Danazol but not gonadotropin-releasing hormone agonists suppresses autoantibodies in endometriosis*

FERTILITY AND STERILITY

Vol. 50, No.6, December 1988

Copyright <> 1988 The American Fertility Society

Printed in U.S.A.

Danazol but not gonadotropin-releasing hormone agonists suppresses autoantibodies in endometriosis* Albert EI-Roeiy, M.D.t:J: W. Paul Dmowski, M.D., Ph.D.§ Norbert Gleicher, M.D.t Ewa Radwanska, M.D., Ph.D.§

Lisa Harlow, B.S.t Zvi Binor, M.D.§ Ian Tummon, M.D.§ Richard G. Rawlins, Ph.D.§

Mount Sinai Hospital and Medical Center, University of Health Sciences, Chicago, Medical School, and Rush Medical College, Chicago, Illinois

The effect of treatment with danazol (n = 10) or gonadotropin-releasing hormone agonists (GnRH-a) (n = 10) on autoantibody (AA) production (IgG, IgM and, IgA to 6 phospholipids, 5 histones, and 4 polynudeotides) in endometriosis was evaluated blindly in a longitudinal, prospective, randomized study. Clinical improvement, ovarian suppression, and resolution of endometriosis were comparable in both groups. Approximately 50% of patients had significant AA abnormalities initially. During treatment with danazol but not GnRH-a, AA gradually decreased in concentration and in number/patient. Total immunoglobulin levels (IgG, IgM, and IgA) also decreased only in the danazol group. This study indicates that danazol, but not GnRH-a, lowers abnormal AA associated with endometriosis. Fertil Steril50:864, 1988

Endometriosis is a disease affecting women in their reproductive years. Its incidence is unknown and its prevalence ranges between 0% and 50% depending on the specific study population. The cause of endometriosis is also unknown and its histogenesis remains unclear. Several recent studies1-4 have suggested that the occurrence of this disease may be linked to alterations in the immune function. Deficient cell-mediated immunity has been observed in rhesus monkeys1 and in women with endometriosis. 2 Antiendometrial and antiReceived June 17, 1988; revised and accepted July 18, 1988.

* Presented in part at the 35th Annual Meeting of the Society for Gynecologic Investigation, March 17-20, 1988, Baltimore, MD. t Department of Obstetrics and Gynecology, Division of Immunology, Mount Sinai Hospital and Medical Center, University of Health Sciences, Chicago Medical School. :j: Reprint requests: Albert El-Roeiy, M.D., Department of Obstetrics and Gynecology, Mount Sinai Hospital Medical Center, California Avenue at 15th Street, Chicago, Illinois 60608. § Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology/Infertility, Rush Medical College.

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ovarian autoantibody production has also been described. 3 We recently reported circulating immunoglobulin (Ig), IgG, IgA, and IgM autoantibodies against phospholipids, histones, and nucleotides in approximately two thirds of women with endometriosis. 4 Hormonal treatment of endometriosis involves suppression of ovarian function and induction of the hypoestrogenic state, during which endometriotic implants undergo atrophy and resolution. Several hormonal preparations, capable of direct or indirect effects on the ovary, have been recommended for this purpose. Danazol, a C-19 steroid derivative, has been the principal therapeutic agent in the management of endometriosis for over a decade. 5 It effectively inhibits ovarian function through two apparently independent mechanisms: indirectly through suppression of gonadotropin secretion and directly through inhibition of ovarian steroidogenesis. The hypoestrogenic state that develops results in endometrial atrophy and in resolution of endometriotic lesions. However, danazol is an interesting compound with multiple and di-

Danazol and immune function in endometriosis

Fertility and Sterility

vergent biologic effects outside of the reproductive system. It has been demonstrated that danazol can suppress antiplatelet antibody production in idiopathic thrombocytopenic purpura (ITP), resulting in clinical remission. 6 A similar suppressive effect on autoantibody (AA) levels also results in clinical remission in systemic lupus erythematosus (SLE).7 In vitro studies indicate that danazol has immunosuppressive effects comparable to those of glucocorticoids.8 All of these observations suggest that similar immunosuppressive effects on the immune system may also be observed in endometriosis and may contribute to the drug's therapeutic effectiveness. Gonadotropin releasing hormone agonists (GnRH-a), when administered continuously, suppress gonadotropin secretion and ovarian function after an initial stimulatory period. They have been found effective in the management of endometriosis.9 However, GnRH -a are small polypeptides with a primary effect at the pituitary level and without the diverse steroidal effects characteristic of danazol. Consequently, there is no reason to anticipate that GnRH -a may affect immune functions. In an attempt to determine whether potential suppression of the humoral arm ofthe immune system plays a therapeutic role in the management of endometriosis, we compared the effect of danazol and GnRH-a on AA production and clinical outcome in two randomly selected groups of patients with the disease. MATERIALS AND METHODS Study Populations

