Saliva versus serum estradiol: implications for research studies using postmenopausal women

Gonads under stress: A systematic review and meta-analysis on the effects of acute psychosocial stress on gonadal steroids secretion in humans

Animal research has shown that the hypothalamus-pituitary-gonadal (HPG) axis is inhibited by (chronic and/or severe) stress, which can lead to impaired fertility and reproductive functioning, presumably caused by the inhibition of gonadal steroid secretion and in interactions with glucocorticoids. However, what has not been clarified is how acute psychosocial stress modulates gonadal steroid secretion in humans. Here we summarize the experimental research on the acute effects of stress on the secretion of gonadal steroids in humans. A systematic literature search revealed 21 studies (with N=881 individuals) measuring testosterone, progesterone or estradiol in response to a standardized acute laboratory stressor in healthy humans. Both our literature review and quantitative meta-analysis suggest that in humans, acute stress stimulates rather than inhibits HPG axis activity, although there is a considerable heterogeneity in the reported methods and results. Increased gonadal steroids in response to acute stress contrasts with many animal studies reporting the opposite pattern, at least regarding severe and/or chronic stressors. We discuss methodological issues and challenges for future research and hope to stimulate experimental studies within this area. A better understanding of these mechanisms is needed, and may have important implications for health and disease, as well as the modulation of various behaviors by acute stressors.

Endogenous estrogen metabolites as oxidative stress mediators and endometrial cancer biomarkers

BACKGROUND

Endometrial cancer is the most common gynecologic malignancy found in developed countries. Because therapy can be curative at first, early detection and diagnosis are crucial for successful treatment. Early diagnosis allows patients to avoid radical therapies and offers conservative management options. There are currently no proven biomarkers that predict the risk of disease occurrence, enable early identification or support prognostic evaluation. Consequently, there is increasing interest in discovering sensitive and specific biomarkers for the detection of endometrial cancer using noninvasive approaches.

CONTENT

Hormonal imbalance caused by unopposed estrogen affects the expression of genes involved in cell proliferation and apoptosis, which can lead to uncontrolled cell growth and carcinogenesis. In addition, due to their ability to cause oxidative stress, estradiol metabolites have both carcinogenic and anticarcinogenic properties. Catechol estrogens are converted to reactive quinones, resulting in oxidative DNA damage that can initiate the carcinogenic process. The molecular anticancer mechanisms are still not fully understood, but it has been established that some estradiol metabolites generate reactive oxygen species and reactive nitrogen species, resulting in nitro-oxidative stress that causes cancer cell cycle arrest or cell death. Therefore, identifying biomarkers that reflect this hormonal imbalance and the presence of endometrial cancer in minimally invasive or noninvasive samples such as blood or urine could significantly improve early detection and treatment outcomes.

Analyzing the atypical - Methods for studying the menstrual cycle in adolescents

BACKGROUND

The female pubertal transition is characterized by a rapidly changing hormone milieu, which is heavily influenced by the first menstrual cycle - menarche. The first year following menarche is associated with menstrual cycles that are irregular and anovulatory. Peripuberty also marks the beginning of a female-biased risk for suicidality and depression, suggesting some influence by the menstrual cycle and ovarian hormone fluctuations. However, there are limited methods and guidelines for studying the menstrual cycle and related affective symptoms in this developmental window. Thus, this study's objective was to identify the most accurate methods for detecting ovulation in irregular cycles (Part 1) and develop guidelines based on these methods for determining menstrual cycle phases. These methods were applied to investigate hormones and affective symptoms based on cycle phase and ovulation status in a sample of peripubertal females (Part 2).

METHODS

Thirty-two peripubertal females (ages 11-14) provided daily urine samples of estrogen (E1G) and progesterone (PdG) metabolites and luteinizing hormone (LH), and ratings of affective symptoms for one menstrual cycle. Ten literature-derived methods for determining the presence of an LH-peak or PdG rise were compared, focusing on their feasibility for psychological research.

RESULTS

Methods by Sun et al. (2019) and Park et al. (2007) most accurately detected PdG rises and LH peaks in this sample, identifying 40.6% of cycles as ovulatory. As expected, ovulatory participants showed greater LH in the periovulatory phase (p = .001), greater PdG in the mid-luteal phase (p < .0001), and greater E1G in the periovulatory phase (p = .001) compared with anovulatory participants. Exemplary methods to compare psychological symptoms between both groups are provided.

CONCLUSIONS

Recommendations and guidelines for studying the menstrual cycle in irregular cycling adolescents are offered. Novel methods for ovulation detection identified phase-specific hormonal patterns in anovulatory and ovulatory adolescent cycles.

Association Between Estradiol and Human Aggression: A Systematic Review and Meta-Analysis

OBJECTIVE

Although several studies have examined the association between estradiol and human aggression, a consistent understanding of their correlation has yet to be established. This study aimed to investigate this relationship comprehensively.

METHODS

We systematically searched five English databases (PubMed, Web of Science, EMBASE, Cochrane Library, and CINAHL) from their inception to June 5, 2023. Two authors independently screened publications and extracted data based on predefined inclusion and exclusion criteria. Statistical analyses were performed using Review Manager 5.4, and a random-effects model was used to pool the data.

RESULTS

We identified 14 eligible studies comprising data from 1820 participants that met the inclusion criteria. This meta-analysis indicated a positive correlation between estradiol and human aggression, albeit a weak one. The pooled Fisher z value was 0.16 (95% confidence interval = 0.05-0.26; I2 = 73%, p <.00001). Furthermore, we found that participants' sex and age, the measures of aggression, and the literature quality might be sources of heterogeneity.

CONCLUSIONS

Human aggression exhibited a weak positive correlation with estradiol concentration, whereas this relationship was influenced by participants' sex and age, the measure of aggression used, and the quality assessment of the literature. Gaining a better understanding of the association between estradiol and aggression could aid in the identification of populations prone to aggression.

