Endometriosis Pain Treatments, Endometriosis Natural Treatment Options, Alternative Treatments for Endometriosis

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ENDOMETRIOSIS

Patient Summary:

Endometriosis is a very common illness found in as many as 10-15% of reproductive-age women.
It is characterized by endometrial tissue outside of the uterus; and causes infertility, adhesion formation, and chronic pain.
It has been shown that stress causes decreased oxygen in the tissues, which can cause endometriosis.
In our clinic, we have had promising results treating endometriosis utilizing STS treatments. These treatments are primarily designed to create VIP (Vasoactive Intestinal Polypeptide).
Medical literature is quoted below showing that this has a broad base of support.

Physician Summary:

Emotional or psychological stress increases the production of norepinephrine.
Norepinephrine increases vasoconstriction and areas of hypoxia.
Hypoxia creates reactive oxygen species (ROS).
ROS activates cytokines, including interleukin (IL)-6, IL-8, vascular endothelial growth factor (VEGF), and tumor necrosis factor-alpha (TNF-alpha). These cytokines control the implantation and the growth of endometrial cells outside the uterus.
Hypoxia creates substance P. Substance P is a known stimulator of tumor necrosis factor-alpha (TNF-alpha) release and a promoter of interleukin-8 (IL-8)
Substance P acts upon the mast cells to produce a proteolytic enzyme, which deactivates calcitonin gene-related peptide (CGRP).
Decreased CGRP decreases vascular perfusion of tissues creating hypoxia.
IL-8 stimulates the adhesion of endometrial cells
Substance P is a known stimulator of tumor necrosis factor-alpha (TNF-alpha) release and a promoter of interleukin-8 (IL-8).
Among other things, STS treatments are designed to create Vasoactive Intestinal Polypeptide (VIP).
STS treatments are designed to decrease norepinephrine and substance P.
VIP inhibits the production of pro-inflammatory agents (cytokines, chemokines, and nitric oxide), and stimulates the production of the anti-inflammatory cytokine IL-10.
VIP inhibits the production of macrophage-derived tumor necrosis factor-alpha, interleukin (IL-6), nitric oxide, and IL-12.
There are indications that endometriosis is due to immune system dysfunction.
Adequate VIP is critical for normal immune system function.
It appears that decreased VIP is the common pathogenesis of both endometriosis and asthma. Pride et al reported that several patients with endometriosis in whom treatment with danazol resulted in a concomitant remission of asthma.
When lung sections of non-asthmatic and asthmatic patients were compared, no VIP producing neurons were seen in any of 468 asthmatic lung sections that were evaluated. Whereas, in non-asthmatic lung sections, 92 % of the sections evaluated had VIP producing neurons.

MEDICAL JOURNAL BACKGROUND INFORMATION

In a recent study performed by Ernesto Guido, M.D., treatments utilizing the Dynatronic STS system were shown to successfully decrease the objective signs and subjective symptoms of peripheral neuropathy patients. During that study, daily skin temperatures were obtained from the palmar surface of the thumbs and the plantar surface of the bilateral hallux. It was found in that study that there was a partial or complete normalization of the actual skin temperature and the skin temperature gradient, left to right. Guido E. "Effects of Sympathetic Therapy on Chronic Pain in Peripheral Neuropathy Subjects". American Journal of Pain Management 2002 Jan; 12(1):31-34.

In reviewing that study's results, it could be hypothesized that improved micro- circulation to the nerves resulted in the improvement in the peripheral neuropathy patients. If this is true, then it could be hypothesized that the improvement in the patients' skin temperatures was due to an improved skin microcirculation probably caused by the creation of various neuropeptides, including Vasoactive Intestinal Polypeptide. In addition, heart rate variability (HRV) has been shown to be a reliable indicator of autonomic nervous system function. In our clinic, HRV studies are performed before and after an STS treatment (usually the first treatment). With the exception of those patients on significant amounts of narcotics, there is almost always a total or partial normalization of the HRV. This data will result in an upcoming publication.

The current working hypothesis is that the STS treatments are effective due to a combination of the following aspects of the treatments: low frequency electrical current passing through long sections of nerves; electrode pad placement; production of cyclic adenosine monophosphate; the choice of the peripheral nerves being stimulated so that there is a cross-over effect in the Central Nervous System; leakage of action potentials from the nerves being stimulated into nerves entering the sympathetic ganglia; the quadrilateral location of stimulation; creation of action potentials through sympathetic nerve fibers, in the peripheral nerves being stimulated; creation of action potentials in peripheral nerves being stimulated; activation of the sodium pump, in the nerves being stimulated; production of ACTH; production of dynorphins, enkephalins or beta-endorphins; creation of action potentials in sympathetic fibers within the peripheral nerves being stimulated, which enter the sympathetic ganglia directly; analgesia causing a reduction in the production of substance P; and/or the production of circulation altering neuropeptides such as vasoactive intestinal polypeptide(VIP) and calcitonin gene-related peptide (CGRP).

There is considerable peer review medical journal literature to support these hypotheses.

STS treatments are designed to create vasoactive intestinal polypeptide (VIP). It has been demonstrated that STS treatments increase and normalize skin temperatures. It has been shown the type of electrical stimulation utilized in the STS increased the plasma VIP 60%. Since VIP is not a blood-borne hormone, an increase in plasma VIP in the systemic circulation represents an overflow from synapses. Guido E. "Effects of Sympathetic Therapy on Chronic Pain in Peripheral Neuropathy Subjects". American Journal of Pain Management 2002 Jan; 12(1):31-34. Kaada B "Promoted healing of chronic ulceration by transcutaneous nerve stimulation (TNS)." Vasa. 1983;12(3):262-9. Kaada, B "Successful treatment of esophageal dysmotility and Raynaud's phenomenon in systemic sclerosis and achalasia by transcutaneous nerve stimulation. Increase in plasma VIP concentration." Scand J Gastroenterol. 1987 Nov;22(9):1137-46. Kaada B "Systemic sclerosis: successful treatment of ulcerations, pain, Raynaud's phenomenon, calcinosis, and dysphagia by transcutaneous nerve stimulation. A case report." Acupunct Electrother Res. 1984;9(1):31-44. Kaada B "Vasodilation induced by transcutaneous nerve stimulation in peripheral ischemia (Raynaud's phenomenon and diabetic polyneuropathy). Eur Heart J. 1982 Aug;3(4):303-14. Kaada B, Lygren I "Lower plasma levels of some gastrointestinal peptides in Raynaud's disease. Influence of transcutaneous nerve stimulation." Gen Pharmacol.1985;16(2):153-6.