Twenty women of reproductive age with laparoscopically diagnosed and staged endometriosis were studied. They were enrolled in two prospective, open label, randomized clinical trials, which compared the effectiveness of danazol against one of two GnRH -a. Ten patients were treated with danazol in the dose of 200 mg four times daily and ten were treated with GnRH -a. In the GnRH -a group four patients received Buserelin (Hoechst-Roussel Pharmaceuticals, Somerville, NJ) intranasally (IN) 0.4 mg three times a day, four Buserelin subcutaneously (SC) 0.2 mg daily, and two leuprolide IN 1.6 mg daily. The treatment with all agents continued for 6 months and laparoscopy was repeated on the last day of treatment. Clinical assessments and measurements of serum estradiol (E 2 ), progesterone (P), follicle stimulating hormone (FSH), Vol. 50, No.6, December 1988

and luteinizing hormone (LH) were performed using routine radioimmunoassay techniques at 2- to 4-week intervals before, during, and after completion of treatment. Laparoscopic staging of endometriosis before and after treatment was performed according to the revised American Fertility Society Classification. 10 Points assigned for endometriotic lesions but not those for adhesions were used to calculate before- and after-treatment scores. Serum samples for immunologic studies were obtained from all patients 8 and 4 weeks before, every 4 weeks for a period of 26 weeks during, and at 4 and 8 weeks after treatment. Two control groups consisted of 200 female blood donors and 50 fertile women with normal pelvic organs and no evidence of either endometriosis or active inflammatory disease at the time of laparoscopic tubal sterilization. Because AA results were identical in both groups, the data were pooled into a single control group. None of the study or control subjects reported either a history and/or symptoms· compatible with an autoimmune disease, acute or chronic infection, malignancy, or drug abuse at the time of blood collection. None of the controls was pregnant at the time of blood collection, and routine studies (hepatitis-B Ag, Venereal Disease Research Laboratory [VDRL], Human Immunodeficiency Virus [HIV] antibodies) were negative. Blood samples for immunologic studies were obtained by venipuncture and clotted at room temperature. The serum was separated and stored within 2 hours at -70°C at Rush Presbyterian-St. Luke's Medical Center. After completion of treatment and 8 weeks of follow-up, all sera were coded and transferred to the laboratory at Mount Sinai Hospital Medical Center, where they were stored until tested simultaneously. The laboratory results were decoded and analyzed only after all data had been reported. Immunologic Studies

Total immunoglobulin (IgG, IgM, and IgA) concentrations were measured using a Highland nephelometer with monospecific antisera and standards according to the manufacturer's instructions (Highland Diagnostic, Cooper Biomedical, Malvern, PA). The investigated AA profile included AA to six phospholipids (cardiolipin, phosphatidylserine, phosphatidylglycerol, phosphatidic acid, phosphatidylethanolamine, and phosphatidylinositol), to total histones and four histone subfractions (HI,

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,

H2A, H2B, H3, and H4), and to four polynucleotides (ssDNA, dsDNA, poly [I], poly [dTD. All three isotypes IgG, IgM, and IgA of AA were measured using Enzyme Linked Immunosorbent Assay (ELISA) technology and were reported as optical density (OD). A detailed description of all methods has been recently reported. l l Sera from the control group (n = 250) were utilized to establish medians and the 99% confidence intervals for all AA. A positive result was thus defined as an OD above the 99% confidence interval for each antibody and isotype. Statistical Analysis

