Chronic hepatitis C (CHC) course revealed differences between men and women. Male gender and postmenopausal women are thought to be of the critical factors affecting HCV infection progression. The study aimed to assess female sex hormones and their relation to disease severity and treatment in HCV infected females. Subjects were divided to 2 groups: 44 CHC female patients and 44 controls. Both groups were classified to premenopausal and postmenopausal females. Serum estradiol (E2), progesterone (PRG), and total testosterone (TT) were assessed using chemiluminescent immunoassay. Our results showed that menopausal patients had significantly higher levels of estradiol, total testosterone, and progesterone compared to controls (
Hepatitis C is caused by HCV infection. It is estimated that about 3% of the world’s population has been infected with HCV and 170 million are chronic carriers at risk of developing liver cirrhosis and/or liver cancer [
The clinical course of chronic hepatitis C revealed several differences between men and women. Male gender is thought to be one of the critical factors in the progression of HCV infection [
Sex differences are believed to be one of the factors affecting response to therapy. Female sex correlated positively with sustained virological response (SVR) [
Descriptive analytical study included 44 female patients, proven to have chronic hepatitis C infection [
Patients were recruited from Virology Center in Ismailia Fever Hospital, a referral center for treatment of HCV in Ismailia under the supervision of the Ministry of Health as part of the national project for combating viral hepatitis. Patients were subjected to thorough history taking, clinical examination, and routine workup including complete blood picture (CBC), serum transaminases (AST, ALT), total bilirubin, albumin, International Normalized Ratio (INR), alpha fetoprotein (AFP), and HCV quantitative PCR. Histopathological examination of histological activity and degree of hepatic fibrosis, of ultrasound guided percutaneous liver biopsy, was performed according to Metavir’s score. Blood samples were included in the study between May 2013 and October 2013.
Serum estradiol, progesterone, and total testosterone were assessed using IMMULITE 1000 (Siemens, IMMULITE, catalog number LKE21 for estradiol, LKTW1 for total testosterone, and LKPW1 for progesterone), a solid-phase enzyme-labeled, chemiluminescent immunoassay. Chemiluminescence generates electromagnetic radiation as light. The light intensity depends on a chemical reaction using a labeled enzyme and a chemiluminescent compound supplied as the enzyme substrate in excess to assure saturation kinetics. Light intensity is measured using stored master curves based on manufacturer’s instructions.
Patients were classified according to their reproductive status to 22 premenopausal and 22 postmenopausal females in each group (patients and controls). Further grouping of female patients according to (1) treatment (combined interferon and ribavirin therapy) response (nonresponders: patients who had detectable HCV RNA at weeks 12, 24, and 48; relapsers: patients who had detectable HCV RNA 24 weeks after stopping treatment; and responders: patients with sustained virological response (SVR) with undetectable HCV RNA six months after stopping treatment), (2) viral load (<600,000 and ≥600,000), and (3) fibrosis stage (≤F2 and >F2) was done to compare between groups.
Females included were nonsmokers, of reproductive age group (i.e., with regular menses, not pregnant or lactating), ≥18 years, and postmenopausal females (i.e., no menstrual period for 12 consecutive months).
CHC females having hepatocellular carcinoma (HCC), coinfection with human immunodeficiency virus (HIV), coinfection with hepatitis B virus (HBV), other causes of liver disease (alcoholic, autoimmune, and Wilson disease), previous liver transplant, hormone replacement therapy, hormonal contraception, and history of active substance or alcohol consumption were excluded.
All regulations adopted by the ethics committee in Faculty of Medicine, Suez Canal University, including patient consent were considered and approved.
Quantitative parametric variables were presented by mean and standard deviation (SD) and compared by Student’s
The demographic, clinical, biochemical, and histopathological data of the studied subjects are shown in Table
Demographic, clinical, biochemical, and histopathological data of patients and healthy controls.
