Effects of Ulipristal Acetate on Reactive Oxygen Species and Proinflammatory Cytokine Release by Epithelial and Stromal Cells from Human Endometrium and Endometriosis

Endometriosis is a condition characterized by increased oxidative stress and chronic inflammation, which can be treated with progestins and other progesterone receptor ligands. However, some patients are refractory to this treatment and the reason is uncertain. Here we investigated the effects of the selective progesterone receptor modulator ulipristal acetate (UPA) on proliferation, reactive oxygen species (ROS), and proinflammatory cytokine production by endometriotic cells and endometrial cells from women with histologically proven endometriosis (n = 22) and endometriosis-free controls (n = 6). Epithelial and stromal cells were isolated and treated in triplicate for 24 h with 1 μM, 10 μM, or 100 μM UPA. Cells were tested for proliferation and ROS production, while cell supernatants were assayed for interleukin (IL)-6, C-C motif chemokine ligand 2 (CCL2), and tumor necrosis factor (TNF)-α concentrations. Proliferation, ROS production, and IL-6 and CCL2 secretion were increased in non-stimulated epithelial and stromal cells from endometriotic lesions compared to endometrial cells from endometriosis patients and controls. UPA induced a dose-dependent increase of cell proliferation only in endometriosis, while enhancing ROS production by all cell types evaluated. UPA reduced CCL2 production in controls but failed to do that in endometriosis, whereas TNF-α was undetectable. We conclude that treatment of endometriotic cells with UPA stimulated in vitro proliferation and ROS production and failed to revert the proinflammatory cytokine excess that characterized these cells, unravelling possible mechanisms of drug resistance in the treatment of endometriosis. Similar content being viewed by others Data Availability The datasets generated during the current study are available from the corresponding author on request. Code Availability Not applicable.

