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Estrogens play a critical role in the pathogenesis of endometriosis and it is logical to assume that lowering estradiol levels with oral gonadotropin-releasing hormone (GnRH) antagonists may prove effective, especially in women who fail to respond to progestogens. Indeed, due to progesterone resistance, oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis, but are ineffective in 33% of women. Oral GnRH antagonists have therefore been evaluated for management of premenopausal women with endometriosis-associated pelvic pain. The first publication on these drugs reported the efficacy of elagolix. The present paper is a narrative review of linzagolix, which is an orally administered GnRH receptor antagonist with low pharmacokinetic/pharmacodynamic variability. It binds to and blocks the GnRH receptor in the pituitary gland, resulting in a dosedependent drop in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) production. This reduction in LH and FSH levels in turn leads to a dose-dependent decline in estrogen. Phase 2 and 3 trials are reviewed and discussed here. There is a place for GnRH antagonists in the management of symptomatic endometriosis, and linzagolix with or without add-back therapy (ABT) is one option that can be used at low doses, avoiding the need for ABT, which is contraindicated in some patients.

Objective To study the impact of aneuploid granulosa and stromal cells on folliculogenesis of small ovarian follicles from mosaic Turner syndrome patients using a murine xenograft model. Design Laboratory study Subjects Ovarian cortical tissue was obtained by laparoscopic surgery from 18 mosaic TS patients (aged 5-19 years) and 13 controls (aged 5-18 years). Intervention Part of each tissue fragment was used to karyotype ovarian cells in non-grafted tissue by fluorescence in situ hybridization. The remaining tissue was xenografted to severe combined immunodeficient mice for 5 months. Grafted tissue was analyzed for aneuploidy, and follicle density and morphology were determined. Expression of proliferating cell nuclear antigen and anti-Müllerian hormone were investigated by immunohistochemistry. Main Outcome Measures The impact of aneuploid granulosa and stromal cells on folliculogenesis. Fluorescence in situ hybridization of ovarian tissue before grafting was performed to determine the level of aneuploidy in stromal cells, and oocytes and granulosa of small follicles. After xenografting the level of aneuploidy of the newly formed layers of granulosa cells was again determined in secondary and antral follicles. Results Follicle density in ovarian tissue from Turner syndrome patients was significantly lower than in controls before grafting. Fluorescence in situ hybridization analysis confirmed that 101/104 oocytes from non-grafted tissue of Turner syndrome patients showed normal X chromosome content, while granulosa and stromal cells were mainly 45,X. Fragments from 12 Turner syndrome patients contained follicles at all stages after xenografting, including secondary and antral follicles. Follicle density in Turner syndrome patients and controls decreased significantly after grafting. Moreover, a shift from high to low proportions of 45,X granulosa cells was observed during folliculogenesis. Expression of PCNA in follicles from TS patients increased significantly during grafting. Secretion of AMH was impaired before grafting in peri-/postpubertal TS girls, but recovered after grafting. Conclusion Our study showed that small follicles from mosaic Turner syndrome patients undergo folliculogenesis, despite the presence of aneuploid granulosa and stromal cells. Ovarian tissue cryopreservation could therefore be a valid option to preserve fertility in young mosaic Turner syndrome patients if sufficient numbers of follicles are present, thus preferably before the age of 12. Key words Turner syndrome, fertility preservation, xenografting, mosaicism

To study the effect of freezing, in vitro culture (IVC) and grafting to chorioallantoic membrane (CAM) on follicle outcomes in human ovarian tissue. An experimental study. University-based research laboratory. Fresh and cryopreserved ovarian tissue from 10 patients was donated to research with their consent and institutional review board approval. Fresh and frozen-thawed ovarian cortical pieces were in vitro-cultured and compared (fresh-IVC vs FT-IVC). The FT-IVC fragments were then examined against fragments grafted to CAM (FT-CAM). After both IVC and CAM grafting, ovarian cortical pieces (4×2×1 mm) were analyzed on days 0, 1, and 6. Follicle analyses included histology (count and classification) and immunohistochemistry (Ki67 [proliferation], caspase-3 [apoptosis], 1A and 1B light chain 3B [autophagy], p-Akt, FOXO1, and p-rpS6 [PI3K activation]). Droplet digital polymerase chain reaction further explored expression of PI3K pathway- and oocyte-related genes in tissue sections. No major differences were detected between fresh-IVC and FT-IVC tissues in any conducted analyses. Although a significant drop was observed in primordial follicle (PF) proportions in the fresh-IVC and FT-IVC groups (d0 vs. d6, P.05). The PF rates were also significantly higher in the FT-CAM group than the FT-IVC group on d6 (P=.02). Importantly, avian erythrocytes were already present in 30% of implants from d1. Apoptotic and autophagic follicle rates increased during IVC (P