Although peritoneal endometriosis was recognized in 1860, its pathogenesis still remains unclear. Several theories attempt to explain the pathogenesis of this condition. From these, the implantation theory maintains that peritoneal endometriosis is the result of implantation and subsequent growth of retrogradely shed viable endometrial cells. Based on a second theory, the peritoneal mesothelium transforms to an endometrium-like tissue under the influence of products of regurgitated endometrium (induction). Cell adhesion molecules could be functionally involved in the binding of the endometrial cells to the peritoneal lining. In peritoneal endometriosis, a delicate equilibrium seems to exist between attacking forces (retrograde menstruation) and the defense mechanisms. van der Linden PJQ. "Endometriosis. A review on its pathogenesis." Front Biosci 1997 Aug 1;2:e48-52.

Endometriosis is a debilitating disease found in 10-15% of reproductive-age women and is characterized by the presence of endometrial tissue outside of the uterus. Pitt JA, Feng L, Abbott BD, Schmid J, Batt RE, Costich TG, Koury ST, Bofinger DP. "Expression of AhR and ARNT mRNA in cultured human endometrial explants exposed to TCDD." Toxicol Sci 2001 Aug;62(2):289-98.

Sampson's theory stating that endometrial cells and fragments desquamate during the menstrual period are transported through Fallopian tubes into the peritoneal cavity where they implant, proliferate and develop into endometriotic lesions is generally accepted. Accumulating data suggest that deficient immunity against retrograde endometrium during menstruation may be involved in the pathophysiology of endometriosis. Recent studies in women with endometriosis have demonstrated functional changes in several immunologic components in the peritoneal fluid as well as in sera of those patients. It was shown, for instance, that a wide pattern of cytokines are involved during endometrial cells implantation, proliferation and forming of endometriotic lesions. Those factors play a critical role in decreased immunologic surveillance, recognition and destruction of ectopic endometrial cells and possible facilitation of the implantation of ectopic endometrial tissues. Barcz E, Kaminski P, Marianowski L. "Role of cytokines in pathogenesis of endometriosis." Med Sci Monit 2000 Sep-Oct;6(5):1042-6

The theory of Sampson that endometrial cells and fragments desquamated during the menstrual period are transported through fallopian tubes into the peritoneal cavity where they implant, proliferate and develop into endometriotic lesions is generally accepted. Accumulating data suggest that deficient immunity against retrograde endometrium during menstruation may be involved in the pathophysiology of endometriosis. Recent studies in women with endometriosis demonstrated functional changes in several immunologic components in the peritoneal fluid as well as in sera of those patients. Among others it was shown that a wild pattern of cytokines take part in events occurring during endometrial cells implantation, proliferation and forming of endometriotic lesions. One of them VEGF seems to play a very important role in neovascularisation and implantation of ectopic endometrial lesions. In their study, Barcz et al evaluated the concentrations of VEGF in serum of patients with endometriosis and showed negative correlation between AFS score and VEGF concentration in peritoneal endometriosis. Above results do not confirm former observations indicating the role of VEGF in endometriosis pathogenesis. Barcz E, Kaminski P, Marianowski L.Serum. "VEGF (vascular endothelial growth factor) concentration in patients with endometriosis." Ginekol Pol 2000 Sep;71(9):993-1000.

There is evidence to suggest that alterations in the immune response, whether genetically transmitted or environmentally induced, predispose women to the ectopic implantation of endometrial cells transported into the peritoneal cavity by way of retrograde menstruation. Gazvani R, Templeton A. "New considerations for the pathogenesis of endometriosis." Int J Gynaecol Obstet 2002 Feb;76(2):117-26

Endometriosis is defined by the presence of viable endometrial tissue outside the uterine cavity. Today, a composite theory of retrograde menstruation with implantation of endometrial fragments in conjunction with peritoneal factors to stimulate cell growth is the most widely accepted explanation. There is substantial evidence that immunological factors and angiogenesis play a decisive role in the pathogenesis of endometriosis. In women with endometriosis, there appears to be an alteration in the function of peritoneal macrophages, natural killer cells and lymphocytes. Furthermore, growth factors and inflammatory mediators in the peritoneal fluid, produced mainly by peritoneal macrophages, are altered in endometriosis, indicating a role for these immune cells and mediators in the pathogenesis of this disease. Gazvani R, Templeton. "A.Peritoneal environment, cytokines and angiogenesis in the pathophysiology of endometriosis." Reproduction 2002 Feb;123(2):217-26.

Angiogenesis is likely to be involved in the pathogenesis of endometriosis. According to the transplantation theory, when the exfoliated endometrium is attached to the peritoneal layer, the establishment of a new blood supply is essential for the survival of the endometrial implant and development of endometriosis. From the known angiogenic factors, vascular endothelial growth factor (VEGF) has emerged as a pivotally important regulator of normal angiogenesis and pathological neovascularization. Donnez J, Smoes P, Gillerot S, Casanas-Roux F, Nisolle M. "Vascular endothelial growth factor (VEGF) in endometriosis." Hum Reprod 1998 Jun;13(6):1686-90.

Endometriosis is classically defined as the growth of endometrial cells at sites outside the uterus. It is a common disease characterized by infertility, chronic pain and adhesion formation. Immune dysregulation, evidenced by decreased clearance of endometrial cells and aberrant production of cytokines by peritoneal fluid leukocytes, has been proposed as a mechanism which allows implantation and growth of ectopic endometrium. Cytokines are primary components of intercellular signaling between uterine epithelial and stromal cells, leukocytes, and the developing conceptus. Because their production is regulated by sex hormones, cytokines are well-placed to play a key role in the extensive tissue remodeling required to accommodate menstruation, implantation and pregnancy. Rier SE, Yeaman GR. "Immune aspects of endometriosis: relevance of the uterine mucosal immune system." Semin Reprod Endocrinol 1997;15(3):209-20.

