STATE OF THE ART ASSESSMENT OF ENDOCRINE DISRUPTERS Final Report Project Contract Number 070307/2009/550687/SER/D3 Annex 1 SUMMARY OF THE STATE OF THE SCIENCE Revised version, 29 January 20121 Authors: Andreas Kortenkamp, Richard Evans, Olwenn Martin, Rebecca McKinlay, Frances Orton, Erika Rosivatz Draft 31.01.2012 1 This is a revised version of the draft published in June 2011 by the European Commission, DG Environment TABLE OF CONTENTS TABLE OF CONTENTS 1 THE STATE OF THE SCIENCE ON ENDOCRINE DISRUPTERS - INTRODUCTION ..................................... 4 1.1 SCOPE OF THE REPORT ................................................................................................................. 4 1.2 LITERATURE SEARCH STRATEGY AND SOURCES OF INFORMATION ............................................. 4 1.3 STRUCTURE OF THE REPORT ......................................................................................................... 5 1.4 CHAPTER ORGANISATION ............................................................................................................. 6 1.5 WEIGHT OF EVIDENCE................................................................................................................... 7 2 DEFINITIONS OF ENDOCRINE DISRUPTING CHEMICALS ...................................................................... 9 2.1 EARLY DEFINITIONS ....................................................................................................................... 9 2.2 ENDOCRINE DISRUPTION AS A “MODE OF ACTION” .................................................................. 10 2.3 THE WHO/IPCS DEFINITION ........................................................................................................ 11 2.4 REGULATORY IMPLICATIONS ...................................................................................................... 12 3 OVER-ARCHING ISSUES / EMERGING ISSUES ..................................................................................... 14 3.1 RECEPTOR SIGNALLING AND ITS RELEVANCE TO ENDOCRINE DISRUPTION .............................. 14 3.2 LOW DOSE EFFECTS..................................................................................................................... 65 3.3 MULTIPLE CHEMICAL EXPOSURES TO ENDOCRINE DISRUPTING CHEMICALS ............................ 78 3.4 EPIGENETICS................................................................................................................................ 91 3.5 PROSTAGLANDINS..................................................................................................................... 102 4 HUMAN HEALTH ENDPOINTS – REPRODUCTIVE HEALTH ................................................................ 110 4.1 MALE REPRODUCTIVE HEALTH ................................................................................................. 110 4.2 FEMALE PRECOCIOUS PUBERTY ................................................................................................ 130 4.3 FEMALE FECUNDITY .................................................................................................................. 146 4.4 POLYCYSTIC OVARIES SYNDROME (PCOS) ................................................................................ 166 4.5 FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES .................................................... 178 4.6 ENDOMETRIOSIS ....................................................................................................................... 198 4.7 UTERINE FIBROIDS .................................................................................................................... 218 5 HUMAN HEALTH ENDPOINTS- HORMONAL CANCERS..................................................................... 233 5.1 BREAST CANCER ........................................................................................................................ 233 5.2 PROSTATE CANCER.................................................................................................................... 254 5.3 TESTIS CANCER .......................................................................................................................... 268 5.4 THYROID CANCER ...................................................................................................................... 279 5.5 Other hormonal cancers: ovarian and endometrial cancers .................................................... 292 TABLE OF CONTENTS 6 HUMAN HEALTH ENDPOINTS – METABOLISM AND DEVELOPMENT .............................................. 295 6.1 DEVELOPMENTAL NEUROTOXICITY .......................................................................................... 295 6.2 METABOLIC SYNDROME AND RELATED CONDITIONS .............................................................. 326 6.3 NEUROIMMUNE DISORDERS .................................................................................................... 340 7 WILDLIFE ENDPOINTS ...................................................................................................................... 363 7.1 INVERTEBRATES ........................................................................................................................ 363 7.2 FISH ........................................................................................................................................... 378 7.3 AMPHIBIANS ............................................................................................................................. 408 7.4 REPTILES .................................................................................................................................... 423 7.5 BIRDS ......................................................................................................................................... 432 7.6 MAMMALS ................................................................................................................................ 448 8 CHEMICALS OF CONCERN ................................................................................................................ 463 9 APPENDICES ..................................................................................................................................... 464 9.1 ANALYSIS OF EU PROJECT REPORTS.......................................................................................... 464 9.2 ABBREVIATIONS ........................................................................................................................ 485 INTRODUCTION 1 THE STATE OF THE SCIENCE ON ENDOCRINE DISRUPTERS - INTRODUCTION This report describes the state of the science on endocrine disrupters up to 2010. According to the tender specifications, pertinent findings published after the release of the WHO/IPCS Global Assessment of the State-of-the-Science on Endocrine Disrupters in 2002 (WHO 2002) were to be summarised, with the aim of preparing the ground for an analysis of results of regulatory relevance to the scientific debate about endocrine disrupting properties of chemical substances. The WHO (2002) report was to form the starting point for this summary. 1.1 SCOPE OF THE REPORT Accordingly, this report is not intended to be a comprehensive scholarly review of scientific findings in the field of endocrine disrupter research since 2002, which was judged to be far beyond the scope of this Project. Rather, it is perhaps best characterised as a “review of reviews”, although primary scientific literature has also found entry into this summary. Every effort was made to provide a balanced overview, with an emphasis on key findings and knowledge gaps. With the intention of preparing the ground for an analysis of the regulatory relevance of the scientific progress made since 2002, the strength of evidence for associations between human and wildlife effects and exposures to endocrine disrupting chemicals was assessed. As much as possible, chemicals of concern were identified. In the subsequent stages of the Project, this assessment will be used to investigate whether proposed regulatory approaches to dealing with endocrine disrupting chemicals in the European Union are consistent with the state of the science in this field. The development of such approaches is currently ongoing in various EU member states and the European Commission. It is to be expected that significant developments will occur in 2011, and that these may trigger a re-examination of the scientific literature. Therefore, the work process of summarising the state of the science leading up to the preparation of the final report later in 2011 had to be iterative. 1.2 LITERATURE SEARCH STRATEGY AND SOURCES OF INFORMATION The search for relevant literature focused on papers that appeared after publication of the WHO (2002) report. Since the effective literature cut-off date of the WHO assessment was the year 2000, papers with a publication date between 2000 and 2010 formed the basis of the present report. Papers that appeared after December 2010 could normally not be considered, although we cited some pertinent papers that appeared in 2011. Older literature was referred to as appropriate. The search strategy followed two approaches; 1) a keyword search and 2) a citation search. The keyword search combined the term “endocrine disrupt*” with terms denoting organ systems or systemic endpoints of interest, producing search strings of the kind “endocrine disrupt* AND uterus” or”endocrine disrupt* AND fertility”. The citation search used highly cited papers that detailed important findings and traced the content of publications that cited that piece of work. Page 4 of 486 INTRODUCTION In preparing this report, some recently published reviews were drawn upon, particularly the US Endocrine Society Statement “Endocrine-Disrupting Chemicals” for human health endpoints (Diamanti-Kandarakis et al. 2009). The papers by Sharpe (2009) and the European Science Foundation (European Science Foundation 2010) provided useful guidance in the area of male reproductive health. A global review of wildlife effects of endocrine disrupters is not currently available, but an overview of the topic has been prepared as a summary of the “Weybridge plus 10” conference in Helsinki, 2006. The proceedings of this conference have not yet been published, but a draft was available and proved to be helpful in collating the section on wildlife effects. Other more sectorial review papers are mentioned in the respective chapters of the report. Opinions of EU Scientific Committees on matters relevant to endocrine disruption were a valuable source for the summary of the state of the science, although these opinions are not described or paraphrased as such. Similarly, the final reports of European Union-funded research projects on endocrine disruption also proved immensely useful in informing the literature search for this summary of the endocrine disrupter science. Again, these project reports are not dealt with as separate recognizable entities in the main body of this report, but an overview of these projects and their research direction is given in the Appendix (9.1). 1.3 STRUCTURE OF THE REPORT The report opens with a consideration of definitions for endocrine disrupters, with the aim of assessing their usefulness as a basis for chemicals regulations. The main body of the report is structured into six parts: Overarching and emerging issues A number of major issues of an overarching and cross-cutting nature are dealt with in the opening chapters. These include an overview of the advances made since 2000 in understanding the molecular biology of steroid receptor signalling and the relevance of these findings for identifying endocrine disrupting chemicals. This is followed by a brief review of the so-called “low dose” discussion in the endocrine disrupter field. Since 2000, combined exposures to endocrine disrupters have become a major research topic, and this area is briefly summarised, followed by an investigation of the importance of imprinting and epigenetics in shaping hormone responses that are largely irreversible. All these topics have considerable regulatory implications and have not been addressed in the WHO 2002 report. The section concludes with a discussion of a major emerging issue, that of the role of prostaglandins signalling in regulating male sexual development. In the following sections, the state of the science on effects of endocrine disrupters on human health is summarised. Epidemiological studies form the starting point of the analysis. This was deliberately chosen to provide a point of reference for the discussion of the suitability of animal models. A second reason for taking the epidemiological perspective was that for many human health effects appropriate experimental models are missing altogether. Human health endpoints – reproductive health This addresses one of the key topics of human health effects of endocrine disrupters, that of impacts on male and female reproductive health. The issue of male reproductive health is dealt with in one Page 5 of 486 INTRODUCTION section; this was possible because of the development of one unifying hypothesis, the testicular dysgenesis syndrome. Due to a lack of similar theory advances, female reproductive health had to be discussed by considering relevant health outcomes separately, such as precocious puberty, female fecundity, polycystic ovary syndrome, fertility, endometriosis and uterine fibroids. Human health endpoints – hormonal cancers Since the early days of endocrine disrupter research, hormonal cancers have been an important topic. Key advances in understanding the role of endocrine disrupters in cancers of the breast, prostate, testes and thyroid are summarised in this section. Due to a lack of relevant research findings, other hormonal cancers such as ovarian neoplasms and endometrial cancers are not considered. Human health endpoints – development and metabolism In this final part of a discussion of human health endpoints, firstly the state of the science in the field of developmental neurotoxicity with respect to endocrine disrupters is summarised. This covers a considerable variety of hormone systems, including the thyroid system and arylhydrocarbon receptor signalling, to name a few. Secondly, the topic of chemical exposures and their role in the ongoing obesity epidemic is dealt with in the section on the metabolic syndrome, an issue that has only fairly recently entered the main stream of endocrine disrupter research. Wildlife endpoints The summary of pertinent research findings in the arena of wildlife endocrine disrupter research is structured according to major species and phyla. This proved to be more manageable than a discussion of the material using endpoints of endocrinological and toxicological relevance as the organising principle. This would have led to a structure with many disparate topics in one and the same section, difficult to recognise in view of the predominant specialisations in the field. The section deals with invertebrates, fish, amphibians, reptiles, birds and mammals. Chemicals of concern Finally, there is a brief section highlighting groups of chemicals of concern as they appear from the evidence reviewed in the preceding parts. It is not intended as a comprehensive review of the effects of specific EDCs, but rather directs the reader to sections which deal with specific chemicals under the various health endpoints and wildlife effects. Certain effect and health endpoints that were followed up in the WHO (2002) report were not dealt with in the present report. Examples are immune effects as they relate to the endocrine system. Since 2002, this area has not been covered extensively by European or international research, and very little progress has been made. 1.4 CHAPTER ORGANISATION All of the chapters dealing with human health endpoints have a uniform common structure; each wildlife section also has a common coherent structure, although the nature of the material dictated a structure that differs slightly from that of the human endpoint sections. In adopting these common Page 6 of 486 INTRODUCTION structures, use was made of the criteria proposed by WHO (2002) for attributing effects to endocrine disruption. It was felt that this would most readily allow an assessment of the material in terms of regulatory relevance. Accordingly, the sections dealing with human endpoints first summarise the natural history of the condition under consideration, including an examination of incidence trends. This is followed by an assessment of the evidence for an involvement of endocrine mechanisms in the respective health endpoints. This sets the scene for an evaluation of the evidence for a role of chemical exposures, especially endocrine disrupters, in these endpoints. Periods of heightened vulnerability during development are examined next. Finally, the question as to the availability and applicability of assays and test systems is addressed, followed by a concluding section highlighting the advances made since the WHO 2002 report. The WHO 2002 criteria for attribution to an endocrine mode of action are applied to each human health endpoint. In a slightly different, but broadly analogous fashion, the wildlife sections begin by summarising the evidence for effects in the field, with a statement of reasons for concern. Field effects, if they occur, are analysed in terms of the biological plausibility for attribution to an endocrine-related mechanism. This is followed by a review of findings from controlled laboratory experiments and concludes by examining whether assays and test systems are available for the identification of chemicals that might induce the effect under consideration. 1.5 WEIGHT OF EVIDENCE There is a recognised lack of consensus over the term вЂ�weight-of-evidence’ (WoE) which refers very generally to the synthesis or pooling of different lines of evidence. It has been used to refer to a summary narrative of the result of hazard assessment where the methodological approach remains unspecified, systematic narrative reviews, criteria-based methods of causal inference, quantitative statistical techniques such as meta-analysis or as a label to a conceptual framework. Historically, WoE is distinct from an alternative approach referred to as вЂ�strength of evidence’ which analyses the degree of positive evidence from a subset of key studies that demonstrate a statistically significant result. In contrast, WoE requires the synthesis of вЂ�all’ the evidence and to achieve this goal the analysis of evidence across several dimensions needs to be conducted, and this includes large or small, strong or weak, old and new studies over scales ranging from human populations to cellular systems. It particularly necessitates the combination of results from both human and animal studies. A comparison of the strengths and weaknesses of epidemiological criteria of causal inference and quality criteria for toxicological studies is detailed in the main report. It is important to stress that the objective here was to summarise the state-of-the-science in terms of the involvement of chemical exposures in the aetiology of specific endocrine sensitive human diseases or wildlife endpoints, not assess the strength of the evidence that specific chemicals have endocrine disrupting properties. This required an assessment of diverse lines of evidence in terms of incidence trends and risk factors, epidemiological evidence, medical knowledge and experimental evidence. A review of reviews approach was thought to best suited to summarise the state-of-knowledge in such a wide array of disciplines as comprehensively as possible. As such, the inclusion of results from individual studies is dependent on the judgement of experts in their respective field and this approach does therefore not allow the systematic scoring of the quality of individual studies. Whilst it may be Page 7 of 486 INTRODUCTION argued that this introduces a publication bias, this bias itself is representative of the views of published scientific experts. A systematic element was nonetheless introduced for the assessment of WoE for a chemical aetiology via an ED mechanism as illustrated by the common chapter structures for human health and wildlife endpoints respectively. References Diamanti-Kandarakis E, Bourguignon JP, Giudice LC, Hauser R, Prins GS, Soto AM, Zoeller RT, Gore AC. 2009. Endocrine-Disrupting Chemicals: An Endocrine Society Scientific Statement. Endocrine Reviews 30:293-342. European Science Foundation. Male reproductive health - Its impacts in relation to general wellbeing and low European fertility rates. Science Policy Briefing 40. 2010. ESF. Sharpe RM. Male reproductive health disorders and the potential role of exposure to environmental chemicals. Report for ChemTrust. available: http://www.chemtrust.org.uk/documents/ProfRSHARPE-MaleReproductiveHealth-CHEMTrust09.pdf. 2009. WHO. Global assessment of the state-of-the-science of endocrine disrupters. 2002. Page 8 of 486 EDC DEFINITIONS 2 DEFINITIONS OF ENDOCRINE DISRUPTING CHEMICALS A number of definitions of endocrine disrupting chemicals were developed in the late 1990s by national and international governmental agencies. Certain non-governmental organisations have also proposed their own definitions of endocrine disrupters, but these have been drafted with the objective of informing the general public rather than for the specific purpose of regulation of toxic substances and are therefore not discussed further in this report. 2.1 EARLY DEFINITIONS The public health concerns about chemicals with endocrine disrupting properties led the Office for Research and Development of the United States Environment Protection Agency (USEPA) to organise a workshop in April 1995 in Raleigh, North Carolina, with the aim of developing a national research strategy on endocrine disrupters. The first definition of what constitutes an endocrine disrupter was published in a report of the outcomes of the workshop in the peer-reviewed literature. Kavlock et al. (1996) defined an endocrine disrupter as: “(...) an exogenous agent that interferes with the production, release, transport, metabolism, binding, action or elimination of natural hormones in the body responsible for the maintenance of homeostasis and the regulation of developmental processes”’ Subsequently, a workshop entitled "The Impact of Endocrine Disrupters on Human Health and Wildlife" was held in Weybridge, United Kingdom, in December 1996 to address the scope of the endocrine disrupter issue within the European Union context. One of the main outcomes of this workshop was an agreement of a definition of an endocrine disrupter as: “(...) an exogenous substance that causes adverse health effects in an intact organism, or its progeny, secondary to changes in endocrine function.” A further definition was also agreed, concerning potential endocrine disrupters as “a substance that possesses properties that might be expected to lead to endocrine disruption in an intact organism” (MRC Institute for Environment and Health, 1997). Unlike the definition documented in Kavlock et al. (1996), the “Weybridge definition” uses the term “adverse”, and this introduces a problematic issue. For a chemical to be considered an endocrine disrupter, its biological effect must amount to an adverse effect on the individual or population and not just a change which falls within the normal range of physiological variation. But what should constitute an adverse effect is left open in the Weybridge definition. This means that the issue is in effect shifted towards the problem of defining adversity, with all the assumptions, presumptions and epistemiological problems that this entails. Currently, there are no universally agreed criteria for defining “adversity”, and it is well known that definitions of adversity have changed with time according to toxicological context. On the other hand, some kind of criteria is needed to differentiate “effects” in the sense of a neutral concept of biological responses from effects of toxicological relevance. Page 9 of 486 EDC DEFINITIONS The inclusion of the term “intact organism” also has its difficulties, and there are important implications for the screening and testing of chemicals for endocrine disrupting properties. It refers specifically to experimental models using for example ovariectomised or castrated animals as providing merely mechanistic information. The demand for observations of effects in intact organisms would deem irrelevant any findings derived from such models for judgements in terms of adversity. A dilemma with the criterion “intact organism” might arise when it comes to the interpretation of test outcomes with genetically engineered (knockout) animal models. Clearly, like ovariectomised animals, these are constructs for the purpose of scientific examination, but should effects observed with such constructs be dismissed because they do not fulfill the demand for “intactness”? Irrespective of intactness, such models might generate valuable insights relevant to risk assessment and regulation. 2.2 ENDOCRINE DISRUPTION AS A “MODE OF ACTION” Following the publication of the Weybridge definition, the US Environmental Protection Agency’s Endocrine Disrupter Screening and Testing Advisory Committee (Endocrine Disruptor Screening and Testing Advisory Committee, 1998) discussed the following definition: вЂ�An exogenous substance that changes endocrine function and causes [adverse] effects at the level of the organism, its progeny, and/or (sub)populations of organisms’. The US Environment Protection Agency detailed its position on adversity of effect in a subsequent memo by stating that it “...does not consider endocrine disruption to be an adverse effect per se, but rather to be a mode or mechanism of action potentially leading to other outcomes, for example carcinogenic, reproductive, or developmental effects, routinely considered in reaching regulatory decisions. Evidence of endocrine disruption alone can influence priority setting for further testing and the assessment of the results of this testing could lead to regulatory action if adverse effects are shown to occur” (Endocrine Disruptors Screening Program archive, no date). This statement exposes one of the main weaknesses of definitions of “endocrine disrupter”, namely that they are not anchored to precisely defined assay outcomes, in the same way that e.g. carcinogens, mutagens or reproductive toxicants are. In these latter cases, more or less specific assays are available that allow the identification of carcinogens, mutagens or reproductive toxicants in terms of observable effects and endpoints, without the need to infer anything in terms of underlying mechanisms or modes of actions. With endocrine disrupters, the situation is very different. The spectrum of effects that might arise from “endocrine disruption” as a mode of action is potentially manifold and complex, but inadequately defined in terms of clearly circumscribed assay outcomes. Appropriate assays that capture “endocrine disruption” are correspondingly varied, their development is in flux, and in many cases adequate model systems or assays are simply not available. However, chemicals regulation and risk assessment has to rely on the identification of hazardous chemicals, and this can only be done on the basis of tests with clearly defined endpoints. The insertion of the phrase “(sub)populations of organisms” in the “EDSTAC” definition is also significant in that it can be interpreted as the first explicit reference to effects seen in wildlife. Page 10 of 486 EDC DEFINITIONS Concurrently, the Japan Environment Agency (former Ministry for the Environment) established the вЂ�Exogenous Endocrine Disrupting Chemical Working Group’ in March 1997 and its report, the “Strategic Programs on Environmental Endocrine Disruptors 98”, thereafter referred to as SPEED ’98, defined exogenous endocrine disrupting chemicals as: ”(...) exogenous substances which interfere with the normal function of hormones when taken into the body” (Japan Environment Agency, 1998). Environment Canada enshrined the concept of endocrine disruption in law as early as 1999, defining “hormone disrupting substance” in the Canadian Environmental Protection Act 1999 as: “(...) a substance having the ability to disrupt the synthesis, secretion, transport, binding, action or elimination of natural hormones in an organism, or its progeny, that are responsible for the maintenance of homeostasis, reproduction, development or behaviour of the organism” (Canadian Environment Protection Act, 1999). There are echoes with the earlier definition in Kavlock et al. (1996). Notable is the relatively open definition of effects in terms of “maintenance of homeostasis, reproduction, development or behavior” that avoids the use of the term “adverse”, although the phrase “disrupt the synthesis … of natural hormones…” could be interpreted as implying a concept of adversity. However, like other definitions, this version leaves open how “endocrine disruption” should be operationalised in terms of assay outcomes. This is not surprising, considering the difficulties with appropriate test systems. 2.3 THE WHO/IPCS DEFINITION The International Programme for Chemical Safety (IPCS - which involves WHO, UNEP and ILO) has, together with Japanese, USA, Canadian, OECD and European Union experts, developed a consensus working definition for endocrine disrupters that was also adopted as a working definition in the European Community Strategy for Endocrine Disrupters (International Programme on Chemical Safety, 2002): “An endocrine disrupter is an exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects in an intact organism, or its progeny, or (sub)populations.вЂќпЂ пЂ It is often overlooked that the Community Strategy as well as the WHO/IPCS definitions also made an effort to describe what a potential endocrine disrupter should be: “A potential endocrine disrupter is an exogenous substance or mixture that possesses properties that might be expected to lead to endocrine disruption in an intact organism, or its progeny, or (sub)populations.” The IPCS definition was also published in the WHO “Global Assessment of the State-of-the-Science on Endocrine Disruption” (International Programme on Chemical Safety, 2002). It makes reference to the earlier EDSTAC definition of endocrine disruption as a mechanism, and at the same time attempts to link these “mechanisms” to endpoints of toxicological relevance by re-introducing the concept of adversity. Furthermore, this definition includes the term “(sub)populations”, presumably with the aim of balancing the perceived human health bias implied by “adverse health effects”. It Page 11 of 486 EDC DEFINITIONS also includes the idea that endocrine disrupting effects may arise as a consequence of exposures not only to single substances, but also mixtures. Although this definition is widely accepted as a working definition, a number of modifications have been proposed. In September 2009, the OECD organised a workshop in Copenhagen on “Countries Activities Regarding Testing, Assessment and Management of Endocrine Disrupters”. It was discussed to widen the concept of causality in the WHO/IPCS definition by adding the phrase “or is causally linked to”, to give “…and exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes, or is causally linked to, adverse health effects…”. This would allow newer (and potentially more cost-effective) toxicological methods that assess events upstream of the adverse effect itself to be used in hazard or risk assessment, for which there is a precedent. However, no consensus on this recommendation was reached (Organisation for Economic Co-operation and Development, 2009). The WHO/IPCS definition was further discussed during a workshop organised by the German Federal Institute for Risk Assessment (BfR) in Berlin in November 2009, particularly in terms of definitions of “adverse effect”. It was proposed to adopt and extend the WHO/IPCS definition of adversity by the addition of the term “reproduction” (Federal Institute for Risk Assessment, 2009): “A change in morphology, physiology, growth, reproduction, development or lifespan of an organism which results in impairment of functional capacity or impairment of capacity to compensate for additional stress or increased susceptibility to the harmful effects of other environmental influences”. 2.4 REGULATORY IMPLICATIONS The WHO/IPCS definition (International Programme on Chemical Safety, 2002) has some important implications in terms of regulation which are open to interpretation. There are clearly two requirements for a substance to be defined as an endocrine disrupter, namely that of the demonstration of an adverse effect and of an endocrine disruption mode-of-action. Particular attention should be paid to interpretations of the following terms: Adverse effects: As discussed above, the notion of adversity implies hidden value judgments and therefore definitions have been proposed in terms of “capacity to compensate for additional stress or increased susceptibility to the harmful effects of other environmental influences” (Federal Institute for Risk Assessment, 2009). These aspects may be difficult to implement from a regulatory standpoint. Assessments of the “capacity to compensate for additional stress or increased susceptibility to the harmful effects of other environmental influences” may conflict with the requirements for controlled experimental conditions and considerations of animal welfare in testing. Intact organism: The definition requires an adverse effect in an intact organism. As discussed above, this can only be interpreted in regulatory terms as a requirement for a positive result in an in vivo assay. This will require repeated or chronic exposure regimens, and specifically exclude simpler test systems with castrated or ovariectomised animals. Progeny: As effects are sometimes only seen in the progeny of exposed animals, exposure regimens need to include sensitive periods of development and may require tests to include two or more generations of animals. The associated financial burden, as well as ethical considerations for the Page 12 of 486 EDC DEFINITIONS number of animals required, probably prompted the discussion during the 2009 OECD workshop about lowering this requirement for evidence of causal linkages and upstream events. (sub)populations: The term intends to make explicit the inclusion of ecological targets in the definition. It is commonly accepted that for legislation related to the protection or enhancement of biodiversity, an adverse effect needs to be demonstrated not in individual organisms but in a population. However, most testing protocols are designed to detect effects at the individual level and results need to be extrapolated to the (sub)population level. The WHO/IPCS definition leaves the interpretation of which modes-of-action should be considered to “alter the function of the endocrine system” relatively open. The concept of endocrine disruption was first developed when it was observed that some environmental chemicals were able to mimic the action of the sex hormones oestrogens and androgens. It has now evolved to encompass a range of mechanisms incorporating the many hormones secreted directly into the blood circulatory system by the glands of the endocrine system and their specific receptors, transport proteins and associated enzymes. Further, the definition does not explicitly address the issue of indirect endocrine toxicity, or when an effect on endocrine function is observed secondary to overt toxicity in other organs or systems. This is related to what is referred to as “specificity” or sometimes also “lead toxicity”, to describe the requirement for endocrine disruption to occur at lower doses than other mechanisms of toxicity. In summary, currently available definitions of “endocrine disrupter” are either neutral in terms of specifying the toxicological relevance of the effects to be described, or they introduce the idea of adversity. The former is in danger of being insufficiently discriminatory, the latter shifts the problem to defining what adversity should mean in an endocrine context, which could be too restrictive and not inclusive enough. At the core of this dilemma is the fact that “endocrine disruption” cannot presently be anchored to specific assay outcomes in a straightforward way. References 1999. Canadian Environmental Protection Act. Endocrine Disruptors Screening Program Archive. no date. Definition of "endocrine disruptor".[ONLINE] http://www.epa.gov/endo/pubs/edsparchive/2-3attac.htm (last accessed 29/01/2011) Endocrine Disruptor Screening and Testing Advisory Committee. 1998. Final Report. U.S. Environment protection Agency. Endocrine Disruptors Screening Program Archive. no date. Definition of "endocrine disruptor".[ONLINE] file:///C:/Documents%20and%20Settings/olwenn.martin/My%20Documents/My%20Dropbox/sotaAED/OM/Task%202/Compet ing%20Economies/USA/USEPA/EDSP/EDSP%20archive%20definition%20memo.htm (last accessed 29/01/2011) Federal Institute for Risk Assessement. 2009. Establishment of assessment and decision criteria in human health risk assessment for substances with endocrine disrupting properties under the EU plant protection product regulation - Report of a Workshop hosted at the German Federal Institute for Risk Assessment (BfR) in Berlin, Germany, from Nov. 11th till Nov. 13th 2009. Berlin. International Programme on Chemical Safety. 2002. Global Assessment of the State-of-the-Science of Endocrine Disruptors. Geneva: World Health Organization. Japan Environment Agency. 1998. Strategic Programs on Environmental Endocrine Disruptors. Kavlock, R. J., Daston, G. P., Derosa, C., Fenner-Crisp, P., Gray, L. E., Kaattari, S., Lucier, G., Luster, M., Mac, M. J., Maczka, C., Miller, R., Moore, J., Rolland, R., Scott, G., Sheehan, D. M., Sinks, T. & Tilson, H. A. 1996. Research needs for the risk assessment of health and environmental effects of endocrine disruptors: a report of the U.S. EPA-sponsored workshop. Environ Health Perspect, 104 Suppl 4, 715-40. MRC institute for Environment and Health. 1997. European workshop on the impact of endocrine disrupters on human health and wildlife. Brussels: European Commission. Organisation for Economic Co-operation and Development. 2009. Workshop Report on OECD Countries Activities regarding testing, assessment and managemnt of endocrine disrupters. In: PROGRAMME, Advisory Group on Endocrine Disrupters Testing and Assessment (EDTA) of the Test Guidelines Programme (ed.). Copenhagen, Denmark. Page 13 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3 OVER-ARCHING ISSUES / EMERGING ISSUES 3.1 RECEPTOR SIGNALLING AND ITS RELEVANCE TO ENDOCRINE DISRUPTION This chapter reviews the current understanding of receptor signalling as it pertains to endocrine disruption. The focus is on receptors that are important in the endocrine system, and for the most part we have limited the scope to the nuclear receptor family; a notable exception being the AhR receptor, which is included due to its importance in the actions of dioxin-like endocrine disruptors. General background is provided in section 3.1.1, followed by a description of receptor signalling (section 3.1.2) and a review of available information for five selected receptors (section 3.1.3). Finally available assays that are relevant to receptor signalling are reviewed (section 3.1.4). Our coverage aims to reflect ongoing discussion in the field and, in this spirit, we review ligand features that may be characteristic of potential candidates as endocrine disrupting chemicals. However the links between receptor level effects and apical human outcomes are not yet strong and this has consequences for the design and selection of assays that are both based on our understanding of receptor molecular biology and that also have plausible links to human outcomes. 3.1.1 Background 3.1.1.1 A brief overview of the endocrine system The endocrine system is a communications system comprising endocrine glands that secrete hormones into the blood stream and thus regulate many bodily functions. The hormones act on receptors in the target cells of that hormone. The endocrine system coordinates and programs related bodily functions and is primarily regulated through negative feedback control. Endocrine glands are ductless and vascular, and include pituitary, thyroid and adrenal glands, and parts of the kidney, liver, heart and gonads. Endocrine glands may signal to each other in series, and thereby form an endocrine axis; three important endocrine axes are the hypothalamus-pituitarygonad (HPG) axis; the hypothalamic-pituitary-adrenal (HPA) axis and the hypothalamic-pituitarythyroid (HPT) axis. The operation of endocrine axes has been well reviewed (IPCS/WHO 2002) and further details will not be given here in order to focus on the receptor level. Hormones are “chemical messengers that are released in one tissue and transported via the circulation to reach target cells in other tissues” (Martini 1995). Hormones can be split into three classes: 1) amino acid derivatives such as norepinephrine, thyroid hormones and melatonin; 2) peptides such as oxytocin (9aa) and growth hormone (191aa), and which make up the largest class of hormones. 3) lipid derivatives such as steroid hormones and eicosanoids. Eicosanoids are mainly considered to be paracrine, but also have secondary roles as hormones. Hormone receptors include both cell surface and nuclear receptors, and the main groupings are shown in Table 1. The main focus here will be on receptors in the nuclear receptor (NR) family, of Page 14 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING which the human genome contains 48 members (Germain et al. 2006). Endogenous ligands have been identified for many of the NRs, however around half are вЂ�orphan’ receptors for which an endogenous ligand is not known. In some cases crystallographic analysis has suggested that the receptor possesses a ligand binding pocket that is unlikely to actually accommodate a ligand. Steroid receptors form group 3 of the nuclear receptor family and include the receptors for estrogen, androgen and progesterone but not those for thyroid hormones (group 1) or the aryl hydrocarbon receptor. An overview of the nomenclature of nuclear receptors has been provided by the IUPHAR (Germain et al. 2006), and provided detailed reviews of many of the major groups of NRs, see the special issue of Pharmacological Reviews 2006, 58(4): 684-836. The IUPHAR also maintain a useful nuclear hormone receptor database (www.iuphar-db.org). 3.1.1.2 Nuclear receptors (NRs) A list of nuclear receptors is provided in Table 2. When activated, NRs undergo conformational changes that allow recruitment of coregulatory molecules and the chromatin modifying machinery of the cell. The ultimate action of NRs is to influence the interaction of the transcriptional machinery with target genes. NRs also interact with other signalling pathways, see section 3.1.2.3 on off-target effects/crosstalk and details for specific receptors in section 3.1.3. Nuclear receptors differ in their unliganded states. Unliganded steroid hormone receptors form inactive complexes with heat shock proteins in cytoplasm or nucleus. Ligand binding causes dissociation from HSPs, dimerisation, activation, translocation to nucleus and recruitment of coactivators. Conversely, unliganded thyroid hormone, retinoid, vitamin D and PPAR receptors bind tightly to chromatin, often as dimers with the retinoid X receptor. If the gene is positively regulated by ligand then the unliganded NR will be recruiting corepressors (RARs, TRs). Then, ligand binding prompts dissociation of corepressors and association of coactivators, resulting in overall activation. The function of orphan receptors, for whom a ligand has not been identified, remains uncertain; ligands may be identified in the future, or the receptor may have important functions through a ligand independent mode of action (Benoit et al. 2006; Germain et al. 2006). Orphan nuclear receptors have been reviewed in detail (Benoit et al. 2006). 3.1.1.2.1 Structural features, domain organisation All members of the nuclear receptor family have a similar modular structure comprising 5 or 6 domains of homology, the domains are lettered from A to F, from the N terminal to the C terminal. This structure is illustrated in Figure 1, reproduced from (Germain et al. 2006) and outlined in brief here: A/B domains (N-terminal, transcriptional activation). These domains contain one of the two transcriptional activation functions, AF-1, through which NRs influence transcription. The other function, AF-2, is located in the LBD (domain E) and is ligand dependent, whilst AF-1 can act autonomously from ligand binding, although it is influenced by ligand binding. The A/B domains also interact with coactivators and other transcription factors. C domain (DNA binding domain, DBD). The DBD is highly conserved and contains a core of 66 residues that interacts with specific DNA response elements. Changes in a single residue can convert Page 15 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING the receptor from recognising one response element to another. The DBD is also the target for posttranslational modifications, and plays a role in nuclear localisation and interactions with transcription factors and coactivators. D domain (hinge). This poorly conserved domain acts as a hinge to allow the DBD to rotate relative to the LBD; this might allow receptor conformations that would otherwise suffer steric hinderance. The domain may also be involved in nuclear localisation. E domain (ligand binding domain, LBD; transcriptional activation). The LBD is highly conserved, although less so than the DBD, and contains four surfaces: 1) a variable ligand binding pocket (LBP); 2) a dimerisation surface through which interaction with partner LBDs occurs; 3) a coregulatory binding surface and 4) the ligand dependent transcriptional activation function, AF-2. Structurally the LBD comprises 12 alpha helices and a short beta turn arranged in three layers. The AF-2 corresponds to helix 12 (H12) of the LBD. The position of H12 is flexible and is dependent on the ligand. In the unliganded LBD, H12 is positioned downward from the LBD, binding of an agonist ligand results in intermolecular repositionings that allows H12 to swing into a position that generates an interaction surface for transcriptional coactivators. NRs recruit large corepressor or coactivator complexes, depending on the cellular environment and state of activation, and the complex modulates gene expression by modifying chromatin or contacting the basal transcription machinery. The position of helix 12 (H12) influences the population of coregulators that bind, thus the position of H12 drives ligand binding to an agonist or antagonist outcome (Heldring et al. 2007). F domain. The F domain is not present in all NRs, and its function is poorly understood. Further details on specific selected receptors, including steroid receptors, other nuclear receptors and non-nuclear receptors, is provided in section 3.1.3. The receptors included are ER, AR, PR, TR, and AhR, and the ligands for these receptors are shown in Figure 2. Page 16 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 1: Hormone receptor classes CELL SURFACE Group name Seven-transmembrane domain receptors, also known as G-protein coupled receptors (GPCRs), Receptors with intrinsic enzyme activity Cytokine receptors Ligand transporters NUCLEAR Examples of ligands catecholamines, prostaglandins, ACTH, glucagon, PTH, TSH, LH insulin, EGF, ANP, TGFОІ TNFalpha, GH, leptin regulated acetylcholine Nuclear receptors (NR) notes Enzyme activity include tyrosine kinase Receptor associates with cytoplasmic kinases In this group the second messenger is an ion flux steroid hormones, vitamin D, thyroid hormones, retinoids, fatty acids, bile acids, eicosanoids, xenobiotics Page 17 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 2: Nuclear receptors Family Receptor common name Receptor nomenclature 1A. Thyroid Hormone Receptors Thyroid hormone receptor-О± NR1A1 Human gene name THRA Thyroid hormone receptor-ОІ NR1A2 THRB Retinoic acid receptor- О± Retinoic acid receptor-ОІ Retinoic acid receptor-Оі Peroxisome proliferatoractivated receptor- О± Peroxisome proliferatoractivated receptor-ОІ/Оґ Peroxisome proliferatoractivated receptor-Оі NR1B1 NR1B2 NR1B3 NR1C1 RARA RARB RARG PPARA NR1C2 PPARD NR1C3 PPARG 1D. Rev-Erb receptors Rev-Erb-О± Rev-Erb-ОІ NR1D1 NR1D2 NR1D1 NR1D2 1F. RAR-related orphan receptors RAR-related orphan receptor-О± RAR-related orphan receptor-ОІ RAR-related orphan receptor-Оі Farnesoid X receptor NR1F1 RORA cholesterol NR1F2 RORB all-trans-retinoic acid NR1F3 RORC NR1H4 NR1H4 Farnesoid X receptor-ОІ NR1H5 NR1H5P Liver X receptor-О± NR1H3 NR1H3 Liver X receptor-ОІ Vitamin D receptor Pregnane X receptor Constitutive androstane receptor Hepatocyte nuclear factor-4О± Hepatocyte nuclear factor-4Оі Retinoid X receptor-О± Retinoid X receptor-ОІ Retinoid X receptor-Оі Testicular receptor 2 Testicular receptor 4 NR1H2 NR1I1 NR1I2 NR1I3 NR1H2 VDR NR1I2 NR1I3 NR2A1 HNF4A NR2A2 HNF4G NR2B1 NR2B2 NR2B3 NR2C1 NR2C2 RXRA RXRB RXRG NR2C1 NR2C2 1B. Retinoic acid receptors 1C. Peroxisome proliferatoractivated receptors 1H. Liver receptor-like receptors 1I. Vitamin receptor-like receptors X D 2A. Hepatocyte nuclear factor-4 receptors 2B. Retinoid X receptors 2C. Testicular receptors Ligand L-thyroxine, 3,3',5triiodothyroacetic acid, 3,5,3'-triodo-Lthyronine 3,3',5triiodothyroacetic acid, 3,5,3'-triodo-Lthyronine, L-thyroxine all-trans-retinoic acid all-trans-retinoic acid all-trans-retinoic acid 8S-HETE, pristanic acid all-trans-retinoic acid linoleic acid, 15-deoxyОґ; 12 14-prostaglandin J2 22(R)-hydroxycholest erol, chenodeoxycholic acid, lithocholic acid, cholic acid lanosterol, desmosterol, cholesten, vitamin D3 27-hydroxycholesterol, 24(S)hydroxycholesterol, 22(R)-hydroxycholest erol lanosterol vitamin D3 all-trans-retinoic acid all-trans-retinoic acid all-trans-retinoic acid Page 18 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Family Receptor common name Receptor nomenclature 2E. Tailess-like receptors TLX PNR NR2E1 NR2E3 Human gene name NR2E1 NR2E3 2F. COUP-TFlike receptors 3A. Estrogen receptors COUP-TF1 COUP-TF2 V-erbA-related gene Estrogen receptor-О± Estrogen receptor-ОІ NR2F1 NR2F2 NR2F6 NR3A1 NR3A2 NR2F1 NR2F2 NR2F6 ESR1 ESR2 3B. Estrogenrelated receptors Estrogen-related receptor-О± Estrogen-related receptor-ОІ Estrogen-related receptor-Оі NR3B1 NR3B2 NR3B3 ESRRA ESRRB ESRRG 3C. Ketosteroid receptors Androgen receptor Glucocorticoid receptor Mineralocorticoid receptor Progesterone receptor Nerve Growth factor IB Nuclear receptor related 1 Neuron-derived orphan receptor 1 NR3C4 NR3C1 NR3C2 NR3C3 NR4A1 NR4A2 NR4A3 AR NR3C1 NR3C2 PGR NR4A1 NR4A2 NR4A3 5A. Fushi taruzu F1-like receptors Steroidogenic factor 1 Liver receptor homolog-1 NR5A1 NR5A2 NR5A1 NR5A2 6A. Germ cell nuclear factor receptors 0B. DAX-like receptors Germ cell nuclear factor NR6A1 NR6A1 DAX1 SHP NR0B1 NR0B2 NR0B1 NR0B2 3- 4A. Nerve growth factor IB-like receptors Ligand 17ОІ; -estradiol 17ОІ; -estradiol testosterone cortisol aldosterone progesterone Table compiled from the IUPHAR online data file, downloaded 11.11.2010, from www.iuphar-db.org. Page 19 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Figure 1: structural and function organisation of the nuclear receptor superfamily A, nuclear receptors consist of six domains (A-F) based on regions of conserved sequence and function. The evolutionarily conserved regions C and E are indicated as boxes, and a black bar represents the divergent A/B, D, and F regions. Domain functions are given above the scheme. B, schematic drawing of the agonist-bound NR LBDs. The О± helices (H1-H12) are depicted as ribbons, and the ОІ-turn as broad arrows. The activation helix, H12, which harbors the residues of the core AF-2, is shown in red. The surface that interacts with coactivators (the LxxLL motif) is highlighted by the dotted oval line. Image courtesy of Dr. William Bourguet, Institut National de la SantГ© et de la Recherche MГ©dicale, Centre de Biochimie Structurale, Montpellier, France. C, superposition of [(E)-4-[2-(5,6,7,8-tetrahydro-5,5,8,8tetramethyl-2-naphthalenyl)propen-1-yl]benzoic acid] (TTNPB)-RARОІ (blue) and 9-cis-retinoic acid-RARОі (gray) LBDs. The subtype-specific residues are shown in cyan (RARОІ) and orange (RARОі), and TTNPB is in yellow. The carboxylate anchoring residues are illustrated as ball-and-sticks. H bonds are represented as dashed lines. Image courtesy of Dr. Sabrina Kammerer, Swiss Federal Institute of Technology, Zurich, Switzerland. D, superimposition of RARОІ (blue) and RARОі (gray) LBPs. Crystal structure of the RARОІ LBD-TTNPB complex reveals an additional cavity in the RARОІ LBP. The arrow points to the additional cavity in RARОІ. Image courtesy of Dr. Sabrina Kammerer. E, the three divergent residues in the LBPs of RARО±, RARОІ, and RARОі are located in helices 3, 5, and 11. The residues that differ between RARО± and RARОІ LBPs are displayed in blue; those differing between RARОІ and RARОі are shown in red. F, schematic representation of the major phosphorylation sites (in green) of mouse RARОі2. The 3D structure of ERО± DBD was obtained from X-ray crystal structure analyses. The various structural elements (Zn2+ fingers and D and P boxes) are indicated. Image courtesy of Dr. William Bourguet. Figure and legend reproduced from Germain et al. (2006) Page 20 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Figure 2: ligands for selected nuclear receptors ER: estradiol; AR (testosterone, dihydrotestosterone); PR (progesterone); TR (thyroxine and thyronine); AhR (dioxin). Page 21 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.2 Nuclear receptor signalling 3.1.2.1 Evolutionary history of steroid receptors The evolutionary history of steroid receptors has been very recently reviewed (Eick and Thornton 2010). The first steroid receptor to evolve is thought to have been an estrogen receptor, which initially had low specificity for its ligand (Baker 2004; Eick and Thornton 2010; Thornton 2001). The major mode of evolution in the steroid receptor family is thought to be partial loss, or subtle modification of, function from a hormone sensitive ancestral receptor (Keay and Thornton 2009). The evolution of receptors for progesterone, testosterone, glucocorticoid and mineralocorticoid is thought to have followed that of the estrogen receptor through a process of вЂ�ligand exploitation’ ,whereby gene duplication of the estrogen receptor allowed evolution of new receptors that were liganded by the intermediates in the synthetic pathways of the older receptor (Thornton 2001). Alternatively the ligands that were most relevant to the evolving receptors may not have been the вЂ�classic’, specific ligands that are considered as the cognate receptor ligands today but may have been other related steroids (Baker 2004). Steroid receptors are thought to have evolved at least 540 million years ago, from an ancestral nuclear receptor in a primitive vertebrate (Baker 2004). Sequence analysis indicates that the enzymes that generate and that inactivate steroids also arose at the same time. Receptors, their ligands and the metabolic pathways that synthesise and degrade ligands are intimately linked throughout evolution, although the relationship may have varied. Modern receptors have specific endogenous ligands whilst evolutionarily receptors may have had less specificity and ligand effects were achieved by attaining high ligand concentrations through increased synthesis or decreased degradation (Baker 2004). It is possible that the ligands for the вЂ�orphan’ receptors (Benoit et al. 2006) will be identified as intermediates in existing synthetic pathways (Thornton 2001). The varied importance of specific ligands remains apparent in the greater receptor promiscuity of species that are вЂ�old’ in evolutionary terms, such as fish, and has implications for the application of endocrine disruption concerns from mammalian to other species. Screening systems that are predicated on mammalian receptor-ligand relationships and characteristics may be inadequate for purpose in non-mammalian species (Keay and Thornton 2009). Additionally, the role of metabolic enzymes can be pivotal in situations where ligand affinity is not high, and this possibility underlines the importance of steroidogenesis assays to partner the increasingly available receptor binding and activation assays. 3.1.2.2 Classical genomic pathway There are two routes in the classical genomic pathway of nuclear receptor signalling. In both routes a steroid ligand diffuses into the cell then either: (a) The ligand encounters cytoplasmic receptors, causes receptor dimerisation, translocation of the dimer complex to nucleus, DNA binding, recruitment of coactivators, and ultimately transcription; or (b) The ligand diffuses to the nucleus, interacts with steroid receptor already bound to DNA but with a corepressor population bound. Ligand binding promotes coactivator binding instead of corepressors, and releases the repression of transcription. Page 22 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Hormone response elements (HREs) NRs interact with DNA by binding to hormone response elements (HREs) in the promoter sequence of target genes OR by binding to other transcription factors associated with target genes. HREs are usually a repeated hexanucleotide separated by a spacer of a variable number of nucleotides and arranged as a direct repeat, a palindrome or a reverse palindrome. See anatomy of the estrogen response element (Gruber et al. 2004) and “the rules of DNA recognition by the androgen receptor” (Denayer et al. 2010). The receptors for androgens, progesterone, glucocorticoids and mineralocorticoids tend to act via response elements comprising an inverted repeat of AGAACA; whilst estrogen receptors tend to act on elements with an inverted repeat of AGGTCA (Eick and Thornton 2010). 3.1.2.3 Off-target effects/crosstalk Off-target effects, or cross-talk, refer to effects of a receptor on genes that do not possess a response element for that receptor. Many transcription factors, including NRs and the AhR, have the ability to modulate transcription in a DNA-binding independent fashion (Beischlag et al. 2008). The assumption that the major effects of NRs only occurred through their cognate response elements was challenged by studies showing that mice expressing a NR which was unable to bind DNA remained viable whilst null receptor mice did not (Reichardt et al. 1998). Protein interactions by NRs can modulate the activity of heterologous DNA bound transcription factors such as AP1, Sp1 and NFkB, primarily leading to ligand dependent repression of activity of the factor. The TR, ER and GR can all repress AP-1 and NFОєB through direct protein-protein interactions whilst the AR can repress Smad and Ets and can itself be repressed by AP-1; reviewed in (Beischlag et al. 2008). Further examples of receptor crosstalk, including that between the estrogen, arylhydrocarbon and retinoid receptors are given in section 3.1.3. 3.1.2.4 Rapid effects The rapid effects of steroids has been recently reviewed (Wendler et al. 2010). Of particular relevance to endocrine disruption is the observed ability of, for example, xenoestrogens to disrupt the rapid effects of estradiol with different potencies to their effects on classical, genomic responses (Watson et al. 2007). Currently, it is well established that rapid effects occur, and that they can be seen for every type of steroid. Interest in rapid effects followed the observation that aldosterone had rapid effects that could not be blocked by mineralocorticoid receptor inhibitors, and that rapid effects could be observed in cells that lacked classical receptors. Rapid effects include a stress response to secreted glucocorticoids, rapid cardiac actions of thyroid hormones, and the acute uterine/vaginal response to injected estrogen (Levin 2008). The rapid effects of steroids are vulnerable to disruption by environmental chemicals but these effects are not typically measured in the assays that are available (Watson et al. 2007). Rapid effects may involve the classical receptors (for example if localised to the membrane by palmitoylation) but there is also strong evidence that additional structures are involved. (Wendler et al. 2010). At the molecular level, rapid effects could be mediated through a specialised membrane receptor (progesterone, estrogen) or by a classical NR that is localised to the membrane and interacting with inner membrane surface proteins such as Src (tyrosine kinase) or PI3K. As well as receptor mediated events, non-genomic effects can include modulation of the activity of ion Page 23 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING channels, kinases, phosphatases or other enzymes (Ordonez-Moran and Munoz 2009). The signalling cascades involved in rapid effects include PI3K, MAPK, tyrosine kinases and the JAK/STAT pathways (Wendler et al. 2010). Many studies of rapid effects have used supraphysiological concentrations of steroids, nonetheless physiological relevant effects have been reported, see table 1 in (Wendler et al. 2010). Rapid effects at supraphysiological concentrations may be relevant to pharmacological applications of steroids. Because circulating hormone levels do not change rapidly it might be predicted that the consequences of rapid events will be persistent, however relatively little is known about the occurrence or extent of desensitisation or secondary genomic effects after rapid, non-genomic events (Wendler et al. 2010). The general principles of rapid, non-genomic effects of steroids are now illustrated with reference to estrogens. In addition to the genomic effects of estradiol through ERО± and ERОІ, estradiol has rapid, non-genomic effects on cells (Wendler et al. 2010). These effects were identified when it was observed that application of estradiol could have effects that occurred too rapidly to be explained by the classical, genomic mechanism which is relatively slow because of the requirement for gene transcription and protein translation (Levin 2008); that estradiol could evoke cellular events even when it was attached to large bulky molecules that could not traverse the cell membrane and activate cytoplasmic receptors (Zivadinovic et al. 2005); and that estradiol could trigger events in cells without classical receptors or that could not be blocked by inhibitors of the classical receptors. Rapid effects include changes in cellular cAMP and intracellular calcium and modulation of ion channels, kinases, phosphatases and other enzymes, for example the rapid effects of estradiol on voltage gated sodium channel may play a role in cell adhesion (Fraser et al. 2010). A recent review of non-genomic actions of androgens concluded that the accumulated evidence supports rapid effects of androgens through both androgen receptor dependent and independent mechanisms (Foradori et al. 2008). Rapid effects of androgens include changes in intracellular calcium, altered membrane flexibility, activation of second messenger signalling and regulation of gonadotropin-releasing hormone (GnRH) release. The presence and role of membrane androgen receptors in prostate and breast cancer cells have been recently reviewed (Papadopoulou et al. 2009). 3.1.2.4.1 Cell surface receptors for steroids Because of the universal occurrence of rapid effects (Wendler et al. 2010) it seems possible that nonconventional or membrane receptors will exist for most steroids; here the evidence for the existence of such receptors for estrogens, androgens, progestins and thyroid hormones is briefly reviewed. GPR30 is a G-protein coupled receptor that has been identified as a membrane receptor for estradiol (Mizukami 2010). GPR30 could be the mediator of rapid effects of estrogens, either directly or through transactivation of the epidermal growth factor receptor (EGFR, (Filardo 2002; Filardo et al. 2008)) or rapid effects may be mediated by the classical receptors relocated to the membrane (Levin 2009). There is still controversy over the role of novel structures in rapid effects, for example see (Otto et al. 2009). The xenoestrogen, bisphenol A, has been reported to induce rapid activation of Erk1/2 through GPR30 in human breast cancer cells (Dong et al. 2010). Page 24 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING A novel membrane-associated androgen receptor has been postulated for a number of cell types, however this putative receptor has not been cloned or characterised (Foradori et al. 2008). It remains unclear whether a specific novel receptor is involved or if rapid effects occur through existing molecules, such as the steroid hormone-binding globulin receptor (SHBGR), a Src kinase complex, GABA receptors and other ion channel or G-protein coupled receptors. A membrane progesterone receptor (mPR) was first identified in teleost fish, and subsequently in mammals (Dressing et al. 2010).In fish, mPR is thought to be involved in oocyte maturation, whilst in mammals expression has been reported in many tissues, including reproductive, immune, neuroendocrine tiisues and in tumours. The main mammalian role of mPR is probably in male and female reproductive function, although other roles in the brain and immune systems are possible (Dressing et al. 2010). The presence, possible identity and function of cell surface receptor for thyroid hormone has been reviewed (Davis et al. 2010; Davis et al. 2005). Certain thyroid hormone actions have been identified that are dependent on the MAPK signalling pathway, including stimulation of the plasma membrane ion pump and phosphorylation of the nuclear TR. These actions may be mediated through a cell surface receptor for thyroid hormone that is present on the extracellular domain of integrin alpha V beta 3 (Davis et al. 2005). 3.1.2.5 Further feature of ligands 3.1.2.5.1 Ligand independent activation (LIA) Nuclear receptors can also be activated by second messenger signalling systems, instead of by binding a ligand agonist. This indicates that membrane receptors are able to communicate with NRs and that the cellular environment can modulate NR function. Ligand independent actions may be important in neurobehaviour and development (Baum 2005; Blaustein 2004); in pathological processes, such as inflammation (Al-Rasheed et al. 2004; Rundhaug and Fischer 2008); and in hormone dependent cancers (Culig et al. 2005). Examples in the endocrine system include a potential role for ligand independent activation of the progesterone receptor in female sexual behaviour (Auger 2001) and the possible contribution of neonatal ligand-independent activation of estradiol receptors to male-typical sexual differentiation of brain and behaviour (Baum 2005). The presence of LIA provides a further opportunity for chemical modulation: receptors that have functional actions when unliganded can have those actions perturbed by ligands simply through a alteration in their tonic, physiological role. The observation of ligand independence suggests a role for so-called вЂ�orphan’ receptors; which may not possess a cognate ligand but instead may function as unliganded receptors (Benoit et al. 2006). The arylhydrocarbon receptor is considered to have important physiological roles in the absence of a known ligand, see section 3.1.3.5. 3.1.2.5.2 Ligand nature Receptor ligands can have diverse outcomes after receptor binding, including agonism, antagonism, acting as an inverse agonist, as a partial agonist/antagonist or as a mixed agonist-antagonist, and modulation. As well as the ligand nature, the outcome can be driven by tissue type and activation status. In some cases, a molecular basis has been found, for example whether or not a ligand agonises or antagonises the ERО± may depend on its ability to induce interaction with coactivators Page 25 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING bearing the LxxLL motif (Bourgoin-Voillard et al. 2010). Modulators of receptor function are of pharmaceutical interest, and include drugs such as tamoxifen and raloxifene which are important breast cancer therapeutics and that are classified as a selective estrogen receptor modulator(SERM) instead of as receptor agonists or antagonists (for example fulvestrant, ICI 182,780). All the cognate NR ligands are small and hydrophobic, however they are otherwise diverse (Germain et al. 2006). Most NRs are potentially promiscuous, a feature which may increase the potential for endocrine disruption. Because of the similarity in ligands for the different nuclear receptors, metabolism can convert a molecule’s affinity from one type to another, for example the ER agonist DDT is metabolised into the AR antagonist DDE. 3.1.2.6 Species differences The AhR provides a useful example of species differences. TCDD toxicity is seen in, for example, mammalian, avian and piscine embryos, and is manifest through the AhR in all cases (Mandal 2005), nonetheless LD50 values for TCDD can vary between species by more than three orders of magnitude (Hengstler et al. 1999). Some details of the molecular underpinnings of species differences have been elucidated and are reviewed in (Ramadoss et al. 2005). There are species differences in both the primary sequence and activity of AhR. For example the AhR of C57BL/6 mice has higher ligand affinity than that of DBA/2 mice, and correspondingly C57B/L mice show higher CYP1A1 induction and a greater sensitive to TCDD. The Han-Wistar rat strain is relatively insensitive to TCDD, and the insensitivity is associated with a C-terminal deletion in the AhR resulting in the loss of 38 or 43 amino acid residues. Guinea pigs are around a thousand times more sensitive to TCDD than are hamsters, and whilst the Guinea pig AhR has an extended transactivation domain, the hamster AhR has a transactivation domain that is restructured, as does the вЂ�resistant’ Han-Wistar rat. Species differences could have important implications for toxicology testing because the majority of toxicology tests use mice. Mouse and human AhR differ in the rate of unliganded cytoplasm-nucleus shuttling of the receptor, the role and identity of chaperone proteins, and the ligand binding potential. A humanised AhR mouse (C57BL/6 mouse knocked in with hAhR) shows lower induction of 1A1 and 1B1 than wildtype mice (Ramadoss et al. 2005). The main details of AhR toxicity were derived from studies of mammals, however the AhR is also important in non-mammalian vertebrates; fish, birds and other vertebrates are sensitive to TCDD and show CYP1A induction in response to halogenated aromatic hydrocarbons (Hahn 1998). Comparative studies of mammals, non-mammalian vertebrates and invertebrates have been reviewed (Hahn 1998; Hahn et al. 2006). In contrast to mammals, in whom only one AhR gene has been found, non-mammalian vertebrates show additional AhR diversity, for example the chicken and the zebrafish have three predicted AhR genes whilst the pufferfish has five whilst invertebrates appear to possess single AhRs, but that differ from those in mammals in being ligand-independent (Hahn et al. 2006). Whether the additional AhR genes/proteins are functional, and if so, what their function is, remains to be elucidated. Nuclear receptors are found in vertebrates and invertebrates, but not in yeast or plants (Baker 2004). It was considered that steroid receptors were vertebrate-specific (Baker 2004), however steroid receptors have now been identified in invertebrates including mollusks and annelids (Keay and Thornton 2009) although many other invertebrate genomes do indeed lack steroid receptor Page 26 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING genes (Eick and Thornton 2010). The notion that invertebrates may not be sensitive to endocrine disruption is somewhat supported by the general finding that invertebrate steroid receptors tend not to be ligand sensitive, however an invertebrate orthologs of vertebrate androgen progestin and corticosteroid receptors that is sensitive to estrogens and can bind to estrogen response elements has been reported (Bridgham et al. 2008). More recently, a functional ER has been reported in the invertebrates, annelids, and this finding indicates that phyla in the same lineage as the annelids (platyhelminthes, brachiopods, nemerteans, phoronids and echiura) would also be expected to contain estrogen-sensitive ER (Keay and Thornton 2009). The implications of these findings for endocrine disruption in wildlife have been discussed (Keay and Thornton 2009). Invertebrates should be considered vulnerable to endocrine disruption through mechanisms involving steroid receptors, as vertebrates are; however testing strategies based on vertebrate models may not be sufficiently protective for invertebrates. Page 27 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.3 Selected receptors This section covers the receptors for estrogens, androgens, progesterone, thyroid hormones, and the arylhydrocarbon receptor. The nomenclature for these receptors is presented in Table 3. Assays that are relevant to these receptors are reviewed in section 3.1.4. Table 3: nomenclature of selected receptors Receptor Estrogen receptor alpha (ERО±) Estrogen receptor beta (ERОІ) вЂ�NR’ nomenclature (IUPHAR) NR3A1 Approved gene name (HUGO, HGNC) estrogen receptor 1 NR3A2 estrogen ESR2 receptor 2 (ER beta) Estrogen receptor beta ESR2_HUMAN androgen receptor AR Androgen receptor ANDR_HUMAN progesterone receptor PGR Progesterone PRGR_HUMAN receptor Androgen NR3C4 receptor (AR) Progesterone NR3C3 receptor (PR) Thyroid NR1A1 hormone receptor alpha (TRО±) Thyroid hormone receptor (TRОІ) NR1A2 beta Arylhydrocarbon receptor (AhR) Gene Protein name UniProt entry symbol (UniProt) name (HUGO) ESR1 Estrogen ESR1_HUMAN receptor thyroid hormone THRA receptor, alpha (erythroblastic leukemia viral (verb-a) oncogene homolog, avian) thyroid hormone THRB receptor, beta (erythroblastic leukemia viral (verb-a) oncogene homolog 2, avian) aryl hydrocarbon AHR receptor Thyroid hormone receptor alpha THA_HUMAN Thyroid hormone receptor beta THB_HUMAN Aryl hydrocarbon receptor AHR_HUMAN IUPHAR: www.iuphar-db.org; HUGO (Human Genome Organisation): www.hugo-international.org; HGNC (HUGO Gene Nomenclature Committee): www.genenames.org; UniProt: www.uniprot.org Page 28 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.3.1 Estrogen receptors (ER) Background and nomenclature. There are two estrogen receptors in the NR family, estrogen receptor О± (ERО±, NR3A1, gene ESR1) and estrogen receptor ОІ (ERОІ, NR3A2, gene ESR2) (Germain et al. 2006). ERО± was cloned in 1986 and considered to be the only ER until ERОІ was cloned in 1996. A non-nuclear receptor for estrogen has been proposed, GPR30, and is described in section 3.1.2.4.1. To what extent does ERО± or ERОІ activation make a ligand estrogenic? Prior to interest in ERОІ, вЂ�estrogenic’ was defined as “stimulation of uterine growth and induction of the progesterone receptor in the uterus” (Dahlman-Wright et al. 2006), however these effects are a result of ERО± activation and not ERОІ, to use this definition would mean that ERОІ ligands did not qualify as estrogens. Induction of a proliferative response in reproductive tissues may be the hallmark of ERО± activation however such a clear apical response is harder to select for ERОІ, and it may be that ERОІ ligands evoke a range of different effects through ERОІ, or that ERОІ itself has a wider repertoire of effects (Koehler et al. 2005). Endocrine disruption via ERОІ has been reviewed (Swedenborg et al. 2010). Tissue expression and physiology. ERО± and ERОІ tissue expression is overlapping but does not always co-vary. Both receptors may be expressed in the same organ but in different constituent cells, for example in the prostate ERО± is expressed in stromal cells whilst ERОІ is expressed in epithelial cells; in the ovary ERО± is expressed in thecal cells and ERОІ is expressed in granulosa cells. Both receptors are also expressed in the testis, bone/bone marrow and certain brain regions. ERО± is expressed in the uterus, epididymis, breast, liver and white adipose tissue. ERОІ is expressed in colon, salivary gland and vascular epithelium. The roles of ERО± and ERОІ have received interest in relation to particular human diseases, including breast cancer and prostate cancer, where the target organs express both receptors. In part this interest is due to the possibility that receptor selective therapies may achieve useful therapeutic effects that have not currently been possible with non-selective approaches. When ERО± and ERОІ are expressed in the same cell, it has generally been found that ERОІ opposes the effects of ERО±, for example the genomic and proteomic effects of genistein on T47D cells engineered with tetracycline-dependent ERОІ expression (Sotoca et al. 2010). However in most cases the subtypes may be expressed in different, perhaps neighboring cells – in the same tissue, not the same cell. Molecular biology. The two estrogen receptors share a high degree of similarity in amino acid sequence but have a major difference in their molecular function: ERО± depends on two activation functions (AF); AF1 is constitutively active and located in the N-terminal domain and AF2 is ligand dependent and located in the C-terminal domain. However ERОІ has a weaker AF1 function than ERО± and so its transcriptional activation is more dependent on ligand dependent AF2 function (DahlmanWright et al. 2006). The molecular basis for this difference is reported to be due to the absence of a crucial hydrogen bonding reside in the ERОІ protein so that the position of helix 12 tends to the antagonistic position rather than the agonist position (as in ERО±)(Koehler et al. 2005). The relative importance of AF1 and AF2 for transcriptional activation is also affected by the cellular context, for example growth state. Page 29 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING To regulate transcription, ERs dimerise, interact with a coregulatory complex of coactivators and corepressors and then interact with DNA through estrogen response elements (ERE). A consensus ERE sequence has been identified (Gruber et al. 2004), however most known estrogen responsive genes lack the consensus sequence, including pS2, cathepsin D and PR genes. In these cases it is believed that the ER is binding to an imperfect ERE, termed an estrogen response unit (ERU) or is acting through binding to other transcription factors which do have sites on the regulated genes, such as AP-1 (Kushner et al. 2000) (Bjornstrom and Sjoberg 2004) and Sp1(Khan et al. 2006) (Safe 2001). Structural features of receptor ligands. ER ligands usually have a hydroxyl group on the 3 position of the steroid backbone (Eick and Thornton 2010). Subtypes. ERО± and ERОІ are able to bind to the same EREs, although ERОІ generally has a slightly lower affinity than ERО±, however the consequence of ERE binding depends on the subsequent recruitment of coregulators in a cell and context dependent fashion. Studies of heterofusion proteins that resemble ER dimers suggest that ERО± is the dominant monomer (Powell and Xu 2008), however the outcome of estrogen exposure is also likely to depend on cell and tissue characteristics, not just on the ERО±/ERОІ ratio. One of the mechanisms through which the different effects of ER subtypes occurs is through differential tethering to target genes, tethering occurs when the receptors does not directly interct with DNA but rather interacts with another transcription factor that is interacting with DNA. Examples of genes for which tethering is different for ERО± and ERОІ include Cyclin D1, IGF1, Col and RARО± (Fox et al. 2008; Zhao et al. 2008), the molecular explanations for these effects include the presence or absence of a ERU in the promoter region of the gene, and the presence of other transcription factor sites, such as Sp1 (Khan et al. 2006) (Safe 2001) and AP1 (Kushner et al. 2000) (Bjornstrom and Sjoberg 2004). Further details are also found in (Glidewell-Kenney et al. 2005), (O'Lone et al. 2004) and (Zhang and Trudeau 2006). Examples of potential endocrine (ER-mediated) disruptors include: alklyphenols, bisphenol A, heavy metals, parabens, perfluorinated chemicals, pesticides, pharmaceuticals, phthalates, phytoestrogens, polybrominated diphenyl ethers, polychlorinated biphenyls, dioxins and furans. 3.1.3.2 Androgen receptor (AR) Background and nomenclature. The androgen receptor (AR, NR3C4, gene: AR) is classified into the same group (group 3C) as the receptors for mineralocorticoid (MR), glucocorticoid (GR) and progesterone (PR, see next ) (Lu et al. 2006). The predominant human androgen is testosterone (T); men produce around 8mg daily from the testes, and women produce around 0.25mg from the ovary and by peripheral conversion of androstenedione from the adrenal gland. Only around 2% of circulating testosterone is free, the majority is bound to sex hormone binding globulin (SHBG) or albumin. In androgen target tissues such as the prostate and the skin, testosterone is reduced to 5dihydrotestosterone (DHT), which then acts as the active hormone. Tissue expression and physiology. In males there are three periods of life when testosterone levels are elevated; during embryonic development (8th week to birth), during neonatal period (up to 1year of age) and from puberty throughout adult life (until a gradual decline in senescence). During embryonic life, androgens virilise the urogenital tract of the male embryo. Genetic conditions in Page 30 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING which the AR does not fully function result in incomplete male genitalia, or a female external phenotype. Neonatally, androgens are thought to play a role in neurodevelopment. In puberty, androgens are responsible for the development of secondary sexual characteristics, an increase in height through growth and development of skeletal musculature. Androgens also play a role in aggressive behaviour. Clinical uses. Androgen therapy is used clinically in male hypogonadism and in aging; it is also used in boys with delayed puberty and in women with endometriosis (the weak androgen danazol). Androgen antagonists (e.g. flutamide, nilutamide, bicalutamide) are used for androgen blockade in the treatment of prostate cancer, where they are usually given in combination with a long acting analogue of luteinising-hormone releasing hormone. Androgen blockade is thought to induce apoptosis in primary and metastatic lesions, and thereby achieve a volume decrease, however androgen-refractory status, with fatal outcome, often develops. A state of recurrent prostate cancer is thought to result from increased AR signalling as a result of increased AR expression; increased synthesis of testosterone, mutations in AR and ligand independent AR activation. Adverse effects. In men, androgen treatment can be associated with sleep apnea, polycythemia, azoospermia, decreased testicular size, aggression and psychosis. Androgen blockade can be associated with hot flushes, loss of libido, loss of sexual potency, bone loss, osteoporosis. In women, androgen treatment can be associated with adverse effects such as hirsutism, acne, amenorrhea, clitoral enlargement and deepening of the voice. Molecular biology. The AR differs from other NR in that ligand binding (T, DHT) stabilises the structure by allowing the N-terminal FxxLF motif to bind to the AF2 in the LBD. The unliganded AR also has a cytoplasmic location. The requirements for DNA recognition by the AR have been reviewed (Denayer et al. 2010). The transcriptional activity of the AR can be increased by chemicals, such as methoxyacetic acid, that act via a tyrosine kinase pathway involving PI3-kinase (Bagchi et al. 2008). Structural features of receptor ligands. AR ligands usually have a keto group at the 3-position on the steroid backbone (Eick and Thornton 2010). Structural features have been revealed by quantitative structure activity studies, e.g. (Hong et al. 2003; Tamura et al. 2006). Examples of potential endocrine (AR-mediated) disruptors include: phthalates, pesticides, plasticisers, polyhalogenated compounds 3.1.3.3 Progesterone receptor (PR) Background and nomenclature. The progesterone receptor (PR, NR3C3) is the receptor for human progestins, of which progesterone is the most important (Lu et al. 2006). Progesterone is synthesised from circulating cholesterol in ovary (corpus luteum), testis, adrenal glands and placenta (during pregnancy), and also serves as a precursor for the synthesis of estrogens, androgens and adrenocortical steroids. Only around 10% of circulating progesterone is unbound, the remainder is bound to corticosteroid binding globulin (CBG) and albumin. Tissue expression and physiology. Males and females secrete around 1-5mg progesterone daily, although female levels are raised during the follicular phase of the menstrual cycle. During the luteal phase of the cycle and in the third trimester of pregnancy, levels increase to 10-200mg/day. Levels rise to several hundred mg/day in the latter stages of pregnancy. PR is expressed in the female Page 31 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING reproductive tract, mammary gland, brain and pituitary gland. The expression of PR is can be induced by estrogen, and PR expression is considered a clinical and research marker for estrogen action. Progestins often promote differentiation and oppose cell proliferation, in opposition to estrogens. Progesterone plays crucial roles in ovulation, implantation, development of the mammary gland, maintenance of pregnancy and behaviour. Progesterone also has effect on respiration during pregnancy and during the luteal phase of the menstrual cycle; has depressant and hypnotic actions in the CNS and may play a role in male reproduction, see (Gadkar-Sable et al. 2005). Clinical uses. Progestins are used clinically for contraception, either alone or with estrogen, and for hormone replacement therapy (HRT, see chapter 5.1). Progestins are also used for ovarian suppression in the treatment of dysmenorrheal, endometriosis, hirsutism and uterine bleeding. RU486 is a potent antagonist of the GR and the PR, it can delay or prevent ovulation, prevent implantation and terminate pregnancy. Molecular biology. The PR seems to fit the basic NR paradigm for the genomic pathways and forms PR-PR homodimers. From the one PR gene there are three protein isoforms: PR-A, PR-B and PR-C which is truncated (Gadkar-Sable et al. 2005). The different ratio of PR-A and PR-B in different tissues or at different developmental stages may allow receptor ligands to regulate different genes populations as appropriate. The PR is located in the cytoplasm. Structural features of receptor ligands. Progestin ligands usually have a keto group at the 3-position on the steroid backbone (Eick and Thornton 2010). Non-genomic effects. Like many of the NRs a membrane-located progesterone receptor with nongenomic effects has been proposed, and is reported to be present on aortic endothelial cells, hepatocytes, brain cells, mammary gland, ovary, granulosa cells and spermatozoa (Gadkar-Sable et al. 2005). It has been suggested that because spermatozoa contain tightly packed DNA that is inaccessible for transcription, they constitute an ideal system for studying non-genomic effects of, i.e. progesterone. In spermatozoa, progesterone has been shown to have rapid effects including stimulation of calcium influx, tyrosine phosphorylation, chloride efflux and to increase cAMP levels; apically resulting in crucial processes such as capacitation, hyperactivated motility and the acrosome reaction (Gadkar-Sable et al. 2005). On the same cell type, spermatozoa, estrogen reportedly has rapid effects that oppose the actions of progesterone, by inhibiting the plateau phase of calcium influx and inhibiting the acrosome reaction. Examples of potential endocrine (PR-mediated) disruptors include: antioxidants (butylated hydroxyanisol), fungicides (benomyl and vinclozolin), herbicides (alachlor and atrazine), organochlorine insecticides (DDT and its metabolites, methoxychlor, aldrin, dieldrin, chlordecone, lindane, trichlorobenzene), estrogenic insecticides (endosulfan, toxaphene, nonachlor), industrial chemicals (nonylphenol, bisphenol A, diphenylphtalate), polycyclic musks, UV filters (Schreurs et al. 2005; Scippo et al. 2004; Viswanath et al. 2008) 3.1.3.4 Thyroid hormone receptors (TR) Background and nomenclature. There are two thyroid hormone (TH) receptors in the NR family, TH receptor О± (TRО±, NR1A1) and TH receptor ОІ (TRОІ, NR1A2), TRОІ has two isoforms and a third isoform, TRОІ3, is thought to be rat-specific (Germain et al. 2006). The main TR ligand is 3,5,3’ triiodo-Lthyronine (T3), which is produced by deiodination of thyroxine (T4) secreted by the thyroid gland Page 32 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING (Flamant et al. 2006). In TH signalling, regulated local concentrations of active TH are more important than circulating hormone levels (Schweizer et al. 2008). Tissue expression and physiology. TRО± is ubiquitously expressed whilst TRОІ is developmentally regulated and mainly expressed in liver, pituitary, inner ear, retina and certain brain regions. Treatment with T4 and T3 has beneficial effects including lowering of body weight and of plasma cholesterol; however an excess in T3 results in bone and muscle loss, and tachycardia possibly leading to atrial arrhythmia. Adult, circulating levels of T4 and T3 are usually stable; hyperthyroidism can result in goiter, periorbital oedema, weight loss, tachycardia, palpitations, muscle weakness, osteoporosis (especially in post-menopausal women), and mood disorders. Hypothyroidism can result in goiter, myxedema, fatigue, cold-intolerance, thinning hair, depression, dry skin, constipation, and bradycardia. Untreated fetal and neonatal hypothyroidism can limit bone growth, result in deafness and cause cretinism, an irreversible mental retardation. In developed countires, these effects are largely avoided by established neonatal screening programs for TH levels (Flamant et al. 2006). Genetic studies in mice have shown that postnatally TRО±1 is a main regulator of intestinal remodeling, cerebellum development, spleen erythropoiesis, bone growth, cardiac function and thermogenesis. TRОІ1 is important for regulation of liver function and the development of hearing. TRОІ1 and TRОІ2 together play a major role in the feedback regulation of the HPT axis. TRОІ2 is also important in the development of colour vision and the auditory system. Molecular biology. TRs act mainly as heterodimers with RXR although TRОІ1 homodimers and TR/retinoic acid receptor heterodimers can also form. X-ray crystallographic studies suggest that T3 binding causes the C-terminal helix 12 to fold into the scaffold formed by helices 3,4, and 5; creating a surface with a hydrophobic cleft that favours coactivator recruitment and prevents corepressor interaction. TR/RXR heterodimers interact with DR-4 elements in DNA; the DR-4 element has two binding sites spaced to accommodate the TR/RXR heterodimer. Known TR target genes include those encoding type1 deiodinase, the basic transcription element binding protein, Hairless corepressor and neurogranin. The full repertoire of TR regulated genes is yet to be clearly defined, however it is likely to be large. Many putative TR genes are downregulated by T3 and, as for ER target genes, may not possess a consensus recognition site and may be regulated indirectly by the TR. T3 is structurally unrelated to other nuclear receptor ligands (Flamant et al. 2006) and see Figure 2. Like the ER, nongenomic effects are also reported for thyroid hormones and these effects are said to be TR-independent (Davis et al. 2005). The TR can also regulate gene expression without being liganded (Flamant et al. 2006). Examples of potential endocrine (TR-mediated) disruptors include: PCBs, bisphenol A, perchlorate, dioxins and furans, pentachlorophenol, PBDEs, phytoestrogens, phthalates, parabens and pesticides (Moriyama et al. 2002; Patrick 2009). A list of around 150 synthetic chemicals that could influence thyroid hormone function, through many diverse sites of action, can be found as Table 1 of (Howdeshell 2002). 3.1.3.5 Arylhydrocarbon receptor (AhR) Background and nomenclature. The arylhydrocarbon receptor (AhR) is not a nuclear receptor, but it is included in this section because of the importance of AhR ligands, such as TCDD (dioxin), in Page 33 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING endocrine disruption. The AhR shares no sequence homology with steroid receptors, but has functional similarities, and has very similar physicochemical similarities to the glucocorticoid receptor (GR) (Beischlag et al. 2008). The AhR is a member of the basic helix-loop-helix (bHLH)/PAS transcription factor family, and it is the only ligand activated member of the family (Mandal 2005). AhR regulates key enzymes in the metabolism of endogenous molecules and xenobiotics, including P450 cytochromes 1A1, 1B1 1A2 and 2S1 (Ramadoss et al. 2005). Other AhR controlled genes include uridine diphosphate gylcosyltransferase I family polypeptide A1 (UGT1A1), glutathione S-transferase (GST)-Ya subunit, NADPH-quinoine-oxidoreductase, p27Kip1 and N-myristoyl-transferase-2. AhR ligands include вЂ�dioxin’ (2,3,7,8-tetrachlorodibenzo-para-dioxin, TCDD); polycyclic aromatic hydrocarbons (PAHs), such as benzo[a]pyrene; benzimidazoles and flavonoids (Ramadoss et al. 2005). The dioxin вЂ�family’ is a group of chemicals that share a common toxic effect and structural motif, and includes 7 dioxins, 10 furans and 12 PCBs (Mandal 2005). TCDD is considered the prototypic AhR ligand and was classified as a human carcinogen (IARC group I) in 1997 (Ramadoss et al. 2005). Tissue expression and physiology. AhR is expressed in many tissues and cell types (Mandal 2005; McMillan and Bradfield 2007). In mammals, the AhR is expressed in numerous embryonic and adult tissues, including early expression in brain/neurons that dissipates as gestation proceeds (McMillan and Bradfield 2007). The targets of AhR may also show distinct patterns of tissue expression, for example in humans, CYP1A1 is primarily extrahepatic, in contrast to rodents, and whilst CYP1B1 and CYP251 are also extrahepatic, CYP1A2 is primarily hepatic (Ramadoss et al. 2005). Interest in the AhR initially arose due to the toxicity that it mediates, especially that of dioxin (TCDD), and interest in the receptor’s potential physiological roles has increased more recently. Toxicity. Toxic effects of potent AhR ligands, like TCDD, occur in a variety of organs, and include chloracne, non-genotoxic carcinogenesis and teratogenesis, immunotoxicity and wasting syndrome (Bradshaw and Bell 2009; Mandal 2005). In experimental animals, TCDD results in death from wasting, with an irreversible and progressive loss of body weight that is only weakly dose-dependent (Mandal 2005). An exact mechanism from ligand binding to effect is not available, although both the presence of AhR and gene transcription are known to be required (Bradshaw and Bell 2009). Adverse effects mediated through AhR could include the bioactivation of procarcinogens or the disruption of homeostasis (Ramadoss et al. 2005). Interestingly although TCDD is carcinogenic, it is also antiestrogenic and inhibits E2 induced cell proliferation, progesterone receptor (PR) gene expression and PR binding (Bradshaw and Bell 2009). TCDD inhibits spontaneous, age-dependent and carcinogen induced mammary tumour formation and growth (SD rats), and reduces uterine tumour incidence (Bradshaw and Bell 2009). The half life of TCDD in humans is around 7-11 years, this is reduced in humans exposed to high doses of TCDD, and in infants, and is also species-dependent – for example the half-life is only 2-3 weeks in rats (Bradshaw and Bell 2009; Ramadoss et al. 2005). AhR ligands that are less stable than TCDD, are correspondingly less toxic. LD50 values for TCDD can vary between species by more than three orders of magnitude (Hengstler et al. 1999). Drug metabolism. AhR ligands can lead to drug-drug interactions by inducing cytochrome P450 enzymes with subsequent effects on the metabolism and pharmacokinetics of other drugs (Bradshaw and Bell 2009). The role of AhR in drug metabolism has been reviewed (Ramadoss et al. 2005). Polymorphisms in AhR or in enzymes regulated by AhR, mean that individuals can show significant variations in response, e.g. to drugs directed at the AhR. At least three pharmaceuticals are AhR ligands: leflunomide (used for arthritis treatment), flutamide (prostate cancer) and Page 34 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING nimodipine (calcium antagonist) (Bradshaw and Bell 2009). However the use of these pharmaceuticals has not been associated with either AhR toxicity or CYP1A1 induction and so it seems probable that they may not reach high enough levels to act as ligands after clinical application. Endogenous ligands. Three lines of evidence suggest a physiological role for AhR, and imply the presence of an endogenous ligand: 1) the AhR has been evolutionarily conserved; 2) AhR mutant mice show an aberrant phenotype; and 3) genes known to be DRE-responsive show increased expression during development; reviewed by Nguyen and Bradfield (2008). The endogenous AhR ligand has not yet been identified (Nguyen and Bradfield 2008), and this is also the case for a number of nuclear receptors, which are referred to as вЂ�orphan receptors’ for this reason (Benoit et al. 2006). Potential endogenous AhR ligands include eicosanoids, such as prostaglandins (weak agonists) and a product of arachidonic acid metabolism, lipoxin A4 (potent ligand); indirubin; bilirubin; cAMP (very weak) and tryptophan (after enzymic or UV activation) (Bradshaw and Bell 2009). Nguyen and Bradfield (2008) have provided a thorough review of endogenous and xenobiotic AhR ligands, and also noted that the endogenous activator of AhR may not even be a ligand. Instead, activation of unliganded AhR could be driven by cell signalling pathways, cell-cell contact, cellular stress or changes in cell morphology. The invertebrate orthologs of AhR are considered not to bind ligands (McMillan and Bradfield 2007), indicating that ligand dependency is not a conserved feature of the AhR. Physiological roles. The potential physiological roles of the AhR have been reviewed (Barouki et al. 2007). Proteins in the bHLH/PAS family, to which the AhR belongs, are involved in diverse physiological processes including circadian rhythm, organ development, neurogenesis, metabolisms and the stress response to hypoxia (Barouki et al. 2007). The AhR-deficient mouse phenotype includes cardiac hypertrophy, immune system alterations, skin alterations, altered formation and number of primordial follicles with associated difficulties in pregnancy maintenance and poor pup survival in lactation and weaning (Barouki et al. 2007). AhR-null mice show a hepatic phenotype of smaller size, portal fibrosis, early lipid accumulation and vascular defects. The AhR also influences cell proliferation, for example sustaining cell proliferation through a interaction with NFОєB, through the p65/RelA subunit, to transactivate the c-myc proto-oncogene; or suppressing proliferation through activation of the tumour suppressors p27Kip1 or retinoblastoma tumour suppressor protein (pRb). In human breast cancer cells, it has been reported (Barhoover et al. 2010) that the unliganded AhR can form a complex with CDK4 and CCND1, and thus recruits RB1 and allows its phosphorylation by CDK4. Phosphorylation inactivates RB1 and removes its repressive effect on cell cycle progression. Conversely, the addition of an AhR ligand, TCDD, disrupts the AhR/CDK4/CCND1 complex and removes its tonic contribution to cell cycle progression. Whether AhR promotes or inhibits cell proliferation appears to depend on cell phenotype, however further clarification of the pathways and proteins involved is required. Further interest in AhR as a target for human cancer treatments seems likely (Barouki et al. 2007). Studies of AhR orthologs in invertebrates suggest possible roles in defects of neurodevelopment, cognition and behaviour (Barouki et al. 2007). In vitro studies suggest a role for AhR in cell adhesion and migration, including the observation that prevention of cell-cell contacts can activate the AhR in the absence of ligand. A recent genomewide analysis of AhR binding targets in mouse hepatoma cells found that the naive receptor, in unstimulated cells, is bound to gene clusters that control morphogenetic and developmental programs and that activation of the receptor by a xenobiotic Page 35 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING increases binding to gene clusters involved in xenobiotics metabolism (Sartor et al. 2009). These genomic studies support the theory that AhR has important physiological roles that are then disrupted by xenobiotic binding (Beischlag et al. 2008). There are clues as to the endogenous functions of AhR in the Caenorhabditis elegans homologue CeAhR (Bradshaw and Bell 2009). CeAhR defects affect neuronal migration, specific neural cell and axonal migration, and cell fate. The physiological functions of AhR suggested by studies using three genetic model systems, Mus musculus, C. elegans and Drosophila melanogaster, have been reviewed (McMillan and Bradfield 2007).In C. elegans and D. melanogaster loss of AhR function generally affects environmental sensation, for example AhR seems to be required for proper development of antennae and eyes. In M. musculus AhR is highly expressed in olfactory organs and the retina but functional studies have not been conducted into whether these tissues are affected by loss of AhR. Loss of AhR function in the murine model affects the liver, kidney, oocyte and reproductive functions. The AhR knockout mouse is resistant to TCDD toxicity (Bradshaw and Bell 2009). The knockout condition is fatal for around half of the mice, the survivors are viable and fertile and neonatal lethality is lost in their offspring. Knockouts show reduced weight gain, reduced liver weight – due to a defect in vasculature development that is present not only in liver but also eye and kidney (Bradshaw and Bell 2009). Molecular biology. The molecular mechanisms by which AhR interacts with gene expression have been comprehensively reviewed (Beischlag et al. 2008). The AhR is present in the cytosol in complex with chaperone proteins, heat-shock protein 90 (HSP90) and AhR-interacting protein (AIP)(Beischlag et al. 2008; Bradshaw and Bell 2009) The complex is required for the AhR to fold into a conformation that is capable of ligand binding, and this requirement means that expression levels of ligandbinding, competent AhR are low (Bradshaw and Bell 2009). On ligand binding, AhR translocates to the nucleus, dissociates from chaperones and dimerises with a second PAS family protein, arnt. The AhR-arnt dimer can bind to DNA response elements termed xenobiotic response elements (XRE), and sometimes also referred to as dioxin (DRE) or AhR (AhRE) response elements. The consensus DRE is 5’-TA/TGCGTG-3’, and differs from the palindromic response elements of steroid receptors in being asymmetric (Beischlag et al. 2008). Binding of the AhR-arnt dimer to a DRE is influenced by the recruitment of coregulator proteins, reviewed and listed by (Hankinson 2005) and in (Beischlag et al. 2008). The transcriptional activation domains of AhR-arnt are structurally different from those of the nuclear receptors, described earlier, however a coactivator that is recruited uniquely to the AhR and not to an nuclear receptor has not been described and it appears that even structurally divergent receptors can share in a common pool of coactivators (Beischlag et al. 2008). Ligand bound AhR is rapidly exported from the nucleus and degraded (Bradshaw and Bell 2009). The AhR rapidly вЂ�shuttles’ between cytosol and nucleus in a ligand-independent manner, and this may serve to increase the rapidity of response to AhR ligands (Ramadoss et al. 2005). Comparative genomic studies of AhR(Hahn 1998; Hahn et al. 2006) were reviewed in section 3.1.2.6. Structural features of receptor ligands. Structure activity relationship (SAR) studies suggest that AhR ligands have the following characteristics, reviewed by (Nguyen and Bradfield 2008). AhR ligands are hydrophobic; belong to the PAH or halogenated aromatic hydrocarbon (HAH) structural classes; tend to be planar (although absolute planarity is not a requirement, co-planarity is a steric factor); are 1214Г… in length, less than 12Г… wide and less than 5Г… deep. For HAHs the polarizability of substituents controls receptor affinity and receptor activation. Ligand properties that influence receptor interaction include electronegativity, hydrophobicity and hydrogen bonding. Page 36 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Cross-talk. Through its roles in physiology and xenobiotic response, AhR sits at the crossroads of multiple signalling pathways and has interactions with cell cycle regulation, protein kinase cascades, differentiation and apoptosis (Ma et al. 2009). AhR activation also exhibits rapid effects, including changes in intracellular calcium, accumulation of FOS and JUN mRNAs, and large increases in AP-1 transcription factor activity (Mandal 2005). The importance of rapid effects in receptor signalling is described in section 3.1.2.4. AhR interacts with both the ER and the AR (Ramadoss et al. 2005). Crosstalk between the AhR and ER has received most interest, and has been recently reviewed (Beischlag et al. 2008). TCDD is antiestrogenic in vivo, antagonises the ER and inhibits the expression of E2 inducible genes including pS2, cathepsin D, c-fos and Cyclin D1. AhR and ER ligands may overlap in effects due to similarities in chemical structure. Cross-talk mechanisms include: induction of P450 enzymes that metabolise estrogen; downregulation of cell cycle genes; induction of proteasomal degradation of ER; transcriptional interference e.g. through binding to DRE that overlap with ERE, thus preventing ERE binding; the presence of inhibitory DRE in E2-inducible gene promoters; and direct transrepression between AhR and ER. AhR can also have estrogenic effects, for example the AhR can recruit unliganded ER to promoters and promote transcription; AhR can recruit coactivators to the ER and promote transcription; and, conversely, AhR can recruit corepressors and suppress transcription (Beischlag et al. 2008; Ramadoss et al. 2005). AhR and retinoic acid signalling pathways also show cross-talk, as reviewed (Murphy et al. 2007). The retinoids, the most important of which is retinoid acid (RA) derived from dietary vitamin A, are vital for biological functions of embryogenesis, growth and differentiation, vision and reproduction. RA binds to retinoic acid receptors (RARs) and retinoid X receptors (RXRs), which interact with DNA at retinoic acid response elements (RAREs). Interest in AhR / retinoid crosstalk arose because lesions due to vitamin A deficiency are similar to those of TCDD exposure. Mechanisms of crosstalk include the ability of retinoids to act as AhR ligands, effects of AhR and AhR ligands such as TCDD on RA biosynthesis, metabolism and storage, and molecular interactions. Molecular interactions include the presence of both DRE and RARE in a gene’s promoter, effects of RA on AhR expression, effects of AhR on RAR and RXR expression, and an overlapping use of common coactivators or corepressors (Murphy et al. 2007). Mechanistic links to endocrine disruption. The role of AhR in the female reproductive system has been specifically reviewed (Hernandez-Ochoa et al. 2009). The reviewers propose that the AhR has a physiological role in ovarian function, establishment of an optimum environment for fertilisation, embryo nourishment, maintenance of pregnancy, regulation of reproductive lifespan and fertility (Hernandez-Ochoa et al. 2009). The AhR pathway may also be critical for the sexual differentiation of neuroendocrine functions, and it has been proposed that the mechanism whereby perinatal exposure to AhR ligands disrupts neural development may be through a dysregulation of GABAergic systems (Petersen et al. 2006). Examples of potential endocrine (AhR-mediated) disruptors include: dioxins and PCBs, products of incomplete combustion; herbicide and pesticide contaminants; indoles (3-carbinol, metabolites include a potent and a weak AhR agonist); flavonoids (biochanin A, formononetin); sulforophane (broccoli) (Bradshaw and Bell 2009). Page 37 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.4 Assays based on receptor signalling This section describes assays that are based on receptor signalling through the same five receptors (ER, AR, PR, TR, AhR) that are covered throughout this over-arching issue. The types of assays include receptor binding studies using displacement of a radiolabelled ligand (Table 4); receptor activation studies using recombinant yeast or mammalian systems, such as luciferase or galactosidase reporter genes (Table 5, Table 6); and receptor activation studies using a cellular endpoint such as proliferation (Table 7). Selected miscellaneous assays with diverse endpoints are listed (Table 8). Computational models were tabulated (Table 9, Table 10), for example SAR, QSAR and 3D-QSAR and other computational projects, which are usually based on, and then extend, a large data set from an experimental assay. Animal studies are included where the endpoint is thought to be strongly indicative of receptor mediated effects, for example the rat uterotrophic assay for the estrogen receptor and the Hershberger assay for the androgen receptor (Table 11). Knockout mouse models are also listed (Table 12). Finally, studies that allow comparison of assays or large numbers of ligands are documented (Table 13, Table 14). It is important to note that this section does not cover all of the receptors that are potentially relevant to endocrine disruption, being limited to ER, AR, PR, TR and AhR, and the scope was also limited to assays and assay types that can be compared across receptors, i.e. assay types that are only relevant to one receptor were not included. The focus is also on studies using human receptors when possible, the reader is referred to studies that compare the results of using receptors from different species, for example Dang et al. found broad comparability between the results for ligands screened in assays using either the human or fish estrogen receptors, and they review the regulatory implications of this (Dang et al. 2011). 