Journal of Reproductive Immunology 146 (2021) 103338

Contents lists available at ScienceDirect

Journal of Reproductive Immunology

journal homepage: www.elsevier.com/locate/jri

Review article

Leptin concentrations in endometriosis: A systematic review and

meta-analysis
Dimitrios Rafail Kalaitzopoulos a, *, Ioannis G. Lempesis b, c, d, Nicolas Samartzis e,
Georgios Kolovos e, Ioannis Dedes a, Angelos Daniilidis f, Konstantinos Nirgianakis g,
Brigitte Leeners h, Dimitrios G. Goulis i, Eleftherios Pierre Samartzis a
a
Department of Gynecology, University Hospital Zurich, Frauenklinikstr. 10, CH 8091 Zurich, Switzerland
b
Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
c
Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
d
Department of Human Biology, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
e
Department of Gynecology and Obstetrics, Cantonal Hospital Schaffhausen, Geissbergstrasse 81, 8208, Schaffhausen, Switzerland
f
2nd University Department of Obstetrics and Gynecology, Hippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
g
Department of Obstetrics and Gynaecology, University Hospital of Bern, Inselspital, Friedbühlstrasse 19, 3010, Bern, Switzerland
h
Division of Reproductive Endocrinology, University Hospital Zurich, Frauenklinikstr. 10, CH 8091 Zurich, Switzerland
i
Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Endometriosis is an inflammatory condition, affecting mainly women of reproductive age. Leptin is
Endometriosis a regulator of food intake and energy expenditure, posing pleiotropic actions, and regulating immunity and
Endometrioma fertility. The aim of this study was to systematically review the literature regarding leptin concentrations in
Leptin
biological fluids and tissues of women with endometriosis, and to investigate and propose a possible role of leptin
Adiponectin
Leptin-binding protein
in the pathophysiology of endometriosis.
Leptin receptor Materials and methods: A systematic search of the literature was conducted in two electronic databases (MED­
Peritoneal fluid LINE, COCHRANE) and grey literature for original research articles on humans, published in any language.
Serum Results: Twenty-nine studies with 1291 women with endometriosis and 1664 controls were included in the
Plasma systematic review. Peritoneal fluid and follicular fluid leptin concentrations were higher in endometriosis
Follicular fluid compared with control group [mean difference (MD) 7.10, 95 % confidence interval (CI) 4.76 to 9.44 ng/mL, 18
studies), (MD 1.35, 95 % CI 0.54–2.17 ng/ml, 2 studies) respectively. No differences were evident in serum (MD
0.92, 95 % CI -0.84 to 2.68 ng/mL, 12 studies) or plasma (MD -0.95, 95 % CI -4.63 to 2.72 ng/mL, 3 studies)
between the groups. No meta-analysis was conducted for ovarian tissue leptin (2 studies).
Conclusions: This meta-analysis provided evidence for increased leptin concentrations in both peritoneal fluid and
follicular fluid of women with endometriosis compared with control; these differences were not present in the
serum or plasma. The above results support a potential pathophysiologic role for leptin in the local microen­
vironment while declines its use as a blood diagnostic marker. Furthermore, we propose a possible role of leptin
in the pathophysiology of endometriosis.

1. Introduction and infertility. The roles of genetic, environmental, and immunological

Endometriosis is an inflammatory condition, characterized by
endometrium-like lesions outside the uterine cavity (Kalaitzopoulos
et al., 2020; Zondervan et al., 2020). It mainly affects women of
reproductive age, with a prevalence ranging between 5 and 10 %
(Zondervan et al., 2020). The clinical phenotype includes pelvic pain
factors have been reported in the pathogenesis of endometriosis (Zon­
dervan et al., 2020); the latter remains to be fully elucidated. The extend
of the disease (peritoneal endometriosis, ovarian endometrioma, deep
infiltrating endometriosis) could partially explain the discrepancies in
clinical manifestations and pathophysiology (Chapron et al., 2019a;
Nirgianakis et al., 2020). As a hormone-depended tissue,

* Corresponding author.
E-mail address: dimkal1991@windowslive.com (D.R. Kalaitzopoulos).