Recent studies suggest that the peritoneal fluid of women with endometriosis contains an increased number of activated macrophages that secrete various local products, such as growth factors and cytokines. Levels of several cytokines were reported to be elevated in the peritoneal fluid of women with endometriosis. Because the peritoneal environment may be controlled by locally regulated factors, cytokines are believed to play a role in the development and progression of endometriosis and endometriosis-associated infertility. A possible pathogenic mechanism links cytokines with endometriosis.

CONCLUSION(S):

Cytokines, which are produced by many cell types including endometriotic tissues, play diverse roles in the pathogenesis of endometriosis and endometriosis-associated infertility. Harada T, Iwabe T, Terakawa N. "Role of cytokines in endometriosis." Fertil Steril 2001 Jul;76(1):1-10.

Braun et al found that endometrial cells from women with endometriosis can utilize factors in peritoneal fluids, such as TNF-alpha, to facilitate proliferation in ectopic environments. Endometrial cells from women without endometriosis do not share this ability, suggesting that this abnormality is etiologically related to development of the disease. They concluded that therapy with agents that block the effects of TNF-alpha may be warranted. Braun DP, Ding J, Dmowski WP. "Peritoneal fluid-mediated enhancement of eutopic and ectopic endometrial cell proliferation is dependent on tumor necrosis factor-alpha in women with endometriosis." Fertil Steril 2002 Oct;78(4):727-32.

Substance P is a known stimulator of tumor necrosis factor-alpha (TNF-alpha) release and a promoter of interleukin-8 (IL-8), which are increased in sickle cell disease. These cytokines enhance adhesion of leukocytes to endothelium and may play a role in vaso-occlusive events. (22) 22 Michaels LA, Ohene-Frempong K, Zhao H, Douglas SD. "Serum levels of substance P are elevated in patients with sickle cell disease and increase further during vaso-occlusive crisis." Blood 1998 Nov 1;92(9):3148-51.

The peritoneal cavity of the normal women has the capacity to prevent the evolution towards endometriosis. The reasons of an evolution towards the endometriosis and its symptoms (pain, sterility, adherences are probably numerous implying the immune system, the endometrium, the macrophages, the cells natural killer, the peritoneum the fallopian tubes. The failure to remove the peritoneal cavity of the fragments would induce an inflammatory local state with hyperactivation of the macrophages which secrete many molecules, of which some could lead the metaplasia of the peritoneum or the development of mullerian residues. Vinatier D, Dufour P, Leroy JL. "The mechanisms of endometriosis." Rev Prat 1999 Feb 1;49(3):254-7.

Peritoneal fluid in women with endometriosis contains an increased number of activated macrophages that secrete a variety of cytokines, including interleukin (IL)-6, IL-8, vascular endothelial growth factor, and tumor necrosis factor-alpha (TNF-alpha). Cytokines may be involved in the control of implantation and the growth of endometrial cells outside the uterus. In addition, several cytokines have been implicated in or directly associated with angiogenic activity in endometriosis. There could be a relationship between the levels of cytokines in the peritoneal fluid of patients with endometriosis and the status of the lesions in such patients. Peritoneal endometriosis can be classified as having red, black, or white lesions. Red lesions are known to be an active form of early endometriosis, because vascularization and mitotic activity are shown to be most prominent in these lesions. We found that the peritoneal fluid levels of TNF-alpha and IL-8 were significantly higher in patients with endometriosis, and correlated with the size and number of active lesions. In addition, TNF-alpha and IL-8 stimulated the growth of ectopic endometrial stromal cells. These cytokines with angiogenic activity may therefore have significant roles in the pathogenesis of endometriosis. Harada T, Enatsu A, Mitsunari M, Nagano Y, Ito M, Tsudo T, Taniguchi F, Iwabe T, Tanikawa M, Terakawa N. "Role of cytokines in progression of endometriosis." Gynecol Obstet Invest 1999;47 Suppl 1:34-9; discussion 39-40.

Endometriosis, defined by the presence of viable endometrial tissue outside the uterine cavity, is among the most common gynecologic disorders affecting women of reproductive age. Endometriosis is associated with an inflammatory peritoneal environment, where multiple cytokines and growth factors are found at elevated levels. Interleukin-8 (IL-8) is a cytokine that induces chemotaxis of neutrophils and is a potent angiogenic agent. In addition, IL-8 was recently found to stimulate proliferation of various cells. We have observed that IL-8 is elevated in the peritoneal fluid of women with endometriosis and the levels correlate with the severity of the disease. We hypothesized that IL-8 may play a role in the growth and maintenance of ectopic endometrial tissue not only by chemoattracting and stimulating leukocytes to secrete growth factors and cytokines, but also by directly affecting endometrial cell proliferation. We found that IL-8 mRNA and protein levels in the endometrium were significantly higher during early proliferative and late secretory phases than during the mid-cycle. IL-8 receptors A and B are also expressed in the endometrium mostly localized in the stroma. Interestingly, IL-8 receptor expression is higher in the eutopic endometrium of women with endometriosis compared to the endometrium of women without endometriosis. Endometrial cells in culture proliferate significantly when treated with IL-8, which is inhibited by anti-IL-8 neutralizing antibody. More convincingly, IL-8 antisense oligonucleotide treatment decreases IL-8 production by endometrial cells as well as cell proliferation when compared to non-sense oligonucleotide treatment. The addition of IL-8 reverses the inhibitory effect of IL-8 antisense oligonucleotides on cell proliferation. These findings suggest that IL-8 may act as an autocrine growth factor in the endometrium. We have also studied the effect of endometrial cell adhesion on IL-8 expression and observed that IL-8 stimulates the adhesion of endometrial cells to fibronectin. Treatment of the cells with anti-IL-8 neutralizing antibody inhibited partially the cell adhesion. Thus, IL-8 may also be relevant for stimulating the attachment of endometrial implants in the pathogenesis of endometriosis. In addition, adherence of endometrial cells induced further IL-8 expression by an integrin-dependent mechanism. In summary, IL-8 may act as an autocrine growth factor in the endometrium and may also play a role in the pathogenesis of endometriosis by promoting the vicious circle of endometrial cell attachment, cell growth, and further secretion of this cytokine. Arici A. "Local cytokines in endometrial tissue: the role of interleukin-8 in the pathogenesis of endometriosis." Ann N Y Acad Sci 2002 Mar;955:101-9; discussion 118, 396-406.

