Age and sex differences of dehydroepiandrosterone sulfate (DHEAS) and cortisol (CRT) plasma levels in normal controls and Alzheimer's disease (AD)

Intact circadian rhythm despite cortisol hypersecretion in Alzheimer's disease: A meta-analysis

Hypersecretion of the glucocorticoid steroid hormone cortisol by individuals with Alzheimer's disease (AD) has been suspected for several decades, during which time dozens of examinations of this phenomenon have been conducted and published. The goals of this investigation were to summarize this sizeable body of literature, test whether participant and methodological characteristics modify the magnitude of the AD-associated basal cortisol hypersecretion, and examine whether cortisol circadian rhythmicity is maintained among individuals with AD. To this end, the present meta-analysis and systematic review examined over 300 comparisons of indices of basal HPA-axis functioning between individuals with AD and cognitively normal older adults. AD was associated with basal cortisol elevations (g = 0.45) but the magnitude of the effect was not systematically impacted by any of the participant characteristics considered or the time-of-day of the cortisol sampling. Further, there was no evidence of group differences among direct indices of circadian rhythmicity such as the cortisol awakening response or the diurnal cortisol slope. These results suggest that basal hypersecretion of cortisol, but not circadian dysrhythmia, is characteristic of individuals with AD. Mechanistically, the observed hypersecretion is consistent with the theorized AD-driven deterioration of the hippocampus and subsequent reduction in hypothalamic-pituitary-adrenal axis inhibition. Further investigation is warranted to elucidate the role and timing of cortisol elevations in the progression of AD.

Cerebral perfusion in depression: Relationship to sex, dehydroepiandrosterone sulfate and depression severity

BACKGROUND

Major depressive disorder (MDD) is a leading cause of disease burden and shows a marked sexual dimorphism. Previous studies reported changes in cerebral perfusion in MDD, an association between perfusion and dehydroepiandrosterone sulfate (DHEAS) levels, and large sex differences in perfusion. This study examines whether perfusion and DHEAS might mediate the link between sex and depressive symptoms in a large, unmedicated community sample.

METHODS

The sample included 203 healthy volunteers and 79 individuals with past or current MDD. Depression severity was assessed with the Hamilton Depression Scale (HAM-D) and Montgomery-Asberg Depression Rating Scale (MADRS). 3 T MRI perfusion data were collected with a pseudocontinuous arterial spin labelling sequence and DHEAS was measured in serum by LC-MS/MS.

RESULTS

Large sex differences in perfusion were observed (p < 0.001). Perfusion was negatively correlated with DHEAS (r = -0.23, p < 0.01, n = 250) and with depression severity (HAM-D: r = -0.17, p = 0.01, n = 242; partial Spearman correlation, controlling for age and sex), but not with anxiety. A significant sex*perfusion interaction on depression severity was observed. In women, perfusion showed more pronounced negative correlations with depressive symptoms, with absent or, in the case of the MADRS, opposite effects observed in men. A mediation analysis identified DHEAS and perfusion as mediating variables influencing the link between sex and the HAM-D score.

CONCLUSION

Perfusion was linked to depression severity, with the strongest effects observed in women. Perfusion and the neurosteroid DHEAS appear to mediate the link between sex and HAM-D scores, suggesting that inter-individual differences in perfusion and DHEAS levels may contribute to the sexual dimorphism in depression.

Impact of adrenal hormones, reproductive aging, and major depression on memory circuitry decline in early midlife

Dehydroepiandrosterone-sulfate (DHEAS) is an adrenal androgen that is, in part, aromatized to estradiol. It continues to be produced after menopause and provides estrogenicity after depletion of ovarian hormones. Estradiol depletion contributes to memory circuitry changes over menopause, including changes in hippocampal (HIPP) and dorsolateral- and ventrolateral-prefrontal cortex (DLPFC; VLPFC) function. Further, major depressive disorder (MDD) patients have, in general, lower levels of estradiol and lower DHEAS than healthy controls, thus potentially a higher risk of adverse menopausal outcomes. We investigated whether higher DHEAS levels after menopause is associated with better memory circuitry function, especially in women with MDD. 212 adults (ages 45-55, 50% women) underwent clinical and fMRI testing. Participants performed a working memory (WM) N-back task and an episodic memory verbal encoding (VE) task during fMRI scanning. DHEAS levels were significantly associated with memory circuitry function, specifically in MDD postmenopausal women. On the WM task, lower DHEAS levels were associated with increased HIPP activity. On the VE task, lower DHEAS levels were associated with decreased activity in the HIPP and VLPFC. In contrast, there was no association between DHEAS levels and memory circuitry function in MDD pre/perimenopausal women, men, and non-MDD participants regardless of sex and reproductive status. In fact, MDD postmenopausal women with higher levels of DHEAS were similar to MDD pre/perimenopausal women and men. Thus, memory circuitry deficits associated with MDD and a lower ability of the adrenal gland to produce DHEAS after menopause may contribute to a lower ability to maintain intact memory function with age.

Dehydroepiandrosterone and Dehydroepiandrosterone Sulfate in Alzheimer's Disease: A Systematic Review and Meta-Analysis

Background and Purpose: Previous studies found inconsistent results for the relationship between Alzheimer's disease and the levels of dehydroepiandrosterone and dehydroepiandrosterone sulfate. This study performed a systematic review and meta-analysis to evaluate previous studies' results on this relationship. Method: Studies related to this outcome were obtained using a systematic search from the electronic databases of PubMed, Embase, Web of Science, and Psyc-ARTICLES in March 2018. The random-effects model was used to measure the strength of the association between Alzheimer's disease and the levels of dehydroepiandrosterone and dehydroepiandrosterone sulfate, using the standardized mean difference. Results: Thirty-one eligible studies were included in the final analysis. There was no statistically significant association between the level of dehydroepiandrosterone and Alzheimer's disease (standardized mean difference: 0.51, 95% confidence interval: -0.44 to 1.45, Z = 1.06, p = 0.29). On the other hand, lower level dehydroepiandrosterone sulfate was observed in patients with Alzheimer's disease than in controls (standardized mean difference: -0.69, 95% confidence interval: -1.17 to -0.22, Z = -2.84, p < 0.01). Conclusion: Decreased dehydroepiandrosterone sulfate concentrations may be an important indicator for Alzheimer's disease, although whether dehydroepiandrosterone sulfate could be used as a diagnostic tool requires further research.

