子宫内膜异位症异位内膜的实验研究
摘要
子宫内膜异位症(内异症，endometriosis，EMS)是育龄妇女的常见病，发病机理尚未完全清楚。目前，为多数学者所接受的是经血逆流子宫内膜种植学说，但此学说不能解释为什么多数妇女有经血逆流，却只有极少数发生内膜异位种植。研究表明，个体因素如遗传、内分泌障碍、免疫功能异常影响着内异症的发病。
以往对内异症发病机理的基础研究主要集中在内异症患者腹腔内微环境的变化方面，认为腹腔局部调控因素如免疫、内分泌、细胞因子等的改变，导致腹腔内微环境的变化，与内异症的发生发展有关。近年来，关于内异症异位病灶本身所具有的特点及其在内异症发病中所起的作用，受到了广泛的重视。
在内异症异位内膜的研究方面，由于对内异症患者异位病灶的取材上存在着相当的困难，一定程度上影响了对该病的研究；同时，随着对治疗内异症药物研究的进展，人们在不断地寻找理想的内异症动物模型，近来研究指出，大鼠是内异症动物模型的较好选材。
内异症的发生与机体免疫反应异常有关，内异症患者腹腔中存在着免疫炎症反应，免疫异常在内异症的发病中起着重要作用。白细胞介素-6(IL-6)是细胞因子网络中的一种多功能细胞因子，它可由多种细胞产生，也可作用于多种不同类型的细胞而产生广泛的生物学效应，已有实验表明，IL-6与内异症的发病有着密切关系。
内异症为性激素依赖性疾病，子宫内膜是雌激素受体(ER)和
孕激素受体（PR）含量最丰富的组织，随着分子生物学研究的进展，
发现性激素和性激素受体在内异症的发生与发展中，可能起着重要
作用。
丹那哇（Danazol）是 17 a 乙炔宰丸酮的异恶哇衍生物，为目
前治疗内异症较有效的药物之一，其作用结果可使体内雌激素水平
下降，雄激素活性增强，导致异位子宫内膜的萎缩；此外，近年来
的研究表明，丹那哩的免疫调节作用也可能是治疗内异症的机理之
从目前对内异症的研究状况分析可知：1．虽然大鼠是内异症
动物模型的较好材料并已成功地建立了此模型，但未对模型的稳定
性及异位子宫内膜在内异症病程发展过程中的变化进行观察；2．虽
然己有实验表明，IL—6 与内异症的发病关系密切，内异症时IL
—6的改变影响异位子宫内膜的生长、增殖，但这些实验多数是观
察内异症时血清、腹腔液以及巨噬细胞分泌IL—6的变化情况，而
未对异位子宫内膜本身IL—6的变化进行详细分析，特别是未对内
异症发展过程中异位子宫内膜IL—6 的改变与内异症发病的关系
进行探讨；3．此外，也有研究显示，性激素受体在内异症的发生
中起着重要作用，内异症时异位子宫内膜激素受体含量不同于在位
子宫内膜，异位内膜雌激素受体及孕激素受体水平较在位内膜低，
但对于异位内膜雌激素受体和孕激素受体降低水平的差异及其意
义未作进一步探讨；4．丹那哩用于治疗内异症效果肯定，但治疗
时间长短不同对异位内膜的影响如何？丹那哇对异位内膜
IL－6mRNA的表达有何影响？如此一系列问题，均需加以探讨。
为此，我们将通过建立内异症大鼠动物模型，探讨内异症在发
生、发展和维持的过程中，异位内膜的形态学变化；利用分子生物
学技术，研究内异症发生、发展和维持的过程中，异位内膜IL—6
mRNA 表达情况及其与内异症发病的关系；分析异位内膜ER、PR
mRNAs表达的改变在内异症发病中的作用；了解丹那哩治疗内异症
对异位内膜 IL－6mRNA表达的影响及丹那哇用药时间长短对异位内
膜的影响。希望通过以上研究为阐明内异症的发病机理及其防治提
3
供理论与实验依据。
第一部分
大鼠子宫内膜异位症动物模型的制备及异位内
膜的形态学变化
目的：制备大鼠实验性子宫内膜异位症（内异症）动物模型，在
内异症发生、发展和维持的过程中，观察异位内膜的形态学变化，
为内异症的研究提供有价值的研究工具。
方法：雌性SD大鼠，利用阴道涂片确定其动情周期的动情期，
择动情期采用 自身子宫内膜移植法建立大鼠内异症动物模型
（n＝27）或进行假手术（n＝24）。手术后第3周，第二次剖腹，观
察异位内膜的生长情况，测量移植物的体积。将己成模大鼠随机分
为
Endometriosis is a common gynecological disorder affecting women of reproductive age. The pathogenesis remains enigmatic. Retrograde menstruation and transplantation theory is the most widely accepted explanation for endometriosis. However retrograde menstruation, occurs in high percentage of women , but a much lower prevalence for endometriosis, suggests that other factors besides retrograde (immunologic changes, genetic factors and endocrine factors) may determine the susceptibility to develop endometriosis.
