Sex Steroid Hormones and Risk of Breast Cancer

A Two-Sample Mendelian Randomization Study

Aayah Nounu; Siddhartha P. Kar; Caroline L. Relton; Rebecca C. Richmond


Breast Cancer Res. 2022;24(66) 

In This Article

Abstract and Introduction


Background: Breast cancer (BC) has the highest cancer incidence and mortality in women worldwide. Observational epidemiological studies suggest a positive association between testosterone, estradiol, dehydroepiandrosterone sulphate (DHEAS) and other sex steroid hormones with postmenopausal BC. We used a two-sample Mendelian randomization analysis to investigate this association.

Methods: Genetic instruments for nine sex steroid hormones and sex hormone-binding globulin (SHBG) were obtained from genome-wide association studies (GWAS) of UK Biobank (total testosterone (TT) N: 230,454, bioavailable testosterone (BT) N: 188,507 and SHBG N: 189,473), The United Kingdom Household Longitudinal Study (DHEAS N: 9722), the LIFE-Adult and LIFE-Heart cohorts (estradiol N: 2607, androstenedione N: 711, aldosterone N: 685, progesterone N: 1259 and 17-hydroxyprogesterone N: 711) and the CORtisol NETwork (CORNET) consortium (cortisol N: 25,314). Outcome GWAS summary statistics were obtained from the Breast Cancer Association Consortium (BCAC) for overall BC risk (N: 122,977 cases and 105,974 controls) and subtype-specific analyses.

Results: We found that a standard deviation (SD) increase in TT, BT and estradiol increased the risk of overall BC (OR 1.14, 95% CI 1.09–1.21, OR 1.19, 95% CI 1.07–1.33 and OR 1.03, 95% CI 1.01–1.06, respectively) and ER + BC (OR 1.19, 95% CI 1.12–1.27, OR 1.25, 95% CI 1.11–1.40 and OR 1.06, 95% CI 1.03–1.09, respectively). An SD increase in DHEAS also increased ER + BC risk (OR 1.09, 95% CI 1.03–1.16). Subtype-specific analyses showed similar associations with ER+ expressing subtypes: luminal A-like BC, luminal B-like BC and luminal B/HER2-negative-like BC.

Conclusions: TT, BT, DHEAS and estradiol increase the risk of ER+ type BCs similar to observational studies. Understanding the role of sex steroid hormones in BC risk, particularly subtype-specific risks, highlights the potential importance of attempts to modify and/or monitor hormone levels in order to prevent BC.


Breast cancer (BC) is the most common cancer in women worldwide and is the leading cause of cancer mortality in females.[1] Early menarche and a later age at menopause have been shown to be associated with an increased risk of breast cancer.[2] Furthermore, a study conducted on postmenopausal women showed that a higher number of lifetime cumulative menstrual cycles increased BC risk.[3] Taken together, susceptibility to BC appears to be associated with ovarian hormones related to the menstrual cycle, although the biological basis for this is still not understood.[4]

The association of oral contraceptive use and hormone replacement therapy (HRT) with BC risk provides further evidence for the role of ovarian hormones in BC. A systematic review that included 44 BC studies showed that oral contraceptive use increased the risk of BC.[5] A large-scale meta-analysis combining case–control data from 58 studies found that HRT use was associated with an increased risk of BC within 4 years of current use, with the increasing risk associated with a longer duration of current use.[6]

Analyses looking specifically at blood levels of nine sex steroid hormones and BC risk concur with evidence surrounding factors associated with the menstrual cycle, oral contraceptive and HRT use with BC risk. A pooled analysis of nine prospective studies on 663 BC cases and 1765 controls found that increasing concentrations of oestrone, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulphate (DHEAS) and testosterone were associated with increased risk of BC in postmenopausal women.[7] Whilst most of these associations were thought to be due to the conversion of androgens (DHEA, DHEAS, testosterone and androstenedione)[8,9] to estradiol, these associations remained even after adjustment for circulating estradiol levels.[7,10] Androgen receptors have been shown to increase proliferation when expressed in triple-negative breast cancer (TNBC), further providing evidence for the role of androgens in BC risk independent of estradiol.[11] Positive associations with premenopausal BC were also found for estradiol, androstenedione, DHEAS and testosterone in a pooled analysis of seven prospective studies including 767 women with BC and 1699 controls;[12] however, a much larger study conducted in UK Biobank among 30,565 premenopausal women and 133,294 postmenopausal women found that testosterone and sex hormone-binding globulin (SHBG) increased and decreased BC risk in postmenopausal women, respectively, but did not influence premenopausal BC risk.[13]

Common metabolic pathways may underlie the relationship between sex hormones and BC risk. They are all produced from cholesterol and are synthesized in the gonads, adrenal cortex and placenta.[14] Cholesterol is first transported into the mitochondrion and converted to pregnenolone—the precursor for all sex hormones (Figure 1).[15–17] Whilst approximately half of the testosterone originates from the adrenal glands and the ovaries, the remainder is derived from the conversion of proandrogens (DHEA, DHEAS and androstenedione) in the periphery.[18] In postmenopausal women, the primary source of estradiol is from the conversion of androgens.[19]

Figure 1.

Sex steroid hormone metabolism pathway. Metabolites/hormones are displayed in black text and the enzymes that catalyse the reaction are in blue text. The hormones that are investigated in this analysis are shown in purple boxes. This diagram was adapted from Pott et al. [37]

Much of the current evidence surrounding sex hormones and BC risk comes from observational epidemiological studies. However, these studies are prone to confounding, selection bias and other biases.[20,21] The most reliable method for evaluating the effects of exogenous sex hormones on BC risk is through conducting randomized controlled trials (RCTs), but these are time-consuming and costly,[22] especially in the case of primary prevention trials of cancer. For this reason, other approaches to causal inference such as Mendelian randomization (MR) can be used to provide evidence for or against the role of sex hormones. MR uses genetic variants that predict changes in exposures (e.g. hormone levels) and assesses their effect on outcome (e.g. BC).[21,23,24] MR is analogous to an RCT as genetic variants are randomly allocated at conception, similar to random allocation of intervention at the start of a trial,[25,26] and fixed thereafter. This reduces the impact of confounding encountered in observational epidemiology.[25]

Previous MR studies have been carried out looking at the effect of testosterone (total and bioavailable) and sex hormone-binding globulin (SHBG) on overall, ER+ and ER–BC risk.[27,28] In this two-sample MR study, we expanded the analysis to include seven other sex steroid hormones as well as investigating the effect of the hormones on subtype-specific BC risk (luminal A-like BC, luminal B-like BC, luminal B/HER2-negative-like BC, HER2-enriched-like BC, TNBC and BRCA1 mutated TNBC).