The distributions of AA and total immunoglobulin levels were analyzed using the KolmogorovSmirnov D test. The frequency of positive antibodies in both groups was evaluated using the chisquare test. To evaluate changes in AA, total immunoglobulin, and hormonal levels before, during, and after treatment, a multivariant repeated measures analysis with grouping factors for two groups was performed. 12 Differences in scores of endometriosis between groups before and after treatment were evaluated using the Mann-Whitney U test and before and after treatment in each group, using the Wilcoxon's rank sign test. To control for the effect of confounding variables upon AA levels such as age, length of infertility, and hormone levels, a stepwise regression analysis within each group was performed. All probability values were two-tailed. Statistics were done using a Systat statistical analysis program run on a Compaq AT 286 computer (Compaq, Santa Barbara, CA). Statistical significance for all tests was set at P s 0.05. RESULTS

The mean age was similar in both groups and was not different from the mean age of the normal control group. Length of infertility was also similar in both groups (Table 1). During treatment amenorrhea and suppressed ovarian function were observed in all subjects. A significant decrease in hormone levels was seen during the treatment period for E2 (Wilk's lambda = 0.2~ F-statistic = 4.26 P < 0.015), P (Wilk's lambda = 0.28, F-statistic = 3.32 P < 0.05), FSH (Wilk's lambda = 0.29, Fstatistic = 4.27 P < 0.015), and LH (Wilk's lambda = 0.30, F-statistic = 3.12 P < 0.05). The degree of ovarian suppression did not differ between the two groups (Fig. 1). The extent of endometriosis before 866

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Table 1 Clinical Characteristics of the Subjects, Endocrine Tests During Treatment, and Endometriosis Scores Before and After Treatment (mean ± SE) GnRH·a group (n = 10)

Danazol group (n = 10)

Clinical characteristics of the subjects Age (yr) 31.0 ± 1.1 30.7± 1.5 Infertility (mo) 44.3 ± 6.9 48.0 ± 11.0 Endocrine tests during treatment E2 (pg/ml) 29.5 ± 3.3 37.7± 2.9 FSH (mlU/ml) 9.8±0.8 11.4 ± 0.7 LH(m1U/ml) 11.4 ± 1.4 10.7± 1.2 Endometriosis scores Before treatment 18.3 ± 4.8 14.2 ± 2.8 After treatment 7.7 ± 2.8 c 4.2± 2.2c

Normal controls (n = 250)

P

31 ± 1 NAa

NS b

NA NA NA

NS NS NS

NA NA

NS NS

a NA, not applicable. b NS, not significant. c Significantly different from pretreatment values (P < 0.05).

treatment was similar in both groups, and there was no difference in either stage or score of the disease between the groups after treatment. A significant and comparable degree of resolution of the disease during treatment was observed in both groups (Table 1). Total Immunoglobulin Levels

Total IgG, IgM, and IgA levels in study subjects and controls are summarized in Table 2. Immunoglobulin levels were similar in all groups before treatment. During danazol treatment mean IgG levels decreased significantly (P < 0.02) as did mean IgM (P < 0.04) and IgA levels (P < 0.05). There were no changes in IgG, IgA, or IgM levels during GnRH -a treatment. Abnormally high IgG levels (>1800 mg/dl) were observed in two patients in the danazol group (in one before treatment and in another at 8 weeks after treatment). Abnormally high IgM levels (>275 mg/dl) were found in three of ten patients in the danazol group (in one before treatment, in one at all times during the study, and in one 8 weeks after treatment) and in four of ten patients in the GnRH-a group (in two at all times during the study and in two at 8 weeks after cessation of treatment). IgA levels were increased (>395 mg/dl) only in one of ten patients in the danazol group (8 weeks after cessation oftreatment) and in three of ten patients in the GnRH-a group (at all times during the study). The frequency of abnormal immunoglobulin levels between the groups was not significantly different. Prior to treatment a significant correlation was found between the stage of

Danazol and immune function in endometriosis

Fertility and Sterility

PROGESTERONE

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Figure 1 E 2 , P, FSH, and LH in patients treated with danazol or GnRH-a. A significant decrease in hormone levels was found in both groups during treatment compared to initial levels (P < 0.05, repeated measures analysis). The degree of decrease was not significantly different between the groups.

the disease and total IgG as well as IgM levels (for IgG, R2 = 0.68, P < 0.02; IgM, R2 = 0.54, P < 0.05). Autoantibody Levels The levels of AA decreased gradually only in patients treated with danazol. Figure 2 demonstrates this finding for nine autoantibody isotypes in which the decrease was statistically significant. Before treatment all patients in the danazol and GnRH-a groups tested positive for at least one of the 45 AA isotypes (Fig. 3). There was no difference in the frequency of autoantibodies between the groups. The number of abnormal antibodies per Table 2

