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PROGINS receptor gene polymorphism is associated with endometriosis
FERTILITY AND STERILITY威 VOL. 77, NO. 2, FEBRUARY 2002 Copyright ©2002 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
PROGINS receptor gene polymorphism is associated with endometriosis Fritz Wieser, M.D.,a Christian Schneeberger, Ph.D.,a Dan Tong, Ph.D.,b Clemens Tempfer, M.D.,b Johannes C. Huber, M.D, Ph.D.,a and Rene Wenzl, M.D.a University of Vienna, Vienna, Austria
Objective: To investigate the association between the 306 – base pair insertion polymorphism in intron G of the progesterone receptor (PROGINS) and endometriosis. Design: Case-control study. Setting: Tertiary care center. Patient(s): Ninety-five white women with surgically diagnosed and histologically confirmed endometriosis and 107 white women without endometriosis (controls). Intervention(s): Determination of PROGINS was performed by polymerase chain reaction and gel electrophoresis. Main Outcome Measure(s): Frequency and distribution of the PROGINS allele. Result(s): Frequencies of the mutant allele T2 was 0.17 among women with endometriosis and 0.08 among controls (odds ratio, 2.41 [CI, 1.31– 4.53]). Homozygosity for allele T2 was present in 3.2% of women with endometriosis and 0.9% of controls. Conclusion(s): PROGINS appears to be associated with endometriosis in white persons. (Fertil Steril威 2002; 77:309 –12. ©2002 by American Society for Reproductive Medicine.) Key Words: PROGINS, endometriosis, progesterone receptor, white population, polymorphism
Received May 15, 2001; revised and accepted August 13, 2001. Reprint requests: Rene Wenzl, M.D., Department of Obstetrics and Gynecology, Division of Gynecological Endocrinology and Reproductive Medicine, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria (FAX: 43-1-40400-2817; E-mail: [email protected]). a Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Vienna. b Division of Gynecology and Obstetrics, Department of Obstetrics and Gynecology, University of Vienna. 0015-0282/02/$22.00 PII S0015-0282(01)02984-3
Endometriosis affects up to 15% of women of reproductive age and is a common cause of infertility and pelvic pain (1). Susceptibility to endometriosis depends on a complex interaction of immunologic, genetic and hormonal factors (2). Sensitivity of endometriosis to hormonal stimuli is clearly documented in the literature (2). Estrogen and progesterone receptors (ER-␣) were found to be expressed in endometriotic tissues (3). Therefore, hormonal treatment with danazol, progestins, and gonadotropin-releasing hormone (GnRH) analogues are prescribed to treat endometriosis-associated symptoms (1, 4). In addition, expression of variants of the progesterone receptor (PR-A and PR-B) were shown to be aberrant in endometriotic tissues, which may indicate a role of the progesterone receptor in the pathogenesis of endometriosis (3, 5–7). It has been suggested that endometriosis has a genetic basis (8, 9). Epidemiologic data show a familial tendency: The incidence of endome-
triosis is increased in first-degree relatives compared with controls (6.9% vs. 0.9%, respectively) (9). Concordance in twins has also been demonstrated (9). DNA studies examining the role of loss of heterozygosity in endometriotic lesions have identified candidate suppressor gene loci, including 9q, 11q, and 22q (9, 10). Alterations in chromosome arms 5q, 6q, 11q, and 22q were observed in 25% to 30% of women with endometriosis and associated carcinoma of the ovary (11). Genetic studies also detected an association between endometriosis and polymorphic mutations of several genes, including the N-acetyltransferase 2 gene, the glutathione S-transferase M gene, and the ER␣ gene (12–14). A genomic polymorphism has been identified in the progesterone receptor gene, consisting of a 306 – base pair insertion of the PV/ HS-1 Alu subfamily in intron G of the progesterone receptor gene (PROGINS) (15). This polymorphism has been studied in association with breast cancer and ovarian cancer 309
FIGURE 1 Photograph of a 1.5% agarose gel stained with SYBR Green to resolve the 306 – base pair intron G insertion polymorphism of the progesterone receptor gene. The 149 – base pair band represents the wild-type allele (allele T1) and the 455– base pair band represents the mutant allele (allele T2). Lane 1 indicates the molecular weight markers; lanes 2, 3, and 4 show the homozygous mutant, heterozygous, and homozygous wild-type patterns, respectively.