Previous basic studies on the pathogenesis with greater focus on peritoneal microenvironment suggested, that alteration of local regulatory factors such as immunity, endocrine and cytokine in the peritoneal cavity, which interfered with the peritoneal microenvironment, was related to the occurrence of endometriosis. In recent years, extensive attention was paid to its features and roles of primary endometriotic lesions in the pathogenesis of endometri os i s.
It is difficult to obtain endometriotic lesions directly from patients, which has partly hindered the advancement of
understanding the disorder. Recently, it has been extablizlied that rats as a good animal model can be used for study of drugs, useful in the treatment of endometriosis.
The formation and progress of endometriosis is associated with abnormal immune and inflammatory responses in the peritoneal cavity of these patients. Immunological factors play a major role in the pathogenesis of endometr iosi s. IL~6, a multifunctional cytokine in a complex network of cytokines, which can be produced by and has effects on many types of cells, has broad effects in many biological events, Previous studies have demonstrated that IL-6 was involved in the onset of endometriosis.
Endometriosis is a hormone -related disease and the endometrium contains a plenty of progesterone receptor (PR) and estrogen receptor (ER). With the development in molecular biology, PR and ER were found to contribute to forming and progressing the endometriosis.
Danazol (17-a ethisterone), a derivative of isoxazole, is an effective drug for the treatment of endometriosi s. It has the androgenic effects and tends to suppress the output of pituitary gonadotrophins resulting in lowering of ovarian sex hormone production, which consequently causes atrophy of lesions. Recent works has revealed that immunologic regulation of danazol may be beneficial in the treatment of endometriosis.
Based on the understanding of endometriosis at the present time: 1. there is no observation on the state of ectopic endometrium in the whole course of this illness and stability of the rat model, although rat model was considered as the better experimental models and was established successfully.
2. Experimental studies have demonstrated that IL-6 correlates well with endometriosis and affects the growth of ectopic endometrium. But these data were acquired through serum, peritoneal fluid and the level of IL-6 produced by macrophage in patients, no detailed description of change of IL-6 in ectopic endometrium was found, especially of relation of alteration of IL-6 level in ectopic endometrium with the progress of endometriosis during the whole process of endometriosis. 3. furthermore, present researches have showed that the levels of ER and PR in ectopic endometrium were lower than those in eutopic endometrium. However, there was only a few reports about the differences and significance of the levels of ER and PR in ectopic tissue. 4. In spite of curative effect of Danazol, more questions need to be answered such as: How does the treatment duration affect the lesions? How does Danazol affect the expression of IL-6 mRNA level in ectopic endometrium?