https://doi.org/10.1016/j.jri.2021.103338
Received 10 February 2021; Received in revised form 21 April 2021; Accepted 25 May 2021
Available online 1 June 2021
0165-0378/© 2021 Elsevier B.V. All rights reserved.
D.R. Kalaitzopoulos et al.
endometrial-like lesions could be affected by a variety of circulating or
locally produced molecules, including sex steroids (Zondervan et al.,
2018). Apart from these hormones, evidence suggests the connection
with other molecules, such as the leptin.
Leptin is a 16-kDa peptide of 167 amino-acids. It constitutes the
seminal adipokine secreted by white adipose tissue (WAT); it is also
produced by other tissues, including the endometrium, placenta and
ovary (Margetic et al., 2002; Mantzoros et al., 2011; Friedman, 2019;
González et al., 2000; Lima-Couy et al., 2004). Its circulating concen­
trations are strongly positively correlated to WAT mass (Mantzoros
et al., 2011). Leptin is circulating in free form and bound to proteins. Its
actions are mediated via binding to leptin receptors (LepRb/ ObR, a
cytokine family receptor), located in the central nervous system and
various peripheral tissues (Fasshauer and Bluher, 2015; Mantzoros et al.,
2011; Friedman, 2019; Kitawaki et al., 2000). It is a key regulator of
food intake and energy expenditure, providing feedback regarding en­
ergy storage in the body, and it poses pleiotropic actions by regulating
immunity and fertility (Dardeno et al., 2010; Lempesis et al., 2019;
Fasshauer and Bluher, 2015; Celik et al., 2015). Lately, it has been
associated with inflammatory and autoimmune disorders, including
endometriosis (Chapron et al., 2019b; Zondervan et al., 2020, 2018; La
Cava et al., 2004), (Gonçalves et al., 2015; Matarese et al., 2000; Carino
et al., 2008; Gonzalez et al., 2006; Milewski et al., 2008; Wu et al., 2002;
Mitchell et al., 2005).
The aim of this study was to systematically review the literature
regarding leptin concentrations in biological fluids and tissues of women
with endometriosis, and to investigate and propose a possible role of
leptin in the pathophysiology of endometriosis.
2. Materials and methods
This systematic review was conducted based on the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
guidelines (Moher et al., 2009; Shamseer et al., 2015) and published via
PROSPERO (ID CRD42021237453).
2.1. Search criteria
A search of the literature for eligible studies was conducted in two
electronic databases, namely MEDLINE, COCHRANE, and grey litera­
ture. Combinations of the terms, “leptin”, “adiponectin”, “leptin-binding
protein”, “leptin receptor”, “endometriosis” and “endometrioma” were
used. Studies until 01.11.2020, in all languages were included. Refer­
ence sections of all relevant studies, key journals, and abstracts from
major annual meetings in the fields of Endocrinology and Gynecology
were reviewed for relevant studies. Two investigators (D-RK, KG)
completed the main search independently. Any discrepancy was solved
by consultating an investigator not involved in the initial procedure
(IGL).
2.2. Inclusion and exclusion criteria
Inclusion/exclusion criteria were established before the literature
search. The following inclusion criteria were applied: 1) case-control
studies, where both cases (endometriosis) and controls were assessed;
2) description of the methods of endometriosis diagnosis and assess­
ment, and 3) data on serum, plasma, peritoneal fluid, follicular fluid or
ovarian tissue leptin concentrations. Exclusion criteria were: 1) data
from sources other than original full publications (reviews, abstracts,
oral presentations, national or local health statistics), 2) studies without
control group, 3) studies with outcomes other than leptin concentra­
tions, such as genetic variations of leptin-related genes.
2.3. Data extraction
Two reviewers (D-RK, KG) extracted information independently
2
Journal of Reproductive Immunology 146 (2021) 103338
from each study, using a standardized data extraction form, which
included general study characteristics and patients’ clinical character­
istics [author, year of publication, country, design, number of patients
and controls, age and body mass index (BMI) of patients and controls,
method of endometriosis assessment, severity of endometriosis accord­
ing to the revised American Society of Reproductive Medicine (rASRM)
score, leptin assay). All study outcomes were recorded and double-
checked. Disagreement was resolved by consensus.
2.4. Outcome measures
The outcome was serum, peritoneal fluid, plasma, follicular fluid and
ovarian tissue leptin concentrations.
2.5. Risk of bias and study quality
The RTI Item Bank Tool for observational studies was used (Viswa­
nathan et al., 2013) to assess the quality of the included studies.
Assessment for different types of bias (selection, performance, detection,
attrition, reporting) for every study was performed independently by
two investigators (D-RK, KG). Any discrepancy was solved by consulting
an investigator not involved in the initial procedure (IGL).
2.6. Statistics
Mean difference (MD) for continuous outcomes and their respective
95 % confidence intervals (CI) were calculated for all studies included in
the meta-analyses (DerSimonian and Laird, 1986). Mean (MD) and
Standard Deviation (SD) were converted from Median and Interquartile
Range (IQR) according to Wan et al. (Wan et al., 2014). Heterogeneity
among the outcomes of the studies was examined by the I2 index (Egger
et al., 2001), with I2 ≥50 % indicating high heterogeneity (Higgins et al.,
2003). A random-effects model was applied in every outcome. Publi­
cation bias was tested by the Harbord-Egger’s test (Harbord et al.,
2006). Statistical significance was set at a p-level of 0.05. The
meta-analysis was conducted using the Review Manager (RevMan) for
Mac (version 5.3. Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014). The report of the study was com­
plemented in adherence with the Preferred Reporting Items for Sys­
tematic Reviews and Meta-Analyses (PRISMA) group standards for
reporting meta-analysis of observational studies (Moher et al., 2009).
2.7. Ethics
No ethics board approval was requested, as the data were extracted
from published papers.
3. Results
The study flow-chart is presented in in Fig. 1. Twenty-nine studies
(endometriosis: n = 1291; controls: n = 1664) were included in the
systematic review (Table 1 and Supplementary Tables 1–2), examining
leptin concentrations in serum (n = 12), peritoneal fluid (n = 18),
plasma (n = 3), follicular fluid (n = 3) and ovarian tissue (n = 2). Some
studies examine differences in leptin concentrations between control
and endometriosis groups both in serum and peritoneal fluid (n = 5)
(Matarese et al., 2000; Wertel et al., 2005; Pandey et al., 2010; Gon­
çalves et al., 2015, Osman HG, 2010), plasma and peritoneal fluid
(n = 2) (Gungor et al., 2009; Gogacz et al., 2001), serum and follicular
fluid (n = 1) (Wu et al., 2003) and serum, peritoneal fluid and ovarian
tissue (n = 1) (Zendron et al., 2014). The risk of bias assessment for each
study is presented in Table 2.
3.1. Serum leptin concentrations (Fig. 2)
There was no evidence of a difference between endometriosis and
D.R. Kalaitzopoulos et al.
Fig. 1. Study flow chart.
control groups (12 studies, 330 vs. 247 women; MD 0.92, 95 % CI -0.84
to 2.68 ng/mL). In addition no difference was found between endome­
triosis rASRM I–II and control group (4 studies, 46 vs. 85 women; MD
5.92, 95 % CI -4.71 to 16.55 ng/mL), endometriosis rASRM III-IV and
control group (7 studies, 91 vs. 131 women; MD 0.99, 95 % Cl -1.82 to
3.80 ng/mL) or endometriosis rASRM I–II and rASRM III-IV (4 studies,
46 vs. 44 women; MD 4.59, 95 % CI -4.53 to 13.70 ng/mL).
3
Journal of Reproductive Immunology 146 (2021) 103338
3.2. Peritoneal fluid leptin concentrations (Fig. 3)
Leptin concentrations were higher in endometriosis compared with
control group (18 studies, 531 vs. 331 women; MD 7.10, 95 % CI
4.76–9.44 ng/ml). In addition, leptin concentrations were higher in
endometriosis rASRM I–II compared with controls (12 studies, 207 vs.
246 women; MD 8.67, 95 % CI 4.35–13.00 ng/ml) and in endometriosis
rASRM III-IV vs compared with controls (13 studies, 218 vs. 238 women;
MD 5.90, 95 % CI 3.24, 8.56 ng/mL). Finally, no difference was found
 Table 1
Main findings of the studies included in the qualitative synthesis.
id Study Main findings

