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INTRODUCTION: Heavy menstrual bleeding (HMB) is a common, chronic, debilitating and often underreported condition affecting at least 1 in 4 women of reproductive age. There is an unmet for managing the symptom of HMB. Selective Progesterone Receptor Modulators (SPRMs) are a class of drugs that interact with the progesterone receptor (PR) in a mixed agonist and antagonist fashion and may present an alternate medical solution. However, there is limited evidence examining the endometrial impact of SPRMs, their mechanism of action at a molecular and cellular level and the reversibility of the molecular signature of these drugs. This study examined the effect of two SPRMs on the human endometrium: Ulipristal acetate (UPA) and Vilaprisan (VPR). Studies presented in this thesis propose the overarching hypotheses that SPRMs would alter the structure and function of the endometrium and that the endometrial impact would be reversible on discontinuation of the drug. MATERIALS AND METHODS: Ulipristal acetate (UPA): Endometrial biopsies (n=46) were available from 16 participants with HMB (with and without benign structural uterine abnormalities) in an embedded mechanism of action component of a large multicentre study, the UCON trial (EudraCT 2014-003408-65; REC14/LO/1602). Endometrial biopsies were obtained before UPA treatment, at six months of UPA treatment, and at the end of UPA treatment following a withdrawal bleed (twelve months). Reverse transcription quantitative real time polymerase chain reaction (RTqPCR), immunohistochemistry (IHC) and digital image analysis (DIA) using Qupath were undertaken. Vilaprisan (VPR): From 4 women with HMB and associated fibroids, where eight endometrial biopsies (fresh frozen endometrium) were utilised from the BAYER 15791 clinical trial (EudraCT Number: 2017-000468-13). Participants received treatment with VPR 2 milligrams once daily (OD) for 8-12 weeks. The participants had 2 endometrial biopsies performed (one pre-treatment and one on VPR treatment). From 13 women with HMB and associated fibroids who were recruited as a part of the ASTEROID 6 (EudraCT Number: 2016-004822-41) study. Participants received treatment with VPR 2 milligrams OD for a duration of > 12 weeks. Participants had 2 endometrial biopsies performed (one pre-treatment and one on VPR treatment). RNA for the experiment was obtained from Formalin-Fixed Paraffin-Embedded (FFPE) blocks. In addition to RTqPCR, IHC and DIA using Qupath were also performed specifically for Ki67. Lexogen QuantSeq 3” mRNA sequencing method was used for RNA sequencing followed by detailed bioinformatic analyses using the Ingenuity Pathway Analysis (IPA). For both SPRM studies, statistical analysis was undertaken using GraphPad Prism 8.0. p |