An immunologic basis has long been considered to be very important in the pathogenesis of endometriosis. Interactions of the peritoneal cells, which comprise macrophages, B cells, T cells, natural killer (NK) cells, and retrograde endometrial cells, are critical, but remain controversial, for exploring the pathogenesis of endometriosis. The data show that peritoneal macrophages are activated by the recurrent reflux of menstrual shedding. Humoral and local endometrial autoantibodies are detected in patients with endometriosis, but B cells are not quantitatively increased. There is decreased NK cell activity in the peritoneal cavity and peripheral blood, and this decreased activity may be related to the failure to clear out the ectopic endometrial tissue. Peritoneal T cells are predominant by Th1 inflammatory cells, and these cells are impaired because of a decrease in activation (especially HLA-DR+CD4+CD3+ population) and in the production of interleukin-2. Inflammatory cytokines such as interleukin-1, interleukin-6, and tumor necrosis factor-alpha are elevated in the peritoneal fluid of women with endometriosis. The peritoneal NK and T lymphocytes are suppressed in women with endometriosis. Ho HN, Wu MY, Yang YS. "Peritoneal cellular immunity and endometriosis." Am J Reprod Immunol 1997 Dec;38(6):400-12.

Pride et al reported that several patients with endometriosis in whom treatment with danazol resulted in a concomitant remission of asthma. Pride SM, Yuen BH. "Relief of asthma in two patients receiving danazol for endometriosis." Can Med Assoc J 1984 Oct 1;131(7):763-4

Wieser et al state that the estradiol metabolites, 2-hydroxy and 4-hydroxy catechols, which have been implicated in the pathogenesis of endometriosis and that Catechol-O-methyltransferase (COMT) inactivates these estradiol metabolites. Wieser F, Wenzl R, Tempfer C, Worda C, Huber J, Schneeberger C. "Catechol-O-methyltransferase polymorphism and endometriosis." J Assist Reprod Genet 2002 Jul;19(7):343-8

Lavigne et al stated that mounting evidence suggests that catechol metabolites of estradiol may contribute to the development of estrogen-induced cancers. O-Methylation, catalyzed by catechol-O-methyltransferase (COMT), inactivates catechol estrogens. COMT is polymorphic in the human population, with 25% of Caucasians being homozygous for a low activity allele of the enzyme (COMT(LL)). Their study showed that low activity COMT radically increases the risk of human breast cancer. Lavigne JA, Helzlsouer KJ, Huang HY, Strickland PT, Bell DA, Selmin O, Watson MA, Hoffman S, Comstock GW, Yager JD. "An association between the allele coding for a low activity variant of catechol-O-methyltransferase and the risk for breast cancer." Cancer Res 1997 Dec 15;57(24):5493-7

Compared to women with COMT(Val/Val), COMT(Met/Met) resulted in lower levels of COMT and was associated with a significantly increased risk of breast cancer. Mitrunen K, Jourenkova N, Kataja V, Eskelinen M, Kosma VM, Benhamou S, Kang D, Vainio H, Uusitupa M, Hirvonen A. "Polymorphic catechol-O-methyltransferase gene and breast cancer risk." Cancer Epidemiol Biomarkers Prev 2001 Jun;10(6):635-40. Yim DS, Parkb SK, Yoo KY, Yoon KS, Chung HH, Kang HL, Ahn SH, Noh DY, Choe KJ, Jang IJ, Shin SG, Strickland PT, Hirvonen A, Kang D. "Relationship between the Val158Met polymorphism of catechol O-methyl transferase and breast cancer." Pharmacogenetics 2001 Jun;11(4):279-86. Thompson PA, Shields PG, Freudenheim JL, Stone A, Vena JE, Marshall JR, Graham S, Laughlin R, Nemoto T, Kadlubar FF, Ambrosone CB. "Genetic polymorphisms in catechol-O-methyltransferase, menopausal status, and breast cancer risk." Cancer Res 1998 May 15;58(10):2107-10

Vasoactive intestinal peptide (VIP) and its two G protein-coupled receptors, VPAC1 and VPAC2, are quantitatively prominent and functionally critical in the immune system. Transgenic (T) mice constitutively expressing VPAC2 selectively in CD4 T cells, at levels higher than those found after maximal induction in CD4 T cells of wild-type (N) mice, have elevated blood concentrations of IgE, IgG1, and eosinophils; enhanced immediate-type hypersensitivity; and reduced delayed-type hypersensitivity. In contrast, VPAC2-null (K) mice manifest decreased immediate-type hypersensitivity and enhanced delayed-type hypersensitivity. Voice JK, Grinninger C, Kong Y, Bangale Y, Paul S, Goetzl EJ. "Roles of vasoactive intestinal peptide (VIP) in the expression of different immune phenotypes by wild-type mice and T cell-targeted type II VIP receptor transgenic mice." J Immunol 2003 Jan 1;170(1):308-14.

The immunoregulatory neuropeptides VIP and PACAP favor Th2-type immune responses. Antigen-stimulated Th2 cells produce VIP, VIP/PACAP induce Th2 cytokine responses, and promote the preferential survival of Th2 effectors. Jiang X, Jing H, Ganea D. "VIP and PACAP down-regulate CXCL10 (IP-10) and up-regulate CCL22 (MDC) in spleen cells." J Neuroimmunol 2002 Dec;133(1-2):81-94.

