{"paper_id":"f146f4b0-d6f5-49ea-9a31-ea3491067fd6","body_text":"Combined Effect of the PGR þ331C > T,\nCYP17A1 -34A > G and CYP19A1 1531G > A\nPolymorphisms on the Risk of Developing\nEndometriosis\nEfeito combinado dos polimor fismos PGR þ331C > T,\nCYP17A1 -34A > G e CYP19A1 1531G > An or i s c od e\ndesenvolvimento da endometriose\nJéssica Vilarinho Cardoso 1,2 Daniel Escorsim Machado 1 Renato Ferrari 3 Mayara Calixto da Silva 1\nPlínio Tostes Berardo 4 Jamila Alessandra Perini 1,2\n1 Research Laboratory of Pharmaceutical Sciences, Pharmacy Unit,\nCentro Universitário Estadual da Zona Oeste, Rio de Janeiro, Rio de\nJaneiro, Brazil\n2 Post-graduation in Public Health and Natural Environment Program,\nEscola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo\nCruz (National School of Public Health, Oswaldo Cruz Foundation),\nRio de Janeiro, Rio de Janeiro, Brazil\n3 Gynecology Institute, Universidade Federal do Rio de Janeiro,\nHospital Moncorvo Filho, Rio de Janeiro, Rio de Janeiro, Brazil\n4 Gynecology Service, Hospital Federal dos Servidores do Estado,\nRio de Janeiro, Rio de Janeiro, Brazil\nRev Bras Ginecol Obstet 2017;39:273 –281.\nAddress for correspondence Jamila Alessandra Perini, PhD, Research\nLaboratory of Pharmaceutical Sciences, Pharmacy Unit, Centro\nUniversitário Estadual da Zona Oeste, Av. Manoel Caldeira de\nAlvarenga, 1203 - Campo Grande, 23070-200 - Rio de Janeiro, RJ, Brazil\n(e-mail: jamilaperini@yahoo.com .br; jamila.perini@pq.cnpq.br).\nKeywords\n► polymorphisms\n► estrogens\n► endometriosis\n► biomarkers\nAbstract Purpose To evaluate the magnitude of the association of the polymorphisms of the\ngenes PGR, CYP17A1 and CYP19A1 in the development of endometriosis.\nMethods This is a retrospective case-control study involving 161 women with\nendometriosis (cases) and 179 controls . The polymorphisms were genotyped by\nreal-time polymerase chain reaction usin g the TaqMan system. The association of\nthe polymorphisms with endometriosis was evaluated using the multivariate logistic\nregression.\nResults The endometriosis patients were signi ficantly younger than the controls\n(36.0 /C6 7.3 versus 38.0 /C6 8.5 respectively, p ¼ 0.023), and they had a lower body\nmass index (26.3 /C6 4.8 versus 27.9 /C6 5.7 respectively, p ¼ 0.006), higher average\nduration of the menstrual flow (7.4 /C6 4.9 versus 6.1 /C6 4.4 days respectively,\np ¼ 0.03), and lower average time intervals between menstrual periods (25.2 /C6 9.6\nversus 27.5 /C6 11.1 days respectively, p ¼ 0.05). A higher prevalence of symptoms of\ndysmenorrhea, dyspareunia, chronic pelvic pain, infertility and intestinal or urinary\nchanges was observed in the case group when compared with the control group. The\nreceived\nAugust 23, 2016\naccepted\nMarch 23, 2017\npublished online\nJune 14, 2017\nDOI https://doi.org/\n10.1055/s-0037-1604097.\nISSN 0100-7203.\nCopyright © 2017 by Thieme Revinter\nPublicações Ltda, Rio de Janeiro, Brazil\nTHIEME\nOriginal Article 273\n\n\nIntroduction\nEndometriosis is a benign gynecological estrogen-depen-\ndent disease characterized by the presence of endometrial\ntissue out of the uterine cavity, affecting nearly 10% of\nwomen of reproductive age. Symptoms may include dysme-\nnorrhea, dyspareunia, chronic pelvic pain and infertility.\n1\nThe pathogenesis and the molecular mechanisms that are\ninvolved in the development of endometriosis are not yet\nclear, and hereditary susceptibility is an area of growing\ninvestigation for the identification of genetic polymorphisms\nthat may lead to an increased risk of developing the\ndisease.\n2,3\nEstrogen performs a fundamental role in endometriosis,\nwhich predominantly occurs in women of reproductive age\nwho have high estrogen production.