Estrogen in Psychiatry | PsychEducation
Everyone knows estrogen has something to do with mood, right? multiple effects on serotonin, and even an effect on blood tryptophan levels (the the sleep-regulating hormone (complex relationship, different in different animal species);. Estrogen, the body's natural mood stabilizer and antidepresseant, is necessary for The relationship between estrogen and serotonin is not entirely understood, . Further studies are needed in order to unmask the precise molecular relationship between estrogen and serotonin and to document the clinical applications of.
Serotonergic regulation of fibromyalgia is supported by evidence that fibromyalgia is comorbid with other serotonin-related pathologies,[ 50 ] and that fibromyalgia patients have altered tryptophan metabolism[ 51 ] and can be treated with 5HT2A antagonists [ 50 ].
E2's effect on serotonin could also explain why fibromyalgia is more frequently observed in females than males [ 52 ]. Females are also at greater risk for headaches,[ 43 ] which can result from vasodilation in the brain [ 53 ]. Activation of an additional serotonin receptor, 5HT1B, is one mechanism by which vasodilation occurs. Under normal conditions, upregulation and activation of 5HT2A receptors enable them to balance the effects of 5HT1B receptors [ 272855 ]. We suggest that females' increased headache risk might result if high serotonin concentrations are maintained without adequate compensatory 5HT2A activity.
Two of the major side effects of E2 treatment are dizziness and nausea, which are controlled in the CNS. The mechanism by which these side effects occur has not been fully elucidated.
It is possible that E2's effect on serotonin pathways is responsible for these symptoms, as 5HT2A receptors activate vestibular neurons which maintain balance [ 56 ] and are found in emetic centers, which are involved in chemically-induced vomiting [ 57 ]. Our hypothesis is corroborated by the use of serotonergic drugs to minimize these side effects of E2 treatment [ 58 ]. The loss of estrogen at menopause results in decreased density of 5HT2A receptors and lower activity of serotonin, which could explain aberrant temperature regulation, including hot flashes and night sweats.
Although the effects of temperature changes are felt throughout the body, 5HT2A receptors in the CNS are responsible for temperature regulation. Administration of drugs acting at the 5HT2A receptor restores normal temperature regulation following ovariectomy[ 59 ] and chemically induced changes in body temperature[ 60 ] The nighttime prevalence of hot flashes and night sweats could be a result of the conversion of serotonin to melatonin at night, resulting in lower circulating serotonin levels [ 61 ].
Depression is more common in women than in men and is known to be mediated by serotonin receptor levels [ 4363 ]. Specifically, depression is linked to decreased density of serotonin receptors and decreased efficacy of serotonin in the brain. The increased risk, timing of onset, and effectiveness of treatment of depression in women may be mediated by estrogen's effect on serotonin receptors.
The onset of depression in women is a characteristic of times when estrogen levels are relatively low in early pregnancy, postpartum, and around and following menopause or low in comparison to progesterone the luteal phase of the menstrual cycle [ 6465 ].
In women with depression around or following menopause, the effectiveness of treatment with selective serotonin reuptake inhibitors SSRIs is enhanced by simultaneous administration of estrogen,[ 63 ] and doses of estrogen alone are effective at treating premenstrual, postpartum, and perimenopausal depression, especially for depression linked to aberrant expression of 5HT2A receptors [ 2566 ].
The increased levels of serotonin and increased activity of the 5HT2A receptor caused by E2 could be the mechanism for E2's antidepressant effects, in which case 5HT2A receptor agonists could also enhance the anti-depressant effects of E2. The skeletal system Estrogen and serotonin also affect the skeletal system. As bones grow, they are continually remodeled and reshaped. Normal bone development is affected by growth hormone, parathyroid hormone, calcitonin, and environmental factors like dietary calcium intake and physical activity.
In addition to these factors, estrogen and serotonin play an important role in the development and maintenance of bone mass. For bone growth to occur, two types of cells are required: During puberty, osteoclasts and osteoblasts are in balance and resorb and build bone simultaneously, but osteoporosis results when osteoclasts increase relative to osteoblasts. These effects have been linked to E2 concentrations in both males and females,[ 6869 ] and we propose that they can be explained by examining E2-produced changes in serotonergic function in bone growth and loss.