D.R. Kalaitzopoulos et al.

Serum leptin
• Higher serum leptin concentrations in patients with endometriosis compared with controls
1. Matarese et al., 2000
• Higher serum leptin concentrations in the earlier stages compared with advanced stage disease
2. Matalliotakis et al., 2000 • Danazol and leuprolide increased the serum leptin concentrations (unclear mechanism)
3. Viganò et al., 2002 • Similar serum leptin concentrations in patients with endometriosis compared with controls
4. Wu et al., 2003 • Similar serum leptin concentrations between patients with endometriosis and tubal infertility
5. Wertel et al., 2004 • Similar serum leptin concentrations between patients with endometriosis and unexplained infertility
• A three-marker panel (CA-125, macrophage chemotactic protein-1, leptin) could diagnose endometriosis with a sensitivity of 89 %
6. Seeber et al., 2008
• A four-marker panel (CA-125, macrophage chemotactic protein-1, leptin, macrophage migration inhibitory factor) could diagnose endometriosis with a sensitivity of 93 %
7. Pandey et al., 2010 • Similar serum leptin concentrations between patients with endometriosis and controls
8. Osman et al., 2010 • Similar serum leptin concentrations between patients with endometriosis and controls
9. Ozhan et al., 2014 • Similar serum leptin concentrations between patients with endometriosis compared with controls
10. Zendron et al., 2014 • Similar serum leptin concentrations between patients with endometriosis compared with controls
11. Chmaj-Wierzchowska et al., 2015 • Similar serum leptin concentrations between patients with endometrioma compared with teratoma.
• Higher serum leptin concentrations in patients with endometriosis compared with controls
12. Gonçalve et al., 2015
• Higher serum leptin concentrations in patients with ovarian implants compared with patients without
13. Hussein et al., 2020 • Higher serum leptin concentrations in patients with endometriosis compared with controls

Peritoneal fluid (PF) leptin

1. Matarese et al., 2000 • Higher PF leptin concentrations in patients with endometriosis compared with controls
• Higher PF leptin concentrations in patients with endometriosis compared with controls
2. De Placido et al., 2001
• Higher PF leptin concentrations in patients with endometriosis rAFS I-II compared with patients with endometriosis rAFS III-IV
3. Gogacz et al., 2001 • Similar PF leptin concentrations in patients with endometriosis, compared to women with unexplained infertility
• Higher PF leptin concentrations in patients with endometriosis compared with controls
4. Mahutte et al., 2003
• Higher PF leptin concentrations in patients with superficial, minimal-mild stage endometriosis compared with patients with advanced stage of endometriosis
• Similar PF leptin concentrations between patients with endometriosis compared with women with unexplained infertility
5. Wertel et al., 2004
• Higher PF leptin concentrations in patients with endometriosis rAFS III-IV compared with patients with minimal stage of endometriosis
• Similar PF leptin concentrations between patients with endometriosis and controls
6. Barcz et al., 2008
• Similar PF leptin concentrations among patients with different endometriosis stages
4

• Higher PF leptin concentrations in patients with endometriosis compared with controls

7. Milewski et al., 2008
• No correlation between endometriosis stage and PF leptin concentrations
• Higher PF leptin concentrations in patients with ovarian endometrioma compared with controls
8. Alviggi et al., 2009
• Higher PF leptin concentrations in patients with superficial endometrioma compared with patients with deep endometrioma
• Higher PF leptin concentrations in patients with endometriosis compared with controls
9. Gungor et al., 2009
• Positive correlation between PF leptin concentrations and the endometriosis stage (r = 0.51, p = 0.01)
10. Wu et al., 2010 • Higher PF leptin concentrations in patients with endometriosis compared with controls
11. Pandey et al., 2010 • Higher PF leptin concentrations in patients with endometriosis compared with controls
12. Tao et al., 2011 • Similar PF leptin concentrations in patients with endometriosis compared with controls
13. Osman et al., 2010 • Higher PF leptin concentrations in patients with endometriosis compared with controls
• Higher PF leptin concentrations in patients with endometriosis compared with controls
14. Malhotra et al., 2012
• Lower PF leptin concentrations in patients with endometrioma compared with patients with implants
Higher PF leptin concentrations in patients with endometriosis compared with patients with idiopathic infertility and controls

