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Estrogen and progesterone regulate secretion of insulin-like growth factor binding proteins by human breast cancer cells.

We examined the effects of estradiol and progesterone agonist, promegestone (R5020), on secretion of insulin-like growth factors (IGF) and binding proteins (IGFBPs) by T-47D human breast cancer cells cultured in a serum-free defined medium. Estrogen, IGF-I and IGF-II promoted and R5020 inhibited growth under these conditions. Cells secreted IGFs and four IGFBPs. The amounts of all IGFBPs in cell-conditioned media were increased by estradiol and reduced by R5020, which also abolished the stimulatory effect of estradiol on IGFBPs without inducing an IGFBP protease. Therefore estrogen and progesterone may alter growth of breast cancers by regulating tumour secretion of IGFBPs and hence change carcinoma responsiveness to IGFs.

Breast Neoplasms↗

Early glycogenesis in the uterine glandular cells of the rabbit induced by progestins: a quantitative investigation.

A single administration of progesterone (P) to primed immature rabbits induces the appearance of glycogen in uterine glandular cells. This phenomenon, which is rapid and transitory, precedes a mitotic surge in the glandular epithelium. Ultrastructural studies allowed us to observe the beginning of glycogenesis as early as 1 h after the injection of P. Quantitative image analysis in the course of a kinetic study showed that glycogen levels reached a maximum at the sixth h and after 24 h had fallen dramatically. Promegestone, a potent progestomimetic compound, gave similar results, but estradiol, testosterone and dexamethasone failed to induce the appearance of glycogen in the uterine glands. Mifepristone (RU 486) had an antagonistic effect on the action of P. These results suggest that early P-dependent glycogenesis in the endometrial glandular cells of the rabbit may play an important role in the increased rate of mitosis and cellular proliferation that are necessary events in preparing the endometrium for implantation.

Animals↗

A prospective two-year study of progestin given alone in postmenopausal women: effect on lipid and metabolic parameters.

OBJECTIVE: A controlled study was conducted to assess the long-term effect of a progestin with very low androgenic potency given alone on serum lipoprotein profile, serum renin substrate, sex hormone-binding globulin levels, and serum antithrombin III activity in early postmenopausal women. STUDY DESIGN: Thirty-five early postmenopausal women who had not received any form of hormonal treatment after menopause were randomly assigned to a 2-year regimen of 500 micrograms of a progestin derived from 19-norprogesterone (promegestone) or a placebo for 21 days of a 28-day treatment cycle. Serum lipid and lipoprotein levels and other biochemical parameters were measured in the two groups, and differences were sought by statistical analysis. RESULTS: After 2 years of treatment the women in the two groups showed no statistically significant variation from baseline values in the concentrations of any of the biochemical parameters studied. CONCLUSIONS: The results show that a progestin with very low androgenic activity given alone has no influence on lipid profile and hepatic synthesis of several proteins in early postmenopausal women.

Antithrombin III↗

Effect of photoaffinity labeling on rabbit uterine progesterone receptor.

Photoaffinity labeling with [17 alpha-methyl-3H]promegestone ([ 3H]R5020) is an effective technique for the covalent labeling of the progesterone receptor (PR), which allows monitoring of the steroid receptor complex under denaturing conditions. The present study was initiated to evaluate whether photolabeled PR could be used also as a marker for PR under nondenaturing conditions. Accordingly, the effect of irradiation on each component of the reaction was evaluated separately. When [3H]R5020 alone was irradiated, there was a rapid (less than 5 min), light dependent destruction of [3H]R5020, as evident from increased formation of a more polar tritiated product on TLC and a concomitant decrease in the ability of the irradiated preparation to bind to PR. When rabbit uterine PR was irradiated in the absence of steroid, a gradual decrease in the binding capacity was observed, reaching 70% of the nonirradiated control in 10 min. The optimal irradiation time for covalent [3H]R5020-PR complex formation was determined by irradiation for up to 5 min, and separation of the products by sodium dodecylsulfate (SDS)-polyacrylamide gel electrophoresis. Specific labeling of proteins of Mr 116,000 and 85,000 was observed, with the rate of labeling of the two being similar, and reaching a plateau by 4 min of irradiation. The photolabeling efficiency ranged from 2 to 12%. Sucrose gradient ultracentrifugation of photolabeled PR revealed that both the irradiated sample and the nonirradiated control sedimented to the same position. Subsequent SDS-polyacrylamide gel electrophoresis of the sucrose gradient peak from the photolabeled sample showed the presence of both labeled proteins of Mr 116,000 and 85,000. In addition, photolabeled rabbit uterine PR (Mr 116,000 and 85,000) could be immunoprecipitated with a guinea pig antiserum raised against rabbit uterine PR. Analysis of the photoaffinity labeling procedure in our system revealed that the photodestruction of [3H]R5020 was very rapid. However, maximal labeling with [3H]R5020 was obtainable with minimal photodestruction of PR which suggests that photolabeled receptor can be used as a marker for PR under nondenaturing conditions.

