## 4.2.8. Endocrine disruption

Author: Majorie van Duursen

Reviewer: Timo Hamers, Andreas Kortenkamp

Learning objectives

You should be able to

- explain how xenobiotics can interact with the endocrine system and hormonal actions;
- describe the thyroid system and molecular targets for thyroid hormone disruption;
- explain the concept “it’s the timing of the dose that makes the poison”.

Keywords: Endocrine system; Endocrine Disrupting Chemical (EDC); DES; Thyroid hormone disruption; Multi- and transgenerational effects

Short history

The endocrine system plays an essential role in the short- and long-term regulation of a variety of biochemical and physiological processes, such as behavior, reproduction, growth as well as nutritional aspects, gut, cardiovascular and kidney function and the response to stress. As a consequence, chemicals that cause changes in hormone secretion or in hormone receptor activity may target many different organs and functions and may result in disorders of the endocrine system and adverse health effects. The nature and the size of endocrine effects caused by chemicals depend on the type of chemical, the level and duration of exposure as well as on the timing of exposure.

The “DES drug disaster” is one of the most striking examples that endocrine-active chemicals can have severe adverse health effects in humans. There was a time when the synthetic estrogen diethylstilbestrol (DES) was considered a miracle drug (Figure 1). DES was prescribed from the 1940s-1970s to millions of women around the world to prevent miscarriages, abortion and premature labor. However, in the early 1970s it was found that daughters of mothers who took DES during their pregnancy have an increased risk of developing a specific vaginal and cervical cancer type. Other studies later demonstrated that women who had been exposed to DES in the womb (in utero) also had other health problems, like increased risk of breast cancer, increased incidence of genital malformations, infertility, miscarriages, and complicated pregnancies. Now, even two generations later, babies are born with reproductive tract malformations that are suspected to be caused by this drug their great grandmothers took during pregnancy. The effects of DES are attributed to the fact that it is a synthetic estrogen (i.e. a xenobiotic compound having similar properties as the natural estrogen 17β-estradiol), thereby disrupting normal endocrine regulation as well as epigenetic processes during development (link to section on Developmental Toxicity).

Around the same time of the DES drug disaster, Rachel Carson wrote a New York Times best-seller called Silent Spring. The book focused on endocrine disruptive properties of persistent environmental contaminants, such as the insecticide DDT (Dichloro Diphenyl Trichloroethane). She wrote that these environmental contaminants were badly degradable in the environment and cause reproductive failure and population decline in a variety of wild life. At the time the book was published, endocrine disruption was a controversial scientific theory that was met with much scepticism as empirical evidence was largely lacking. Still, the book of Rachel Carson has encouraged scientific, societal and political discussions about endocrine disruption. In 1996, another popular scientific book was published that presented more scientific evidence to warn against the effects of endocrine disruption: Our Stolen Future: Are We Threatening Our Fertility, Intelligence, and Survival? A Scientific Detective Story by Theo Colborn, Dianne Dumanoski and John Peterson Myers.

Figure 1: Advertisement from the 1950s for desPLEX, a synthetic drug containing diethylstilbestrol.

Currently, endocrine disruption is a widely accepted concept and many scientific studies have demonstrated a wide variety of adverse health effects that are attributed to exposure to endocrine active compounds in our environment. Human epidemiological studies have shown dramatic increases in incidences of hormone-related diseases, such as breast, ovarian, testicular and prostate cancer, endometrial diseases, infertility, decreased sperm quality, and metabolic diseases. Considering that hormones play a prominent role in the onset of these diseases, it is highly likely that exposure to endocrine disrupting compounds contributes to these increased disease incidences in humans. In wildlife, the effects of endocrine disruption include feminizing and demasculinizing effects leading to deviant sexual behaviour and reproductive failure in many species, such as fish, frogs, birds and panthers. A striking example of endocrine disruption can be found in the lake Apopka alligator population. Lake Apopka is the third largest lake in the state of Florida, located a few kilometres north west of Orlando. In July 1980, heavy rainfall caused the spill of huge amounts of DDT in the lake by a local pesticide manufacturer. After that, the alligator population in Lake Apopka started to show a dramatic decline. Upon closer examination, these alligators had higher estradiol and lower testosterone levels in their blood, causing poorly developed testes and extremely small penises in the male offspring and severely malformed ovaries in females.

What’s in a name: EDC definition

Since the early discussions on endocrine disruption, the World Health Organisation (WHO) has published several reports to present the state-of-the-art in scientific evidence on endocrine disruption, associated adverse health effects and the underlying mechanisms. In 2002, the WHO proposed a definition for an endocrine disrupting compound (EDC), which is still being used. According to the WHO, an EDC can be defined as “an exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects in an intact organism, or its progeny, or (sub) populations.” In 2012, WHO stated that “EDCs have the capacity to interfere with tissue and organ development and function, and therefore they may alter susceptibility to different types of diseases throughout life. This is a global threat that needs to be resolved.” The European Environment Agency concluded in 2012 that “chemically induced endocrine disruption likely affects human and wildlife endocrine health the world over.” A recent report (Demeneix & Slama, 2019) that was commissioned by the European Parliament concluded that the lack of EDC consideration in regulatory procedures is “clearly detrimental for the environment, human health, society, sustainability and most probably for our economy”.