Journal of Reproductive Immunology 146 (2021) 103338

•
15. Bedaiwy et al., 2012
• PF leptin concentrations positively correlated with the stage of endometriosis (r = 0.45, p = 0.03) and pelvic pain in patients with endometriosis (r = 0.49, p = 0.001)
16. Rathore et al., 2014 • Higher PF leptin concentrations in patients with endometriosis compared with controls
17. Zendron et al., 2014 • Similar PF leptin concentrations in patients with endometriosis compared with controls
• Similar PF leptin concentrations in patients with endometriosis, compared to control group
18. Gonçalve et al., 2015
• Higher leptin concentrations in women without ovarian implants

Follicular fluid (FF) leptin

1. Wu et al., 2003 • Similar FF concentrations of leptin in women with endometriosis compared to controls
2. Wunder et al., 2005 • Similar FF leptin concentrations between IVF patients with and without endometriosis
3. Radel Kucera et al., 2018 • Lower FF concentrations of leptin in women with endometriosis compared to controls

Plasma leptin
1. Gogacz et al., 2001 • Similar plasma leptin concentrations between women with endometriosis and unexplained infertility
2. Gungor et al., 2009 • Similar plasma leptin concentrations between women with different endometriosis stages
3. Shah et al., 2013 • Similar plasma leptin concentrations in women with endometriosis compared to controls

Ovarian tissue (OS) leptin

1. Choi et al., 2013 • Expression rates of leptin were higher in ovarian endometrioma compared with normal endometrium
2. Zendron et al., 2014 • Similar OS leptin concentrations between patients with endometrioma and controls
D.R. Kalaitzopoulos et al. Journal of Reproductive Immunology 146 (2021) 103338

Table 2
Risk of bias assessment (QUIPS Tool).
id Study (First author, Year) Study Study Prognostic factor Outcome Study Statistical Overall
participation attrition measurement measurement confounding analysis assessment

Leptin and endometriosis

1. Mataresse et al., 2000 L L L L L L L
2. Matalliotakis et al., 2000 L L L L M L L
3. Gogacz et al., 2001 L L L L M L L
4. Viganò et al., 2002 L L L L M L L
5. De Placido et al., 2001 L L L L L L L
6. Wu et al., 2003 L L L L L L L
7. Mahutte et al., 2003 L L L L M L L
8. Wertel et al., 2004 L L L L L L L
9. Wunder et al., 2005 L L L L L L L
10. Bedaiwy et al., 2006 L L L L L L L
11. Seeber et al., 2008 L L L L M L L
12. Barcz et al., 2008 L L L L L L L
13. Milewsky et al., 2008 L L L L L L L
14. Alviggi et al., 2009 L L L L L L L
15. Gungor et al., 2009 L L L L L L L
16. Osman et al., 2010 L L L L L L L
17. Wu et al., 2010 L L L L L L L
18. Pandey et al., 2010 L L L L L L L
19. Tao et al., 2011 L L L L L L L
20. Malhotra et al., 2012 L L L L L L L
21. Shah et al., 2013 L L L L L L L
22. Choi et al., 2013 L L L L L L L
23. Rathore et al., 2014 L L L L L L L
24. Zendron et al., 2014 L L L L M L L
25. Ozhan et al., 2014 L L L L L L L
26. Chmaj-Wierzchowska et al., L L L M M L L
2015
27. Gonçalve et al., 2015 L L L L M L L
28. Radel Kucera et al., 2018 L L L L M L L
29. Hussein et al., 2020 L L L L M L L

L: low risk; M: moderate risk; H: high risk.

between endometriosis rASRM I–II and rASRM III-IV (10 studies, 171
vs. 182 women; MD 2.69, 95 % CI -2.12 to 7.50 ng/mL).
3.3. Plasma leptin concentrations (Fig. 4)
There was no evidence of a difference between endometriosis and
control groups (2 studies, 69 vs. 305 women; MD -0.95, 95 % CI -4.63 to
2.72 ng/mL).
3.4. Follicular fluid leptin concentrations (Fig. 5)
Leptin concentrations were higher in endometriosis compared with
control group (2 studies, 69 vs. 305 women; MD 1.35, 95 % CI
0.54–2.17 ng/ml).
difference for the studies which used RIA (3 studies, 67 vs. 49 women;
MD 4.04 ng/mL, CI 95 % -4.77 to 12.84 ng/mL). Finally, both studies
with small (<40) and large (≥ 40) sample sizes showed higher leptin
concentrations in endometriosis compared with control group: 8 studies,
132 vs. 122 women; MD 7.85, CI 95 % 3.70–12.00 ng/ml, and 10
studies, 399 vs. 209 women; MD 6.61, CI 95 % 3.01–10.20 ng/ml).
Higher leptin concentrations were found in endometriosis compared
with control group adjusted for BMI (14 studies, 432 vs. 259 women; MD
9.02, 95 % CI 6.19, 11.84 ng/mL).
3.6. Publication bias
No publication bias was detected for the study outcome (Supple­
mentary Fig. 1).

