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Testosterone, androstenedione and dihydrotestosterone concentrations are elevated in female patients with major depression
Psychoneuroendocrinology 25 (2000) 765–771 www.elsevier.com/locate/psyneuen
Testosterone, androstenedione and dihydrotestosterone concentrations are elevated in female patients with major depression Bettina Weber a,*, Sabina Lewicka b, Michael Deuschle a, Michael Colla a, Isabella Heuser a a
b
Central Institute of Mental Health, PO Box 122120, 68072 Mannheim, Germany Department of Pharmacology, University of Heidelberg, INF 366, 69120 Heidelberg, Germany Received 24 January 2000; accepted 19 April 2000
Abstract Hyperactivity of the HPA–system in major depression is reflected by an increased secretion of adrenal hormones especially cortisol and dehydroepiandrosterone (DHEA). In women for whom androgenicity is associated with cardiovascular disorders the dominant source of androstenedione and testosterone secretion are the adrenal glands. To date, there is only sparse information about the regulation of androstenedione, testosterone and dihydrotestosterone (DHT) concentrations in women with severe major depression. Therefore, 11 pre- and postmenopausal, severely depressed, hypercortisolemic women (Hamilton Depression Scale, 31.3±5.9; age, 28–77 yrs; mean, 48.1±18.1 yrs) and 11 agematched healthy female controls (age, 24–81 yrs; mean, 47.9±21.5 yrs) underwent a 24 hour (h) blood sampling starting at 0800 h with 30-minute sampling intervals. By applying multivariate analysis of covariance with age as covariate, androstenedione, testosterone and DHT plasma levels at 0900 h show a trend for elevated concentrations in depressed women compared to controls (F1,19=2.7; P=0.057). Univariate F tests reveal a significant difference between the groups for androstenedione (4.19±1.571 vs 2.584±1.257 nmol/l; P⬍0.05) testosterone (1.110±0.278 vs 0.833±0.347 nmol/l; P⬍0.05) and DHT (0.656±0.207 vs 0.483±0.242 nmol/l; P⬍0.05). Mean ACTH (16.4±10.4 vs 10.4±2.4 pmol/l; P=0.89), LH (13.5±11.8 vs 8.9±9.2 IU/l; P=0.12), FSH (35.2±33.1 vs 31.3±35.7 IU/l; P=0.67) and estradiol (135.4±157.4 vs 82.2±85.1 pmol/l; P=0.20) plasma levels did not differ between patients and controls. Further, there was a trend towards an age related decline in testosterone secretion in
* Corresponding author. Tel.: +49-621-1703601; fax: +49-621-1703891. E-mail address: [email protected] (B. Weber). 0306-4530/00/$ - see front matter 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 5 3 0 ( 0 0 ) 0 0 0 2 3 - 8
766
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healthy controls (r=⫺0.24; P=0.08) which did not occur in depressed patients (r=0.17; P=0.96), while the calculated ratio of DHEA to testosterone was similar in both groups (0.2±0.14 vs 0.13±0.7; P=0.21, unpaired t–test). In conclusion, androstenedione, testosterone and DHT concentrations all were increased in hypercortisolemic women with severe major depression. These findings are best explained as a consequence of an overstimulation of the adrenal glands through pituitary and hypothalamic sites of the HPA–system. 2000 Elsevier Science Ltd. All rights reserved. Keywords: Major depression; Women; Testosterone; Dihydrotestosterone; Androstenedione; HPA–system
1. Introduction
Hyperactivity of the hypothalamus–pituitary–adrenal (HPA) system is a frequent finding in major depression, resulting in an elevation of adrenal steroid hormone secretion such as hypercortisolemia and increased concentrations of dehydroepiandrosterone (DHEA), a precursor of androstenedione and testosterone synthesis (Heuser, 1998; Heuser et al., 1998). In women, approximately 60–70% of circulating androstenedione and testosterone are produced by the adrenal glands and are regulated by ACTH, only 25–40% by the ovaries (Vermeulen, 1983). The regulator of the ovarian androgen production is the ratio of luteinizing hormone (LH) to follicle stimulating hormone (FSH). Within most androgen target tissues, testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5–alpha–reductase. DHT exerts its effects through the same androgen receptor as testosterone, with a 1.25 higher biological activity (Coffey, 1988). Elevated concentrations of circulating testosterone in women combined with low levels of sex–hormone–binding globulin (SHBG) are suggested to be risk factors for the development of cardiovascular diseases such as insulin resistance and visceral obesity (Ivandic et al., 1998). Major depression is also associated with an increased risk for cardiovascular morbidity and mortality (Glassmann and Shapiro, 1998), presumably at least partly due to endocrine and metabolic dysfunctions. Given these facts, it is surprising that there is only sparse information about the regulation of adrenal androgens in women with major depression. One study reported increased levels of circulating testosterone in premenopausal women with major depression (Baischer et al., 1995) and another in bulimia nervosa (Sundblad et al., 1994). Within the framework of the present sudy, we examined androstenedione, testosterone and DHT concentrations in pre- and postmenopausal women with severe major depression compared to an age-matched group of healthy controls. We hypothesize that in depressed women, synthesis of adrenal androgens is elevated as a result of supraadrenal hypothalamic–pituitary (HP) overactivity.
