International Journal of Obesity (1999) 23, 595±602 ß 1999 Stockton Press All rights reserved 0307±0565/99 $12.00 http://www.stockton-press.co.uk/ijo Dehydroepiandrosterone alters the growth of stromal vascular cells from human adipose tissue MK McIntosh1*, YR Lea-Currie1, C Geigerman1 and L Patseavouras2 1 Department of Nutrition and Foodservice Systems, School of Environmental Health Sciences, University of North Carolina at Greensboro, Greensboro, NC 27402 ± 6170, USA; and 2Patseavouras Center for Facial Plastic and Laser Surgery, 530 North Elam Ave Greensboro, NC 27403, USA OBJECTIVE: The purpose of this study was to determine if the antiobesity actions of dehydroepiandrosterone (DHEA) observed in vivo are due to an in¯uence on the proliferation and differentiation of primary cultures of stromal-vascular (SV) cells isolated from human adipose tissue. DESIGN: SV cells were isolated from subcutaneous adipose tissue obtained from a young adult female undergoing elective liposuction. For the proliferation assay (Experiment 1), cultures were fed proliferation media containing 0, 5, 25 or 100 mM DHEA for 3 d. At the end of this treatment period, cultures were either prepared for counting or for determining their metabolic activity using the Alamar Blue staining procedure. For the differentiation assays (Experiment 2), cultures were fed differentiation media containing 0, 25 or 50 mM DHEA for 20 d. At the end of this treatment period, cultures were either prepared for lipid staining using Oil Red O or for marker enzyme analysis (glycerol-3-phosphate dehydrogenase activity; GPDH). To determine if the stimulatory effects of DHEA on SV cell differentiation were dependent on the presence of thiazolidinediones (Experiment 3), cultures of differentiating SV cells were incubated in the presence and absence of BRL 49653 and either 0, 25 or 50 mM DHEA. RESULTS: In Experiment 1, cultures treated with 25 and 100 mM DHEA had fewer cells than cultures treated with either 0 or 5 mM DHEA. Alamar Blue staining decreased as the level of DHEA in the cultures increased. In Experiment 2, cultures treated with DHEA had more lipid and GPDH activity than control cultures. In Experiment 3, cultures treated with BRL 49653 had more triglyceride than cultures treated without BRL 49653. Likewise, cultures treated with DHEA had more triglyceride than their non-DHEA controls. Regardless of the BRL status, cultures supplemented with DHEA had more triglyceride than control cultures. CONCLUSION: These data suggest that in cultures of SV cells from human adipose tissue, DHEA supplementation attenuates proliferation and enhances differentiation. These data support the hypothesis that DHEA directly attenuates preadipocyte proliferation in humans as we previously demonstrated in primary cultures of pig and rat SV cells and in cultures of 3T3-L1 preadipocytes. In contrast, DHEA stimulated the differentiation of human preadipocytes, which is contrary to its actions in differentiating cultures of preadipocytes from animals. Keywords: dehydroepiandrosterone; preadipocyte proliferation and differentiation; human stromal vascular cells Introduction Dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEAS) are the most abundant steroids in human plasma.1,2 Plasma concentrations of DHEA(S) decrease steadily as adults age.1,2 In contrast, aging is associated with increased adiposity and decreased lean body mass. Therefore, maintaining `youthful' or higher levels of DHEA(S) may prevent the development of obesity. Alternatively, treating obese individuals with DHEA(S) may attenuate adiposity, returning their body fat levels back to `normal'. Indeed, many studies have shown that administration *Correspondence: Michael K McIntosh, Department of Nutrition and Foodservice Systems, University of North Carolina at Greensboro, PO Box 26170, Greensboro, NC 27402-6170, USA. E-mail: [email protected] Received 15 September 1998; revised 28 December 1998; accepted 14 January 1999 of DHEA, the intracellular form of the steroid, to rodents reduces adipose tissue mass.2 ± 11 Moreover, several clinical trials have demonstrated that DHEA treatment reduces body fat12,13 and increases both lean body mass13 and muscle strength14,15 in mature adults. Furthermore, recent studies by our group indicate that DHEAS is more effective than DHEA in reducing adipose tissue mass and cellularity in rats.16,17 We have preliminary data suggesting that DHEA directly alters the growth of adipose tissue. We found that treating 3T3-L1 preadipocytes18 and stromalvascular (SV) cells from adipose tissue of pigs and rats19 with DHEA attenuated cellular proliferation and differentiation. The 3T3-L1 preadipocytes are nontransformed cell line of preadipocytes of embryonic murine origin that is capable of differentiating into adipose-like cells. Furthermore, treatment of differentiating preadipocytes with DHEA decreased the expression of CCAAT=enhancer binding protein alpha (C=EBPa), a `master' regulator of adipogenesis. Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al 596 Moreover, there was a dose-dependent increase in the expression of an unknown protein that may be a repressor of C=EBPa and adipogenesis. In contrast to the antiadipogenic actions of DHEA, DHEAS had no impact on 3T3-L1 preadipocyte proliferation or differentiation. Our data demonstrate that DHEA, or a downstream metabolite, attenuates murine, rat and pig preadipocyte growth. Furthermore, they suggest that DHEA attenuates the growth of preadipocytes from animals by impairing cell proliferation (for example, apoptosis or growth arrest) and attenuating differentiation (for example, decreased C=EBPa expression). However, it is not known if DHEA attenuates the growth of human preadipocytes from adults as it does in animals. Furthermore, the antiadipogenic mechanism of action of DHEA is not known. Based on these data concerning DHEA, obesity and adipose tissue growth, the speci®c aim of this study was to investigate if DHEA attenuates the proliferation and differentiation of human preadipocytes from an adult female. Materials and methods Isolation and culture of SV cells from human adipose tissue Abdominal adipose tissue was obtained from a female donor aged 34 y with a body mass index (BMI) of 31.9 kg=m during liposuction. SV cells were isolated and cultured using modi®ed procedures described by Entenmann and Hauner.20 Brie¯y, adipose tissue was enzymatically digested for 45 min in a Krebs-Ringer buffer containing 1 mg=ml collagenase (CLS-1, Worthington Biochemical, Freehold, NJ), 15 mg=ml BSA, 5 mM glucose and 100 mM HEPES. The ratio of digestion solution to adipose tissue mass was 5 ml=1 g. The digesta was then ®ltered through 200- and 60micron mesh and pelleted at 600 g for 5 min. The SV cells were resuspended in a RBC lysis buffer (0.154 M ammonium chloride, 10 mM potassium bicarbonate, 0.1 mM EDTA) for 10 min and then ®ltered and recentrifuged to remove contaminating endothelial cells. Cultures of SV cells were grown in proliferation medium containing 90% DMEM=Hams F-12 (1:1), 10% FBS, and penicillin=streptomycin=gentamicin= fungizone (50 U=ml; 50 mg=ml; 25 mg=ml; 0.5 mg= ml). Cultures were incubated at 37 C in a humidi®ed O2:CO2 (95:5%) atmosphere. Initially, freshly isolated SV cells were grown to 80% con¯uency and then frozen in liquid nitrogen in aliquots (1106 cells=ml). Aliquots were subsequently thawed and seeded for these studies. After two passages, cells were plated for the proliferation study (Experiment 1) or the differentiation studies (Experiment 2 and Experiment 3). Induction of cell proliferation. Freshly split SV cells were seeded (5103=cm2) in 12-well Falcon dishes and cultured in basal proliferation medium containing 90% DMEM=Hams F-12 (1:1), 10% FBS, and antibiotics=antimycotics. Cultures were incubated at 37 C in a humidi®ed O2:CO2 (95:5%) atmosphere. Medium was changed every 2 ± 3 d. At this seeding density, cells reached con¯uency in about 8 d. Induction of cell differentiation. Freshly split SV cells were seeded (4104=cm2) in 12-well Falcon dishes and allowed to attach for 18 ± 24 h in DMEM=F-12 containing 10% FBS and antibiotics=antimycotics. Following attachment, cultures were grown in differentiation media for the next 3 d containing DMEM=F-12 Ham's (1:1), 10% FBS, antibiotics=antimycotics, 33 mM biotin, 17 mM pantothenate, 100 nM human insulin, 1 mM dexamethasone, 0.5 mM isobutylmethaxanthine (IBMX), and 1 mM BRL 49653 at 37 C and incubated in humidi®ed O2:CO2 (95:5%) atmosphere for 3 d. Thereafter, cultures were exposed to an adipocyte media containing 97% DMEM=F-12 Ham's (1:1), 3% FBS, antibiotics=antimycotics, 33 mM biotin, 17 mM pantothenate, 100 nM human insulin, 1 mM dexamethasone, and 1 mM hydrocortisone. Under these growth conditions, oil droplets began to appear in the cells by day 7 and maximum lipid accumulation and glycerol-3-phosphate dehydrogenase (GPDH) activity occurred by day 15 ± day 20. Experiment 1. Impact of DHEA on SV cell proliferation Proliferation of cultures of precon¯uent SV cells treated with either 0, 5, 25 or 100 mM DHEA for 3 d was determined by counting cells on a haemocytometer and measuring the metabolic activity of the cells using the AlamarBlue procedure.21 Freshly split SV cells were seeded at 5103=cm2 in 12-well dishes for measuring cell proliferation via direct counting (n 6=trt) and by the AlamarBlue procedure (n 6=trt). To access metabolic activity, AlamarBlue (AccuMed International, Inc, Westlake, OH) was added to the test wells on day 3 of treatment, at a concentration of 1% of the total well volume. The medium was then transferred to a 96 well dish and the absorbency was quanti®ed at 570 nm on a microtiter plate reader (Tecan-SLM, Research Triangle Park, NC, USA). This procedure incorporates a colorimetric oxidation-reduction indicator that changes colour in response to cell metabolic activity and growth. This indicator is not toxic to cells within the ®rst 24 h of use. We have found a good correlation between cell numbers and metabolic activity using this indicator with SV cells from human adipose tissue. Experiment 2. Impact of DHEA on SV cell differentiation The degree of differentiation of cultures of SV cells exposed to either 0, 25 or 50 mM DHEA was determined on day 20 by standard lipid staining procedures Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al (n 3=trt) and by measuring the activity of GPDH (n 3=trt) of the cultures. determined at 492 nm on a microtiter plate reader (Tecan-SLM). Measuring marker enzyme activity. Cultures were rinsed twice with HBSS and scraped into an ice cold sucrose buffer (29 mM sucrose, 73 mM Tris, 24 mM EDTA, 0.02% b-mercaptoethanol) and stored at 7 20 C. The resulting extract was sonicated with two 5 s bursts and centrifuged for 30 min at 16 000 g at 4 C. GPDH activity was determined spectrophotometrically by measuring the oxidation of NADH at 340 nm using dihydroxyacetone phosphate as the substrate, as previously described.19 Protein content of the supernatant was determined using a commercially available kit (Bio-Rad Labs, Richmond, CA). Statistical analyses Staining lipid droplets. The presence of lipid within adipocytes was visualized and quanti®ed by staining with Oil Red O. Cultures were washed twice with 1 ml HBSS, then ®xed for 1 h in a 10% formalin solution (10% formalin, 4% calcium chloride, deionized water) at 4 C. The cells were then washed twice with distilled water and stained using a 0.3% oil red O in isopropanol for 15 min at room temperature. Following staining, cells were rinsed several times using deionized water to remove any undissolved stain. The cells were then observed under an Olympus IMT-2 inverted microscope (Mellville, NY, USA) and photographs of representative cells taken for documentation. The amount of Oil Red O staining was quanti®ed according to the method of Phillips et al.22 Brie¯y, the stain was solubilized in 0.5 ml of a 4% Nonidet P-40 (NP-40) solution (in isopropanol) for 5 min. The resulting fraction was transferred to a 1 ml polystyrene cuvette and the absorbance measured at 540 nm on a Beckman DU64 spectrophotometer (Beckman Instruments, Palo Alto, CA, USA). The absorbance at 540 nm is proportional to the amount of stainable lipid accumulated in the cell monolayers.22 Data were analysed by the Least Squares ANOVA General Linear Models Procedures (PROC GLM) of SAS (SAS Institute, Cary, NC, USA). For Experiment 1 and Experiment 2, one-way ANOVA were conducted.23 For Experiment 3, the main effects of BRL (n 2), DHEA (n 3) and the BRL by DHEA interactions (n 6) were compared for signi®cance at the P < 0.05 level.23 The means s.e.m. of the treatment interactions and their statistical differences are presented in the ®gures. Results Experiment 1. Impact of DHEA on SV cell proliferation SV cell numbers decreased as the level of DHEA increased above 5 mM (Figure 1). The metabolic activity of proliferating cultures of human SV cells decreased as the level of DHEA in the cultures increased (Figure 2). Experiment 2. Impact of DHEA on SV cell differentiation The activity of the adipocyte enzyme marker GPDH was higher in cultures treated with 25 and 50 mM DHEA compared to the control cultures (Figure 3). Likewise, the amount of stainable lipid in the cultures Experiment 3. Impact of DHEA on SV cell differentiation in the