Based on rat experimental model using modern techniques of molecular biology the aims of our investigations are to explore the state and morphologic change of implants, the alterations of IL-6,ER and PR mRNA in ectopic endometrium and their association with pathogenesis of endometriosis , to explore the effect of Danazol on expre
以往对内异症发病机理的基础研究主要集中在内异症患者腹腔内微环境的变化方面，认为腹腔局部调控因素如免疫、内分泌、细胞因子等的改变，导致腹腔内微环境的变化，与内异症的发生发展有关。近年来，关于内异症异位病灶本身所具有的特点及其在内异症发病中所起的作用，受到了广泛的重视。
在内异症异位内膜的研究方面，由于对内异症患者异位病灶的取材上存在着相当的困难，一定程度上影响了对该病的研究；同时，随着对治疗内异症药物研究的进展，人们在不断地寻找理想的内异症动物模型，近来研究指出，大鼠是内异症动物模型的较好选材。
内异症的发生与机体免疫反应异常有关，内异症患者腹腔中存在着免疫炎症反应，免疫异常在内异症的发病中起着重要作用。白细胞介素-6(IL-6)是细胞因子网络中的一种多功能细胞因子，它可由多种细胞产生，也可作用于多种不同类型的细胞而产生广泛的生物学效应，已有实验表明，IL-6与内异症的发病有着密切关系。
内异症为性激素依赖性疾病，子宫内膜是雌激素受体(ER)和
孕激素受体（PR）含量最丰富的组织，随着分子生物学研究的进展，
发现性激素和性激素受体在内异症的发生与发展中，可能起着重要
作用。
丹那哇（Danazol）是 17 a 乙炔宰丸酮的异恶哇衍生物，为目
前治疗内异症较有效的药物之一，其作用结果可使体内雌激素水平
下降，雄激素活性增强，导致异位子宫内膜的萎缩；此外，近年来
的研究表明，丹那哩的免疫调节作用也可能是治疗内异症的机理之
从目前对内异症的研究状况分析可知：1．虽然大鼠是内异症
动物模型的较好材料并已成功地建立了此模型，但未对模型的稳定
性及异位子宫内膜在内异症病程发展过程中的变化进行观察；2．虽
然己有实验表明，IL—6 与内异症的发病关系密切，内异症时IL
—6的改变影响异位子宫内膜的生长、增殖，但这些实验多数是观
察内异症时血清、腹腔液以及巨噬细胞分泌IL—6的变化情况，而
未对异位子宫内膜本身IL—6的变化进行详细分析，特别是未对内
异症发展过程中异位子宫内膜IL—6 的改变与内异症发病的关系
进行探讨；3．此外，也有研究显示，性激素受体在内异症的发生
中起着重要作用，内异症时异位子宫内膜激素受体含量不同于在位
子宫内膜，异位内膜雌激素受体及孕激素受体水平较在位内膜低，
但对于异位内膜雌激素受体和孕激素受体降低水平的差异及其意
义未作进一步探讨；4．丹那哩用于治疗内异症效果肯定，但治疗
时间长短不同对异位内膜的影响如何？丹那哇对异位内膜
IL－6mRNA的表达有何影响？如此一系列问题，均需加以探讨。
为此，我们将通过建立内异症大鼠动物模型，探讨内异症在发
生、发展和维持的过程中，异位内膜的形态学变化；利用分子生物
学技术，研究内异症发生、发展和维持的过程中，异位内膜IL—6
mRNA 表达情况及其与内异症发病的关系；分析异位内膜ER、PR
mRNAs表达的改变在内异症发病中的作用；了解丹那哩治疗内异症
对异位内膜 IL－6mRNA表达的影响及丹那哇用药时间长短对异位内
膜的影响。希望通过以上研究为阐明内异症的发病机理及其防治提
3
供理论与实验依据。
第一部分
大鼠子宫内膜异位症动物模型的制备及异位内
膜的形态学变化
目的：制备大鼠实验性子宫内膜异位症（内异症）动物模型，在
内异症发生、发展和维持的过程中，观察异位内膜的形态学变化，
为内异症的研究提供有价值的研究工具。
方法：雌性SD大鼠，利用阴道涂片确定其动情周期的动情期，
择动情期采用 自身子宫内膜移植法建立大鼠内异症动物模型
（n＝27）或进行假手术（n＝24）。手术后第3周，第二次剖腹，观
察异位内膜的生长情况，测量移植物的体积。将己成模大鼠随机分
为
Endometriosis is a common gynecological disorder affecting women of reproductive age. The pathogenesis remains enigmatic. Retrograde menstruation and transplantation theory is the most widely accepted explanation for endometriosis. However retrograde menstruation, occurs in high percentage of women , but a much lower prevalence for endometriosis, suggests that other factors besides retrograde (immunologic changes, genetic factors and endocrine factors) may determine the susceptibility to develop endometriosis.
