Progesterone Resistance Research Articles

Abstract 4964: Signaling through the progesterone receptor in the tumor microenvironment regulates hormonal sensitivity in endometrial carcinoma.

Abstract Progesterone, an agonist for the progesterone receptor (PR), can be an efficacious and well tolerated oral treatment for subsets of women with endometrial cancer. Clinically, progesterone is under-utilized as reliable predictors of response are not available. Although progesterone has been used for decades in treatment of endometrial neoplasia, its mechanism and site of action remain unknown. Our study aims to determine how and through which tumor cell types does progesterone exert its anti-tumor effects. To address these questions we first established an in vivo endometrial cancer model based on the two most common genetic mutations seen in human endometrial carcinoma: cell autonomous loss of PTEN with or without activation of Kras. Importantly in this model we can genetically manipulate the tumor epithelium and stroma independently. Mouse endometrial tumors generated in this system closely resemble human disease. The progesterone hormone with or with out estrogen was administered to tumor bearing mice. When both hormones were co-administered to mice bearing PTEN null endometrial tumors complete resolution of the cancer was achieved. Abundant expression of PR was detected in the tumor stroma throughout this therapeutic time-course. When progesterone was administered without estrogen, PTEN-null tumors persisted and stromal expression of PR diminished. Conditional stromal-specific deletion of PR in PTEN-null tumors was sufficient to convert these hormone sensitive cancers to a progesterone resistant tumor despite estrogen and progesterone co-administration. These results suggest that stromal expression of PR is necessary for anti-tumor effects of progesterone and dual hormone administration is critical for achieving a therapeutic response. Cell-autonomous activation of K-ras is commonly detected in the context of PTEN loss and this genetic combination in our model resulted in a hormone refractory endometrial cancer. A significant reduction in stromal PR expression was found in the PTEN-null/Kras hormone refractory tumors compared to PTEN-null sensitive cancers. Loss of stromal PR in all cases was coupled with diminished phosphorylation of estrogen receptor α at serine 118. We demonstrate that anti-tumor effects of progesterone are exerted through stromal PR signaling. The loss of PR expression in the tumor microenvironment confers progesterone resistance; therefore pharmacologic restoration of stromal PR should be investigated as a therapeutic intervention in hormone refractory tumors. Regulation of PR in the tumor stroma may be modulated by estrogen signaling. Defining mechanisms of resistance and sensitivity to hormonal therapy will facilitate individualization and wider application of hormonal therapy in patients suffering from endometrial cancer. Citation Format: Deanna M. Janzen, Miguel A. Rosales, Daniel Y. Paik, Daniel A. Smith, Donghui Cheng, Owen N. Witte, Luisa Iruela-Arispe, Sanaz Memarzadeh. Signaling through the progesterone receptor in the tumor microenvironment regulates hormonal sensitivity in endometrial carcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4964. doi:10.1158/1538-7445.AM2013-4964

Eutopic Endometrium in Women with Endometriosis: Ground Zero for the Study of Implantation Defects

The endometrium is ground zero when it comes to understanding how implantation occurs and how it might also fail, resulting in infertility or pregnancy loss. Many of the causes of diminished uterine receptivity are acquired during a woman's lifetime. Endometriosis, a major inflammatory disease affecting women, is also a leading cause of infertility and miscarriage. Once established, the inflammatory changes can, in some women, lead to progesterone resistance and downstream changes in endometrial gene expression. Much is now known about how inflammation translates to progesterone resistance and infertility, but much remains to be learned. In this review we provide an overview for understanding how the endometrium becomes dysfunctional, what biomarkers may hold promise for the diagnosis of endometriosis, and how progesterone resistance leads to infertility. Understanding the pathophysiology of this disease will likely lead to better treatment options.