3.1.4.1 Radiolabelled ligand displacement assays Table 4 lists the availability of radioloabelled binding assays. All five receptors have been studied in radiolabelled ligand displacement studies, including subtype specific studies of estrogen and thyroid hormone receptors. Such assays measure receptor binding of a test chemical by recording displacement of a radiolabelled ligand from receptors either purified from tissues or produced from recombinant technologies. Binding assays cannot differentiate between agonists and antagonists, and lack any cellular context, such as the presence of coregulator molecules. Results are usually expressed as relative binding affinity (RBA), with the binding of the reference ligand set to 100. Binding assays and the OECD conceptual framework Binding assays have been proposed for use in strategies such as the OECD conceptual framework (in level 2). As of 2010 no such assays have been adopted by the OECD although the development and validation process is underway. AR binding assays using the recombinant rat AR have been proposed for use in the OECD framework (Freyberger et al. 2010; Freyberger and Ahr 2004; Kim et al. 2010). Page 38 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.4.2 Cell based assays Cell based assays are listed in Table 5 (yeast-based reporter gene system), Table 6 (mammalian cellbased reporter gene systems) and Table 7 (cell proliferation assays). Miscellaneous assays of interest are listed in Table 8. 3.1.4.2.1 Reporter-gene, yeast Table 5 lists the availability of reporter gene systems based on yeast. Yeast systems are available or all five receptors, including subtype specific assays for estrogen and thyroid hormone receptors. 3.1.4.2.2 Reporter-gene, mammalian Table 6 lists the availability of reporter gene systems in mammalian cells. Systems are available for all five receptors, however there is a wide range of cell types used, although many are breast cancer cell lines. Some groups have begun efforts to produce systems for different receptors but using the same cell host, which would have advantages in exploring mechanisms of signalling cross-talk or non-conventional signalling when different cell backgrounds can be a confounding factor. Mammalian reporter-gene assays include the CALUX type assays (Chemically Activated LUciferase eXpression). In many cases the system consists of a cell line that endogenously expresses a receptor of interest and that has been stably transfected with a, for example, luciferase reporter-gene linked to the appropriate response element. However the receptor can also be transfected in, allowing a series of assays to be developed on the same background or allowing subtype specific assays to be developed. This approach provides consistency of background, but the resulting cells can lack comodulator molecules that markedly skew the outcome of ligand interaction with the receptor. In general, systems using stable transfection have been preferred over transient transfection because they can be characterised and their responses should be highly reproducible between laboratories. Transient transfection has been used mainly for research purposes and can allow greater control over the receptor and signalling molecules that are present, for example Koohi et al have proposed a modular, transient transfection approach that would allow selection of the host cell, receptor, response element and reporter (Koohi et al. 2007). For chemical screening purposes stably transfected systems are likely to remain the approach of choice, due to their ease of use and expected reproducibility. Reporter gene assays and the OECD conceptual framework An OECD test using a reporter-gene (human cell) system has been adopted. Test no 455, “The Stably Transfected Human Estrogen Receptor-alpha Transcriptional Activation Assay for Detection of Estrogenic Agonist-Activity of Chemicals”, uses hERalpha-HeLa-9903 cell line derived from a human cervical tumour and stably transfected, measure transactivation of luciferase gene expression. The MELN cell line was developed with the intention of inclusion in the OECD conceptual framework (Witters et al. 2010). 3.1.4.2.3 Cell proliferation, вЂ�SCREEN’, assays Table 7 lists the availability of cell proliferation assays. Assays are available for the ER, AR and TR, however the AR assay, A-Screen, is dependent on a suppressive effect of AR on ER signalling which Page 39 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING requires co-exposure to estrogen and therefore the assay does not indicate AR activity in isolation. Because these assays are not engineered, the expressed receptor and subtypes depends on the endogenous expression of the cell. This can complicate interpretation of results since the cell may not have been exhaustively charaterised for expression of receptor types other than the one of interest, and indeed could potentially alter expression in response to chemical stimuli. 3.1.4.3 Computational models The use of computational methods in the toxicological assessement fo chemicals in food has been comprehensively reviewed (Worth et al 2011) and only limited coverage of this area will be provided in this report. The reader is referred to Worth et al for deeper coverage (Worth et al 2011). Table 9 lists the availability of computational models for the various receptors and Table 10 lists computational models that are specific to particular groups of chemicals, for example polybrominated diphenyl ethers (PBDEs) (Gu et al. 2010). All of the five receptors have been the subject of computational models, although the level of interest is unequal, and the ER and AhR appear to have received most attention, followed by the AR and TR, and then the PR. In the tables, computational models that have been used for screening environmental chemicals, rather than those used for pharmacological drug design, have been included, when possible. This usage, chemical screening, appeared to be more prominent for estrogen, androgen and arylhydrocarbon receptors than for progesterone and thyroid receptors. Computational models include structure-activity relationship (SAR), quantitative SAR (QSAR), threedimensional QSAR (3D-QSAR) and comparative molecular field analysis (CoMFA), a 3D-QSAR technique. In all cases the aim is to predict receptor binding or activity from the properties of a ligand. Generally a dataset of chemical effects in a standardised assay, such as a receptor binding assay, and a dataset of chemical properties are compiled and subjected to regression and pattern analysis in an attempt to link the two datasets in a predictive fashion. Experimental efforts to produce computational models that included the generation of a data set for high numbers of chemicals are also tabulated in Table 13. The VirtualToxLab project provides a multi-dimensional QSAR (mQSAR) for 12 targets, including estrogen receptors alpha and beta, the androgen receptor, thyroid receptors alpha and beta and the aryl hydrocarbon receptor (Vedani et al. 2009). Although the progesterone receptor is not included, the project does include the glucocorticoid, mineralocorticoid, liver X and peroxisome proliferatoractivated receptor gamma (PPARОі) and the cytochrome P450 3A4 (CYP 3A4) and 2A13 (CYP 2A13) enzymes. Computational models in the OECD conceptual framework The OECD framework proposes the use of computational models, such as QSAR, in the lower levels. A QSAR for estrogen activity under the OECD principles has been proposed (Liu et al. 2006). 3.1.4.4 In vivo assays Table 11 lists the available in vivo assays that are available and that are considered to reflect receptor activity relatively directly. More complex in vivo assays that are not clearly associated with receptor activity are not included. In mammals, there are well established in vivo assays for estrogen (rat uterotrophic bioassay) and androgen (Hershberger assay) receptor activity, both of which have Page 40 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING been adopted by the OECD. However in vivo tests have not generally been adopted for other receptors, and a significant amount of work on assay development and standardisation may be required before adoption can be envisaged. The amphibian metamorphosis assay is considered to reflect thyroid activity and, although the species is non-mammalian, may be a convenient assay to screen for the likelihood of activation of TR in mammals, as well as directly indicating potential effects on amphibians. 3.1.4.4.1 Knockout (KO) mice models Table 12 lists the available KO mice models. KO models are available for all five receptors ER and TR subtype specific models are also available. These models are typically used to investigate actions of the targeted receptor, and do not have a place in chemical testing. KO models could be used to demonstrate that the toxic effects of a chemical are lost if the proposed receptor target is removed, however this seems unlikely to be widely adopted or used for screening purposes. 3.1.4.5 Computational approaches/projects The successful use of computational models with literature and assay results databases to inform, and perhaps perform, risk assessment is an important direction in toxicology. The advantages of this approach would include the ability to increase coverage of chemicals without linearly scaling up animal use and experimental costs, and the opportunity to maximise use of comparative information, some of which already exists. The disadvantages include the unfamiliar nature of the approach and the change in uncertainties compared to established toxicology testing. The initial use of computational approaches may be to prioritise chemicals in low tiers/levels of assessment schemes in order to concentrate resources at higher stages on the priority chemicals. Selected relevant projects are now briefly described; the EDKB is specific to endocrine disruption whilst the NCCT and TOXNET have a wider toxicology focus. 3.1.4.5.1 Endocrine disruptor knowledge base (EDKB) www.edhb.fda.gov/webstart/edkb/index.html The EDKB compiles data from the US FDAs National Centre for Toxicological Research (NCTR) and from the literature for five types of assay: 1) ER binding, 2) ER reporter-gene activation, 3) cell proliferation (estrogen), 4) rodent uterotrophic assay, 5) AR binding (Ding et al. 2010). The EDKB began in the 1990s and, in 2010, contained around 3,250 records consisting of data for more than 1,800 putative endocrine disruptors. The EDKB is publicly available and a graphical user interface is provided. The EDKB focuses heavily on estrogens/estrogen receptor, although a single AR binding assay type is included. The EDKB does not compile data from assays related to the progesterone, thyroid hormone, aryl hydrocarbon or other receptors. 3.1.4.5.2 National Center for Computational Toxicology (NCCT) The NCCT has several relevant projects: ToxCast http://www.epa.gov/ncct/toxcast/); Page 41 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING In phase 1 of ToxCast over 300 well-characterised chemicals (primarily pesticides) were profiled in over 500 high-throughput screens with endpoints include biochemical assays of protein function, cell-based transcriptional reporter and gene expression, cell line and primary cell functional, and developmental endpoints in zebrafish embryos and embryonic stem cells. These profiles will be compared to animal toxicology data already acquired and recorded in the ToxRefDB database. Phase II is expected to cover a further 700 chemicals. Tox21 is not limited to, or focused on, endocrine disruption; however a number of the included high-throughput screens are relevant (Reif et al. 2010). Tox21 http://www.epa.gov/ncct/Tox21/ Tox21 is a collaborative US project using higher throughput in vitro methods to prioritise compounds for further study, identify mechanisms of action and ultimately develop predictive models for adverse health effects in humans (Shukla et al. 2010). TOXicology data NETwork (TOXNET) http://toxnet.nlm.nih.gov TOXNET is a collection of databases at the US National Library of Medicine (NLM) covering toxicology, hazardous chemicals, environmental health and toxic releases. Coverage is detailed on the TOXNET factsheet (http://www.nlm.nih.gov/pubs/factsheets/toxnetfs.html), and includes TOXLINE (bibliographic references), ChemIDplus (structural search capabilities), and IRIS (Integrated Risk Information System). TOXNET is not limited to, or focused on, endocrine disruption. 3.1.4.6 Comparative studies Table 13 provides details of experimental studies that have employed some of the assays listed in the preceding sections to screen large numbers of chemicals. In many cases these data sets were compiled as part of an endeavour to develop a computational model, such as a quantitative structure activity relationship (QSAR), see the earlier section on computational models, section 3.1.4.3. The tabulated studies are dominated by studies of the ER and AR, which reflects that literature focus on these targets. Table 14 lists experimental studies that employed three or more assays, for example different assays for one of the receptors allowing for evaluation of the assays and selection of the more suitable assay; or assays for several different receptors, allowing comparison of ligands and their specificity for particular receptors. Page 42 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING 3.1.4.7 Data tables Table 4: radiolabelled ligand displacement assays Receptor Typical radiolabel Studies using recombinant receptors ER [3H]-17ОІ-estradiol AR PR [3H]-mibolerone androgen); [3H]-R1881 (methyltrienolone, androgen) [3H]-progesterone ERО± (Akahori et al. 2008; Kuiper et al. 1998) ERОІ(Kuiper et al. 1998) (synthetic AR (Janne et al. 1993) (Freyberger and Ahr 2004) TR [125I]-thyronine (T3) AhR [125I]-dioxin (TCDD) synthetic PR (Viswanath et al. 2008) Rat TR (Moriyama et al. 2002); TRО±, competition assay using ligand binding domain (LBD) only (Chapo et al. 2007) TRОІ, competition assay using ligand binding domain (LBD) only (Chapo et al. 2007) (Chae et al. 1984) (Bradfield and Poland 1988) Page 43 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 5: cell based assays, reporter-gene, yeast Receptor Species, reporter Reference ER Human ERО± with LacZ reporter (yeast estrogen screen, вЂ�YES’) Human ERО± or ERОІ, GFP (Arnold et al. 1996), also (Gaido et al. 1997) (Bovee et al. 2004), also(Rajasarkka and Virta 2010). (Sohoni and Sumpter 1998), also (Gaido et al. 1997), (Rajasarkka and Virta 2010). (Tran et al. 1996), also (Gaido et al. 1997) (Shiizaki et al. 2010) ERО± ERОІ AR Human AR, LacZ reporter (yeast estrogen screen, вЂ�YAS’) PR Human PR TRО± TRОІ TRОІ AhR Human TRО± or TRОІ; with coactivator SRC-1 Recombinant TRОІ Human AhR, LacZ (Li et al. 2008b) (Rowlands and Gustafsson 1995), also (Rajasarkka and Virta 2010) Page 44 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 6: cell based assays, reporter-gene, mammalian Receptor ER Parent cell T47D T47D U2-OS MCF7 ERО±, ERОІ AR HeLa MDAMB-453 U2-OS PR T47D U2-OS HEK-293 TR GH3 HepG2 Parent type human breast cancer human breast cancer human osteosarco ma Human breast cancer Human cervical cancer human breast cancer human osteosarco ma Transfected cell line Reference ER-CALUX (Legler et al. 1999) T47D-Kbluc (Wilson et al. 2004) ERО±-CALUX (Sonneveld et al. 2005) MELN cell line (Witters et al. 2010). plasmid: ERE-ОІGlob-LucSVNeo HELN Plasmid: ERE-bGlobin-LucSVNeo HELN-ERО± Plasmid: pSG5-ERО±-puro HELN-ERОІ Plasmid: pSG5-ERОІ-puro (Balaguer et al. 2001; Escande et al. 2006) Note: HeLa cells with no endogenous ER expression were stably transfected with an ERE-lined luciferase reporter; the established HELN cell line was then stably transfected with either ERО± or ERОІ (Wilson et al. 2002) AR-CALUX (Sonneveld et al. 2005) Note: Validation by comparison to other in vitro assays and the McPhail in vivo rabbit test (Sonneveld et al. 2010). human breast cancer T47D-YA T47D-YB (Sartorius et al. 1994) human osteosarco ma Human embryonic kidney rat pituitary tumour human hepatoblas toma PR-CALUX (Schreurs et al. 2005) Note: Allows comparison of PR isoforms in the same cell background; a stable PR-negative clone of T47D was selected, then transfected with expression vectors for PR isoform A (T47D-YA)or B (T47D-YB) Transiently transfected. (Viswanath et al. 2008) Plasmid: pGL2-PRE-Luc and pSG5-hPR-B GH3.TRE-Luc (Freitas et al. 2010) Plasmid: pGL4CP-SV402xtaDR4 Transiently transfected. (Moriyama et al. 2002) Plasmids: ME-tk-Luc Page 45 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Receptor TRО± TRО± TRОІ AhR Parent cell PC12 Parent type Rat pheochrom ocytoma (adrenal medulla) TSA 201 Human (HEK 293 embryonic clone) kidney H4IIE rat hepatoma Transfected cell line Reference PC-DR-LUC; transiently (Jugan et al. 2007) Note: Expresses the avian TRО±1 protein transfected. Plasmid: pGL3-DR4, pTK-PAL Transiently transfected. Plasmids: (UAS)-E1BTATA-Luc pCMX-humanTRГџ1 pCMX-humanTRО±1 pCMX-ratTRГџ2 AhR-CALUX (Moriyama et al. 2002) (Murk et al. 1996) Note: Similar lines are also referred to as dioxin-receptor-CALUX (DR-CALUX) Page 46 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 7: cell based assays, cell proliferation Receptor Screen Assay principle Notes ER E-screen Positive effects in ESCREEN probably indicate effects on ERО± AR A-screen Cell proliferation, human breast cancer cell line (MCF7) (Soto et al. 1994; Soto et al. 1995; Villalobos et al. 1995) Androgens prevent estrogeninduced cell proliferation, MCF7 cells transfected with AR (MCF7AR1)(Szelei et al. 1997) PR TR T-screen Antiandrogenic: DDE (Aube et al. 2008), salbutamol (von Bueren et al. 2007) Cell proliferation, rat pituitary T-screen assay has been used with tumour cell line (GH3) (Gutleb et human liver S9 mix and PCB-induced rat al. 2005; Schriks et al. 2006); microsomes to include a consideration of metabolic effects(Taxvig et al. 2010) AhR Page 47 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 8: Additional assays Receptor Effect of interest Assay description ER AR PR TR Metabolism Inhibition of estrogen sulfotransferase (Kester et al. 2000) LNCaP cells. AhR Bioavailability/transport Competition with thyroxine for binding to plasma transport protein transthyretin (TTR) (Lans et al. 1993) Receptor activation Induction of CYP1A1, for example measure by EROD activity Page 48 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 9: computational models, SAR, QSAR Receptor Model Details Reference ER ER binding; 230 ligands Hong et al used data sets for 232 chemicals built by Blair and Branham (Blair et al. 2000) to build a QSAR model that was then validated on a test set of 463 chemicals from Nishihara et al (Nishihara et al. 2000). The validated QSAR was then applied to 58,000 chemicals. QSAR developed for estrogen activity using OECD principles AR binding; 28 ligands AR binding; 202 ligands AR binding affinity; 146 ligands (Fang et al. 2001) (Hong et al. 2002). AR binding affinity; 397 ligands Used neural networks to improve QSAR designs for AR antagonism, and also compared with a QSAR for ER binding Nonsteroidal progesterone receptor ligands; focus was development of pharmacological antiprogestins TRОІ agonism; 12 ligands TRО±, TRОІ; 55 ligands AhR binding; 99 ligands (Vinggaard et al. 2008) (Li and Gramatica 2010) SAR QSAR QSAR AR PR TR AhR 3D-SAR SAR 3DQSAR QSAR QSAR 3DQSAR QSAR QSAR 3DQSAR 3DQSAR 3DQSAR QSAR (Liu et al. 2006) (Waller et al. 1996a) (Fang et al. 2003) (Hong et al. 2003) (Soderholm et al. 2006) (Du et al. 2008) (Valadares et al. 2007) (Waller and McKinney 1995) Used CoMFA and comparative molecular similarity (Ashek et al. 2006) indices analysis (CoMSIA); structurally diverse AhR ligands Used CoMFA, VolSurf (computational procedure to (Lo et al. 2006) produce 2D molecular descriptors from 3D molecular interaction energy grid maps), hologram QSAR (HQSAR), and hybrid models; 84 AhR ligands Developed a categorical COmmon REactivity PAttern (Petkov et al. 2010) (COREPA)-based SAR suitable for ligands with binding affinity in different ranges Page 49 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 10: QSARs applied to specific groups of chemicals Chemical group Brominated flame retardants Polybrominated ethers (PBDEs) Hydroxylated PBDEs Pesticides Receptors considered Reference ER agonism, metabolism (SULT inhibition); (Papa et al. 2010) PR antagonism; TR binding (T4 competitive binding); AhR binding, activity (EROD) and agonism. diphenyl AhR binding (Gu et al. 2010) TRОІ ERО±, ERОІ binding. (Li et al. 2010a) (Gatonovic-Kustrin al. 2010) et Page 50 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 11: in vivo assays Receptor Assay name ER Validation, studies п‚· Rodent uterotrophic bioassay OECD Test No. 440: Uterotrophic Bioassay in Rodents. A short-term screening test for oestrogenic properties; based on an increase in uterine weight or uterotrophic п‚· response. п‚· п‚· AR PR п‚· Hershberger assay OECD Test No. 441: Hershberger Bioassay in Rats. A Shortterm Screening Assay for (Anti)Androgenic Properties; based on changes in weight of five androgen-dependent п‚· tissues in the castrate-peripubertal male rat; anti-androgens can be screened by coexposure to a reference androgen agonist. Lu et al identify the following as functional tests for the PR: п‚· Inhibition of proliferation in endometrial cells caused by treatment of ovariectomised (estrogen-treated) mice with progesterone п‚· Mammary gland ductal tree branching and lobuloalveolar development in ovariectomised (estrogen-treated) mice treated with progesterone (Lu et al. 2006). comparison Compared to ER binding, for 65 chemicals (Akahori et al. 2008); Validated use of intact rat weanling instead or ovariectomisation (Tyl et al. 2010); Critical assessment of the OECD collaborative study (Combes 2003) Test of 18 chemicals, and test of30 chemicals in the Hershberger assay (Yamasaki et al. 2003) Compared to AR binding, for 12 chemicals (Yamasaki et al. 2004) Test of 30 chemicals, and test of 16 chemicals in uterotrophic assay (Yamasaki et al. 2003) McPhail assay TR AhR Zoeller et al have proposed that, for the purposes of assessing TR effects in vivo. the endpoints of thyroid gland weight, histopathology, circulating thyroid hormone measurements, and circulating thyroid-stimulating hormone (TSH) could be added to the existing OECD in vivo assays for reproduction, development, and neurodevelopment (Zoeller et al. 2007). Amphibian Metamorphosis Assay OECD Test No. 231: Amphibian Metamorphosis Assay; intended to screen for substances that may interfere with the HPT axis recommended species is Xenopus laevis, for which the assay was validated; Assay commences with tadpoles and lasts for 21days with endpoints at 7 and 21 days Dioxin and dioxin like chemicals are regulated through the Animal strain and the use of toxic equivalency factors (TEF), which is predicated selected toxic endpoint Page 51 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Validation, comparison studies on the identification of these substances as AhR agonists can influence the setting and an expectation of the additivity of their effects (Van of TEFs (Pohjanvirta et al. den Berg et al. 2006; van den et al. 1998). TEFs have been 1995) derived in in vivo assays such as those used by: п‚· US National Toxicology Program (NTP) Toxicology and Carcinogenesis studies, e.g. TCDD (NTP 2006a), PCB126 (NTP 2006b). Receptor Assay name Page 52 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 12: knockout (KO) mice models Receptor KO Reported phenotype ERО± ERKO Non-lethal; Fertility: Both sexes are infertile; Female reproductive (Couse et tract: develops normally neonatally, estrogen insensitive in al. 1995) adulthood, ovaries develop normally but are anovulatory in adulthood, incidence of ovarian tumour is 30-40% by 18mo; Mammary gland: normal prenatal development, insensitive to estrogen-induced development in adulthood; Male reproductive tract: normal pre and neonatal development, age related decrease in sperm count, disrupted sperm function (inability to fertilise), decrease in testis and seminal vesicle weight; Neuroendocrine: alterations in anterior pituitary, hypothalamus and in serum levels of some hormones, the rapid effects of estradiol in the hippocampus are preserved; Behaviour: females show loss of estrogen and progesterone induced sexual behaviour, increased aggression and infanticide; males show normal mounting and attraction towards females, but complete lack of intromission and ejaculation, and reduced aggression; Other: reduced estrogen induced angiogenesis, decrease in basal NO levels; increased expression of L-type calcium channels; arrested growth of longitudinal bones, impaired glucose tolerance. Phenotype reviewed by (Couse and Korach 1999). ERОІ ОІERKO, Non-lethal; fertility: Female is subfertile (reduced litter size), male is BERKO fertile; Female reproductive tract: develops normally neonatally, (Krege et estrogen sensitive in adulthood, ovaries develop normally but show al. 1998) abnormal frequency of ovulation in adulthood, severely attenuated response to superovulation therapy (reduced oocyte number, multiple trapped preovulatory follicles); Mammary gland: normal development, gross appearance same as wild type; normal differentiation in pregnancy and motherhood; Male reproductive tract: normal pre and neonatal development, no effects on spermatogenesis, no effect on fertility; Behaviour: no defects. Phenotype reviewed by (Couse and Korach 1999). ERО± and Alpha beta Both sexes show normal reproductive tract development but are ERОІ ERKO infertile; (Couse et Ovaries show follicle transdifferentiation to structures resembling al. 1999) seminiferous tubules of the testis, including Sertoli-like cells and expression of Mullerian inhibiting substance, sulfated glycoprotein-2, and Sox9. AR ARKO Males have a female-like appearance and body weight; testes are 80% (Yeh et al. smaller; serum testosterone concentrations are lower than wild-type; 2002) Spermatogenesis is arrested at pachytene spermatocytes; number and size of adipocytes are altered; cancellous bone volume is reduced. Females have litters with reduced number of pups (indicative of fertility or ovulation defects). NOTE: use of “ArKO” to refer to an aromatase knockout model is common, e.g. (Fisher et al. 1998; Hill and Boon 2009) Page 53 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Receptor KO PR TRО± TRОІ AhR AhR Reported phenotype PRKO Both sexes develop normally to adulthood. Adult females show an (Lydon et inability to ovulate, uterine hyperplasia and inflammation, severely al. 1995) limited mammary gland development, and inability to exhibit sexual behaviour. A conditional PR knockout, using the cre/lox approach is available (Hashimoto-Partyka et al. 2006) (Wikstrom Overall behaviour and reproduction are normal; et al. 1998) Thyroid: Mild hypothyroidism; Cardiovascular: Average heart rate 20% lower than that of control animals, prolonged QRS- and QTenddurations; Body temperature: 0.5 degrees C lower than normal (Forrest et Thyroid: Goitre and elevated levels of thyroid hormone; Thyroidal. 1996) stimulating hormone (TSH) was present at elevated levels Most half of the mice died shortly after birth, whereas survivors (Fernandez- reached maturity and were fertile. Immune system: showed Salguero et decreased accumulation of lymphocytes in the spleen and lymph al. 1995) nodes, but not in the thymus; Hepatic: livers were reduced in size by 50 percent and showed bile duct fibrosis (Schmidt et Viable and fertile; al. 1996) Hepatic: show a spectrum of hepatic defects that indicate a role for the AHR in normal liver growth and development Page 54 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 13: studies comparing large numbers of ligands Ref EDKB?* n (ligand) Receptor Receptor species Assay type, cell/system species Study of 202 natural, synthetic, and environmental chemicals for binding to the androgen receptor The estrogen receptor relative binding affinities of 188 natural and xenochemicals: structural diversity of ligands. Quantitative structure-activity relationships (QSARs) for estrogen binding to the estrogen receptor: predictions across species Ligand-based identification of environmental estrogens 202 AR Rat AR binding 188 ER Rat ER binding 69 ER Bovine ER binding 58 ER Mouse ER binding Binding of Phytoestrogens and Mycoestrogens to the Rat Uterine Estrogen Receptor Interaction of estrogenic chemicals and phytoestrogens with estrogen receptor beta Comparison of the ligand binding specificity and transcript tissue distribution of estrogen receptors alpha and beta Three-dimensional quantitative structure-activity relationship study of nonsteroidal estrogen receptor ligands using the comparative molecular field analysis/cross-validated r2guided region selection approach Three-dimensional quantitative structure--activity relationships for androgen receptor ligands Several Environmental Pollutants Have Binding Affinities for Both Androgen Receptor and Estrogen Receptor alpha Rapid screening of environmental chemicals for estrogen receptor binding capacity Using three-dimensional quantitative structure-activity relationships to examine estrogen receptor binding affinities of polychlorinated hydroxybiphenyls Screening of anti-progestins using in vitro human uterine progesterone receptor assay system 46 ER rat ER binding 46 ERО± ERОІ Human Human ER binding 37 ERО± ERОІ Rat Rat ER binding 30 ER Mouse ER binding 28 AR Mouse AR binding 22 AR ERО± Human Human AR binding ER binding 15 ERО± Human ER binding 14 ER Mouse ER binding 62 PR Human; uterus, hysterec tomy PR binding Title RECEPTOR BINDING (Fang et al. YES 2003) (Blair et al. YES 2000) (Tong et al. YES 1997) (Waller et YES al. 1996b) (Branham YES et al. 2002) (Kuiper et YES al. 1998) (Kuiper et YES al. 1997) (Sadler et YES al. 1998) (Waller et YES al. 1996a) (Satoh et al. 2001) (Bolger et YES al. 1998) (Waller et YES al. 1995) (Verma and Laumas 1981) Page 55 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Ref EDKB?* Receptor Receptor species 517 ERО± Rat Screening of 397 chemicals and development of a quantitative structure--activity relationship model for androgen receptor antagonism Screening for estrogen and androgen receptor activities in 200 pesticides by in vitro reporter gene assays using Chinese hamster ovary cells. 397 AR Human 200 ERО± ERОІ AR Human Evaluation of a recombinant yeast cell estrogen screening assay 53 ERО± Human Interference of endocrine disrupters with thyroid hormone receptor-dependent transactivation Evaluation of chemicals with endocrine modulating activity in a yeast- based steroid hormone receptor gene transcription assay 25 TRО± TRОІ Rat Human 16 ER Human ER activation (yeast, reporter gene) The E-SCREEN assay as a tool to identify estrogens: an update on estrogenic environmental pollutants. 81 ER Human MCF7 ER activation (human, cell proliferation) Uterotrophic Endocrine Bioassay Data, 1968 1585 ER Mouse ER activation (mouse, uterotrophic assay) Relationship between the results of in vitro receptor binding assay to human estrogen receptor alpha and in vivo uterotrophic assay: comparative study with 65 selected chemicals. Immature rat uterotrophic assay of 18 chemicals and Hershberger assay of 30 chemicals 65 ER ERО± Human ER activation (rat, uterotrophic assay); ER binding 18 (RUA) 30 (HBA) ER AR Rat ER activation (rat, uterotrophic assay, RUA); AR activation (rat, Hershberger assay, HBA) RECEPTOR ACTIVATION: YEAST OR MAMMALIAN Estrogenic Activities of 517 (Nishihara YES chemicals by Yeast Two-Hybrid et al. 2000) assay (Vinggaard et al. 2008) (Kojima et al. 2004). (Coldham et al. 1997) YES (Hofmann et al. 2009) (Gaido et YES al. 1997) Assay type, cell/system species n (ligand) Title ER activation (yeast twohybrid) AR activation (CHO, reporter) ER activation (CHO,reporte r); AR activation (CHO, reporter) ER activation (yeast, reporter gene) TR activation (HepG2, reporter) CELL PROLIFERATION (Soto et al. YES 1995) WHOLE ANIMAL Hilgar et al YES 1968. (Data compiled in EDKB) (Akahori et al. 2008) (Yamasaki et al. 2003) Page 56 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Ref EDKB?* Title n (ligand) Receptor Receptor species (Yamasaki et al. 2004) Comparison of the Hershberger assay and androgen receptor binding assay of twelve chemicals 12 AR Rat (Shelby et YES al. 1996) Assessing environmental chemicals for estrogenicity using a combination of in vitro and in vivo assays 10 ER Mouse, Crl:CD1(ICR) Welch et YES al, 1971; ABSTRACT ONLY (Coldham YES et al. 1997) Effect of halogenated hydrocarbon insecticides on the metabolism and uterotropic action of estrogens in rats and mice Evaluation of a recombinant yeast cell estrogen screening assay 10 ER Rat, Sprague -Dawley 9 ER (Zacharews YES ki et al. 1998) Examination of the in vitro and in vivo estrogenic activities of eight commercial phthalate esters 8 ER (Odum et YES al. 1997) The rodent uterotrophic assay: critical protocol features, studies with nonyl phenols, and comparison with a yeast estrogenicity assay 8 ER Mouse, pubertal CFLP (Harlan) Rat, Sprague Dawley, ovariect omised Rat, immatur e Alpk:AP Estrogenic action of DDT and its 6 Welch et YES ER analogs al, 1969; ABSTRACT ONLY *indicates if the dataset was compiled (www.edhb.fda.gov/webstart/edkb/index.html), searched 7.12.2010. Rat, Sprague -Dawley into Assay type, cell/system species AR activation (rat, Hershberger assay); AR binding ER activation (mouse, uterotrophic assay) ER activation (rat, uterotrophic assay) ER activation (mouse, uterotrophic assay) ER activation (rat, uterotrophic assay) ER activation (rat, uterotrophic assay) ER activation (rat, uterotrophic assay) the EDKB Page 57 of 486 OVER ARCHING ISSUES RECEPTOR SIGNALLING Table 14: studies comparing three or more assays Reference Receptors Multiple receptors (Gaido et al. ER, 1997) AR, PR (Rajasarkka ERО±, and Virta ERОІ, 2010). AR, AhR (Li et al. ERО±, 2008a; Li et AR, al. 2010b) PR, estrogenrelated receptor –gamma (ERRОі) (Kojima et ERО± al. 2010) ERОІ AR TRО± TRОІ PXR PPARОі AhR Multiple assays for one receptor (Fang et al. ER 2000) (Gutendorf and Westendorf 2001) ER (Korner et AR al. 2004) (Sonneveld et al. 2010) PR Assays Notes Yeast Yeast miniaturised form; 384- and 1536well microplates Yeast Examined agonism or antagonism Transactivation-assay based screening, see Comparison also (Kojima et al. 2004). 200 pesticides 1. ER binding 2. ER yeast 3. ESCREEN 1. MVLN; reporter gene assay, cells derived from MCF7 2. HGELN; reporter gene assay, cells derived from HeLa 3. binding assay, recombinant human ERО± 4. binding assay, recombinant human ERОІ 5. ESCREEN cell proliferation assay. 1: Cell proliferation, human mammary carcinoma cells stably transfected with human AR; reporter gene, 2: stably transfected human prostate carcinoma cells; 3: reporter gene, stably transfected human mammary carcinoma cells; 4: reporter gene, transiently transfected CHO cells 1. PR-CALUX bioassay 2. PR reporter gene assay, CHO cells 3. PR binding assay (PR-BIN) 4. 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Zoeller RT, Tyl RW, Tan SW. 2007. Current and Potential Rodent Screens and Tests for Thyroid Toxicants. Critical Reviews in Toxicology 37:55-95. Page 64 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS 3.2 LOW DOSE EFFECTS Public health standards have been relying for a long time on the central dogma, that health effects that do not occur at high levels of exposure to a chemical cannot be induced by much lower levels of exposure to that same chemical. In connection with efforts to characterise the risks associated with EDCs it has been argued that this risk assessment paradigm needs modification or has become obsolete, because EDCs elicit effects at doses much lower than normally used in regulatory testing. The “low dose” hypothesis of endocrine disruption (vom Saal and Hughes 2005) has expressed two separate, although connected, aspects of the issue: (1) Risks to human health are feared at current exposure levels, because several studies have described effects of EDC in animal experiments at doses that approach the exposures experienced by humans. (2) Non-monotonic dose response relationships have been observed with EDCs for certain endpoints. It has been argued that this challenges an assumption implicit in current risk assessment, namely that effects seen at high doses can be used for extrapolations into the low dose range. With non-monotonic dose response curves, this key assumption is no longer tenable, and it has been proposed that “low dose” testing should be performed routinely, in order to provide the basis for more protective points of departure (e.g. NOAELs or benchmark doses) that are subsequently used for deriving human reference doses. Biologically relevant non-monotonic curves including “U-shaped” or “inverted-U-shaped” dose response relationships have been described (Davis and Svendsgaard 1990). Because such curves reflect an apparent reversal or inversion in the effect at a low region of the dose continuum, questions arose about the appropriateness of assuming monotonicity as a basis for chemical risk assessments of EDCs. The reasons why dose responses to toxicants may be non-monotonic can be manifold: AdaptiveThe reasons why dose responses to toxicants may be non-monotonic can be manifold: The induction of metabolising enzymes or conjugation substrates may result in a U-shaped dose response for some endpoints, with effects at low and at high levels of exposure, and diminished or nonexistent effects at intermediate levels, due to metabolic clearance. A recently published in vitro study may help to explain such a nonlinear dose response of Sertoli cells to bisphenol A (Gualtieri et al. 2010). When primary Sertoli cells were exposed to various doses of bisphenol A (0.5nM-100 ВµM), only intermediate doses of 10 ВµM and 50 ВµM, but not lower doses, induced an increment in glutathion levels. Hence, the detoxification through direct conjugation was enhanced at those intermediate dose levels, but not at lower doses. Thus, cell viability was negatively affected at high doses (100 ВµM bisphenol A) and at low doses of bisphenol A exposure, where the cells are not capable of eliciting a cell defence response. Only in the intermediate dose range the cells’ viability was not negatively affected and cell numbers were highest, thereby challenging the anticipated decrease in cell death upon dose reduction from 50 ВµM to 0.5 nM. Page 65 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS Furthermore, adaptive responses through complex cell signalling pathways and feed-back mechanisms could cause non-monotonic effects that are inconsistent with the traditionally expected dose-response curves based on extrapolation of high dose data predicting a decreasing effect for lower doses. E.g. Bouskine et al. report (2009) that bisphenol A stimulates JKT-1 cell proliferation in vitro in an inverse U-shape dose response curve, with a weak stimulation of proliferation in the picomolar range and the Figure 3 Bisphenol A stimulates JKT-1 cell proliferation in vitro in an inverse Umicromolar rage, but notably a maximum effect in shape dose response curve. Taken from between - at around 10 nM (see Figure 3). This can be Bouskine et al. (2009) explained through dose-dependent changes in mechanisms. Here the authors propose a model where low doses of bisphenol A activate both cAMP-dependent protein kinase (PKA) and cGMP-dependent protein kinase (PKG) pathways through binding of bisphenol A to a G-protein-coupled membrane ER (GPCR). This triggers a rapid phosphorylation of the transcription factor cAMP response-elementbinding protein (CREB) and the cell cycle regulator retinoblastoma protein (Rb). These phosphorylations are part of a well known pathway that hormones (estrogens) can induce and which occurs in a very short time frame, within minutes or even seconds (see 3.1.2.4). These rapid actions do not fit the classical "genomic" model of steroid action where receptor-mediated changes occur within a much longer time frame and require translocation to the nucleus of the ligand-activated receptor, followed by modulation of gene expression usually involving de novo synthesis of genes. The stimulation of this pathway through low doses of bisphenol A, which promotes JKT-1 cell proliferation through GPCR, was reproduced by using an estradiol conjugate with the protein bovine serum albumin which cannot traverse the cell membrane. However, unconjugated estradiol was without this effect. Instead, it triggered a significant decrease of cell proliferation at a physiologic intratesticular concentration of 1 nM. As bisphenol A has a low affinity for ER-ОІ with a 1,000-fold weaker affinity than estradiol in JKT-1 cells (Alonso-Magdalena et al. 2005), high micromolar concentrations of bisphenol A may trigger a suppressive effect via ER-ОІ as does estradiol, thereby neutralising the fast-acting signalling through phosphorylations of CREB and Rb. At low concentrations the relatively slow transcriptional effect via ER-ОІ is absent, allowing the fast phosphorylation reactions of CREB and Rb to be displayed because of the high affinity of bisphenol A for the GPCR. When mixed together at this low concentration, bisphenol A and estradiol are mutually antagonistic, thus explaining effects at very low doses (Bouskine et al. 2009). Non-monotonic dose responses have not only been described for EDs. A review by Conolly and Lutz presents several examples from other biological disciplines. They demonstrate that nonmonotonic dose-response relationships can result from superimposition of monotonic dose responses of component biological reactions. Examples include (i) a membrane-receptor model with receptor subtypes of different ligand affinity and opposing downstream effects (adenosine receptors A1 vs. A2), (ii) androgen receptor-mediated gene expression driven by homodimers, but not mixed-ligand dimers, (iii) repair of background DNA damage by enzymatic activity induced by adducts formed by a xenobiotic, (iv) rate of mutation as a consequence of DNA damage times rate of cell division, the Page 66 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS latter being modulated by cell-cycle delay at low-level DNA damage, and cell-cycle acceleration due to regenerative hyperplasia at cytotoxic dose level. In summary, modern scientific research that combines toxicology, developmental biology, endocrinology and biochemistry has shown that many dose-response relationships do not simply describe an increase or decrease of the measured effect over the entire dose range. While a chemical’s effect over a certain dose range may decrease as the dose is reduced, at very low doses the effect may actually become greater. This phenomenon has initially been labelled “low dose” effect. 3.2.1 Evolution of the meaning definitions of “low dose” in the ED field As non-monotonic dose-response curves were described for an increasing number of EDCs, the “low dose” concept caught the attention of the ED field and regulatory toxicology. However, with the rising interest in the evaluation of the evidence for low-dose effects and nonmonotonic doseresponse relationships of EDCs, the term “low dose” was and is still being used in different contexts. Firstly, in the EDC relevant literature “low dose effects” often describe biological changes that occur at environmentally relevant exposure levels. Hence, doses in the range of exposures experienced by humans and wildlife are referred to as “low dose”. The disadvantage of this is that exposure levels are often controversial and little is known about internal concentrations. The effect of the actual doses of daily life is hardly ever tested. Secondly, “low dose” has been used to describe doses that are lower than those typically used in standard toxicity testing. The disadvantage here is that these values are derived from rodent studies and it is debateable whether these are relevant endpoints for human exposure. Furthermore the duration and route of administration have a big influence on the actual internal dose but this is often not considered in these values. Thirdly, doses associated with small effects, usually in the range of no-observed adverse effect levels (NOAELs) or below. This has sometimes led to the assumption that any difference between treated and control animals occurring at a dose lower than the current NOAEL are a low dose effect and no consideration is given to whether the change was an adverse effect or not, and whether the endpoint was previously measured. To conclude, none of these definitions in use necessarily encompass the concept of a non-monotonic dose-response relationship. The term “low dose” is open to interpretation and its different meanings cause confusion. Page 67 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS 3.2.2 The low dose controversy exemplified by bisphenol A In the late 90s a number of studies were published that reported for the first time that bisphenol A exposure at doses below the presumed NOAEL resulted in effects on the reproductive and endocrine system in animals (Colerangle and Roy 1997; Nagel et al. 1997; Steinmetz et al. 1997; Vom Saal et al. 1998). Two coordinated studies designed to repeat the same experiment as reported by vom Saal et al. (1998) failed to find adverse effects on the male reproductive system in mice at the same low doses of bisphenol A (Cagen et al. 1999; Ashby et al. 1999). Both of these studies were designed and funded by the Society of the Plastics Industry (SPI) and the Bisphenol A Sector Group of the European Chemical Industry Council (CEFIC), which has provoked a heated controversy in the field, with claims of bias due to sources of research funding. Due to the difficulties with replication of observations and the debates about the toxicological significance of low dose effects, the U.S. Environmental Protection Agency (EPA) requested from the National Toxicology Program (NTP)/National Institute of Environmental Health Sciences (NIEHS) to conduct an independent and open peer review that was aimed at evaluating the scientific evidence on reported low-dose effects of endocrine disrupting chemicals (NTP 2001). The review confirmed that many EDCs have effects at low, environmentally relevant doses, but the toxicological significance of these effects was unclear. It concluded that “the current testing paradigm used for the assessment of reproductive and developmental toxicity should be revisited” (Melnick et al. 2002). As this has largely been ignored, the following section will briefly summarise the findings of the NTP report on the bisphenol A low dose literature and then focus on what progress has been made since the subpanel’s recommendations and whether evidence has accumulated that low doses should be considered "adverse". Bisphenol A has solely been chosen because of the abundance of information regarding this EDC. 3.2.3 NTP low dose peer review findings (2001) The organising committee had instructed the bisphenol A subpanel of reviewers to use 5 mg/kgВ·day as definition of the low dose cut-off for bisphenol A, despite the original decision of the subpanel to use 0.050 mg/kgВ·day. Their reasoning was that this dose level was in the range of NOAEL in EPA’s standard toxicity tests. Using this approach of simply defining a cut-off dose without further constraints has the drawback that studies will be compared although they differ in the experimental approaches such as the age of the animal at the time of administration and route of exposure etc. With the constraints given by the NTP, the reviewers concluded that there are several studies that provide evidence for low dose effects of bisphenol A on reproductive or developmental endpoints in rodents but also some that demonstrate the lack of those. The reviewers were asked to evaluate the discrepancy between the study outcomes and consequently scrutinised mainly studies by vom Saal (1998) and Ben-Jonathan (Khurana et al. 2000) versus studies carried out by Ashby (Ashby et al. 1999) and Cagen (Cagen et al. 1999). The low dose effects of bisphenol A that could not be reproduced by the latter two studies concerned the endpoints of prostate size, daily sperm production, uterine epithelial cell height and uterine weight. The reviewing subpanel commented on differences in the animals’ diet (background level of estrogens from dietary sources), strains of mice used, route of administration of bisphenol A, the purity of bisphenol A used, housing and bedding of the animals as possible cause for the discrepancies. The subpanel also mentioned that the sample Page 68 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS size was significantly different between the studies, but emphasised that this was unlikely to explain the discrepancies and thus the studies indeed observed different outcomes. In conclusion, both factions were seen as correct, those supporting low dose effects and those failing to demonstrate such effects. Importantly, the subpanel pointed out that pharmacokinetic information on bisphenol A, such as bioavailability, half-life and placental transfer etc. was too scarce to strengthen or to dismiss the plausibility of low dose effects of bisphenol A. Due to the lack of this information and insufficient data to establish a bisphenol A dose-response relationship, the subpanel abstained from an overall conclusion as to whether bisphenol A can cause low dose effects on developmental and reproductive endpoints. They reasoned that the observed low dose effects in some studies could mechanistically not be explained due to the pharmacokinetic data gaps and that therefore the biological relevance of such effects was unclear. In addition to the knowledge gap pointed out above, the subpanel for the NTP review recommended additional research to resolve the low dose question: п‚· п‚· п‚· п‚· п‚· п‚· п‚· п‚· Multiple doses of bisphenol A in the low dose range should be tested, both in utero and in neonatal life. Different strains of rats and mice should be used for establishing pharmacokinetic data of bisphenol A. The occupancy of the estrogen receptors following exposure during different stages of development and various organs should be investigated. The mechanistic actions of bisphenol A during the whole lifespan of an animal through pharmacological (specific receptor antagonists) and genetic (knock-out mice) studies need to be carried out. Studies on how the intrauterine position might affect endogenous hormone levels and how these and other differences in background estrogen levels influence the outcome of bisphenol A administration. Genetic and epigenetic factors that influence bisphenol A response. Non-genomic actions of bisphenol A Biomarker and endpoint identification that can be reproducibly used to investigate low dose effects. 3.2.4 Reviews subsequent to the NTP peer review After NTP published their peer review, a number of further reviews of the low dose topic became available. In his analysis of low dose effects of xenoestrogens, Witorsch (2002) advanced the argument that the effects observed in rodents cannot be extrapolated to the human, because of substantial inter-species differences in the ways in which the estrogen hormone system operates. The perspective developed by Witorsch leaves unanswered the question as to whether rodent models produce results that are at all useful for human risk assessment. Hayes (2004) presented an analysis of low dose studies on amphibian development with the pesticide atrazine. He focused on studies that demonstrated the induction of gonadal abnormalities Page 69 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS at low atrazine doses. His analysis of studies which could not demonstrate such effects pinpointed several experimental flaws, including contamination of controls with atrazine, and other problems. The analysis by Kamrin (2007) focused on the question of reproducibility (or the lack thereof) of experimental low dose observations. He listed criteria that should be fulfilled in support of the low dose hypothesis – these were: reproducibility of experimental observations, consistency of study results (with a consistent pattern of low dose effects observed across a variety of conditions and species) and proper study conduct (inclusion of appropriate study controls, dose-response analysis). If these conditions are not fulfilled, he argued, the low dose hypothesis cannot be accepted. He went on to note a lack of reproducibility of study results, but did not attempt a thorough analysis of the causes of this lack of reproducibility. Kamrin also pointed out that many “low dose” data sets are difficult to use for the purposes of risk assessment because of a lack of clear dose-response relationships. This applies particularly to experiments that used only one dose in addition to a control group. Vom Saal and Welshons (2006) analysed low dose studies that used bisphenol A and listed more than 100 studies that reported effects below the lowest-observed-adverse-effect of bisphenol A. More than 40 studies demonstrated adverse effects below the dose of 50 Вµg/kg/d judged by US regulatory bodies to be an exposure acceptable to humans. 3.2.5 New insights In the 10 years that have passed since the recommendations were made in the NTP review, many of these points have been addressed (see 3.2.5.1.). Naturally, new questions have arisen and a very recent EFSA report on Endocrine Active Substances (EAS) (EFSA 2010) points out “that despite the many more publications on low-dose effects since the NTP report, difficulties outlined therein remain”. Study outcomes from sources funded by chemical corporations often contradict the vast amount of government funded studies. Vom Saal posted on his website a literature analysis (2009) of published low dose studies and concludes that no chemical industry funded study finds that low doses of bisphenol A cause harm (14 out of 14) whereas 202 out of 217 academic studies report significant, and in many cases, clearly adverse effects (http://endocrinedisruptors.missouri.edu/vomsaal/vomsaal.html). One contentious issue is that the current NOAEL of bisphenol A used for regulatory purposes in Europe and the USA is 5 mg/kgВ·day, which is based on two multigenerational studies in rodents (Tyl et al. 2002; Tyl et al. 2008). However, in many studies an effect of bisphenol A is reported when animals were exposed in the range of two to three orders of magnitude lower doses. On the basis of such studies,As this is within the range of human exposure levels (Richter et al. 2007) many members of the scientific community believe that there is a risk to humans of adverse health effects (Richter et al. 2007). As extensively discussed in Beronius et al. (Beronius et al. 2010) the differences in conclusions regarding human health risks of bisphenol A are due to differing opinions concerning the reliability and relevance of studies reporting low dose effects. Often quoted are issues with the credibility of the data due to drawbacks in the statistical analysis, the background estrogens masking or enhancing the effects of bisphenol A, and the use of strains sensitive or resistant to hormonal Page 70 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS disturbances in utero etc. And while EFSA and the FDA dismiss low dose findings due to these reliability issues, some expert groups (the ECB, Health Canada, the EC Health & consumer Protection DG and the NTPC) warn these data cannot be entirely dismissed as insignificant for human health risk assessment (Beronius et al. 2010). What has not been sufficiently appreciated by some regulatory agencies is that the current NOAEL was derived from studies that are not exempt from the drawbacks they criticise in academic low dose studies. The often commended GLP studies tested only for a limited number of effects, such as major changes in tissue weight and appearance. By contrast, the latest academic and government studies on bisphenol A find effects the researchers in private labs did not even look for. These comprise developmental neurotoxicity (Leranth et al. 2008; MacLusky et al. 2005), sex-difference sensitivity for certain reproductive problems (Cabaton et al. 2010), and changes to growth in prostate (Prins et al. 2010) and breast tissue (Durando et al. 2007) leading to precancerous lesions. Scholze and Kortenkamp (2007) see the root of the ED low dose impasse in the low dose estimates, such as the NOAELs. The presence or absence of low dose effects is often compromised by statistical power of the experimental design. They demonstrate that NOAELs are sensitive to the specific features of the chosen experimental design and the choices of statistical methods. Below the statistical detection limit of the particular experimental arrangement used it can only be concluded that the presence of effects can neither be proven nor ruled out. Scholze and Kortenkamp (2007) suggest that the procedures used to estimate NOAELs “could be put on a better footing if decisions about a biological or toxicologic effect size of relevance would form the starting point of power analyses. Power considerations could then reveal which resources are necessary to demonstrate such effects.” Quantitative approaches to defining effects of relevance are discussed in their summary. At a workshop held in Baltimore, Maryland, on 23–24 April 2007, sponsored by the U.S. Environmental Protection Agency and Johns Hopkins Risk Sciences and Public Policy Institute, a multidisciplinary group of experts reviewed the state of the science regarding low-dose extrapolation modelling and its application in environmental health risk assessments (White et al. 2009). A wide-ranging discussion of estimating dose-response relationships in the low dose range was initiated at this workshop. This wider discussion has assumed urgency with recent epidemiological studies of very large populations (up to several 100,000), where thresholds (with chemicals not noted as endocrine disrupters) were not observed, independent of whether cancer or non-cancer outcomes were analysed. Instead, risks increased linearly with dose in the low dose range. These observations have been made in studies investigating the effects of ozone, tobacco smoke, nitric oxide and sulphur dioxide, particulate matter and lead. On the basis of these epidemiological findings, workshop participants questioned the current dichotomy in risk assessment, which deals with non-carcinogens by assuming thresholds, and maintains that the risks associated with carcinogens decrease with dose, but in a threshold-independent fashion. It has been proposed to put this dichotomy aside and to deal with pollutants in a uniform manner where threshold-independent action can also be assumed for non-carcinogens. Two aspects of importance for the debate of low dose effects of EDCs have emerged from this debate: (1) Attempts to categorically define modes of action that can inform low dose Page 71 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS extrapolations, and (2) consideration of conditions that render thresholds not applicable for human populations. In most cases, the existence of dose thresholds cannot be proven or ruled out by experimental approaches, because methods for measuring effects have their limits of detection which will obscure thresholds, if they exist. Additional complicating factors are related to normal biological variation and the limited power that is available with the size of dose groups normally used in toxicity testing (Slob 1999, Scholze and Kortenkamp 2007). For these reasons, criteria for assuming thresholdindependence of certain classes of pollutants derive from considerations of their mode of action, as for example with genotoxic carcinogens, where it is assumed that small numbers of irreversible events (mutations) can form the starting point of malignancies. However, a thorough understanding of the events that lead from exposure to disease, and the modes of action involved in these steps is lacking for most environmental pollutants in general, and for EDCs in particular. A comprehensive elucidation of all the mechanisms involved is so dataextensive, that application to risk assessment remains quite a distant prospect. Conversely, the current concepts of mode of action in risk assessment are too general to be useful in informing low dose extrapolations. These difficulties have given impetus to proposing categories of modes of action that are more amenable to low dose extrapolations, by considering the reversibility of key events, the rates of repair, if there is reversibility, and by examining the irreversibility of key steps. Three generic categories have been suggested (White et al. 2009): (a) low dose reversible (e.g. irritants), (b) low dose irreversible (e.g. mutagens) and (c) chronic cumulative, irreversible events (e.g. neuronal loss in Parkinson’s disease). In applying such categories to EDCs, it becomes imperative to examine whether there is evidence for mode of action categories “low dose irreversible” or “chronic cumulative, irreversible”. Although the events that lead to exposure-related diseases may be non-linear in the low dose range, thresholds are obscured when the analysis is conducted at the human population level. Even under the assumption of thresholds for individuals (this will forever remain hypothetical, because thresholds cannot be verified at the individual level, even if present) thresholds are obscured at the population level by inter-individual variations in sensitivity and by background exposures or endogenous exposures that also have an impact on the health endpoint in question. As a result, dose-response relationships often appear low dose linear at the population level, without evidence for a threshold, even though thresholds may exist for individuals. Population dose-response relationships then reflect a multitude of individuals’ thresholds, with the consequence that a threshold cannot be established for the population (see the excellent discussion of this topic in Slob (1999)). A point of immediate relevance for EDCs concerns background exposures and endogenous exposures that play a role in disease processes. This scenario applies to pollutants that mimic the action of endogenous hormones, for example estrogens. Because of pre-existing internal exposures to steroidal estrogens, it can be inferred that any quantum of externally added estrogenic agent adds to the internal load, thereby exhibiting activity in a threshold-independent fashion. This is an important consideration for the role of estrogens in breast cancer (see 5.1), during the programming Page 72 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS of the neuroendocrine system and timing of puberty (4.2) and the role of xenoestrogens in influencing the sex determination in turtle eggs (Sheehan et al. 1999). 3.2.5.1 Recent key low dose studies There is a wealth of data on animal studies that investigate the effects of exposure to low doses of bisphenol A on reproductive organs as discussed above. It is emerging that low doses of bisphenol A may pose cancer risks and affect neurobehavioral endpoints. 3.2.5.1.1 Prostate cancer A study published in early 2006 helped explain how early exposure to bisphenol A could increase rats' susceptibility to prostate cancer (Ho et al. 2006). The work complements a growing body of research suggesting that the chemical poses a cancer risk at environmentally relevant doses. Recent studies in neonates highlight that the timing of exposure is also critical to the understanding of doseresponse relationships for EDCs which could be a reason why such effects have not been found earlier. As opposed to the in utero prostate morphogenesis in humans, it occurs during the perinatal period in rodents. Using neonatal rodents Prins et al. (2007) found that environmentally relevant bisphenol A exposures result in an increased incidence and susceptibility to neoplastic transformation of the prostate gland in the aging male. Taking into account the natural history of prostate cancer (see 5.2) this may provide a foetal basis for this adult disease (Prins et al. 2010). 3.2.5.1.2 Breast cancer For the mammary gland it is the perinatal bisphenol A exposure in rodents that causes changes in organisation of this tissue which is a known risk factor for breast cancer in humans (Vandenberg et al. 2009; Markey et al. 2003). A study by Durando et al. (2007) showed that prenatal exposure to low doses of bisphenol A perturbs mammary gland histoarchitecture and increases the carcinogenic susceptibility to a chemical challenge by N-nitroso-N-methylurea (NMU) administered 50 days after the end of bisphenol A exposure. A study by MuГ±oz-de-Toro et al. (2005) determined the effects of perinatal exposure to low, doses of bisphenol A (25 and 250 ng bisphenol A/kgВ·d) on the peripubertal development of the mammary gland and found persistent alterations in mammary gland morphogenesis, such as increased terminal end bud density at puberty as well as the increased number of terminal ends in adult animals. These two structures belong to the sites at which breast cancer is thought to arise also in humans. 3.2.5.1.3 Neurotoxicity Because synaptic remodeling has been postulated to contribute to the rapid effects of estrogen on hippocampus-dependent memory, environmental bisphenol A exposure may interfere with the development and expression of normal sex differences in cognitive function, via inhibition of estrogen-dependent hippocampal synapse formation (see 6.1.3.1.5). It may also exacerbate the impairment of hippocampal function observed during normal aging, as endogenous estrogen production declines. MacLusky et al. (2005) showed that treatment of ovariectomised rats with only Page 73 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS 40 ug/kgВ·d bisphenol A significantly inhibit the estrogen-induced formation of dendritic spine synapses on pyramidal neurons in the hippocampus. A limitation of this study is that it uses a rodent animal model, which may not be representative of the effects of human bisphenol A exposure. To address this issue, the same research group recently examined the influence of continuous low dose bisphenol A administration on estradiol-induced spine synapse formation in the hippocampus and prefrontal cortex of a nonhuman primate model and found that 50 ug/kgВ·day bisphenol A completely abolished the synaptogenic response to estradiol (Leranth et al. 2008). This study is the first to demonstrate an adverse effect of bisphenol A on the brain in a non-human primate model but caused controversy, as it used subcutaneous continuous-release exposures which are higher than potential physiological levels of bisphenol A after ingestion (Mathews 2008). 3.2.5.1.4 Mode of action There is a growing need to uncover potential mechanisms of bisphenol A at low doses in order to improve model systems, modeling approaches and biomarker development. A recent microarray study compared transcript responses and mechanisms of response using mouse reproductive tracts after treatment with estradiol. Notably, low doses of bisphenol A are able to mimic estradiol in samples from mice expressing a DNA binding-deficient ERО±, indicating that bisphenol A can act via the tethering mode of ERО± signalling. In this mode ERО± can affect the rate of transcription via interaction with other DNA-binding transcription factors, such as AP-1 (activator protein 1) or Sp1 (specificity protein-1), which then interact with their respective DNA motifs, leading to estrogen-dependent control of target genes lacking EREs. As no response was detected in ERО±-null uteri, ERО± seems to mediate the responses (Hewitt and Korach 2011). These findings, the aforementioned non-genomic effects via GPCR (Bouskine et al. 2009), and the increasing evidence that bisphenol A affects the epigenome (Weng et al. 2010) are just a few examples of mechanistic insights into low dose effects that could be crucial in the development of biomarkers for future evaluation of modes of action and mechanisms of other potentially estrogenic chemicals. 3.2.5.2 Data gaps As already pointed out in the NTP report in 2001, there are data gaps in our knowledge about the pharmacokinetics low doses of bisphenol A. These data gaps have remained largely unaddressed. An interesting study has recently been published that measured serum levels of unconjugated and conjugated bisphenol A levels in adult female rhesus monkeys and mice following oral administration of chemical, and compared findings in mice and monkeys with prior published data in women (Taylor et al. 2010). They concluded that bisphenol A pharmacokinetics in women, female monkeys and mice is very similar and that the total daily human exposure is via multiple routes and much higher than previously assumed. This is consistent with another recent study that demonstrates that free bisphenol A can indeed be absorbed through the skin explaining why bisphenol A levels in the general population appear to be higher than doses theoretically received through food and drink (Zalko et al. 2011). This also explains the outcome of a recent study that measured urinary bisphenol A concentrations during pregnancy and found that compared with other occupations, cashiers had the highest bisphenol A concentrations (Braun et al. 2011). This might be due to the sustained contact with carbonless paper receipts used in convenience and grocery stores Page 74 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS which have been shown to contain bisphenol A (Vom Saal and Myers 2008). A great deal of the debate about bisphenol A and the low dose issue revolves around the question of the effective internal levels of unconjugated (active) vs conjugated (presumed to be inactive) levels of the chemical. In both non-human primates and rodents, levels of unconjugated bisphenol A are low, and pharmacokinetics models were developed (Doerge et al. 2011) to resolve why unconjugated bisphenol A could not be detected in the serum of human volunteers after bisphenol A dosing (Voelkel et al. 2002). Further knowledge gaps are concerning the mechanisms of low dose actions including epigenetics and non-genomic pathways. Also the mechanistic actions how endogenous hormone levels / background estrogen levels influence the effects of low doses of bisphenol A are widely unknown. Another persistent issue is the lack of full dose response curves, and the spread or complete absence of data points in the low dose range. Page 75 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS 3.2.6 References Alonso-Magdalena P, Laribi O, Ropero AB, Fuentes E, Ripoll C, Soria B, Nadal A. 2005. Low doses of bisphenol A and diethylstilbestrol impair Ca2+ signals in pancreatic alpha-cells through a nonclassical membrane estrogen receptor within intact islets of Langerhans. Environ Health Perspect 113:969-977. Ashby J, Tinwell H, Haseman J. 1999. Lack of effects for low dose levels of bisphenol A and diethylstilbestrol on the prostate gland of CF1 mice exposed in utero. Regul Toxicol Pharmacol 30:156-166. Beronius A, Ruden C, Hakansson H, Hanberg A. 2010. Risk to all or none? A comparative analysis of controversies in the health risk assessment of Bisphenol A. Reprod Toxicol 29:132-146. Bouskine A, Nebout M, Brucker-Davis F, Benahmed M, Fenichel P. 2009. Low doses of bisphenol A promote human seminoma cell proliferation by activating PKA and PKG via a membrane G-protein-coupled estrogen receptor. Environ Health Perspect 117:10531058. Braun JM, Kalkbrenner AE, Calafat AM, Bernert JT, Ye X, Silva MJ, Barr DB, Sathyanarayana S, Lanphear BP. 2011. Variability and predictors of urinary bisphenol A concentrations during pregnancy. Environ Health Perspect 119:131-137. Cabaton NJ, Wadia PR, Rubin BS, Zalko D, Schaeberle CM, Askenase MH, Gadbois JL, Tharp AP, Whitt GS, Sonnenschein C, Soto AM. 2010. Perinatal Exposure to Environmentally Relevant Levels of Bisphenol-A Decreases Fertility and Fecundity in CD-1 Mice. Environ Health Perspect. 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Research Triangle Park, NC, NationalToxicologyProgram.9-2006. Prins GS, Ye SH, Birch L, Ho SM, Kannan K. 2010. Serum bisphenol A pharmacokinetics and prostate neoplastic responses following oral and subcutaneous exposures in neonatal Sprague-Dawley rats. Reprod Toxicol. Prins GS, Birch L, Tang WY, Ho SM. 2007. Developmental estrogen exposures predispose to prostate carcinogenesis with aging. Reproductive Toxicology 23:374-382. Richter CA, Birnbaum LS, Farabollini F, Newbold RR, Rubin BS, Talsness CE, Vandenbergh JG, Walser-Kuntz DR, Vom Saal FS. 2007. In vivo effects of bisphenol A in laboratory rodent studies. Reprod Toxicol 24:199-224. Scholze M, Kortenkamp A. 2007. Statistical power considerations show the endocrine disruptor low-dose issue in a new light. Environ Health Perspect 115 Suppl 1:84-90.:84-90. Sheehan DM et al. 1999. No threshold dose for estradiol induced sex reversal of turtle embryos: how little is too much? Environ Health Perspect 107: 155-159. Slob W. 1999. Thresholds in Toxicology and Risk Assessment. International Journal of Toxicology 18:259-268. Steinmetz R, Brown NG, Allen DL, Bigsby RM, Ben-Jonathan N. 1997. The environmental estrogen bisphenol A stimulates prolactin release in vitro and in vivo. Endocrinology 138:1780-1786. Taylor JA, Vom Saal FS, Welshons WV, Drury B, Rottinghaus G, Hunt PA, Vandevoort CA. 2010. Similarity of Bisphenol A Pharmacokinetics in Rhesus Monkeys and Mice: Relevance for Human Exposure. Environ Health Perspect. Page 76 of 486 OVERARCHING ISSUES LOW DOSE EFFECTS Tyl RW, Myers CB, Marr MC, Sloan CS, Castillo NP, Veselica MM, Seely JC, Dimond SS, Van Miller JP, Shiotsuka RN, Beyer D, Hentges SG, Waechter JM, Jr. 2008. Two-generation reproductive toxicity study of dietary bisphenol A in CD-1 (Swiss) mice. Toxicol Sci 104:362384. 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Toxicol Ind Health 14:239-260. vom Saal FS and Hughes C. 2005. An extensive new literature concerning low-dose effects of bisphenol A shows the need for a new risk assessment. Environ Health Perspect 113:926-933. vom Saal FS and Welshons WV. 2006. Large effects from small exposures. II. The importance of positive controls in low-dose research on bisphenol A. Environmental Research 100:50-76 Vom Saal FS, Myers JP. 2008. Bisphenol A and risk of metabolic disorders. JAMA 300:1353-1355. Weng YI, Hsu PY, Liyanarachchi S, Liu J, Deatherage DE, Huang YW, Zuo T, Rodriguez B, Lin CH, Cheng AL, Huang TH. 2010. Epigenetic influences of low-dose bisphenol A in primary human breast epithelial cells. Toxicol Appl Pharmacol 248:111-121. White RH, Cote I, Zeise L, Fox M, Dominici F, Burke TA, White PD, Hattis DB, Samet JM. 2009. State-of-the-science workshop report: issues and approaches in low-dose-response extrapolation for environmental health risk assessment. Environ Health Perspect 117:283-287. Witorsch RJ. 2002. Low-dose in utero effects of xenoestrogens in mice and their relevance to humans: an analytical review of the literature. Food Chem Toxicol 40: 905 Zalko D, Jacques C, Duplan H, Bruel S, Perdu E. 2011. Viable skin efficiently absorbs and metabolizes bisphenol A. Chemosphere 82:424430. Page 77 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs 3.3 MULTIPLE CHEMICAL EXPOSURES TO ENDOCRINE DISRUPTING CHEMICALS The focus of the WHO (2002) Global Assessment of the State-of-The-Science of Endocrine Disrupters (WHO 2002) was on evaluating cause-effect relationships for specific chemicals. The document highlighted the problems associated with investigating exposure-effect relationships in epidemiological and wildlife studies where good measures of exposures are often not available. The issue is particularly problematic for chemicals that degrade rapidly after they have come into contact with the human body or the environment. In such cases, the exposures that may have caused adverse effects, are not detectable anymore when responses become manifest. As a result, exposure-effect relationships cannot be examined. As a way of dealing with this difficulty, the WHO Global Assessment focused on persistent chemicals with endocrine disrupting effects, such as PCBs or dioxins. Because of their persistence, these agents remain in the body or the environment long after the events that may have set the course of adverse events. In such cases, cause-effect relationships, if they exist, can be re-constructed and exposure-response relationships examined. It is well acknowledged that these problems, which limit the analysis to persistent chemicals due to a lack of data about other agents, are still relevant today. With the realisation that not only persistent, but also many polar chemicals have endocrine disrupting properties, the focus of the debate has shifted towards considering chemical exposures in their entirety. As part of this change in perspective, the need to consider simultaneous exposures to multiple EDCs is now well recognised. Although the WHO Global Assessment had mentioned the topic and its possible implications in terms of effect modifications (i.e. synergisms, additivity or antagonisms), it was not discussed further. In the ten years that followed the publication of the 2002 document, numerous experimental studies dealing with combinations of EDCs have appeared. Initially, these studies were motivated by the search for synergistic effects, but soon the importance of additivity also came into focus. Particular attention has been paid to the question as to whether combination effects between EDCs are to be expected when each individual chemical is present at doses that on its own do not induce observable effects. One of the key aspirations of mixture toxicology is to anticipate quantitatively the effects of combinations of chemicals from knowledge about the effects of their individual components. This can be achieved by making the assumption that the chemicals in the mixture act in concert by exerting their effects without diminishing or enhancing each others’ toxicity, the so-called noninteraction or additivity assumption. Concentration (or dose) addition and independent action are the two concepts available for formulating the null hypothesis of additivity. Synergisms or antagonisms can then be defined in relation to this additivity assumption as upwards or downwards deviations, respectively. A discussion of general concepts for the evaluation of mixtures can be found in (Kortenkamp et al. 2009). Reviews of EDC mixture effects are available (Kortenkamp et al. 2007; Kortenkamp 2007; Kortenkamp 2008). The purpose of this section is to briefly summarise the state of the art and to consider the implications for human and environmental risk assessment. Page 78 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs In doing so, it is helpful to make a distinction between assessment concepts for cumulative action (dose addition, independent action), and risk assessment approaches for dealing with mixtures of EDCs (hazard index, point of departure index and TEF approach for the evaluation of dioxin combinations). From a science perspective, it is important to evaluate how well assessment concepts for cumulative action are able to anticipate experimentally observed EDC combination effects and to investigate the cause for possible deviations from predicted additivity. Although these issues also have a bearing on the validity of risk assessment approaches, conservatism in safeguarding against underestimations of combination effects will take precedence over concerns regarding accuracy of mixture effect predictions. The following sections approach the topic of EDC mixtures in a step-wise fashion: First, studies aimed at establishing the type of combination effect (additive, synergistic, antagonistic) by testing the “non-interaction” null hypothesis will be briefly summarised. Here, the emphasis is on judging how well mixture effect assessment concepts are able to approximate EDC combination effects. Second, the topic of combination effects of EDC at low doses will be considered, and the consequences for risk assessment approaches discussed. Finally, the implications for health impact assessments and epidemiology will be outlined. 3.3.1 Experimental studies with EDC mixtures The mixture studies that appeared while the 2002 WHO report was drawn up, had taken insufficient account of the importance of additivity assumptions, and most published studies operated without an additivity null hypothesis (critically reviewed by (Kortenkamp and Altenburger 1998). During the last ten years, however, the field has undergone a remarkable and productive development. Whilst before, scientists had focused mainly on combinations of only two chemicals, a significant number of well-designed and decisive studies are now available that involve multi-component mixtures of EDCs. This has extended from in vitro assays to in vivo studies (see the reviews by (Kortenkamp 2007; Kortenkamp 2008; Kortenkamp et al. 2009). EDC mixture studies have overwhelmingly focused on EDCs with a similar mode of action, i.e. those that target the same hormonal system. Most experiments have used estrogen mixtures, while combinations of (anti)androgens and thyroid disrupters are less well researched. Work on dioxins and the AhR receptor has preceded that on other EDC mixtures and there is a rich literature concerning the application of the dioxin toxicity equivalents approach to dioxin mixtures. Studies involving other hormone systems such as progesterones or glucocorticoids are missing completely. Relatively few experiments have combined EDCs with dissimilar modes of action, and information about the impact of agents devoid of ED effects on EDC combinations is sparse. 3.3.1.1 Mixtures of estrogenic chemicals Estrogenicity can be defined in terms of binding to the estrogen receptor(s) (ER), ER activation, cell proliferation in ER-competent cells and physiological responses (proliferation of uterine tissue in rodents, induction of vitellogenin in fish). With the exception of ER binding, mixture studies with endpoints at all these levels of biological organisation have been conducted. This included not only binary mixtures, but mixtures with up to Page 79 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs 12 estrogenic agents, as well as in vivo studies with vitellogenin induction in fish (Brian et al. 2005) and uterotrophic responses in rats (Charles et al. 2002) as endpoints of estrogen action. A wide variety of estrogenic chemicals has been used in mixture experiments, including steroidal estrogens, phytoestrogens, phenolic compounds such as bispenol A, UV filter substances and persistent organochlorines such as p,p’-DDE, o,p’-DDT and certain PCBs. Generally, dose (concentration) addition proved to be a valid tool for the prediction and assessment of combination effects of estrogen mixtures, although small deviations from expected additivity suggestive of weak antagonisms have been observed with cell proliferation assays and reporter gene assays (Charles et al. 2007; Rajapakse et al. 2004). Independent action generally led to underestimations of the observed effects. 3.3.1.2 Mixtures of anti-androgenic chemicals Anti-androgenicity has been defined narrowly as androgen receptor (AR) antagonism, but a broader definition in terms of counteracting the effects of androgens in a functional sense (which would include inhibition of uptake of testosterone precursors, and of testosterone synthesis steps) has also been useful. Compared with estrogenic agents, fewer studies with anti-androgens are available. Chemicals employed in mixture experiments include azole pesticides, phthalates and pharmaceuticals such as flutamide or finasteride. At the level of AR antagonism in vitro, mixture effects in line with concentration addition expectations have been observed. However, the number of mixture components was comparatively small; studies with more than 3 components have not been published. AR antagonists have also been evaluated in vivo in a rat reproductive toxicity model. Administration of a combination of three AR antagonists throughout gestation led to dose additive effects on a series of developmental landmarks representative of male sexual differentiation (Hass et al. 2007; Metzdorff et al. 2007). Anti-androgens able to suppress fetal testosterone synthesis have been assessed in vivo. Phthalates fall into this group of anti-androgens, and a mixture of five phthalates was found to produce effects in good agreement with dose addition predictions (Howdeshell et al. 2008). Of particular significance are a number of studies that have combined anti-androgens with dissimilar modes of action, including those that act by suppressing fetal androgen synthesis and others that diminish androgen action by antagonising the AR (Christiansen et al. 2008; Christiansen et al. 2009; Rider et al. 2008). Dose addition generally was superior to independent action in approximating the experimentally observed effects, and independent action led to underestimations of combined responses (Rider et al. 2008). 3.3.1.3 Mixtures of thyroid-disrupting chemicals Thyroid-disrupting chemicals are the least well studied endocrine disrupters and it is therefore not surprising, that only a few mixture studies are documented using this kind of agents (Crofton et al. 2005; Desaulniers et al. 2003; Flippin et al. 2010). Page 80 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs Desaulniers et al. (2003) found that the effects of 16 polychlorinated biphenyls, dioxins and furans on circulating thyroxin levels could be predicted well by using the TCDD equivalents approach which an application of dose addition. Effects suggestive of slight synergisms relative to dose addition predictions were observed by Crofton et al. (2005) in a study of a multi-component mixture of PCDDs, PCDFs and PCBs on the levels of circulating T4 levels in rats. Filippin et al. (2010) investigated the effects of thyroid-disrupting chemicals that operate by different mechanisms in reducing T4 levels in rats (dioxins, furans and PCBs combined with the pesticides thiram, pronamide, and mancozeb. The results support the use of dose addition in predicting the effects of complex mixtures of thyroid disrupters. 3.3.1.4 Mixtures of dioxins and dioxin-like chemicals Combinations of polychlorinated dioxins and also polychlorinated furans and co-planar PCBs – the latter two groups often referred to as “dioxin-like compounds (DLC) – are commonly assessed by using the Toxicity Equivalency (TEQ) approach. The TEQ approach works on the basis of Toxicity Equivalency Factors (TEFs) that are intended to express the potency of specific DLC congeners in terms of the most toxic chemical of the group, 2.3.7.8 TCDD. In this way, the levels of specific DLCs are converted to equitoxic concentrations of TCDD, so-called TCDD equivalents (TCDD EQs). By summing up these TCDD EQs, the joint effect of a DLC combination can be anticipated. In effect, this approach is an application of the concentration addition concept. It is discussed here in more detail because suggestions have been made to apply the TEQ approach also to mixtures of other EDCs. Although the TEQ approach with its TEFs has evolved to deal with mixtures of DLC, the concept was originally designed to estimate the toxicity of untested DLC congeners, and not of mixtures. The TEF concept rests on the assumption that all compounds produce effects via a similar mechanism (binding to the Ah receptor), and that their potency can be expressed in relation to a reference chemical (2,3,7,8 TCDD). Based on relative effect potency (REP) values that are determined for specific DLCs in relation to specific endpoints, a TEF is assigned to that DLC congener. In assigning a global TEF to a specific DLC, the assumption is made that maximal response and shape of the doseresponse curves, especially their slopes, should be similar for DLC congener and the reference chemical TCDD. Essentially, the curves should be parallel. If the demand for parallel curves is not met, the REPs (and consequently the TEFs) should change according to the effect level that is chosen for analysis. In practice, this would make the entire concept unworkable, and global TEFs could not be assigned. However, the demand for parallelity of dose-response curves is often not met, with the consequence that the value of REPs depends on the effect level chosen for potency comparisons. Furthermore, the REPs that have been determined for specific DLC congeners in relation to specific effects endpoints and assays usually vary by several orders of magnitude, and a “global” TEF is chosen to reflect the midpoint of that range. Despite these inaccuracies it turned out that the TEQs calculated for DLC mixtures by using global TEFs agreed reasonably well with the experimentally determined responses (Desaulniers et al. 2003; Hamm et al. 2003; Van den Berg 2006). However, the application of the TEQ approach to other classes of EDCis complicated by the fact that the dose-response relationships for individual chemicals exhibit widely varying slopes and shapes Page 81 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs (see for example (Christiansen et al. 2008) and that obvious reference chemicals analogous to TCDD are missing. 3.3.1.5 Synergisms Deviations from anticipated additivity suggestive of synergisms or antagonisms have rarely been observed. The originally reported strong synergisms with certain estrogenic pesticides (Arnold et al. 1996) could not be reproduced (Ashby et al. 1997; Ramamoorthy et al. 1997) and the paper has been retracted. Small synergisms in relation to dose addition predictions were described with a multi-component mixture of thyroid-disrupting PCDDs, PCDFs and PCBs with levels of circulating T4 in rats as the endpoint of evaluation (Crofton et al. 2005). Recently, Christiansen et al. (2009) reported synergisms with respect to the occurrence of penile malformations in the offspring of rats that had been dosed with a mixture of the phthalate DEHP, two fungicides present in food, vinclozolin and prochloraz, and a pharmaceutical, finasteride. However, the molecular mechanisms that might explain this synergism remain elusive. The combined effects of that same mixture were dose additive in relation to other hallmarks of disrupted male sexual development, including changes in anogenital distance, retained nipples, and sex organ weights. Although it is generally accepted that co-planar PCBs are DLCs and should be evaluated together with other dioxins and furans by using the TEQ approach, a debate has concerned the question as to whether non-coplanar PCBs should also be included. In reviewing this topic, Van den Berg et al. (1998) have highlighted various examples of synergistic or antagonistic effects that were observed with combinations of non-coplanar PCBs and DLCs. Antagonistic effects were found with respect to inductions of EROD activity in chicken embryo hepatocytes, spleen responses to sheep erythrocytes in mice, induction of cleft palates in fetal mice, and malformations in chicken embryos. There were also synergistic effects of non-coplanar PCBs and dioxins in the development of porphyria in rats, CYP1A1 induction, changes in thyroid hormone levels and associated enzyme activities. Van den Berg et al. (1998) emphasised that these deviations from additivity require further investigation in order to assess the extent to which they undermine the usefulness of the TEQ concept. 3.3.1.6 Summary The majority of EDC mixture studies have demonstrated that dose addition provides good approximations of experimentally observed combination effects. Independent action has yielded predictions that underestimated the observed effects. Deviations from expected additivity effects, indicating synergisms or antagonisms were rarely observed, and when they occurred, the magnitude of over- or underestimation was small. Page 82 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs 3.3.2 EDC mixture effects at low levels of the individual components Many of the mixture experiments conducted with EDCs were motivated by testing “non-interaction” hypotheses and establishing cases of additivity, synergy or antagonism. That effort often required the administration of doses associated with measurable effects but far higher than exposures experienced by humans or wildlife. However, a key issue in human and environmental risk assessment is to evaluate whether EDCs produce combination effects when they are present at levels that individually do not induce observable effects, or even at levels similar to those found in the environment. 3.3.2.1 Definitions of the term “low dose” in a mixture context The term “low dose” is not universally defined and has different meanings, depending on context. In the endocrine disrupter field in general, “low dose” has been used to denote 1) doses lower than normally used in toxicity testing, 2) doses in the range of exposures experienced by humans and wildlife and 3) doses associated with small effects, usually in the range of NOAELs or below (see 3.2.1). Confusingly, definition 3) is often conflated with the term “threshold”, in the sense of “subthreshold” doses. Although experiments describing combinations of EDCs at environmental levels have recently appeared, the term “low dose” in the sense of “doses associated with small effects, in the range of NOAELs” has initially driven a great deal of experimental studies. This was largely motivated by theory expectations about the occurrence of low dose mixture effects that can be derived from the two assessments concepts dose addition and independent action. 3.3.2.2 Theory expectations about the occurrence of low dose mixture effects It has been argued that the question of low dose mixture effects in general cannot be decided without considering the mode of action of the chemicals that occur together at low levels. A distinction should be made between agents that act through a common mechanism (“similar action”) and those that show diverse or “dissimilar” mechanisms of action (Committee on Toxicity of Chemicals in Food (COT) 2002). This distinction has significant practical implications: According to the principles of dose addition, similarly acting chemicals can replace one another, without loss of effectiveness. For this reason, combination effects can be expected even at doses well below no-observed adverse effect levels (NOAELs). The point can be illustrated by considering a dose fractionation experiment, where e.g. a dose equivalent to 4 x 10-2 M produces an effect of measurable magnitude. The same effect will be reached when instead this dose is administered in 10 portions of 4 x 10 -3 M, or when 10 portions of 10 different chemicals of equal potency are used simultaneously. A joint effect will occur even when the response of one of those dose fractions individually is not measurable. This means that combination effects will appear at doses well below NOAELs, provided a sufficiently large number of chemicals is simultaneously administered. In such situations, traditional risk assessment approaches with their focus on single chemicals may be limiting because considerations of individual NOAEL do Page 83 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs not reveal much about possible risks without information about exposure to other simultaneously occurring agents. The situation is thought to be completely different when exposure is to chemicals with diverse modes of action. Such mixtures are assumed to follow the independent action principle. Because these chemicals interact independently with different sub-systems of the affected organisms, so the assumption, mixtures pose no health concerns as long as the levels of each component stay below their NOAELs (COT 2002; Feron et al. 1995). However, that view presupposes that NOAELs can be equated with zero effect levels, an opinion heavily criticised by biometricians and statisticians (see Kortenkamp et al. 2007) Until recently, empirical evidence with EDC mixtures to either confirm or refute these expectations was missing. From 2002 onwards, several studies were conducted with the proclaimed aim to assess the occurrence of combination effects when EDCs were combined at doses (or concentrations) around the NOAELs (NOECs) of the individual components. Before these studies are summarised, important design issues need to be considered with a view to draw up quality criteria for the assessment of experimental studies. 3.3.2.3 Design issues and quality criteria A requirement for experimental studies intended to address the issue of mixture effects at doses below NOAELs is that such estimates are derived for each mixture component by using the same assay system (and endpoint) that is chosen for the mixture study, ideally under identical experimental conditions. Ignoring that demand can lead to the inadvertent administration of some or all mixture components at doses exceeding their NOAELs, which would undermine the aim of the experiment. But delivery of doses smaller than NOAEL, either by design or inadvertently, might present problems if the experimental system lacks the statistical power to detect effects. For example, it would be futile to attempt an experiment where two agents are combined at 1/100 of their individual NOEL. The resulting mixture effect, if it exists, would be too small to be detectable in most cases, and the experiment would be inconclusive. Based on these considerations, the following two minimal quality criteria for low dose mixture experiments have been proposed for assessments of studies (Kortenkamp 2008): п‚· The effects of individual mixture components should have been determined under similar conditions as the mixture. п‚· NOAEL (or NOELs and NOECs when a neutral effect concept is adopted) should have been estimated for each mixture component, and the absence of observable effects demonstrated directly. In addition to these two minimal requirements, it would be desirable to calculate quantitative additivity expectations. This would allow evaluations of combination effects in terms of synergism, antagonism or additivity. Page 84 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs 3.3.2.4 Evidence for low dose mixture effects from studies with estrogenic, anti-androgenic and thyroid-disrupting EDCs A number of experiments where groups of estrogenic, anti-androgenic and thyroid-disrupting chemicals were combined at low doses have been published in the literature. In all of these studies, well-founded statistical criteria were used to derive low dose estimates for single compounds (often NOELs), and the experimental power of the chosen assays was sufficient to demonstrate mixture effects of the combinations at their respective NOELs. Silva et al. (2002) combined eight xenoestrogens at levels equivalent to 50% of their individual NOECs in the yeast estrogen screen. Responses of up to 40% of a maximal estrogenic effect were observed. Using the same assay, Rajapakse et al. (2002) investigated whether low levels of weak xenoestrogens would be able to modulate the effects of E2. A combination of eleven xenoestrogens, all present at levels around their individual NOECs, led to a doubling of the effects of E2. The overall mixture effect was concentration additive. In subsequent studies, the analysis of low dose mixture effects has been extended to in vivo endpoints. Tinwell and Ashby (2004) combined eight estrogenic chemicals at doses that gave no statistically significant uterotrophic responses when tested on their own. When administered together, quite strong uterotrophic effects were observed in the rat. In this study, no attempts were made to anticipate combination effects quantitatively and to examine their agreement with an additvity expectation. Brian et al. (2005) examined a mixture of five estrogenic chemicals in fish (Pimephales promelas) with vitellogenin induction as the endpoint. Marked effects well in agreement with concentration addition where found when all five chemicals were combined at concentrations that individually did not induce vitellogenin synthesis. Hass et al. (2007) studied combinations of three similarly acting androgen receptor antagonists in an extended rat developmental toxicity model. The male offspring of female rats which were dosed over the entire duration of pregnancy showed significant signs of feminisation (reduced anogenital index, retained nipples) with a mixture of antiandrogens at their individual NOELs for these endpoints. Quantitatively, these effects agreed well with the responses anticipated by dose addition. Christiansen et al. (2009) observed changes in anogenital index of male rats dosed in utero with a combination of four dissimilarly acting antiandrogens when all agents were combined at doses equivalent to their NOAEL. Although not designed for such purposes, the experiment by Howdeshell et al. ((Howdeshell et al. 2008)) on suppression of testosterone synthesis after developmental exposure to five phthalates indicates that phthalates are able to work together when present at individually ineffective doses. Similarly, the NRC report found that the study by Rider et al. (2008) provided some indications of combined effects of phthalates and AR antagonists at low doses. Although the dose-response data on the individual chemicals are of insufficient quality to derive doses without observable effects, they nevertheless suggest that the doses are ineffective on their own. Crofton et al. (2005) analysed 18 thyroid-disrupting chemicals in terms of their ability to induce changes in T4 levels and observed clear mixture effects (slightly stronger than anticipated by dose Page 85 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs addition) when all chemicals were combined at doses equivalent to their individual NOELs, or even below. 3.3.2.5 Studies with equivocal or lacking evidence of low dose mixture effects The effects of mixtures of 18 endocrine active organochlorine pesticides and environmental contaminants, including 2,3,7,8-TCDD on rats were investigated by Wade et al. ((Wade et al. 2002)). The animals were treated for 70 days with a combination of all chemicals at their respective minimal residue levels or ADI values. This so-called “ADI mixture” did not produce observable effects. The experiment is difficult to interpret, because minimal requirements for low dose mixture studies were not met: None of the agents were tested individually, and information about their NOAELs in relation to the endpoints examined in this study was not available. The ADI values for most of the chemicals were derived based on endpoints unrelated to those measured in this study. This raises doubts as to whether the statistical power of this experiment (10 animals per dose group) was sufficient to demonstrate effects at these low doses. A combination equivalent to doses 10 times higher than those administered in the “ADI mixture” study led to decreases in epididymus weights. However, TCDD alone, at the dose present in the “10 times ADI mixture”, also produced this effect which indicates that the observed responses were attributable solely to TCDD, and that the contribution of the remaining agents to this effect was negligible. It is likely that a true combination effect between TCDD and the other components had not occurred. More recently, van Meeuwen et al. (2007) presented the results of experiments with a combination of estradiol, phytoestrogens and synthetic estrogens in the rat uterotrophic assay. The composition of the phytoestrogen and xenoestrogen mixtures was based on data about serum levels and on human dietary intake of the chemicals. While mixtures of estradiol and phytoestrogens acted in a dose additive fashion, the combination of synthetic estrogens (4-nonyl phenol, 4-octyl phenol, bisphenol A, ОІ-HCH, methoxychlor and dibutyl phthalate) did not lead to modulations of the effects of estradiol. This was because the xenoestrogen mixture was ineffective when administered without estradiol, even at doses equivalent to 100,000 times the human intake. However, considering the individual potency of the chosen xenoestrogens in the rat uterotrophic assay, this outcome is perhaps not surprising. Doses equivalent to 1,000,000 should have been administered for effects to be observed with any degree of certainty – a reflection of the insensitivity of the uterotrophic assay. The authors concluded that the contribution of xenoestrogens to total estrogenicity in the human diet can probably be neglected. However, this conclusion is problematic, because the minimal criteria for low dose mixture experiments set out above were not met in this study. It is unclear what motivated the selection of the six xenoestrogens, and more agents could have been included in the mixture. The authors noted that the composition of their phytoestrogen and xenoestrogen mixtures was not intended to represent all possible endocrine active compounds that humans are exposed to, but this somewhat diminishes the conclusions of this paper. 