\n4,5 An increase in en-\nzyme expression is responsible for the estrogen synthesis\nand reduction of progesterone receptor (PGR) expression\ninterval between the onset of symptoms and the de finitive diagnosis of endometriosis\nwas 5.2 /C6 6.9 years. When comparing both groups, signi ficant differences were not\nobserved in the allelic and genotypic frequencies of the polymorphisms PGR þ331C\n> T, CYP17A1 -34A > G and CYP19A1 1531G > A,e v e nw h e nc o n s i d e r i n gt h es y m p -\ntoms, classi fication and stage of the endometriosis. The combined genotype PGR\nþ331TT/CYP17A1 -34AA /CYP19A11531AA is positively associated with endometriosis\n(odds ratio [OR] ¼ 1.72; 95% con fidence interval [95%CI] ¼ 1.09–2.72).\nConclusions The combined analysis of the polymorphisms PGR-CYP17A1-CYP19A1\nsuggests a gene-gene interaction in the susceptibility to endometriosis. These results\nmay contribute to the identi fication of biomarkers for the diagnosis and/or prognosis of\nthe disease and of possible molecular targets for individualized treatments.\nResumo Objetivo Avaliar a magnitude de associação de polimor fismos nos genes PGR,\nCYP17A1 e CYP19A1 no desenvolvimento da endometriose.\nMétodos Este é um estudo retrospectivo do tipo caso-controle, envolvendo 161\nmulheres com endometriose (casos) e 179 controles. Os polimor fismos foram ge-\nnotipados pela reação em cadeia da polimerase em tempo real utilizando o sistema\nTaqMan. A associação dos polimor fismos estudados com a endometriose foi avaliada\npela regressão logística multivariada.\nResultados As pacientes com endometriose eram signi fic a t i v a m e n t em a i sj o v e n sd o\nque os controles (36,0 /C6 7,3 versus 38,0 /C6 8,5, respectivamente, p ¼ 0,023), apre-\nsentaram um índice de massa corporal menor (26,3 /C6 4,8 versus 27,9 /C6 5,7, respec-\ntivamente, p ¼ 0,006), maior tempo médio de duração do fluxo menstrual (7,4 /C6 4,9\nversus 6,1 /C6 4,4 dias, respectivamente, p ¼ 0,03) e menor tempo médio do intervalo\nentre as menstruações (25,2 /C6 9,6 versus 27,5 /C6 11,1 dias, respectivamente,\np ¼ 0,05). Uma maior prevalência dos sintomas de dismenorreia, dispareunia, dor\npélvica crônica, infertilidade, alterações i ntestinais e urinárias foi observada no grupo\ncasos comparado ao grupo controle. O tempo médio entre o início dos sintomas e o\ndiagnóstico de finitivo de endometriose foi de 5,2 /C6 6,9 anos. Comparando os dois\ngrupos, não foram observadas diferenças signi fic a t i v a sn a sf r e q u ê n c i a sa l é l i c a se\ngenotípicas dos polimor fismos PGR þ331C > T, CYP17A1 -34A > G e CYP19A1 1531G\n> A, e nem considerando os sintomas, a classi ficação e o estadiamento da endo-\nmetriose. O genótipo combinado PGR þ331TT/CYP17A1 -34AA /CYP19A11531AA está\nassociado positivamente com a endometriose (razão de possibilidades [RP] ¼ 1,72;\nintervalo de con fiança de 95% [IC95%] ¼ 1,09\n–2,72).\nConclusões A análise combinada dos polimor fismos PGR-CYP17A1-CYP19A1 sugere\numa interação gene-gene na susceptibilidade à endometriose. Estes resultados podem\ncontribuir para a identi ficação de biomarcadores para o diagnóstico e/ou prognóstico\nda doença, assim como de possíveis alvos moleculares para um tratamento\nindividualizado.\nPalavras-chave\n► polimor fismos\n► estrógenos\n► endometriose\n► biomarcadores\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al.274\n\n\nobserved in samples of endometrial injuries, but these\nphenomena are not found in controls. 6,7 As endometriosis\nis an estrogen-dependent disease, genetic polymorphisms\ninvolved in the biosynthesis and regulation of estrogens\ncould be considered possible biomarkers for its diagnosis\nand/or prognosis. Cytochrome P450 17A1 (CYP17A1) is\ninvolved in the initial stages of estrogen synthesis, convert-\ning pregnenolone into 17 α-hydroxypregnenolone and, sub-\nsequently, into dehydroepiandrosterone. Furthermore,\ncytochrome P450 19A1 (CYP19A1) acts in the final stage\nby converting androstenedione into estrone, and testoster-\none into estradiol.\n4,8 T h ee n z y m eC Y P 1 7 A 1 ,a l s ok n o w na s1 7\nα-hydroxylase, is encoded by the gene with the same name,\nlocated in chromosome 10q24.3. 