3.5. Subgroup analyses 4. Discussion

Concerning serum leptin concentrations (Fig. 2), no differences were
found between endometriosis and control groups, when the studies were
classified according to sample size (<40 vs. ≥ 40), BMI (< 25 vs. ≥
25 kg/m2) and leptin assay [radioimmunoassay (RIA) vs. enzyme-linked
immunosorbent assay (ELISA)]. In addition, there was no difference
between endometriosis and control groups adjusted for BMI (8 studies,
242 vs. 187 women; MD -0.14, 95 % CI -1.45 to 1.18 ng/mL).
Concerning peritoneal fluid leptin concentrations (Fig. 3), these were
higher for studies with mean BMI < 25 kg/m2 in endometriosis
compared with control group (16 studies, 423 vs. 297 women; MD 7.15
CI 95 % 4.71–9.59 ng/ml), whereas there was no difference for the
studies with mean BMI ≥ 25 kg/m2 (2 studies, 108 vs. 34 women; MD
6.63, CI 95 % -7.25 to 20.52 ng/mL). Studies which used ELISA as the
leptin assay showed higher leptin concentrations in endometriosis
compared with control group (15 studies, 464 vs. 282 women; MD
7.59 ng/mL, CI 95 % 5.11–10.07 ng/ml), whereas there was no
This systematic review and meta-analysis presented the available
literature on the association between endometriosis and leptin concen­
trations. It provided evidence for higher peritoneal fluid and follicular
fluid but not serum or plasma leptin concentrations in women with
endometriosis compared with controls. One recent meta-analysis
showed higher leptin levels in peritoneal fluid in women with endo­
metriosis in comparison to control groups and no difference as far as
serum is concerned. This meta-analysis includes only 18 studies and no
outcomes about follicular fluid and plasma are reported (Tian et al.,
2020). Another meta-analysis showed higher circulating levels of leptin
in women of endometriosis, without separating the studies for peritoneal
fluid and serum (Zhao et al., 2021).
Obese individuals have higher circulating leptin concentrations
compared with lean ones, indicating leptin resistance (Park and Ahima,
2015). Endometriosis has been associated with low BMI and a low
waist-to-hip ratio (Shafrir et al., 2018). In the present study, after

5
D.R. Kalaitzopoulos et al.
Fig. 2. Serum leptin concentrations.
adjusting the endometriosis and control groups for BMI, the difference in
leptin concentrations remained significant for peritoneal fluid. In addi­
tion, the peritoneal fluid leptin concentrations remained higher in
endometriosis compared with the control group only for studies with a
normal mean BMI (<25 kg/m2). Finally, peritoneal fluid leptin con­
centrations were comparable between subgroups with moderate
(rASRM I–II) and advanced (rASRM III-IV) endometriosis. All these data,
taken together, indicates a local production of leptin into the peritoneal
fluid, which is independent of the severity of the disease.
The leptin assay is of notice. In peritoneal fluid, leptin concentrations
measured by ELISA were higher in endometriosis compared with con­
trols, whereas this was not the case with RIA. This discrepancy could be
attributed to insufficient detection limit of RIA to measure concentra­
tions in the peritoneal fluid, similarly to the cerebrospinal fluid (Imag­
awa et al., 1998).
6
Journal of Reproductive Immunology 146 (2021) 103338
As leptin production is increased in obesity and potentially mediates
pro-inflammatory messages, it could be hypothesised that increased
visceral adipose tissue is related to endometriosis (Matarese et al.,
2000). However, among the risk factors for endometriosis are low BMI
and low waist-to-hip ratio (Shafrir et al., 2018). This discrepancy could
be partially explained by the body fat distribution, as the location of the
adipocytes may affect the secretion of adipokines and have a different
impact on the risk for a particular disease (Fasshauer and Bluher, 2015;
Manolopoulos et al., 2010) Leptin concentrations are higher in women
compared to men, and this could be explained by a relative leptin
resistance (Marshall et al., 2000).
In the present study, serum leptin concentrations were comparable
among endometriosis and control groups. This is of interest and may
support a potential mechanistic link between peritoneal fluid leptin and
endometriosis’ niche and not circulating levels (Fig. 5). Both leptin and
D.R. Kalaitzopoulos et al. Journal of Reproductive Immunology 146 (2021) 103338

Fig. 3. Peritoneal fluid leptin concentrations.

Fig. 4. Plasma leptin concentrations.