Affinity Labels↗

Estrogen-sensitive progestin-binding sites in the female rat brain and pituitary.

The following properties of the cytoplasmic progestin receptor were studied in the hypothalamus, cortex, pituitary and uterus of the estrogen-primed castrated adult female rat using the highly potent progestin R 5020 (promegestone). (a) Sedimentation pattern. In sucrose density gradients, the R 5020-progestin receptor complex sedimented with a coefficient of about 6 to 7S. (b) Binding parameters. R 5020 bound to the progestin receptor with an intrinsic dissociation constant of about 10(-9) M as measured by a Dextran-coated charcoal (DCC) technique. The number of binding sites, however, differed widely. (c) Specificity. Only progestins competed for [3H]R 5020 binding. (d) Estrogen-dependency. In both immature and castrated adult rats, estrogen administration increased the number of R 5020-specific binding sites, assayed in vitro by a DCC technique, in the uterus, pituitary and hypothalamus, but not in the amygdala, hippocampus nor in the cortex. The increase was maximum between 40 and 48 h after priming with the potent estrogen, moxestrol, and could not be induced by androgens nor by progestins.

Adrenalectomy↗

Characterization of 7-8S progestin binding protein in human prostate using vertical tube rotor.

The specific binding of the synthetic progestin, 17 alpha-methyl[3H]promegestone (R5020), to the cytosol of human benign hyperplastic prostate has been studied in sucrose density gradients using a vertical tube rotor. The cytosol of human prostate was shown to contain substantial amounts of a 7-8S macromolecule with a high affinity (Kd = 0.5-1 nM) for R5020 which is saturated at low concentrations (10 nM). The conventional technique of sucrose density gradient analysis in a swinging bucket rotor was not suitable for reproducible optimal analysis of a 7-8S high affinity complex. The use of the salt, Na2MoO4, had a stabilizing effect on the complex. Comparison of saturation analysis assays using dextran charcoal assay and vertical tube rotor assay showed that the charcoal assay can give an over-estimation of the 7-8S saturable binding. Progestational steroids competed with R5020 for binding to 7-8S, whereas androgenic steroids, with the exception of 19-nor-testosterone, did not compete. Incubation of cytosol at elevated temperatures in the presence of DNA-cellulose resulted in the binding of the hormone-protein complex to DNA-cellulose. High ionic strength buffer was required to extract the complex which sedimented at 4.5S in sucrose gradients prepared in 0.4 M KCl. Based on the data presented, progestin binding in human prostate is clearly similar in physical chemical properties to progesterone receptors in "classical" target tissues. However, rapid sucrose gradient analysis with a vertical tube rotor is preferred over conventional techniques to evaluate progestin receptor binding in human prostate.

Cellulose↗

Sucrose density gradient centrifugation of human myometrial and myomal progestin receptors.

Progestin receptors present in cytosols of myomal and myometrial origin were analyzed on sucrose density gradients of low ionic strength using a vertical tube rotor. Short term incubations (90 min) contained mainly 8S receptors. Most myometrial but few myomal preparations contained an additional 4S component, the presence of which was hormone dependent. None could be detected if the serum concentration of estradiol was high. Myometrial receptors incubated over night exhibited only a 4S peak, whereas many myomal ones still sedimented as 8S peaks. The 8 to 4S shift represented a transformation of the receptors and not a sequential interaction of the hormone with first an 8S and then a 4S entity. The transforming activity contained in the myometrial cytosol could also attack the myomal receptor as shown by mixing experiments. Only the 8S peak was observed, whenever the cytosol was first fractionated and then incubated with the hormone. Thus the transformation occurred only in presence of [3H]promegestone. It could be suppressed with protease inhibitors. It is concluded that these tissues contain a receptor processing protease which (1) is much less prominent in myomal than myometrial cytosol, which (2) attacks only the occupied receptors, and (3) the activity of which is hormone dependent.