presence and absence of BRL49653. Cultures of SV cells were grown in the presence or absence of BRL 49653 and treated with either 0, 25 or 50 mM DHEA in this 25 factorial design. The degree of differentiation of SV cells was determined on day 12 by measuring the triglyceride content (n 8=trt) and the activity of GPDH (n 8=trt). Measuring triglyceride content. Cellular triglyceride content was determined by using a colormetric kit (TG-INT #336, Sigma Chemical Co., St Louis, MO, USA). Brie¯y, cells were harvested in an isotonic sucrose buffer (29 mM sucrose, 73 mM Tris, 24 mM EDTA) and sonicated at 20% output for 10 s. Aliquots of this crude cell sonicate were incubated for 2 h with the triglyceride reagent and then the absorbance Figure 1 The effect of dehydroepiandrosterone (DHEA) treatment for 3 d on cell number in replicating cultures of stromalvascular (SV) cells from human adipose tissue. Values represent the least square means s.e.m. Means not sharing a common superscript (a, b, c) are signi®cantly (P < 0.05) different. 597 Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al 598 Figure 2 The effect of dehydroepiandrosterone (DHEA) treatment for 3 d on metabolic activity in replicating cultures of stromal-vascular (SV) cells from human adipose tissue. Values represent the least square means s.e.m. Means not sharing a common superscript (a, b, c) are signi®cantly (P < 0.05) different. Figure 4 The effect of dehydroepiandrosterone (DHEA) treatment for 20 d on Oil Red O-stained lipid content in differentiating cultures of stromal-vascular (SV) cells from human adipose tissue. Values represent the least square means s.e.m. Means not sharing a common superscript (a, b, c) are signi®cantly (P < 0.05) different. Experiment 3. Impact of DHEA on SV cell differentiation in the presence and absence of BRL49653 BRL supplemented cultures had more triglyceride than non-BRL supplemented cultures (main effect BRL; P 0.001). Likewise, SV cultures treated with DHEA had more triglyceride than non-DHEA treated cultures (main effect DHEA; P 0.001). Regardless of the BRL status of the cultures, cultures treated with 25 and 50 mM DHEA had more triglyceride than nonDHEA treated cultures (Figure 6). Treatment effects on the activity of GPDH were similar to those of the cellular triglyceride data and therefore these data are not shown. Discussion Figure 3 The effect of dehydroepiandrosterone (DHEA) treatment for 20 d on the activity of glycerol-3-phosphate dehydrogenase (GPDH), an enzyme marker of late differentiation, in differentiating cultures of stromal-vascular (SV) cells from human adipose tissue. Values represent the least square means s.e.m. Means not sharing a common superscript (a, b, c) are signi®cantly (P < 0.05) different. treated with 25 and 50 mM DHEA was higher than that of the non-DHEA treated cultures (Figure 4). As seen in Figure 5, there are more clusters of larger lipid droplets in the cultures treated with DHEA compared to the controls. The present study provides direct evidence that DHEA treatment attenuates proliferation and stimulates differentiation in primary cultures of SV cells isolated from human adipose tissue. To our knowledge this is the ®rst time the antiproliferative yet proadipogenic actions of DHEA have been demonstrated in primary cultures of SV cells isolated from human abdominal adipose tissue. The antiproliferative effects of DHEA in SV cells from human adipose tissue corresponds with previous data from our laboratory, demonstrating the antiproliferative effects of DHEA in pig and rat SV preadipocytes19 and in the 3T3-L1 preadipocyte cell line.18 Furthermore, several clinical trials have demonstrated that treatment with DHEA Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al 599 Figure 6 The effect of BRL 49653 and dehydroepiandrosterone (DHEA) treatment for 12 d on the triglyceride content in differentiating cultures of stromal-vascular (SV) cells from human adipose tissue. Values represent the least square means s.e.m. Means not sharing a common superscript (a, b, c, d) are signi®cantly (P < 0.05) different. Figure 5 Micrographs (10x) of cultures of stromal-vascular (SV) cells from human adipose tissue treated with dehydroepiandrosterone (DHEA) for days and stained with Oil Red O. Arrowheads indicate adipocytes loaded with Oil Red O-stained droplets. reduces body fat12,13 and increases lean body mass and muscle strength14,15 in mature adults. Moreover, low