Estradiol Is a Critical Mediator of Macrophage-Nerve Cross Talk in Peritoneal Endometriosis

Abstract

Endometriosis occurs in approximately 10% of women and is associated with persistent pelvic pain. It is defined by the presence of endometrial tissue (lesions) outside the uterus, most commonly on the peritoneum. Peripheral neuroinflammation, a process characterized by the infiltration of nerve fibers and macrophages into lesions, plays a pivotal role in endometriosis-associated pain. Our objective was to determine the role of estradiol (E2) in regulating the interaction between macrophages and nerves in peritoneal endometriosis. By using human tissues and a mouse model of endometriosis, we demonstrate that macrophages in lesions recovered from women and mice are immunopositive for estrogen receptor b, with up to 20% being estrogen receptor a positive. In mice, treatment with E2 increased the number of macrophages in lesions as well as concentrations of mRNAs encoded by Csf1, Nt3, and the tyrosine kinase neurotrophin receptor, TrkB. By using in vitro models, we determined that the treatment of rat dorsal root ganglia neurons with E2 increased mRNA concentrations of the chemokine C-C motif ligand 2 that stimulated migration of colony-stimulating factor 1edifferentiated macrophages. Conversely, incubation of colony-stimulating factor 1 macrophages with E2 increased concentrations of brainderived neurotrophic factor and neurotrophin 3, which stimulated neurite outgrowth from ganglia explants. In summary, we demonstrate a key role for E2 in stimulating macrophage-nerve interactions, providing novel evidence that endometriosis is an estrogen-dependent neuroinflammatory disorder. Endometriosis affects 10% of reproductive age women and is associated with persistent pelvic pain. 1 It is defined by the presence of endometrial-like tissue (lesions) found outside the uterus, most commonly on the peritoneum. The mechanisms underlying endometriosis-associated pain are poorly understood, but it has been postulated that estrogen-dependent neuroinflammation may be involved. 2 Notably, the presence of endometrial tissue fragments on the peritoneum elicits an immune response, including recruitment of macrophages, 3 blood vessels, and nerve fibers into the resultant lesions. 4,5 Within the lesions, CD68 þ macrophages have been detected in close association with nerve fibers. 6 Studies investigating macrophage activation and recruitment have revealed that endometriosis-associated macrophages exhibit a phenotype consistent with the alternative end of the macrophage activation spectrum. 7,8 In a mouse model of endometriosis that included cell transfer of polarized macrophages, Bacci et al 7 reported that mice injected with proinflammatory macrophages [macrophage (interferon g)] developed microscopic lesions, but those injected with alternatively activated macrophages [macrophage (IL-4)] developed larger lesions with a well-developed vasculature. Our studies in a mouse model of endometriosis have revealed that macrophages resident in peritoneal lesions can originate from both the peritoneum and the endometrium. 9

Nerve fiber overgrowth in patients with symptomatic diverticular disease

“…Macrophages have been reported to control tissue innervation also in the brown‐adipose tissue and can also produce cytokines, including TNF‐α, which can induce acute peripheral mechanical sensitization by acting on TNF receptor‐1 in primary afferent neurons . The neuroimmune interaction is likely bidirectional: Nerves can produce factors that influence immune cells, including colony‐stimulating factor 1 (CSF‐1) and chemokine (C‐C motif) ligand 2 (CCL‐2) which promote the recruitment of macrophages …”

“…48 The neuroimmune interaction is likely bidirectional: Nerves can produce factors that influence immune cells, including colony-stimulating factor 1 (CSF-1) and chemokine (C-C motif) ligand 2 (CCL-2) which promote the recruitment of macrophages. 49 The contribution of nerve sprouting and macrophage-nerve sprouting and remodeling, typical of tissue dysfunction and pain generation needs to be further elucidated in the pathophysiology of SUDD and symptom development. 12,46 Starting from the present study, we speculate that interactions between immune cells and nerves could play a role in maintaining neuro-inflammation and pain development in diverticular disease.…”

Research Priorities for Endometriosis: Recommendations From a Global Consortium of Investigators in Endometriosis

“…99,100 Two new animal models have been used to investigate the link between estrogen and pain. Evidence that estrogenic ligands may directly regulate factors such as Slits 101 and production of inflammatory factors by macrophages 102 known to regulate nerve cell migration has been obtained using the new mouse model, demonstrating its potential as a platform for basic research and testing of potential therapies to treat endometriosis-associated pain using Von Frey and other techniques. A rat model has been developed in which endometrial tissue is transplanted to the gastrocnemius muscle; this has subsequently been used to explore the role of leptin in estrogen-dependent chronic pain.…”

Involvement of immune cells in the pathogenesis of endometriosis

“…In endometriotic lesions, nerve fibers were co‐located with concentrations of macrophages . Further, estradiol‐mediated crosstalk between macrophages and nerve fibers from peritoneal endometriosis has been demonstrated . Clearly, an understanding of the role of macrophages in the pain symptoms associated with endometriosis is in its infant stages and requires more investigation.…”