Vascular endothelial growth factor gene polymorphisms and pre-eclampsia

Vascular endothelial growth factor (VEGF) plays a crucial role in physiological vasculogenesis and vascular permeability and has been implicated in the pathogenesis of pre-eclampsia. Our present study was undertaken to identify associations between three functional VEGF gene polymorphisms, linked with altered VEGF gene responsiveness, and pre-eclampsia. The study involved 42 pre-eclamptic and 73 healthy control women who were genotyped for the -2578C/A, -634G/C and 936C/T polymorphisms of the VEGF gene. No significant association between genotypic or allelic frequencies in women with pre-eclampsia relative to controls was found. A statistically significant difference was found for allelic frequencies of the 936C/T polymorphism between women with severe pre-eclampsia and controls (odds ratio: 2.70; 95% confidence interval: 1.09-6.63; P = 0.019). VEGF gene polymorphisms studied are unlikely to be major predisposing factors for pre-eclampsia. The presence of the 936T allele probably has a considerable effect on disease modification.     

Genetic polymorphisms of vascular endothelial growth factor in severe pre-eclampsia

Several lines of evidence support the hypothesis that vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of pre-eclampsia (PE). VEGF is a key component in the regulation of vascular remodelling and the survival of cytotrophoblasts in the placenta. In this case-control study, we aimed to test whether VEGF genetic polymorphisms are associated with the risk of severe PE. We enrolled 84 nulliparous pregnant women with severe PE (PE group). Their VEGF G(+405)C and VEGF C(-2578)A genotypes were determined by PCR-restriction fragment length polymorphism (PCR-RFLP) from venous blood samples and were compared with the corresponding VEGF genotypes of 96 nulliparous patients with uncomplicated pregnancies (control group). Carriers of the VEGF(+405)G allele occurred less frequently in PE than in the control group [P = 0.039; adjusted odds ratio (aOR) = 0.28, range: 0.08-0.93]. Hypertension and proteinuria were diagnosed earlier (by 1.6 weeks and 1.9 weeks, respectively) in PE patients with VEGF(-2578)A only after adjustment of this association for risk factors of PE. Our results suggest that carriers of VEGF(+405)G allele have a decreased susceptibility to PE and that the progression of PE may be modified by the presence of VEGF(-2578)A allele. Nevertheless, the clinical significance of these findings remains to be determined.     

Gestational hypertension but not pre-eclampsia is associated with insulin resistance syndrome characteristics.

The aim of this study was to assess whether the metabolic characteristics of insulin resistance syndrome are present in pre-eclamptic (PE), gestational (GH) and chronic hypertensive (CH) pregnancies. Glucose and insulin serum concentrations, both fasting and after oral administration of a glucose tolerance test, were evaluated in 26 hypertensive pregnant women (10 PE, 10 GH and six CH patients) and in 10 healthy controls during the third trimester of gestation. Insulin sensitivity was assessed using the hyperinsulinaemic-euglycaemic clamp technique. The plasma concentrations of triglyceride (TG), high density (HDL), low density (LDL), and very low density (VLDL) lipoprotein cholesterol, apolipoproteins AI and B, and non-esterified fatty acid (NEFA) were also measured. Women with GH exhibited approximately 40% lower steady-state insulin sensitivity index (ISI) compared to controls (3.75 versus 6.34, P < 0.03), as well as approximately 33% higher mean plasma TG (3.57 versus 2.68 mmol/l, P < 0.01), and approximately 69% higher mean NEFA (0.59 versus 0.35 mmol/l, P < 0.01). Women with PE showed similar ISI but reduced insulin and glucose areas under curve compared to controls (P < 0.006, P < 0.0005 respectively). Women with PE also had higher HDL-cholesterol and apo-AI than controls. Patients with CH had similar lipid and carbohydrate metabolism to control subjects. In conclusion, women with GH exhibit metabolic features similar to those of patients with insulin resistance syndrome, suggesting that similar abnormalities could be involved in the pathogenesis of these disorders. In contrast, our data do not support an association between insulin resistance syndrome and hypertension in pregnant women with PE and chronic hypertension.     

