Background: Endometriosis is a chronic, gynecological disorder, and the disease’s pathogenesis is still debatable. Genes related to apoptosis have been revealed to be deregulated in endometriosis.

Objective: This study investigates the relationship between polymorphic variants of Bax -248G>A and Bcl-2 -938C>A promoter regions with endometriosis risk in an Iranian population.

Materials and Methods: In this case-control study, the polymorphisms of Bax -248G>A and Bcl-2 -938C>A promoter regions were analyzed in 127 Iranian cases and 125 controls who were referred to Ali-ibn-Abi Taleb Educational hospital, Zahedan, Iran between May 2022 and February 2023. The genotypic analysis was performed for all the subjects using the polymerase chain reaction-restriction fragment length polymorphism method.

Results: The frequencies of mutant allele A carriers and the A allele of Bax -248G>A polymorphism showed about 2-fold significant increase of endometriosis risk (p = 0.04; p = 0.01, respectively). The frequencies of the mutant genotype AA and A allele carriers of Bcl-2 -938C>A polymorphism were approximately 4 and 2.5-fold higher in endometriosis compared to the control women, which were highly significant (p > 0.001). Moreover, the allele A frequency of Bcl-2 -938C>A was associated with a 2-fold higher risk of endometriosis (p > 0.001). Furthermore, the combination effects of these 2 single nucleotide polymorphisms showed that women with Bax -248G>A GG and Bcl-2 -938C>A AA variant alleles were associated with about 5 times higher risk of endometriosis (p > 0.001). Notably, a significant difference was observed in mutant allele distribution between minimal/mild (stage I and II) and moderate/severe (stage III and IV) women with endometriosis disease.

Conclusion: The results of our study provide evidence that Bcl-2 -938C>A and Bax -248G>A single nucleotide polymorphisms might be associated with the risk of endometriosis.

Key words: Endometriosis, Apoptosis, Genetic polymorphism, Bax, Bcl-2.

[2] Gurgan T, Bektas G. Endometriosis and infertility. In: Lagana AS, Guglielmino A. Management of infertility. US: Academic Press; 2023.

[3] Amro B, Ramirez Aristondo ME, Alsuwaidi S, Almaamari B, Hakim Z, Tahlak M, et al. New understanding of diagnosis, treatment and prevention of endometriosis. Int J Environment Res Public Health 2022; 19: 6725.

[4] Koninckx PhR, Ussia A, Adamyan L, Tahlak M, Keckstein J, Wattiez A, et al. The epidemiology of endometriosis is poorly known as the pathophysiology and diagnosis are unclear. Best Pract Res Clin Obstet Gynaecol 2021; 71: 14–26.

[5] Azam INA, Abdul Wahab N, Mokhtar MH, Shafiee MN, Mokhtar NM. Roles of microRNAs in regulating apoptosis in the pathogenesis of endometriosis. Life 2022; 12: 1321.

[6] Laganà AS, Garzon S, Götte M, Viganò P, Franchi M, Ghezzi F, et al. The pathogenesis of endometriosis: Molecular and cell biology insights. Int J Mol Sci 2019; 20: 5615.

[7] Saxena A, Moshynska O, Sankaran K, Viswanathan S, Sheridan DP. Association of a novel single nucleotide polymorphism, G(-248)A, in the 5'-UTR of Bax gene in chronic lymphocytic leukemia with disease progression and treatment resistance. Cancer Lett 2002; 187: 199– 205.

[8] Czabotar PE, Garcia-Saez AJ. Mechanisms of BCL-2 family proteins in mitochondrial apoptosis. Nat Rev Mol Cell Biol 2023; 24: 732–748.

[9] da Silva Lawisch GK, Biolchi V, Kaufmann G, Nicolai G, Capitaneo E, Rosembach TR, et al. The role of FASL, BCL-2 and BAX polymorphisms in brazilian patients with prostate cancer and benign prostatic hyperplasia. Mol Biol Rep 2022; 49: 9445–9451.

[10] D’Aguanno S, Del Bufalo D. Inhibition of anti-apoptotic Bcl-2 proteins in preclinical and clinical studies: Current overview in cancer. Cells 2020; 9: 1287–1299.

[11] Hafezi S, Rahmani M. Targeting BCL-2 in cancer: Advances, challenges, and perspectives. Cancers 2021; 13: 1292–1298.

[12] Kawiak A, Kostecka A. Regulation of Bcl-2 family proteins in estrogen receptor-positive breast cancer and their implications in endocrine therapy. Cancers 2022; 14: 279.

[13] Abdel-Maksoud MA, Ullah S, Nadeem A, Shaikh A, Zia MK, Zakri AM, et al. Unlocking the diagnostic, prognostic roles, and immune implications of BAX gene expression in pan-cancer analysis. Am J Transl Res 2024; 16: 63–69.

[14] Alam M, Kashyap T, Mishra P, Panda AK, Nagini S, Mishra R. Role and regulation of proapoptotic Bax in oral squamous cell carcinoma and drug resistance. Head Neck 2019; 41: 185–197.

[15] Fernandes ATG, Rocha NP, Vendrame E, Russomano F, Grinsztejn BJ, Friedman RK, et al. Polymorphism in apoptotic BAX (-248G>A) gene but not in antiapoptotic BCL-2 (-938C>A) gene and its protein and mRNA expression are associated with cervical intraepithelial neoplasia. Apoptosis 2015; 20: 1347– 1357.