Variation in maternal urinary cortisol profiles across the peri-conceptional period: a longitudinal description and evaluation of potential functions

STUDY QUESTION

How do women's first morning urinary cortisol levels, a marker of stress axis activity, vary during the peri-conceptional period (the 12 weeks around conception)?

SUMMARY ANSWER

First morning urinary cortisol follows an overall increasing trajectory across the peri-conceptional period, interrupted by 2 week-long decreases during the week preceding conception and the fifth week following conception.

WHAT IS KNOWN ALREADY

Later gestational stages (i.e. second and third trimesters) are characterized by increasing levels of circulating cortisol. This increase is hypothesized to constitute a response to the energy demands imposed by fetal growth, and the development of energy reserves in preparation for nursing and performing regular activities while carrying pregnancy's extra weight and volume.

STUDY DESIGN, SIZE, DURATION

This study is based on a data set collected as part of a longitudinal, naturalistic investigation into the interactions between the stress (hypothalamic-pituitary-adrenal axis (HPAA)) and reproductive (hypothalamic-pituitary-gonadal axis (HPGA)) axes. Biomarkers of HPAA and HPGA function were quantified in first morning urinary specimens collected every other day from 22 healthy women who conceived a pregnancy during the study. We analyzed the longitudinal within- and between-individual variation in first morning urinary cortisol levels across the 12-week peri-conceptional period.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were recruited from two rural, aboriginal, neighboring communities in Guatemala. Cortisol, estradiol and progesterone metabolites (estrone-3-glucuronide and pregnanediol glucuronide, respectively) and hCG levels were quantified in first morning urinary specimens using immunoassays to determine time of conception and confirm pregnancy maintenance. Linear mixed-effects models with regression splines were used to evaluate the magnitude and significance of changes in cortisol trajectories.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, maternal first morning urinary cortisol increased from 6 weeks prior to conception (geometric mean ± SD = 58.14 ± 36.00 ng/ml) to 6 weeks post-conception (89.29 ± 46.76 ng/ml). The magnitude of the increase between the pre- and post-conception periods varied significantly between women (likelihood ratio test statistic = 8.0017, P = 0.005). The peri-conceptional period is characterized by an increasing cortisol trajectory (+1.36% per day; P = 0.007) interrupted by a week-long decline immediately prior to conception (-4.02% per day; P = 0.0013). After conception cortisol increased again (+1.73% per day; P = 0.0008) for 4 weeks, fell in the fifth week (-6.60% per day; P = 0.0002) and increased again in post-conceptional week 6 (+8.86% per day; P = 0.002). Maternal urinary cortisol levels varied with sex of the gestating embryo. During gestational week 2, mothers carrying female embryos (N = 10) had higher mean cortisol levels than those carrying male embryos (N = 9) (t(17) = 2.28, P = 0.04).

LIMITATIONS, REASONS FOR CAUTION

Our results are based on a relatively small sample (n = 22) of women. However, our repeated-measures design with an average of 27 ± 8 (mean ± SD) data points per woman strengthens the precision of estimates resulting in high statistical power. Additionally, our study population's high degree of ethnic and cultural homogeneity reduces the effects of confounders compared with those found in industrialized populations. This higher level of homogeneity also increases our statistical power. However, since there may be small differences in absolute cortisol values among ethnic groups, the social and biological background of our sample may affect the generalizability of our results. General patterns of HPAA activity, however, are expected to be universal across women. Finally, as there is, to the best of our knowledge, no evidence to the contrary, we assumed that urinary cortisol levels reflect HPAA activity and that changes in gonadal steroids across the menstrual cycle do not affect the levels of free cortisol measured in urine.

WIDER IMPLICATIONS OF THE FINDINGS

To our knowledge, this is the first longitudinal profile of basal maternal HPAA activity across the peri-conceptional period. A basic understanding of the normative (basal as opposed to stress-induced) changes in HPAA activity across this period is needed to accurately assess women's stress at this juncture. Importantly, changes in HPAA activity are likely to play a critical role in ovulation, fertilization, implantation, placentation and embryonic programing. Thus, this novel information should aid in the development of interventions aimed at preventing or moderating undesired effects of maternal physiological stress during the peri-conceptional period on reproductive outcomes as well as embryonic development.

STUDY FUNDING/COMPETING INTERESTS

This research was funded by a CIHR IGH Open Operating grant (CIHR 106705) to P.A.N. and L.Z.; a Simon Fraser University (SFU) President's Start-up grant, a Community Trust Endowment Fund grant through SFU's Human Evolutionary Studies Program and a Michael Smith Foundation for Health Research Career Investigator Scholar Award to P.A.N.; an NSERC Discovery grant to L.Z.; a CIHR Post-Doctoral Fellowship to C.K.B. and an NSERC Undergraduate Student Research Award to H.M. and J.C.B. The funding agencies had no role in the design, analysis, interpretation or reporting of the findings. There are no competing interests.

TRIAL REGISTRATION NUMBER

Not applicable.

An investigation into the relationship between age and physiological function in highly active older adults

KEY POINTS

The relationship between age and physiological function remains poorly defined and there are no physiological markers that can be used to reliably predict the age of an individual. This could be due to a variety of confounding genetic and lifestyle factors, and in particular to ill-defined and low levels of physical activity. This study assessed the relationship between age and a diverse range of physiological functions in a cohort of highly active older individuals (cyclists) aged 55-79 years in whom the effects of lifestyle factors would be ameliorated. Significant associations between age and function were observed for many functions. V̇O2max was most closely associated with age, but even here the variance in age for any given level was high, precluding the clear identification of the age of any individual. The data suggest that the relationship between human ageing and physiological function is highly individualistic and modified by inactivity.

ABSTRACT

Despite extensive research, the relationship between age and physiological function remains poorly characterised and there are currently no reliable markers of human ageing. This is probably due to a number of confounding factors, particularly in studies of a cross-sectional nature. These include inter-subject genetic variation, as well as inter-generational differences in nutrition, healthcare and insufficient levels of physical activity as well as other environmental factors. We have studied a cohort of highly and homogeneously active older male (n = 84) and female (n = 41) cyclists aged 55-79 years who it is proposed represent a model for the study of human ageing free from the majority of confounding factors, especially inactivity. The aim of the study was to identify physiological markers of ageing by assessing the relationship between function and age across a wide range of indices. Each participant underwent a detailed physiological profiling which included measures of cardiovascular, respiratory, neuromuscular, metabolic, endocrine and cognitive functions, bone strength, and health and well-being. Significant associations between age and function were observed for many functions. The maximal rate of oxygen consumption (V̇O2max) showed the closest association with age (r = -0.443 to -0.664; P < 0.001), but even here the variance in age for any given level was high, precluding the clear identification of the age of any individual. The results of this cross-sectional study suggest that even when many confounding variables are removed the relationship between function and healthy ageing is complex and likely to be highly individualistic and that physical activity levels must be taken into account in ageing studies.

