibrosis begets stiffening matrix, propagating fibrosis to neighboring EMI and eutopic endometrium, resulting in reduced PGE2 and HIF‐1α signaling, and thus likely reduced hypoxia necessary for endometrial repair, leading to HMB.

The Sonographic Appearance of Endometrial Intraepithelial Neoplasia.

To describe the sonographic findings of endometrial intraepithelial neoplasia (EIN), a precursor of endometrial cancer. Cases were found by word search of pathology database 1/2013 to 6/2019. One hundred and seventy-eight patients with ultrasound <1 year prior to biopsy were included. Medical records were searched for patient data. Two radiologists blindly classified images. Differences of opinion were decided by clinical report. Univariate and multivariate analyses were performed. Median time between ultrasound and first sampling procedure was 49 days. Median age was 55 (range 28-85) years. Endometrial thickness ranged from 2 to 90 mm. Mean endometrial thickness was 13 ± 6 mm in the noncancer group and 16 ± 11 mm in the cancer group (P=.02). The endometrium was almost always heterogeneous 175/178 (98%). Cysts were almost always multiple (89/109, 82%) and >1 mm (72/109, 66%). Masses were most often >5 mm (56/105, 55%) and ill-defined (41/105, 39%). Vascularity was present in 93/178 examinations (52%) and always associated with cysts and/or mass. There were 92 cancers, 25 with invasion (including 4 with tumor extension into adenomyosis). In 47 cases, the endometrial-myometrial interface was graded as ill-defined, 39 of whom had hysterectomy. There was macroscopic cancer in 11, microscopic cancer in 4, and invasive carcinoma in 12 patients (P for invasive cancer versus other outcomes=.02). Depth of invasion was 5- >95%, with 6 cancers >50%. Multivariate analysis showed thickness, polyps, and type of bleeding as the best set of independent variables for cancer (area under the receiver operating characteristic (ROC) curve [AUC]=.75). Replacing type of bleeding with age or menopausal status had AUC of .73 and .74, respectively. EIN has a variety of sonographic appearances with thickened endometrium with cysts and masses being common. Ill-definition of the endometrial-myometrial interface is a poor prognostic finding when seen in the absence of adenomyosis.

Integrating Network Pharmacology and Experimental Validation Deciphers the Mechanism of Guizhi Fuling Wan against Adenomyosis.

Aim This study aimed to predict the key targets and endocrine mechanisms of Guizhi Fuling Wan (GZFLW) in treating adenomyosis (AM) through network pharmacology, molecular docking, and animal experiment verification. Methods The related ingredients and targets of GZFLW in treating AM were screened out using TCMSP, BATMAN-TCM, SwissTargetPrediction, and PubChem Database. Then, the protein-protein interaction (PPI) analysis and the network of compound-hub targets were constructed. At the same time, the key targets were uploaded to the Metascape Database for KEGG pathway enrichment analysis. After that, the molecular docking technology of the main active components and hub targets was performed. Furthermore, animal experiments were used to verify the results of network pharmacology analysis. Results A total of 55 active ingredients of GZFLW and 44 overlapping targets of GZFLW in treating AM were obtained. After screening, 25 hub targets were collected, including ESR1, EGF, and EGFR. Then, the KEGG pathway enrichment analysis results indicated that the endocrine therapeutic mechanism of GZFLW against AM is mainly associated with the estrogen signaling pathway, endocrine resistance, and an EGFR tyrosine kinase signaling pathway. Then, molecular docking showed that the significant compounds of GZFLW had a strong binding ability with ERα and EGFR. More importantly, the animal experiments confirmed that the GZFLW could downregulate the abnormal infiltration of the endometrial epithelium into the myometrium and had no interference with the normal sexual cycle. This effect may be directly related to intervening the local estrogen signaling pathway of the endometrial myometrial interface (EMI). It may also be associated with the myometrium cells' estrogen resistance via GPER/EGFR signaling pathway. Conclusion The endocrine mechanism of GZFLW in treating AM was explored based on network pharmacology, molecular docking, and animal experiments, which provided a theoretical basis for the clinical application of GZFLW.