Emerging free oxygen radicals are the main factor causing ischemia reperfusion induced cell damage. Many different agents acting against these free oxygen radicals as antioxidant and anti-inflammatory substrates that support the protective mechanisms for all organs are tested experimentally, and their effectiveness has been evaluated [5, 6, 15]. In this study, we attempted to evaluate Bromelain for its antioxidant effects.
Root bromelain, a widely used phytotherapeutic member of the sulfhydryl proteolytic enzyme family, is derived from Ananas comosus and has a significant clinical interest [7]. Bromelain comprises endo-peptidase, glycoprotein, and carbohydrates [17]. It has fibrinolytic, anti-thrombotic, and anti-inflammatory properties; these effects have been documented in animal and human studies [10, 17]. Bromelain's anti-inflammatory effect is associated with its protease activity [18]. Furthermore, Bromelain has antioxidant activity [19]. Bromelain's therapeutic effects have been demonstrated in diseases such as angina pectoris, bronchitis, sinusitis, surgical trauma, thrombo-phlebitis, osteoarthritis, diarrhea, cancer, and cardiovascular disorders [20]. It has been reported in the literature that the use of recipes containing Bromelain together with N-acetyl cysteine and alpha lipoic acid in the treatment of endometriosis has an anti-inflammatory effect in vivo and in vitro environments [21]. Again, in a clinical study conducted on patients with endometriosis, it was stated that the use of preparations containing N-acetyl cysteine, alpha lipoic acid, and Bromelain reduced the level of pain and led to lower analgesic need [22]. Although the use and efficacy of Bromelain in many tissues have been demonstrated, to our knowledge, there are no studies investigating the effect of Bromelain on ischemia-reperfusion injury in ovarian torsion.
In the literature, there are many studies on ovarian ischemia, edema, follicular cell damage, vascular occlusion, hemorrhage, neutrophil infiltration, histopathology evaluation, and apoptosis index [5]. The presence of cystic follicles, increased plasma testosterone concentration, and an increase in the number of atretic follicles have been shown in animal models with DHEA-induced PCOT compared to controls [23]. However, an ovarian torsion model created by PCOT has not been encountered in the literature; hence, the histopathology images that may occur after torsion are unknown. Nevertheless, in line with the data obtained from this study, we demonstrated that there might be less bleeding due to the scarcity of atretic follicles and the tissue around the follicles. In this study, vacuolization was observed in the cytoplasm of granulosa lutein cells in the corpus luteum in P-S. In P-IR, bleeding in atretic follicles and surrounding tissue was observed. When Bromelain was administered, the bleeding decreased in P-IR, and vacuolization in the cytoplasm of luteal cells in the corpus luteum and healthy primordial follicles were found.
The accumulation of abnormal cellular free oxygen radicals and I / R damage damages cell proteins and membranes and causes damage by activating the pro-apoptotic pathways[6]. Nuclear factor kappa Beta (NF-κβ) is one of the pleiotropic transcription factors and markers that play an essential role in inflammatory processes. NF-κβ activation occurs through radical oxygen substrates (ROS) and cytokines. The NF-κβ signaling pathway may increase inflammation and apoptosis [24]. In this study, as expected, NF-κβ had similar intensity in both N-S and P-S (P > 0.05), significantly increasing compared to all other groups. However, no difference was found between normal and PCOT ovarian tissues (P < 0.05). Administration of Bromelain significantly reduced the NF-κβ (P < 0.05). This indicates that Bromelain significantly reduced the apoptosis caused by ovarian torsion. Our results are consistent with the other results in the literature [24–26].
TUNEL tests showed that the number of apoptotic cells significantly increased in the direction of PCOT between normal and PCOT ovarian I / R tissues. It was determined that bromelain administration significantly reduced the number of apoptotic cells in both standard and PCOT ovarian tissue. Our results are consistent with the other results in the literature [27, 28]. Interestingly, Bromelain was seen to reduce the number of apoptotic cells encountered in PCOT significantly. This suggests that using Bromelain in treating PCOT can open new horizons and that further studies can be conducted on this issue.
Reperfusion of ischemic tissue leads to more severe tissue damage than ischemia [29]. Therefore, studies to prevent reperfusion injury gain importance [30]. Lipid peroxidation in the cell is the most harmful effect of free oxygen radicals, accompanied by a decrease in membrane potential and subsequent cell damage. Malondialdehyde (MDA), one of the end products of lipid peroxidation, causes severe cell damage [31]. In our study, MDA levels increased significantly in the P-IR. There was a significant difference in MDA levels between N-S and P-S (P < 0.05) .The MDA levels decreased in the P-IRB, and no significant statistical difference was found in the NI-R compared to the P-IRB. Our results for Bromelain are similar to those in the literature [24, 27, 32].
The ischemia perfusion damage in polycystic ovarian tissue may be higher than that of normal ovarian tissue. However, there needs to be a literature study investigating this issue. In these respects, this study is the first in the literature.
Bromelain can be used to prevent I/R injury due to ovarian torsion of PCOT. It is also thought that Bromelain may have a function in treating ovarian torsion, and further studies can be conducted on this subject.