Neurobiology of DHEA and effects on sexuality, mood and cognition

Dehydroepiandrosterone (DHEA) and its sulfate ester, DHEAS, are the most abundant steroid hormones in the humans. However, their physiological significance, their mechanisms of action and their possible roles as treatment are not fully clarified. Biological actions of DHEA(S) in the brain involve neuroprotection, neurite growth, neurogenesis and neuronal survival, apoptosis, catecholamine synthesis and secretion, as well as anti-oxidant, anti-inflammatory and antiglucocorticoid effects. In addition, DHEA affects neurosteroidogenis and endorphin synthesis/release. We also demonstrated in a model of ovariectomized rats that DHEA therapy increases proceptive behaviors, already after 1 week of treatment, affecting central function of sexual drive. In women, the analyses of clinical outcomes are far from being conclusive and many issues should still be addressed. Although DHEA preparations have been available in the market since the 1990s, there are very few definitive reports on the biological functions of this steroid. We demonstrate that 1 year DHEA administration at the dose of 10mg provided a significant improvement in comparison with vitamin D in sexual function and in frequency of sexual intercourse in early postmenopausal women. Among symptomatic women, the spectrum of symptoms responding to DHEA requires further investigation, to define the type of sexual symptoms (e.g. decreased sexual function or hypoactive sexual desire disorder) and the degree of mood/cognitive symptoms that could be responsive to hormonal treatment. In this regard, our findings are promising, although they need further exploration with a larger and more representative sample size. This article is part of a Special Issue entitled: Essential role of DHEA.

Sex differences in drug disposition

Physiological, hormonal, and genetic differences between males and females affect the prevalence, incidence, and severity of diseases and responses to therapy. Understanding these differences is important for designing safe and effective treatments. This paper summarizes sex differences that impact drug disposition and includes a general comparison of clinical pharmacology as it applies to men and women.

Preclinical challenges in steroid analysis of human samples

Preclinical challenges in the analysis of steroid hormones are primarily determined by biological factors involved in the physiology and pathophysiology of hormone secretion. Major biologically influencing factors like age, sex, pubertal stage, pregnancy, phase of the menstruation, and diurnal rhythm have to be considered in the definition of reference ranges for steroids and their clinical interpretation. Hitherto, in clinical routine laboratories steroids were mainly determined by direct immunoassays applied on automated platforms, which are simple, rapid and cheap if a high number of samples are measured. However, technical factors like cross-reactivity of related steroid metabolites or limited analytical ranges have to be taken in account and may impair accuracy and precision of these direct methods. The actual development of mass spectrometry based analytical platforms for the determination of single steroid or steroid patterns seems to be an alternative analytical approach combining multi-parametric analysis, high sensitivity and specificity as well simple sample pre-treatment, robustness and low running costs for steroid analysis. This short review will give an overview about biological influencing factors and technical disturbing factors of routinely used immunoassay for the analysis of steroids. The application of LC-MS/MS as an alternative routine high-throughput platform for steroid analysis and its perspective role in the standardization and harmonisation of steroid measurements in clinical routine application will be discussed.

Sex differences in pharmacokinetics and pharmacodynamics

Significant differences that exist between the sexes affect the prevalence, incidence and severity of a broad range of diseases and conditions. Men and women also differ in their response to drug treatment. It is therefore essential to understand these reactions in order to appropriately conduct risk assessment and to design safe and effective treatments. Even from that modest perspective, how and when we use drugs can result in unwanted and unexpected outcomes. This review summarizes the sex-based differences that impact on pharmacokinetics, and includes a general comparison of clinical pharmacology as it applies to men, women and pregnant women. Sex-related or pregnancy-induced changes in drug absorption, distribution, metabolism and elimination, when significant, may guide changes in dosage regimen or therapeutic monitoring to increase its effectiveness or reduce potential toxicity. Given those parameters, and our knowledge of sex differences, we can derive essentially all factors necessary for therapeutic optimization. Since this is a rapidly evolving area, it is essential for the practitioner to review drug prescribing information and recent literature in order to fully understand the impact of these differences on clinical therapeutics.

Neurobiological and neuropsychiatric effects of dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS)

DHEA and DHEAS are steroids synthesized in human adrenals, but their function is unclear. In addition to adrenal synthesis, evidence also indicates that DHEA and DHEAS are synthesized in the brain, further suggesting a role of these hormones in brain function and development. Despite intensifying research into the biology of DHEA and DHEAS, many questions concerning their mechanisms of action and their potential involvement in neuropsychiatric illnesses remain unanswered. We review and distill the preclinical and clinical data on DHEA and DHEAS, focusing on (i) biological actions and putative mechanisms of action, (ii) differences in endogenous circulating concentrations in normal subjects and patients with neuropsychiatric diseases, and (iii) the therapeutic potential of DHEA in treating these conditions. Biological actions of DHEA and DHEAS include neuroprotection, neurite growth, and antagonistic effects on oxidants and glucocorticoids. Accumulating data suggest abnormal DHEA and/or DHEAS concentrations in several neuropsychiatric conditions. The evidence that DHEA and DHEAS may be fruitful targets for pharmacotherapy in some conditions is reviewed.

Analysis of the adult human plasma metabolome

OBJECTIVE

It is well established that disease states are associated with biochemical changes (e.g., diabetes/glucose, cardiovascular disease/cholesterol), as are responses to chemical agents (e.g., medications, toxins, xenobiotics). Recently, nontargeted methods have been used to identify the small molecules (metabolites) in a biological sample to uncover many of the biochemical changes associated with a disease state or chemical response. Given that these experimental results may be influenced by the composition of the cohort, in the present study we assessed the effects of age, sex and race on the relative concentrations of small molecules (metabolites) in the blood of healthy adults.