B. Weber et al. / Psychoneuroendocrinology 25 (2000) 765–771
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2. Methods 2.1. Subjects This study was approved by the local ethics committee and all subjects had given informed written consent. Only female in-patients with major depression were included in this study. Inclusion criteria were 1) major depression according to DSM– IV (American Psychiatric Association, 1994), 2) at least 18 points on the 21-item Hamilton Depression Scale (Hamilton, 1960), 3) no history of substance abuse or dependency, 4) absence of neurological or relevant medical disorders, and 5) no psychotropic drugs for at least seven days prior to entering the study, except for zolpidem given in cases of sleep difficulties. The healthy control group was recruited through newspaper advertisement. In this group a standardized psychiatric interview provided no evidence for an individual or family history of psychiatric disorders. In all subjects, a thorough physical examination including routine laboratory test and magnetic resonance imaging of the brain, electrocardiogram, and electroencephalogram revealed no signs of physical illness. Eleven female depressed patients (age, 28–77 yrs; mean, 48.1±18.1 yrs; body mass index, 18.6–29.5 kg/m2; mean, 22.7±3.9 kg/m2; HAMD, 21–40, mean, 31.3±5.9) as well as 11 healthy female volunteers (age, 24–81 yrs, 47.9±21.5 yrs; mean body mass index, 18.4–26.1 kg/m2, mean, 21.7±2.7 kg/m2) participated in this study. Each group included six pre- and five postmenopausal women without hormone replacement therapy. 2.2. 24 h blood sampling All subjects underwent a 24-hour blood sampling period starting at 0800 h. Blood was drawn through an indwelling forearm catheter for measurement of androstenedione, testosterone, DHT, cortisol, DHEA, ACTH, LH, FSH and estradiol plasma concentrations. Between blood samplings, the tubing system was kept patent by saline infusion at a rate of 50 ml/h. Each sample was immediately centrifuged and stored at ⫺20°C for determinations of androstenedione, testosterone, DHT, cortisol, DHEA, LH, FSH and estradiol and at ⫺80°C for ACTH measurement. Subjects remained sedentary in bed with free access to food and lights were off at 2300 h. Patients and controls spent most of the time reading or watching television. Daytime napping was not allowed. 2.3. Hormone assays Cortisol was measured using a commercial RIA–Kit (ICN Biomedicals, Cersa, CA). Plasma ACTH concentrations were measured by immunoradiometric assay using a commercial kit (Nichols Institute, San Juan Capistrano, CA). The intra- and interassay variabilities were less than 8%. DHEA analyses were performed in duplicate without a prior serum extraction step using the coated-tube RIA kit Active DHEA from Diagnostic Systems Laboratories (Webster, TX). The lower limit was
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0.09 nmol/l; interassay coefficients of variation were 14.7% at 3.27 nmol/l and 7.0% at 18.4 nmol/l. LH and FSH were measured with an immunoradiometric assay provided by Serono. Intraassay variability was less than 5% and interassay variability was between 7 and 9% at 4.2 IU/l for LH and 8.5 IU/l for FSH. Serum estradiol concentrations were measured by RIA after ether extraction (Radio Isotopen Service, Wu¨renlingen, Switzerland). The intraassay coefficient of variation was below 7%, the interassay coefficient of variation below 10% at a serum estradiol level of 270 pmol/l. Testosterone and DHT were measured with RIAs after extraction and chromatographic separation applying in-house method. Briefly, extracts of one ml serum samples were chromatographed and separated testosterone and DHT fractions were then quantified with specific RIAs. The sensitivity, intraassay variation and interassay variation were 0.01 nmol/l, 8% and 10% for the testosterone RIA 0.01 nmol/l, 10% and 12% for the DHT RIA, respectively (Table 1). Androstenedione was measured after extraction of 50 µl serum sample with inhouse RIA. Sensitivity of the method was 0.03 nmol/l intraassay variation 5% and interassay variation 7% (Table 1). The RIA results of all assays were corrected with individually (for each sample) determined procedural losses. 2.4. Statistical analysis Multivariate analysis of covariance (MANCOVA) with diagnosis as independent variable, and age as covariate, was applied to test the significance of the dependent variables, i.e. the above mentioned hormones. In case of significant differences, local effects were determined by univariate F tests. Further statistical analysis comprised two-tailed t–test, regression analysis and correlation analysis. A P-value below 0.05 was considered significant.