Wieser. PROGINS associated with endometriosis. Fertil Steril 2002.
(16 –18). The data indicate that a mutated progesterone receptor gene contributes to the development of disease in hormone-sensitive tissues (19). We investigated the frequency of the PROGINS polymorphism as a potentially predisposing marker for endometriosis.
MATERIALS AND METHODS Patients The cohort was comprised of 95 white women with surgically and histologically confirmed endometriosis. According to the revised American Fertility Society classification (20), all women were staged in four groups. Controls were 107 white women admitted for diagnostic laparoscopy or laparotomy to treat benign diseases other than endometriosis. All patients were recruited from the Division of Gynecological Endocrinology and Reproductive Medicine, University of Vienna, from January 2000 to November 2000. The study was approved by the ethics committee, and all participants gave written informed consent.
Genotyping Human leukocyte genomic DNA was extracted from whole peripheral blood samples by using the QIAGEN System (QIAmp DNA Blood Midi Kit; QIAGEN, Hilden, Germany). The DNA was stored at 4°C until analyzed. Following the polymerase chain reaction (PCR) strategy described by Lancaster et al. (18), we used the following oligonucleotide primers for in vitro amplification of specific progesterone receptor gene fragment: ⬘5-GGC AGA AAG CAA AAT AAA AAG A-3⬘ (forward) and 5⬘-AAA GTA TTT TCT TGC TAA ATG TC-3⬘ (reverse). The PCR involved an 310
Wieser et al.
PROGINS associated with endometriosis
initial denaturing step at 95°C for 1 minute, followed by 30 cycles at 95°C for 30 seconds, 55°C for 30 seconds, and 72°C for 30 seconds, and a final extension at 72°C for 5 minutes. The T1 allele of the progesterone receptor was defined as the absence of insertion, as described by Rowe et al. (15). When this PCR strategy was used, the wild-type allele (allele T1) generated a 149 – base pair fragment and the polymorphic allele (allele T2) generated a 455– base pair. Polymerase chain reaction products were resolved on a 1.5% agarose gel and stained with SYBR Green I (FMC Bio Products Europe, Vallensbaek Stranol, Denmark) (Fig. 1). Alleles were recorded according to the molecular weight of the respective bands.
Statistical Analysis Allele and genotype frequencies in the patient and control groups were compared by using the multiple Pearson 2 test of independence or the Fisher exact test. The odds ratio (OR) was used to measure the strength of the association between the frequencies of allele and genotype and endometriosis. The software SAS/PROC GLM (SAS Institute Inc., Cary, NC) was used for statistical analyses. All P values were two-tailed, and 95% CIs were calculated. P⬍.05 was considered statistically significant.
RESULTS The median age was 36 years (range, 22– 60 years) among women with endometriosis and 39 years (range, 18 –76 years) among controls. Seventeen women with endometriosis had stage I disease, 22 had stage II disease, 38 had stage III disease, and 18 had stage IV disease. Vol. 77, No. 2, February 2002
TABLE 1 Genotype and allele frequencies among women with endometriosis and controls. Women with endometriosis (n ⫽ 95)
Controls (n ⫽ 107)
Odds ratio (95% CI)
P value
65 (68.4%) 27 (28.4%) 3 (3.2%) 30 (31.6%)
91 (85.0%) 15 (14.0%) 1 (0.9%) 16 (14.9%)
2.63 (1.32–5.21)
.004a,b
157 (82.6%) 33 (17.4%)
197 (92.1%) 17 (7.9%)
2.41 (1.31–4.53)
.005
Genotypes T1/T1 T1/T2 T2/T2 T1/T2 and T2/T2 Alleles T1 T2
Unless otherwise stated, data are numbers of patients (percentage). a T1/T2 and T2/T2 vs. T1/T1. b 2 test. Wieser. PROGINS associated with endometriosis. Fertil Steril 2002.