[16] Dholariya S, Mir R, Zuberi M, Yadav P, Gandhi G, Khurana N, et al. Potential impact of (rs 4645878) BAX promoter -248G>A and (rs 1042522) TP53 72Arg>pro polymorphisms on epithelial ovarian cancer patients. Clin Transl Oncol 2016; 18: 73–81.

[17] Cardoso-Duarte LC, Fratelli CF, Pereira AS, Souza JN, Freitas RD, Morais RM, et al. BAX gene (-248 G> A) polymorphism in a sample of patients diagnosed with thyroid cancer in the Federal District, Brazil. Int J Biol Marker 2021; 36: 21–26.

[18] Mohammadpour-Gharehbagh A, Jahantigh D, Eskandari M, Sadegh MH, Nematollahi MH, Rezaei M, et al. Genetic and epigenetic analysis of the BAX and BCL-2 in the placenta of pregnant women complicated by preeclampsia. Apoptosis 2019; 24: 301–311.

[19] Chatterjee K, De S, Deb Roy S, Sahu SK, Chakraborty A, Ghatak S, et al. BAX -248 G>A and BCL-2 -938 C>A variant lowers the survival in patients with nasopharyngeal carcinoma and could be associated with tissue-specific malignancies: A multi-method approach. Asian Pac J Cancer Prev 2021; 22: 1171–1181.

[20] Degtyareva AO, Antontseva EV, Merkulova TI. Regulatory SNPs: Altered transcription factor binding sites implicated in complex traits and diseases. Int J Mol Sci 2021; 22: 6454.

[21] Gadducci A, Zannoni GF. Endometriosis-associated extraovarian malignancies: A challenging question for the clinician and the pathologist. Anticancer Res 2020; 40: 2429–2438.

[22] Chiorean DM, Mitranovici MI, Toru HS, Cotoi TC, Tomu? AN, Turdean SG, et al. New insights into genetics of endometriosis: A comprehensive literature review. Diagnostics 2023; 13: 2265.

[23] Turesheva A, Aimagambetova G, Ukybassova T, Marat A, Kanabekova P, Kaldygulova L, et al. Recurrent pregnancy loss etiology, risk factors, diagnosis, and management: Fresh look into a full box. J Clin Med 2023; 12: 4074.

[24] Samimi M, Pourhanifeh MH, Mehdizadehkashi A, Eftekhar T, Asemi Z. The role of inflammation, oxidative stress, angiogenesis, and apoptosis in the pathophysiology of endometriosis: Basic science and new insights based on gene expression. J Cell Physiol 2019; 234: 19384–19392.

[25] Bedoui S, Herold MJ, Strasser A. Emerging connectivity of programmed cell death pathways and its physiological implications. Nat Rev Mol Cell Biol 2020; 21: 678–695.

[26] Rahman N, Khan H, Zia A, Khan A, Fakhri S, Aschner M, et al. Bcl-2 modulation in p53 signaling pathway by flavonoids: A potential strategy towards the treatment of cancer. Int J Mol Sci 2021; 22: 11315–11343.

[27] Moawadh MS, Mir R, Tayeb FJ, Asim O, Ullah MF. Molecular evaluation of the impact of polymorphic variants in apoptotic (Bcl-2/Bax) and proinflammatory cytokine (TNF-??/IL-8) genes on the susceptibility and progression of myeloproliferative neoplasms: A casecontrol biomarker study. Curr Issues Mol Biol 2023; 45: 3933–3952.

[28] Kolahdouz-Mohammadi R, Delbandi AA, Khodaverdi S, Arefi S, Arablou T, Shidfar F. The effects of resveratrol treatment on Bcl-2 and bax gene expression in endometriotic compared with non-endometriotic stromal cells. Iran J Public Health 2020; 49: 1546–1554.

[29] Nikmohammadi N, Sarbakhsh P, Goudarzi MM, Talebi M, Farshdousti-Hagh M, Malakouti J, et al. The effect of B-cell lymphoma 2 and BCL2-associated X polymorphisms on the survival of acute lymphoblastic leukemia patients: Application of frailty survival models. Iran J Public Health 2022; 51: 895–899.

[30] Jiang P, Tang J, Shao Q, Cai Y. Interactive effect of BCL2 and BAX polymorphisms with cigarette smoking on the risk of non-small cell lung cancer: A case-control study in China. Acta Biochimica et Biophysica Sinica 2019; 51: 1178–1181.

[31] Moazami-Goudarzi M, Farshdousti-Hagh M, Hoseinpour-Feizi A, Talebi M, Movassaghpour-Akbari AA, Shams-Asanjan K, et al. The acute lymphoblastic leukemia prognostic scoring whether it is possible by BCL-2, BAX gene promoter genotyping. Caspian J Intern Med 2016; 7: 105–112.

[32] Feng Y, Chen X, Zheng Y, Liu Q, Chen H, Cai Y, et al. Prognostic value and susceptibility of BAX rs4645878 polymorphism in cancer: A systematic review and metaanalysis. Medicine 2018; 97: 1151–1159.

[33] Michita RT, Zambra FMB, Fraga LR, Sanseverino MT, Schuler-Faccini L, Chies JAB, et al. The role of FAS, FASL, BAX, and BCL-2 gene polymorphisms in determining susceptibility to unexplained recurrent pregnancy loss. J Assist Reprod Genet 2019; 36: 995–1002.