Previous basic studies on the pathogenesis with greater focus on peritoneal microenvironment suggested, that alteration of local regulatory factors such as immunity, endocrine and cytokine in the peritoneal cavity, which interfered with the peritoneal microenvironment, was related to the occurrence of endometriosis. In recent years, extensive attention was paid to its features and roles of primary endometriotic lesions in the pathogenesis of endometri os i s.
It is difficult to obtain endometriotic lesions directly from patients, which has partly hindered the advancement of
understanding the disorder. Recently, it has been extablizlied that rats as a good animal model can be used for study of drugs, useful in the treatment of endometriosis.
The formation and progress of endometriosis is associated with abnormal immune and inflammatory responses in the peritoneal cavity of these patients. Immunological factors play a major role in the pathogenesis of endometr iosi s. IL~6, a multifunctional cytokine in a complex network of cytokines, which can be produced by and has effects on many types of cells, has broad effects in many biological events, Previous studies have demonstrated that IL-6 was involved in the onset of endometriosis.
Endometriosis is a hormone -related disease and the endometrium contains a plenty of progesterone receptor (PR) and estrogen receptor (ER). With the development in molecular biology, PR and ER were found to contribute to forming and progressing the endometriosis.
Danazol (17-a ethisterone), a derivative of isoxazole, is an effective drug for the treatment of endometriosi s. It has the androgenic effects and tends to suppress the output of pituitary gonadotrophins resulting in lowering of ovarian sex hormone production, which consequently causes atrophy of lesions. Recent works has revealed that immunologic regulation of danazol may be beneficial in the treatment of endometriosis.
Based on the understanding of endometriosis at the present time: 1. there is no observation on the state of ectopic endometrium in the whole course of this illness and stability of the rat model, although rat model was considered as the better experimental models and was established successfully.
2. Experimental studies have demonstrated that IL-6 correlates well with endometriosis and affects the growth of ectopic endometrium. But these data were acquired through serum, peritoneal fluid and the level of IL-6 produced by macrophage in patients, no detailed description of change of IL-6 in ectopic endometrium was found, especially of relation of alteration of IL-6 level in ectopic endometrium with the progress of endometriosis during the whole process of endometriosis. 3. furthermore, present researches have showed that the levels of ER and PR in ectopic endometrium were lower than those in eutopic endometrium. However, there was only a few reports about the differences and significance of the levels of ER and PR in ectopic tissue. 4. In spite of curative effect of Danazol, more questions need to be answered such as: How does the treatment duration affect the lesions? How does Danazol affect the expression of IL-6 mRNA level in ectopic endometrium?
Based on rat experimental model using modern techniques of molecular biology the aims of our investigations are to explore the state and morphologic change of implants, the alterations of IL-6,ER and PR mRNA in ectopic endometrium and their association with pathogenesis of endometriosis , to explore the effect of Danazol on expre
引文
1．乐杰主编，妇产科学．人民卫生出版社，北京．2000年第5版第387页
2. Van der linder PJQ, Dunsel man GAJ, Goeij AFPM, et al. Eipithelial cells in peritoneal fluid of endometrial
origin? .Am J Obstet Gynecol, 1995,173:566-570．
3． Senturk LM,Arici A.Immunology of endometriosis.J Reprod Immunol, 1999, 43(1) :67-83．
4． Lewis TLT.Progress in clinical obstetrics and gynecology.2 nd ed.Churchi11:London,1964,514．