Genotyping was performed in all women to detect the wild-type T1 and mutant T2 alleles. Women with endometriosis and controls differed significantly in distribution of genotype frequencies for allele T2 (T1/T2 and T2/T2 vs. T1/T1: OR, 2.63 [95% CI: 1.32–5.21]; P⫽.004) (Table 1) and in the frequency of the mutant T2 allele (0.17 vs. 0.08; OR, 2.41 [95% CI: 1.31– 4.53; P⫽.005) (Table 1). Three women in the study group and one woman in the control group were homozygous for allele T2.
otic lesions compared with eutopic tissue (5–7). Misao et al. (5) detected progesterone receptor-B in ovarian endometriosis, whereas Attia et al. (7) did not detect progesterone receptor-B expression in endometriotic tissues. Because progesterone receptor is abnormally expressed in endometriotic tissues and because the progesterone receptor is located on chromosome 11, a frequent site of loss of heterozygosity in women with endometriosis, polymorphic mutation in the progesterone receptor gene may be associated with endometriosis.
DISCUSSION
We investigated the characteristics of PROGINS, a common polymorphism of the progesterone receptor gene, in white women with endometriosis. We found an increased frequency of the mutated allele in our cohort. This is the first report of a genetic variant of the progesterone receptor gene in women with endometriosis. It has been speculated that this insertion results in expression of an aberrant splice form of progesterone receptor, since it introduces a consensus splice acceptor site downstream of a consensus splice donor site (15). Mutated progesterone receptor-A was shown to inhibit progesterone receptor-B to a lesser extent and at higher levels (20). The receptor changes caused by the PROGINS mutation may affect ligand and hormone binding properties and hence lead to inadequate control of estrogen receptor– driven proliferation. The presence of a mutated progesterone receptor supports the theory of estrogen overactivation in endometriosis.
Large cohort studies have shown that the PROGINS polymorphism is associated with ovarian cancer and has a protective effect against breast cancer in premenopausal women (15, 16). We describe a novel genetic association between PROGINS and endometriosis. Endometriosis is a benign hormone-sensitive disease that has characteristics of malignant disease, including unregulated growth of cells lining the endometrium. Investigations have shown overexpression of several oncogenes, such as c-fos, c-erbB-1/-2, and ras in endometriotic lesions (21). In this context, an increased risk of breast, ovarian, and hematopoietic cancers in women with endometriosis has been shown (22). The progesterone receptor is located in chromosome region 11q22-23 (23), a proposed site of tumor suppressor genes and a site of loss of heterozygosity in women with endometriosis (10). Progesterone binds to the A and B isoforms of the progesterone receptor, which are both products of the progesterone receptor gene (24). Progesterone receptor-A represses estrogen receptor and progesterone receptor-B gene activation, whereas progesterone receptor-B tends to be a stronger activator of progesterone target genes (25, 27). Progesterone receptor-A and progesterone receptor-B were shown to be aberrantly expressed in endometriFERTILITY & STERILITY威
In conclusion, our data suggest that PROGINS is associated with endometriosis in white women. References 1. Olive DL, Schwartz LJ. Endometriosis. N Engl J Med 1993;328:1759 – 69. 2. Bergqvist IA. Hormonal regulation of endometriosis and the rationales and effects of gonadotrophin-releasing hormone agonist treatment: a review. Hum Reprod 1995;10:446 –2. 3. Nisolle M, Casanas-Roux F, Donnez J. Immunohistochemical analysis of proliferative activity and steroid receptor expression in peritoneal and ovarian endometriosis. Fertil Steril 1997;68:912–9.