Within-person changes in reproductive hormones and cognition in the menopause transition

OBJECTIVES

Most women complain of cognitive deficits in the menopause transition, though the cause is unclear. The current study investigated the role that within-person changes in reproductive hormones, particularly estradiol, may play in triggering such perimenopausal cognitive difficulties.

STUDY DESIGN

Participants were 43 women aged 45-55 years and currently in the menopause transition. Once a week for 12 weeks, participants provided a urine sample for the measurement of estrone glucuronide (E1G), a urinary metabolite of estradiol. Every three weeks across the 12-week period, participants also underwent cognitive testing, including assessments of immediate and delayed memory, attention, and executive function, and completed questionnaires assessing subjective cognitive performance. Potential confounding variables including sleep quality, vasomotor symptoms, and depressive symptoms were also assessed.

RESULTS

Within-person E1G was positively associated with objective measures of attention, particularly the ability to passively register auditory information on the first pass, as well as subjective measures of memory, specifically relating to a lower frequency of forgetting things in everyday life. Perimenopausal women with lower estimated levels of intellectual functioning furthermore exhibited a stronger relationship between E1G changes and objective cognitive performance. While depressive mood, poor sleep, and vasomotor symptoms were all negatively associated with at least one aspect of cognitive function, the E1G-cognition relationship was not explained by these factors.

CONCLUSIONS

This study provides evidence that validates perimenopausal women's cognitive complaints but also suggests that cognitive deficits are generally mild and transient.

Not within spitting distance: Salivary immunoassays of estradiol have subpar validity for predicting cycle phase

Salivary steroid immunoassays are widely used in psychoneuroendocrinological studies of menstrual cycle phase, puberty, and menopause. Though manufacturers advertise their assays as suitable, they have not been rigorously validated for these purposes. We collated data from eight menstrual cycle studies across > 1200 female participants and > 9500 time points. Seven studies collected saliva and one collected serum. All assayed estradiol and progesterone and had an independent measure of cycle phase (LH-surge, menstrual onset). In serum, cycle phase measures strongly predicted steroid concentrations. In saliva, cycle phase poorly predicted estradiol values, which showed an upward bias compared to expectations from serum. For salivary progesterone, predictability from cycle phase was mixed, low for enzyme-linked assays and moderate for tandem mass spectrometry. Imputing the population-average serum steroid changes from cycle phase may yield more valid values of hormonal changes for an independent person than directly assessing their hormone levels using salivary immunoassays.

Correlations between salivary- and blood-derived gonadal hormone assessments and implications for inclusion of female participants in research studies

Even in the 21st century, female participants continue to be underrepresented in human physiology research. This underrepresentation is attributable in part to the perception that the inclusion of females is more time consuming, less convenient, and more expensive relative to males because of the need to account for the menstrual cycle in cardiovascular study designs. Accounting for menstrual cycle-induced fluctuations in gonadal hormones is important, given established roles in governing vascular function and evidence that failure to consider gonadal hormone fluctuations can result in misinterpretations of biomarkers of cardiovascular disease. Thus, for cardiovascular researchers, the inclusion of females in research studies implies a necessity to predict, quantify, and/or track indexes of menstrual cycle-induced changes in hormones. It is here that methodologies are lacking. Gold standard measurement requires venous blood samples, but this technique is invasive and can become both expensive and technically preclusive when serial measurements are required. To this end, saliva-derived measures of gonadal hormones provide a means of simple, noninvasive hormone tracking. To investigate the feasibility of this technique as a means of facilitating research designs that take the menstrual cycle into account, the purpose of this review was to examine literature comparing salivary and blood concentrations of the primary gonadal hormones that fluctuate across the menstrual cycle: estradiol and progesterone. The data indicate that there appear to be valid and promising applications of salivary gonadal hormone monitoring, which may aid in the inclusion of female participants in cardiovascular research studies.

Assessment of estrogen exposure from transdermal estradiol gel therapy with a dried urine assay

Transdermal estradiol gel is a commonly used menopausal hormone therapy. In research studies investigating the pharmacokinetics and clinical utility of transdermal estradiol gels, serum is often used to measure estradiol levels. Serum results only represent a moment in time during phlebotomy and thus provide little information and allow for limited inference unless serial measurements are performed. In contrast, dried urine may provide a representation of serum estradiol levels over a longer period of time, while also being non-invasive and easier to collect. The primary aim of this study was to evaluate a dried urine method to determine if it may be a viable option for evaluating estrogen exposure resulting from transdermal estradiol gel use. A secondary aim was to explore differences in the urinary estrogen profiles of premenopausal women on no therapy and postmenopausal women who were either on transdermal estradiol gel therapy or no therapy at all. The results of this study demonstrated that the expected dose-proportional changes in estrogen exposure can be observed in the urinary estrogen profile using a GC-MS/MS dried urine assay. The GC-MS/MS assay also showed the differences in the urinary estrogen profiles of premenopausal women, postmenopausal women on estrogen replacement therapy, and postmenopausal women on no therapy.

Steroid Hormone Secretion Over the Course of the Perimenopause: Findings From the Swiss Perimenopause Study

Background: Perimenopause is characterized by a decline in the steroid hormones, estradiol, and progesterone. By contrast, the steroid hormone cortisol, a marker of the hypothalamic–pituitary–adrenal (HPA) axis, increases. Recent longitudinal studies reported fluctuations in steroid hormone levels during perimenopause, and even increases in estradiol levels. To understand these confounding results, it is necessary to conduct a longitudinal, highly standardized assessment of steroid hormone secretion patterns in perimenopausal women.

Methods: This longitudinal study investigated 127 perimenopausal women aged 40–56 years for 13 months. Estradiol, progesterone, and cortisol were assessed using saliva samples, which were collected for two (during months 2 and 12 for estradiol and progesterone) or three (during months 2, 7, and 12 for cortisol) non-consecutive months over the course of the study. A total of 14 saliva samples per participant were analyzed to investigate the courses of estradiol and progesterone. Cortisol awakening response and fluctuations of cortisol throughout the day were measured using a total of 11 saliva samples per participant (on awakening, +30 min, +60 min, at 12:00 p.m., and before going to bed) for months 2, 7, and 12.