Total Immunoglobulin Levels (Mean ± SD) GnRH-a group

IgG (mg/dJ) Before treatment After treatment IgM (mg/dJ) Before treatment After treatment IgA (mg/dJ) Before treatment After treatment

(n = 10)

Danazol group (n = 10)

Normal controls (n = 250)

1334 ± 377 1317±405

1376 ± 418 1056 ± 228"

1220 ± 350 NAb

201 ± 89 183 ± 97

193 ± 96 126 ± 92"

180± 68 NA

197 ± 105 201 ± 90

135 ± 51 105± 45"

165± 75 NA

" Significantly different from pretreatment values (P < 0.05). b NA, not applicable.

Vol. 50, No.6, December 1988

patient decreased gradually during danazol treatment. No such decrease was observed in the GnRH-a group (Fig. 3). The most frequently elevated AA were those toward phospholipids, followed by antibodies to polynucleotides, and histones. A significant decrease was observed during danazol treatment in the concentration of nine of 45 investigated AA isotypes (Fig. 2). They were predominantly antibodies toward phospholipids and of the IgG isotype. IgG autoantibodies, which decreased in concentration during danazol treatment, included the following: anticardiolipin by 83% (Wilk's lambda = 0.11, F-statistic = 10.9, P < 0.001), anti-phosphatidylserine by 90% (Wilk's lambda = 0.07, F-statistic = 16.5, P < 0.01), antiphosphatidylethanolamine by 85% (Wilk's lambda = 0.12, F-statistic = 11.2, P < 0.05), antiphosphatidylinositol by 86% (Wilk's lambda = 0.31, F-statistic = 3.1, P < 0.045), anti-H 2A by 91% (Wilk's lambda = 0.26, F-statistic = 3.9, P < 0.02), and anti-dsDNA by 66% (Wilk's lambda = 0.19, F-statistic = 5.65, P < 0.005). IgM antibodies, which significantly decreased in concentration during danazol treatment were those directed toward phosphatidylethanolamine by 93% (Wilk's lambda = 0.09, F-statistic = 13.7, P < 0.001) andphosphatidylinositol by 94% (Wilk's lambda = 0.23, F-statistic = 4.5, P < 0.012). The only IgA AA that decreased

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IgG Anti-Cardiolipin

IgG Anti-P.Serine

IgG Anti-P .Inositol

IgG Anti-H2A

IgG Anti-P.Ethanoiamine

IgG Anti-dsONA

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Figure 2 AA levels in patients treated with danazol or GnRH -a before, during, and after treatment. Only patients treated with danazol showed a significant decrease in AA levels (P < 0.05, repeated measures analysis). The figure demonstrates nine AA isotypes in which the decrease reached significance.

in the danazol group was against phosphatidylethanolamine by 87.5% (Wilk's lambda = 0.17, F-statistic = 6.5, P < 0.003). There were no significant changes in the concentration of any of the 45 autoantibodies in the GnRH -a group. No significant correlations between total immunoglobulin and AA levels (all isotypes) in either study subjects or controls were apparent. Nor was there a correlation between antibody and hormone levels in the study subjects. Stepwise regression analysis excluded age, length of infertility, total immunoglobulin and hormone levels within each group as confounding variables in the decline of AA production. However, a trend toward an inverse relationship between AA levels and stage of disease was apparent. Post-treatment Conceptions and Pregnancy Outcome

Five of 10 patients (50%) in the danazol group and four of 10 (40%) in the GnRH-a group conceived during more than 1 year of follow-up after treatment. Three of the five patients who con868

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ceived after danazol therapy initially had significant elevation of more than five AA. Of those, one demonstrated initially nine, one 16 and one 19 autoantibodies (patient nos. 1, 2, and 11; Fig. 3). All antibodies in these three patients decreased significantly during treatment (Fig. 3). Two of the conceptions occurred 12 weeks after completion of danazol therapy and have since delivered normally at term. One patient conceived after 32 weeks and the pregnancy is presently progressing normally. The two remaining patients who conceived after danazol initially demonstrated only two elevated AA, which normalized during treatment. One conceived 20 weeks after treatment but experienced a spontaneous first trimester abortion. The other conceived 36 weeks after treatment and delivered normally at term. In the GnRH -a group three of four patients who conceived initially demonstrated <5 elevated AA. One showed 3 and two 1 (patient nos. 12, 13, and 18; Fig. 3). Essentially no change in either number or concentration of elevated antibodies occurred during treatment. Conceptions occurred at 12, 20,

