Platelets are an unindicted culprit in the development of endometriosis: clinical and experimental evidence
Abstract
STUDY QUESTION: Do platelets play any role in the development of endometriosis? SUMMARY ANSWER: Activated platelets aggregate in endometriotic lesions and play important roles in the development of endometriosis. WHAT IS KNOWN ALREADY: Platelets play important roles in cancer development and metastasis but there is no published study on their role in the development of endometriosis, even though endometriotic lesions undergo repeated cycles of tissue injury and repair, which characteristically involve platelets. STUDY DESIGN, SIZE, DURATION: Cross-sectional clinical studies of women with and without endometriosis, in vitro experimentation, and animal studies using platelet and/or macrophage depletion. PARTICIPANTS/MATERIALS, SETTING, METHODS: Immunohistochemistry analysis of ectopic/eutopic endometrial tissues from 58 women with and 47 without endometriosis. Proliferation assay, cell cycle analysis by flow cytometry, gene expression and protein analysis for COX-2, VEGF, MMP-9, and Bcl-2 using primary cell culture, and evaluation of the rate of platelet activation induced by peritoneal fluid from women with and without endometriosis. Two mouse experiments, one that evaluated the effect of platelet depletion on lesion development and its associated phenotypic changes, and the other, the effect of platelet and/or macrophage depletion. MAIN RESULTS AND THE ROLE OF CHANCE: We found that platelets aggregated in endometriotic lesions, concomitant with elevated VEGF expression and microvessel density. Co-culture of endometriotic stromal cells with platelets enhanced cellular proliferation, and increased the expression of COX-2, MMP-9, VEGF, and Bcl-2. IL-1β-induced COX-2 up-regulation and increased production of the coagulant TXA(2) in endometriotic stromal cells. Tissue factor (TF) expression was elevated in endometriosis and TF concentrations were significantly elevated both in the supernatant of cultured primary endometriotic stromal cells and in peritoneal fluid from women with endometriosis. Platelet depletion resulted in significantly reduced lesion size and improved hyperalgesia in mice with induced endometriosis. LIMITATIONS, REASONS FOR CAUTION: This study is limited by its cross-sectional design and by its focus on ovarian endometriomas. WIDER IMPLICATIONS OF THE FINDINGS: The demonstration that platelets are involved in the development of endometriosis provides a rationale for the use of anti-coagulants to treat endometriosis, and opens prospects for developing novel biomarkers for diagnostic or prognostic purposes. STUDY FUNDING/COMPETING INTERESTS: Financial support for this study was provided by grants from the National Science Foundation of China, a grant from the Shanghai Science and Technology Commission, support from the Key Specialty Project of the Ministry of Health, People's Republic of China. None of the authors has any conflict of interest to disclose.
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Many non-endometriotic cells in the lesional microenvironment, such as platelets, macrophages, and nerve fibers, are actively involved in facilitating lesional development.
“many non-endometriotic cells in the lesional microenvironment, such as platelets21,23, macrophages19,24, and now nerve fibers25,26, are actively involved in facilitating lesional development.”
From Platelets induce increased estrogen production through NF-κB and TGF-β1 signaling pathways in endometriotic stromal cells (2020) · cites this paper as [23]
Platelets play roles in the development of endometriosis.
“the roles of platelets in the development of endometriosis has been demonstrated only recently23”
From Platelets induce increased estrogen production through NF-κB and TGF-β1 signaling pathways in endometriotic stromal cells (2020) · cites this paper as [23]
Many other cells in its microenvironment. Platelets, neutrophils, macrophages, and recently nerve fibers all have been identified to be accessories to aid and abet the lesional development.
“Platelets21,23, neutrophils69, macrophages19,24, and recently nerve fibers25,26 all have been identified to be accessories to aid and abet the lesional development.”