Results: Multilevel analyses revealed variance in intercept and slope across participants for estradiol [intercept: SD = 5.16 (95% CI: 4.28, 6.21), slope: SD = 0.50 (95% CI: 0.39, 0.64)], progesterone [intercept: SD = 34.77 (95% CI: 25.55, 47.31), slope: SD = 4.17 (95% CI: 2.91, 5.99)], and cortisol (intercept: SD = 0.18 (95% CI: 0.14, 0.23), slope: SD = 0.02 (95% CI: 0.01, 0.02)]. Time predicted cortisol levels [b = −0.02, t₍₉₇₉₎ = −6.63, p < 0.0001]. Perimenopausal status (early vs. late) did not predict estradiol [b = −0.36, t₍₁₆₀₈₎ = −0.84, p = 0.400], progesterone [b = −4.55, t₍₁₇₂₃₎ = −0.87, p = 0.385], or cortisol [b = 0.01, t₍₁₁₂₄₎ = 0.61, p = 0.542] scores over time.

Discussion: Our results are consistent with previous findings emphasizing highly individual fluctuations of estradiol and progesterone levels during perimenopause. However, our findings do not suggest a continuous decline during the observed transition phase, implying relatively stable periods of fluctuating hormone levels. Furthermore, given the lack of significant group differences, it may not be necessary to differentiate between early and late perimenopause from the standpoint of hormonal progression.

Changes in the Oral Cavity in Menopausal Women-A Narrative Review

Oral health awareness during the menopausal period is essential to minimize the inevitable inconveniences which may occur due to hormonal changes. The decrease in estrogen hormone concentration impacts the oral mucosa in a similar way to the vaginal mucosa due to the presence of estrogen receptors in both of these structures. An estrogen deficiency also affects the maturation process of the oral mucosal epithelium and can lead to its thinning and atrophy, making it more susceptible to local mechanical injuries, causing a change in pain tolerance and problems in the use of removable prosthetic restorations. Mucosal epithelium during the menopausal period is more vulnerable to infections, candidiasis, burning mouth syndrome, oral lichen planus (OLP), or idiopathic neuropathy. Moreover, salivary glands are also hormone-dependent which leads to changes in saliva secretion and its consistency. In consequence, it may affect teeth and periodontal tissues, resulting in an increased risk of caries and periodontal disease in menopausal women. Due to the large variety of complaints and symptoms occurring in the oral cavity, menopausal women constitute a significant group of patients who should receive special preventive and therapeutic care from doctors and dentists in this particular period.

The role of estradiol fluctuation in the pathophysiology of perimenopausal depression: A hypothesis paper

The menopause transition, which constitutes the five or so years surrounding the final menstrual period, has been established as a time of increased risk for depressive symptoms. While mounting research suggests that exposure to more extreme and fluctuating levels of estradiol (E2) plays a role, it remains unclear which specific trigger is most strongly implicated in the development of depressive mood: acute E2 withdrawal or extreme increases in E2. The current review summarises the literature supporting the role of each, considering research pertaining to perimenopausal depression as well as other reproductive mood disorders in which ovarian hormone change is believed to play a key role, namely premenstrual dysphoric disorder and postpartum depression. Taking together the available research pertaining to the various reproductive mood disorders, we propose that women may exhibit one of four E2 sensitivity profiles, each of which may have important implications for the expected timing and severity of depressive mood during the menopause transition: the E2-increase sensitive profile, developing depressive mood in response to elevations in E2, the E2-decrease sensitive profile, for whom E2 withdrawal triggers negative mood, the E2-change sensitive profile, characterised by mood sensitivity to E2 change in either direction, and the E2 insensitive profile for whom changes in E2 have negligible psychological effects. The evidence supporting the existence of such profiles are summarised, potential biological mechanisms are briefly highlighted, and implications for future research are discussed.

Endocrine and psychosocial moderators of mindfulness-based stress reduction for the prevention of perimenopausal depressive symptoms: A randomized controlled trial

BACKGROUND

The menopause transition is associated with an increased risk of depressive symptoms. The current study aimed to test whether Mindfulness-Based Stress Reduction, an 8-week group intervention involving meditation and yoga, might reduce the risk of depressive symptoms among perimenopausal women. A secondary aim was to examine baseline characteristics, including sensitivity to estradiol fluctuation, as a moderator of treatment effects.

METHODS

104 healthy women from the community in the menopause transition were enrolled and randomized to MBSR (n = 52) or a waitlist control condition (n = 52). Randomization was carried out using a random number generator and opaque sealed envelopes. Depressive symptoms, the main outcome, were assessed every two weeks for 6 months using the Center for Epidemiologic Studies Depression Scale (CES-D). The occurrence of an elevated CES-D score (≥16) and of a major depressive episode were pre-identified secondary outcomes. The following surveys were used to assess additional outcomes of interest every two months: the Perceived Stress Scale, Spielberger Trait Anxiety Inventory, Connor-Davidson Resilience Scale, and Pittsburgh Sleep Quality Index. Baseline characteristics examined as potential moderators of treatment benefit included: baseline CES-D score, past depressive episodes, recent stressful life events, a history of physical or sexual abuse, and emotional sensitivity to reproductive hormone fluctuation. Outcome assessors were blinded to the participants' assigned treatment arm.

RESULTS

Outcome data were available for 44 women assigned to MBSR and 51 women in the waitlist condition. Women randomized to MBSR reported fewer depressive symptoms, less perceived stress, less anxiety, increased resilience, and improved sleep (ps < 0.001). Furthermore, several baseline characteristics predicted a greater mood benefit of MBSR, including: a history of major depression (p for the interaction <0.001), a greater number of recent stressful life events (p < .001), being in the early menopause transition (p = .002), and an increased emotional sensitivity to reproductive hormone fluctuation (p = .004). There were no group differences in the occurrence of major depressive episodes (p > .05).

