The Double Engines and Single Checkpoint Theory of Endometriosis
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Abstract
Endometriosis is a chronic disease characterized by the ectopic localization of the endometrial tissue in the peritoneal cavity. Consequently, it causes local pathological changes and systemic symptoms, affecting at least one in every ten women. This disease is difficult to diagnose early, it is prone to dissemination, is difficult to eradicate, tends to recur, and is regarded as “a cancer of no kill”. Indeed, the development of endometriosis closely resembles that of cancer in the way of mutagenesis, pelvic spreading, and immunological adaptation. While retrograde menstruation has been regarded as the primary cause of endometriosis, the role of ovulation and menstrual stimuli in the development of endometriosis has long been overlooked. The development of ovarian and peritoneal endometrioses, similar to the development of high-grade serous carcinoma in the fallopian tube fimbriae with intraperitoneal metastasis, depends highly on the carcinogens released during ovulation. Moreover, endometriosis carries an extremely hypermutated genome, which is non-inferior to the ultra-mutated endometrial cancer. The hypermutation would lead to an overproduction of new proteins or neoantigens. Because of this, the developing endometriosis may have to turn on the PD-1/PDL-1 “self-tolerance” checkpoint to evade immune surveillance, leaving an Achilles tendon for an immune checkpoint blockade. In this review, we present the double engines and single checkpoint theory of the genesis of endometriosis, provide the current pieces of evidence supporting the hypothesis, and discuss the new directions of prevention and treatment.
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Flagged first, then by citations
4 of the 121 references couldn’t be matched to a known paper.
Cited by
Sorted by citations
Epigenetic regulation and T-cell responses in endometriosis – something other than autoimmunity
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Heme induced progesterone-resistant profiling and promotion of endometriosis in vitro and in vivo
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Self-citationPeripheral blood leukocyte Telomere length and endometriosis: A Mendelian randomization study
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Machine Learning-Based Diagnosis And Modeling Research in EndometriosisPreprint
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Associations between granulysin and ovarian endometriosis: A 2-sample Mendelian randomization study
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Phytochemicals Modulating Receptor Tyrosine Kinase Signaling Networks in Endometriosis
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Self-citation
- Authors
- Hsu, C.-F., Khine, A. A., Huang, H.-S., & Chu, T.-Y.
- Affiliations
- Tzu Chi Foundation (TW)
- Tzu Chi University (TW)
- Corresponding author
- Hsu, Che-Fang
- Venue
- Biomedicines
- Publisher
- MDPI AG
- Published
- 2022-06-14
- Volume
- 10
- Issue
- 6
- Pages
- 1403
- ISSN
- 2227-9059 (ISSN-L)
- PMC
- PMC9219825
- OpenAlex
- W4282914803
- Cited by
- 12
- References
- 121
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 2 · 2023: 1 · 2022: 1
- FWCI
- 0.36
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Biomedicines (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- Ministry of Science and Technology, Taiwan, ROC (MOST 107-2314-B-303-013-MY3, MOST 110-2314-B-303-008, TCMMP108-01-01)
- Buddhist Tzu Chi General Hospital, Taiwan, ROC (MOST 107-2314-B-303-013-MY3, MOST 110-2314-B-303-008, TCMMP108-01-01)
- Topics
- Health Sciences › Medicine › Reproductive Medicine › Endometriosis Research and Treatment
- Health Sciences › Medicine › Obstetrics and Gynecology › Endometrial and Cervical Cancer Treatments
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ectopic Pregnancy Diagnosis and Management
- Keywords
- endometriosis, retrograde menstruation, ovulation, endometrioma, peritoneal endometriosis, hypermutation, neoantigens, PD-1/PD-L1 immune checkpoint, immune evasion, immune checkpoint blockade, carcinogenesis
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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