Variables | Controls (RA) | Cases |
Controls |
Cases |
---|---|---|---|---|
|
22 | 22 | 22 | 22 |
Age (yrs) | 34.32 ± 8.39 | 38.27 |
57.09 ± 3.73 |
55.32 ± 3.80 |
BMI (kg/m2) | 24.45 ± 3.17 | 25.14 ± 3.63 | 27.45 ± 3.23 |
26.27 ± 3.31 |
AAM (yrs) | 11.41 ± 1.50 | 12.18 ± 1.62 | 11.41 ± 1.84 | 11.18 ± 1.74 |
Married (%) | 14 (63.6%) | 18 (81.1%) | 21 (95.4%) |
21 (95.4%) |
Parity | 2.29 ± 1.27 | 2.78 ± 1.11 | 3.33 ± 1.39 |
3.38 ± 1.20 |
DM (%) | 3 (13.6%) | 3 (13.6%) | 10 (45.5%) |
7 (31.8%) |
HTN (%) | 3 (13.6%) | 5 (22.7%) | 9 (40.9%) |
10 (45.5%) |
Hemoglobin (12–16 g/dL) | 12.43 ± 0.96 | 12.6 ± 1.2 | 12.37 ± 1.05 | 12.52 ± 1.47 |
TLC (4.000–11.000/mm3) | 7543.63 ± 2432.9 | 7081.82 ± 2194.56 | 7140.45 ± 2241.4 | 6215.0 ± 2279.34 |
Platelets (150.000–400.000/mm3) | 233000 ± 66960.5 | 214954.5 ± 86489.46 | 226136.4 ± 59978.8 | 154818.2 ± 46953.5 |
ALT (40) IU/L | 23.68 ± 5.07 | 51.99 ± 31.93 |
24.4 ± 3.87 | 57.86 ± 29.3 |
AST (40) IU/L | 23.18 ± 4.97 | 48.6 ± 19.87 |
25 ± 3.48 | 61.90 ± 27.8 |
Bilirubin (0–2 mg/dL) | 0.63 ± 0.32 | 0.563 ± 0.22 | 0.66 ± 0.28 | 0.66 ± 0.25 |
Albumin (3.5–5 g/dL) | 3.96 ± 0.24 | 3.9 ± 0.49 | 3.87 ± 0.28 | 3.56 ± 0.58 |
INR (0.9–1.1) | 0.95 ± 0.2 | 1.09 ± 0.12 | 0.91 ± 0.27 | 1.26 ± 0.24 |
AFP (10 ng/dL) | — | 3.56 ± 3.04 | — | 5.56 ± 3.7 |
HCV RNA (IU/mL) |
— | 577340 ± 293440 | — | 587400 ± 230269 |
Histological parameters | ||||
≤F2 number (%) | — | 16 (72.7%) | — | 9 (40.9%) |
>F2 number (%) | — | 6 (27.3%) | — | 13 (59.1%) |
<A2 number (%) | — | 11 (50%) | — | 8 (36.4%) |
≥A2 number (%) | — | 11 (50%) | — | 14 (63.6%) |
Response to treatment | ||||
Responders number (%) | — | 17 (77.3%) | — | 9 (40.9%) |
Nonresponders number (%) | — | 3 (13.6%) | — | 12 (54.4%) |
Relapsers number (%) | — | 2 (9.1%) | — | 1 (4.5%) |
Hormonal levels | ||||
E2 (pg/mL) | 106.5 ± 50.85 | 120.0 ± 56.74 | 20.43 ± 2.12 |
94.91 ± 46.82 |
TT (ng/dL) | 19.9 ± 0.85 | 20.51 ± 2.88 | 19.97 ± 1.02 | 31.6 ± 13.0 |
PRG (ng/mL) | 1.15 ± 0.76 | 1.21 ± 0.76 | 0.30 ± 0.133 |
0.60 ± 0.32 |
A, activity; AAM, age at menarche; ALT, alanine aminotransferase; AFP, alpha fetoprotein; AST, aspartate aminotransferase; BMI, body mass index; DM, diabetes mellitus; E2, estradiol; F, fibrosis; HTN, hypertension; INR, International Normalized Ratio; M, menopausal group;
Hormonal levels in the studied subjects showed that estradiol level is higher in menopausal patients compared to their healthy controls (
The relation between fibrosis and hormonal levels in reproductive aged and menopausal patients is shown in Table
The relation between fibrosis and hormonal levels in reproductive aged and menopausal patients.