METHODS

Using gas- and liquid-chromatography in combination with mass spectrometry, a nontargeted metabolomic analysis was performed on plasma collected from an age- and sex-balanced cohort of 269 individuals.

RESULTS

Of the more than 300 unique compounds that were detected, significant changes in the relative concentration of more than 100 metabolites were associated with age. Many fewer differences were associated with sex and fewer still with race. Changes in protein, energy and lipid metabolism, as well as oxidative stress, were observed with increasing age. Tricarboxylic acid intermediates, creatine, essential and nonessential amino acids, urea, ornithine, polyamines and oxidative stress markers (e.g., oxoproline, hippurate) increased with age. Compounds related to lipid metabolism, including fatty acids, carnitine, beta-hydroxybutyrate and cholesterol, were lower in the blood of younger individuals. By contrast, relative concentrations of dehydroepiandrosterone-sulfate (a proposed antiaging androgen) were lowest in the oldest age group. Certain xenobiotics (e.g., caffeine) were higher in older subjects, possibly reflecting decreases in hepatic cytochrome P450 activity.

CONCLUSIONS

Our nontargeted analytical approach detected a large number of metabolites, including those that were found to be statistically altered with age, sex or race. Age-associated changes were more pronounced than those related to differences in sex or race in the population group we studied. Age, sex and race can be confounding factors when comparing different groups in clinical studies. Future studies to determine the influence of diet, lifestyle and medication are also warranted.

Estimation of individual reference intervals in small sample sizes

In occupational health studies, the study groups most often comprise healthy subjects performing their work. Sampling is often planned in the most practical way, e.g., sampling of blood in the morning at the work site just after the work starts. Optimal use of reference intervals requires that the population, on which the reference interval is based, is representative for the study group in question. The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommends estimating reference interval on at least 120 subjects. It may be costly and difficult to gain group sizes of that order of magnitude for all topics in question. Therefore, new methods to estimate reference intervals for small sample sizes are needed. We present an alternative method based on variance component models. The models are based on data from 37 men and 84 women taking into account biological variation from various variables such as gender, age, BMI, alcohol, smoking, and menopause. The reference intervals were compared to reference intervals calculated using IFCC recommendations. Where comparable, the IFCC calculated reference intervals had a wider range compared to the variance component models presented in this study. The presented method enables occupational health researchers to calculate reference intervals for specific groups, i.e. smokers versus non-smokers, etc. In conclusion, the variance component models provide an appropriate tool to estimate reference intervals based on small sample sizes.

Impairment of CREB phosphorylation in the hippocampal CA1 region of the senescence-accelerated mouse (SAM) P8

Senescence-accelerated mouse P8 (SAMP8) mice show deficits of learning and memory at an early age. However, no evidence of neurochemical changes was found in the hippocampus of SAMP8 at an early age. After electric shock in the passive avoidance test, SAMR1 (normal aging mice) showed biphasic responses in the phosphorylated CREB (p-CREB) level in the hippocampal CA1 region: an early peak detected at 1 to 3 h was followed by a marked drop at 6 h, and a second peak rise starting after 9 to 12 h after electric stimulation. On the other hand, SAMP8 manifested one peak in the p-CREB level 9 h after the stimulation. Since the phosphorylation of CREB plays an important role for synaptic plasticity and consolidation of long-term memory, the impairment of CREB phosphorylation in the hippocampal CA1 region of SAMP8 may cause learning and memory deficits.

Effects of DHEA administration on episodic memory, cortisol and mood in healthy young men: a double-blind, placebo-controlled study

RATIONALE

Dehydroepiandrosterone (DHEA) has been reported to enhance cognition in rodents, although there are inconsistent findings in humans.

OBJECTIVES

The aim of this study was to investigate the effects of DHEA administration in healthy young men on episodic memory and its neural correlates utilising an event-related potential (ERP) technique.

METHODS

Twenty-four healthy young men were treated with a 7-day course of oral DHEA (150 mg b.d.) or placebo in a double blind, random, crossover and balanced order design. Subjective mood and memory were measured using visual analogue scales (VASs). Cortisol concentrations were measured in saliva samples. ERPs were recorded during retrieval in an episodic memory test. Low-resolution brain electromagnetic tomography (LORETA) was used to identify brain regions involved in the cognitive task.

RESULTS

DHEA administration led to a reduction in evening cortisol concentrations and improved VAS mood and memory. Recollection accuracy in the episodic memory test was significantly improved following DHEA administration. LORETA revealed significant hippocampal activation associated with successful episodic memory retrieval following placebo. DHEA modified ERPs associated with retrieval and led to a trend towards an early differential activation of the anterior cingulate cortex (ACC).

CONCLUSIONS

DHEA treatment improved memory recollection and mood and decreased trough cortisol levels. The effect of DHEA appears to be via neuronal recruitment of the steroid sensitive ACC that may be involved in pre-hippocampal memory processing. These findings are distinctive, being the first to show such beneficial effects of DHEA on memory in healthy young men.

Dehydroepiandrosterone sulfate (DHEA-S) and Alzheimer's dementia in older subjects

OBJECTIVES AND METHODS

We investigated the association of serum dehydroepiandrosterone sulfate (DHEA-S) levels with dementia of Alzheimer's type (DAT) and impairment in selected cognitive domains (memory, language, attention and working memory) in 158 patients (75.5+/-6.7 years, 46 men) with first-diagnosed probable DAT and in 158 age- and sex-matched controls. As secondary goal, we evaluated whether DHEA-S baseline levels were associated with cumulative 6-year mortality.

RESULTS

A negative correlation between DHEA-S levels and age was observed (R=-0.25, p<0.001). Age-stratified analysis did not show significant differences of DHEA-S levels between DAT patients and controls. No significant association was found between DHEA-S levels and impairment in selected cognitive domains. Cox regression analysis showed that baseline DHEA-S levels were not associated with cumulative 6-year mortality.

CONCLUSIONS

In a sample of newly-diagnosed DAT patients, we did not find significant association between presence of DAT or impairment in cognitive domains and DHEA-S levels; baseline DHEA-S levels are not associated with cumulative mortality in patients and controls.