Are M2 macrophages implicated in endometrial invasiveness in adenomyosis? Seventeen formalin-fixed paraffin-embedded uterine samples and 16 fresh endometrial biopsies were collected from women with or without adenomyosis. Double immunofluorescence was performed to determine the predominant macrophage population in adenomyosis between M1 and M2 phenotypes. The invasion capacity of endometrial cells was assessed by invasion assays and quantitative polymerase chain reaction for genes involved in cell motility and epithelial-mesenchymal transition (EMT). Specific mechanisms of invasion were investigated by immunohistochemistry for E-cadherin, N-cadherin and matrix metalloproteinase 9 (MMP9). Only M2 macrophages were found to accumulate in adenomyosis, in higher numbers in both eutopic endometrium (P = 0.0109) and lesions (P = 0.0267) than healthy tissue. Co-culture with M2 macrophages significantly boosted invasion capacity in endometrial epithelial (P = 0.0002; P = 0.002) and stromal cells (P = 0.0469; P = 0.0047) from both adenomyosis patients and healthy controls. No gene expression differences indicating EMT were noted, either between co-cultured and control cells, or between healthy and adenomyotic cells. E- and N-cadherin protein expression did not differ significantly between endometrium from adenomyosis subjects and healthy tissue but MMP9 expression was increased in eutopic stroma from adenomyosis patients (P = 0.0492). In adenomyosis, both E-cadherin (P = 0.0379) and N-cadherin (P = 0.0196) were more extensively expressed in basal glands than functional glands. M2 macrophages accumulate in adenomyosis and enhance invasion capacity of adenomyotic and even healthy endometrial cells, implying that macrophage infiltration alone may be sufficient to promote the disease. This study failed to detect any changes pointing to EMT, suggesting an alternative mode of invasion. Strong E- and N-cadherin-positive intercellular junctions in basal (invasive) glands suggest the involvement of collective cell migration in the invasion process of endometrium.

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Frozen-thawed human ovarian tissue endures large-scale follicle loss in the early post-grafting period, characterized by hypoxia lasting around 7 days. Tissue revascularization occurs progressively through new vessel invasion from the host and neoangiogenesis from the graft. Such reoxygenation kinetics lead to further potential damage caused by oxidative stress. The aim of the present manuscript is to provide a systematic review of proangiogenic growth factors, hormones and various antioxidants administered in the event of ovarian tissue transplantation to protect the follicle pool from depletion by boosting revascularization or decreasing oxidative stress. Although almost all investigated studies revealed an advantage in terms of revascularization and reduction in oxidative stress, far fewer demonstrated a positive impact on follicle survival. As the cascade of events driven by ischaemia after transplantation is a complex process involving numerous players, it appears that acting on specific molecular mechanisms, such as concentrations of proangiogenic growth factors, is not enough to significantly mitigate tissue damage. Strategies exploiting the activated tissue response to ischaemia for tissue healing and remodelling purposes, such as the use of antiapoptotic drugs and adult stem cells, are also discussed in the present review, since they yielded promising results in terms of follicle pool protection.

PURPOSE: To investigate whether mitochondrial content, activity, and morphology differ in prepubertal versus adult ovarian follicles. METHODS: Ovarian tissue was collected from 7 prepubertal girls (age 1-10 years) and 6 adult women (age 20-35 years). Primordial and primary follicles were isolated from frozen-thawed prepubertal and adult ovarian tissue and their viability was assessed. Mitochondrial content was investigated by TOMM20 immunostaining of prepubertal and adult ovarian tissue, while mitochondrial activity in isolated follicles was analyzed by MitoTracker CM-H2XRos and JC-1. Frozen-thawed ovarian tissue from the same patients was also evaluated by transmission electron microscopy to examine mitochondrial morphology. RESULTS: Higher TOMM20 staining was detected in prepubertal follicles compared to their adult counterparts, indicating the presence of more mitochondria in prepubertal follicles. Analysis of mitochondrial activity by MitoTracker showed higher fluorescence intensity in prepubertal follicles, suggesting that follicles in this group are more active than adult follicles. JC-1 analysis did not reveal any statistically significant difference in the inactive/active ratio between the two groups. Moreover, ultrastructural analysis by TEM detected morphological differences in the shape and cristae of prepubertal mitochondria, probably suggesting a mechanism of response to autophagy. CONCLUSION: Differences in the number, activity, and morphology of mitochondria were reported, suggesting that consequential modifications might occur during puberty, which could be the window of opportunity required by mitochondria to undergo changes needed to reach maturity, and hence the capacity for ovulation and fertilization.