Dienogest increases the progesterone receptor isoform B/A ratio in patients with ovarian endometriosis

BackgroundThe resistance of endometriotic tissue to progesterone can be explained by alterations in the distribution of progesterone receptor (PR) and estrogen receptor (ER) isoforms. The aims of this study were to examine the expressions of PR-A, PR-B, ERα and ERβ in endometrioma and assess whether these expressions are affected by dienogest or leuprolide acetate (LA) treatment.MethodsWe enrolled 60 females, including 43 patients with endometriosis (14 who received no medical treatment, 13 who received dienogest and 16 who received LA before undergoing laparoscopic surgery) and 17 patients with leiomyoma. The expression levels of PR and ER isoforms in eutopic and ectopic endometrium were assayed with quantitative real-time PCR, and confirmed with immunohistochemistry.ResultsA decreased PR-B/PR-A ratio and an increased ERβ/ERα ratio were demonstrated in ectopic endometrium derived from females with endometriosis compared with the ratios observed in eutopic endometrium obtained from females without endometriosis. Although LA treatment did not affect the PR-B/PR-A and ERβ/ERα ratios, dienogest treatment increased the PR-B/PR-A ratio and decreased the ERβ/ERα ratio in patients with endometriomas.ConclusionsDienogest may improve progesterone resistance in endometriotic tissue by increasing the relative expressions of PR-B and PR-A, and decreasing the relative expressions of ERβ and ERα.

Endometriosis and Infertility – a consensus statement from ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence)

Endometriosis is common in women with infertility but its management is controversial and varied. This article summarises the consensus developed by a group of Australasian subspecialists in reproductive endocrinology and infertility (the Australasian CREI Consensus Expert Panel on Trial evidence group) on the evidence concerning the management of endometriosis in infertility. Endometriosis impairs fertility by causing a local inflammatory state, inducing progesterone resistance, impairing oocyte release and reducing sperm and embryo transport. Medical treatments have a limited role, whereas surgical and assisted reproductive treatments improve pregnancy rates. The role of surgery for deep infiltrative endometriosis and repeat surgery requires further evaluation and there is insufficient evidence for the use of anti-adhesives to improve fertility. Intrauterine insemination (IUI) and in vitro fertilisation (IVF) improve pregnancy rates but women with endometriosis have lower pregnancy rates than those with other causes of infertility. The decision about whether to operate or pursue assisted reproduction will depend on a variety of factors such as the patient's symptoms, the presence of complex masses on ultrasound, ovarian reserve and ovarian access for IVF, risk of surgery and cost. Some women with infertility and endometriosis may benefit from a combination of assisted reproduction and surgery.

Treatment of endometrial carcinoma with metformin and progesterone in vitro and in vivo

Objective: Hormonal treatment of both early and advanced stage endometrial cancer is limited by progesterone resistance. To address this issue we investigated the addition of metformin to progesterone treatment of endometrial cancer.

Aberrant steroid hormone response and increased pro-inflammatory cytokine secretion in endometrial stromal fibroblasts from women with PCOS

The endometrium of women with polycystic ovary syndrome (PCOS) is associated with progesterone (P4) resistance and abnormal steroid receptor/co-activator profile which likely contribute to increased miscarriage rate and risk of endometrial cancer in these women. Whether there is an inflammatory component in PCOS endometrium that relates to endometrial dysfunction is not known. We hypothesized that endometrial stromal fibroblasts (eSF) show aberrant steroid hormone responsiveness and production of pro-inflammatory cytokines in PCOS.

Cutting SRC-1 down to size in endometriosis

Endometriosis is an estrogen-dependent disease. The biologically active estrogen, estradiol, aggravates the pathological processes (e.g., inflammation and growth) and the symptoms (e.g., pain) associated with endometriosis. Abundant quantities of estradiol are available for endometriotic tissue via several mechanisms including local aromatase expression. The question remains, then, what mediates estradiol action. Because estrogen receptor (ER)β levels in endometriosis are >100 times higher than those in endometrial tissue, this review focuses on this nuclear receptor. Deficient methylation of the ERβ promoter results in pathological overexpression of ERβ in endometriotic stromal cells. High levels of ERβ suppress ERα expression. A severely high ERβ-to-ERα ratio in endometriotic stromal cells is associated with suppressed progesterone receptor and increased cyclo-oxygenase-2 levels contributing to progesterone resistance and inflammation. ERβ-selective estradiol antagonists may serve as novel therapeutics of endometriosis in the future.