5． D'Hooghe TM.Clinical relevance of the baboon as a model for the study of endometriosis.Fertil Steril,1997,68: 613-625．
6． Schenken RS, Asch RH, William RF, et al.Etiology of infertility in monkeys with endometriosis: luteinized unruptured follicles,luteal phase defects,pelvic adhesions,and spontaneous abortions.Fertil Steril , 1984, 41:122-127．
7． Kaplan CR, Eddy CA,Olive DL, et al.Effects of ovarian endometriosis on ovulation in rabbits.Am J Obstet Gynecol, 1989, 40:160-164．
8． Vernon MW, Wilson EA.Studies on the surgical induction of endometriosis in the rat.Fertil Steril, 1985, 44:684-694．
9． Golan A,Dargenio R,Winston RM.The effect of treatment on experimentally produced endometrial peritoneal implants.Fertil Steril, 1986,46:954-958．
10． Simms JS, Chegini N, Williams RS, et al.Identification of epidermal growth factor, transforming growth factor-alpha and epidermal growth factor receptor in surgically induced endometriosis in rats.Obstet Gynecol, 1991, 78:850-857．
11． Sakata M, Terakawa N, Mizutani T, et al.Effects of danzol,gonadotropin-releasing hormone against and a combination of danazol and gonadotropin-releasing
hormone against on experimental endometriosis.Am J Obstet Gynecol, 1990, 163:1679-1684．
12． Jones RC.The effect of a luteinizing hormone releasing hormone(LRH) agonist (Wy-40, 972) ,1evonorgestrel, danazol and ovariectomy on experimental endometriosis in the rat.Acta Endocrinologica, 1984,106:282-288．
13． Witz C A,Schenken R S.Pathogenesis.Semin Reprod Endocrinol, 1997, 15(3) : 199-206．
14． Tagoh H, Nishimoto N, Ogata A, et al.Multiplicity in the production and the function of IL-6． Clin Immunol Immunopathol ,1989,21:1225-1241．
15． Ray P,Ghosh SK,Zhang DH,et al.Repression of interleukin-6 expression by 17B-estradiol;inhibition of the DNA-binding activity of the transcription factors NF-IL6 and NF-kB by the estrogen receptor.FEBS Lett, 1997,409:79-85．
16． 马保锋,郑辉.白细胞介素-6与子宫内膜异位症发病的研究进展.生理通讯, 2001,20(suppl.1) :104-107．
17． Braun DP,Gebel H,House,et al .Spontaneous and induced synthesis of cytokines by peripheral blood monocytes in patients with endometriosis.Fertil Steril, 1996, 65: 1125-1129．
18． Frauenklinik DME,Rheinisch WTH.Interleukin-6 and soluble interleukin-6 receptor in peritoneal fluid and serum of patients with endometriosis.Clin Exp Obstet Gynecol, 1996, 23: 10-14．
19． Lim YT,Schenken RS.Interleukin-6 in experimental endometriosis.Fertil Steril, 1993, 59:912-916．
20． Wu MY,Ho HN,Chen SU,et al.Increase in the production of interleukin-6, interleukin-10, and interleukin-12 by
1ipopolysaccharide-stimulated peritoneal macrophages from women with endometriosis.Am J Reprod Immunol,1999, 41: 106-111．
21． Boutten A,Dehoux M,Edelman P,et al.IL6 and acute phase plasma proteins in peritoneal fluid of women with endometriosis.Clin Chim Acta, 1992, 210: 187-195．
22． Ho HN,Wu MY,Yang YS,et al.Peritoneal cellular immunity and endometriosis.Am J Reprod Immunol, 1997,38:400-412．
23． Harada T,Yoshioka H,Yoshida S,et al.Increased interleukin-6 levels in peritoneal fluid of infertile patients with active endometriosis.Am J Obstet Gynecol, 1997, 176 (3) : 593-597．
24． Rier SE, Zarmakoupis PN, Hu X, et al.Dysregulation of inter1eukin-6 responses in ectopic endometrial stromal cells: correlation with decreased soluble receptor levels in peritoneal fluid of women with endometriosis.J Clin Endocrinol Metab,1995, 80 (4) : 1431-1437．
25． Pellicer A, Albert C, Garrido N, et al.The pathophysiology of endometriosis-associated infertility: follicular environment and embryo quality.J Reprod Fertil Suppl, 2000, 55: 109-119．
26． Noble LS,Simpson ER,Johns A,et al.Aromatase expression in endometriosis.J Clin Endocrinol Metab,1996, 81: 174-179．
27． Craig A, Witz MD.Interleukin-6: another piece of the endometriosis-cytokine puzzle.Fertil Steril,2000, 73(2) :212-214．
28． Tamaya T ,Motoyama T, Ohono Y, et al.Steroid receptor levels and histology of endometriosis and adenomyosis.