Centrifugation, Density Gradient↗

Characterization of estrogen-induced progestin binding in cytosol of the R3327 prostatic carcinoma of the rat.

High affinity binding of the synthetic steroids methyltrienolone (R1881) and promegestone (R5020) to cytosol protein from the Dunning (R3327) experimental prostatic carcinoma of the rat was investigated. Animals bearing tumours of approx 1.5 cm mean diameter were either left untreated, or were administered diethylstilbestrol diphosphate (DESP) in the drinking water in doses close to those used clinically for the treatment of human prostatic carcinoma. Tumours were excised after 10-40 days, and binding of [3H]R1881 and [3H]R5020 to tumour cytosol was characterized using Scatchard analysis, sucrose density gradient centrifugation, and steroid competition, under conditions optimal for the conservation and assay of progesterone receptor. Both ligands were bound in much higher concentrations by cytosol from DESP-treated tumours than from untreated tumours. Binding was of high affinity (Kd congruent to 1 nM), was specific for progestins, and sedimented in peaks at approximately 8S and approximately 4S in sucrose density gradients. We conclude the DESP treatment of rats bearing the R3327 prostatic carcinoma induces synthesis of progesterone receptor in this tumour.

Adenocarcinoma↗

Evidence for a Leydig cell progesterone receptor in the rat.

Tritiated promegestone [3H] R 5020 is bound with high affinity by charcoal-treated cytosol prepared from purified Leydig cells. The binding is characterized by high affinity (Kd = 2 x 10(-9) M) and specificity (R 5020 = progesterone greater than testosterone = dehydrotestosterone greater than hydroxyprogesterone greater than cortisol = dexamethasone greater than estradiol) appropriate for progesterone receptors. In vitro, progestin-bound cytosol was quantitatively translocated to nuclei fractions, only if cytosol samples were previously labeled at 25 degrees C. However no translocation of binding activity was observed when previous cytosol labeling was done in the presence of sodium molybdate. Effects of glucocorticoids, androgens and estrogens on the Leydig cell are well documented, the demonstration of a putative progesterone receptor raises the possibility of direct effect of progesterone on the Leydig cell.

Animals↗

Presence of progesterone receptors and absence of oestrogen receptors in human intracranial meningioma cytosols.

The occurrence of oestrogen and progestin receptors in cytosols from human intracranial meningiomas was studied with a dextran-coated charcoal assay and Scatchard plot analysis. [3H]-Oestradiol and [3H]-promegestone (17 alpha, 21-dimethyl-19-norpregna-4,9-diene-3,20-dione, R-5020) were used as tracers. Using this method, no high-affinity binding sites for oestradiol were observed, whereas progestin binding was identified in 18 out of 20 meningioma cytosols. The number of progestin binding sites was identical in meningioma cytosols obtained from female patients (192 +/- 57 fmol/mg protein, mean +/- S.E.M., n = 12) and those obtained from male patients (230 +/- 57 fmol/mg protein, n = 6), as was the dissociation constant of the complex (1.5 +/- 0.3 vs 1.4 +/- 0.3 nmol/l respectively). Only progestins (progesterone, R-5020 and megestrol acetate) competed successfully with tritiated R-5020. Oestrogens, androgens and cortisol showed no appreciable cross-reaction. It was concluded that the cytosols from human intracranial meningiomas contain progesterone receptors in the absence of oestrogen receptors. The presence of these progesterone receptors may indicate that (anti)-progestational treatment could be of potential value in cases which cannot be treated by surgery alone.

Adult↗

Target tissue uptake selectivity of three fluorine-substituted progestins: potential imaging agents for receptor-positive breast tumors.

