, Estrogens and placental and uterus cell differentiation and proliferation 603 E2 contributes to trophoblast cell proliferation but also stimulates villous CT differentiation into STs 604 which in turn synthesize estrogens and enhance both CT proliferation and maturation (186,187)
, Estrogens modulate the fetal hypothalamic-pituitary-adrenal axis through the upregulation of placental 609
, These low fetal 610 cortisol levels stimulate ACTH release from the fetal pituitary gland which then increases DHEA 611 synthesis by the fetal adrenal glands. However, fetal adrenal glands express ER? and ER? and their 612 activity is controlled by estrogens (247), HSD11B2 (245)
risk factors and estrogen synthesis/signaling deficiencies 619 We reviewed available data on potential links between well-established risk factors of PE and 620 abnormal E2 synthesis and/or signaling, in order to strengthen the hypothesis that PE is associated 621 with estrogen deficiency. Maternal conditions such as obesity, diabetes and chronic hypertension, are 25 622 well known risk factors of PE (16). Similarly, the risk of PE is increased in women with renal 623 transplantation (250) ,
,
, Over two thirds of women of reproductive age are overweight or obese in the United States (251), i.e., 627 with a body mass index over 25 and 30 kg/m 2 , respectively. Central distribution of body fat (marker of 628 visceral fat) is the main risk factor for cardiovascular disease including PE (252). Adipocytes/adipose 629 tissue-resident macrophages produce estrogens by converting androgens through CYP 19
, Excessive 632 production of TNF-? and interleukin (IL)-6 by adipose tissue-resident macrophages has been 633 described in both obese pregnant and non-pregnant women (253,255). These pro-inflammatory 634 adipokines display paracrine effects (local increase of leptin synthesis) (253), promote insulin 635 resistance and participate in the systemic low-grade inflammatory state, vol.253, pp.255-258
Nevertheless, plasma leptin levels have 637 been found to be higher in obese women with PE than in controls (254) ,
, While TNF-? stimulates aromatase expression in adipose tissue stromal cells (261), leptin-mediated
, TNF-? upregulation induces an excess of CT and ST apoptosis in the placenta (262-264), thus 641 decreasing placental steroid biosynthesis
,
, Chronic low-grade inflammation promotes insulin 646 resistance mainly via TNF-? and IL-6 but also via other inflammatory cytokines (268). Maternal as 647 well as fetal reactive hyperinsulinemia affect placental cells (269)
Uzelac et al (271) reported reduced aromatase protein concentrations but 651 no change in placental mRNA levels in women with GDM compared to those without GDM. This 652 result suggests a post-transcriptional event. Increases in insulin-like growth factor-I and II ,
, 274) seem to be involved as well (274), 654 though controversial results have been reported about IGFI and II plasma levels during GDM or type 2 655 diabetes, which share structural similarities with insulin, vol.273
, C. Chronic hypertension
, Based on the obesity model, we suggest that the low-grade inflammation present in CH induces 660 endothelial dysfunction and placental inflammation and could enhance placental necrosis/apoptosis 661 and insulin resistance thus contributing to E2 deficiency
Kidney transplantation ,
, This pattern could 667 be related to numerous factors such as immune response to the grafted tissues and possibly to disease-668 related renal impairment. As described above, chronic inflammation could promote endothelial injury, 669 placental apoptosis and insulin resistance, and then facilitate the subsequent disruption of placental 670 steroidogenesis. Finally, in addition to kidney disease itself, drugs such as prednisone not only induce 671 diabetes (280) but have also been shown to enhance placental vasoconstriction, induce fetal and 672 placental growth restriction and prevent normal vascularization in rat placenta via a reduction in 673 VEGF expression (281), These patients frequently 664 gain weight early after transplantation leading to overweight or obesity (278)
, Although all these risk factors of PE can promote direct systemic endothelial injury, they also have a 676 negative impact on the placenta, including inflammation and excess of placental necrosis/apoptosis, p.27
, well as impacting aromatase production. They may thus induce an estrogen deficiency which further
, Kanasaki et al (112) successfully 682 reverted PE features with a subcutaneous administration of 2-ME2 in COMT -/-mice. Djordejvic et al 683 (284) showed that intramuscular short-term administration of E2 in women with PE reduced mean 684 arterial blood pressure. Furthermore, Genistein, a phytoestrogen with ER? selectivity as well as an 685 affinity for GPER (285,286), has also been assessed in the prevention of PE (287)
, The mechanisms of action of genistein may include GPER binding, SF1 activation and aromatase 689 modulation. The regulation of aromatase expression, and therefore its activity, is highly tissue specific
, All in all, 691 these data open up an interesting potential therapeutic field using estrogen itself or regulators of its
, Abnormal estrogen levels and dysregulation of the enzymes involved in estrogen biosynthesis have 695 been described during PE. An increasing number of studies highlight a marked decrease of estrogens 696 in maternal circulation, especially E2, the most potent ER ligand. However, published studies report 697 conflicting results possibly due to small sample sizes and mixed PE types
, Moreover, most of the studies only focus on specific targeted steroids rather than comprehensive 699 steroid profiling and also fail to assess their bioactivities. The mechanisms of E2 deficiency may 700 include changes in the regulation of expression of the main steroidogenic enzymes (aromatase, 701 HSD17B1) possibly via miRNAs and transcription factors such as USF1 and 2
, However, the major role of estrogens during physiological placental development and pregnancy 703 supports the hypothesis that low estrogen levels may play a central role in PE physiopathology
, Moreover, the close interaction between estrogens and angiogenic/antiangiogenic balance
, Further studies are required to confirm previous findings and develop clinical applications. We would 709 encourage larger studies with comprehensive steroid profiling using only analytically reliable mass 710 spectrometric procedures
, Major pending issues for clinical applications include: a) determining if estrogen deficiency is a 712 consequence of a hypoxic placenta or rather the cause or one of the initial causes of PE; b) evaluating 713 potential useful biomarkers of estrogens for PE screening and; c) assessing if natural estrogens and/or
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