There is increasing evidence that the cutaneous nervous system modulates physiological and pathophysiological effects including cell growth and differentiation, immunity and inflammation as well as tissue repair. Both cutaneous nervous fibers and inflammatory cells are able to release neuromediators and thereby activate specific receptors on target cells in the skin or transient immunocompetent cells. Cutaneous neuromediators include classical neurotransmitters such as catecholamines and acetylcholine being released from the automatic nervous system or cutaneous cells. On the other hand neuropeptides including substance P, calcitonin gene related peptide (CRGP), vasointestinal peptide (VIP) or proopiomelanocortin (POMC) derived peptides such as alpha melanocyte stimulating hormone (alphaMSH) may be released from sensory or autonomic nerve fibers and several epidermal as well as dermal cells. Neuropeptides are known to activate a variety of cutaneous cells through high affinity neuropeptide receptors or by direct activation of intracellular G-protein signalling cascades. Via the modulation of transcription factor activation (NF-kappaB, AP-1, STAT-3) they regulate the expression of adhesion molecules and proinflammatory cytokines in different cells and thereby function as modulators of immune and inflammatory reactions. Accordingly, neuropeptides such as CGRP or alphaMSH in vitro were found to downregulate costimulatory molecule expression on dendritic cells and in vivo via the generation of suppressor T-lymphocytes to induce hapten specific tolerance. Proteinases such as tryptase or neural endopeptidase inactivate neuropeptides in the extracellular space or at the cell surface thereby terminating neuropeptide induced inflammatory or immune responses. Proteinase-activated receptors (PAR) are recently described receptors that may have high impact in regulating cutaneous neurogenic inflammation. In the skin PAR-2 being expressed on sensory neurons and endothelial cells is self activated by tethered peptide ligands that are exposed after extracellular amino-terminal cleavage by trypsin or mast cell tryptase. PAR-2 agonists were found to induce the release of CGRP and SP which mediate vasodilation, plasma extravasation as well as the expression of adhesion molecules on vascular endothelial cells and thus elicit neurogenic inflammation. These findings indicate that the neuromediator network including neuropeptide receptors as well as proteinases play an important role in the maintenance of tissue integrity and the regulation of inflammatory and immune responses in the skin. Luger A. "Neuromediators-a crucial component of the skin immune system." J Dermatol Sci 2002 Nov;30(2):87-93.

Vasoactive intestinal peptide (VIP) and its two G protein-coupled receptors, VPAC1R and VPAC2R, are prominent in the immune system and potently affect T cells and macrophages. AC1Rs are expressed constitutively by blood and tissue T cells, with an order of prevalence of Th2>Th1z.Gt;Ts, and transmit signals suppressive for migration, proliferation and cytokine production. Immune activation of T cells downregulates VPAC1Rs and upregulates VPAC2Rs. VPAC2Rs mediate T cell chemotaxis, stimulation of some Th2-type cytokines, and inhibition of some Th1-type cytokines. A tentative hypothesis that the VIP-VPAC2R axis is the major neuroregulator of Th2/Th1 balance has been confirmed by finding an increased ratio in CD4 T cells of transgenic (TG) mice, expressing high levels of VPAC2Rs, and a decreased ratio in CD4 T cells of VPAC2R-null (K/O) mice. VPAC2R TG mice exhibit an allergic phenotype, whereas the K/O mice are hypoallergic and have heightened delayed-type hypersensitivity. The mechanisms of VIP-VPAC2R effects include decreased Th2 apoptosis, increased Th2-type cytokine production, and greater generation of Th2 memory cells. VPAC2R antagonists are being developed to alleviate allergic diseases and strengthen effector Th1 cell-mediated immunoprotection. Voice JK, Dorsam G, Chan RC, Grinninger C, Kong Y, Goetzl EJ. "Immunoeffector and immunoregulatory activities of vasoactive intestinal peptide." Regul Pept 2002 Nov 15;109(1-3):199-208.

The structurally related neuropeptides VIP and PACAP are released within the lymphoid organs following antigenic stimulation, and modulate the function of inflammatory cells through specific receptors. In activated macrophages, VIP and PACAP inhibit the production of pro-inflammatory agents (cytokines, chemokines, and nitric oxide), and stimulate the production of the anti-inflammatory cytokine IL-10. These events are mediated through the VIP/PACAP effects on de novo expression or nuclear translocation of several transcription factors, i.e., NFkappaB, CREB, c-Jun, JunB, and IRF-1. The in vivo administration of VIP/PACAP results in a similar pattern of cytokine and chemokine modulation, which presumably mediates the protective effect of VIP/PACAP in septic shock. In addition, VIP/PACAP reduce the expression of the co-stimulatory molecules B7.1/B7.2, and the subsequent stimulatory activity of macrophages for T-helper cells. In T-cells expressing specific VIP/PACAP receptors, VIP and PACAP inhibit the expression of FasL through effects on NFkappaB, NFAT, and Egr2/3. The reduction of FasL expression has several biological consequences: inhibition of antigen-induced cell death in CD4 T-cells, inhibition of the FasL-mediated cytotoxicity of CD8 and CD4 effectors against direct and bystander targets, and promotion of long-term memory Th2 cells, through a positive effect on the survival of Th2, but not Th1, effectors. Ganea D, Delgado M. "Vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase-activating polypeptide (PACAP) as modulators of both innate and adaptive immunity." Crit Rev Oral Biol Med 2002;13(3):229-37.

Inflammatory chemokines recruit immune cells, which initiate and maintain the inflammatory response. Although such a response is necessary for the elimination of the antigen, the inflammation has to be eventually resolved. Peptides such as vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase-activating polypeptide (PACAP), released following antigenic stimulation, contribute to the termination of an inflammatory response primarily by inhibiting the production of proinflammatory cytokines. They found that VIP and PACAP inhibit the expression of the macrophage-derived CXC chemokines MIP-2 and KC (IL-8), and of the CC chemokines MIP-1a, MIP-1b, MCP-1 and RANTES in vivo and in vitro. The decrease of chemokine gene expression correlates with an inhibitory effect of VIP/PACAP on NFkB binding. In an in vivo model of acute peritonitis, the inhibition of chemokine production by VIP/PACAP leads to a significant reduction in the recruitment of PMNs, macrophages and lymphocytes into the peritoneal cavity. These findings support the proposed role of VIP and PACAP as key endogenous anti-inflammatory agents, and describe a novel mechanism, i.e., the inhibition of the production of macrophage-derived chemokines. Delgado M, Ganea D. "Inhibition of endotoxin-induced macrophage chemokine production by VIP and PACAP in vitro and in vivo." Arch Physiol Biochem 2001 Oct;109(4):377-82.