8 The single nucleotide\npolymorphism (SNP) CYP17A1 -34A > G is located in the 5 ′\nuntranslated region (UTR) of the CYP17A1 gene, and it causes\na significant increase in the expression of 17 α-hydroxylase.8\nA different gene product, the aromatase enzyme, is encoded\nby the gene CYP19A1, which is located in chromosome\n15q21. The SNP CYP19A1 1531G > A is found in the 3 ′UTR\nof this gene, and it causes a signi ficant change in the levels of\ncirculating estradiol. 8 Progesterone is also involved in the\npathogenesis of endometriosis, as it is a strong antagonist of\nestrogen, and thus plays an essential role in the regulation of\nendometrial cell proliferation.\n6 The PGR gene, located in\nchromosome 11q22 – q23, is responsible for encoding both\nprogesterone receptor isoforms (PR-A and PR-B) by tran-\nscribing from alternative promoters. 9 The SNP PGR þ331C/T,\nlocated in the gene promoter region, creates an additional\nTATA box, and causes higher transcription of PR-B.\n9\nAs the SNPs PGR þ331C > T, CYP17A1 -34A > G and\nCYP19A1 1531G > A are located near potential elements\nthat regulate their respective genes, interfering with the\nlevels of expression of the corresponding proteins, it be-\ncomes relevant to evaluate the in fluence of these SNPs in the\ndevelopment of endometriosis. To date, 12 studies have\nevaluated the association of the SNPs PGR þ331C > T,\nCYP17A1 -34A > G and CYP19A1 1531G > A in the develop-\nment of endometriosis in different populations. However,\nthe results of the analyses are controversial. 10–21 In this\ncontext, the objective of this study was to evaluate the\nmagnitude of the association of the SNPs PGR þ331C > T,\nCYP17A1 -34A > G and CYP19A1 1531G > A with the devel-\nopment of endometriosis in women treated in two public\nreference hospitals in Brazil.\nMethods\nStudy Design\nThis was a retrospective, case-control study approved by the\nHuman Research Ethics Committees of two of our institu-\ntions (under protocols number 414/11 and 1.244.29 respec -\ntively), both located in the city of Rio de Janeiro, Brazil. All\nparticipating patients ( n ¼ 340) provided written informed\nconsent, and visited one of the two institutions between\nMarch 2011 and October 2015. The research was conducted\nin accordance with the Declaration of Helsinki, which was\nrevised in 2008. Patients with a surgical diagnosis (after\nlaparoscopy or laparotomy) of endometriosis with histologi-\ncal confirmation of the disease, as well as those diagnosed by\nmagnetic resonance imaging (MRI), were considered the case\ngroup ( n ¼ 161). The control group ( n ¼ 179) consisted of\nwomen with a negative diagnosis of endometriosis, after\nlaparoscopy or laparotomy for tubal ligation ( n ¼ 48) or for\nthe treatment of benign diseases, such as myoma ( n ¼ 52),\novarian cysts ( n ¼ 30), hydrosalpinx ( n ¼ 5), or for other\nreasons ( n ¼ 44). Women with any history or diagnosis of\ncancer or adenomyosis were excluded.\n2\nThe stage of the endometriosis was determined according\nto the revised American Fertility Society classi fication, which\ndivides the disease into four stages: I (minimum), II (mild), III\n(moderate) and IV (severe). 22 Regarding the classi fication of\nthe endometriosis, we considered the proposal of Nisolle and\nDonnez:23 superficial endometriosis (SUP), ovarian endome-\ntrioma (OMA), and deep in filtrative endometriosis (DIE).\nSuperficial endometriosis and ovarian endometrioma may\nbe found in association with deep endometriosis, 24 and the\ncases in which this association was observed were consid-\nered DIE.\nThe body mass index (BMI) was calculated as the weight (kg)\ndivided by the height squared (m\n2). Only severe and incapaci-\ntating symptoms of pain were included. Women who failed to\nconceive after one year of regular, contraceptive-free inter-\ncourse were considered infertile. Cyclical intestinal or urinary\nsymptoms were defined as bowel and/or urinary pain and/or\nbleeding coinciding with menstrual periods.\nGenotyping\nGenomic DNA was extracted from the peripheral blood\nsample using a genomic DNA extraction kit (Genomic DNA\nExtraction, Real Biotech Corporation, Banqiao City, Taiwan),\naccording to the manufacturer ’ s instructions.