7
D.R. Kalaitzopoulos et al.
Fig. 5. A potential mechanistic role for leptin in the endometriotic niche.
leptin receptors are expressed in normal endometrial cells (González
et al., 2000) and endometriomas (Choi et al., 2013; Nácul et al., 2013).
Leptin was shown to induce in vitro human endometriotic epithelial cells
growth, migration and invasion, involving the JAK2/STAT3 pathway
(Oh et al., 2012; Ahn et al., 2015). Ablation of leptin signalling was
shown to disrupt endometriosis-like lesions in mice (Styer et al., 2008).
Based on the peritoneal fluid and follicular fluid differences showed in
this meta-analysis and the available mechanistic studies, it could be
hypothesized that leptin is locally produced and targets the endo­
metriotic lesion’s cells and immune cells, acting in a paracrine or
autocrine manner. Various cells of the innate and adaptive immunity
express leptin receptors, something previously shown for macrophages
in patients with endometriosis (La Cava, 2017; Wu et al., 2010). Overall,
leptin could act as a mediator of inflammatory messages.
This meta-analysis was conducted according to PRISMA guidelines.
The observational design of the included studies and their heterogeneity
are two of sources of potential bias in our study. The heterogeneity of the
included studies was addressed by sensitivity analysis for potential
confounders (BMI, sample size, leptin assay, stage of endometriosis).
In conclusion, this systematic review and meta-analysis provided
evidence for increased leptin concentrations in peritoneal fluid and
follicular fluid of women with endometriosis compared to controls,
whereas this difference was not apparent in serum and plasma. Despite
the relatively large number of the available studies, the heterogeneity
among them has to be taken into consideration; it could be attributed to
differences in demographical factors, fat distribution and severity of the
illness. The high leptin concentrations in the peritoneal fluid and
follicular fluid could indicate a novel mechanism of local leptin pro­
duction or resistance, which should be examined in future studies.
Funding
The authors received no financial support for the research.
Declaration of Competing Interest
The authors report no declarations of interest.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
8
Journal of Reproductive Immunology 146 (2021) 103338
online version, at doi:https://doi.org/10.1016/j.jri.2021.103338.
References
Ahn, J.-H., et al., 2015. Leptin promotes human endometriotic cell migration and
invasion by up-regulating MMP-2 through the JAK2/STAT3 signaling pathway. Mol.
Hum. Reprod. 21 (10), 792–802.
Alviggi, C., Clarizia, R., Castaldo, G., Matarese, G., Colucci, C.C., Conforti, S., Pagano, T.,
Revelli, A., De Placido, G., 2009. Leptin concentrations in the peritoneal fluid of
women with ovarian endometriosis are different according to the presence of a
’deep’ or ’superficial’ ovarian disease. Gynecol Endocrinol. 25 (9), 610–615. https://
doi.org/10.1080/09513590903015577. PMID: 19544117.
Barcz, E., Milewski, L., Radomski, D., Dziunycz, P., Kamiński, P., Roszkowski, P.I.,
Malejczyk, J., 2008. A relationship between increased peritoneal leptin levels and
infertility in endometriosis. Gynecol Endocrinol. 24 (9), 526–530. https://doi.org/
10.1080/09513590802288200. PMID: 18958774.
Bedaiwy, M.A., Falcone, T., Goldberg, J.M., Sharma, R.K., Nelson, D.R., Agarwal, A.,
2006. Peritoneal fluid leptin is associated with chronic pelvic pain but not infertility
in endometriosis patients. Hum Reprod. 21 (3), 788–791. https://doi.org/10.1093/
humrep/dei376. Epub 2005 Nov 3. PMID: 16269446.
Carino, C., et al., 2008. Leptin regulation of proangiogenic molecules in benign and
cancerous endometrial cells. Int. J. Cancer 123 (12), 2782–2790.
Celik, O., et al., 2015. Peptides: basic determinants of reproductive functions. Peptides
72, 34–43.
Chapron, C., et al., 2019a. Rethinking mechanisms, diagnosis and management of
endometriosis. Nat. Rev. Endocrinol. 15 (11), 666–682.
Chapron, C., et al., 2019b. Rethinking mechanisms, diagnosis and management of
endometriosis. Nat. Rev. Endocrinol. 15 (11), 666–682.
Chmaj-Wierzchowska, K., Kampioni, M., Wilczak, M., Sajdak, S., Opala, T., 2015. Novel
markers in the diagnostics of endometriomas: Urocortin, ghrelin, and leptin or
leukocytes, fibrinogen, and CA -125? Taiwan J Obstet Gynecol. 54 (2), 126–130.
https://doi.org/10.1016/j.tjog.2014.08.004. PMID: 25951715.
Choi, Y.S., et al., 2013. Expression of adiponectin, leptin, and their receptors in ovarian
endometrioma. Fertil. Steril. 100 (1), 135-141.e2.
Dardeno, T.A., et al., 2010. Leptin in human physiology and therapeutics. Front.
Neuroendocrinol. 31 (3), 377–393.
De Placido, G., Alviggi, C., Carravetta, C., Pisaturo, M.L., Sanna, V., Wilding, M., Lord, G.
M., Matarese, G., 2001. The peritoneal fluid concentration of leptin is increased in
women with peritoneal but not ovarian endometriosis. Hum Reprod. 16 (6),
1251–1254. https://doi.org/10.1093/humrep/16.6.1251. PMID: 11387300.
Dersimonian, R., Laird, N., 1986. Meta-analysis in clinical trials. Control. Clin. Trials 7
(3), 177–188.
Egger, M., D. S. G, Altman, D., 2001. Systematic Reviews in Health Care: Meta-Analysis
in Context. BMJ Publishing Group, London.
Fasshauer, M., Bluher, M., 2015. Adipokines in health and disease. Trends Pharmacol.
Sci. 36 (7), 461–470.