CONCLUSIONS

MBSR appears to be an effective intervention for the prevention of depressive symptoms in the menopause transition.

Mood sensitivity to estradiol predicts depressive symptoms in the menopause transition

BACKGROUND

The risk for depression markedly rises during the 5-6 years leading up to the cessation of menstruation, known as the menopause transition. Exposure to extreme estradiol levels may help explain this increase but few studies have examined individual sensitivity to estradiol in predicting perimenopausal depression.

METHOD

The current study recruited 101 perimenopausal women. During Phase 1, we quantified each woman's sensitivity to changes in estradiol using 12 weekly measures of estrone-3-glucuronide (E1G), a urinary metabolite of estradiol, and concurrent depressive symptoms. The weekly cortisol awakening response was measured to examine the hypothalamic-pituitary-adrenal (HPA) axis in mediating mood sensitivity to estradiol. In Phase 2, depressive symptoms and major depression diagnoses were assessed monthly for 9 months. The relationship between Phase 1 E1G sensitivity and Phase 2 depressive symptoms and major depressive episodes was examined. Several baseline characteristics were examined as potential moderators of this relationship.

RESULTS

The within-person correlation between weekly E1G and mood varied greatly from woman to woman, both in strength and direction. Phase 1 E1G mood sensitivity predicted the occurrence of clinically significant depressive symptoms in Phase 2 among certain subsets of women: those without a prior history of depression, reporting a low number of baseline stressful life events, and reporting fewer months since their last menstrual period. HPA axis sensitivity to estradiol fluctuation did not predict Phase 2 outcomes.

CONCLUSION

Mood sensitivity to estradiol predicts risk for perimenopausal depression, particularly among women who are otherwise at low risk and among those who are early in the transition.

Individual variation of follicular phase changes in endothelial function across two menstrual cycles

NEW FINDINGS

What is the central question of this study? The purpose of this study was to determine intra-individual reproducibility of follicular phase changes in endothelial function (flow-mediated dilatation) over two menstrual cycles in healthy, premenopausal women. What is the main finding and its importance? Phase changes in endothelial function were not consistent at the individual level across two menstrual cycles, which challenges the utility of interpreting individual responses over one cycle.

ABSTRACT

Evidence regarding the impact of menstrual phase on endothelial function is conflicting, and studies to date have examined responses only over a single cycle. It is unknown whether the observed inter-individual variability of phase changes in endothelial function reflects stable, inter-individual differences in responses to oestrogen (E₂ ; a primary female sex hormone). The purpose of this study was to examine changes in endothelial function from the early follicular (EF; low-E₂ ) phase to the late follicular (LF; high-E₂ ) phase over two consecutive cycles. Fourteen healthy, regularly menstruating women [22 ± 3 years of age (mean ± SD)] participated in four visits (EF_Visit 1 , LF_Visit 2 , EF_Visit 3 and LF_Visit 4 ) over two cycles. Ovulation testing was used to determine the time between the LF visit and ovulation. During each visit, endothelial function [brachial artery flow-mediated dilatation (FMD)], E₂ and progesterone were assessed. At the group level, there was no impact of phase or cycle on FMD (P = 0.48 and P = 0.65, respectively). The phase change in FMD in cycle 1 did not predict the phase change in cycle 2 (r = 0.03, P = 0.92). Using threshold-based classification (2 × typical error threshold), four of 14 participants (29%) exhibited directionally consistent phase changes in FMD across cycles. Oestrogen was not correlated between cycles, and this might have contributed to variability in the FMD response. The intra-individual variability in follicular fluctuation in FMD between menstrual cycles challenges the utility of interpreting individual responses to phase over a single menstrual cycle.

The NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty: Protocol and rationale for methods and measures

Delineating the relationship between human neurodevelopment and the maturation of the hypothalamic-pituitary-gonadal (HPG) axis during puberty is critical for investigating the increase in vulnerability to neuropsychiatric disorders that is well documented during this period. Preclinical research demonstrates a clear association between gonadal production of sex steroids and neurodevelopment; however, identifying similar associations in humans has been complicated by confounding variables (such as age) and the coactivation of two additional endocrine systems (the adrenal androgenic system and the somatotropic growth axis) and requires further elucidation. In this paper, we present the design of, and preliminary observations from, the ongoing NIMH Intramural Longitudinal Study of the Endocrine and Neurobiological Events Accompanying Puberty. The aim of this study is to directly examine how the increase in sex steroid hormone production following activation of the HPG-axis (i.e., gonadarche) impacts neurodevelopment, and, additionally, to determine how gonadal development and maturation is associated with longitudinal changes in brain structure and function in boys and girls. To disentangle the effects of sex steroids from those of age and other endocrine events on brain development, our study design includes 1) selection criteria that establish a well-characterized baseline cohort of healthy 8-year-old children prior to the onset of puberty (e.g., prior to puberty-related sex steroid hormone production); 2) temporally dense longitudinal, repeated-measures sampling of typically developing children at 8-10 month intervals over a 10-year period between the ages of eight and 18; 3) contemporaneous collection of endocrine and other measures of gonadal, adrenal, and growth axis function at each timepoint; and 4) collection of multimodal neuroimaging measures at these same timepoints, including brain structure (gray and white matter volume, cortical thickness and area, white matter integrity, myelination) and function (reward processing, emotional processing, inhibition/impulsivity, working memory, resting-state network connectivity, regional cerebral blood flow). This report of our ongoing longitudinal study 1) provides a comprehensive review of the endocrine events of puberty; 2) details our overall study design; 3) presents our selection criteria for study entry (e.g., well-characterized prepubertal baseline) along with the endocrinological considerations and guiding principles that underlie these criteria; 4) describes our longitudinal outcome measures and how they specifically relate to investigating the effects of gonadal development on brain development; and 5) documents patterns of fMRI activation and resting-state networks from an early, representative subsample of our cohort of prepubertal 8-year-old children.