In an immune response, antigen-specific CD4 T cells proliferate and differentiate into effector cells capable to produce large amounts of cytokines upon restimulation. Most effector T cells are later eliminated through antigen-induced cell death (AICD), mediated through FasL/Fas interactions. A low percentage of effector T cells survive and differentiate into long-lived memory cells. Mechanisms must operate not only to destroy no longer needed and even potentially damaging T cells, but also to allow the survival of a small number of activated T cells. Little is known about the factors and mechanisms that regulate the shift from an apoptosis-sensitive to an apoptosis-resistant phenotype. VIP and the structurally related peptide, PACAP, synthesized and/or released in the immune organs act on both innate and adaptive immunity. Recently, VIP and PACAP were shown to inhibit AICD in peripheral CD4 T cells by down-regulating FasL expression. It was found that both neuropeptides promote the in vivo effector function and memory phenotype of Th2, but not Th1 cells, by preferentially inhibiting the clonal deletion of Th2 cells. Therefore, VIP and PACAP generate memory T cells. This was the first report describing the role of a neuropeptide present in the lymphoid microenvironment on the generation and maintenance of long-lived memory T cells. Delgado M, Ganea D. "VIP and PACAP enhance the in vivo generation of memory TH2 cells by inhibiting peripheral deletion of antigen-specific effectors." Arch Physiol Biochem 2001 Oct;109(4):372-6.

The vasoactive intestinal peptide (VIP) and the structurally related neuropeptide pituitary adenylate cyclase-activating polypeptide (PACAP) act as "macrophage-deactivating factors". It has been shown that VIP and PACAP inhibit the production of macrophage-derived tumor necrosis factor-alpha, interleukin (IL)-6, nitric oxide, and IL-12. VIP and PACAP inhibit the synthesis of the interferon responsive factor-1. Delgado M, Ganea D. "Vasoactive intestinal peptide and pituitary adenylate cyclase-activating polypeptide inhibit interleukin-12 transcription by regulating nuclear factor kappaB and Ets activation." J Biol Chem 1999 Nov 5;274(45):31930-40 Tumor necrosis factor alpha (TNFalpha), an early cytokine produced by activated macrophages, plays an essential role in normal and pathological inflammatory reactions. The excessive production of TNFalpha is prevented by the so-called "macrophage-deactivating factors." This study examines the role of two structurally related neuropeptides, the vasoactive intestinal peptide (VIP) and the pituitary adenylate cyclase-activating peptide (PACAP), as inhibitors of TNFalpha. Both VIP and PACAP inhibit TNFalpha production from lipopolysaccharide-stimulated RAW 246.7 cells in a dose- and time-dependent manner. Because TNFalpha plays a central role in various inflammatory diseases such as endotoxic shock, multiple sclerosis, cerebral malaria, and various autoimmune conditions, the down-regulatory effect of VIP/PACAP may have a significant therapeutic potential. Delgado M, Munoz-Elias EJ, Kan Y, Gozes I, Fridkin M, Brenneman DE, Gomariz RP, Ganea D. "Vasoactive intestinal peptide and pituitary adenylate cyclase-activating polypeptide inhibit tumor necrosis factor alpha transcriptional activation by regulating nuclear factor-kB and cAMP response element-binding protein/c-Jun." J Biol Chem 1998 Nov 20;273(47):31427-36.

The vasoactive intestinal peptide (VIP) and the pituitary adenylate cyclase activating polypeptide (PACAP), two immunomodulatory neuropeptides that affect both innate and acquired immunity, downregulate TNFalpha expression in LPS-stimulated peritoneal macrophages and Raw 264.7 cells. It has been shown that VIP/PACAP change the composition of the CRE-binding complex in the TNFalpha promoter from highc-Jun/(low)CREB, characteristic for LPS-stimulated macrophages, to lowc-Jun/(high)CREB, characteristic for the unstimulated cells. Treatment with VIP or PACAP results in a decrease in AP-1 binding, and a marked change in the composition of the AP-1 complexes from c-Jun/c-Fos to JunB/c-Fos. Western blots confirm that VIP stimulates JunB production in LPS-stimulated macrophages. Both the inhibition of the MEKK1/MEK4/JNK pathway, leading to the reduction in phosphorylated c-Jun, and the stimulation of JunB, are mediated through the specific VPAC1 receptor and the cAMP/PKA pathway. The VIP/PACAP interference with the stress-induced SAPK/JNK pathway in stimulated macrophages may represent a significant element in the regulation of the inflammatory response by the endogenous neuropeptides. Delgado M, Ganea D.

"Vasoactive intestinal peptide and pituitary adenylate cyclase activating polypeptide inhibit the MEKK1/MEK4/JNK signaling pathway in LPS-stimulated macrophages." J Neuroimmunol 2000 Oct 2;110(1-2):97-105.

Heimler et al found that dioxin increases apoptotic cell death in a dose- and time-dependent fashion. Heimler I, Rawlins RG, Owen H, Hutz RJ. "Dioxin perturbs, in a dose- and time-dependent fashion, steroid secretion, and induces apoptosis of human luteinized granulosa cells." Endocrinology 1998 Oct;139(10):4373-9.

Endometriosis has been shown to occur after exposure to dioxin. Rier S, Foster WG. "Environmental dioxins and endometriosis." Toxicol Sci 2002 Dec;70(2):161-70.

Researchers studying women exposed to dioxin following a factory explosion in Italy, which caused the highest known population exposure to dioxin, found that there was a significant increase in the risk of developing endometriosis. Eskenazi B, Mocarelli P, Warner M, Samuels S, Vercellini P, Olive D, Needham LL, Patterson DG Jr, Brambilla P, Gavoni N, Casalini S, Panazza S, Turner W, Gerthoux PM. "Serum dioxin concentrations and endometriosis: a cohort study in Seveso, Italy." Environ Health Perspect 2002 Jul;110(7):629-34. Eskenazi B, Mocarelli P, Warner M, Samuels S, Vercellini P, Olive D, Needham L, Patterson D, Brambilla P.Seveso. "Women's Health Study: a study of the effects of 2,3,7,8-tetrachlorodibenzo-p-dioxin on reproductive health." Chemosphere 2000 May-Jun; 40(9-11): 1247-53.

Rier et al. found that there is a dioxin dose-dependent increase in the incidence and severity of endometriosis in the rhesus monkey. Rier SE. "The potential role of exposure to environmental toxicants in the pathophysiology of endometriosis." Ann N Y Acad Sci 2002 Mar;955:201-12; discussion 230-2, 396-406.

