Social psychogenic stress promotes the development of endometriosis in mouse  Sun-Wei Guo, Qi Zhang, Xishi Liu  Reproductive BioMedicine Online  Volume 34, Issue 3, Pages 225-239 (March 2017) DOI: 10.1016/j.rbmo.2016.11.012 Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 1 The set-up for the predatory stress. (A) The time schedule for the induction of predatory stress during the entire course of the experiment. To induce psychological stress mice in the STRESSED group were exposed to the one-year-old male cats for 24 h every other day from the second day after the endometriosis-inducing surgery for 14 days. (B) The cage-in-cage set-up for the induction of predatory stress. The predator, the cat, was housed in a large outer cage, constantly watching its prey, the mice, which were housed in a small inner cage. (C) The time schedule for the 3 predatory ‘shifts’ in a time span of 24 h. This set-up was intended to avoid habituation and ensure constant stress. The predator cat was ‘on duty’ of harassment for 8 h and replaced by another cat during the 24-h stress period. Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 2 The effect of psychological stress on mice. (A) Mean plasma corticosterone concentrations. Mice in the STRESSED group had higher plasma CORT concentrations than other groups of mice. (P = 0.0003, R2 = 0.62). (B) Mean bodyweight. Mice in the STRESS group had significantly lower bodyweight at day 14 among the four groups (P = 1.3 × 10−5, R2 = 0.54). Boxplot of H3K9me3 (C) and H3K4me3 (D) staining levels in the dentate gyrus (DG) and H3K9me3 (E) staining in the CA1 region of the hippocampus among different treatment groups. (F) Boxplot of total lesion size in stressed and unstressed mice. The mice subjected to the psychological stress had significantly increased lesion size as compared with those without stress (P = 0.0034). (G) Mean hotplate latency. The presence of endometriosis and stress was negatively associated with the hotplate latency. Mice in stressed (STRS) and unstressed (UNSTRS) groups had undergone endometriosis-inducing surgery, while mice in the SHAM group underwent non-endometriosis-inducing surgery. Mice in unstressed (UNSTRS), SHAM and control (CTL) groups were not exposed to stress. *: P < 0.05; **: P < 0.01. The statistical significance level was based on a multiple linear regression analysis. CTL = control; SHAM = Sham surgery; STRS = Stressed; UNSTRS = Unstressed. Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 3 Immunoreactivity staining results showing epigenetic changes in the hippocampus. (A) Representative immunoreactivity staining of H3K9me3 in the hippocampal dentate gyrus (DG) and CA1 subregions in different groups of mice. H3K9me3 was localized in the cell nucleus. Magnification: × 100. Scale bar = 502 µm; ×200, scale bar = 251 µm. (B) Representative immunoreactivity staining of H3K4me3 in the hippocampal DG subregion in different groups of mice. H3K4me3 was localized in the cell nucleus. Magnification: ×100 (left column). Scale bar = 502 µm; ×200 (right column), Scale bar = 251 µm. Mice in stressed (STRS) and unstressed (UNSTRS) groups had undergone endometriosis-inducing surgery, while mice in the SHAM group underwent non-endometriosis-inducing surgery. Mice in unstressed (UNSTRS), SHAM and control (CTL) groups were not exposed to stress. Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 4 Immmunoreactivity staining of different markers in ectopic lesions in different groups. (A) Representative immunostaining of ADRB2 in endometrium in CONTROL and SHAM mice and in ectopic endometrium in STRESSED and UNSTRESSED mice. ADRB2 and DRD2 immunoreactivity was both seen primarily in glandular epithelial cells and was localized in the cytoplasm. Scale bar = 125 µm. (B) Representative immunostaining of DRD2, VEGF, CD31, CD41, F4/80, PCNA and α-SMA in the ectopic lesions in UNSTRESSED and STRESSED groups. VEGF immunoreactivity was seen primarily in glandular epithelial cells and was localized in the cytoplasm. CD31 immunostainings were seen mostly in vascular endothelial cells. CD41 shows the extent of platelet aggregation and F4/80 immunoreactivity represents the extent of macrophage infiltration. PCNA immunoreactivity was seen both in glandular epithelial cells and stromal cells were localized in the cell nucleus, but the change of immunoreactivity in glandular epithelial cells was more obvious. α-SMA staining were seen mostly in the stromal component of the ectopic lesions. Scale bar = 125 µm. Mice in stressed (STRS) and unstressed (UNSTRS) groups had undergone endometriosis-inducing surgery, while mice the SHAM group underwent non-endometriosis-inducing surgery. Mice in unstressed (UNSTRS), SHAM and control (CTL) groups were not exposed to stress. Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 5 Boxplots of immunostaining levels of (A) ADRB2 in ectopic endometrium in STRESSED and UNSTRESSED mice and in endometrium in SHAM and control (CTL) mice, and (B) DRD2 staining levels, (C) VEGF staining levels, (D) CD31-MVD, (E) the extent of platelet aggregation (CD41), (F) the extent of macrophage infiltration (F4/80), (G) PCNA staining levels, and (H) α-SMA staining levels in ectopic endometrium. The statistical significance levels shown in the figures are for the difference between the STRESSED and UNSTRESSED groups. *: P < 0.05; **: P < 0.01; ***: P < 0.001 (Wilcoxon's rank test). Mice in stressed (STRS) and unstressed (UNSTRS) groups had undergone endometriosis-inducing surgery, while mice in the SHAM group underwent non-endometriosis-inducing surgery. Mice in unstressed (UNSTRS), SHAM and CTL groups were not exposed to stress. Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions

Figure 6 (A) Representative immunoreactivity against ADRB2 in control endometrium and eutopic and ectopic endometrium from women with ovarian endometriomas. Scale bar = 125 µm. (B) ADRB2 staining levels in control endometrium, eutopic and ectopic endometrium from patients with ovarian endometriomas; (C) Endometrial ADRB2 staining levels in women with different severity of dysmenorrhoea; (D) Lesional ADRB2 staining levels as a function of severity of dysmenorrhoea in women with ovarian endometriomas; (E) Scatter plot of lesional ADRB2 staining levels and the rASRM scores in women with ovarian endometriomas. In (C) and (D), the numeric shows the Spearman's correlation coefficient and its statistical significance level. The dashed line in (E) represents the linear regression, and the numeric shows the correlation coefficient and its statistical significance level. *: P < 0.05; **: P < 0.01; ***: P < 0.001; NS = not statistically significant (i.e. P > 0.05 by Wilcoxon rank test). Reproductive BioMedicine Online 2017 34, 225-239DOI: (10.1016/j.rbmo.2016.11.012) Copyright © 2016 Reproductive Healthcare Ltd. Terms and Conditions