Exogenous female sex steroid hormones and risk of asthma and asthma-like symptoms: a cross sectional study of the general population

Age at menarche and asthma onset among US girls and women: findings from NHANES, 2001-2018

PURPOSE

To quantitatively estimate the association of age at menarche with the risk of childhood- and adult-onset asthma separately.

METHODS

A retrospective cohort study of 24,282 US girls and women was conducted using continuous National Health and Nutrition Examination Survey (NHANES) data from 2001 to 2018, and Cox proportional hazards regression models with censoring ages of 19 and 79 years were employed to separately estimate hazard ratios of childhood- and adult-onset asthma associated with age at menarche.

RESULTS

Each one-year increase in age at menarche was significantly associated with a 16% (hazard ratio [HR] = 0.84; 95% confidence interval [CI]: 0.77-0.91) decrease in the risk of childhood-onset asthma. Compared with age at menarche of 12-14 years, we observed a 56% (HR = 1.56; 95% CI: 1.19-2.04) increased risk of childhood-onset asthma for early menarche (age at menarche < 12 years) and a 40% (HR = 0.60; 95% CI: 0.32-1.10) decreased risk for late menarche (age at menarche ≥ 15 years). No significant association was noted between age at menarche and adult-onset asthma.

CONCLUSIONS

Early menarche may represent a risk factor for childhood-onset asthma, which indicates the need for timely and effective management of individuals with early menarche to prevent asthma.

Hormonal Contraceptives Are Associated With an Increase in Incidence of Asthma in Women

BACKGROUND

Use of exogenous female sex hormones is associated with the development of asthma, but the question of whether the effect is protective or harmful remains unresolved.

OBJECTIVE

To investigate whether initiation of hormonal contraceptive (HC) treatment was associated with development of asthma.

METHODS

We performed a register-based, exposure-matched cohort study including women who initiated HC treatment of any kind between 10 and 40 years of age and compared the incidence of asthma with women who did not initiate HCs. Asthma was defined as 2 redeemed prescriptions of inhaled corticosteroids within 2 years. Data were analyzed using Cox regression models adjusted for income and urbanization.

RESULTS

We included 184,046 women with a mean age of 15.5 years (SD 1.5 y), in which 30,669 initiated HC treatment and 153,377 did not. We found that initiation of HCs was associated with an increased hazard ratio (HR) of developing new asthma by 1.78 (95% CI 1.58-2.00; P < .001). The cumulative risk of new asthma was 2.7% after 3 years among users of HCs compared with 1.5% in nonusers. In the different subtypes of HCs, second- and third-generation contraceptives carried significant associations (second-generation HR 1.76; 95% CI 1.52-2.03; P < .001; third-generation HR 1.62 95% CI 1.23-2.12; P < .001). The association with increased incidence was seen only in women younger than 18 years.

CONCLUSIONS

In this study, first-time users of HCs had an increased incidence of asthma compared with nonusers. Clinicians prescribing HCs should be aware that airway symptoms may develop.

Sexual dimorphism in chronic respiratory diseases

Sex differences in susceptibility, severity, and progression are prevalent for various diseases in multiple organ systems. This phenomenon is particularly apparent in respiratory diseases. Asthma demonstrates an age-dependent pattern of sexual dimorphism. However, marked differences between males and females exist in other pervasive conditions such as chronic obstructive pulmonary disease (COPD) and lung cancer. The sex hormones estrogen and testosterone are commonly considered the primary factors causing sexual dimorphism in disease. However, how they contribute to differences in disease onset between males and females remains undefined. The sex chromosomes are an under-investigated fundamental form of sexual dimorphism. Recent studies highlight key X and Y-chromosome-linked genes that regulate vital cell processes and can contribute to disease-relevant mechanisms. This review summarises patterns of sex differences in asthma, COPD and lung cancer, highlighting physiological mechanisms causing the observed dimorphism. We also describe the role of the sex hormones and present candidate genes on the sex chromosomes as potential factors contributing to sexual dimorphism in disease.