Table 1 Crossreactivity, calculated from 50% displacement, of the antibodies applied for measurements of testosterone, dihydrotestosterone and androstenedione (Abraham, 1969)
Testosterone Dihydrotestosterone Androstenedione Corticosterone Cortisol 11-Deoxycortisol Progesterone DHEA
Testosterone
Dihydrotestosterone
Androstenedione
100 73 3 0 0 0 0 0.13
40 100 11 0.02 0 0.02 0 3
8 4 100 0.01 0.02 0.01 0.07 4
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3. Results Both age and body mass index were similar in both groups. MANCOVA indicated an overall difference in hormone concentrations between depressed patients and controls (Wilks’ Lamda, F1,19=2.7; P=0.057). Analysis of local effects revealed circulating concentrations of androstenedione, testosterone and DHT to be elevated in depressed women compared to healthy controls (see Table 2). Similarly, 24 h mean cortisol and mean DHEA concentrations were significantly higher in patients than in controls (see Table 2). No significant group differences could be demonstrated for 24 h mean ACTH, LH, FSH and estradiol (see Table 2). The calculated ratios of DHEA to testosterone were similar in patients and controls. Regression analysis showed a statistical trend towards an age related decline in testosterone concentrations in healthy probands (coefficient:⫺0.24; P=0.08), but not in depressed women (r=0.17; P=0.96). There was no correlation between 24 h mean cortisol and testosterone concentrations in patients (r=0.12; P=0.75). Finally, none of the patients had clinical signs and symptoms of hyperandrogenism e.g. hirsutism.
4. Discussion The main findings of this study were that, in comparison to healthy controls, circulating concentrations of androstenedione, testosterone and dihydrotestosterone were increased in hypercortisolemic depressed women. Further, mean ACTH, LH, FSH and estradiol plasma levels were similar in patients and controls. These results are in agreement with the well known findings of an overactivity of Table 2 Endocrine data of subjects are expressed in mean±standard deviation; normal range for women: testosterone 0.694–2.776 nmol/l; DHT: 0.104–0.794 nmol/l; androstenedione: 2.968–9.603 nmol/l Comparison group n=11 Androstenedione nmol/l Testosterone nmol/l DHT nmol/l Cortisol nmol/l DHEA nmol/l ACTH pmol/l LH IU/l FSH IU/l Estradiol pmol/l
2.548±1.257 0.833±0.347 0.488±0.242 75.6±11.4 3.5±2.8 10.4±2.4 8.9±9.2 31.3±35.7 135.4±157.4
Major depression n=11 4.190±1.571 1.110±0.278 0.656±0.207 104.1±29.2 6.4±4.4 16.4±10.4 13.5±11.8 35.2±33.1 82.2±85.1
P⬍0.05 P⬍0.05 P⬍0.05 P⬍0.05 P⬍0.05 P=0.39 P=0.12 P=0.67 P=0.20
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the HPA–system in severely depressed patients (Heuser, 1998). In contrast to men, however, as we have demonstrated in a previous study (Schweiger et al., 1999), female depressives have an unchanged hypothalamic–pituitary–gonadal–system (HPG). In another study, testosterone plasma concentrations were elevated in a sample of premenopausal women with depression comparable to our patients (Baischer et al., 1995). As in our study, there was no difference in LH, FSH, estradiol, prolactin and progesterone concentrations between patients and controls and patients did not have symptoms of hyperandrogenism. However, this study provided no information about HPA–system activity. We now suggest that elevated concentrations of androstenedione, testosterone, DHT and DHEA in hypercortisolemic depressed women are a result of an supraadrenal overstimulation of the adrenal glands, which are the main source of these hormones in women. The dissociation between normal ACTH concentrations and increased cortisol plasma levels is mainly due to the method of low frequency blood sampling with 30 minute intervals which does not reflect the greater frequency of ACTH release and its short half life. DHEA is one important precursor of androstenedione and testosterone synthesis in the adrenal glands. In a previous study we have reported elevated concentrations of DHEA in hypercortisolemic patients with