311
4. Lessey BA. Medical management of endometriosis and infertility. Fertil Steril 2000;73:1089 –96. 5. Misao R, Iwagaki S, Fujimoto J, Sun W, Tamaya T. Dominant expression of progesterone receptor form B mRNA in ovarian endometriosis. Horm Res 1999;52:30 – 4. 6. Misao R, Sun WS, Iwagaki S, Fujimoto J, Tamaya T. Identification of various exon-deleted progesterone receptor mRNAs in human endometrium and ovarian endometriosis. Biochem Biophys Res Commun 1998;252:302– 6. 7. Attia GR, Zeitoun K, Edwards D, Johns A, Carr BR, Bulun SE. Progesterone receptor isoform A but not B is expressed in endometriosis. J Clin Endocrinol Metab 2000;85:2897–902. 8. Kennedy S, Mardon H, Barlow D. Familial endometriosis. J Assist Reprod Genet 1995;12:32– 4. 9. Bischoff FZ, Simpson JL. Heritability and molecular genetic studies of endometriosis. Hum Reprod Update 2000;6:37– 44. 10. Jiang X, Hitchcock A, Bryan EJ, Watson RH, Englefield P, Thomas EJ, et al. Microsatellite analysis of endometriosis reveals loss of heterozygosity at candidate ovarian tumor suppressor gene loci. Cancer Res 1996;56:3534 –9. 11. Jiang X, Morland SJ, Hitchcock A, Thomas EJ, Campbell IG. Allelotyping of endometriosis with adjacent ovarian carcinoma reveals evidence of a common lineage. Cancer Res 1998;58:1707–12. 12. Georgiou I, Syrrou M, Bouba I, Dalkalitsis N, Paschopoulos M, Navrozoglou I, et al. Association of estrogen receptor gene polymorphisms with endometriosis. Fertil Steril 1999;72:164 – 6. 13. Baranova H, Canis M, Ivaschenko T, Albuisson E, Bothorishvilli R, Baranov V, et al. Possible involvement of arylamine N-acetyltransferase 2, glutathione S-transferases M1 and T1 genes in the development of endometriosis. Mol Hum Reprod 1999;5:636 – 41. 14. Baranova H, Bothorishvilli R, Canis M, Albuisson E, Perriot S, Glowaczower E, et al. Glutathione S-transferase M1 gene polymorphism and susceptibility to endometriosis in a French population. Mol Hum Reprod 1997;3:775– 80. 15. Rowe SM, Coughlan SJ, McKenna NJ, Garrett E, Kieback DG, Carney DN, et al. Ovarian carcinoma-associated TaqI restriction fragment
312
Wieser et al.
PROGINS associated with endometriosis
16. 17.
18. 19.
20. 21. 22. 23. 24.
25.