How to study the menstrual cycle: Practical tools and recommendations

Despite decades of research on the physiological and psychological effects of the menstrual cycle, studies have not sufficiently adopted consistent methods for operationalizing the menstrual cycle. This has resulted in substantial confusion in the literature and limited possibilities to conduct systematic reviews and meta-analyses. In order to facilitate more rapid accumulation of knowledge on cycle effects, the present paper offers a set of integrative guidelines and standardized tools for studying the menstrual cycle as an independent variable. We begin with (1) an overview of the menstrual cycle and (2) premenstrual disorders, followed by (3) recommendations and tools regarding data collection in cycle studies. These recommendations address selecting the appropriate study design and sampling strategy, managing demand characteristics, identifying a sample of naturally-cycling individuals, and measuring menstrual bleeding dates, ovarian hormones, and ovulation. We proceed with suggestions for (4) data preparation and coding of cycle day and phases, as well as (5) data visualization, statistical modeling, and interpretation of menstrual cycle associations. We also provide (6) recommendations for using menses start day and ovulation testing to schedule visits in laboratory studies and end with a (7) comprehensive summary and conclusion. Regardless of whether the influence of the menstrual cycle is of central interest in a study or should be controlled to accurately assess the effects of another variable, the use of these recommendations and tools will help make study results more meaningful and replicable.

Female sex as an independent prognostic factor in the development of oral mucositis during autologous peripheral stem cell transplantation

Oral mucositis (OM) is a frequent complication of stem cell transplantation-associated toxicity in haematological malignancies, contributing to mortality. Therapy still remains mainly supportive. We assessed risk factors in retrospective analysis of 192 autologous peripheral stem cell transplantation patients with lymphoma and multiple myeloma (MM), respectively. Futhermore, we examined the hormone levels both in serum and saliva during transplantation in 7 postmenopausal female patients with lymphoma compared to healthy controls using electrochemiluminescence immunoassay (ECLIA). Multivariable analysis revealed neutrophil engraftment (p < 0.001; p = 0.021) and female sex (p = 0.023; p = 0.038) as independent predictive factors in the combined patient group and in the lymphoma group, and neutrophil engraftment (p = 0.008) in the MM group. Of the 85 female participants 19 were pre- and 66 postmenopausal. Fifteen of the pre-, and 49 of the postmenopausal women developed ulcerative mucositis (p = 0.769), more often with lymphoma than MM (p = 0.009). Serum estrogen decreased significantly both in postmenopausal controls and transplantated patients compared to premenopausals, with no difference in saliva. Serum progesterone level was significantly (p = 0.026) elevated at day + 7 of transplantation, while salivary progesterone increased at day + 7 and + 14. Our results indicate a predominantly negative effect of female sex hormones on oral immunity with role in the aetiopathogenesis of OM.

Estradiol Fluctuation, Sensitivity to Stress, and Depressive Symptoms in the Menopause Transition: A Pilot Study

The menopause transition is associated with an increased risk of depressed mood. Preliminary evidence suggests that increased sensitivity to psychosocial stress, triggered by exaggerated perimenopausal estradiol fluctuation, may play a role. However, accurately quantifying estradiol fluctuation while minimizing participant burden has posed a methodological challenge in the field. The current pilot project aimed to test the feasibility of capturing perimenopausal estradiol fluctuation via 12 weekly measurements of estrone-3-glucuronide (E1G), a urinary metabolite of estradiol, using participant-collected urine samples in 15 euthymic perimenopausal women ages 45-55 years. Furthermore, it aimed to correlate E1G fluctuation (standard deviation across the 12 E1G measurements) with weekly mood and cardiovascular, salivary cortisol, and subjective emotional responses to the Trier Social Stress Test (TSST) at weeks 4, 8, and 12. Protocol acceptability and adherence was high; furthermore, E1G fluctuation was positively associated with anhedonic depressive symptoms and weekly negative affect. E1G fluctuation was also associated with increased heart rate throughout the TSST as well as higher levels of rejection, anger, and sadness. E1G fluctuation was not significantly associated with TSST blood pressure or cortisol levels. This study suggests a feasible method of assessing estradiol fluctuation in the menopause transition and provides support for the hypothesis that perimenopausal estradiol fluctuation increases sensitivity to psychosocial stress and vulnerability to depressed mood.

Psychobiological Factors of Sexual Functioning in Aging Women - Findings From the Women 40+ Healthy Aging Study

Background: A variety of biological and psychosocial factors are associated with women’s sexual health in midlife and older age. Evidence suggests a decline in sexual functioning in the context of aging and the menopausal transition, including changes in sexual desire, arousal, lubrication, orgasm, pain, and/or contentment. However, not all women in midlife and older age experience such a decline, and it remains unclear how the endocrine environment and psychosocial aspects contribute to the maintenance of healthy sexual functioning. Therefore, the aim of this study was to examine psychobiological predictors of sexual functioning in healthy middle-aged and elderly females.

Methods: A total of 93 healthy, sexually active women aged 40–73 years completed a battery of validated psychosocial questionnaires, including measures of sexual functioning (Female Sexual Function Index) and of protective psychological traits and interpersonal variables. The steroid hormones estrogen, testosterone, progesterone and dehydroepiandrosterone sulfate were determined in saliva samples, while follicle-stimulating hormone, luteinizing hormone and sex hormone-binding globulin were determined in dried blood spots. The findings were statistically adjusted for multiple testing.