major depression (Heuser et al., 1998). The present data confirm and extend these results. Especially the finding that there are no differences in the calculated ratio of DHEA to testosterone between patients and controls supports the notion that in depressive women testosterone originates mainly from the adrenals. This hypothesis of an adrenal origin of elevated concentrations of testosterone in depressed women is further supported by the observed trend towards an age-related decline in testosterone secretion in healthy probands which was absent in depressed women. During postmenopause, synthesis of ovarian hormones ceases so that circulating concentrations of testosterone are also decreased (Plouffe, 1998). Consequently, an overstimulation of the adrenal glands due to an increased activity of the HP– system in depressed women compensates for this age associated decline in hormone secretion. Several studies suggest a relationship between androgenicity and coronary heart diseases in women (Phillips et al., 1997). Hyperandrogenism is found to be associated with visceral obesity and insulin resistance (Ivandic et al., 1998), two important risk factors for the development of myocardial infarction. Similarly, patients with major depression show impaired glucose tolerance (Weber et al., 2000) and increased accumulation of intraabdominal fat (Thakore et al., 1997). Therefore, one might speculate that elevated concentrations of androstenedione, testosterone and DHT in depressed hypercortisolemic women contribute to the endocrine and metabolic inbalance which increases the risk for cardiovascular disorders in major depression. In conclusion, we constate that androstenedione, testosterone and DHT concentrations are elevated in women suffering from severe major depression as a consequence of an overstimulation of the adrenal glands by HPA–system hyperactivity.
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Acknowledgements We thank Ms Angela Heuer for expert technical assistance, Dr Bertram Krumm for statistical analysis and Ms Waltraud VanSyckel for preparing the manuscript.
References Abraham, G.E., 1969. A solid phase radioimmunoassay of estradiol–17β. J. Clin. Endocrinol. Metab. 29, 866–875. American Psychiatric Association, 1994. Diagnostic Criteria from DSM–IV. American Psychiatric Association, Washington DC. Baischer, W., Koinig, G., Hartman, B., Huber, J., Langer, G., 1995. Hypothalamic–pituitary–gonadal axis in depressed premenopausal women: elevated blood testosterone concentrations compared to normal controls. Psychoneuroendocrinology 20, 553–559. Coffey, D.S., 1988. Androgen action and the sex accessary tissues. In: Knobil, E., Neill, J. (Eds.), The Physiology of Reproduction. Raven Press, New York, pp. 1081–1119. Glassmann, A., Shapiro, P., 1998. Depression and the course of coronary artery disease. Am. J. Psychiatry 155 (1), 4–11. Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry 23, 56–62. Heuser, I., 1998. The hypothalamic–pituitary–adrenal system in depression. Pharmacopsychiatry 31, 10–13. Heuser, I., Deuschle, M., Luppa, P., Schweiger, U., Standhardt, H., Weber, B., 1998. Increased diurnal plasma concentrations of dehydroepiandrosterone in depressed patients. J. Clin. Endocrinol. Metab. 83, 3130–3133. Ivandic, A., Prpic-Krizevak, I., Sucic, M., Juric, M., 1998. Hyperinsulinemia and sex hormones in healthy premenopausal women: relative contribution of obesity, obesity type, and duration of obesity. Metabolism 47, 13–19. Phillips, G., Pinkernekk, B., Jing, T., 1997. Relationship between serum sex hormones and coronary artery disease in postmenopausal women. Arterioscler. Thromb. Vasc. Biol. 17, 695–701. Plouffe, L., 1998. Ovaries, androgens and the menopause. Pract. Seminars in Reprod. Endocrinol. 16, 117–120. Schweiger, U., Deuschle, M., Weber, B., Ko¨rner, A., Lammers, C.-H., Schmider, J., Gotthardt, U., Heuser, I., 1999. Testosterone, gonadotropin, and cortisol secretion in male patients with major depression. Psychosom. Med. 61, 292–296. Sundblad, C., Bergman, L., Eriksson, E., 1994. High levels of free testosterone in women with bulimia nervosa. Acta Psychiatr. Scand. 