Danazol and immune function in endometriosis

Fertility and Sterility

Num~r

of positive antibodies

,c,HI. ~~~~~~~~~::~~ 12W

before

15W

during

after

GnRH-a Number of positive antibodies

,~~~~ o

before

12W

15W

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Figure 3 Number of positive AA in patients treated with danazol or GnRH-a. Only patients treated with danazol demonstrated a decrease in the number of AA after treatment (P < 0.05, sign rank test). Numbers above each graph represent consecutive number of each patient in the study. Patients no. 1,2, 11, 17, and 19 in the danazol group and patients no. 12, 13, 14, and 18 in the GnRH-a group conceived at 12, 12, 20, 32, and 36 and at 28, 12, 20, and 24 weeks after treatment, respectively.

and 24 weeks after treatment. All three patients delivered healthy infants at term. The fourth pregnant patient in the GnRH-a group initially demonstrated 22 abnormally elevated AA and no change in either their number or concentration during treatment (patient no. 14; Fig. 3). She conceived 28 weeks after treatment but experienced a first trimester spontaneous abortion. She did not conceive again during 12 months of subsequent follow-up.

DISCUSSION

Endometriosis is an enigmatic disease of unknown etiology and poorly understood histogenesis. Several reports have indicated alterations in cell-mediated1.2 and humora13.4.13.14 immunity in women with endometriosis. These findings imply that altered immune function may playa role in the pathophysiology of this disease and may be causally related to infertility. Our recent study demonstrated that 40% to 60% of women with endometriosis exhibit in their sera a variety of AA against phospholipids, histones, and polynucleotides. 4 In the present randomized and blinded study, we confirmed the high frequency of these AA in endometriosis and also evaluated the effect of Vol. 50, No.6, December 1988

medical therapy with either danazol or GnRH -a on abnormal AA levels. Patient assignment to either danazol or GnRH-a treatment was at random. As expected, no significant differences were detected between the two treatment groups in endometriosis score, in total immunoglobulin levels, or in the frequency of AA prior to treatment. During treatment in both groups a comparable degree of ovarian suppression was indicated by serum E 2 , P, FSH, and LH levels, and a significant decrease in the endometriosis score was observed. Thus, both regimens effectively suppressed, although through different mechanisms, ovarian steroid production, resulting in the atrophy of endometriotic lesions. A significant decrease in total immunoglobulins, IgG, IgM, and IgA and in AA concentrations was observed only after danazol treatment. All autoantibodies that had been abnormally increased prior to treatment decreased during danazol therapy. This occurred to a variable extent, ranging from 66% to 94%. After treatment for up to 8 weeks, AA concentrations further decreased, remained unchanged, or began a slight increase (Fig. 2). Similarly, the number of abnormal AA in each patient decreased significantly during danazol treatment (Fig. 3), with the average number of abnormal autoantibody isotypes per patient decreasing from 9.9 to 2.9. In contrast, no significant changes in either AA concentrations or number of abnormal AA occurred during GnRH -a treatment. Total IgG, IgM, and IgA were similar in control groups and study subjects. Other investigators reported an increase,4.11 a decrease,14.15 as well as l.).nchanged2 •13 immunoglobulin levels in endometriosis. Interestingly, a positive correlation between the stage of the disease and total immunoglobulin levels was observed in this study. It is unclear why only some women with endometriosis produce AA. Although there was no significant correlation between AA levels and total immunoglobulins, a trend toward a negative correlation between the stage of the disease and AA levels was noted. We reported a similar trend in a larger study of women with endometriosis. 4 This seems contrary to the typical findings in other autoimmune diseases in which increased autoantibody production usually correlates with increased severity of the disease. The observation is puzzling and may indicate that autoantibody production in endometriosis represents a secondary event. As suggested by Weed and Arguembourg,14 autoantibody responses may develop following ectopic implantation of the endo-