length polymorphism in intron G of the progesterone receptor gene is due to an Alu sequence insertion. Cancer Res 1995;55:2743–5. Wang-Gohrke S, Chang-Claude J, Becher H, Kieback DG, Runnebaum IB. Progesterone receptor gene polymorphism is associated with decreased risk for breast cancer by age 50. Cancer Res 2000;60:2348 –50. McKenna NJ, Kieback DG, Carney DN, Fanning M, McLinden J, Headon DR. A germline TaqI restriction fragment length polymorphism in the progesterone receptor gene in ovarian carcinoma. Br J Cancer 1995;71:451–5. Lancaster JM, Berchuck A, Carney ME, Wiseman R, Taylor JA. Progesterone receptor gene polymorphism and risk for breast and ovarian cancer. Br J Cancer 1995;71:341–5. Kieback DG, Tong XW, Weigel NL, Agoulnik IU. A genetic mutation in the progesterone receptor (PROGINS) leads to an increased risk of non-familial breast and ovarian cancer causing inadequate control of estrogen receptor driven proliferation [abstract]. J Soc Gynecol Investig 1998:5:40a. Buttram VC Jr. Evolution of the revised American Fertility Society classification of endometriosis. Fertil Steril 1985;43:347–50. Bergqvist A, Borg A, Ljungberg O. Protooncogenes in endometriotic and endometrial tissue. Ann N Y Acad Sci 1991;626:276 – 83. Brinton LA, Gridley G, Persson I, Baron J, Bergqvist A. Cancer risk after a hospital discharge diagnosis of endometriosis. Am J Obstet Gynecol 1997;176:572–9. Rousseau-Merck MF, Misrahi M, Loosfelt H, Milgrom E, Berger R. Localization of the human progesterone receptor gene to chromosome 11q22-q23. Hum Genet 1987;77:280 –2. Kastner P, Krust A, Turcotte B, Stropp U, Tora L, Gronemeyer H, et al. Two distinct estrogen-regulated promoters generate transcripts encoding the two functionally different human progesterone receptor forms A and B. EMBO J 1990;9:1603–14. Vegeto E, Shahbaz MM, Wen DX, Goldman ME, O’Malley BW, McDonnell DP. Human progesterone receptor A form is a cell- and promoter-specific repressor of human progesterone receptor B function. Mol Endocrinol 1993;7:1244 –55.
Vol. 77, No. 2, February 2002
PROGINS receptor gene polymorphism is associated with endometriosis Fritz Wieser, M.D.,a Christian Schneeberger, Ph.D.,a Dan Tong, Ph.D.,b Clemens Tempfer, M.D.,b Johannes C. Huber, M.D, Ph.D.,a and Rene Wenzl, M.D.a University of Vienna, Vienna, Austria
Objective: To investigate the association between the 306 – base pair insertion polymorphism in intron G of the progesterone receptor (PROGINS) and endometriosis. Design: Case-control study. Setting: Tertiary care center. Patient(s): Ninety-five white women with surgically diagnosed and histologically confirmed endometriosis and 107 white women without endometriosis (controls). Intervention(s): Determination of PROGINS was performed by polymerase chain reaction and gel electrophoresis. Main Outcome Measure(s): Frequency and distribution of the PROGINS allele. Result(s): Frequencies of the mutant allele T2 was 0.17 among women with endometriosis and 0.08 among controls (odds ratio, 2.41 [CI, 1.31– 4.53]). Homozygosity for allele T2 was present in 3.2% of women with endometriosis and 0.9% of controls. Conclusion(s): PROGINS appears to be associated with endometriosis in white persons. (Fertil Steril威 2002; 77:309 –12. ©2002 by American Society for Reproductive Medicine.) Key Words: PROGINS, endometriosis, progesterone receptor, white population, polymorphism
Received May 15, 2001; revised and accepted August 13, 2001. Reprint requests: Rene Wenzl, M.D., Department of Obstetrics and Gynecology, Division of Gynecological Endocrinology and Reproductive Medicine, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria (FAX: 43-1-40400-2817; E-mail: [email protected]). a Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, University of Vienna. b Division of Gynecology and Obstetrics, Department of Obstetrics and Gynecology, University of Vienna. 0015-0282/02/$22.00 PII S0015-0282(01)02984-3