Objective To investigate whether adipose tissue-derived stem cells (ASCs) modulate hypoxia and oxidative stress in human ovarian tissue transplants. Design Prospective experimental study Setting Gynecological research unit in a university hospital Patient(s) Cryopreserved ovarian cortex from 5 adult women. Intervention(s) Thirty mice were grafted with frozen-thawed human ovarian tissue, with or without ASCs (2-step/ASCs+ovarian tissue [OT] group and OT group). The ovarian grafts were retrieved on days 3 (n = 5), 10 (n = 5), and 21 (n = 5). The 10 animals grafted for 21 days underwent in vivo evaluations using microdialysis. One piece of ovarian tissue per patient was fixed for analysis after thawing (non-grafted controls). Main Outcome Measure(s) Direct reactive oxygen species were collected every second day after grafting by means of microdialysis. Analyses of ovarian fragments included immunolabeling for double CD34 (revascularization by host and graft components); immunofluorescence for hypoxia-inducible factor 1α (hypoxia-related response), nuclear factor erythroid 2-related factor 2 (oxidative stress-related response), and 8-hydroxy-deoxyguanosine (oxidative stress-related DNA damage); and gene expression (quantitative reverse transcription polymerase chain reaction) for vascular endothelial growth factor-A (neoangiogenesis), superoxide dismutase 2 (antioxidant activity), and nuclear respiratory factor 1 (mitochondrial biogenesis). Result(s) Reactive oxygen species peaked earlier in the ASC group (day 2) compared with that in the OT group (day 10) after grafting. Total vascularization was stable in the ASC group at all time points, while it was lower in the OT group 3 days after grafting. Hypoxia-inducible factor 1α expression, also detected in non-grafted controls, was significantly lower in the ASC group than in the OT group on days 3 and 10. The increase in VEGF gene expression lasted significantly longer in the ASC group than in the OT group. There was no significant upturn in the oxidative stress-related response (nuclear factor erythroid 2-related factor 2 pathway) or oocyte DNA damage (8-hydroxy-deoxyguanosine) in any of the grafted groups. Conclusion(s) Use of ASCs allows faster ovarian graft reperfusion and mitigates the hypoxia-related response through rapid revascularization, sustained by prolonged increase in vascular endothelial growth factor after grafting. No evidence of oxidative stress-related damage was detected irrespective of the transplantation strategy.

Without an animal model and a non-invasive diagnosis, the pathophysiology of endometriosis is unclear and information is limited to symptomatic women. Lesions are biochemically variable. Medical therapy cannot be blinded and extensive surgery combines low numbers with variable difficulty and surgical skills. Experience is spread among specialists in imaging, medical therapy, infertility, pain and surgery. Besides the recent changes in interpreting statistical analyses, the limited good-quality evidence increases the importance of clinical experience. Therefore trial design, analysis and judgment of results should be done by experts in the different disciplines of endometriosis, before being translated into guidelines.