90, 397–398. Thakore, J., Richards, P., Reznek, R., Martin, A., Dinan, T., 1997. Increased intraabdominal fat deposition in patients with major depressive illness as measured by computed tomography. Biol. Psychiatry 41, 1140–1142. Vermeulen, A., 1983. Androgen secretion by the adrenals and gonads. In: Mahesh, V.B., Greenblatt, R.B. (Eds.), Hirsutism and Virilism: Pathogenesis, Diagnosis and Management. John Wright, Bristol, pp. 17–34. Weber, B., Schweiger, U., Deuschle, M., Heuser, I., 2000. Major depression and impaired glucose tolerance. Exp. Clin. Endocrinol. Diabetes 108, 187–190.
Testosterone, androstenedione and dihydrotestosterone concentrations are elevated in female patients with major depression Bettina Weber a,*, Sabina Lewicka b, Michael Deuschle a, Michael Colla a, Isabella Heuser a a
b
Central Institute of Mental Health, PO Box 122120, 68072 Mannheim, Germany Department of Pharmacology, University of Heidelberg, INF 366, 69120 Heidelberg, Germany Received 24 January 2000; accepted 19 April 2000
Abstract Hyperactivity of the HPA–system in major depression is reflected by an increased secretion of adrenal hormones especially cortisol and dehydroepiandrosterone (DHEA). In women for whom androgenicity is associated with cardiovascular disorders the dominant source of androstenedione and testosterone secretion are the adrenal glands. To date, there is only sparse information about the regulation of androstenedione, testosterone and dihydrotestosterone (DHT) concentrations in women with severe major depression. Therefore, 11 pre- and postmenopausal, severely depressed, hypercortisolemic women (Hamilton Depression Scale, 31.3±5.9; age, 28–77 yrs; mean, 48.1±18.1 yrs) and 11 agematched healthy female controls (age, 24–81 yrs; mean, 47.9±21.5 yrs) underwent a 24 hour (h) blood sampling starting at 0800 h with 30-minute sampling intervals. By applying multivariate analysis of covariance with age as covariate, androstenedione, testosterone and DHT plasma levels at 0900 h show a trend for elevated concentrations in depressed women compared to controls (F1,19=2.7; P=0.057). Univariate F tests reveal a significant difference between the groups for androstenedione (4.19±1.571 vs 2.584±1.257 nmol/l; P⬍0.05) testosterone (1.110±0.278 vs 0.833±0.347 nmol/l; P⬍0.05) and DHT (0.656±0.207 vs 0.483±0.242 nmol/l; P⬍0.05). Mean ACTH (16.4±10.4 vs 10.4±2.4 pmol/l; P=0.89), LH (13.5±11.8 vs 8.9±9.2 IU/l; P=0.12), FSH (35.2±33.1 vs 31.3±35.7 IU/l; P=0.67) and estradiol (135.4±157.4 vs 82.2±85.1 pmol/l; P=0.20) plasma levels did not differ between patients and controls. Further, there was a trend towards an age related decline in testosterone secretion in
* Corresponding author. Tel.: +49-621-1703601; fax: +49-621-1703891. E-mail address: [email protected] (B. Weber). 0306-4530/00/$ - see front matter 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 4 5 3 0 ( 0 0 ) 0 0 0 2 3 - 8
766
B. Weber et al. / Psychoneuroendocrinology 25 (2000) 765–771
healthy controls (r=⫺0.24; P=0.08) which did not occur in depressed patients (r=0.17; P=0.96), while the calculated ratio of DHEA to testosterone was similar in both groups (0.2±0.14 vs 0.13±0.7; P=0.21, unpaired t–test). In conclusion, androstenedione, testosterone and DHT concentrations all were increased in hypercortisolemic women with severe major depression. These findings are best explained as a consequence of an overstimulation of the adrenal glands through pituitary and hypothalamic sites of the HPA–system. 2000 Elsevier Science Ltd. All rights reserved. Keywords: Major depression; Women; Testosterone; Dihydrotestosterone; Androstenedione; HPA–system
1. Introduction