\nGenotyping ofPGR þ331C > T (rs10895068),CYP17A1 -34A\n> G (rs743572) and CYP19A1 1531G > A (rs10046) SNPs was\nperformed by real-time polymerase chain reaction (PCR) using\nthe TaqMan system. Oligonucleotides and probes speci fict o\neach SNP were obtained from Applied Biosystems:\nrs10895068 (C_27858738_10), rs743572 (C_2852784_30)\nand rs10046 (C_8234731_30). For all SNPs, PCRs were per-\nformed with 30 ng of template DNA, 1 /C2 TaqMan Universal\nMaster Mix (Applied Biosystems, Foster City, CA, US), and with\neach primer and probe assay at 1 /C2 dilution, and H2O to 8 μL.\nThe PCR conditions were: 95°C for 10 minutes, followed by 40\ncycles of denaturation at 92°C for 15 seconds, and annealing at\n60°C for 1 minute. Allele-detection was performed on a 7500\nReal-Time System (Applied Biosystems, Foster City, CA, US),\nand the genotypes were then determined directly.\nStatistical Analyses\nThe continuous variables were expressed as the mean /C6\nstandard deviation (SD), and the differences between\nmeans were evaluated using the Student ’ s t-test. The cate-\ngorical data were expressed as percentages, and evaluated\nby the Chi-square ( χ2) test or Fisher ’ s exact test, when\napplicable. For each SNP, the Hardy-Weinberg equilibrium\n(HWE) was calculated, and the allelic and genotypic\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al. 275\n\n\nTable 1 Demographic and clinical characteristics of the study population ( N ¼ 340)\nVariable Controls\n(N ¼ 179)\nCases\n(N ¼ 161)\np/C3\nAge (years) n (%)\n18–29 30 (16.8) 29 (18.0) 0.011\n30–39 60 (33.5) 79 (49.1)\n/C21 40 86 (48.0) 48 (29.8)\nNo information 3 (1.7) 5 (3.1)\nMarital status\nMarried/partner 96 (53.6) 111 (68.9) 0.046\nSingle 53 (29.6) 38 (23.7)\nDivorced/Widow 5 (2.8) 1 (0.6)\nNo information 25 (14.0) 11 (6.8)\nLevel of Schooling\nElementary education 38 (21.3) 24 (14.9) < 0.001\nHigh school 89 (49.7) 60 (37.3)\nHigher education 26 (14.5) 67 (41.6)\nNo information 26 (14.5) 10 (6.2)\nBMI\n< 18.5 3 (1.7) 7 (4.4) 0.013\n18.5–24.9 48 (26.8) 48 (29.8)\n25–29.9 50 (27.9) 63 (39.1)\n30–40 65 (36.3) 35 (21.7)\n> 40 13 (7.3) 8 (5.0)\nInfertility\nPrimary 19 (10.6) 53 (32.9) < 0.001\nSecondary 3 (1.7) 16 (9.9)\nNone\n/C3/C3 133 (74.3) 58 (36.1)\nNo attempt 20 (11.2) 32 (19.9)\nNo information 4 (2.2) 2 (1.2)\nParity\n0 19 (10.6) 53 (32.8) < 0.001\n1 23 (12.8) 37 (23.0)\n2 58 (32.5) 27 (16.8)\n3o rm o r e 5 5( 3 0 . 7 ) 1 0( 6 . 2 )\nNo attempt 20 (11.2) 32 (20.0)\nNo information 4 (2.2) 2 (1.2)\nSymptoms\n/C3/C3/C3\nDysmenorrhea 29 (16.1) 77 (47.5) < 0.001\nChronic pelvic pain 70 (38.9) 124 (76.5)\nDyspareunia 50 (27.8) 102 (63.0)\nCyclical urinary complaints /C3/C3/C3/C3 9 (6.4) 41 (27.5)\nCyclical intestinal complaints /C3/C3/C3/C3 8 (6.0) 74 (49.7)\nAbbreviation: BMI, body mass index.\nNotes:/C3 p-value obtained by Pearson ’sC h i - s q u a r e d(χ2) test. /C3/C3 Number of fertile women. /C3/C3/C3 The same woman can have more than one symptom.\n/C3/C3/C3/C3 Pain or bleeding during the menstrual period.\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al.276\n\n\ndistributions were compared between cases and controls by\nthe χ2 test or Fisher ’ s exact test. To evaluate the association\nbetween the SNPs and the development of endometriosis,\nas well as the presence of symptoms, the classi fication and\nstaging of the disease were used to estimate the odds ratios\n(ORs) and their respective 95% con fidence intervals (95%\nCIs), with adjustment for possible confounding factors,\nusing a multivariate logistic regression. Values of p < 0.05\nwere considered statistically signi ficant. All analyses were\nperformed using the Statistical Package for the Social\nSciences (SPSS, IBM Corp., Armonk, NY, US) software,\nversion 20.0.