Friedman, J.M., 2019. Leptin and the endocrine control of energy balance. Nature
Metabolism 1 (8), 754–764.
Gogacz, M., et al., 2001. Peritoneal fluid leptin concentration in infertile patients.
J. Reprod. Immunol. 51 (2), 159–165.
Gonçalves, H.F., Zendron, C., Cavalcante, F.S., Aiceles, V., Oliveira, M.A., Manaia, J.H.,
Babinski, M.A., Ramos, C.F., 2015. Leptin, its receptor and aromatase expression in
D.R. Kalaitzopoulos et al.
deep infiltrating endometriosis. J Ovarian Res. 8, 53. https://doi.org/10.1186/
s13048-015-0180-0. PMID: 26242176; PMCID: PMC4523920.
Gonzalez, R.R., et al., 2006. Leptin signaling promotes the growth of mammary tumors
and increases the expression of vascular endothelial growth factor (VEGF) and its
receptor type two (VEGF-R2). J. Biol. Chem. 281 (36), 26320–26328.
González, R.N.R., et al., 2000. Leptin and leptin receptor are expressed in the human
endometrium and endometrial leptin secretion is regulated by the human
Blastocyst1. J. Clin. Endocrinol. Metab. 85 (12), 4883–4888.
Gungor, T., et al., 2009. Peritoneal fluid and serum leptin concentrations in women with
primary infertility. Arch. Gynecol. Obstet. 279 (3), 361–364.
Harbord, R.M., et al., 2006. A modified test for small-study effects in meta-analyses of
controlled trials with binary endpoints. Stat. Med. 25 (20), 3443–3457.
Higgins, J.P., et al., 2003. Measuring inconsistency in meta-analyses. BMJ 327 (7414),
557–560.
Hussein, S.S., Farhan, F.S., Ibrahim Ali, A., 2020. Serum Leptin as a Marker for Severity
of Endometriosis. Obstet Gynecol Int 2020, 6290693. https://doi.org/10.1155/
2020/6290693. PMID: 32963544; PMCID: PMC7492927.
Imagawa, K., et al., 1998. Development of a sensitive ELISA for human leptin, using
monoclonal antibodies. Clin. Chem. 44 (10), 2165–2171.
Kalaitzopoulos, D.R., et al., 2020. Association between vitamin D and endometriosis: a
systematic review. Hormones 19 (2), 109–121.
Kitawaki, J., et al., 2000. Expression of leptin receptor in human endometrium and
fluctuation during the menstrual cycle. J. Clin. Endocrinol. Metab. 85 (5),
1946–1950.
Kucera, R., Babuska, V., Ulcova-Gallova, Z., Kulda, V., Topolcan, O., 2018. Follicular
fluid levels of anti-Müllerian hormone, insulin-like growth factor 1 and leptin in
women with fertility disorders. Syst Biol Reprod Med 64 (3), 220–223. https://doi.
org/10.1080/19396368.2018.1450906. Epub 2018 Mar 29. PMID: 29595066.
La Cava, A., 2017. Leptin in inflammation and autoimmunity. Cytokine 98, 51–58.
La Cava, A., et al., 2004. Unraveling the multiple roles of leptin in inflammation and
autoimmunity. J. Mol. Med. 82 (1), 4–11.
Lempesis, I.G., et al., 2019. Oxygenation of adipose tissue: a human perspective. Acta
Physiol. 0 (0), e13298.
Lima-Couy, I., et al., 2004. Endometrial leptin and leptin receptor expression in women
with severe/moderate endometriosis. Mol. Hum. Reprod. 10 (11), 777–782.
Mahutte, N.G., Matalliotakis, I.M., Goumenou, A.G., Vassiliadis, S., Koumantakis, G.E.,
Arici, A., 2003. Inverse correlation between peritoneal fluid leptin concentrations
and the extent of endometriosis. Hum Reprod. 18 (6), 1205–1209. https://doi.org/
10.1093/humrep/deg233. PMID: 12773447.
Malhotra, N., Karmakar, D., Tripathi, V., Luthra, K., Kumar, S., 2012. Correlation of
angiogenic cytokines-leptin and IL-8 in stage, type and presentation of
endometriosis. Gynecol Endocrinol. 28 (3), 224–227. https://doi.org/10.3109/
09513590.2011.593664. Epub 2011 Aug 17. PMID: 21848410.
Manolopoulos, K.N., et al., 2010. Gluteofemoral body fat as a determinant of metabolic
health. Int. J. Obes. (Lond.) 34 (6), 949–959.
Mantzoros, C.S., et al., 2011. Leptin in human physiology and pathophysiology. Am. J.
Physiol.-Endocrinol. Metab. 301 (4), E567–E584.
Margetic, S., et al., 2002. Leptin: a review of its peripheral actions and interactions. Int.
J. Obes. 26 (11), 1407–1433.
Marshall, J.A., et al., 2000. Percent body fat and lean mass explain the gender difference
in leptin: analysis and interpretation of leptin in hispanic and non-hispanic white
adults. Obes. Res. 8 (8), 543–552.
Matarese, G., Alviggi, C., Sanna, V., Howard, J.K., Lord, G.M., Carravetta, C., Fontana, S.,
Lechler, R.I., Bloom, S.R., De Placido, G., 2000. Increased leptin levels in serum and
peritoneal fluid of patients with pelvic endometriosis1. J. Clin. Endocrinol. Metab.
85 (7), 2483–2487. https://doi.org/10.1210/jcem.85.7.6703. PMID: 10902797.
Matalliotakis, I.M., Koumantaki, Y.G., Neonaki, M.A., Goumenou, A.G., Koumantakis, G.
E., Kyriakou, D.S., Koumantakis, E.E., 2000. Increase in serum leptin concentrations
among women with endometriosis during danazol and leuprolide depot treatments.
Am J Obstet Gynecol. 183 (1), 58–62. PMID: 10920309.
Barcz, E., Dziunycz, P., Radomski, D., Kamiński, P., Roszkowski, P.I., Korczak-
Kowalska, G., Malejczyk, J., 2008. Association of leptin with inflammatory cytokines
and lymphocyte subpopulations in peritoneal fluid of patients with endometriosis.
J. Reprod. Immunol. 79 (1), 111–117. https://doi.org/10.1016/j.jri.2008.08.007.
Epub 2008 Sep 23. PMID: 18814918.
Mitchell, M., et al., 2005. Adipokines: implications for female fertility and obesity.
Reproduction 130 (5), 583–597.
Moher, D., et al., 2009. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. BMJ 339, b2535.
Nácul, A.P., et al., 2013. Gene expression of leptin and long leptin receptor isoform in
endometriosis: a case-control study. Obstet. Gynecol. Int. 2013, 879618.