3.3.2.6 Interpretation of empirical findings in relation to theory expectations The experimental studies with mixtures of estrogens, anti-androgens and thyroid-disrupters are in agreement with theory expectations. In all these cases, the components in the mixture interacted Page 86 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs with the same molecular target (receptors) and therefore combination effects at low levels were to be expected according to the dose addition principles. However, considering the diversity of mechanisms by which thyroid disrupting chemicals exert their effects, the assumption of similarity can be questioned. It is conceivable that the principles of independent action might be fulfilled with these mixtures. Nevertheless, significant mixture effects at doses well below NOELs were observed (Crofton et al. 2005). It appears that this is not restricted to thyroid disrupting chemicals and may apply also to combinations of antiandrogens with diverse modes of action but a common adverse outcome (Christiansen et al. 2009). If the above combinations of thyroid disrupters and antiandrogens are classed as “dissimilar” mixtures, these observations of low dose effects would contradict the view that mixtures of dissimilarly acting chemicals are “safe” as long as all components are present at levels below their individual NOAELs. The fidings by Crofton et al. and Christiansen et al. may also suggest that the distinctions according to modes of action often made to anticipate (or rule out) the potential for mixture effects at low doses are not be productive for EDC mixtures. However, more experimental evidence is needed before firm conclusions can be reached Taken together, there is good evidence that combinations of endocrine disrupters are able to cause significant mixture effects at doses below NOAELs. Lacking or equivocal evidence in some studies can be explained in terms of problematic selections of dose levels. These examples illustrate the difficulties with experiments aimed at investigating mixture effects at “environmentally relevant levels” and highlight the need to consider experimental power and choice of chemicals. With a number of chemicals and animals that are manageable in laboratory experiments, mixture effects at “realistic” doses may be hard to demonstrate. A lack of studies with combinations of different classes of endocrine disrupters (e.g. estrogenic plus anti-androgenic agents) has been noted (Kortenkamp 2008). 3.3.3 Implications for risk assessment and epidemiology In chemicals regulation and risk assessment, NOAELs are combined with so-called safety factors to derive acceptable or tolerable daily intakes for humans (ADI, TDI). Exposures below these ADI are regarded as safe. The question is whether EDCs pose no harm when exposure is to a large number of chemicals, all at levels around their ADI. According to theoretical considerations, and on the basis of the available experimental evidence, the possibility of combination effects cannot easily be ruled out. On the other hand, potential risks cannot readily be confirmed either. To decide the issue on a sound scientific basis, knowledge about relevant combined exposures is essential. Data on exposures to individual EDCs are uninformative, as long as knowledge about exposure to similarly acting chemicals, their number and their levels is not available. This information is currently at best fragmentary, but indications are that large numbers of agents are involved. To fill this gap, exposure assessment concepts that adopt a more holistic approach, instead of focusing on single chemicals or groups of chemicals, are urgently needed. The advances made with assessing the effects of multiple endocrine disrupters at low doses in laboratory experiments have yet to be fully realised in epidemiology. EDC epidemiology has overwhelmingly focused on individual chemicals, although there are interesting recent Page 87 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs epidemiological studies that deal explicitly with the mixtures issue (Damgaard et al. 2006; Fernandez et al. 2007; Ibarluzea et al. 2004; Main et al. 2006; Swan et al. 2005). Swan et al (2005) found that decreases in anogenital distance among male infants are associated with prenatal exposure to several phthalates. Earlier, Pierik et al. (2004) identified paternal exposures to pesticides and smoking as factors associated with these congenital malformations. Damgaard et al (2006) observed an association between congenital cryptorchidism and a summative parameter of the levels of certain organochlorine pesticides in mothers’ milk. Main et al. (2007) found associations between the sum of polybrominated biphenyl ethers in breast milk and cryptorchidisms in newborn boys. Fernandez et al. (2007) reported associations between cryptorchidisms in boys and the estrogenic load from non-steroidal estrogens in mothers’ placentas. In most of these publications, effects were not associated with individual chemicals, yet indications of combined effects were apparent. In this, there are echoes with the results of experimental low dose mixture studies, where chemicals worked together at low levels to yield effects. However, before firm conclusions can be drawn, epidemiology needs to embrace the reality of mixture effects at low doses by developing better tools for the investigation of cumulative exposures. The application of biomarkers able to capture cumulative internal exposures, such as in the studies by Fernandez et al. (2007) and Ibarlucea et al. (2005) holds great promise in this respect. Page 88 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs 3.3.4 References Arnold SF, Klotz DM, Collins BM, Vonier PM, Guillette LJ, McLachlan JA. 1996. Synergistic activation of estrogen receptor with combinations of environmental chemicals. Science 272:1489-1492. Ashby J, Lefevre PA, Odum J, Harris CA, Routledge EJ, Sumpter JP. 1997. Synergy between synthetic oestrogens? Nature 385:494. Brian JV, Harris CA, Scholze M, Backhaus T, Booy P, Lamoree M, Pojana G, Jonkers N, Runnalls T, Bonfa A, Marcomini A, Sumpter JP. 2005. Accurate prediction of the response of freshwater fish to a mixture of estrogenic chemicals. Environmental Health Perspectives 113:721-728. Charles GD, Gennings C, Tornesi B, Kan HL, Zacharewski TR, Gollapudi BB, Carney EW. 2007. Analysis of the interaction of phytoestrogens and synthetic chemicals: An in vitro/in vivo comparison. Toxicology and Applied Pharmacology 218:280-288. Charles GD, Gennings C, Zacharewski TR, Gollapudi BB, Carney EW. 2002. An approach for assessing estrogen receptor-mediated interactions in mixtures of three chemicals: A pilot study. Toxicological Sciences 68:349-360. Christiansen S, Scholze M, Axelstad M, Boberg J, Kortenkamp A, Hass U. 2008. Combined exposure to anti-androgens causes markedly increased frequencies of hypospadias in the rat. Int J Androl 31:241-248. 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Main KM, Mortensen GK, Kaleva MM, Boisen KA, Damgaard IN, Chellakooty M, Schmidt IM, Suomi AM, Virtanen HE, Petersen JH, Andersson AM, Toppari J, Skakkebaek NE. 2006. Human breast milk contamination with phthalates and alterations of endogenous reproductive hormones in infants three months of age. Environmental Health Perspectives 114:270-276. Metzdorff SB, Dalgaard M, Christiansen S, Axelstad M, Hass U, Kiersgaard MK, Scholze M, Kortenkamp A, Vinggaard AM. 2007. Dysgenesis and histological changes of genitals and perturbations of gene expression in male rats after in utero exposure to antiandrogen mixtures. Toxicological Sciences 98:87-98. Pierik FH, Burdorf A, Deddens JA, Juttmann RE, Weber RFA. 2004. Maternal and paternal risk factors for cryptorchidism and hypospadias: A case-control study in newborn boys. Environmental Health Perspectives 112:1570-1576. Rajapakse N, Silva E, Kortenkamp A. 2002. Combining xenoestrogens at levels below individual No-observed-effect concentrations dramatically enhances steroid hormone action. Environmental Health Perspectives 110:917-921. Rajapakse N, Silva E, Scholze M, Kortenkamp A. 2004. Deviation from additivity with estrogenic mixtures containing 4-nonylphenol and 4tert-octylphenol detected in the E-SCREEN assay. Environmental Science & Technology 38:6343-6352. Ramamoorthy K, Wang F, Chen IC, Safe S, Norris JD, McDonnell DP, Gaido KW, Bocchinfuso WP, Korach KS. 1997. Potency of combined estrogenic pesticides. Science 275:405. Rider CV, Furr J, Wilson VS, Gray LE. 2008. A mixture of seven antiandrogens induces reproductive malformations in rats. International Journal of Andrology 31:249-262. Page 89 of 486 OVERARCHING ISSUES MULTIPLE CHEMICAL EXPOSURES TO EDCs Silva E, Rajapakse N, Kortenkamp A. 2002. Something from "nothing" - Eight weak estrogenic chemicals combined at concentrations below NOECs produce significant mixture effects. Environmental Science & Technology 36:1751-1756. Swan SH, Main KM, Liu F, Stewart SL, Kruse RL, Calafat AM, Mao CS, Redmon JB, Ternand CL, Sullivan S, Teague JL. 2005. Decrease in anogenital distance among male infants with prenatal phthalate exposure. Environmental Health Perspectives 113:1056-1061. Tinwell H, Ashby J. 2004. Sensitivity of the immature rat uterotrophic assay to mixtures of estrogens. Environmental Health Perspectives 112:575-582. Van den Berg M. 2006. The 2005 WHO re-evaluation of toxic equivalency factors for dioxin like compounds - Implications for risk assessment and limitations of the concept. Toxicology Letters 164:S55-S56. Van den Berg M, Birnbaum L, Bosveld ATC, Brunstrom B, Cook P, Feeley M, Giesy JP, Hanberg A, Hasegawa R, Kennedy SW, Kubiak T, Larsen JC, van Leeuwen FXR, Liem AKD, Nolt C, Peterson RE, Poellinger L, Safe S, Schrenk D, Tillitt D, Tysklind M, Younes M, Waern F, Zacharewski T. 1998. Toxic equivalency factors (TEFs) for PCBs, PCDDs, PCDFs for humans and wildlife. Environmental Health Perspectives 106:775-792. van Meeuwen JA, Van den Berg M, Sanderson JT, Verhoef A, Piersma AH. 2007. Estrogenic effects of mixtures of phyto- and synthetic chemicals on uterine growth of prepubertal rats. Toxicology Letters 170:165-176. Wade MG, Foster WG, Younglai EV, McMahon A, Leingartner K, Yagminas A, Blakey D, Fournier M, Desaulniers D, Hughes CL. 2002. Effects of subchronic exposure to a complex mixture of persistent contaminants in male rats: systemic, immune, and reproductive effects. Toxicol Sci 67:131-143. WHO. Global assessment of the state-of-the-science of endocrine disrupters. 2002. Page 90 of 486 EMERGING ISSUES EPIGENETICS 3.4 EPIGENETICS In the last five years it emerged that well known EDCs have the ability to alter the epigenome and the potential to cause transgenerational effects via epigenetic mechanisms. Some studies have caused considerable attention and controversy and therefore this chapter is designed to shed light on how epigenetic mechanisms might indeed contribute to ED. Additionally, it is important to discriminate between a chemical’s ability of inducing epigenetic changes and a chemical’s ability to cause endocrine disruption via epigenetic mechanisms. To be able to fully understand this issue, it is necessary to first explain the basic molecular mechanisms of epigenetics (3.4.2), before we focus on chemicals that have been identified to act via epigenetic mechanisms to cause endocrine disruption in 3.4.3. 3.4.1 What is epigenetics? Genetic information is not only encoded by the linear sequence of DNA, but also by DNA modifications which are by definition “beyond the genome” (epigenetic). These non-sequencedependent DNA variations include the modification of the chromatin structure through DNA methylation and covalent modification of DNA binding proteins and are an essential regulator of gene expression. Epigenetic mechanisms form the basis of differential gene expression and explain why all cells of an organism have the same genome but still form different tissues. It is mainly epigenetics that gives rise to specialised cells. Epigenetic mechanisms are responsible for genomic imprinting, whereby some genes derived from the paternal gamete and maternal gametes are differentially expressed (Frost and Moore 2010). Imprinting is also a defence mechanism for an organism to silence viral DNA that has been integrated into its genome (Hotta and Ellis 2008). Furthermore, as epigenetic changes can occur throughout the lifetime of an organism and are mitotically heritable, it is suggested that they are a mechanism to allow an organism to react to environmental factors with changes in gene expression patterns. 3.4.2 Molecular mechanisms The majority of epigenetic mechanisms described have been found in mammals with a focus on the rodent and human genome. Although epigenetic changes also take place in bacteria (Casadesus and Low 2006) and invertebrates, the following description focuses on mammalian mechanisms. 3.4.2.1 DNA methylation The most-studied epigenetic modification is DNA methylation, which is a covalent modification that predominantly takes place at cytosine bases located 5’ to guanosine (CpG). These CpGs are vastly underrepresented in the genome, as compared to what would be expected by chance. CpG rich regions often cluster in the promoter regions and first exons of specific genes. The enzymes involved in DNA methylation include the DNA methyltransferases (DNMTs). Upon methylation of DNA, the methyl groups protrude from the CpGs into the major DNA groove, thus inhibiting the binding of Page 91 of 486 EMERGING ISSUES EPIGENETICS transcription factors that would normally bind to that part of the DNA (Figure 4). Instead, methylCpG-binding domain proteins (MBDs) 1, 2, 3, 4 and MeCP2 get attracted which in turn recruit histone deacetylases (HDAC). Deacetylation of the tails of the histone proteins results in the condensation of chromatin which impedes the access of transcription factors. Thus condensed parts of the DNA are not transcribed into mRNA, the genes are “silenced”. For a review refer to (Barros and Offenbacher 2009). Whereas the acquisition of DNA methylation is now well understood, the mechanisms involved in DNA demethylation remain elusive. In early development a genome-wide removal of DNA methylation occurs in the primordial germ cells. It is known that following fertilisation, the DNA methylation pattern in the sperm-derived pronucleus is actively removed (excluding imprinted genes). However, the enzymatic machinery responsible for demethylation is largely unknown. Recently, Activation-Induced cytidine Deaminase (AID) has been found to be highly expressed in primordial germ cells. Until then, AID was known to act as a single-strand DNA deaminase in developing B cells, where deamination of cytosine residues leads to U-G mismatches which give rise to double-strand breaks inducing somatic hyper-mutation (Maul and Gearhart 2010). This mechanism is involved in recombination at the immunoglobulin genes during class switch but AID activity may also play a role in DNA demethylation in primordial germ cells and in the early embryo . 3.4.2.2 Histone modification In eukaryotic cells, DNA is wrapped around the nucleosomes, each formed of an octamer of the four core histones (H2A, H2B, H3 and H4) with H1 sitting outside on the nucleosome in the linker region. The amino terminal tails of the histones are subject to various covalent modifications, such as phosphorylation, acetylation, methylation and ubiquitinylation. These changes alter the affinity of histones to DNA, thereby either condensing or decondensing the chromatin. They can either silence or activate genes in a reversible, but also heritable, manner (Strahl and Allis 2000). Here, we only focus on histone methylation, as it has recently been linked to ED. Histone methylation (Figure 4) is the most dynamic epigenetic modification and can be mitotically heritable (Bannister et al. 2001; Smallwood et al. 2007). Methylation of the lysines or arginines of the histone tails has been linked to both, transcriptional activation or repression. Lysine residues on histones H1, H2A, H3 and H4 can become mono-, di-, or trimethylated and arginine residues can become mono- or dimethylated by histone methyl-transferases (HMTs). Amongst other regulatory mechanisms, HMTs are regulated via the PI3K signalling transduction pathway. E.g. the HMT Enhancer of Zeste Homolog 2 (EZH2) is phosphorylated by AKT in a PI3K dependent fashion, which causes its dissociation from chromatin, thereby enhancing gene expression by facilitating access for transcription factors (Cha et al. 2005). On the other hand, treatment of MDA-MB453 breast cancer cells with PI3K inhibitor LY294002 disrupts the association of EZH2 with AKT and increases chromatin bound EZH2. Methylation, and in particular trimethylation, of histones has long been regarded as irreversible due to the high stability of the N-CH3 bond. However, Shi et al. identified in 2004 the amine oxidase Lysine Demethylase 1 (LSD1 or KDM1) which specifically catalyses the demethylation of mono- and dimethylated H3K4 and H3K9. KDM1 is found in co-repressor complexes and promotes repression of Page 92 of 486 EMERGING ISSUES EPIGENETICS gene expression, but has recently also been association with activation of gene expression (Metzger et al. 2005; Shi and Whetstine 2007). Recently another histone demethylase family that is even capable of demethylating trimethylated substrates has been characterised (Tsukada et al. 2006). The Jumonji (JMJC) catalytic domain containing demethylases, of which 15 specific ones have been published so far, demethylate lysines and arginines in the H3 tails (Cloos et al. 2008; Kim et al. 2009). They comprise the FBXL cluster, JMJD1 cluster, JMJD2 cluster, JARID1 cluster, UTX cluster, JARID2 cluster, PHD HSPBAP1 finger cluster and others. Due to their recent and partly simultaneous identification/characterisation by different research groups, their nomenclature and categorisation is very confusing. Cloos et al. (2008) give a good overview of JMJC protein names and their synonyms 3.4.3 Epigenetics and endocrine disruption 3.4.3.1 Is there any evidence that epigenetic alterations are linked with EDCs? Many EDCs can alter epigenetic patterns, e.g. bisphenol A and p,p′-DDE have been shown to induce DNA hypomethylation, although the mechanism remains elusive (Dolinoy et al. 2007; Rusiecki et al. 2008). This is undoubtedly very interesting and of relevance for the toxicological assessment of a chemical, but the capability of a substance to induce epigenetic changes does not necessarily render it an endocrine disrupter. p,p′-DDE and bisphenol A happen to be classified as EDCs, because of their actions as an ER agonist/ AR antagonist, but they would not be termed as such, was it only for their DNA methylation status modifying activities. In recent years, environmental chemicals have been increasingly implicated in transgenerational actions by epigenetic mechanisms (Anway et al. 2006b; Heindel 2006; Skinner et al. 2010). E.g. Vinclozolin, a fungicide with antiandrogenic activity, is known to inhibit androgen-dependent male reproductive tract development (Gray et al. 1994). Embryonic exposure to Vinclozolin influences male sexual differentiation and development as well as adult spermatogenesis (Uzumcu et al. 2004). Interestingly, Anway et al. (2006a) report that a transient exposure at the time of male sex determination to Vinclozolin can induce a transgenerational phenotype with reduced spermatogenic capacity in rats. They found that adult rats from the F1 generation and all subsequent generations examined (F1–F4) developed a number of diseases and abnormalities, including prostate disease, kidney disease, immune system abnormalities, testis abnormalities, and tumour development despite not having been directly exposed to Vinclozolin. As these effects correlated with altered DNA methylation patterns in the germ line, and specifically with reduced expression of DNA methyl transferases, they suggested that the molecular basis for the transgenerational disease states observed may be epigenetic and in part due to a permanent reprogramming of the germ line (Anway et al. 2005). However, in a study by BASF (Ludwigshafen, Germany), the company that produces Vinclozolin, the reproductive capacity of F1-F3 offspring was not affected and the spermatogenetic abnormalities found were not statistically significant (Schneider et al. 2008). These different findings might be partly due to the different study design (e.g. oral administration of Vinclozolin as opposed to intra Page 93 of 486 EMERGING ISSUES EPIGENETICS peritoneal administration used by Anway et al. (2005). Unfortunately, in this follow-up study the status of DNA methylation of the germline of F1-F3 offspring has not been investigated. A recent study carried out in the same lab as the Anway study with the same setup but using the latest techniques for assessing DNA methylation, confirmed the previous findings that Vinclozolin has the ability to induce transgenerational epigenetic modification (Guerrero-Bosagna et al. 2010). With a genome-wide approach using Methylated DNA Immune-Precipitation (MeDIP) followed by tiling array analysis (MeDIP- Chip) they identified several promoter regions that have altered DNA methylation status three generations after the initial exposure (for a more detailed information on the methods refer to paragraph 3.4.4). Stouder and Paoloni-Giacobino (2010) reported the transgenerational transfer of differentially methylated DNA domains in the sperm of mice dosed in utero with Vinclozolin. The effects on DNA methylation disappeared gradually from the F1 to the F3 generation. Sperm quality was compromised in the F1 generation, but recovered in the F2 and F3 generations. The effects of Vinclozolin appeared to be transgenerational, and the authors suggest that the harmful effects of Vinclozolin on the reproductive system are mediated by imprinting defects in the sperm. Anway’s original observations were further examined by Inagawa et al. (2009). Pregnant SpragueDawley rats were dosed intra-peritoneally with Vinclozolin, Procymidone or Flutamide during gestational days (GD) 8-15, the period when gonadal differentiation and sex determination takes place in the rat. The study design was very similar to that employed by Anway et al. (2006a), but the authors failed to observe any effects on DNA methylation. Gray and Furr (2010) examined transgenerational effects of Vinclozolin in rats during the period of gonadal differentiation (GD 8-15) and during the phase of androgen-dependent differentiation of reproductive tissues (GD 13-17). Administration of Vinclozolin during gonadal differentiation, the period chosen by Anway, did not reduce the fertility of male offspring in the F1 or F2 generation. After administration of Vinclozolin during androgen-dependent differentiation there were marked effects on developmental landmarks in male offspring (demasculinisation, with retained nipples and feminised anogenital distance), but these effects were not transmitted to the F2 generation. DNA methylation patterns were not measured in this study. Cowin et al. (2010) did not conduct a transgenerational study of the effects of Vinclozolin, but set out to examine some of Anway’s observations, more specifically, that Vinclozolin modifies the developing testis and prostate transcriptome by reducing the expression of DNA methyl transferases. Reductions of certain DNA methyl transferases in the testis were observed, in broad agreement with Anway’s findings. These changes in DNA methyl transferases did not play a role in the antiandrogenic effects of Vinclozolin: while co-administration of testosterone reversed the physiological endocrine disrupting effects of Vinclozolin, testosterone did not influence the expression of DNA methyl transferases/ While the ability of an environmental chemical to alter the epigenetic transgenerational background is a novel and potentially important molecular mechanism to consider for disease aetiology, it is contentious to label it as an endocrine disrupting mechanism of action. Therefore, the following tries to shed light on how epigenetic mechanisms are linked to endocrine disruption. We attempt to give examples of epigenetic mechanisms that directly change endocrine function/activity and cause Page 94 of 486 EMERGING ISSUES EPIGENETICS effects at the level of the organism or its progeny, rather than listing EDCs that also act generally on the epigenome. 3.4.3.2 Endocrine disruption via epigenetic mechanisms A recent review by Zhang and Ho (2011) summarises various mechanisms involved in the epigenome and endocrine regulation. Two different mechanisms can be distinguished: Epigentic regulation of hormone action involves the silencing (e.g. by methylation) of important hormone-synthesising and –regulating enzymes, such as CYP 19A1 (aromatase), CYP 17A1, or the sodium iodide symporter (SLC5A5) important in the thyroid hormone system. The re-activation of permananently silenced steroidogenesis genes e.g in prostate cancer give an impression of the significance of this mode of action for carcinogenesis and is an exciting research area. The second mechanism revolves around the endocrine regulation of key epigenetic modifying enzymes, of which examples are given below. Hormone nuclear receptors are intimately linked with epigenetics in that they are a class of inducible transcription factors that must overcome condensed chromatin to access and bind to DNA. Hormone receptors have been shown to promote epigenetic changes and in the complex, mostly unknown, regulatory mechanisms involved in this process, there is a potential for dysregulation and disruption. 3.4.3.2.1 ER signalling and epigenetic mechanisms In 2005, Cha et al. described for the first time that the HMT EZH2 is regulated by phosphorylation through AKT (Cha et al. 2005). It was found that phosphorylated EZH2 has a lower affinity for its substrate H3, resulting in a decrease of trimethylated K27 of H3 which ultimately disrupts gene silencing (Figure 4). Recently, this HMT has been found to be a target in rapid ER signalling (Bredfeldt et al. 2010). This is not surprising, given that there is a cross-talk between the ER and the IGF1 receptor (IGF1R) (Mendoza et al. 2011; Song et al. 2007; Surmacz and Bartucci 2004). ER is thought to interact with IGF1R at multiple levels and in multiple fashions in uterus and breast tissue, ultimately resulting in increased signalling through IGF1R which in turn activates the PI3K/AKT pathway (Fagan and Yee 2008). Additionally, it has been known for some time that exposure to the xenoestrogen DES during development re-programs gene expression which is linked to uterine leyomyoma and other uterine abnormalities in adults (Greathouse et al. 2008; Cook et al. 2007) (see section 4.5.3.1). The ability of DES to reprogram gene expression and the knowledge of AKT involvement in ER signalling led to the assumption that xenoestrogens could modulate HMTs via rapid ER signalling. In fact, Bredfeldt et al. (2010) who identified the novel biological function of EZH2 in rapid ER signalling showed that this also takes place during developmental xenoestrogen exposure. Both E2 and DES induced EZH2 phosphorylation through PI3K/AKT signalling in vitro (in MCF-7 breast cancer cells and uterine myometrial cells) and in vivo (uteri of neonatal Eker rats and WT mice) which corresponded to a reduction in trimethylated K27 on H3 levels in chromatin. However, the uteri of ERKO mice failed to increase EZH2 phosphorylation upon DES treatment, demonstrating the pathway is ER mediated. Page 95 of 486 EMERGING ISSUES EPIGENETICS This provides solid evidence for the first mechanism whereby xenoestrogens can developmentally reprogram gene expression via an ER mediated epigenetic mechanism. There is the possibility that environmental chemicals might act via other epigenetic mechanisms linked to ER, as ER gene expression itself is regulated by DNA methylation (Wilson et al. 2008; Wilson and Westberry 2009). In the brain cortex, ERО± mRNA expression is dynamically regulated during development. Recently, the progressive methylation of two of the ERО± promoters that are expressed in the neonatal mouse cortex have been described (Prewitt and Wilson 2007). Both Exon A and Exon C of the mouse ERО± gene become methylated at postnatal day 10. This age corresponds with the beginning of the decline in ERО± mRNA expression in the cortex. Methylation may therefore play a role in the suppression of ERО± mRNA in the developing brain and other tissues, such as the endometrium (Xue et al. 2007). However, to the best of our knowledge, no environmental chemicals have been identified so far which would target for instance DNMTs and MBD proteins specifically involved in ER gene methylation. 3.4.3.2.2 AR signalling and epigenetic mechanisms Similar to the ER dependent action on HMT EZH2, androgen dependent transcription involves the regulation of histone demethylases (Metzger et al. 2010). KDM1 has been found to specifically associate with chromatin on the promoter regions of AR target genes in either the absence or presence of a ligand. Once AR binds to the ARE (3.1.3.2), KDM1 and AR form a transcriptionally active multi-protein complex that demethylates mono- and dimethylated K9 on H3 (Metzger et al. 2005). In addition, ligand-activated AR recruits KDM2 which acts together with KDM1 on dimethylated K9 (Yamane et al. 2006). Furthermore, a recent discovery that PKCОІ1 phosphorylates T3 on H3 in AR-regulated genes, led to the finding that KDM1 can also demethylate K4 on H3, provided the H3T6 has no phosphorylation mark (Metzger et al. 2010). Several other demethylases were shown to collaborate for transcriptional activation of AR target genes (for an extensive list of demethylases involved see Lim et al. (2010). This might in the future provide an explanation for transgenerational or mitotically heritable effects of anti-androgens, such as Vinclozolin; however the exact mechanism is yet to be discovered. 3.4.4 Assays The following gives a very brief overview of the techniques in use to analyse epigenetic modifications. This is by far incomplete but represents the main methodologies used in the publications cited above. For more detailed descriptions the reader is advised to refer to the references. 3.4.4.1 Small scale DNA methylation analysis 3.4.4.1.1 Bisulphite sequencing technique The Bisulphite sequencing technique works on the basis that bisulphite can deaminate cytosine to uracil under conditions where 5-methyl cytosine is not deaminated. Thus, when treated DNA is amplified and sequenced all methylated cytosine residues show as cytosine whereas nonmethylated cytosines have become thymines (Frommer M. et al, 1992). Page 96 of 486 EMERGING ISSUES EPIGENETICS 3.4.4.1.2 Restriction enzyme analysis There are restriction enzymes which recognise (usually four or six bases) of DNA sequences and cut only unmethylated sites in the DNA. Alternatively, there are pairs of restriction enzymes which recognise the same base sequences, but only one of them would cut this sequence when it is methylated. An example for those isoschizomers, are HpaII and MspI. Both cut DNA at GCGC sites, but only MspI cuts this sequence if the internal C is methylated. Originally, Southern blots were used to determine whether a given sequence containing a GCGC site was methylated or not (Doerfler 1981). A limitation of the method is that it detects only a subset of possible methylation sites, usually about 10%. 3.4.4.1.3 5-Azacytidine Another rather historic method is the use of the nucleoside analogue 5-azacytidine. This is incorporated into DNA, inactivates DNA methyl transferase and thereby demethylates DNA. It was shown in many contexts that azacytidine reactivates silent genes (Jones 1985). This included the reactivation of genes on the inactive X chromosome. It had been shown that strains could be isolated in cultured mammalian cells which had biochemical deficiencies. Originally it was thought that these were mutations, but with this method it became apparent that they were often genes silenced by methylation, reactivatable by 5-azacytidine. 3.4.4.1.4 Mass spectrometry For a quantitative analysis, methylated DNA can be subjected to homogenous base specific cleavage followed by matrix assisted laser desorption/ionisation time-of-flight mass spectrometry (Ehrich et al. 2005). 3.4.4.2 High-throughput array-based DNA methylation analysis 3.4.4.2.1 Methylated DNA immunoprecipitation (MeDIP) This method applies the immunoprecipitation of methylated DNA with an antibody for methylated cytosine. The enriched methylated DNA can then be hybridised with a differentially labelled DNA control to an oligonucleotide array (MeDIP-Chip) (Weber et al. 2005). This method is a genome-wide approach and has been used to map the methylome of cancer cells and whole organisms such as Arabidopsis thaliana (Tomazou et al. 2008). 3.4.4.2.2 HpaII tiny fragment enrichment by ligation-mediated PCR (HELP) Based on the outdated method explained above, DNA is digested in parallel with MspI (resistant to DNA methylation) and HpaII followed by ligation mediated PCR. Then each of the products are hybridised to a microarray using separate fluorochromes (usually Cy3 and Cy5) (Suzuki and Greally 2010). Although the method has been brought up to the standard of a genome-wide approach, it is still limited by the number of methylated restriction sites in the genome. Page 97 of 486 EMERGING ISSUES EPIGENETICS 3.4.4.2.3 Fractionation by McrBC and CHARM McrBC is an enzyme that cuts methylated DNA promiscuously. With a recognition sequence of RmC(N)55-103RmC it cleaves half of the methylated DNA in the genome and all methylated CpG islands. The enzyme is used on 1.5-4.0 kb DNA fragments and the products are comparatively hybridised with untreated DNA on high density arrays. A recently developed approach that combines microarray design with statistical procedures, termed Comprehensive High-throughput Arrays for Relative Methylation (CHARM), can detect DNA genome-wide methylation with up to 100% sensitivity and 90% specificity (Irizarry et al. 2008). 3.4.4.3 Histone modification analysis 3.4.4.3.1 Protein microsequencing With this method numerous modification sites have been identified. However, it requires large and highly purified samples. Researchers have therefore been turning increasingly to mass spectrometry. 3.4.4.3.2 Antibodies If the modification site is already known, i.e. has been identified in one of the methods above, antibodies can be raised against such specific modifications. This opens the possibility for Chromatin Immunoprecipitation (CHIP) or high throughput analyses of modification sites with for e.g. an ELISA based approach (Kimura et al. 2004). Examples of specific antibodies available for ELISA are against methylated H3K4, H3K9, H3K27. Active Motif, Carlsbad, CA http://www.activemotif.com/ 3.4.4.3.3 Mass spectrometry A series of mass spectrometry-based technologies have been dedicated to the characterisation and quantification of different histone forms. Please refer to the reviews by Freitas et al. (2004) and Su et al. (Su et al. 2007) which focus on the discussion of mass spectrometry-based strategies used for the characterisation of histones and their post-translational modifications. Page 98 of 486 EMERGING ISSUES EPIGENETICS Figure 4 Epigenetic Modifications. (1) DNA Methylation. (a) DNA methyltransferases (DNMTs) catalyse the methylation of cytosine. The methyl groups (depicted as red triangles) protrude into the major DNA groove, thus inhibiting the binding of transcription factors (TF). Methyl-CpG-binding domain proteins (MBDs) get attracted which recruit histone deacetylases (HDAC). (b) Deacetylation of the tails of the histone proteins results in the condensation of chromatin which impedes the access of transcription factors. Thus condensed parts of the DNA are not transcribed into mRNA, the genes are “silenced”. (2) Histone Methylation. Methylation of the lysines or arginines of the histone tails has been linked to both, transcriptional activation or repression. Histones H1, H2A, H3 and H4 can become mono-, di-, or trimethylated by histone methyl-transferases (HMTs). The amine oxidase Lysine Demethylase 1 (LSD1) catalyses the demethylation. Amongst other regulatory mechanisms, HMTs are regulated via the PI3K signalling transduction pathway. The HMT Enhancer of Zeste Homolog 2 (EZH2) is phosphorylated by AKT in a PI3K dependent fashion, which causes its dissociation from chromatin resulting in a decrease of trimethylated K27 of H3 due to decreased recruitment of HMT. HMT is therefore a target in rapid ER signalling, as ER is thought to interact with IGF1R at multiple levels, ultimately resulting in increased signalling through IGF1R which in turn activates the PI3K/AKT pathway. Page 99 of 486 EMERGING ISSUES EPIGENETICS 3.4.5 References Anway MD, Cupp AS, Uzumcu M, Skinner MK. 2005. Epigenetic transgenerational actions of endocrine disruptors and male fertility. Science 308:1466-1469. Anway MD, Leathers C, Skinner MK. 2006a. Endocrine disruptor vinclozolin induced epigenetic transgenerational adult-onset disease. Endocrinology 147:5515-5523. Anway MD, Memon MA, Uzumcu M, Skinner MK. 2006b. Transgenerational effect of the endocrine disruptor vinclozolin on male spermatogenesis. Journal of Andrology 27. 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Maternal exposure to antiandrogenic compounds vinclozolin, flutamide and procymidone has no effects on spermatogenesis and DNA methylation in male rats of subsequent generations. Toxicol Appl Pharmacol 237:178-187. Irizarry RA, Ladd-Acosta C, Carvalho B, Wu H, Brandenburg SA, Jeddeloh JA, Wen B, Feinberg AP. 2008. Comprehensive high-throughput arrays for relative methylation (CHARM). Genome Res 18:780-790. Jones PA. 1985. Altering gene expression with 5-azacytidine. Cell 40:485-486. Kim JK, Samaranayake M, Pradhan S. 2009. Epigenetic mechanisms in mammals. Cell Mol Life Sci 66:596-612. Kimura H, Tada M, Nakatsuji N, Tada T. 2004. Histone code modifications on pluripotential nuclei of reprogrammed somatic cells. Mol Cell Biol 24:5710-5720. Lim S, Metzger E, Schule R, Kirfel J, Buettner R. 2010. Epigenetic regulation of cancer growth by histone demethylases. Int J Cancer 127:1991-1998. Maul RW, Gearhart PJ. 2010. AID and Somatic Hypermutation. In: Advances in Immunology (Frederick WA, ed.).Academic Press, 159-191. Mendoza RA, Enriquez MI, Mejia SM, Moody EE, Thordarson G. 2011. Interactions between IGF-I, estrogen receptor-{alpha} (ER{alpha}), and ER{beta} in regulating growth/apoptosis of MCF-7 human breast cancer cells. J Endocrinol 208:1-9. Metzger E, Imhof A, Patel D, Kahl P, Hoffmeyer K, Friedrichs N, Muller JM, Greschik H, Kirfel J, Ji S, Kunowska N, Beisenherz-Huss C, Gunther T, Buettner R, Schule R. 2010. Phosphorylation of histone H3T6 by PKCbeta(I) controls demethylation at histone H3K4. Nature 464:792-796. Metzger E, Wissmann M, Yin N, Muller JM, Schneider R, Peters AH, Gunther T, Buettner R, Schule R. 2005. LSD1 demethylates repressive histone marks to promote androgen-receptor-dependent transcription. Nature 437:436-439. Prewitt AK, Wilson ME. 2007. Changes in estrogen receptor-alpha mRNA in the mouse cortex during development. Brain Res 1134:62-69. Rusiecki JA, Baccarelli A, Bollati V, Tarantini L, Moore LE, Bonefeld-Jorgensen EC. 2008. Global DNA hypomethylation is associated with high serum-persistent organic pollutants in Greenlandic Inuit. Environ Health Perspect 116:1547-1552. Schneider S, Kaufmann W, Buesen R, van Ravenzwaay B. 2008. Vinclozolin--The lack of a transgenerational effect after oral maternal exposure during organogenesis. Reproductive Toxicology 25:352-360. Page 100 of 486 EMERGING ISSUES EPIGENETICS Shi Y, Lan F, Matson C, Mulligan P, Whetstine JR, Cole PA, Casero RA, Shi Y. 2004. Histone demethylation mediated by the nuclear amine oxidase homolog LSD1. Cell 119:941-953. Shi Y, Whetstine JR. 2007. Dynamic regulation of histone lysine methylation by demethylases. Mol Cell 25:1-14. Skinner MK, Manikkam M, Guerrero-Bosagna C. 2010. Epigenetic transgenerational actions of environmental factors in disease etiology. Trends Endocrinol Metab 21:214-222. Smallwood A, Esteve PO, Pradhan S, Carey M. 2007. Functional cooperation between HP1 and DNMT1 mediates gene silencing. Genes Dev 21:1169-1178. Song RX, Zhang Z, Chen Y, Bao Y, Santen RJ. 2007. Estrogen signalling via a linear pathway involving insulin-like growth factor I receptor, matrix metalloproteinases, and epidermal growth factor receptor to activate mitogen-activated protein kinase in MCF-7 breast cancer cells. Endocrinology 148:4091-4101. Stouder C, Paoloni-Giacobino A. 2010. Transgenerational effects of the endocrine disrupter vinclozolin on the methylation pattern of imprinted genes in the mouse sperm. Reproduction 139:373-379. Strahl BD, Allis CD. 2000. The language of covalent histone modifications. Nature 403:41-45. Su X, Ren C, Freitas MA. 2007. Mass spectrometry-based strategies for characterization of histones and their post-translational modifications. Expert Rev Proteomics 4:211-225. Surmacz E, Bartucci M. 2004. Role of estrogen receptor alpha in modulating IGF-I receptor signalling and function in breast cancer. J Exp Clin Cancer Res 23:385-394. Suzuki M, Greally JM. 2010. DNA methylation profiling using HpaII tiny fragment enrichment by ligation-mediated PCR (HELP). Methods 52:218-222. Tomazou EM, Rakyan VK, Lefebvre G, Andrews R, Ellis P, Jackson DK, Langford C, Francis MD, Backdahl L, Miretti M, Coggill P, Ottaviani D, Sheer D, Murrell A, Beck S. 2008. Generation of a genomic tiling array of the human major histocompatibility complex (MHC) and its application for DNA methylation analysis. BMC Med Genomics 1:19. Tsukada Y, Fang J, Erdjument-Bromage H, Warren ME, Borchers CH, Tempst P, Zhang Y. 2006. Histone demethylation by a family of JmjC domain-containing proteins. Nature 439:811-816. Uzumcu M, Suzuki H, Skinner MK. 2004. Effect of the anti-androgenic endocrine disruptor vinclozolin on embryonic testis cord formation and postnatal testis development and function. Reproductive Toxicology 18. Weber M, Davies JJ, Wittig D, Oakeley EJ, Haase M, Lam WL, Schubeler D. 2005. Chromosome-wide and promoter-specific analyses identify sites of differential DNA methylation in normal and transformed human cells. Nat Genet 37:853-862. Wilson ME, Westberry JM. 2009. Regulation of oestrogen receptor gene expression: new insights and novel mechanisms. J Neuroendocrinol 21:238-242. Wilson ME, Westberry JM, Prewitt AK. 2008. Dynamic regulation of estrogen receptor-alpha gene expression in the brain: a role for promoter methylation? Front Neuroendocrinol 29:375-385. Xue Q, Lin Z, Cheng YH, Huang CC, Marsh E, Yin P, Milad MP, Confino E, Reierstad S, Innes J, Bulun SE. 2007. Promoter methylation regulates estrogen receptor 2 in human endometrium and endometriosis. Biol Reprod 77:681-687. Yamane K, Toumazou C, Tsukada Y, Erdjument-Bromage H, Tempst P, Wong J, Zhang Y. 2006. JHDM2A, a JmjC-containing H3K9 demethylase, facilitates transcription activation by androgen receptor. Cell 125:483-495. Zhang X, Ho SM. 2011. Epigenetics meets endocrinology. J Mol Endocrinol 46: R11-R32. Page 101 of 486 EMERGING ISSUES PROSTAGLANDINS 3.5 PROSTAGLANDINS 3.5.1 What are prostaglandins? The discovery of prostaglandins (PGs) and determination of their structure began in the 1930s. It was Ulf von Euler of Sweden who gave them their name, thinking they had come from the prostate gland, when he first isolated them first from human semen. It has since been determined that PG production is not limited to the prostate, in fact, there is virtually no soft tissue in the body that does not produce PGs. As they are not produced at a discrete site, but in many places throughout the body, they are cannot be strictly defined as hormones. However, PGs act as chemical messengers and are simply considered as a corollary of the endocrine system. Also, their target cells are present in the immediate vicinity of the site of their excretion. Hence they are autocrines or paracrines (Smyth et al. 2009; Roth and Siok 1978). PG signalling occurs via specific cell surface G-protein coupled receptors, e.g. the four distinct PGE2 receptors (the EP1–4) and two PGD2 receptors (DP1 and DP2) (Hata and Breyer 2004). They are coupled to classical adenylate cyclase and ligand binding usually results in increased cyclic AMP (cAMP) production, protein kinase A (PKA) activation and the phosphorylation of CREB that stimulates expression from the cAMP response element (CRE) (Dorsam and Gutkind 2007). In addition, PGs can act via inositol phosphate signalling pathways by stimulating the EGFR-signalling network (Sales et al. 2004; Pai et al. 2002; Selinsky et al. 2001; Takai et al. 2006). It has also been shown that some PG isomers directly activate nuclear receptors (Holla et al. 2006; Bhattacharya et al. 1998; Helliwell et al. 2004b) see 3.1.2. Chemically, PGs are part of the eicosanoids, which is a family of lipophilic signalling molecules derived from the 20 carbon fatty acid arachidonic acid (AA). Other eicosanoids are prostacyclins, thromboxanes and leukotrienes (Wolfe 1982). All mammalian cells with the exception of red blood cells produce PGs and other eicosanoids, which have profound physiological effects (Funk 2001). For example, they are involved in the inflammatory response (Rocca and FitzGerald 2002; Yoshikai 2001; Harris et al. 2002), regulation of vasodilatation (Boushel et al. 2004), pain (Ito et al. 2001; Trebino et al. 2003), and female and male reproduction (Fortier et al. 2008). 3.5.2 Biochemical synthesis 3.5.2.1 Cyclooxygenase and peroxidase reaction In humans, the most important PG precursor is AA, which is released from either diacylglycerol or phospholipids by membrane bound phospholipases in response to extracellular stimuli (PLA2 (Flower and Blackwell 1976) and PLC (Bell et al. 1979; Kennerly et al. 1979)). The first and committed step in the production of PGs from AA is the addition of two O2 molecules to AA (bis-oxygenation) to form PGG2 in a cyclooxygenase reaction. This is followed by the reduction to PGH2 in a peroxidase reaction, converting the hydroperoxy group (OOH) to a hydroxyl group (OH). Both these reactions are catalysed by one enzyme, the PGH2 synthase, also known as cyclooxygenase (COX) (Smith et al. 2000; Rouzer and Marnett 2009). The nomenclature is sometimes confusing in the literature as the Page 102 of 486 EMERGING ISSUES PROSTAGLANDINS term refers either to the cyclooxygenase activity or to the whole enzyme with both cyclooxygenase and peroxidase activity. 3.5.2.2 COX There is more than one type of COX, including COX -1 and COX-2. COX-1 is constitutively expressed in most mammalian cells and therefore thought to be responsible for normal physiological production of PGs (Chandrasekharan and Simmons 2004). COX-2 expression is induced by cytokines, mitogens and endotoxins in inflammatory cells and responsible for the production of PGs in inflammation. More recently, it has been shown to be upregulated in various carcinomas and to have a central role in tumorigenesis (Maloberti et al. 2010; Wang et al. 2010; Dore 2010). COX-2 is also essential for several reproductive and developmental events that include ovulation, fertilisation, implantation, and decidualisation (Simmons et al. 2004; Morham et al. 1995). In contrast, these processes are apparently normal in COX-1-deficient mice (Langenbach et al. 1995), suggesting that COX-1 is not essential for these events. The COX isozymes are of such interest as one of the most highly utilised classes of pharmaceutical agents in medicine act as inhibitors of the COX active site. Nonsteroidal anti-inflammatory drugs (NSAIDs) act through inhibiting PG synthesis, usually by binding to the active centre of COX-1 and COX-2, sterically hindering the entrance of the physiological binder AA. They have been prominent analgesic/anti-inflammatory/antipyretic medications since 1898 when aspirin was first marketed (Gotzsche 2007). COX-2-selective drugs were introduced in 1999 (Llorens et al. 2002) (see Box 1). It is also conceivable that the COX enzyme could be a target for environmental chemicals and known EDCs, considering the structural similarity that some phenolic compounds, phthalates and parabens share with, for example, aspirin (Tavares and Vine 1985; Dewhirst 1980; Limongelli et al. 2010) (for the chemical structure of aspirin refer to Box 1). 3.5.2.3 Specific prostaglandin synthases The third and terminal enzymatic step after phospholipase and COX activities in PG synthesis is the isomerisation of PGH2 to bioactive PGs (including PGD2, PGE2, PGF2a, and PGI2) by the respective PG synthases, which have different structures and exhibit cell- and tissue-specific distributions (Helliwell et al. 2004a). Of current interest is whether COX isozymes are coupled with these downstream synthases to cause selective production of specific eicosanoids. It was found that coupling depends on cell types and stimulation status of cells; and it may involve intracellular translocation of isomerases or distinct subcellular locations of COXs (Ueno et al. 2001; Schade et al. 2002). More recent evidence suggests that lineage-specific terminal prostanoid synthases, including PGE2, PGD2, PGF2a, PGI2, and thromboxane synthases, show distinct functional coupling with upstream COX isozymes (Ueno et al. 2005). However, the details and exact mechanisms remain to be elucidated. An example for one of the specific synthases is PGD synthase (PGDS), which isomerises PGH2 to PGD2. It occurs in two distinct forms: the hematopoietic PGDS (H-PGDS) and the lipocalin-type PGDS (L-PGDS), a secreted enzyme known as пЃў-trace abundantly present in the central nervous system (Nagata et al. 1991) and also expressed in testes and prostate (Moniot et al. 2009; Saito et al. 2002). Page 103 of 486 EMERGING ISSUES PROSTAGLANDINS Implications of the AA cascade involvement and PG synthesis in the development of the male embryo has been known for more than 20 years (Gupta and Goldman 1986; Gupta 1989), but in recent years the importance of, in particular, PGD2 during male fetal development has been elucidated. 3.5.3 Role of prostaglandin D2 in male sex determination in mammals During mammalian embryogenesis two antagonising molecular pathways form the basis of sex determination and gonadal differentiation in the somatic cells of the bipotential gonad. The predomination of the female pathway results in differentiation of ovarian cells, while the prevalence of the male pathway leads to the differentiation of Sertoli cells, which act as an organisational centre of testis development (Piprek 2009). The sex-determining cues are controlled by the gonadal environment (signalling molecules) as well as the sex chromosome constitution of the germ cells. Two genes have been implicated in translating the male sex chromosome constitution of the embryo into sexual differentiation of the gonadal somatic cells are SRY (sex-determining region of Y chromosome) and SOX9 (SRY box containing gene 9) (Fleming and Vilain 2005; Wilhelm et al. 2007; Matzuk and Lamb 2008). The master effector gene SOX9 encodes a transcription factor that belongs to the High Mobility Group (HMG) superfamily and its embryonic male-specific gonadal activation depends directly on SRY (Foster and Graves 1994). SRY is expressed only during a brief window of time to induce the initial transcriptional pulse of the SOX9 gene (Sinclair et al. 1990; Sekido and Lovell-Badge 2008). In contrast, the expression of SOX9 continues throughout the process of testis development and has a pivotal role for the reproductive capacity of the species later on in life. In mouse studies, it has been shown that loss of function mutation (Wagner et al. 1994) or deletion (Barrionuevo et al. 2006; Chaboissier et al. 2004) of SOX9 induces male-to-female sex reversal (XY female). These individuals are sterile because of the discrepancy between the germline chromosomal content and the gonadal environment. The activation of SOX9 has two main functions: Firstly, SOX9 represses the transcription of SRY and maintains its own expression in an auto-regulatory loop. Secondly, it is responsible for the activation of a network of genes driving Sertoli cell differentiation. Cells expressing SOX9 differentiate into Sertoli cells, which subsequently coordinate the differentiation of all other testis-specific cell types (Wilhelm et al. 2007). To ensure differentiation of sufficient Sertoli cells, a non-cell-autonomous mechanism exists in addition to the cell autonomous SRY induction of SOX9. Interestingly, SRY and SOX9 serve to upregulate PGDS, which leads to PGD2 synthesis and secretion. PGD2 can act, via its DP receptor, to upregulate SOX9 expression in a paracrine manner. Thus, supporting cells that fail to reach a threshold of SRY expression can still be induced to up-regulate SOX9 and subsequently differentiate into Sertoli cells. Since there is a threshold for Sertoli cell numbers to guarantee testis differentiation, requiring approximately 20% of cells to differentiate into Sertoli cells, it is plausible that PGD2 functions as a backup mechanism in case of impaired SRY function (Wilhelm et al. 2007) (see Figure 5). Page 104 of 486 EMERGING ISSUES PROSTAGLANDINS This mechanism was first suggested in 2002 by Adams and McLaren (Adams and McLaren 2002) and has been confirmed in more recent studies (Wilhelm et al. 2007; Wilhelm et al. 2005; Moniot et al. 2009). However, the upregulation of SOX9 expression does not seem to be the only role for PGD2 in Sertoli cell differentiation in the developing testis. SRY and SOX9 are transcription factors and must reach the nucleus after their translation in order to function. Before the sex-determining period, SOX9 is localised in the cytoplasm, while after the onset of SRY expression, SOX9 is co-localised with SRY in the nucleus. Malki et al. (2005) found that activation of PKA induces the phosphorylation of SOX9 on two sites, and thereby its nuclear localisation through enhancing SOX9 binding to the nucleocytoplasmic transport protein Importin-ОІ. They demonstrated that PGD2 induces PKA phosphorylation (and subsequently SOX9 nuclear translocation) via its DP1 receptor and the stimulation of the cAMP pathway. Expression patterns, cAMP assays and gonad culture studies suggest that PGD2 might act as an autocrine factor for SOX9 nuclear translocation. In summary, it has become clear over the last ten years that PGs, and especially PGD2, have an important function in the regulation of Sertoli cell differentiation. The initiation of the SRY-SOX9PGD2 cascade is the hormone-independent part of male sexual differentiation, and is responsible for the differentiation of relevant cell types. It is plausible that disruption of this pathway could contribute to testicular dysgenesis syndrome (TDS) (see 4.1) . Only after the relevant cell types have differentiated can hormones take over in the next steps of sexual differentiation (masculinisation). 3.5.4 Prostaglandins and endocrine disruption Inhibition and disruption of the PG pathway may be an unrecognised target for endocrine disruption by numerous known EDCs. The possibility that ED might occur at the level of PG signalling was however mentioned as early as 1997 when DDE-induced eggshell thinning in raptors was linked to a direct inhibition of PG synthesis in the shell gland mucosa and interference with calcium metabolism (Lundholm 1997). It was not until 2002, when L. Guillette (Guillette, Jr. 2006) took up the subject again and pointed out that descriptions of endocrine disruption have largely been driven by observations documenting estrogenic, androgenic, anti-androgenic, and anti-thyroid actions. However, few studies have examined PGs as a target for endocrine disruption, despite their role in reproduction, immune responses, and cardiovascular physiology. It was only recently that inhibition of PG synthesis has moved into the limelight as a vital endpoint in ED research. Two studies published in 2010 (Kristensen et al. 2010; Jensen et al. 2010) addressed the effects of male fetal exposure to NSAIDs and their association with reproductive disorders. Based on the knowledge of PGD2’s involvement in normal testicular development, they asked the question of whether or not the consumption of PG synthesis inhibiting compounds during early pregnancy could interfere with this process. The most widely used over-the counter pain-relief medicine, commonly recommended to children and pregnant women, is paracetamol (see Box 1). Paracetamol is known to cross the human placenta but due to its widespread and long-standing use, it is regarded as safe (Wilkes et al. 2005). The mechanism by which paracetamol exerts its clinical action is still uncertain Page 105 of 486 EMERGING ISSUES PROSTAGLANDINS (Anderson 2008; Smith 2009), but inhibition of the peroxidase reaction has been suggested (Aronoff et al. 2006). In the study that combines in vivo and ex vivo studies in rats with a prospective birth cohort study, PG synthesis inhibiting compounds seem to interfere with normal testicular development (Kristensen et al. 2010). The authors report that intake of paracetamol during pregnancy, in particular during the first and second trimester and for longer than 2 weeks, increased the risk of giving birth to boys with cryptorchidism. The risk was even higher for mothers who had taken more than one compound, such as aspirin and ibuprofen, simultaneously. This association between the use of NSAIDs during pregnancy and prevalence of cryptorchidism was only found in a Danish mother-child cohort, whereas the same study reports that there was no increased risk for cryptorchidism found in a Finnish cohort. However, an independent Danish study also reports an association between the use of paracetamol in weeks 8-14 and a moderate increase in the occurrence of cryptorchidism (Jensen et al. 2010). Already in 1996, Berkowitz and Lapinski (1996) reported that the use of analgesics during pregnancy was a risk factor for cryptorchidism. Drug use was established by questionnaire, but the authors did not record which analgesics the women had used. Therefore, it is difficult to establish whether these drugs had the ability to inhibit prostaglandin synthesis. Despite this lack of detail, this study lends further support to the idea that analgesics contribute to the risk of developing this disorder. Kristensen et al. (2010) further demonstrated that paracetamol reduced testosterone production in the developing testis ex vivo. Furthermore, in an in vivo experiment where pregnant Wistar rats were dosed with either paracetamol or aspirin from gestational day (GD) 13-21, paracetamol (at only three times the dose recommended for humans) reduced the anogenital distance (AGD) of male pups, which is indicative of feminised male offspring. 3.5.5 Conclusions Despite some discrepancies in the reported severity of the effects in epidemiological studies, the results point to the same trend and raise the worrying possibility that pharmaceutical PG synthesis inhibitors (NSAIDs) may act as endocrine disruptors. If PG synthesis inhibition is an endpoint in the mode of action of some environmental EDCs, these together with the widespread use of NSAIDs, might be a major contributor to the decrease in male reproductive health observed in recent decades. Finally, NSAIDs themselves are widespread environmental contaminants of surface water and might contribute to the concentration addition effects of mixtures of EDCs we are exposed to (Antonic and Heath 2007; Cleuvers 2004). Page 106 of 486 EMERGING ISSUES PROSTAGLANDINS Box 1 The most widely used Nonsteroidal anti-inflammatory drugs (NSAIDs) Aspirin (acetylsalicylic acid) covalently modifies a residue in the substrate entering tunnel of COX (acetylation of the hydroxyl group of Ser 530 of COX-1), thus irreversibly inactivating both COX-1 and COX-2 by excluding access for arachidonic acid by steric hindrance (Botting 2010). Because the catalytic pocket of the channel is somewhat larger in COX2 than in COX-1 the transacetylation efficiency in COX-2 is reduced. This accounts for the 10- to 100-fold lowered sensitivity to aspirin of COX-2 in comparison to COX-1 (Simmons et al. 2004). Chemical structure acetylsalicylic acid of Ibuprofen acts instead by competing in a fast reversible fashion for the substrate binding site in the tunnel (Selinsky et al. 2001). Flurbiprofen and indomethacin cause a slow, time-dependent inhibition of COX-1 and COX-2, apparently via formation of a salt bridge between a carboxylate on the drug and an Arginine, which lies in the substrate entering tunnel of the COX enzymes (Simmons et al. 2004). Paracetamol (Acetaminophen) has analgesic and antipyretic properties but no anti-inflammatory action. It has been shown to act as a weak inhibitor of both COX-1 and COX-2 in cultured cell and human whole blood assays. It is a good inhibitor of a canine brain COX-1 splice variant, COX-3 (Hinz et al. 2008). There may be multiple mechanisms explaining its analgesic activity, such as paracetamol’s effects on the opioid and cannabinoid pathways, but its actions on the COX enzymes are still a matter of debate (Smith 2009). Figure 5 PGD2 can act, via its DP receptor, to up-regulate SOX9 expression in a paracrine and possibly also an autocrine manner. Thus, supporting cells (that failed to reach a threshold of SRY expression) can be induced to up-regulate SOX9 and differentiate as Sertoli cells. PGD2 might functions as a backup mechanism in case of impaired SRY function. Reprinted from Developmental Biology Vol.287/1, Wilhelm et al., Sertoli cell differentiation is induced both cell-autonomously and through prostaglandin signalling during mammalian sex determination, pages 111-124, Copyright (2005), with permission from Elsevier. Page 107 of 486 EMERGING ISSUES PROSTAGLANDINS 3.5.6 References Adams IR, McLaren A. 2002. Sexually dimorphic development of mouse primordial germ cells: switching from oogenesis to spermatogenesis. Development 129:1155-1164. Anderson BJ. 2008. Paracetamol (Acetaminophen): mechanisms of action. Paediatr Anaesth 18:915-921. Antonic J, Heath E. 2007. 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Roles of prostaglandins and leukotrienes in acute inflammation caused by bacterial infection. Curr Opin Infect Dis 14:257263. Page 109 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4 HUMAN HEALTH ENDPOINTS – REPRODUCTIVE HEALTH 4.1 MALE REPRODUCTIVE HEALTH In the context of male reproductive health and exposure to EDCs three groups of adverse health outcomes are commonly considered together: 1) Declines in reproductive function, as manifested by reduced semen quality and compromised male infertility; 2) disruption of male foetal development resulting in congenital malformations of the urogenital tract - non-descent of testes (cryptorchidism) and abnormal positioning of the opening of the urethra (hypospadia); and 3) testicular germ cell tumours (Diamanti-Kandarakis et al. 2009; European Science Foundation 2010). This chapter will focus on declining reproductive function and disruption of male foetal development; testicular germ cell tumours are dealt with together with other hormonal cancers (section 5). 4.1.1 Natural history of declining male reproductive health In this section, male reproductive disorders are discussed as they become apparent along the time line of a man’s life, in the sequence cryptorchidism, hypospadia and lowered semen quality. 4.1.1.1 Cryptorchidism Cryptorchidism is the most common congenital malformation in male babies at birth. Depending on country and geographical location, it affects 2 – 4% of boys, but according to recent estimations this can be as high as 9% in some countries (see below). Normal testis descent occurs in two phases. Early in gestation, the foetal testes migrate from their point of origin near the kidneys into the pelvis (transabdominal phase). Later, towards the end of gestation, descent from the pelvis into the scrotum is accomplished (transinguinal phase). The second, transinguinal phase is androgen dependent, and disruption of this phase appears to be the most common cause of cryptorchidism at birth. The burst of androgen synthesis that occurs during the “mini puberty” in the first 3-5 months after birth probably helps to revert many cryptorchidisms diagnosed at birth. Approximately 50% of cryptorchidisms diagnosed at birth resolve themselves within the first 3 months of life. The earlier, transabdominal phase of descent is triggered by insulin-like factor 3 (Insl3), a peptide hormone, and disruption of Insl3 action causes complete failure of testicular descent. Trends in incidence rates Although a series of recent studies in Europe has shown quite high incidences of cryptorchidism, it is difficult to judge whether incidence has increased in time. This is due to an absence of uniformly applied diagnostic criteria in the past. For this reason, results from different countries and different studies have to be compared with great care. For example, Boisen et al. 2004 reported cryptorchidisms in 9% of boys in a Danish population, while Cortes et al. 2008 put this at around 0.5%, despite the fact that the populations examined in these two studies came from the same region in Denmark. However, unlike most other authors, Cortes et al. (2008) did not classify high scrotal testes as a form of mild cryptorchidism, thus explaining the comparatively low rates estimated in this study. Page 110 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH Nevertheless, studies that have adopted similar classification strategies and case ascertainment protocols suggest that several European countries (England, Denmark, The Netherlands, Lithuania) have experienced increases in incidence during recent years (Boisen et al. 2004; Pierik et al. 2005; Preiksa et al. 2005, reviewed by Main et al. 2010). Standardised comparative studies have shown marked regional differences in prevalence, with rates higher in Denmark than in Finland (Boisen et al. 2004; Boisen et al. 2005; Virtanen et al. 2001). 4.1.1.2 Hypospadias Hypospadias affect around 0.2 – 4% of boys at birth. Androgen action in foetal life is crucially important to ensure proper location of the urethral opening at the tip of the glans penis. If androgen action is diminished, the urethra opens on the underside of the glans penis (mild, so-called glanular hypospadias). In severe case, the opening is positioned on the shaft of the penis, or even near the scrotal sack. Trends in incidence rates Similar to cryptorchidisms, uniformly adopted diagnostic criteria are missing, with milder forms of hypospadias often not reported. For this reason, registry data, which do not encompass milder forms of hypospadia, are regarded as unreliable in judging trends in incidence rates. Despite these difficulties, studies from different continents using similar diagnostic criteria all indicate that incidence has risen in recent decades (Nassar et al. 2007; Nelson et al. 2005; Pierik et al. 2002). Denmark has one of the highest prevalence (4%, Boisen et al. 2005). 4.1.1.3 Reduced semen quality Semen quality, as determined by sperm counts, sperm motility, sperm concentration, ejaculation volume and other parameters, is notoriously variable. It can be affected by numerous factors, including abstinence, ethnicity, infectious disease, season, clothing and drug abuse. All this enormously complicates comparisons between studies conducted at different times or in different countries. Original reports of declining semen quality over time (Carlsen et al. 2005; Swan et al. 2000) have therefore attracted considerable debate and controversy (Jouannet et al. 2001). However, as pointed out by Sharpe (Sharpe 2009), an explanation as to why such variability has resulted in a consistent downward trend in measures of semen quality across many studies, instead of an increase in overall variability, has yet to be put forward. Time trends The difficulties in measuring semen quality with reliability have led to concerted efforts in harmonising diagnosis and in developing and adopting uniform methodologies and standardised techniques. Data from some countries where such uniform techniques were applied suggest a significant decline in semen quality according to year of birth, with younger men showing poorer semen quality. Similarly, coordinated studies in several European countries, including Germany, Denmark, Sweden, Norway, Finland, Estonia and Lithuania show that average sperm counts are quite low (Carlsen et al. 2005; Jorgensen et al. 2002; Jorgensen et al. 2006; Paasch et al. 2008). Approximately 20% of young men in countries such as Denmark and Germany have sperm Page 111 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH concentrations below the lower limit of 20 Million per ml set by the World Health Organisation (Paasch et al. 2008, European Science Foundation 2010). 4.1.1.4 Overall patterns Countries with a high prevalence of cryptorchidism also show high rates of hypospadias and poor semen quality, and vice versa. Furthermore, these three health endpoints correlate with the incidence of testicular germ cell cancers. The two best studied countries in this respect are Denmark and Finland. Denmark has one of the highest rates of cryptorchidism, hypospadia and testicular germ cell cancers, and poor semen quality, while the prevalence of these disorders in Finland is significantly lower. Semen quality in Finnish men is comparatively high (see the reviews by Main et al. 2010, European Science Foundation 2010). 4.1.1.5 Risk factors for congenital malformations of the urogenital tract A number of conditions and risk factors have been identified that increase the risk of cryptorchdisms and hypospadias in boys. These include low birth weight, premature birth, diets during pregnancy that lack fish and meat, and alcohol consumption (Akre et al. 2008; Berkowitz and Lapinski 1996; Damgaard et al. 2008; Pierik et al. 2004). Fathers with poor semen quality, cryptorchidisms or hypospadia are more likely to sire boys with hypospadias or cryptorchidisms (Asklund et al. 2007; Berkowitz and Lapinski 1996; Brouwers et al. 2007). 4.1.2 Evidence for endocrine mechanisms in declining male reproductive health Testicular dysgenesis syndrome The observation in high- and low-incidence countries of a link between cryptorchidism, hypospadias and poor semen quality does not seem to be coincidental. In fact, the three disorders are risk factors for each other. Furthermore, they all are predictive of the risk of developing testicular germ cell cancers. These findings have led Skakkebaek et al. (2001) to suggest that it is inappropriate to consider each of these conditions in isolation, as has been clinical practice. Instead, they suggest that all four disorders share a common aetiological origin and constitute a syndrome, termed testicular dysgenesis syndrome (TDS). The TDS hypothesis derives from the foetal origin of cryptorchidisms, hypospadias, testicular germ cell cancers and poor semen quality and proposes that the syndrome goes back to diminished androgen action in foetal life which has a negative impact on the proper functioning of Sertoli cells (the cells supporting germ cells) and Leydig cells (where androgen synthesis takes place). It also proposes a strong environmental component and chemical exposures as the aetiological factor. Evidence for endocrine mechanisms in TDS Androgens have a profound role in initiating the developmental programme that “makes a male” by switching the male embryo from developing into a phenotypic female (which is the default trajectory) to a male. Any disruption of androgen action has demasculinising effects of varying degrees. This is most dramatically illustrated by cases of complete androgen insufficiency syndrome Page 112 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH where the absence of a functional androgen receptor means that the hormone cannot relay its signals, with the consequence that genotypic males develop into phenotypic females. There are indications of a relationship between low testosterone levels and poor semen quality. In both Danish and US American men testosterone levels declined according to year of birth, similar to the trends observed for semen quality (Andersson et al. 2007; Travison et al. 2007). However, identifying environmental causes and chemical exposures in humans is difficult, mainly because foetal tissues are inaccessible for examination. Evidence for endocrine mechanisms in these disorders therefore comes mainly from animal experiments. It is possible to experimentally induce all the elements of TDS, except testicular germ cell cancers, by exposing pregnant rats to certain phthalates and other chemicals that block androgen action. In male rats, the spectrum of disorders produced in this way has been called “phthalate syndrome” (Foster 2005; Foster 2006). It comprises non-descent of testes, malformations of the external genitalia, similar to hypospadias, poor semen quality, and malformations of other sex organs. The causes of the phthalate syndrome are well understood; they go back to suppression of foetal androgen action, as predicted by the TDS hypothesis. In foetal life, testosterone is a key driver of the differentiation of the Wolffian duct system (from which male reproductive organs derive) into the vas deferens, epididymis, seminal vesicles and external genitalia. Certain chemicals (e.g. phthalates) are able to lower testosterone levels, by interfering with the uptake of steroid hormone precursors into foetal Leydig cells where steroid synthesis takes place. In the rat, malformations of internal reproductive organs (epididymis, testes) are the consequence. The development of the male reproductive tract also depends on dihydrotestosterone (DHT), a more potent androgen derived from testosterone. DHT is essential for the development of the prostate gland and the external genitalia. Therefore, lower testosterone concentrations can also affect the development of these tissues, with hypospadias as the consequence. In rats, DHT is further required for the regression of nipple anlagen in male rats and for the growth of the perineum to produce the normal male anogenital distance (AGD) which is longer than in females. Due to reduced DHT levels in the wake of suppressed testosterone synthesis, retained nipples and feminised AGDs are also seen in male rats exposed to chemicals capable of reducing foetal androgen synthesis (reviewed by Foster 2005, 2006). Other chemicals (e.g. certain azole pesticides) are able to suppress foetal androgen action by blocking the androgen receptor, or by interfering with the conversion of testosterone into DHT. These agents produce a spectrum of effects similar to the phthalate syndrome, but with more pronounced effects on genital malformations, retained nipples and decreased anogenital distance. Androgen action in foetal life is essential for the proliferation of Sertoli cells, the cells that provide important cues for the development of germ cells. Because a given number of Sertoli cells can only support a limited number of germ cells, the Sertoli cells available at the end of male sexual differentiation critically determine sperm counts. This provides an explanation as to how diminished androgen action in foetal life may negatively impact on semen quality later in life (see the review by Sharpe 2009). Male programming window Another development that highlights the importance of hormone action in foetal life for the occurrence of male reproductive disorders has been the discovery of the male programming window Page 113 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH in experimental studies with the rat (Carruthers and Foster 2005; Welsh et al. 2008). Androgens are crucially important in setting up the entire programme for the development of the male reproductive tract. This process starts when the foetal testes begin to synthesise testosterone, although the actions of the hormone do not yet become manifest in terms of morphological changes at this stage. However, cryptorchidisms and hypospadias in the rat can only be induced by blocking androgen action when testes begin to synthesise androgens. Blocking androgen action at an earlier or a later stage has no effect. For this reason, this critical time interval has been termed the male programming window (Welsh et al. 2008, Sharpe 2009). Anogenital distance as a biomarker for diminished androgen action Human studies have shown a relationship between decreased AGD in male babies and risk of cryptorchidisms and hypospadias (Swan et al. 2005). This suggests that changes in anogental distance in humans may serve as a valuable biological marker of disruption of androgen action in foetal life, just as in experimental studies in the rat. Once determined by foetal androgens, AGD is fixed for life and only changes in proportion of the growth of the rest of the body. Prostaglandins and male sexual development During the last 10 years it has become clear that prostaglandins, and especially prostaglandin D2 (PGD2), have an important role in the regulation of Sertoli cell differentiation (covered in detail in section 3.5.3). Two critical genes serve the function of initiating male sexual differentiation, SRY (sexdetermining region of Y chromosome) and SOX9 (SRY box containing gene 9). In the foetal testes anlagen, SRY is expressed only during a brief period to induce synthesis of the SOX9 gene product. The activation of SOX9 has two main functions: Firstly, the SOX9 protein represses transcription of SRY and maintains its own expression in an auto-regulatory loop. Secondly, it is responsible for the activation of a network of genes that drive Sertoli cell differentiation. Cells expressing SOX9 differentiate into Sertoli cells, which subsequently coordinate the differentiation of all other testisspecific cell types. To ensure differentiation of sufficient numbers of Sertoli cells, a mechanism exists that drives SOX9 expression independent of SRY: Both SRY and SOX9 serve to upregulate prostaglandin D synthase, which leads to PGD2 synthesis and secretion. In turn, PGD2 acts to upregulate SOX9 expression and in doing so can support cells that have expressed insufficient amounts of SRY protein. This ensures that these cells can stimulate SOX9 expression independent of SRY to subsequently differentiate into Sertoli cells. In this way, PGD2 functions as a backup mechanism for Sertoli cell differentiation in case of impaired SRY function. This would suggest that inhibition of PGD2 function may impact negatively on male sexual differentiation. The consequences PG synthesis inhibitions have only recently become the focus of intensive research. Two studies have addressed the question as to whether drugs that inhibit PG synthesis contribute to the risk of developing cryptorchidisms or hypospadias: Kristensen et al. (2011) and Swan et al. (2005) reported that intake of paracetamol (an inhibitor of PG synthesis) during pregnancy, in particular during the first and second trimester and for longer than 2 weeks, increased the risk of giving birth to boys with cryptorchidism. The risk was even higher for mothers who had taken more than one compound, such as aspirin and ibuprofen, simultaneously. In the same study, the association between the use of analgesics during pregnancy and cryptorchidism was not found in a Finnish cohort. However, another, independent Danish study also observed an association between the use of paracetamol in weeks 8-14 of pregnancy and a moderate increase in the Page 114 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH occurrence of cryptorchidism (Jensen et al. 2010). Already in 1996, Berkowitz and Lapinski (1996) reported that the use of analgesics during pregnancy was a risk factor for cryptorchidism. Drug use was established by questionnaire, but the authors did not record which analgesics the women had used. Therefore, it is difficult to establish whether these drugs had the ability to inhibit prostaglandin synthesis. Despite this lack of detail, this study lends further support to the idea that analgesics contribute to the risk of developing this disorder. Other causes Not all cases of cryptorchidisms, hypospadias or poor semen quality develop as part of the TDS, although it is safe to say that most men suffering from testicular germ cell cancer exhibit some or all of the other disorders. There are certain mutations that predispose to cryptorchidisms and hypospadias, without being related to diminished androgen action. Poor semen quality can result from events and exposures experienced in adult life. Page 115 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4.1.3 Evidence for a role of chemical exposures in declining male reproductive health through an endocrine disruption mechanism A fundamental issue with epidemiological studies aiming to investigate links between EDCs and disorders of male reproductive health are the difficulties encountered in capturing exposures that have occurred during pregnancy, the aetiological period. Often, this was not possible, and in such cases investigators had to rely on indirect measurements of exposures during pregnancy. In the case of highly persistent and bioaccumulating contaminants, the mothers’ current body burden can be assumed to be similar to the time of pregnancy, but with more polar chemicals this assumption is not tenable. The tissues and body fluids that were commonly used to estimate in utero exposures of the developing male included mothers’ serum (taken during pregnancy), placenta extracts and mothers’ milk. In rare cases, biopsies of adipose tissues taken from boys during the neonatal period were available for analysis. Other approaches to estimating exposures during the aetiological period of these disorders have also proved to be productive, among them the application of job-exposure matrices for the estimation of EDC exposures. Such studies have yielded valuable indications that maternal and paternal exposures associated with occupations in agriculture can pose risks for the developing male. 4.1.3.1 Cryptorchidisms 4.1.3.1.1 DES There is evidence that exposure to DES during foetal life increases the risk of developing cryptorchidisms. Among the sons of mothers who used DES during their pregnancy significantly increased risks were found, particularly when exposure took place during the first 11 weeks of pregnancy (Palmer et al. 2009). 4.1.3.1.2 PCBs The evidence for associations between cryptorchidisms and maternal PCB exposure during pregnancy is weak. Three case-control studies did not find any relationships, while another one offered qualified support for an association. Hosie et al. (2000) analysed fatty tissues from children undergoing surgery for a series of persistent organochlorines, including PCBs. There were 18 cases of cryptorchidism and 30 children without the condition. PCBs were found in all samples, but statistically significant associations with cryptorchidisms were not seen. Similarly, Mol et al. (2002) failed to observe significant associations when they measured maternal PCB serum levels. In a large case-control study of cryptorchidism in boys (230 cases, 593 controls), McGlynn et al. (2009) also did not observe relationships with PCB levels in maternal serum collected during the third trimester of pregnancy. Page 116 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH Collostrum samples were analysed for PCBs and a variety of other organochlorines in 56 cases of cryptorchidism and 69 controls. Mothers with the highest PCB levels were more likely to bear a son with cryptorchidisms (Brucker-Davis et al. 2008). 4.1.3.1.3 DDT/DDE The relationships between maternal DDT/DDE serum levels and cryptorchidism in their boys were studied among a cohort that experienced quite high DDT exposures. The outcome of most published studies has been inconclusive (Bhatia et al. 2005; Longnecker et al. 2002), although Brucker-Davies et al (2008) found associations in the group with the highest DDE levels in mother’s milk. 4.1.3.1.4 Polybrominated biphenyls (PBDE) The levels of the sum of PBDEs in mother’s milk were significantly higher in boys with cryptorchidism than in healthy boys. This relationship was not found when levels of individual congeners were compared (Main et al. 2007). Similarly, Carmichael et al. (2010) analysed PBDEs in midterm maternal serum from mothers of cryptorchid boys in relation to those of mothers of healthy boys. Elevated levels were found in the mothers of cryptorchid boys. However, for none of the analysed individual congeners these elevations reached statistical significance, likely due to the comparatively small size of the study. 4.1.3.1.5 Other chemicals A highly significant association between heptachlor epoxide and HCB levels in fatty tissues from boys and cryptorchidism was observed by (Hosie et al. 2000). This relationship did not become apparent in a USA cohort where maternal serum levels of heptachlor epoxide and HCB were measured. There were however slightly elevated levels of beta-hexachlorocyclohexane, suggestive of an association, but the outcome of the study was inconclusive (Pierik et al. 2007). The dibutyl phthalate levels in the collostrum of mothers with cryptorchid boys did not differ from those found in samples from mothers of healthy boys (Brucker-Davies et al. 2008). Fernandez et al. (2007) examined the relationship between the estrogencity of extracts from placenta homogenates and the prevalence of congenital urogenital malformations. In this study, cryptorchidisms and hypospadias were evaluated together. Statistically significant associations between higher risks of malformations and elevated levels of o,p’-DDT, p,p’-DDT, endosulfan alpha, lindane and mirex were found. Interestingly, there were elevated concentrations of total extractable estrogenic agents in the polar placenta extracts from mothers who gave birth to boys with urogential malformations. A Danish case-control study investigated whether mothers’ milk from mothers with cryptorchid boys showed higher levels of persistent organochlorine pesticides (Damgaard et al. 2006). Statistically significant differences were observed only for the pesticide trans-chlordane. Over 20 other pesticides were analysed, but individually none differed between cases and controls. However, a sum parameter of the level of the eight most prevalent pesticides in mothers’ milk was significantly higher in mothers of cryptorchid boys (p,p’-DDE, beta-hexachlorocyclohexane, alpha endosulfan, oxychlordane, p,p’-DDT, dieldrin and cis-heptachlor epoxide). Page 117 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4.1.3.1.6 Occupational exposures to pesticides Several studies suggest associations between cryptorchidisms and paternal or maternal exposure to pesticides. In an ecological study in the province of Granada, Spain, Garcia-Rodriguez et al. (1996) investigated patterns of variation in the surgical treatment of cryptorchidisms (orchidopexy). Orchidopexy operations were more frequent among boys from districts where intensive farming occurred, and the association tended to become stronger with higher level of use. Garry et al. (1996) reported higher frequencies of urogenital malformations among children of pesticide applicators in Minnesota, USA. In a Dutch study, a job-exposure matrix was used to estimate the exposure to classes of EDCs, based on the judgments of occupational hygienists. The risk of developing cryptorchidisms was statistically significantly associated with paternal exposure to pesticides, mainly in greenhouses for the production of vegetables and flowers (Pierik et al. 2004). In an investigation conducted in the 12 agricultural municipalities of Ragusa, Sicily, municipalities were ranked according to measures of intensity of agricultural activities (Carbone et al. 2006). Associations with cryptorchidisms did not reach statistical significance, but a higher birth prevalence of hypospadias became apparent (see below). The prevalence of cryptorchidism in the sons of women employed in Danish greenhouses was considerably higher than that among boys born in the Copenhagen area (Andersen et al. 2008). The boys of mothers working in greenhouses had decreased penis length, lower testis volume and lowered serum testosterone levels. 4.1.3.2 Hypospadias 4.1.3.2.1 DES, progestins The transgenerational effects of DES were investigated in the Netherlands. The sons of mothers who reported to have been exposed to DES in utero (“DES daughters”) were more likely to suffer from hypospadias (Klip et al. 2002). This transgenerational effect could be confirmed in a subsequent study in the Netherlands (Brouwers et al. 2006). However, increased risks of hypospadias did not become apparent in a USA cohort of DES daughters and their sons (Palmer et al. 2005). Progestin use in early pregnancy was found to increase the risk of hypospadias (Carmichael et al. 2005). 4.1.3.2.2 Organochlorines: PCBs, DDT/DDE, HCB There is no evidence linking maternal serum levels of PCBs or DDT and its metabolite DDE to increased risks of hypospadias. The three case-control studies that have investigated a possible relationship have all reported a lack of association or inconclusive results (Bhatia et al. 2005, Longnecker et al. 2002, McGlynn et al. 2009). Page 118 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH An association of elevated maternal serum HCB levels with an increased likelihood of bearing a son with hypospadias was observed by (Giordano et al. 2010). (Giwercman et al. 2006) investigated the prevalence of hypospadias in Greenland. They found a remarkably low prevalence, although the exposure to PCBs and other persistent organochlorine pollutants is very high. In interpreting their findings, they discuss the significance of certain androgen receptor genotypes present among the Greenland population, and the role of these genotypes in suppressing the occurrence of hypospadias. 4.1.3.2.3 Complex occupational exposures Several recent studies have demonstrated associations between complex maternal and paternal exposures to EDCs and risk of hypospadias. In most of these studies, exposure was inferred by utilising sophisticated job-exposure matrices, but not by chemical analytical determination of specific chemicals. Municipalities in Sicily, Italy, were ranked according to measures of intensity of agricultural activities (Carbone et al. 2006). A higher birth prevalence of hypospadias in districts with agriculture became apparent. Paternal exposure to pesticides during the three months preceding conception appears to increase the risk of hypospadias in their sons (Brouwers et al. 2007). An increased risk of hypospadias was found among the sons of hairdressers who reported occupational exposure to hairspray (Ormond et al. 2009). Because hairsprays contain volatile phthalates, among other chemicals, a link to phthalate exposure is suggestive, but not established beyond doubt. Giordano et al. (2010) evaluated occupational exposures to EDC with the help of a job-exposure matrix for the purpose of classifying jobs in terms of likely EDC exposures. They found an increase in the likelihood of hypospadias when mothers were engaged in jobs with exposure to phthalates, alkylphenols and biphenolic compounds. Paternal exposure to alkylphenols was also associated with increased risks. This study also identified increased risks for hypospadias after high maternal consumption of fish and shellfish during pregnancy, but this is contradicted by the observation that fish consumption in pregnancy goes hand in hand with fewer hypospadias (Akre et al. 2010). In a registry-based case-control study in Australia, (Nassar et al. 2010) found strong associations between maternal exposures to heavy metals and increased risks of hypospadias in their sons. Similar associations became apparent for phthalate exposures. The nature of exposures was established by questionnaire. Paternal exposure to polychlorinated organics and biphenolics was also linked with increased risk, although that relationship was weaker than for maternal exposures. 4.1.3.3 Poor semen quality Most epidemiological studies of relationships between exposure to EDCs and poor semen quality have correlated exposures experienced in adulthood. Attempts to investigate the consequences of exposures in foetal life are few and far between. Page 119 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4.1.3.3.1 PCBs and DDE The only study of the consequences of PCB exposures in foetal life for semen quality in adulthood has been conducted among victims of the Yuscheng incident in Taiwan. Between 1978 and 1979 large quantities of cooking oil contaminated with PCBs and PCDFs were consumed by Taiwanese people. Guo et al. (2000) examined the semen quality among boys whose mothers consumed the oil during their pregnancy. The boys exposed in utero had sperm with abnormal morphology and reduced motility. A similar pattern was observed in men who consumed the cooking oil in their adulthood (Hsu et al. 2003). These men had higher numbers of sperm with abnormal morphology than unexposed men, but other determinants of semen quality were similar between the two groups. A comparison of men with poor and normal semen quality in terms of blood PCB levels did not reveal any differences, but among men with normal semen quality sperm counts decreased with rising PCB levels (Dallinga et al. 2002). Several studies suggest that PCB body burden is associated with decreased sperm motility, but not with other measures of semen quality. The study by Richthoff et al. (2003) tentatively suggests weak effects of PCB 153 on a decrease in motility. Similarly, Hauser et al. (2003) observed that increasing levels of PCB 138 in serum were associated with a decrease in sperm motility and abnormal morphology, but no such effects were observed for DDE. Men with the highest levels of PCB 153 in their serum tended to have sperm with lower mobility (Rignell-Hydbom et al. 2004). 4.1.3.3.2 TCDD Men exposed to 2.3.7.8 TCDD during the Seveso accident were investigated for parameters of semen quality later in their life (Mocarelli et al. 2008). Exposure to TCDD during infancy led to reductions in sperm motility and sperm concentration. Strikingly, the opposite effect was observed among men who were exposed during puberty. 4.1.3.3.3 Phthalates Only a few studies have addressed associations between measures of phthalate exposure in adulthood and semen quality. A large study of male partners of subfertile couples in Massachusetts established associations between metabolites of dibutyl phthalate and the likelihood of having sperm concentrations and motilities below the WHO reference value (Duty et al. 2004; Hauser et al. 2006). However, such associations were not found in a Swedish study of younger men from the general population (Jonsson et al. 2005). The differences between the US American and the Swedish findings can be attributed to the features of the study populations: The Swedish men were younger, while the American men were from an infertility clinic. 4.1.3.4 Changes in anogenital distance Several human studies have investigated changes in anogenital distance (determined as “anogenital index”) and its relationship to maternal levels of urinary phthalate metabolites (Swan et al. 2005). The authors found significant relationships between the highest levels of maternal phthalates and shortened (“feminised”) anogenital index in young boys. This finding mirrors experimental evidence Page 120 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH obtained with rats in controlled laboratory exposures (see below) and suggests that developmental phthalate exposures in humans contribute to disruptions of androgen action. Viewed in the context of what is known about the relationship between decreased anogenital distances in male babies and risk of cryptorchidisms and hypospadias (Swan et al. 2005), this observation is of clinical relevance. A more recent expansion of the earlier Swan study to incorporate a larger number of mother-infant pairs (Swan 2008) has confirmed the earlier results. Another study of Mexican women also found correlations between reduced AGD in boys and maternal exposure to phthalates (BustamanteMontes et al. 2008). Evidence for a lowering of androgen levels in newborn boys in response to phthalate exposures was obtained by (Main et al. 2006). In this study, gestational exposures to phthalates were inferred from analyses of phthalate metabolites in mothers’ milk. Of note is that strong associations between urinary metabolites derived from diethylphthalate became apparent in the studies by Swan et al. (2005, 2008) and Bustamante-Montes et al. (2008). This phthalate has not been linked to reproductive abnormalities in rats that had been treated by oral administration. 4.1.3.5 Indications of cumulative effects Several epidemiological studies provided indications of cumulative effects of chemicals, although associations with individual chemicals either did not become apparent or were considerably weaker. For example, the statistically significant links between cryptorchidisms and a sum parameter of PBDE levels in mothers’ milk found by Main et al. (2007) were not evident when the analysis was based on individual congeners. Similarly, there were no significant relationships between individual persistent pesticides and cryptorchidisms in the study by Damgaard et al. (2006), but the sum of the eight most prevalent pesticides was significantly associated with the condition. The combined estrogenicity of placenta extracts was strongly related to the likelyhood of cryptorchidisms (Fernandez et al. 2007). These observations echo the “something from nothing” phenomenon that has emerged from experimental studies with endocrine disrupter mixtures where EDC were shown to act together in combination although they were present at concentrations that individually did not induce observable effects (see section 3.3). Experimental studies in rodents have shown that mixtures of chemicals able to disrupt male sexual development in different ways can work together to produce reproductive abnormalities. The effect of the mixture was usually stronger those of the most potent component in the mixture (Christiansen et al. 2009; Hass et al. 2007; NRC (National Research Council) 2008; Rider et al. 2010). 4.1.3.6 Endocrine disrupting properties of chemicals shown to be associated with declining male reproductive health The most convincing epidemiological data that link exposures to EDCs to cryptorchidisms and/or hypospadias are those investigating pesticide exposures in an agricultural occupational context. However, by design, these studies cannot provide insights into the possible causative chemicals. According to the TDS hypothesis, chemicals expected to interfere with male reproductive health are likely to do so by disrupting androgen action in fetal life. This can be achieved by androgen receptor Page 121 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH antagonist properties, by suppression of foetal androgen synthesis or by inhibition of steroidconverting enzymes. The new insights into the role of prostaglandins in male sexual differentiation suggest that chemicals capable of inhibiting PGD2 synthesis might also contribute to the genesis of the above disorders. Although it is very difficult to establish the mechanisms by which chemicals found to be associated with adverse health outcomes in epidemiological studies exert their effects in humans, it is instructive to list whether any of the relevant substances have been shown to possess ED potential. DES and progestins can contribute to cryptorchidisms and hypospadias, and these chemicals are androgen receptor antagonists in vitro (Vinggaard et al. 2008), supporting the notion that they might compromise androgen action during the stages of male sexual development. Trans-chlordane appears to be associated with cryptorchidisms (Damgaard et al. 2006). This pesticide is an in vitro androgen receptor antagonist (Kojima et al. 2004). Fernandez et al. (2007) found associations between cryptorchidisms and o,p’-DDT, p,p’-DDT, endosulfan alpha, lindane and mirex. Of these, o,p’-DDT, p,p’-DDT and endosulfan alpha are established in vitro androgen receptor antagonists (Kojima et al. 2004, Vinggaard et al. 2008). The association of polybrominated biphenyls with cryptorchidisms (Main et al. 2007, Carmichael et al. 2010) can be interpreted in light of their androgen receptor antagonist potential (Ermler et al. 2010; Stoker et al. 2005). Information about the ability of any of these chemicals to suppress foetal androgen synthesis or to inhibit PDG2 synthesis is not available. 4.1.4 Do experimental tools exist for the study of male reproductive health, and are assays applicable to, and adequate for, the assessment of chemicals? The reproductive toxic effects of phthalates and other EDCs have long been overlooked, mainly because teratology test guidelines did not stipulate dosing during the period when male programming takes place. Another difficulty was that only a few pups were examined for effects, dramatically increasing the likelihood of overlooking effects. The effects of certain phthalates became apparent when dosing took place in the correct time window during gestation, and when all male pups were examined (for a narrative of relevant developments see NRC 2008). It has since become clear that all the constituent elements of the TDS can be recapitulated in the rat, with the exception of testicular germ cell cancers. A reproductive toxicity model where test chemicals are administered to dams during gestation, during the male programming window, has been widely used to assess the potential of chemical substances to induce reproductive anomalies (Foster 2005; Foster 2006; Gray et al. 2006; Hass et al. 2007). Chemicals able to suppress foetal androgen synthesis, such as certain phthalates with an ester sidechain length of between four and six carbons, induce a spectrum of reproductive abnormalities in the rat model which is characterised by changes in AGD, retained nipples and malformation of Page 122 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH internal reproductive organs. Phthalates with shorter side chains, such as diethylphthalates, are inactive in the rat. Chemicals with androgen receptor antagonist properties, including vinclozolin, procymidone, prochloraz and other azole pesticides as well as substances able to interfere with steroid-converting enzymes such as finasteride, prochloraz, linuron also disrupt male sexual differentiation. These agents induce an effect spectrum characterised by AGD changes, retained nipples and malformations of external sex organs, such as hypospadias. The effects on AGD and retained nipples are more pronounced than those seen with phthalates (for further details see Foster 2005, 2006; Gray et al. 2006, Hass et al. 2007, Wilson et al. 2008, Christiansen et al. 2009, Rider et al. 2010). Prostaglandin synthesis inhibitors such as paracetamol also produce demasculinising effects in male rats exposed in utero (Kristensen et al. 2010). With respect to steroidogenesis, some differences exist between the rat and humans (discussed by Scott et al. 2009), but in general the processes underlying male development are remarkably similar in both species. Therefore, the rat is generally seen as an appropriate model for possible effects in humans (NRC 2008, Foster 2005, 2006). The draft OECD test guidelines for the extended one generation reproductive toxicity test in rodent species (to be published in 2011) will incorporate relevant endpoints for the detection of chemicals that might interfere with male sexual development. In vitro assays sensitive to androgen receptor antagonists and to inhibition of steroidogenesis are available for the screening of chemicals that potentially possess in vivo effects (Ermler et al. 2010; Hecker et al. 2007; Korner et al. 2004; Wilson et al. 2002). The Hershberger assay detects in vivo androgen receptor antagonist activity. However, very little is known about correlations between in vitro activity and disruption of male sexual development in vivo that would allow valid in vitro –in vivo extrapolations. An assay for the screening of in vitro PDG2 synthesis inhibitors is available, but has not been used widely. Page 123 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH In view of the rapidity with which these changes have occurred, environmental factors, including chemical exposures are likely to play a role. INTACT criteria MET MULTI-LEVEL criteria MET HORMONE criteria MOSTLY MET PRIMARY EFFECT criteria MET EXPOSURE criteria MET SENSITIVE LIFESTAGE PHARM. RESTORATION criteria MET Attribution criteria: The available evidence suggests that several countries have experienced recent rises in the incidence of male reproductive disorders including cryptorchidisms and hypospadias. There are also strong indications of significant declines in the semen quality of young men. criteria MET MALE REPRODUCTION 4.1.5 CONCLUSIONS SUPPORTING DATA The most convincing evidence of a role of chemical exposures in these disorders comes from studies of paternal and maternal pesticide exposures in agricultural occupational settings. There is also good evidence for associations of DES with cryptorchidisms or hypospadias, and some evidence implicating polybrominated biphenyls and certain persistent pesticides such as chlordane, endosulfan alpha and others. Several human studies have reported relations between phthalate exposure during pregnancy and changes in AGD. These observations are of relevance considering that AGD is a read-out of diminished androgen action in fetal life, but it remains to be seen whether phthalates are capable of contributing to cryptorchidisms, hypospadias or reduced semen quality. All in all, the associations found in epidemiological studies with respect to individual chemicals were relatively weak. However, several studies give indications of cumulative effects of simultaneous exposures, although methods for exploring this systematically are currently lacking. The human epidemiology in this field of study has not yet found ways of dealing comprehensively with design issues that might improve establishing associations between exposures in foetal life and health effects. In particular with polar chemicals that do not remain for very long in the human body after exposure, new methods for collecting biosamples and new techniques for the chemical analysis will have to be developed. It is striking that human biomonitoring approaches for many of the pesticides that have been shown to be active in rodent assays are not available, thus severely hampering any epidemiological studies. Significant progress has been made in elucidating factors that contribute to deteriorating male reproductive health since the 2002 WHO report: o The formulation of the TDS hypothesis has proved to be very productive in structuring experimental and epidemiological work; diminished androgen action in foetal life is now recognised as the main mechanism that drives the aetiology of reproductive disorders; o New evidence of the importance of paternal and maternal exposures to pesticides in occupational settings as a risk factor for malformations of the male genital tract; o The discovery that many aspects of the TDS can be recapitulated in rodent models and the subsequent identification of chemicals as capable of inducing male reproductive Page 124 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH abnormalities in the rat; this opened the way for relevant epidemiological studies e.g. of phthalates and polybrominated biphenyls; o The discovery of the male programming window and its importance in male sexual development; evidence that many of these programming events are irreversible; o Demonstration of combined effects of reproductive toxicants in models of reproductive toxicity; o Discovery of inhibition of prostaglandin synthesis as another contributory factor in producing reproductive disorders. Below we summarise the state of the science by using the WHO/IPCS 2002 criteria for attribution to an endocrine mode of action. Page 125 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4.1.5.1 Can declines in male reproductive health be attributed to endocrine disruption? Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criterion met? Criteria MET Criteria MET Evidence summary The rat developmental toxicity model can recapitulate most aspects of human health effects, with similar mechanisms Responses at the molecular, cellular and tissue levels are suitably understood, including the processes of androgen synthesis, and androgen action Criteria MET The mechanisms by which reproductive abnormalities in the rat are induced are understood mechanistically – they go back to disruption of androgen action during the male programming window Criteria MOSTLY MET With many chemicals disruption of foetal androgen action is the lead toxic effect and not secondary to other toxicities Criteria MET Criteria MET Discovery of the male programming window Not applicable Criteria MET Assays monitoring the androgen receptor antagonist properties of chemicals and their ability to suppress foetal androgen synthesis are available Page 126 of 486 HUMAN HEALTH ENDPOINTS MALE REPRODUCTIVE HEALTH 4.1.6 References Akre O, Boyd HA, Ahlgren M, Wilbrand K, Westergaard T, Hjalgrim H, Nordenskjoeld A, Ekborn A, Melbye M. 2008. 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Urinary phthalate metabolites and biomarkers of reproductive function in young men. Epidemiology 16:487-493. Jorgensen N, Asklund C, Carlsen E, Skakkebaek NE. 2006. Coordinated European investigations of semen quality: results from studies of Scandinavian young men is a matter of concern. International Journal of Andrology 29:54-60. Jorgensen N, Carlsen E, Nermoen I, Punab M, Suominen J, Andersen AG, Andersson AM, Haugen TB, Horte A, Jensen TK, Magnus O, Petersen JH, Vierula M, Toppari J, Skakkebaek NE. 2002. East-West gradient in semen quality in the Nordic-Baltic area: a study of men from the general population in Denmark, Norway, Estonia and Finland. Human Reproduction 17:2199-2208. Jouannet P, Wang C, Eustache F, Kold-Jensen T, Auger J. 2001. Semen quality and male reproductive health: the controversy about human sperm concentration decline (Reprinted from vol. 109, pg. 333, 2001). Apmis 109:S48-S59. Klip H, Verloop J, van Gool JD, Koster META, Burger CW, van Leeuwen FE. 2002. Hypospadias in sons of women exposed to diethylstilbestrol in utero: a cohort study. Lancet 359:1102-1107. Kojima H, Katsura E, Takeuchi S, Niiyama K, Kobayashi K. 2004. Screening for estrogen and androgen receptor activities in 200 pesticides by in vitro reporter gene assays using Chinese hamster ovary cells. Environmental Health Perspectives 112:524-531. Korner W, Vinggaard AM, Terouanne B, Ma RS, Wieloch C, Schlumpf M, Sultan C, Soto AM. 2004. Interlaboratory comparison of four in vitro assays for assessing androgenic and antiandrogenic activity of environmental chemicals. Environmental Health Perspectives 112:695-702. Kristensen DM, Hass U, Lesne L, Lottrup G, Jacobsen PR, sdoits-Lethimonier C, Boberg J, Petersen JH, Toppari J, Jensen TK, Brunak S, Skakkebaek NE, Nellemann C, Main KM, Jegou B, Leffers H. 2011. Intrauterine exposure to mild analgesics is a risk factor for development of male reproductive disorders in human and rat. Human Reproduction 26:235-244. Longnecker MP, Klebanoff MA, Brock JW, Zhou HB, Gray KA, Needham LL, Wilcox AJ. 2002. Maternal serum level of 1,1-dichloro-2,2-bis(pchlorophenyl)ethylene and risk of cryptorchidism, hypospadias, and polythelia among male offspring. American Journal of Epidemiology 155:313-322. Main KM, Kiviranta H, Virtanen HE, Sundqvist E, Tuomisto JT, Tuomisto J, Vartiainen T, Skakkebaek NE, Toppari J. 2007. Flame retardants in placenta and breast milk and cryptorchidism in newborn boys. Environ Health Perspect 115:1519-1526. Main KM, Mortensen GK, Kaleva MM, Boisen KA, Damgaard IN, Chellakooty M, Schmidt IM, Suomi AM, Virtanen HE, Petersen JH, Andersson AM, Toppari J, Skakkebaek NE. 2006. Human breast milk contamination with phthalates and alterations of endogenous reproductive hormones in infants three months of age. Environmental Health Perspectives 114:270-276. Main KM, Skakkebaek NE, Virtanen HE, Toppari J. 2010. Genital anomalies in boys and the environment. Best Practice & Research Clinical Endocrinology & Metabolism 24:279-289. McGlynn KA, Guo XG, Graubard BI, Brock JW, Klebanoff MA, Longnecker MP. 2009. Maternal Pregnancy Levels of Polychlorinated Biphenyls and Risk of Hypospadias and Cryptorchidism in Male Offspring. Environmental Health Perspectives 117:1472-1476. Mocarelli P, Gerthoux PM, Patterson DG, Milani S, Limonta G, Bertona M, Signorini S, Tramacere P, Colombo L, Crespi C, Brambilla P, Sarto C, Carreri V, Sampson EJ, Turner WE, Needham LL. 2008. Dioxin exposure, from infancy through puberty, produces endocrine disruption and affects human semen quality. Environmental Health Perspectives 116:70-77. Mol NM, Sorensen N, Weihe P, Andersson AM, Jorgensen N, Skakkebaek NE, Keiding N, Grandjean P. 2002. Spermaturia and serum hormone concentrations at the age of puberty in boys prenatally exposed to polychlorinated biphenyls. European Journal of Endocrinology 146:357-363. Nassar N, Abeywardana P, Barker A, Bower C. 2010. 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Page 129 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2 FEMALE PRECOCIOUS PUBERTY The overall incidence of sexual precocity is estimated between 1 in 5,000 and 1 in 10,000 with females being ten times more likely to be affected (Partsch et al. 2001). Idiopathic precocious puberty is diagnosed when there is no evidence of organic cause provided through history, physical examination, or brain imaging. This proportion is greater in girls than in boys, who show a higher prevalence of recognizable organic forms (Parent et al. 2003). Accordingly, research on the potential influence of exogenous chemicals on the timing of puberty has focussed on female precocious puberty and this will be mirrored throughout this section. Puberty is a complex developmental process in late childhood characterised by the acceleration of growth, appearance of secondary sexual characteristics and ultimately fertility. If untreated, the prematurity of the pubertal growth spurt can result in reduced adult height. It is also associated with a higher risk of developing breast cancer and polycystic ovaries syndrome (DiVall et al. 2009). Asynchrony between biological development and social expectations can also have serious psychological consequences depending on the sociocultural context (Waylen et al. 2004); some studies indicate that girls who become sexually mature early are more likely to engage in risk-taking behaviours such as cigarettes, alcohol, drugs, and unprotected sex (Cesario et al. 2007), and are also at higher risk of depression and sexual victimisation (Crain et al. 2008). The 4- to 5-yr physiological variation in age at onset of puberty that is observed among normal individuals despite relatively similar life conditions is a peculiarity of the human species (Parent et al. 2003). Although this individual variability indicates the importance of the genetic control of pubertal timing, environmental signals may play a crucial permissive role in the occurrence of abnormally precocious or delayed puberty. 4.2.1 The natural history of age at puberty 4.2.1.1 Puberty onset, its incidence and assessment Puberty refers to a complex sequence of maturational events in late childhood resulting in fertility. Thelarche, the onset of breast development, is characterised by the formation of tender nodules of firm tissue centered on the aerolae, following an increase in serum estradiol. Estradiol is also responsible for the pubertal growth spurt as it influences linear bone growth and epiphyseal fusion. Pubarche or adrenarche is the onset of androgen-dependent signs of puberty (pubic hair, acne, and adult body odor). While in boys, either adrenal or gonadal maturation can prompt adrenarche, in females, it is the result of adrenocortical activity (Muir 2006). Menarche, the occurrence of first menstruation, is a relatively late marker of female puberty, dependent on the maturation of the HPG axis. Menarcheal age is highly correlated with thelarche and occurs on average 2 years later. Nonetheless, early thelarche results in a longer interval between thelarche and menarche; and inversely, the later the onset of thelarche the shorter the interval. Premature thelarche and premature adrenarche are regarded as partial forms of precocious puberty, although premature thelarche can occasionally transform into overt central precocious puberty (Buck Louis et al. 2008). An association of precocious pubarche with intrauterine growth restriction (IUGR), ovarian hyperandrogenism, ovulatory dysfunction, hyperinsulinism, and dyslipidemia has been proposed to Page 130 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY comprise a polyendocrine-metabolic syndrome in the female, similar to the testicular dysgenesis syndrome (TDS) proposed in the male (Ibanez et al. 1998). Diagnosis Some of the controversy surrounding studies of trends in incidence of precocious puberty are related to different assessment methods (Himes 2006). Precocious puberty was defined as the appearance of secondary sex characteristics before the age of 8 years or the onset of menarche before age 9, based on 2.5 standard deviations from the means derived from the examination of 192 English girls over 30 years ago (Cesario et al. 2007). Tanner stages were derived from the same study and are used as a guide to the “normal” process of puberty usually completed over a period of approximately 4.5 years. In overweight girls, palpation is essential to distinguish breast from adipose tissue. Because visual examination of a nude child or adolescent by a trained examiner is necessary to use the Tanner method, many clinicians have proposed the use of self-assessment techniques (Parent et al. 2003). Sexual precocity is classified as central, gonadotropin-dependent, when it results primarily from early hypothalamic-pituitary maturation. Central precocious puberty represents four fifths of the total number of patients with precocious puberty and is much more frequently seen in girls than in boys. Idiopathic central precocious puberty represents between 58 and 96% of cases and is diagnosed when early pubertal development (including acceleration of growth and bone maturation) is associated with an increased LH secretion. In peripheral, gonadotropin-independent sexual precocity, the primary event is increased secretion of adrenal or gonadal sex steroids or exposure to exogenous steroids (Parent et al. 2003). There are biochemical markers for female puberty that can be assayed before the onset of physical signs such as elevations in reproductive hormones (eg, luteinising hormone [LH], follicle-stimulating hormone [FSH], 17ОІ-estradiol [E2], inhibin A and B), or bone age determinations (radiograph of left wrist) and ultrasonographic assessment of ovarian and uterine volume (Buck Louis et al. 2008). 4.2.1.2 Secular and geographical trends Between the mid-19th and mid-20th century, the average age at menarche (first menstruation) decreased steadily from 17 to under 14 years old in the United States and Western Europe. This has been attributed to the evolution of living standards and supports the role of nutrition, health status, or socioeconomic status. Whereas reference data seemed to have stabilised in most industrialised countries during the 1990s, two American studies highlighted an unexpected and unexplained advance in physiological age at the onset of breast budding (Parent et al. 2003). The American Academy of Pediatrics - Pediatric Research in Office Settings (PROS) network report found the mean age at Tanner stage B2 to be 10.0 yr in White American girls and 8.9 yr in African-American girls, with lower limits (2 standard deviations) of 6.3 and 5.0 yr respectively, based on examination of more than 17,000 girls (HermanGiddens et al. 1997). In another large cross-sectional American study (the National Health and Nutrition Examination Survey, NHANES III), a similarly early median age of 9.7 yr at B2 was found in White Americans, although slightly less advanced median ages of 10.4 yr (White Americans) and 9.5 yr (Black Americans) have since been reported in subgroups from that cohort (Sun et al. 2002). Page 131 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY Results of both the NHANES III and the PROS studies were criticised for their cross-sectional designs, the fact that they involved many different observers, and did not mention the systematic use of palpation to assess breast tissue development. The mean menarcheal age found in the PROS study (12.9 yr in White Americans and 12.7 yr in Black Americans) was unchanged. In the NHANES III study, which involved subjects aged up to 17 yr, menarche occurred in White Americans at an age (12.5 yr) similar to that extrapolated in the PROS study. In two recent studies based on the NHANES III data and the National Health Examination Survey data, the median menarcheal age in the U.S. girls studied around 1990 was 12.43 or 12.54 yr with a reduction of 0.34 yr in 30 yr or 0.21 yr in 25 yr, respectively. These differences are much less than that for breast development in the same period. There is now evidence of a similar trend in Europe. One of the epidemiological studies carried out as part of the PIONEER European project found a trend towards acceleration of parameters of puberty onset and progression in two recent German cohorts, and a historical Swiss cohort (Heger et al. 2008). Concurrently, the Copenhagen Puberty study examined 2,095 girls between 5.6 and 20.0 years old at fifteen years interval. Onset of thelarche (Tanner stage 2) occurred significantly earlier in the 2006 cohort (estimated mean age: 9.86 years) when compared with the 1991 cohort (estimated mean age: 10.88 years). Mean menarcheal age were 13.42 and 13.13 years in the 1991 and 2006 cohorts, respectively. Significantly lower serum estradiol levels were found in 8-10 years-old girls from the 2006 cohort while FSH and LH did not differ (Aksglaede et al. 2009b). A multidisciplinary expert panel sponsored by the US Environmental Protection Agency, the National Institute of Environmental Health Sciences, and Serono Symposia International convened in 2003 to examine the evidence of a secular trend and identify potential environmental factors of concern. The majority of the panelists concluded that the girls’ data are sufficient to suggest a secular trend toward earlier breast development onset and menarche (Euling et al. 2008). Data published on the age at onset of breast development and menarche in different European countries was reviewed in Parent et al. (2003) and revealed a north-south gradient. The average menarcheal age in Western Europe currently varies between 12.0 yr in Italy and 13.5 yr in the eastern part of Germany. The mean menarcheal ages in France and the Mediterranean countries are lower than in other Western European countries. Precocious puberty is also observed more frequently in immigrant or adopted girls from less developed countries. In studies of foreign children with sexual precocity, evidence of early hypothalamic-pituitary maturation and normal brain imaging has been provided, leading to the diagnosis of idiopathic central precocious puberty (Parent et al. 2003). 4.2.1.3 Aetiological hypotheses for idiopathic precocious puberty An increased proportion of idiopathic forms of precocious puberty was unexpected in light of the diagnostic advances made during the past decades using nuclear magnetic resonance imaging, and denotes a change of aetiology. Studies of menarcheal age in homozygotic twins, heterozygotic twins, sisters, and unrelated women indicate that up to 86% of the variance in pubertal timing can be explained by genetic factors (Parent et al. 2003; Wehkalampi et al. 2008). The etiological hypothesis that has received most scientific attention is undoubtedly the association between precocious puberty and obesity. This is relevant to endocrine disruption in view of the Page 132 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY recent interest in a putative role for endocrine disrupters in the obesity epidemics (discussed in detail in section 6.2). This focus can be related to the Frisch and Revelle hypothesis formulated in the 1970’s stating that puberty is triggered by a critical body mass (later revised to a critical amount of body fat). However, increases in body mass index (BMI) and adiposity during female puberty are physiologically normal and therefore precocious puberty will cause increases in parameters frequently used to define obesity (Himes 2006). A recent review of American studies revealed that at least two longitudinal studies found that increased body fat or a rapid increase in BMI predicts earlier sexual maturation (Kaplowitz 2008). The association of puberty onset with obesity in several European cohorts was examined as part of the PIONEER European project. A cross-sectional study of 1,840 healthy German school girls aged 10–15 years was conducted in 2006–2007 in Berlin and did not find an earlier age at menarche despite the 10% obesity prevalence, although body mass index (BMI) – standard deviation score (SDS) was significantly associated with early menarche (Bau et al. 2009). Another cross-sectional study of 1,488 German children from Leipzig attending different types of schools found higher BMIs seen in children attending Hauptschule or Realschule compared to those of children attending Gymnasium were associated with an earlier onset of puberty, although the difference in Tanner staging between the two educational groups was not significant (Gelbrich et al. 2008). The Copenhagen Puberty Study also found an association between BMI and onset of growth spurt and peak height velocity. However a downwards trend for age at puberty onset was observed for both boys and girls regardless of BMI that suggested that obesity alone does not explain the trend for earlier puberty onset (Aksglaede et al. 2009a). Rather the increased time-span between onset of breast development and menarche suggests an influence of exogenous substances or other environmental factors (Mouritsen et al. 2010). Early hypotheses to explain sexual precocity in foreign adopted children after migration have incriminated the transition from an underprivileged to a privileged environment. An underprivileged life setting might involve nutritional problems, high energy expenditure, insufficient public health, individual diseases, large family size, and social and emotional injuries (Cataldo et al. 2006). Geographical differences might involve altitude, temperature, humidity, and lighting. The occurrence of precocious puberty in non-adopted migrating children suggests the possible role of factors related to migration and change of environment as the impact of former nutritional and emotional stress is less likely in children moving together with their original families. Ethnic or racial characteristics could contribute to the sexual precocity of foreign migrating children, in addition to environmental factors, studies of the contribution of environmental or genetic factors in migrant populations yielded contradictory results (Parent et al. 2003). Different stresses, such as acute or chronic illnesses and adverse physical or psychological conditions, are known to depress the hypothalamicpituitary-gonadal system and delay puberty. For example, intensive physical training and sport competition, can result in physical, psychological, and nutritional stresses. A delay in menarcheal age was observed in Bosnia and Croatia and linked to the nutritional deprivation and psychological or emotional insult experienced in war conditions (Parent et al. 2003). There is some indirect evidence of a role of exposure to light as several studies have suggested that menarche starts relatively more frequently in winter than in summer, suggesting an inhibitory effect of photostimulation. Nonetheless, the influences of light and temperature on the human reproductive axis are thought to be rather minor compared with seasonally breeding animals (Parent et al. 2003). Page 133 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2.2 Evidence for endocrine mechanisms in female precocious puberty The timing of puberty can be influenced by central signals, neuropeptides and neurotransmitters originating from the hypothalamus, in addition to peripheral or gonadal signals. Environmental signals such as nutrition, light, exogenous chemicals or other stressors could affect the hypothalamic signalling network either directly or through peripheral signals. A central event in the onset of puberty is the increase of frequency and amplitude of gonadotropin releasing hormone (GnRH) secretion by the hypothalamus. This in turn induces the secretion of gonadotropins (LH and FSH) by the pituitary gland in a pulsatile fashion, particularly at night (Bourguignon et al. 2010; Muir 2006). This event is controlled by redundant inhibitory or excitatory mechanisms (Bourguignon et al. 2010). The maturation of gonadotropin secretion promotes ovarian follicular development, estradiol production, and eventually ovulation. The gonads and pituitary also secrete a number of proteins (inhibins, activins, follistatins) that exert regulatory effects on the hypothalamic-pituitary-thyroid endocrine axis (HPG). FSH release is inbited by inhibin B and stimulated by activins (Root 2005). Gonadotropin-driven ovarian estrogen production initiates and promotes thelarche as well as contributes to the pubertal changes of body fat composition and distribution (Solorzano et al. 2010). Menarche does not necessarily imply ovulatory cycles, which typically develop within 2 years of menarche. The pubertal growth spurt is marked by increases of not only estradiol, but also growth hormone (GH) and the insulin-like growth factor 1 (IGF1). Adrenarche is a strictly primate phenomenon that typically occurs between 6 and 8 years of age in both genders. It is marked by increased activity of the CYP17 enzyme resulting in increased dehydroepiandrosterone (DHEA), its sulphate (DHEAS) and androstenedione production (Buck Louis et al. 2008). The factors responsible for adrenal maturation remain unclear, but are partly dependent on pituitary secretion of adrenocorticotropic hormone (ACTH). Although pubarche is closely associated with the timing of pubertal onset, it can be temporally unrelated to gonadotropin production, while the role of adrenal androgen production in the central initiation of puberty remains unknown (Solorzano et al. 2010). In recent years, major advances have been made towards understanding the neuroendocrine signals which control puberty onset, particularly in relation to those shared with metabolic control due to the association of female precocious puberty with obesity. These have been extensively reviewed recently (Fernandez-Fernandez et al. 2006; Tena-Sempere 2010a; Tena-Sempere 2010b; TenaSempere 2010c) and some of the endogenous ligands for which there is evidence of hormonal control or involvement are briefly referred to in this section. A breakthrough came with the identification in late 2003 of the role of kisspeptins (formerly known as mestatins due to their antimetastatic activity) and their G-protein coupled receptor GPR54 in the control of reproduction as part of the EDEN European project (Navarro et al. 2004b). The regulation of the hypothalamic expression of the KiSS-1 and GPR54 genes by estrogens and androgens was demonstrated a year later in rodents. These insights into the positive and negative feedback control of gonadotropin secretion also provided a mechanistic basis for xenobiotics effects on pubertal timing (Navarro et al. 2008). Identification of other peripheral regulators of KiSS-1 expression also uncovered pathways for the metabolic control of puberty onset and GnRH secretion. There is compelling evidence that the Page 134 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY adipose hormone, leptin, is such a peripheral hormonal regulator (Roa et al. 2008; Tena-Sempere 2010c). This paved the way for the identification of other peripheral hormones involved in the integration of metabolism and reproductive function such as insulin, or the gut-derived ghrelin and PYY3-36 (Fernandez-Fernandez et al. 2006). Ghrelin, the endogenous ligand of GH secretagogue receptor type 1 a, inhibits LH secretion and this negative control is modulated by estrogens (Fernandez-Fernandez et al. 2007; Tena-Sempere 2008). Peptides produced by peripheral tissues appear to play a more important role in maintaining pubertal progression rather than its initiation, although IGF1 has been reported to accelerate pubertal initiation in rodents and primates (Buck Louis et al. 2008). Knowledge of the major central regulators of kisspeptin neurons is more limited and may include, in addition to neuropeptide Y and IGF1, melatonin, the pineal gland hormone which circulates in high concentrations at night. However their putative role in the physiologic control of the KiSS-1 system under different conditions such as changes in photoperiod or metabolic stress remains to be fully elucidated (Tena-Sempere 2010a). Epidermal growth factor (EGF)-like ligands and members of the EGF receptor family are involved in the glia-to-neuron signalling pathways that facilitate GnRH secretion (Ojeda et al. 2003). Oxytocin neurons have also recently been involved in the control of GnRH secretion. Results suggest that oxytocin facilitates female sexual development and that this effect is mediated by a mechanism involving glial production of prostaglandin E2 (PGE2) (Parent et al. 2008). 4.2.3 Evidence for a role of chemical exposures in female precocious puberty Evidence that exposure to excess sex steroids can induce the premature development of secondary sex characteristics (gonadotropin-independent pseudo peripheral precocious puberty) stems from congenital conditions such as adrenal hyperplasia or following tumoral secretion of sex steroids. If prolonged, it can result in the maturation of the central nervous system and lead to central gonadotropin-dependent precocious puberty (Partsch et al. 2001). Premature thelarche or pubarche have also been associated with the systemic absorption of certain cosmetic and hair care products containing estrogen or placenta, when unintentionally ingested or inhaled, applied to the breast area, or used as a topical treatment for diaper rash or scalp conditions (Partsch et al. 2001). There are also clinical accounts of infants born with breast or pubic hair following conception using assisted reproductive technologies, which rely on hormonal use to induce ovulation (Rojas-Marcos et al. 2005). Epidemiological studies assessing an association between pubertal timing and environmental chemicals have been reviewed recently (Buck Louis et al. 2008; Rasier et al. 2006; Roy et al. 2009) and results are summarised in Table 15. The motivation for studying the association between exposure to specific exogenous chemicals and pubertal timing can often be related to their estrogenic or dioxin-like activities. No association with the timing of thelarche or pubarche could be found for bisphenol A or dichlorodiphenyldichloroethylene (DDE). It cannot be definitely concluded that exposure to DDE advances the age at menarche, regardless of whether concentrations were measured perinatally. Such an association was nonetheless found with polychlorinated biphenyls (PCBs), when only estrogenic congeners were taken into consideration. There are also some reports of higher concentrations of phthalates or lower concentrations of phytoestrogens found in girls with more advanced breast development. Overall, results from studies where PCBS, polybrominated diphenyl Page 135 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY ethers (PBDEs), polychlorinated dibenzodioxins (PCDDs), polychlorinated dibenzofurans (PCDFs) or tetrachlorodibenzodioxin (TCDD) do not support an influence of dioxin-like compounds. There are however some suggestions of a possible delaying effect on thelarche, while polybromobiphenyls (PBBs) were associated with earlier pubarche and menarche. There is conclusive evidence of a delaying effect of lead on menarche but whether this is subsequent to endocrine disruption remains subject to debate. While a detailed discussion of the limitations of the various study designs and analysis of the studies is beyond the scope of this summary, it is important to consider these negative or inconsistent results in the light of the timing of exposure in relation to the critical window of susceptibility. The possibility of mixture effects is also of particular interest, as exogenous chemicals appear to be able to either delay or advance pubertal development. When effects have been found, the timing of menarche, pubarche or thelarche have not necessarily all been affected, pointing to differential effects that could be the result from different mode of action, either acting centrally on gonadotropin secretion, or peripherally directly on breast tissue, the adrenal or the ovary. Evidence from experimental studies with animals yields much more consistent and convicing results (reviewed in Buck Louis et al. (2008)). It is well established that prenatal and/or neonatal treatment with ER agonist accelerate pubertal onset while the AhR agonists TCDD results in delayed vaginal opening in the female rat. Peripubertal exposure to steroidogenesis inhibitors have also been found to delay pubertal onset, while the delay following peripubertal atrazine exposure, which is purported to interact directly with the central nervous system neuroendocrine function, is associated with reduced LH and prolactin levels (Buck Louis et al. 2008). There is also in vitro evidence that estrogenic chemicals can accelerate the glutamate-evoked pulsatile secretion of GnRH in hypothalamic explants from immature female rats (Rasier et al. 2008) as well as stimulatory effects on GnRH nuclear transcription in cultured immortalised GnRH neurons (Gore 2002). The relevance of these assay systems is discussed further in paragraph 4.2.5 of this section. Page 136 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY Table 15. Summary of studies of the association between exogenous chemicals and female pubertal timing Chemical Biospecimen Population (sample size) Endpoints Study results Reference bisphenol A Urine US, New York (192) Serum Maternal blood, cord blood, and placenta; breast milk Serum US/Canada Mohawk Nation (138) US, North Carolina (326) No association No association No association No association No association No association Higher in foreignborn girls (Wolff et al. 2008) DDE Pubarche Thelarche Menarche Menarche Pubarche Thelarche Concentration Serum in adulthood Maternal serum Plasma Chinese textile workers (466) US, Michigan daughters of women who consumed Great Lakes fish (151) US, New York (192) Dioxin-like activity Serum; CALUX Belgium, from polluted and non-polluted areas (120) Hexachlorobenzene Lead Serum Serum Serum Blood US/Canada Mohawk Nation (138) US/Canada Mohawk Nation (138) US, NHANES III (2186) US, New York (192) Serum US, NHANES III (1706) Mercury Mirex PBB Serum Serum Maternal serum after exposure US/Canada Mohawk Nation (138) US/Canada Mohawk Nation (138) US, Michigan, accidental in utero and/or lactational exposure (327) PBDEs mother’s milk, serum The Netherlands, Amsterdam (18) Menarche Menarche Thelarche Pubarche Thelarche Pubarche Menarche Menarche Menarche Puberty Pubarche Thelarche Menarche Pubarche Thelarche Menarche Menarche Menarche Pubarche Thelarche Thelarche Menarche Advance Advance No association No association Delay No association No association No association Delay Delay No association No association Delay Delay No association Advance? No association Advance Advance No association No association No association Girls with precocious puberty: Foreign-born (26); Belgian (15) (Denham et al. 2005) (Gladen et al. 2000) (KrstevskaKonstantinova et al. 2001) (Ouyang et al. 2005) (Vasiliu et al. 2004) (Wolff et al. 2008) (Den Hond et al. 2002) (Denham et al. 2005) (Denham et al. 2005) (Selevan et al. 2003) (Wolff et al. 2008) (Wu et al. 2003) (Denham et al. 2005) (Denham et al. 2005) (Blanck et al. 2000) (Leijs et al. 2008) (continued overleaf) Page 137 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY Chemical Biospecimen Population (sample size) Endpoints Study results Reference PCBs Maternal serum after exposure US, Michigan, accidental in utero and/or lactational exposure (327) US/Canada Mohawk Nation (138) Belgium, from polluted and non-polluted areas (120) Maternal blood, cord blood, and placenta; breast milk mother’s milk, serum (dioxin-like PCBs) Maternal serum Plasma US, North Carolina (326) Not measured Mother’s milk, serum Serum Serum Urine Taiwan, Yucheng girls exposed to contaminated oil (27) and controls (21) The Netherlands, Amsterdam (18) Puerto Rico, precocious thelarche (41 cases, 35 controls) China, Shanghai (precocious puberty: 110; control: 100) US, New York (192) Not measured US, Iowa (fed soy-based formula: 128; fed cow’s milk formula: 268) serum collected soon after the explosion Seveso, Italy (282) No association No association No association Advance No association No association No association No association No association No association No association No association No association No association No association No association Delay Higher in cases Higher in cases Lower with breast development No association No association No association (Blanck et al. 2000) Serum (estrogenic) Serum Menarche Pubarche Thelarche Menarche Thelarche Menarche Pubarche Menarche Pubarche Thelarche Thelarche Menarche Menarche Pubarche Thelarche Menarche Thelarche Concentration Concentration Concentration PCBs/PCDFs PCDD/Fs Phthalates Phytoestrogens TCDD The Netherlands, Amsterdam (18) US, Michigan daughters of women who consumed Great Lakes fish (151) US, New York (192) Menarche Thelarche Menarche (Denham et al. 2005) (Den Hond et al. 2002) (Gladen et al. 2000) (Leijs et al. 2008) (Vasiliu et al. 2004) (Wolff et al. 2008) (Yang et al. 2005) (Leijs et al. 2008) (Colon et al. 2000) (Qiao et al. 2007) (Wolff et al. 2008) (Strom et al. 2001) (Warner et al. 2004) Page 138 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2.4 Critical windows of susceptibility Both low birth weight and weight gain in childhood have been associated with earlier pubertal onset (Sloboda et al. 2007). These associations offer some insights into the critical windows of development that may also be particularly susceptible to the influence of exogenous chemicals. Intra-uterine growth restriction (IUGR) is associated with adiposity and early pubarche as well as early and rapid pubertal development (de Zegher and Ibanez 2004). Prenatal growth restraint has also been putatively associated with higher FSH levels and insulin resistance (Ibanez et al. 2006). Of potential relevance to foreign children immigrating from formely deprived conditions, an association has recently been found between female idiopathic precocious puberty and constitutional advancement of growth. This refers to a growth pattern characterised by growth acceleration soon after birth followed by normalisation of the growth rate until the onset of puberty (Papadimitriou 2010). Lee 2007 et al. (2007) had also observed a positive association between BMI z-scores at 36 months, the rate of change of BMI between 36 months and grade 1, well before the onset of puberty. The causal association between EDCs and obesity has been the focus of recent research (refer to section 6.2). IUGR may have multiple causes including xenobiotic substances and it is increasingly being recognised that abnormal intrauterine environment may alter the endocrine status and sensitivity of the receptors for endocrine and metabolic signalling pathways, which may in turn have an effect on brain differentiation (Schoeters et al. 2008). In female rodents, there is evidence that several critical developmental periods are particularly sensitive to the accelerating influence of exogenous estrogenic compounds on vaginal opening (reviewed in (Rasier et al. 2006)); namely, the prenatal period of reproductive tract development, perinatal period of brain differentiation as well as the prepubertal period. In terms of neural imprinting, there is recent evidence that neonatal administration of estrogenic compounds impairs the hypothalamic KiSS-1 system. Subcutaneous injection of estradiol benzoate or a high dose of bisphenol A on day 1 postpartum, the period of brain differentiation in the rat, resulted in a dosedependent decrease in hypothalamic KiSS-1 mRNA levels at the prepubertal stage and a related decrease of serum LH concentrations (Navarro et al. 2009). A similar lowering of KiSS-1 mRNA levels was observed in the offspring of female dams that had been undernourished during gestation to mimic catch-up growth, despite significantly higher leptin levels. The timing of vaginal opening was delayed in the undernourished offsprings compared to those that had received normal nutrition (Iwasa et al. 2010). 4.2.5 Do current experimental approaches capture relevant endpoints/mechanisms? In animal experiments, the influence of exogenous chemicals on pubertal timing is routinely assessed as the age at vaginal opening in female rodents or preputial separation in male rodents. Age at first estrus is used to assess the completion of pubertal development in females. Vaginal opening is the physiological manifestation of the estrogenic rise that accompanies the onset of puberty and the initial sign gonadotropin-dependent ovarian activity (Rasier et al. 2006). Age and body weight at vaginal opening is recorded in validated OECD guideline studies such as the вЂ�Two Generations Reproduction Toxicity Study’ (TG 416) and the вЂ�Developmental Neurotoxicity Study’ (TG426) in F1 or F2 rats exposed in utero. Body weight and age at vaginal opening and first estrus are Page 139 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY also recorded in the вЂ�Extended One Generation Reproductive Toxicity Study’ now validated under the auspices of the OECD Endocrine Disrupter Testing and Assessment (EDTA) Task Force as well as in the Female Pubertal Assay, validated by the USEPA and included in the OECD Conceptual Framework for Testing and Assessment of Endocrine Disrupting Substances, in which SpragueDawley rats are exposed pre-pubertally (before postnatal day 22). Additional endpoints such as age of breast cell differentiation events have also been used in peer-reviewed rodent studies (Buck Louis et al. 2008). A fundamental difference in the neuroendocrine initiation of puberty in rodents compared to primates is the strong inhibitory control by steroids during juvenile development, whereas this is achieved in primates by central mechanisms independent of gonadal steroidogenesis. Despite this difference, GnRH release appears to be regulated by similar excitatory and inhibitory pathways in rodents and primates. Few chemicals have been studied in both animals and humans (eg TCDD, lead, DDE, PCBs, pharmaceutical estrogens), but similar findings tend to be observed across species (Buck Louis et al. 2008). As previously mentioned, pubarche is a strictly primate phenomenon. Hence, there are no apical endpoints related specifically to adrenarche in rodent assays. The adrenal competence can be assessed in vivo by an ACTH challenge. The absence of a corticosterone response in blood provides evidence of adrenocortical suppression (Harvey et al. 2007). In vitro, the human adrenocortical carcinoma cell line H295R is currently being validated by the OECD as a screening test to identify steroidogenesis inhibitors (Hecker et al. 2007). These tests would not however detect substances able to advance rather than delay pubarche. There are two in vitro approaches that have been successfully used to investigate the effects of chemicals on gonadotropin secretion. A reduction in GnRH interpulse intervals in hypothalamic explants from infantile female rats was measured by radioimmunoassay following incubation with medium and estradiol or DDT isomers. Similar effects were observed ex-vivo, and earlier vaginal opening was also observed in vivo. In vitro effects were prevented by antagonists of О±-amino-3-hydroxy-5-methyl-isoxazole-4 propionic acid (AMPA)/kainate subtype of glutamate receptors and estrogen receptor. o,p'-DDT effects could be prevented by an antagonist of the aryl hydrocarbon orphan dioxin receptor (AhR) (Rasier et al. 2007). This method however still requires the sacrifice of animals and this may limit its interest to the elucidation of mechanistic pathways rather than the routine use for screening in a regulatory setting. Another in vitro system that has been used to test several estrogenic compounds is based on the immortalised hypothalamic neuronal cell line, GT1-7 (Mellon et al. 1990). GnRH mRNA and GnRH gene expressions and release are measured after 24-hour treatments. The PCB mixtures Aroclor 1221 and Aroclor 1254 stimulated translational activity and inhibited transcriptional activity at high doses respectively. The involvement of ER receptors was also investigated using the ER antagonist ICI 182,780 (Gore et al. 2002). Similarly, the effects of coumestrol on GnRH mRNA expression in GT1-7 cells, were studied alone and combined with ER antagonists. Results suggest that ERОІ is involved in the suppression of GnRH mRNA expression by coumestrol (Bowe et al. 2003). In the same system, methoxychlor and chlorpyrifos had significant effects on GnRH gene transcription and GnRH mRNA levels, but these effects were neither consistently blocked by ICI nor did they consistently mimic those of estrogen, suggesting a mechanism independent of the ER. Page 140 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2.6 Conclusions INTACT criteria MOSTLY MET MULTI-LEVEL criteria MOSTLY MET HORMONE criteria MET PRIMARY EFFECT criteria PARTLY MET EXPOSURE criteria MET SENSITIVE LIFESTAGE Attribution criteria: criteria MET PRECOCIOUS PUBERTY It is clear that the timing of puberty in human is under genetic control and may also be influenced by many environmental factors. While obesity itself is a putative consequence of EDC effect on fetal programming, the trend for earlier thelarche and arguably menarche cannot be attributed to the rising trend for obesity alone. The last decade has witnessed important criteria advances in our understanding of the PHARM. RESTORATION MET neuroendocrine control of puberty initiation. criteria PARTLY SUPPORTING DATA MET If no unequivocal evidence emerges from epidemiological studies, it is important to stress again the limitations of such studies due to the latency between exposure and manifestation of puberty, the importance of the timing of exposure during several potential critical windows of exposure, diagnosis and the potential for different effects associated with different endpoints. There is nonetheless substantial experimental evidence that exogenous chemicals can influence pubertal timing at particularly susceptible developmental stages. This is mirrored in humans by the influence of metabolism at specific life-stages. Screening and testing for endocrine disrupters routinely include endpoints related to central pubertal development. The validity and usefulness of including breast development parameters or adrenal competence in order to detect peripheral precocious (or delayed) puberty should be examined. The 2002 Global Assessment of Endocrine Disrupters stated that вЂ�possible mechanisms of action and role of other factors such as nutrition need to be clarified’. Over the last 10 years, key developments include: п‚· п‚· п‚· п‚· Evidence of a downwards trends in age at thelarche in European countries mirroring that found in the United States Empirical evidence of an association between IUGR or low birth weight, constitutional advancement of growth or obesity in childhood, both of which may potentially be causally related to fetal exposure to EDCs, with earlier pubertal onset in girls Scientific advances unravelling both the genetic control and the neuroendocrine signalling pathways involved in the timing of puberty Experimental evidence that exogenous chemicals can interfere with these signalling pathways Page 141 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2.6.1 Can female idiopathic precocious puberty be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (yes/no) Criteria MET Evidence summary Age at vaginal opening is a routinely monitored endpoint in rodent studies. Criteria MOSTLY MET For central precocious puberty, effects can be related from KiSS-1 mRNA expression, gonadotropin serum levels, to overt sexual precocity. Criteria MOSTLY MET The neuroendocrine signalling pathways involved in puberty initiation are being unraveled, a major development being of the discovery of the indispensable role played by kisspeptin. Exposure to exogenous chemicals that induce earlier vaginal patency have also been shown to affect kisspeptin and GnRH levels. (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations Criteria MET Validated EDC screening tests such as the вЂ�Enhanced TG407’ monitor endocrine sensitive endpoints as well as hepatic or renal toxicity. Criteria PARTLY MET There is evidence for endocrine modes of actions from known congenital defects or other organic causes of precocious puberty as well as clinical evidence from assisted reproduction therapies. Exposure to exogenous steroid estrogens can result in peripheral precocious puberty. (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences Criteria MET (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criteria MET Epidemiological evidence of the influence of metabolism during fetal life and rate of growth in early childhood (catch-up growth) as well as experimental evidence in animals of particularly sensitive windows of development such as prenatal development of the reproductive axis, perinatal brain differentiation and the prepubertal period. Hormonal therapy is used in the management of precocious puberty. In gonadectomised rats, sex steroid replacement prevents the hormonal (LH) and KiSS-1 response (Navarro et al. 2004a). Criteria PARTLY MET In vitro evidence from hypothalamic explants and GT1-7 cell line. Page 142 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY 4.2.7 References Aksglaede L, Juul A, Olsen LW, Sorensen TIA. 2009a. Age at Puberty and the Emerging Obesity Epidemic. Plos One 4. Aksglaede L, Sorensen K, Petersen JH, Skakkebaek NE, Juul A. 2009b. Recent Decline in Age at Breast Development: The Copenhagen Puberty Study. Pediatrics 123:E932-E939. Bau AM, Ernert A, Schenk L, Wiegand S, Martus P, Grueters A, Krude H. 2009. Is there a further acceleration in the age at onset of menarche? A cross-sectional study in 1840 school children focusing on age and bodyweight at the onset of menarche. European Journal of Endocrinology 160:107-113. Blanck HM, Marcus M, Tolbert PE, Rubin C, Henderson AK, Hertzberg VS, Zhang RH, Cameron L. 2000. 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Navarro VM, Fernandez-Fernandez R, Castellano JM, Barreiro ML, Roa J, Mayen A, Aguilar E, Dieguez C, Pinilla L, Tena-Sempere M. 2004a. Hypothalamic KiSS-1/GPR54 system and reproductive function: Pattern of gene expression, potent LH releasing activity, and role in puberty onset. Proceedings of the 12Th International Congress of Endocrinology1375-1380. Navarro VM, Fernandez-Fernandez R, Castellano JM, Roa J, Mayen A, Barreiro ML, Gaytan F, Aguilar E, Pinilla L, Dieguez C, Tena-Sempere M. 2004b. Advanced vaginal opening and precocious activation of the reproductive axis by KiSS-1 peptide, the endogenous ligand of GPR54. Journal of Physiology-London 561:379-386. Navarro VM, Tena-Sempere M. 2008. The KiSS-1/GPR54 system: putative target for endocrine disruption of reproduction at hypothalamicpituitary unit? International Journal of Andrology 31:224-232. Ojeda SR, Prevot V, Heger S, Lomniczi A, Dziedzic B, Mungenast A. 2003. 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Female sexual maturation and reproduction after prepubertal exposure to estrogens and endocrine disrupting chemicals: A review of rodent and human data. Molecular and Cellular Endocrinology 254:187-201. Roa J, Vigo E, Garcia-Galiano D, Castellano JM, Navarro VM, Pineda R, Dieguez C, Aguilar E, Pinilla L, Tena-Sempere M. 2008. Desensitization of gonadotropin responses to kisspeptin in the female rat: analyses of LH and FSH secretion at different developmental and metabolic states. American Journal of Physiology-Endocrinology and Metabolism 294:E1088-E1096. Rojas-Marcos PM, David R, Kohn B. 2005. Hormonal Effects in Infants Conceived by Assisted Reproductive Technology. Pediatrics 116:190194. Root AW. 2005. Sexual precocity: a historical perspective and update. Fetal Pediatr Pathol 24:39-62. Roy JR, Chakraborty S, Chakraborty TR. 2009. Estrogen-like endocrine disrupting chemicals affecting puberty in humans - a review. Medical Science Monitor 15:RA137-RA145. Schoeters G, Den Hond E, Dhooge W, Van Larebeke N, Leijs M. 2008. Endocrine Disruptors and Abnormalities of Pubertal Development. Basic & Clinical Pharmacology & Toxicology 102:168-175. Selevan SG, Rice DC, Hogan KA, Euling SY, Pfahles-Hutchens A, Bethel J. 2003. Blood lead concentration and delayed puberty in girls. New England Journal of Medicine 348:1527-1536. Sloboda DM, Hart R, Doherty DA, Pennell CE, Hickey M. 2007. Age at Menarche: Influences of Prenatal and Postnatal Growth. J Clin Endocrinol Metab 92:46-50. Solorzano C, McCartney CR. 2010. Obesity and the pubertal transition in girls and boys. Reproduction 140:399-410. Strom BL, Schinnar R, Ziegler EE, Barnhart KT, Sammel MD, Macones GA, Stallings VA, Drulis JM, Nelson SE, Hanson SA. 2001. Exposure to soy-based formula in infancy and endocrinological and reproductive outcomes in young adulthood. Jama-Journal of the American Medical Association 286:807-814. 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Serum dioxin concentrations and age at menarche. Environmental Health Perspectives 112:1289-1292. Waylen A, Wolke D. 2004. Sex 'n' drugs 'n' rock 'n' roll: the meaning and social consequences of pubertal timing. Eur J Endocrinol 151 Suppl 3:U151-9.:U151-U159. Page 144 of 486 HUMAN HEALTH ENDPOINTS FEMALE PRECOCIOUS PUBERTY Wehkalampi K, Silventoinen K, Kaprio J, Dick DM, Rose RJ, Pulkkinen L, Dunkel L. 2008. Genetic and environmental influences on pubertal timing assessed by height growth. American Journal of Human Biology 20:417-423. Wolff MS, Britton JA, Boguski L, Hochman S, Maloney N, Serra N, Liu ZS, Berkowitz G, Larson S, Forman J. 2008. Environmental exposures and puberty in inner-city girls. Environmental Research 107:393-400. Wu TJ, Buck GM, Mendow P. 2003. Blood lead levels and sexual maturation in US girls: The Third National Health and Nutrition Examination Survey, 1988-1994. Environmental Health Perspectives 111:737-741. Yang CY, Yu ML, Guo HR, Lai TJ, Hsu CC, Lambert G, Guo YLL. 2005. The endocrine and reproductive function of the female Yucheng adolescents prenatally exposed to PCBs/PCDFs. Chemosphere 61:355-360. Page 145 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY 4.3 FEMALE FECUNDITY In the WHO/IPCS 2002 Global Assessment of Endocrine Disrupters, fecundity and fertility were not addressed separately for men and women. Endocrine processes that underlie the functioning of the female reproductive are very complex and exhibit great plasticity throughout a woman’s lifetime. The possibility that chemical exposures could affect a woman’s ability to conceive is not new but in recent years the fact that EDCs could contribute to female fecundity and fertility outcomes has received greater interest. Although the terms fecundity and fertility are often used interchangeably, fecundity can be defined as the biological capacity for conception, whereas fertility refers to the ability to deliver a live-born infant. Fecundity is necessary but not sufficient for fertility (Buck Louis et al. 2006). In this section, the evidence that EDCs could be implicated in female subfecundity is addressed from an ovarian perspective, while endocrine-disrupting effects are covered in section 4.5. In general, one in ten couples experiences delay or inability to conceive. It is a source of social and psychological suffering and can lead to stigmatisation in some cultures, while there are substantial costs and potentially unknown health consequences associated with the assisted reproduction procedure (World Health Organisation 2001). While the global decrease in fertility (United Nations 2010) is often interpreted as cause for concern regarding fecundity, fertility rates, the average number of children born per woman, are subjects to many socioeconomic factors unrelated to a couple’s ability to conceive. Infertility rates, the number of couples who wish to but are unable to conceive, are more informative and have remained stable, ranging from 3.5 to 16.7 % in developed countries, compared to 6.9 to 9.3 % in less developed countries (Foster et al. 2008). Changes in the European population of infertile couples have been analysed and revealed a trend of increased women’s age but also men’s age when desiring their first child (Dupas et al. 2008). Paternal exposures resulting in reduced sperm number or quality could have an effect on a couple’s fecundity and male fertility is discussed in section 4.1. Geographical differences in fecundability (the probability that conception will occur within a given time) remain unexplained and do not appear to be associated with differences in semen quality (Sallmen et al. 2005). Female fecundity encompasses a wide spectrum of endpoints related to the ability to conceive, including hormonal profile, menstruation, early pregnancy loss, ovarian reserve and failure, and reproductive senescence or menopause. Beside polycystic ovaries syndrome (PCOS), endometriosis and uterine fibroids (discussed in sections 4.4, 4.6 and 4.7, respectively), causes of female subfecundity include disturbance to menstrual cycles or anovulatory cycles, premature menopause, implantation disorders related to tubal defects and uterine anomalies. Because the latter are also closely related to many pregnancy outcomes, these are covered in section 4.5 and spontaneous abortions will only be discussed in this section from an ovarian perspective. 4.3.1 The natural history of female fecundity The female reproductive system seems to be very vulnerable to environmental interferences such as lifestyle factors (smoking, alcohol and caffeine consumption), psychological stress, as well as various occupational factors. The number of working hours, physically demanding work, prolonged standing, Page 146 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY shift or night work seem to disturb menstrual cycles, delay conception, increase the risk of miscarriage or interfere with the growth of the fetus (Axmon et al. 2006a). There is strong evidence that age and weight impact on female reproductive performance. Obese women are less likely to conceive in a given menstrual cycle (Brewer et al. 2010). Evidence of an influence of diet or physical activity on fecundity is more equivocal (Homan et al. 2007). There are also reports of racial differences in the United States with infertility being more common among black than white women. This disparity was not explained by common risk factors for infertility, such as smoking and obesity, socioeconomic factors such as access to healthcare or gynaecologic risk factors such as fibroids and ovarian volume, but besides genetic or epigenetic variation may also be putatively related to a higher prevalence of sexually transmitted disease in black women (Wellons et al. 2008). Nonetheless, female biological factors such as age and menstrual cycle length have been found to be more important predictors of fecundity than lifestyle factors such as smoking habits and working hours (Axmon et al. 2006a). Menstrual abnormalities An association between menstrual cycle characteristics and sub-fecundity and spontaneous abortion has been observed. Furthermore lifelong menstrual patterns have been associated with chronic diseases including breast and ovarian cancer, uterine fibroids, diabetes and cardiovascular disease (Small et al. 2006). Menorrhagia refers either to excessive or prolonged bleeding, while amenorrhea is defined as having no menses for six months. Some causes of anovulation include disorders of androgen excess (eg PCOS), eating disorders and exercise-induced amenorrhea (Hillard 2008). Chronic anovulation is a well-established cause of female infertility. The few studies of menstrual cycle characteristics and fecundity have found that shorter cycles were less likely to be followed by conception, while both shorter and longer cycles were more likely to be spontaneously aborted. Cycles with up to 4 days menstrual bleeding had lower fecundity and spontaneous abortion was less likely after cycles with more than 5 days menstrual bleeding (Small et al. 2006). First term spontaneous abortion Spontaneous abortions are defined as “the expulsion or extraction from its mother of an embryo or fetus weighing 500 g or less”. Those that occur before week 12 of gestation are referred to as early spontaneous abortions (Weselak et al. 2008). It is estimated that 20-40% of pregnancy losses occur before clinical detection. The majority of spontaneous abortions are due to chromosomal abnormalities and cytogenetic studies indicate that such anomalies occur in 21% to 50% of first-term spontaneous abortions. Aneuploidy is the most commonly identified chromosomal abnormality, occurring in at least 7-10% of clinically recognised pregnancies (Hunt et al. 2008). Menopause Natural menopause is defined as the cessation of menses for at least 12 months (for other than medical reasons). Premature menopause, before age 40, is associated with risk of cardiovascular disease and osteoporosis and occurs in about 1 % of women of reproductive age (DiamantiKandarakis et al. 2009). Age at menopause has been found to be influenced by lifestyle factors (smoking, physical activity, education, parity), body weight and socioeconomic status. Despite Page 147 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY increasing trends in some factors associated with early menopause, reports in European and nonEuropean countries suggest a secular trend of increased menopausal age. There are however methodological issues in determining menopausal age when hormone replacement therapy (HRT) is continued for many years (Pakarinen et al. 2010). 4.3.2 Evidence of an endocrine mechanism in female fecundity 4.3.2.1 Cyclicity Cycle length is the manifestation of underlying biological mechanisms that may impact on fecundity. 84% of cycle variability is due to variation in length of the follicular phase. Short follicular phases are associated with higher estrogen among women 20 to 39 years old. Similarly in aging women, the changes in gonadotropin and ovarian hormones, including increased follicular phase estrogen results in decreased cycle length and decreased fertility. Conversely, low follicular phase estrogen has been associated with lower fecundity (Small et al. 2006). A small proportion of short cycles may reflect short luteal phases, associated with low progesterone, and therefore an impaired ability to maintain pregnancy (Small et al. 2006). Cycles shorter than 25 days or longer than 32 days, or bleeds longer than 7 days have been found more likely to be anovulatory. There are two main lines of enquiries that have been followed when investigating causes for abnormal cycles, central dysregulation of gonadotropin at the hypothalamus-pituitary level or locally, altered development or maturation of oocytes or associated somatic cells within the ovary. A large body of research has concentrated on understanding the latter and this will form the main focus of this section. Nonetheless, kisspeptins have not only emerged as pivotal signals for puberty onset (refer to section 4.2), and their recently discovered role as hypothalamic triggers for the preovulatory surge of gonadotropins, and hence also ovulation, ought to be mentioned. Further to the neuroendocrine control of ovulation, they are involved in the metabolic gating of reproductive function, i.e. the subfecundity observed in underweight or overweight women (Roa et al. 2008). The KiSS-1 gene has also recently been found to be expressed in the ovary during the preovulatory period and suggests a role of locally produced kisspeptin in the control of ovulation (Castellano et al. 2006). Interestingly, COX-2 inhibitors, known to disrupt follicular rupture and ovulation, have been shown to alter the expression of KiSS-1 gene in the rat. Prolactin is another peptide hormone produced by the anterior pituitary by lactotrophic cells. Its role in reproductive control is primarily related to the stimulation of growth and development of the mammary gland during pregnancy, but it also acts directly on the ovary and uterus. Prolactin secretion is under the inhibitory control of hypothalamic dopaminergic neurons that can itself be reduced express by estrogens (Miller et al. 2004). 4.3.2.2 Oogenesis Maternal RNAs and proteins synthesised during oogenesis play a critical role in supporting embryonic development between fertilisation and the so-called maternal-embryonic transition, when the transcriptional activity of the embryonic genome becomes fully functional (Brevini et al. 2005). While the myriad of endogenous growth factors, cytokines, gonadotropins and steroid Page 148 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY hormones involved in the regulation of ovarian development is still being uncovered, any perturbation of the complex and intricate processes at play could reduce oocyte competence and therefore impair fertilisation or arrest embryonic development. The successful development of functioning ovaries begins with the migration of primordial germ cell from the yolk sac to the genital ridge during the first trimester of gestation followed by differentiation into oocytes and associated somatic cells. In the human fetal ovary, germ cells undergo a brief period of mitotic proliferation characterised by incomplete cytokinesis, this creates groups of interconnected cells, called germ cell cysts, and these germ cells form oocyte nests that enter meiosis from 11-12 weeks gestation onwards, subsequent to a retinoic acid signal, and arrest in prophase I (Hunt et al. 2008). Follicle formation occurs during the second trimester (neonatally in the mouse), and requires the breakdown of intracellular bridges between oocytes and enclosure of individual oocytes by somatic cells (pregranulosa cells). Most of the germ cells undergo apoptosis during this process. The remaining primordial follicles stay quiescent until recruited for growth. Follicular assembly and initial recruitment are mostly regulated by local growth factors and the predominant ovarian steroid hormones (i.e., estrogens, androgens, progesterone), although FSH may exert some species-specific supportive function (Uzumcu et al. 2007). Progesterone is thought to inhibit apoptosis in oocytes during follicular assembly and estradiol has been found to affect oocyte nests breakdown in rodents (Crain et al. 2008). After puberty, during each menstrual cycle, the growth of individual primordial follicles into primary follicles is stimulated. The primary follicles evolve into secondary (preantral) and tertiary (early antral) follicles through a process characterised by the proliferation of follicular cells and their gradual differentiation into cumulus and granulosa cells, recruitment of interstitial stromal cells and blood vessels in the theca layers and onset of the formation of the antral cavity that serves as a source of nutrients, hormones, growth factors to support oocyte maturation. In humans, follicle growth takes approximately 85 days (2 weeks in mice). Ovarian steroidogenesis promotes follicle growth and differentiation via direct intraovarian action as well as endocrine feedback to the hypothalamic-pituitary. Estradiol is the predominant bioactive steroid hormone in these processes, however progesterone may also mediate early follicular development. Effects of exogenous androgens have also been observed in animals and are believed to be related to the induction of atresia (Uzumcu et al. 2007). In the tertiary/antral stage, one follicle (in mono-ovulators) is selected to complete folliculogenesis to ovulation and luteogenesis. The production of aromatisable androgens within theca cells, estradiol and progesterone is required for the maturation of healthy follicles, ovulation and luteal development. According to the вЂ�two-cell, two-gonadotropin’ theory, androstenedione synthesised in theca cells diffuses in to granulosa cells in response to LH, where it is aromatised to estrone and estradiol following FSH receptor mediated stimulation of cytochrome P450 (CYP) c19 (aromatase). LH first stimulates the uptake of cholesterol in theca cells via cyclic adenosine monophosphate (cAMP). Insulin-like growth factors (IGFs) are of particular interest and their involvement in intraovarian regulation of follicle growth, selection, atresia, cellular differentiation, steroidogenesis, oocyte maturation and cumulus expansion has been recently reviewed (Kwintkiewicz et al. 2009). The estradiol produced stimulates the growth of antral follicles to the preovulatory stage by binding to ERО± and ERОІ. Evidence for a central role of the ERОІ in folliculogenesis has been recently reviewed (Drummond et al. 2010). Page 149 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY The preovulatory surge of gonadotropins induces a cascade of processes culminating in ovulation. One of the most marked of these processes is FSH-induced cumulus expansion, known to be mediated by cAMP. Cumulus cells produce large amounts of hyaluronic acid, extracellular matrix and proteglycans causing a characteristic dramatic volumetric enlargement of the cumulus-oocyte complex (COC), dissociation of from the follicle wall and its extrusion at ovulation. Active components of the extracellular matrix are either synthesised directly by cumulus cells under the control of endocrine- and oocyte-derived factors, secreted by mural granulosa cells, or enter the follicle from blood plasma. Extracellular matrix is essential for ovulation, efficient passage of the oocyte through the oviduct, and for fertilisation (Mlynarcikova et al. 2009). The gonadotropin surge that precedes ovulation is characterised by a profound increase in LH that stimulates the terminal differentiation of granulosa cells that switch from the almost exclusive production of estradiol to the production of both estradiol and progesterone (luteinisation). Following ovulation, the remaining granulosa cells and theca cells are further stimulated by LH to terminally differentiate into the corpus luteum, whose progesterone production is essential for enabling the initial stages of pregnancy (Uzumcu et al. 2007). Endogenously stored as well as extracellular calcium may signal the resumption of meiosis. It has recently been shown that estradiol shortened the duration of Ca2+ oscillations in a dose-dependent manner and produced an irregular pattern of the oscillations, strongly suggesting a rapid effect of estradiol on the plasma membrane of the oocyte (Mlynarcikova et al. 2009). The role of the AhR in female reproduction has been the focus of much research on the effects of xenobiotics on female fertility and has been recently reviewed (Hernandez-Ochoa et al. 2009). Briefly, studies suggest that the AhR is involved in modulating follicular steroidogenesis possibly by regulating the steroidogenic cascade at more than one site. Further, it may facilitate responsiveness of follicles to the gonadotropin surge required for ovulation, as well as modulate factors required for follicle rupture such as COX2, and play a role in the resumption of meiosis. Aneuploidy The interest of scientists researching female meiosis in relation to endocrine disruption was triggered by observations of a sudden increase in meiotic disturbances, including aneuploidy, interpreted as the consequence of inadvertent exposure of experimental mice to bisphenol A released from plastic cages and water bottles following the use of the wrong detergent (Hunt et al. 2003). Four other studies examined the effects of BPA on periovulatory follicles and all observed meiotic disturbances but not aneuploidy (Can et al. 2005; Lenie et al. 2008; Pacchierotti et al. 2008; Eichenlaub-Ritter et al. 2008). Further experiments indicated a potential influence of dietary phytoestrogens, a high phytoestrogen diet apparently protecting against the effect of low doses of BPA compared to controls (Muhlhauser et al. , 2009). The elevated incidence of Down syndrome in very young mothers suggests the influence of the endocrine regulation of oogenesis on the production of aneuploid gametes (Pacchierotti et al. 2006). It has also been suggested that the changing endocrine environment underlies the age-related increase in human aneuploidy (Hunt et al. 2008). Most aneuploidies are not viable and this is thought to be a leading cause of early pregnancy loss (approximately one-third of miscarriages are aneuploid) (Hassold et al. 2001). Defects could also result in the elimination of a large number of oocytes likely to reduce the reproductive lifespan by decreasing the follicle reserve, leading to premature ovarian failure or earlier onset of Page 150 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY age-related aneuploidy (Hunt et al. 2008). Disruption of meiosis either at MI or MII may result in non-disjunction of homologous chromosomes or sister chromatids and an abnormal number of chromosomes in the ovulated oocyte. High concentrations of estradiol are required for normal meiotic maturation (Mlynarcikova et al. 2005), however an endocrine mechanism in meiosis onset in the fetal ovary remains hypothetical. 4.3.3 Evidence of chemical causation 4.3.3.1 Analogy with oral contraceptives Oral contraceptives inhibit folliculogenesis via a negative feedback mechanism on the central release of gonadotropins. A detailed study found that the hypothalamic-pituitary axis of 40 long-term users of low-dose contraceptives aged 22-36 years seemed to recover completely during the 7-day pillfree interval (Axmon et al. 2006a). There is however epidemiological evidence that oral contraceptives affect fecundity subsequent to discontinuation. A study of 2,841 pregnant women in northern England found that hormonal contraceptives increased time-to-pregnancy 1.5- to 3-fold. All levonorgestrel (a progestagen) intra-uterine device users (n = 13) conceived within 1 month of cessation (Hassan et al. 2004). 4.3.3.2 Evidence of an effect of environmental contaminants Epidemiological evidence of effects of environmental contaminants on female fecundity has been the subject of recent reviews (Buck Louis et al. 2006; Mendola et al. 2008; Woodruff et al. 2008). Results of relevant studies on effect on cyclicity, fecundity and menopause are summarised in Table 16, Table 17 and Table 18, respectively. Time-to-pregnancy (TTP) as an endpoint for the epidemiology of subfecundity Epidemiological studies of fecundity following exposure to specific chemical agents generally use the concept of time to pregnancy (TTP). It however suffers from a number of limitations and potential biases that should be taken in consideration when interpreting such epidemiological evidence. The notion of fecundability has been used by demographers since the term was first coined in the 1920s and is generally measured using the concept of time to pregnancy, the number of menstrual cycles or months of unprotected sexual intercourse required to conceive (Leridon 2007). A major critique of retrospective TTP studies is the exclusion of women who never conceive (Axmon et al. 2006a). Furthermore, if older couples are less persistent and are thereby excluded, the subfertile subgroup may be overrepresented among those that discontinue their attempts to conceive. This may explain why several retrospective TTP studies have found higher fecundity among older women (Bonde et al. 2006). Conversely, with more effective and safe contraception, more highly fertile couples (those who conceive despite using contraception) are kept in the population with an eligible TTP value. Cross-sectional TTP studies also suffer from truncation bias as short TTP values will be overrepresented in recent pregnancies. In occupational studies, new mothers may not return to full-time employment resulting in an “reproductively-unhealthy worker effect” (Bonde et al. 2006). The probability of becoming pregnant in a menstrual cycle depends on male and female biological fecundity, as well as on the timing and frequency of unprotected intercourse (Stanford et Page 151 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY al. 2007). These biases may be adjusted for in prospective studies by collecting detailed records of menstrual bleeding, occurrences of intercourse and a marker of ovulation in each menstrual cycle (Tingen et al. 2004). Summary of epidemiological evidence It must be stressed that the epidemiological evidence summarised in Table 16, Table 17 and Table 18 is far from an exhaustive review of the published data. Such evidence of an effect on female fecundity has generally been restricted to accidental and occupational exposures. There is some evidence of an effect of occupational exposure to heavy metals and pesticides in general on menstrual cycles (Table 16), and this is overall mirrored by an effect on fecundability (Table 17). TTP is a combined measure of both paternal and maternal fecundity and this hampers the interpretation of results. Data also appear to support an effect of the organochlorines that were investigated on menstrual endpoints such as cycle length, despite a lack of consistently similar effect on the said endpoints (Table 16). Exposure to phytoestrogens during the neonatal period was found to have an effect on menstrual flow, however the control cohort was fed cow’s milk formula which is itself unlikely to be devoid of estrogenic activity (Table 16). TTP in relation to consumption of contaminated fish gives a less consistent picture (Table 17), and this is probably related with the known beneficial effects of high fish consumption (Grandjean et al. 2001). In this context, it is interesting that an effect may only become significant in subsets with other known risk factors such as age or smoking. The opposite effects on female fecundity of prenatal exposure to dichlorodiphenyldichloroethane (DDT), depending on whether higher concentrations of DDT or its metabolite dichlorodiphenyldichloroethylene (DDE) were measured in their mothers’ serum, also raise interesting questions and suggest the potential importance of maternal differences in metabolism and genetic susceptibility (Table 17). Perfluorinated chemicals such as perfluorooctanoate (PFOA) and perfluorooctane sulfonate (PFOS) are emerging contaminants that are suspected of having endocrine disrupting properties, and a positive association with time-topregnancy is particularly significative and warrants serious concerns (Table 17). There are still relatively few studies of the influence of environmental contaminants on age-atmenopause (Table 18). The available data does not support an effect of polychlorinated biphenyls (PCBs), while pesticide use appears to delay menopause. There is some evidence that DDE and tetrachlorodibenzodioxin (TCDD) advance the age at menopause. Page 152 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY Table 16. Epidemiological studies of the association between relevant chemicals and altered cyclicity Chemical Exposure assessment Population (sample size) Endpoints Study results Reference Cadmium Lead Urine Interview Young girls living close to a lead-zinc mine, Zhenhe, China Lead battery plant workers Exposure to vapour Pesticide use Increased odds Increased odds Increased odds Increased odds Increased odds (Wang et al. 2004) Cited in (Mendola et al. 2008) Mercury Menstrual abnormalities Polymenorrhea Long menses Menorrhagia Dysmenorrhea Cycle length Missed periods Intermenstrual bleeding Irregular cycle Cycle length Irregular cycles Bleeding duration Dysmenorrhea Cycle length Cycle length Menses duration Menstrual flow Short cycle Long cycle Ovulatory estrogen Luteal progesterone (Farr et al. 2004) (Mendola et al. 1997) Pesticides mercury female workers in lamp factory (296) and from food processing plants (394) Women living on farms in Iowa and North Carolina (3,103) DDE Blood sample during third trimester of pregnancy Collaborative Perinatal Project, United States (2,314) DDE/DDT Serum Serum Laotian-born women, San Francisco, United States (50) Young Chinese women, Shanghai, China (60) DDT Serum Chinese textile workers (466) Serum Chinese textile workers (287) Contaminated (Baltic Sea) fish consumption Contaminated fish consumption Swedish fishermen’s wives and sisters (2,357) Cycle length Increased Increased odds 2 Increased odds Decreased odds No association 3 Dose-response No association No association Shorter luteal phase No association No association No association Increased odds No association Negative doseresponse Negative doseresponse Reduced New York State Angler Cohort (2,223) Cycle length Reduced Organochlorines 2 3 (Yang et al. 2002) (Cooper et al. 2005) (Windham et al. 2005) (Chen et al. 2005) (Ouyang et al. 2005) (Perry et al. 2006) (Axmon et al. 2004a) With lindane, atrazine, mancozeb and maneb After adjustment for confounding factors Page 153 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY Chemical Exposure assessment Population (sample size) Endpoints Study results Reference PCBs Blood sample during third trimester of pregnancy Collaborative Perinatal Project, United States (2,314 ) Laotian-born women, San Francisco, United States (50) Taiwan Yucheng cohort (356, control=312) TCDD Serum collected soon after explosion Seveso women health study (301) Phytoestrogens Soy or cow milk formula during infancy Controlled feeding studies conducted at the University of Iowa (811) Increased 3 Dose-response No association No association No association Increased No association No association 5 Increased No association No association Less likely to be 5 scanty No difference Longer No association No association No association No association Increased risk (Cooper et al. 2005) Serum Contaminated cooking oil Cycle length Irregular cycles Bleeding duration Dysmenorrhea Cycle length Abnormal bleeding Irregular cycles dysmenorrhea Cycle length Irregular cycles Bleeding duration Menstrual flow PCBs/PCDFs 4 5 4 Cycle length Menses duration Irregular cycle Menstrual flow Missed period Abnormal bleeding Dysmenorrhea (Windham et al. 2005) (Yu et al. 2000) (Eskenazi et al. 2002) (Strom et al. 2001) Polychlorinated dibenzofurans Significant associations for women who were premenarchal at the time of the explosion but not for women who were postmenarchal Page 154 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY Table 17. Epidemiological studies of the association between relevant chemicals and subfecundity Chemical Exposure assessment Population (sample size) Endpoints Study results Reference Cadmium Occupational exposure Urine Denmark, medical records Young girls living close to a lead-zinc mine, Zhenhe, China Association Increased odds (Rachootin et al. 1983) (Wang et al. 2004) Lead Occupational exposure Blood Association Increased risk (Rachootin et al. 1983) (Chang et al. 2006) Mercury Pesticides Occupational exposure Occupational and home exposure Herbicide and fungicide use/application Questionnaire Denmark, medical records Women from an infertility clinic (64) and post-partum clinic in Kaohsiung, Taiwan Denmark, medical records Migrant farm workers (402), California, United States Time-to-pregnancy Difficulties becoming pregnant Time-to-pregnancy Infertility Time-to-pregnancy Time-to-pregnancy Association Increased (Rachootin et al. 1983) (Harley et al. 2008) Infertility More common in infertile women No consistent association 6 Increased Association with agricultural work 7 Increased No association Decreased Increased (Greenlee et al. 2003) Negative doseresponse (Gerhard et al. 1999) Spraying of pesticides Occupational histories DDE DDE DDT Blood Serum Maternal serum (1–3 days after delivery) DDT Blood Women who sought treatment at a medical clinic in Wisconsin (644 cases and controls) Ontario Farm Family Health Study (2,012 planned pregnancies) Female members of the Danish Gardeners Trade Union (492) Medically confirmed infertile and post-partum women at a Midwest clinic (497) US Collaborative Perinatal Project (390) Migrant farm workers (289), California, United States Daughters of women enrolled in the Kaiser Permanente Health Plan and the Child Health and Development studies, Oakland, United States (289) Infertile women (489) from Mannheim and Heidelberg, Germany Time-to-pregnancy Time-to-pregnancy Infertility risk Time-to-pregnancy Time-to-pregnancy Time-to-pregnancy Number of pregnancies (Curtis et al. 1999) (Abell et al. 2000) (Fuortes et al. 1997) (Law et al. 2005) (Harley et al. 2008) (Cohn et al. 2003) (continued overleaf) 6 7 With the non-use of gloves Not statistically significant Page 155 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY Chemical Exposure assessment Population (sample size) Endpoints Study results Organochlorines Contaminated (Baltic Sea) fish consumption Contaminated (Baltic Sea) fish consumption Blood Swedish fishermen's wives (1,335) Time-to-pregnancy Increased Swedish fishermen's sisters (1,812) Time-to-pregnancy 9 Subfecundity Time-to-pregnancy (Axmon et al. 2002) Time-to-pregnancy No association 10 Increased risk Weak 11 association Increased New York State Angler cohort (88) Swedish fishermen's wives (286) Time-to-pregnancy Time-to-pregnancy Increased Decreased Preconception blood New York State Angler cohort (83) Time-to-pregnancy Increased Blood Contaminated cooking oil Plasma at week 4-14 of pregnancy US Collaborative Perinatal Project (390) Taiwan Yucheng cohort (342, control=302) Danish National Birth Cohort (1,240) Time to pregnancy Time to pregnancy Time-to-pregnancy Increased No association Positive doseresponse Positive doseresponse (Buck et al. 2002) (Axmon et al. 2004b) (Buck Louis et al. 2009) (Law et al. 2005) (Yu et al. 2000) (Fei et al. 2009) Contaminated fish consumption Blood Plasma PCBs PCBs/PCDFs PFOA PFOS Women from Warsaw (376), Kharkiv (307), Inuits (520), and Swedish fishermen’s wives (519) New York State Angler cohort (575) 8 12 7 Reference (Axmon et al. 2000) (Axmon et al. 2006b) (Buck et al. 2000) 8 In the heavy smokers subset Women who had unsuccessfully tried to conceive for more than 12 months or conceived following medical treatment were classified as subfertile 10 In the older women subset 11 In highly exposed Inuit women only 12 with estrogenic and anti-estrogenic groupings of PCBs (not statistically significant) 9 Page 156 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY Table 18. Epidemiological studies of the association between relevant chemicals and menopause Chemical Exposure assessment Population (sample size) Endpoints Study results Reference DDE Plasma Age at menopause Advanced (Cooper et al. 2002) Pesticides PCBs Pesticide use Plasma Time to menopause Age at menopause Increased No association (Farr et al. 2006) (Cooper et al. 2002) PCBs/PBBs PCBs/PCDFs TCDD Serum at time of enrolment Contaminated cooking oil Serum collected soon after explosion Carolina Breast Cancer Study (748 breast cancer cases and and 659 controls) Women living on farms in Iowa and North Carolina (8,038) Carolina Breast Cancer Study (748 breast cancer cases; 659 controls) Michigan PBB cohort (990) Taiwan Yucheng cohort (342, control=302) Seveso women health study (600), premenarchal at time of explosion Time to menopause Age at menopause Age at menopause No association No association Negative dose13 response (Blanck et al. 2004) (Yu et al. 2000) (Eskenazi et al. 2005) 13 up to about 100 ppt TCDD, but not above Page 157 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY 4.3.4 Critical windows of susceptibility Neonatal exposure to estrogens is known to prevent the maintenance of regular estrous cycles in rodents. Hormonal disruption of developmental processes could target both the ovary and the hypothalamic circuitry of cyclicity. The effects of in utero exposure to several known EDCs on the neuroendocrine system and the ovary were reviewed by Miller et al (2004). There is also some evidence that the prepubertal and pubertal periods may be particularly sensitive. Nonetheless, as one of the peculiarities of the female germ cells is a life-cycle of up to 50 years, the specific sensitivity of oocytes to chronic chemical injuries even during adulthood should not be overlooked. 4.3.4.1 Ovarian development The number of oocytes available for recruitment, maturation and ovulation over a woman’s life span is generally accepted to depend on the ovarian pool that is determined prenatally. Toxicity in the ovary may not be confined to one cell type, i.e. the oocyte itself, but also target granulosa cells and theca cells. It may also vary depending on the developmental stage of the ovary, e.g. primordial, primary, preantral, antral, and corporea lutea. Follicles containing two or more oocytes have been observed in wildlife and experimental animals following prenatal exposure to estrogenic substances, indicating that contaminants may interfere with the breakdown of intercellular bridges necessary for follicle formation. This suggests their action coincides or precedes the formation of primordial follicles. The AhR has been implicated in the regulation of the rate of apoptosis of oocytes in germ cell nests (Hernandez-Ochoa et al. 2009) and in utero exposure to TCDD and PCBs have been shown to result in premature reproductive senescence (Brevini et al. 2005). The transition from primordial to primary follicle is inhibited by estrogen and EDCs such as metoxychlor have been found to inhibit folliculogenesis (Uzumcu et al. 2006), while prenatal treatment with androgens in ewes has been shown to alter expression of the AR in granulosa cells (Ortega et al. 2009), and the altered equilibrium of ER and AR protein expression in antral follicular granulosa cells was proposed to explain postnatal ovarian dysfunction. The hypothesis that disturbance of the endocrine and paracrine regulation of meiosis could disrupt chromosome segregation suggests that chronic rather than acute exposures may be required to induce changes in hormonal homeostasis (Pacchierotti et al. 2006). The events of pairing, recombination and synapsis taking place during meiotic prophase have been shown to be essential for germ cell survival and meiotic progression. More recently, the earlier events of mitotic proliferation of germ cells have also been implicated. Finally, a disruption of the final meiotic stages of periovulatory oocytes in prepubertal and sexually mature females could all result in meiotic disturbances and aneuploidy (Hunt et al. , 2003; Hassold and Hunt, 2009). 4.3.4.2 Brain differentiation The ability of the adult central nervous system (particularly the hypothalamus) to respond to hormonal and environmental inputs is acquired perinatally in the last third of gestation to infancy, when different blood levels of testosterone induce a sexually dimorphic differentiation of speciп¬Ѓc neuronal networks. Further hormonally-driven refinement of the neural circuitry is acquired during puberty. Testosterone needs to be locally converted into active metabolites, both estradiol that will Page 158 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY act through the ERО± and/or ERОІ and dihydrotestosterone (DHT) that will then act through the AR. The right amount of estradiol and DHT are regulated by gender-specific expression patterns of aromatase and 5О±-reductase (Colciago et al. 2009). Prenatal and/or neonatal exposure to several EDCs have been shown to suppress GnRH activity in adulthood, affect the hypothalamic expression the ER, AR, aromatase or 5О±-reductase, or secretion of prolactin by the pituitary (Miller et al. 2004). Such hormonal disturbances would then affect menstrual cyclicity and may result in difficulties conceiving. 4.3.5 Do current experimental approaches capture relevant endpoints/mechanisms? In vivo experimental models In vivo screening guideline studies for reproductive toxicants or endocrine disrupters such as the OECD TG407 assess reproductive organ weight and hispopathology after exposing healthy young adults for a limited period (28 days in TG 407). For the USEPA Female Pubertal Assay, effects on estrous cyclicity are assessed by vaginal cytology. In longer term studies such as the draft OECD extended one-generation reproduction toxicity study and the OECD two-generation reproduction toxicity study (TG416 enhanced), that include in utero exposure the precoital interval (pairing to insemination) is also recorded and is of relevance to fecundity. Guideline studies do not however at present include reproductive senescence. TCDD has been shown to induce premature reproductive senescence at low doses (Shi et al. 2007). In vitro assays Beside estrogenic/anti-estrogenic and androgenic/anti-androgenic modes of action, binding to the AhR is thought to be an important mode of endocrine disruption of ovarian processes and female reproductive health. Interestingly, the AhR displays interspecies differences. While the human AhR has a 10-fold lower affinity for the prototypical ligands such as TCDD than the mouse AhR, it has greater affinity and subsequent transcriptional potency for compounds such as the chemotherapeutic agent indirubin (Flaveny et al. 2009). Therefore such sensitivity differences between species should be taken into consideration when interpreting results from binding or transcriptional assays. A number of in vitro bioassay were developed and assessed for their transferability and interlaboratory variability within the ReProTect project under the umbrella of the Sixth Framework Programme of the European Union. Of particular interest to female fecundity are the mouse follicle bioassay and the bovine in vitro maturation and fertilisation assays (Schenk et al. 2010). In order to extend in vitro maturation tests to earlier stages of oogenesis and folliculogenesis, an assay with mouse preantral follicle cultures was established to permit the identification of direct effects of environmental chemicals on the oocyte and also indirect effects on the somatic compartment, the follicle and theca cells, that may lead to disturbances of oocyte growth, maturation and chromosome segregation. The follicle-enclosed oocytes resume maturation and are ovulated in vitro after stimulus with recombinant human gonadotrophins and epidermal growth factor. Preantral follicle culture could therefore offer a method to assess the effects of potential endocrine disputers, Page 159 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY as well as potential mutagens (Sun et al. 2004). Porcine cumulus-oocyte-complexes have been used by some researchers because they closely resemble human ones, taking into account both their morphology and the timing of meiotic maturation in the mammalian oocyte (Mlynarcikova et al. 2009). Bovine models were favoured in the ReProtect project because bovine gametes are available in large numbers from slaughter houses. The in vitro bovine oocyte maturation and fertilisation assays use denuded oocytes and were developed to detect compounds that could interfere with the resumption of meiosis, perturbation of the oocyte cell cycle or DNA and oxidative damage (Lazzari et al. 2008; Luciano et al. 2010). Page 160 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY 4.3.6 Conclusions Attribution criteria: FEMALE FECUNDITY Oocytes are among the longest lived cells in an criteria organism and ovaries are also among the most INTACT MET criteria dynamic and plastic tissues. This is thought to PARTLY MULTI-LEVEL MET render them particularly prone to chemical criteria PARTLY HORMONE injury and other environmental or lifestyle MET factors. It is biologically plausible that criteria PRIMARY EFFECT MET disruption of the neuroendocrine or endocrine criteria and paracrine processes that regulate EXPOSURE MET oogenesis, folliculogenesis and ovulation could criteria SENSITIVE LIFESTAGE MET result in such an effect. When the endocrine criteria disrupting properties of specific chemicals or PHARM. RESTORATION MET groups of chemicals on female reproduction criteria PARTLY SUPPORTING DATA have been reviewed, such as for MET organochlorines (Tiemann 2008), it becomes clear that compounds can act concurrently at several sites where they may act via or independently of classical hormonal receptor pathways. The 2002 Global Assessment of Endocrine Disrupters covered fecundity from a couple’s perspective rather than address female fecundity separately. It stated that TTP studies could “be useful in providing corroborative evidence in exploring the significance of geographical differences in sperm quality”. While paternal exposure can influence TTP, the same can be said of maternal exposure and in many instances, when both maternal and paternal exposures were investigated, an association with maternal levels rather than paternal levels was found. Moreover, studies on menstrual cycle characteristics demonstrate unequivocally that female fecundity can be affected by chemicals. Over the last 10 years, key developments include: п‚· п‚· п‚· There has been an increase in interest in the processes regulating the menopause as well as epidemiological evidence that subtle effects of chemicals may only be revealed when combined with other risk factors such as age or smoking. Research has started to unravel the complex neuroendocrine, endocrine, paracrine and autocrine regulatory pathways that moderate female fecundity. Increasing experimental evidence that chemicals can interfere with these pathways. Page 161 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY 4.3.6.1 Can female subfecundity be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (yes/no) Criteria MET (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criteria PARTLY MET Criteria PARTLY MET Evidence summary Number and stage of development of follicles in ovaries are routinely monitored in rodent reproduction assay Effects can be seen on levels of steroid and gonadotropin hormones, expression of their respective receptors in various tissues, at tissue level on the ovary and finally by monitoring time to insemination. However mechanistic links between levels of biological organisation need to be clarified. In guideline studies altered hormone levels can be related to number, size and stage of follicles but due to the self-selected high fecundity of strains of experimental rodents, whether an effect on time-toinsemination may also be detected remains unclear. Criteria MET Validated EDC screening studies monitor circulating hormone levels and as well as hepatic or renal toxicity. Criteria MET Female contraception is based on those principles. Experimental evidence demonstrates that chemicals will have differential action at various sites along the signalling pathway (and these may change depending on developmental stage), such that a substance will not strictly mimic the action of the endogenous hormone (that may also be true of pharmaceuticals). Criteria MET Experimental evidence in animals of particularly sensitive windows of development such as prenatal development of the reproductive axis, perinatal brain differentiation and the prepubertal period. Criteria MET OCs can be prescribed to вЂ�regularise’ irregular cycles, this would however not restore fecundity. Hormonal treatments are used in assisted reproduction. Criteria PARTLY MET In vitro evidence from binding and transcriptional assays as well as with oocyte cultures. However the various modes of actions that may result in subfecundity remain to be clarified. Page 162 of 486 HUMAN HEALTH ENDPOINTS FEMALE FECUNDITY 4.3.7 References Abell A, Juul S, Bonde JPE. 2000. 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Menstruation and reproduction in women with polychlorinated biphenyl (PCB) poisoning: longterm follow-up interviews of the women from the Taiwan Yucheng cohort. International Journal of Epidemiology 29:672-677. Page 165 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 4.4 POLYCYSTIC OVARIES SYNDROME (PCOS) 4.4.1 The natural history of polycystic ovaries The polycystic ovaries syndrome is a heterogeneous endocrine disorder considered the most common endocrine abnormality in women of childbearing age. Many body systems are aп¬Ђected in polycystic ovary syndrome, resulting in several health complications, including menstrual dysfunction, infertility, hirsutism, acne, obesity, and metabolic syndrome, which have substantial psychological, social, and economic consequences. This heterogeneity in presentation has led to sustained controversy over diagnostic criteria. It is useful to discuss those briefly first before considering the prevalence trends, co-morbidity and aetiology of this syndrome. 4.4.1.1 Diagnostic criteria Symptoms of PCOS usually manifest close to the onset of puberty. Precocious pubarche and adolescent hyperandrogenemia with or without insulin resistance may represent a precursor of adult PCOS (Diamanti-Kandarakis et al. 2005). The clinical picture is somewhat unpredictable, as the phenotype may change through the life cycle of women; moreover due to the heterogeneity in presentation, both definition and diagnosis of PCOS remain controversial. The four most common definitions of the syndrome are given in Table 19. Table 19. Commonly used definition of polycystic ovary disease (reproduced from Bremer (2010) Definition/year Diagnostic criteria National Institutes of Health, 1990 Requires the simultaneous presence of: 1. 2. Rotterdam, 2003 Requires the presence of at least two criteria: 1. 2. 3. Androgen Excess Society, 2006 Hyperandrogenism (clinical and/or biochemical) Ovarian dysfunction Polycystic ovarian morphology Requires the presence of hyperandrogenism (clinical and/or biochemical) and either: 1. 2. Androgen Excess and PCOS Society, 2009 Hyperandrogenism (clinical and/or biochemical) Ovarian dysfunction Ovulatory dysfunction Polycystic ovarian morphology Requires the simultaneous presence of: 1. 2. Hyperandrogenism (clinical and/or biochemical) Ovarian dysfunction (ovulatory dysfunction and/or polycystic ovarian morphology) Three key diagnostic features are proposed with varying emphasis; namely, hyperandrogenism, chronic anovulation or oligomenorrhoea (ovulatory dysfunction) and polycystic ovaries on ultrasonography. All definitions also require the elimination of conditions known to mimic the symptoms of PCOS such as congenital adrenal hyperplasia, Cushing’s syndrome, androgen-secreting tumours, hyperprolactinaemia, thyroid dysfunction or syndromes of severe insulin resistance (Table Page 166 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 19). Although obesity, insulin resistance, and metabolic syndrome are frequently present in women with polycystic ovary syndrome, they are not regarded as intrinsic disturbances of the disorder (Norman et al. 2007). The 1990 National Institutes of Health highlighted the perceived importance of hyperandrogenism in the syndrome’s aetiology. In contrast, the 2003 Rotterdam [European Society for Human Reproduction and Embryology and American Society for Reproductive Medicine (ESHRE/ASRM)] broadened the PCOS phenotype to include women with ovulatory dysfunction and polycystic ovaries but without hyperandrogenism, and eumenorrheic women with hyperandrogenism and polycystic ovaries (often called вЂ�вЂ�ovulatory’’ PCOS). However, the 2006 Androgen Excess Society and 2009 Androgen Excess and Polycystic Ovary Syndrome Society’s deп¬Ѓnitions reemphasised the importance of hyperandrogenism in the aetiology of PCOS. Although women with chronic anovulation and polycystic ovaries without overt hyperandrogenism have subtle endocrine and metabolic features consistent with a mild form of the syndrome, disagreement continues as these are sometimes considered as too mild to be associated with the increased risk of developing metabolic disease characteristic of women with PCOS (Norman et al. 2007). 4.4.1.2 Prevalence and trends The prevalence of PCOS is traditionally estimated at 4 to 8% from studies performed in Greece, Spain and the USA using the 1990 National Institutes of Health criteria (Teede et al. 2010). Adoption of the 2003 Rotterdam criteria increases those estimates due to its broader inclusion scope. Indeed, a recent study using the Rotterdam diagnostic criteria found a prevalence of 18% and 70% of these women were previously undiagnosed (although this prevalence is based on estimates of polycystic ovaries for women who had not had an ultrasound) (Teede et al. 2010). Polycystic ovaries themselves were found in over a fifth of females in studies conducted in the UK and Australasia. In some populations, much higher prevalences have been observed; polycystic ovaries were diagnosed in 45% of Yoruba women from western Nigeria attending a UK fertility clinic and over half of randomly selected South Asians living in the UK (Shaw et al. 2008). Despite the fact that different diagnostic criteria hamper comparisons between populations, there are suggestions of cultural or geographical variations. Mexican American women might have higher prevalence of PCOS than white or black American women (Norman et al. 2007). Population-based phenotypic differences have also been observed (Shaw et al. 2008). There are to our knowledge no reports of secular trends but the prevalence of PCOS is thought likely to rise with increasing rates of obesity (Mason et al. 2008; Solorzano et al. 2010a). Obesity in women with polycystic ovary syndrome is more prevalent in North America than in their European counterparts, and this is thought to reflect the high prevalence of obesity in the general population (Norman et al. 2007). Obesity is one of the complications of the disease whilst it also exacerbates other complications of the syndrome and nutritional and other life-style changes are often the first line of treatment of the syndrome. 4.4.1.3 Symptoms, risk factors and co-morbidities There are reports of an increased prevalence of metabolic syndrome in women with polycystic ovary syndrome. An increase in central fat, hyperinsulinaemia, glucose intolerance, increased blood pressure, and other features of metabolic syndrome are more common in women with PCOS although it is unclear whether this is a feature of PCOS or the result of adiposity. Nonetheless, excess androgen in women has been shown to be a risk factor for metabolic syndrome independent of Page 167 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME obesity and insulin resistance (Norman et al. 2007). Insulin resistance is associated with abnormalities in fatty acid metabolism characterized by inappropriate lipid accumulation in atypical locations such as liver, muscle, and pancreatic cells (Witchel 2006). Impaired glucose tolerance and diabetes mellitus are more prevalent in women with PCOS and up to 10% of women with this disorder develop diabetes during the third or fourth decade (Norman et al. 2007). There is also some evidence that women with PCOS may be at an increased risk of cardiovascular disease. Cardiovascular risk factors such as hyperlipidemia, hyperandrogenemia, hypertension, markers of a prothrombotic state, and markers of inflammation are increased (Norman et al. 2007). Early clinical and subclinical markers of atherosclerosis are increased in young women with PCOS and exacerbated by obesity (Teede et al. 2010). Although increased death rates from cardiovascular disease have been shown in women with menstrual irregularity (possibly with polycystic ovary syndrome) in the Nurses’ Health Study (Norman et al. 2007), there is currently a lack of long-term studies that support an increased risk of cardiovascular disease in PCOS, and further research is needed (Teede et al. 2010). Impaired fetal growth as well as higher weight at birth have been associated with the subsequent development of PCOS in adulthood. PCOS is also associated with precocious pubarche, however effects of age at menarche are unclear; there is evidence both of an increased risk of precocious puberty, and conversely there is evidence suggesting that menarche occurs later in these girls (Hart et al. 2004). PCOS is a leading cause of subfecundity and anovulatory infertility, and there is also evidence of an association with adverse pregnancy outcomes. Pregnancies of women with the syndrome are more likely to be complicated by gestational diabetes, pre-eclampsia, pregnancy hypertension, and preterm labour, and this may be related to the incidence of gestational diabetes in PCOS as well as higher weight gain during pregnancy (Altieri et al. 2010; Iavazzo et al. 2010; Norman et al. 2007). Furthermore, women with PCOS seem to experience increased risk of Cesarean delivery while their newborns face increased perinatal morbidity and mortality, and neonates are more likely to be admitted to intensive care with a higher perinatal mortality rate (Boomsma et al. 2008; Iavazzo et al. 2010). Further a higher prevalence of small for gestational age (SGA) infants has been observed in PCOS mothers (Sir-Petermann et al. 2005). Unopposed estrogens arising from chronic anovulation may constitute a risk for endometrial hyperplasia and cancer and PCOS has also been associated with endometrial cancer in premenopausal women (Pillay et al. 2006). Obesity, acne and excess hair, as well as infertility and long-term health concerns both challenge feminine identity and body image and compromise quality of life and psychological well-being. There are some reports that women who have PCOS are more prone to depression, anxiety, low selfesteem, negative body image, and psychosexual dysfunction (Teede et al. 2010). 