Hyperactivity of the hypothalamus–pituitary–adrenal (HPA) system is a frequent finding in major depression, resulting in an elevation of adrenal steroid hormone secretion such as hypercortisolemia and increased concentrations of dehydroepiandrosterone (DHEA), a precursor of androstenedione and testosterone synthesis (Heuser, 1998; Heuser et al., 1998). In women, approximately 60–70% of circulating androstenedione and testosterone are produced by the adrenal glands and are regulated by ACTH, only 25–40% by the ovaries (Vermeulen, 1983). The regulator of the ovarian androgen production is the ratio of luteinizing hormone (LH) to follicle stimulating hormone (FSH). Within most androgen target tissues, testosterone is converted to dihydrotestosterone (DHT) by the enzyme 5–alpha–reductase. DHT exerts its effects through the same androgen receptor as testosterone, with a 1.25 higher biological activity (Coffey, 1988). Elevated concentrations of circulating testosterone in women combined with low levels of sex–hormone–binding globulin (SHBG) are suggested to be risk factors for the development of cardiovascular diseases such as insulin resistance and visceral obesity (Ivandic et al., 1998). Major depression is also associated with an increased risk for cardiovascular morbidity and mortality (Glassmann and Shapiro, 1998), presumably at least partly due to endocrine and metabolic dysfunctions. Given these facts, it is surprising that there is only sparse information about the regulation of adrenal androgens in women with major depression. One study reported increased levels of circulating testosterone in premenopausal women with major depression (Baischer et al., 1995) and another in bulimia nervosa (Sundblad et al., 1994). Within the framework of the present sudy, we examined androstenedione, testosterone and DHT concentrations in pre- and postmenopausal women with severe major depression compared to an age-matched group of healthy controls. We hypothesize that in depressed women, synthesis of adrenal androgens is elevated as a result of supraadrenal hypothalamic–pituitary (HP) overactivity.
B. Weber et al. / Psychoneuroendocrinology 25 (2000) 765–771
767
2. Methods 2.1. Subjects This study was approved by the local ethics committee and all subjects had given informed written consent. Only female in-patients with major depression were included in this study. Inclusion criteria were 1) major depression according to DSM– IV (American Psychiatric Association, 1994), 2) at least 18 points on the 21-item Hamilton Depression Scale (Hamilton, 1960), 3) no history of substance abuse or dependency, 4) absence of neurological or relevant medical disorders, and 5) no psychotropic drugs for at least seven days prior to entering the study, except for zolpidem given in cases of sleep difficulties. The healthy control group was recruited through newspaper advertisement. In this group a standardized psychiatric interview provided no evidence for an individual or family history of psychiatric disorders. In all subjects, a thorough physical examination including routine laboratory test and magnetic resonance imaging of the brain, electrocardiogram, and electroencephalogram revealed no signs of physical illness. Eleven female depressed patients (age, 28–77 yrs; mean, 48.1±18.1 yrs; body mass index, 18.6–29.5 kg/m2; mean, 22.7±3.9 kg/m2; HAMD, 21–40, mean, 31.3±5.9) as well as 11 healthy female volunteers (age, 24–81 yrs, 47.9±21.5 yrs; mean body mass index, 18.4–26.1 kg/m2, mean, 21.7±2.7 kg/m2) participated in this study. Each group included six pre- and five postmenopausal women without hormone replacement therapy. 2.2. 24 h blood sampling All subjects underwent a 24-hour blood sampling period starting at 0800 h. Blood was drawn through an indwelling forearm catheter for measurement of androstenedione, testosterone, DHT, cortisol, DHEA, ACTH, LH, FSH and estradiol plasma concentrations. Between blood samplings, the tubing system was kept patent by saline infusion at a rate of 50 ml/h. Each sample was immediately centrifuged and stored at ⫺20°C for determinations of androstenedione, testosterone, DHT, cortisol, DHEA, LH, FSH and estradiol and at ⫺80°C for ACTH measurement. Subjects remained sedentary in bed with free access to food and lights were off at 2300 h. Patients and controls spent most of the time reading or watching television. Daytime napping was not allowed. 2.3. Hormone assays Cortisol was measured using a commercial RIA–Kit (ICN Biomedicals, Cersa, CA). Plasma ACTH concentrations were measured by immunoradiometric assay using a commercial kit (Nichols Institute, San Juan Capistrano, CA). The intra- and interassay variabilities were less than 8%. DHEA analyses were performed in duplicate without a prior serum extraction step using the coated-tube RIA kit Active DHEA from Diagnostic Systems Laboratories (Webster, TX). The lower limit was