Contribution of Maternal NODAL to Term Pregnancy

Contribution of Maternal NODAL to Term Pregnancy

The Endometrium in Adenomyosis

Eutopic and ectopic endometria of women with adenomyosis show a series of metabolic and molecular abnormalities that increase angiogenesis and proliferation, decrease apoptosis, allow local production of estrogens, create progesterone resistance, and impair cytokine expression. These changes enhance the ability of the endometrium to infiltrate the junctional zone myometrium and the growth of ectopic tissue. In addition, in these subjects several immunological abnormalities have been observed, together with an increased production of 'free radicals' leading to excessive growth of endometrial stromal cells that may facilitate the establishment of adenomyosis. A limiting factor is that these studies have been performed on hysterectomy specimens representing final stages of the disease. This increased knowledge has created new therapeutic options, including the block of local aromatase production through the use of selective estrogen receptor modulators, estrogen-progestin combinations and gonadotropin-releasing hormone super agonists. Also promising are investigations into the mechanism of dysmenorrhea and abnormal uterine bleeding.

Progesterone Resistance, Aromatase, and Inflammation: The Important Relationships Between Hormones and Inflammation

Endometriosis is a complex gynecologic disorder in which alterations of specific biological processes involving both the endocrine and the immune systems have been identified. Recently, a reduced endometrial responsiveness to progesterone has been suggested as a crucial element in the pathophysiology of the disease but it is unclear whether this reduced sensitivity to the steroid is involved in the disease induction or is simply a consequence of the disease condition. Indeed, endometriosis is associated with a local and systemic inflammatory process that is strongly inter-related to the steroid activity, and both the systems mutually interact in a complex loop that strongly influences the disease development and maintenance. The link between prostaglandin E2 (PGE2), aromatase activity, and local estrogen synthesis represents a paradigm of this loop. A better understanding of the pathophysiology of this interaction should enable researchers to develop targeted therapeutics that may limit this self-supporting pathologic loop.

Adiponectin and leptin systems in human endometrium during window of implantation

To measure the expression of adiponectin, leptin, and their respective receptors in the human endometria of fertile women compared with women with unexplained recurrent implantation failure (IF) during the window of implantation. Controlled, prospective, clinical study. Teaching hospital and university research laboratory. Thirty-one endometrial biopsies from women with IF and 19 fertile controls. Human endometrial biopsies. Gene and protein expression of endometrial biopsies. Endometrial leptin expression was significantly lower in the IF group compared with fertile women. In contrast, leptin receptor (Ob-R) expression was higher in endometria of women with IF. Concerning the adiponectin system, adiponectin was expressed to the same extent in both groups. Conversely, the expression of its two receptors, AdipoR1 and AdipoR2, was reduced in endometria of women with IF compared with fertile women. Although progesterone resistance seems to be a common state of the endometrium in some human reproductive disorders, such as endometriosis or polycystic ovary syndrome, modification in leptin endometrial expression seems to be specific to IF. These results strongly suggest that changes in Ob-R and AdipoR expression profiles [1] should be implicated in the development of uterine receptivity, and [2] may therefore be potential new targets for prediction of IF.

Krüppel-Like Factor 9 and Progesterone Receptor Coregulation of Decidualizing Endometrial Stromal Cells: Implications for the Pathogenesis of Endometriosis

Endometriosis is characterized by progesterone resistance and associated with infertility. Krüppel-like factor 9 (KLF9) is a progesterone receptor (PGR)-interacting protein, and mice null for Klf9 are subfertile. Whether loss of KLF9 expression contributes to progesterone resistance of eutopic endometrium of women with endometriosis is unknown. The aims were to investigate 1) KLF9 expression in eutopic endometrium of women with and without endometriosis, 2) effects of attenuated KLF9 expression on WNT-signaling component expression and on WNT inhibitor Dickkopf-1 promoter activity in human endometrial stromal cells (HESC), and 3) PGR and KLF9 coregulation of the stromal transcriptome network. Transcript levels of KLF9, PGR, and WNT signaling components were measured in eutopic endometrium of women with and without endometriosis. Transcript and protein levels of WNT signaling components in HESC transfected with KLF9 and/or PGR small interfering RNA were analyzed by quantitative RT-PCR and Western blot. KLF9 and PGR coregulation of Dickkopf-1 promoter activity was evaluated using human Dickkopf-1-luciferase promoter/reporter constructs and by chromatin immunoprecipitation. KLF9 and PGR signaling networks were analyzed by gene expression array profiling. Eutopic endometrium from women with endometriosis had reduced expression of KLF9 mRNA together with those of PGR-B, WNT4, WNT2, and DKK1. KLF9 and PGR were recruited to the DKK1 promoter and modified each other's transactivity. In HESC, KLF9 and PGR coregulated components of the WNT, cytokine, and IGF gene networks that are implicated in endometriosis and infertility. Loss of KLF9 coregulation of endometrial stromal PGR-responsive gene networks may underlie progesterone resistance in endometriosis.