However, bone loss begins around age 30 in men and women and this early bone loss cannot be entirely explained by differences in E2 concentrations or by our proposed model [ 78 ]. The vascular system In the vascular system, estrogen and serotonin have been shown to individually alter clotting, cholesterol, vasoconstriction, and heart attacks. Both high and low levels of E2 have been associated with increased risk of thromboembolism; high levels result in increased clot formation, while low levels result in slower clot breakdown.
Unusually high concentrations of estrogen beyond normal physiological levels directly increase the likelihood of clotting by increasing production of clotting factors VII through X in the liver [ 41 ]. In addition, these levels of E2 might increase clotting by increasing serotonin, which is constitutively present in human plasma and platelets and works to promote clotting[ 679 ] and increase density of platelets [ 58 ].
Increased clotting and thromboembolism at low concentrations of E2 [ 80 ] can also be explained using serotonergic changes. Postmenopausal women have longer latency to lysis of clots, and E2 replacement therapy returns latencies to pre-menopausal levels [ 81 ]. Patients with slower clot breakdowns have decreased uptake and release of serotonin from platelets,[ 82 ] and at low E2 levels serotonin's ability to break down clots via the 5HT2A receptor is limited,[ 8384 ] so we suggest that lower serotonin activity associated with lower E2 levels could also contribute to increased clotting.
Increased concentrations of E2 are also associated with decreased cholesterol, and at menopause, there is an increase in total serum cholesterol, which is reduced by estrogen-containing hormone replacement therapy [ 85 ]. We suggest higher cholesterol after menopause is linked to the effects of serotonin. Serotonin increases membrane fluidity by incorporation of cholesterol into membranes, decreasing bioavailable cholesterol [ 8687 ].
Increased membrane fluidity also increases serotonergic function, creating a positive feedback loop [ 8889 ]. If serotonin is an intermediary between estrogen and cholesterol, then in the presence of high concentrations of E2, we would expect more cholesterol incorporated into membranes, thereby reducing cholesterol present in the plasma.
Our hypothesis would be supported if the administration of drugs that reduce concentrations of serotonin in the plasma cause increases in plasma cholesterol despite consistent levels of E2."Sleep" Hormones
Both clotting and cholesterol contribute to heart attack risk. Women are at lower risk of heart attack than men prior to menopause, but changes in the vascular system after menopause result in the loss of protection from heart disease [ 4143 ]. In females, recent evidence suggests that physiological levels of E2 protect against heart attacks, while testosterone makes heart attacks more likely [ 90 ]. We hypothesize that these effects in females can be explained in part by serotonin receptor changes.
After menopause, when 5HT2A receptors have been down regulated, serotonin instead acts on 5HT1A receptors, which cause adrenergic stimulation of smooth muscle[ 92 ] and increase likelihood of cardiac vasospasm [ 93 ]. This increases the risk of heart attack [ 9294 - 96 ].
In addition, testosterone, which increases following menopause, compounds the actions of serotonin at 5HT1A receptors by preventing desensitization of 5HT1A receptors [ 97 ]. These changes in sensitivity of cardiac vessels, combined with increased clotting and lipid levels, would be expected to increase heart attack risk, arteriosclerosis and strokes. However, E2 is not solely responsible for protection from heart attack, progesterone also plays a role. Hormone replacement therapy HRT containing E2 and medroxyprogesterone instead of E2 and progesterone has been shown to increase heart attack [ 98 ].
Although the study showing increased heart attack risk during HRT is controversial,[ 99 ] it is possible that decreased concentrations of serotonin produced by treatment with medroxyprogesterone[ 93] could contribute to this increased risk. The immune system Both E2 and serotonin are also active in the immune system, and in this system, their interaction is well-documented. E2 suppresses major histocompatibility complex II MHC II proteins in a tissue-specific manner [ ] and acts centrally to suppress the immune system[ ] by helping to activate 5HT2A receptors in the thymus [ 28- ].
Although self-reactive TH1 cells are present, we hypothesize that E2's suppression of MHC II prevents them from becoming activated, and therefore while sufficient E2 is present they fail to attack tissues. Following menopause, or when E2 levels are unusually low, suppression of MHC II and immune function is lost, allowing self-reactive TH1 cells to become active and pathogenic.
