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Zhang C, Bjornson E, Arif M, Tebani A, Lovric A, Benfeitas R, Ozcan M, Juszczak K, Kim W, Kim JT, Bidkhori G, Ståhlman M, Bergh P, Adiels M, Turkez H, Taskinen M, Bosley J, Marschall H, Nielsen J, Uhlén M, Borén J, Mardinoglu A. The acute effect of metabolic cofactor supplementation: a potential therapeutic strategy against non-alcoholic fatty liver disease. Mol Syst Biol 2020; 16:e9495. [PMID: 32337855 PMCID: PMC7184219 DOI: 10.15252/msb.209495] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 12/21/2022] Open
Abstract
The prevalence of non-alcoholic fatty liver disease (NAFLD) continues to increase dramatically, and there is no approved medication for its treatment. Recently, we predicted the underlying molecular mechanisms involved in the progression of NAFLD using network analysis and identified metabolic cofactors that might be beneficial as supplements to decrease human liver fat. Here, we first assessed the tolerability of the combined metabolic cofactors including l-serine, N-acetyl-l-cysteine (NAC), nicotinamide riboside (NR), and l-carnitine by performing a 7-day rat toxicology study. Second, we performed a human calibration study by supplementing combined metabolic cofactors and a control study to study the kinetics of these metabolites in the plasma of healthy subjects with and without supplementation. We measured clinical parameters and observed no immediate side effects. Next, we generated plasma metabolomics and inflammatory protein markers data to reveal the acute changes associated with the supplementation of the metabolic cofactors. We also integrated metabolomics data using personalized genome-scale metabolic modeling and observed that such supplementation significantly affects the global human lipid, amino acid, and antioxidant metabolism. Finally, we predicted blood concentrations of these compounds during daily long-term supplementation by generating an ordinary differential equation model and liver concentrations of serine by generating a pharmacokinetic model and finally adjusted the doses of individual metabolic cofactors for future human clinical trials.
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Affiliation(s)
- Cheng Zhang
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
- School of Pharmaceutical SciencesZhengzhou UniversityZhengzhouChina
| | - Elias Bjornson
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
- Department of Biology and Biological EngineeringChalmers University of TechnologyGothenburgSweden
| | - Muhammad Arif
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Abdellah Tebani
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Alen Lovric
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
- Present address:
Division of Clinical PhysiologyDepartment of Laboratory MedicineKarolinska InstitutetKarolinska University HospitalStockholmSweden
- Present address:
Unit of Clinical PhysiologyKarolinska University HospitalStockholmSweden
| | - Rui Benfeitas
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
- Present address:
Science for Life LaboratoryDepartment of Biochemistry and BiophysicsNational Bioinformatics Infrastructure Sweden (NBIS)Stockholm UniversityStockholmSweden
| | - Mehmet Ozcan
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Kajetan Juszczak
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Woonghee Kim
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Jung Tae Kim
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Gholamreza Bidkhori
- Centre for Host‐Microbiome InteractionsFaculty of Dentistry, Oral & Craniofacial SciencesKing's College LondonLondonUK
| | - Marcus Ståhlman
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
| | - Per‐Olof Bergh
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
| | - Martin Adiels
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
| | - Hasan Turkez
- Department of Medical BiologyFaculty of MedicineAtatürk UniversityErzurumTurkey
| | - Marja‐Riitta Taskinen
- Research Programs Unit, Diabetes and ObesityDepartment of Internal MedicineHelsinki University HospitalUniversity of HelsinkiHelsinkiFinland
| | | | - Hanns‐Ulrich Marschall
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
| | - Jens Nielsen
- Department of Biology and Biological EngineeringChalmers University of TechnologyGothenburgSweden
| | - Mathias Uhlén
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
| | - Jan Borén
- Department of Molecular and Clinical MedicineUniversity of Gothenburg and Sahlgrenska University Hospital GothenburgGothenburgSweden
| | - Adil Mardinoglu
- Science for Life LaboratoryKTH—Royal Institute of TechnologyStockholmSweden
- Centre for Host‐Microbiome InteractionsFaculty of Dentistry, Oral & Craniofacial SciencesKing's College LondonLondonUK