levels of serum DHEA(S) have been correlated with high levels of body fat in both men24,25 and women.26 ± 28 Therefore, DHEA may antagonize adiposity by reducing preadipocyte proliferation. In support of this concept, it is well documented that the rate of conversion of preadipocytes to mature adipocytes directly affects the development of obesity.29 The observed DHEA-mediated reduction in proliferation of the preadipocyte pool would limit the number of cells that could be induced to differentiate into mature lipid-®lled adipocytes. Therefore, we speculate that the decline in DHEA levels that occurs with age may in¯uence the size of the preadipocyte pool, by allowing greater proliferation of cells capable of accumulating signi®cant amounts of lipid as evidenced in obese subjects. These data suggest that the antiobesity effects of DHEA observed in humans may be due to the direct attenuation of preadipocyte proliferation by DHEA or down-stream metabolites. However, since we did not distinguish between the proliferation of preadipocytes and other supporting SV cells such as (pre)myocytes or (pre)chondrocytes in our cultures, we must con®rm these results by directly measuring preadipocyte proliferation. The mechanism by which DHEA attenuates preadipocyte proliferation is not known. DHEA may be reducing proliferation by: 1) antagonizing the actions of a gene whose activation is essential for cell growth; 2) limiting substrate availability for growth; 3) causing growth arrest; or 4) being cytotoxic. Schultz et al 30 demonstrated that DHEA treatment of HT-29 SF cells (a human colonic adenocarcinoma cell line) inhibited cell proliferation and arrested the cells in the G1 phase of the cell cycle. Supplementation with mevalonic acid and=or isoprenoids reversed the DHEA-mediated growth arrest. Mevalonic acid is an essential substrate for the biosynthesis of cholesterol and the precursor for farnesyl-pyrophosphate, an Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al 600 important substrate for the post-translational modi®cation and activation of p21ras=G-protein.31 Moreover, mevalonic acid provides isoprene units for the post-translational modi®cation of proteins integral to proliferation and differentiation.30 These data suggest that DHEA may reduce isoprenoid synthesis, thereby limiting the availability of compounds essential for cell proliferation.30 Furthermore, 3-hydroxy-3methylglutaryl coenzyme A (HMG-CoA) reductase, the rate limiting microsomal enzyme in de novo cholesterol and isoprenoid biosynthesis, is inhibited by DHEA treatment.32 Moreover, the HMG-CoA reductase inhibitor lovastatin has been shown to inhibit 3T3-L1 preadipocyte differentiation by limiting the farnesylation of p21ras.33 Therefore, DHEA may alter preadipocyte proliferation by interfering with cholesterol and isoprene biosynthesis. In contrast to the antiproliferative effects of DHEA, treatment of cultures of human SV cells with DHEA enhanced preadipocyte differentiation. The pro-adipogenic actions of DHEA in human SV cells are in contrast to our previous studies demonstrating that DHEA attenuated the differentiation of cultures of 3T3-L1 preadipocytes18 and primary cultures of rat and pig SV preadipocytes.19 Several other groups have also reported that DHEA reduced the rate of differentiation of 3T3-L1 cells into mature, lipid-®lled adipocytes by as much as 50%.9,10 The reason for this differential effect of DHEA on preadipocyte differentiation between cultures of animal and human preadipocytes is not known. However, DHEA's in¯uence of preadipocyte growth may be affected by: 1) the culturing conditions of the cells; 2) the age, body mass index (BMI); and gender of the subject; and 3) the site from which the adipose tissue was collected. The culturing conditions for preadipocyte differentiation of humans cells differed from that of animal cells in that the thiazolidinedione BRL 49653 was supplemented during the ®rst 5 d of the human differentiation protocol. The thiazolidinediones have insulin sensitizing and adipogenic properties33,34 and are used to enhance adipogenesis in cultures of human preadipocytes. DHEA stimulated differentiation in the presence and absence of the BRL 49653 (Figure 3, Figure 4 and Figure 6). The further stimulation of lipid accumulation in the presence of BRL 49653 may be due to the fact that BRL 49653 is a potent ligand for peroxisome proliferator activated receptor gamma (PPAR-g2).34 The