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B. Weber et al. / Psychoneuroendocrinology 25 (2000) 765–771
0.09 nmol/l; interassay coefficients of variation were 14.7% at 3.27 nmol/l and 7.0% at 18.4 nmol/l. LH and FSH were measured with an immunoradiometric assay provided by Serono. Intraassay variability was less than 5% and interassay variability was between 7 and 9% at 4.2 IU/l for LH and 8.5 IU/l for FSH. Serum estradiol concentrations were measured by RIA after ether extraction (Radio Isotopen Service, Wu¨renlingen, Switzerland). The intraassay coefficient of variation was below 7%, the interassay coefficient of variation below 10% at a serum estradiol level of 270 pmol/l. Testosterone and DHT were measured with RIAs after extraction and chromatographic separation applying in-house method. Briefly, extracts of one ml serum samples were chromatographed and separated testosterone and DHT fractions were then quantified with specific RIAs. The sensitivity, intraassay variation and interassay variation were 0.01 nmol/l, 8% and 10% for the testosterone RIA 0.01 nmol/l, 10% and 12% for the DHT RIA, respectively (Table 1). Androstenedione was measured after extraction of 50 µl serum sample with inhouse RIA. Sensitivity of the method was 0.03 nmol/l intraassay variation 5% and interassay variation 7% (Table 1). The RIA results of all assays were corrected with individually (for each sample) determined procedural losses. 2.4. Statistical analysis Multivariate analysis of covariance (MANCOVA) with diagnosis as independent variable, and age as covariate, was applied to test the significance of the dependent variables, i.e. the above mentioned hormones. In case of significant differences, local effects were determined by univariate F tests. Further statistical analysis comprised two-tailed t–test, regression analysis and correlation analysis. A P-value below 0.05 was considered significant.
Table 1 Crossreactivity, calculated from 50% displacement, of the antibodies applied for measurements of testosterone, dihydrotestosterone and androstenedione (Abraham, 1969)
Testosterone Dihydrotestosterone Androstenedione Corticosterone Cortisol 11-Deoxycortisol Progesterone DHEA
Testosterone
Dihydrotestosterone
Androstenedione
100 73 3 0 0 0 0 0.13
40 100 11 0.02 0 0.02 0 3
8 4 100 0.01 0.02 0.01 0.07 4
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3. Results Both age and body mass index were similar in both groups. MANCOVA indicated an overall difference in hormone concentrations between depressed patients and controls (Wilks’ Lamda, F1,19=2.7; P=0.057). Analysis of local effects revealed circulating concentrations of androstenedione, testosterone and DHT to be elevated in depressed women compared to healthy controls (see Table 2). Similarly, 24 h mean cortisol and mean DHEA concentrations were significantly higher in patients than in controls (see Table 2). No significant group differences could be demonstrated for 24 h mean ACTH, LH, FSH and estradiol (see Table 2). The calculated ratios of DHEA to testosterone were similar in patients and controls. Regression analysis showed a statistical trend towards an age related decline in testosterone concentrations in healthy probands (coefficient:⫺0.24; P=0.08), but not in depressed women (r=0.17; P=0.96). There was no correlation between 24 h mean cortisol and testosterone concentrations in patients (r=0.12; P=0.75). Finally, none of the patients had clinical signs and symptoms of hyperandrogenism e.g. hirsutism.