Nirgianakis, K., et al., 2020. Recurrence patterns after surgery in patients with different
endometriosis subtypes: a long-term hospital-based cohort study. J. Clin. Med. 9 (2).
Journal of Reproductive Immunology 146 (2021) 103338
Oh, H.K., et al., 2012. Leptin receptor is induced in endometriosis and leptin stimulates
the growth of endometriotic epithelial cells through the JAK2/STAT3 and ERK
pathways. Mol. Hum. Reprod. 19 (3), 160–168.
Osman, Hg, Aziz Aafa, E.-R.A., Ama, El-Sokkary, Ra, El-Saeed, 2010. Leptin and
antioxidant profile in infertile women with endometriosis. J. Endometr. 2 (3), 135-
14.
Ozhan, E., Kokcu, A., Yanik, K., Gunaydin, M., 2014. Investigation of diagnostic
potentials of nine different biomarkers in endometriosis. Eur J Obstet Gynecol
Reprod Biol. 178, 128–133. https://doi.org/10.1016/j.ejogrb.2014.04.037. Epub
2014 May 6. PMID: 24813083.
Pandey, V., et al., 2010. Artemin reduces sensitivity to doxorubicin and paclitaxel in
endometrial carcinoma cells through specific regulation of CD24. Transl. Oncol. 3
(4), 218-IN5.
Park, H.K., Ahima, R.S., 2015. Physiology of leptin: energy homeostasis, neuroendocrine
function and metabolism. Metabolism 64 (1), 24–34.
Rathore, N., Kriplani, A., Yadav, R.K., Jaiswal, U., Netam, R., 2014. Distinct peritoneal
fluid ghrelin and leptin in infertile women with endometriosis and their correlation
with interleukin -6 and vascular endothelial growth factor. Gynecol Endocrinol 30
(9), 671–675. https://doi.org/10.3109/09513590.2014.920318. Epub 2014 May
20. PMID: 24845415.
Seeber, B., Sammel, M.D., Fan, X., Gerton, G.L., Shaunik, A., Chittams, J., Barnhart, K.T.,
2008. Panel of markers can accurately predict endometriosis in a subset of patients.
Fertil Steril. 89 (5), 1073–1081. https://doi.org/10.1016/j.fertnstert.2007.05.014.
Epub 2007 Aug 13. PMID: 17706208.
Shafrir, A.L., et al., 2018. Risk for and consequences of endometriosis: a critical
epidemiologic review. Best Pract. Res. Clin. Obstet. Gynaecol. 51, 1–15.
Shah, D.K., Correia, K.F., Harris, H.R., Missmer, S.A., 2013. Plasma adipokines and
endometriosis risk: a prospective nested case-control investigation from the Nurses’
Health Study II. Hum Reprod 28 (2), 315–321. https://doi.org/10.1093/humrep/
des411. Epub 2012 Nov 27. PMID: 23188112; PMCID: PMC3545640.
Shamseer, L., et al., 2015. Preferred reporting items for systematic review and meta-
analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ Br. Med. J.
349, g7647.
Styer, A.K., et al., 2008. Ablation of leptin signaling disrupts the establishment,
development, and maintenance of endometriosis-like lesions in a murine model.
Endocrinology 149 (2), 506–514.
Tao, Y., Zhang, Q., Huang, W., Zhu, H., Zhang, D., Luo, W., 2011. The peritoneal leptin,
MCP -1 and TNF-α in the pathogenesis of endometriosis-associated infertility. Am J
Reprod Immunol. 65 (4), 403–406. https://doi.org/10.1111/j.1600-
0897.2010.00920.x. Epub 2010 Sep 6. PMID: 20825374.
Tian, Z., et al., 2020. Serum and peritoneal fluid leptin levels in endometriosis: a
systematic review and meta-analysis. Gynecol. Endocrinol. 1–5.
Viganò, P., Somigliana, E., Matrone, R., Dubini, A., Barron, C., Vignali, M., di Blasio, A.
M., 2002. Serum leptin concentrations in endometriosis. J Clin Endocrinol Metab. 87
(3), 1085–1087. https://doi.org/10.1210/jcem.87.3.8286. PMID: 11889169.
Viswanathan, M., et al., 2013. Assessing Risk of Bias and Confounding in Observational
Studies of Interventions or Exposures: Further Development of the RTI Item Bank.
AHRQ Methods for Effective Health Care, Rockville (MD).
Wan, X., et al., 2014. Estimating the sample mean and standard deviation from the
sample size, median, range and/or interquartile range. BMC Med. Res. Methodol. 14,
135.
Wertel, I., Gogacz, M., Polak, G., Jakowicki, J., Kotarski, J., 2005. Leptin is not involved
in the pathophysiology of endometriosis-related infertility. Eur. J. Obstet. Gynecol.
Reprod. Biol. 119 (2), 206–209. https://doi.org/10.1016/j.ejogrb.2004.08.004.
PMID: 15808381.
Wu, M.-H., et al., 2002. Increased leptin expression in endometriosis cells is associated
with endometrial stromal cell proliferation and leptin gene up-regulation. Mol. Hum.
Reprod. 8 (5), 456–464.
Wu, M.H., et al., 2003. Three-dimensional power Doppler imaging of ovarian stromal
blood flow in women with endometriosis undergoing in vitro fertilization.
Ultrasound Obstet. Gynecol. 21 (5), 480–485.
Wu, M.-H., et al., 2010. ORIGINAL ARTICLE: leptin on peritoneal macrophages of
patients with endometriosis. Am. J. Reprod. Immunol. 63 (3), 214–221.
Wunder, D.M., Mueller, M.D., Birkhäuser, M.H., Bersinger, N.A., 2005. Steroids and
protein markers in the follicular fluid as indicators of oocyte quality in patients with
and without endometriosis. J Assist Reprod Genet 22 (6), 257–264. https://doi.org/
10.1007/s10815-005-5149-2. PMID: 16021855; PMCID: PMC3455727.
Zendron, C., et al., 2014. Increased expression of the leptin receptor in human ovaries
affected by endometrioma and detection of high levels of leptin in the ovarian
endometriomal fluid. J. Ovarian Res. 7 (1), 2.
Zhao, Z., et al., 2021. Association of leptin and adiponectin levels with endometriosis: a
systematic review and meta-analysis. Gynecol. Endocrinol. 1–9.
Zondervan, K.T., et al., 2018. Endometriosis. Nat. Rev. Dis. Primers 4 (1), 9.
Zondervan, K.T., et al., 2020. Endometriosis. N. Engl. J. Med. 382 (13), 1244–1256.