Endometriosis is a disease that affects women of reproductive age and has a significantly negative impact on their well-being. The main symptoms are dysmenorrhoea, chronic pelvic pain and infertility. In many patients the diagnostic process is very long and can take up to 8–12 years. Laparoscopy, an invasive method, is still necessary to confirm the diagnosis. Therefore, development of more effective diagnostic markers appears to be of the utmost importance for early diagnosis of endometriosis and provision of appropriate treatment. From a clinical point of view, detection of early-stage endometriosis in asymptomatic patients is an ideal situation since early diagnosis of endometriosis may delay the onset of symptoms as well as prevent progression and complications. In the meantime, Cancer Antigen 125 (CA-125) is still the most frequently studied and used marker. Other glycoproteins, growth factors and immune markers seem to play an important role. However, the search for an ideal endometriosis marker is still underway. Further studies into the pathogenesis of endometriosis will help to identify biomarkers or sets of biomarkers with the potential to improve and speed up the diagnostic process in a non-invasive way.

https://www.mdpi.com/2077-0383/10/13/2762/pdf

The Potential of Non-Invasive Biomarkers for Early Diagnosis of Asymptomatic Patients with Endometriosis.

Aim Endometriosis is a common gynecological disorder characterized by chronic pelvic pain and infertility, which negatively affects women's health worldwide. AFAP1-AS1 has been implicated in endometriosis lesions recently, but its mechanism of endometriosis progression remains unclear. Methods Endometrial stromal cells (ESCs) were used to identify the role of AFAP1-AS1 in endometriosis. The migratory capability was determined by transwell. Gene and protein expressions were identified by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blotting. Cell viability and apoptosis were detected by MTT assays and flow cytometry, respectively. Luciferase report assays were used to identify the interaction of AFAP1-AS1, miR-424-5p and signal transducer and activator of transcription 3 (STAT3). Results AFAP1-AS1 knockdown or miR-424-5p overexpression inhibited proliferation and migration, and promoted apoptosis in ESCs. In addition, knockdown of AFAP1-AS1 repressed the expression of ki-67 and Bcl-2, and promoted the levels of cleaved caspase-3 and Bax. Furthermore, knockdown of AFAP1-AS1 inhibited the conversion of E-cadherin to N-cadherin and the expression of Snail. Moreover, AFAP1-AS1 activated the STAT3/transforming growth factor-β1 (TGF-β1)/Smad2 axis via directly targeting miR-424-5p. The regulatory effect of AFAP1-AS1 silencing in ESC migration, proliferation, and apoptosis was reversed by miR-424-5p inhibition or STAT3 overexpression. Conclusions AFAP1-AS1 silencing could inhibit cell proliferation and promote apoptosis by regulating STAT3/TGF-β/Smad signaling pathway via targeting miR-424-5p in ESCs. AFAP1-AS1 may be a potential therapeutic target of controlling the progression of endometriosis.

LncRNA AFAP1-AS1 regulates proliferation and apoptosis of endometriosis through activating STAT3/TGF-β/Smad signaling via miR-424-5p.

Could extracellular vesicle-derived long non-coding RNA (lncRNA) serve as promising circulating biomarkers for endometriosis?To obtain novel diagnostic markers, 85 patients with endometriosis were enrolled as the endometriosis group and 86 unaffected participants as the control group. RNA sequencing was performed to identify extracellular vesicle-derived lncRNA that were differentially expressed between women with endometriosis (n = 5) and unaffected participants (n = 6). Messenger RNA and lncRNA sequences of the plasma extracellular vesicles were analysed using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses. lncRNA expression levels were further validated using quantitative reverse transcriptase polymerase chain reaction. Moreover, receiver operating characteristic curve analysis was performed to determine the diagnostic value of candidate lncRNA. Clinical features were correlated to the expression levels of candidate lncRNA.It was found that 210 lncRNA were significantly dysregulated; among these, expression of LINC01569, RP3-399L15.2, FAM138B and CH507-513H4.6 was significantly decreased, whereas expression of RP11-326N17.2, KLHL7-AS1 and MIR548XHG was increased, in the plasma of patients with endometriosis. Combined expression level of RP3-399L15.2 and CH507-513H4.6 was used to distinguish patients with endometriosis from control participants; the results revealed a sensitivity of 80.00% and specificity of 85.45% at the cut-off point, and an area under the ROC curve of 0.9045. The findings demonstrated the potential of these two lncRNA as diagnostic biomarkers for endometriosis. Moreover, CH507-513H4.6 alone may be useful in detecting early-stage endometriosis lesions.The combination of RP3-399L15.2 and CH507-513H4.6 may be a potential candidate for endometriosis biomarkers. 