4. Discussion The main findings of this study were that, in comparison to healthy controls, circulating concentrations of androstenedione, testosterone and dihydrotestosterone were increased in hypercortisolemic depressed women. Further, mean ACTH, LH, FSH and estradiol plasma levels were similar in patients and controls. These results are in agreement with the well known findings of an overactivity of Table 2 Endocrine data of subjects are expressed in mean±standard deviation; normal range for women: testosterone 0.694–2.776 nmol/l; DHT: 0.104–0.794 nmol/l; androstenedione: 2.968–9.603 nmol/l Comparison group n=11 Androstenedione nmol/l Testosterone nmol/l DHT nmol/l Cortisol nmol/l DHEA nmol/l ACTH pmol/l LH IU/l FSH IU/l Estradiol pmol/l
2.548±1.257 0.833±0.347 0.488±0.242 75.6±11.4 3.5±2.8 10.4±2.4 8.9±9.2 31.3±35.7 135.4±157.4
Major depression n=11 4.190±1.571 1.110±0.278 0.656±0.207 104.1±29.2 6.4±4.4 16.4±10.4 13.5±11.8 35.2±33.1 82.2±85.1
P⬍0.05 P⬍0.05 P⬍0.05 P⬍0.05 P⬍0.05 P=0.39 P=0.12 P=0.67 P=0.20
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the HPA–system in severely depressed patients (Heuser, 1998). In contrast to men, however, as we have demonstrated in a previous study (Schweiger et al., 1999), female depressives have an unchanged hypothalamic–pituitary–gonadal–system (HPG). In another study, testosterone plasma concentrations were elevated in a sample of premenopausal women with depression comparable to our patients (Baischer et al., 1995). As in our study, there was no difference in LH, FSH, estradiol, prolactin and progesterone concentrations between patients and controls and patients did not have symptoms of hyperandrogenism. However, this study provided no information about HPA–system activity. We now suggest that elevated concentrations of androstenedione, testosterone, DHT and DHEA in hypercortisolemic depressed women are a result of an supraadrenal overstimulation of the adrenal glands, which are the main source of these hormones in women. The dissociation between normal ACTH concentrations and increased cortisol plasma levels is mainly due to the method of low frequency blood sampling with 30 minute intervals which does not reflect the greater frequency of ACTH release and its short half life. DHEA is one important precursor of androstenedione and testosterone synthesis in the adrenal glands. In a previous study we have reported elevated concentrations of DHEA in hypercortisolemic patients with major depression (Heuser et al., 1998). The present data confirm and extend these results. Especially the finding that there are no differences in the calculated ratio of DHEA to testosterone between patients and controls supports the notion that in depressive women testosterone originates mainly from the adrenals. This hypothesis of an adrenal origin of elevated concentrations of testosterone in depressed women is further supported by the observed trend towards an age-related decline in testosterone secretion in healthy probands which was absent in depressed women. During postmenopause, synthesis of ovarian hormones ceases so that circulating concentrations of testosterone are also decreased (Plouffe, 1998). Consequently, an overstimulation of the adrenal glands due to an increased activity of the HP– system in depressed women compensates for this age associated decline in hormone secretion. Several studies suggest a relationship between androgenicity and coronary heart diseases in women (Phillips et al., 1997). Hyperandrogenism is found to be associated with visceral obesity and insulin resistance (Ivandic et al., 1998), two important risk factors for the development of myocardial infarction. Similarly, patients with major depression show impaired glucose tolerance (Weber et al., 2000) and increased accumulation of intraabdominal fat (Thakore et al., 1997). Therefore, one might speculate that elevated concentrations of androstenedione, testosterone and DHT in depressed hypercortisolemic women contribute to the endocrine and metabolic inbalance which increases the risk for cardiovascular disorders in major depression. In conclusion, we constate that androstenedione, testosterone and DHT concentrations are elevated in women suffering from severe major depression as a consequence of an overstimulation of the adrenal glands by HPA–system hyperactivity.
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Acknowledgements We thank Ms Angela Heuer for expert technical assistance, Dr Bertram Krumm for statistical analysis and Ms Waltraud VanSyckel for preparing the manuscript.
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