Uterine fibroids are common non-cancerous neoplasm that cause heavy menstrual bleeding and other signs. Linzagolix is an oral gonadotropin-releasing hormone receptor antagonist taken once per day that dose-dependently suppresses gonadal steroids and might reduce uterine-fibroid-associated signs. Two phase 3 trials were conducted to confirm the efficacy and safety of linzagolix at full-suppression (200 mg) and partial-suppression (100 mg) doses with or without hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate) compared with placebo for the treatment of symptomatic uterine fibroids.PRIMROSE 1 and PRIMROSE 2 were identical 52-week, randomised, parallel, double-blind, placebo-controlled, phase 3 trials conducted at clinics in the USA (PRIMROSE 1) and Europe and the USA (PRIMROSE 2). Eligible women with uterine fibroid-associated heavy menstrual bleeding (menstrual blood loss80 mL per cycle) were randomly assigned in a 1:1:1:1:1 ratio to one of five masked treatments: (1) placebo, (2) 100 mg linzagolix per day alone, (3) 100 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate), (4) 200 mg linzagolix per day alone, or (5) 200 mg linzagolix per day with once-per-day hormonal add-back therapy (1 mg oestradiol and 0·5 mg norethisterone acetate). The primary endpoint was a response (menstrual blood loss ≤80 mL and ≥50% reduction from baseline) at 24 weeks in women who received at least one dose of treatment and did not meet any exclusion criteria based on predosing assessments. These trials are registered with ClinicalTrials.gov (NCT03070899 and NCT03070951). The trials have been completed.Between May, 2017, and October, 2020, in PRIMROSE 1, 574 women were enrolled, of which 48 discontinued and 15 were excluded; therefore, 511 women were included in the full analysis set; and in PRIMROSE 2, 535 women were enrolled, of which 24 did not receive the study drug and ten women were excluded from the study, resulting in 501 women being included in the full analysis set. In both trials, a significantly higher proportion of women had a reduction in heavy menstrual bleeding in all linzagolix (with or without add-back therapy) treatment groups compared with the placebo group (p≤0·003). In PRIMROSE 1, the response rates were 56·4% (95% CI 45·8-66·6%) in the 100 mg group, 66·4% (56·6-75·2%) in the 100 mg plus add-back therapy group, 71·4% (61·8-79·8%) in the 200 mg group, and 75·5% (66·0-83·5%) in the 200 mg plus add-back therapy group, compared with 35·0% (25·8-45·0%) in the placebo group. In PRIMROSE 2, the response rates were 56·7% (46·3-66·7%) in the 100 mg group, 77·2% (67·8-85·0%) in the 100 mg plus add-back therapy group, 77·7% (68·4-85·3%) in the 200 mg group, and 93·9% (87·1-97·7%) in the 200 mg plus add-back therapy group, compared with 29·4% (20·8-39·3%) with placebo. The most common adverse events up to 24 weeks were hot flushes (35% of participants in PRIMROSE 1 and 32% in PRIMROSE 2 with linzagolix [200 mg] alone and 3-14% in all other groups).Linzagolix (100 mg or 200 mg) with or without add-back therapy significantly reduced heavy menstrual bleeding. Partial suppression with once-per-day linzagolix (100 mg) without add-back therapy potentially provides a unique option for the chronic treatment of symptomatic uterine fibroids in women who cannot or do not want to take concomitant hormonal add-back therapy.ObsEva.

Deep endometriosis (DE) is considered to be one of the most challenging conditions to manage, especially when it invades surrounding organs like the rectum. Surgical excision of deep rectovaginal endometriosis is required when lesions are symptomatic, impairing bowel, urinary, sexual, and reproductive functions, or if they evolve. Preoperative radiological examination should be extensive to determine the appropriate surgery: laparoscopic shaving, disc excision, or rectal resection. We demonstrated that in the hands of experienced surgeons, rectal shaving is possible for DE in more than 95% of cases, with low complication rates compared to rectal resection. Shaving and bowel resection are associated with comparable recurrence rates. As shaving is indicated whatever the size of deep lesions, surgeons should first consider rectal shaving to remove DE. Bowel resection should only be performed in case of major rectal stenosis (>80%), multiple and/or posterior rectal lesions and stenotic sigmoid colon lesions.

Objective To characterize ovarian tissue from pediatric patients by evaluating development and vascularization in follicle populations and comparing it with adult tissue after xenografting. Design Prospective experimental study. Setting Academic research center. Patient(s) Five children (median age 3 years) and seven women (median age 28 years). Intervention(s) Hematoxylin and eosin staining, immunofluorescence, and transmission electron microscopy (TEM) evaluation before and after grafting. Main Outcome Measure(s) Follicle density, morphology, classification, and size, ovarian tissue vascularization, follicle ultrastructure. Result(s) Frozen-thawed ovarian tissue was divided into three fragments: nongrafted controls, TEM, and xenografting for 20 weeks. Follicle density was statistically significantly higher in pediatric than adult patients; even though it decreased in both groups after transplantation, it remained higher in pediatric patients. In the pediatric group, quiescent-stage follicles were the majority of the follicle pool before and after grafting, while growing follicles statistically significantly increased in both groups after grafting. Abnormal and atretic follicles were also observed in pediatric tissue and declined with age and after grafting. Pediatric ovarian tissue contained more and larger immature vessels, while mature vessels were larger in adults. The TEM analysis of abnormal pediatric follicles showed loss of shape and vacuolization of the cytoplasm without organelle damage. Conclusion(s) Statistically significant differences in follicle density were observed between pediatric and adult patients, but the follicle proportions were similar before and after grafting, with the exception of atretic and abnormal follicles. Pediatric tissue contains more and larger immature vessels than adult tissue, and the posttransplantation revascularization process is accelerated in this group.