\nResults\nThe endometriosis cases were diagnosed through laparosco-\npy ( n ¼ 90, 55.9%), laparotomy ( n ¼ 27, 16.8%) or MRI\n(n ¼ 44, 27.3%), and 87 (54%) were classi fied as DIE. Of the\n117 surgery cases, 37 (31.6%) presented stages I-II diseases,\nand 80 (68.4%) presented stages III-IV. The most common\nlocations of the endometriotic lesions were in the ovary\n(31%), followed by the intestine (19%), and the uterosacral\nligaments (15%). The average age of the endometriosis\npatients at the time of diagnosis was 31.5 /C6 7.5, and the\naverage time for disease diagnosis, which was the time since\nthe beginning of the symptoms until the de finitive diagnosis,\nwas 5.2 /C6 6.9 years.\nIn\n►Table 1 , the demographic and clinical data from the\nstudy population are described. The patients with endometri-\nosis were significantly younger than the controls (36.0 /C6 7.3\nversus 38.0 /C6 8.5 respectively, p ¼ 0.023), and presented a\nhigher education level (41.6% versus 14.5%), as well as a lower\nBMI (26.3 /C6 4.8 versus 27.9 /C6 5.7 respectively, p ¼ 0.006).\nThe number of infertile women (primary or secondary) was\nsignificantly higher in the case group (42.9%) than in the\ncontrol group (12.3%), and nearly 63% of the women from\nthe control group had 2 or more children. The patients with\nendometriosis presented a higher prevalence ( p < 0.001) of\nsymptoms, including dysmenorrhea, dyspareunia, chronic\npelvic pain, and urinary and intestinal changes. Considering\nthe characteristics of the menstrual cycle, a signi ficant differ-\nence was detected between cases and controls in relation to\nthe average duration of the menstrual flow (7.4 /C6 4.9 versus\n6.1 /C6 4.4 days respectively,p ¼ 0.03) and the average interval\nbetween menstrual periods (25.2 /C6 9.6 versus 27.5 /C6 11.1\ndays respectively, p ¼ 0.05).\nWhen comparing the allelic and genotypic frequencies of\nthe SNPs PGR þ331C > T, CYP17A1 -34A > G and CYP19A1\nG > A between the cases and controls (\n►Fig. 1 ), no signi fi-\ncant differences were detected, even when considering the\nstaging and endometriosis classi fication (data not shown).\nThe allelic distribution of the SNPs PGR þ331C > T, CYP17A1\n-34A > G and CYP19A1 G > A in relation to the absence or\npresence of symptoms (dysmenorrhea, pelvic pain, dyspar-\neunia, infertility, and urinary and intestinal problems, for\nexample) in the endometriosis patients is summarized\nin\n►Fig. 2 . Considering the symptoms of the disease, no\nsignificant differences were found.\nA combined analysis of the three studied SNPs ( PGR\nþ331C > T, CYP17A1 -34A > G and CYP19A1 G > A), com-\npared between the endometriosis cases and controls, was\nperformed to investigate whether the presence of more than\n1 SNP would increase the risk of developing the disease\n(\n►Table 2 ). It has been observed that relative to the com-\nbined wild-type genotype ( PGR þ331CC/CYP17A1 -34AA /\nCYP19A11531GG), the combined genotype PGR þ331TT/\nCYP17A1 -34AA /CYP19A11531AA is associated with an in-\ncreased risk of developing endometriosis. A combined anal-\nysis of the PGR þ331C > T, CYP17A1 -34A > G and CYP19A1\nG > A genotypes was also performed in relation to the\nabsence or presence of symptoms (dysmenorrhea, pelvic\npain, dyspareunia, infertility, and urinary and intestinal\nproblems, for example) in the endometriosis patients. How-\never, no significant differences were found (data not shown).\nIn\n►Table 3 , we describe the variant allele frequencies of\nthe SNPs PGR þ331 T , CYP17A1 -34 G and CYP19A1A in\nFig. 1 Allelic and genotypic frequencies of the polymorphisms PGR\nþ331C > T, CYP17A1 -34A > G and CYP19A1 G > A in the study\npopulation.\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al. 277\n\n\ndifferent populations. The allele frequency PGR þ331 T varied\nbetween 2% and 10% and 5% and 10% in the cases and controls\nrespectively, based on 3 studies that have evaluated this SNP,\nincluding the present one. The SNP rs743572 has been\nevaluated in 7 studies, in addition to the present study,\nand the frequency of the CYP17A1 -34 G allele varied between\n35% and 58% in the cases and between 31% and 63% in the\ncontrols. In addition to our study, 4 other studies also\nevaluated the SNP rs10046, and the allele frequency of\nCYP19A1 1531A varied between 35% and 58% and between\n41% and 60% in the cases and controls respectively.