Results: Age and postmenopausal status were negatively associated with overall sexual functioning, arousal, and lubrication. Regression analyses revealed that relationship satisfaction, emotional support, self-esteem, optimism, and life satisfaction each significantly predicted overall sexual functioning or specific aspects of sexual functioning, including arousal, contentment, orgasm, and pain (all p < 0.029). For desire and lubrication, no associations were found with the tested psychosocial factors. In terms of steroid hormones, testosterone was positively linked to orgasm (p = 0.012). In this sample, 79.6% reported to have healthy sexual functioning according to the questionnaires’ cutoff. Younger age (OR = 0.911, 95% CI 0.854–0.970, p = 0.004) and a higher level of emotional support (OR = 1.376, 95% CI 1.033–1.833, p = 0.029) were associated with the presence of healthy sexual functioning.

Discussion: Although aging and menopause negatively affected aspects of sexual functioning, the accompanying endocrine correlates were not predictive for sexual functioning in this healthy sample of middle-aged and older females. Instead, our findings suggest that sexual functioning is highly dependent on psychosocial aspects related to well-being. Accordingly, personality traits such as optimism, and interpersonal aspects such as emotional support and relationship satisfaction were identified as important predictors of sexual functioning.

Chemical analysis in saliva and the search for salivary biomarkers – a tutorial review

A review of the uses of saliva biomarkers, detection methods and requirements for new biomarkers.

Risky decision-making in adolescent girls: The role of pubertal hormones and reward circuitry

Adolescence is a developmental period characterized by a greater tendency to take risks. While the adult literature has shown that sex steroids influence reward-related brain functioning and risk taking, research on the role of these hormones during puberty is limited. In this study, we examined the relation between pubertal hormones and adolescent risk taking using a probabilistic decision-making task. In this task, participants could choose on each trial to play or pass based on explicit information about the risk level and stakes involved in their decision. We administered this task to 58 11-to-13-year-old girls while functional MRI images were obtained to examine reward-related brain processes associated with their risky choices. Results showed that higher testosterone levels were associated with increased risk taking, which was mediated by increased medial orbitofrontal cortex activation. Furthermore, higher estradiol levels were associated with increased nucleus accumbens activation, which in turn related to decreased risk taking. These findings offer potential neuroendocrine mechanisms that can explain why some adolescent girls might engage in more risk taking compared to others.

Naturally Occurring Changes in Estradiol Concentrations in the Menopause Transition Predict Morning Cortisol and Negative Mood in Perimenopausal Depression

Risk of depression increases considerably during the menopause transition (or perimenopause) - the 5-6 years surrounding the last menstrual period. While the mechanisms underlying this increased risk are unknown, we have hypothesized that excessive estradiol (E2) fluctuation, which accompanies the perimenopause, may be implicated. We have furthermore proposed that dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis may underlie E2 fluctuation's effect on mood. This study examined the relationship between weekly changes in salivary E2, salivary cortisol levels and weekly mood in 30 perimenopausal women recruited to achieve equal numbers of women with current depression, past depression, and no history of depression. Greater weekly increases in E2 were associated with increased cortisol among past and currently depressed women; greater E2 increases were also associated with negative mood among currently depressed women. These findings provide evidence that HPA axis dysregulation, correlated with E2 fluctuation, may be implicated in the pathophysiology of perimenopausal depression.

The influence of sex hormones on anterior cruciate ligament ruptures in males

PURPOSE

The purpose of this study is to determine the difference in the concentrations of testosterone, 17-β estradiol and progesterone between male patients with and without ACL rupture, as well as the possible effect of these hormones on generalized joint laxity.

METHODS

Male subjects with non-contact knee joint injury were included in this study. Two groups were formed: the examined group, consisting of subjects with ACL rupture and the control group consisting of patients without ACL rupture. After this, the patients from these two groups were paired off on the basis of three factors, level of professional involvement in sports (including the type of sports activity), left or right side of the body and the age of the subjects. In the end, there were 29 pairs (58 subjects). The concentration of sex hormones was determined from saliva specimens with the aid of the Salimetrics enzyme immunoassay. The testing of generalized joint laxity was performed with the aid of the "laxity score" according to Beighton et al.

RESULTS

Subjects with ACL rupture have highly statistically significantly greater concentrations of testosterone (p < 0.01), statistically significantly greater concentrations of 17-β estradiol (p < 0.05), and a highly statistically significantly greater generalized joint laxity score than subjects with an intact ACL (p < 0.01).

CONCLUSION

Increased concentrations of testosterone or 17-β estradiol may be a risk factor leading to ACL rupture. Also, generalized joint laxity may be a factor leading to ACL rupture, but none of the monitored hormones can be set down as the cause of its existence. Young male athletes with higher concentrations of testosterone and greater hyperelasticity should plan preventive programs of physiotherapy for ACL preservation since they present a vulnerable group susceptible to ACL rupture.

LEVEL OF EVIDENCE

Diagnostic study, Level II.

The utility and dynamics of salivary sex hormone measurements in the National Social Life, Health, and Aging Project, Wave 2

OBJECTIVES

Sex hormones affect physical, mental, and social health, yet their role in mediating social effects on aging is understudied. To facilitate such analyses with the National Social Life, Health & Aging Project Wave 2, we summarize the conceptual background, collection protocols, laboratory assays, and data analysis strategies for biologically active (free) levels of testosterone, estradiol, progesterone, and dehydroepiandrosterone (DHEA).

METHOD

Saliva from passive drool was collected from returning Wave 1 respondents and non-respondents as well as their partners during an in-home interview. Specimens were frozen and sent to Dresden LabService GmbH for duplicate assays of biologically active steroids using identical assay kits from National Social Life, Health, and Aging Project (NSHAP) Wave 1 (SaliCap, Catalog No. RE69995). Overall, 2,772 testosterone, 2,504 estradiol, 2,714 progesterone, and 2,800 DHEA measurements are publically available for Wave 2 analyses. Through a series of weighted linear regressions, all 4 steroids are compared by gender and age and to Wave 1 measurements.

RESULTS

Men had higher levels of both free testosterone and progesterone than women; women and men had the same levels of estradiol and DHEA. Both free testosterone and DHEA decreased with age. We also found significant wave effects for all 4 sex hormones.