Vascular endothelial growth factor in allergen-induced nasal inflammation

Background Increased vessel number and permeability are important features of the nasal mucosa in allergic rhinitis (AR), and are mediated in part by the cytokine vascular endothelial growth factor (VEGF). Eosinophils are the major effector cells in the nasal secretions of patients with AR during the responses to allergen challenges. To evaluate the involvement of VEGF in nasal allergic inflammation, we monitored the levels of VEGF, eosinophil cationic protein (ECP), and specific antibodies in the nasal lavage fluids (NLFs) of patients with AR in response to Dermatophagoides pteronyssinus ( Dpt ).
Methods Sixty-three subjects with sensitization to Dpt were enrolled: 29 patients with AR (group I) who showed positive responses in a nasal provocation test (NPT) with Dpt ; and 34 asymptomatic controls (group II) who showed sensitization to Dpt but negative NPT results. NLF samples were collected at baseline, 10, 30, and 60 min, and at 3, 6, and 24 h during the NPT. The ECP levels in the NLF samples were measured using the ImmunoCAP system. VEGF and Dpt -specific IgE, IgA, and IgG in the NLF samples were detected by ELISA.
Results The eosinophil counts and ECP levels in the samples were significantly increased in group I, but not in group II, during the early and late responses. Although the baseline VEGF level was not significantly different between groups I and II, increased VEGF production was noted in group I after the NPT, especially during the early response. The level of Dpt -specific IgA was significantly increased in group I during the NPT. A relationship was found between the levels of VEGF and ECP or Dpt -specific IgA in the NLF samples collected at 10 min and at 3–6 h ( P <0.05, respectively).
Conclusion Nasal VEGF secretion in response to allergen exposure may augment eosinophilic inflammation in the nasal mucosa of patients with AR.     

Apelin and vascular endothelial growth factor are associated with mobilization of endothelial progenitor cells after acute myocardial infarction

This study was designed to determine the levels of early endothelial progenitor cells(EPCs),apelin,vascu-lar endothelial growth factor(VEGF) and stromal cell-derived growth factor-1(SDF-1) after acute myocardial infarction(AMI),and to investigate the relationships between these cytokines and early EPCs.Early EPCs,de-fined as CD133+,KDR+,and CD34+ cells,were quantified by flow cytometry.The levels of early EPCs and those cytokines in AMI patients were significantly different from those with coronary artery disease or controls(P < 0.05).Plasma apelin levels were inversely correlated with Gensini score and early EPCs(both P < 0.01).Early EPCs,VEGF and SDF-1 showed different patterns of changes in AMI patients during the first 24 h.The trend in the change of early EPCs was proportionally correlated with that of VEGF(P < 0.05).AMI patients exhibited in-creased early EPCs with remarkably decreased apelin levels and enhanced VEGF levels.     

血管内皮细胞生长因子与大肠癌治疗

血管内皮细胞生长因子（VEGF）在大肠癌组织中高表达，与肿瘤血管生成，肿瘤细胞增殖、转移，肿瘤预后关系密切。目前各种针对VEGF及其受体开展的抑制肿瘤血管生成的药物研究广泛开展，有的已经批准上市，用于大肠癌的临床治疗，为大肠癌的治疗开辟了新的途径。     

Vascular endothelial growth factor A and C gene expression in endometriosis

Angiogenesis is essential for the pathogenesis of endometriosis. Gene expression levels of vascular endothelial growth factor (VEGF) A and C in 10 eutopic endometrial, 23 normal peritoneal, and 62 endometriotic tissues surgically obtained from 47 women with endometriosis (group 2) were compared with those in 12 control eutopic endometrial and 9 normal peritoneal tissues from 15 women without endometriosis (group 1). VEGF-A mRNA expression levels in eutopic endometrium of group 2 were higher than those of group 1 throughout the menstrual cycle (P <0.01) and increased in the secretory phase. VEGF-A gene expression in peritoneal endometriotic lesion was statistically higher than that in normal peritoneum (P <0.01) and similar to that in eutopic endometrium of group 2. In contrast, gene expression levels of VEGF-C were relatively lower than those of VEGF-A in each lesion, and no cyclic variation was found. VEGF-A and C mRNA expression levels were significantly higher in ovarian endometriomas >6 cm in size than in those <6 cm in size. Immunohistochemical expression of VEGF-A and C was detected in the cytoplasm of glandular epithelial and stromal cells of ovarian endometrioma. These results suggest that endometriosis may arise from eutopic endometrium with higher levels of angiogenic activity possibly induced by VEGF-A in women with endometriosis. Moreover, VEGF-C as well as VEGF-A may be involved in the pathogenesis of ovarian endometrioma.     