Purpose: The aim of this study was to elucidate whether ovarian tissue is able to withstand a double freezing-thawing procedure. Methods: Human ovarian cortical biopsies from 4 thawed whole ovaries were divided into 4 experimental subgroups: (a) frozen-thawed non-grafted group, (b) frozen-thawed xenografted group, (c) refrozen-rethawed non-grafted group, and (d) refrozen-rethawed xenografted group. Xenografting was performed using 8 severe combined immunodeficient mice for a total duration of 21 days. The following analyses were conducted: classic hematoxylin and eosin staining, Ki67 immunolabeling, transmission electron microscopy, Masson's green trichrome, and double CD34 immunostaining. Results: Morphologically normal preantral follicles were detected in all groups. We observed a dramatic decline of more than 65% in early preantral follicle survival rates after grafting of both frozen-thawed (p < 0.0001) and refrozen-rethawed (p < 0.0001) ovarian tissue. However, mean follicle densities remained comparable between the frozen-thawed and refrozen-rethawed non-grafted groups, as well as both grafted groups. Equivalent proportions of proliferating early preantral follicles were identified in frozen-thawed and refrozen-rethawed samples, whether the tissue was grafted or not. Furthermore, we did not observe any significant difference in atretic follicle rates between any of the four groups, and the ultrastructural quality of follicles appeared unaffected by the refreezing procedure. Similar proportions of fibrosis were noted in the frozen-thawed and refrozen-rethawed groups, irrespective of grafting. Finally, no significant differences were witnessed in terms of vascularization. Conclusion: We were able to demonstrate, for the first time, that refrozen-rethawed ovarian tissue has the same functional characteristics as frozen-thawed ovarian tissue.

Chemotherapy-induced ovarian damage:apoptosis and/or in vitro activation?The term‘‘ovarian reserve’’is typically used to refer to the pop-ulation ofprimordial follicles (PMFs) .This population is very sensitive to cytotoxic drugs, especially alkylating agents (cyclo-phosphamide, busulfan, ifosfamide). Among them, cyclophos-phamide (CPA) is the alkylating agent that causes the mostdamage to oocytes and granulosa cells. Alkylating-like plat-inum complexes (such as cisplatin, anthracyclanes [includingdoxorubicin]) should also be considered as ovo-toxic drugs. [...]

(150 words) Gonadotoxic treatments like chemotherapy or radiotherapy and ovarian surgery may result in accelerated depletion of the ovarian reserve and subsequent premature ovarian insufficiency. Patient age, ovarian reserve, type of treatment and administered dose are important determinants of this risk, requiring fertility preservation strategies when it is high. Oocytes and ovarian tissue can both be cryopreserved, with encouraging results in terms of pregnancy and live birth rates according to recent publications. Moreover, since ovarian tissue transplantation also results in long-term endocrine resumption, it may represent a potential future therapeutic option for complete ovarian function restoration in patients with premature ovarian insufficiency.

Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.

Introduction In recent decades, anticancer treatments have become increasingly effective, yielding signifcantly improved survival rates in cancer patients. Nevertheless, young women of reproductive age are at high risk of experiencing chemo/ radiotherapy-induced premature ovarian insuffciency and subsequent infertility .....

Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.

Objective To compare the efficacy of a selective progesterone receptor modulator, ulipristal acetate, and a gonadotropin-releasing hormone antagonist, linzagolix, in a case of severe uterine adenomyosis. Design Case report. Setting Private clinic and infertility research unit. Patient One patient born in 1981 who presented because of heavy menstrual bleeding, pelvic pain, and dysmenorrhea due to diffuse and disseminated uterine adenomyosis confirmed by magnetic resonance imaging (MRI). Intervention The patient received a first treatment of 5 mg UPA daily for one course of 3 months. This therapy was discontinued because MRI revealed a worsened aspect. One year later, a once-daily dose of 200 mg linzagolix administered orally was initiated for 3 months, followed by another 3-month course of 100 mg once daily. Main Outcome Measures Clinical symptoms and MRI aspect. Results During treatment with UPA, the symptoms (pelvic pain, dysmenorrhea, bulk symptoms) worsened and MRI revealed aggravation of the adenomyotic lesions. During the 12-week course of once-daily 200 mg linzagolix, the patient remained in amenorrhea and noted a very significant improvement in symptoms. On MRI, the uterine volume had fallen from 875 cm3 to 290 cm3, and the adenomyotic lesions had significantly regressed. During the 100-mg linzagolix course (weeks 13–24), the patient reported continued alleviation of her symptoms. Conclusion To our knowledge, this is the first reported use of linzagolix, a new oral gonadotropin-releasing hormone antagonist that significantly reduced lesion size and improved quality of life in a patient with severe adenomyosis, who was previously nonresponsive to treatment with a selective progesterone receptor modulator, ulipristal acetate.

