17-HYDROXYSTEROID DEHIDROGENASE (17BHSD) TYPE 2 EXPRESSION

IN ENDOMETRIOSIS TISSUE

Sinuhaji AO, Siregar HS, Sidabutar ER, Lintang LS, Tala RZ, Adella CA
Fertility and Endocrinology Reproduction - The Department Obstetrics and Gynecology
Faculty of Medicine, University of Sumatera Utara
Medan, Indonesia, June 2015

ABSTRACT

Objective: To determine differences in the expression of type 2 17HSD between ectopic

endometrial tissue of endometriosis patients compared to normal endometrial tissue.
Methods: This study is an analytic study using case control study which examined
immunohistochemistry on paraffin tissue blocks endometriosis and paraffin blocks of normal
endometrial tissue to look at differences in the expression of 17HSD type 2. The study was
conducted at the Department of Obstetrics and Gynecology Hospital. H. Adam Malik Medan.
Immunohistochemical examination conducted by the Department of Pathology Hospital. H.
Adam Malik Medan from June to July 2015. The research sample consisted of two groups:
one group of paraffin blocks that had previously been diagnosed as endometriosis that meet
the inclusion and exclusion criteria. This research will use the samples for each group of 20
people.
Results: In the endometriosis group found expression intensity 17HSD type 2 more with a
negative score by the number of 12 people (60%), followed by a score of +1 to the number of
8 (40%), and no score +2 and +3. Where as in normal endometrium group found expression
intensity 17HSD more type 2 with a score of +3 with the number 14 (70%), followed by a
score of +2 the number 6 (30%) and negative score and +1 was not found. Based on
statistical test with Fisher's Exact test p value of 0.018 (p <0.05), which means there is a
significant difference between the intensity values 17HSD expression of type 2
endometriosis tissue with normal endometrial tissue.
17HSD intensity of expression of type 2 with a negative score more in stage IV
endometriosis with the number 5 (41.7%), followed by stage II with the number 4 (33.3%)
and stage III with an amount of 3 (25%). While the intensity of expression 17HSD type 2
with a score of +1 more on endometriosis stage III with number 6 (75%), followed by the
number 1 stage IV (12.5%) and stage II with the number 1 (12.5%). Statistically by Fisher's
Exact test p value 0.88 (p> 0.05), which means there is no significant difference in the
expression intensity values 17HSD type 2 on the network based on the stage of
endometriosis endometriosis.
Conclusion: There are differences in the expression of type 2 17HSD endometriosis tissue
compared to normal endometrium of endometriosis where the intensity of expression
17HSD type 2 lower compared with normal endometrium. The results support the theory
that the enzyme 17HSD endometriosis pathogenesis of type 2 decreased in endometriosis.
There is no significant relationship between the intensity of expression 17HSD type 2 based
on the stage of endometriosis.
Keyword: Endometriosis, 17HSD type 2, Immunohistochemistry.
Introduction
Endometriosis is one of the gynecology benign diseases that many get the attention of
experts. Developed countries and developing countries have done a lot of research on
endometriosis, but until now the cause and pathogenesis is not known for sure. But in one
way the experts agree that the growth of endometriosis is strongly influenced by steroid
hormones, especially estrogen. Most experts agree that pelvic pain, menstrual pain and
infertility are closely related to endometriosis.1
Endometriosis was first published in 1800 but until now the disorder is not fully
understood. Many hypotheses have been suggested about the pathogenesis of endometriosis,
but John Sampson's 1921 hypothesis of retrograde menstruation that led to the inclusion of
endometriotic tissue outside the uterine cavity is still widely accepted with all the debate.
However, other factors such as genetic factors, immunological storage as well as local
peritoneal factors are involved in the pathogenesis of endometriosis.2,3,4
Based on laboratory evidence indicates that endometriosis is an estrogen-dependent
disease. Estrogen formation of steroids C19 is catalyzed by aromatase P450, which is found
to increase in stromal cells and endometriosis tissue but not increase in normal endometrium.
Based on this the idea arises that the estrogen structure plays a role in the development and
growth of endometriosis implantation. The C19 primary substrate for aromatase in
extraglandular tissue such as fatty tissue and endometriosis tissue circulating androstenedione
is converted to estrone. Estrone is a weak estrogen. By 17-Hydroxysteroid Dehydrogenase
(17HSD) type 1 estrone was converted to a powerful estrogen of 17 estradiol. 17HSD
type 2 catalyzes the change of 17 estradiol to estrone and testosterone to androstenedione.
Progesterone has a role in stimulating the enzyme 17HSD type 2.5,6,7,8
The 17HSD enzyme is an enzyme that plays a role in regulating the biological
potential of steroid hormones in terms of oxidation and reduction catalyzing. 17HSD type 2
plays a role in the inactivation of female steroid sex such as catalyzing the change of strong
estradiol to weak estrone. 17HSD type 2 is produced by the endometrium and governed by
progesterone. Endometriosis is an estrogen-dependent disease, abnormalities of action or
production of steroids have a role in the pathophysiology of endometriosis. The absence of
production or deficiency of 17HSD type 2 causes high estrogen levels that play a role in the
development and survival of endometriosis implantation.7,8,9,10,11
Based on research conducted by Carneiro M.Met al (2007), there was a significant
difference in the expression of 17HSD type 2 in endometriosis compared with normal
endometrium in the uterine cavity. Serdan et al (2010) also conducted a study with the result
of a decrease of 17HSD type 2 in endometriosis tissue compared with normal
endometrium.12