Vascular endothelial growth factor, epidermal growth factor and fibroblast growth factor-4 and -10 stimulate trophoblast plasminogen activator system and metalloproteinase-9

Trophoblast invasion, accompanied by degradation of extracellular matrix, is crucial to normal pregnancy development, whereas shallow placental invasion and implantation likely plays a role in the subsequent development of pre-eclampsia. The growth factors vascular endothelial growth factor (VEGF), epidermal growth factor (EGF) and fibroblast growth factor (FGF) are placental growth factors that activate degradation of extracellular matrix. We determined the effect of VEGF, EGF, FGF-2, FGF-4 and FGF-10 on the plasminogen activator system of first trimester cytotrophoblasts cultured in vitro. We studied the activity of urokinase plasminogen activator (uPA), its inhibitor plasminogen activator inhibitor-1 (PAI-1), and 92 kDa gelatinase-B (matrix metalloproteinase-9, MMP-9), using protein gel and reversed gel zymography. The expression pattern of FGF-4 and FGF-10 in human placental sections was determined by immunohistochemistry. FGF-4 was expressed in first trimester villi stroma, primarily in endothelial cells. FGF-10 expression was localized to first trimester extravillous trophoblasts. VEGF, EGF, FGF-4 and FGF-10, but not FGF-2, stimulate the activity of trophoblast uPA, PAI-1 and MMP-9. These results support the hypothesis that specific growth factors modulate the invasive potential of trophoblasts, and therefore may play an important role in early placental development. Our findings may contribute to the understanding of the pathophysiology of diseases associated with shallow placentation, such as pre-eclampsia.     

Vascular endothelial growth factor gene polymorphisms in Turkish patients with sarcoidosis

Polymorphism at +813 locus of vascular endothelial growth factor (VEGF) gene is considered to decrease predisposition to sarcoidosis. Our study aimed to investigate the roles of this polymorphism in the development and extent of sarcoidosis. We examined polymorphisms of the VEGF gene in 90 cases with histopathological diagnosis of sarcoidosis and in 110 healthy subjects. VEGF +813 gene polymorphisms were determined using a polymerase chain reaction-based method after DNA isolation. A significant increase in the frequency of the T allele was found in healthy subjects (odds ratio 0.55; 95% confidence interval 0.32-0.97, P<0.05). Our results suggest that increase in rarer T allele at + 813 locus of VEGF gene may diminish susceptibility to sarcoidosis in Turkish population.     

Vascular endothelial growth factor in children with cyanotic and acyanotic and congenital heart disease

Introduction

Vascular endothelial growth factor is a potent stimulator of angiogenesis. Children with cyanotic congenital heart disease often experience the development of widespread formation of collateral blood vessels, which may represent a form of abnormal angiogenesis resulting in increased morbidity and mortality. We undertook the present study to determine whether children with cyanotic congenital heart disease have elevated serum levels of vascular endothelial growth factor compared to children with acyanotic heart disease.

Material and methods

Serum was obtained from 35 children with cyanotic congenital heart disease and 30 children with acyanotic heart disease. Vascular endothelial growth factor levels were measured in the serum of these patients by sandwich enzyme immunoassay.

Results

Vascular endothelial growth factor was significantly elevated in children with cyanotic congenital heart disease compared to children with acyanotic heart disease (150.3 ±48.1 vs. 85.4 ±18.7 pg/ml, respectively, p < 0.001). In the cyanotic group, oxygen saturation (SaO₂) was negatively correlated with VEGF (r=–0.631, p < 0.001) while haemoglobin was positively correlated (r=0.781, p = 0.007). No significant correlations were found in the acyanotic group.

Conclusions

Children with cyanotic congenital heart disease have elevated systemic levels of vascular endothelial growth factor directly related to the degree of cyanosis (SaO₂ and haemoglobin levels). These findings suggest that the widespread formation of collateral vessels in these children may be mediated by vascular endothelial growth factor.     