\nDiscussion\nEndometriosis is a complex multifactorial gynecological\ndisease caused by the combination of hormonal, genetic\nand environmental factors, as well as immunological pro-\ncesses. Estrogen and progesterone are essential in the regu-\nlation of endometrial tissue growth, and, as such, they may\nplay a central role in the pathogenesis of endometriosis. 5,6 In\nthis study, a positive association between the combined\ngenotype PGR þ331TT/CYP17A1 -34AA/CYP19A1 1531AA\nand the development of endometriosis was observed.\nSupporting our results, neither Lamp et al,\n18 in Estonia,\nnor Trabert et al, 19 in the United States, could find an\nassociation with only the PGR þ331T allele. However, van\nKaam et al,15 in the Netherlands, observed a protective effect\n(OR ¼ 0.22; 95%CI ¼ 0.06– 0.77) for the development of en-\ndometriosis. In agreement with our findings, 5 studies from\nChina,13 Japan,10 Turkey,17 Italy16 and the United States 19\nfailed to observe an association between the SNP CYP17A1\n-34G and endometriosis. However, 2 studies in the Chinese\npopulation11,12 found a positive association between endo-\nmetriosis and the CYP17A1 -34A allele ( p ¼ 0.046 and\np ¼ 0.009). With relation to the SNP CYP19A1 1531G > A,\nnone of the studies found an association with endometriosis,\nFig. 2 Minor allelic frequencies of the polymorphisms studied among symptomatic and asymptomatic endometriosis patients.\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al.278\n\n\nTable 2 Combined genotype frequencies of the polymorphisms PGR þ331C > T, CYP17 -34A > G and CYP19 1531G > A between\ncontrols and cases, and their association with the risk of endometriosis\nGenotypes Controls\nN( % )\nCases\nN( % )\np /C3 OR\n(95%CI) /C3/C3\nPGR þ331C > T, CYP17 -34A > G and CYP19 1531G > A\nWT / WT / WT 23 (13.5) 11 (7.3) 1 /C3/C3/C3\nWT / WT / VAR 29 (17.1) 28 (18.6) 0.20 1.82 (0.73 –4.57)\nWT / VAR / VAR 70 (41.2) 60 (40.0) 0.17 1.35 (0.88 –2.05)\nVAR / WT / WT 2 (1.2) 4 (2.7) 0.18 1.57 (0.82 –3.00)\nVAR / VAR / WT 7 (4.1) 10 (6.7) 0.20 1.23 (0.90 –1.67)\nVAR / WT / VAR 1 (0.6) 7 (4.7) 0.02 1.72 (1.09 –2.72)\nWT / VAR / WT 25 (14.7) 22 (14.7) 0.15 1.13 (0.96 –1.34)\nVAR / VAR / VAR 13 (7.6) 8 (5.3) 0.87 1.02 (0.85 –1.21)\nAbbreviations: 95%CI, 95% con fidence interval; OR, odds ratio.\nNotes: WT/WT/WT, CC/AA/GG ;W T / W T / V A R ,CC/AA/GA or CC/AA/AA ; WT/VAR/VAR, CC/GG/AA or CC/AG/GA or CC/AG/AA or CC/GG/GA;V A R / W T / W T ,CT/\nAA/GG or TT/AA/GG ; VAR/VAR/WT, CT/AG/GG or CT/GG/GG or TT/AG/GG or TT/GG/GG ;V A R / W T / V A R ,CT/AA/GA or CT/AA/AA or TT/AA/GA or TT/AA/AA ;\nWT/VAR/WT, CC/GG/GG or CC/AG/GG; VAR/VAR/VAR, TT/GG/AA ; /C3 p-value obtained through the Chi-squared test (Pearson P-value) or Fisher ’se x a c t\ntest. /C3/C3 Adjusted by age and BMI. /C3/C3/C3 Reference group.\nTable 3 Frequency of the studied polymorphisms among different populations (endometriosis patients and controls)\nPolymorphism Population N /C3 Frequency among\nthe controls (%)\nFrequency\namong the\ncases (%)\nAssociation with\nendometriosis\nReference\nPGR þ331 C > T\n(rs10895068)\nPGR þ331 T\nEstonia 349 8.8 6.7 No association Lamp et al 18\nUnited States 823 4.8 5.1 No association Trabert et al 19\nNetherlands 165 9.7 2.3 Protective (T allele) van Kaam et al 15\nBrazil 179 6.6 10.1 No association Present study\nCYP17A1 -34 A > G\n(rs743572)\nCYP17A1 -34 G\nTurkey 93 30.8 57.6 No association Bozdag et al 17\nChina 247 60.2 50.8 Risk (A allele) Hsieh et al 11\nChina 227 62.9 50.8 Risk (A allele) Hsieh et al 12\nChina 510 54.3 58.2 No association Juo et al 13\nJapan 317 39.8 42.9 No association Kado et al 10\nUnited States 823 39.3 34.8 No association Trabert et al 19\nItaly 190 37.2 42.3 No association Vietri et al 16\nBrazil 180 42.7 44.4 No association Present study\nCYP19A1 1531 G > A\n(rs10046)\nCYP19A1 1531 A\nKorea 412 55.9 55.8 No association Hur et al 14\nEstonia 349 59.8 55.0 No association Lamp et al 18\nChina 371 56.4 57.5 No association Wang et al 20\nChina 202 41.0 35.3 No association Yang et al 21\nBrazil 180 39.4 40.6 No association Present study\nAbbreviations: CYP17A1, cytochrome P450 17A1; CYP19A1, cytochrome P450 19A1; PGR, progesterone receptor.