Extracellular vesicle-derived long non-coding RNA as circulating biomarkers for endometriosis

Objective: To investigate whether miRNAs have a remarkable pooled diagnostic accuracy, sensitivity, and specificity as noninvasive biomarkers to distinguish endometriosis patients from non-endometriosis women.Methods: A comprehensive literature search of PubMed, Embase, and ProQuest was performed through February 21, 2021 to find relevant studies. Two reviewers independently screened each article, and discrepancies were resolved by consensus. Deeks' funnel plot asymmetry test was performed to assess the publication bias of included studies. The STATA software and RevMan 5.4 were used for data analysis and quality assessment, respectively.Results: The overall quality of the studies was moderate to high. In total 87 datasets were assessed miRNAs' performance which results in sensitivity: 0.82, specificity: 0.79, DOR: 18, NPV: 0.80, PPV: 0.78, PLR: 3.97, and NLR: 022. We conducted subgroup analyses, which showed panels of miRNAs (DOR: 54) and serum (DOR: 43) as a target tissue was more reliable to utilize as biomarkers. Deeks' funnel plot showed that there is no publication bias (P-value = 0.25).Conclusions: Panels of miRNAs differentiate endometriosis patients from non-endometriosis women with high sensitivity and specificity; therefore, it has the potential to use as a noninvasive biomarker.

microRNAs as novel diagnostic biomarkers in endometriosis patients: a systematic review and meta-analysis.

Biomarker identification could help in deciphering endometriosis pathophysiology in addition to their use in the development of non invasive diagnostic and prognostic approaches, that are essential to greatly improve patient care. Despite extensive efforts, no single potential biomarker or combination has been clinically validated for endometriosis.Many studies have investigated endometriosis-associated biological markers in specific tissues, but an integrative approach across tissues is lacking. The aim of this review is to propose a comprehensive overview of identified biomarkers based on tissue or biological compartment, while taking into account endometriosis phenotypes (superficial, ovarian or deep, or rASRM stages), menstrual cycle phases, treatments and symptoms.We searched PubMed and Embase databases for articles matching the following criteria: 'endometriosis' present in the title and the associated term 'biomarkers' found as Medical Subject Headings (MeSH) terms or in all fields. We restricted to publications in English and on human populations. Relevant articles published between 01 January 2005 (when endometriosis phenotypes start to be described in papers) and 01 September 2022 were critically analysed and discussed.Four hundred forty seven articles on endometriosis biomarkers that included a control group without endometriosis and provided specific information on endometriosis phenotypes are included in this review. Presence of information or adjustment controlling for menstrual cycle phase, symptoms and treatments is highlighted, and the results are further summarized by biological compartment. The 9 biological compartments studied for endometriosis biomarker research are in order of frequency: peripheral blood, eutopic endometrium, peritoneal fluid, ovaries, urine, menstrual blood, saliva, feces and cervical mucus. Adjustments of results on disease phenotypes, cycle phases, treatments and symptoms are present in 70%, 29%, 3% and 6% of selected articles, respectively. A total of 1107 biomarkers were identified in these biological compartments. Of these, 74 were found in several biological compartments by at least two independent research teams and only 4 (TNF-a, MMP-9, TIMP-1 and miR-451) are detected in at least 3 tissues with cohorts of 30 women or more.Integrative analysis is a crucial step to highlight potential pitfalls behind the lack of success in the search for clinically relevant endometriosis biomarkers, and to illuminate the physiopathology of this disease. 

An integrated multi-tissue approach for endometriosis candidate biomarkers: a systematic review

Endometriosis is a common reproductive system disease worldwide that mainly causes chronic pelvic pain and infertility. Despite its high prevalence, the diagnosis of some patients with endometriosis is delayed for several years, which may be because the gold standard for diagnosis is an expensive and invasive surgical assessment by laparoscopy or laparotomy. Circulating microRNAs (miRNAs) play an important role in a wide range of diseases, including endometriosis, and have been discovered to be potential diagnostic markers. This meta-analysis, which was designed to investigate the diagnostic value of circulating miRNAs for endometriosis, summarizes miRNA articles that met a set of inclusion criteria. Using a bivariate model, we calculated the sensitivities, specificities, and area under the curve (AUC) values of individual miRNAs and miRNA panels. The pooled diagnostic sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic (AUROC) curve were 0.86 (95% CI 0.79–0.90), 0.88 (95% CI 0.80–0.93), 7.05 (95% CI 4.20–11.84), 0.16 (95% CI 11–0.24), and 0.93, respectively. Taken together, these findings indicate that circulating microRNAs may serve as potential noninvasive biomarkers of endometriosis.

Diagnostic Value of Circulating MicroRNAs for Endometriosis: a Meta-analysis

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Diagnostic Value of Circulating MicroRNAs for Endometriosis: a Meta-analysis