Physiologic aspects of aging: impact on cancer management and decision making, part II

In this second article of our two-part review, we focus on age-associated physiologic changes involving the nervous, endocrine, hematologic, immune, and musculoskeletal systems, with close attention to the interconnected nature of these systems. There is a well-known connection between the neuroendocrine and immune systems via the hypothalamic-pituitary-adrenal axis and via interaction by means of cytokines, hormones, and neurotransmitters. These changes may lead to a loss of integration and resiliency with age, thus decreasing the ability of the elderly patient with cancer to adapt to stressful circumstances. Prominent changes include decline in memory and cognition, and increased susceptibility to peripheral neuropathy. Hematologic and immune changes like reduced bone marrow reserve and increased susceptibility to infections have far reaching implications for cancer care in the elderly. Gradual decline in hormone levels, and changes in muscle and body composition, can lead to functional decline and frailty. Use of the clinical interventions suggested in this article, along with an appreciation of the interplay of these age-related physiologic changes and their consequences, allows oncology professionals to customize therapy and minimize side effects in the geriatric oncology patient.

Relationship between cortisol and age-related memory impairments in Holocaust survivors with PTSD

RATIONALE

Holocaust survivors with PTSD appear to show an accelerated aging effect as evidenced by their performance on tests of explicit memory, and also show more exaggerated patterns on age-related alterations in cortisol release over the diurnal cycle than Holocaust survivors without PTSD and nonexposed subjects. To investigate the implications of age-related HPA axis alterations on cognition, we examined correlations between parameters reflecting circadian cortisol release and implicit and explicit memory performance.

METHODS

Nineteen Holocaust survivors with PTSD (7 men, 12 women), 16 Holocaust survivors without PTSD (7 men, 9 women), and 28 non-exposed healthy comparison subjects (13 men, 15 women) collected salivary samples at six times over the diurnal cycle, and were tested with Paired Associates and Word Stem Completion Tests.

RESULTS

Negative correlations were observed between several measures of salivary cortisol concentrations and explicit memory in Holocaust survivors with PTSD after adjusting for IQ, years of education and current age reflecting poorer performance in association with higher cortisol levels. This relationship was absent in Holocaust survivors without PTSD and in demographically-comparable subjects who were not exposed to the Holocaust or other extremely traumatic events.

CONCLUSION

The significantly different relationship between cortisol and memory performance in these groups suggests that the neuropsychological impairments observed in Holocaust survivors with PTSD may reflect an interaction of PTSD and aging effects.

The Use of Dehydroepiandrosterone Therapy in Clinical Practice

Dehydroepiandrosterone (DHEA) therapy is controversial due to sensationalized reports of epidemiologic studies and the over-the-counter availability of DHEA. Human clinical trials have investigated the potential efficacy of DHEA therapy in multiple conditions with resultant inconsistencies in findings. DHEA is unique compared with other adrenal steroids because of the fluctuation in serum levels found from birth into advancing age. The lower endogenous levels of DHEA and DHEA sulfate found in advancing age have been correlated with a myriad of health conditions. Also, some studies suggest gender-specific actions of endogenous and exogenous DHEA. We reviewed only pharmacokinetic studies and human clinical trials investigating the efficacy of DHEA therapy that were placebo-controlled as these provided the most reliable scientific basis for the evaluation of DHEA therapy. Pharmacodynamic studies suggest that doses of 30-50mg of oral DHEA may produce physiologic androgen levels, especially in women. These studies report a dose-dependent effect and lack of accumulation of serum androgen levels. Pharmacologic studies also reveal a gender-specific response to DHEA therapy such that testosterone levels are increased in women but not in men. Clinical trials suggest that 50mg of oral DHEA, but not <30mg, can increase serum androgen levels to within the physiologic range for young adults with primary and secondary adrenal insufficiency, possibly improve sexual function, improve mood and self-esteem, and decrease fatigue/exhaustion. Whereas DHEA replacement therapy may be effective in treating patients with adrenal insufficiency, human clinical trials investigating its efficacy in conditions such as systemic lupus erythematosus, HIV, Alzheimer disease, advancing age, male sexual dysfunction, perimenopausal symptoms, depression, and cardiovascular disease have not provided consistent findings.

DHEAS as a new diagnostic tool

Dehydroepiandrosterone sulfate (DHEAS) is a 19-carbon steroid, situated along the steroid metabolic pathway. It is the most abundant circulating steroid hormone in the body and can be converted to either androgens or estrogens. Their physiological and pathological functions have not yet been fully identified. Serum DHEAS concentrations peak at around age 25 years and then decline steadily over the following decades. Due to its long half-life and high concentration in the blood, the levels of DHEAS remain the same 24 h a day. This makes DHEAS a very interesting new diagnostic tool for both scientific research and clinical diagnostics. Moreover, circulating concentrations of DHEAS can be changed by many factors, such as endogenous production, hormone supplementation, many kinds of drugs, and many types of disease states. As research moves forward to better understand the relationships of DHEAS with health and disease, it is essential that studies should be designed to control for the influence of many factors on serum DHEAS concentrations.

Steroid hormones and neurosteroids in normal and pathological aging of the nervous system

Without medical progress, dementing diseases such as Alzheimer's disease will become one of the main causes of disability. Preventing or delaying them has thus become a real challenge for biomedical research. Steroids offer interesting therapeutical opportunities for promoting successful aging because of their pleiotropic effects in the nervous system: they regulate main neurotransmitter systems, promote the viability of neurons, play an important role in myelination and influence cognitive processes, in particular learning and memory. Preclinical research has provided evidence that the normally aging nervous system maintains some capacity for regeneration and that age-dependent changes in the nervous system and cognitive dysfunctions can be reversed to some extent by the administration of steroids. The aging nervous system also remains sensitive to the neuroprotective effects of steroids. In contrast to the large number of studies documenting beneficial effects of steroids on the nervous system in young and aged animals, the results from hormone replacement studies in the elderly are so far not conclusive. There is also little information concerning changes of steroid levels in the aging human brain. As steroids present in nervous tissues originate from the endocrine glands (steroid hormones) and from local synthesis (neurosteroids), changes in blood levels of steroids with age do not necessarily reflect changes in their brain levels. There is indeed strong evidence that neurosteroids are also synthesized in human brain and peripheral nerves. The development of a very sensitive and precise method for the analysis of steroids by gas chromatography/mass spectrometry (GC/MS) offers new possibilities for the study of neurosteroids. The concentrations of a range of neurosteroids have recently been measured in various brain regions of aged Alzheimer's disease patients and aged non-demented controls by GC/MS, providing reference values. In Alzheimer's patients, there was a general trend toward lower levels of neurosteroids in different brain regions, and neurosteroid levels were negatively correlated with two biochemical markers of Alzheimer's disease, the phosphorylated tau protein and the beta-amyloid peptides. The metabolism of dehydroepiandrosterone has also been analyzed for the first time in the aging brain from Alzheimer patients and non-demented controls. The conversion of dehydroepiandrosterone to Delta5-androstene-3beta,17beta-diol and to 7alpha-OH-dehydroepiandrosterone occurred in frontal cortex, hippocampus, amygdala, cerebellum and striatum of both Alzheimer's patients and controls. The formation of these metabolites within distinct brain regions negatively correlated with the density of beta-amyloid deposits.