4.4.1.4 Aetiology Familial aggregation of PCOS has been recognised for many years and supports the role of genetic factors. The heterogeneity of phenotypic features even within the same family suggests the importance of gestational environment, lifestyle or both (Norman et al. 2007). PCOS does not show Page 168 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME clear Mendelian inheritance and genetic analysis is hampered by low fecundity, age-related changes in reproductive phenotype and different diagnostic criteria. The nature of a male phenotype remains controversial, with familial traits of hyperandrogenism, insulin resistance and associated dyslipidemia found to affect both male and female relatives by some researchers (Kent et al. 2008). Molecular defects in gonadotropins and their receptors, in enzymes involved in steroidogenesis, sex hormone binding globulin, the androgen receptor as well as those underlying insulin action and secretion pathways, have been investigated with variable results and are reviewed by Prapas (2009). A promising candidate gene associated with PCOS is located in a region on chromosome 19 (19p13.2), a region which lies within an intron of the gene encoding for the protein п¬Ѓbrillin 3, which is located near the insulin receptor gene. Although the biological function of п¬Ѓbrillin-3 is unknown, п¬Ѓbrillins can bind transforming growth factor-ОІ (TGF-ОІ) and have been implicated in early follicle development and theca cell formation (Bremer 2010; Mason et al. 2008). Epigenetic variation has also been proposed as a confounding factor. Over time, the focus for the aetiology of PCOS has shifted from the ovary to the hypothalamic–pituitary axis and to defects of insulin activity. There is evidence to all three pathological causes as they interact to regulate ovarian function, and it is possible that many primary disturbances result in the same pathological outcome (Norman et al. 2007). 4.4.2 Evidence for endocrine mechanisms in PCOS The multiple physiological processes involved in PCOS (neuroendocrine, ovarian steroidogenesis and folliculogenesis, insulin resistance) are regulated by hormonal and metabolic parameters, and have been the subject of intense scrutiny and research. In order to comprehend the putative mode-ofaction by which chemicals with endocrine disrupting properties may be involved in the development of the disease, it is important to summarise briefly current knowledge and recent advances. Most women with PCOS have polycystic ovaries (refer to Table 19), characterised by a two- to sixfold increase in the numbers of primary, secondary and tertiary follicles compared to normal ovaries (Shayya et al. 2010). Whether the greater number of follicles is the result of a greater ovarian reserve, an increase in the rate of entry into the growing pool or a decrease in the rate of apoptosis and atresia remains unclear. Many women with polycystic ovaries continue to ovulate (Mason et al. 2008). In anovulatory PCOS, antral follicle growth stops before the selection of a dominant preovulatory follicle. Follicular arrest is associated with excessive stimulation of follicular cells by insulin, LH and a hyperandrogenic environment. A majority of women (60-80%) with PCOS have high concentrations of circulating testosterone and about 25% have high concentration of dehydroepiandrosterone sulphate (DHEAS) (Norman et al. 2007). In premenopausal women, circulating testosterone is derived from the ovary and adrenal, or from the conversion of androstenedione in peripheral tissues, such as adipose tissues (Solorzano et al. 2010a). Adrenal hyperresponsiveness to adrenocorticotropic hormone (ACTH) is a feature in 25% of women with PCOS and leads to excess dehydroepiandrosterone (DHEA), DHEAS and androstenedione (Bremer 2010). Women with PCOS also display abnormal patterns of gonadotropin pulsatility resulting in excessive secretion of luteinising hormone (LH) (Norman et al. 2007). Page 169 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 4.4.2.1 Ovarian steroidogenesis and follicullogenesis Ovarian hyperandrogenism is a result of excessive production by theca cells, and increased circulating androgen levels are due to an intrinsic defect in those cells rather than increased follicle number (Diamanti-Kandarakis et al. 2005). Activity and expression of some steroidogenic enzymes are increased in PCOS thecal cells; particularly, P450c17 and 3ОІ-HSD. Increased intraovarian androgens cause an increase in the proportion of primary follicles. ARs are not detected in primordial follicles and AR mRNA begins to be expressed once follicles reach the primary stage (Mason et al. 2008). The influence of androgens on early follicle growth in polycystic ovaries and is supported by the finding that therapeutic use of the anti-androgen flutamide reduces ovarian volume and improved the abnormal follicle profile of adolescent girls with PCOS (Norman et al. 2007). However androgen production is increased in ovulatory and anovulatory polycystic ovaries and other factors must be involved in anovulation (Mason et al. 2008). In anovulatory PCOS, the increased density of small pre-antral follicles point to an intrinsic abnormality of folliculogenesis in PCOS at the very earliest stages of follicle development and abnormal granulosa cell proliferation. Abnormal local signalling of anti-MГјllerian hormone (AMH), a member of the TGF-ОІ superfamily may play a part in disrupted folliculogenesis (Franks et al. 2008). AMH is thought to have an inhibitory effect on FSH-stimulated follicle growth. Serum levels of AMH in women with PCOS are increased two- or three-fold and AMH produced by granulosa cells from size-matched follicles from ovulatory polycystic and anovulatory polycystic ovaries was found to be on average four times and 75 times higher than in normal ovaries. This suggests that AMH may play a significant role in the inhibition of follicle growth in anovulatory PCOS (Mason et al. 2008). Research centred on finding other locally produced inhibitors of follicle growth found that insulinlike growth factor binding proteins (IGFBP)-2 and -4 were elevated in PCOS follicles and it has been proposed that this extra binding capacity may remove free insulin-like growth factor (IGF) required for the synergistic stimulation of follicle selection of FSH (Mason et al. 2008). 4.4.2.2 Hyperinsulinemia and insulin resistance Insulin resistance in PCOS is tissue-specific whereby some tissue such as skeletal or muscle tissue are highly resistant and others such as the ovary and adrenal are sensitive. Further in PCOS granulosa cells, glucose metabolism is impaired but insulin-stimulated steroidogenesis is normal (Norman et al. 2007). Insulin resistance may contribute to hyperandrogenism and gonadotropins abnormalities through several mechanisms. Insulin can act as a co-gonadotropin with LH in theca cells to increase androgen production and high doses of insulin have been found to stimulate androgen production even in the absence of LH (Solorzano et al. 2010a). Its favourable action on 17О±-hydroxylase, P450c17 and P450scc has been incriminated in the direct stimulation of ovarian androgen production (Diamanti-Kandarakis et al. 2005). Hyperinsulinemia may also promote androgen production by the adrenal gland (Solorzano et al. 2010a), and increase adrenal responsiveness to ACTH for further androgen production (Solorzano et al. 2010b). High concentrations of insulin also decrease hepatic production of sex hormone binding globulin (SHBG), thereby increasing the bioavailability of testosterone. Insulin might also act directly on the regulation of gonadotropin release by the hypothalamus-pituitary, although the Page 170 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME contribution of such as mechanism in PCOS remains uncertain (Norman et al. 2007). The association between hyperinsulinemia and hyperandrogenism is verified by the decrease in serum androgen following treatment with insulin-lowering drugs such as metformin (Shayya et al. 2010). 4.4.2.3 Gonadotropin abnormalities The most common neuroendocrine aberration in women with PCOS is an acceleration of gonadotrophin releasing hormone (GnRH) pulse frequency and amplitude resulting in elevated serum LH concentrations and LH:FSH ratio. This in turns stimulates androgen production in thecal cells (Bremer 2010). The pulse frequency is regulated by progesterone negative feedback, although estradiol also probably plays a permissive role by inducing the expression of progesterone receptors in the hypothalamus. It is now generally accepted that the persistently rapid GnRH pulse frequency in PCOS is not a primitive phenomenon but secondary to impaired ovarian feedback, whereby existing hyperandrogenism impairs the response to progesterone feedback and the maintenance of increased LH pulse frequency stimulating further ovarian androgen production (Solorzano et al. 2010a). 4.4.2.4 Adrenal The adrenal gland may be an important source of hyperandrogenism in non-obese subjects. Hypersecretion of adrenocortical products basally and in response to ACTH stimulation has been observed by some researchers in PCOS women and this was not attributed to the altered sensitivity of the pituitary to stimulation with corticotrophin-releasing hormone, or increased sensitivity of the adrenal to ACTH stimulation but to the increased activity of P450c17 (Bremer 2010; Yildiz et al. 2007). 4.4.3 Evidence for a role of chemical exposures in PCOS Although the disturbed endocrine processes involved in the development and clinical manifestations of PCOS are well described, research into the aetiology of the syndrome has focused on genetics and there is a dearth of evidence that exposure to exogenous chemicals is involved in PCOS. This may be explained by the fact that the endocrine disruption mechanism of interest is excess androgens and until recently very few environmental chemicals had been shown to have androgenic properties. Some flame retardants (hexabromocyclodecane, penta-bromodiphenylether and hexabromodiphenylether) and the antimicrobial compounds triclosan and triclocarban which are widely used in personal care products have now been shown to exhibit androgenicity in in vitro assays (Christen et al. 2010). Screening compounds for androgenic activity as well as epidemiological studies investigating an association with PCOS should be a priority for endocrine disruption research. An interest in an androgenic mode-of-action is derived to experimental models of the syndrome whereby prenatal androgens elicit traits that mimic the manifestation of PCOS in humans. Animal models are discussed in more detail in 4.4.4 and 4.4.5. This does not however preclude the possibility that other endocrine disruption modes-of-action may contribute to the development of the disorder, as illustrated by the interactions between neuroendocrine, ovarian, adrenal and metabolic processes described in the previous section. Moreover, there is recent evidence that Page 171 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME gonadotropin-suppressive therapy increases the risk of developing PCOS in girls with precocious puberty, although it could be argued that there are underlying anomalies in endocrine processes in this population (Chiavaroli et al. 2010). To our knowledge, the only environmental contaminant that has been associated with PCOS is bisphenol A. Bisphenol A levels were significantly increased in the serum of women with PCOS. However elevated androgen concentrations decrease bisphenol A clearance and the raised bisphenol A levels in serum of PCOS women may be a consequence of hyperandrogenism rather than implicated in the aetiology of the syndrome (Crain et al. 2008). 4.4.4 Critical windows of susceptibility Evidence of a fetal origin for the development of the PCOS phenotypes stems both from animal models and epidemiological studies. Experimental data from animal models is relevant to endocrine disruption as putative androgenic mode-of-action, whilst a potential association between birth weight and exposure to endocrine-disrupting chemicals is discussed in more details in the chapter on fertility and birth outcomes. Prenatal treatment of non-human primates, sheep and rats gives rise to phenotypes sharing several features of the PCOS phenotype in humans. Intrauterine androgen exposure leads to the development of hyperandrogenism, LH hypersecretion, oligo- or anovulation and insulin resistance associated with visceral adiposity, impaired glucose metabolism, and dyslipidemia in monkeys (Bremer 2010). Prenatally testosterone-treated female monkeys also show adrenal hyperandrogenism, presumably resulting from enhanced P450c17 activity, while basal and ACTHstimulated cortisol levels are normal (Bremer 2010; Dumesic et al. 2007). IUGR and low birth weight is observed in prenatally androgenised female sheep and rats, but not in monkeys. Further in a sheep model when exposed to testosterone near term, IUGR is followed by postnatal weight gain (catch-up growth); whereas monkeys exposed early in gestation exhibit increased body weight during infancy and late adolescence as well as delayed puberty. The sheep model also shows a proportionate increase in fetal adrenal weight with growth retardation. The sheep and rat models have been argued to be suitable models of PCOS with placental insufficiency (Dumesic et al. 2007). Therefore, in addition to the heterogeneity of phenotypes in humans, the study of critical windows of exposure in animal models is further complicated by the fact that their relevance may be limited to specific features of the syndrome. Limitations of animal models are further discussed in 4.4.5. In the literature, it is generally accepted that different PCOS phenotypes are associated with different PCOS symtoms such as low and high birth weight or birth from overweight mothers (Diamanti-Kandarakis et al. 2005). The picture emerging from recent epidemiological studies is however more ambiguous. A recent prospective birth cohort study in Brazil found a higher prevalence of PCOS in women born SGA, while hyperandrogenism and lower circulating sex hormone binding globulin (SHBG) were also associated with SGA (Melo et al. 2010). A case-control study found that infants of women with PCOS were more likely to be large for gestational age and cord blood levels of androstenedione and estradiol were also decreased in female offspring of PCOS women (Anderson et al. 2010). However, a large familial study failed to link birth weight with familial Page 172 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME phenotype and found no significant difference between birth weight in PCOS families and controls or US population data (Legro et al. 2010). As the full spectrum of symptoms associated with PCOS does not become apparent until puberty, a “two-hit” hypothesis has been proposed. An initial androgen excess resulting from one or more of a number of possible mechanisms, including primary adrenal, ovarian, neuroendocrine abnormalities, hyperinsulinemia, and prenatal, perinatal or peripubertal androgen exposure leads to hyperandrogenism. This hyperandrogenism impairs the sensitivity of the GnRH pulse to progesterone-mediated feedback initiating a vicious circle of sustained hyperandrogenism (see section 4.4.2.3) that eventually leads to ovulatory dysfunction and PCOS (Bremer 2010). 4.4.4.1 Androgen excess and fetal programming Exposure of the female fetus to androgens at a time when target organ systems such as those regulating reproduction and metabolism are differentiating could alter their ontogenic development and phenotypic expression. The hyperandrogenic phenotype of PCOS ovarian theca cells is thought to be programmed during tissue differentiation by an altered intrauterine hormonal milieu (Xita et al. 2006). This is consistent with the increased risk of women with congenital adrenal hyperplasia or congenital adrenal virilising tumours of developing PCOS in adolescence, despite the normalisation of androgen levels after birth (Bremer 2010). Both maternal and fetal hyperandrogenism are plausible mechanisms of fetal androgen excess and programming of PCOS, although transmission of androgen excess from mother to female fetus has been thought not to occur unless fetal function is compromised. Barry et al (2010) measured umbilical vein testosterone levels in female infants of PCOS women comparable to that of boys of normal women, while another study found no association between prenatal androgen levels and the PCOS in adolescence (Hickey et al. 2009). Although these results may appear contradictory, they seem to highlight the aetiological importance of genetic susceptibility, as elevated androgen levels in pregnancy would not be sufficient to program PCOS in the offspring. Another mechanism of fetal programming by androgen excess which has incited much interest is epigenetic change in gene expression, as it may explain the heterogenous phenotypic presentation of the syndrome that occurs in sisters with the same genotype. Hickey et al (2006) presented evidence that differential X chromosome inactivation occurred in the majority of such cases. Zhu et al (2010) showed that high levels DHEA induce demethylation of the LHR in an artificial PCOS mouse model. If the DHEA-induced demethylation of the luteinising hormone receptor (LHR) may only be relevant to the mouse, rather than the human situation, it provides evidence that epigenetic changes may play a role in the aetiology of PCOS. Further AR signalling has recently been shown to be involved in epigenetic mechanisms (refer to 3.4). 4.4.4.2 Hyperinsulinemia and dyslipidemia Obesity-related hyperinsulinemia has received attention as an etiological factor in the development of PCOS. The potential contribution of EDCs to obesity is discussed in 6.2. Obesity-related hypersinsulinemia is hypothesised to lead to hyperandrogenism during the pubertal transition thereby promoting progression towards the PCOS phenotype. It is also possible that other factors Page 173 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME associated with obesity such as inflammation markers and changes in cytokines and adipokines play a role in obesity associated hyperandrogenemia (Solorzano et al. 2010a). Fat deposition in humans is sexually dimorphic, and another hypothesis is that visceral fat deposition may be a metabolic trait reprogrammed in utero at a time of tissue differentiation (Xita et al. 2006). 4.4.5 Do current experimental approaches capture relevant endpoints/mechanisms? Chronic OECD guideline studies such as the 1-generation assay (TG 415 enhanced) or 2-generation assay (TG 416 enhanced) require the histopathology of reproductive organs and as such the number of primordial and small growing follicles should be enumerated. The use of rodents in such guideline studies offers advantages in terms of their short life-cycle and constant genetic background. Interpretation of any ovarian abnormalities has to be made in the light of differences between rodents and primates and multiple cystic follicles in anovulatory rodents do not necessarily equate to polycystic ovaries in humans (Franks 2009). There are differences between non-primate mammals and primates in the mechanism of anovulation induced by prenatal or perinatal exposure to androgens. Androgen excess in nonprimates suppresses the ability of the hypothalamus-pituitary to generate the LH surge necessary to induce ovulation in response to rising estradiol levels and the ovary appears functionally unaffected. In non-human primates however the mechanisms involved in anovulation are altered steroid negative feedback regulation of LH and hyperinsulinemia, reflecting a more subtle form of ovulatory dysfunction more akin to the ovulatory abnormality found in PCOS women. In prenatally androgenised ewes, there is a finite development period during which androgen excess can abolish the hypothalamic GnRH surge and there is evidence that ovarian function may also be compromised (Abbott et al. 2005). Thus, whilst rodent studies should in theory be able to detect compounds acting via an androgenic mode of action, the relevance and sensitivity of the endpoints monitored would give little information on the potential increased risk of genetically susceptible women to develop PCOS. Page 174 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 4.4.6 Conclusions Attribution criteria: PCOS Whilst the pathophysiological endocrine criteria INTACT MET processes involved in PCOS are fairly well criteria described, there is still a lack of consensus MET MULTI-LEVEL over which comprise the syndrome. Genetic criteria MOSTLY HORMONE markers of the disease have remained elusive MET evidence and are consistent with an interaction UNCLEAR PRIMARY EFFECT between genetic susceptibility and criteria PARTLY environmental and lifestyle factors. As stated EXPOSURE MET in the 2002 Global Assessment of Endocrine criteria MET SENSITIVE LIFESTAGE Disrupters, вЂ�the interest in this syndrome in criteria MOSTLY relation to environmental chemicals stems PHARM. RESTORATION MET criteria from the animal literature’ and the dearth of MOSTLY SUPPORTING DATA MET epidemiological research addressing a potential increased risk from environmental contaminants is striking and ought to be addressed in the light of the common prevalence of this disorder, and its consequences on the quality of life of the individuals affected and the associated economic burden. Page 175 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 4.4.6.1 Can PCOS be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. (yes/no) Criteria MET Evidence summary Ovary, adrenal, hypothalamus-pituitary Criteria MET The syndrome is characterised by abnormal circulating hormone levels such as androgens, gonadotropins or insulin and this can be related for example to steroidogenic activity of theca cells. Criteria MOSTLY MET Several animal models develop PCOS traits after prenatal androgen exposure, but their relevance to the syndrome in humans is still being questioned. Evidence unclear Association with IUGR could be interpreted by some as general toxicity? Search did not yield clear doseresponse data, however there is no evidence of systemic toxicity either. Criteria PARTLY MET GnRH suppression in girls with precocious puberty? Criteria MET Prenatal and peripubertal stage Criteria MOSTLY MET Metformin treatment Criteria MOSTLY MET Yes if an androgenic mode of action is assumed. Page 176 of 486 HUMAN HEALTH ENDPOINTS POLYCYSTIC OVARIES SYNDROME 4.4.7 References Abbott DH, Barnett DK, Bruns CM, Dumesic DA. 2005. Androgen excess fetal programming of female reproduction: a developmental aetiology for polycystic ovary syndrome? Human Reproduction Update 11:357-374. Altieri P, Gambineri A, Prontera O, Cionci G, Franchina M, Pasquali R. 2010. Maternal polycystic ovary syndrome may be associated with adverse pregnancy outcomes. European Journal of Obstetrics & Gynecology and Reproductive Biology 149:31-36. Anderson H, Fogel N, Grebe SK, Singh RJ, Taylor RL, Dunaif A. 2010. Infants of Women with Polycystic Ovary Syndrome Have Lower Cord Blood Androstenedione and Estradiol Levels. Journal of Clinical Endocrinology & Metabolism 95:2180-2186. Barry JA, Kay AR, Navaratnarajah R, Iqbal S, Bamfo JEAK, David AL, Hines M, Hardiman PJ. 2010. Umbilical vein testosterone in female infants born to mothers with polycystic ovary syndrome is elevated to male levels. Journal of Obstetrics and Gynaecology 30:444-446. Boomsma CM, Fauser BCJM, Macklon NS. 2008. Pregnancy complications in women with polycystic ovary syndrome. Seminars in Reproductive Medicine 26:72-84. Bremer AA. 2010. Polycystic Ovary Syndrome in the Pediatric Population. Metabolic Syndrome and Related Disorders 8:375-394. Chiavaroli V, Liberati M, D'Antonio F, Masuccio F, Capanna R, Verrotti A, Chiarelli F, Mohn A. 2010. GNRH analog therapy in girls with early puberty is associated with the achievement of predicted final height but also with increased risk of polycystic ovary syndrome. European Journal of Endocrinology 163:55-62. Christen V, Crettaz P, Oberli-Schrammli A, Fent K. 2010. Some flame retardants and the antimicrobials triclosan and triclocarban enhance the androgenic activity in vitro. Chemosphere 81:1245-1252. Crain DA, Janssen SJ, Edwards TM, Heindel J, Ho SM, Hunt P, Iguchi T, Juul A, McLachlan JA, Schwartz J, Skakkebaek N, Soto AM, Swan S, Walker C, Woodruff TK, Woodruff TJ, Giudice LC, Guillette LJ, Jr. 2008. Female reproductive disorders: the roles of endocrinedisrupting compounds and developmental timing. Fertil Steril 90:911-940. Diamanti-Kandarakis E, Piperi C. 2005. Genetics of polycystic ovary syndrome: searching for the way out of the labyrinth. Human Reproduction Update 11:631-643. Dumesic DA, Abbott DH, Padmanabhan V. 2007. Polycystic ovary syndrome and its developmental origins. Reviews in Endocrine & Metabolic Disorders 8:127-141. Franks S. 2009. Do Animal Models of Polycystic Ovary Syndrome Help to Understand Its Pathogenesis and Management? Yes, but Their Limitations Should be Recognized. Endocrinology 150:3983-3985. Franks S, Stark J, Hardy K. 2008. Follicle dynamics and anovulation in polycystic ovary syndrome. Human Reproduction Update 14:367-378. Hart R, Hickey M, Franks S. 2004. Definitions, prevalence and symptoms of polycystic ovaries and polycystic ovary syndrome. Best Practice & Research in Clinical Obstetrics & Gynaecology 18:671-683. Hickey M, Sloboda DM, Atkinson HC, Doherty DA, Franks S, Norman RJ, Newnham JP, Hart R. 2009. The Relationship between Maternal and Umbilical Cord Androgen Levels and Polycystic Ovary Syndrome in Adolescence: A Prospective Cohort Study. Journal of Clinical Endocrinology & Metabolism 94:3714-3720. Hickey TE, Legro RS, Norman RJ. 2006. Epigenetic modification of the X chromosome influences susceptibility to polycystic ovary syndrome. Journal of Clinical Endocrinology & Metabolism 91:2789-2791. Iavazzo C, Vitoratos N. 2010. Polycystic ovarian syndrome and pregnancy outcome. Archives of Gynecology and Obstetrics 282:235-239. Kent SC, Gnatuk CL, Kunselman AR, Demers LM, Lee PA, Legro RS. 2008. Hyperandrogenism and hyperinsulinism in children of women with polycystic ovary syndrome: A controlled study. Journal of Clinical Endocrinology & Metabolism 93:1662-1669. Legro RS, Roller RL, Dodson WC, Stetter CM, Kunselman AR, Dunaif A. 2010. Associations of Birthweight and Gestational Age with Reproductive and Metabolic Phenotypes in Women with Polycystic Ovarian Syndrome and Their First-Degree Relatives. Journal of Clinical Endocrinology & Metabolism 95:789-799. Mason H, Colao A, Blume-Peytavi U, Rice S, Qureshi A, Pellatt L, Orio F, Atkin SL. 2008. Polycystic ovary syndrome (PCOS) trilogy: a translational and clinical review. Clinical Endocrinology 69:831-844. Melo AS, Vieira CS, Barbieri MA, Rosa-e-Silva A, Silva AAM, Cardoso VC, Reis RM, Ferriani RA, Silva-de-Sa MF, Bettiol H. 2010. High prevalence of polycystic ovary syndrome in women born small for gestational age. Human Reproduction 25:2124-2131. Norman RJ, Dewailly D, Legro RS, Hickey TE. 2007. Polycystic ovary syndrome. Lancet 370:685-697. Pillay OC, Te Fong LFW, Crow JC, Benjamin E, Mould T, Atiomo W, Menon PA, Leonard AJ, Hardiman P. 2006. The association between polycystic ovaries and endometrial cancer. Human Reproduction 21:924-929. Prapas N, Karkanaki A, Prapas I, Kalogiannidis I, Katsikis I, Panidis D. 2009. Genetics of Polycystic Ovary Syndrome. Hippokratia 13:216-223. Shaw L, Elton S. 2008. Seasonality, Climatic Unpredictability, Food Deprivation, and Polycystic Ovary Syndrome. Medicine and Evolution: Current Applications, Future Prospects 48:77-97. Shayya R, Chang RJ. 2010. Reproductive endocrinology of adolescent polycystic ovary syndrome. Bjog-An International Journal of Obstetrics and Gynaecology 117:150-155. Sir-Petermann T, Hitchsfeld C, Maliqueo M, Codner E, Echiburu B, Gazitua R, Recabarren S, Cassorla F. 2005. Birth weight in offspring of mothers with polycystic ovarian syndrome. Human Reproduction 20:2122-2126. Solorzano C, McCartney CR. 2010a. Obesity and the pubertal transition in girls and boys. Reproduction 140:399-410. Solorzano CMB, McCartney CR, Blank SK, Knudsen KL, Marshall JC. 2010b. Hyperandrogenaemia in adolescent girls: origins of abnormal gonadotropin-releasing hormone secretion. Bjog-An International Journal of Obstetrics and Gynaecology 117:143-149. Teede H, Deeks A, Moran L. 2010. Polycystic ovary syndrome: a complex condition with psychological, reproductive and metabolic manifestations that impacts on health across the lifespan. Bmc Medicine 8. Witchel SF. 2006. Puberty and polycystic ovary syndrome. Molecular and Cellular Endocrinology 254:146-153. Xita N, Tsatsoulis A. 2006. Review: Fetal programming of polycystic ovary syndrome by androgen excess: Evidence from experimental, clinical, and genetic association studies. Journal of Clinical Endocrinology & Metabolism 91:1660-1666. Yildiz BO, Azziz R. 2007. The adrenal and polycystic ovary syndrome. Reviews in Endocrine & Metabolic Disorders 8:331-342. Zhu JQ, Zhu L, Liang XW, Xing FQ, Schatten H, Sun QY. 2010. Demethylation of LHR in dehydroepiandrosterone-induced mouse model of polycystic ovary syndrome. Molecular Human Reproduction 16:260-266. Page 177 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES 4.5 FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES In the WHO/IPCS 2002 Global Assessment of Endocrine Disrupters, fecundity and fertility were not addressed separately for men and women. Endocrine processes that underlie the functioning of the female reproductive are very complex and exhibit great plasticity throughout a woman’s lifetime. The possibility that chemical exposures could affect pregnancy outcomes is not new but in recent years the fact that EDCs could contribute to female fertility outcomes has received greater interest. Although the terms fecundity and fertility are often used interchangeably, fecundity can be defined as the biological capacity for conception, whereas fertility refers to the ability to deliver a live-born infant (Buck Louis et al. 2006). In this section, the evidence that EDCs could be implicated in female fertility is addressed from a uterine perspective, while endpoints primarily related to fecundity and ovarian dysfunction are discussed in section 4.3. Adverse pregnancy outcomes include spontaneous abortion, ectopic pregnancies, fetal death, stillbirth, preterm delivery, low birth weight, sex ratio and certain congenital defects. It is important to note that if these endpoints are considered here primarily from a female reproductive health perspective, there are toxicological studies demonstrating an effect of male parent exposure to drugs and chemicals on preimplantation loss, embryonic death and morphologic abnormalities as well as epidemiological studies that have reported associations between paternal exposure and adverse developmental outcome in surviving children (Silbergeld et al. 2005). 4.5.1 The natural history of female fertility and adverse pregnancy outcomes There is evidence of an association between subfecundity and adverse pregnancy outcomes. A prolonged time-to-pregnancy (TTP) was found for pregnancies ending in miscarriage and extrauterine pregnancies. A long TTP has also been found to be a risk factor for preterm delivery, low birth weight and neonatal death (Axmon et al. 2005; Raatikainen et al. 2010). However, unless biological measures to detect pregnancy such as chorionic gonadotropin are used in a TTP study, the difference between a prolonged TTP and early miscarriage depends on a woman’s own ability to detect pregnancy. Increased TTPs have been observed after a miscarriage or termination (Hassan et al. 2005). 4.5.1.1 Spontaneous abortions due to uterine defects Spontaneous abortions are defined as “the expulsion or extraction from its mother of an embryo or fetus weighing 500 g or less”. Those that occur before week 12 of gestation are referred to as early spontaneous abortions, with late spontaneous abortions being those that occur from week 12 to 20 of pregnancy (Weselak et al. 2008). It is estimated that 20-40% of pregnancy losses occur before clinical detection and to our knowledge, there are no reports of incidence trends in the rate of clinically recognised spontaneous abortions. Pregnancy loss is thought to be related to genetic, infectious, hormonal and/or immunological factors. Page 178 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Congenital malformations of the uterus, acquired uterine defects such as fibroids and cervical incompetence are commonly considered to be associated with spontaneous abortion. Uterine abnormalities are thought to occur in 1.9% of the female population and 13-30% of women with recurrent spontaneous abortions (Weselak et al. 2008). 4.5.1.2 Preterm delivery and low birth weight Prematurity has been defined as a birth weight less than or equal to 2,500 g. This definition does however encompass three types of infants: those born preterm, those born at term but whose growth was restricted in utero and those who are both growth-retarded and premature. Current WHO nomenclature refers to an infant as вЂ�low birth weight’ if it weighs less than 2,500g at birth, and вЂ�preterm’ refers to a birth that occurs before 37 complete weeks of gestation. Many preterm infants are also growth-retarded suggesting some overlap between the etiological risk factors for preterm birth and intrauterine growth restriction (IUGR) (Berkowitz et al. 1993). Birth weight and gestational age are important predictors of neonatal and infant health, and small for gestational age (SGA) infants have a 4-to 5-fold higher risk of infant mortality. IUGR also carries a significant risk of morbidity later in life such as chronic hypertension, heart disease, lung disease and type 2 diabetes (Stillerman et al. 2008). 4.5.1.2.1 Preterm delivery The principal pathways leading to preterm birth are spontaneous preterm labour (28 to 64 %) and premature rupture of the membranes (7 to 51 %), iatrogenic causes accounting for 19 to 29 % of preterm delivery in a review of published reports (Berkowitz et al. 1993). Inconsistent case definitions have been proposed to explain the wide ranges. Pregnancy complications associated with preterm delivery include placental abruption, antepartum bleeding, cervical incompetence and uterine anomalies. Intrauerine infections may also play an important etiological role in preterm delivery (Berkowitz et al. 1993). Increases in preterm birth rates have been reported in the United States and Canada (Stillerman et al. 2008; Wen et al. 2003). In 2004, 12.5 % of births were reported as preterm in the United States, a rise of more than 30 % since 1981 (Stillerman et al. 2008). There are also racial differences in the United States, with black women having a higher rate of preterm births than white women (Berkowitz et al. 1993). There is some evidence of a seasonal pattern of preterm births, thought to be consistent with an infectious aetiology. Endocrine and nutritional factors could also follow seasonal patterns, and it is equally possible that temporal patterns reflect demographic characteristics related to the season of conception (Berkowitz et al. 1993). 4.5.1.2.2 Low birth weight Trends for weight at birth differ across countries. In the United States, following declines in the 1970s and early 1980s, the proportion of newborns with low birth weight has risen 16% since the 1990s to 8.1% of births in 2004 (Stillerman et al. 2008). In Canada, a temporal increase in fetal growth (birth weight for gestational age) has been observed (Edwards et al. 2010; Wen et al. 2003). An increase in weight at birth has also been observed in Australia and Denmark (Lahmann et al. 2009; Schack-Nielsen et al. 2006). In Australia, the increase in mean birth weight and prevalence of high birth weight were confined to non-Indigenous newborns (Lahmann et al. 2009). In contrast, in Argentina, a negative secular trend for birth weight was observed with a concurrent increase in low Page 179 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES and very low birth weight infants (Grandi et al. 2008). An association between low weight at birth and stress was shown both in Bosnia-Herzegovina and Croatia, with lower birth weight during the 1992-1995 war than before or after (Bralic et al. 2006; Skokic et al. 2006). In the United States, an increase in multiple births, which often occur preterm, as well as changes in obstetric practices such as the induction of labour have been hypothesised to contribute to lower birth weight (Stillerman et al. 2008; Zhang et al. 2010). Nonetheless, the rate of low birth weight in singleton births has also increased and labour induction could not explain the negative trend in another recent study (Donahue et al. 2010). In Canada and Denmark, increasing maternal age and weight were offered as likely explanations for the increases in birth weight (Edwards et al. 2010; Schack-Nielsen et al. 2006). 4.5.1.3 Hypertensive disorders Hypertensive disorders of pregnancy include pregnancy-induced hypertension and pre-eclampsia (newly diagnosed hypertension is accompanied by proteinuria) and complicate 2–8% of all pregnancies. There is recent evidence that their incidence may be increasing in the United States (Wallis et al. 2008). Pre-eclampsia is a major cause of maternal and perinatal morbidity and mortality (Steegers et al. 2010), and severe pregnancy-induced hypertension has been reported to have similar effects on stillbirths and neonatal death (Ananth et al. 2010). Poor early placentation is associated with early onset disease while predisposing cardiovascular or metabolic risks such as diabetes dominate in the origins of late onset pre-eclampsia (Steegers et al. 2010). Little is known about the potential impact of environmental factors in the aetiology of these disorders. 4.5.1.4 Birth defects Estimates for the United States indicate that 1 in 33 infants has a congenital anomaly, the most commonly reported being cleft lip/palate (75.9 per 100 000 births in 2003) and heart malformations and other circulatory/respiratory anomalies (255 per 100 000 births). Orofacial clefts and Down Syndrome affect approximately 6,800 and 5,500 infants annually in the United States. Male urogenital abnormalities such as cryptorchidism and hypospadia have been associated with the testicular dysgenesis syndrome and are discussed in detail in section 4.1. 4.5.1.5 Sex ratio The expected ratio of male to female births is generally believed to be 1.05, equivalent to a proportion of male births of 0.515. National sex ratios are known to vary over time, and these variations have been ascribed to changing methods of reporting, as well as reductions in the rates of spontaneous abortions due to a healthier population and/or better gynaecologic or antenatal care (James 2006a). The proportion of male births (sex ratio at birth) declined in Brazil between 1979 and 1993, followed by a subsequent rise of this ratio between 1995 and 2004. Geographical differences suggest the influence of different environmental factors such as demographic changes, access to public health services distribution, exposure to environmental stressors (Gibson et al. 2009). Sex ratio at birth has also declined in Japan (1970-2002) and the United States (1970-2002). Concurrent increasing trends for the male proportion of fetal death were also observed. No declining trend was observed in African Americans, whose sex ratio at birth remains significantly lower than that of whites (Davis et al. 2007). Several medical conditions in men and women prior to conception have been found to influence sex ratio in offspring, and it has been proposed that endocrine changes Page 180 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES subsequent to the disease or its treatment could influence the gender of the offspring (James 2001). Other putative factors include changes in parental age, obesity, assisted reproduction and nutrition. 4.5.2 Evidence of endocrine mechanisms in female fertility & other pregnancy outcomes Dysfunction of the uterus or other MГјllerian tissues (oviduct, cervix, and upper vagina) can result in infertility, pregnancy loss, or fetal compromise, and maldevelopment. Miscarriage, pre-eclampsia, and IUGR are the most common pregnancy complications and are principally disorders of implantation (abnormal placentation and abnormal decidual-placental interactions) (Crain et al. 2008). They share a fundamental mechanism based on oxidative damage and it has been proposed to be the result of disruption of the endocrine processes that prepare the uterus for pregnancy during the menstrual cycle. If the embryo survives beyond the first trimester, reduced placental blood flow would result in progressive placental damage, IUGR, preterm birth of the fetus, and preeclampsia in the mother. A number of endocrine disorders are implicated in spontaneous abortions, including diabetes, hypoand hyperthyroidism, oligomenorrhea, PCOS, hyperandrogenemia, hyperprolactinemia (Weselak et al. 2008). Lower midluteal progesterone has been associated with failure to conceive and women with ectopic pregnancies have been found to have lower progesterone levels than those with normal intrauterine pregnancies (Axmon et al. 2005). It has been reported than even a partial withdrawal of progesterone in late pregnancy reduces placental and fetal growth, while low estrogen has also been associated with adverse pregnancy outcomes (Bowman et al. 2010). 4.5.2.1 The oviduct and ectopic pregnancy The oviduct or Fallopian tube is a thin muscular tube that consists of internal stroma tissue covered with ciliated and secretory epithelial cells whose secretions coat the ovum and provide nutrition to the embryonic blastocyst. Its main functions also include the synchronised transport of male and female gametes, fertilisation and transport of the embryo to the uterus for implantation (Hernandez-Ochoa et al. 2009). Implantation within the oviduct itself must be avoided. Propulsion through the oviduct is achieved via the complex interactions of muscle contractions, ciliate activity and the flow of tubular secretions. Proliferation, differentiation and motility of ciliated cells require the coordinated regulation and interaction of estrogens and progesterone. Evidence suggests that the AhR is involved in controlling activity of the ciliated cells by modulating the ER-signalling pathway (Hernandez-Ochoa et al. 2009). Kisspeptins have been proposed to regulate implantation by limiting the invasion of the trophoblast into the maternal deciduas, and their cycle-specific pattern of expression in the rat oviduct has been proposed to play a role in the prevention of tubal implantation (Gaytan et al. 2007). 4.5.2.2 The uterine endometrium, implantation and placentation Implantation is a complex event requiring synchronisation between the developing embryo and the receptivity of the uterine endometrium. Estrogens and progesterone prepare the endometrium for implantation during the menstrual cycle. Progesterone acts by inhibiting contraction of the uterus and the development of new follicles. Estrogens cause a thickening of the endometrium as a result Page 181 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES of both stromal and surface epithelium cell proliferation. This proliferative phase is followed by the secretory phase or pre-implantation period, when a rise in progesterone stimulates the secretion of glycoproteins, sugars and amino acids (Bowman et al. 2010). Following fertilisation, the developing embryo secretes human chorionic gonadotropin, which sustains progesterone levels (Weselak et al. 2008). Early gestation is characterised by the luteal-placental shift in estrogen and progesterone production initiated around the time of implantation. This shift appears to be regulated in part by locally produced growth factors including insulin growth factors (IGFs) coincident with decreased estrogen receptors (ERs) and increased IGF1 and prolactin secretion by the stroma (Bowman et al. 2010). This triggers uterine proliferation and formation of the decidua. The primary function of the placenta is to provide the embryo with nutrients and oxygen, and remove waste. This exchange is driven by both maternal and fetal endocrine signals (Bowman et al. 2010). Several signalling pathways in the various processes of implantation and placentation have been the focus of particular scientific attention. The role of IGF signalling in placental maintenance, placental function of nutrient transporters, placental cellular differentiation/turnover/apoptosis, and critical signalling necessary to maintain pregnancy has been recently reviewed (Bowman et al. 2010). The involvement of prostaglandins in implantation has also been reviewed (Kennedy et al. 2007). Finally, the role played by Homeobox (HOX) genes in implantation has come to the fore. HOX genes have a well characterised role in embryonic development, where they determine identity along the anteroposterior body axis. HOXA10 and HOXA11 show a temporal pattern of expression in uterine epithelium through the reproductive cycle, with significantly higher levels in the mid- and late secretory phases that correspond to peak functional differentiation (Daftary et al. 2006). In the event of pregnancy, persistent high HOXA10 mRNA levels are observed in the deciduas, consistent with its role in implantation. HOXA10 and HOXA11 are expressed in term human deciduas suggesting a role for Hox genes in duration of gestation downstream of progesterone. Estradiol, progesterone, testosterone, retinoic acid, and vitamin D have been shown to regulate Hox genes expression (Daftary et al. 2006). 4.5.2.3 Sex ratio If it is widely accepted that endocrine disruptors and other environmental factors can induce changes in sex ratio in many animal species including mammals, there is a general agreement that adaptive variation of sex ratio at birth has not been decisively demonstrated in primates (James 2006b). The traditional view is that sex ratio is the sole result of sex-related fetal mortality. Higher mortality of male embryos is putatively explained by the fact that deleterious genes on the Xchromosome are not compensated for by normal genes on a second X-chromosome. Epigenetic differences produced by the presence of one or two X-chromosomes have recently been proposed as the principal cause of the male and female pre-implantation differences (Gutierrez-Adan et al. 2006). Some illnesses associated with altered hormone levels such as Non-Hodgkin’s lymphoma or testicular cancer in men or multiple sclerosis and PCOS in women are associated with excess daughters or sons, respectively (James 2006b). This with evidence that accidental or occupational exposure to some chemicals could induce similar effects led James to formulate his hypothesis that hormone levels in each parent at the time of conception would influence the sex ratio of their offspring. The mechanism proposed is one by which hormones differentially affect the probability of Page 182 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES an X- or Y-bearing chromosome to fertilise the ovum. Jongbloet et al (2002) proposed that the sex ratio may be influenced by oocyte maturation and the quality of the cervical mucus and that disruption of optimal hormonal modulation of this mechanism may result in differential migration of of Y-chromosome and X-chromosome bearing sperm. 4.5.3 Evidence for a role of chemical exposures in female fertility and pregnancy outcomes 4.5.3.1 DES and other pharmaceutical hormones Uterine and cervical abnormalities, including cervical incompetence are known to be associated with in utero exposure to diethylstilbestrol (DES) and the female offspring of women prescribed DES during pregnancy have also been found to have higher rates of preterm delivery (Berkowitz et al. 1993). If prenatal exposure to DES is associated with anatomic anomalies of the reproductive tract in women and of the urogenital tract in men, a recent large, multi-centre study of prenatal DES exposure reported an association with birth defects generally, and an excess of heart defects in third generation daughters (Titus-Ernstoff et al. 2010). A systematic review of the benefits and harm of progesterone administration for the prevention of preterm birth found it was associated with a significant reduction in preterm birth before 34 weeks and no statistically significant difference in perinatal death (Dodd et al. 2008). In contrast, unintentional pregnancies that occur 1 to 2 months after administration of the injectable progestin contraceptive Depo-Provera have been found to be at increased risk for fetal growth restriction, low birth weight and neonatal death (Crain et al. 2008). With regards to aneuploidy, no significant association was found between fertility drugs and oral contraceptive use during pregnancy and Down Syndrome (reviewed in Pacchierotti et al. (2006)). However these studies did not categorise cases by parent of origin and timing of meiotic error. Yang et al. (1999) found an association between maternal smoking and a subset of cases in younger mothers and the risk was further increased by oral contraceptive use around the time of conception, although contraceptive use alone was not itself found to be a risk. 4.5.3.2 Smoking and pregnancy Cigarette smoke consists of a complex mixture of substances including polycyclic hydrocarbons, lead and cadmium. Infants born to smokers weigh substantially less than infants born to non-smokers and exposure to second hand smoke is also a risk factor for low birth weight and preterm birth. However due to the number of chemicals contained in cigarette smoke, it is not possible to attribute these effects to the EDCs contained in this complex mixture. 4.5.3.3 Environmental contaminants Epidemiological evidence of effects of environmental contaminants on female fertility has been the subject of recent reviews (Buck Louis et al. 2006; Mendola et al. 2008; Woodruff et al. 2008). Results of relevant studies on effects on pregnancy outcomes are summarised in Table 20. Like TTP in relation to female fecundity, any fertility or pregnancy outcome endpoint suffers from the difficulty to differentiate between effects of paternal and maternal exposure. Page 183 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Again, the epidemiological evidence summarised here is far from an exhaustive review of the vast literature on effects of environmental contaminants on female fertility and birth outcomes. Studies are somewhat less restricted to accidental or occupational exposures to persistent contaminants. Evidence of an effect of lead remains inconclusive from results of the recently reviewed epidemiological studies (Table 20). The sample size for the study of bisphenol A was small and the association with recurrent miscarriage should be explored further (Table 20). Aneuploidy is a common cause of spontaneous abortion (see section 4.3) and recent interest in the endocrine or paracrine control of meiosis was sparked by effects of bisphenol A on the incidence of aneuploid oocytes in mice. The relatively rare incidence of genetic diseases impedes the epidemiological study of clusters of cases and environmental influences. A cluster of congenital abnormalities including Down syndrome in a Hungarian village was connected to the excessive use of the widely used organophosphorus pesticide Trichlorfon at local fish farms (Table 20). A ten-year study found higher bisphenol A concentrations in the maternal serum of mothers of foetuses with an abnormal kariotype compared to that of mothers of foetuses with a normal kariotype (Table 20). Studies of pesticides where the pesticide class or active ingredient is not specified give conflicting results (Table 20). Agricultural workers come in contact with a variety of other agents such as dust, molds, mycotoxins, and zoonoses, which may have an impact on the outcome (Weselak et al. 2008). One study in the Philippines compared households that use integrated pest management to households who used pesticides conventionally. Approximately 1,400 different brands of pesticides were used in the conventional use households, compared to only 399 brands among the integrated pest management households and the risk of spontaneous abortion was over six-fold greater in households that used pesticides conventionally. Interestingly, a study of flower growers in Mexico found an association between exposure to pesticides and low birth weight in a subset of women with a specific genetic polymorphism for the paraoxonase (PON1) which detoxifies organophosphates. Studies of specific pesticide classes were more likely to detect associations with adverse birth outcomes, although some were potentially related to paternal exposure. Dichlorodiphenyldichloroethylene (DDE) was found to be associated with spontaneous abortion, fetal loss and preterm birth but not recurrent miscarriage (Table 20). Evidence of an effect on birth weight remains inconclusive. Dichlorodiphenyltrichloroethane (DDT) was associated with spontaneous abortion but not miscarriage in infertile women, a selected population (Table 20). Pentachlorophenol concentrations in the blood of infertile women from the same cohort were however positively associated with miscarriage. The association between hexachlorobenzene and birth weight was only seen in current and past smokers, highlighting again the importance of the combination of risk factors (Table 20). Exposure to organochlorines has been assessed in relation to the consumption of contaminated fish and the potential protective effects of essential fatty acids in fish were highlighted in 4.3.3. There is very little epidemiological evidence of an association between polychlorinated biphenyls (PCBs), polybrominated biphenyls (PBBs) or polychlorinated dibenzofurans (PCDFs) with pregnancy loss, while there are some inconsistent suggestions of a weak association with birth weight (Table 20). These inconsistencies should be considered in the light of the findings of the study by Sweeney and Symanski (2007) that indicates that age at exposure was the critical determinant of an association between increased birth weight and PBB exposure. Another source of Page 184 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES variation that may preclude the detection of effects in epidemiological studies depending on design and analysis of results is illustrated by the study conducted by Hertz-Picciotto et al (2005) that detected sexually dimorphic associations with birth outcomes. Nonhuman primates exposed to PCB via concrete sealant in their cages or ingestion of 2.5–5 ppm PCB in their diet showed an increased incidence of spontaneous abortions and stillbirths (Weselak et al. 2008). The study on urban exposure to polyaromatic hydrocarbons highlights racial or genetic differences as a source of variability which may hinder the detection of statistically significant associations (Table 20). A few studies have started to investigate the impacts of both environmental and genetic factors on children’s development. Several xenobiotic-metabolising genes have been reported to confer genetic susceptibility to low birth weight. For example, birth weight was found to be significantly lower among infants born to smoking women having the speciп¬Ѓc AHR, CYP1A1, GSTM1, CYP2E1 and NQO1 genotypes (Kishi et al. 2008). Page 185 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Table 20. Epidemiological studies of the association between relevant chemicals and pregnancy outcomes Chemical Exposure assessment Population (sample size) Endpoints Study results Reference Lead Interview Lead battery plant workers Spontaneous abortion Increased odds bisphenol A Plasma Serum Semiha Sakir Hospita, Turkey (40) Patients with a history of miscarriage (45) and nulliparous controls (32), Nagoya, Japan 248 pregnant women undergoing genetic amniocentesis, Japan Farming households in Nueva Ecija, Philippines (676) Spontaneous abortion Recurrent miscarriage No association Association Abnormal karyotype Spontaneous abortion Birth defects Higher maternal serum Increased risk Increased risk Cited in (Mendola et al. 2008) (Faikoglu et al. 2006) (Sugiura-Ogasawara et al. 2005) (Yamada et al. 2002) Licensed pesticide appliers in Minnesota (4,935) Birth defects Excess frequency (Garry et al. 1996) Norwegian farmholders (253,768 births) Gestation age Birth weight Late-term abortion Perinatal death Birth defects (Kristensen et al. 1997) IUGR Increased Increased 14 Increased odds No association Association with specific defects 15 Increased odds Low birth weight Odds increased Pregnancy-induced hypertension Pre-eclampsia Association Association Pesticides Maternal serum and amniotic fluid Conventional pesticide use against integrated pest management Minnesota Department of Agriculture registry Agricultural censuses and Medical Registry Agricultural censuses and Medical Registry Plant Health authorities Questionnaire Self-reported exposure during the first trimester Norwegian farmholders (253,768 births) Agricultural communities in Chihuahua, Mexico (371) Mexico, female flower growers or female spouses of male flower growers (527 healthy term births) Agricultural Health Study, North Carolina, United States (11,274 women) 16 (Crisostomo et al. 2002) (Kristensen et al. 1997) (Levario-Carrillo et al. 2004) (Moreno-Banda et al. 2009) (Saldana et al. 2009) (continued overleaf) 14 Results suggested that occupational exposure to grain mycotoxins may induce early labour Effects of pesticides assumed to be related to acetylcholinesterase inhibition 16 for women with the PON1 Q192R polymorphism 15 Page 186 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Chemical Exposure assessment Organophospates Maternal urine pregnancy Pesticide use Phenoxy herbicides Glyphosphate Thiocarbamates Chlorpyrifos Chlorpyrifos and diazinon Propoxur Trichlorfon DDE during Pesticide use Cord blood Contaminated fish Blood Blood Serum during pregnancy Serum during pregnancy Cord blood Blood DDT Preconception serum Blood Hexachlorobenzene Blood Cord blood Breast milk Population (sample size) Endpoints Study results Reference Agricultural community in Salinas Valley, California Gestation length Fetal growth Spontaneous abortion (<12 weeks) Spontaneous abortion (<20 weeks) Birth weight Decreased No association (Eskenazi et al. 2004) Birth weight Birth weight Congenital abnormalities Spontaneous abortion Recurrent miscarriage Lowered No association Cluster Increased risk No association Fetal loss Preterm birth Small for gestational age Birth weight Increased risk Positive trend Positive trend No association Birth weight Negative association Positive trend No dose-response (Weisskopf et al. 2005) No association (Sugiura-Ogasawara al. 2003) (Sagiv et al. 2007) Ontario Farm Family Health Study (2,012 planned pregnancies) Ontario Farm Family Health Study (2,012 planned pregnancies) Columbia Center for Children’s Environmental Health cohort, New York City 15 live births in one Hungarian village Chinese textile workers, 22-34 years old (30) Patients with a history of miscarriage (45), Nagoya, Japan US Collaborative Perinatal project (1,717 births) US Collaborative Perinatal project (2,380 births) Mothers residing near Superfund site in Massachusetts, United States (722 births) Great Lakes Captains’ and infrequent consumers cohorts (609) Chinese textile workers (388) Infertile women (489) from Mannheim and Heidelberg, Germany Patients with a history of miscarriage (45), Nagoya, Japan Mothers residing near Superfund site in Massachusetts, United States (722 births) Norwegian Human Milk Study (326) Spontaneous abortion Proportion of miscarriages Recurrent miscarriage 17 Increased risk 17 Increased risk 17 Increased risk Lowered Birth weight No association Small for gestational age Association only with past and current smokers (Arbuckle et al. 1999) (Arbuckle et al. 2001) (Whyatt et al. 2004) (Czeizel et al. 1993) (Korrick et al. 2001) (Sugiura-Ogasawara et al. 2003) (Longnecker et al. 2005) (Longnecker et al. 2001) (Sagiv et al. 2007) (Venners et al. 2005) (Gerhard et al. 1999) (Eggesbo et al. 2009) (continued overleaf) 17 Following preconceptional exposure, possibly paternal Page 187 of 486 et HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Chemical Exposure assessment Population (sample size) Endpoints Study results Reference Organochlorines Contaminated (Baltic Sea) fish consumption Blood Swedish fishermen's wives (1,812) Miscarriage Stillbirth Recurrent miscarriage No association No association 18 No association (Axmon et al. 2002) Stillbirth No association (Mendola et al. 1995) No association No association 19 Increased risk (Rylander et al. 1999) New York State Anglers cohort (2,237 births) Neonatal death Birth defects Birth defects Swedish fishermen's sisters (4,401 births) Low birth weight Increased risk (Rylander et al. 2000) Swedish fishermen's wives (72 cases and 144 controls) Infertile women (489) from Mannheim and Heidelberg, Germany Low birth weight Increased risk (Rylander et al. 1996) Miscarriage Positive response (Gerhard et al. 1999) Pentachlorophenol Consumption of contaminated fish Contaminated (Baltic Sea) fish consumption Consumption of contaminated fish Contaminated (Baltic Sea) fish consumption Contaminated (Baltic Sea) fish consumption Blood Women with repeated miscarriages, Heidelberg, Germany (89) New York State Anglers cohort (1,820) Swedish fishermen's wives (3,335 births) dose- (Gerhard et al. 1998) (Mendola et al. 2005) (continued overleaf) 18 Levels of at least one organochlorine higher than reference in 20% of cases, organochlorines significantly associated with changes in hormonal and immunological changes 19 Statistically significant for boys only Page 188 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY AND ADVERSE PREGNANCY OUTCOMES Chemical Exposure assessment Population (sample size) Endpoints Study results Reference PCBs Plasma Blood Miscarriage Recurrent miscarriage Decreased risk No association Birth weight Low birth weight Weak negative association Increased risk (Axmon et al. 2004) (Sugiura-Ogasawara al. 2003) (Sagiv et al. 2007) Birth weight No association (Weisskopf et al. 2005) Gestational age Birth weight Spontaneous abortion Gestational age 20 Birth weight Spontaneous abortion Stillbirth Child death Spontaneous abortion Pregnancy loss Preterm delivery Birth weight Reduced in girls Reduced in boys No association No association Positive trend No association No association Increased 21 More frequent 21 More frequent Increased risk Negative association in African Americans (Hertz-Picciotto et al. 2005) (Small et al. 2007) (Sweeney et al. 2007) PCBs/PBBs Serum at time of enrolment Serum at time of enrolment Swedish fishermen's wives (286) Patients with a history of miscarriage (45), Nagoya, Japan Mothers residing near Superfund site in Massachusetts, United States Swedish fishermen's wives (57 birth cases and 135 controls) Great Lakes Captains’ and infrequent consumers cohorts (609) Child Health and Development Study, San Francisco Bay, United States (399) Michigan PBB cohort (1,344 pregnancies) Michigan PBB cohort (1,207 births) PCBs/PCDFs Contaminated cooking oil Taiwan Yucheng cohort (342, control=302) PCBs/PCDFs Contaminated cooking oil Yusho women (512 pregnancies) Polyaromatic hydrocarbons Personal air sampling during pregnancy Columbia Center for Children’s Environmental Health cohort Cord blood Plasma Blood Serum of pregnant women 20 21 et (Rylander et al. 1998) (Yu et al. 2000) (Tsukimori et al. 2008) (Perera et al. 2003) Only statistically associated with in subgroup that was exposed ≤ 10 years Not statistically significant Page 189 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY 4.5.3.4 Sex ratio Epidemiological studies of the influence of paternal or maternal exposures on the sex ratio of the offspring (Table 21) do not allow us to draw conclusions of consistent associations, with perhaps the exception of tetrachlorodibenzodioxin (TCDD) and DES daughters. Evidence from animal experiments is also lacking, at least in mammals. A re-examination of a comprehensive threegeneration feeding study of TCDD in rats found no statistically significant treatment-related changes in sex ratio in any generation of treated animals. It is possible that inconsistent findings on sex ratio of the offspring of male rats exposed to TCDD in utero is due to random variation associated with a relatively small sample size, although differences between studies in strain of rat, dose regimen, and day of ascertainment of sex ratio cannot be ruled out (Rowlands et al. 2006). Table 21. Epidemiological studies of the association between relevant chemicals and sex ratio Chemical Biospecimen Population (sample size) Study results DES Medical record of DES in utero exposure National Cancer Institute (NCI) DES Combined Cohort Study, daughters (3,771) National Cancer Institute (NCI) DES Combined Cohort Study, sons (2,496) Mexico city (1,980) Increased Michigan Anglers (208 children) No association Children of mothers and fathers from the Great Lakes (381) No association Swedish fishermen's wives (4,054 births) Lowered Michigan Anglers (208 children) Increased with paternal exposure Lowered with maternal exposure Lowered Medical record of DES in utero exposure Maternal and cord blood Maternal and paternal serum Serum Lead DDE Organochlorines PCBs PCBs/PCDFs TCDD TCDD activity Contaminated (Baltic Sea) fish consumption Maternal and paternal serum Serum Serum of pregnant women Contaminated oil consumption Contaminated oil consumption Maternal and paternal serum Blood Children of mothers and fathers from the Great Lakes (381) Child Health and Development Study, San Francisco Bay, United States (399) Live births in Fukuoka and Nagasaki, Japan (85) Live births in women affected during the Yusheng incident, Taiwan (137) Children born 9 months after the explosion in the Seveso, Italy (74) Pesticide factory workers, Ufa, Russia (150 men and 48 women) 22 No association No association No association No association Lowered Lowered with paternal exposure Reference (Wise et 2007a) al. (Wise et 2007b) (Jarrell et 2006) (Karmaus et 2002) (Weisskopf al. 2003) al. al. et (Rylander et al. 1995) (Karmaus et al. 2002) (Weisskopf et al. 2003) (Hertz-Picciotto et al. 2008) (Yoshimura /20) (Rogan et al. 1999) (Mocarelli et al. 1996) (Ryan et al. 2002) 4.5.4 Critical Windows of susceptibility There is an increasing understanding that the fetus can be extremely sensitive during specific windows of development and that the intrauterine milieu contributes to adult health and disease onset. The focus is on female reproductive health and critical windows of susceptibility for 22 al. Among women first exposed to DES earlier in gestation and to a higher cumulative dose Page 190 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY pregnancy outcomes are considered here from the maternal rather than fetal perspective, more specifically relating to the maldevelopment of MГјllerian tissues and subsequent disorders of placentation in adult life. In the human female fetus, the MГјllerian ducts differentiate into the oviducts, uterus, cervix and upper vagina between 9.5 and 11.5 weeks of gestation. Uterine endometrial gland development is completed during puberty (Crain et al. 2008). Effects of in utero exposure to EDCs on the oviduct, placenta, uterus, vagina and cervix were reviewed by Miller et al. (2004). DES in utero exposure is characterised by abnormalities such as a T-shaped uterus and abnormal oviductal and cervical anatomy (Diamanti-Kandarakis et al. 2009). Several other EDCs have been found to cause urogenital dysmorphogenesis in animals. For example, TCDD and chlordecone were found to inhibit the apoptotic events responsible for the regression of the Wolffian ducts, whose remnants then interfere with the structural development of the genitourinary system (Silbergeld et al. 2005). DES in utero exposure was recently found to result in hypermethylation of the HOXA10 gene, which controls uterine organogenesis, and long-term altered HOXA10 expression (Bromer et al. 2009). Neonatal exposure to bisphenol A or DES alters Hoxa-10 and Hoxa-11 mRNA uterine expression in the rat and showed impaired proliferative response to steroid treatment associated with silencing of Hoxa-10 that was not associated with changes in the methylation pattern (Varayoud et al. 2008). In utero exposure to isoflavones, on the other hand, had no lasting effect on HOXA-10 expression in the exposed offspring (Varayoud et al. 2008). 4.5.5 Do current experimental approaches capture relevant endpoints/mechanisms? A number of guideline studies have been validated specifically for the detection of endocrine disrupters and uterine endpoints are included. The relevance and adequacy of these endpoints to the hormonal disruption of human implantation is however questionable. The OECD validated uterotrophic assay (TG 440) utilises the hypertrophic response of the rodent uterus to estrogenic stimulus to detect EDCs with an estrogenic mode of action. It relies on the change of weight in animal tissue and some have expressed concern about its sensitivity and proposed early biomarkers of estrogenic effects. Calbindin-D9k is a cytosolic calcium-binding protein that can be induced by estrogenic compounds. Further genes identified as marker genes for estrogenicity in the endometrium include Hox genes and gap junction protein connexion 26 and 43 (Tiemann 2008). Whereas in the rat uterus, calbindin-D9k is mainly regulated by estradiol, in the immature mouse, it is predominantly regulated by progesterone. This model could therefore potentially be applied to the detection of estrogenic and progestagenic activities of EDCs (Ji et al. 2006; Jung et al. 2005). Guideline studies whose aims are to provide data on the specific reproductive effects of EDCs, level 5 of the OECD conceptual framework, such as the extended F1 reproduction toxicity study currently under development and the enhanced two-generation reproduction toxicity study (TG416) include endpoints related to fertility and pregnancy outcomes such as a record of the duration of gestation (from insemination to parturition), of any signs of dystocia (abnormal or difficult labour), the number, sex and weight of pups, the number of live and still births, and any signs of gross anomalies. After the parent (or F1 if applicable) generation females have been sacrificed, they are examined for Page 191 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY the presence and number of implantation sites. Implantation is classified in three categories depending on different types of blastocyst-uterine cells interactions: centric, eccentric and interstitial. Mice, rats and hamsters have eccentric implantation, where the luminal epithelium forms an invagination to surround the trophoblast. Humans and guinea pigs have interstitial implantation, in which the trophoblast passes through the luminal epithelium to invade the endometrial stroma and become imbedded in the uterine wall. Due to the rapidity of eccentric implantation, mice and rats have been argued to be poor models of human early implantation (Lee et al. 2004). ReProTect is a 6th European Framework Program project whose aims were to develop alternative in vitro methods to replace animal experimentation in the field of reproductive toxicology. Of interest, an assay using cultured human endometrial epithelial adenocarcima Ishikawa cells was developed to detect chemicals with the potential to compromise receptivity of human endometrium for embryo implantation (Schaefer et al. 2010). Other experimental in vitro model systems have been developed recently to mimic the different stages of human embryo implantation. These include solid-phase assays of blastocyst attachment and trophoblast invasion, and two- and three-dimensional blastocyst-endometrial cell cocultures (reviewed in (Mardon et al. 2007)). Additionally, the human choriocarcinoma cell line JEG-3 has been used as a model for the placental syncytiotrophoblast (Crain et al. 2008). Page 192 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY 4.5.6 Conclusions Attribution criteria: PREGNANCY OUTCOMES Although most adverse pregnancy outcomes criteria INTACT MET are the result of oxidative stress, this can be criteria aetiologically related to disorders of MULTI-LEVEL MET implantation. The importance of steroidal criteria HORMONE MET hormones in implantation renders adverse evidence pregnancy outcomes a biologically plausible UNCLEAR PRIMARY EFFECT consequence of endocrine disruption. Given criteria EXPOSURE MET the emerging role of intrauterine milieu for adult health and disease onset, a potential criteria SENSITIVE LIFESTAGE MET effect of chemicals on these endpoints criteria deserves to be given careful attention. Trends PHARM. RESTORATION MET for weight at birth may be obscured by trends criteria SUPPORTING DATA MET for age and weight of mothers, and trends for other preterm births and fetal death are greatly influenced by the quality of prenatal care available. The increasing trend for preterm birth in North America should nonetheless raise concern. The only adverse pregnancy outcome considered in the 2002 Global Assessment of Endocrine Disrupters was spontaneous abortion and the report concluded that there were “substantial gaps in our knowledge about whether exposure to environmental chemicals has an impact on spontaneous abortion rates”. Over the last ten years, major advances have been made to address some of these gaps: п‚· п‚· п‚· п‚· There have been advances in the scientific understanding of the hormonal processes supporting implantation. There are suggestions that consequences of maternal chemical exposure, potentially during foetal life rather than during pregnancy, may influence birth outcomes other than urogenital abnormalities, and that such effects may be sexually dimorphic (birth weight in boys, heart defects in DES daughters) This sexual dimorphism could help explain an effect on sex ratio. According to the hypothesis that the hormonal status could influence the gender of the offspring, effects of chemical maternal or paternal exposure may be divergent and sex ratio at birth may therefore not be useful as a biomarker of exposure to EDCs. Mice and rats are inadequate models of human implantation and a number of in vitro bioassays have been developed that could be applied in toxicology testing and screening. Page 193 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY 4.5.6.1 Can adverse pregnancy outcomes be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. (yes/no) Criteria MET Criteria MET Evidence summary Many adverse pregnancy outcomes are implantation disorders, and the response could be isolated to the uterus. The association with prenatal DES exposure and uterine abnormalities is well known. Alteration of HOX genes expression by steroidal hormones is a particularly interesting mechanistic pathway that could explain an association between EDCs and adverse birth outcomes. The above evidence would support this at least with a potent estrogen such as DES. Evidence unclear This can be argued from the maternal perspective but for the embryo/fetus? Criteria MET Epidemiological and experimental evidence of the effects of prenatal DES exposure offers a good phenotypic model. Criteria MET Epidemiological and experimental evidence of the effects of prenatal DES exposure offers a good phenotypic model. Criteria MET A meta-analysis of clinical evidence found that administration of progestagens reduced the risk of preterm birth. 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Saldana TM, Basso O, Baird DD, Hoppin JA, Weinberg CR, Blair A, Alavanja MCR, Sandler DP. 2009. Pesticide Exposure and Hypertensive Disorders during Pregnancy. Environmental Health Perspectives 117:1393-1396. Schack-Nielsen L, Molgaard C, Sorensen TIA, Greisen G, Michaelsen KF. 2006. Secular change in size at birth from 1973 to 2003: National data from Denmark. Obesity 14:1257-1263. Page 196 of 486 HUMAN HEALTH ENDPOINTS FEMALE FERTILITY Schaefer WR, Fischer L, Deppert WR, Hanjalic-Beck A, Seebacher L, Weimer M, Zahradnik HP. 2010. In vitro-Ishikawa cell test for assessing tissue-specific chemical effects on human endometrium. Reproductive Toxicology 30:89-93. Silbergeld EK, Patrick TE. 2005. Environmental exposures, toxicologic mechanisms, and adverse pregnancy outcomes. American Journal of Obstetrics and Gynecology 192:S11-S21. Skokic F, Muratovic S, Radoja G. 2006. Perinatal and maternal outcomes in Tuzla Canton during 1992-1995 war in Bosnia and Herzegovina. Croatian Medical Journal 47:714-721. Small CM, Cheslack-Postava K, Terrell M, Blanck HM, Tolbert P, Rubin C, Henderson A, Marcus M. 2007. Risk of spontaneous abortion among women exposed to polybrominated biphenyls. Environmental Research 105:247-255. Steegers EAP, von Dadelszen P, Duvekot JJ, Pijnenborg R. 2010. Pre-eclampsia. Lancet 376:631-644. Stillerman KP, Mattison DR, Giudice LC, Woodruff TJ. 2008. Environmental exposures and adverse pregnancy outcomes: A review of the science. Reproductive Sciences 15:631-650. Sugiura-Ogasawara M, Ozaki Y, Sonta S, Makino T, Suzumori K. 2003. PCBs, hexachlorobenzene and DDE are not associated with recurrent miscarriage. American Journal of Reproductive Immunology 50:485-489. Sugiura-Ogasawara M, Ozaki Y, Sonta SI, Makino T, Suzumori K. 2005. Exposure to bisphenol A is associated with recurrent miscarriage. Human Reproduction 20:2325-2329. Sweeney AM, Symanski E. 2007. The influence of age at exposure to PBBs on birth outcomes. Environmental Research 105:370-379. Tiemann U. 2008. In vivo and in vitro effects of the organochlorine pesticides DDT, TCPM, methoxychlor, and lindane on the female reproductive tract of mammals: a review. Reprod Toxicol 25:316-326. Titus-Ernstoff L, Troisi R, Hatch EE, Palmer JR, Hyer M, Kaufman R, Adam E, Noller K, Hoover RN. 2010. Birth defects in the sons and daughters of women who were exposed in utero to diethylstilbestrol (DES). International Journal of Andrology 33:377-384. Tsukimori K, Tokunaga S, Shibata S, Uchi H, Nakayama D, Lshimam T, Nakano H, Wake N, Yoshimura T, Furue M. 2008. Long-term effects of polychlorinated biphenyls and dioxins on pregnancy outcomes in women affected by the Yusho incident. Environmental Health Perspectives 116:626-630. Varayoud J, Ramos JG, Bosquiazzo VL, Munoz-de-Toro M, Luque EH. 2008. Developmental exposure to Bisphenol a impairs the uterine response to ovarian steroids in the adult. Endocrinology 149:5848-5860. 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Wise LA, Titus-Ernstoff L, Palmer JR, Hoover RN, Hatch EE, Perez KM, Strohsnitter WC, Kaufman R, Anderson D, Trosi R. 2007b. Time to pregnancy and secondary sex ratio in men exposed prenatally to diethylstilbestrol. American Journal of Epidemiology 166:765-774. Woodruff TJ, Carlson A, Schwartz JM, Giudice LC. 2008. Proceedings of the Summit on Environmental Challenges to Reproductive Health and Fertility: executive summary. Fertility and Sterility 89:281-300. Yamada H, Furuta I, Kato EH, Kataoka S, Usuki Y, Kobashi G, Sata F, Kishi R, Fujimoto S. 2002. Maternal serum and amniotic fluid bisphenol A concentrations in the early second trimester. Reproductive Toxicology 16:735-739. Yang QH, Sherman SL, Hassold TJ, Allran K, Taft L, Pettay D, Khoury MJ, Erickson JD, Freeman SB. 1999. Risk factors for trisomy 21: Maternal cigarette smoking and oral contraceptive use in a population based case control study. Genetics in Medicine 1:80-88. Yoshimura T. /20. - Sex ratio in offspring of those affected by dioxin and dioxin-like compounds: the Yusho, Seveso, and Yucheng incidents. - 58:-541. Yu ML, Guo YLL, Hsu CC, Rogan WJ. 2000. Menstruation and reproduction in women with polychlorinated biphenyl (PCB) poisoning: longterm follow-up interviews of the women from the Taiwan Yucheng cohort. International Journal of Epidemiology 29:672-677. Zhang X, Joseph KS, Kramer MS. 2010. Decreased term and postterm birthweight in the United States: impact of labor induction. American Journal of Obstetrics and Gynecology 203. Page 197 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6 ENDOMETRIOSIS Endometriosis is a common gynaecological disorder characterised by ectopic endometrium (presence of endometrial glands and stroma outside the uterus) causing benign endometrium-like inflammatory lesions outside the uterine cavity and is a major cause of chronic pelvic pain and infertility. Retrograde menstruation and transplantation of endometrial fragments and cells in the peritoneal cavity (Sampson’s hypothesis) is widely accepted as the major pathogenesis leading to peritoneal endometriosis. However, nearly all women have retrograde menstruations whilst few develop endometriosis (Crain et al. 2008; Diamanti-Kandarakis et al. 2009). The aetiology of this disorder is believed to be due to the combined effects of genetic susceptibility, altered immune and hormonal response and environmental factors. 4.6.1 The natural history of endometriosis Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus and diagnosis requires the identification of both entities on histologic inspection of biopsies obtained after laparoscopy (Mcleod et al. 2010). There is no non-invasive diagnostic tool available. Endometriotic lesions can occur adjacent to the eutopic endometrium, e.g. within the myometrium (adenomyosis) or fallopian tubes, the ovaries (endometriomas, endometriotic cysts), Douglas pouch, uterine ligaments, vagina, vulva, or perineum or within the pelvic cavity, septum rectovaginale, intestine, and ureter (Tariverdian et al. 2007). 4.6.1.1 Prevalence and incidence trends Estimates of the prevalence of endometriosis vary widely between 6-15% of women of reproductive age and up to 50% of women with pelvic pain and infertility (Crain et al. 2008; Diamanti-Kandarakis et al. 2009). Studies of the prevalence of endometriotic lesions in women undergoing surgery for fibroids suggest a prevalence of about 10%, but uterine fibroids might share some risk factors with endometriosis (Vigano et al. 2004). Determining the prevalence of endometriosis is complicated by issues surrounding diagnosis, and to our knowledge there are no published studies on representative samples of the general population. Variations in prevalence can be explained by differences in indications for laparoscopy and laparotomy, differing diagnostic criteria and different levels of clinical interest in endometriosis (Vigano et al. 2004). The occurrence of endometriotic lesions has been most frequently determined in three groups of patients; namely, asymptomatic patients undergoing an unrelated procedure (2-18%), symptomatic patients undergoing laparoscopy or surgery (5-21%), and infertile patients (5-50%) (Mcleod et al. 2010). The study of the incidence of endometriosis is further complicated by the fact that the precise timing of the onset of disease is generally not known. It has been suggested that incidence may have increased over the past 50 years, as well as the age at diagnosis, decreasing. The condition has been traditionally associated with delayed childbearing (Birnbaum et al. 2002). While this may be partly explained by changing reproductive habits, more young women now undergo laparoscopy for infertility than in the past, when laparotomy was necessary to diagnose endometriosis. Pelvic endometriosis is rare before menarche and its incidence tends to decrease after the menopause. There is no apparent relationship between age at diagnosis and severity of the disease (Vigano et al. 2004). Page 198 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.1.2 Co-morbidities The pelvic pain associated with endometriosis is a major cause of disability and compromised quality of life. In addition, endometriosis is associated with increased risks of certain cancers and some immune disorders. Endometriosis seems to predispose women to ovarian cancer, this association being restricted to endometrioid and clear cell malignancies (Brinton et al. 2005a). Increased risks of colon cancer, thyroid cancers and melanomas have also been observed (Brinton et al. 2005b). The risk for breast cancer appears to be modified by age at diagnosis of endometriosis; women under 40 when diagnosed were found to have a reduced risk while women diagnosed after 40 had an increased risk (Bertelsen et al. 2007). This may be explained by anti-estrogenic treatments for endometriosis in women diagnosed at a younger age while there may be common risk factors between postmenopausal endometriosis and breast cancer. An association with non-Hodgkin lymphomas has also been suggested and would support the hypothesis that the cause of endometriosis includes immunological mechanisms (Vigano et al. 2004). Women with endometriosis also have an increased familial risk of cancer generally and breast cancer specifically (Matalliotakis et al. 2008b; Mcleod et al. 2010). In the Endometriosis Family Study in which 4,000 patients responded to questionnaires, the prevalence of immune disorders such as rheumatoid arthritis, systemic lupus erythematosus, hypoor hyperthyroidism, and multiple sclerosis was higher in women with endometriosis than the general population (Mcleod et al. 2010; Vigano et al. 2004). This supports the theory that the immune system plays a role in the pathogenesis of endometriosis. 4.6.1.3 Risk factors 4.6.1.3.1 Reproductive history Menstrual characteristics Early menarche, short and heavy menstrual cycles have fairly consistently been found associated with an increased risk of endometriosis (Matalliotakis et al. 2008b; Mcleod et al. 2010; Vigano et al. 2004). This is consistent with the reflux hypothesis already mentioned and a higher likelihood of pelvic contamination with menstrual endometrial material. A recent study also found that late age at menarche (> 14 years) was a protective factor (Treloar et al. 2010). Dysmenorrhea is considered both a symptom and a risk factor for the disease (Mcleod et al. 2010; Treloar et al. 2010). Dysmenorrhea is thought to correlate with stronger uterine contractions leading to stronger uterine cramping and outflow obstruction and therefore increased retrograde menstruation. Cycle irregularity, but not irregular cycle duration, has also been associated with an increased risk of endometriosis (Mcleod et al. 2010). Parity Epidemiological studies have also consistently found that nulliparous women are at an increased risk (Mcleod et al. 2010; Vigano et al. 2004). Parity is, in fact, linked to a decreased risk of endometriosis, probably owing to the decreased lifetime number of months exposed to menstrual flow. Similarly, lifetime duration of lactation was associated with a decrease in risk, however this was primarily seen among those who had given birth within the past 5 years (Mcleod et al. 2010). Page 199 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Oral contraceptive use Data regarding the association between oral contraceptive use and endometriosis give conflicting results. Large cohort studies have found that the prevalence of endometriosis was lower among current or recent users than never users whereas women who had stopped the pill a few years previously had an increased risk (Vigano et al. 2004). Oral contraceptive usage may decrease the risk via ovulation cessation, which decreases the volume of menstrual flow, although exposure to exogenous hormones may simultaneously increase the likelihood of implantation and lesion growth (Mcleod et al. 2010). Dysmenorrhea is a frequent indication for the prescription of oral contraceptives, therefore women with endometriosis-induced dysmenorrhea might be selectively excluded from the вЂ�never users’ category while current oral contraceptive use reduces dysmenorrhea and thereby the likelihood of a diagnosis for endometriosis. A lack of association with duration of use does not support a causal relationship (Vigano et al. 2004). 4.6.1.3.2 Family history First degree female relatives of women with endometriosis have been reported to have a 4 to 11fold increase in the risk of endometriosis compared to the general population (Matalliotakis et al. 2008a; Mcleod et al. 2010; Vigano et al. 2004). Women with endometriosis may recall a family history of the disease more accurately than control individuals and information bias cannot be excluded. Nonetheless a study of sister pairs found a significant linkage to a locus on chromosome 10q26 (Mcleod et al. 2010). 4.6.1.3.3 Race and social status Early studies reported double the prevalence of endometriosis in white women and historically many gynaecologists believed that the disease was confined almost exclusively to white women (Jacoby et al. 2010). Most studies were carried out in the United States where black women tend to experience lower socio-economic conditions and access to healthcare. Similarly, a greater frequency of endometriotic lesions was found in women of higher social class further suggesting a diagnostic bias (Vigano et al. 2004). More recent studies have reported conflicting results for racial and ethnic differences. Asian women have been found to have 9-fold greater odds of endometriosis compared with white women (Jacoby et al. 2010), and a 40% lower rate was found in Hispanic and African American women (Missmer et al. 2004a). However other studies reported no significant differences in prevalence of the disease in women of different races (Jacoby et al. 2010; Mcleod et al. 2010). 4.6.1.3.4 Body habitus An inverse relation with body weight or body mass index has been reported (Matalliotakis et al. 2008b; Mcleod et al. 2010; Missmer et al. 2004a). Increased weight, body mass index and waist-tohip ratios decrease risk. This was putatively explained by the fact that women with these traits are more likely to have irregular menses and anovulatory cycles. Taller women are also tend to have higher follicular-phase estradiol levels and may be at an increased risk of endometriosis (Mcleod et al. 2010). Page 200 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.1.3.5 Lifestyle factors An association with lifestyle factors such as smoking, alcohol intake, diet and exercise remain controversial. A finding that heavy smokers may be at a decreased risk of endometriosis was explained by the antiestrogenic effects of smoking (Vigano et al. 2004). An increased risk associated with alcohol intake has been reported in some but not all studies (Heilier et al. 2007; Matalliotakis et al. 2008b; Missmer et al. 2004a) and could be explained by the increased levels of estrogens related to moderate alcohol intake (Vigano et al. 2004). A high intake of saturated fats is associated with increased risks of benign or malignant gynaecological conditions and several studies support the contention that the risk of endometriosis is elevated with dietary fats consumption (Mcleod et al. 2010; Missmer et al. 2010). Regular physical activity may be linked to lower levels of estrogens and regular exercise has been associated with a 40-80% reduction in risk of endometriosis (Vitonis et al. 2010b). However the symptoms of endometriosis may render women with the disease whether diagnosed or not less likely to exercise than healthy controls. 4.6.1.4 Aetiology There is a general consensus that the survival, adhesion, proliferation, invasion and vascularisation of endometrial tissue regurgitated through the fallopian tubes are the main events involved in the pathogenesis of peritoneal endometriotic lesions. The etiopathogenesis of ovarian and rectovaginal endometriosis is however still controversial , and it has been argued that the different forms of the disease may not have a unique common aetiology but represent separate entities with different pathogeneses (Crain et al. 2008; Vigano et al. 2004). The focus is here on peritoneal disease which has been more extensively studied. Endometriosis is a hormone-dependent disease characterised by inflammation, excessive production of estrogens and progesterone resistance. It is also considered a benign metastatic disease related to cancer. It is also thought that endometriosis may be the result of abnormalities in eutopic endometrium resulting from genetic predisposition or epigenetic alterations during embryonic life (Borghese et al. 2010). This section will briefly summarise scientific achievements related to these two etiological causes. 4.6.1.4.1 Evidence of genetic predisposition The contribution of genetic variation to the development of endometriosis has been the focus of scientific investigation and has been recently extensively reviewed (Falconer et al. 2007; Guo 2009; Montgomery et al. 2008; Siristatidis 2009; Vigano et al. 2007). Genetic variants in over 75 genes have been examined for an association, however reviews found a strikingly large amount of conflicting results. Few positive findings have been replicated. About half of reviewed linkage analysis and association studies reported correlations of different polymorphisms and endometriosis. The main candidates have been those involved in detoxification processes, steroidogenesis and steroid action, and immune regulation. Genome-wide association studies using clearly defined disease classifications and replication studies using thousands of cases and controls have been recommended. Moreover, a recent assessment of achievements in identifying complex disease genes has indicated that genetic polymorphisms associated with disease risk contribute little to relative risks (Guo 2009). Page 201 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.1.4.2 Epigenetics Guo (2009) has argued that endometriosis is an epigenetic disease and reviewed the evidence for this hypothesis, the main lines of evidence are briefly summarised in the following paragraph (for more information on epigenetic mechanisms refer to section 3.4). Three genes coding for DNA methyl transferases (DNMT1, DNMT3A and DNMT3B) are overexpressed in endometriosis. DNMTs are involved in de novo as well as maintenance methylation and methylation is also linked with chromatin remodelling. Steroidogenic factor-1 (SF-1) is a transcription factor involved in the activation of multiple steroidogenic genes for estrogen biosynthesis that is usually undetectable in normal endometrial stromal cells but overexpressed in endometriotic stromal cells. The SF-1 promoter has been found to be hypermethylated in endometrial cells but hypomethylated in endometriotic cells. ERОІ has also been found to be hypomethylated in endometriotic cells. MicroRNA (miRNA) deregulation may also be involved in endometriosis. An inverse correlation was found between four miRNAs differentially expressed in ectopic and eutopic endometrium and their predicted target genes, StAR protein, aromatase and COX-2. Further, the expression of these miRNAs and their target genes was differentially regulated by 17ОІ-estradiol, medroxyprogesterone acetate, ER antagonist ICI-182780 and RU486. However epigenetic aberrations may merely be the consequence of endometriosis. Nonetheless DNA methylation is thought to be induced by various factors such as aging, diet, chronic inflammation, maternal care and developmental exposure to chemicals. 4.6.2 Evidence of endocrine mechanisms in endometriosis Endometriosis is clearly a hormone-dependent disease and endocrine processes involved in the manifestation and progression of the disease are well characterised. However the molecular alterations found in the ectopic endometrium and eutopic endometrium of women with the disease could be a consequence rather than a cause of the disease and the exact aetiology of endometriosis onset remains unclear. In order to understand the mechanisms by which endocrine disrupters could contribute to the progression or onset of the disease, it is useful to summarise the current understanding of the endocrine processes involved in apoptosis, invasion, adhesion and proliferation of ectopic endometrial cells, as well as angiogenesis, immune response and inflammation. Apoptosis Apoptosis is thought to be involved in the maintenance of cellular homeostasis during the menstrual cycle by eliminating senescent cells from the uterine endometrium during the late secretory and menstrual phases of the cycle and that in healthy women the majority of menstruated cells undergo programmed cell death. In women with endometriosis the number of apoptotic endometrial cells is greatly reduced and endometriotic lesions have been hypothesised to originate from these physiologically active endometrial cells. Indeed, the anti-apoptotic gene Bcl-2 is overexpressed in the endometrium of patients. There is evidence that this gene is regulated by estrogens as its expression in normal endometrium varies with the menstrual cycle phase being higher in proliferative glandular endometrium (Vigano et al. 2004). Page 202 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Invasion and adhesion Matrix metalloproteinases (MMP) are enzymes that play a role in the regulation of extracellular matrix turnover and the cyclic changes of growth and tissue breakdown in the endometrium. MMPs are synthesised during the proliferative phase probably following stimulation by estrogens. Progesterone on the other hand decreases the transcription and secretion of MMPs (Vigano et al. 2004). Peritoneal invasion by endometrial tissue is thought to be dependent on MMPs and their specific tissue inhibitors and this supported by evidence that levels of MMP-2 in peritoneal fluid is correlated positively with estradiol levels and negatively with progesterone levels (Tariverdian et al. 2007). The main mediators of cell-cell and cell-matrix adhesion are integrins and cadherins. Integrins are expressed by the endometrium throughout the menstrual cycle and have been shown to form cell-surface complexes with MMPs to facilitate matrix degradation and motility, thereby facilitating invasion. E-cadherin is expressed in eutopic endometrium and in peritoneal and ovarian endometriotic lesions however, a population of E-cadherin-negative cells has been found in epithelial glands in peritoneal endometriotic lesions and the absence of E-cadherin is involved in the acquisition of an invasive phenotype (Vigano et al. 2004). Angiogenesis Peritoneal fluid from women with endometriosis exhibits increased activity of angiogenic factors. A family of plycoproteins, the vascular endothelial growth factor (VEGF) family has received particular attention as a significant regulator of both physiological and pathological angiogenesis. In normal endometrium, VEGF expression is highest during the secretory phase of the menstrual cycle and its expression in normal human endometrial cells is acutely upregulated by estradiol in vitro (Vigano et al. 2004). Both estradiol and progesterone increase the release of VEGF from peritoneal macrophages, and may therefore be involved in the promotion of angiogenesis in endometriotic lesions (Tariverdian et al. 2007). Proliferation Endometriotic lesions require estrogen for their continued growth and tend to regress in its absence. Aromatase is known to play an important role in endometriotic growth. It is found exclusively in endometriotic stroma where it converts androgens to E1 which is then converted to E2 by 17ОІ-HSD type 1 (Tariverdian et al. 2007). Prostaglandin(PG)E2 is a potent inducer of aromatase activity in endometriotic cells. COX-2 activity is promoted by estradiol via ER-ОІ resulting in up-regulation of PGE2 formation. Therefore a positive feedback loop of estrogen and PGE2 production is established in pathological tissue (Vigano et al. 2004). The nuclear receptor SF1 is a key transcription factor that mediates the expression of several steroidogenic genes such as StAR and CYP19A1 (dependent of PGE2 and cAMP), and its promoter is hypomethylated in endometriotic cells. This supports the hypothesis that epigenetic mechanisms play an important role in the pathogenesis of endometriosis (Bulun 2009). Moreover, both ER-ОІ and ER-О± are overexpressed in endometriotic tissue; ER-ОІ and ER-О± levels have been reported to be 142-fold and 9-fold higher respectively in those tissues compared to normal endometrium. Epigenetic events including promoter hypomethylation have been invoked in the overexpression of ER-ОІ. Increased ER-ОІ binding to the progesterone-receptor (PR) promoter hereby mediating the down-regulation of expression of PRs (Bulun 2009). Page 203 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Progesterone resistance is now accepted as a critical component of the disease process. In normal uterine epithelium, progesterone inhibits estradiol-dependent proliferation and this anti-estrogenic effect is mediated at least in part by the induction of 17ОІ-HSD type 2 which catalyses the conversion of estradiol to the much less potent estrone (Bulun 2009; Tariverdian et al. 2007). Levels of the PR isoforms, PR-B and PR-A increase progressively during the proliferative phase and peak before ovulation. Endometriotic tissue is characterised by large quantities of progesterone and much lower levels of PR than normal endometrium; PR-A expression is markedly reduced and PR-B is undetectable (Bulun 2009). PR-B is a more potent activator of progesterone target genes while PR-A acts as a dominant repressor of PR-B as well as decreasing the response to other steroid hormones such as androgens and estrogens. Progesterone resistance in endometriotic tissues could therefore be explained by the inhibitory action of the PR-A in the absence of the stimulatory PR-B (Vigano et al. 2004). Further 17ОІ-HSD type 2 is undetectable in endometriotic tissue and further contributing to the accumulation of E2 in endometrial tissues (Bulun 2009; Tariverdian et al. 2007; Vigano et al. 2004). An epigenetic mechanism has been proposed to mediate progesterone resistance as the PR-B promoter has been shown to be hypermethylated in endometriosis and this provides a plausible explanation for the persistent down-regulation of PR-B (Cakmak et al. 2010; Guo 2009). Cross-talk between proliferation and immunological response The mechanisms by which menstrual endometrial tissue is cleared from the peritoneal cavity are poorly understood but a role for immunosurveillance has been suggested. Therefore a capacity of endometriotic cells to evade immunological response is thought to be involved in the pathogenesis of the disease (Vigano et al. 2004). Although a role for estrogens and androgens in immunomodulation is well established, the role of progesterone is less well understood but is emerging as an important immune regulator of female reproductive function. For a general review of the role of steroid hormones, specifically glucocorticoids and progesterone, in inflammatory responses, refer to Tait et al (2008). Prostaglandins are involved in inflammation and pain. The vasoconstrictive properties of PGF2О± and its ability to cause uterine contractions are thought to contribute to dysmenorrhea while PGE2 is directly involved in pelvic pain. Ectopic endometrium induces inflammation in the peritoneal cavity resulting in the formation of cytokines such as interleukin-1 and VEGF that can induce COX-2 leading in turn to increased levels of PGE2. This further contributes to the positive feedback loop of estrogen and prostaglandin formation described previously. This model of crosstalk between inflammation and proliferation in endometriosis is described in greater detail in Rizner (2009) and Bulun (2009). 