We have studied three new fluorine-substituted progestins (1-3) as potential imaging agents for progesterone receptor (PgR)-positive human breast tumors. Two of these are fluorine-substituted analogs of the potent progestin R5020 (promegestone), derived from (21S)-hydroxy R 5020 (RU 27987) and (21R)-hydroxy R 5020 (RU 27988), known metabolites of R 5020, which have affinities for PgR that are 116 and 4%, respectively (relative to R 5020 = 100%). These precursors were protected as their 3,3-dioxolane derivatives and converted to the 21-trifluoromethanesulfonate derivatives. Fluoride ion displacement, followed by acid-catalyzed deprotection, furnished in good yield the epimeric fluoroanalogs, (21S)- and (21R)-fluro R 5020 (1 and 2, affinities for PgR, 11 and 45%, respectively). These compounds were also prepared in 18F labeled form by the same route, in 14-32% overall radiochemical yield (decay corrected; synthesis time 90 min; sp. act. 370-1060 Ci/mmol). In tissue distribution studies in estrogen-primed immature rats, uterus-to-muscle ratios were 4.3 at 1 h for the 21S-epimer and 1.1 for the 21R-epimer, paralleling their relative binding affinities. Considerable metabolic defluorination was observed. The third fluorine-substituted progestin, DU 41165, has a novel retroprogesterone (9 beta, 10 alpha) structure, substituted with fluorine at C-6; its binding affinity is 145% relative to R 5020, and it was prepared in tritium-labeled form by acetylation of DU 41231, the 17 alpha-hydroxy precursor, with [3H]acetic anhydride. In estrogen-primed immature rats, this compound shows uterus-to-muscle ratios of 15 at 1 h, and 18-71 between 2 and 6 h, suggesting that compounds in this retroprogesterone series may be very promising candidates for selective imaging of PgR-positive tissues and tumors.

Animals↗

Immunocytochemical determination of estrogen and progesterone receptors in human endometrial adenocarcinoma cells (Ishikawa cells).

The regulation of both estrogen and progesterone receptor levels in human endometrial adenocarcinoma cells of the Ishikawa line was investigated immunocytochemically by using monoclonal antibodies. Positive staining for estrogen and progesterone receptors was observed in the nuclei of Ishikawa cells. Intercellular heterogeneity in receptor content was evident from the presence of receptor-positive or -negative cells and from differences in staining intensity of positive cells. Quantitative analysis was performed by scoring the staining intensity and the proportion of positively stained cells. The time and dose-dependent stimulatory effect of estradiol added to culture media on progesterone receptor levels was studied by applying both immunocytochemical and biochemical methods. Estradiol at 10 nM (optimal concentration) increased the intensity score for PR from an initial value of 10.1 to 78.3 after 72 h incubation, and the proportion of the positive staining cells from 6.7 to 42.7%. Promegestone (R5020) was effective at 1 microM concentration in decreasing the intensity score for ER from 31.1 to 14.6 after 72 h exposure and the proportion of positive cells from 19.0 to 11.4%.

Adenocarcinoma↗

Inhibition by nomegestrol acetate and other synthetic progestins on proliferation and progesterone receptor content of T47-D human breast cancer cells.

Progesterone receptors (PgR) of human breast cancer T47-D cells grown in an estrogenic environment (presence of phenol red, natural estrogens of foetal calf serum and insulin) were found to be present in considerable amounts (1-3 pmol/mg protein and 20 pmol/mg DNA), and to specifically bind progestins with a high affinity characterized by a Kd around 3 nM for ORG2058, and 4 nM for nomegestrol acetate (NOM; 17 alpha-acetoxy-6-methyl-19-nor-pregna-4,6-diene-3, 20-dione), when measured under equilibrium conditions. Both compounds formed an highly stable ligand-receptor complex with a dissociation constant (k-1) around 1 x 10(-5) s-1. At high pharmacological concentrations, NOM, ORG2058 and other synthetic progestins including promegestone (R5020), medroxy-progesterone acetate and norethindrone acetate (NOR), induced a dose-dependent inhibition of cell proliferation as measured by [3H]thymidine incorporation. Dexamethasone, which did not bind to PgR, did not reproduce this inhibitory effect. NOM, R5020 and NOR treatments of T47-D cells at concentrations around Kd resulted in an 80% decrease in PgR content. Our data on NOM as compared to other progestins are consistent with their antiproliferative effects on human breast cancer cells grown in estrogenic conditions.

Breast Neoplasms↗

Endometrial integrin expression is independent of estrogen or progestin treatment in vitro.

