EditorialsEstrogen-Induced Cholestasis: Clues to Pathogenesis and Treatment Estrogen-related cholestasis has been of clinical interest for nearly three decades. The clinical spectrum of intrahepatic cholestasis of pregnancy and pruritus gravidarum was first characterized in 1955 (1-5). Although its pathogenesis remains unknown, epidemiologic and experimental data suggest an inheritable abnormality in hepatic reactivity to circulating estrogens. Oral contraceptives were introduced in 1960. It was soon observed that a small percentage of women using these drugs develop intrahepatic cholestasis (6-10, Sotaniemi, E. et al. Brit Med J 1964; 2:1264-1265, Correspondence) and approximately 50% of these individuals have intrahepatic cholestasis of pregnancy (11-13, Holzbach, R. T. and Sanders, H. H. Gastroenterology 1965;482322, Abstract). A "cholestatic" response to oral contraceptive steroids was noted in several hepatic disorders, including cirrhosis and the Dubin-Johnson syndrome (14-16). Data from rechallenge experiments suggests that the estrogenic component is the important agent, although progestins may augment the effect (17-21). The hepatic defect that enhances the effect of estrogens and the pathogenesis of cholestasis remain undefined. These clinical observations stimulated research into the concept that the liver is an important target organ for estrogenic effects and that estrogen-induced cholestasis is an excellent model for study of intrahepatic cholestasis.Recent basic science advances have advanced understanding of the molecular correlates of estrogen effects. Specific estrogen receptors have been demonstrated on plasma membranes (22-23) and in cytosol (24-26), microsomal components (27), and nuclei (25, 28) of hepatocytes in animals. The significance of these receptors is unclear; however, the data suggest that estrogen is transported across the plasma membrane and translocated to the nucleus. Within the nucleus, estrogens bind to DNA (29), stimulate RNA synthesis (30, 31), activate RNA methylating enzymes (32), and inhibit RNA deactivating enzymes (33).Hepatic effects of estrogens are dose-dependent. At the high levels achieved during pregnancy or with ad-
~ ~The authors were supported in part by RCDA (AM-00347) to Francis R. Simon and NIH Training Grant (T32 AM07038-07) to Allen J. Schreiber.