Taylor HS, Kotlyar AM, Flores VA. Endometriosis is a chronic systemic disease: clinical challenges and novel innovations. Lancet. 2021;397:839–52. Chapron C, Marcellin L, Borghese B, Santulli P. Rethinking mechanisms, diagnosis and management of endometriosis. Nat Rev Endocrinol. 2019;15:666–82. Reis FM, Coutinho LM, Vannuccini S, Batteux F, Chapron C, Petraglia F. Progesterone receptor ligands for the treatment of endometriosis: the mechanisms behind therapeutic success and failure. Hum Reprod Update. 2020;26:565–85. Reis FM, Petraglia F, Taylor RN. Endometriosis: hormone regulation and clinical consequences of chemotaxis and apoptosis. Hum Reprod Update. 2013;19:406–18. Vercellini P, Buggio L, Berlanda N, Barbara G, Somigliana E, Bosari S. Estrogen-progestins and progestins for the management of endometriosis. Fertil Steril. 2016;106:1552-71.e2. Fazleabas AT. Progesterone resistance in a baboon model of endometriosis. Semin Reprod Med. 2010;28:75–80. Singh SS, Evans D, McDonald S, Senterman M, Strickland S. Ulipristal acetate prior to surgery for endometriosis. Reprod Sci. 2020;27:1707–14. Whitaker LH, Murray AA, Matthews R, Shaw G, Williams AR, Saunders PT, et al. Selective progesterone receptor modulator (SPRM) ulipristal acetate (UPA) and its effects on the human endometrium. Hum Reprod. 2017;32:531–43. Salas A, Vázquez P, Bello AR, Báez D, Almeida TA. Dual agonist-antagonist effect of ulipristal acetate in human endometrium and myometrium. Expert Rev Mol Diagn. 2021;21:851–7. Kannan A, Bhurke A, Sitruk-Ware R, Lalitkumar PG, Gemzell-Danielsson K, Williams ARW, et al. Characterization of molecular changes in endometrium associated with chronic use of progesterone receptor modulators: ulipristal acetate versus mifepristone. Reprod Sci. 2018;25:320–8. González-Foruria I, Santulli P, Chouzenoux S, Carmona F, Chapron C, Batteux F. Dysregulation of the ADAM17/Notch signalling pathways in endometriosis: from oxidative stress to fibrosis. Mol Hum Reprod. 2017;23:488–99. Ngô C, Chéreau C, Nicco C, Weill B, Chapron C, Batteux F. Reactive oxygen species controls endometriosis progression. Am J Pathol. 2009;175:225–34. Santulli P, Chouzenoux S, Fiorese M, Marcellin L, Lemarechal H, Millischer AE, et al. Protein oxidative stress markers in peritoneal fluids of women with deep infiltrating endometriosis are increased. Hum Reprod. 2015;30:49–60. Su RW, Strug MR, Jeong JW, Miele L, Fazleabas AT. Aberrant activation of canonical Notch1 signaling in the mouse uterus decreases progesterone receptor by hypermethylation and leads to infertility. Proc Natl Acad Sci U S A. 2016;113:2300–5. Bateman J, Bougie O, Singh S, Islam S. Histomorphological changes in endometriosis in a patient treated with ulipristal: a case report. Pathol Res Pract. 2017;213:79–81. Chapron C, Lafay-Pillet MC, Monceau E, Borghese B, Ngo C, Souza C, et al. Questioning patients about their adolescent history can identify markers associated with deep infiltrating endometriosis. Fertil Steril. 2011;95:877–81. Maignien C, Santulli P, Chouzenoux S, Gonzalez-Foruria I, Marcellin L, Doridot L, et al. Reduced α-2,6 sialylation regulates cell migration in endometriosis. Hum Reprod. 2019;34:479–90. Peyneau M, Kavian N, Chouzenoux S, Nicco C, Jeljeli M, Toullec L, et al. Role of thyroid dysimmunity and thyroid hormones in endometriosis. Proc Natl Acad Sci U S A. 2019;116:11894–9. Nandakumar R, Praditpan P, Westhoff CL, Cremers S. A UPLC-MS/MS method for the quantitation of ulipristal acetate in human serum. J Chromatogr B Analyt Technol Biomed Life Sci. 2017;1059:43–8. Bressler LH, Bernardi LA, Snyder MA, Wei JJ, Bulun S. Treatment of endometriosis-related chronic pelvic pain with ulipristal acetate and associated endometrial changes. HSOA J Reprod Med Gynaecol Obstet. 2017;2:008. Grandi G, Mueller M, Bersinger N, Papadia A, Nirgianakis K, Cagnacci A, et al. Progestin suppressed inflammation and cell viability of tumor necrosis factor-alpha-stimulated endometriotic stromal cells. Am J Reprod Immunol. 2016;76:292–8. Gou Y, Li X, Li P, Zhang H, Xu T, Wang H, et al. Estrogen receptor beta upregulates CCL2 via NF-kappaB signaling in endometriotic stromal cells and recruits macrophages to promote the pathogenesis of endometriosis. Hum Reprod. 2019;34:646–58. Coutinho LM, Vieira EL, Dela Cruz C, Casalechi M, Teixeira AL, Del Puerto HL, et al. Apoptosis modulation by activin A and follistatin in human endometrial stromal cells. Gynecol Endocrinol. 2016;32:161–5. Nasu K, Narahara H, Matsui N, Kawano Y, Tanaka Y, Miyakawa I. Platelet-activating factor stimulates cytokine production by human endometrial stromal cells. Mol Hum Reprod. 1999;5:548–53. Machin D, Campbell MJ, Fayers PM, Pinol APY. Sample size tables for clinical studies. 2nd ed. Blackwell Science; 1997. Zondervan KT, Becker CM, Missmer SA. Endometriosis. N Engl J Med. 2020;382:1244–56. Mangioni S, Vigano P, Florio P, Borghi O, Vignali M, Petraglia F, et al. Effect of activin A on tumor necrosis factor-alpha/intercellular adhesion molecule-1 pathway in endometrial stromal cells. Eur J Obstet Gynecol Reprod Biol. 2005;123:218–23. Wei X, Liu Y, Li W, Shao X. Nucleotide-binding oligomerization domain-containing protein 1 regulates inflammatory response in endometriosis. Curr Protein Pept Sci. 2022;23:121–8. Chodankar RR, Murray A, Nicol M, Whitaker LHR, Williams ARW, Critchley HOD. The endometrial response to modulation of ligand-progesterone receptor pathways is reversible. Fertil Steril. 2021;116:882–95. Kolanska K, Sbeih M, Canlorbe G, Mekinian A, Varinot J, Capmas P et al. Ulipristal acetate modifies miRNA expression in both superficial and basal layers of the human endometrium. J Clin Med. 2021;10:4442. Lete I, Mendoza N, de la Viuda E, Carmona F. Effectiveness of an antioxidant preparation with N-acetyl cysteine, alpha lipoic acid and bromelain in the treatment of endometriosis-associated pelvic pain: LEAP study. Eur J Obstet Gynecol Reprod Biol. 2018;228:221–4. Amini L, Chekini R, Nateghi MR, Haghani H, Jamialahmadi T, Sathyapalan T, et al. The effect of combined vitamin C and vitamin e supplementation on oxidative stress markers in women with endometriosis: a randomized, triple-blind placebo-controlled clinical trial. Pain Res Manag. 2021;2021:5529741. Khodarahmian M, Amidi F, Moini A, Kashani L, Salahi E, Danaii-Mehrabad S, et al. A randomized exploratory trial to assess the effects of resveratrol on VEGF and TNF-α 2 expression in endometriosis women. J Reprod Immunol. 2021;143:103248.

FMR received a grant from Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, Brazil, # 201876/2017-5). Author information Authors and Affiliations Corresponding authors Ethics declarations Ethics Approval This study was conducted as an extension of the protocol titled “genomics and proteomics of endometriosis” approved by the local institutional review board (approval number 05-2006 provided by the “Comité de Protection des Personnes et des Biens dans la Recherche Biomédicale” of Paris Cochin). Consent to Participate All participants gave written informed consent. Consent for Publication Not applicable. Conflicts of Interest The authors declare no competing interests. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Reis, F.M., Chouzenoux, S., Bourdon, M. et al. Effects of Ulipristal Acetate on Reactive Oxygen Species and Proinflammatory Cytokine Release by Epithelial and Stromal Cells from Human Endometrium and Endometriosis. Reprod. Sci. 31, 260–266 (2024). https://doi.org/10.1007/s43032-023-01341-6 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s43032-023-01341-6