OBJECTIVE: To examine the regulation of endometrial integrin expression by estrogens and progestins in vitro. DESIGN: Immunocytochemical study. SETTING: Academic research unit. PATIENT(S): Twenty-five regularly cycling women without endometrial pathology, of whom seven had endometriosis. INTERVENTION(S): Endometrial cells obtained by aspiration curettage were treated with diethylstilbestrol, promegestone, and antiprogestin. Immunocytochemistry was performed with antibodies directed against integrins alpha 1 beta 1, alpha 2 beta 1, alpha 4 beta 1, alpha 5 beta 1, alpha v beta 3, and beta 3 integrin subunit. MAIN OUTCOME MEASURE(S): Semiquantitative staining score. RESULT(S): Endometrial cells express several integrins in vitro in a consistent and cell specific pattern. Neither differences between treated and untreated cells nor an effect of treatment duration or dosage were observed. Cells from patients with and without endometriosis showed similar patterns. CONCLUSION(S): The cellular distribution of integrin expression was similar to that described in vivo. In contrast, a steroid regulated expression could not be detected in vitro. Rather, a derepression by a factor not included in our model could be responsible for the cyclic appearance of some integrins. In endometriosis, no fundamental difference of integrin expression was detected.

Cells, Cultured↗

Zinc concentration and progestin receptor in human benign hyperplastic prostate.

The effect of cationic zinc on the specific binding of the synthetic progestin, promegestone (17 alpha-21-dimethyl-19-nor-pregna-4,9-diene-3,20-dione, R5020), has been investigated in cytosols from human benign hyperplastic prostate. Zinc was analyzed using flameless atomic absorption spectrometry. Progestin specific binding was assayed using sucrose density gradient centrifugation in a vertical tube rotor. The concentration of endogenous zinc in benign hyperplastic prostate cytosols was 0.53 mM +/- 0.26 (range 0.15 mM to 0.88 mM). No significant relationship was observed between zinc concentration in cytosols and the amount of progestin specific binding in the 7-8S peak in sucrose density gradients. Addition of excess zinc to cytosols (1.6 mM) in the presence or absence of monothioglycerol had no effect on the total amount of 7-8S progestin specific binding observed. Removal of free zinc by gel filtration of cytosols on Sephadex G-25 did not change the amount of 7-8S cytosolic receptor binding observed. The addition of the chelating agents, 2,2',2''-tripyridine, 9,10-phenanthroline or EGTA, after the gel filtration step had no apparent effect on the 7-8S progestin specific binding. The anionic chelator, EDTA, inhibited the 7-8S specific binding in a dose dependent manner. However, this inhibition was not reversed by the addition of excess zinc (6 mM) and was observed at very high concentrations of EDTA. This suggests that the effect of EDTA was due to its anionic effect rather than to its effect as a chelator. We conclude that cationic zinc in concentrations up to 2 mM does not change the amount of 7-8S progestin specific receptor binding in cytosols from BPH tissue.

Chelating Agents↗

Progesterone receptor is not required for progesterone action in the rat corpus luteum of pregnancy.

In this study, we investigated whether progesterone exerts a local action regulating the function of the corpus luteum of pregnancy in rats. The luteal activities of the enzymes 3beta-hydroxysteroid dehydrogenase (3beta-HSD), involved in progesterone biosynthesis, and 20alpha-hydroxysteroid dehydrogenase (20alpha-HSD), that catabolizes progesterone and reduces progesterone secretion by the corpus luteum, were evaluated after intrabursal ovarian administration of progesterone in pregnant rats that had received a luteolytic dose of prostaglandin F2alpha (PGF2alpha). Luteal 3beta-HSD activity decreased and 20alpha-HSD activity increased after PGF2alpha treatment (100 microg x 2 intraperitoneally on Day 19 of pregnancy at 12:00 p.m. and 4:00 p.m.) when compared with controls sacrificed at 8:00 p.m. on Day 20 of pregnancy. This effect of PGF2alpha on the luteal 3beta-HSD and 20alpha-HSD activities was abolished in animals that also received an intraovarian dose of progesterone (3 microg/ovary on Day 19 of pregnancy at 8:00-9:00 a.m.). In a second functional study, luteal cells obtained from 19-day pregnant rats responded to the synthetic progestin promegestone (R5020) in a dose-dependent manner, with an increase in the progesterone output. In addition, the glucocorticoid agent hydrocortisone did not affect progesterone accumulation in the same luteal cell culture. We also examined by immunocytochemistry the expression of progesterone receptors (PR) in the corpora lutea during pregnancy and demonstrated the absence of PR in this endocrine gland in all the days of pregnancy studied. In the same pregnant rats, positive staining for PR was observed in cells within the uteroplacental unit, such as cells of the decidua basalis and trophoblast giant cells of the junctional zone. In addition, positive PR staining was observed in the ovarian granulosa and theca cells of growing follicles, but not in corpora lutea of ovaries obtained from cycling rats at proestrus. In summary, this report provides further evidence of a local action of progesterone regulating luteal function in the rat despite the absence of a classic PR.