CONCLUSION

NSHAP Waves 1 and 2 are the first U.S. probability sample studies to measure these 4 salivary sex hormones simultaneously, providing individual profiles 5 years apart. Wave 2 data demonstrate differences by gender and trends by age that are similar to those found in other saliva-based and serum-based studies of free steroid levels. The differences between waves arising from the change in assay laboratory need to be adjusted in future longitudinal analyses using NSHAP Wave 1 and Wave 2 steroid data.

Menopause and oral health

Different phases of a woman's life: Puberty, menses, pregnancy, and menopause have varied influence on her oral health. During the menopause, women go through biological and endocrine changes, particularly in their sex steroid hormone production, affecting their health. Because the oral mucosa contains estrogen receptors, variations in hormone levels directly affect the oral cavity. A few oral conditions and or diseases are seen more frequently during post menopausal years. Role of hormones affecting the health of oro-dental tissues, as well as treatment by HRT in ameliorating these conditions is not clear. There is paucity of randomized controlled trials in this field and more data is needed, before the recommendations for oral health care in post menopausal women can be made. A gynecologist sitting in menopausal clinic should be aware of oral changes happening during this period, and dental needs of these women and should refer them to the dental specialists accordingly. On the other hand, a dentist should also be sensitized about the menopausal status of the woman, her HRT status and special preventive and treatment needs.

Steroid concentrations in antepartum and postpartum saliva: normative values in women and correlations with serum

Background

Saliva has been advocated as an alternative to serum or plasma for steroid monitoring. Little normative information is available concerning expected concentrations of the major reproductive steroids in saliva during pregnancy and the extended postpartum.

Methods

Matched serum and saliva specimens controlled for time of day and collected less than 30 minutes apart were obtained in 28 women with normal singleton pregnancies between 32 and 38 weeks of gestation and in 43 women during the first six months postpartum. Concentrations of six steroids (estriol, estradiol, progesterone, testosterone, cortisol, dehydroepiandrosterone) were quantified in saliva by enzyme immunoassay.

Results

For most of the steroids examined, concentrations in antepartum saliva showed linear increases near end of gestation, suggesting an increase in the bioavailable hormone component. Observed concentrations were in agreement with the limited data available from previous reports. Modal concentrations of the ovarian steroids were undetectable in postpartum saliva and, when detectable in individual women, approximated early follicular phase values. Only low to moderate correlations between the serum and salivary concentrations were found, suggesting that during the peripartum period saliva provides information that is not redundant to serum.

Conclusions

Low correlations in the late antepartum may be due to differential rates of change in the total and bioavailable fractions of the circulating steroid in the final weeks of the third trimester as a consequence of dynamic changes in carrier proteins such as corticosteroid binding globulin.

Saliva in perimenopausal and early postmenopausal women. A 2-year follow-up study

This study aims to investigate salivary flow and biochemical constituents of menopausal-age women with the hypothesis that women using hormone therapy (HT) might present better saliva values than non-users. Two hundred HT users and 200 non-users were selected at random from a cohort study of 3,173 peri- and postmenopausal women and invited to a 2-year clinical follow-up study. Clinical examination with saliva sampling was made at baseline and 2 years later. Salivary total protein, albumin, and immunoglobulin (Ig) concentrations were analyzed. Final material included 106 consistent HT users and 55 non-users. Backward logistic regression analysis was made to determine the risk factors for higher or lower than medium salivary protein values. No difference was seen in salivary flow rate, total protein, and IgA values between baseline and follow-up measurements or between the groups. Albumin, IgG, and IgM concentrations were significantly lower in the 2-year samples of the HT group when compared with baseline. IgA and IgM values were higher in the non-HT 2-year samples when compared with the corresponding HT samples. The only significant explanatory factor for higher than median salivary albumin concentration was the number of teeth both at baseline and 2 years later. HT possibly improved epithelial integrity since the concentrations of serum components albumin, IgG, and IgM decreased during the follow-up. HT as such does not seem to affect saliva, although it may modify it. The clinical relevance of these results needs to be assessed in future studies.

Salivary sex hormone measurement in a national, population-based study of older adults

OBJECTIVES

To describe the methods used for, correlates of cooperation with, and validity of in-home salivary specimens collected from older adults.

METHODS

Salivary specimens were collected between 2005 and 2006 during in-home interviews with a probability sample of 3,005 U.S. men and women, ages 57-85 years. Sex hormone levels were assessed by enzyme-linked immunoassay conducted at Salimetrics, LLC (State College, PA). Mean salivary sex hormone concentrations were compared by gender and in relation to medication use and health conditions.

RESULTS

Self-collected saliva specimens were provided by 2,722 (90.6%) individuals; 95.8% of these were adequate for analysis. Black participants were significantly less likely than individuals of other racial/ethnic groups to provide a salivary specimen; age, gender, education, and self-rated health were not associated with participation. Mean testosterone levels were higher in men compared with women, and estradiol levels were higher in women using estrogens. Salivary hormone measurements obtained in the National Social Life, Health, and Aging Project (NSHAP) and other studies are of similar magnitude.

CONCLUSION

NSHAP is the first large, population-based study of older adults to measure salivary estradiol, progesterone, dehydroepiandrosterone (DHEA), and, in women, testosterone. These data demonstrate a high cooperation rate with in-home salivary specimen collection from older adults and good validity of sex hormone measurements.

The menopause and oral health

OBJECTIVES

To review the literature about oral symptoms and signs at the menopause with an emphasis on hormone replacement therapy (HRT). To give practical guidelines for women and their physicians in menopause-related oral health problems.

METHODS

The PubMed and Cochrane databases was searched until mid January 2009 with key words such as "menopause", "menopausal complaints", "postmenopausal complaints" and "oral diseases", "oral discomfort", "dental health", "dental diseases", "saliva", "burning mouth syndrome", "dry mouth", "xerostomia". Because of a scarcity of controlled studies no systematic review could be conducted.