In vitro metabolism of dehydroepiandrosterone (DHEA) to 7alpha-hydroxy-DHEA and Delta5-androstene-3beta,17beta-diol in specific regions of the aging brain from Alzheimer's and non-demented patients

The description of dehydroepiandrosterone (DHEA) as a neuroactive neurosteroid has raised the important question of whether the steroid itself and/or its metabolite(s) are active in the brain. Classical transformations of DHEA in brain and peripheral tissues include its conversion to testosterone and estradiol. In the human brain, the metabolism of DHEA to other metabolites is still poorly understood, particularly in aging people and Alzheimer's patients. The present study describes the in vitro transformation of DHEA into 7alpha-hydroxy-DHEA and Delta5-androstene-3beta,17beta-diol, for the first time in the aging brain of patients with Alzheimer's disease in comparison with non-demented controls. Formal identification of DHEA metabolites is provided by gas chromatography-mass spectrometry, thus indicating the presence of NADPH-dependent 7alpha-hydroxylase and 17beta-hydroxysteroid oxidoreductase activities. Under our experimental conditions, the synthesis of 7alpha-hydroxy-DHEA and Delta5-androstene-3beta,17beta-diol occurs in the frontal cortex, hippocampus, amygdala, cerebellum and striatum of both Alzheimer's patients and non-demented controls. In both groups of patients, the pattern of DHEA metabolism is similar, but significant higher synthesis of 7alpha-hydroxy-DHEA in the frontal cortex and Delta5-androstene-3beta,17beta-diol in the cerebellum and striatum were observed compared with those in other brain regions. In addition, a trend toward a significant negative correlation is found between the density of cortical amyloid deposits and the amount of 7alpha-hydroxy-DHEA formed in the frontal cortex and that of Delta5-androstene-3beta,17beta-diol in the hippocampus. Therefore, the biosynthesis of 7alpha-hydroxy-DHEA and/or Delta5-androstene-3beta,17beta-diol is likely to regulate DHEA cerebral concentrations and may contribute to the control of DHEA activity in the aging brain including in Alzheimer's disease.

Cortisol and dehydroepiandosterone sulfate plasma levels and their relationship to aging, cognitive function, and dementia

We have studied the relationship between dehydroepiandrosterone sulfate (DHEAS), cortisol, and cognitive function in a population of demented patients (n=29), age-matched controls (n=46), and younger subjects (n=11). All were submitted to morning collection of blood for determination of plasma cortisol and DHEAS measured by 125I radioimmunoassay. DHEAS levels and cortisol/DHEAS ratios were significantly different among groups with higher DHEAS levels and lower cortisol/DHEAS ratios in younger people (Bonferroni p<.05). Cortisol levels were associated to the presence of dementia (Odds ratio=.93; 95% CI,.86-1.01). There was no difference between DHEAS levels of demented and age-matched controls; however, demented patients showed a trend for higher cortisol/DHEAS ratios than age-matched controls and the latter showed higher ratio values than younger subjects. DHEAS and cortisol plasma values were significantly correlated in all individuals (p<.01). In this study cortisol was independently associated to the presence of dementia.

Neurosteroid quantification in human brain regions: comparison between Alzheimer's and nondemented patients

Some neurosteroids have been shown to display beneficial effects on neuroprotection in rodents. To investigate the physiopathological significance of neurosteroids in Alzheimer's disease (AD), we compared the concentrations of pregnenolone, pregnenolone sulfate (PREGS), dehydroepiandrosterone, dehydroepiandrosterone sulfate (DHEAS), progesterone, and allopregnanolone, measured by gas chromatography-mass spectrometry, in individual brain regions of AD patients and aged nondemented controls, including hippocampus, amygdala, frontal cortex, striatum, hypothalamus, and cerebellum. A general trend toward decreased levels of all steroids was observed in all AD patients' brain regions compared with controls: PREGS and DHEAS were significantly lower in the striatum and cerebellum, and DHEAS was also significantly reduced in the hypothalamus. A significant negative correlation was found between the levels of cortical beta-amyloid peptides and those of PREGS in the striatum and cerebellum and between the levels of phosphorylated tau proteins and DHEAS in the hypothalamus. This study provides reference values for steroid concentrations determined by gas chromatography-mass spectrometry in various regions of the aged human brain. High levels of key proteins implicated in the formation of plaques and neurofibrillary tangles were correlated with decreased brain levels of PREGS and DHEAS, suggesting a possible neuroprotective role of these neurosteroids in AD.

Involvement of steroids and cytochromes P(450) species in the triggering of immune defenses

In vertebrates the wide variety of cytochromes P(450) (P(450)) is a key for elimination of low molecular weight xenobiotics and for the production and metabolism of steroid hormones. In contrast, xenobiotics of large molecular weight are processed and eliminated after the immune response. The suppression of immune response by native P(450)-produced glucocorticoid (GC) hormones constitutes a first link between P(450) and immunity. In the last decade, mechanisms and molecules responsible for the triggering of immune response were investigated and results showed that many tissues and organs transform native 3beta-hydroxysteroids into 7-hydroxylated metabolites that trigger immunity. Present data suggest that 7-hydroxysteroids are native anti-GCs that block the GC-induced immunosuppression. Because specific P(450) are responsible for the production of 7-hydroxylated steroids resulting into increased immunity, a second link exists between P(450) and immunity. Taken together, these findings support the proposal that P(450) are keys to all of the known defense mechanisms of vertebrates against all xenobiotic forms.

