h2.Endometriosis and its hormonal therapy
Endometriosis is a disease of ectopic occurrence and growth of endometrium in the ovary, oviduct and pouch of Douglas. The disease causes inflammation at the site and development of severe menstrual and lower abdominal pain at times other than the menstrual period (1. Chapron C, Fauconnier A, Dubuisson JB, et al: Deep infil- trating endometriosis: Relation between severity of dysmen- orrhea and extent of disease. Hum Reprod 2003;18:760–766). Endometriosis is estimated to affect 2-3% of the general female population, between the ages of 18-42, and may cause dysmenorrhea, dyspareunia, chronic pelvic pain, and primary or secondary infertility.
Because of its dependence on follicular hormones (estrogens), the disease increases gradually in menstruating women and decreases and disappears postmenopausally because of the reduced production of estrogens (2. Pellicer A, Navarro J, Bosch E, et al: Endometrial quality in infertile women with endometriosis. Ann N Y Acad Sci 2001; 943:122–130). Because of that endometriotic implants tend to regress in a hypoestrogenic enviroment. That has brought the development of several medical antigonadotropic and antiestrogenic treatments for endometriosis. Because of their anabolic and androgenic side effects, danazol and the progestogens have been replaced by the Gn-RH analogs. This treatment is conducted usually for 6 months, effectively alleviating or eliminating menstrual pain due to endometriosis and pain from other causes. However, symptoms of ovarian deficiency appear with high frequency during treatment, seriously impairing the quality of life. Moreover, the incidence of subsequent recurrence of endometriosis is extremely high after treatment. Because of the risks of these hormonal treatments, there is a need for effective treatment of endometriosis without long-lasting adverse effects.
h2.Pycnogenol: French Pinus pinaster bark extract, charachteristics
Pycnogenol® (French Pinus pinaster bark extract) contains polyphenolic compounds (these compounds consist of catechin, taxifolin, procyanidins of various chain lengths formed by catechin and epicatechin units, and phenolic acids) capable of producing diverse potentially protective effects against chronic and degenerative diseases. Several in vitro studies have revealed that PBE has anti-inflammatory effects and inhibits the initiation of inflammation by preventing the release of pro-inflammatory mediators regulated by oxidative stress. PBE inhibits the pro-inflammatory mediators in keratinocytes (epidermal cells), leukocytes, and endothelial cells. Furthermore, an in vitro study has shown that PBE and its metabolites inhibit the release of tissue destroying enzymes (matrix metalloprotein-ases) collagenase, elastase, and gelatinase from inflammatory cells (3. Antioxidant activity and inhibition of matrix metalloproteinases by metabolites of maritime pine bark extract (pycnogenol). Grimm T, Schäfer A, Högger P. Free Radic Biol Med. 2004 Mar 15; 36(6):811-22). It has also reported that after oral intake of PBE, the enzymatic activity of Cyclo-oxygenase (COX-1 and COX-2) in serum samples of human volunteers was inhibited. Cyclo-oxygenase is responsible for formation of biological mediators, such as prostaglandins, prosta-cyclin, and thromboxane. Pharmacological Inhibition of this enzyme can provide relief from the symptoms of inflammation and pain (4. Inhibition of COX-1 and COX-2 activity by plasma of human volunteers after ingestion of French maritime pine bark extract (Pycnogenol). Schäfer A, Chovanová Z, Muchová J, Sumegová K, Liptáková A, Duracková Z, Högger P. Biomed Pharmacother. 2006 Jan; 60(1):5-9).
Moreover the effects of bioflavonoids extracted from the bark of Pinus maritima Pycnogenol on free radical formation, activation of redox sensitive transcription factors, as well as interleukin-1 beta (IL-1 beta) production were investigated in murine macrophage cell lines. PBE exerted strong scavenging activities against reactive oxygen species generated either by H(2)O(2) or PMA in RAW 264.7 and IC-21 cells, respectively. In situ ELISA, immunoblot analysis, and competitive RT-PCR demonstrated that PBE pretreatment of LPS-stimulated RAW 264.7 cells dose-dependently reduced both the production of IL-1 beta and its mRNA levels. Furthermore, in the same cells, PBE blocked the activation of nuclear factor kappa B (NF-kappa B) and activator protein-1 (AP-1), two major transcription factors centrally involved in IL-1 beta gene expression. When RAW 264.7 cells were stimulated with LPS, the inhibitor protein I kappa B largely disappeared from cytosolic fractions. However, pretreatment of the cells with PBE abolished the LPS-induced I kappa B degradation. These results suggest that PBE can inhibit the expression of the proinflammatory cytokine IL-1 by regulating redox-sensitive transcription factors. This study may support the possibility that bioflavonoids including PBE can be used as antiinflammatory and immunosuppressive drugs based on their radical scavenging activities (5. Cho KJ, Yun CH, Yoon DY, et al: Effect of bioflavonoids ex- tracted from the bark of Pinus maritima on proinflammato- ry cytokine interleukin-1 production in lipopolysaccharide- stimulated RAW 264.7. Toxicol Appl Pharmacol 2000;168: 64–71). Moreover treatment with Pycnogenol showed good efficacy in treating menstrual cramps and pain in clinical trials: in 1 investigation, women with severe menstrual pain and endometriosis showed a high response rate (71– 100%) after supplementation with Pycnogenol (6. Kohama T, Suzuki N: The treatment of gynaecological disor- ders with Pycnogenol®. Eur Bull Drug Res 1999;7:30–32). In another clinical trial with patients complaining of dysmenorrhea, we could observe a significant alleviation of abdominal and lower back pain (p < 0.01). Patients reported fewer days of pain, and use of analgesics dropped (7. Kohama T, Suzuki N, Ohno S, et al: Analgesic efficacy of French maritime pine bark extract in dysmenorrhea: An open clinical trial. J Reprod Med 2004;49:828–832).