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metrial cells. In the peritoneal cavity, endometrial cells are processed by an activated monocyte-macrophage system 16 and are presented to T cells. 17 Under the influence of macrophage-released lymphopkines, T cells proliferate and differentiate into functional subsets with helper, suppressor, suppressor-inducer, and cytotoxic properties. 17 A host of T cell-derived factors then plays a critical role in the activation of B cells from the resting into a proliferative state and into further differentiation and antibody secretion. The activated B cells may then produce autoantibodies against endometrial cells, as observed by Mathur et al. 3 or against endometrial cell-derived phospholipids, histones, or nucleotides, as previously reported by us 4 and confirmed in this study. In support of this concept, it has been reported that in women with endometriosis, endometrial cells are increased in the peritoneal cavity,18 that peritoneal macrophages are increased in number and activational status,16,19 that the ratio of peritoneal T-helper to T-suppressor cells is increased,20 and that complement and immunoglobulin deposits can be identified in the uterine endometrium. 14 It is also possible that in advanced endometriosis, because of a profound connective tissue reaction, endometriotic foci are walled off and less accessible to the peritoneal macrophages, with a resulting decrease in the AA production. An alternative explanation for reduced AA levels in women with advanced endometriosis may lie in the increasing absorption capacity of the disease as it progresses. This would suggest that AA abnormalities precede endometriosis. Furthermore, if AA abnormalities are the cause of infertility and pregnancy wastage associated with endometriosis, then similar AA abnormalities should also be detectable in infertility and pregnancy wastage in the absence of endometriosis. Such observations have been made previously. 21 Infertility and increased pregnancy wastage are characteristic features of endometriosis. Weed and Arguembourg14 postulated that abnormal autoantibodies in women with endometriosis may contribute to implantation failure and to the high incidence of spontaneous abortions. This study suggests that abnormal AA 1]lay contribute to infertility and recurrent abortions in women with endometriosis. Pregnancies occurred in both danazol and GnRH-a-treated patients but progressed normally to term only in AA-negative patients or after danazol suppression of AA abnormalities. One patient in the GnRH-a group, who conceived in spite 870

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of 22 elevated AA, miscarried in the first trimester and did not conceive again during subsequent 12 months of follow-up. AA levels decreased in danazol-treated but not in GnRH-a-treated patients. Both regimens effectively suppressed ovarian function and decreased peripheral E2 concentrations to the same level. Furthermore, suppression of endometriosis was similar with both regimens. It is therefore not the suppression of either ovarian E2 or endometriosis itself that appears to lower autoantibody concentrations. Danazol, in contrast to GnRH-a, alters the androgenic milieu and may in this way affect the immune system. In the peripheral circulation danazol increases free testosterone (T) by displacing bound T from the sex hormone binding globulin (SHBG) and by decreasing SHBG levels through a direct effect on the liver. In peripheral tissues danazol binds to androgen receptors and has inherent weak androgenic properties. Its metabolites, such as ethisterone, also have androgenic effects. Androgens have been reported to decrease immunoglobulin production and to have an inhibitory effect on the immune system. 22 However, in vitro studies indicate that immunosuppressive effects of danazol are significantly higher than those of androgens or estrogens8 and comparable to those of glucocorticoids. Danazol binds not only to androgen, but also to progesterone and glucocorticoid receptors. Hormone receptors have been identified on T cells23 and on thymic structures. 24 Recently, Mylvaganam et al. 25 reported that danazol modulates the ratio of T -helper jinducer cells resulting in the activation of T-suppressor cells. The activated T-suppressor cells then probably inhibit B cell proliferation and AA production in autoimmune diseases such as SLE 7 and ITp6 and in endometriosis, as demonstrated in this report. In conclusion, this study clearly demonstrates that danazol, which has been the standard therapy for endometriosis for over a decade, significantly reduces endometriosis-associated autoimmune abnormalities. GnRH -a do not seem to have such an effect. Because AA abnormalities have been associated with infertility and pregnancy wastage, danazol may represent a superior treatment to GnRH-a in women with endometriosis and increased AA production. Whether a decrease of abnormal AA levels improves fertility and decreases pregnancy wastage remains to be established in larger patient populations.