Dehydroepiandrosterone sulphate prevents oxygen-glucose deprivation-induced injury in cerebellar granule cell culture

Decreased levels of dehydroepiandrosterone sulphate have been hypothesized to contribute to increased vulnerability of the ageing or stressed human brain to ischemia. To help to address the question of whether of dehydroepiandrosterone sulphate has a possible neuroprotective effect against ischemic neuronal injury, we tested its effect on the neurodegeneration induced by oxygen-glucose deprivation in rat cultured cerebellar granule cells. Dehydroepiandrosterone sulphate added to the medium after injury demonstrated a neuroprotective effect with a median inhibitory concentration of 0.5 microM. At 10 microM concentration almost full neuroprotection was observed. Even more pronounced neuroprotective effect was found when dehydroepiandrosterone sulphate was added for 48h before injury. Furthermore, partial neuroprotection of dehydroepiandrosterone sulphate was also found against 1-methyl-4-phenylpyridinium, colchicine, glutamate and N-methyl-D-aspartate-induced toxicity. Further analysis demonstrated that dehydroepiandrosterone sulphate eliminated the apoptotic features of the oxygen-glucose deprivation-induced neuronal death: DNA fragmentation and nuclear condensation/fragmentation.Thus, our data suggest that dehydroepiandrosterone sulphate may have therapeutic potential in the prevention and treatment of ischemic/hypoxic neuronal damage. The neuroprotective action of dehydroepiandrosterone sulphate was inhibited by both a GABA(A) receptor-linked chloride channel agonist and an antagonist, pentobarbital and picrotoxin, respectively. It seems that GABA(A) receptor-mediated neuronal inhibition as well as neuronal excitation can reduce the neuroprotective action of dehydroepiandrosterone sulphate.

Effect of dehydroepiandrosterone and its sulfate and fatty acid ester derivatives on rat brain membranes

The effects of dehydroepiandrosterone (DHEA) as well as its sulfate and fatty acid ester derivatives on rat brain membrane fluidity was investigated by fluorescence depolarization of a lipid probe 1,6-diphenyl-1,3,5-hexatriene and compared to its effect on phospholipid conformation investigated by Fourier transform infrared spectroscopy. In rat brain, membrane fluidity varied rostro-caudally, the frontal cortex showing the highest fluidity compared to the hypothalamus, hippocampus, striatum, thalamus, and hindbrain. As previously reported, it was observed that cholesteryl hemisuccinate and stearic acid rigidify striatal membrane whereas linoleic acid and L-alpha-phosphatidylcholine increase the membrane fluidity. Striatal fluidity was increased in vitro with increasing concentrations of DHEA, this effect was greater with the DHEA fatty acid ester derivatives (DHEA-L), DHEA-undecanoate, and DHEA-stearate, whereas no effect was observed with DHEA-sulfate (DHEA-S). In the frontal cortex only the two DHEA-L derivatives increased membrane fluidity, whereas DHEA and DHEA-S were without effect. The effect of DHEA-L on synthetic dimyristoylphosphatidylcholine-d54 phospholipid membranes indicates a disordering effect of DHEA-undecanoate and DHEA-stearate as reflected by increased trans-gauche isomerization of the acyl chains of the lipid. Hence, DHEA-L increase the disorder and/or fluidity of brain membranes; interestingly, these compounds are abundant in the brain where they are generally considered as storage compounds that slowly release the active unconjugated steroid hormone.

Actions of dehydroepiandrosterone and its sulfate in the central nervous system: effects on cognition and emotion in animals and humans

Dehydroepiandrosterone (DHEA) and its sulfate ester, DHEAS, exert multiple effects in the rodent central nervous system (CNS). Most of them seem to be mediated through their non-genomic action on several neurotransmitter receptors. DHEA(S) increases neuronal excitability, enhances neuronal plasticity and also has neuroprotective properties. In line with these observations DHEA(S) treatment in rodents enhances memory in several paradigms. Even more studies show antiamnestic effects of the steroids. However, DHEA(S) has also anxiolytic and anti-aggressive properties. In humans cross-sectional and longitudinal studies suggest that DHEAS might be associated with global measures of well-being and functioning; however, a relationship with cognition could not be detected to date. Moreover, studies investigating DHEAS levels in neurodegenerative diseases have produced conflicting results. Experimental studies in elderly humans have revealed preliminary evidence for mood enhancing and antidepressant effects of DHEA treatment, while positive effects on measures of memory and attention could not be found. However, electrophysiological studies demonstrated that DHEA treatment has effects on the human CNS. Several reasons for the discrepancy between data obtained in rodents and humans are discussed and research perspectives are outlined which might help to improve interpretation of results obtained in the two species.

Relationships between dehydroepiandrosterone sulfate (DHEAS) and cortisol (CRT) plasma levels and everyday memory in Alzheimer's disease patients compared to healthy controls

Fifty-two age-matched Alzheimer's disease (AD) patients (26 men, 26 women), mean age 76.2 years, were assessed with the Rivermead Behavioural Memory Test, a test of everyday memory, coincident with the measurement of plasma cortisol (CRT) and dehydroepiandrosterone sulfate (DHEAS) via radioimmunoassay. The AD patients were compared to a control group of age- and gender-matched healthy elderly men and women. No differences were found between the AD patients and the controls in DHEAS or CRT levels, or in the DHEAS/CRT ratio. There were no gender differences in DHEAS or CRT levels, or in the DHEAS/CRT ratio in subjects with AD. However, AD patients with higher levels of DHEAS scored better than those with lower levels on the subtests of Remembering a Name associated with a picture, Digit Span Total and Forward, and the Mini Mental Status Exam. AD patients with higher CRT levels performed worse on Delayed Route Recall than those with lower levels. These findings suggest that AD patients with higher endogenous levels of DHEAS may perform better on some memory tasks than those with lower levels, while AD patients with lower levels of CRT may perform better than those with higher CRT.

Relationships among cortisol (CRT), dehydroepiandrosterone-sulfate (DHEAS), and memory in a longitudinal study of healthy elderly men and women

At test times 18 months apart (Time 1 and Time 2), men (n Time 1 = 31, Time 2 = 23), women estrogen-users (n Time 1 = 14, Time 2 = 10), and women estrogen non-users (n Time 1 = 41, Time 2 = 27), whose average age was 72.1 and 73.4 years at Time 1 and Time 2, respectively, were tested with a battery of neuropsychological tests measuring verbal memory, visual memory, concentration/attention, language fluency and semantic memory. Plasma levels of CRT and DHEAS were assayed by radioimmunoassay at both test times. The men had higher DHEAS levels than both groups of women at both test times (p < 0.001) and also had a higher DHEAS/CRT ratio compared to the estrogen non-users (p < 0.05). Although there were no group differences in CRT levels at either time, CRT levels increased in the estrogen non-using women from Time 1 to Time 2 (p < 0.001). Subjects with lower CRT levels performed better than those with higher levels on several tests of declarative memory (p < 0.05). Men and estrogen-users had higher Digit Span scores compared to female estrogen non-users at both test times (p < 0.01), and women estrogen-users also had higher Backward Digit Span scores than non-users (p < 0.05). Both groups of women performed better than men on Category Retrieval (p < 0.01). These findings suggest that higher CRT levels in elderly men and women are associated with poorer explicit memory functioning; however, these results failed to provide any evidence that DHEAS is protective against declarative memory decline with aging.