Objective To study the effect of a new investigational oral gonadotropin-releasing hormone antagonist, linzagolix, on endometriosis-associated pain (EAP). Design A multinational, parallel group, randomized, placebo-controlled, double-blind, dose-ranging trial. Setting Clinical centers. Patient(s) Women aged 18–45 years with surgically confirmed endometriosis and moderate-to-severe EAP. Intervention(s) The interventions were 50, 75, 100, or 200 mg linzagolix (or matching placebo) administered once daily for 24 weeks. Main Outcome Measure(s) The primary endpoint was the number of responders (≥30% reduction in overall pelvic pain) after 12 weeks. Other endpoints included dysmenorrhea, non-menstrual pelvic pain, serum estradiol, amenorrhea, quality of life (QoL) measures, and bone mineral density (BMD). Result(s) Compared with placebo, doses ≥ 75 mg resulted in a significantly greater proportion of responders for overall pelvic pain at 12 weeks (34.5%, 61.5%, 56.4%, and 56.3% for placebo, 75, 100, and 200 mg, respectively). A similar pattern was seen for dysmenorrhea and non-menstrual pelvic pain. The effects were maintained or increased at 24 weeks. Serum estradiol was suppressed, QoL improved, and the rate of amenorrhea increased in a dose-dependent fashion. Mean BMD loss (spine) at 24 weeks was Conclusion(s) Linzagolix significantly reduced EAP and improved QoL at doses of 75–200 mg and decreased BMD dose-dependently. Clinical Trial Registration Number NCT02778399

Uterine adenomyosis is a common chronic disorder frequently encountered in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Despite its high prevalence, its etiopathogenesis is not yet fully understood, so there are currently no specific drugs to treat the disease. A number of dysregulated mechanisms are believed to contribute to adenomyosis development and symptoms, including sex steroid signaling, endometrial proliferation and invasiveness, and aberrant immune response. Abnormal sex steroid signaling, particularly hyperestrogenism and subsequent progesterone resistance, are known to play a pivotal role in its pathogenesis, which is why various antiestrogenic agents have been used to manage adenomyosis-related symptoms. Among them, gonadotropin-releasing hormone (GnRH) antagonists are swiftly gaining ground, with recent studies reporting efficient lesion regression and symptom alleviation. The aim of the present review is to compile available information on the pathogenesis of adenomyosis, explore the etiology and mechanisms of hyperestrogenism, and discuss the potential of antiestrogenic therapies for treating the disease and improving patient quality of life.

Research question Does a once-daily regimen of linzagolix, a new oral gonadotrophin-releasing hormone (GnRH) antagonist, given at a fully suppressive dose (200 mg) for 12 weeks, followed by a partially suppressive dose (100 mg) for a further 12 weeks, reduce adenomyotic uterine size and associated symptoms? Design Eight women (aged 37–45 years) with adenomyosis confirmed by magnetic resonance imaging (MRI) were enrolled in a single-centre, open-label pilot study. The primary efficacy end-point was the change in uterine volume on MRI at 24 weeks. Secondary efficacy end-points included serum oestradiol, overall pelvic pain, dysmenorrhoea, non-menstrual pelvic pain, dyspareunia, dyschezia and quality of life (QoL). Bone mineral density (BMD) was assessed at baseline and 24 weeks. Results At baseline, uterine volume (mean ± SD) was 333 ± 250 cm3. After 24 weeks, it was 204 ± 126 cm3, a reduction of 32% from baseline (P = 0.0057). After 12 weeks, it was 159 ± 95 cm3, a reduction of 55% (P = 0.0001). Median serum oestradiol was suppressed below 20 pg/ml during the 12 weeks on 200 mg linzagolix, and maintained below 60 pg/ml on 100 mg linzagolix. Improvements in overall pelvic pain, dysmenorrhoea, non-menstrual pelvic pain, dyspareunia, dyschezia and QoL were observed. Mean percentage change in BMD loss at 24 weeks was –2.4%, –1.3% and –4.1% for the spine, femoral neck and total hip, respectively. The most common adverse events were hot flushes. Conclusions A once-daily regimen of 200 mg linzagolix for 12 weeks and then 100 mg for another 12 weeks decreased adenomyotic uterine volume and improved associated symptoms.