Hormones | Fibrosis stage | Activity grade | Fibrosis stage | Activity grade | ||||
---|---|---|---|---|---|---|---|---|
≤F2 | >F2 | <A2 | ≥A2 | ≤F2 | >F2 | <A2 | ≥A2 | |
(RA) | (M) | |||||||
|
16 (72.7%) | 6 (27.3%) | 11 (50%) | 11 (50%) | 9 (40.9%) | 13 (59.1%) | 8 (36.4%) | 14 (63.6%) |
E2 (pg/mL) | 139.4 ± 50.72 | 68.25 ± 37.25 |
142.67 ± 49.31 | 97.3 ± 56.54 | 127.6 ± 44.3 | 72.3 ± 34.17 |
113.96 ± 52.29 | 84.04 ± 41.47 |
TT (ng/dL) | 19.95 ± 1.55 | 22.0 ± 4.89 | 21.6 ± 3.67 | 19.4 ± 1.18 | 22.1 ± 3.67 | 38.23 ± 13.09 |
21.13 ± 3.18 | 37.64 ± 12.68 |
PRG (ng/mL) | 1.30 ± 0.82 | 0.97 ± 0.54 | 1.5 ± 0.8 | 0.90 ± 0.51 | 0.407 ± 0.18 | 0.717 ± 0.34 |
0.33 ± 0.14 | 0.74 ± 0.30 |
The relation between virological response and hormonal levels in the studied groups is shown in Table
The relation between virological response and hormonal levels in reproductive aged and menopausal patients.
Hormones | Responders | Nonresponders | Relapsers | Responders | Nonresponders | Relapsers |
---|---|---|---|---|---|---|
(RA) | (M) | |||||
|
17 (77.3%) | 3 (13.6%) | 2 (9.1%) | 9 (40.9%) | 12 (54.4%) | — |
E2 (pg/mL) | 120.01 ± 58.49 | 148.33 ± |
77.35 ± |
106.4 ± 54.4 | 86.13 ± 42.9 | — |
TT (ng/dL) | 19.6 ± |
22.14 ± |
25.85 ± |
20.21 ± 0.64 | 40.42 ± 11.43 |
— |
PRG (ng/mL) | 1.14 ± |
1.46 ± |
1.41 ± |
0.30 ± 0.11 | 0.81 ± 0.27 |
— |
Table
The relation between viral load and hormonal levels in reproductive aged and menopausal patients.
Hormones | HCV RNA (IU/mL) [baseline before treatment] | |||
---|---|---|---|---|
(RA) | (M) | |||
<600,000 | ≥600,000 | <600,000 | ≥600,000 | |
|
10 (45.5%) | 12 (54.5%) | 10 (36.4%) | 12 (63.6%) |
E2 (pg/mL) | 135.38 ± 58.13 | 107.18 ± 54.65 | 106.71 ± 52.69 | 85.09 ± 41.02 |
TT (ng/dL) | 20.25 ± 1.66 | 20.73 ± 3.67 | 29.11 ± 9.99 | 33.73 ± 15.18 |
PRG (ng/mL) | 1.02 ± 0.64 | 1.37 ± 0.83 | 0.55 ± 0.24 | 0.62 ± 0.38 |
The correlations between hormonal levels in reproductive aged and menopausal patients and the fibrosis stage, activity grade, and virological response.
Hormones | Fibrosis stage | Activity grade | Treatment | Fibrosis stage | Activity grade | Treatment |
---|---|---|---|---|---|---|
(RA) | (M) | |||||
E2 (pg/mL) | −0.68 | −0.43 | −0.29 | −0.60 | −0.21 | 0.18 |
TT (ng/dL) | 0.37 | −0.35 | 0.20 | 0.69 | 0.74 | −0.66 |
PRG (ng/mL) | −0.04 | −0.23 | −0.04 | 0.46 | 0.62 | −0.63 |
Table
The relation between fibrosis and estradiol level in reproductive aged and menopausal patients.
(RA) | (M) | |||
---|---|---|---|---|
Age | 20–35 yrs |
35–50 yrs |
47–55 yrs |
55–60 yrs |
E2 (pg/mL) | ||||
Fibrosis stage | ||||
≤F2 | 152.1 ± 43.57 |
129.6 ± 56.11 |
147.22 ± 23.13 |
103.15 ± 55.6 |
>F2 | 83.0 ± 36.77 |
60.88 ± 40.56 |
54.15 ± 13.48 |
101.26 ± 38.46 |
|
||||
Activity grade | ||||
<A2 | 148.28 ± 51.51 |
138.00 ± 51.8 |
129.18 ± 48.78 |
68.30 ± 41.01 |
≥A2 | 122.25 ± 51.78 |
83.1 ± 57.8 |
56.31 ± 12.97 |
111.8 ± 41.01 |
The relation between virological response and estradiol level in reproductive aged and menopausal patients.