4.6.3 Evidence for a role for chemical exposures in endometriosis Non-surgical therapies for endometriosis include agents directed to minimise inflammation (NSAID), progestins and androgens, GnRH analogs (to inhibit gonadotropin secretion and thus ovarian estradiol production), and aromatase inhibitors (to inhibit estradiol synthesis by the ovary and endometriotic lesions) and demonstrate the ability of exogenous chemicals to influence the growth of endometriotic lesions (Diamanti-Kandarakis et al. 2009). Page 204 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS The results of epidemiological studies investigating a potential association between environmental exposures and endometriosis have been reviewed (Buck Louis et al. 2006; Crain et al. 2008; Mendola et al. 2008; Woodruff et al. 2008). These data are compiled and summarised in Table 22 with results from more recent studies. Phytoestrogens One study has investigated the influence of dietary phytoestrogens in infertile Japanese women, particularly the isoflavones daidzein and genistein (Table 22), and found a protective effect. Interestingly, the effect of genistein was modified in women with advanced disease who possess a polymorphism for the ERОІ. This may suggest that the protective action of genistein is mediated via the ERОІ. Plasticisers A recent study has examined levels of the bisphenols A and B in fertile women undergoing laparoscopy, and found that both these compounds were more often detected in cases of endometriosis than controls (Table 22). Early reports that phthalate esters levels in blood were associated with endometriosis have not been confirmed in recent studies measuring phthalate metabolites in urine (Table 22). Contamination of samples is a major problem with ubiquitous phthalate esters. The issue of the relevance of contaminant levels measured at the time of diagnosis is also particularly tricky when the timing of disease onset is unknown and the chemical of interest is pseudo-persistent, i.e. both relatively quickly metabolised by the body but so omnipresent in the environment that exposure takes place almost continuously. Further, if no direct associations were detected in the large prospective National Health and Nutrition Examination Survey (NHANES) study, there was a significant association with monobutylphthalate and endometriosis and uterine fibroids when both endpoints were considered together (Table 22). Organochlorine pesticides Organochlorine pesticides have also been the focus of some scientific attention due to their estrogenicity. However, most studies have not detected any association between specific organochlorine compounds and endometriosis (Table 22). However, organochlorines have not been investigated in large prospective studies of the general population. Epidemiological studies of endometriosis are hindered by the need for invasive surgery for diagnosis and controls are often by necessity women who are infertile or who suffer from other gynaecological complaints. As organochlorines have also been implicated in other female reproductive health outcomes, the lack of association in such case-control studies should be interpreted with caution. Polybrominated and polychlorinated biphenyls (PBBs and PCBs) Polyhalogenated compounds have been received much interest due to the dioxin-like, estrogenic and/or anti-estrogenic properties of specific congeners. If epidemiological studies appear to yield conflicting results (Table 22), the limitations of studies of endometriosis mentioned above with regards to organochlorines equally apply here. Particular attention should therefore be granted to the large prospective study of the Michigan Health study of women accidentally exposed to PBBs. Although no association with PBB levels in the serum of these women was found, the increased risk associated with PCBs, albeit just short of statistical significance, suggest an association with PCBs. Page 205 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Efforts to identify associations with mechanistic groupings of PCBs however have not yielded consistent results. Dioxins The evidence that the dioxin TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin) increases both the incidence and severity of endometriosis in monkeys spurred the scientific interest in detecting a similar association in humans (Birnbaum et al. 2002). Dioxins are of particular interest as they have been incriminated in disruption of both the immune and endocrine systems. Again, epidemiological studies have yielded somewhat conflicting results (Table 22). This has led some authors to conclude that evidence of such an association in humans was insufficient (Guo et al. 2009). Again the results of a prospective study following the Seveso accident in Italy should be given particular consideration in view of the source of bias in case-control studies of endometriosis, and these are suggestive of an association. Recent reviews of the association between endometriosis and dioxin-like compounds have stressed the potential importance of early life exposures (Bruner-Tran et al. 2010b). Page 206 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Table 22.Summary of studies of the association between exogenous chemicals and endometriosis Chemical Biospecimen Population (sample size) Study results Daidzein Genistein Cadmium Urine Urine Urine/blood 138 infertile Japanese women 138 infertile Japanese women Belgian patients with peritonea] endometriosis, deep endometriotic nodules (DEN) and controls (n =59) 119 patients with peritoneal endometriosis and/or DEN and 25 controls, Belgium 128 infertile Japanese women 1,425 women from the NHANES study, United States 119 patients with peritoneal endometriosis and/or DEN and 25 controls, Belgium 1,425 women from the NHANES study, United States 1,425 women from the NHANES study, United States 69 fertile women undergoing laparoscopy, Naples, Italy 69 fertile women undergoing laparoscopy, Naples, Italy 220 South Indian women undergoing laparoscopy 108 South Indian women undergoing laparoscopy 59 fertile women undergoing laparoscopy 59 fertile women undergoing laparoscopy 1,227 women from the NHANES study, United States 109 women undergoing laparotomy, Taiwan 137 infertile Japanese women undergoing laparoscopy 1,227 women from the NHANES study, United States 109 women undergoing laparotomy, Taiwan 137 infertile Japanese women undergoing laparoscopy 1,227 women from the NHANES study, United States 109 women undergoing laparotomy, Taiwan 137 infertile Japanese women undergoing laparoscopy 1,227 women from the NHANES study, United States 109 women undergoing laparotomy, Taiwan 137 infertile Japanese women undergoing laparoscopy 109 women undergoing laparotomy, Taiwan Decreased risk 23 Decreased risk No association (Tsuchiya et al. 2007) (Tsuchiya et al. 2007) (Heilier et al. 2004b) No association No association Increased risk Lower in cases No association No association Detected in cases Detected in cases Increased risk Increased risk Higher in cases No association No association No association No association 24 No association Increased in cases No association No association No association No association No association No association No association No association (Heilier et al. 2006) (Itoh et al. 2008) (Jackson et al. 2008) (Heilier et al. 2006) (Jackson et al. 2008) (Jackson et al. 2008) (Cobellis et al. 2009) (Cobellis et al. 2009) (Reddy et al. 2006b) (Reddy et al. 2006a) (Cobellis et al. 2003) (Cobellis et al. 2003) (Weuve et al. 2010) (Huang et al. 2010) (Itoh et al. 2009) (Weuve et al. 2010) (Huang et al. 2010) (Itoh et al. 2009) (Weuve et al. 2010) (Huang et al. 2010) (Itoh et al. 2009) (Weuve et al. 2010) (Huang et al. 2010) (Itoh et al. 2009) (Huang et al. 2010) Lead Mercury Bisphenol A Bisphenol B Phthalate esters Diethylphthalate Monoethylphthalate Monobutylphthalate Monobenzylphthalate Monoethylhexylphthalate Monomethylphthalate Urine/blood Urine Whole blood Blood Whole blood Whole blood Serum Serum Blood plasma Serum Blood/peritoneal fluid Blood/peritoneal fluid Urine Urine Urine Urine Urine Urine Urine Urine Urine Urine Urine Urine Urine Reference 23 (continued overleaf) 23 24 In cases of advanced disease, an ESR2 polymorphism also modified the effects of genistein Significant association with endometriosis and uterine fibroids when considered together Page 207 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Chemical Biospecimen Population (sample size) Study results Reference О’-benzenehexachloride Aldrin Chlordane DDE Blood Blood Plasma Serum Plasma Blood Whole blood Plasma Serum Whole blood Blood Plasma Whole blood Plasma Whole blood Plasma Blood Plasma Plasma Blood 100 women undergoing laparoscopy, United States 100 women undergoing laparoscopy, United States 156 women undergoing laparoscopy, Quebec, Canada 158 women in Rome, Italy 156 women undergoing laparoscopy, Quebec, Canada 100 women undergoing laparoscopy, United States 489 women infertile women, Heidelberg, Germany 156 women undergoing laparoscopy, Quebec, Canada 158 women in Rome, Italy 489 women infertile women, Heidelberg, Germany 100 women undergoing laparoscopy, United States 156 women undergoing laparoscopy, Quebec, Canada 489 women infertile women, Heidelberg, Germany 156 women undergoing laparoscopy, Quebec, Canada 489 women infertile women, Heidelberg, Germany 156 women undergoing laparoscopy, Quebec, Canada 100 women undergoing laparoscopy, United States 156 women undergoing laparoscopy, Quebec, Canada 156 women undergoing laparoscopy, Quebec, Canada 100 women undergoing laparoscopy, United States No association No association No association 25 Increased risk No association No association No association No association No association No association Increased risk No association No association No association No association No association No association No association No association No association (Cooney et al. 2010) (Cooney et al. 2010) (Lebel et al. 1998) (Porpora et al. 2009) (Lebel et al. 1998) (Cooney et al. 2010) (Gerhard et al. 1999) (Lebel et al. 1998) (Porpora et al. 2009) (Gerhard et al. 1999) (Cooney et al. 2010) (Lebel et al. 1998) (Gerhard et al. 1999) (Lebel et al. 1998) (Gerhard et al. 1999) (Lebel et al. 1998) (Cooney et al. 2010) (Lebel et al. 1998) (Lebel et al. 1998) (Cooney et al. 2010) DDT Hexachlorobenzene Hexachlorocyclohexane Pentachlorophenol Mirex Oxychlordane Nonachlor (continued overleaf) 25 Non-significant Page 208 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Chemical Biospecimen Population (sample size) Study results Reference PBBs PCBs Serum at enrolment Serum Michigan female health study (n = 943) Belgian patients with peritoneal endometriosis, DEN and controls (n = 27) (Hoffman et al. 2007) (Heilier et al. 2004a) Blood 22 Italian and 18 Belgian gynaecology patients 80 patients undergoing laparoscopy, Rome (Italy) 158 women in Rome, Italy 84 women undergoing laparoscopy, United States 489 women infertile women, Heidelberg, Germany 220 South Indian women undergoing laparoscopy 156 women undergoing laparoscopy, Quebec, Canada 139 infertile Japanese women 124 patients, Atlanta, United States Michigan female health study (n = 943) Group Health enrollees (n = 789) Belgian women with peritoneal endometriosis or DEN and controls (n = 71) Belgian infertile patients (n = 69) Belgian population-based study (n = 142, 10 cases) 158 women in Rome, Italy 202 infertile Belgian women 124 patients, Atlanta, United States 22 Italian and 18 Belgian gynaecology patients 139 infertile Japanese women 139 infertile Japanese women Residents of the Seveso area (Italy) who were ≤ 30 years old in 1976 (n = 296) 79 infertile women, Israel No association Elevated in DEN patients No association Increased risk Increased risk 26 Increased risk Increased risk Increased risk No association No association No association 27 Increased risk No association Increased risk No association No association No association Increased risk No association No association Higher in controls No association 28 No trend Detected in cases Noncoplanar PCBs Dioxins PCDDs/PCDFs PCDDs PCDFs TCDD Serum Serum Whole blood Blood plasma Plasma Serum Serum (TEQ) Serum at enrolment Serum (TEQ) Serum (TEQ) Serum (TEQ) Serum (TEQ) Serum Plasma (TEQ) Serum (TEQ) Blood Serum Serum Serum Blood (De Felip et al. 2004) (Porpora et al. 2006) (Porpora et al. 2009) (Buck Louis et al. 2005) (Gerhard et al. 1999) (Reddy et al. 2006b) (Lebel et al. 1998) (Tsukino et al. 2005) (Niskar et al. 2009) (Hoffman et al. 2007) (Trabert et al. 2010) (Heilier et al. 2005) (Pauwels et al. 2001) (Fierens et al. 2003) (Porpora et al. 2009) (Simsa et al. 2010) (Niskar et al. 2009) (De Felip et al. 2004) (Tsukino et al. 2005) (Tsukino et al. 2005) (Eskenazi et al. 2002) (Mayani et al. 1997) 26 For anti-estrogenic PCBs Not statistically significant 28 Non-significant risk for endometriosis among women with serum TCDD levels of 100 ppt or higher, but no clear dose response 27 Page 209 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.4 Critical windows of susceptibility The relation between fetal environment and endometriosis was investigated in a large prospective cohort study and revealed a modest increase in incidence of the disease with decreasing birth weight (Missmer et al. 2004b). A link between a history of lower body mass index (BMI) during childhood and adolescent has been investigated in more recent studies and yielded conflicting results finding that both a lean physique during adolescence and young adulthood (Hediger et al. 2005; Vitonis et al. 2010a) and being overweight in late childhood (Nagle et al. 2009) were associated with endometriosis. The study by Missmer et al (2004b) also found that women who were one of a multiple fetal gestation were 70% more likely to be diagnosed with endometriosis. This could be putatively related to the fact that maternal endogenous estrogens are elevated in multiple pregnancies compared to those found in singleton births. More importantly, convincing evidence that fetal exposures to exogenous agents could be involved in the aetiology of endometriosis was uncovered by the same study as the prevalence of endometriosis was 80% greater among women exposed to diethylstilbestrol in utero (Missmer et al. 2004b). The recent demonstration that prenatal exposure to DES resulted in Hoxa10 hypermethylation, accompanied by overexpression of Dnmt1 and Dnmt3b in mice (Bromer et al. 2009) has already been mentioned in relation to fertility and adverse pregnancy outcomes (see section 4.5) and is also particularly relevant to the aetiology of endometriosis. HOX genes are necessary for endometrial growth, differentiation, and implantation. In human endometrium, the expression of HOXA10 and HOXA11 is driven by sex steroids, with peak expression occurring during the midsecretory phase of the menstrual cycle corresponding to the time of implantation in response to rising progesterone levels. However, the maximal HOXA10 and HOXA11 expression fails to occur in women with endometriosis, indicating some defects in uterine receptivity which may be responsible for reduced fertility in women with endometriosis (Cakmak et al. 2010; Guo 2009). The putative promoter of HOXA10 in endometrium from women with endometriosis is hypermethylated as compared with that from women without endometriosis and HOXA10 hypermethylation has recently been demonstrated to silence HOXA10 gene expression and account for decreased HOXA10 in the endometrium of women with endometriosis. There is therefore mounting evidence that epigenetic changes are involved in endometriosis and furthermore there is convincing evidence that such changes can be induced by in utero exposure to exogenous chemicals. A recently published study reports that developmental exposure of mice to TCDD led to a progesterone-resistant phenotype that persisted for several generations (Bruner-Tran et al. 2010a). 4.6.5 Do current experimental approaches capture relevant endpoints/mechanisms? Endometriosis is a primate-specific disease as estrous animals do not shed their endometrial tissue and do not develop endometriosis spontaneously. Several non-human primates have been used as experimental models of human endometriosis. The baboon (Papio Anubis) is generally favoured because baboons have menstrual cycles similar to humans in both duration and endometrial remodelling, similar changes take place in the eutopic endometrium at the time of uterine Page 210 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS receptivity and their placentation is similar to that seen in humans. Further, baboons spontaneously develop endometriotic lesions that resemble those in humans (Braundmeier et al. 2009). There is little doubt that primate models for endometriosis most closely resemble the human situation and are therefore most appropriate to investigate both initiation and progression of the disease as well as cause and effect of the disease (Grummer 2006). However, ethical considerations as well as the high costs and time-consuming aspects of this model limit its application in endometriosis research and would certainly prevent its use in a regulatory setting. Rodent models of endometriosis have been developed whereby the disease is induced by surgical transplantation of endometrial tissue to ectopic sites. There are two types of models; namely, homologous models when endometrium of the same or syngeneic animals is transplanted in immunocompetent animals, and heterologous models when human endometrial fragments are transferred either intraperitoneally or subcutaneously to immunodeficient mice. Autotransplantation of uterine tissue has been established not only in rats and mice but also in hamsters and rabbits (Grummer 2006). Advantages and disadvantages of rodent models have been the subject of debate. Ectopic lesions were found to be small and not physiologically similar to those found in human disease. With the heterologous models, the use of immunocompromised animals eliminates the investigation of the immumoregulatory component of the disease (Braundmeier et al. 2009). On the other hand, autotransplanted uterine tissue shows steroid hormone dependency. Further, it can be used to investigate the effects of environmental contaminants on disease progression. Methoxychlor was shown to support the development of endometric sites in an ovariectomised rat model (Cummings et al. 1995a). There is evidence, however, that the immune system of the rat responds differently from the mouse to environmental chemicals and the mouse may be a better animal model for evaluating potential chemical effects on endometriosis that may be related to the immune response (Cummings et al. 1995b). Furthermore, prenatal exposure to TCDD preceding the surgical induction of endometriosis produced a dose-dependent increase in endometriotic site diameter in such a mouse model (Cummings et al. 1999). The profile of altered gene expression of endometriotic lesions in the autologous mouse model has recently been investigated and authors argued that the mouse model was a good model for the pathophysiology of human disease (Pelch et al. 2010). There has also been some research directed at identifying relevant endpoints in intact animals. In a recently published study, developmental exposure of BalbC mice to bisphenol A resulted in endometriosis-like structure in the adipose tissue surrounding the genital tract (Signorile et al. 2010). Molecular endpoints have also been proposed to investigate the effects of exposure to contaminants at critical development time points. The uterus of mice prenatally exposed to TCDD were examined for progesterone receptor expression and steroid responsive transforming growth factor-beta 2 expression in adult animals and the uterine phenotype of toxicant-exposed mice was argued to be similar to the endometrial phenotype of women with endometriosis (Nayyar et al. 2007). Nonetheless, a recent review of new non-surgical therapies for endometriosis found a gap between promising preclinical findings and clinical trial outcomes that brings the adequacy of animal model of endometriosis into question (Guo 2008). In vitro short-term cultures of human endometrial cells have also been used to investigate effects of environmental contaminants, e.g. TCDD was found to alter the expression of PR isotypes (Nayyar et al. 2007). Page 211 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Overall, if there are some remaining doubts over the validity of available experimental models to detect an effect of chemical exposures on disease progression, there is at present no adequate experimental model that would allow the investigation of effects of environmental contaminants on the onset of endometriosis. Page 212 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.6 Conclusions Attribution criteria: ENDOMETRIOSIS criteria The 2002 Global Assessment of Endocrine INTACT MET Disrupters stated that, for endometriosis, criteria MULTI-LEVEL MET вЂ�human studies were all small, indicating that criteria more powerful analyses are required. Possible HORMONE MET mechanisms linking the endocrine and evidence UNCLEAR PRIMARY EFFECT immune systems in this disease also require further study’. Considerable progress has been criteria EXPOSURE MET made towards understanding the criteria biomolecular processes underlying the SENSITIVE LIFESTAGE MET criteria manifestation and progression of the disease. MOSTLY PHARM. RESTORATION MET However, the etiological mechanisms involved criteria in disease onset remain elusive. There is SUPPORTING DATA MET increasing evidence that epigenetic changes are a key component of this disorder and are involved in the changes in eutopic endometrium in women with the disease. It is still unclear if those are a cause or consequence of the disease. Recent developments do nonetheless implicate developmental exposures to exogenous chemicals in heritable epigenetic changes that may contribute the disease development. Page 213 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS 4.6.6.1 Can female endometriosis be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. (yes/no) Criteria MET Evidence summary Uterine endometrium is an endocrine sensitive tissues whether eutopic or ectopic. Criteria MET The molecular biology underlying the various processes involved in disease manifestation is well characterised. Criteria MET The proliferation of endometriotic dependent on estrogens. Evidence unclear There is no evidence that general toxicity is involved in endometriosis. It is unclear whether a doseresponse relationship between e.g. lesion diameter and treatment regimen has been established in animal models. Criteria MET Prenatal exposure to DES is associated with an increased risk of endometriosis Criteria MET See (5) Criteria MOSTLY MET Hormonal treatment is used to relieve some of the symptoms. 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Relationship of benign gynecologic diseases to subsequent risk of ovarian and uterine tumors. Cancer Epidemiology Biomarkers & Prevention 14:2929-2935. Brinton LA, Westhoff CL, Scoccia B, Lamb EJ, Althuis MD, Mabie JE, Moghissi KS. 2005b. Causes of infertility as predictors of subsequent cancer risk. Epidemiology 16:500-507. Bromer JG, Wu J, Zhou Y, Taylor HS. 2009. Hypermethylation of homeobox A10 by in utero diethylstilbestrol exposure: an epigenetic mechanism for altered developmental programming. Endocrinology 150:3376-3382. Bruner-Tran KL, Ding TB, Osteen KG. 2010a. Dioxin and Endometrial Progesterone Resistance. Seminars in Reproductive Medicine 28:5968. Bruner-Tran KL, Osteen KG. 2010b. Dioxin-like PCBs and Endometriosis. Systems Biology in Reproductive Medicine 56:132-146. Buck Louis GM, Lynch CD, Cooney MA. 2006. Environmental influences on female fecundity and fertility. Semin Reprod Med 24:147-155. Buck Louis GM, Weiner JM, Whitcomb BW, Sperrazza R, Schisterman EF, Lobdell DT, Crickard K, Greizerstein H, Kostyniak PJ. 2005. Environmental PCB exposure and risk of endometriosis. Human Reproduction 20:279-285. Bulun SE. 2009. Mechanisms of Disease Endometriosis. New England Journal of Medicine 360:268-279. Cakmak H, Taylor HS. 2010. Molecular mechanisms of treatment resistance in endometriosis: the role of progesterone-hox gene interactions. Semin Reprod Med 28:69-74. Cobellis L, Colacurci N, Trabucco E, Carpentiero C, Grumetto L. 2009. Measurement of bisphenol A and bisphenol B levels in human blood sera from endometriotic women. Biomedical Chromatography 23:1186-1190. Cobellis L, Latini G, DeFelice C, Razzi S, Paris I, Ruggieri F, Mazzeo P, Petraglia F. 2003. High plasma concentrations of di-(2-ethylhexyl)phthalate in women with endometriosis. Human Reproduction 18:1512-1515. Cooney MA, Louis GMB, Hediger ML, Vexler A, Kostyniak PJ. 2010. Organochlorine pesticides and endometriosis. Reproductive Toxicology 30:365-369. Crain DA, Janssen SJ, Edwards TM, Heindel J, Ho SM, Hunt P, Iguchi T, Juul A, McLachlan JA, Schwartz J, Skakkebaek N, Soto AM, Swan S, Walker C, Woodruff TK, Woodruff TJ, Giudice LC, Guillette LJ, Jr. 2008. Female reproductive disorders: the roles of endocrinedisrupting compounds and developmental timing. Fertil Steril 90:911-940. Cummings AM, Hedge JM, Birnbaum LS. 1999. Effect of prenatal exposure to TCDD on the promotion of endometriotic lesion growth by TCDD in adult female rats and mice. Toxicological Sciences 52:45-49. Cummings AM, Metcalf JL. 1995a. Effects of Estrogen, Progesterone, and Methoxychlor on Surgically Induced Endometriosis in Rats. Fundamental and Applied Toxicology 27:287-290. ----- 1995b. Induction of Endometriosis in Mice - A New Model Sensitive to Estrogen. Reproductive Toxicology 9:233-238. De Felip E, Porpora MG, di Domenico A, Ingelido AM, Cardelli M, Cosmi EV, Donnez J. 2004. 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Gerhard I, Monga B, Krahe J, Runnebaum B. 1999. Chlorinated hydrocarbons in infertile women. Environmental Research 80:299-310. Grummer R. 2006. Animal models in endometriosis research. Human Reproduction Update 12:641-649. Guo SW. 2009. Epigenetics of endometriosis. Molecular Human Reproduction 15:587-607. ----- 2008. Emerging drugs for endometriosis. Expert Opinion on Emerging Drugs 13:547-571. Guo SW, Simsa P, Kyama CM, Mihalyi A, Fulop V, Othman EER, D'Hooghe TM. 2009. Reassessing the evidence for the link between dioxin and endometriosis: from molecular biology to clinical epidemiology. Molecular Human Reproduction 15:609-624. Hediger ML, Hartnett HJ, Louis GMB. 2005. Association of endometriosis with body size and figure. Fertility and Sterility 84:1366-1374. Heilier JF, Donnez J, Nackers F, Rousseau R, Verougstraete V, Rosenkranz K, Donnez O, Grandjean F, Lison D, Tonglet R. 2007. Environmental and host-associated risk factors in endometriosis and deep endometriotic nodules: A matched case-control study. Environmental Research 103:121-129. Heilier JF, Donnez J, Verougstraete V, Donnez O, Grandjean F, Haufroid V, Nackers F, Lison D. 2006. Cadmium, lead and endometriosis. Int Arch Occup Environ Health 80:149-153. Heilier JF, Ha AT, Lison D, Donnez J, Tonglet R, Nackers F. 2004a. Increased serum polychlorobiphenyl levels in Belgian women with adenomyotic nodules of the rectovaginal septum. Fertility and Sterility 81:456-458. Heilier JF, Nackers F, Verougstraete V, Tonglet R, Lison D, Donnez J. 2005. Increased dioxin-like compounds in the serum of women with peritoneal endometriosis and deep endometriotic (adenomyotic) nodules. Fertility and Sterility 84:305-312. Heilier JF, Verougstraete V, Nackers F, Tonglet R, Donnez J, Lison D. 2004b. Assessment of cadmium impregnation in women suffering from endometriosis: a preliminary study. Toxicology Letters 154:89-93. Hoffman CS, Small CM, Blanck HM, Tolbert P, Rubin C, Marcus M. 2007. Endometriosis among women exposed to polybrominated biphenyls. Annals of Epidemiology 17:503-510. Huang PC, Tsai EM, Li WF, Liao PC, Chung MC, Wang YH, Wang SL. 2010. Association between phthalate exposure and glutathione Stransferase M1 polymorphism in adenomyosis, leiomyoma and endometriosis. Human Reproduction 25:986-994. Page 215 of 486 HUMAN HEALTH ENDPOINTS ENDOMETRIOSIS Itoh H, Iwasaki M, Hanaoka T, Sasaki H, Tanaka T, Tsugane S. 2009. Urinary phthalate monoesters and endometriosis in infertile Japanese women. Science of the Total Environment 408:37-42. Itoh H, Iwasaki M, Nakajima Y, Endo Y, Hanaoka T, Sasaki H, Tanaka T, Yang B, Tsugane S. 2008. A case-control study of the association between urinary cadmium concentration and endometriosis in infertile Japanese women. Science of the Total Environment 402:171175. Jackson LW, Zullo MD, Goldberg JM. 2008. The association between heavy metals, endometriosis and uterine myomas among premenopausal women: National Health and Nutrition Examination Survey 1999-2002. Human Reproduction 23:679-687. Jacoby VL, Fujimoto VY, Giudice LC, Kuppermann M, Washington AE. 2010. Racial and ethnic disparities in benign gynecologic conditions and associated surgeries. American Journal of Obstetrics and Gynecology 202:514-521. Lebel G, Dodin S, Ayotte P, Marcoux S, Ferron LA, Dewailly E. 1998. Organochlorine exposure and the risk of endometriosis. Fertility and Sterility 69:221-228. Matalliotakis IM, Arici A, Cakmak H, Goumenou AG, Koumantakis G, Mahutte NG. 2008a. Familial aggregation of endometriosis in the Yale Series. Archives of Gynecology and Obstetrics 278:507-511. Matalliotakis IM, Cakmak H, Fragouli YG, Goumenou AG, Mahutte NG, Arici A. 2008b. Epidemiological characteristics in women with and without endometriosis in the Yale series. Archives of Gynecology and Obstetrics 277:389-393. Mayani A, Barel S, Soback S, Almagor M. 1997. Dioxin concentrations in women with endometriosis. Human Reproduction 12:373-375. Mcleod BS, Retzloff MG. 2010. Epidemiology of Endometriosis: An Assessment of Risk Factors. Clinical Obstetrics and Gynecology 53:389396. Mendola P, Messer LC, Rappazzo K. 2008. Science linking environmental contaminant exposures with fertility and reproductive health impacts in the adult female. Fertil Steril 89. Missmer SA, Chavarro JE, Malspeis S, Bertone-Johnson ER, Hornstein MD, Spiegelman D, Barbieri RL, Willett WC, Hankinson SE. 2010. A prospective study of dietary fat consumption and endometriosis risk. Human Reproduction 25:1528-1535. Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Marshall LM, Hunter DJ. 2004a. Incidence of laparoscopically confirmed endometriosis by demographic, anthropometric, and lifestyle factors. American Journal of Epidemiology 160:784-796. Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Michels KB, Hunter DJ. 2004b. In utero exposures and the incidence of endometriosis. Fertility and Sterility 82:1501-1508. Montgomery GW, Nyholt DR, Zhao ZZ, Treloar SA, Painter JN, Missmer SA, Kennedy SH, Zondervan KT. 2008. The search for genes contributing to endometriosis risk. Human Reproduction Update 14:447-457. Nagle CM, Bell TA, Purdie DM, Treloar SA, Olsen CM, Grover S, Green AC. 2009. Relative weight at ages 10 and 16 years and risk of endometriosis: a case-control analysis. Human Reproduction 24:1501-1506. Nayyar T, Bruner-Tran KL, Piestrzeniewicz-Ulanska D, Osteen KG. 2007. Developmental exposure of mice to TCDD elicits a similar uterine phenotype in adult animals as observed in women with endometriosis. Reproductive Toxicology 23:326-336. Niskar AS, Needham LL, Rubin C, Turner WE, Martin CA, Patterson DG, Hasty L, Wong LY, Marcus M. 2009. Serum dioxins, polychlorinated biphenyls, and endometriosis: A case-control study in Atlanta. Chemosphere 74:944-949. Pauwels A, Schepens PJC, D'Hooghe T, Delbeke L, Dhont M, Brouwer A, Weyler J. 2001. The risk of endometriosis and exposure to dioxins and polychlorinated biphenyls: a case-control study of infertile women. Human Reproduction 16:2050-2055. Pelch KE, Schroder AL, Kimball PA, Sharpe-Timms KL, Davis JW, Nagel SC. 2010. Aberrant gene expression profile in a mouse model of endometriosis mirrors that observed in women. Fertility and Sterility 93:1615-1627. Porpora MG, Ingelido AM, di Domenico A, Ferro A, Crobu M, Pallante D, Cardelli M, Cosmi EV, De Felip E. 2006. Increased levels of polychlorobiphenyls in Italian women with endometriosis. Chemosphere 63:1361-1367. Porpora MG, Medda E, Abballe A, Bolli S, De Angelis I, di Domenico A, Ferro A, Ingelido AM, Maggi A, Panici PB, De Felip E. 2009. Endometriosis and Organochlorinated Environmental Pollutants: A Case-Control Study on Italian Women of Reproductive Age. Environmental Health Perspectives 117:1070-1075. Reddy BS, Rozati R, Reddy BVR, Raman NVVS. 2006a. Association of phthalate esters with endometriosis in Indian women. Bjog-An International Journal of Obstetrics and Gynaecology 113:515-520. Reddy BS, Rozati R, Reddy S, Kodampur S, Reddy P, Reddy R. 2006b. High plasma concentrations of polychlorinated biphenyls and phthalate esters in women with endometriosis: a prospective case control study. Fertility and Sterility 85:775-779. Rizner TL. 2009. Estrogen metabolism and action in endometriosis. Molecular and Cellular Endocrinology 307:8-18. Signorile PG, Spugnini EP, Mita L, Mellone P, D'Avino A, Bianco M, Diano N, Caputo L, Rea F, Viceconte R, Portaccio M, Viggiano E, Citro G, Pierantoni R, Sica V, Vincenzi B, Mita DG, Baldi F, Baldi A. 2010. Pre-natal exposure of mice to bisphenol A elicits an endometriosis-like phenotype in female offspring. General and Comparative Endocrinology 168:318-325. Simsa P, Mihalyi A, Schoeters G, Koppen G, Kyama CM, Den Hond EM, Fulop V, D'Hooghe TM. 2010. Increased exposure to dioxin-like compounds is associated with endometriosis in a case-control study in women. Reproductive Biomedicine Online 20:681-688. Siristatidis C. 2009. What have the 'omics done for endometriosis? Medical Science Monitor 15:RA116-RA123. Tait AS, Butts CL, Sternberg EM. 2008. The role of glucocorticoids and progestins in inflammatory, autoimmune, and infectious disease. Journal of Leukocyte Biology 84:924-931. Tariverdian N, Theoharides TC, Siedentopf F, Gutierrez G, Jeschke U, Rabinovich GA, Blois SM, Arck PC. 2007. Neuroendocrine-immune disequilibrium and endometriosis: an interdisciplinary approach. Seminars in Immunopathology 29:193-210. Trabert B, De Roos AJ, Schwartz SM, Peters U, Scholes D, Barr DB, Holt VL. 2010. Non-Dioxin-Like Polychlorinated Biphenyls and Risk of Endometriosis. Environmental Health Perspectives 118:1280-1285. 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Page 217 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7 UTERINE FIBROIDS Uterine fibroids (also often referred to as leiomyomas, myomas or leiomyomatas) are benign monoclonal tumours of the smooth muscle cells of the myometrium. Although their morbidity is associated with local disease rather than distant metastasis, their presence in the uterus and pelvic cavity can cause menorrhagia, abdominal pain, pelvic prolapse, infertily and pregnancy complications, and they are a leading cause of hysterectomy (Diamanti-Kandarakis et al. 2009; Othman et al. 2008). They are thought to occur in 25-50% of all women with a preponderance occurring in African American women and as a hormonally dependent tumour, the potential role of EDCs in their aetiology has received particular interest. 4.7.1 The natural history of uterine fibroids The symptoms associated with fibroids vary and include pelvic pain, congestion, bloating, dyspareunia, urinary frequency, constipation, abnormal uterine bleeding and reproductive dysfunction. However the majority of fibroids (estimated to be in excess of 50%) are asymptomatic. The presence of fibroids does not necessarily lead to menorrhagia but abnormal bleeding occurs in 30% of patients (Gupta et al. 2008; Parker 2007). It is generally diagnosed by sonographic examination although other imaging techniques such as hysteroscopy or MRI can be used for definitive diagnosis and selection of optimal medical therapy (Parker 2007). 4.7.1.1 Prevalence Uterine fibroids are clinically apparent in up to 25% of all women and up to 30-40% of women over 40 years of age. However because most are asymptomatic, a large proportion of fibroids remain undiagnosed. Further, most imaging techniques lack resolution below 1cm, and it is equally possible that the true incidence is underestimated, although the clinical significance of small fibroids is unknown (Okolo 2008; Parker 2007). Fine sectioning of hysterectomy specimens revealed the presence of fibroids in 77% of cases (Othman et al. 2008). Fibroids were not found less frequently in women who had hysterectomies for other indications, although they were smaller and less numerous. It has been argued that reports based on histology may overestimate the true incidence as they are related to women with symptoms in which non-surgical treatments have failed (Parker 2007). Any study of prevalence and incidence trends is therefore flawed with many issues and few studies have actually addressed this topic. Fibroids seem to be less prevalent in European populations as well as in Asian and Hispanic women and are preponderant in African-American women (Blake 2007). 4.7.1.2 Comorbidities The fact that these tumours do not metastasise belies the extent of their impact on the quality of life of women affected. Although it is thought that 27% of infertile women have uterine fibroids, it is unclear whether this proportion exceeds that in fertile women. Fibroids have however been implicated in recurrent pregnancy loss and first and second trimester miscarriage (Gupta et al. 2008). In late pregnancy, fibroids may enlarge and are associated with an increased risk of several Page 218 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS obstetric complications, including caesarean delivery, malpresentation, postpartum haemorrhage, intrauterine growth restriction, preterm labor and placental abruption (Gupta et al. 2008; Olive et al. 2010). An association with polycystic ovaries syndrome (PCOS), particularly in lean women, has also been shown and was putatively related to luteinising hormone hypersecretion, insulin resistance and increased insulin-like growth factor -1 (IGF1) levels (Okolo 2008). Although uterine fibroids have been associated with a substantially increased risk of uterine malignancies (Brinton et al. 2005), malignant transformation of fibroids themselves is extremely rare and the general consensus is that leiomyosarcomas arise de novo rather than develop from benign fibroids (Gupta et al. 2008). 4.7.1.3 Risk factors Reproductive history Hormonal and anatomical changes associated with menstruation and pregnancy influence uterine fibroid incidence. Earlier and later age at menarche both have been associated with increased and decreased risk respectively (Crain et al. 2008; Okolo 2008; Terry et al. 2010). The risk of developing fibroids increases with age during the premenopausal years, but tumours typically regress or become asymptomatic with the onset of menopause (Othman et al. 2008). Use of oral contraceptives, longer menstrual factors and breastfeeding all have been identified as protective factors (Crain et al. 2008; Terry et al. 2010). Further, the risk of parous women is approximately half that of nulliparous women, and increased parity decreases the incidence of clinically apparent fibroids (Crain et al. 2008; Parker 2007), although this association appears to occur mainly in White but not Black women (Okolo 2008). Fibroids share some of the characteristics of normal myometrium during pregnancy, such as increased production of extracellular matrix and increased expression of peptide and steroid hormone receptors (Parker 2007). There is evidence that fibroids initially increase in size in the trimester of pregnancy and regress over the next two trimesters and this lends support to the theory that endogenous hormones inhibit fibroid growth during pregnancy despite the pregnancy-induced hypertrophy of the uterus (Okolo 2008). The postpartum myometrium undergoes substantial tissue remodelling to return to normal weight, blood flow and cell size via apoptosis and dedifferentiation and this process has been advanced as being responsible for the involution of fibroids (Okolo 2008; Parker 2007). Family history There is some epidemiological evidence that this condition is heritable to some extent. Cross sectional studies of mainly Caucasian populations have reported odds ratio of 2.2-4 for first degree relatives of women with fibroids and twin pair studies also indicate that monozygous twins are more likely to be hospitalised for treatment of fibroids than heterozygous twins (Okolo 2008; Parker 2007). Race Increased prevalence of fibroids in African American women was observed more than 100 years ago. Recent studies have confirmed this, reporting a risk almost 3-fold greater for African-American than for Caucasian women that was unrelated to other known risk factors (Parker 2007). Black women are also diagnosed younger, have more numerous and larger fibroids and are more likely to report severe symptoms (Othman et al. 2008). The molecular background behind this ethnic disparity is not Page 219 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS fully understood; leiomyma tissues from African-American women exhibit a higher expression of aromatase which may result in elevated concentrations of estrogen (Ishikawa et al. 2009), and some polymorphisms of genes involved in estrogen synthesis or metabolism, aberrant expression of miRNAs or variation in the expression of steroid or retinoic acid nuclear receptors have been proposed as potential mechanisms (Othman et al. 2008). Weight and metabolism Obesity has been linked to the development of uterine fibroids and women presenting with fibroids are more likely to be obese or severely obese (Okolo 2008; Terry et al. 2007). Moreover, the risk for fibroids increases with body weight and body mass index (BMI) (Parker 2007). This association has been conferred to the hyper-estrogenic state linked to obesity and the peripheral conversion of androgens to estrogens and decreased hepatic production of sex hormone binding globulin (Okolo 2008; Parker 2007). Several recent studies have also consistently found associations between uterine fibroids and factors associated with the metabolic syndrome such as blood pressure, serum triglyceride, fasting plasma glucose, diabetes mellitus (Boynton-Jarrett et al. 2005; Okolo 2008; Sadlonova et al. 2008; Takeda et al. 2008). However insulin resistance was not shown to be a risk factor for fibroids (Sadlonova et al. 2008). Lifestyle factors Smoking has been found to reduce the risk of developing uterine fibroids, however this effects appears not to extend to Black women (Okolo 2008; Parker 2007). In African-American women, the risk of uterine fibroids was also associated with current alcohol consumption (Wise et al. 2004). A few studies have examined potential association with diet and there are some suggestions that a diet rich in red meat increases risk (Okolo 2008; Parker 2007). High dietary glycemic index and glycemic load are hypothesised to promote tumorigenesis by increasing endogenous concentrations of IGF1 or the bioavailability of estradiol and have also been linked to an increased risk of uterine fibroids in some women in a recently published study (Radin et al. 2010). Finally, exercise has a protective effect that may be related to leaner body mass and lower conversion rates of androgens to estrogens (Parker 2007). 4.7.1.4 Aetiology Fibroid neoplasms are monoclonal and about 40% are chromosomally abnormal (Parker 2007). The origin of the transformation from a normal myometrial cell to an abnormal myocyte remains unclear but in view of its high prevalence, it is reasonable to assume that it must be a frequent occurrence. Research has focused on determining genetic causes for the development of fibroids and more than 100 genes have been found to be up-regulated or down-regulated in myoma cells. Many of these genes appear to regulate cell growth, differentiation, proliferation, and mitogenesis and include the sex-steroid associated genes ER-О±, ER-ОІ, PR-A, PR-B, growth hormone receptor, prolactin receptor, extracellular matrix genes, and collagen genes (Parker 2007). Page 220 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.2 Evidence of an endocrine mechanism in uterine fibroids Circulating levels of ovarian steroids in women with clinically detectable fibroids are similar to those measured in normal women. There are however quantifiable differences in tissue expression of receptors for both estradiol and progesterone between autologous normal myometrial tissue and leiomyoma tissue, implicating local intrauterine factors in the development of fibroids (Blake 2007; Okolo 2008). Investigators have also examined levels of steroidogenic enzymes as well as cellular proliferative factors in fibroids and current knowledge is briefly summarised in this section. 4.7.2.1 Evidence of estrogen dependency There are significantly higher concentrations of both ER-О± and ER-ОІ in leiomyomas compared with normal myometrium and levels of both isoforms mRNA fluctuate in a similar during the menstrual cycle. However levels of ER-О± are greater than ER-ОІ and there are indications that ER-ОІ is only expressed in myometrial and leiomyoma microvascular endothelial cells (Blake 2007). In in vitro cultures, rodent leiomyoma cells proliferate in response to estrogen and this response is inhibited by estrogen antagonists (Othman et al. 2008). Levels of estradiol in fibroids are also elevated compared to normal myometrium. Increased levels of aromatase and low levels of arylsulfatase are thought to contribute to the accumulation of estradiol, leading in turn to hyper-responsiveness to estrogen, upregulation of ERs and PRs and proliferation (Parker 2007). Recent evidence also suggests a role for rapid E2-signalling pathways in the promotion of leiomyomas (Nierth-Simpson et al. 2009). 4.7.2.2 Evidence of progesterone dependency In recent years, a role for progesterone in promoting fibroid growth has emerged. Uterine fibroids exhibit increased mitosis in the progesterone-dominant luteal phase of the menstrual cycle and during pregnancy as well as in women treated with the progestagen medroxyprogesterone acetate compared with untreated controls and a combined oral contraceptive (Blake 2007; Okolo 2008; Parker 2007). In myoma cell cultures, both the addition of estradiol or progesterone increases the mitotic rate, while in normal myometrial cells, only estradiol elicits a proliferative response (Blake 2007). Moreover, both progesterone receptors isoforms PR-A and PR-B are overexpressed in leiomyoma tissue compared with autologous normal myometrium (Blake 2007; Okolo 2008; Parker 2007). 4.7.2.3 Estrogen and progesterone Fibroid growth is therefore stimulated in response to a mixture of endogenous hormones, estrogen and progesterone, rather than one or the other. The myometrium, like the endometrium, expresses cyclic changes regulated by estrogen and progesterone in preparation for pregnancy. Sequential ovarian secretion of estrogen and progesterone results in a gradual rise in myometrial ERs and PRs levels during the follicular phase. By the mid-luteal phase, during progesterone dominance, ER levels decline while PR content remains significant into the follicular phase. Subsequently during the late luteal phase, lower levels of both ER and PR are present. This oscillating pattern is absent in leiomyomas and transformed myocytes retain high levels of PRs throughout the ovarian cycle and elevated levels of ERs at the beginning of the follicular proliferative phase (Blake 2007). Page 221 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.2.4 Signalling pathways and growth factors The response of myomas to the changing hormonal milieu involves the expression of specific growth factors, proteins or polypeptides produced locally by smooth muscle cells and fibroblasts, that control cell proliferation and tumour growth primarily by increasing extracellular matrix. Some of the growth factors implicated include transforming growth factor-ОІ (TGF-ОІ), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF) and prolactin (Blake 2007; Parker 2007). Many are over-expressed in myomas and can affect cells in complex ways by increasing smooth muscle proliferation, increase DNA synthesis, stimulate synthesis of extracellular matrix and promote miotgenesis or angiogenesis. Coordinated action of both estradiol and progesterone have been postulated to up-regulate EGF receptors and EGF-like proteins respectively and result in higher levels of EGF during the secretory phase of the menstrual cycle. Downstream effects of progesterone intracellular action extend to the synthesis of extracellular matrix stimulated by TGF-ОІ (Blake 2007). Other factors regulating apoptosis have been subject to investigation, such as the anti-apoptotic protein, Bcl-2 that is upregulated by progesterone and downregulated by estradiol in vitro, and tumour necrosis factor-О± (TNF-О±) whose expression is also thought to be influenced by the hormonal environment (Blake 2007). Other dysregulated signalling pathways have been implicated in the growth of uterine leiomyomas, specifically the mammalian target of rapamycin (mTOR) (Crabtree et al. 2009) and retinoid pathways (Lattuada et al. 2007). Negative cross-talk between peroxisome proliferator activated receptor-Оі (PPAR-Оі) and ER signalling pathways inhibited growth of myomas (Houston et al. 2003). 4.7.2.5 Epigenetics Differential expression of hormone receptors in uterine leiomyomas and normal myometrium has led some investigators to explore potential mechanisms of epigenetic modulation (for a description of epigenetic mechanisms, please refer to section 3.4) in the development of this tumour. Evidence to that effect includes global hypomethylation and differential expression of DNA methyltransferases (DNMTs) in leiomyoma tissue (Li et al. 2003). A more recent study also observed hypomethylation of CpG sites in the distal region of the ER-О± promoter in leiomyomas (Asada et al. 2008). 4.7.3 Evidence for a role of chemical exposures in uterine fibroids Epidemiological associations between environmental contaminants and uterine fibroids have only recently been subject to examination and there is no recent extensive review of such studies. A few recent studies could nonetheless be located and their results are summarised in Table 23. Pharmaceutical hormones Gonadotrophin-releasing hormone agonists suppress ovarian estrogen production to postmenopausal levels and result in regression of uterine fibroids (Othman et al. 2008). Although an increased risk of fibroids with the use of oral contraceptive has been reported, another study found Page 222 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS no association with duration of use and a decreased risk has also been reported although it may be due to selection bias as women with fibroids may be prescribed oral contraceptive less frequently. Postmenopausal hormonal therapy is not associated with uterine growth in the majority of women. A higher dose of progestagen however has been shown to increase myoma size in 50% of women (Parker 2007). Phytoestrogens Recent studies of an association between phytoestrogen consumption and uterine fibroids do not provide convincing evidence of an effect. Exposure has been generally established using a questionnaire rather than measurement, although a study using excreted levels in urine found a decreased risk with lignans but not isoflavones (Table 23). It is interesting that another study had found an increased risk associated with being fed soy formula as an infant. This outcome suggests an age-specific effect. The effects of genistein a soy-derived isoflavone have been studied in vitro and its effects were found to be concentration-dependent; at lower concentration it was found to elicit proliferative effects on cultured uterine leiomyomas cell, whereas at higher concentrations it increased apoptosis (Moore et al. 2007). Inhibitory effects on estradiol-induced leiomyoma cell proliferation have recently been shown to be mediated via PPAR-Оі (Miyake et al. 2009). Phthalate esters One study examined the association between urinary levels of phthalate metabolites and uterine fibroids and did not find any significant association (Table 23). Heavy metals A recent epidemiological study has found associations between the concentrations of several heavy metals in subcutaneous fat and uterine fibroids in Chinese women (Table 23), namely arsenic, lead, mercury, selenium and zinc. However, of those associations that were investigated in another recent study using measured levels in whole blood, only an association with mercury was corroborated. It is unclear whether this disparity reflects the fact that metal levels measured in fat are more relevant to past exposures or that Chinese women are exposed to higher levels of heavy metals. Polycyclic Aromatic Hydrocarbons (PAHs) The same Chinese study examined associations between various PAHs and uterine fibroids and found that levels of pyrene, benzanthracene and benzofluoranthene were significantly higher in the subcutaneous fat of cases than of controls (Table 23). Organochlorine pesticides Qin et al (2010) also investigated the association between organochloride pesticides and uterine fibroids (Table 23) and an association was found for all the compounds investigated. This is consistent with in vitro evidence showing that organochlorine pesticides act as estrogen receptor agonists in Eker rat uterine myometrial cells (Hodges et al. 2000). Page 223 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS Polyhalogenated compounds and dioxins Associations were also found for some polychlorinated biphenyls (PCBs) and polybrominated fire retardants diphenyl ethers (PBDEs) whereas the tetrachlorodibenzodioxin (TCDD) was found to have a protective effect in women exposed accidentally during the Seveso explosion (Table 23). Page 224 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS Table 23.Summary of studies of the association between exogenous chemicals and uterine fibroids Chemical Biospecimen Population (sample size) Study results Reference Soy intake Soy formula Questionnaire Questionnaire 22,120 premenopausal US Black Women's Health Study participants 19,972 non-Hispanic white women from the NIEHS sister study, United States Soy isoflavone Isoflavone Questionnaire Urine 285 premenopausal Japanese women 243 members of Group Health Cooperative, Washington State, united States No association Increased 29 risk No association No association Lignan Urine 243 members of Group Health Cooperative, Washington State, united States (Wise et al. 2010) (D'Aloisio et al. 2010) (Nagata et al. 2009) (Atkinson et al. 2006) (Atkinson et al. 2006) (Weuve et al. 2010) (Weuve et al. 2010) (Weuve et al. 2010) (Weuve et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Jackson et al. 2008) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Jackson et al. 2008) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Jackson et al. 2008) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) Monoethylphthalate Urine Monobutylphthalate Urine Monobenzylphthalate Urine Monoethylhexylphthalate Urine Arsenic Subcutaneous fat Cadmium Subcutaneous fat Whole blood 1,227 women from the NHANES study, United States 1,227 women from the NHANES study, United States 1,227 women from the NHANES study, United States 1,227 women from the NHANES study, United States Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) 1,425 women from the NHANES study, United States Decreased 30 risk No association No association No association No association Association Association No association Chromium Copper Iron Lead Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Whole blood Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) 1,425 women from the NHANES study, United States No association No association No association Association No association Nickel Manganese Mercury Subcutaneous fat Subcutaneous fat Subcutaneous fat Whole blood Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) 1,425 women from the NHANES study, United States Selenium Tin Zinc Subcutaneous fat Subcutaneous fat Subcutaneous fat Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) No association No association Association Increased 31 risk Association No association Association (continued overleaf) 29 Not statistically significant In highest quartile 31 No longer statistically significant when adjusted for race/ethnicity, smoking status at diagnosis, use of birth control pills prior to diagnosis and age 30 Page 225 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS Chemical Biospecimen Population (sample size) Study results Reference Naphthalene Phenanthrene Fluoranthene Pyrene Benzanthracene Chrysene Benzofluoranthene Hexachlorobenzene Hexachlorocyclohexane DDE DDD DDT PCB-123 PCB-118 PCB-126 PCB-180 PCB-169 PBDE47 PBDE100 PBDE119 PBDE99 PBDE85 PCB-118 TCDD Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Subcutaneous fat Serum collected after explosion Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) Patients in 6 hospitals and 6 cosmetic surgery clinics, Hong Kong, China (n=40) 956 women enrolled in the Seveso Women’s Health Study, Italy No association No association No association Association Association No association Association Association Association Association Association Association Association No association Association Association No association No association Association Association Association Association No association Decreased risk (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Qin et al. 2010) (Eskenazi et al. 2007) Page 226 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.4 Critical windows of susceptibility The most convincing evidence that early-life factors could promote fibroid pathogenesis arises from the recent study by D’Aloisio et al (2010). As mentioned in the previous section a greater risk of early fibroid diagnosis was associated with soy formula during infancy and reported in utero DES exposure, but associations were also found with gestational diabetes and preterm birth (D'Aloisio et al. 2010). Developmental exposures to DES and bisphenol A have been the focus of research for an association and potential mechanism of developmental reprogramming and recent findings are briefly reported here. 4.7.4.1 Diethylstilbestrol (DES) Epidemiological evidence that fetal exposure to DES is associated with the development of uterine fibroids remains controversial. Apart from the more recent study mentioned above, two studies had addressed this question and arrived at conflicting conclusions depending on the diagnostic methods used; no association was found in the study where histological confirmation was sought after surgical removal of fibroids, whereas a significant relationship was found when ultrasonographic detection of fibroids was used (Baird et al. 2005; Crain et al. 2008; Wise et al. 2005). An association with DES is however supported by experimental evidence in rodents. The incidence of uterine fibroids is significantly increased in CD-1 mice exposed prenatally or neonatally (Crain et al. 2008). Eker rats are genetically predisposed to develop uterine fibroids due to a germline defect in the tuberous sclerosis complex-2 (Tsc-2) tumour suppressor gene and developmental exposure of these rats to DES results in increase tumour incidence, multiplicity and size(Crain et al. 2008). Eker rats were exposed to DES at different periods important to reproductive tract development and differentiation on either postnatal days 3 to 5, 10 to 12, or 17 to 19. DES exposure at days 3 to 5 and 10 to 12 but not 17 to 19 significantly increased the incidence of uterine leiomyomas and gene expression analysis revealed that this was accompanied by a reprogramming of estrogen-responsive genes calbindin D9K and progesterone receptor in the aduly myometrium of females exposed during the susceptible period compared to the resistant period. Interestingly, the resistant period (days 17 to 19) corresponds with the time at which the reproductive tract is exposed to endogenous estrogens, suggesting that target tissues are most vulnerable during the period at which they would normally be maintained in an estrogen-naive state (Cook et al. 2007). A further study found that the expression of 6 estrogen-responsive genes were reprogrammed following neonatal DES exposure in the myometrium of exposed animal sprior to onset of tumorigenesis (Greathouse et al. 2008). 4.7.4.2 Bisphenol A The long-term effects of developmental exposure to bisphenol A were investigated in the CD-1 mouse model that had previously demonstrated such effects with DES mentioned above. Leiomyomas were observed in some animals exposed by subcutaneous injection of 10-1000 Ојg/kg/day on days 1 to 5 but not controls (Newbold et al. 2007). Furthermore, the expression of the homeobox gene Hoxa10 (refer to sections 4.5 and 4.6) has been shown to be altered following in utero bisphenol A exposure. Decreased DNA methylation led to an increase in binding of ER-О± to the Hoxa10 estrogen-responsive element both in vitro and in vivo and again epigenetic alteration of sensitivity to estrogen has been proposed as a a general mechanism through which endocrine disruptors exert their action on uterine tissues (Bromer et al. 2010). Page 227 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.5 Do current experimental approaches capture relevant endpoints/mechanisms? Uterine leiomyomas have been observed in mice, dogs and Baltic grey seals, but the best characterised experimental animal model is the Eker rat mentioned in the previous section. Sixtyfive percent of female Eker rats carrying the Tsc-2 mutation spontaneously develop uterine leiomyomas by 12-16 months of age that are hormone dependent, occur with a similar frequency and share many phenotypic characteristics with human fibroids (Hodges et al. 2001; Walker et al. 2003). This has been argued to be a useful model to investigate the potential impact of EDCs. Developmental exposure to DES failed to induce tumours in wild-type rats but did affect the expression of estrogen-responsive genes in the developing uterine endometrium (Crain et al. 2008), and early molecular events in other strains of rat may be suitable for the investigation of the effects of environmental contaminants on the propensity to develop uterine fibroids (Crain et al. 2008). In addition to in vivo studies, several cell lines have been developed from Eker rat uterine leiomyomas. Five Eker leiomyoma tumour-derived (ELT) cell lines have been established and characterised and vary with respect to steroid hormone receptor expression. Several in vitro assays using ELT cell lines have been developed to assess the estrogenic activity of potential EDCs (Hodges et al. 2001; Walker et al. 2003). Page 228 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.6 Conclusions Attribution criteria: UTERINE FIBROIDS The 2002 Global Assessment of Endocrine criteria INTACT MET Disrupters did not cover uterine fibroids. criteria These extremely common tumours of the MOSTLY MULTI-LEVEL MET female reproductive tract are however known criteria PARTLY HORMONE to be responsive to steroid. Although benign, MET criteria fibroids are a leading cause of hysterectomy PRIMARY EFFECT MET and have therefore both a considerable criteria MOSTLY EXPOSURE impact in terms of public health as well as on MET the personal lives of women affected. criteria SENSITIVE LIFESTAGE MET Epidemiological evidence of an association criteria remains sparse but considerable advances in PHARM. RESTORATION MET the understanding of the molecular criteria SUPPORTING DATA MET mechanisms underlying estrogen and progesterone dependence of these tumours have been made in the last ten years. There is also increasing evidence that epigenetic mechanisms may be involved in the association between known EDCs such as DES and bisphenol A and uterine leiomyomas in some rodents. Further epidemiological studies should be a priority for further research. Page 229 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.6.1 Can uterine fibroids be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. (yes/no) Criteria MET Evidence summary Uterine fibroids are benign tumours derived from the myometrium. Criteria MOSTLY MET Leiomyomas are known to respond to endogenous levels of estrogen and progesterone and this response is well characterised at different levels of organisation, however the same cannot be said of tomourigenesis. Criteria PARTLY MET The hormonal profiles of women with fibroids are similar to healthy women, however treatment of Eker rats with known estrogenic EDCs has been found to increase the incidence of leiomyomas. Criteria MET There is convincing evidence that leiomyomas respond to changes to ovarian steroid hormones during the menstrual cycle. Criteria MOSTLY MET Criteria MET There convincing evidence that DES increases the number and size fibroids in susceptible rodent models but human epidemiological evidence is inconclusive. The critical window of susceptibility has been investigated in Eker rats exposed neonatally to DES. Criteria MET Gonadotropin agonists lead to the regression of tumours. Criteria MET In vitro assays have been developed from Eker rat leiomyoma cells. Page 230 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS 4.7.7 References Asada H, Yamagata Y, Taketani T, Matsuoka A, Tamura H, Hattori N, Ohgane J, Hattori N, Shiota K, Sugino N. 2008. Potential link between estrogen receptor-alpha gene hypomethylation and uterine fibroid formation. Molecular Human Reproduction 14:539-545. Atkinson C, Lampe JW, Scholes D, Chen C, Wahala K, Schwartz SM. 2006. Lignan and isoflavone excretion in relation to uterine fibroids: a case-control study of young to middle-aged women in the United States. American Journal of Clinical Nutrition 84:587-593. Baird DD, Newbold R. 2005. Prenatal diethylstilbestrol (DES) exposure is associated with uterine leiomyoma development. Reproductive Toxicology 20:81-84. Blake RE. 2007. Leiomyomata uteri: Hormonal and molecular determinants of growth. 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Lattuada D, Vigano P, Mangioni S, Sassone J, Di Francesco S, Vignali M, Di Blasio AM. 2007. Accumulation of retinoid X receptor-alpha in uterine leiomyomas is associated with a delayed ligand-dependent proteasome-mediated degradation and an alteration of its transcriptional activity. Mol Endocrinol 21:602-612. Li SF, Chiang TC, Richard-Davis G, Barrett JC, McLachlan JA. 2003. DNA hypomethylation and imbalanced expression of DNA methyltransferases (DNMT1, 3A, and 3B) in human uterine leiomyoma. Gynecologic Oncology 90:123-130. Miyake A, Takeda T, Isobe A, Wakabayashi A, Nishimoto F, Morishige KI, Sakata M, Kimura T. 2009. Repressive effect of the phytoestrogen genistein on estradiol-induced uterine leiomyoma cell proliferation. Gynecological Endocrinology 25:403-409. Moore AB, Castro L, Yu L, Zheng X, Di X, Sifre MI, Kissling GE, Newbold RR, Bortner CD, Dixon D. 2007. 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Olive DL, Pritts EA. 2010. Fibroids and Reproduction. Seminars in Reproductive Medicine 28:217-226. Othman EER, Al-Hendy A. 2008. Molecular genetics and racial disparities of uterine leiomyomas. Best Practice & Research in Clinical Obstetrics & Gynaecology 22:589-601. Parker WH. 2007. Etiology, symptomatology, and diagnosis of uterine myomas. Fertility and Sterility 87:725-736. Qin YY, Leung CKM, Leung AOW, Wu SC, Zheng JS, Wong MH. 2010. Persistent organic pollutants and heavy metals in adipose tissues of patients with uterine leiomyomas and the association of these pollutants with seafood diet, BMI, and age. Environmental Science and Pollution Research 17:229-240. Page 231 of 486 HUMAN HEALTH ENDPOINTS UTERINE FIBROIDS Radin RG, Palmer JR, Rosenberg L, Kumanyika SK, Wise LA. 2010. Dietary glycemic index and load in relation to risk of uterine leiomyomata in the Black Women's Health Study. American Journal of Clinical Nutrition 91:1281-1288. Sadlonova J, Kostal M, Smahelova A, Hendl J, Starkova J, Nachtigal P. 2008. Selected metabolic parameters and the risk for uterine fibroids. International Journal of Gynecology & Obstetrics 102:50-54. Takeda T, Sakata M, Isobe A, Miyake A, Nishimoto F, Ota Y, Kamiura S, Kimura T. 2008. Relationship between metabolic syndrome and uterine leiomyomas: A case-control study. Gynecologic and Obstetric Investigation 66:14-17. Terry KL, De Vivo I, Hankinson SE, Missmer SA. 2010. Reproductive characteristics and risk of uterine leiomyomata. Fertility and Sterility 94:2703-2707. Terry KL, De Vivo I, Hankinson SE, Spiegelman D, Wise LA, Missmer SA. 2007. Anthropometric Characteristics and Risk of Uterine Leiomyoma. Epidemiology 18:758-763. Walker CL, Hunter D, Everitt JI. 2003. Uterine leiomyoma in the Eker rat: A unique model for important diseases of women. Genes Chromosomes & Cancer 38:349-356. Weuve J, Hauser R, Calafat AM, Missmer SA, Wise LA. 2010. 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Page 232 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER 5 HUMAN HEALTH ENDPOINTS- HORMONAL CANCERS 5.1 BREAST CANCER Of all the hormone-dependent cancers, breast cancer is by far the most extensively studied. The relationship between breast cancer risks and exposure to environmental pollutants has been reviewed recently (Brody et al. 2007; Gray et al. 2009; Salehi et al. 2008). The purpose of this section is to summarise pertinent findings, with a view to assessing whether there are associations between chemical exposures and the disease, and whether any can be attributed to endocrine disrupting mechanisms and to endocrine disrupting chemicals. During the last ten years, new evidence has emerged to show that exposure to pharmaceutical steroidal estrogens including diethylstilbestrol (DES) and steroids used in hormone replacement therapy (HRT) increase breast cancer risks. These discoveries have produced insights into determinants of the disease process and have added weight to the idea that any estrogen, including xenoestrogens, might contribute to breast cancer risks. Before dealing with endocrine disrupters and breast cancer, we will therefore first consider endogenous estrogens and pharmaceutical estrogens (including DES), with the aim of recognising important general principles that derive from these studies. 5.1.1 Natural history of breast cancer Breast cancer is the most common malignancy in females and an estimated 1.4 million new cases diagnosed are yearly (IARC/GLOBOCAN 2010). The incidence of breast cancer shows a wide variation with geography, described below, suggesting a possible role for environmental factors in aetiology. Risk factors for breast cancer include late age at first birth, nulliparity, socioeconomic status, primary family history of breast cancer, early age of menarche, exposure to ionising radiation, a high fat diet, adult weight gain and alcohol consumption (Madigan et al. 1995). Genetics explain only a small fraction of breast cancers. Around 1 in 20 cases are believed to be due to an inherited predisposition, a mutation in the BRCA1 and BRCA2 genes (King et al. 2003), but for the overwhelming majority of women the disease is not passed on through genes but thought to be acquired during their lifetime. A proposed role for human exposure to endocrine disrupting chemicals in the causation of breast cancer follows on from the associations of steroidal estrogens with breast cancer. The discovery of estrogenic properties of many chemical pollutants found in the environment, food and consumer products has led to the suggestion that the significant rise of new breast cancer cases in industrialised countries may be, at least partly, due to exposure to such estrogen-like chemicals (Davis et al. 1993). Mechanisms by which such chemicals, so-called xenoestrogens, might increase breast cancer risks include mimicry of the action of endogenous estrogens. Other mechanisms have also been proposed, such as the role of dioxins and the Ah receptor pathway in interfering with estrogen signalling. Page 233 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Trends in incidence rates Breast cancer incidence rates are increasing in almost all industrialised countries (WHO 2010; Hery et al. 2008). However, survival rates are improving due to advances in early detection methods and the introduction of large-scale screening in many countries. As a result, mortality rates are stabilising or even decreasing in some countries (Autier et al. 2010). The observed incidence rate can be affected by changes in diagnosis, such as the introduction of mammographic screening, however the typically acute nature of such changes does not prevent the observation of trends that begin before, and continue after, the effect of diagnosis is seen. Consequently, it is hard to explain the rise in incidence solely in terms of higher numbers of diagnosed cases through screening (Coleman 2000). Incidence rates vary widely globally, as shown in the graphic below (IARC/GLOBOCAN 2010). The risk of developing breast cancer is highest in Northern and Western Europe where incidence rates are rising slowly or are leveling off at high values (IARC/GLOBOCAN 2010; WHO 2010; Hery et al. 2008). In some regions, such as the US, rates have stabilised at high levels (Jemal et al. 2010). Eastern European countries are currently experiencing the fastest rises in breast cancer, although initial rates are lower than in Western Europe. The Janus face of estrogens: essential for breast development, contributing to breast cancer Mammary glands are composed of a tree-like ductal structure that converges at the nipple for the release of milk. The functional secretory tubules are embedded in a cellular stroma that can influence the growth and differentiation of the epithelial compartment through the actions of cytokines, growth factors and matrix components (Stamp 2001). Each tubule is lined by cuboidal epithelial cells surrounded by a layer of basal of myoepithelial cells. Breast cancers typically arise from epithelial cells, and only very rarely from myoepithelial cells. Page 234 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Mammary gland structures are not fully developed and functional at birth, at which stage the duct structure only extends a small distance from the nipple. The ducts grow in proportion with the rest of the body until puberty, when steroidal estrogens trigger a massive growth phase (Russo and Russo 1998). Ovarian estrogens, which signal through estrogen receptors О± and ОІ, are thought to stimulate cell division in the blind ends of the ducts, the “end buds”. This process leads to the elongation and branching of the ducts, which arborise into the fatty mass of the breast. With every secretion of estrogens during ovulation, the entire structure becomes more elaborate and branched. It is thought that incompletely differentiated cells that are formed through the mitogenic action of ovarian estrogens are the cell populations from which cancerous cells derive (Russo and Russo 1998). The final phase of development occurs during pregnancy when there is a further massive branching of ducts and the entire system matures fully. After breastfeeding and weaning, many of the ducts grown in pregnancy are remodeled to resemble the state before pregnancy (Russo and Russo 1998). 5.1.2 Evidence for an endocrine mechanism in breast cancer Ovarian estrogens have been implicated in breast cancer by a series of observations, authoritatively reviewed by (Travis and Key 2003): п‚· п‚· п‚· п‚· Many of the accepted risk factors for breast cancer can be related to estrogen and estrogen levels, including age at menarche, first pregnancy menopause, lactation, and parity.. High endogenous estrogen levels are associated with an increased risk of breast cancer. Endocrine directed treatments have been the most successful approaches to cancer prevention. In animal models, estradiol exposure results in mammary tumour promotion and tumour occurrence is reduced by oophrectomy or administration of anti-estrogens. It has been estimated that around 40% of breast cancer cases in US can be attributed to the risk factors of late age at first birth, nulliparity, socioeconomic status and a primary family history of breast cancer (Madigan et al. 1995). Inclusion of early age of menarche, prior benign disease and exposure to ionising radiation was expected to explain a further 10-12%, leaving around half of cases unexplained. These remaining cases could be due to additional risk factors including a high fat diet, adult weight gain, alcohol consumption or as yet unidentified factors, however the major additional risk factor seems likely to be occupational and environmental factors which would include exposure to chemicals such as organochlorine pesticides and PCBs and to potential stressors such as electromagnetic fields (Madigan et al. 1995). Endogenous steroid hormones and breast cancer The cyclical secretion of estrogen during a woman’s life has long been established as a key determinant of breast cancer risk: the more estrogen reaches the sensitive structures in the breast during her lifetime, the higher the overall risk. Therefore, it was hypothesised that women suffering from the disease should show elevated serum levels of sex hormones compared to women free from breast cancer. Page 235 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Intriguingly, efforts to prove this link empirically have produced varied results. In the earlier studies, blood samples were drawn at a time when the women enlisted as breast cancer cases had already developed the disease. It was later revealed that neoplasms of the breast take up estrogens which they require for growth, thereby lowering sex hormone serum levels and obscuring the relationship between hormone levels and breast cancer risks. To demonstrate a link between endogenous sex hormones and breast cancer, prospective studies are needed where blood samples are collected from women before they developed breast cancer (Toniolo 1997). A prospective study design is also essential for assessing associations between xenoestrogens and breast cancer, but has not always been applied (see below). During the 1990s, nine prospective case control studies of endogenous sex hormones and breast cancer in post-menopausal women appeared (reviewed in: The Endogenous Hormones and Breast Cancer Collaborative Group 2002) and it was these investigations that finally provided the evidence sought in support of the idea that endogenous estrogens are linked with breast cancer. In a pooled analysis of these studies statistically significant increases in breast cancer risk were found with rising serum levels of estradiol (total, free, and the biologically available fraction, not bound to sex hormone binding globulin, SHBG) (The Endogenous Hormones and Breast Cancer Collaborative Group 2002). Estrone, testosterone and a number of other steroid precursors also correlated with risk. As well as estrogens, the role of other hormones in breast cancer should be considered, including progesterone, prolactin and testosterone (Travis and Key 2003). The mechanisms through which breast cancer initiation by estrogens could occur remain unclear. The possibilities discussed in the literature include: 1) stimulation of cellular proliferation through hormone receptors, the increased number of cell division events increases the chance that a mutation will occur (Travis and Key 2003).; 2) direct genotoxicity by mutations following P450 mediated metabolic activation (Liehr 2001), 3) induction of aneuploidy (Russo and Russo 2006; Liehr 2001), and 4) estrogens enhancing tissue remodeling through stroma-epithelium interactions, thereby increasing the likelihood of abnormal tissue organisation and cancer (Soto and Sonnenschein 2010); (Diamanti-Kandarakis et al. 2009). More than 70% of breast tumours in women in Western industrialised countries are estrogen receptor positive and rely on estrogen for growth (Robbins and Clarke 2007). The majority of breast cancers in Western women derive from end buds, where the cells that contain estrogen receptors and are most responsive to estrogens during breast development are located (Russo and Russo 2006). The most successful therapies for breast cancer target the endocrine system, including antagonists and modulators of the estrogen receptors, and aromatase inhibitors (Howell 2008). This efficacy indicates the intimate involvement of the endocrine system in breast cancer. 5.1.3 Evidence for a role of chemical exposures in breast cancer through an endocrine disruption mechanism It is possible to gain an impression of the relative contribution of environmental factors, including chemical exposures, and heritable factors to breast cancer through analyses of differences in the cancer incidence among identical twins, who share a similar genetic background. Recent studies Page 236 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER among Scandinavian twins suggest that heritability accounts for 27% of the variation in susceptibility to breast cancer, whilst shared environmental factors explain 6%, but environmental factors not in common explain 67% (Lichtenstein et al. 2000; Luke et al. 2005). Studies of families with a heritable predisposition to breast cancer also support the view that environmental factors influence breast cancer risks to a larger degree than genetic background. For example, women who carry a mutated form of the tumour suppressor genes BRCA1 and BRCA2 suffer from a significantly higher risk of developing breast and ovarian cancer than women not afflicted by this genetic change (King et al. 2003). The risk is greater for carriers born after 1940 (67% of the afflicted women have breast cancer by age 50) than those born before (24% with breast cancer by age 50), and is also greater for carriers who are obese or who lack physical exercise (King et al. 2003). The potential role for xenoestrogens as a causative factor for breast cancer has been discussed (Davis et al. 1993). The mechanisms through which xenoestrogens exert their effects could include direct mimicry of estradiol or indirect effects on the metabolism of estradiol, for example to direct endogenous metabolism toward more estrogenic and toxic metabolites (Telang et al. 1992). 5.1.3.1 Pharmaceutical estrogens Not only endogenous ovarian hormones, but also external steroidal estrogens administered as oral contraceptives, anti-miscarriage drugs or as hormone replacement therapy (HRT) for the suppression of menopausal symptoms have been associated with breast cancer. The use of these therapies has increased enormously during the last decades, for example hundreds of millions of women worldwide have taken estrogen and progestin as oral contraception (Travis and Key 2003). In 2003, one third of all women in Britain aged 50-64 used hormone replacement therapy (HRT) for the alleviation of menopausal symptoms (see the authoritative review by Travis and Key 2003). Hormone replacement therapy (HRT) Combined estrogen-progesterone HRT is the most widely prescribed regimen in Europe and the USA. The potential benefits and harms of HRT were tested in controlled clinical trials. In 2002, one of these trials, the Women’s Health Initiative (WHI) trial, had to be stopped early because estrogenprogesterone HRT led to increased risks of breast cancer among the participating women. These risks were judged to outweigh the benefits of this form of HRT in terms of reduced bone fractures and reduced colon cancer risks (Rossouw et al. 2002). The WHI trial included an estrogen-only HRT arm that was not suspended early, and which found decreased breast cancer risks in women who received estrogen-only HRT (Stefanick et al. 2006). The observation was not anticipated and is in conflict with the results of other observational studies, such as the Million Women Study, see below. A meta-analysis of a large number of HRT studies and trials carried out worldwide found that estrogen-only HRT is associated with breast cancer (Greiser et al. 2005). A protective role for estrogen-only HRT has been maintained (Simon et al. 2010) and additional studies may be required if the issue is to be resolved. Coinciding with the completion of the WHI trial, the results of a very large UK observational study of women receiving mammography screening, the Million Women Study, were published. It showed that all forms of HRT, including estrogen-only and estrogen-progesterone, increased breast cancer Page 237 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER risks. The study authors estimated that the use of HRT during the last decade in the UK alone had resulted in an extra 20,000 breast cancer cases (Million Women Study Collaborators 2003). A more recent US study found that postmenopausal women taking combined estrogen and progestin hormone replacement therapy for three years or longer run four times the risk of developing lobular breast cancer (Li et al. 2008). Following the WHI and Million Women Study, the use of HRT declined. Sharp and significant reductions in breast cancer occurred between 2001-2002 and 2005-2006 in many European and US populations which was temporally consistent with changes in the use of HRT (Verkooijen et al. 2009). A recent US study was able to demonstrate a quantitative link between changes in HRT use and incidence (Robbins and Clarke 2007). This analysis showed that, from 2001 to 2004, the incidence of breast cancer declined by 8.8% in regions with the smallest reductions in HRT prescriptions, by 13.9% in those with intermediate reductions, and by 22.6% in areas with the greatest reductions in combination HRT. The reductions in breast cancer were largely confined to women above the age of 50 and to patients with estrogen receptor positive tumours, both features that lend further support to the idea that changes in HRT use played a role. It has been argued that HRT stimulates the growth of existing small tumour nests, which would otherwise be undiagnosed, rather than initiating primary breast cancers (Dietel 2010). The recent decline in breast cancer in certain countries has not only been attributed to reduced HRT use; additional factors related to screening might be involved (Gompel and Plu-Bureau 2010). Diethylstilbestrol (DES) DES is a synthetic estrogen that was first synthesised in 1938 and was approved for use as an antiabortive agent based on the theory that problematic pregnancies were due to a hormone imbalance (Veurink et al. 2005). DES was administered to several millions of pregnant women worldwide until the 1970s when maternal use of DES was strongly associated with the occurrence of clear cell adenocarcinoma (CCA) in their daughters (Veurink et al. 2005). During this time it also emerged that DES was not effective for its clinical usage, with no effect on premature birth, miscarriage, risk of pre-eclampsia, fetal weight or placental weight (Veurink et al. 2005). Studies have shown a moderate increase in breast cancer risk among women who took DES during pregnancy (вЂ�DES mothers’), reviewed by (Veurink et al. 2005). Studies of the daughters of women who took DES during pregnancy (вЂ�DES daughters’) have identified twice the normal breast cancer risk in subjects aged >40 years (Palmer et al. 2006) (Troisi et al. 2007). The risk is expected to grow further as more “DES daughters” reach menopausal age. A Dutch study has very recently reported no excess breast cancer risk in DES daughters, whilst being able to confirm the elevated risk of CCA (Verloop et al. 2010). This study included 6,084 DES daughters aged 40-49 years and 2,479 aged >50 years; however documented DES exposure was not available for the majority of study participants and the criteria used to assign DES daughter status may have influenced the findings, see discussion in Verloop et al. (2010). A study of third generation effects of DES (i.e. the offspring of DES daughters) found no overall increase in cancer risk, however the study had limited statistical power and the study population was too young to offer a meaningful assessment of breast cancer risk at this time (Titus-Ernstoff et al. 2008). Studies of DES relevant to the developmental origin of breast cancer are discussed further in section 4. Page 238 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER 5.1.3.2 Environmental chemicals The epidemiological evidence of associations between environmental pollutants and breast cancer has been reviewed (Brody et al. 2007). This review of 152 studies of the association between breast cancer and environmental pollutants found that there was evidence to support an association with polychlorinated biphenyls (PCBs), and polycyclic aromatic hydrocarbons (PAHs), as well as evidence to suggest an association with polychlorinated dioxins and furans (PCDD/F) and organic solvents. However, there is a lack of evidence for association with DDT/DDE, other organochlorine pesticides and drinking water disinfection byproducts. Organochlorine pesticides Associations between breast cancer and exposure to organochlorine pesticides such as o,p’-DDT, p,p’-DDE, dieldrin, ОІ-hexachlorocyclohexane (ОІ-HCH), trans-nonachlor have been studied extensively. Many of these chemicals are in vitro estrogen receptor agonists (Soto et al. 1995; Silva et al. 2007). Most frequently, a case-control design was adopted, with the aim of measuring differences in the serum levels of pollutants between cases and controls. The majority of studies published during the 1990s (comprehensively reviewed by Snedeker 2001; Mendez and Arab 2003; Lopez-Cervantes et al. 2004) have not produced evidence of associations between organochlorine pesticide exposure and breast cancer risks, but in many cases, possible associations may have been obscured by the fact that blood samples were drawn when the disease had already become manifest (lack of a prospective design). In their meta-analysis of 35 publications on o,p’-DDT and p,p’-DDE, Lopez-Cervantes and colleagues (2004) identified only 10 prospective case control studies. More recent studies among US African Americans (Gatto et al. 2007), US women (Xu et al. 2010) and Japanese women (Itoh et al. 2009; Iwasaki et al. 2008) have also failed to demonstrate associations between organochlorine pesticide blood levels and breast cancer. With the exception of Iwasaki et al. who adopted a prospective case-control study design, all these studies undertook exposure measurements outside the etiological period of the disease. The importance of chemical exposure before or during puberty has been shown in a study of breast cancer and DDT exposure at young age, again highlighting the importance of a prospective design. It was found that in women born after 1931, high levels of p,p’-DDT were associated with a 5-fold increased breast cancer risk (Cohn et al. 2007). The case has been made that the focus of breast cancer epidemiology on single organochlorines is problematic from the view point of mixture toxicology. At the levels normally encountered in Western countries, these weak xenoestrogens have a minimal impact on the action of endogenous steroids, making it very hard to attribute additional breast cancer risks to individual organochlorines (Kortenkamp 2006). Organochlorines such as DDE are an inadequate biomarker of the range of exposures experienced by women today, and this argues for broadening the selection of chemicals considered as risk determinants. An ecological analysis investigated whether agricultural pesticide use in California was linked with breast cancer, but no significant associations were found (Reynolds et al. 2005). Very recently, links between residential pesticide use and breast cancer risks in young Brazilian women were reported (Jacome et al. 2010). Page 239 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Polychlorinated biphenyls (PCBs) Studies of associations between internal PCB exposure and breast cancer in the general population have produced inconsistent results (reviewed by Brody et al. 2007). While initial investigations showed elevated PCB levels in plasma and serum of breast cancer sufferers, this was not observed in more recent studies. However, several epidemiological studies have demonstrated that women carrying mutations in the CYP1A1 gene suffer increased breast cancer risks when exposed to PCBs (Moysich et al. 1999; Laden et al. 2002; Zhang et al. 2004; Li et al. 2005). Certain of these CYP1A1 polymorphisms, but especially A2455G, confer increased enzyme activity. In turn, this is assumed to promote the formation of elevated levels of PCB metabolites implied in breast carcinogenesis; some PCBs and their metabolites are estrogen receptor agonists. A recent meta-analysis showed that the A2455G polymorphism in exon 7 of the CYP1A1 gene generally predisposes to higher breast cancer risks (Sergentanis and Economopoulos 2010). Polychlorinated dioxins and furans (PCDD/F) Studies of accidential exposures in Seveso, Italy and of environmental contamination in Chapaevsk, Russia have produced evidence that PCDD/F exposures lead to increased breast cancer risks. The Seveso Women's Health Study (SWHS) investigated a cohort of women who resided in the most contaminated areas at the time of the Seveso explosion and who were infants and up to 40 years of age at that time. Every 10-fold increase in serum TCDD levels was shown to be associated with a doubling of breast cancer risks (Warner et al. 2002). Similar results were obtained in a subsequent study (Pesatori et al. 2009). Women who lived around a chemical plant in Chapaevsk, Russia, had a two-fold higher risk of breast cancer (Revich et al. 2001), presumably due to the very high serum levels of TCDD and other organochlorines that were measured in these women. Associations between high TCDD serum levels in women and breast cancer risks were also found in populations highly exposed to TCDD during other accidents in chemical plants (Kogevinas et al. 1997). (Dai and Oyana 2008) observed that soil contamination with dioxins in a polluted area in Michigan (USA) is associated with breast cancer. Similar relationships did not become apparent in women living in the vicinity of PCDD/F-emitting municipal waste incinerators (Viel et al. 2008). The mechanisms by which dioxins may promote breast cancer are not fully resolved; PCDD/F are not capable of activating the estrogen receptor. Polycyclic aromatic hydrocarbons (PAHs) Associations between PAH exposure and breast cancer were analysed in the Long Island breast cancer study. Blood samples were measured for PAH-DNA adducts. Among breast cancer cases, increased levels of DNA adducts in white blood cells were found. The age-adjusted odds ratio (OR) for breast cancer indicated slightly elevated risks (OR 1.51, 95% confidence interval (CI), 1.04-2.20), but a consistent trend with increasing adduct levels was not observed (Gammon et al. 2002). More recently, exposure to traffic emissions at the time of menarche was found to be linked with higher risks of premenopausal breast cancer. When exposures occurred during the time of a woman's first birth, increased risks for postmenopausal breast cancer also became apparent. These Page 240 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER associations could only be observed among lifetime non-smokers, not among smokers (Nie et al. 2007). In that study, PAH exposure was modeled by using residency life-time histories and taking residency as proxy. However, in a case-control study of women in Shanhai, associations between PAH exposure and breast cancer did not become apparent (Lee et al. 2010). In that study, urinary 1hydroxypyrene and 2-naphthol were measured as indicators of PAH metabolism and urinary levels of 8-hydroxy-2'-deoxyguanosine and malondialdehyde were taken as biomarkers of oxidative stress. The Long Island cohort was used to investigate interactions between various gene polymorphisms, PAH exposure and breast cancer risk. Polymorphisms in glutathione-S-transferases (McCarty et al. 2009) or xeroderma pigmentosa gene status did not modify breast cancer risks from PAHs (Shen et al. 2008). (Shen et al. 2009) considered the relationship between telomere length and breast cancer risk and found that urinary 15-F-2-isoprostanes (15-F-2t-IsoP) and 8-oxo-7,8-dihydrodeoxyguanosine (8-oxodG) or dietary antioxidant intake did not modify that relationship. However, a significantly increased breast cancer risk was found among premenopausal women carrying shorter telomeres. Solvents Possible associations between perchloroethylene exposure and breast cancer were investigated in Cape Cod, Massachusetts, USA. In the 1960, the solvent had leached into the water supplies of Cape Cod from an inner vinyl liner used to cover asbestos cement pipes. (Aschengrau et al. 2003) investigated women who resided in this area and found elevated breast cancer risks among highly exposed subjects. Exposure was estimated by an algorithm that modeled the release of perchloroethylene into the drinking water, depending on pipe surface and water flow rate. (Brody et al. 2007) listed several epidemiological studies that allow the conclusion that exposure to unspecified industrial solvents in occupational settings is linked to increased breast cancer risks. More recent studies of workplace exposures to organic solvents support these findings: Among occupationally exposed women in Montreal, Quebec, Canada, the odds ratio for developing estrogen receptor-positive mammary tumours increased with exposure to monoaromatic hydrocarbons and polycyclic aromatic hydrocarbons from petroleum sources (Labreche et al. 2010). Occupational exposure to benzene among shoe factory workers in Italy was also found to be a risk factor for breast cancer (Costantini et al. 2009). Cadmium Cadmium is able to act as an estrogen mimick, and this has renewed the interest in considering exposure to this heavy metal as a risk factor for mammary cancers. Studies of occupational settings have provided indications of a role of cadmium in breast cancer. (Cantor et al. 1995) examined death certificates attributed to breast cancer. By making comparisons with non-cancer death certificates they found that mortality from breast cancer was linked with occupational exposure to cadmium. Among White women, cadmium exposure was associated with an 8-20% increase in breast cancer risk. This rose to 50-130% among African-American women. The authors asserted that their method of establishing cadmium exposure (by occupation listed on the death certificate) may have led to misclassifications leading to underestimations of risk, because more people may have come into contact with cadmium occupationally than listed. Page 241 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER A cohort of Swedish women engaged in metal plating and coating also suffered increased breast cancer risks (Ursin et al. 1994). These workers were exposed not only to cadmium, but also to hexavalent chromium and organic solvents, and this makes it difficult to attribute the observed increases in breast cancer solely to cadmium. In a population-based study of 246 women with breast cancer and 254 age-matched control subjects suffering from other cancers, but not breast cancer, women with the highest urinary cadmium levels showed two-fold increased breast cancer risks compared to those with the lowest cadmium levels (McElroy et al. 2006). A clear association with smoking – a major source of cadmium - was not found, mainly due to the small number of smokers enrolled in the study. Phytoestrogens Phytoestrogens, plant-derived estrogens such as genistein, are of particular interest since they were initially considered to have beneficial effects in breast cancer based on the observations that breast cancer incidence is low in areas that traditionally have a phytoestrogen-rich diet, for example high soy consumption in Asia. Adoption of a more Westernised diet with less phytoestrogen content has been proposed to explain the continuous rise in breast cancer cases in East Asian women since the early 1980s (Minami et al. 2004). However concern has also been raised that phytoestrogens, such as genistein, can stimulate the growth of estrogen-dependent tumours in mice (Allred et al. 2001). The вЂ�pros and cons’ of phytoestrogens for breast cancer and for other health effects have been comprehensively reviewed (Patisaul and Jefferson 2010). The possible protective effects of phytoestrogens on breast cancer have been assessed in numerous epidemiological studies but comparison of these studies is complicated because researchers used different measures of exposure to soy and phytoestrogens. A meta-analysis of studies conducted between 1978 and 2004 standardised phytoestrogen exposure in terms of soy protein intake and concluded that that soy intake is associated with a modest reduction in breast cancer risk (Trock et al. 2006). It is possible that phytoestrogen intake during critical developmental windows may be more important than, for example, intake in the adult diet. The protective effects of soy-rich diets became more apparent in studies that included women whose consumption began already in early childhood (Trock et al. 2006). Breast cancer status could also be important, for example it may be desirable to have low levels of estrogens, including phytoestrogens, post-treatment for breast cancer to reduce the chance of estrogen-dependent recurrence (Shu et al. 2009). The proposed mechanisms through which phytoestrogens influence breast cancer include activities related to the estrogen receptor, cell growth and proliferation, tumour development, signalling pathways, and estrogen-metabolising enzymes (Mense et al. 2008). A review of the published evidence concluded that the actual mechanism of action remains unknown despite many studies, and that it is unclear if phytoestrogens are chemoprotective or if they are simply an indicator of a healthy diet, or indeed if they may produce adverse outcomes (Mense et al. 2008). It is also unclear whether the mechanisms through which phytoestrogens have been proposed to be protective in breast cancer can occur at the levels achievable through a soy-rich diets (Messina et al. 2006) or if pharmacological doses are required. Page 242 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Total xenoestrogen load A link between total xenoestrogen exposure and breast cancer is suggested by a study among Spanish women in which tissue extracts from adipose tissue were prepared, separated from more polar substances including steroidal estrogens, and examined in an in vitro screen for estrogenicity. Among women with higher levels of estrogenicity, breast cancer cases were more frequent (Fernandez et al. 2007; Ibarluzea et al. 2004). This is the first evidence that chemicals in our environment, with estrogenic properties that are вЂ�accidental’ may contribute to the development of breast cancer. This study is also significant in that it suggests that the levels of single, most highly persistent organochlorines such as o,p’-DDT, p,p’-DDE and PCBs are insufficient as biomarkers for breast cancer risks, and that biomarkers representative of combined exposures to non-polar and more polar substances should be considered. Methodological issues that complicate the interpretation of epidemiological results A number of methodological issues can be identified that complicate the interpretation of epidemiological studies of breast cancer, and are likely to obscure risks. These include inadequate exposure assessment, at time points outside the periods important in causing the disease, especially during development. There is a lack of both highly and non-exposed populations and this further complicates reliable exposure classifications. In addition, preclinical markers are missing which would be especially relevant for the theory that breast cancer has a long latency. It is important to note that only a limited set of chemicals were investigated in measuring exposures. Most of the chemicals that are postulated to be of concern for an association with breast cancer, for example the 216 animal mammary gland carcinogens documented by Rudel et al. , have not been studied epidemiologically (Brody et al. 2007; Rudel et al. 2007). Epidemiological studies of possible effects of other estrogenic chemicals, including UV-filter agents, cosmetic ingredients (e.g. parabens) or other widely used chemicals in consumer products are completely missing. Another limitation is the absence of a conceptual framework in epidemiology to deal with the issue of simultaneous exposure to combinations of chemicals and their impact on breast cancer. Experimental studies have revealed that several xenoestrogens, combined at levels that individually did not produce observable effects, can work together to induce significant joint effects (see section 3.3). To take account of such phenomena in epidemiological studies presents a major challenge. 5.1.4 Is there evidence of a developmental vulnerability in breast cancer? The breast is particularly vulnerable to cancer-causing influences during the periods when the duct structures grow; two especially sensitive periods are 1) during development in the womb, when the breast tissue is laid down (Soto et al. 2008) and 2) during puberty, when the breast experiences the first significant growth phase of the ductal system. Page 243 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Development in the womb Elevated levels of natural estrogens during pregnancy, for example in twin pregnancies, are associated with increased breast cancer risks of the affected daughters later in life (Weiss et al. 2006). In the womb, estrogen influences the number of end buds in the primitive duct structure of the foetus: higher estrogen levels induce the growth of more end buds, thereby enlarging the cell pool from which cancer cells derive (Russo and Russo 1998). The demonstration of elevated breast cancer risks in the daughters of women who took diethylstilbestrol (DES) to avoid miscarriages (Palmer et al. 2006) suggests that synthetic estrogens can have similar effects. The risk is expected to grow further as these so-termed “DES daughters” reach menopausal age. Studies of this cohort indicate that DES daughters aged 40 years or older have a 2.5 fold higher risk of breast cancer that do unexposed women. It is thought that DES exposure of the developing foetus in the womb may have promoted the growth of ductal end buds, thereby enlarging the number of cells from which cancer can develop later in life. Studies with laboratory animals also suggest that exposure to xenoestrogens during development can alter the development of the mammary tissue with possible consequences for breast cancer (Munoz-de-Toro et al. 2005, Maffini et al. 2006). Fetal exposure of rats to bisphenol A induced the development of ductal hyperplasias and carcinoma in situ by postnatal days 50 and 95 (Murray et al. 2007). Tumour growth is most pronounced when the cancer-causing agent is given to young animals in which the mammary gland is developing, whereas adult animals are almost immune (Russo and Russo 1998). Some hormonally active chemicals, such as dioxins, can increase the sensitivity of rats to other breast cancer-causing substances when given at critical times during development in the womb (Birnbaum and Fenton 2003). Studies of rats exposed prenatally to DES showed an increased incidence of mammary tumours in adulthood (following a DMBA challenge) (Boylan and Calhoon 1979). Puberty The increased sensitivity of the breast tissue during puberty was first noticed in the aftermath of the atomic bombs in Hiroshima and Nagasaki. As a result of the massive levels of radioactivity, breast cancer in Japanese women increased significantly, but only in women who were exposed during puberty or at an even younger age. Older women experienced far less pronounced breast cancer risks (McGregor et al. 1977). The importance of chemical exposure before or during puberty has been shown in a study of breast cancer and DDT exposure at young age. It was found that in women born after 1931, high levels of p,p’-DDT were associated with a 5-fold increased breast cancer risk (Cohn et al. 2007). When DDT came into widespread use, these women were under 14 years of age, and mostly under 20 when DDT use in the USA peaked. 