\nNote: /C3 N total number of individuals included in the study (cases þ controls).\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al. 279\n\n\nwhich is similar to our results. 14,18,20,21 To date, no study has\ninvestigated the combined effect of the SNPs PGR þ331TT/\nCYP17A1 -34AA/CYP19A1 1531AA on the development of\nendometriosis.\nThe strength of the present study is that it is the first study\nperformed in the Brazilian population that evaluated the\nSNPs PGR þ331C > T, CYP17A1 -34A > G and CYP19A1 1531G\n> A in terms of endometriosis development, while consider-\ning the symptoms of the disease. All control patients were\nsurgically evaluated to con firm a negative diagnosis of\nendometriosis; 27% of them had previously undergone ster-\nilization, and 63% had already had 2 or more children. A\nlimitation of this study was that the controls also included\nwomen with other gynecological diseases, providing lower\nrisk estimations. Furthermore, considering the endometri-\nosis patients, 27% were diagnosed by MRI. However, this has\nbeen a specific and accurate method for the detection of deep\nendometriosis.\n25–28\nIn conclusion, the combined analysis of the polymor-\nphisms PGR-CYP17A1-CYP19A1 suggests a gene-gene inter-\naction in the susceptibility to endometriosis. The results may\ncontribute to the identi fication of genetic biomarkers that\nare able to help in disease diagnosis and/or prognosis, as well\nas in the identi fication of possible molecular targets for\nindividualized treatments.\nConflicts of Interest\nThe authors have no con flicts of interest to disclose.\nAcknowledgment\nThe authors would like to thank Lucas Rafael Lopes and\nCaroline Passos from Centro Universitário Estadual da\nZona Oeste, Rio de Janeiro, Brazil, for their technical\nassistance. This study was supported by the Brazilian\nagencies Conselho Nacional de Desenvolvimento Cientí-\nfico e Tecnológico (CNPq), Fundação de Amparo à Pesquisa\ndo Estado do Rio de Janeiro (FAPERJ) and Fundação Ary\nFrauzino - Oncobiologia.\nReferences\n1 Acién P, Velasco I. Endometriosis: a disease that remains enig-\nmatic. ISRN Obstet Gynecol 2013;2013:242149\n2 Perini JA, Cardoso JV, Berardo PT, et al. Role of vascular endothelial\ngrowth factor polymorphisms (-2578C > A, -460 T > C, -1154G\n> A, þ405G > Ca n d þ936C > T) in endometriosis: a case-con-\ntrol study with Brazilians. BMC Womens Health 2014;14:117\n3 Zondervan KT, Rahmioglu N, Morris AP, et al. Beyond endome-\ntriosis genome-wide association study: from genomics to phe-\nnomics to the patient. Semin Reprod Med 2016;34(04):242 – 254\n4 Bell DW, Brannigan BW, Matsuo K, et al. Increased prevalence of\nEGFR-mutant lung cancer in women and in East Asian popula-\ntions: analysis of estrogen-related polymorphisms. Clin Cancer\nRes 2008;14(13):4079 – 4084\n5 Barcelos ID, Donabella FC, Ribas CP, et al. Down-regulation of the\nCYP19A1 gene in cumulus cells of infertile women with endome-\ntriosis. Reprod Biomed Online 2015;30(05):532 – 541\n6 Bedaiwy MA, Dahoud W, Skomorovska-Prokvolit Y, et al. Abun-\ndance and Localization of Progesterone Receptor Isoforms in\nEndometrium in Women With and Without Endometriosis and\nin Peritoneal and Ovarian Endometriotic Implants. Reprod Sci\n2015;22(09):1153– 1161\n7 Lafay Pillet MC, Schneider A, Borghese B, et al. Deep in filtrating\nendometriosis is associated with markedly lower body mass\nindex: a 476 case-control study. Hum Reprod 2012;27(01):\n265– 272\n8 Ghisari M, Eiberg H, Long M, Bonefeld-Jørgensen EC. Polymorph-\nisms in phase I and phase II genes and breast cancer risk and\nrelations to persistent organic pollutant exposure: a case-control\nstudy in Inuit women. Environ Health 2014;13(01):19\n9 De Vivo I, Huggins GS, Hankinson SE, et