Sex Plays a Multifaceted Role in Asthma Pathogenesis

Sex is considered an important risk factor for asthma onset and exacerbation. The prevalence of asthma is higher in boys than in girls during childhood, which shows a reverse trend after puberty—it becomes higher in adult females than in adult males. In addition, asthma severity, characterized by the rate of hospitalization and relapse after discharge from the emergency department, is higher in female patients. Basic research indicates that female sex hormones enhance type 2 adaptive immune responses, and male sex hormones negatively regulate type 2 innate immune responses. However, whether hormone replacement therapy in postmenopausal women increases the risk of current asthma and asthma onset remains controversial in clinical settings. Recently, sex has also been shown to influence the pathophysiology of asthma in its relationship with genetic or other environmental factors, which modulate asthmatic immune responses in the airway mucosa. In this narrative review, we highlight the role of sex in the continuity of the asthmatic immune response from sensing allergens to Th2 cell activation based on our own data. In addition, we elucidate the interactive role of sex with genetic or environmental factors in asthma exacerbation in women.

Perimenstrual Asthma in Adolescents: A Shared Condition in Pediatric and Gynecological Endocrinology

Asthma is a frequent medical condition in adolescence. The worsening of the most common symptoms perimenstrually is defined as perimenstrual asthma (PMA). The cause of PMA remains unclear, but a role for hormonal milieu is plausible. Data on PMA in adolescents are limited, and its management is not fully established. We aimed to discuss the PMA phenomenon in young females from pathophysiology to preventive strategies, focusing on the relationship with the hormonal pattern. The fluctuation of estrogens at ovulation and before menstruation and the progesterone secretion during the luteal phase and its subsequent withdrawal seem to be the culprits, because the deterioration of asthma is cyclical during the luteal phase and/or during the first days of the menstrual cycle. Conventional asthma therapies are not always effective for PMA. Preventive strategies may include innovative hormonal contraception. Even a possible beneficial effect of other hormonal treatments, including estrogens, progestogens, and androgens, as well as leukotriene receptor antagonists and explorative approach using microbial-directed therapy, is considered. The underlying mechanisms, through which sex-hormone fluctuations influence asthma symptoms, represent a challenge in the clinical management of such a distressing condition. Further studies focused on young females are mandatory to promote adolescent health.

Population-based study of the association between asthma and exogenous female sex hormone use

OBJECTIVES

Several studies have suggested the influence of exogenous hormones on asthma, but the results are still conflicting. Moreover, there has been little associated research on Asian population. This study aimed to assess the association between use of exogenous female sex hormones and asthma in Korean women.

DESIGN

Korea National Health and Nutrition Examination Survey (KNHANES) is a nationwide programme to assess national health and nutritional status in Korea. A population-based study was conducted to analyse the relationship between self-reported asthma and exogenous hormones using the KNHANES between 2007 and 2012.

PARTICIPANTS

The study sample included 6874 premenopausal and 4912 postmenopausal women aged 30-65.

OUTCOME MEASURES

KNHANES data comprised health interviews and physical examinations. Questionnaires regarding asthma, reproductive factors and exogenous hormones were included.

RESULTS

Among postmenopausal women, 3.4% reported doctor-diagnosed asthma. Hormone replacement therapy (HRT) was associated with increased odds of doctor-diagnosed asthma (OR 1.56; 95% CI 1.04 to 2.35), while the association between HRT and wheeze in the last 1 year was not significant (OR 1.37; 95% CI 0.95 to 1.96). In premenopausal women, the prevalence of asthma was 2.3%. Use of oral contraceptives (OCs) was associated with an increased odds of doctor-diagnosed asthma (OR 1.67; 95% CI 1.01 to 2.76) and wheeze in the last 1 year (OR 1.88; 95% CI 1.31 to 2.69). These associations were dominant among non-obese women (body mass index <25 kg/m²; OR 2.36; 95% CI 1.34 to 4.17 for asthma and OR 2.15; 95% CI 1.43 to 3.23 for wheeze).

CONCLUSIONS

HRT and OCs were associated with increased asthma in postmenopausal and premenopausal women, respectively. The association between OC use and asthma was strong in non-obese premenopausal women.

Hormone Replacement Therapy and Development of New Asthma

BACKGROUND

Hormone replacement therapy (HRT) is prescribed to millions of women worldwide. Previous studies have suggested that HRT has both protective and harmful effects in asthma.

RESEARCH QUESTION

Is HRT in menopause associated with new development of asthma?

STUDY DESIGN AND METHODS

We undertook a nested case-control study based on the Danish registers from June 1, 1995, through December 31, 2018. A diagnosis of asthma was defined as two redeemed prescriptions of inhaled corticosteroids within 2 years. HRT was defined as two redeemed prescriptions of female sex hormones within 6 months. Data were analyzed using a conditional logistic regression model.