It is possible that estrogen and serotonin's modulation of the immune system prevents immune attack on offspring during pregnancy when estrogen is at relatively high concentrations and avoids infection after delivery when estrogen is relatively low [ ]. MHC II protein and self-reactive T cells appear to be the common denominators among autoimmune disorders in women, suggesting a role for E2 and serotonin in mediating these disorders. Multiple sclerosis MS is associated with the presence of MHC II protein polymorphic pathogenic alleles and serotonin depletion[ ] This serotonin depletion could be a consequence of low E2, so the decrease in MS symptoms during pregnancy [ ] could be explained by higher concentrations of E2.
Also the severity of MS symptoms increases as serotonin levels decrease[ ], symptoms worsen in phases of the menstrual cycle when there is low E2[ ], and low levels of E2 result in changes in the 5HT signaling pathway [ ]. In female SERT knockout mice, symptoms of experimental allergic encephalomyelitis a MS model are less severe and have a greater latency to occurrence, possibly as a result of increased serotonin availability [ ].
Not only may low serotonin levels be linked to MS, but the effects of serotonin on MS may involve 5HT2 receptors in particular. Gene-microarray analysis of brain lesions found lower 5HT2 receptor expression in all 4 MS patients that analysis was preformed for compared to that of 2 controls [ ]. Serotonin depletion could also be produced by conversion of serotonin to melatonin in the absence of light, which might explain the increased incidence of MS in more northern climates[ ] where daylight periods are shorter and the reason that light therapy can be effective in reducing symptoms of MS [ ].
Similarly, self-reported incidence of Type I diabetes IDDM is negatively correlated with exposure to UV radiation and positively correlated with latitude in Australia [ ].
Melatonin suppresses estrogen function [ 61 ] and suppresses 5HT2A receptor activity [ ]. Over expression of the MHC II following failure to select against self-reactive T-cells is also a useful model for rheumatoid arthritis, Graves disease, and Hashimoto's thyroiditis, in which T-cells react to proteins produced in the body, failing to discriminate them from invading organisms [ ].
Women in whom estrogen-regulated serotonin signaling is compromised would be expected to have higher levels of MHC class II protein expression and may present these pathologies. However, simply over-expressing MHC II proteins is not sufficient to activate the immune system and induce autoimmune disorders [ ].
The links between autoimmune disorders, serotonergic systems, and E2 suggest that manipulation of serotonin or E2 could be used to successfully treat these pathologies. Consistent with this suggestion, ER agonists reduce the symptoms of autoimmune disorders .
Breast cancer Carcinogenesis is conceptualized as consisting of three distinct phases: Initiation is the irreversible alteration of a normal cell; promotion involves both proliferation of initiated cells and suppression of apoptosis of these cells; and progression is the irreversible conversion of one of the promoted initiated cells to an invasive, metastatic tumor cell [ ].
Therefore, any endogenous milieu that induces apoptosis or suppresses mitogenesis of initiated cells could reduce breast cancer risk. For breast cancer, one of the prevailing theories for the role of E2 is that longer duration of lifetime exposure to E2 is associated with increased risk, so that early menarche and late menopause result in greater likelihood of developing breast cancer [ ]. Adding a role for serotonin does not conflict with this idea, but it does help explain several epidemiological findings that are not accounted for by a relationship between increased E2 exposure alone and breast cancer.
First, the highest breast cancer incidence is in post-menopausal women, when endogenous E2 levels are much lower than before menopause. As described above, the higher E2 concentrations in the presence of progesterone prior to menopause cause an increase in 5HT2A receptor density and serotonin activity that promotes apoptosis.
An overlooked connection: serotonergic mediation of estrogen-related physiology and pathology
In contrast, 5HT1A activation which occurs preferentially after menopause decreases apoptotic signaling via caspase-3 suppression [ 38 ]. Therefore, if E2 is acting on breast cancer in part by serotonin modulation, then we would predict that the decrease in E2 after menopause should increase risk of breast cancer. This is consistent with the observed breast cancer incidence curve [ ]. The failure of low levels of E2 to inhibit cancer growth is also reflected in patterns of tumor development within the estrous cycle.
In mice, breast tumor growth occurs primarily in diestrus when E2 is lowand tumor size is maintained or shrinks when E2 levels are high [ ]. Second, in Pike's Breast Tissue Age model, a one-time rapid increase in breast tissue age and therefore breast cancer risk is included immediately following the first full-term pregnancy [ ].
The extension of Pike's model includes multiple births by incorporating smaller increases in risk at each additional full-term pregnancy [ ]. This pattern of increased risk for breast cancer immediately following full-term pregnancies is well-documented [ - ].