Progestins/Antiprogestins: Role in Pathogenesis and Treatment for Endometriosis

Endometriosis is a painful gynecological condition in the fertile-age in which presence of endometrial tissue develops outside the uterus, which under normal situation found only in the inside lining of the uterus, attach to pelvic floor, endometrium or peritoneal cavity. Endometriosis cause abdominal pain, bleeding, irregular menstrual cycles with excessive pain, inflammatory responses and infertility. Retrogressive menstruation and invasion theories have been well studied in the pathogenesis of endometriosis. Role of steroids including estrogen, gonadotropin releasing hormones has been documented and major treatment strategies are based on steroid biology of endometriosis. Current treatment strategies are less successful and solely focusing on the late phase of the disease. The exact role of progesterone in the initiation (initial phase) of endometriosis has not been well studied or overshadowed by the concept of progesterone resistance that occurs in late phase in endometriosis. In this review, we are discussing the role of progesterone and potential use of anitprogestins or possible combination treatment strategies which may help to combat initiation and progression of endometriosis.

Role of Estrogen Receptor-β in Endometriosis

Endometriosis is an estrogen-dependent disease. The biologically active estrogen, estradiol, aggravates the pathological processes (e.g., inflammation and growth) and the symptoms (e.g., pain) associated with endometriosis. Abundant quantities of estradiol are available for endometriotic tissue via several mechanisms including local aromatase expression. The question remains, then, what mediates estradiol action. Because estrogen receptor (ER)β levels in endometriosis are >100 times higher than those in endometrial tissue, this review focuses on this nuclear receptor. Deficient methylation of the ERβ promoter results in pathological overexpression of ERβ in endometriotic stromal cells. High levels of ERβ suppress ERα expression. A severely high ERβ-to-ERα ratio in endometriotic stromal cells is associated with suppressed progesterone receptor and increased cyclo-oxygenase-2 levels contributing to progesterone resistance and inflammation. ERβ-selective estradiol antagonists may serve as novel therapeutics of endometriosis in the future.

Physiologic activation of nuclear factor kappa-B in the endometrium during the menstrual cycle is altered in endometriosis patients

To evaluate nuclear factor kappaB (NF-κB) activation and NF-κB-p65 subunit activation, immunolocalization, and expression in the endometrium of healthy women and endometriosis patients throughout the menstrual cycle. Prospective observational study. Affiliated hospital and university research laboratory. Twenty-four healthy women and 24 endometriosis patients. Menstrual, proliferative, and secretory endometrial biopsies. Assessment of NF-κB and p65 activation by protein-DNA binding assays and p65 localization and expression by immunohistochemistry. Total NF-κB-DNA binding was constitutive and variable in human endometrium accross the menstrual cycle. Healthy women (physiologic conditions) showed higher p65-DNA binding in proliferative than in menstrual and secretory endometrium. Conversely, in endometriosis patients, p65-DNA binding was higher in proliferative and secretory endometrium than in menstrual endometrium. Endometrial epithelial cells showed higher p65 expression level score than endometrial stromal cells. NF-κB activity is constitutive, physiologic, and variable in human endometrium. The physiologic cyclic p65 activation pattern was altered in endometriosis patients, showing no cyclic variation between the proliferative and secretory phase of the menstrual cycle. The absence of decreased p65 activity in secretory endometrium from endometriosis patients is concurrent with progesterone resistance and could participate in endometrial biologic alterations during the implantation window in endometriosis patients.