Endometriosis affects up to 15% of women of reproductive age and is a common cause of infertility and pelvic pain (1). Susceptibility to endometriosis depends on a complex interaction of immunologic, genetic and hormonal factors (2). Sensitivity of endometriosis to hormonal stimuli is clearly documented in the literature (2). Estrogen and progesterone receptors (ER-␣) were found to be expressed in endometriotic tissues (3). Therefore, hormonal treatment with danazol, progestins, and gonadotropin-releasing hormone (GnRH) analogues are prescribed to treat endometriosis-associated symptoms (1, 4). In addition, expression of variants of the progesterone receptor (PR-A and PR-B) were shown to be aberrant in endometriotic tissues, which may indicate a role of the progesterone receptor in the pathogenesis of endometriosis (3, 5–7). It has been suggested that endometriosis has a genetic basis (8, 9). Epidemiologic data show a familial tendency: The incidence of endome-
triosis is increased in first-degree relatives compared with controls (6.9% vs. 0.9%, respectively) (9). Concordance in twins has also been demonstrated (9). DNA studies examining the role of loss of heterozygosity in endometriotic lesions have identified candidate suppressor gene loci, including 9q, 11q, and 22q (9, 10). Alterations in chromosome arms 5q, 6q, 11q, and 22q were observed in 25% to 30% of women with endometriosis and associated carcinoma of the ovary (11). Genetic studies also detected an association between endometriosis and polymorphic mutations of several genes, including the N-acetyltransferase 2 gene, the glutathione S-transferase M gene, and the ER␣ gene (12–14). A genomic polymorphism has been identified in the progesterone receptor gene, consisting of a 306 – base pair insertion of the PV/ HS-1 Alu subfamily in intron G of the progesterone receptor gene (PROGINS) (15). This polymorphism has been studied in association with breast cancer and ovarian cancer 309
FIGURE 1 Photograph of a 1.5% agarose gel stained with SYBR Green to resolve the 306 – base pair intron G insertion polymorphism of the progesterone receptor gene. The 149 – base pair band represents the wild-type allele (allele T1) and the 455– base pair band represents the mutant allele (allele T2). Lane 1 indicates the molecular weight markers; lanes 2, 3, and 4 show the homozygous mutant, heterozygous, and homozygous wild-type patterns, respectively.
Wieser. PROGINS associated with endometriosis. Fertil Steril 2002.
(16 –18). The data indicate that a mutated progesterone receptor gene contributes to the development of disease in hormone-sensitive tissues (19). We investigated the frequency of the PROGINS polymorphism as a potentially predisposing marker for endometriosis.
MATERIALS AND METHODS Patients The cohort was comprised of 95 white women with surgically and histologically confirmed endometriosis. According to the revised American Fertility Society classification (20), all women were staged in four groups. Controls were 107 white women admitted for diagnostic laparoscopy or laparotomy to treat benign diseases other than endometriosis. All patients were recruited from the Division of Gynecological Endocrinology and Reproductive Medicine, University of Vienna, from January 2000 to November 2000. The study was approved by the ethics committee, and all participants gave written informed consent.
Genotyping Human leukocyte genomic DNA was extracted from whole peripheral blood samples by using the QIAGEN System (QIAmp DNA Blood Midi Kit; QIAGEN, Hilden, Germany). The DNA was stored at 4°C until analyzed. Following the polymerase chain reaction (PCR) strategy described by Lancaster et al. (18), we used the following oligonucleotide primers for in vitro amplification of specific progesterone receptor gene fragment: ⬘5-GGC AGA AAG CAA AAT AAA AAG A-3⬘ (forward) and 5⬘-AAA GTA TTT TCT TGC TAA ATG TC-3⬘ (reverse). The PCR involved an 310
Wieser et al.
PROGINS associated with endometriosis
initial denaturing step at 95°C for 1 minute, followed by 30 cycles at 95°C for 30 seconds, 55°C for 30 seconds, and 72°C for 30 seconds, and a final extension at 72°C for 5 minutes. The T1 allele of the progesterone receptor was defined as the absence of insertion, as described by Rowe et al. (15). When this PCR strategy was used, the wild-type allele (allele T1) generated a 149 – base pair fragment and the polymorphic allele (allele T2) generated a 455– base pair. Polymerase chain reaction products were resolved on a 1.5% agarose gel and stained with SYBR Green I (FMC Bio Products Europe, Vallensbaek Stranol, Denmark) (Fig. 1). Alleles were recorded according to the molecular weight of the respective bands.