Study question Is a once daily regimen of the GnRH antagonist, linzagolix, high-dose (200mg) for 12 weeks then low-dose (100mg) for 12 weeks, effective in severe adenomyosis? Summary answer After 12 weeks, there was marked shrinkage of uterine volume, regression of adenomyotic lesions and symptom improvement (pain, anemia), 24 weeks data is pending. What is known already Suppression of estradiol using GnRH antagonists has been shown to be an effective treatment for endometriosis and uterine fibroids. Linzagolix is an investigational, oral GnRH receptor antagonist, which dose-dependently reduces E2 levels, providing full suppression (serum E2 < 20 pg/mL) and partial suppression with once daily oral dosing of 200 mg and 100 mg, respectively. We hypothesized that a regimen of full suppression for 12 weeks followed by partial suppression maintenance therapy for 12 weeks could be effective for the treatment of severe adenomyosis. Study design, size, duration This was a single-center, open-label exploratory study in women with symptomatic adenomyosis confirmed by Magnetic Resonance Imaging (MRI) (EudraCT number: 2017–004–042–14). Patients were recruited from a single private clinic and infertility research unit between March 2019 to June 2020. Participants/materials, setting, methods Eligible patients were premenopausal women 18 to 48 years old with symptomatic uterine adenomyosis confirmed by MRI, moderate-to-severe pain and abnormal uterine bleeding. The primary measure of efficacy was the reduction in uterine volume assessed by MRI. Other endpoints included adenomyosis lesion volume, pelvic pain, haemoglobin, uterine bleeding and quality of life (EHP–30 domains: pain, control and powerlessness, emotional well-being, social support and self-image). Main results and the role of chance Eight (3 black and 5 white) enrolled subjects had mean±SD age 42±3 years and weight 75±19 kg. At baseline (day 2 of the cycle) all patients presented with pelvic pain, severe dysmenorrhea and heavy menstrual bleeding. In all cases, MRI showed an enlarged uterus (mean±SD volume 343±253 cm3) with severe adenomyosis characterized by heterogenous myometrium with multiple myometrial cysts. The mean±SD junctional zone was 29.0±14.2 mm. Median serum estradiol was suppressed to 12 pg/mL by 4 weeks and this was maintained up to 12 weeks. After 12 weeks, mean±SD uterine volume was 162±117 cm3, a 57±16% reduction from baseline, with marked regression of adenomyotic lesions and the junctional zone was 21.0±13.4 mm. Mean±SD overall pelvic pain score (0–10 NRS) was reduced from 8.4±1.1 at baseline to 2.4±3.4 (p = 0.0035) and there were also improvements in dysmenorrhea, dyspareunia, non-menstrual pelvic pain and dyschezia scores. No subjects reported uterine bleeding between Weeks 4 to 12. Mean±SD haemoglobin was 12.1±2.0 at baseline and 12.8±1.1 at 12 weeks. Anemia at baseline (≤10g/dL) was resolved by 12 weeks. Substantial improvements were observed on each of the EHP–30 domains. The most common side effect was the expected hypoestrogenic side effects of hot flushes, which were reported by 6/8 subjects. Limitations, reasons for caution This was a single-centre, open-label pilot study in 8 patients with symptomatic adenomyosis. We report the results after the first 12 weeks treatment of a high full suppression dose of linzagolix. Results after 24 weeks will further inform on the potential for a low partial suppression dose to maintain efficacy. Wider implications of the findings: The initial results of this open-label pilot study in women with severe adenomyosis indicate that a high full suppression dose of linzagolix 200 mg is effective in reducing uterine and adenomyosis lesion size, reducing abnormal uterine bleeding and pelvic pain and improving quality of life. Trial registration number EudraCT number: 2017–004–042–14