Effects of AKT and MEK1/2 inhibition on stromal cell viability and proliferation in endometriosis

Endometriosis is characterized by progesterone resistance and hyperactivity of the AKT and MAPK pathways. We previously demonstrated that inhibition of AKT or MEK1/2 increases progesterone receptor levels in endometriotic stromal cells, and that aberrantly active AKT and MAPK may contribute to the pathogenesis of the disease. The objective of this study was to measure the effects of AKT and MEK1/2 inhibition on endometriotic stromal cell viability and proliferation.

Endometrial Indian hedgehog expression is decreased in women with endometriosis

Nuclear and cytoplasmic endometrial expression of Indian hedgehog increased from the late proliferative to mid and late secretory phases in 26 healthy volunteers compared with 30 women with endometriosis. The abnormal expression of Indian hedgehog protein in women with endometriosis suggests a resistance to P action.

Progesterone Resistance in PCOS Endometrium: A Microarray Analysis in Clomiphene Citrate-Treated and Artificial Menstrual Cycles

Polycystic ovary syndrome (PCOS), the most common endocrinopathy of reproductive-aged women, is characterized by ovulatory dysfunction and hyperandrogenism. The aim was to compare gene expression between endometrial samples of normal fertile controls and women with PCOS. We conducted a case control study at university teaching hospitals. Normal fertile controls and women with PCOS participated in the study. Endometrial samples were obtained from normal fertile controls and from women with PCOS, either induced to ovulate with clomiphene citrate or from a modeled secretory phase using daily administration of progesterone. Total RNA was isolated from samples and processed for array hybridization with Affymetrix HG U133 Plus 2 arrays. Data were analyzed using GeneSpring GX11 and Ingenuity Pathways Analysis. Selected gene expression differences were validated using RT-PCR and/or immunohistochemistry in separately obtained PCOS and normal endometrium. ANOVA analysis revealed 5160 significantly different genes among the three conditions. Of these, 466 were differentially regulated between fertile controls and PCOS. Progesterone-regulated genes, including mitogen-inducible gene 6 (MIG6), leukemia inhibitory factor (LIF), GRB2-associated binding protein 1 (GAB1), S100P, and claudin-4 were significantly lower in PCOS endometrium; whereas cell proliferation genes, such as Anillin and cyclin B1, were up-regulated. Differences in gene expression provide evidence of progesterone resistance in midsecretory PCOS endometrium, independent of clomiphene citrate and corresponding to the observed phenotypes of hyperplasia, cancer, and poor reproductive outcomes in this group of women.

Subfertility Linked to Combined Luteal Insufficiency and Uterine Progesterone Resistance

Early pregnancy loss is common and can be caused by a range of factors. The Brown Norway (BN) rat exhibits reproductive dysfunction characterized by small litter size and pregnancy failure and represents a model for investigating early pregnancy loss. In this study, we investigated the establishment of pregnancy in the BN rat and gained insight into mechanisms causing its subfertility. Early stages of BN uteroplacental organization are unique. The BN primordial placenta is restricted in its development and correlates with limited BN uterine decidual development. BN uterine decidua was shown to be both structurally and functionally distinct and correlated with decreased circulating progesterone (P4) levels. Ovarian anomalies were also apparent in BN rats and included decreased ovulation rates and decreased transcript levels for some steroidogenic enzymes. Attempts to rescue the BN uterine decidual phenotype with steroid hormone therapy were ineffective. BN uteri were shown to exhibit reduced responsiveness to P4 but not to 17beta-estradiol. P4 resistance was associated with decreased transcript levels for the P4 receptor (Pgr), a P4 receptor chaperone (Fkbp4), and P4 receptor coactivators (Ncoa1 and Ncoa2). In summary, the BN rat exhibits luteal insufficiency and uterine P4 resistance, which profoundly affects its ability to reproduce.

Immunology of Endometriosis

Endometriosis is a common condition with a varied phenotype. Symptomatic cases have been associated with progesterone resistance and dysregulated cytokine production in both ectopic and eutopic endometrium. In at least some cases, this seems to be associated with chronic local inflammation and antibody self-reactivity. Coexistence of endometriosis with autoimmune disease has been documented in a small number of cases, and the presence of autoreactive antibodies in the serum of some patients with endometriosis is commonly reported. This paper briefly reviews the association between endometriosis and autoimmune disease and describes the potential role of inflammation in the development of immunologic self-reactivity in these patients.