expression of PPAR-g2 has been shown to be essential for terminal adipocyte differentiation.34 ± 36 This transcription factor binds to the promoter regions of genes involved in adipogenesis such as the fatty acid binding protein aP2, lipoprotein lipase (LPL), and acyl CoA synthase.35,36,37 DHEA and DHEAS have been shown to enhance the size and numbers of peroxisomes4,38 and peroxisomal betaoxidation in rodent liver.4,39,40 Therefore, it is possible that DHEA stimulates adipogenesis in cultures of human SV cells by activating PPAR-g2, thereby stimulating differentiation by a mechanism similar to that of BRL 49653. In the current study, we observed an additive, but not synergistic, effect of BRL 49653 in cultures treated with DHEA (Figure 6). Future studies will examine whether DHEA increases the expression of PPAR-g2. Another possible reason for the differential effect of DHEA between human and animal preadipocytes may be due to the age and the degree of adiposity of the subjects. The 3T3-L1 preadipocytes we used18 are of embryonic origin and the animal SV cells were from pigs aged 7 d and rats aged 3 weeks.19 In contrast, the human SV cells were obtained from a female aged 34 y. It is therefore possible that DHEA may either attenuate or stimulate differentiation, depending on the age-related expression of genes that control adipogenesis. In support of this concept, it is well documented that certain hormone receptors are expressed maximally during speci®c windows of time during development.41 Failure of these receptors to be activated by their respective ligands may result in permanent aberrations in growth and development, regardless of hormone supplementation outside these time periods. For example, cretinism is a permanent neurological and skeletal retardation resulting from inadequate thyroid hormone during fetal and neonatal life.41 Whereas iodine or thyroid hormone supplementation gestationally or neonatally prevents cretinism, post-natal supplementation does not reverse retardation.41 Therefore, future studies will examine whether the age or the BMI of the donor affects DHEA's in¯uence of adipogenesis. The speci®c site from which the SV cells were obtained, may also in¯uence the actions of DHEA. For the primary culture of animal cells, we collected dorsal fat from the pigs and inguinal fat from the rats.19 In contrast, we obtained abdominal fat from the human subject. Regional differences in fat depot metabolism have been observed in animals42 and humans.43 Future studies need to address the tissue speci®c effects of DHEA to determine whether DHEA's in¯uence on adipogenesis is dependent on the site of adipose tissue. Lastly, gender may in¯uence DHEA's actions on adipogenesis. We obtained animal SV cells from males whereas the human SV cells were obtained from a female. Gender differences in adipose tissue distribution and metabolism are well documented.44 Furthermore, steroid hormone pro®les differ between genders. Therefore, it is possible that the differential in¯uence of DHEA we found between animal and human SV cells may be due to gender differences. Future studies will address this gender issue. Conclusion In summary, this study demonstrates that DHEA possesses antiproliferative effects in cultures of Dehydroepiandrosterone alters human preadipocyte growth MK McIntosh et al human SV cells from adipose tissue as it does in rat, pig and 3T3-L1 preadipocytes. In contrast, DHEA stimulated human preadipocyte differentiation. Future studies will determine if DHEA increases PPAR-g2 expression in cultures of SV cells from human adipose tissue and whether the age, gender, BMI or site of adipose tissue of the subject in¯uences DHEA's impact on adipogenesis. Acknowledgements This research was supported by the North Carolina Agricultural Research Service Project No. 05773 and the UNC Institute of Nutrition. We thank Beth Alexander for technical assistance with helping establish the preadipocyte cultures and the proliferation assays. References 1 Orentreich N, Brind J, Rizer R, Vogelman J. Age changes and sex differences in serum DHEA-sulfate concentrations throughout adulthood. J Clin Endocrinol Metab 1985; 59: 551 ± 555. 2 Orentreich N, Brind J, Vogelman J, Andres R, Baldwin H. Long term longitudinal measurements of plasma DHEA sulfate in normal men. J Clin Endocrinol Metab 1992; 75: 1002 ± 1004. 3 Nestler J, Clore J, Blackard W. 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