To Evaluate The Effect Of GnRH Agonist Combined With Add-back Therapy In The Treatment Of Endometriosis And The Influence On T Lymphocytes Function

Endometriosis is a common gynecologic disease,with a trend of increased incidence.Although gonadotropin releasing hormone agonist(GnRHa) is the major treatment of endometriosis,the study of add-back therapy is still not systemized.The effect of immune factors on the development of endometriosis has been focused on,but the influence of GnRHa combined with add-back therapy on endometriosis is still little to know.Partâ… The effect of GnRH agonist combined with add-back therapy in the treatment of endometriosisObjectiveTo compare the effect of GnRH agonist combined with transdermal estrogen and medroxyprogesterone acetate as add-back therapy and GnRH agonist alone in the treatment of endometriosis.MethodsFrom January 1,2007 to July 31,2007,28 patients with endometriosis treated in our hospital and diagnosed by laparoscope were randomly divided into two groups, which were marked as GnRHa group(Group A) and GnRHa plus add-back therapy group(Group B).Patients in group A received goserelin(Zoladx,AstraZeneca) every 28 days for 3 times.Patients in group B received goserelin every 28 days for 3 times plus transdermal E₂(50μg Fem7,Merk) one half of piece every week and daily oral medroxyprogesterone acetate 6mg.Before the treatment,the degree of pain was measured according to a visual analog scale(VAS),the quality of life and health-related satisfaction were assessed with the Medical Outcomes Survey Short Form 36(SF-36) and bone mineral density(BMD) of the lumbar spine was measured by dual x-ray absorptiometry.At the same time venous blood was collected by venipuncture to detect the level of FSH,E2 and BGP in serum by fully auto microparticle chemiluminescence immune assay(ACCESS) and enzyme linked immunosorbent assay(ELISA) respectively.Besides the form of kupperman,the previous subjects were detected once after three months treatment.After the menstruation came back,the degree of pain was measured again.Results1,After three months treatment,the value of the total score of the degree of pain and pelvic pain was significantly decreased and the symptoms of dyspareunia disappeared in both groups(P＜0.01).While the total scores of the degree of pain and the value of pelvic pain were higher in group B than those in group A.However, the difference was not significant.After the menstruation came back,the value of the total scores of the degree of pain,pelvic pain were a little incerased or remained unchanged in both groups compared with those of last stage of treatment,while the difference was of no significance.And the socre of dysmenorrhea was significantly decreased in both groups(P＜0.01).Each score of those in group B was higher than that in group A;but the difference was also not significant.2,After treatment the patients in group B had better quality of life than group A, especially in vitality and physical function.The patients in both groups were satisfied with the control of pain,but the scores of vitality and physical function in group A were significantly descended(P＜0.05 and P＜0.01,respectively).3,There was no difference in the value of the form of kupperman between two groups after three months treatment.But the incidence of hot flush and sweatness among the form of kupperman in group B was significantly lower than that of group A (P＜0.05).4,Bone mineral density of the lumbar spine(L1-L4) was significantly decreased after three months treatment in group A(P＜0.01);it was also decreased in group B,but the difference was not significant.A significant increase of the level of serum BGP was observed in group A(P＜0.01) after the treatment.Similar increase also occurred in group B,while the difference was of no significance.5,After the treatment,the level of serum FSH and E₂ in both group declined significantly compared with the level before treatment(P＜0.01);the level of serum E₂ in group B was significantly higher than that in group A(P＜0.01);and the level of serun FSH in group B was significantly lower than that in group A(P＜0.05).Conclusions1,The significant decrease of the score of the degree of pain,pelvic pain and dysmenorrheal and the disappearance of dyspareunia in group B suggests that our project of add-back therapy could relieve the pain of women with endometriosis and could be the same with GnRHa alone.2,The patients receiving add-back therapy may have a better quality of life than GnRHa alone,especially in pain control,vitality and physical function.3,Not all the symptoms of hypoestrogenism induced by GnRHa could be eliminated by add-back therapy,while hot flush and sweatness was ameliorated remarkably.It is speculated that the level