Vascular endothelial growth factor gene polymorphisms and recurrent pregnancy loss

PROBLEM: To be successful, pregnancy must induce its own blood supply through angiogenesis and vascular endothelial growth factor (VEGF) is the best characterized regulator of angiogenesis and one polymorphism of the VEGF gene, -1154, has been suggested to be associated with recurrent spontaneous abortion. The aim of this study was to confirm or refute the relationship of VEGF -1154 to recurrent pregnancy loss (RPL). METHOD OF STUDY: Buccal swabs were obtained from 152 women with history of two or more consecutive spontaneous abortions and 65 control women. DNA was extracted from the buccal swabs and analyzed for the presence of the VEGF -1154A/A gene. RESULTS: The frequency of homozygosity of the VEGF -1154A gene was significantly higher among women experiencing RPL compared with fertile control women (16% versus 6%, P < 0.05). CONCLUSION: Homozygosity of the VEGF -1154A gene may serve as a susceptibility factor affecting for RPL.     

Vascular endothelial growth factor expression correlates with tumour grade and vascularity in gliomas

AIMS: Tumour vascularity and vascular endothelial growth factor (VEGF) expression were studied in 41 primary brain tumours of astrocytic and oligodendroglial origin, in order to define the potential role of VEGF in the vascularization and growth of these tumours. METHODS AND RESULTS: Two commercial monoclonal antibodies to the VEGF protein (from R&D Systems and NeoMarkers), raised against different isoforms, were utilized. Each monoclonal antibody consistently detected the expression of VEGF in different cell types. The R&D Systems antibody only produced surface staining of endothelial cells in tumour capillaries, whereas staining with the Neomarkers antibody was largely confined to tumour cell cytoplasm. High levels of staining were seen with the R&D Systems and NeoMarkers antibodies in 13 and 14 of 15 glioblastomas, respectively, four and three of five oligodendrogliomas, four and seven of 10 anaplastic astrocytomas, one and three of six low-grade astrocytomas and none and none of five pilocytic astrocytomas. There was a close correlation between VEGF expression, tumour vascularity and grade. CONCLUSIONS: These findings support a role for VEGF in the angiogenesis of glioblastoma, anaplastic astrocytoma and oligodendroglioma. The distinct immunoreactivities of the two commercial monoclonal antibodies indicate either there is expression of different splice variants of VEGF or that the epitopes are differentially revealed during synthesis, secretion and receptor-binding of the growth factor. This highlights the importance of using more than one antibody in the evaluation of tissue VEGF expression.     

Vascular endothelial growth factor in tumor tissue and blood serum from patients with breast cancer

Enzyme immunoassay showed that the content of free vascular endothelial growth factor increases in tumor cytosols and blood serum from patients with breast cancer. A positive correlation was found between the contents of vascular endothelial growth factor in tumor cytosols and blood serum. After removal of the tumor the content of vascular endothelial growth factor decreased only in 49% patients. It should be emphasized that changes in these parameters did not depend on their initial values.     

Vascular endothelial growth factor gene polymorphisms in spontaneously aborted fetuses

Citation Jeon YJ, Kim JH, Rah HC, Kim SY, Yoon TK, Choi DH, Cha SH, Shim SH, Kim NK. Vascular endothelial growth factor gene polymorphisms in spontaneously aborted fetuses. Am J Reprod Immunol 2011; 66: 544–553 Problems The VEGF?1154G>A polymorphism has been reported to be a genetic risk factor for recurrent spontaneous abortion in various studies; however, these studies have focused on genetic analyses of pregnant women rather than aborted fetuses. To evaluate and confirm the association between the VEGF?1154G>A polymorphism and spontaneous abortion, we focused on the relationship between four polymorphisms in the VEGF gene (?2578C>A, ?1154G>A, ?634G>C, and 936C>T) and spontaneously aborted fetuses (SAFs). Method of study The subjects included 118 SAFs at <20 weeks gestation and 380 normal controls consisting of children and adults. The polymorphisms were genotyped by polymerase chain reaction–restriction fragment length polymorphism analysis. Results Spontaneously aborted fetuses exhibited significantly different frequencies of the ?2578CA+AA/?634CC and ?1154GA+AA/?634CC combined genotypes compared with control subjects. The frequency of the ?2578A/?1154A/?634C/936C haplotype was significantly higher in SAFs. Conclusions VEGF genes ?2578CA+AA/?634CC and ?1154GA+AA/?634CC in the fetus are possible risk factors for spontaneous abortion.     