Concern has been expressed that rayon tampons contain dioxins as a result of chlorine bleaching and, further, that the dioxins in tampons may increase the risk of endometriosis. However, Sciall found that rayon tampons do not contain 2,3,7,8-tetrachlorodibenzo-p-dioxin and that there does not appear to be a link between tampons and endometriosis. Scialli AR. "Tampons, dioxins, and endometriosis." Reprod Toxicol 2001 May-Jun;15(3):231-8.

Studies performed by Rier et al suggest that immune mechanisms participate in dioxin-mediated toxicity and the pathogenesis of endometriosis. They found that rhesus monkeys exposed to dioxin had increased tumor necrosis factor-alpha (TNFalpha) secretion. Rier SE, Coe CL, Lemieux AM, Martin DC, Morris R, Lucier GW, Clark GC. "Increased tumor necrosis factor-alpha production by peripheral blood leukocytes from TCDD-exposed rhesus monkeys." Toxicol Sci 2001 Apr;60(2):327-37.

Bulun et al found that transcripts of dioxin receptor, its nuclear translocator, and two dioxin-induced target genes (CYP1A2 and CYP1B1) were demonstrated during follicular and luteal phases of the cycle in both eutopic endometrial tissues and tissues affected by pelvic endometriosis, with no readily detectable differences between these tissues. On the other hand, levels of transcripts of another dioxin-induced gene, CYP1A1, were found to be strikingly higher in endometriotic tissues than in the eutopic endometrium. Mean levels in endometriotic tissues were 8.7 times those found in eutopic endometrium. Various hormonal treatments of endometriotic stromal cells did not significantly alter these levels. They concluded that the expression of dioxin-related transcription factors aryl hydrocarbon receptor and aryl hydrocarbon receptor nuclear translocator protein and target genes CYP1A1, CYP1A2, and CYP1B1 in endometriotic tissues and stromal cells. Strikingly elevated CYP1A1 transcripts in endometriosis may give rise to significantly increased P-4501A1 enzyme activity and thus promote the development and growth of endometriosis by either activating procarcinogens or inducing the formation of catechol estrogens or both. In fact, the proposed link between dioxin exposure and endometriosis may be explained in part by the up-regulation of the CYP1A1 gene expression in endometriotic tissues. Bulun SE, Zeitoun KM, Kilic G. "Expression of dioxin-related transactivating factors and target genes in human eutopic endometrial and endometriotic tissues." Am J Obstet Gynecol 2000 Apr;182(4):767-75.

Environmental contaminants that are known to disrupt steroid action can influence the development of reproductive diseases. Bruner-Tran et al stated that dioxin can disrupt steroid regulation of endometrial matrix metalloproteinase (MMP) expression. The MMPs regulate extracellular matrix turnover in normal tissues, but the inappropriate expression of these enzymes is associated with numerous disease states that involve invasive processes. They had previously shown that secretion of MMPs by human endometrium is critical for establishment of ectopic lesions in a nude mouse model of experimental endometriosis. They also show that TCDD exposure promotes establishment of experimental endometriosis by interfering with the ability of progesterone to suppress endometrial MMP expression. Bruner-Tran KL, Rier SE, Eisenberg E, Osteen KG. "The potential role of environmental toxins in the pathophysiology of endometriosis." Gynecol Obstet Invest 1999;48 Suppl 1:45-56.

Eiserich et al showed that reaction of nitrite (NO2-), the autoxidation product of nitric oxide (NO) represent a previously unrecognized mediator of inflammation-mediated protein modification and tissue injury. Eiserich JP, Cross CE, Jones AD, Halliwell B, van der Vliet A. "Formation of nitrating and chlorinating species by reaction of nitrite with hypochlorous acid. A novel mechanism for nitric oxide-mediated protein modification." J Biol Chem 1996 Aug 9;271(32):19199-208.

S-nitrosothiols are biological metabolites of nitric oxide. It has often been suggested that they represent a more stable metabolite of nitric oxide that can either be stored, or transported. Hogg N. "The biochemistry and physiology of S-nitrosothiols." Annu Rev Pharmacol Toxicol 2002;42:585-600.

Nitric oxide (*NO) and nitrogen dioxide (*NO2) are hydrophobic gases. Therefore, lipid membranes and hydrophobic regions of proteins are potential sinks for these species. In these hydrophobic environments, reactive nitrogen species will exhibit different chemistry than in aqueous environments due to higher local concentrations and the lack of hydrolysis reactions. The peroxynitrite anion (ONOO-) and peroxynitrous acid (ONOOH) can freely pass through lipid membranes, making peroxynitrite-mediated reactions in a hydrophobic environment also of extreme relevance. The reactions observed by these reactive nitrogen species in a hydrophobic milieu include oxidation, nitration and even potent chain-breaking antioxidant reactions. Goss SP, Singh RJ, Hogg N, Kalyanaraman B. "Reactions of *NO, *NO2 and peroxynitrite in membranes: physiological implications." Free Radic Res 1999 Dec;31(6):597-606.

Khorram et al determined that in patients with endometriosis, expression of endometrial endothelial nitric oxide synthase (eNOS) protein was significantly increased in the glandular and luminal epithelium compared to patients without endometriosis. Khorram O, Lessey BA. "Alterations in expression of endometrial endothelial nitric oxide synthase and alpha(v)beta(3) integrin in women with endometriosis." Fertil Steril 2002 Oct;78(4):860-4.

Dong et al found that an increased peritoneal level of nitric oxide is a common alteration in endometriosis and endometriosis-associated infertility and may be associated with the pathogenesis of these diseases. Dong M, Shi Y, Cheng Q, Hao M. "Increased nitric oxide in peritoneal fluid from women with idiopathic infertility and endometriosis." J Reprod Med 2001 Oct;46(10):887-91.

Partial reduction of molecular oxygen can generate reactive oxygen species (ROS), including the hydrogen peroxide, and the free radicals superoxide and hydroxyl. The formation of ROS is a feature of many degenerative diseases. Free radicals are also involved in signal transduction pathways. For example, the free radical nitric oxide is involved in signal transduction in both the cardiovascular and central nervous systems. The interplay between nitric oxide and ROS has been a major focus of recent studies, as nitric oxide is an efficient radical scavenger. However, in some cases, such as in the formation of peroxynitrite from nitric oxide and superoxide, the product is potentially more deleterious that the parent radicals. Hogg N. "Free radicals in disease." Semin Reprod Endocrinol 1998;16(4):241-8. Darley-Usmar V, Halliwell B. "Blood radicals: reactive nitrogen species, reactive oxygen species, transition metal ions, and the vascular system." Pharm Res 1996 May;13(5):649-62.