Fertil Steril, 1979,31:396-402．
29． Lessay BA, Metzger DA, Haney AF, et al.Imraunohistochemocal analysis of estrogen and progesterone receptors in endometriosis: comparison with normal endometrium during the menstrual cycle and the effect of medical therapy.Fertil Steril, 1989, 51:409-416．
30． Prentice A.Ovarian steroid receptor expression in endometriosis and in two potential parent epithelis: endometrium and peritoneal mosothelium.Hum Reprod, 1992,7:1318-1324．
31． Brandenberger AW, Lebovic DI, Tee MK, et al.Oestrogen receptor (ER)-alpha and ER-beta isoforms in normal endometrial and endometriosis derived stromal cells.Mol Hum Reprod, 1999,5:651-655．
32． Sachiko M, Takashi M, Shigeki U, et al.Expression of estrogen receptor alpha and beta in peritoneal and ovarian endometriosis.Fertil Steri1,2001,75 (6) : 1198-1205．
33． Misao R, Iwagaki S, Fujimoto J, et al.Dominate expression of progesterone receptor form B mRNA in ovarian endometriosis.Horm Res, 2000,52:30-34．
34． 孙桂英,金志军,杨云纺.雌激素受体的变异及其临床意义.国外医学妇产科学分册 , 1999,26(3) : 159-161．
35． 桂耀庭,吴熙瑞.子宫内膜异位症的药物治疗进展.现代诊断与治疗 .1995,6 (1) : 51-53．
36． Igarashi M,Iizuka M,Abe Y,et al.Novel vaginal danazol ring therapy for pelvic endometriosis,in particular deeply infiltrating endometriosis.Human Reproduction, 1998, 13(7) : 1952-1956．
37． Dmowski WP.Danazol-a synthetic steroid with diverse
biologic effects. J Reprod Med, 1990, 35:69-72.
38. Tamaya T, Wada K, Fujimoto J, et al. Danazol binding to steroid receptors in human uterine endometrium Fertil Steril, 1984, 41 (5): 732-734.
39．黄荷凤，王曼．醋酸棉酚、GnRH-A等药物对人子宫内膜细胞雌、孕激素受体的影响．中国中西医结合杂志，1994，14(6)：352-353．
40．谢幸，A G F Stevenson，P Kunstmann．丹那唑对体外培养的原位与异位子宫内膜细胞生长的影响．中华病理学杂志，1994，23(3)：170-172．
41. Ioannis MM, Irene A, Anastasia GG, et al. The possible anti-inflammatory role of circulating human leukocyte antigen levels in women with endometriosis after treatment with danazol and leuprorelin acetate depot. Mediators of Inflammation, 2001, 10(2):75-80.
42. Christine J, Andre L, Ali A. Comparative effect of danazol and a GnRH agonist on monocyte chemotactic protein-1 expression by endometriotic ceils. American Journal of Reproductive Immunology, 2001, 45(2):86-93.
43. Rapkin A, Morgan M, Bonpane C, et al. Peritoneal fluid interleukin-6 in women with chronic pelvic pain. Fertil Steril, 2000, 74: 325-328.
44. Keenan JA, Chen TT, Chadwell NL, et al. Interferon-gamma and interleukin-6 in peritoneal fluid and macrophage-conditioned media of women with endometriosis . Am J Reprod Immunol, 1994, 32(3):180-183.
45. Yoshioka H, Harada T, Iwabe T, et al. Menstrual cycle-specific inhibition of the proliferation of endometrial stromal ceils by interleukin 6 and its soluble receptor. Am J Obstet Gynecol, 1999, 180(3): 1088 -1094.