Method
This study was an analytical study using case control design where
immunohistochemical examination of endometriosis tissue paraffin block and paraffin
normal endometrial tissue block to see difference of expression of 17HSD type 2.
The study was conducted in the Department of Obstetrics and Gynecology RSUP. H.
Adam Malik Medan. Immunohistochemical examination performed by Department of
Anatomical Pathology RSUP. H. Adam Malik Medan from June to July 2015.
The case study subjects were paraffin endometriektopic tissue block in endometriosis
patients obtained from laparotomy or laparoscopic action. While the subjects of the control
group study were paraffin blocks of normal endometrial tissue, derived from curettage or
hysterectomy.
After obtaining approval from the ethical commission to conduct the study, the study
began by collecting data from histopathologic patients who had been examined for
histopathology and diagnosed as endometriosis (according to inclusion and exclusion
criteria). While the control group was taken from the histopathology data of the PA
department on the patients who performed curettage or hysterectomy.
The results of this study are presented in the frequency distribution table. To analyze
the difference of 2 observer accuracy is calculated kappa value and valid if value obtained>
75% meaning not found significant difference between observer observation, while
correlation between variable is done Fisher exact statistic test with degree of confidence 95%
(p <0,05 ).

Results and Discussion

This study used a sample of cases of endometriosis and endometrium each of 20
people.
Table 1 Distribution of subject characteristics by age and parity.
Subject
Characteristics Endometriosis Normal Total

Endometrium
N % n %
Age (year)
< 30 1 5 2 10 3
30-40 10 50 8 40 18
>40 9 45 10 50 19

Parity
0 15 75 6 30 21
1-3 5 25 10 50 15
4 0 0 4 20 4

The table shows that the age characteristics of the study subjects in the endometriosis
group were greater than the age of 30-40 years as many as 10 people (50%) , followed by age
over 40 years as many as 9 people (45%) and lowest age under 30 years as many as 1 person
(5%). While in the normal endometrial group more than 40 years old as many as 10 people
(50%), followed by age 30-40 years as many as 8 people (40%), and the lowest age under 30
years as many as 2 people (10%).
Based on the parity characteristics of the subjects, the endometriosis group was higher
with parity of 0, 15 people (75%), followed by parity 1-3 for 5 people (25%), and not found
in parity 4 (0%). While in the normal endometrial group more with 1-3 parity as many as
10 people (50%), followed by parity 0 of 6 people (30%), and the lowest parity 4 as many
as 4 people (20%).

Table 2. Distribution of frequency based on endometriosis stage.

Stage Endometriosis
N %
I 0 0
II 5 25
III 9 45
 IV 6 30

Based on the table found 9 stage endometriosis III (45%), endometriosis stage IV as
many as 6 people (30%), most slightly endometriosis stage II as many as 5 people (25%) and
no endometriosis found stage I.

Table 3. The conformity of the observer's assessment of expression of 17HSD type 2 in

endometriosis tissue and normal endometrial tissue.
Symmetric Measures
Value Asymp. Std. Approx. Approx.
Errora Tb Sig.
Measure of .785 .144 4.693 .000
Kappa
Agreement
N of Valid Cases 20

Assessment of two observers in determining the intensity value of expression of

17HSD type 2 based on immunohistochemical staining tissue yields Kappa value of 0.785.
This means there is good (excellence) and significant (p <0.05), so we can use
immunohistochemical results from one of the observers only.