Statistical Analysis Allele and genotype frequencies in the patient and control groups were compared by using the multiple Pearson 2 test of independence or the Fisher exact test. The odds ratio (OR) was used to measure the strength of the association between the frequencies of allele and genotype and endometriosis. The software SAS/PROC GLM (SAS Institute Inc., Cary, NC) was used for statistical analyses. All P values were two-tailed, and 95% CIs were calculated. P⬍.05 was considered statistically significant.
RESULTS The median age was 36 years (range, 22– 60 years) among women with endometriosis and 39 years (range, 18 –76 years) among controls. Seventeen women with endometriosis had stage I disease, 22 had stage II disease, 38 had stage III disease, and 18 had stage IV disease. Vol. 77, No. 2, February 2002
TABLE 1 Genotype and allele frequencies among women with endometriosis and controls. Women with endometriosis (n ⫽ 95)
Controls (n ⫽ 107)
Odds ratio (95% CI)
P value
65 (68.4%) 27 (28.4%) 3 (3.2%) 30 (31.6%)
91 (85.0%) 15 (14.0%) 1 (0.9%) 16 (14.9%)
2.63 (1.32–5.21)
.004a,b
157 (82.6%) 33 (17.4%)
197 (92.1%) 17 (7.9%)
2.41 (1.31–4.53)
.005
Genotypes T1/T1 T1/T2 T2/T2 T1/T2 and T2/T2 Alleles T1 T2
Unless otherwise stated, data are numbers of patients (percentage). a T1/T2 and T2/T2 vs. T1/T1. b 2 test. Wieser. PROGINS associated with endometriosis. Fertil Steril 2002.
Genotyping was performed in all women to detect the wild-type T1 and mutant T2 alleles. Women with endometriosis and controls differed significantly in distribution of genotype frequencies for allele T2 (T1/T2 and T2/T2 vs. T1/T1: OR, 2.63 [95% CI: 1.32–5.21]; P⫽.004) (Table 1) and in the frequency of the mutant T2 allele (0.17 vs. 0.08; OR, 2.41 [95% CI: 1.31– 4.53; P⫽.005) (Table 1). Three women in the study group and one woman in the control group were homozygous for allele T2.
otic lesions compared with eutopic tissue (5–7). Misao et al. (5) detected progesterone receptor-B in ovarian endometriosis, whereas Attia et al. (7) did not detect progesterone receptor-B expression in endometriotic tissues. Because progesterone receptor is abnormally expressed in endometriotic tissues and because the progesterone receptor is located on chromosome 11, a frequent site of loss of heterozygosity in women with endometriosis, polymorphic mutation in the progesterone receptor gene may be associated with endometriosis.
DISCUSSION
We investigated the characteristics of PROGINS, a common polymorphism of the progesterone receptor gene, in white women with endometriosis. We found an increased frequency of the mutated allele in our cohort. This is the first report of a genetic variant of the progesterone receptor gene in women with endometriosis. It has been speculated that this insertion results in expression of an aberrant splice form of progesterone receptor, since it introduces a consensus splice acceptor site downstream of a consensus splice donor site (15). Mutated progesterone receptor-A was shown to inhibit progesterone receptor-B to a lesser extent and at higher levels (20). The receptor changes caused by the PROGINS mutation may affect ligand and hormone binding properties and hence lead to inadequate control of estrogen receptor– driven proliferation. The presence of a mutated progesterone receptor supports the theory of estrogen overactivation in endometriosis.