Study question Are symptomatic improvements in women with UF observed after 24 weeks of linzagolix treatment with or without add-back therapy (ABT) maintained over 52 weeks? Summary answer Improvements in anemia, pain and quality of life previously reported at 24 weeks were maintained at 52 weeks. What is known already We previously reported that partial or full suppression of estradiol (E2) with once daily doses of either 100 or 200 mg linzagolix for 24 weeks, with or without ABT, were effective in reducing heavy menstrual bleeding associated with uterine fibroids, improving other symptoms such as pain and anemia and improving quality of life. Here we report the maintenance of effect on secondary endpoints after 52 weeks of treatment. Study design, size, duration Linzagolix is an investigational, oral GnRH antagonist being developed to treat HMB due to UF. PRIMROSE 1 (P1, USA, NCT03070899) and PRIMROSE 2 (P2, Europe and USA, NCT03070951) are randomized, double-blind, placebo-controlled Phase 3 trials, with essentially identical design, investigating the efficacy and safety of linzagolix with and without hormonal add-back therapy (ABT: 1 mg estradiol/0.5 mg norethindrone acetate) once daily for 52 weeks. Participants/materials, setting, methods Participants had HMB due to UF (>80mL menstrual blood loss (MBL)/cycle) and were equally randomized to: placebo, linzagolix 100mg, linzagolix 100mg+ABT, linzagolix 200mg, or linzagolix 200mg+ABT. After 24 weeks, subjects originally randomized to placebo or linzagolix 200mg were switched to linzagolix 200mg+ABT except in P1 where 50% placebo subjects continued placebo until 52 weeks. Secondary efficacy assessments included hemoglobin, pain (0–10 numeric rating scale) and health related quality of life (HRQL) on the UF-QoL questionnaire. Main results and the role of chance P1 trial subjects (n = 526) had a mean age of 42 years, pain score of 6.6 and HRQL total score (0–100) of 36.4 and 63% were Black. P2 trial subjects (n = 511) had a mean age of 43 years, pain score 4.8 and HRQL total score of 46.1 and 5% were Black. Mean baseline MBL was about 200 mL per cycle in both studies. In both trials, significant improvements compared to placebo observed at week 24 for secondary endpoints, including pain, anemia and QoL in all linzagolix treatment groups were maintained at 52 weeks. Mean±SD hemoglobin levels in anemic patients ( Mean±SD change from baseline in pain scores were -3.3±3.1, -2.7±3.2, -2.6±3.0, -3.9±3.2 in P1 and -2.6±3.1, -2.6±2.8, -3.0±2.6, -2.8±3.0 in P2 in the 100mg, 100mg+ABT, 200mg/200mg+ABT, 200mg+ABT groups, respectively, compared to -0.4±2.5 with placebo (P1). Mean±SD change in HRQL total scores were 25.0±26.2, 34.2±30.1, 29.7±29.2, 38.3±29.2 in P1 and 16.8±24.0, 29.6±23.2, 31.9±26.8, 30.7±26.0 in P2 in the 100mg, 100mg+ABT, 200mg/200mg+ABT, 200mg+ABT groups, respectively, compared to 14.6±23.9 with placebo (P1). Limitations, reasons for caution Here we report data in both trials up to 52 weeks of treatment. No statistical comparisons were done at 52 weeks (the primary analysis was done after 24 weeks treatment). Post-treatment follow-up will provide more information in symptom recurrence after stopping treatment. Wider implications of the findings All linzagolix treatments provided sustained benefit. Two regimens previously identified for potential long-term treatment, 200mg with ABT and 100mg without ABT, provided sustained improvements of anemia, pain and associated quality of life. These different treatment regimens could be important to address the diverse needs of women suffering from uterine fibroids. Trial registration number ClinicalTrials.gov: NCT03070899, NCT03070951

Oxidative stress, mitochondria, and infertility: is the relationship fully established? Oxygen is thought to have been formed in the universe when stars much larger than our own sun were born, burning their stored hydrogen and creating heavier chemical elements by nuclear fusion reactions. Explosions of these giant dying stars scattered all chemical elements into space as stardust, which became the base material for the formation of our solar system. Nevertheless, diatomic oxygen, or free oxygen, which now makes up 20.9% of our atmosphere, appeared much later than the earth itself. In fact, when life was evolving 2.4 billion years ago, cyanobacteria able to use sunlight to produce energy in the form of carbohydrate and oxygen as a waste product of such chemical processes emerged. Oxygen levels increased over time, resulting in the development of new bacteria with more efficient oxygen-dependent energy-producing systems. These prokaryotic bacteria, known as mitochondria ancestors, were incorporated into larger host cells to serve as engines for energy supply. The payoff of this successful endosymbiosis approximately 1.5 billion years ago was the appearance of the aerobic eukaryotic cell, which further evolved into multicellular organisms, leading to the development of specialized organs for oxygen intake, distribution, and processing to supply the body’s constant metabolic need for energy production in all cell compartments