The endocrine system

Higher animals, including humans, have developed an endocrine system that allows them to regulate their internal environment. The endocrine system is interconnected and communicates bidirectionally with the neuro- and immunesystems. The endocrine system consist of glands that secrete hormones, the hormones themselves and targets that respond to the hormone. Glands that secrete hormones include the pituitary, thyroid, adrenals, gonads and pancreas. There are three major classes of hormones: amino-acid derived hormones (e.g. thyroid hormones T3 and T4), peptide hormones (e.g. pancreatic hormones) and steroid hormones (e.g. testosterone and estradiol). Hormones elicit a wide variety of biological responses, which almost always start with binding of a hormone to a receptor in its target tissue. This will trigger a chain of intracellular events and eventually a physiological response. Understanding the chemical characteristics of a hormone and its function, may help explain the mechanisms by which chemicals can interact with the endocrine system and subsequently cause adverse health effects.

Mechanism of action

Inherent to the complex nature of the endocrine system, endocrine disruption comes in many shapes and forms. It can occur at the receptor level (link to section on Receptor Interaction), but endocrine disruptors can also disturb the synthesis, metabolism or transport of hormones (locally or throughout the body), or display a combination of multiple mechanisms. For example, DDT can decrease testosterone levels via increased testosterone conversion by the aromatase enzyme, but also acts like an anti-androgen by blocking the androgen receptor and as an estrogen by activating the estrogen receptor. PCBs, polychlorinated biphenyls, are well-characterized thyroid hormone disrupting chemicals. PCBs are industrial chemicals that were widely used in transformators until their ban in the 1970s, but, due to their persistency, PCBs can still ubiquitously be found in the environment, human and wildlife blood and tissue samples (link to section on POPs). PCBs are known to interfere with the thyroid system via inhibition of thyroid hormone synthesis and/or increasing thyroid hormone metabolism, inhibiting binding of thyroid hormones to serum binding proteins, or blocking the ability of thyroid hormones to thyroid hormone receptors. These thyroid disrupting effects can occur in different organs throughout the body (see Figure 2).

Figure 2: Possible sites of action of environmental contaminants on the hypothalamus-pituitary-thyroid axis. Thyroid disruption can occur via interaction with thyroid receptors in a target cell (9) or disruption of thyroid hormone secretion (1), synthesis (2, 4, 8) and metabolism (5), transport (3, 7) and excretion (6). In this Figure, the target cell for thyroid disruption is a neuron. Altered thyroid action in neuronal cells can lead to functional changes in the brain that may become apparent as disorders such as learning deficits, hearing loss and loss of IQ. Redrawn from Gilbert et al. (2012) by Evelin Karsten-Meessen.

The dose concept

In the 18th Century, physician and alchemist Paracelsus phrased the toxicological paradigm: “Everything is a poison. Only the dose makes that something is not a poison” (link to section Concentration-response relationships, and to Introduction). Generally, this is understood as “the effect of the poison increases with the dose”. According to this paradigm, upon deteriming the exposure levels where the toxic response begins and ends, safety levels can be derived to protect humans, animals and their environment. However, interpretation and practical implementation of this concept is challenged by issues that have arisen in modern-day toxicology, especially with EDCs, such as non-monotonic dose-response curves and timing of exposure.

To establish a dose-response relationship, traditionally, toxicological experiments are conducted where adult animals are exposed to very high doses of a chemical. To determine a safe level, you determine the highest test dose at which no toxic effect is seen (the NOAEL or no observed adverse effect level) and add an additional "safety" or "uncertainty" factor of usually 100. This factor 100 accounts for differences between experimental animals and humans, and differences within the human population (see chapter 6 on Risk assessment). Exposures below the safety level are generally considered safe. However, over the past years, studies measuring the effects of hormonally active chemicals also began to show biological effects of endocrine active chemicals at extremely low concentrations, which were presumed to be safe and are in the range of human exposure levels. There are several physiological explanations to this phenomenon. It is important to realize that endogenous hormone responses do not act in a linear, mono-tonic fashion (i.c. the effect goes in one direction), as can be seen in Figure 2 for thyroid hormone levels and IQ. There are feedback loops to regulate the endocrine system in case of over- or understimulation of a receptor and there are clear tissue-differences in receptor expression and sensitivity to hormonal actions. Moreover, hormones are messengers, which are designed to transfer a message across the body. They do this at extremely low concentrations and small changes in hormone concentrations can cause large changes in receptor occupancy and receptor activity. At high concentrations, the change in receptor occupancy is only minimal. This means that the effects at high doses do not always predict the effects of EDCs at lower doses and vice versa.