Large cohort studies have shown that the PROGINS polymorphism is associated with ovarian cancer and has a protective effect against breast cancer in premenopausal women (15, 16). We describe a novel genetic association between PROGINS and endometriosis. Endometriosis is a benign hormone-sensitive disease that has characteristics of malignant disease, including unregulated growth of cells lining the endometrium. Investigations have shown overexpression of several oncogenes, such as c-fos, c-erbB-1/-2, and ras in endometriotic lesions (21). In this context, an increased risk of breast, ovarian, and hematopoietic cancers in women with endometriosis has been shown (22). The progesterone receptor is located in chromosome region 11q22-23 (23), a proposed site of tumor suppressor genes and a site of loss of heterozygosity in women with endometriosis (10). Progesterone binds to the A and B isoforms of the progesterone receptor, which are both products of the progesterone receptor gene (24). Progesterone receptor-A represses estrogen receptor and progesterone receptor-B gene activation, whereas progesterone receptor-B tends to be a stronger activator of progesterone target genes (25, 27). Progesterone receptor-A and progesterone receptor-B were shown to be aberrantly expressed in endometriFERTILITY & STERILITY威
In conclusion, our data suggest that PROGINS is associated with endometriosis in white women. References 1. Olive DL, Schwartz LJ. Endometriosis. N Engl J Med 1993;328:1759 – 69. 2. Bergqvist IA. Hormonal regulation of endometriosis and the rationales and effects of gonadotrophin-releasing hormone agonist treatment: a review. Hum Reprod 1995;10:446 –2. 3. Nisolle M, Casanas-Roux F, Donnez J. Immunohistochemical analysis of proliferative activity and steroid receptor expression in peritoneal and ovarian endometriosis. Fertil Steril 1997;68:912–9.
311
4. Lessey BA. Medical management of endometriosis and infertility. Fertil Steril 2000;73:1089 –96. 5. Misao R, Iwagaki S, Fujimoto J, Sun W, Tamaya T. Dominant expression of progesterone receptor form B mRNA in ovarian endometriosis. Horm Res 1999;52:30 – 4. 6. Misao R, Sun WS, Iwagaki S, Fujimoto J, Tamaya T. Identification of various exon-deleted progesterone receptor mRNAs in human endometrium and ovarian endometriosis. Biochem Biophys Res Commun 1998;252:302– 6. 7. Attia GR, Zeitoun K, Edwards D, Johns A, Carr BR, Bulun SE. Progesterone receptor isoform A but not B is expressed in endometriosis. J Clin Endocrinol Metab 2000;85:2897–902. 8. Kennedy S, Mardon H, Barlow D. Familial endometriosis. J Assist Reprod Genet 1995;12:32– 4. 9. Bischoff FZ, Simpson JL. Heritability and molecular genetic studies of endometriosis. Hum Reprod Update 2000;6:37– 44. 10. Jiang X, Hitchcock A, Bryan EJ, Watson RH, Englefield P, Thomas EJ, et al. Microsatellite analysis of endometriosis reveals loss of heterozygosity at candidate ovarian tumor suppressor gene loci. Cancer Res 1996;56:3534 –9. 11. Jiang X, Morland SJ, Hitchcock A, Thomas EJ, Campbell IG. Allelotyping of endometriosis with adjacent ovarian carcinoma reveals evidence of a common lineage. Cancer Res 1998;58:1707–12. 12. Georgiou I, Syrrou M, Bouba I, Dalkalitsis N, Paschopoulos M, Navrozoglou I, et al. Association of estrogen receptor gene polymorphisms with endometriosis. Fertil Steril 1999;72:164 – 6. 13. Baranova H, Canis M, Ivaschenko T, Albuisson E, Bothorishvilli R, Baranov V, et al. Possible involvement of arylamine N-acetyltransferase 2, glutathione S-transferases M1 and T1 genes in the development of endometriosis. Mol Hum Reprod 1999;5:636 – 41. 14. Baranova H, Bothorishvilli R, Canis M, Albuisson E, Perriot S, Glowaczower E, et al. Glutathione S-transferase M1 gene polymorphism and susceptibility to endometriosis in a French population. Mol Hum Reprod 1997;3:775– 80. 15. Rowe SM, Coughlan SJ, McKenna NJ, Garrett E, Kieback DG, Carney DN, et al. Ovarian carcinoma-associated TaqI restriction fragment
312
Wieser et al.
PROGINS associated with endometriosis
16. 17.
18. 19.
20. 21. 22. 23. 24.
25.
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