46． Koumantakis E, Matal1iotakis I, Neonaki M, et al.Soluble serum interleukin-2 receptor, interleukin-6 and interleukin-la in patients with endometriosis and in controls.Arch Gynecol Obstet, 1994, 255(3) : 107-112．
2. Van der linder PJQ, Dunsel man GAJ, Goeij AFPM, et al. Eipithelial cells in peritoneal fluid of endometrial
origin? .Am J Obstet Gynecol, 1995,173:566-570．
3． Senturk LM,Arici A.Immunology of endometriosis.J Reprod Immunol, 1999, 43(1) :67-83．
4． Lewis TLT.Progress in clinical obstetrics and gynecology.2 nd ed.Churchi11:London,1964,514．
5． D'Hooghe TM.Clinical relevance of the baboon as a model for the study of endometriosis.Fertil Steril,1997,68: 613-625．
6． Schenken RS, Asch RH, William RF, et al.Etiology of infertility in monkeys with endometriosis: luteinized unruptured follicles,luteal phase defects,pelvic adhesions,and spontaneous abortions.Fertil Steril , 1984, 41:122-127．
7． Kaplan CR, Eddy CA,Olive DL, et al.Effects of ovarian endometriosis on ovulation in rabbits.Am J Obstet Gynecol, 1989, 40:160-164．
8． Vernon MW, Wilson EA.Studies on the surgical induction of endometriosis in the rat.Fertil Steril, 1985, 44:684-694．
9． Golan A,Dargenio R,Winston RM.The effect of treatment on experimentally produced endometrial peritoneal implants.Fertil Steril, 1986,46:954-958．
10． Simms JS, Chegini N, Williams RS, et al.Identification of epidermal growth factor, transforming growth factor-alpha and epidermal growth factor receptor in surgically induced endometriosis in rats.Obstet Gynecol, 1991, 78:850-857．
11． Sakata M, Terakawa N, Mizutani T, et al.Effects of danzol,gonadotropin-releasing hormone against and a combination of danazol and gonadotropin-releasing
hormone against on experimental endometriosis.Am J Obstet Gynecol, 1990, 163:1679-1684．
12． Jones RC.The effect of a luteinizing hormone releasing hormone(LRH) agonist (Wy-40, 972) ,1evonorgestrel, danazol and ovariectomy on experimental endometriosis in the rat.Acta Endocrinologica, 1984,106:282-288．
13． Witz C A,Schenken R S.Pathogenesis.Semin Reprod Endocrinol, 1997, 15(3) : 199-206．
14． Tagoh H, Nishimoto N, Ogata A, et al.Multiplicity in the production and the function of IL-6． Clin Immunol Immunopathol ,1989,21:1225-1241．
15． Ray P,Ghosh SK,Zhang DH,et al.Repression of interleukin-6 expression by 17B-estradiol;inhibition of the DNA-binding activity of the transcription factors NF-IL6 and NF-kB by the estrogen receptor.FEBS Lett, 1997,409:79-85．
16． 马保锋,郑辉.白细胞介素-6与子宫内膜异位症发病的研究进展.生理通讯, 2001,20(suppl.1) :104-107．
17． Braun DP,Gebel H,House,et al .Spontaneous and induced synthesis of cytokines by peripheral blood monocytes in patients with endometriosis.Fertil Steril, 1996, 65: 1125-1129．
18． Frauenklinik DME,Rheinisch WTH.Interleukin-6 and soluble interleukin-6 receptor in peritoneal fluid and serum of patients with endometriosis.Clin Exp Obstet Gynecol, 1996, 23: 10-14．
19． Lim YT,Schenken RS.Interleukin-6 in experimental endometriosis.Fertil Steril, 1993, 59:912-916．
20． Wu MY,Ho HN,Chen SU,et al.Increase in the production of interleukin-6, interleukin-10, and interleukin-12 by
1ipopolysaccharide-stimulated peritoneal macrophages from women with endometriosis.Am J Reprod Immunol,1999, 41: 106-111．
21． Boutten A,Dehoux M,Edelman P,et al.IL6 and acute phase plasma proteins in peritoneal fluid of women with endometriosis.Clin Chim Acta, 1992, 210: 187-195．
22． Ho HN,Wu MY,Yang YS,et al.Peritoneal cellular immunity and endometriosis.Am J Reprod Immunol, 1997,38:400-412．
23． Harada T,Yoshioka H,Yoshida S,et al.Increased interleukin-6 levels in peritoneal fluid of infertile patients with active endometriosis.Am J Obstet Gynecol, 1997, 176 (3) : 593-597．
24． Rier SE, Zarmakoupis PN, Hu X, et al.Dysregulation of inter1eukin-6 responses in ectopic endometrial stromal cells: correlation with decreased soluble receptor levels in peritoneal fluid of women with endometriosis.J Clin Endocrinol Metab,1995, 80 (4) : 1431-1437．
25． Pellicer A, Albert C, Garrido N, et al.The pathophysiology of endometriosis-associated infertility: follicular environment and embryo quality.J Reprod Fertil Suppl, 2000, 55: 109-119．
26． Noble LS,Simpson ER,Johns A,et al.Aromatase expression in endometriosis.J Clin Endocrinol Metab,1996, 81: 174-179．
27． Craig A, Witz MD.Interleukin-6: another piece of the endometriosis-cytokine puzzle.Fertil Steril,2000, 73(2) :212-214．
28． Tamaya T ,Motoyama T, Ohono Y, et al.Steroid receptor levels and histology of endometriosis and adenomyosis.