Due to this background Kohama et al. have put forward a study comparing effects and efficency of french maritime pine bark extract and leuprolelin acetate in the endometriosis medical treatment (8. Effect of French maritime pine bark extract on endometriosis as compared with leuprorelin acetate. Kohama T, Herai K, Inoue M. J Reprod Med. 2007 Aug;52(8):703-8).
From 1999 to 2004, 58 women participated in this study, their ages ranging from 21 to 38 years (mean, 33.2 ± 4.0). They had undergone conservative oper- ations for endometriosis within the previous 6 months. They were surgically diagnosed in accordance with Revised American Fertility Society (R- AFS) classification: stage II, 22 cases; stage III, 28 cases; and stage IV, 12 cases. The patients refused to undergo further surgery and were diagnosed having recurrent moderate to severe dysmenorrhea or other pelvic pain or disorders. Patients gave informed consent prior to the study and could leave the study at any time.
After confirming regular menstruation and ovulation with the basal body temperature (BBT) for 3 months before treatment, the patients were examined before and at 4, 12, 24 and 48 weeks after starting treatment to check for symptom control (pain score and urinary and bowel symptom scores), breakthrough bleeding and side effects of the medication. Pain was evaluated by patients’ self-assessment score of the severity of dysmenorrhea and pelvic pain since their previous visit. The investigator interviewed and performed a gynecologic examination on each patient. The smear test examination of the uterine cervix, ultrasonography, magnetic resonance imaging and serologic hormonal examinations of all patients, in- cluding CA-125 and estradiol in the middle of the proliferative phase, were performed before treatment.
Patients were randomized to 2 groups: Pycnogenol or Gn-RHa.
1. Patients in the Pycnogenol group took 30 mg Pycnogenol orally as capsules twice a day (total, 60 mg) for 48 weeks immediately after morning and evening meals. Treatment started on the eighth day of the menstrual cycle after reporting pain scores during a whole cycle before treatment. If a patient did not take the prescribed amount of capsules on a certain day, she was instructed to increase the dosage accordingly on the next day. The patients did not take psychotropic drugs, vitamins or Chinese kampo medicines during treatment with Pycnogenol. Also, physical therapy could not be introduced during the study period. Laxatives and medications necessary to continue with existing therapy were allowed. The use of analgesics was not re- stricted during the study; however, the dosage and type of analgesic had to be reported to a physician. The patients kept BBT charts during observation. If symptom control was unsatisfactory or side effects became significant, the patient could choose to terminate the medication or switch to another therapy.
2. The patients who received Gn-RHa therapy received injected leuprorelin acetate depot, 3.75 mg intracutaneously, 6 times every 4 weeks.10 Add- back therapy, hormonal replacement with Premarin (Wyeth Medica Ireland, Newbridge, Co. Kil- dare, Ireland), 1.25 mg/d, during Gn-RHa treatment was performed if necessary. After 6 treatments with Gn-RHa, patients did not receive other hormonal therapy. The patients were supposed to start checking their BBT at the onset of menstruation after the last treatment with Gn-RHa during observation.
The characteristics of the treatment groups showed no differences at the start of treatment:
In the Pycnogenol group, 32 patients were included (mean age, 33.6 ± 4.1 years; range, 24–39). Endometriosis was surgically diagnosed as stage II in 12 cases, stage III in 14 cases and stage IV in 6 cases according to the R-AFS.
In the Gn-RHa group 26 patients were included (mean age, 32.8 ± 3.8 years; range, 21–38). Endometriosis was diagnosed as stage II in 10 cases, stage III in 10 cases and stage IV in 6 cases.