An overlooked connection: serotonergic mediation of estrogen-related physiology and pathology
E2 concentrations increase steadily during pregnancy, peaking at about times normal cycling levels [ 3 ]. In the days around parturition, these concentrations drop precipitously to levels below those of normal cycling females, where they are maintained for at least a month and potentially much longer depending on suckling suppression [ ].
We postulate that the observed increase in breast cancer risk may be accounted for by the concurrent decrease in E2 and therefore changes in 5HT2A receptor function immediately prior to parturition. While E2's effect on serotonin could account for the immediate increase in risk, it cannot explain the long-term reduction in risk, which is likely related to other changes associated with parturition or lactation.
Third, obesity exerts differential effects on breast cancer risk over the lifespan; decreasing risk prior to menopause and increasing risk following menopause . Under the prevailing theory of cumulative E2 exposure, obesity which increases E2 levels[ ] would always be expected to increase breast cancer risk.
However, the effect of E2 using serotonin mediation described above can account for the observed differential effects. Increased E2 in the presence of progesterone increases activation of 5HT2A receptors, while increased E2 in the absence of progesterone increases activation of 5HT1A receptors. The effects of these two receptors on apoptotic activity would predict that obesity exerts a protective effect before menopause and increases risk after menopause. The importance of the presence of progesterone for this protective effect is underscored by recent HRT studies, which show that the use of estrogen and progesterone does not increase breast cancer risk,[ ] while the use of estrogen and medroxyprogesterone which decreases serotonin in some tissues[ 14] has been shown to increase breast cancer risk.
Summary Most research on pathologies in women's health has centered on changes in E2. Our review of data from a variety of fields suggests that serotonin is one way that estrogen is exerting its effects on physiology and pathology in women.
The primary function of E2 is reproductive, and serotonergic mediation of the estrogen system likely provides reproductive benefits that are not yet understood. Several of the effects we have discussed could produce reproductive benefits: Notably, the same mechanism that results in these potential benefits in the reproductive system also produces changes in the remainder of the body that have consequences for women's physiology and pathologies.
We suggest serotonergic mediation might contribute to explaining E2's effects on some pathologies, including heart attacks, multiple sclerosis, and breast cancer. Altering specific aspects of the serotonergic system, rather than simply increasing E2, could allow clinicians to target treatments in particular tissues or towards particular receptor types, alleviating undesirable side effects of E2 administration.
Further studies are needed in order to unmask the precise molecular relationship between estrogen and serotonin and to document the clinical applications of this putative relationship. Competing interests The author s declare that they have no competing interests.
Authors' contributions LAR developed the original idea and was primarily responsible for the content in the paper. MJB was responsible for verifying the effects of E2 in all systems and integrating the contents of the paper provided by other coauthors. DRP wrote and provided content in relation to breast cancer and epidemiologic review of the other pathologies as well as contributed to the writing of the rest of the manuscript.
SMM provided cross species analysis and contributed to the writing of the manuscript.
RMG wrote and provided content for the skeletal section. DLH contributed to the genetic information in this paper. Mykhaylo Korda, and Christine Mikkola for their insightful comments on earlier drafts of this manuscript. It remains unexplained why anxiety disorders are more prevalent in women than in men, and how female hormone-related events such as menstrual cycle and postpartum influence the course of anxiety disorders. Several studies have shown progesterone to have anxiolytic anti-anxiety effects by acting on gamma-aminobutyric acid GABA receptors in the brain.
GABA is an inhibitory neurotransmitter that aids in relaxation and sleep. In the brain, GABA helps balance excitation with inhibition. Furthermore, withdrawal from endogenous progesterone supplementation after chronic administration increases anxiety via declining levels of its potent GABA-modulatory metabolites.
Progesterone's many functions in the body include: Testosterone Testosterone is a vital sex hormone that plays an important role in puberty. In men, testosterone not only regulates sex drive libidoit also helps regulate bone mass, fat distribution, muscle mass and strength, and the production of red blood cells and sperm.
But contrary to what some people believe, testosterone isn't exclusively a male hormone. Women produce small amounts of it in their bodies as well.
In men, testosterone is produced in the testes, the reproductive glands that also produce sperm. The amount of testosterone produced in the testes is regulated by the hypothalamus and the pituitary gland.