al. A functional poly-\nmorphism in the promoter of the progesterone receptor gene\nassociated with endometrial cancer risk. Proc Natl Acad Sci U S A\n2002;99(19):12263– 12268\n10 Kado N, Kitawaki J, Obayashi H, et al. Association of the CYP17\ngene and CYP19 gene polymorphisms with risk of endometriosis\nin Japanese women. Hum Reprod 2002;17(04):897 – 902\n11 Hsieh YY, Chang CC, Tsai FJ, Lin CC, Tsai CH. Cytochrome\nP450c17alpha 5 ′-untranslated region /C3 T/C polymorphism in en-\ndometriosis. J Genet 2004;83(02):189 – 192\n12 Hsieh YY, Chang CC, Tsai FJ, Lin CC, Tsai CH. Estrogen receptor\nalpha dinucleotide repeat and cytochrome P450c17alpha gene\npolymorphisms are associated with susceptibility to endome-\ntriosis. Fertil Steril 2005;83(03):567 – 572\n13 Juo SH, Wang TN, Lee JN, Wu MT, Long CY, Tsai EM. CYP17, CYP1A1\nand COMT polymorphisms and the risk of adenomyosis and\nendometriosis in Taiwanese women. Hum Reprod 2006;21(06):\n1498– 1502\n14 Hur SE, Lee S, Lee JY, Moon HS, Kim HL, Chung HW. Polymorph-\nisms and haplotypes of the gene encoding the estrogen-metabo-\nlizing CYP19 gene in Korean women: no association with\nadvanced-stage endometriosis. J Hum Genet 2007;52(09):\n703– 711\n15 van Kaam KJ, Romano A, Schouten JP, Dunselman GA, Groothuis\nPG. Progesterone receptor polymorphism þ331G/A is associated\nwith a decreased risk of deep in filtrating endometriosis. Hum\nReprod 2007;22(01):129 – 135\n16 Vietri MT, Ciof fi M, Sessa M, et al. CYP17 and CYP19 gene\npolymorphisms in women affected with endometriosis. Fertil\nSteril 2009;92(05):1532 – 1535\n17 Bozdag G, Alp A, Saribas Z, Tuncer S, Aksu T, Gurgan T. CYP17 and\nCYP2C19 gene polymorphisms in patients with endometriosis.\nReprod Biomed Online 2010;20(02):286 – 290\n18 Lamp M, Peters M, Reinmaa E, et al. Polymorphisms in ESR1, ESR2\nand HSD17B1 genes are associated with fertility status in en-\ndometriosis. Gynecol Endocrinol 2011;27(06):425 – 433\n19 Trabert B, Schwartz SM, Peters U, et al. Genetic variation in the\nsex hormone metabolic pathway and endometriosis risk: an\nevaluation of candidate genes. Fertil Steril 2011;96(06):\n1401 – 1406.e3\n20 Wang L, Lu X, Wang D, et al. CYP19 gene variant confers suscept-\nibility to endometriosis-associated infertility in Chinese women.\nExp Mol Med 2014;46:e103\n21 Yang X, Chen SQ, Liu M. [Association of the CYP19 gene poly-\nmorphism with genetic susceptibility to endometriosis]. Zhon-\nghua Yi Xue Yi Chuan Xue Za Zhi 2010;27(06):692 – 696\n22 Revised American Society for Reproductive Medicine classi fica-\ntion of endometriosis: 1996. Fertil Steril 1997;67(05):817 – 821\n23 Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endome-\ntriosis, and adenomyotic nodules of the rectovaginal septum are\nthree different entities. Fertil Steril 1997;68(04):585 – 596\n24 Chapron C, Santulli P, de Ziegler D, et al. Ovarian endometrioma:\nsevere pelvic pain is associated with deeply in filtrating endome-\ntriosis. Hum Reprod 2012;27(03):702 – 711\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al.280\n\n\n25 Bianek-Bodzak A, Szurowska E, Sawicki S, Liro M. The importance\nand perspective of magnetic resonance imaging in the evaluation\nof endometriosis. BioMed Res Int 2013;2013:436589\n26 Ma K, Majumder K, Clayton R, Rajashanker B, Ed-Osagie E.\nCorrelation between magnetic resonance imaging results and\nfindings at surgery for cases of severe endometriosis. J Minim\nInvasive Gynecol 2015;22(6S):S55\n27 Barcellos MB, Lasmar B, Lasmar R. Agreement between the\npreoperative findings and the operative diagnosis in patients\nwith deep endometriosis. Arch Gynecol Obstet 2016;293(04):\n845– 850\n28 Ito TE, Abi Khalil ED, Taffel M, Moawad GN. Magnetic resonance\nimaging correlation to intraoperative findings of deeply in filtra-\ntive endometriosis. Fertil Steril 2017;107(02):e11 – e12\nRev Bras Ginecol Obstet Vol. 39 No. 6/2017\nCombined Effect of Gene Polymorphisms on the Risk of Developing Endometriosis Cardoso et al. 281","source_license":"CC0","license_restricted":false}