In the Pycnogenol group, 3 patients stopped treatment after 8 weeks; after 16 weeks, 2 patients requested another treatment. Of the remaining 29 patients, 5 became pregnant (after 4–12 weeks, 2 cases; after 12–24 weeks, 3 cases). Their data before they left the study were used for statistical evalua- tion.
In the Gn-RHa group, 5 patients stopped therapy due to general malaise after 12 weeks of treatment and 1 patient stopped therapy because of pro- longed, massive uterine bleeding after 8 weeks of treatment.
Patients in both groups reported severe pain, pelvic tenderness and pelvic indurations at the start of treatment. Treatment with Pycnogenol slowly but steadily reduced all the symptom scores from severe to moderate. Treatment with Gn-RHa reduced the scores more efficiently; how- ever, 24 weeks after the end of treatment the scores demonstrated the recurrence of symptoms.
As expected, Gn-RHa suppressed menstruation during treatment, whereas in the Pycnogenol group no influence of treatment on menstrual cycles was observed. Gn-RHa lowered estrogen levels drastically; in contrast, the estradiol values of the Pycnogenol group showed no systematic changes over the observation period.
The values of serum marker CA-125 for endometriosis decreased in both treatment groups. Patients with smaller endometriomas responded better to treatment as compared to patients with large endometriomas. The lowering of CA-125 concentrations was by far more pronounced in the Gn-RHa group; however, a clear rebound effect was observable in the Gn-RHa group in contrast to the Pycnogenol group, where values remained at a lower level.
Side effects observed in the Pycnogenol group were mild and transient, none of the patients left the study because of side effects. In the Gn-RHa group, hot flushes, general malaise and lumbago were reported. Five patients reported general malaise stopped treat- ment because of its severity. Add-back therapies had to be prescribed in 8 cases of general malaise after the last treatment with Gn-RHa. The period from last treatment with Gn-RHa to onset of first menstruation was 13.2 ± 2 weeks and of first ovulaItion, 11.4 ± 2.2 weeks.
CA-125 is a good predicting marker for the evaluation and treatment of advanced endometriosis in patients with an initially elevated CA-125 level. CA-125 is a glycoprotein with a molecular weight of approximately 200 kd expressed on the cell surface of some derivatives of celomic epithelium. Accord- ing to Barbieri et al (9. Barbieri RL, Niloff JM, Bast RC Jr, et al: Elevated serum con- centrations of CA-125 in patients with advanced en- dometriosis. Fertil Steril 1986;45:630–634). Two mechanisms may be responsible for elevated blood levels of CA-125 in endometriosis. First,
to normal endometrium. Second, the local inflammation associated with endometriosis may increase the rate at which CA-125 is shed from the membranes of endometriotic lesions into the circulation. Inflammation-induced leakage of capillary endothelium could also explain why serum CA-125 increases in patients with acute pelvic inflammatory disease.
The reduction of symptoms could be the result of the combined action of the constituents of Pyc- nogenol, which contains a number of phenolic acids. Two of them, ferulic and caffeic acid, have a spasmolytic effect on the isolated uteri of rats (10. Ortiz de Urbina JJ, Martin ML, Sevilla MA, et al: Antispas- modic activity on rat smooth muscle of polyphenol com- pounds caffeic and protocathechic acids. Phytother Res 1990;4:71–72). Ferulic acid especially can inhibit uterine contractions in rodents in vivo. These constituents of Pycnogenol, perhaps together with other phenolic acids in Pycnogenol, could be responsible for the relief from cramping pain. Recently a close relationship was demonstrated between reactive oxygen species and endometriosis. Pycnogenol shows strong free radical–scavenging activity against reactive oxygen and nitrogen species such as inactivation of the superoxide and hydroxyl radical, inhibition of singlet oxygen formation and protective effects against lipid peroxidation, thiobarbituric acid reactive products generation, and oxidative hemolysis induced by peroxide hydrogen; that indicates that Pycnogenol’s antioxidant capacity could also cause an improvement in endometriosis, especially long-term treatment. During treatment with Gn-RHa, estradiol in all patients was extremely lowered by the reduction of ovarian function, the main mechanism to inactivate endometrial cells due to their estrogen dependency. The result is a reduction in inflammatory changes inside the tissues that cause several symptoms of endometriosis. However, this deactivated ovarian function quite frequently causes adverse effects, such as hot flushes, general malaise or loss of bone mineral. The profound hypoestrogenism is an inherent disadvantage of treatment with Gn-RHa. Moreover, after the end of treatment with Gn-RHa, estradiol levels increase rapidly around 3 months after the end of the therapy, causing recurrence of endometriosis, as demonstrated in this study by the increase in scores of pelvic pain, tenderness and induration after the end of treatment. In contrast, Pycnogenol treatment did not reduce estradiol, so endometriosis patients never lost the normal hormonal milieu.