Vascular endothelial growth factor up-regulation and bronchial wall remodelling in asthma

BACKGROUND: There is increasing in vitro evidence to support a role for vascular endothelial growth factor (VEGF), a major regulator of angiogenesis, as a mediator of fibrosis associated with neovascularization. OBJECTIVE: We tested the hypothesis that VEGF is involved both in increased airway mucosal vascularity and in the subepithelial fibrosis of asthmatic patients. METHODS: Bronchial biopsies were performed in 24 asthmatic patients and eight healthy controls. Immunostaining, using computerized image analysis, was performed using monoclonal antibodies against VEGF(+) cells, type IV collagen, to outline the basement membrane thickness, and tryptase and EG2, to identify mast cells and eosinophils, respectively. RESULTS: The counts of VEGF(+) cells (P<0.05), mast cells and EG2(+) cells (both P<0.01) were higher in asthmatics than in controls. The number of vessels, the vascular area in the lamina propria, and the basement membrane thickness were significantly higher in asthmatics than in healthy volunteers (P<0.01). Moreover, in asthmatic patients, the number of VEGF(+) cells was significantly related to the number of vessels (P<0.01), to mast cells (P<0.01) and to basement membrane thickness (P<0.01). A colocalization study also revealed that mast cells were a relevant cellular source of VEGF. High doses of inhaled fluticasone propionate significantly reduced VEGF(+) cells (P<0.05), vessel number (P<0.05), vascular area (P<0.05) and basement membrane thickness (P<0.05) in a subgroup of asthmatic patients. CONCLUSIONS: This study shows that VEGF, in addition to being involved in the vascular component of airway remodelling, may play a role in the thickening of the basement membrane in asthma.     

Vascular endothelial growth factor and neovascularization in astrocytic tumors

It has been widely recognized that the vascular structure is an important factor when making a histopathological diagnosis and assessing the malignancy potential, especially of astrocytic tumors. The vascular endothelial growth factor (VEGF), which is thought to be regulated by the p53 gene, is a regulation factor for tumor neovascularization. The relationship between VEGF distribution and neovasculature was studied in 42 cases of astrocytic tumors (grades 1–4), which were obtained from surgical material, and the St Anne-Mayo grading system was applied. The relationship between the labeling indices (LI) of VEGF and LI of p53 protein in tumor cells was also studied using immunohistochemistry. The VEGF LI in high-grade malignancy potential tumors, such as grade 3 and grade 4 tumors, was significantly higher than those that were low grade. In grade 4 tumors, a significant correlation between the VEGF LI and the proliferation indices of endothelial cells of neovasculatures was observed. No significant correlation was noted between p53 LI and VEGF LI, as well as p53 LI and histopathological grade. In astrocytic tumors, expression of VEGF may be correlated to tumor neovascularization, and can be considered as an indicator of malignancy potential in astrocytic tumors.     

Serum levels of macrophage colony stimulating, vascular endothelial, and placenta growth factor in relation to later clinical onset of pre-eclampsia and a small-for-gestational age birth

PROBLEM: The multisystem disorder of pre-eclampsia (PE) becomes manifest in late gestation, but the pathology originates in early pregnancy by the deleterious action of placental substances to the maternal endothelial system. These factors were searched for in the attempt to identify, as early as possible, the pregnancies with an increased risk of developing pre-eclampsia. The literature is equivocal regarding the usefulness of various markers including vascular endothelial growth factor (VEGF) and macrophage colony-stimulating factor (M-CSF). Results are often confounded by a varying fraction of pregnancies affected by foetal growth restriction (FGR) amongst the case and control groups. METHOD OF STUDY: In a nested case-control study we compared the serum levels of M-CSF, VEGF, and placenta growth factor (PLGF) in 23 pregnancies with subsequent mild PE without FGR and nine FGR pregnancies without PE with 40 matched controls at 17, 25, and 33 weeks of gestation cross-sectionally and longitudinally. RESULTS: VEGF levels were reduced in FGR but not in subsequently pre-eclamptic pregnancies at 17, 25, and 33 weeks. In contrast, PLGF was reduced in the PE but not in the FGR group. M-CSF did not differ between the three groups. CONCLUSION: Depending on which growth factor is found to be reduced, an early distinction can be made in terms of an increased risk for PE or FGR. Inconsistencies in the literature may reflect differences in PE disease severity between studies and the presence of a varying fraction of cases with FGR.     