20-Hydroxysteroid Dehydrogenases↗

Photoaffinity labelling of the human mineralocorticoid receptor with steroids having a reactive group at position 3, 18 or 21.

The ability of a glucocorticoid (triamcinolone acetonide: TA) and three progesterone derivatives with photoreactive groups at different positions (promegestone: R5020; 18-oxo-18-vinylprogesterone: 18OVP; 21-diazoprogesterone: 21DP) to bind covalently to the human mineralocorticoid receptor (hMR) expressed in Sf9 insect cells was assessed. Sedimentation gradient analysis and exchange assays with aldosterone showed that [3H]TA, a partial mineralocorticoid agonist, and [3H]R5020, a pure antimineralocorticoid, were covalently bound to hMR after UV irradiation, with a labelling efficiency of approx. 3-5%. UV irradiation did not alter the heterooligomeric structure of the hMR, since the irradiated [3H]TA- and [3H]R5020-hMR complexes sedimented at approx. 9-10 S, as did the non-irradiated complexes. Sodium dodecyl sulphate-polyacrylamide gel electrophoresis revealed a band labelled by [3H]TA or [3H]R5020, having a molecular mass of 120 kDa. This band was not detected in the presence of an excess of the corresponding unlabelled steroid or when the cytosol was recovered from non-infected Sf9 cells. Electrophoresis of a truncated hMR (hMRDelta(1-351)) photolabelled with [3H]TA revealed a 80 kDa band, compatible with the molecular mass of the truncated hMR. Limited chymotrypsin proteolysis of the [3H]TA photolabelled hMR generated a 30 kDa fragment covalently associated with [3H]TA. As the 30 kDa fragment generated by chymotrypsin has been shown to encompass the entire ligand-binding domain of the hMR (B. Couette, J. Fagart, S. Jalaguier, M. Lombès, A. Souque, M.E. Rafestin-Oblin, Biochem. J. 315 (1996) 421-427), the present experiments provide evidence that [3H]TA is covalently bound to the ligand binding domain of the hMR. Exchange assays with [3H]A also revealed that unlabelled 18OVP and 21DP, two mineralocorticoid agonists bearing photoreactive groups at skeleton positions crucial for the ligand-MR interaction, are covalently bound to hMR with an approx. 30-35% labelling efficiency.

Animals↗

Regulation of matrix metalloproteinases and their inhibitors in uterine endometrial cells of patients with and without endometriosis.

OBJECTIVE: To determine whether alterations in the secretion and regulation of matrix metalloproteinases (MMPs) and their inhibitors are present in uterine endometrial cells from endometriosis patients. STUDY DESIGN: In an in vitro study, uterine endometrial cells from 19 regularly cycling women with and 32 without endometriosis were treated with diethyl stilbestrol, promegestone (R5020), interleukin-1 (IL-1) and tumor necrosis factor a (TNF-alpha). Culture supernatants were assayed for MMPs 1, 2, 3, and 9, and for tissue inhibitors of MMP (TIMP-1 and TIMP-2) by ELISA. RESULTS: MMP-3 was secreted in high concentrations, moderate concentrations were seen for MMP-1 and MMP-2, and very low concentrations for MMP-9. Substantially more TIMP-1 than TIMP-2 was secreted. MMP-1 and MMP-3 were uniformly attenuated by R5020, while MMP-2 was not influenced by hormone treatment. MMP-3 was upregulated by TNF-alpha in all samples while IL-1 only increased secretion in cells from endometriosis patients. CONCLUSION: The upregulation of MMP-3 by IL-1 may contribute to an increased invasiveness of uterine endometrial fragments in endometriosis patients.

Adult↗