5.1.5 Do experimental tools exist for the study of breast cancer, and are assays applicable to, and adequate for, the assessment of chemicals? A plethora of experimental systems exist for the study of breast cancer, however the construction of a coherent framework for the interpretation of all of the available assay is severely hampered by the Page 244 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER lack of fundamental knowledge about the mechanisms involved in cancer generally, the specific mechanisms involved in breast cancer, and the extent to which observations in experimental models are relevant to the human situation. One example of this is the widely used test for mutagenicity, the Ames test (Felton and Wu 2003). This assay serves to detect mutations, such as would be considered to underlie every cancer in the somatic cell mutation theory. However the alternative theory, the tissue organisation field theory (TOFT), considers a mutation to be unnecessary and would rate results from the Ames test accordingly (Soto and Sonnenschein 2010). An increased understanding of molecular biology has resulted in the availability of many receptor ligand assays, for example reporter gene assays for estrogen receptor activation (Wilson et al. 2004); however the direct link between receptor activation and breast cancer cannot be assumed so that the interpretation of a positive result in such assays is not clear. This type of assay is likely to be used for screening in order to prioritise chemicals for testing in more resource intensive assays. The two year rodent chronic carcinogenicity bioassay The utility and value of the two year chronic carcinogenicity bioassay to human breast cancer risk has been critically reviewed (Rudel et al. 2007). Rudel et al. considered that the animal bioassay is expensive ($2 million per test) and found that it is not applied or interpreted consistently, i.e. the regulatory action following identification of a positive effect varies (Rudel et al. 2007). The full animal bioassay is too resource intensive to be used as a screening tool, and consequently most chemicals have not been tested in it. Rudel et al. identified 216 chemicals as being deemed mammary gland carcinogens based on the outcome of this animal bioassay; of which 29 are produced in the US in amount >= 1 million pounds per year, 73 are found in consumer products or are food additives, and 25 have occupational exposure to greater than 5 thousand women. The two year chronic carcinogenicity bioassay conducted by the US National Toxicology Programme (NTP) uses the F344/N rat and the B6C3F1/N mouse. These rodent strains are not intended as models for the demonstration of mammary carcinogenesis; the aim is to identify the ability of test chemicals to induce tumours, regardless of specific tissues. The F344/N rat shows a high background incidence of testicular and other tumours, the B6C3F1/N mouse suffers from a high spontaneous rate of liver tumours. Rudel et al. noted the following issues in application of results from routinely used animal bioassays to human breast cancer risks: п‚· п‚· п‚· п‚· п‚· п‚· An animal mammary carcinogen may be a human carcinogen but not necessarily with the breast as the target organ, or they may not be human carcinogens at all. Mechanisms operating at the high doses that are tested may not occur at low doses. Mechanisms operating in humans may not be present in the selected animal or species, and vice versa. Animal bioassays may omit developmental windows or be of a duration that is too short to detect risks that might occur over the lifespan of a human. Animal bioassays do not consider the joint effects of chemical mixtures. The animal bioassay may be adequate for testing chemicals with what is seen as a genotoxic mechanism, but it may be inadequate for chemicals with a hormonally mediated mechanisms Page 245 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER There is a need for relevant assays that can be used to screen chemicals for prioritisation for subsequent testing in the full animal bioassay. Animal models for mammary carcinogenesis not routinely used for testing In a variety of animal models with specific rat and mouse strains, DES, estradiol and other steroidal estrogens were found to induce mammary tumours. The ACI rat is the only rat strain that develops mammary tumours with high incidence when exposed to DES, steroidal estrogens, including estradiol (Shull et al. 1997; Ravoori et al. 2007) or equine estrogens used in HRT (Okamoto et al. 2010). Catechols derived from steroidal estrogens are ineffective in the ACI rat (Turan et al. 2004). The ACI strain is not highly susceptible to other types of neoplasms, and does not develop a high number of spontaneous tumours. Mammary tumour incidence after estradiol exposure decreases in animals that have been ovariectomised. This indicates that formation of neoplasms is dependent on another ovarian factor, presumably progesterone (Shull et al. 1997). Further evidence for an estrogen receptor-mediated mode of action stems from the observation that estradiol-induced mammary neoplasms could be suppressed completely by co-treatment with the estrogen receptor antagonist tamoxifen (Li et al. 2002). The ACI rat, seem to be valuable tools for the identification of mammary tumours induced by estrogenic agents, yet, to our knowledge, other chemicals with estrogenic activity have not been tested in these models. The Syrian hamster has also been used for carcinogenicity studies with estradiol and related compounds, but these hormones induce kidney tumours, not mammary cancers (Liehr 2001). Models used to explore the consequences of developmental exposures to estrogenic agents for susceptibility to mammary carcinogenesis Various research models have been developed to explore the developmental anomalies that increase the susceptibility to mammary gland neoplasia later in life (summarised by Soto and Sonnenschein 2010). The xenoestrogen bisphenol A has been used as a tool to explore these processes. It appears that exposure to bisphenol A during organogenesis induces profound alterations in the mammary gland that render it more susceptible to neoplasia. These changes include accelerated maturation of fat pads and alterations within the epithelium (decreased cell size, delayed lumen formation, increased ductal area and ductal extension). The accelerated maturation of the adipose tissue pad may be responsible for the epithelial changes and make the epithelium more sensitive to estrogens at later developmental stages. Consequently, increased sensitivity of the mammary glands to estradiol at puberty was observed in these animals, followed later by intraductal hyperplasia (a precancerous lesion) and carcinoma in situ (Durando et al. 2007; Murray et al. 2007; Vandenberg et al. 2008). Similarly, exposure to bisphenol A during nursing, followed by a challenge with DMBA produced increased numbers of tumour per rat and a shortened latency period (Jenkins et al. 2009). Seen in this developmental context, the study of accelerated growth and branching of the mammary gland is a valuable tool for the identification of agents that heighten the susceptibility of the mammary gland to neoplasia. Page 246 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER 5.1.6 CONCLUSIONS Attribution criteria: BREAST CANCER Although it is clear that many factors criteria play a role in breast cancer, a MET INTACT criteria contribution of environmental MOSTLY MULTI-LEVEL chemicals cannot be dismissed. The MET criteria continuing rise in breast cancer MET HORMONE incidences cannot be explained solely in criteria terms of established risk factors. Twin MOSTLY PRIMARY EFFECT MET studies have highlighted the importance criteria of environmental factors, including EXPOSURE MET chemical exposures. Indeed, concerns criteria SENSITIVE LIFESTAGE MET are mounting although many human studies suffer from methodological criteria PHARM. RESTORATION MET limitations (exposure measurements at criteria the wrong time point, disregard for the PARTLY SUPPORTING DATA MET effect of combined exposures). In view of the proven role of natural and therapeutically used estrogens in human breast cancer, it is biologically plausible that less potent hormonally active chemicals may also contribute to risks. The health experience of Spanish women where breast cancer was related to total estrogen load in blood serum supports this idea (Ibarluzea et al. 2004). The most convincing evidence for associations between environmental pollutants and breast cancer stems from epidemiological studies involving agents devoid of estrogenic activity (PCDD/F, PCBs and CYP polymorphisms, organic solvents). Studies seeking to demonstrate risks associated with estrogenic pollutants such as DDE, DDT or various estrogenic pesticides (e.g. dieldrin, nonachlor and related chemicals), have yielded inconclusive results, largely due to methodological limitations. Where DDT/DDE exposures during earlier life stages (puberty) could be reconstructed, breast cancer risks became apparent as in the study by Cohen et al. 2007. This echoes the insight of the DES epidemiology which also demonstrated the importance of periods of heightened vulnerability during development (Palmer et al. 2006). There are indications that exposure to cadmium, an estrogen mimick, is associated with breast cancer. Epidemiological studies of more polar xenoestrogens, such as UV filter substances and phenolic agents, are missing altogether. By adopting targeted research strategies which take account of the origin of breast cancer early in life (prospective design) and consider exposures to a multitude of chemicals, these issues should be pursued further with urgency. The tools currently in use for the identification of mammary carcinogens suffer from deficiencies. The routinely used two year chronic carcinogenicity bioassay may lack the specificity that is needed to identify mammary carcinogens with a hormonal mode of action. Conversely, the assays that are responsive to mammary carcinogens with an endocrine mode of action have not been investigated for their sensitivity. Assays with endpoints relevant to mammary gland development may prove to be useful tools in identifying chemicals that increase the susceptibility of this tissue to neoplasia, but these assays require validation. None of the in vivo bioassays currently proposed as part of the OECD framework for the testing of endocrine disrupters are able to identify mammary carcinogens. Page 247 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER The 2002 Global Assessment of Endocrine Disrupters considered that the evidence linking exposure to environmental EDCs with breast cancer was inconclusive (IPCS/WHO 2002) and concluded that the scientific evidence did not support a direct association between exposure to environmental EDCs and increased risk of breast cancer. Several research needs were identified in 2002: п‚· п‚· п‚· studies of developmental exposure and adult disease, perhaps using cancer registries; development of appropriate animal models since human epidemiology may not be feasible due to the potentially long latency; and studies of the interaction of causative factors, including chemical exposure. The calls for studies of developmental exposures, for the development and validation of better animal models and for analyses of combined exposures remain valid today. Nevertheless, research over the past 10 years has significantly improved the state of the science. Key discoveries include: o Better understanding of the impact of environmental factors (including chemical exposures) on breast cancer risks; o Empirical evidence of the involvement of ovarian steroids in breast cancer; o The demonstration of a role of pharmaceutical estrogens (HRT) in breast cancer; o Strengthening of the evidence linking dioxin exposure to breast cancer risks; o Improved understanding of the interaction between gene polymorphisms and breast cancer risks due to PCB exposures; o Empirical evidence of the importance of timing of exposures and periods of heightened sensitivity during development; o Appreciation of the importance of combined effects of estrogenic agents and understanding of the determinants of additivity (see section on MIXTURES) Below we summarise the state of the science by using the WHO 2002 criteria for attribution to an endocrine mode of action. Page 248 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER 5.1.6.1 Can breast cancer be attributed to endocrine disruption? Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criteria met? Criteria MET Evidence summary Animal models responsive to carcinogenesis by estrogens are available Criteria MOSTLY MET The determinants of susceptibility to mammary neoplasia begin to emerge in specifically designed animal models Criteria MET High endogenous estrogen levels and elevated total estrogenic load from chemical exposures are linked to breast cancer Criteria MOSTLY MET Disruption of the reciprocal interactions between the mesenchyme and the epithelium of the mammary gland, due to the perturbance of endocrine signalling Criteria MET Exposure to pharmaceutical estrogens increases breast cancer risks; endocrine-directed therapies successfully prevent breast cancer (Howell 2008). 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The effects of steroidal estrogens in ACI rat mammary carcinogenesis: 17 beta-estradiol, 2-hydroxyestradiol, 4-hydroxyestradiol, 16 alpha-hydroxyestradiol, and 4-hydroxyestrone. J Endocrinol 183:91-99. Ursin G, Bernstein L, Pike MC. 1994. Breast-Cancer. Cancer Surveys 20:241-264. Vandenberg LN, Maffini MV, Schaeberle CM, Ucci AA, Sonnenschein C, Rubin BS, Soto AM. 2008. Perinatal exposure to the xenoestrogen bisphenol-A induces mammary intraductal hyperplasias in adult CD-1 mice. Reproductive Toxicology 26:210-219. Verkooijen HM, Bouchardy C, Vinh-Hung V, Rapiti E, Hartman M. 2009. The incidence of breast cancer and changes in the use of hormone replacement therapy: A review of the evidence. Maturitas 64:80-85. Verloop J, van Leeuwen FE, Helmerhorst TJ, van Boven HH, Rookus MA. 2010. Cancer risk in DES daughters. Cancer Causes Control 21:9991007. Veurink M, Koster M, Berg LT. 2005. The history of DES, lessons to be learned. Pharm World Sci 27:139-143. Viel JF, Clement MC, Hagi M, Grandjean S, Challier B, Danzon A. 2008. Dioxin emissions from a municipal solid waste incinerator and risk of invasive breast cancer: a population-based case-control study with GIS-derived exposure. International Journal of Health Geographics 7. Warner M, Eskenazi B, Mocarelli P, Gerthoux PM, Samuels S, Needham L, Patterson D, Brambilla P. 2002. Serum dioxin concentrations and breast cancer risk in the Seveso Women's Health Study. Environmental Health Perspectives 110:625-628. Weiss J, Wallin E, Axmon A, Jonsson BAG, Akesson H, Janak K, Hagmar L, Bergman A. 2006. Hydroxy-PCBs, PBDEs, and HBCDDs in Serum from an Elderly Population of Swedish Fishermen's Wives and Associations with Bone Density. Environ Sci Technol 40:6282-6289. WHO. 2010. European Health for All database (HFA-DB). 2010. Wilson VS, Bobseine K, Gray LE, Jr. 2004. Development and characterization of a cell line that stably expresses an estrogen-responsive luciferase reporter for the detection of estrogen receptor agonist and antagonists. Toxicol Sci 81:69-77. Xu X, Dailey AB, Talbott EO, Ilacqua VA, Kearney G, Asal NR. 2010. Associations of serum concentrations of organochlorine pesticides with breast cancer and prostate cancer in U.S. adults. Environ Health Perspect 118:60-66. Page 252 of 486 HUMAN HEALTH ENDPOINTS BREAST CANCER Zhang YW, Wise JP, Holford TR, Xie H, Boyle P, Zahm SH, Rusiecki J, Zou KY, Zhang B, Zhu Y, Owens PH, Zheng TZ. 2004. Serum polychlorinated biphenyls, cytochrome P-450 1A1 polymorphisms, and risk of breast cancer in Connecticut women. American Journal of Epidemiology 160:1177-1183. Page 253 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2 PROSTATE CANCER Summarising the state of knowledge in 2000, WHO (2002) stated that there was a lack of clear evidence of links of EDC exposure with prostate cancer. On the other hand, WHO pointed out that there was not enough information to completely reject the hypothesis that endocrine disrupters could play a role. The last ten years have seen significant advances in our knowledge of EDC exposures and prostate cancer. 5.2.1 Natural history of prostate cancer Prostate cancer rarely appears before the age of 40 years and is normally diagnosed in men of around 70 years of age. Essentially all men with circulating androgens will develop microscopic prostate cancers, provided they live long enough. It has been said that more men die with prostate cancer than from it (Bostwick et al. 2004). Known risk factors include family history, ethnicity and internal exposure to androgens. Having a first- or second-degree relative with prostate cancer increases the risk of developing the disease. The highest incidence of prostate cancer is found among US African-American men, considerably higher than in white US men; however, these differences may also reflect differences in access to health care (Bostwick et al. 2004). Prostate cancers require androgens for growth, and withdrawal of androgens has long been the principal approach to treating prostate cancer. Elevated levels of testosterone and dihydrotestosterone (DHT) in the prostate are thought to increase the risk of developing cancer (Hsing et al. 2008), and estrogens are thought to play a role as well (Harkonen and Makela 2004, Prins and Korach 2008). Trends in incidence rates In Europe and in the USA, prostate cancer is one of the most commonly diagnosed malignancies in men. Annual age-adjusted incidence rates vary considerably across Europe. Nevertheless, all European countries (except in the high incidence countries The Netherlands and Austria) have in recent years experienced dramatically increasing incidence trends. The highest rates occur in Finland, Sweden and Austria (114, 112 and 106 cases per 100,000, respectively), while Poland, Croatia, Slovenia, Malta and Denmark have comparatively low incidence rates (24, 35, 37, 46 and 50 cases per 100,000, respectively) (Karim-Kos et al. 2008). In the USA, rates have increased during the last decade. The introduction of prostate-specific antigen (PSA) screening has led to an apparent spike in incidence, followed by a drop, but since 1998 rates are slowly rising (currently at around 160 cases per 100,000) (Jemal et al. 2010b). (Before introduction of PSA, prostate cancer diagnosis depended largely on examination by touch, which is highly unreliable). In East Asian countries, incidences of prostate cancer are considerably lower than in Europe and the USA. In 2002, rates in Japan or the Philippines were comparable with those in low incidence European countries, such as Croatia or Slovenia (Jemal et al. 2010a). However, in East Asia there is currently also a significant upsurge in incidence (Sim and Cheng 2005). The development of prostate cancer Prostate cancer derives from epithelial cells of the prostate gland. Not long after the prostate has attained its adult size (a few years after puberty), microscopic foci of epithelial prostatic hyperplasia Page 254 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER can be detected. These foci develop into hyperplastic nodules and then prostatic intraepithelial neoplasia (PIN). PIN is regarded as a pre-cancerous lesion; it later gives rise to microfoci of early cancers. Both these lesions are astonishingly common – they can be found in the prostates of nearly 30% of Western men between the ages of 30 – 40 years, and are just as prevalent in Japanese men of comparable age (for details see the authoritative review by Bostwick et al. 2004). It appears that the progress from microfoci to fully malignant forms of the cancer is restrained in East Asian men, very likely because of dietary influences. There is good evidence that phytoestrogens slow down the events of progression to advanced disseminated prostate cancer (Adlercreutz et al. 2000) and that high consumption of phytoestrogens is protective (Hwang et al. 2009). Prostate cancer has been described as an enigma; it begins to develop shortly after a man’s puberty, yet it remains without detectable symptoms well past middle age. As a cancer it is quite unusual in that it grows extraordinarily slowly for decades and then progresses fairly rapidly to the malignant, metastasising phenotype. 5.2.2 Evidence for an endocrine mechanism in prostate cancer Androgens play a key role in the aetiology of prostate cancer. Castrated men do not develop prostate cancer, and regression of the disease can be achieved (at least initially) by androgen withdrawal (Huggins and Hodges 1941). These observations formed the basis of the hypothesis that elevated levels of testosterone and DHT in the prostate gland increase cancer risks (summarised by Hsing et al. 2008). Testosterone synthesised in the testes reaches the prostate via the blood, and once inside the gland, is irreversibly converted to DHT. DHT is an important mitogenic factor, but it does not directly stimulate proliferation of epithelial cells. Rather, by activating androgen receptors in epithelial and stromal cells of the prostate, the hormone induces the secretion and biological action of a variety of peptide growth factors in neighbouring cells through paracrine and autocrine loops. These growth factors direct the development and differentiation of the prostate. Attempts to demonstrate the androgen hypothesis of prostate carcinogenesis empirically by relating blood androgen levels to cancer risk have run into difficulties. In a meta-analysis of 18 prospective studies, (Roddam et al. 2008) did not find any associations between androgen blood levels and prostate cancer risks. However, the relationship between serum testosterone levels and concentrations of DHT within the prostate is complex. Measurements of serum androgen levels do not reflect the androgen exposures of target cells within the prostate at times critical for the aetiology of the disease, and it may therefore not be feasible to capture androgen exposure of the prostate with currently available technology (Roddam et al. 2008, Hsing et al. 2008, Platz and Giovannucci 2004). A recent longitudinal study among older men with aggressive prostate cancer has shown that elevated serum testosterone levels (diagnosed before the disease became detectable) are associated with risk (Pierorazio et al. 2010). The role of estrogens in prostate cancer has been recognised relatively late, but has received considerable recent attention. Several lines of evidence support the idea that prostate cancer risk is associated with a combination of internal exposure to estrogens and androgens (Gann et al. 1996; Page 255 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER Ellem and Risbridger 2009). Concentrations of androgens and estrogens were higher in early pregnancy blood samples from African-American mothers than in White women (Henderson et al. 1988, Potischman et al. 2005), offering a potential explanation for the higher incidence of prostate cancer in black men. Conversely, Japanese men, with their low incidence of the disease, show lower serum estradiol levels compared with aged-matched European Caucasion men (Dejong et al. 1991). In a recent study of prostate cancer cases, high serum levels of estrone were related to elevated cancer risks. Associations with other steroidal hormones did not become apparent in this study (Daniels et al. 2010). Estrogens are thought to be involved in the aetiology of prostate cancer by inducing growth and differentiation defects which ultimately predispose the gland to malignant lesions (reviewed by Huang et al. 2004, Harkonen et al. 2004, Ellem and Risbridger 2009). Although men usually have low levels of circulating steroidal estrogens, there are two periods when exposure to estrogens is high: during development in the womb and after middle age. During the third trimester of pregnancy, there is a maternal estrogen surge which, together with declining fetal androgen levels, leads to a change in the estrogen / androgen ratio in favour of estrogen. During middle age, men’s androgen levels decline, while the concentrations of circulating free estrogens remain constant. The result is a significant change in the estrogen / androgen balance in favour of estrogen, and this increased estrogenic stimulation of the prostate may lead to the activation of growth of precancerous lesions with subsequent neoplastic transformation (Prins and Korach 2008). 5.2.3 Evidence for a role of chemical exposures in prostate cancer through an endocrine disruption mechanism The upsurge in the incidence of prostate cancer in many countries has been attributed partly to changes in diagnostic methods. The introduction of prostate-specific antigen (PSA) as a method of screening during the last decade has led to an increase in incidences, but this alone cannot explain the continuing rises. Changes in prostate cancer incidence among migrant populations and studies of twins show that environmental factors, including diet and chemical exposures also contribute. Studies of migrants between countries with differing prostate cancer incidences have consistently shown that prostate cancer incidences in the migrating populations shifted towards those of the population in the new host country (reviewed by Bostwick et al. 2004). For example, the prostate cancer incidence of Japanese men in the USA is intermediate between the low rate in Japan and the high rate among White men in the USA. These changes typically occur within a few generations, and cannot therefore be explained solely in terms of genetic factors. This argues for the importance of environmental factors as contributing to the disease. Approximately 40% of prostate cancer risks among twins can be explained by the shared genetic factors and developmental milieu, and 60% are due to the environment that was not shared (Lichtenstein et al. 2000). However, the spectrum of the environmental factors that may influence prostate cancer risks is difficult to define; without a doubt dietary factors play an important role. In terms of chemical exposures, epidemiological studies have identified pesticide application in agriculture, pesticide Page 256 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER manufacture, certain organochlorines and heavy metals including cadmium and arsenic as issues of concern. 5.2.3.1 Pesticide application in agriculture and pesticide manufacture Cancer risks among pesticide applicators and workers engaged in pesticide manufacture have been studied extensively, and these studies provide a valuable source of information about possible links with prostate cancer. However, this type of epidemiology cannot easily pinpoint specific chemicals as associated with prostate cancer, for two reasons (Mink et al. 2008): п‚· Exposures were often inferred from the job titles, and there were few attempts to verify exposure levels, the nature of the pesticides used, or to validate exposures by chemical analyses of tissues or body fluids. п‚· Adjustments for potential confounders other than age and duration of exposure were rarely made; lacking in particular are adjustments for family history of prostate cancer and for ethnicity. Pesticide applicators A meta-analysis of 22 epidemiological studies established that pesticide applicators suffer from statistically significantly increased risks of developing prostate cancer. The risk estimates varied according to geographical location, with studies from North America reporting higher prostate cancer risks than European studies (van Maele-Fabry and Willems 2004). Statistically significant excesses of prostate cancer were also observed in the US Agricultural Health Study, a prospective cohort study of 52,394 licensed private pesticide applicators in Iowa and North Carolina, 32,346 spouses of the applicators and 4916 licensed commercial applicators from Iowa (Alavanja et al. 2003, Koutros et al. 2010). Increased risks were seen among private and licensed commercial applicators. Meyer et al. (2007) found that farming was associated with increased prostate cancer risks among White US Americans, but not African Americans. Farmers engaged in mixing and applying pesticides had elevated risks. The authors concluded that prostate cancer risks may be attributable to pesticide exposure, but information about specific contributing pesticides was not gathered in this study. Pesticide manufacture In a meta-analysis of 18 studies among workers engaged in the manufacture of pesticides of varying chemical classes, van Maele-Fabry et al. (2006) found consistently elevated prostate cancer risks for all types of pesticides. A grouping according to chemical class revealed increased risks within each group, but statistical significance was reached only for workers dealing with phenoxy herbicides contaminated with dioxins and furans. This meta-analysis points to pesticide exposure as a risk factor for prostate cancer, and highlights phenoxy herbicides as specifically linked with this cancer. On the basis of the available evidence, however, it is difficult to identify manufacture of other specific pesticides as associated with prostate cancer. Page 257 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.3.2 Specific pesticides Methyl bromide, organophosphates The US Agricultural Health Study pinpointed methyl bromide as a prostate cancer risk for pesticide applicators (Alavanja et al. 2003). In addition, exposure to six pesticides was linked with elevated prostate cancer risks among applicators with a family history of the disease: chlorpyrifos, fonofos, coumaphos, phorate, permethrin and butylate. A recent analysis of the same cohort also revealed associations between prostate cancer and exposure to the organophosphate terbufos (Bonner et al. 2010). The authors were cautious in interpreting these associations as “suggestive” and pointed out that earlier reports of the Agricultural Health Study (e.g. Alavanja et al. 2003) did not find evidence in support of links between terbufos and prostate cancer. Organochlorine pesticides In a hospital-based case control study in Italy, “ever being employed in agriculture” was associated with increased prostate cancer risks (Settimi et al. 2003). The analysis identified elevated risks among farmers who applied DDT and dicofol. Prostate cancer cases from a small hospital-based study in the USA showed higher oxychlordane serum levels than controls, with statistically significantly elevated odds ratios (Ritchie et al. 2003). Hardell et al. (2006) detected increased levels of trans-chlordane among Swedish prostate cancer cases. Plasma chlordecone was associated with increased prostate cancer risks among men in the French West-Indies (Multigner et al. 2010). In men with a family history of prostate cancer, the association was even stronger. Data about serum levels of several organochlorines from the US National Health and Nutrition Examination Survey (NHANES) were used to examine possible links with prostate cancer. There was a statistically significant association with serum concentrations of ОІ-hexachlorocyclohexane, trans-nonachlor and dieldrin (Xu et al. 2010). The increased risks associated with oxychlordane, trans-chlordane, ОІ-hexachlorocyclohexane and trans-nonachlor did not become apparent among Japanese men (Sawada et al. 2010), despite the fact that the serum levels for some of these organochlorines were higher in Japanese than US American men. Whether the absence of apparent risks among Japanese men can be attributed to the protective influence of dietary factors is not clear. A Canadian case-control study among incident prostate cancer cases also did not reveal any associations with organochlorine pesticides (Aronson et al. 2010). 5.2.3.3 Environmental chemicals Polychlorinated biphenyls Links between prostate cancer and PCB exposures have been investigated in studies of the general population and of occupationally exposed subjects. Prostate cancer cases from a small hospitalbased study in the USA were analysed for serum levels of thirty different PCB congeners. PCB 180 was significantly associated with the disease (Ritchie et al. 2003). These data were re-analysed by using various PCB groupings, and in this analysis moderately chlorinated persistent PCBs of the phenobarbital type, including PCBs 138, 153 and 180, could be linked with prostate cancer. There were no associations with PCB congeners of the co-planar, dioxin-like type (Ritchie et al. 2005). In a Page 258 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER small case-control study of Swedish prostate cancer patients Hardell et al. (2006) found significantly increased serum levels of PCB 153. Grouping of PCB congeners according to structural features and biological activity revealed significantly increased risks for phenobarbital-like and for lower chlorinated congeners. However, a Canadian case-control study among incident prostate cancer cases did not show any associations with PCB serum levels (Aronson et al. 2010). Mortality from prostate cancer among USA electric utility workers was associated with PCB exposure (Charles et al. 2003). There was a strong exposure-response relationship for PCBs and prostate cancer mortality among USA workers engaged in capacitor manufacturing (Prince et al. 2006). Cadmium Cadmium exposure has been linked to prostate cancer in some, but not all epidemiological studies, and most positive studies indicate weak associations (comprehensively reviewed by Bostwick et al. 2004, Parent and Siemiatycki 2001, Verougstraete et al. 2003, Sahmoun et al. 2005). However, in patients with aggressive prostate cancer, the association with cadmium was stronger (Bostwick et al. 2004). This was recently confirmed in a Taiwanese study, where men with advanced prostate cancer showed significantly elevated cadmium levels in their blood and urine than men suffering from benign prostate hyperplasia. These relationships did not become apparent when comparisons were made between all prostate cancer cases and controls (Chen et al. 2009). In a population drawn from the US NHANES, associations between elevated PSA levels and urinary cadmium were seen in men with low zinc intake, but not among those with high zinc intake (van Wijngaarden et al. 2008). On the basis of the available epidemiological evidence, it cannot be judged with certainty whether environmental exposure to cadmium is linked with prostate cancer. Despite the equivocal epidemiological evidence, many authors (Parent and Siemiatycki 2001, Sahmoun et al. 2005, van Wijngaarden et al. 2008) do not dismiss cadmium as a possible risk factor, mainly because of the numerous experimental studies showing cadmium as a prostate carcinogen in rodents (reviewed by Goyer et al. 2004). Arsenic Arsenic exposure is strongly associated with prostate cancer (authoritatively reviewed by Benbrahim-Tallaa and Waalkes 2008 and Schuhmacher-Wolz et al. 2009). The link came to light in a population in southwest Taiwan heavily exposed to arsenic via drinking water, where the “blackfoot disease” was endemic. In this part of Taiwan, prostate cancer mortality was nearly six times higher than in the general population, and a dose-response relationship according to arsenic levels in drinking water could be constructed (Chen et al. 1988, Chen and Wang 1990). The relations between arsenic and prostate cancer could also be demonstrated in Australia and the USA. In Australia, geographical areas with high soil and drinking water levels of arsenic were selected and associations with general cancer incidence analysed. Significantly elevated incidences were observed for prostate cancer (Hinwood et al. 1999). Increased mortality from prostate cancer also occurred in areas with arsenic contaminated drinking water in Utah, USA. Analysis according to low, medium and high arsenic concentrations provided evidence for a dose-response relationship (Lewis et al. 1999). Page 259 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.3.4 Endocrine disrupting properties of chemicals shown to be associated with prostate cancer The precise mechanisms by which the chemicals demonstrated in epidemiological studies as being related to prostate cancer induce the carcinogenic process remain to be resolved. However, in the context of current understanding of the aetiology of the disease, agents with androgenic and estrogenic activity are likely to be relevant. There is good evidence that the organochlorine pesticides shown to be associated with increased prostate cancer risks, including trans-chlordane, chlordecone, and trans-nonachlor, have estrogenlike activities (Soto et al. 1995). Cadmium also acts as an estrogen mimick, and arsenic seems capable of activating the estrogen receptor. In addition, the metal compound can lead to phosphorylations of the MAP kinases Erk 1 and 2, effects also induced by steroid hormones. Upregulation of these kinases has been suggested as a mechanism of bypassing androgen receptordependent growth in prostate cancer cells (Benbrahim-Tallaa and Waalkes 2008). Many of the organophosphate pesticides identified in the US Agricutural Health Study as linked with prostate cancer are acetylcholine esterase inhibitors, and have not been shown to possess direct endocrine activity. However, they are capable of inhibiting cytochrome P450 enzymes (CYP1A2, 3A4) which metabolise estradiol, estrone and testosterone in the liver. By interfering with the metabolic conversion of steroid hormones, these pesticides might indirectly disturb the normal hormonal balance, with negative consequences for prostate cancer risks (Prins 2008), but the details of their mode of action need to be resolved. Page 260 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.4 Evidence of developmental vulnerability in prostate cancer The developing prostate gland is exquisitely sensitive to estrogen exposure. In humans, prostate morphogenesis occurs in fetal life during the second and third trimester and is complete at the time of birth. Although estrogens, together with androgens, also play a role in normal prostate development (Harkonen and Makela 2004), several lines of evidence support the notion that estrogen exposure during morphogenesis can profoundly alter the developmental trajectory of the gland, sensitising it to hyperplasia and cancer later in life. п‚· The higher estradiol levels measured in African-American women during pregnancy (Henderson et al. 1988, Potischmann et al. 2005) suggest a link with the aetiology of the disease. п‚· Conversely, the occurrence of pre-eclampsia (associated with lower estradiol levels during pregnancy) has been shown to result in decreased prostate cancer risks (Ekbom et al. 1996). п‚· In the sons of mothers who used DES during pregnancy more extensive prostatic squamous metaplasia was observed compared with mothers who did not use the drug. This metaplasia disappeared in post natal life, but changes in the architecture of the gland remained (reviewed by Prins 2008). Men exposed to DES in fetal life can therefore be expected to experience higher prostate cancer risks, but thus far, epidemiological studies of DES and prostate cancer have not established increased risks (Giusti et al. 1995), presumably because the men have not yet reached the age where prostate cancer becomes manifest. Strong evidence for the developmental vulnerability of the prostate gland to estrogen exposures comes from experimental studies with rodents where the details of the key events that underlie this process have been worked out (summarised by Huang et al. 2004, Harkonen and Makela 2004, Prins et al. 2007): Rats exposed to pharmacological doses of estradiol during prostate morphogenesis (which occurs in perinatal life, and not in fetal life as in humans) showed disorganised prostate epithelia. With aging, these lesions developed into epithelial piling, high grade PIN and carcinoma. Similar observations have been made with bisphenol A (Ho et al. 2006). These experiments show that estrogen exposure during morphogenesis induces disruptions of normal epithelial cell differentiation that persist into later life. The molecular pathways that lead to these changes have been characterised in the rat (Huang et al. 2004, Prins et al. 2007): Normally, the androgen receptor (AR) is the dominant steroid receptor in epithelial and stromal cells of the developing rodent prostate. Androgens that reach the prostate induce stromal cells to produce paracrine factors important for gland development and differentiation. During the process of differentiation, AR levels increase and expression of estrogen receptor ОІ (ERОІ) is induced in epithelial cells, together with low levels of other steroid receptors including ERО± and retinoic acid receptors throughout the prostate. In contrast, brief exposure to estrogens perinatally, induces suppressions of AR expression in epithelial and stromal cells leading to a dampening of androgen signalling. ERО± expression in the Page 261 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER stroma is upregulated, and as a consequence, there is induction of progesterone receptor (PR) expression, together with a significant up-regulation of retinoic acid receptors. In summary, there is a switch from a prostate characterised by androgen signalling to one regulated predominantly by estrogens, progesterone and retinoids. Together, this leads to disruptions in the finely coordinated expression of critical genes involved in prostate gland development and differentiation, including homeobox genes and secreted factors responsible for outgrowth and branching of the ducts of the gland. The results are permanent defects in growth, branching and differentiation which predispose the rodent prostate to hyperplasia and sensitise it to cancerous lesions later in life (Ho et al. 2006). Investigations of the molecular basis of these processes have brought to light changes in gene imprinting. Exposure to estradiol or bisphenol A in rats during the phase of prostate development induced permanent alterations of the methylation patterns of several genes important in cell-to-cell singalling, cell cycle control and apoptosis. There was hypo-methylation of the phosphodiesterase 4 gene (coding for an esterase involved in degrading cAMP) which led to the continued elevated expression of this gene throughout the life of the exposed rats (Ho et al. 2006). Differential effects of timing and dose level Exposure of mice to low doses of estradiol, bisphenol A or estrogenic UV filters such as MBC in fetal life increased prostate growth, but histopathological abnormalities indicative of cancer were not observed (vomSaal et al. 1997, Hofkamp et al. 2008). Furthermore, due to species differences, variations in background estrogen levels and other experimental factors, this was not observed universally (Ashby et al. 1999). In contrast, exposure to higher estrogen levels during perinatal life, when prostate developments occurs in rodents, decreased the growth of the gland and also led to pathological changes. At low doses of estradiol, lesions indicative of carcinogenesis were not observed. The issue of dosedependence of prostate dysplasia after perinatal estrogen exposure was investigated systematically in the “second hit” model of prostate carcinogenesis (summarised by Prins et al. 2007). In this model, rats exposed perinatally to estrogens, received combined testosterone and estradiol treatment later in life (the second hit). This is necessary to compensate for the decreased testosterone levels that are seen typically after perinatal estrogen exposure due to feedback inhibition of androgen synthesis. Low dose perinatal exposure to estrogens was seen to increase the susceptibility of the rodent prostate to adult onset dysplasia and carcinogenic lesions. 5.2.5 Do experimental tools exist for the study of prostate cancer, and are assays applicable to, and adequate for, the assessment of chemicals? More than ten animal models for prostate carcinogenesis have been described (authoritatively reviewed by Bostwick et al. 2004), but not one single model is able to re-capitulate the key features of the disease in men, which are 1) androgen dependence, 2) developing androgen-independence at more advanced stages, 3) slow growth, with long latency periods, and 4) ability to metastasise to lymph nodes, bones and other organs. Page 262 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER In many rodent strains, including the F344 rat used for carcinogen testing in the US NTP, prostate tumours are not inducible by administration of androgens. Usually, tumours have to be “initiated” by exposure to genotoxic carcinogens such as nitrosoureas, followed by treatment with androgens in a “promotional” period. The Noble rat is a good model for studying hormone-induced prostate cancers, but metastases are rare in this strain. This rat strain has not been widely used for the study of prostate cancers induced by chemicals. Systematic screening exercises with endocrine disrupters for their ability to induce prostate cancers in animal models sensitive to hormonal prostate carcinogenesis have not been conducted, nor have international validation studies been initiated. Page 263 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.6 CONCLUSIONS INTACT criteria MET MULTI-LEVEL criteria MET HORMONE criteria MET PRIMARY EFFECT Attribution criteria: criteria MET PROSTATE CANCER Environmental factors including chemical exposures play a role in the rise of prostate cancer in high incidence countries, but why prostate cancer incidences are rising in so many countries has yet to be explained fully. Good evidence is available that criteria pesticide exposures experienced during MET EXPOSURE pesticide application and manufacture criteria MET SENSITIVE LIFESTAGE contribute to prostate cancer risks. criteria Certain pesticides, among them MET PHARM. RESTORATION organophosphates and organochlorine chemicals have been pinpointed as SUPPORTING DATA associated with the disease. Certain environmental chemicals, including PCBs and the heavy metal metals cadmium and arsenic are also linked to increased prostate cancer risks. The associations found in many epidemiological studies were not strong, and this suggests that other, not yet identified exposures also contribute to risks. Epidemiological studies that address the question of chemical exposures during the etiological period in humans, i.e. during pregnancy and possible in puberty, are missing, as are studies that focus on polar EDCS such as phenolic chemicals, UV filter substances and others. Even so, there has been substantial progress in understanding the role of EDCs in prostate cancer. The achievements during the last 10 years can be summarised as follows: o Better understanding of the impact of environmental factors (including chemical exposures) on prostate cancer risks; o Identification of the importance of estrogen exposures during prostate development in rodents in irreversibly disrupting normal epithelial differentiation thereby predisposing the gland to neoplasia later in life; o Appreciation of the importance of gene imprinting and epigenetics in irreversibly shaping the sensitivity of the prostate to cancerous lesions later in life Below we summarise the state of the science by using the WHO/IPCS 2002 criteria for attribution to an endocrine mode of action. Page 264 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.6.1 Can prostate cancer be attributed to endocrine disruption? Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criterion met? Criteria MET Evidence summary Chronic exposure to testosterone and estradiol induces prostate cancers in the Noble rat Criteria MET Characterisation of cellular changes symptomatic of disruption of epithelial differentiation leading to dysplasia; this could be traced to disruption of signalling of morphogenetic genes and irreversible changes in gene imprinting Criteria MET See above Criteria MET See above Criteria MET Chronic administration of combined testosterone and estrogen leads to prostate dysplasia in rodents; administration of the estrogen bisphenol A during prostate development also leads to dysplasia Epidemiological and experimental evidence that exposures during prostate gland development are critical Criteria MET Criteria MET Effects of androgen withdrawal through castration Not applicable Page 265 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER 5.2.7 References Adlercreutz H, Mazur W, Bartels P, Elomaa VV, Watanabe S, Wahala K, Landstrom M, Lundin E, Bergh A, Damber JE, Aman P, Widmark A, Johansson A, Zhang JX, Hallmans G. 2000. 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Page 266 of 486 HUMAN HEALTH ENDPOINTS PROSTATE CANCER Mink PJ, Adami HO, Trichopoulos D, Britton NL, Mandel JS. 2008. Pesticides and prostate cancer: a review of epiderniologic studies with specific agricultural exposure information. European Journal of Cancer Prevention 17:97-110. Multigner L, Ndong JR, Giusti A, Romana M, acroix-Maillard H, Cordier S, Jegou B, Thome JP, Blanchet P. 2010. Chlordecone Exposure and Risk of Prostate Cancer. Journal of Clinical Oncology 28:3457-3462. Parent ME, Siemiatycki J. 2001. Occupation and prostate cancer. Epidemiologic Reviews 23:138-143. Pierorazio PM, Ferrucci L, Kettermann A, Longo DL, Metter EJ, Carter HB. 2010. Serum testosterone is associated with aggressive prostate cancer in older men: results from the Baltimore Longitudinal Study of Aging. Bju International 105:824-829. Platz EA, Giovannucci E. 2004. The epidemiology of sex steroid hormones and their signalling and metabolic pathways in the etiology of prostate cancer. 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Steroids 73:233-244. Ritchie JM, Vial SL, Fuortes LJ, Guo HJ, Reedy VE, Smith EM. 2003. Organochlorines and risk of prostate cancer. Journal of Occupational and Environmental Medicine 45:692-702. Ritchie JM, Vial SL, Fuortes LJ, Robertson LW, Guo HJ, Reedy VE, Smith EM. 2005. Comparison of proposed frameworks for grouping polychlorinated biphenyl congener data applied to a case-control pilot study of prostate cancer. Environmental Research 98:104-113. Roddam AW, Allen NE, Appleby P, Key TJ. 2008. Endogenous sex hormones and prostate cancer: A collaborative analysis of 18 prospective studies. Journal of the National Cancer Institute 100:170-183. Sahmoun AE, Case LD, Jackson SA, Schwartz GG, Schwartz GG. 2005. Cadmium and prostate cancer: A critical epidemiologic analysis. Cancer Investigation 23:256-263. Sawada N, Iwasaki M, Inoue M, Itoh H, Sasazuki S, Yamaji T, Shimazu T, Tsugane S. 2010. Plasma Organochlorines and Subsequent Risk of Prostate Cancer in Japanese Men: A Nested Case-Control Study. Environmental Health Perspectives 118:659-665. Schuhmacher-Wolz U, Dieter HH, Klein D, Schneider K. 2009. Oral exposure to inorganic arsenic: evaluation of its carcinogenic and noncarcinogenic effects. Critical Reviews in Toxicology 39:271-298. Settimi L, Masina A, Andrion A, Axelson O. 2003. Prostate cancer and exposure to pesticides in agricultural settings. International Journal of Cancer 104:458-461. Sim HG, Cheng CWS. 2005. Changing demography of prostate cancer in Asia. European Journal of Cancer 41:834-845. Soto AM, Sonnenschein C, Chung KL, Fernandez MF, Olea N, Serrano FO. 1995. The E-SCREEN assay as a tool to identify estrogens: an update on estrogenic environmental pollutants. Environ Health Perspect 103 Suppl 7:113-122. van Maele-Fabry G, Libotte V, Willems J, Lison D. 2006. Review and meta-analysis of risk estimates for prostate cancer in pesticide manufacturing workers. Cancer Causes & Control 17:353-373. van Maele-Fabry G, Willems JL. 2004. Prostate cancer among pesticide applicators: a meta-analysis. International Archives of Occupational and Environmental Health 77:559-570. van Wijngaarden E, Singer EA, Palapattu GS. 2008. Prostate-specific antigen levels in relation to cadmium exposure and zinc intake: Results from the 2001-2002 National Health and Nutrition Examination Survey. Prostate 68:122-128. Verougstraete V, Lison D, Hotz P. 2003. Cadmium, lung and prostate cancer: A systematic review of recent epidemiological data. Journal of Toxicology and Environmental Health-Part B-Critical Reviews 6:227-255. vomSaal FS, Timms BG, Montano MM, Palanza P, Thayer KA, Nagel SC, Dhar MD, Ganjam VK, Parmigiani S, Welshons WV. 1997. Prostate enlargement in mice due to fetal exposure to low doses of estradiol or diethylstilbestrol and opposite effects at high doses. Proceedings of the National Academy of Sciences of the United States of America 94:2056-2061. WHO. 2002. Global assessment of the state-of-the-science of endocrine disrupters. World Health Organization. Switzerland. Geneva. Xu XH, Dailey AB, Talbott EO, Ilacqua VA, Kearney G, Asal NR. 2010. Associations of Serum Concentrations of Organochlorine Pesticides with Breast Cancer and Prostate Cancer in US Adults. Environmental Health Perspectives 118:60-66. Page 267 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER 5.3 TESTIS CANCER More than 90% of all tumours that afflict the testes are testicular germ cell tumours (TGCT), of which about 50% occur as seminomas. The remainder are non-seminomas (Garner et al. 2005). Nonseminomas are more aggressive than seminomas and incidence peaks at younger age (25-30 years) than that of seminomas (35-40 years). This overview focuses on TGCT and its relation to endocrine disrupters, and does not deal with other, rarer, forms of testicular cancer. 5.3.1 Natural history of testicular germ cell cancer Testicular germ cell tumours (TGCT) derive from germ cells and show an unusually heterogeneous histology, with many components mimicking any tissue of the body. This histological complexity has been a conundrum until Skakkebaek in 1972 described carcinoma in situ (CIS) cells as the precursor lesion for all testicular germ cell tumours. A close morphological similarity between CIS cells and human fetal gonocytes was noted early on. CIS cells display the features of embryonic stem cells, as judged by their gene expression profiles (see the authoritative review by Rajpert-De Meyts 2006). Today, it is generally accepted that TGCT originate in fetal life which explains the unusual age dependence of this cancer: Incidence peaks between 25 and 40 years of age. Trends in incidence rates During the last 20-30 years there has been an unexplained epidemic of testis cancer in several populations, although there are marked differences between countries. The incidence of TGCT has risen steadily in Caucasian white men (Chia et al. 2010) and is now the most commonly diagnosed malignant neoplasm among men of 15-34 years of age. In general, incidence is highest in Northwest Europe, with up to 12 cases per 100,000 population, and lowest in African countries (< 0.5 cases per 100,000). Norway, Denmark and certain regions in Switzerland, Germany and Chile show the highest prevalence in the world. The continuing rise in TGCT in high incidence countries remains largely unexplained in terms of risk factors and exposures. 5.3.2 Evidence for an endocrine mechanism in testicular germ cell cancer Non-descending testes (cryptorchidism) are a risk factor for TGCT. Since the likelihood of developing cryptorchidism is linked to insufficient androgen action in fetal life, there is a suspected endocrine basis for TGCT. Men harbouring a lack of function mutation of the androgen receptor also experience increased TGCT risks. Conversely, high testosterone levels (found more frequently among men of African ethnicity than among Caucasians) protect against TGCT risks (Rajpert-de Meyts 2006). Henderson was the first to suggest a possible link between high exposure to estrogens during pregnancy and elevated testis cancer risks. A recent case-control study among Finnish, Swedish and Icelandic maternity cohorts has confirmed this idea (Holl et al. 2009). The sons of mothers with high endogenous androstenedione and total estradiol levels during pregnancy showed an increased risk of developing TGCT. However, maternal exposure to exogenous female sex hormones during pregnancy does not appear to be associated with elevated TGCT risk among their sons (Shankar et al. 2006). Page 268 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER The mechanistic detail of the ways in which a “hormonal imbalance” or a lack of androgen action in fetal life may lead to TGCT is not known. In the human fetus, the differentiation of gonocytes into infantile spermatogonia is a relatively long process, during which embryonic genes need to be repressed, while specific genes with a role in the maturation and differentiation of spermatogonia need to be “switched on”. Factors that delay or inhibit this developmental programme will lead to the retention of embryonic features in these cells, with an increased likelihood of acquiring the CIS cell phenotype, but the role of androgens in these processes is unclear (Rajpert-de Meyts 2006). 5.3.3 Evidence for a role of chemical exposures in testicular germ cell cancer through an endocrine disruption mechanism The continuing rise of TGCT in parts of the world is very likely due to environmental factors that come into play during fetal and neonatal life. Several lines of evidence support this idea: п‚· The increases in incidence seen in Norway, Denmark and other parts of Scandinavia in recent years are too rapid to be attributable to genetic factors. п‚· Several studies among migrants from low-incidence to high-incidence countries (or vice versa) have shown that the TGCT risk among first-generation immigrants mirrors that of their country of origin, while the risk among second-generation immigrants approaches that of their new home country (Hemminki and Li 2002, Ekbom et al. 2003, Myrup et al. 2008). Such rapid adaptations cannot be explained purely in terms of genetic background. However, the nature of the environmental factors that may influence TGCT risks is not well defined. Factors of potential relevance include chemical exposures, especially during fetal life, including exposures from alcohol consumption and smoking. 5.3.3.1 Smoking and alcohol (Clemmesen 1997) observed parallel trends between TGCT and lung and bladder cancers in women. Because these cancers can be attributed to smoking, he suggested that maternal smoking during pregnancy is an important risk factor in TGCT. The idea has since acquired further relevance because maternal smoking has increased in countries with a high incidence in TGCT. Initially, several ecological studies in Scandinavia (reviewed by Tuomisto et al. 2009) appeared to lend support to the idea, but other more controlled epidemiological studies did not provide evidence for smoking as a TGCT risk factor. An issue with many studies of this kind is that smoking status was assessed by questionnaire. There is a need to ascertain smoking status more accurately by objective measurement. Tuomisto and colleagues have addressed this point by conducting a case-control study nested within Finnish, Swedish and Icelandic maternity cohorts in which they examined smoking status directly by measuring cotinine serum levels (Tuomisto et al 2009). There was no statistically significant association between maternal cotinine levels and risk of TGCT among their sons. Tuomisto et al also conducted a meta-analysis of seven earlier epidemiological studies (total number of 2149 cases, 2762 controls) where smoking status was evaluated indirectly (e.g. by Page 269 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER questionnaire). This meta-analysis also failed to reveal a link between maternal smoking and TGCT risk. During pregnancy, maternal serum testosterone levels are lower in women who drink alcohol, and this has been suggested as an explanation for the increased TGCT risk among men whose mothers consumed alcohol during pregnancy (Mongraw-Chaffin et al. 2009). 5.3.3.2 Environmental chemicals A proposed role for human exposure to endocrine disrupting chemicals in the causation of TGCT follows on from the associations of this cancer with lack of androgen action in fetal life. Concerns have arisen over the potential of estrogenic and anti-androgenic chemicals to exacerbate TGCT risk by interfering with androgen action in fetal life. There are etiological links with other disorders attributed to disruption of fetal androgen action (cryptorchidism, hypospadias, poor semen quality) which are discussed in section 4.1. Methodological issues that complicate the interpretation of epidemiological results Considering that the steps leading to TGCT originate in early pregnancy, long before the disease manifests itself in adult life, any demonstration of associations with chemical exposures depends on the ability to relate to events that lie several decades apart. To re-construct the chemical exposures experienced by the developing fetus is often extremely challenging, especially with chemicals that do not remain for long in body tissues. A reasonable reflection of chemical exposures in fetal life is given by chemical analyses of maternal tissues or body fluids. With very persistent chemicals, such as highly lipophilic organochlorine compounds, which stay in the body for very long times, tissue levels found in adult life may also give an indication of the exposures in fetal life. These methodological issues complicate the interpretation of epidemiological studies of TGCT, and are likely to obscure, rather than over-estimate, risks. In many of the relevant epidemiological studies discussed below exposure measurements were conducted during time points outside the period important in causing the disease, when male sexual differentiation occurs in the first trimester of pregnancy. Furthermore, risk estimates had to rely on a comparatively small number of cases, which diminished the statistical power needed to detect associations with a degree of reliability. Only a limited set of chemicals were investigated during exposure measurements. Most of the chemicals that are postulated to be of concern for an association with TGCT, for example phthalates or anti-androgenic endocrine disrupters, have not been studied epidemiologically. Because these chemicals are cleared rather rapidly from human tissues, exposure measurements at times after pregnancy are unreliable surrogates. To investigate the contribution of such chemicals to TGCT will require the design of prospective studies, where exposure measurements are conducted during pregnancy, the aetiological period of the disease. Another limitation is the lack of concepts for dealing with combined exposures in epidemiological studies of TGCT. In all of the studies investigating chemical exposures and their link to TGCT risks, Page 270 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER health outcomes were related to single chemicals. It is likely that risk estimates might increase when exposure to several chemicals is considered, but this requires systematic examination. Persistent organochlorine and polybrominated compounds There are eight epidemiological studies where associations between exposure to persistent organochlorine and polybrominated compounds and risk of TGCT were investigated. In a small hospital-based study with 58 TGCT cases and 61 subjects free of disease (controls), significantly higher serum levels of cis-nonachlor (a congener of the pesticide chlordane) were detected among men suffering from TGCT than among controls. The mothers of men with TGCT showed higher serum levels of chlordane compounds (trans- and cis-chlordane, sum of chlordanes), PCBs and hexachlorobenzene than the mothers of men free of disease (Hardell et al. 2003). The material used in that study was analysed further for additional PCBs and for polybrominated biphenyls (PBDEs). While there were no differences in the PCB or PBDE serum levels of the men with cancer compared to healthy subjects, the mothers of TGCT sufferers had statistically significantly elevated levels of PCBs (Hardell et al. 2004) and of PBDEs (Hardell et al. 2006). In all these studies, blood samples from the men and their mothers were drawn when they were adults. Samples from the time when the mothers were pregnant were not available. Consequently, there is a degree of uncertainty as to how representative the measured concentrations are of those at the time of pregnancy, during the etiological period of the disease. Similar issues complicate the interpretation of the case-control study conducted by (Biggs et al. 2008). Blood specimens were obtained from 18- to 44-year-old male residents of three Washington State counties in the USA (246 cases and 630 controls) and the levels of 11 organochlorine pesticides (ОІ-hexachlorocyclohexane, Оі-hexachlorocyclohexane, dieldrin, hexachlorobenzene, heptachlor, epoxide, mirex, p,p’-DDT, o,p’-DDT, p,p’-DDE, oxychlordane, trans-nonachlor) and 36 PCB congeners determined. Significant differences between the concentrations of any of these chemicals between TGCT cases and controls could not be detected. The authors concluded that their study does not provide support for the hypothesis that adult exposure to organochlorine pesticides is associated with the risk of TGCT. However, they concede that due to uncertainty regarding how well organochlorine levels measured in adulthood reflect exposures during early life, further research is needed using exposure measurements collected in utero or during infancy. In contradiction to the results reported by Biggs et al. 2008, a study conducted among US servicemen involving 754 cases and 928 controls found significantly elevated serum levels of cisnonachlor, trans-nonachlor and p,p’-DDE among TGCT sufferers (McGlynn et al. 2008). However, in the same group of subjects, several PCB congeners were significantly associated with decreased TGCT risk (McGlynn et al. 2009). This finding is not in line with the observation by Hardell et al (2004) of increased TGCT risks after PCB exposure, but the Hardell study is based on comparatively few subjects. The Norwegian Janus Serum Bank cohort offered the opportunity of investigating associations between TGCT risk and organochlorine compounds by using serum collected approximately 20 years before diagnosis. Sera from 49 TGCT cases and 51 controls were analysed for 11 organochlorine insecticide compounds and 34 polychlorinated biphenyl (PCB) congeners. Relative to controls, TGCT Page 271 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER cases showed elevated concentrations of p,p'-DDE, oxychlordane, trans-nonachlor, and total chlordanes, but none of these differences reached statistical significance. Seminoma cases showed significantly lower concentrations of PCB congeners 44, 49, and 52 and significantly higher concentrations of PCBs 99, 138, 153, 167, 183, and 195 (Purdue et al. 2009). The authors concluded that their data provided additional but qualified evidence supporting an association between TGCT risk and exposures to p,p'-DDE and chlordane compounds, and possibly some PCB congeners. Recently, the maternal serum levels of DDT-related compounds were analysed in relation to their son's risk of TGCT 30 years later. Of 9,744 live-born sons, 15 were diagnosed with TGCT and these cases were matched to controls on race and birth year. Maternal serum DDT-related compounds, measured in the early after birth, were associated with the son's risk of TGCT. Despite the low statistical power in this study (due to the small number of cases), mothers of cases had a significantly higher ratio of p,p'-DDT to p,p'-DDE and lower levels of o,p-DDT (Cohn et al. 2010). Diethylstilbestrol (DES) Associations between prenatal diethylstilbestrol (DES) exposure and TGCT in men have been suspected on the basis of the estrogenicity of DES, but findings from case-control studies (authoritatively reviewed by (Strohsnitter et al. 2001) have been inconsistent. To address these inconsistencies, Strohsnitter and colleagues conducted a prospective follow-up study among 3613 men whose prenatal DES exposure status was known. The TGCT incidence rates among these men were compared to those of unexposed men and to the rates in the general population by calculating relative risks. For TGCT, elevated relative risks 3.05 times higher than those of unexposed men (95% CI = 0.65 to 22.0) were found. When compared to the general population, the relative risk was 2.04 times higher (95% CI = 0.82 to 4.20). However, due to the small number of cases in this cohort, these differences did not reach statistical significance, but are suggestive of an association. Summary Associations between TGCT risk and exposure to chlordanes, pp-DDE and certain PCBs have been detected in several epidemiological studies, but the magnitude of effects is relatively small. Very likely only a fraction of the real existing risks has been captured. The table below gives a summary of epidemiological studies of TGCT risk and organohalogen exposures. Page 272 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER Table 24: Summary of epidemiological studies of TGCT risks and chemical exposures to persistence organohalogens Year First author Time point Number of Significant association with TGCT risk? of exposure cases/controls measurment 2003 Hardell Adult life 58/61 Yes: chlordanes, PCB, HCB 2004 Hardell Adult life 58/61 Yes: PCB 2006 Hardell Adult life 58/61 Yes: PBDE 2008 Biggs Adult life 246/630 no 2008 McGlynn Adult life 754/928 Yes: nonachlor, pp-DDE 2009 McGlynn Adult life 754/928 No, decreased risk with PCB 2009 Purdue childhood 49/51 Possibly: pp-DDE, nonachlor oxychlordane, trans- Yes: PCB 99, 138, 153, 167, 183, 195 2010 Cohn neonatal 15/45 Yes: pp-DDT, higher pp-DDT/ppDDE ratio 5.3.3.3 Endocrine disrupting properties of chemicals shown to be associated with TGCT The chemicals found to be associated with TGCT risks in the above epidemiological studies can interfere with endocrine action in several different ways, but of interest in the context of TGCT risks is their ability to disrupt androgen action in fetal life. There is good evidence that chlordanes, p,p’-DDE and PCBs 138 and 167 act as androgen receptor antagonists (Kojima et al. 2004, Vinggaard et al. 2008), supporting the notion that they might compromise androgen action during the stages of male sexual differentiation, and possible also differentiation of spermatogonia. However, the AR antagonist potential of cis- and trans-nonachlor, oxychlordane and PCB 99, 183 and 195 has not been determined. PCB 153 is devoid of AR antagonist effects (Vinggaard et al. 2008). Information about the ability of these chemicals to suppress fetal androgen synthesis is not available. Page 273 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER 5.3.4 Do experimental tools exist for the study of testicular germ cell cancer, and are assays applicable to, and adequate for, the assessment of chemicals? Experiments with rabbits have shown that administration of p,p’-DDT, dibutyl phthalate, or the pesticide vinclozolin can lead to the formation of “germ cell atypia”, a lesion that has similarities with CIS cells in humans (Veeramachaneni et al. 2007, Veeramachaneni 2008). However, it is not known whether this lesion will develop into germ cell tumours in the rabbit. Germ cell tumours are only very rarely observed in rodents. In the US National Toxicology Programme (NTP) long-term carcinogenesis rodent bioassay, very few chemicals have revealed themselves as causing testes tumours. However, spontaneous Leydig cell adenomas are very common in the F344/N rat, the strain that has been widely used by the NTP for the identification of carcinogens. This high background incidence of Leydig cell adenomas makes the F344/N rat unsuitable for the detection of chemically induced testes tumours. In contrast, the B6C3F1/N mouse (also widely used by NTP for identifying carcinogens) shows a very low incidence of spontaneous Leydig cell adenomas and appears to be resistant to developing testes cancer. No chemical has so far been identified that produces testes cancer in the B6C3F1/N mouse. A NTP workshop convened in 2006 on the topic of the relevance of rodent bioassays for the detection of hormonally induced tumours of the reproductive tissues (http://ntp.niehs.nih.gov/go/18592) suggested to take Leydig cell nodules/hyperplasia in the rat as a surrogate marker for germ cell tumours, but overall it was recognised that suitable animal models for TGCT do not exist. The workshop recommended the development of new, more sensitive, models for detecting chemicals that have the potential of inducing TGCT in man. Page 274 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER 5.3.5 CONCLUSIONS INTACT not enough data MULTI-LEVEL not enough data HORMONE not enough data PRIMARY EFFECT Attribution criteria: criteria MET TESTIS CANCER It is clear that environmental factors play a role in the rise of testis cancer in high incidence countries. However, the nature of these factors has been identified only partly. Risk factors for TGCT are linked to diminished androgen action in fetal life. criteria There is good evidence that PARTLY EXPOSURE MET organochlorine chemicals including p,p’criteria DDT, certain PCBs and other SENSITIVE LIFESTAGE MET organochlorine pesticides are not enough associated with the risk of developing PHARM. RESTORATION data TGCT. However, the associations found evidence in epidemiological studies were UNCLEAR SUPPORTING DATA relatively weak, suggesting that other, as yet unrecognised exposures might also play a role. All in all, the published epidemiological studies could not fully address important issues, including exposure measurements during the etiological period of TGCT, and consideration of cumulative exposures simultaneously to several chemicals. This presents particular challenges for studying other chemicals with known ability to interfere with fetal androgen action. These have not been investigated in epidemiological studies. Because many of these chemicals (e.g. certain phthalates, azole fungicides) do not stay for long in human tissues after exposure, it will be important to measure exposures during the critical periods of male sexual differentiation during the first trimester of pregnancy. The 2002 Global Assessment of Endocrine Disrupters considered that there were no published analytical epidemiological studies linking exposure to EDCs to the risk of TGCT. As discussed above, this gap has been bridged somewhat. The 2002 report also noted the absence of reliable and validated animal models for the detection of chemicals that induce testicular cancer. Nothing of substance has happened since to address this issue. Nevertheless, considerable progress has been made in elucidating factors that contribute to TGCT risks. The achievements over the past 10 years can be summarised as follows: o Better understanding of the impact of environmental factors (including chemical exposures) on testicular cancer risks, particularly from migrant studies; o Identification of the importance of factors leading to delays in the differentiation of embryonal germ cells as contributing to TGCT risks; o Strengthening of the evidence linking exposure to persistent halogenated organic chemicals to TGCT risks; o Appreciation of the importance of combined effects of estrogenic agents and understanding of the determinants of additivity (see section 3.3) Page 275 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER Below we summarise the state of the science by using the WHO/IPCS 2002 criteria for attribution to an endocrine mode of action. Page 276 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER 5.3.5.1 Can testicular germ cell cancer be attributed to endocrine disruption? Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criterion met? MET Evidence summary Diminished androgen action recognised as risk factor for TGCT Not data enough Lack of a suitable animal model for testicular cancer Not data enough Lack of a suitable animal model for testicular cancer Not data enough Lack of a suitable animal model for testicular cancer PARTLY MET Indications that exposure to DES during pregnancy contributes to risks (Strohsnitter et al. 2001) MET Epidemiological evidence that exposures in utero and during puberty are critical Not data Evidence unclear enough Assays monitoring the androgen receptor antagonist properties of chemicals are available but the mechanistic links to the steps leading to TGCT remain unclear Page 277 of 486 HUMAN HEALTH ENDPOINTS TESTIS CANCER 5.3.6 References Biggs ML, Davis MD, Eaton DL, Weiss NS, Barr DB, Doody DR, Fish S, Needham LL, Chen C, Schwartz SM. 2008. Serum organochlorine pesticide residues and risk of testicular germ cell carcinoma: A population-based case-control study. Cancer Epidemiology Biomarkers & Prevention 17:2012-2018. Chia VM, Quraishi SM, Devesa SS, Purdue MP, Cook MB, McGlynn KA. 2010. International Trends in the Incidence of Testicular Cancer, 1973-2002. Cancer Epidemiology Biomarkers & Prevention 19:1151-1159. Clemmesen J. 1997. Is pregnancy smoking causal to testis cancer in sons? A hypothesis. Acta Oncologica 36:59-63. Cohn BA, Cirillo PM, Christianson RE. 2010. Prenatal DDT Exposure and Testicular Cancer: A Nested Case-Control Study. Archives of Environmental & Occupational Health 65:127-134. Ekbom A, Richiardi L, Akre O, Montgomery SM, Sparen P. 2003. Age at immigration and duration of stay in relation to risk for testicular cancer among Finnish immigrants in Sweden. Journal of the National Cancer Institute 95:1238-1240. Garner MJ, Turner MC, Ghadirian P, Krewski D. 2005. Epidemiology of testicular cancer: an overview. International Journal of Cancer 116:331-339. Hardell L, Malmqvist N, Ohlson CG, Westberg H, Eriksson M. 2004. Testicular cancer and occupational exposure to polyvinyl chloride plastics: A case-control study. International Journal of Cancer 109:425-429. Hardell L, van Bavel B, Lindstrom G, Carlberg M, Dreifaldt AC, Wijkstrom H, Starkhammar H, Eriksson M, Hallquist A, Kolmert T. 2003. Increased concentrations of polychlorinated biphenyls, hexachlorobenzene, and chlordanes in mothers of men with testicular cancer. Environmental Health Perspectives 111:930-934. Hardell L, van Bavel B, Lindstrom G, Eriksson M, Carlberg M. 2006. In utero exposure to persistent organic pollutants in relation to testicular cancer risk. International Journal of Andrology 29:228-234. Hemminki K, Li X. 2002. Cancer risks in Nordic immigrants and their offspring in Sweden. European Journal of Cancer 38:2428-2434. Holl K, Lundin E, Surcel HM, Grankvist K, Koskela P, Dillner J, Hallmans G, Wadell G, Olafsdottir GH, Ogmundsdottir HM, Pukkala E, Lehtinen M, Stattin P, Lukanova A. 2009. Endogenous steroid hormone levels in early pregnancy and risk of testicular cancer in the offspring: A nested case-referent study. International Journal of Cancer 124:2923-2928. Kojima H, Katsura E, Takeuchi S, Niiyama K, Kobayashi K. 2004. Screening for estrogen and androgen receptor activities in 200 pesticides by in vitro reporter gene assays using Chinese hamster ovary cells. Environmental Health Perspectives 112:524-531. McGlynn KA, Quraishi SM, Graubard BI, Weber JP, Rubertone MV, Erickson RL. 2008. Persistent organochlorine pesticides and risk of testicular germ cell tumors. Journal of the National Cancer Institute 100:663-671. ----- 2009. Polychlorinated Biphenyls and Risk of Testicular Germ Cell Tumors. Cancer Research 69:1901-1909. Mongraw-Chaffin ML, Cohn BA, Anglemyer AT, Cohen RD, Christianson RE. 2009. Maternal smoking, alcohol, and coffee use during pregnancy and son's risk of testicular cancer. Alcohol 43:241-245. Myrup C, Westergaard T, Schnack T, Oudin A, Ritz C, Wohlfahrt J, Melbye M. 2008. Testicular cancer risk in first- and second-generation immigrants to Denmark. Journal of the National Cancer Institute 100:41-47. Purdue MP, Engel LS, Langseth H, Needham LL, Andersen A, Barr DB, Blair A, Rothman N, McGlynn KA. 2009. Prediagnostic Serum Concentrations of Organochlorine Compounds and Risk of Testicular Germ Cell Tumors. Environmental Health Perspectives 117:15141519. Rajpert-De Meyts E. 2006. Developmental model for the pathogenesis of testicular carcinoma in situ: genetic and environmental aspects. Human Reproduction Update 12:303-323. Shankar S, Davies S, Giller R, Krailo M, Davis M, Gardner K, Cai H, Robison L, Shu XO. 2006. In utero exposure to female hormones and germ cell tumors in children. Cancer 106:1169-1177. Strohsnitter WC, Noller KL, Hoover RN, Robboy SJ, Palmer JR, Titus-Ernstoff L, Kaufman RH, Adam E, Herbst AL, Hatch EE. 2001. Cancer risk in men exposed in utero to diethylstilbestrol. Journal of the National Cancer Institute 93:545-551. Tuomisto J, Holl K, Rantakokko P, Koskela P, Hallmans G, Wadell G, Stattin P, Dillner J, Ogmundsdottir HM, Vartiainen T, Lehtinen M, Pukkala E. 2009. Maternal smoking during pregnancy and testicular cancer in the sons: A nested case-control study and a metaanalysis. European Journal of Cancer 45:1640-1648. Veeramachaneni DNR. 2008. Impact of environmental pollutants on the male: Effects on germ cell differentiation. Animal Reproduction Science 105:144-157. Veeramachaneni DNR, Palmer JS, Amann RP, Pau KYF. 2007. Sequelae in male rabbits following developmental exposure to p,p '-DDT or a mixture of p,p '-DDT and vinclozolin: Cryptorchidism, germ cell atypia, and sexual dysfunction. Reproductive Toxicology 23:353-365. Vinggaard AM, Niemela J, Wedebye EB, Jensen GE. 2008. Screening of 397 chemicals and development of a quantitative structure-activity relationship model for androgen receptor antagonism. Chemical Research in Toxicology 21:813-823. Page 278 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER 5.4 THYROID CANCER Summarising the state of knowledge in 2002, the WHO stated that a direct association between exposure to EDCs and thyroid cancer is not supported by published data. On the other hand, it was acknowledged that EDCs can affect the hypothalamic-pituitary-thyroid (HPT) axis, and that therefore the basic mechanisms of thyroid carcinogenesis in humans need to be elucidated, before any further conclusions could be drawn. Although in the last ten years the upward trend in thyroid cancer incidence has persisted, epidemiological studies investigating an association between EDCs and thyroid cancer remain scarce. After a theory on fetal cell carcinogenesis of the thyroid was recently put forward, new mechanisms that link the exposure to EDCs to thyroid cancer have become plausible. 5.4.1 Natural History of Thyroid Cancer In young women, thyroid cancer is the most prevalent endocrine malignancy. However, the incidence rate is lower than for other cancers, with thyroid cancer affecting 1.18 per 100 000 people worldwide. This rate has varied over the decades and varies among different countries, with the highest incidence in Iceland, Hawaii, the Philippines, Japan, and Israel followed by the rest of Europe and North America (Sipos and Mazzaferri 2010). There is also an ethnic variability in thyroid cancer incidence. In the USA, thyroid cancer is more frequent in Caucasians than in Afro-Americans and Hispanics. More cases occur in females aged 15-44 than in any other age group. The incidence rate is about 3fold higher in women compared with men, and peak incidence occurs nearly 20 years earlier in women (Chen et al. 2009). In contrast to other cancers, thyroid cancer is almost always curable. Most thyroid cancers grow slowly and are associated with a very favourable prognosis. The mean survival rate after 10 years is higher than 90%. The mean mortality rate is 1.5% for females and 1.4% for males (Hay et al. 2010). Known risk factors include a family history of thyroid cancer, obesity, a history of thyroid disease, exposure to radiation, and low iodine levels. A history of exposure of the head and neck to x-ray beams, especially during childhood, has been recognised as an important contributing factor for the development of thyroid cancer (Jacob et al. 2006; Ron et al. 1995). Several reports have shown a relationship between iodine deficiency and the incidence of thyroid carcinomas (Boltze et al. 2002). Thyroid cancer comprises a group of tumours with different histological features which have been reviewed in detail in by Sipos et al. (Sipos and Ringel 2009; Sipos and Mazzaferri 2008). п‚· Papillary thyroid carcinoma (PTC) is the most common type and comprises about 80% of all thyroid cancers. It is more frequent in childhood and under 50 years of age. п‚· Follicular thyroid carcinoma (FTC) is a tumour of the thyroid follicular cell and is the second most common thyroid malignancy. It occurs usually in patients under 60 years of age. Page 279 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER п‚· Medullary thyroid carcinoma (MTC), a tumour of the thyroid C cell that secretes calcitonin. This is a rare type of thyroid cancer. It represents only 3% of thyroid malignancies. About 25% of medullary thyroid cancers are caused by an inherited aberrant gene. п‚· Anaplastic thyroid carcinoma (ATC) usually arises from well-differentiated thyroid cancer and represents 2% of thyroid malignancies. This is usually diagnosed in older people, and is more common in women. It is the most aggressive form of thyroid cancer. Trends in incidence rates Since the early 1970s, the incidence of thyroid cancer has more than doubled in most industrialised countries. In the USA, thyroid cancer was diagnosed in 4.9 per 100 000 in 1975, which gradually increased to 11.0 per 100 000 by 2006 (Sipos and Mazzaferri 2010). This represents almost a 2.3-fold increase in the incidence of thyroid cancer in all patients; a trend that has also been observed in many other industrialised countries across the world (Cramer et al. 2010; Rego-Iraeta et al. 2009). European countries reported increases in incidence between 5.3% (Switzerland) and 155.6% (France) (Kilfoy et al. 2009). The greatest worldwide increases occurred in Southern Australia, where there was a 177.8% increase in men and a 252.2% increase in women between 1973 and 2002 (Kilfoy et al. 2009). The increased incidence has in particular been observed in females, children and young adults (Olaleye et al. 2010). In fact, thyroid cancer has become the fastest rising type of cancer among women in North America within the last two decades (Holt 2010). However, overall, thyroid cancer is still not very common with an incidence rate in men of 2.9% and 7% in women in Europe (WHO 2008, http://globocan.iarc.fr/). A debate has taken place whether improved diagnostic histopathology could be the reason for the increase in thyroid cancer incidence. However, if this was the case, the increased incidence would most likely involve small asymptomatic neoplasms. However, the trend seems to be independent of the sizes of the lesions. Hence, there must be other reasons for the increase in clinically significant (>1 cm) well-differentiated thyroid carcinomas and factors such as environmental influences must be taken into account (Cramer et al. 2010). Mortality records in the SEER database from 1973 to 2001 show relatively stable or slightly improved mortality rates for thyroid cancer per 100 000 patients. However, over the same period, SEER mortality rates measured in terms of relative survival show an overall significant decline in mortality rates in women and an increase in mortality rates in men. 5.4.1.1 The development of thyroid cancer In thyroid carcinogenesis in rodents a strong influence of the thyroid stimulating hormone (TSH) has been established. Under healthy conditions, TSH is produced by the pituitary through hypothalamic stimulation and prompts the thyroid to produce thyroid hormone. Cells in the hypothalamus and pituitary respond to levels of circulating thyroid hormone. When levels of thyroid hormone are high, the output of TSH is low. When levels of thyroid hormone are low, the output of TSH is raised, prompting the thyroid to increase the output of thyroxin (T4) and triiodothyronine (T3). The negative feedback loop helps the body to respond to varying demands for thyroid hormone and to maintain Page 280 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER hormone homeostasis. However, persistent elevation of TSH levels stimulates the thyroid gland to deplete its existing stores of thyroid hormone. When the thyroid is not able to keep up with the demand, the follicular cells divide, leading to hyperplasia and nodular hyperplasia. These effects are reversible upon removal of the stimulus, at least early in the process. However, if the stimulus continues, the potential for thyroid cancer is increased upon treatment with mutagens in rodents (Capen and Sagartz 1998). Strikingly, some mouse models have suggested a carcinogenic role for TSH (Brewer et al. 2007). In contrast to rodents, genetic events appear to primarily influence thyroid carcinogenesis in humans. This is supported by the fact that the biggest risk factor for thyroid cancer is exposure to radiation. Since the Chernobyl accident in the former Soviet Union, there has been an increased incidence of papillary thyroid carcinoma in children in the fallout area, and the increased incidence rate has been estimated to be over 200 times that in children not exposed to radiation (Capen and Sagartz 1998). Additionally, a family history of thyroid cancer is another big risk factor, supporting the hypothesis that genetic events are the cause of thyroid cancer. Although there is increasing evidence that higher serum TSH concentrations are found in patients with thyroid cancer and serum TSH levels are higher in patients with more aggressive thyroid cancer, a causal role for TSH in the initiation of thyroid cancer has not been conclusively demonstrated. It has been speculated that serum TSH concentrations are higher as a consequence, rather than as the cause, of the presence of thyroid malignancy (Boelaert 2009). Oncogenes and the multi-step carcinogenesis hypothesis It is widely believed that thyroid cancer cells are derived from well-differentiated normal cells, such as thyrocytes, via multiple incidents of damage to their genome, especially in oncogenes or tumour suppressor genes. These oncogenes can drive clonal progression through accelerated proliferation or foster malignant phenotypes, such as the ability to invade the surrounding tissue or metastasise to distant organs. According to this hypothesis of multi-step carcinogenesis, papillary carcinomas are derived from normal thyrocytes by rearrangements of the RET gene or BRAF mutations. Follicular carcinomas are thought to be generated from thyrocytes via follicular adenomas by RAS mutations or the PAX8-PPARОі1 rearrangement. Poorly differentiated anaplastic carcinomas are generated from these two differentiated carcinomas by TP53 mutations. These and other mutated oncogenes and tumour suppressor genes can be found in thyroid cancers and their possible function in cancer progression has been extensively reviewed by Wynford (1993b; 1993a; 1997; 1999) and Giusti et al. (2010). RAS is the most frequently altered gene found in “spontaneous” thyroid tumours and RET in radiation-associated thyroid tumours. Perhaps the most intensely studied oncogene in thyroid cancer is the B raf proto-oncogene (BRAF). It has varying incidence but pooled analyses suggest that as many as 39% of tumours possess this mutation. However, the clinical significance of this mutation in terms of patient outcome has been controversial. The presence of a BRAF mutation is associated with extrathyroidal invasion, multicentricity, presence of nodal metastases, higher-stage disease, older age at initial presentation, and higher likelihood of recurrent or persistent disease. Conversely, other studies have not shown a significant relationship between the presence of a BRAF mutation and clinical outcome (Sipos and Mazzaferri 2010; Xing 2005). Page 281 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER “Fetal cell carcinogenesis” hypothesis The clinical and molecular findings in thyroid carcinoma, however, raise questions regarding the widely accepted classical model of thyroid carcinogenesis described above. Papillary carcinoma is the most common malignancy in the thyroid and micropapillary carcinomas, which are often observed in autopsies, show a distinct morphological difference from thyrocytes. Takano et al. (2005) have therefore questioned the multi-step carcinogenesis hypothesis and reason “It is hard to believe that these carcinoma cells obtain their cancerous characteristics via multi-step carcinogenesis, since thyrocytes rarely proliferate and papillary carcinoma cells are very slow to grow. They do not divide many times before they are recognized as carcinomas, and thus are not likely to have undergone dramatic changes. Moreover, there are no intermediate types of cells to link thyrocytes and papillary carcinoma cells.” Indeed, there is also no direct evidence to prove the succession of genomic changes from differentiated carcinomas to anaplastic carcinomas, which casts doubt on the hypothesis that these aggressive carcinomas are derived from thyrocytes by the accumulation of genetic changes to their genome. In 2000, Takano et al. proposed a novel hypothesis of thyroid carcinogenesis, the “fetal cell carcinogenesis” hypothesis, in which cancer cells are derived from the remnants of fetal thyroid cells instead of thyrocytes. This idea was supported by the findings of Reya et al. (2001) suggesting striking parallels between stem cells and cancer cells. Meanwhile, a considerable number of researchers have come to believe that cancer cells are derived from immature progenitor or stem cells, but not from well-differentiated cells. The fetal thyroid originates in the pharynx and gradually moves to the front of the neck as it grows slowly. The embryonic thyroid starts to produce thyroglobulin, and then forms follicles. This indicates that fetal thyroid cells have the ability to move through other cells, which is similar to the ability to induce invasion or metastasis. This, and the expression profiles of thyroid cancers, suggests that thyroid carcinomas are generated directly from the remnants of fetal thyroid cells, rather than from de-differentiation of proliferating thyrocytes (Takano and Amino 2005). The existence of stem cells in the thyroid has long been discussed, but identification in humans has not been successful, and there is a big knowledge gap concerning the very early stages of thyroid development. 5.4.2 Evidence for an Endocrine Mechanism in Thyroid Cancer Hypothalamic-pituitary-thyroid (HPT) axis The perturbation in thyroid and pituitary hormones levels is a crucial hallmark of thyroid cancer, but whether this is a cause or a consequence of carcinogenesis is presently not clear. As outlined above, there is no evidence for a direct oncogenic role of TSH in human thyroid carcinogenesis, but recent findings suggest that TSH may play a role in the progression of thyroid carcinomas. A number of studies have suggested that elevated serum levels of TSH are associated with a subsequent diagnosis of thyroid cancer (Boelaert et al. 2006; Jonklaas et al. 2008; Polyzos et al. 2008). Iodine deficiency Page 282 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER causes a reduction in the level of circulating thyroid hormones associated with a consequent rise in serum TSH concentrations, and chronic iodine deficiency is a well-established risk factor for the development of follicular thyroid carcinoma (Feldt-Rasmussen 2001; Nagataki and Nystrom 2002). Moreover, therapy with suppressive doses of thyroxine (T4) has long been known to positively affect outcomes in differentiated thyroid cancer (Mazzaferri and Jhiang 1994) and more recently, prospective studies have indicated reductions in thyroid carcinoma-related death and relapse with TSH suppression therapy (Hovens et al. 2007). Estrogens The incidence of thyroid malignancies is higher in women, and this suggests the possible involvement of estrogen (see 5.4.1). This is underlined by the observation that gender specific incidence ratios differ according to the period of life in which thyroid cancer occurs. In women of childbearing age thyroid cancer incidence is about 3 times higher than in men of similar age. This reduces to 1.5 fold higher incidences in prepubertal and menopause women. Epidemiological studies suggest that the use of estrogens may contribute to the pathogenesis of thyroid tumours (McTiernan et al. 1984). Immunohistochemical studies are however controversial regarding the presence of estrogen receptor (ER) alpha and ERbeta in thyroid cancers. While Kavanagh et al. (2010) have found both receptor types in thyroid tumours, others claim that ERalpha is not detectable in thyroid cancer samples and that ERbeta is the only ER detectable in thyroid tissue but its expression has no significant implications for differentiation between benign and malignant lesions of the thyroid (Vaiman et al. 2010). Nevertheless, there is evidence that the higher incidence of thyroid cancer in women is potentially attributed to the presence of a functional ER that participates in cellular processes contributing to enhanced mitogenic, migratory, and invasive properties of thyroid cells. In in vitro studies estradiol caused a 50-150% enhancement of the proliferation of thyroid cells (Rajoria et al. 2010). Another study demonstrated the presence of ER alpha and beta in thyroid cells derived from human goiter nodules and in a human thyroid carcinoma cell line HTC-TSHr. There was no difference between the expression levels of ER alpha in males and females, but there was a significant increase in expression levels in response to estradiol. Stimulation of benign and malignant thyroid cells with estradiol resulted in an increased proliferation rate and an enhanced expression of cyclin D1 protein, which plays a key role in the regulation of G(1)/S transition in the cell cycle (Manole et al. 2001). Furthermore, rapid effects of ER signalling, such as the activation of the phosphatidylinositol-3-OH kinase (PI3K) signalling cascade, are becoming increasingly recognised as a common feature of thyroid follicular neoplasms (Yeager et al. 2008). A rodent study (Banu et al. 2002) suggests that both TSH and estrogens, enhance thyrocyte proliferation. The mitogenic effect of TSH is greater than that of estrogens but the latter might modulate TSH-induced cell proliferation in a gender-specific manner. Estradiol and very low doses of the synthetic estrogen ОІ-estradiol 3-benzoate (EB) promoted thyroid carcinogenesis initiated by Nbis(2-hydroxypropyl)nitrosamine (DHPN). Similarly, EB enhances thyroid tumourigenesis while increasing ER expression in a two stage thyroid carcinogenesis model using N-methyl-N-nitrosourea (MNU) as an initiator in female ovariectomised rats under conditions of iodine deficiency. This Page 283 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER enhancement was suggested to be caused by the combined effects of stimulation of ER production by the thyroid and elevation of serum TSH (Takagi et al. 2002). 5.4.3 Evidence for a role of chemical exposures in thyroid cancer through an endocrine disruption mechanism There is abundant evidence that several key components of thyroid hormone homeostasis are susceptible to the action of endocrine disruptors (see 6.1.2.1). It is also known that excessive disturbance is likely to result in hypo- or hyper- thyroid clinical states. It is not clearly established whether chemicals that affect thyroid cell growth lead to human thyroid cancer, but as the aetiology of the sporadic forms of thyroid cancer remains speculative, there is the potential that EDCs play a role in the development of thyroid cancer and this might explain the increase in incidence over the last decades. Epidemiological studies investigating exposure to EDCs and the occurrence of thyroid cancer are scarce (see review of the most important epidemiological studies by Leux et al. (2010). This is partly due to the limited number of cases as thyroid cancer represents no more than 1% of all human malignant neoplasms. The following sections will summarise the most important findings of the few epidemiological studies that exist and also cite supporting studies of EDCs in animal models of thyroid cancer. 5.4.3.1 Solvents There are several studies exploring thyroid cancer risk in the Swedish population, associated with occupational exposure to certain chemicals. The study by Lope et al. (2005) suggests a rise in risk of thyroid cancer linked to occupational exposure to solvents in women, as excess risk is concentrated among employees of the footware industry. In men, a non-significant increased risk of thyroid cancer was observed with possible exposure to textile dust. An earlier Swedish case-control study regarding occupational exposure and female papillary thyroid cancer had already seen an increased risk for women who had worked as shoemakers. Those who worked as a dentist/dental assistant, teacher, or warehouse worker also were at the same risk. In addition, occupational contacts with undefined chemicals, x-rays, or video display terminals were indicated as risk factors (Wingren et al. 1995). Another Swedish case-control study conducted by Wingren et al. (1997) showed an increase in the risk of thyroid cancer in women working in a laboratory and in men working as painters or who declared being exposed to solvents. However, the results have to be interpreted carefully as only 31 cases were included. A study investigating the associations between occupational exposures and thyroid cancer in a cohort of 267,400 women employed in the textile industry in Shanghai in 1989 found an increased risk of thyroid cancer in women exposed for at least 10 years to benzene and formaldehyde (Wong et al. 2006). Page 284 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER 5.4.3.2 Pesticides In a study from the Swiss cancer registries on cancer cases recorded between 1980 and 1993, an excess risk of thyroid cancer was observed in agricultural workers who are particularly exposed to pesticides. However, according to the authors, this excess risk could stem from a deficit in iodine in the agricultural regions studied (Bouchardy et al. 2002). In the American prospective cohort on 90,000 pesticide applicators and their wives (Agricultural Health Study, AHS), the incidence of thyroid cancers was increased compared to the general population in the follow-up conducted up to 2001 (Blair et al. 2005). In a publication on the subgroup of pesticide applicators, a moderate nonsignificant increase in the risk for thyroid cancer in agricultural workers exposed to alachlor, an herbicide, was reported, but the authors underscored the lack of power resulting from the low number of cases (Lee et al. 2004). The U.S. Environmental Protection Agency (EPA) developed a science policy for the assessment of thyroid follicular cell tumours and concluded that rodent thyroid tumours were relevant to the assessment of carcinogenicity in humans in 1998. There are a number of pesticides that have been observed to induce thyroid follicular cell tumours in rodents, in accordance with the guidance in the EPA science policy on thyroid tumours. Of 240 pesticides screened, at least 24 (10%) produced thyroid follicular cell tumours in rodents. Interestingly, mutagenicity does not seem to be a major determinant in thyroid carcinogenicity of rodents, with the possible exception of acetochlor. Of the studied chemicals, only bromacil lacks antithyroid activity. Intrathyroidal and extrathyroidal sites of action were found for amitrole, ethylene thiourea, and mancozeb which are thyroid peroxidase inhibitors; and acetochlor, clofentezine, fenbuconazole, fipronil, pendimethalin, pentachloronitrobenzene, prodiamine, pyrimethanil, and thiazopyr which seemed to enhance the hepatic metabolism and excretion of thyroid hormone. Thus, 11 pesticides disrupted thyroidpituitary homeostasis; no chemical was mutagenic only as acetochlor may have both antithyroid and some mutagenic activity (Hurley 1998). 5.4.3.3 Organochlorines and dioxins In Canada, Fincham et al. (2000) studied the risk of thyroid cancer according to occupation in a study including 1272 cases and 2666 population controls. The results demonstrated an increase in the risk of thyroid cancer in people working in the pulp and papermaking industry and in wood processing. A slight increase in risk was also observed in the sale and service industry. Similarly, the increased risk of thyroid cancer in women in pulp and papermaking in Canada is consistent with a similar increase in Swedish women as well as in male woodcutters and construction carpenters in the same study (Lope et al. 2009). Workers in the wood industry are potentially exposed to chlorinated compounds such as dioxins and other chemical compounds but may equally have been exposed to solvents, wood preservatives, and pesticides. The early effects of 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin (TCDD) exposure in the population involved in the Seveso incident in 1976, have been examined in numerous studies. Surveillance programmes were designed in order to follow up the subjects exhibiting immediate, acute effects and to identify in the affected population at large the possible later occurrence of additional health effects in the short- to mid-term period. Cancer incidence findings for the 15-year period after the accident, 1977–1991, report a suggestive, almost significant increase for thyroid cancer (Pesatori et Page 285 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER al. 2003). Thyroid cancer risk was also found to be increased in a large occupational cohort of pesticide sprayers with possible exposure to dioxin (Saracci et al. 1991). The potential carcinogenic risk to humans of xenobiotic chlorinated compounds, particularly pesticides and related substances which may act as endocrine disruptors, has been covered in great detail by a number of IARC workshops. TCDD was tested for carcinogenicity by oral administration in three experiments in mice and in three experiments in rats. It was also tested by exposure of immature mice and by intraperitoneal or subcutaneous injection in one study in hamsters, and by skin application in mice. In three experiments in two strains of mice, administration of TCDD orally by gastric instillation increased the incidence of hepatocellular adenomas and carcinomas in both males and females. In one of these three experiments, TCDD increased the incidence of follicular-cell adenomas of the thyroid (IARC 1997). 5.4.3.4 PCBs Finally, exposure to industrial polyhalogenated pollutants, such as PCBs or polybromobiphenyls (PBBs), can occur in workers in agricultural machinery manufacture, computer and accessory manufacture, or in the electric installation sector; and increases in the incidence of thyroid cancer have also been described for workers in these sectors (Lope et al. 2005). 5.4.4 Endocrine disrupting properties of chemicals shown to be associated with thyroid cancer The current understanding of the aetiology of thyroid cancer does not clearly link it to disruption of an endocrine mechanism. However, chemicals disrupting the HPT axis and xenoestrogens seem to be of importance at least in the progression of the disease. Therefore, the precise mechanisms by which the chemicals demonstrated in epidemiological studies as being related to thyroid cancer remain to be resolved. There is plenty of evidence that EDCs interfere with thyroid homeostasis through numerous mechanisms of action (see section 6.1.2.1). Many substances exert a direct and/or indirect effect on the thyroid gland by disrupting certain steps in the biosynthesis, secretion, and peripheral metabolism of thyroid hormones (Boas et al. 2006). But it is not clearly established whether chemicals that affect thyroid cell growth lead to human thyroid cancer. Investigations that compare the susceptibility to disruptors associated with thyroid cancer between rodents and humans would be useful. A recent review by Mastorakos (2007) summarises substances that have been found to act as EDCs via the HPT axis in different species. Ten of the listed chemicals have been shown to cause an increased risk of thyroid neoplasms and tumours in rodents and the possible mechanisms are explained. 