Activation of 11 beta-hydroxysteroid dehydrogenase by dehydroepiandrosterone sulphate as an anti-hypertensive agent in spontaneously hypertensive rats

The anti-hypertensive properties of dehydroepiandrosterone sulphate (DHEAS) have been investigated by studying its effects on blood pressure, on serum concentrations of corticosterone and dehydrocorticosterone, and on 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD) activity in spontaneously hypertensive rats (SHR). SHR were given intraperitoneal injections of DHEAS (10 mg day-1 for 70 days) from six to 16 weeks of age. The blood pressure-time curve was significantly (P < 0.05) suppressed immediately after administration of DHEAS. There was no difference between the heart rates of control and DHEAS groups. Serum concentrations of corticosterone and dehydrocorticosterone in the DHEAS group were significantly (P < 0.05) lower than those of the control group. The dehydrocorticosterone/corticosterone concentration ratio was, however, significantly (P < 0.05) higher in the DHEAS group, suggesting that treatment with DHEAS enhanced the overall interconversion of corticosterone to dehydrocorticosterone. The activity of 11 beta-HSD in specific organs of the DHEAS group was affected, characteristic changes being increases in the kidney (14-58%), decreases in the liver (11-27%) and no change in the testis. Direct addition of DHEAS to 11 beta-HSD preparations from the kidneys of control SHR had the same effect as that observed in the in-vivo experiments. The fall in serum corticosterone in the DHEAS group is considered to be related, at least partly, to increased activity of kidney 11 beta-HSD. The inverse correlation of kidney 11 beta-HSD activity with serum corticosterone and blood pressure (-r = 0.628, P < 0.01, and -r = 0.478, P < 0.05, respectively) suggest that DHEAS delayed the development of hypertension in SHR by selective promotion of kidney 11 beta-HSD activity which in turn resulted in lower serum concentrations of corticosterone and its minimal aldosterone-like activity.

Steroid hormones, memory and mood in a healthy elderly population

Men (n = 31), women estrogen-users (n = 14), and women estrogen non-users (n = 41), whose average age was 72.1 +/- 5.6 years, were tested with a battery of psychological tests measuring verbal memory, visual memory, concentration and attention, language fluency and semantic memory, and mood. Plasma levels of testosterone (T), estradiol (E2), cortisol (CRT) and dehydroepiandrosterone-sulfate (DHEAS) were assessed by radioimmunoassay. The ratio of DHEAS to CRT was calculated to determine it's relationship to memory functioning. The men had higher T and DHEAS levels than both groups of women. Women estrogen-users had higher E2 levels than both men and estrogen non-users and the men had higher E2 levels and a higher DHEAS/CRT ratio than the estrogen non-users. There were no group differences in CRT levels. Men and estrogen-users had higher total (p < .01) and forward (p < .001) digit span scores compared with non-users. Women estrogen-users also had higher backward digit span scores than non-users (p < .05), while both groups of women performed better than men on category retrieval (p < .01). The implications of these findings with respect to hormonal influences on memory in elderly men and women are discussed.

Interaction of dehydroepiandrosterone with phospholipid membranes: an infrared spectroscopy investigation

The interaction between dehydroepiandrosterone (DHEA) and its sulfate metabolite (DHEA-S) with deuterated dimirystoylphosphatidylcholine (DMPC-d54) was investigated by FTIR spectroscopy. DHEA, as cholesterol, induces some conformational order in the liquid-crystalline phase of DMPC-d54. Attenuated total reflectance (ATR) measurements performed on oriented DMPC-d54/steroids samples have shown that in the gel phase, the acyl chains of DMPC-d54 become more normal to the bilayer surface in the presence of DHEA or cholesterol. On the other hand, DHEA-S increases the number of gauche conformers along the hydrocarbon chains of DMPC-d54. No evidence for the presence of hydrogen bond was found between both steroids and the 13C labeled carbonyl group of hydrated DMPC.

Dehydroepiandrosterone (DHEA) and aging

Dehydroepiandrosterone sulfate (DHEAS) is the most abundant circulating steroid hormone in humans and can readily be converted to its parent steroid DHEA by tissue sulfatases. Yet, a biologic function for these steroids has not been defined. The link between DHEA and aging has been raised by: (1) its well documented age-related decline, and (2) a preventive effect of DHEA on numerous age-related illnesses: ischemic heart-disease, cognitive impairment, immunodeficiency, malignancies, osteoporosis. These effects have been suggested by epidemiological studies in humans. Animal studies support a protective effect of DHEA on these age-related diseases. However, it remains unknown whether these results in animals can be transposed in humans, because adrenal secretion of DHEA seems to be particular to primates. In humans, only a few studies have been performed. The effects of oral supplementation with DHEA have, so far, focused on the possible metabolic effects of DHEA. A few studies have shown: the absence of any side-effects; no change in body-weight; conflicting results on body-composition and lipids and no effect on insulin-tolerance. The latest study showed a beneficial effect on well-being but these results need to be confirmed.

Serum dehydroepiandrosterone and cortisol measurements in Huntington's chorea

Serum levels of dehydroepiandrosterone sulfate (DHEAS), known to antagonize metabolic effects of glucocorticoids in animals, and cortisol (CRT), already shown to be related to cognitive dysfunction in man and animals, were measured in 11 drug-free male subjects with definite Huntington's chorea (HC) and in 25 age-matched male normal controls. Statistical difference was found between DHEAS serum levels (p < 0.05), CRT levels (p < 0.05) and the DHEAS/CRT ratio (p < 0.01) of HC subjects and normal individuals. These findings may indicate a dysfunction of the hypothalamic-pituitary-adrenal axis (HPAA) and possibly suggest a role of DHEAS as an antiglucocorticoid in HC.