In a captive key note lecture at the 12th World Congress on Endometriosis, Professor Emeritus Ivo Brosens addressed the challenge of “maternal pregnancy hormones and endometriosis”. We are delighted to be able to provide a brief summary of his presentation.
Sampson described in 1927 the origin of endometriosis in his most famous paper entitled “Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity”. However, two fundamental questions have remained unanswered:
- which menstruation is most likely to disseminate endometrial tissue?
- which endometrial tissue is likely to implant?
Which menstruation is most likely to disseminate endometrial tissue?
The first question can be answered by a series of publications hidden in last century scientific literature. Harvard pathologists Ober and Bernstein described in detail the endometrium in an autopsy study of 169 neonates as proliferative in 68%, secretory in 27%, and decidual or menstrual in 5%. Neonatal uterine bleeding was described in the 1970s by several continental authors showing that the visible uterine bleeding occurrs in some 5% of the neonates, but the bleeding is rare in premature and increases towards term to reach 9.1% in postmature neonates. In 25 to 61% the bleeding is occult.
The main reason for retrograde menstruation in the neonate is the functional cervical obstruction. The uterus in the neonate has a tubular structure with a small corpus and a long cervical canal that is obstructed by mucoid secretions. One case of neonate endometriosis was described by Arcellana (1996) showing an hemorrhagic type of endometriosis with endometrial epithelium embedded on the serosal surface of the sigmoid. The neonatal origin of endometriosis may clarify a series of unexplained observations:
- The epidemiological ENDO study showed unexpectantly that preterm birth is at reduced odds of endometriosis (Wolff 2013).
- The occurrence of endometriosis including ovarian endometrioma in the premenarchal girl (Marsh and Laufer 2005);
- The early onset and severity of adolescent endometriosis.
Which endometrial tissue is likely to implant?
The second question has recently been discussed in the work of Caroline Gargett on stem/progenitor and niche cells in the endometrium. When these cells are found in menstrual blood of the adult, it is even more likely that they are present in neonate uterine bleeding.
Clearly, new lines of research are opened for clarifying the exciting questions on the onset of a most mysterious disease.
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Brosens I, Puttemans P, Benagiano G. Endometriosis: A life cycle approach. Am J Obstet Gynecol 2013;209:307-316.
Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum Reprod 2013;28: 2026-2031.
Brosens I, Benagiano G. Is neonatal uterine bleeding involved in the pathogenesis of endometriosis as a source of stem cells? Fertil Steril 2013;100:622-623.
Brosens I, Brosens J, Benagiano G. Neonatal uterine bleeding as antecedent of pelvic endometriosis. Hum Reprod 2013;28:2893-2897.
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Gargett CE, Schwab KE, Brosens JJ, Puttemans P, Benagiano B, Brosens I. Potential role of endometrial stem/progenitor cells in the pathogenesis of early-onset endometriosis. Mol Hum Reprod, doi:10.1093/molehr/gau025
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