5.4.5 Evidence of developmental vulnerability in thyroid cancer There is no evidence that thyroid cancer originates from hormonal disruption during fetal development. However, as children are very vulnerable to radiation induced thyroid cancer, disruption of developmental mechanisms seems a plausible explanation (Jacob et al. 2006). Page 286 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER A few animal studies have examined the effects of fetal and neonatal dioxin or PCB exposure (Morse et al. 1993; Ness et al. 1993). While there were some effects of TCDD on thyroid hormone levels, an increased risk of thyroid cancer was not found. The rather new hypothesis of “fetal cell carcinogenesis” (see 5.4.1.1) gives rise to the possibility that disruption during fetal development could result in an altered number of stem cells or fetal thyroid cells in the adult thyroid which could increase the probability of development of thyroid carcinomas. However, there is no experimental evidence supporting this. 5.4.6 Do experimental tools exist for the study of thyroid cancer, and are assays applicable to, and adequate for, the assessment of chemicals? Several rodent two-step carcinogenesis models have been developed. The most common one is a first hit with DHPN or MNU as thyroid carcinogens and a second hit with sulfadimethoxine (SDM) or propylthiouracil (PTU) as a known thyroid tumour promoters (Kitahori et al. 1984; Son et al. 2000; Takagi et al. 2002). Several EDCs, such as bisphenol A, have been tested for tumour promoting protency in those models by substituting the second hit with the EDC in question. Most studies report that environmental estrogenic compounds do not exert any modifying effects on thyroid carcinogenesis (Son et al. 2000; Takagi et al. 2002). However, there is a possibility that the negative results were due to insufficient sensitivity of the model. Takagi et al. (2002) reports an improvement of the two-stage carcinogenesis model by using the test substance in combination with SDM. Using this rat model, the enhancing effects of EB on the development of thyroid proliferative lesions were discovered. There are also transgenic mouse models trying to explain the role of mutations in oncogenes and tumour suppressor genes in thyroid carcinogenesis. E.g. the involvement of BRAF in thyroid tumorigenesis has been elucidated in studies on transgenic mice with thyroid-specific expression of BRAF V600E (Knauf et al. 2005). In fact, these mice developed thyroid cancer with invasion of blood vessels, thyroid capsule, and perithyroid skeletal muscle. These rodent carcinogenesis models are useful, as little is known about the development of thyroid cancer in general. However, as outlined above, thyroid cancer development in humans seems to differ from that in rodents in that the latter are more sensitive to increased TSH levels. There are also differences in the normal physiological thyroid hormone processes between rats and humans. In rats, 40% of T3 is secreted directly from the thyroid, compared to 20% in humans and the structure of the deiodinase enzyme in rats is different from that of humans (Takser et al. 2005). In humans, circulating thyroid hormones are primarily bound to thyroxine-binding globulin (TBG), with smaller amounts bound to albumin and transthyretin. In developing rats, TBG is not present in the circulation between months two and seven and adult rat thyroid hormones are primarily bound to transthyretin, and, to a lesser extent, albumin. These proteins have a lower affinity for thyroid hormones than TBG resulting in a shorter half-live of thyroid hormones in adult rats (Lans et al. 1994). Page 287 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER 5.4.7 Conclusions INTACT criteria MET MULTI-LEVEL criteria NOT MET HORMONE criteria NOT MET PRIMARY EFFECT criteria MOSTLY MET Attribution criteria: criteria MET THYROID CANCER Although it is clear that genetic factors play a role in the development of thyroid cancer, a contribution of environmental chemicals is possible. There has been a sharp increase in the incidence of thyroid cancer which cannot be entirely explained by improved diagnostics. Several chemicals act as thyroid EXPOSURE “antihormones” through disruption of thyroid criteria MET SENSITIVE LIFESTAGE hormone bioavailability, but there is currently criteria no evidence that the exposure to these EDCs MOSTLY PHARM. RESTORATION MET plays a role in the development of thyroid criteria PARTLY cancer in humans. This is due to the shortage SUPPORTING DATA MET of studies rather than the lack of association. The few epidemiological studies available suffer from low case numbers and circumstantial evidence of exposure (for example through occupation). Another problem is the lack of a suitable animal model. The rodent thyroid hormone system differs in many ways from the human one and antithyroid activity seems to be a more common cause of thyroid cancer in rodents than in humans. However, it is now emerging that estrogens have a role to play in thyroid cancer, as more females suffer from the disease, and in vitro studies confirm that treatment with estradiol increases the proliferation of thyroid cancer cell lines. During the last ten years, research has seen: п‚· п‚· п‚· п‚· A proposed new mechanism of thyroid carcinogenesis The development of more rodent models for thyroid cancer The elucidation of differences between rodent and human thyroid processes A proposed involvement of estrogens in thyroid cancer progression Current research needs include: п‚· п‚· п‚· Elucidation of basic developmental mechanisms of the thyroid Mechanistic studies on the development of thyroid cancer Epidemiological studies to examine the association between thyroid cancer and exposure to environmental chemicals Page 288 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER 5.4.7.1 Can thyroid cancer be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: Criterion met? Evidence summary (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism Criteria MET The thyroid gland is an endocrine sensitive tissue (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology Criteria MET Malignant carcinoma, hyperproliferation (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest Criteria MET NOT Not tested (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity Criteria MET NOT Not tested (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations Criteria MOSTLY MET Animal models (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences Criteria MET Children and women of child bearing age are more affected (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism Criteria MOSTLY MET TSH suppression therapy, transgenic mice (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Criteria PARTLY MET Estrogen sensitivity oncogenes, Page 289 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER 5.4.8 References Banu SK, Govindarajulu P, Aruldhas MM. 2002. Testosterone and estradiol differentially regulate TSH-induced thyrocyte proliferation in immature and adult rats. Steroids 67:573-579. Blair A, Sandler D, Thomas K, Hoppin JA, Kamel F, Coble J, Lee WJ, Rusiecki J, Knott C, Dosemeci M, Lynch CF, Lubin J, Alavanja M. 2005. Disease and injury among participants in the Agricultural Health Study. J Agric Saf Health 11:141-150. Boas M, Feldt-Rasmussen U, Skakkebaek NE, Main KM. 2006. Environmental chemicals and thyroid function. Eur J Endocrinol 154:599-611. Boelaert K. 2009. The association between serum TSH concentration and thyroid cancer. Endocr Relat Cancer 16:1065-1072. Boelaert K, Horacek J, Holder RL, Watkinson JC, Sheppard MC, Franklyn JA. 2006. 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Targeted Expression of BRAFV600E in Thyroid Cells of Transgenic Mice Results in Papillary Thyroid Cancers that Undergo Dedifferentiation. Cancer Research 65:4238-4245. Lans MC, Spiertz C, Brouwer A, Koeman JH. 1994. Different competition of thyroxine binding to transthyretin and thyroxine-binding globulin by hydroxy-PCBs, PCDDs and PCDFs. Eur J Pharmacol 270:129-136. Lee WJ, Hoppin JA, Blair A, Lubin JH, Dosemeci M, Sandler DP, Alavanja MC. 2004. Cancer incidence among pesticide applicators exposed to alachlor in the Agricultural Health Study. Am J Epidemiol 159:373-380. Leux C, Guenel P. 2010. Risk factors of thyroid tumors: role of environmental and occupational exposures to chemical pollutants. Rev Epidemiol Sante Publique 58:359-367. Lope V, Perez-Gomez B, Aragones N, Lopez-Abente G, Gustavsson P, Plato N, Silva-Mato A, Pollan M. 2009. Occupational exposure to chemicals and risk of thyroid cancer in Sweden. Int Arch Occup Environ Health 82:267-274. Lope V, Pollan M, Gustavsson P, Plato N, Perez-Gomez B, Aragones N, Suarez B, Carrasco JM, Rodriguez S, Ramis R, Boldo E, Lopez-Abente G. 2005. Occupation and thyroid cancer risk in Sweden. J Occup Environ Med 47:948-957. Manole D, Schildknecht B, Gosnell B, Adams E, Derwahl M. 2001. Estrogen promotes growth of human thyroid tumor cells by different molecular mechanisms. J Clin Endocrinol Metab 86:1072-1077. Mastorakos G, Karoutsou EI, Mizamtsidi M, Creatsas G. 2007. The menace of endocrine disruptors on thyroid hormone physiology and their impact on intrauterine development. Endocrine 31:219-237. Mazzaferri EL, Jhiang SM. 1994. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med 97:418-428. McTiernan AM, Weiss NS, Daling JR. 1984. Incidence of thyroid cancer in women in relation to reproductive and hormonal factors. Am J Epidemiol 120:423-435. Morse DC, Groen D, Veerman M, van Amerongen CJ, Koeter HB, Smits van Prooije AE, Visser TJ, Koeman JH, Brouwer A. 1993. Interference of polychlorinated biphenyls in hepatic and brain thyroid hormone metabolism in fetal and neonatal rats. Toxicol Appl Pharmacol 122:27-33. Page 290 of 486 HUMAN HEALTH ENDPOINTS THYROID CANCER Nagataki S, Nystrom E. 2002. Epidemiology and primary prevention of thyroid cancer. Thyroid 12:889-896. Ness DK, Schantz SL, Moshtaghian J, Hansen LG. 1993. Effects of perinatal exposure to specific PCB congeners on thyroid hormone concentrations and thyroid histology in the rat. Toxicol Lett 68:311-323. Olaleye O, Ekrikpo U, Moorthy R, Lyne O, Wiseberg J, Black M, Mitchell D. 2010. Increasing incidence of differentiated thyroid cancer in South East England: 1987-2006. Eur Arch Otorhinolaryngol. Pesatori AC, Consonni D, Bachetti S, Zocchetti C, Bonzini M, Baccarelli A, Bertazzi PA. 2003. Short- and long-term morbidity and mortality in the population exposed to dioxin after the "Seveso accident". Ind Health 41:127-138. Polyzos SA, Kita M, Efstathiadou Z, Poulakos P, Slavakis A, Sofianou D, Flaris N, Leontsini M, Kourtis A, Avramidis A. 2008. Serum thyrotropin concentration as a biochemical predictor of thyroid malignancy in patients presenting with thyroid nodules. J Cancer Res Clin Oncol 134:953-960. Rajoria S, Suriano R, Shanmugam A, Wilson YL, Schantz SP, Geliebter J, Tiwari RK. 2010. Metastatic phenotype is regulated by estrogen in thyroid cells. Thyroid 20:33-41. Rego-Iraeta A, Perez-Mendez LF, Mantinan B, Garcia-Mayor RV. 2009. Time trends for thyroid cancer in northwestern Spain: true rise in the incidence of micro and larger forms of papillary thyroid carcinoma. Thyroid 19:333-340. Reya T, Morrison SJ, Clarke MF, Weissman IL. 2001. Stem cells, cancer, and cancer stem cells. Nature 414:105-111. Ron E, Lubin JH, Shore RE, Mabuchi K, Modan B, Pottern LM, Schneider AB, Tucker MA, Boice JD, Jr. 1995. Thyroid cancer after exposure to external radiation: a pooled analysis of seven studies. Radiat Res 141:259-277. Saracci R, Kogevinas M, Bertazzi PA, Bueno de Mesquita BH, Coggon D, Green LM, Kauppinen T, L'Abbe KA, Littorin M, Lynge E, . 1991. Cancer mortality in workers exposed to chlorophenoxy herbicides and chlorophenols. Lancet 338:1027-1032. Sipos JA, Mazzaferri EL. 2008. The therapeutic management of differentiated thyroid cancer. Expert Opin Pharmacother 9:2627-2637. ----- 2010. Thyroid cancer epidemiology and prognostic variables. Clin Oncol (R Coll Radiol ) 22:395-404. Sipos JA, Ringel MD. 2009. Do tumor characteristics predict risk of malignancy in thyroid nodules with indeterminate cytology? Nat Clin Pract Endocrinol Metab 5:140-141. Son HY, Nishikawa A, Ikeda T, Nakamura H, Miyauchi M, Imazawa T, Furukawa F, Hirose M. 2000. Lack of modifying effects of environmental estrogenic compounds on the development of thyroid proliferative lesions in male rats pretreated with N-bis(2hydroxypropyl)nitrosamine (DHPN). Jpn J Cancer Res 91:899-905. Takagi H, Mitsumori K, Onodera H, Nasu M, Tamura T, Yasuhara K, Takegawa K, Hirose M. 2002. Improvement of a two-stage carcinogenesis model to detect modifying effects of endocrine disrupting chemicals on thyroid carcinogenesis in rats. Cancer Lett 178:1-9. Takano T, Amino N. 2005. Fetal cell carcinogenesis: a new hypothesis for better understanding of thyroid carcinoma. Thyroid 15:432-438. Takser L, Mergler D, Baldwin M, de GS, Smargiassi A, Lafond J. 2005. Thyroid hormones in pregnancy in relation to environmental exposure to organochlorine compounds and mercury. Environ Health Perspect 113:1039-1045. Vaiman M, Olevson Y, Habler L, Kessler A, Zehavi S, Sandbank J. 2010. Diagnostic value of estrogen receptors in thyroid lesions. Med Sci Monit 16:BR203-BR207. Wingren G, Hallquist A, Degerman A, Hardell L. 1995. Occupation and female papillary cancer of the thyroid. J Occup Environ Med 37:294297. Wingren GB, Axelson O. 1997. Occupational and Environmental Determinants for Benign Thyroid Disease and Follicular Thyroid Cancer. Int J Occup Environ Health 3:89-94. Wong EY, Ray R, Gao DL, Wernli KJ, Li W, Fitzgibbons ED, Feng Z, Thomas DB, Checkoway H. 2006. Reproductive history, occupational exposures, and thyroid cancer risk among women textile workers in Shanghai, China. Int Arch Occup Environ Health 79:251-258. Wynford-Thomas D. 1993a. In vitro models of thyroid cancer. Cancer Surv 16:115-134. ----- 1993b. Molecular basis of epithelial tumorigenesis: the thyroid model. Crit Rev Oncog 4:1-23. ----- 1997. Origin and progression of thyroid epithelial tumours: cellular and molecular mechanisms. Horm Res 47:145-157. ----- 1999. Molecular basis of tumors arising in thyroid follicular cells. Ann Chir 53:237-243. Xing M. 2005. BRAF mutation in thyroid cancer. Endocr Relat Cancer 12:245-262. Yeager N, Brewer C, Cai KQ, Xu XX, Di CA. 2008. Mammalian target of rapamycin is the key effector of phosphatidylinositol-3-OH-initiated proliferative signals in the thyroid follicular epithelium. Cancer Res 68:444-449. Page 291 of 486 HUMAN HEALTH ENDPOINTS OTHER HORMONAL CANCERSTHYROID CANCER 5.5 OTHER HORMONAL CANCERS: OVARIAN AND ENDOMETRIAL CANCERS Endometrial and ovarian cancers have received comparatively little attention in the field of endocrine disrupter research, and accordingly, less information is available about associations with endocrine disrupting chemicals. 5.5.1 Endometrial cancer 5.5.1.1 Natural history In Western countries, endometrial cancer is one of the most common cancers afflicting the female reproductive tract. In many countries, incidence has been increasing steadily over the past years (Kellert et al. 2009, Lindeman et al. 2010, Evans et al. 2011). There are two types of endometrial cancer, an estrogen-dependent variety, and one not dependent on estrogen. The increases in incidence seem to be limited to the estrogen-dependent type (Evans et al. 2011). 5.5.1.2 Evidence for endocrine mechanisms The disease is most frequently diagnosed in post-menopausal women. As seen with breast cancer, elevated levels of endogenous sex hormones including total and free estradiol, estrone, and total and free testosterone are associated with increased risk (Allen et al. 2008). Not surprisingly, pharmaceutical estrogens used in combination with progestagen as hormone replacement therapy during menopause increase endometrial cancer risks (Jaakola et al. 2011). 5.5.1.3 Evidence for a role of chemical exposures through an endocrine mechanism Although the involvement of estrogenic agents in the disease process would suggest risks also from estrogenic environmental chemicals, only very few investigations of that topic have been conducted. One of the earlier studies looked at possible associations with DDT serum levels, but produced inconclusive results (Sturgeon et al. 1998). In contrast, Hardell and associates (2004) found weak, but significant associations with serum DDE levels. Bisphenol A levels in patients with endometrial hyperplasia did not differ from those in healthy controls, but were lower in women suffering from hyperplasia with malignant potential (Hiroi et al. 2004). Increased endometrial cancer risks could be linked to long-term cadmium intake (Akesson et al. 2008). 5.5.1.4 Do experimental tools exist for the study of endometrial cancer? For the evaluation of drugs in treating endometrial cancer, several experimental models are available (reviewed by Vollmer 2003): spontaneous endometrial tumorigenesis models in inbred animals (Donryu rats, DA/Han rats, BDII/Han rats), inoculation tumors from chunks of tumors (rat EnDA-tumor, human EnCa 101 tumor) or from inoculated tumor cell lines (rat RUCA-I cells, human Ishikawa and ECC-1 cells), developmental estrogenic exposure or chemical carcinogen exposure of Page 292 of 486 HUMAN HEALTH ENDPOINTS OTHER HORMONAL CANCERSTHYROID CANCER CD-1 and ICR mice, transgenic approaches such as mice heterozygous regarding the tumor suppressor gene PTEN (pten(+/-)-mice) and endometrial tumor cell lines cultured under conditions promoting in vivo-like morphology and functions e.g. cell culture on reconstituted basement membrane. Most aspects related to the functions of estrogenic can be studied in these models. However, these experimental models have not been used for the systematic investigation of endocrine disrupting chemicals and their role in endometrial cancer. 5.5.2 Ovarian cancer 5.5.2.1 Natural history Four histological types of ovarian cancer can be distinguished, with the clear cell and mucinous types found at very low frequencies. Endometriod ovarian cancers account for ca. 10% of all ovarian carcinomas, but the most frequent type is the serous, which arises from ovarian epithelial cells (summarised in King et al. 2011). As with breast and endometrial cancer, the incidence trends for ovarian cancer are also pointing upwards (reviewed by Salehi et al. 2008). There are similarities with the risk factors important in breast cancer: increased age at menopause contributes to risks, while pregnancies are protective. Hormone replacement therapy increases the risks of developing ovarian cancer (Anderson et al. 2003, Beral et al. 2007). 5.5.2.2 Evidence for endocrine mechanisms and for a role of chemical exposures The known role of estrogens in ovarian cancer indicates that endocrine disrupters might also unfavourably impact on risks, but very few studies of that issue have been conducted. An association with exposure to triazine pesticides such as atrazine has been reported (Young et al. 2005). 5.5.2.3 Do experimental tools exist for the study of ovarian cancer? Non-human primates, hens and rodents have been used as models for the study of ovarian cancers (King et al. 2011). In laboratory rodents, very few spontaneous ovarian tumour arise. When tumours occur in studies with rodents, their characterisation and the understanding of their origins poses significant difficulties. Ovarian cancers in rodents can be induced by chronic exposure to hormones and to other chemicals (Maronpot 1987), but endocrine disrupting chemicals have thus foar nto been tested. 5.5.3 Conclusions Despite good evidence for an involvement of hormones in endometrial and ovarian cancers, very little is known about the role of endocrine disrupting chemicals in the disease process. Page 293 of 486 HUMAN HEALTH ENDPOINTS OTHER HORMONAL CANCERSTHYROID CANCER 5.5.4 References Akesson A, Julin B, Wolk A. 2008. Log-term dietary cadmium intake and postmenopausal endometrial cancer incidence: A populationbased prospective cohort study. Cancer Res 8:6435-6441. Allen NE, Key TJ, Dossus L, Rinaldi S, Cust A, Lukanova A et al. 2008. Endogenous sex hormones and endometrial cancer risk in women in the European Prospective Investigation into Cancer and Nutrition (EPIC). Endocrine-related Cancer 15:485-497. Anderson GL, Judd HL, Kaunitz AM, Barad DH, Beresford SAA, Pettinger M, Liu J, McNeeley SG, Lopez AM. 2003. Effects of estrogen plus progestin on gynecologic cancers and associated diagnostic procedures. The Women’s Health Initiative Randomized Trial. J. Am. Med. Assoc. 290:1739–1748. Beral V, and Million Women Study Collaborators, Bull D, Green J, Reeves G. 2007. Ovarian cancer and hormone replacement therapy in the Million Women Study. Lancet 369:1703–1710. Evans T, Sany O, Pearmain P, Ganesan R, Blann A, Sundar S. 2011. Differential trends in the rising incidence of endometrial cancer by type: data from a UK population-based registry from 1994 to 2006. Br J Cancer 104:1505-1510. Hardell L, van Bavel B, Lindstrom G, Bjornforth H, Orgum P, Carlberg M, Sorensen CS, Graflund M. 2004. Adipose tissue concentrations of p,p’-DDE and the risk for endometrial cancer. Gynecologic Oncology 95:706-711. Hiroi H, Tsutsumi O, Takeuchi T, Momoeda M, Ikezuki Y et al. 2004. Differences in serum bisphenol A concentrations in premenopausal normal women and women with endometrial hyperplasia. Endocrine J 51: 595-600. Jaakkola S, Lyytinen HK, Dyba T, Ylikorkala O, Pukkala E. 2011. Endometrial cancer associated with various forms of postmenopausal hormone therapy: a case control study. Int J Cancer 128:1644-1651. Kellert IM, Botterweck AAM, Huveneers JAM, Dirx MJM. 2009. Trends in incidence of and mortality from uterine and ovarian cancer in Mid and South Limburg, The Netherlands, 1986-2003. Eur J Cancer Prevention 18:85-89. King, SM , Burdette, Joanna E. 2011. Evaluating the progenitor cells of ovarian cancer: analysis of current animal models. BMB REPORTS 44: 435-445 Lindemann K, Eskild A, Vatten LJ, Bray F. 2010. Endometrial cancer incidence trends in Norway during 1953-2007 and predictions for 20082027. Int J Cancer 127:2661-2668. Maronpot RR. 1987. Ovarian toxicity and carcinogenicity in eight recent NTP studies. Env Health Perspect 73:125-130. Salehi F, Dunfield L, Phillips KP, Krewski D, Vanderhyden BC. 2008. Risk factors for ovarian cancer: An overview with emphasis on hormonal factors. J Toxicol Env Health Part B Crit Rev 11:301-321. Sturgeon SR, Brock JW, Potischman N, Needham LL, Rothman N, Brinton LA, Hoover RN. 1998. Serum concentrations of organochlorine compounds and endometrial cancer risk. Cancer Causes Contr 9:417-424. Vollmer G. 2003. Endometrial cancer: experimental models useful for studies on molecular aspects of endometrial cancer and carcinogenesis. Endocrine Related Cancer 10: 23-42 Young HA, Mills PK, Riordan DG, Cress RD. 2005. Triazine herbicides and epithelial ovarian cancer risk in central California. J. Occup. Environ. Med. 47: 148–1156. Page 294 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6 HUMAN HEALTH ENDPOINTS – METABOLISM AND DEVELOPMENT 6.1 DEVELOPMENTAL NEUROTOXICITY This chapter examines the evidence for a role of endocrine disruption as one of the contributing factors to developmental neurotoxicity. Developmental neurotoxicity is a wide field covering complex human conditions and containing many difficulties for researchers, including the practical difficulties of studying the brain, the importance of the brain to human function and the sensitivities surrounding the associated human conditions. A number of these issues are also good reasons for why it is important to examine any possible link with endocrine disrupting chemicals, e.g. the fundamental importance of the brain to human function. The endocrine disruption mechanism with most support for a role in developmental neurotoxicity appears to be thyroid disruption, due to the crucial role of thyroid hormones in development. Consequently thyroid disruption is covered in detail throughout this chapter. Other mechanisms are also possible and should also be considered. 6.1.1 Natural history of developmental neurotoxicity Adverse effects on neurodevelopmental processes can impact on sensory, motor and cognitive functions and neurobehaviour; the associated functional defects include mild or severe mental retardation, cerebral palsy, psychoses, epilepsy, abnormal neurodevelopment, disrupted maturational milestones, cognitive defects and sensory dysfunction (Tilson 1998). The wide range of endpoints encompassed by developmental neurotoxicity e.g. (DiamantiKandarakis et al. 2009; Grandjean and Landrigan 2006; IPCS/WHO 2002; Wigle et al. 2008) includes: п‚· п‚· п‚· п‚· п‚· п‚· п‚· п‚· п‚· п‚· Cognition, learning and memory Neurodevelopmental disorders including autism, attention deficit disorder (ADD), mental retardation and cerebral palsy вЂ�neuropsychological deficits’: developmental milestones, cognitive function and problem behaviours Motor impairment, memory loss and subtle behavioural changes Movement disorders (hypotonia, hyporeflexia, motor development), generalised slowness and substantial IQ deficits Sensory deficits, including ototoxicity and defects of vision Aggression Altered play behaviour Structural defects such as neural tube defects Gender specific behaviour and perturbed sexual dimorphism An expert committee of the US NRC concluded that 3% of developmental disabilities are the direct result of environmental exposure to lead and other environmental pollutants; and that 25% of defects may be due to combined environmental and genetic factors (US NRC, 2002; reviewed in Page 295 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY (Grandjean and Landrigan 2006). A 2004 literature survey of 48 endocrine disrupting chemicals found that 50% had neurotoxic potential (Choi et al. 2004). Some authors have argued that the potential for toxic causes of mental or psychiatric illnesses have been overlooked clinically, and that there may be a role for endocrine disrupting and/or neurotoxic chemicals in the aetiology of conditions such as bipolar disease, depression, personality and obsessive-compulsive disorders and psychoses (Genuis 2008). These conditions which have a generally adult onset will not be covered in detail in this chapter where the focus will be on conditions with an earlier onset. 6.1.1.1 Incidence trends Although population based statistics are not generally available for neurodevelopmental outcomes, surveys indicate that, for example in the US, several hundred thousand children have disabling childhood mental health conditions including mental retardation, learning disabilities, autism and attention deficit hyperactivity disorder (ADHD) (Wigle et al. 2008). Learning difficulties may affect up to 10% of school children and up to 17% may be affected by conditions including deafness, blindness, epilepsy, speech deficits, cerebral palsy, emotional and behavioural problems and learning difficulties (Schettler 2001). The incidence of childhood psychological and behavioural disorders such as attention deficit disorder and autism spectrum disorders (ASD) has increased (Gore and Patisaul 2010). Around 1% of children (US) have an ASD diagnosis, and rates in boys are four times higher than in girls. The available trends in outcomes for which data are available are now briefly reviewed. Endocrine disruption is unlikely to be the only cause of such trends but may make an important contribution. AUTISM. Autism is a spectrum of disorders (Autism Spectrum Disorders, ASD) characterised by impaired social interaction and communication, with stereotyped and repetitive behaviours, and some level of intellectual impairment in around 75% of cases (Piven 2001). As well as autism, the spectrum includes Rett syndrome, childhood disintegrative disorder, Asperger disorder and pervasive developmental disorder. There is a clear role for genetics in ASD, for example shown by the high concordance rate of monozygotic twins, and by the prevalence of ASD among non-twin siblings, see (Rosenberg et al. 2009). However autism is thought to involve multiple genes, which are not yet identified and which complicates the quantification of the contribution, if any, of environmental factors such as chemical exposures. Some studies have found a dramatic recent increase in incidence of autism. A study of reported autistic spectrum disorders in Israel from 1972 to 2004 found that whilst very few cases were reported in the 1970s, incidence rate rose gradually through the 1980s to around 30 (cases per million capita under 18yrs of age) in 1995 (Senecky et al. 2009). There was an abrupt rise in 1997 to 125 per million and rates have remained high, reaching almost 200 per million in 2004. Other authors have suggested these rates may be underestimates (Gal and Gross 2009) and that rates worldwide approach 40 per 10,000 births, for example, as found in a UK study (Baird et al. 2006). A Californian study found that autism incidence rose from 6.2 (per 10,000 births, diagnosed by age 5) in 1990 to 42.5 in 2001; their analysis found that changes in diagnosis or inclusion criteria could not explain the overall increase although changes in the age of diagnosis explained 12% of the increase and the inclusion of milder cases explained 56% (Hertz-Picciotto and Delwiche 2009). A Danish study Page 296 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY concluded that at least part of the apparent increase in autism is attributable to decreases in the age of diagnosis (Parner et al. 2008). A recent comprehensive review of 43 studies published since 1966 concluded that the prevalence of autistic disorders has indeed increased, and is currently around 20/10,000 (Fombonne 2009). The review concluded that broadening of the concept, expansion of diagnostic criteria, development of services and improved awareness of ASD play a major role in explaining the increased incidence whilst other factors cannot be ruled out. ATTENTION DEFICIT DISORDER (ADD). ADD and attention deficit hyperactivity disorder (ADHD) are charaterised by problems with attention, impulsivity and hyperactivity. ADD and ADHD are conservatively estimated to affect 3-6 % of children, although estimates range up to 17% (Schettler 2001). Childhood ADHD is likely to persist into adulthood and may constitute a lifelong impairment (Kooij et al. 2010). The diagnostic criteria for disorders such as ADHD are variable, and changes in diagnostic practice are the probable reason for any apparent increase in incidence over time (Pallapies 2006). ADHD has recently been reviewed from an environmental health perspective, and the authors concluded that comparisons of the behavioural changes associated with ADHD and with exposure to environmental chemicals, such as lead and PCBs, may help to identify environmental risk factors for ADHD, or to reveal common mechanisms (Aguiar et al. 2010; Eubig et al. 2010). CEREBRAL PALSY. Cerebral palsy is a clinical description of conditions with an unknown aetiology. Cerebral palsy includes conditions that meet the following three criteria: (1) the condition is a disorder of movement or posture; (2) the condition results from a static abnormality in the brain; and (3) the condition is acquired early in life (Blair and Watson 2006). Known causes of cerebral palsy that are now routinely avoided include: consanguineous marriage, maternal iodine deficiency, methyl mercury ingestion, rhesus isoimmunisation, true cephalo-pelvic disproportion, cord prolapse and infant cerebral infections (Blair and Watson 2006). Cerebral palsy affects around 1-3 births per 1000 and is more common in preterm births; the improved survival of pre-term births was expected to result in a moderate increase in cases of cerebral palsy however a recent Icelandic study found that the incidence of cerebral palsy remained stable over a 14 year period from 1990 to 2003 (Sigurdardottir et al. 2009). This observation is supported by long-term trends spanning 1959 to 1998 in Australia, Sweden and the UK, which show a rate of 2 cases per 1000 live births that is generally stable over time (Blair and Watson 2006). NEURAL TUBE DEFECTS (NTDs). NTDs are malformations of the brain, skull and spinal column that arise in early prenatal development; in open defects failure of neural tube closure leaves the brain or spinal cord open dorsally, in herniation defects skeletal abnormalities allow the central nervous system to herniate through an opening in the skull or spinal column, finally, in closed defects disturbed development of the tail bud during secondary neurulation, produces abnormalities in both the spinal cord and spinal column at low levels of the body axis (Copp 2008). Severe NTDs include anencephaly, which is incompatible with survival after birth, and open spina bifida, which is an important cause of severe disability in children. Severe NTDs have a prevalence of 0.5-2 per 1000 births, and a higher frequency among spontaneously aborted fetuses. Mild NTDs include spina bifida occulta, incomplete formation of the neural arches of several vertebrae, which is usually asymptomatic and may be present in up to 10% Page 297 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY of people (Copp 2008). The prevalence of NTDs varies with geographical location and ethnic origin. The occurrence of NTDs may be substantially reduced by the use of folic acid supplements before and during pregnancy (the periconception period), and wider coverage of the population with this intervention might be achieved by fortification of common food items with folic acid (Blencowe et al. 2010). Before the introduction of folic acid supplementation and fortification, incidence rates of NTDs were considered to be stable, and have generally declined after introduction of the intervention, e.g. (Bower et al. 2009) and review in (Copp 2008). Risk factors for NTDs include genetic, chemical and physical factors. Chemical exposures considered to merit attention as risk factors for NTDs include organic solvents; agricultural chemicals, including pesticides; water nitrates; heavy metals such as mercury; ionising radiation; and water disinfection by products (Sever 1995). 6.1.2 Evidence for endocrine mechanisms in developmental neurotoxicity Neurodevelopment progresses in defined phases, including neurogenesis, migration, synaptogenesis, gliogenesis and myelination (Tilson 1998), and this ordered nature is vulnerable to disruption. The timelines of brain and thyroid development in human and rats have been usefully reviewed and compared (Howdeshell 2002). The period of development of the rat brain that parallels human brain development from conception to birth is considered to be from conception to postnatal day (PND) 20 (Howdeshell 2002). Both the nervous and endocrine systems are complex and thus have vulnerability to disruption. Chemical effects on the nervous system can be direct or indirect, although adult neurobehaviour is typically not directly altered by chemicals but by chemical-induced changes in morphology or function. Such changes may have a greater impact if they occur during neurodevelopment than in adulthood. Specific endocrine mechanisms of developmental neurotoxicity include 1) interference with neuroendocrine (hypothalamus-pituitary) function, which is key to reproductive and sexually dimorphic behaviour and 2) interference with circulating hormones, including thyroid hormones and estrogen and androgens, which all control neurodevelopment. The interactions between brain development and thyroid hormone have been exhaustively reviewed (Ahmed et al. 2008). The fetal mechanisms involved in neurodevelopmental disorders have been reviewed and include the endocrine disruption of cell programs, developmental trajectories, synaptic plasticity and maturation of oligodendrocytes (Connors et al. 2008). There is comorbidity between autism and other disorders of almost 40%, indicating that shared fetal mechanisms may contribute to clinical separate conditions. This is also supported by the overlap in behavioural characteristics, for example mood regulation is affected in autism, attention deficit hyperactivity disorder and bipolar disorder. 6.1.2.1 Thyroid disruption Thyroid hormone function is considered essential for normal brain development (Ahmed et al. 2008; Howdeshell 2002) and explanations for neurobehavioural dysfunction through endocrine dysfunction have focused on thyroid hormones because of their established role in development generally, and brain development specifically (IPCS/WHO 2002). Thyroid hormones have effects on neuronal proliferation, migration, synaptogenesis and myelination (Darras 2008; Howdeshell 2002). Thyroid hormone plays a crucial role in cerebellar development (Koibuchi 2008). Thyroid hormones Page 298 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY also play a role in the development of the retina and cochlea, with the potential for disruption of vision and hearing respectively if normal thyroid function is perturbed. Mechanistically, thyroid disruption could occur at the following targets, reviewed by (Patrick 2009). п‚· п‚· п‚· п‚· п‚· Iodide uptake, thyroxine (T4) and 3,5,3’ triiodo-L-thyronine (T3) synthesis, targets include: sodium-iodide symporter (NIS), thyroperoxidase (TPO), thyroid-stimulating hormone (TSH), deiodinases Transport proteins (TP), including transthyretin (TTR). Environmental chemicals have been observed to particularly compete with TTR, which is the main TP in rodents, but not with thyroid binding globulin (TBG), which is the main human TP. However TTR is the main TP in human brain and may be involved in T4 delivery across the blood-brain barrier and across the placenta (Patrick 2009). Cellular receptors, e.g. TSH receptor Thyroid hormone receptors Thyroid hormone target genes Although a range of thyroid hormone related molecules are commonly measured in humans, for example T3, T4 and TSH, permanent biomarkers of human thyroid disruption are required, and although the normal ranges for thyroid hormone metrics are wide, individual variations are known to be narrower suggesting that even small variations may have an impact on the individual (Boas et al. 2009). A list of around 150 synthetic chemicals that could influence thyroid hormone function, through many diverse sites of action, can be found as Table 1 of (Howdeshell 2002). Primary environmental chemicals considered as thyroid disruptors include PCBs, bisphenol A, perchlorate, dioxins and furans, pentachlorophenol, PBDEs and phytoestrogens (Patrick 2009). Phthalates, parabens and pesticides are also receiving increasing attention (Patrick 2009), as are triclosan, styrenes, and ultraviolet filter agents (Pearce and Braverman 2009). 6.1.2.1.1 Hypothyroidism The link between hypothyroidism and mental retardation is well-established and forms the basis for a successful clinical intervention. Hypothyroidism is a deficiency in thyroid hormone, and is classified as congenital or acquired according to onset, as primary or secondary according to the level of endocrine dysfunction, and as overt (clinical) or mild (subclinical) according to severity (Roberts and Ladenson 2004). Onset of hypothyroidism before or at birth results in growth failure and mental retardation, whilst later onset may lead to growth failure but does not appear to affect intelligence. Untreated congenital hypothyroidism results in a syndrome of cretinism, comprising mental retardation, deafness, short stature and characteristic facial deformities (Roberts and Ladenson 2004). Worldwide screening programs at birth are in place, and treatment with thyroxine (levothyroxine sodium) have reduced growth failure and essentially eliminated mental retardation associated with hypothyroidism (Gardner and Shoback 2007). The incidence of congenital hypothyroidism is reported to be increasing, for example studies in the United States reported an 73% increase in incidence from 1 per 4,100 live births in 1987 to 1 per 2,350 in 2002 (Hinton et al. 2010). Around 40% of this increase may be due to demographic Page 299 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY characteristics including race, ethnicity, sex, birth plurality, birth weight and maternal age (Hinton et al. 2010). A UK study of disease prevalence from 1991 to 2001 found considerable increases in the prevalence of hypothyroidism, by 85 and 48% in males and females respectively (Fleming et al. 2005). Chemical causes for hypothyroidism are not frequently examined, even though the condition is generally considered to be sporadic with only 2% of cases being identified as familial (Castanet et al. 2010). The causes typically considered, after dietary iodine deficiency, are mutations in genes involved in thyroid hormone biosynthesis, autoimmune factors and thyroid injury (Roberts and Ladenson 2004). Drugs that can cause acquired hypothyroidism include iodine (in pharmacological quantities), lithium (interferes with glandular hormone release), aminoglutethimide (inhibits thyroid hormone synthesis) and interferon О± (triggers thyroid autoimmunity). Toxic injury of the thyroid gland following polybrominated/chlorinated biphenyl exposure may result in hypothyroidism, and exposure to resorcinol, thalidomide and stavudine have all been associated with hypothyroidism. Perchlorate exposure through contaminated drinking water has not so far been associated with hypothyroidism in epidemiological studies (Roberts and Ladenson 2004). 6.1.2.2 Sex hormone disruption In addition to thyroid function, normal neurodevelopment also relies on estrogen and androgen signalling. Sex steroid receptors are expressed in the brain and could be targets for chemicals, for example DES has actions on the pituitary and hypothalamus, both of which contain an abundance of estrogen receptors (Gore and Patisaul 2010). The role of estrogens in the mechanisms underlying diseases of mental health have recently been reviewed (Watson et al. 2010). In addition to established effects on reproductive behaviours, such as sexual receptivity and maternal behaviour, estrogens can also modify behaviour through mechanisms that have been localised to specific brain areas. Examples include actions on the medial preoptic area which influences locomotion, actions on the amygdala with effects on anxiety and conditioned fear and actions on the cerebellum that have effects on development and tumour growth. The effects of estrogens may be mediated directly through estrogen receptors such as the ERО±, ERОІ or the membrane associated forms, or through downstream signalling, for example through peptide hormones, or through rapid signalling processes. 6.1.2.2.1 Neurosteroids and neural plasticity In 2002 the IPCS conclusions and recommendations on neurobehaviour stated that, at the time, there was no information on the effects of potential EDCs on neurosteroids. It also noted that effects on neural plasticity could impair the ability of adult organisms to adapt to environmental changes (IPCS/WHO 2002). Since 2002 the area has received some attention but does not appear to be a major topic of research in endocrine disruption. Kawato approached endocrine disrupters as disrupters of brain function from a neurosteroid viewpoint and reported that bisphenol A or diethylstilbestrol (DES) acutely modulate the local synthesis of estrogen in the embryonic and neonatal rat hippocampus and thereby modulate synaptic plasticity (Kawato 2004). Subsequent studies found a modulatory role for estrogens and potential EDCs (bisphenol A, DES and nonylphenol) on synaptic plasticity in the Page 300 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY hippocampus (Ogiue-Ikeda et al. 2008) and proposed a mechanism for the effects of bisphenol A involving an ER-mediated activation of the NMDA receptor (Xu et al. 2010). The development and function of the hippocampus may therefore be vulnerable to EDCs. Weiss reviewed the plausibility of the case for endocrine disruptors affecting plasticity in the aging brain, and concluded that EDCs could, through an impairment of neurogenesis, represent a hazard to the preservation of cognitive function during the later stages of the life cycle (Weiss 2007). 6.1.2.3 Neuroendocrine disruption Neuroendocrine disruption has been recently reviewed (Gore 2010; Gore and Patisaul 2010). Neuroendocrine disruption of hypothalamic-pituitary regulation can perturb body systems controlling a wide range of biological systems and outcomes, including thyroid function, reproduction, metabolism, obesity, pancreatic hormones, water/electrolyte balance, lactation and growth (Gore and Patisaul 2010). For a review of the consequence of neuroendocrine disruption on reproductive function, with a focus on estrogenic endocrine disrupters, see (Dickerson and Gore 2007). Neuroendocrine disruption could follow from developmental neurotoxicity, thus potentially linking neurotoxicity to perturbation of the function of all the endocrine axes. However neuroendocrine disruption is also caused by events other than developmental neurotoxicity; the neuroendocrine system is vulnerable to disruption because of its position at the junction of two complex systems: the nervous system and the endocrine system. The evidence that developmental exposure to arylhydrocarbon receptor (AhR) ligands, such as dioxin, adversely affects the sexual differentiation of neuroendocrine functions has been reviewed (Petersen et al. 2006). Such effects could occur through crosstalk of the AhR pathway with the estrogen, progestin, androgen, glucocorticoid and thyroid hormone receptor pathways. In rats, the organotin compound triphenyltin, has been shown to have sex-dependent effects on aromatase activity and to cause a greater disturbance in males than on females (Hobler et al. 2010). The importance of effects that show a sex difference to endocrine disruption generally, and in neurotoxicology, has been reviewed (Weiss 2010). 6.1.2.3.1 Brain sexual dimorphism The effects of phytoestrogens and PCBs on the sexual dimorphism of the brain have been reviewed (Dickerson and Gore 2007). Sex differences in reproductive physiology and behaviour arise from morphological and neurochemical differences in hypothalamic brain regions which become organised during a crucial developmental window (late embryonic and early postnatal period in rodents). Disruption of the normal development of sexual dimorphic brain areas could manifest as adult deficits in reproductive function and behaviour. Mechanisms for adverse effects include inappropriate activation of the hormonal and other receptors that are present, and also altered expression of estrogen, androgen, thyroid hormone, progesterone and aryl hydrocarbon receptors (Dickerson and Gore 2007). Animal studies have examined the effects of phytoestrogens, such as genistein, coumestrol and resveratrol, on adult brain regions that normally differ in volume between males and females, which includes the sexually dimorphic nucleus of the preoptic area (SDN-POA), the anteroventral Page 301 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY periventricular nucleus (AVPV) and the locus coeruleus. Although some studies have found demasculinisation of male and masculinisation of female rat brain areas, the literature contains discrepancies that may be due to the methodology used to assess brain morphology and to differences in the route and timing of exposures (Dickerson and Gore 2007). The mechanism through which exogenous estrogens may alter sexual dimorphic brain development is thought to be through an increase or decrease in hormonally-controlled apoptosis during brain development. A single study of female rats exposed to PCBs found no effect on the volume of the AVPV but did detect a decrease in the number of cells expressing the ERОІ receptor (Salama et al. 2003). Further studies using standardised measures and investigating other candidate chemicals will be necessary, and the significant differences between rodent and human brains must be considered when extrapolating from rodent studies. Some of the key differences have been reviewed (Wilson and Davies 2007). For example the driving force for brain differentiation is thought to be testosterone in humans but estrogen, enzymatically produced from testosterone, in rodents. 6.1.3 Evidence for a role of chemical exposures in developmental neurotoxicity through an endocrine disruption mechanism The complex nature of the nervous system and the diverse manifestations of neurotoxicity can make robust epidemiological studies difficult to perform, see review by (Bellinger 2009). Difficulties arise from the need for appropriate adjustment for complex, multi-faceted confounders, and the need to consider co-exposures, genetic or epigenetic factors, and social ecology – for example socioeconomic status. Studying developmental neurotoxicity is challenging because of endpoints with varying definitions and multiple causes, the lack of data on exposure and effect occurrence, the presence of confounders and effect modifiers, and the potentially long latencies between exposures and outcomes (Schettler 2001). A recent review of epidemiological studies of child health outcomes and environmental chemical contaminants (Wigle et al. 2008) examined the evidence linking developmental milestones, cognitive function, problem behaviour, motor function and sensory function to the following chemicals: п‚· Lead, methylmercury, cadmium, arsenic, manganese, PCBs, organophosphate insecticides, herbicides, tobacco smoke and solvents. DDT/DDE, HCB, The available evidence was classified as insufficient, limited or sufficient; sufficient evidence was only found to link: п‚· п‚· п‚· Lead, childhood exposure and deficit in cognitive function (age>3yr) Methylmercury, high-level prenatal exposure and deficits in developmental milestones, cognitive function (age 0-2yr and >3yr), motor function (age 0-2yr), auditory function and visual function; high-level childhood exposure and deficit in visual function PCBs, high-level prenatal exposure and deficits in cognitive function (age 0-2yr and >3yr) and motor function (age 0-2yr). Page 302 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY Epidemiological studies of these and other chemicals, and the evidence supporting an endocrine mechanism in developmental neurotoxicology is now reviewed in the rest of this section. It seems likely that an endocrine-related mechanism for developmental neurotoxicity will involve thyroid disruption, although other endocrine effects may also be causative or contributory. Environmental chemicals that have been linked with an adverse effect on thyroid function include PCBs, dioxins, flame retardants, pesticides, perfluorinated chemicals, phthalates, bisphenol A and uv filters (Boas et al. 2009). Choi et al. reviewed the effects of 48 endocrine disrupters, including pesticides, industrial chemicals and metals (Choi et al. 2004). They found that 81% caused developmental toxicity, 79% were carcinogenic (48% when using IARC criteria), 52% were immunotoxic and 50% were neurotoxic. Effects were attributed to actions on the function of estrogen (especially pesticides) and thyroid hormones (especially heavy metals). The scope of the problem may be substantial, Grandjean and Landrigan considered that only five chemicals have been shown to be toxic to human neurodevelopment (namely lead, methylmercury, arsenic, PCBs and toluene) but estimated that there is experimental evidence of neurotoxicity for around 1000 chemicals and suggested that around 200 chemicals are actually neurotoxic to humans (Grandjean and Landrigan 2006). The proportion of chemicals for which there is concern, and that both have an endocrine disruption mechanism and adversely affect human neurodevelopment requires quantification. A potential confounding factor affecting epidemiological studies of potential EDCs to which humans are exposed through seafood, for example PCBs and mercury, is the widely accepted benefit of seafood consumption on neonatal neurodevelopment, due to the high polyunsaturated fatty acid (PUFA) content of e.g. fish (Suzuki et al. 2010). 6.1.3.1 Epidemiological and mechanistic evidence The endocrine mechanism commonly linked to developmental neurotoxicity is thyroid disruption, and the effects of environmental chemicals on thyroid function have been well reviewed (Boas et al. 2006; Boas et al. 2009; Zoeller 2010). Thyroid function is vulnerable to disruption through multiple mechanisms, see (Boas et al. 2006; Patrick 2009) and the evidence for such mechanisms for particular groups of chemicals is reviewed in the following sections. Much of the evidence has been reviewed by Grandjean and Landrigan, and their review is summarised here and updated to reflect more recent publications (Grandjean and Landrigan 2006). 6.1.3.1.1 Organochlorine pollutants 6.1.3.1.1.1 PCBs Concern over the possible developmental neurotoxicity of PCBs followed two incidences of contamination of cooking oil in Taiwan and Japan, reviewed by (Grandjean and Landrigan 2006). In Taiwan, the contamination was associated with low birth weight, delay in developmental milestones, a lowering of IQ. Exposed boys, but not girls, showed deficits in spatial reasoning. Follow up showed slow development, lack of endurance, clumsy movement, and very low IQs. In Japan, the outcomes of a similar contamination event showed less prominence to neurological effects. In both cases the contamination was mixed, and included substances other than PCBs, making a specific association with PCBs difficult. Epidemiological studies in the USA have associated prenatal exposure to PCBs Page 303 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY and similar chemicals through the maternal diet with subclinical developmental deficits in the most highly exposed children and a 6 point drop in IQ between highest and lowest exposed groups. Cohort studies in the Netherlands and Germany found subclinical defects in neurological and developmental tests. These studies suggested that early deficits could be masked or modified by age, although they remained detectable at age 9, and that postnatal PCB exposure also contributes to neurological defects. Very recently, PCB exposure has been proposed to be a risk factor for ADHD (Eubig et al. 2010). A 2004 review concluded that there was no reliable evidence to link PCBs with either endocrine disruption or “intellectual deterioration in children exposed in utero”(Ross 2004). Ross provides a critical review of the studies available at that time, for example proposing that the symptoms associated with the poisoning cases in Taiwan and Japan should be attributed to furan exposure, rather than PCB exposure. However, the case for PCBs acting through endocrine disruption was examined without reference to effects on the thyroid. A second review of the epidemiology investigating exposure to PCBs, dioxins and furans, concluded that, at background levels, there was a consistent association of defective neurodevelopment of infants in the US and in Europe with background levels of PCBs and dioxins (Arisawa et al. 2005). The review found that associations with altered thyroid function, diabetes and endometriosis were uncertain due to inconsistent results from human studies (of the thyroid), a lack of longitudinal studies (for diabetes) and a lack of studies with sufficient statistical power (for endometriosis) (Arisawa et al. 2005). The mechanisms of developmental neurotoxicity due to PCBs could include interference with maternal thyroid function in a manner that affects neurodevelopment during pregnancy but does not affect adult function (Grandjean and Landrigan 2006). The link between PCBs, and developmental neurotoxicity through endocrine dysfunction involving sex hormones or thyroid hormone was also reviewed (Winneke et al. 2002). PCBs have negative effects on peripheral thyroid hormone levels in rats, mice and monkeys, and can suppress T4, T3 and TSH levels (Boas et al. 2009). Studies in humans and wild animals have also raised concern that PCBs may suppress thyroid hormones, and two studies involving pregnant women have associated environmental PCB levels with suppressed thyroid hormone levels and elevated TSH levels (Chevrier et al. 2008; Takser et al. 2005) although a third study did not confirm the association (Wilhelm et al. 2008). Studies of PCB levels and measures of thyroid hormone activity in newborns have been performed and support a suppression of T4 and an elevation of TSH levels, however results have varied perhaps due to the dynamic nature of thyroid hormone activity at this time, and due to the experimental limitations and differences, reviewed by (Boas et al. 2009). Potential mechanisms of developmental neurotoxicity are not limited to the thyroid and sex hormone systems but include effects of PCBs such as perturbed calcium signalling, for example through activation of ryanodine receptors (Pessah et al. 2010). Effects of PCBs on ryanodine receptors in the cerebellum have been proposed to underlie adverse effects on motor function; however cerebellar development is also vulnerable to an effect of PCBs on thyroid hormone (Roegge and Schantz 2006). Other effect mechanism of PCBs may include interference with the action of neurotransmitters, for example with dopamine transport, or induction of reactive oxygen species (ROS) production (Fonnum et al. 2006). Whether or not PCBs are considered to act as endocrine disrupters and thereby affect human neurodevelopment will depend on the identification of the Page 304 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY most plausible mechanism, given human exposure levels and chemical potencies, and a decision as to the relationship of that mechanism to endocrine function. 6.1.3.1.1.2 Dioxins; TCDD, PCDDs, PDCFs In rats a single dose of dioxin (TCDD) produces a dose-dependent suppression of T4 levels and an elevation of TSH levels, and when administered to pregnant dams, TCDD produced the same effect profile in male offspring (Boas et al. 2009). Human studies of veterans of the Vietnam war showed that those with the highest TCDD exposure had significantly higher TSH levels (Boas et al. 2009). 6.1.3.1.2 Brominated flame retardants (BFRs) BFRs include polybrominated diphenyl ethers (PBDEs), tetrabromobisphenol A (TBBPA) and other similar compounds. BFRs can exert effects on the thyroid, estrogen and androgen pathways in vivo in mammalian and non-mammalian models, and the evidence for this has been recently reviewed (Legler 2008). Legler drew special attention to the neurotoxicological effects of BFRs, which occur at relatively low doses, but concluded that an endocrine-related mechanism remains disputable (Legler 2008). Experimental studies have raised concern that PBDEs may be linked to thyroid disruption, and a recent epidemiological study linked PBDE levels in cord blood to subtle changes in the IQ levels and behaviour of children at 1-4 and 6 years of age (Herbstman et al. 2010). The role of PBDEs as potential autism risk factors has been reviewed (Messer 2010). It was considered that the hypothesis linking PBDEs to autism through thyroid disruption requires testing in animal models using chronic exposure paradigms and monitoring of the PBDE body burden as well as behavioural outcomes. The results from animal test could then be used to prioritise PBDEs for epidemiological studies, if warranted. PBDEs are able to bind TR, and show a preference for TRОІ (Diamanti-Kandarakis et al. 2009). Evidence that PBDEs showed developmental neurotoxicity in animals led Schreiber et al. to investigate whether thyroid hormone disruption might be responsible for such effects using an in vitro culture system comprising primary fetal human neural progenitor cells (hNPCs) grown as neurospheres (Schreiber et al. 2010). PBDEs (BDE47 and BDE99) were found to decrease migration and differentiation of hNPCs, and the effects were reversed by inclusion of a TR agonist triiodothyronine and unaffected by inclusion of a TR antagonist, NH-3. The effects of PBDEs on thyroid hormones have been reviewed (Boas et al. 2009). In rats, PBDEs suppress circulating thyroid hormone levels, when administered as single congeners or as commercial PBDE mixtures, and perinatal maternal exposure has been shown to suppress thyroid hormone levels pre- and post-natally in both the dams and offspring. Similar results have been observed in other species, including fish, kestrels and mink, and in rats and sheep receiving low doses of PBDEs (relative to environmental human exposure). Mechanistic studies suggest that PBDEs act by induction of enzymes involved in glucuronidation, downregulation of the transport protein transthyretin, or downregulation of thyroid hormone transport. Few human studies have been performed, although two studies of males consuming fish from the Great Lakes or the Baltic Sea have been reported. Firstly, a negative association between serum PBDE and TSH levels was reported in the Baltic (Hagmar et al. 2001). Secondly, a study from the Great Lakes reported that Page 305 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY serum PBDE levels were negatively associated with TSH and T3 levels and positively associated with T4 levels (Turyk et al. 2008). A recent study in pregnant women found that serum PBDE levels were inversely associated with TSH levels but not with T4 or FT4 levels and the authors suggested that this association could have implications for both maternal health and fetal development (Chevrier et al. 2010). Flame retardants other than PBDEs, for example halogenated bisphenols such as TBBPA and tetrachlorobisphenol A, have also been reported to be TR agonists. TBBPA may also interfere with thyroid hormone binding proteins, or antagonise the thyroid hormone receptors (Boas et al. 2009). Like PCBs, see above, BFRs might act through effect mechanisms unrelated to endocrine disruption, including interference with the action of neurotransmitters, e.g. dopamine transport, or induction of reactive oxygen species (ROS) production (Fonnum et al. 2006). 6.1.3.1.3 Perchlorate Perchlorate, reviewed in e.g. (Leung et al. 2010; Patrick 2009), occurs naturally in soils and is often found in groundwater due to natural occurrence and due to human use as a propellant in weapons, rockets and fireworks. It is one of the best researched thyroid disrupting chemicals (Patrick 2009). Perchlorate is not a known human neurotoxin, however it blocks iodine uptake by the thyroid (the primary site of toxicity). In pregnancy, inhibition of maternal thyroid function could potentially lead to abnormal brain development of the developing child. Perchlorate has been deemed an “emerging neurotoxic substance” (Grandjean and Landrigan 2006). One epidemiological study has used ecological correlation to link maternal exposure to perchlorate contaminated water (Colorado River, Arizona) to an elevation in TSH levels in babies at birth (Brechner et al. 2000). However a recent comprehensive review of the epidemiology of environmental perchlorate exposure and thyroid function stated that the Brechner study results were at variance with “virtually all other published results” and criticised the experimental design (Tarone et al. 2010). Tarone et al. conclude that “there is no credible or consistent evidence…” to link environmental exposure to perchlorate with any adverse effect on thyroid function, in the USA. They consider that this is most likely due to the generally low level of environmental perchlorate contamination (Tarone et al. 2010). This observation would not preclude perchlorate from contributing to an adverse effect if exposure levels were higher, for example in other geographical regions than the US, or were to rise, or if perchlorate were present in a mixture of similar compounds, see section 3.3. The endocrine mechanism proposed for perchlorate is an inhibition of iodine uptake with subsequent decreases in thyroid hormone production (Leung et al. 2010). This mechanism may require pharmacological doses of perchlorate that are not reached in environmental exposure, and further research is needed into the potential mechanisms, if any, that might operate at typical exposure levels. Human vulnerability to perchlorate might be increased by iodine deficiency, at crucial developmental stages such as foetal neurodevelopment, or during lactation; as reviewed by (Leung et al. 2010). Leung et al. concluded that further research is needed to clarify the potential health effects of low-level chronic environmental perchlorate exposure. Page 306 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6.1.3.1.4 Pesticides Acute neurotoxicity of pesticides in adults is well established, and often occurs through cholinesterase inhibition by organophosphates. Evidence of developmental neurotoxicity is indicated by the following observations, reviewed by (Grandjean and Landrigan 2006): п‚· п‚· п‚· п‚· Mexican children aged 4-5years with high exposure to a mixture of pesticides showed diminished short term memory, hand-eye coordination and drawing ability. Preschool children in USA from agricultural communities showed poorer motor speed and latency. Ecuadorean children whose mothers were exposed to organophosphates showed visuospatial deficits; current urinary pesticide levels were associated with delays in reaction times. Children in the USA who were acutely exposed to the organophosphate methyl parathion, showed persistent deficits in short-term memory and attention span. Maternal residence near agricultural areas where pesticides were applied has been associated with the incidence of ASD in children; organochlorine pesticides, specifically dicofol and endosulfan, showed the strongest association (Roberts et al. 2007). Recently, the Centre for the Health Assessment of Mothers and Children of Salinas (CHAMACOS) study in the US has reported that organophosphate pesticide exposure in utero and postnatally is adversely associated with attention levels in children (Marks et al. 2010). This study measured organochlorine exposure as urinary dialkyl phosphate (DAP) metabolites, which are not specific to a particular parent compound. Humans may be exposed to more than 600 pesticides, and this may make it difficult to attribute developmental neurotoxicity to a specific pesticide (Grandjean and Landrigan 2006). The pesticides that have received most attention regarding thyroid disruption are those that show persistence, for example dichlorodiphenyltrichloroethane (DDT) and hexachlorobenzene (HCB), and both animal and toxicological studies support the concern that multiple pesticides may perturb thyroid hormone function, see (Boas et al. 2009; Boas et al. 2006). An exhaustive review of the effects of pesticides on thyroid hormone parameters is not possible here due to the large number and diverse nature of the chemicals concerned. The reader is referred to Boas et al. for a brief review (Boas et al. 2006). 6.1.3.1.5 Bisphenol A Developmental exposure of rats to bisphenol A has been shown to produce an endocrine profile that resembles thyroid resistance syndrome (Diamanti-Kandarakis et al. 2009; Zoeller et al. 2005).In humans, thyroid resistance syndrome may be associated with ADHD, and bisphenol A-exposed rats also show ADHD-like symptoms (Diamanti-Kandarakis et al. 2009). In vitro, bisphenol A has been shown to bind to the TR, and to act as an antagonist of T3 with inhibitory effects on TR-mediated gene expression, reviewed in (Diamanti-Kandarakis et al. 2009). bisphenol A has also been shown to inhibit human recombinant thyroperoxidase, and to block T3 – induced metamorphism of tadpoles and differentiation of mouse oligodendrocytes (Boas et al. 2009). Page 307 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY Bisphenol A has been tested in a developmental neurotoxicity study (DNS, OECD TG426), and was found to be negative. The report concluded that “There was no evidence that bisphenol A is a developmental neurotoxicant in rats, and the NOAEL for developmental neurotoxicity was 2250 ppm, the highest dose tested (164 and 410 mg/kg/day during gestation and lactation, respectively).” (Stump et al. 2010). 6.1.3.1.6 Perfluorinated chemicals (PFCs) Perfluorinated chemicals include perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS). A recent study has linked serum levels of four PFCs in children aged 12-15 years to small increases in the odds ratio for ADHD (Hoffman et al. 2010). The authors suggest that cohort studies should be carried out to examine this association, especially given the prevalent exposure of humans to PFCs. PFCs such as PFOA and PFOS have been linked with adverse effects on thyroid function, such as decreases in T3 levels in dams and pups following short or long term exposure of animals, reviewed by (Boas et al. 2009). An epidemiological study of serum PFOA levels in fluorochemical production workers found no association between PFOA and TSH or T4 levels, but found a positive association with T3 and a negative association with free T4 (FT4) (Olsen and Zobel 2007). In the general adult population (US NHANES), higher serum levels of PFOA or PFOS has been associated with the occurrence of thyroid disease, although the association with PFOS was only significant in men not women (Melzer et al. 2010). 6.1.3.1.7 Phthalates A study of prenatal phthalate exposure and behaviour and executive functioning up to nine years of age found that levels of low molecular weight phthalates were associated with poor test performance on parameters that are commonly affected in children clinically diagnosed with conduct or attention deficit hyperactivity disorders (Engel et al. 2010). A cross-sectional study found an inverse relationship between phthalate metabolite levels in urine and IQ scores in children aged nine years (Cho et al. 2010). Studies in rats have found adverse effects of dibutylphthalate (DBP) on T3 and T4 levels, and phthalate administration has been associated with histopathological changes in the thyroid, see (Boas et al. 2009). DBP has also been shown to compete with T3 in a reporter gene screening assay (Hofmann et al. 2009). Epidemiological studies have reported negative associations between di(2-ethyhexyl) phthalate (DEHP) exposure and FT4 and T3 levels in men attending a fertility clinic, and between DBP exposure and FT4 and T4 levels in pregnant women. Other studies have failed to find effects, possibly due to a lack of statistical power (Boas et al. 2009). In children aged 4-8 years, phthalate exposure was negatively associated with serum levels of thyroid hormone, however the study did not examine health outcomes or mechanisms (Boas et al. 2010). Page 308 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6.1.3.1.8 UV filter agents Ultraviolet filter agents, including 4-methylbenzylidene-camphor (4MBC), octylmethoxycinnamate (OMC), benzophenone-2 (BP2) and benzophenone 3 (BP3), have been suspected of having thyroid disrupting properties (Boas et al. 2009). For example, 4MBC reduces T4 and increases TSH levels in rats, whilst OMC reduces T4 and T3 but decreases TSH levels. UV filters may also reduce hepatic deiodinase activity (OMC) and inhibit human recombinant thyroperoxidase (BP2). 6.1.3.1.9 Metals A recent review of the effect of metals as endocrine disruptors concluded that heavy metals, including cadmium, mercury, arsenic, lead, manganese and zinc are able to affect the endocrine system and produce alterations in physiological functions (Iavicoli et al. 2009). However a need for greater understanding of the mechanism of action of metals as EDCs was identified. A study of 48 potential EDCs found that heavy metals were found to have effects on thyroid hormone (Choi et al. 2004). The evidence linking three heavy metals, lead, mercury and arsenic, to developmental neurotoxicity is now considered. 6.1.3.1.9.1 Lead (Pb) Early-life lead exposure decreases learning, attention and IQ, and contributes to hyperactivity, impulsiveness and aggression (Schettler 2001). Preschool lead exposure has been associated, using ecological correlation, with complex outcomes as varied as poor school achievement (Nevin 2009), unwed pregnancy (Nevin 2000) and violent crime (Carpenter and Nevin 2010; Nevin 2007). The neurotoxicity of lead has been reviewed (Grandjean and Landrigan 2006). Lead was known to be neurotoxic in Roman times, but the first report in modern times was from Australia around 100 yrs ago describing an epidemic of lead poisoning through paint; similar reports followed from the USA and Europe. Initially lead poisoning was considered an acute illness with fatality the major risk. Longterm consequences were first reported in the 1940s when 19 out of 20 survivors of acute lead poisoning were found to have severe learning and behavioural problems. Lead continued to be used in paints, ceramic glazes and other products throughout much of the twentieth century. In the 1970s widespread subclinical neurobehavioural deficits (including deficits in concentration, memory, cognition and behaviour) were documented in children with raised blood lead concentrations but no acute symptoms of lead poisoning. Recommendations by the WHO resulted in studies in many countries, which confirmed the risks. A consensus on the risks of lead led to the control of many sources of lead exposure; for example the removal of lead additives from petrol was followed by a 90% drop in childhood blood lead concentrations (Grandjean and Landrigan 2006). The reduction in lead levels achieved since 1979, from 15ug/dL to 1.5ug/dL (2008), has been estimated to equate to a 7 point change in IQ, and it has been calculated that, if 1979 levels returned, the number of children diagnosed with mental retardation would be double, and the number defined as �gifted’ would be more than halved (M. Christopher Newland in (Weiss et al. 2008)). Very recently, lead exposure has been proposed to be a risk factor for ADHD (Eubig et al. 2010). Reports that the shape of the lead dose-response curve shows “surprisingly large functional deficits” at low levels has resulted in interest in quantifying the risk associated with low exposure levels (Grandjean and Landrigan 2006). An international pooled analysis of low level environmental lead Page 309 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY exposure and intellectual function in children found an inverse relationship whereby an increased blood lead concentration from 2.4 to 30ug/dL was linked to a decrease in IQ by almost 7 points (Lanphear et al. 2005).The blood lead level defined as “undue lead exposure” was progressively reduced from 60ug/dL in 1970, a level that was often associated with overt signs of lead toxicity, to 10ug/dL in 1995 (WHO). This 1995 level was motivated by evidence that blood concentrations as low as 10ug/dL were associated with adverse effects on children, including lower intelligence (Lanphear et al. 2005). The results of Lanphear et al. led them to conclude that there may be no threshold for adverse effects of lead on neurotoxic effects in children. A review of the history and discovery of low level lead effects concluded that the successful reduction in lead exposure is a public health triumph, but cautions that, whilst lead is perhaps the most thoroughly studied neurotoxicant, other agents may be found to be similarly toxic if afforded the same scrutiny; the most important candidates for this scrutiny were identified as mercury, pyrethroids and phthalates (Needleman 2009). The position of endocrine disruption in the effects of lead and the question of whether the toxic effects of lead are also properties of other endocrine disruptors are important questions. The association of lead with developmental neurotoxicology through an endocrine disruption mechanism is most likely to be made through thyroid disruption and several studies have examined the effect of human lead exposure on levels of T3, T4 and TSH, which are indicators of thyroid function. A study of occupational lead exposure found no effect on T3 or T4 levels but identified a significantly higher TSH levels, which the authors attributed to enhanced pituitary release of TSH (Singh et al. 2000). A study of human cerebrospinal fluid (CSF) levels of lead, transthyretin (TTR) and thyroxine (T4), found an inverse correlation between CSF lead and CSF TTR levels (Zheng et al. 2001), which may point to an effect of lead on the choroid plexus, which constitutes the blood-CSF barrier and is the site of TTR synthesis. Such a link was also proposed from rat studies, where it was found that the choroid plexus avidly sequesters lead, and the authors postulated that lead may depress the production of TTR by the choroid plexus, resulting in deprivation of the brain of thyroid hormones and impairment of brain development in young animals (Zheng et al. 1996). Although this mechanism culminates in an adverse effect on the endocrine system, consideration must be given to whether this constitutes a primary mechanism of endocrine disruption. A study of adolescents exposed to low-level lead through their occupation as auto repairers found lead levels of 7ug/dL, compared to 2ug/dL in controls, and identified an associated reduction in T4 levels without any effect on T3 or TSH levels (Dundar et al. 2006). Lastly, a Canadian study of lead levels in human consumers of fresh water fish found a negative association between lead and TSH levels in females only, and found no effect on T3 or T4 levels in males or females (Abdelouahab et al. 2008). Lead has been studied as an endocrine disruptor in the fruit fly, Drosophila melanogaster (Hirsch et al. 2010). In Drosophila, developmental exposure to lead has been associated with effects on adult locomotion due to changes in gene expression and with effects on synaptic function due to perturbation of intracellular calcium regulation, mechanisms that are endocrine and non-endocrine respectively. The authors suggest that the use of Drosophila as a new model system could allow the effects of lead on behaviour to be attributed to neural mechanisms or to endocrine disruption. 6.1.3.1.9.2 Mercury (Hg), methylmercury (MeHg) The developmental neurotoxicity of methylmercury (MeHg) has been reviewed (Grandjean and Landrigan 2006). MeHg is now considered to show fetal neurotoxicity, and to do so at low exposure Page 310 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY levels. However a recent review of the association between mercury and autism found no causal association between autism and mercury exposure from use of the preservative thimerosal in vaccines, and an ambiguous association with mercury exposure from use in dental amalgams and from environmental release (Schultz 2010). Other potential clinical manifestations of neurotoxicity need to be examined. The toxic effects of MeHg were first established in studies of occupational exposure, and then in two studies of contaminated food in Minamata, Japan and in Iraq, In Minamata, an epidemic of spasticity, blindness and profound mental retardation was observed in infants whose mothers had consumed fish contaminated with MeHg from a plastics plant. Adults were less, or not, affected. In Iraq profound neurodevelopmental disorders similar to those seen in Minamata were observed in Infants whose mothers had consumed grain that had been treated with methylmercury fungicides. The Iraq studies established a crude dose-response relationship between MeHg levels in maternal hair and the risk of neurological abnormality in offspring. More recently, populations with high seafood and freshwater fish consumption have been studied prospectively to evaluate prenatal exposure to MeHg at levels lower than those in Minamata or Iraq. In New Zealand, a 3 point decrement in IQ and changes in affect were observed in children whose mothers had hair levels of MeHg in excess of 6ug/g. In the Faroe Islands, a dose-related impairment in memory, attention, language and visuospatial perception was attributed to MeHg. A study in the Seychelles found that the association between MeHg and neurotoxicity was not observed if postnatal exposure was adjusted for. A review of the endocrine effects of mercury in humans and wildlife identified five main mechanisms (not limited to neurodevelopmental effects): 1) accumulation in the endocrine system; 2) specific cytotoxicity in endocrine tissues; 3) changes in hormone concentrations; 4) interactions with sex hormones; and 5) changes in activity of steroidogenic enzymes (Tan et al. 2009). Mercury may alter reproductive hormone levels and adversely affect spermatogenesis, however it has also been shown, in occupational exposure, to affect thyroid function in the following ways: by increasing T4 levels, increasing the T4/T3 ratio and by decreasing T3 levels (Iavicoli et al. 2009). The mechanism for these effects may be a negative effect on the conversion of T4 to T3 by deiodinase. Mercury has also been reported to increase serum TSH levels (Iavicoli et al. 2009). 6.1.3.1.9.3 Arsenic Industrial pollution with arsenic is widespread and arsenic is present in ground water worldwide. In adults, drinking water contaminated with arsenic has been associated with a peripheral neuropathy. In cross-sectional studies of school-age children, cognitive deficits have been associated with arsenic in drinking water and with urinary arsenic levels. A study of adolescents born during a poisoning episode when powdered milk contaminated with arsenic (Japan, 1955) found a 10-fold increase in the number of mentally retarded individuals. Poor school records, emotional disturbance, and abnormal or borderline ECGs were also more common in exposed individuals. The control group for the study comprised infants who were breast-fed during the poisoning episode or did not consume the contaminated formula. Finally, children living near a hazardous waste site were found to have raised hair levels of arsenic and, when manganese exposure was also included, a possible adverse effect on IQ was reported (Grandjean and Landrigan 2006). Page 311 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY The mechanisms through which arsenic may interact with the endocrine system include disruption of estrogen, androgen, progesterone, glucocorticoid, and mineralocorticoid receptor function, including positive and negative effects on receptor activation, effects on the genomic activity of the receptors, and effects on receptor expression (Iavicoli et al. 2009). 6.1.3.2 Animal studies A 2005 special edition of Brain Research Bulletin was dedicated to the issue of neurobiological effects of environmental estrogens (Panzica et al. 2005). A range of chemicals, effects and species were included. Bisphenol A was reported to alter the distribution of somatostatin receptors in the diencephalic regions of the teleost fish Coris julis (Alo' et al. 2005); to affect the socio-sexual behaviour of juvenile female rats at low doses (Porrini et al. 2005); to affect maternal behaviour of rats during pregnancy and lactation (Seta et al. 2005) and to interfere with pair-bonding and exploration in female Mongolian gerbils (Razzoli et al. 2005). In mice, prenatal treatment with either methoxychlor or bisphenol A prevented the development of place preference in adulthood in females, but not in males (Laviola et al. 2005). The pesticide methoxychlor was also reported to affect neuroendocrine and behavioural outcomes in Japanese quail, and the effects were transgenerational (Ottinger et al. 2005). Also in quail, the synthetic estrogen DES, was shown to disrupt the sexual dimorphism of the vasotocin system and suppress copulatory beahviour in males (Viglietti-Panzica et al. 2005). The insecticide DDT was shown to activate estrogen receptors in the brains of mice pups exposed through dosing of lactating mothers (Mussi et al. 2005). Finally, phytoestrogens were reported to alter the sizes of sexually dimorphic regions of the rat brain (Lephart et al. 2005) and to influence the neuroendocrine control of core body temperature (Bu and Lephart 2005). Recent publications include a report that perinatal exposure to PCBs alters social behaviour in rats, an endpoint that might relate to human social behaviour, social learning and play behaviour (JolousJamshidi et al. 2010). 6.1.4 Evidence of developmental vulnerability in developmental neurotoxicity By definition, developmental neurotoxicity as a toxic endpoint is intimately linked to development, and the developmental vulnerability has therefore been referred to throughout the preceding sections of this chapter. Here, the scientific basis for the concern that the developing nervous system is more vulnerable than the adult system is briefly presented. It is widely accepted that proper thyroid function is crucial in neurodevelopment e.g. (Darras 2008; Howdeshell 2002), hence thyroid disruption is likely to impair development. Thyroid hormones are critical for neurodevelopment in both foetal and post-natal development (Williams 2008). Developing organisms may be particularly sensitive to disruption due to toxicokinetic/toxicodynamic factors, for example the developing nervous system is more vulnerable that the adult due to differences in metabolic enzymes and rates of excretion; the lack of an intact blood-brain barrier and differential binding affinity to target proteins (Tilson 1998). Neurotoxins that have significant effects when encountered during development may have less, or no, effect on the adult nervous system. Compounds that are neurotoxic in adults are also likely to be toxic to neurodevelopment, except in Page 312 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY the few cases where adult metabolism is required to evoke neurotoxicity and thus the immature system would be protected (Grandjean and Landrigan 2006). Developmental impairment could be silent until late adulthood, when they are unmasked and could lead to diseases such as Parkinson’s Disease (Grandjean and Landrigan 2006). A recent review of the environmental contributions to autism risk highlighted early pregnancy as a vulnerable period, concluding that “the most powerful proof-of-concept evidence derives from studies specifically linking autism to exposures in early pregnancy - thalidomide, misoprostol, and valproic acid; maternal rubella infection; and the organophosphate insecticide, chlorpyrifos” (Landrigan 2010). Whilst most of these studies might not be considered endocrine disruption, they highlight the potential for developmental vulnerability to chemical exposures. An important issue is the attribution of neurotoxicity to an endocrine effect. Since neurodevelopment is more vulnerable to adverse events than the adult system, and is also highly dependent on normal endocrine function, a chemical that shows effects on neurodevelopment at much lower levels than neurotoxicity is seen at, should merit attention for a potential endocrine mechanism. Indications of the potential for fetal effects come from animal studies of chlorpyrifos and terbutaline. Chlorpyrifos is an organophosphate pesticide that has subtle and widespread effects on the developing brain. Fetal effects are seen at doses below those at which neurotoxic effects on adults are seen and in the absence of detectable cholinesterase inhibition, which is the neurotoxic mechanism in adults. The fetal effects of chlorpyrifos are through to be due to actions on cell surface receptors and cell signalling pathways to disrupt the ability of neurotrophic factors and neurotransmitters to control differentiation of neuronal cells (T Slotkin, in (Connors et al. 2008)). Terbutaline is a selective agonist of the beta 2 adrenergic receptor, a receptor that is responsible for controlling development of various tissues, for effecting terminal differentiation and for cell regulation. In animal studies, over-stimulation of adrenergic receptors with terbutaline resulted in morphological abnormalities in the brain that were considered analogous to those seen in autism (Connors et al. 2008). Terbutaline-treated rats also showed behavioural abnormalities, including increased activity. Human exposure to terbutaline in pregnancy has been associated with a raised risk of autism (Connors et al. 2005) that may be associated with adrenergic receptor polymorphisms that predispose to overstimulation of the receptor (Liggett 2002). 6.1.5 Do experimental tools exist for the study of developmental neurotoxicity, and are assays applicable to, and adequate for, the assessment of chemicals? Experimental studies of developmental neurodevelopment can be challenging because human neurodevelopment is complex, cannot be recapitulated in vitro, is hard to extrapolate from animals to humans, and can be ethically complex to study in vivo in animals and especially in humans. Assays need to be complex enough that potential endocrine mechanisms are present, but not so complex as to try to fully recapitulate human disorders. Assays could usefully focus on potential mechanisms with biological plausibility for adverse effects. This will not be achieved by dependence on one or two assays, but will require a set of complementary, overlapping assays. Page 313 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY General issues Animal or human toxicity tests are usually aimed at identifying specific traits rather than syndromes; thus tests for deficits in attention or impaired impulse control are more realistic than a test for a diagnostic category such as ADHD (Schettler 2001). Comparison of animal and human data for lead, mercury and PCBs suggest that animal tests underestimate human risk of developmental neurotoxicity by 2-4 orders of magnitude and, as a result, regulatory levels have tended to be continuously revised downwards as more human data become available (Schettler 2001). The challenges of risk assessment in neurotoxicology have been reviewed (Weiss et al. 2008), and the need for assays that reflect the complexity involved, and that are applicable to the typically low doses that may be relevant, was highlighted. The need for experimental approaches is clear. Most chemicals have received no or minimal toxicity testing. Even those identified as neurotoxic in adults have mostly not been tested for developmental effects. Some authors have proposed that subclinical neurotoxicity could underlie a “silent pandemic of neurodevelopmental disorders” due to industrial chemicals, and that “these chemicals might have caused impaired brain development in millions of children worldwide, the profound effects of such a pandemic are not apparent from available health statistics” (Grandjean and Landrigan 2006). 6.1.5.1 Relevant OECD test guidelines There are four adopted OECD test guidelines (TGs) for in vivo assays relating to neurotoxicity, see Table 25. One of the assays, TG426, specifies a developmental neurotoxicity (DNT) study employing daily dosing of pregnant rats with assessment of the offspring for neurologic and behavioural abnormalities (OECD 2007). The history and performance of DNT testing was reviewed as part of the finalisation and implementation of TG426 (Makris et al. 2009). A series of reports from an expert working group on neurodevelopmental endpoints (ILSI Research Foundation/Risk Science Institute) reviewed the following aspect of guideline developmental neurotoxicity studies: identification and interpretation of effects (Tyl et al. 2008); statistical issues and appropriate techniques (Holson et al. 2008); determination of normal variability (Raffaele et al. 2008) and the importance of positive control studies (Crofton et al. 2008). Critical comments regarding the DNT study include claims that it is either insensitive or oversensitive. There are calls to add certain endpoints (such as social behaviour) and to remove others (to reduce the complexity of the study), and calls to integrate the study with other testing procedures rather than performing it stand-alone; reviewed in (Makris et al. 2009). A cohort to assess “the potential impact of chemical exposure on the developing nervous system” is included within the recently adopted Extended One-Generation Reproductive Toxicity Study (TG 443), and the experimental procedures (auditory startle, functional observational battery, motor activity, and neuropathology assessments) follow the requirements of TG424 and 426 (seeTable 25). Makris et al. included a list of 103 chemicals or stressors that had been tested in a DNT, but note that the cost, time-consuming nature and high number of animals used in a DNT study are obstacles to the testing of the thousands of chemicals that have high potential for human exposure. They state that “A pressing goal of future research is to develop a validated true first-tier screening paradigm (e.g., a high-throughput in vitro screening battery) that can rapidly screen large numbers of Page 314 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY chemicals for their potential to cause DNT”; and propose the use of data from DNT studies to validate any in vitro screening approach (Makris et al. 2009). Table 25: OECD test guidelines with relevance to neurotoxicity TG# TG 418 Title Delayed Neurotoxicity of Organophosphorus Substances Following Acute Exposure Delayed Neurotoxicity of Organophosphorus Substances: 28-day Repeated Dose Study TG 419 TG 424 Neurotoxicity Study in Rodents TG 426 Developmental Neurotoxicity Study Dosing Single oral dose Species Hens Duration Observed for 21 days Primary observations Behaviour, weight, and gross and microscopic pathology. Daily oral dosing with an organophos phorous pesticide Daily oral dosing Hens Dosed for 28 days Biochemical and histopathological assessments Rats Behavioral assessments and evaluation of nervous system histopathology. Daily dosing Pregnant rats, n>60 Dosing for 28d (acute), 90d (subchronic) or 1yr or longer (chronic ) From implantation through lactation Offspring are evaluated for neurologic and behavioural abnormalities, and brain weights and neuropathology are assessed at different times through adulthood 6.1.5.2 Animal models of human conditions related to neurodevelopment Animal models of ADHD (Russell 2011) and autism (Bauman et al. 2010) have been reviewed. Interestingly, chemically induced models of ADHD include prenatal or early postnatal exposure to PCBs, as well as to ethanol, nicotine or 6-hydroxydopamine (6-OHDA) (Russell 2011). Genetic and environmental (e.g. social isolation) models are also available but may be more relevant to understanding the underlying and neurobiology of disorders, for example effects on neurotransmission, and genetic causes, rather than examining potential chemical causation. A systematic review of the experimental studies linking PCBs with developmental toxicity identified a number of shortcomings in the available animal studies (Ulbrich and Stahlmann 2004), including:      Exposure to commercial PCB mixtures, which does not reflect human exposure Incomplete reporting of litter data, such as pre- and post-natal losses, signs of toxicity in the dam or offspring, birth weights and growth records Omission of endpoints that are known to be affected by PCBs Lack of measurement of internal exposure levels A relative lack of data on certain persistent PCB congeners. Animal models of complex, subtle human disorders may suffer from the differences between species, however the ability to manipulate e.g. rat, zebrafish or fruit fly models may allow insights to Page 315 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY be gained into human disorders, although the final extrapolation from model mechanism to human situations must always be done with caution. For example Hirsh presents the example of using a fruit fly model to examine the mechanisms of effects of lead, with a view to attributing the effects to endocrine or non-endocrine mechanisms (Hirsch et al. 2010). This attribution may then serve as the default assumption for human situations until better or more direct information is available. Amphibian metamorphosis has been proposed as a model for the study of developmental effects of endocrine disruption in higher vertebrates, such as humans, due to the conserved importance of thyroid hormones in development across species (Heimeier and Shi 2010). As well as serving as model for human effects, animal models may also serve more directly as models of effects on wildlife. In vivo models in species that can be readily handled in the laboratory, for example Xenopus laevis tadpoles, have the potential to be used in high throughput screening, if they can be successfully handled in 96-well plate format (Fini et al. 2007). Fini et al. (2007) implemented a rapid screening protocol using tadpoles genetically engineered with a fluorescent reporter for thyroid hormone activation, and proposed the use of the system in high throughput studies of vertebrate thyroid hormone disruption. 6.1.5.3 in vitro assays In vitro models used in neurotoxicology include studies in culture of effects on neuronal proliferation, viability and neurite outgrowth, see reviews by (Mundy et al. 2010; Radio and Mundy 2008). However the relevance of such assays to endocrine disruption is hampered by the absence of endocrine mechanisms, and their use may be limited to more direct neurotoxicity. In vitro tests are currently used to study mechanisms of toxicity rather than to detect hazards for human health, and the in vitro tests that have been proposed to complement an in vivo DNT study (OECD TG426) do not cover endocrine mechanisms, such as thyroid disruption (Bal-Price et al. 2010). This may be because endocrine mechanisms are expected to be covered by a separate in vitro panel under the rubric of endocrine disruption rather than neurotoxicity. The need for, and potential difficulties of, an approach using computational and in vitro toxicology in the area of neurobehaviour has been reviewed (Bushnell et al. 2010). This could include the use of in vitro and computational assays to assess toxicity pathways, depending on the extent to which scientific knowledge permits the selection of screens that are relevant to the human situation. The prime advantage of such as approach is the potential to design an assay panel that is exactly appropriate to the human condition of concern and which would have the potential to be highly predictive of human risk; however the major downside is the level of information required in order to design the panel, and the possibility that a system built using inappropriate assays would be misleading and uninformative. In the interim, an approach built on the current knowledge base could be used to prioritise chemicals for animal testing, rather than replacing animal testing. 6.1.5.4 Assays of thyroid mechanisms Disruption of thyroid hormone levels has been proposed as a biomarker of adverse outcomes, including neurodevelopment (Miller et al. 2009). Page 316 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY Assays that could identify chemicals with the potential to disrupt thyroid hormone function include:       a thyrotropin releasing hormone (TRH) challenge, to test the integrity of the hypothalamic– pituitary–thyroid axis by measuring TSH production following the administration of TRH; a perchlorate discharge test to detect chemicals that inhibit the uptake of iodide by the thyroid gland; quantification of thyroid peroxidase, the key enzyme in thyroid hormone production that assures the oxidation of iodide, the incorporation of iodide into the tyrosine residues on TBG, and the coupling of the di- and triiodotyrosyl residues on TBG to form thyroid hormone; thyroid hormone competitive binding assays to quantify maternal serum-binding proteins, which can predict changes in fetal thyroid hormone concentrations; a measure of iodothyronine deiodinase activity of the three tissue specific enzymes (type I, II, III proteins) that facilitate the removal of iodine from thyroid hormone; and a measure of the rate of thyroid hormone glucuronidation using an in vivo exposure paradigm followed by ex vivo examination using hepatic microsomes (Howdeshell 2002). Assays for effects on the thyroid hormone receptors, including ligand binding, receptor activation, cell proliferation are reviewed in 3.1. 6.1.5.5 Endpoints used in research A wide array of tests has been used in developmental neurotoxicity research. To illustrate the range of test used the human and animal endpoints considered in the EU-funded projects ANEMONE, DEVNERTOX, ENDOMET and PBDE-NTOX, which focused on neurodevelopment, are now listed:          Adverse effects on cognitive functions Neuropsychological tests to assess early cognitive damage Neurotransmission, o long term potentiation Behavioural tests Electrophysiological endpoints. Serum sex hormone levels Pre-weaning tests o body weight gain, ano-genital distance, pinna detachment, ear opening, incisor eruption, hair growth, eye opening, negative geotaxis, cliff avoidance, righting reflex, free fall righting, forepaw suspension, pole grasping, homing behaviour, and acoustic startle reflex Post-weaning behavioural tests o locomotor activity in an open field, o rotarod (testing motor coordination and balance), o hot plate response (testing sensitivity to pain), o sudden silence test(testing attention), o elevated plus maze (testing anxiety-like behaviour), Novel object test (testing exploration and memory), Page 317 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY    Morris water maze, radial arm maze and passive avoidance (all testing learning and memory). Behavioural (motor) response to an amphetamine challenge dose, Neurobehavioural testing o open field behaviour, o active and passive avoidance, o catalepsy, o sexual differentiation of the brain, o spatial learning and memory, o sleep-wake cycle and o social interaction. Page 318 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6.1.6 Conclusions INTACT criteria PARTLY MET MULTI-LEVEL criteria MET HORMONE criteria MOSTLY MET PRIMARY EFFECT criteria PARTLY MET EXPOSURE criteria MET SENSITIVE LIFESTAGE criteria MET PHARM. RESTORATION The biological plausibility of a role for criteria MOSTLY SUPPORTING DATA chemicals in developmental MET neurotoxicity is strong, and thyroid hormone mechanisms are receiving much attention. Attribution criteria: criteria MET DEVELOPMENTAL NEUROTOXICITY Although the variability in diagnostic criteria can confound the identification of trends in complex human disorders, the generally high incidence rates of neurodevelopmental disorders show that these conditions are important to human health and that the contribution of environmental chemicals as a causative factor is of interest. Other factors, such as genetics are also clearly very important. The dramatic effects of clinical strategies such as neonatal monitoring for hypothyroidism and periconception folic acid supplementation indicates that there is potential to intervene in human conditions of developmental neurotoxicity. From a chemical perspective, the effects of reduced exposure to lead demonstrate that environmental causes of developmental neurotoxicity can be addressed. If endocrine disrupting chemicals are shown to be risk factors, and their exposure is then successfully managed, then there is very real potential for significant human benefit. In 2002, the Global Assessment of Endocrine Disrupters reviewed Neurobehaviour and concluded that:      PCBs had been reported to have a negative impact on neurobehavioural development, and that delays in postnatal psychomotor, neurological or cognitive development have been associated with neonatal PCB exposure. Whether the developmental delay persists was considered controversial, and the mechanistic basis for these effects was unclear, although a hypothyroid mechanism of action related to PCBs was discussed (IPCS/WHO 2002). Behavioural disruption due to interaction of PHAHs (PCBs) with sex hormones was considered to have been clearly shown in rodents, but to lack data in humans. Whether or not an androgenic or antiestrogenic mode of action could be implicated was considered to require closer attention (IPCS/WHO 2002). Little was known about whether effects of pesticides were due to their established neurotoxicity or due to any effect on hormones. Many substances with known endocrine effects have yet to be examined for neurobehavioural effects (IPCS/WHO 2002). Studies of the adult nervous system are relatively lacking (IPCS/WHO 2002). Research over the past 10 years has increased knowledge of the role of PCB exposure and strengthened the evidence for, and interest in thyroid hormone mechanisms. Interest has also Page 319 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY spread to other chemical groups, including many of the groups considered as potential endocrine disrupters. The interest in thyroid hormones has not meant that the potential role of sex steroids has not been disregarded. An increasing focus on neuroendocrine disruption may reflect greater confidence that the role of individual elements of the endocrine system are vulnerable to chemical effects, allowing interest to move on to how those elements are integrated within the endocrine system and with other body systems. Evidence for, and approaches to, identifying endocrine mechanisms has grown, and approaches are being applied to e.g. pesticides. Despite these advances, the large number of chemicals concerned, for pesticides, and endocrine disrupters generally, means that, as was the case in 2002, most chemicals of concern have not been studied. The complexities of studying human conditions and the issues of species extrapolation mean that strong evidence to link complex human disorders, like autism, to single chemicals or mixtures of chemicals has not emerged; however the increased knowledge of mechanisms, such as thyroid hormone disruption, provides an intermediary step that is more amenable to experimentation and to which chemical associations can more meaningfully be studied. Plans for in vitro screening panels, once developed and applied to the thousands of chemicals of concern, may allow the field to progress more systematically, allowing the many relevant endpoints and mechanisms to be studied for many chemicals. It also remains the case that the focus for endocrine disruption is on developmental neurotoxicity rather than adult neurotoxicity; in part this is may be due to strong evidence that has emerged for the greater vulnerability of neurodevelopment and for the potential that early events will have deleterious outcomes throughout life, but may also be due to the great difficulties afforded by the greater complexity of studying adult outcomes, particularly if developmental causes of adult outcomes are considered plausible. Current research needs include:   Validation and adoption of in vitro assays, and their systematic application in screening programs Epidemiological studies that avoid the confounding factors of diagnostic criteria Page 320 of 486 HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6.1.6.1 Can developmental neurotoxicity be attributed to endocrine disruption? The WHO/IPCS 2002 criteria for attribution to an endocrine mode of action are used below to summarise the state-of-the-science. Criterion: (1) Ability to isolate the response to endocrine sensitive tissues in an intact whole organism (2) Analysis of the response at multiple levels of biological organisation—from phenotypic expression to physiology, cell biology, and ultimately molecular biology (3) Direct measurement of altered hormone action (gene induction or repression), hormone release, hormone metabolism, or hormone interactions under the experimental regime in which the toxicologic outcome was manifest (4) Dose–response observations that indicate the perturbance of the endocrine system is a critical response of the organism, and not the secondary result of general systemic toxicity (5) Ability to compare resulting phenotypes with outcomes from exposures to known pharmacological manipulations (6) Indication that there is differential sensitivity of certain lifestages in which dysregulation of a particular endocrine system is known to have adverse health consequences (7) Ability to restore the phenotype or toxicologic outcome via pharmacological manipulations that counter the presumed mode of action on the endocrine system in the intact organism (8) Supporting data on endocrine activity from in vitro binding, transcriptional activation, or cellular response studies. Page 321 of 486 Met? Criteria MET Evidence summary Neurodevelopment depends on thyroid function Criteria PARTLY MET But the complexity of the nervous system means the link from single cells to e.g. mood is not made Criteria MET Hypothyroidism = impaired neurodevelopment Criteria MOSTLY MET Developmental effects of chemicals seen at lower doses than adult neurotoxicity. Developmental effects are not generally considered to follow frank toxicity, e.g. cell death. Criteria PARTLY MET Criteria MET By definition Criteria MET Treatment of impairment, Criteria MOSTLY MET But dependent on acceptance of mechanism, for example thyroid disruption? Strong evidence to link e.g. TR agonist to neurotoxicity not available? hypothyroidism prevents HUMAN HEALTH ENDPOINTS DEVELOPMENTAL NEUROTOXICITY 6.1.7 References Abdelouahab N, Mergler D, Takser L, Vanier C, St-Jean M, Baldwin M, Spear PA, Chan HM. 2008. 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