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Fertility and Sterility

REFERENCES

i: i

1. Dmowski WP, Steele RW, Baker GF: Deficient cellular immunity in endometriosis. Am J Obstet Gynecol 141:377, 1981 2. Steele RW, Dmowski WP, Marmer DJ: Immunologic aspects of human endometriosis. Am J Reprod ImmunoI6:33, 1984 3. Mathur S, Peress MR, Williamson HO, Youmans CD, Maney SA, Garvin AJ, Rust PF, Fudenberg HH: Autoimmunity to endometrium and ovary in endometriosis. Clin Exp ImmunoI50:259, 1982 4. G leicher N, El-Roeiy A, Confino E, Friberg J: Autoantibodies in reproductive failure: I. Is endometriosis an autoimmune disease? Obstet Gynecol 70:115, 1987 5. Dmowski WP: Danazol induced pseudomenopause in the management of endometriosis. Clin Obstet Gynecol. In press. 6. Ahn YS, Harrington WJ, Simon SR, Mylvaganam R, Pall LM, So AG: Danazol for the treatment of idiopathic thrombocytopenic purpura. N Engl J Med 308:1396, 1983 7. Agnello V, Pariser K, Gell J: Preliminary observations on danazol therapy of systemic lupus erythematosus: effects on DNA antibodies, thrombocytopenia and complement. J Rheumatol10:682, 1983 8. Hill JA, Barbieri RL, Anderson DJ: Immunosuppressive effects of danazol in vitro. Fertil Steril48:414, 1987 9. Meldrum DR: Clinical management of endometriosis with luteinizing hormone-releasing hormone analogues. Semin Reprod EndocrinoI3:371, 1985 10. The American Fertility Society: Revised American Fertility Society classification of endometriosis: 1985. Fertil Steril 43:351, 1985 11. El-Roeiy A, Gleicher N, Friberg J, Confino E, Dudkiewicz A: Correlation between peripheral blood and follicular fluid autoantibodies and impact on in vitro fertilization. Obstet Gynecol 70:163, 1987 12. Winer BJ: The analysis of the single parameter with repeated measures. In Statistical Principles in Experimental Design, 2nd edition, Edited by BJ Winer. New York, McGraw-Hill, 1971, p 261 13. Badawy SZ, Cuenca V, Stitzel A, Jacobs RD, Tomar RH:

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14.

15.

16.

17.

18. 19.

20.

21.

22. 23.

24.

25.

Autoimmune phenomena in infertile patients with endometriosis. Obstet GynecoI63:271, 1984 Weed JC, Arguembourg PC: Endometriosis: can it produce an autoimmune response resulting in infertility? Clin Obstet Gynecol 23:885, 1980 Meek SC, Hodge DD, Musich JR: Autoimmunity in infertile patients with endometriosis. Am J Obstet Gynecol158: 1365, 1988 Halme J, Becker S, Wing R: Accentuated cyclic activation of peritoneal macrophages in patients with endometriosis. Am J Obstet GynecoI148:85, 1984 Unanue ER, Allen PM: The basis for the immunoregulatory role of macrophages and other accessory cells. Science 236:551, 1987 Bartosik D, Jacobs SL, Kelly LJ: Endometrial tissue in peritoneal fluid. Fertil Steril 46:796, 1986 Zeller JM, Henig I, Radwanska E, Dmowski WP: Enhancement of human monocyte and peripheral macrophage chemiluminescence activities in women with endometriosis. Am J Reprod ImmunoI13:78, 1987 Hill JA, Faris HMP, Schiff I, Anderson DJ: Characterization of leukocyte subpopulations in peritoneal fluid of women with endometriosis (Abstr. P-136). Presented at the Forty-Third Annual Meeting of The American Fertility Society, Reno, Nevada, September 28-30, 1987. Published by the American Fertility Society in the Program Supplement, 1987,p 55 Cowchock S, Smith B, Gocial B: Autoantibodies to pho!!pholipids and nuclear antigens in patients with repeated abortions. Am J Obstet GynecoI155:1002, 1986 Grossman CJ: Interactions between the gonadal steroids and the immune system. Science 9:257,1985 Cohen JHM, Darrel L, Codier G, Salz S, Revillard JP: Sex steroid receptors in peripheral T cells. Absence of androgen receptors and restriction of estrogen receptors to OKT8positive cells. J ImmunoI131:2767, 1983 Allan LS, McClure JE, Goldstein AL, Barkley MS, Michael SD: Estrogen and thymic hormone interactions in the female mouse. J ReiJrod Immunol 6:25, 1984 Mylvaganam R, Ahn YS, Harrington W J, Kim CI: Immune modulation by danazol in autoimmune thrombocytopenia. Clin Immunol ImmunopathoI42:281, 1987

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