RESULTS

We included 34,533 women with asthma vs 345,116 women without asthma between 40 and 65 years of age. In a multivariate analysis adjusted for age, household income, and educational level, active HRT resulted in a hazard ratio (HR) of 1.63 (95% CI, 1.55-1.71; P < .001) of new asthma development. Women with asthma who terminated HRT were likely to discontinue their asthma treatment subsequently (HR, 2.12; 95% CI, 1.94-2.33; P < .001).

INTERPRETATION

HRT seems to play a role in the development of asthma in mature women. Clinicians prescribing HRT and women receiving HRT should be aware that new airway symptoms can develop, and discontinuation of HRT should be considered.

Hormonal contraceptives and onset of asthma in reproductive-age women: Population-based cohort study

BACKGROUND

Despite well-described sex differences in asthma incidence, there remains uncertainty about the role of female sex hormones in the development of asthma.

OBJECTIVE

We sought to investigate whether hormonal contraceptive use, its subtypes, and duration of use were associated with new-onset asthma in reproductive-age women.

METHODS

Using the Optimum Patient Care Research Database, a UK national primary care database, we constructed an open cohort of 16- to 45-year-old women (N = 564,896) followed for up to 17 years (ie, January 1, 2000, to December 31, 2016). We fitted multilevel Cox regression models to analyze the data.

RESULTS

At baseline, 26% of women were using any hormonal contraceptives. During follow-up (3,597,146 person-years), 25,288 women developed asthma, an incidence rate of 7.0 (95% CI, 6.9-7.1) per 1000 person-years. Compared with nonuse, previous use of any hormonal contraceptives (hazard ratio [HR], 0.70; 95% CI, 0.68-0.72), combined (HR, 0.70; 95% CI, 0.68-0.72), and progestogen-only therapy (HR, 0.70; 95% CI, 0.67-0.74) was associated with reduced risk of new-onset asthma. For current use, the estimates were as follows: any (HR, 0.63; 95% CI, 0.61-0.65), combined (HR, 0.65; 95% CI, 0.62-0.67), and progestogen-only therapy (HR, 0.59; 95% CI, 0.56-0.62). Longer duration of use (1-2 years: HR, 0.83; 95% CI, 0.81-0.86; 3-4 years: HR, 0.64; 95% CI, 0.61-0.67; 5+ years: HR, 0.46; 95% CI, 0.44-0.49) was associated with a lower risk of asthma onset than nonuse.

CONCLUSIONS

Hormonal contraceptive use was associated with reduced risk of new-onset asthma in women of reproductive age. Mechanistic investigations to uncover the biological processes for these observations are required. Clinical trials investigating the safety and effectiveness of hormonal contraceptives for primary prevention of asthma will be helpful to confirm these results.

Sex Steroid Hormones and Asthma in a Nationwide Study of U.S. Adults

Rationale: Women have a higher burden of asthma than men. Although sex hormones may explain sex differences in asthma, their role is unclear.Objectives: To examine sex hormone levels and asthma in adults.Methods: Cross-sectional study of serum levels of free testosterone and estradiol and current asthma in 7,615 adults (3,953 men and 3,662 women) aged 18-79 years who participated in the 2013-2014 and 2015-2016 U.S. National Health and Nutrition Examination Survey. Logistic regression was used for the multivariable analysis of sex hormones and current asthma, which was conducted separately in women and men.Measurements and Main Results: Free testosterone levels in the fourth quartile were associated with lower odds of current asthma in women (odds ratio [OR] for the fourth quartile [Q4] vs. Q1, 0.56; 95% confidence interval [CI], 0.39-0.80). Given an interaction between obesity and sex hormones on current asthma, we stratified the analysis by obesity. In this analysis, elevated free testosterone (OR for Q4 vs. Q1, 0.59; 95% CI, 0.37-0.91) and estradiol (OR for Q4 vs. Q1, 0.43; 95% CI, 0.23-0.78) levels were associated with reduced odds of current asthma in obese women, and an elevated serum estradiol was associated with lower odds of current asthma in nonobese men (OR for Q4 vs. Q1, 0.44; 95% CI, 0.21-0.90).Conclusions: Our findings suggest that sex hormones play a role in known sex differences in asthma in adults. Moreover, our results suggest that obesity modifies the effects of sex hormones on asthma in adults.