Halliwell et al stated that free radicals and other reactive oxygen species (ROS) are constantly formed in the human body, often for useful metabolic purposes. Mild oxidative stress often induces antioxidant defense enzymes, but severe stress can cause oxidative damage to lipids, proteins, and DNA within cells, leading to such events as DNA strand breakage and disruption of calcium ion metabolism. Halliwell B, Cross CE. "Oxygen-derived species: their relation to human disease and environmental stress." Environ Health Perspect 1994 Dec;102 Suppl 10:5-12

Free radicals, such as superoxide, hydroxyl and nitric oxide, and other reactive oxygen species (ROS), such as hydrogen peroxide, are formed in vivo. Imbalance between production of ROS and anti-oxidant defense can result in oxidative stress, which may arise either from deficiencies of anti-oxidants (such as glutathione, ascorbate or alpha-tocopherol) and/or from increased formation of ROS. Oxidative stress can result in glutathione depletion, lipid peroxidation, membrane damage and DNA strand breaks as well as activation of proteases, nucleases and protein kinases. Some degree of oxidative stress occurs in most, if not all, human diseases. Halliwell B. "The role of oxygen radicals in human disease, with particular reference to the vascular system." Haemostasis 1993 Mar;23 Suppl 1:118-26.

Vascular endothelial cell apoptosis has previously been shown to play a role in the pathogenesis of hypertension-induced vessel deletion and damage. Hogg et al showed that oxidative stress significantly increased levels of apoptosis over control cultures and decreased levels of cell proliferation. Treatment with TGF-beta1 protein or SFM plus hypoxia induced greatest levels of apoptosis. Hogg N, Browning J, Howard T, Winterford C, Fitzpatrick D, Gobe G. "Apoptosis in vascular endothelial cells caused by serum deprivation, oxidative stress and transforming growth factor-beta." Endothelium 1999;7(1):35-49.

Oxidative stress is a disturbance in the balance between the production of reactive oxygen species (ROS) and antioxidant defenses. It occurs when excessive production of ROS overwhelms the antioxidant defense system or when there is a significant decrease or lack of antioxidant defenses. Oxidative stress, in turn, is known to cause DNA damage and mutations of tumor suppressor genes that are critical initial events in carcinogenesis. Interestingly, early findings of the studies suggest that environmental factors, such as high psychological stress and poor nutritional profile (eg, low antioxidant and high fat intake), increase ROS production. Kang DH. "Oxidative stress, DNA damage, and breast cancer." AACN Clin Issues 2002 Nov;13(4):540-9.

Kaada felt that the improved microcirculation of the skin was most likely caused by a sympatho-inhibition effectuated through a central serotoninergic link, since the response was blocked by the serotonin blocker cyproheptadine. In addition, the vasodilation was proportional to the increase in plasma VIP.

He stated that the mechanism of the relief of pain from wounds and ulcers was probably due to the vasodilation and endorphins, as well as, the release of ACTH and adrenocortical hormones caused by the electrical stimulation. Naloxone did not alter the vasodilatory effect or pain relief. He felt that this was due to an increase in VIP, which evidently affects the arterio-venous anastomoses. Kaada B "Systemic sclerosis: successful treatment of ulcerations, pain, Raynaud's phenomenon, calcinosis, and dysphagia by transcutaneous nerve stimulation. A case report." Acupunct Electrother Res. 1984;9(1):31-44. Kaada B "Vasodilation induced by transcutaneous nerve stimulation in peripheral ischemia (Raynaud's phenomenon and diabetic polyneuropathy). Eur Heart J. 1982 Aug;3(4):303-14. Kaada B, Lygren I "Lower plasma levels of some gastrointestinal peptides in Raynaud's disease. Influence of transcutaneous nerve stimulation." Gen Pharmacol.1985;16(2):153-6. VIP is not a blood-borne hormone. An increase in plasma VIP in the systemic circulation represents an overflow from synapses, caused either by an increased release or by a reduced degradation of the neuromodulator. An unexpected finding in these studies was that the resting values of plasma VIP were significantly (about 30%) lower in Raynaud and sclerodermic patients than in normal subjects. It has previously been suggested that one explanation could be that this lower plasma VIP concentration represents a defect in the VIP system in these patients and that it is a pathogenetic factor in the disease. Kaada, B "Successful treatment of esophageal dysmotility and Raynaud's phenomenon in systemic sclerosis and achalasia by transcutaneous nerve stimulation. Increase in plasma VIP concentration." Scand J Gastroenterol. 1987 Nov;22(9):1137-46.

Ollerenshaw et al stated that vasoactive intestinal polypeptide (VIP) is a neuropeptide present in the nerve fibers of normal lungs, where it acts to relax bronchial smooth muscle. They examined lung tissue obtained at autopsy or lobectomy from five patients with asthma and nine without asthma to determine its presence or absence in the lungs of patients with asthma. The avidin-biotin-peroxidase complex technique was used to stain tissue for immunoreactivity to VIP. At least 80 tissue sections from each patient were examined microscopically; the airway diameter ranged from 100 microns to 1.2 cm. Immunoreactive VIP was seen within nerves in more than 92 percent of the sections from the lungs of patients without asthma. No VIP was seen in any of 468 sections they could evaluate that were obtained from the lungs of patients with asthma. As a control for the nonspecific destruction of neuropeptides, immunostaining for substance P was also carried out. Abundant amounts of this neuropeptide were seen within nerves in tissue from the lungs of all patients. They concluded that in patients with asthma there is a loss of VIP from the pulmonary nerve fibers that may diminish neurogenically mediated bronchodilation. Ollerenshaw S, Jarvis D, Woolcock A, Sullivan C, Scheibner T. "Absence of immunoreactive vasoactive intestinal polypeptide in tissue from the lungs of patients with asthma." N Engl J Med 1989 May 11;320(19):1244-8.