From Platelets induce increased estrogen production through NF-κB and TGF-β1 signaling pathways in endometriotic stromal cells (2020) · cites this paper as [23]
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Guo, S.-W. (2020) · Human Reproduction Update · doi:10.1093/humupd/dmz047 · Cited by 96 · see citing works
Self-citationGuo, S.-W., Ding, D., Shen, M., & Liu, X. (2015) · Reproductive Sciences · doi:10.1177/1933719115570907 · Cited by 86 · see citing works
Self-citationYan, D., Liu, X., & Guo, S.-W. (2019) · Scientific Reports · doi:10.1038/s41598-019-39170-w · Cited by 82 · see citing works
Self-citationZhang, Q., Liu, X., & Guo, S.-W. (2017) · Reproductive BioMedicine Online · doi:10.1016/j.rbmo.2016.11.006 · Cited by 76 · see citing works
Self-citationSensory nerve-derived neuropeptides accelerate the development and fibrogenesis of endometriosis
Liu, X., Yan, D., & Guo, S.-W. (2019) · Human Reproduction · doi:10.1093/humrep/dey392 · Cited by 51 · see citing works
Self-citationThe establishment of a mouse model of deep endometriosis
Yan, D., Liu, X., & Guo, S.-W. (2019) · Human Reproduction · doi:10.1093/humrep/dey361 · Cited by 47 · see citing works
Self-citationQi, Q., Liu, X., Zhang, Q., & Guo, S.-W. (2020) · Scientific Reports · doi:10.1038/s41598-020-57997-6 · Cited by 44 · see citing works
Self-citationActivated Platelets Induce Estrogen Receptor β Expression in Endometriotic Stromal Cells
Zhang, Q., Ding, D., Liu, X., & Guo, S.-W. (2015) · Gynecologic and Obstetric Investigation · doi:10.1159/000377629 · Cited by 38 · see citing works
Self-citationRafi, U., Ahmad, S., Bokhari, S. S., Iqbal, M. A., Zia, A., Khan, M. A., & Roohi, N. (2021) · Mediators of Inflammation · doi:10.1155/2021/3425560 · Cited by 30 · see citing works
Endometriosis-Derived Thromboxane A2 Induces Neurite Outgrowth
Yan, D., Liu, X., & Guo, S.-W. (2017) · Reproductive Sciences · doi:10.1177/1933719116670037 · Cited by 17 · see citing works
Self-citationLong, Q., Zheng, H., Liu, X., & Guo, S.-W. (2019) · Reproductive Sciences · doi:10.1177/1933719119828066 · Cited by 16 · see citing works
Self-citationQi, Q.-M., Guo, S.-W., & Liu, X.-S. (2019) · Reproductive and Developmental Medicine · doi:10.4103/2096-2924.262390 · Cited by 15 · see citing works
“[30] HIF-1α-induced COX-2 expression leads to elevated prostaglandin E2 (PGE2) levels, which can induce PGE2-mediated vascularization.”
BackgroundInfluentialSelf-citationNie, J., Yi, Y., Liu, X., & Guo, S.-W. (2025) · Human Reproduction Open · doi:10.1093/hropen/hoaf028 · Cited by 11 · see citing works
Self-citation
- Authors
- Ding, D., Liu, X., Duan, J., & Guo, S.-W.
- Affiliations
- Fudan University (CN)
- Corresponding author
- Guo, Sun-Wei
- Venue
- Human Reproduction
- Publisher
- Oxford University Press (OUP)
- Published
- 2015-03-03
- Volume
- 30
- Issue
- 4
- Pages
- 812-832
- ISSN
- 0268-1161 (ISSN-L)
- 1460-2350
- OpenAlex
- W2151756326
- Cited by
- 139
- References
- 90
- Citations by year
- 2026: 8 · 2025: 11 · 2024: 13 · 2023: 10 · 2022: 10 · 2021: 15 · 2020: 13 · 2019: 13 · 2018: 14 · 2017: 8 · 2016: 18 · 2015: 6
- FWCI
- 17.48
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Human Reproduction (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Hematology › Platelet Disorders and Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- endometriosis, platelets, platelet activation, platelet aggregation, endometriotic stromal cells, tissue factor, vascular endothelial growth factor, cyclooxygenase-2, MMP-9, Bcl-2, IL-1β, thromboxane A2, macrophage depletion, platelet depletion, endometrioma, peritoneal fluid, microvessel density
- MeSH terms
- Adult, Animals, Blood Platelets, Cell Cycle, Cross-Sectional Studies, Endometriosis, Endometrium, Female, Gene Expression Regulation, Humans, Macrophages, Male, Mice, Inbred C57BL, Ovary, Platelet Aggregation, Prognosis, Thrombin, Thromboplastin, Thromboxane B2, 6-Ketoprostaglandin F1 alpha, Platelet Activation, Gene Expression Profiling, Cell Proliferation, Mice, Interleukin-1beta, Healthy Volunteers
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