(RA) | (M) | |||
---|---|---|---|---|
Age | 20–35 yrs |
35–50 yrs |
47–55 yrs |
55–60 yrs |
E2 (pg/mL) | ||||
Responders | 137.91 ± 55.68 |
107.48 ± 59.92 |
116.7 ± 55.4 |
70.15 ± 43.63 |
Nonresponders | 132.5 ± 38.89 |
180.00 ± 00.00 |
58.7 ± 12.4 |
113.55 ± 45.7 |
Relapsers | — |
77.35 ± 61.73 |
— |
97.3 ± 00.0 |
The findings of our study reveal that CHC infection is associated with elevated levels of estradiol, total testosterone, and progesterone in both pre- and postmenopausal females when compared to their healthy controls. This may be explained by the impaired metabolism of these hormones as a result of the defective liver function in chronic liver disease patients [
Menopausal HCV infected women had higher levels of estradiol, total testosterone, and progesterone when compared to their healthy controls (
There were higher significant level of total testosterone and lower significant level of progesterone in menopausal women with CHC compared to females of reproductive age with CHC, and this was not the case for estradiol level that showed a slight, however, nonsignificant decrease (
HCV infection is associated with increased hormonal levels of estradiol, total testosterone, and progesterone in both groups reproductive aged and menopausal women; moreover estradiol and progesterone levels decreased with age, while total testosterone level increased with age in HCV group. In addition, although hormonal levels in reproductive aged group were higher than their healthy controls they are of statistically nonsignificant values and appeared to be minimally affected by hepatitis C, while menopausal group had hormonal levels high enough to be statistically significant in all variables compared to their healthy controls, providing evidence that this group was highly affected by hepatitis C.
Our study revealed that women of reproductive age had lower disease severity as measured by the liver necroinflammation activity and fibrosis compared to older menopausal women. The observed changes in the studied hormonal levels could be implicated in these findings. The high estradiol and progesterone levels and low total testosterone level in the reproductive aged patients may in part have protected against the development of severe liver injury. In contrast, menopausal women exhibited greater disease severity, probably due to the decline in estradiol and progesterone levels and the rise in total testosterone level that occurs with menopause development, supporting the concept that the progression of fibrosis in women is not on the same pace: mild during reproductive age and severe after menopause. Similar to our findings, Villa et al. 2012 conducted a study on four groups of women divided according to their reproductive stage (fully reproductive, premenopausal, early menopausal, and late menopausal) in addition to four age-matched groups of men serving as controls [
A number of molecular mechanisms could explain the protective role of E2; for example, E2 inhibits the transforming growth factor- (TGF-) b1 expression and hepatic stellate cell (HSC) activation, thereby suppressing the induction of hepatic fibrosis [
The total testosterone level was significantly higher in menopausal HCV infected females compared to reproductive aged HCV infected females. This finding is in agreement with the recently reported positive correlation between testosterone level and increased risk of both advanced hepatic fibrosis and advanced hepatic inflammatory activity in HCV infected men [
Our findings of excess testosterone-associated risk in HCV positive females are consistent with the findings of increased liver cancer risk in males who abuse anabolic steroids, in androgen-treated Fanconi anemia patients [
To our knowledge no studies addressing the changes in progesterone level have been conducted yet. Our study showed that menopausal patients had poorer responses to combined therapy than reproductive aged patients (menopause versus reproductive age:
The relationship between hormonal parameters in menopausal women and virological response showed that higher total testosterone and progesterone levels were significantly associated with unfavorable outcomes (
Our study revealed that there was a statistically nonsignificant difference regarding viral load values between the two groups. Besides, the comparative relationship of hormonal levels and viral load appeared to be of statistically nonsignificant value in all variables of both groups (menopausal and reproductive aged females). This finding is supported by one in vitro study that treated human hepatoma-derived cell line (Huh-7.5 cells) with E2 and PRG and found inhibition of HCV virion production (in case of E2 only) but not HCV RNA replication or HCV protein synthesis [
The present study explored the possible involvement of female sex hormones in the pathogenesis and/or progression of liver disease in HCV infected Egyptian females. We observed that lower estradiol level is significantly related to fibrosis severity in CHC females, while higher total testosterone and progesterone levels are significantly related to fibrosis severity in CHC menopausal females only. Besides, higher total testosterone and progesterone levels are related to poorer treatment response in CHC menopausal females, while estradiol level is not. Additionally, the detected higher hormonal levels did not have significant relation to viral load in both groups. We suggest that screening of progesterone and total testosterone levels should selectively target females with high grade fibrosis. Our findings underscore the potential favorable effects of antitestosterone treatment to target HCV infected females. We assume that giving hormone replacement therapy to infected menopausal females would not have a beneficial effect regarding HCV course or treatment response.
The authors declare that there is no conflict of interests regarding the publication of this paper.