RESULTS

Oral discomfort is found in many menopausal women in addition to more general climacteric complaints. The principal peri- and postmenopausal symptoms are dry mouth and burning mouth (glossodynia) which, in turn, may increase the occurrence of oral mucosal and dental diseases, such as candidiasis. The mechanisms of hormone-related oral symptoms and signs are not known although oestrogen receptors, for example, have been detected in the oral mucosa and salivary glands. In principle, the histology of oral and vaginal mucosa is very similar and thus their symptoms might share a common cause. Yet, hormone replacement therapy use does not necessarily prevent or help women with oral symptoms.

CONCLUSION

Properly controlled long-term randomized studies are needed to assess the effect of HRT on oral discomfort. Future gene profiling could identify women who may or may not benefit from HRT with regard to oral symptoms.

Salivary steroid assays – research or routine?

Salivary concentrations of unconjugated steroids reflect those for free steroids in serum although concentrations may differ because of salivary gland metabolism. Samples for salivary steroid analysis are stable for up to 7 days at room temperature, one month or more at 4°C and three months or more at −20°C. When assessed against strict criteria, the evidence shows that salivary cortisol in evening samples or following dexamethasone suppression provides a reliable and effective screen for Cushing's syndrome. Sequential salivary cortisol measurements are also extremely helpful for the investigation of suspected cyclical Cushing's syndrome. There is potential for the identification of adrenal insufficiency when used with Synacthen stimulation. Salivary 17-hydroxyprogesterone and androstenedione assays are valued as non-invasive tests for the home-monitoring of hydrocortisone replacement therapy in patients with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. The diagnostic value of salivary oestradiol, progesterone, testosterone, dehydroepiandrosterone and aldosterone testing is compromised by rapid fluctuations in salivary concentrations of these steroids. Multiple samples are required to obtain reliable information, and at present the introduction of these assays into routine laboratory testing is not justified.

The interrelationships among sex hormone concentrations, motoneuron excitability, and anterior tibial displacement in women and men

CONTEXT

Sex hormone fluctuations have been implicated as a contributing factor to the high rates of noncontact injury to the anterior cruciate ligament in females.

OBJECTIVE

To determine the strength of the relationships among variables of sex hormone concentrations, motoneuron excitability, and anterior tibial displacement (ATD) in women and men and to determine if these relationships differ between the sexes.

DESIGN

Cohort study.

SETTING

Sports medicine laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-eight regularly menstruating women (age = 22.4 +/- 3.4 years) and 15 men (age = 22.3 +/- 3.7 years) participated in the study.

INTERVENTION(S)

Fluctuations in sex hormones were determined for the participants. Female participants were tested every other day of their menstrual cycles, whereas male participants were tested every fourth day during the 28-day period.

MAIN OUTCOME MEASURE(S)

We measured Hoffmann reflexes (maximum Hoffmann reflex [H(max)] to maximum M-wave [M(max)] ratio in the soleus), ATD under a 134-N load, and saliva concentrations of estrogen and progesterone. The independent variable was sex. Pearson product moment correlation coefficients were calculated for each participant by pairing measurements made on the same day. Two-tailed independent-samples t tests were used to determine the difference between the male and female correlations for each variable.

RESULTS

Over the course of the study, the relationships between H(max)ratioM(max) and estrogen, H(max)ratioM(max) and progesterone, ATD and estrogen, and ATD and progesterone were not different between the sexes. However, the relationship between ATD and progesterone was different between the sexes (P = .036).

CONCLUSIONS

The observed correlations did not support our hypothesis that the relationships between sex hormone levels and reflex activity or between sex hormone levels and ATD would be different for women compared with men. If sex hormone concentrations significantly contribute to anterior cruciate ligament ruptures because of changes in laxity or in motoneuron excitability, their mechanism of action is likely multifactorial and complex.

Equol producer status, salivary estradiol profile and urinary excretion of isoflavones in Irish Caucasian women, following ingestion of soymilk

Equol production, isoflavone excretion, and the salivary estradiol profile among 36 females, native Irish Caucasian volunteers following ingestion of 200mL soymilk is reported. The soymilk contained daidzein (73+/-6.7mg) and genistein (86+/-10.2mg). Volunteers provided personal and family medical history. Dietary analysis revealed that all volunteers regularly consumed soy-based or soy-supplemented food products. The mean age, mean age at menarche, and body mass index of volunteers were 46.6+/-12.3 years, 13.1 years and 26.1, respectively. The average number of children per volunteer was 2.13. Twelve (34%) of the volunteers were found to be first-degree relatives of breast cancer patients. Following consumption of the soymilk, equol was detected in the urine of 18 (51%) of the volunteers. Mean urinary daidzein and genistein concentrations during the hours following soymilk ingestion were 13.5 and 16.7microg/mg creatinine, respectively, however, some volunteers excreted little (less than 4.0microg/mg) or no isoflavone. Salivary estradiol in most (24) volunteers had decreased from 51.5+/-28.67pmol/L pre-ingestion to 29.75+/-16.13pmol/L 5h after drinking the soymilk. However, the salivary estradiol in 12 subjects (34%) increased from 33.76+/-13.4pmol/L to 137.4+/-65.64pmol/L over the same period. Individuals whose salivary estradiol increased had significantly less children (1.58 (P<0.05)), were more likely to (a) return urine samples with low isoflavone content (50.3% compared to 25%), (b) to be equol producers (67% compared to 41.7%), and (c) to be first-degree relatives of breast cancer patients (41.7% compared to 25%). Volunteers who reported a first-degree link to breast cancer were more likely to have a higher body mass index (29.0 compared to 26.1 (P<0.05)), to be equol producers (75% compared to 51%), and to excrete isoflavones in low quantities only (60% compared to 50%). First-degree relatives also had fewer children (1.75 (P<0.05)). The results indicate a significant, distinctive variation in equol production, isoflavone excretion and salivary estradiol profile among individual volunteers following ingestion of soymilk.