Table 4. Differences in the intensity of expression of 17HSD type 2 in endometrial tissue

and normal endometrial tissue.
The Intensity Subject
of expression Endometriosis Normal Endometrium p* value
of 17HSD (n=20) (n=20)
type 2
Negatif 12 0
+1 8 0 0.018
+2 0 6
+3 0 14
Total 20 20
 Based on the above table it can be seen that in the endometriosis group found the
intensity of expression of 17HSD type 2 more with negative score with the number of 12
people (60%), followed by score +1 with the number 8 (40%), and no score +2 and score +3
in the endometriosis group were found. While in the normal endometrial group, the intensity
of expression of 17HSD type 2 was more with the score of +3 with the amount of 14 (70%),
followed by the score of + 2 with 6 (30%) and no negative and +1 score was found.
Based on statistical test with Fisher Exact test, p value 0.018 (p <0.05) which means
there is a significant difference between intensity value of expression of 17HSD type 2 in
endometriosis tissue with normal endometrial tissue. Based on this research, the research
hypothesis that there is difference of expression of 17HSD type 2 in ectopic endometrial
tissue of endometriosis patient compared with normal endometrium by using
immunohistochemical examination accepted.

Table 5. Relationship intensity expression of 17HSD type 2 with stage endometriosis.

Stage intensity expression of 17HSD type 2 p* value
Negative % +1 %
I 0 0 0 0
II 4 33.3 1 12.5 0.88
III 3 25 6 75
IV 5 41.7 1 12.5
Total 12 100 8 100

Based on the above table it can be seen that the intensity of expression of 17HSD
type 2 with more negative score in stage IV endometriosis with amount of 5 (41.7%),
followed by stage II with 4 (33.3%) and stage III with 3 (25%) . While the intensity of
expression of 17HSD type 2 with score +1 more on endometriosis stage III with amount of
6 (75%), followed by stage IV with amount of 1 (12.5%) and stage II with amount 1 (12.5%).
Statistically with Fisher Exacttest obtained p value 0.88 (p> 0,05) which means there is no
significant difference of intensity value of expression of 17HSD type 2 in endometriosis
tissue based on endometriosis stage
Discussion
Endometriosis affects 5-10% in all women of reproductive age.4,5,6.15,16 The
prevalence of endometriosis is not easy to establish because the gold standard for establishing
endometriosis is by laparoscopy. In the United States, endometriosis affects 5-10% of women
of reproductive age.5 In Indonesia alone the exact incidence of endometriosis is unknown,
about 20-40% of infertile women had endometriosis.6 Based on table 4 it can be seen that the
intensity of expression of 17HSD type 2 in the endometriosis group was higher with a
negative score (60%), followed by a score of +1 (40%) and no score +2 and +3. While in the
normal endometrial group, the intensity of expression of 17HSD type 2 was more with score
+3 (70%), followed by score 2 (30%) and no negative and +1 score was found. This shows
that the intensity of expression of 17HSD type 2 in endometriosis tissue is lower than
normal endometrial tissue.
Based on statistical test with Fisher exact test in table 3 obtained p value <0.05
indicating a significant difference in intensity expression of 17HSD type 2 between
endometriosis tissue with endometrial tissue normal. Based on this research, the research
hypothesis that there is difference of expression of 17HSD type 2 in ectopic endometrial
tissue of endometriosis patient compared with normal endometrium by using
imunohistokimia examination accepted.
This research is in line with research conducted by Serdan et al. (2010) which states
the occurrence of 17HSD type 2 deficiency in endometriosis tissue. Carneiro et al (2007)
found a significant difference in the expression of 17HSD type 2 in endometriosis compared
with the normal endometrium.12,36
A study conducted by Sachiko et al (2006) states that in 8 people with ectopic
endometrium, no expression of 17HSD type 2 in epithelial cells as well as in tissue stromal
cells examined. And in the next eight persons examined, it was found that the expression of
17HSD type 2 weakened in ectopic endometrium tissue when compared with endometrial
tissue of the proliferative phase. A similar statement was also made by Zeitoun et al (2006)
which in his study hypothesized that the enzyme 17HSD type 2 is not found in
endometriosis tissue using Nothern Blot.8,38
17HSD is the group of enzymes responsible for regulating the biological potential of
steroid hormones by catalyzing process oxidation or reduction. 17HSD type 2 plays a
predominant role in the inactivation of female steroid hormones that convert estradiol to
estrone. 17HSD type 2 is produced in the normal endometrium and regulated by the
influence of progesterone. Endometriosis as an estrogen-dependent disease, which is a work-
related abnormality or steroid production plays an important role in the course of the disease.
The slight production or deficiency of the 17HSD type 2 enzyme causes estrogen levels in
the body to remain high thus contributing to the development of an endometriosis.41,42

Conclusion
There is a difference in the expression of 17HSD type 2 in endometriosis tissue
compared to normal endometrium whereas in endometriosis the intensity of expression of
17HSD type 2 is lower than that of the endometrium normal. The results of this study
support the theory of pathogenesis of endometriosis that the enzyme 17HSD type 2
decreases in endometriosis. There is no significant relationship between intensity expression
of 17HSD type 2 based on endometriosis stage.

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