Figure 2. Relation between maternal thyroid hormone level (thyroxine) during pregnancy and (A) offspring cortex volume at the age of 8 years; (B) the predicted probability of offspring having an Intellectual Quotient (IQ) at the age of 6-8 years below 85 points. As women with overt hyperthyroidism or hypothyroidism were excluded, the range of values corresponds to those that can be considered within the normal limits for pregnancy of free thyroxine. Redrawn from Korevaar et al. (2016) by Wilma IJzerman.

It is becoming increasingly clear that not only the dose, but also the timing of exposure plays an important role in determining health effects of EDCs. Multi-generational studies show that EDC exposure in utero can affect future generations (Figure 3). Studies on the grandsons and granddaughters whose mothers were exposed prenatally to DES are limited as they are just beginning to reach the age when relevant health problems, such as fertility, can be studied. However, rodent studies with DES, bisphenol-A and DEHP show that perinatally exposed mothers have grandchildren with malformations of the reproductive tract as well as an increased susceptibility to mammary tumors in female offspring and testicular cancer and poor semen quality in male offspring. Some studies even show effects in the great-grandchildren (F3 generation), which indicates that endocrine disrupting effects have been passed to next generations without direct exposure of these generations. These are called trans-generational effects. Long-term, delayed effects of EDCs are thought to arise from epigenetic modifications in (germ) cells and can be irreversible and transgenerational (link to section on Developmental Toxicity). Consequently, safe levels of EDC exposure may vary, dependent on the timing of exposure. Adult exposure to EDCs is often considered activational, e.g. an estrogen-like compounds such as DES can stimulate proliferation of estrogen-sensitive breast cells in an adult leading to breast cancer. When exposure to EDCs occurs during development, the effects are considered to be organizational, e.g. DES changes germ cell development of perinatally exposed mothers and subsequently leads to genital tract malformations in their grandchildren. Multi-generational effects are clear in rodent studies, but are not so clear in humans. This is because it is difficult to characterize EDC exposure in previous generations (which may span over 100 years in humans), and it is challenging to filter out the effect of one specific EDC as humans are exposed to a myriad of chemicals throughout their lives.

Figure 3: Exposure to EDCs can affect multiple generations. EDC exposure of parents (P0) can be multi-generational and lead to adverse health effects in children (F1) and grandchildren (F2). Some studies show adverse health effects in great-grandchildren (F3) upon exposure of the parent (P0). This is considered trans-generational, which means that no direct exposure of F3 has taken place, but that effects are passed on via epigenetic modifications in the germ cells of P0, F1 and/or F2. Source: https://www.omicsonline.org/open-access/epigenetic-effects-of-endocrine-disrupting-chemicals-2161-0525-1000381.php?aid=76673

EDCs in the environment

Some well-known examples of EDCs are pesticides (e.g. DDT), plastic softeners (e.g. phthalates, like DEHP), plastic precursors (e.g. bisphenol-A), industrial chemicals (e.g. PCBs), water- and stain-repellents (perfluorinated substances such as PFOS and PFOA) and synthetic hormones (e.g. DES). Exposure to EDCs can occur via air, housedust, leaching into food and feed, waste- and drinking water. Exposure is often unintentional and at low concentrations, except for hormonal drugs. Clearly, synthetic hormones can also have beneficial effects. Hormonal cancers like breast and prostate cancers can be treated with synthetic hormones. And think about the contraceptive pill that has changed the lives of many women around the world since the 1960s. Nowadays, no other method is so widely employed in so many countries around the world as the birth control pill, with an estimate of 75 million users among reproductive-age women with a partner. An unfortunate side effect of this is the increase in hormonal drug levels in our environment leading to feminization of male fish swimming in the polluted waters. Pharmaceutical hormones, along with naturally-produced hormones, are excreted by women and men and these are not fully removed through conventional wastewater treatments. In addition, several pharmaceuticals that are not considered to act via the endocrine system, can in fact display endocrine activity and cause reproductive failure in fish. These are for example the beta-blocker atenolol, antidiabetic drug metformin and analgesic paracetamol.

Further reading:

WHO-IPCS. Global Assessment of the State-of-the-Science of Endocrine Disruptors. 2002 https://www.who.int/ipcs/publications/new_issues/endocrine_disruptors/en/

WHO-UNEP. State of the Science of Endocrine Disrupting Chemicals.2012 www.who.int/iris/bitstream/10665/78101/1/9789241505031_eng.pdf

European Environment Agency (EEA) The impacts of endocrine disrupters on wildlife, people and their environments The Weybridge+15 (1996–2011) report. EEA Technical report No 2/2012 EEA Copenhagen. ISSN 1725-2237 https://www.eea.europa.eu/publications/the-impacts-of-endocrine-disrupters

Demeneix, B., Slama, R. (2019) Endocrine Disruptors: from Scientific Evidence to Human Health Protection. Policy Department for Citizens' Rights and Constitutional Affairs Directorate General for Internal Policies of the Union PE 608.866 http://www.europarl.europa.eu/RegData/etudes/STUD/2019/608866/IPOL_STU(2019)608866_EN.pdf