of serum estrogen could be the cause of that.4,Although there was a trend of decrease of BMD in add-back therapy group,the loss of bone mineral was much less than that in GnRHa alone group.And the change of the level of serum BGP had a negative relation with the BMD.It is concluded that our add-back therapy could preotet the patients treated with GnRHa from bone loss.5,The level of serum estrogen in our study could protect patients from bone loss and avoid stimulating the growth of ectopic endometrium.The effect of our add-back therapy is confirmed and safe.Partâ…¡Effect on T lymphocytes of patients with endometriosis after the treatment of GnRH agonist combined with add-back therapyObjectiveTo investigate the effect of GnRH agonist combined with add-back therapy on the expression of different estrogen receptors(ER) subtypes and gonadotropin releasing hormone receptor(GnRHR) of peripheral blood mononuclear cell(PBMC) and T lymphocytes function of patients with endometriosis. Materials and methodsThe inclusion criterion,allocation,and administration of patients with endometriosis were the same with partâ… .During the same period,10 non-endometriosis cases were recruited as the control group(group C).Venous blood was collected from all patients included by venipuncture to exame T lymphocyte subsets of peripheral blood with flow cytometry(FCM) and the specific cytokine(IL-2 and IL-6) secretion of PBMC induced by phytohemagglutinin(PHA) with ELISA and the proliferation of T lymphocytes with Methylthiazoletetrazolium(MTT) method.At the same time,ERα,ERβand GnRHR mRNA expression of PBMC were detected by real time RT-PCR and the ERα,ERβand GnRHR protein expression were detected by western-blot in patients with endometriosis.The peritoneal fluid from part of the patients was collected to mesure the level of IL-2 and IL-6 by ELISA.After 3 months treatment,all contents were detected again in patients with endometiosis except the cytokins from peritoneal fluid.Results1,Before treatment,the percentage of peripheral blood CD4⁺ lymphocytes and the ratio of CD4⁺/CD8⁺ of group A and B were significantly lower than that of group C (P＜0.05).After three months treatment,the percentage of peripheral blood CD4⁺ lymphocytes was significantly increased in both group A and B(P＜0.05) and the ratio of CD4⁺/CD8⁺ of group B was increased significantly than the level before treatment(P＜0.05).Similar increase also occurred in group A,but the difference was of no significance(P=0.055).2,Before treatment,the proliferation of T lymphocytes in group A and B was significantly lower than that in group C(P＜0.05) and after three months treatment, the proliferation of T lymphocytes was increased in both groups(P＜0.01).3,Compared with group C,the level of IL-6 in the supernatants of cultured PHA induced PBMC and peritoneal fluid of group A and B was significantly increased(P＜0.05);the ratio of IL-2/IL-6 in the supernatants and peritoneal fluid of both group A and B was significantly lower than that of group C(P＜0.05).After 3 months treatment,in both group A and B,the levels of IL-6 in the supernatants were significantly decerased,while the radio of IL-2/IL-6 was remarkably increased (P＜0.05,respectively).4,The level of mRNA and protein of ERβof PBMC significantly decreased after three months treatment in group A and B(P＜0.05),while the ERαand GnRHR expression made no obvious difference before and after treatment.Conclusions1,After three months treatment,the percentage of peripheral blood CD4⁺ lymphocytes and the ratio of CD4⁺/CD8⁺ was significantly increased and the proliferation of T lymphocytes was also increased in add-back group just like that of the group of GnRHa alone.It suggests that our add-back therapy with transdermal E₂ 25μg everyday and daily oral medroxyprogesterone acetate 6mg might have the same effect on the improvement of abnormity of cell immunity in patients with endometriosis as GnRHa alone.2,After treatment,the level of IL-6 secretion of T lymphocytes of add-back group decreased,the ratio of IL-2/IL-6 increased,just like that of the group of GnRHa alone and it is concluded that both GnRHa alone and GnRHa combined with add-back therapy could improve Th1/Th2 balance.3,In both endometriosis groups,the expression of ERβof PBMC was significantly decreased after three months treatment.It is speculated that the effect of GnRH agonist on peripheral T lymphocytes might not be the result of the direction effect of GnRH agonist.It might have the relations with the hypoestrogenism.The effect might exert through ERβof T lymphocyte,while the definite mechanism is still unclear and we need further investigation.4,Both GnRHa alone and GnRHa combined with add-back therapy might improve immune function of endometriosis.