Fertil Steril, 1979,31:396-402．
29． Lessay BA, Metzger DA, Haney AF, et al.Imraunohistochemocal analysis of estrogen and progesterone receptors in endometriosis: comparison with normal endometrium during the menstrual cycle and the effect of medical therapy.Fertil Steril, 1989, 51:409-416．
30． Prentice A.Ovarian steroid receptor expression in endometriosis and in two potential parent epithelis: endometrium and peritoneal mosothelium.Hum Reprod, 1992,7:1318-1324．
31． Brandenberger AW, Lebovic DI, Tee MK, et al.Oestrogen receptor (ER)-alpha and ER-beta isoforms in normal endometrial and endometriosis derived stromal cells.Mol Hum Reprod, 1999,5:651-655．
32． Sachiko M, Takashi M, Shigeki U, et al.Expression of estrogen receptor alpha and beta in peritoneal and ovarian endometriosis.Fertil Steri1,2001,75 (6) : 1198-1205．
33． Misao R, Iwagaki S, Fujimoto J, et al.Dominate expression of progesterone receptor form B mRNA in ovarian endometriosis.Horm Res, 2000,52:30-34．
34． 孙桂英,金志军,杨云纺.雌激素受体的变异及其临床意义.国外医学妇产科学分册 , 1999,26(3) : 159-161．
35． 桂耀庭,吴熙瑞.子宫内膜异位症的药物治疗进展.现代诊断与治疗 .1995,6 (1) : 51-53．
36． Igarashi M,Iizuka M,Abe Y,et al.Novel vaginal danazol ring therapy for pelvic endometriosis,in particular deeply infiltrating endometriosis.Human Reproduction, 1998, 13(7) : 1952-1956．
37． Dmowski WP.Danazol-a synthetic steroid with diverse
biologic effects. J Reprod Med, 1990, 35:69-72.
38. Tamaya T, Wada K, Fujimoto J, et al. Danazol binding to steroid receptors in human uterine endometrium Fertil Steril, 1984, 41 (5): 732-734.
39．黄荷凤，王曼．醋酸棉酚、GnRH-A等药物对人子宫内膜细胞雌、孕激素受体的影响．中国中西医结合杂志，1994，14(6)：352-353．
40．谢幸，A G F Stevenson，P Kunstmann．丹那唑对体外培养的原位与异位子宫内膜细胞生长的影响．中华病理学杂志，1994，23(3)：170-172．
41. Ioannis MM, Irene A, Anastasia GG, et al. The possible anti-inflammatory role of circulating human leukocyte antigen levels in women with endometriosis after treatment with danazol and leuprorelin acetate depot. Mediators of Inflammation, 2001, 10(2):75-80.
42. Christine J, Andre L, Ali A. Comparative effect of danazol and a GnRH agonist on monocyte chemotactic protein-1 expression by endometriotic ceils. American Journal of Reproductive Immunology, 2001, 45(2):86-93.
43. Rapkin A, Morgan M, Bonpane C, et al. Peritoneal fluid interleukin-6 in women with chronic pelvic pain. Fertil Steril, 2000, 74: 325-328.
44. Keenan JA, Chen TT, Chadwell NL, et al. Interferon-gamma and interleukin-6 in peritoneal fluid and macrophage-conditioned media of women with endometriosis . Am J Reprod Immunol, 1994, 32(3):180-183.
45. Yoshioka H, Harada T, Iwabe T, et al. Menstrual cycle-specific inhibition of the proliferation of endometrial stromal ceils by interleukin 6 and its soluble receptor. Am J Obstet Gynecol, 1999, 180(3): 1088 -1094.
46． Koumantakis E, Matal1iotakis I, Neonaki M, et al.Soluble serum interleukin-2 receptor, interleukin-6 and interleukin-la in patients with endometriosis and in controls.Arch Gynecol Obstet, 1994, 255(3) : 107-112．