Mifepristone-induced amenorrhoea is associated with an increase in microvessel density and glucocorticoid receptor and a decrease in stromal vascular endothelial growth factor

BACKGROUND: We have previously shown that the progesterone antagonist mifepristone is a contraceptive when given in a dose of 2 or 5 mg per day. The majority of women experience amenorrhoea rather than the irregular break through bleeding usually occurring with other estrogen-free contraceptive pills, such as progestogen-only pill (POP). We investigated the effects of low-dose mifepristone on endometrial parameters which may be associated with changes in endometrial function, such as microvasculature, vascular endothelial growth factor (VEGF) and glucocorticoid receptor (GR) content. METHODS AND RESULTS: Endometrial biopsies were collected from 16 women before (late proliferative phase) and 60 and 120 days after taking 2 or 5 mg mifepristone daily for 120 days. Seven of the eight women who received 2 mg mifepristone and all eight women who received 5 mg were amenorrhoeic during the study. Mean estradiol (E(2)) concentrations remained in the mid-proliferative range, and the majority (9/16) of women showed proliferative endometrial histology at 60 and 120 days following treatment. There was a significant increase in the density of the endometrial stroma (P < 0.05) and microvessels (P < 0.01) following 120 days of treatment. Immunocytochemistry showed that GR, hitherto localized specifically in endometrial stroma, was up-regulated in the nuclei of glands (P < 0.05) and surface (luminal) epithelium (P < 0.01) by 60 days and maintained at 120 days. There was a significant reduction in stromal VEGF protein expression by day 120 of treatment (P < or = 0.01). CONCLUSION: The high incidence of amenorrhoea in women taking mifepristone may be related to changes in the regulation of vascular function.     

Serum inhibin A and activin A are elevated prior to the onset of pre-eclampsia

Serum inhibin A and activin A concentrations increase in pre-eclampsia. We investigated the time courses of the changes in relation to the onset of the maternal syndrome and if their measurement could be useful for clinical prediction particularly in relation to early onset disease, the most severe of the clinical presentations. Serial samples were taken from 1496 healthy nulliparae. Changes in activin A and inhibin A were analysed in women with: early onset pre-eclampsia (n = 11), pre-eclampsia delivering at 34-36 weeks (n = 14), term pre-eclampsia (n = 25) and gestational hypertension (n = 25); and in a subset with uncomplicated pregnancies (n = 25). Serum inhibin A and activin A were increased in all groups prior to pre-eclampsia, before 20 weeks in those with early onset pre-eclampsia. Screening efficacy was determined at 15-19 and 21-25 weeks in all women who developed pre-eclampsia (n = 70) and randomly selected controls (n = 240). Predictive sensitivities were low (16-59%) but much better for early onset pre-eclampsia: 67 and 44% at 15-19 weeks and 89 and 89% at 21-25 weeks for inhibin A and activin A respectively. Hence, serum inhibin A and activin A concentrations increase before the onset of pre-eclampsia at gestational ages that depend on when pre-eclampsia develops. On their own such measures are unlikely to prove efficient for screening.     

Relaxin stimulates expression of vascular endothelial growth factor in normal human endometrial cells in vitro and is associated with menometrorrhagia in women

Although the role of the reproductive hormone, relaxin, in rodents is well documented, its potential contribution to human reproduction is less well defined. In this study, we examine the effects of relaxin on human endometrial cells in vitro and describe the clinical effects of relaxin on menstrual flow in women. In cultured endometrial cells, relaxin specifically induces the expression of an angiogenic agent, vascular endothelial growth factor (VEGF). cAMP is implicated as a second messenger involved in VEGF stimulation. VEGF expression is temporally regulated in the endometrium, and our results suggest that relaxin, which is secreted by the corpus luteum and is present in the endometrium during the menstrual cycle and pregnancy, may be involved in regulating endometrial VEGF expression. Relaxin was recently tested in a clinical trial for efficacy in the treatment of progressive systemic sclerosis, and was administered at levels up to 10 times higher than that measured during pregnancy. The most frequent relaxin-related adverse event reported during the course of the study was the onset of menometrorrhagia, defined in this study as heavier-than-usual or irregular menstrual bleeding. The intensification of menstrual flow observed in these patients is consistent with the hypothesis that relaxin mediates neovascularization of the endometrial lining.