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Lovric A, Granér M, Bjornson E, Arif M, Benfeitas R, Nyman K, Ståhlman M, Pentikäinen MO, Lundbom J, Hakkarainen A, Sirén R, Nieminen MS, Lundbom N, Lauerma K, Taskinen MR, Mardinoglu A, Boren J. Characterization of different fat depots in NAFLD using inflammation-associated proteome, lipidome and metabolome. Sci Rep 2018; 8:14200. [PMID: 30242179 PMCID: PMC6155005 DOI: 10.1038/s41598-018-31865-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 08/21/2018] [Indexed: 02/06/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is recognized as a liver manifestation of metabolic syndrome, accompanied with excessive fat accumulation in the liver and other vital organs. Ectopic fat accumulation was previously associated with negative effects at the systemic and local level in the human body. Thus, we aimed to identify and assess the predictive capability of novel potential metabolic biomarkers for ectopic fat depots in non-diabetic men with NAFLD, using the inflammation-associated proteome, lipidome and metabolome. Myocardial and hepatic triglycerides were measured with magnetic spectroscopy while function of left ventricle, pericardial and epicardial fat, subcutaneous and visceral adipose tissue were measured with magnetic resonance imaging. Measured ectopic fat depots were profiled and predicted using a Random Forest algorithm, and by estimating the Area Under the Receiver Operating Characteristic curves. We have identified distinct metabolic signatures of fat depots in the liver (TAG50:1, glutamate, diSM18:0 and CE20:3), pericardium (N-palmitoyl-sphinganine, HGF, diSM18:0, glutamate, and TNFSF14), epicardium (sphingomyelin, CE20:3, PC38:3 and TNFSF14), and myocardium (CE20:3, LAPTGF-β1, glutamate and glucose). Our analyses highlighted non-invasive biomarkers that accurately predict ectopic fat depots, and reflect their distinct metabolic signatures in subjects with NAFLD.
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Affiliation(s)
- Alen Lovric
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Marit Granér
- Heart and Lung Center, Division of Cardiology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Elias Bjornson
- Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine/Wallenberg Lab, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Muhammad Arif
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Rui Benfeitas
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Kristofer Nyman
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Marcus Ståhlman
- Department of Molecular and Clinical Medicine/Wallenberg Lab, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Markku O Pentikäinen
- Heart and Lung Center, Division of Cardiology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Jesper Lundbom
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Hakkarainen
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Reijo Sirén
- Department of General Practice and Primary Health Care, Health Care Centre of City of Helsinki and University of Helsinki, Helsinki, Finland
| | - Markku S Nieminen
- Heart and Lung Center, Division of Cardiology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Nina Lundbom
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Kirsi Lauerma
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Marja-Riitta Taskinen
- Heart and Lung Center, Division of Cardiology, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland.
| | - Adil Mardinoglu
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden. .,Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden.
| | - Jan Boren
- Department of Molecular and Clinical Medicine/Wallenberg Lab, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden.
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3
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Mardinoglu A, Wu H, Bjornson E, Zhang C, Hakkarainen A, Räsänen SM, Lee S, Mancina RM, Bergentall M, Pietiläinen KH, Söderlund S, Matikainen N, Ståhlman M, Bergh PO, Adiels M, Piening BD, Granér M, Lundbom N, Williams KJ, Romeo S, Nielsen J, Snyder M, Uhlén M, Bergström G, Perkins R, Marschall HU, Bäckhed F, Taskinen MR, Borén J. An Integrated Understanding of the Rapid Metabolic Benefits of a Carbohydrate-Restricted Diet on Hepatic Steatosis in Humans. Cell Metab 2018; 27:559-571.e5. [PMID: 29456073 PMCID: PMC6706084 DOI: 10.1016/j.cmet.2018.01.005] [Citation(s) in RCA: 274] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 12/06/2017] [Accepted: 01/10/2018] [Indexed: 02/07/2023]
Abstract
A carbohydrate-restricted diet is a widely recommended intervention for non-alcoholic fatty liver disease (NAFLD), but a systematic perspective on the multiple benefits of this diet is lacking. Here, we performed a short-term intervention with an isocaloric low-carbohydrate diet with increased protein content in obese subjects with NAFLD and characterized the resulting alterations in metabolism and the gut microbiota using a multi-omics approach. We observed rapid and dramatic reductions of liver fat and other cardiometabolic risk factors paralleled by (1) marked decreases in hepatic de novo lipogenesis; (2) large increases in serum β-hydroxybutyrate concentrations, reflecting increased mitochondrial β-oxidation; and (3) rapid increases in folate-producing Streptococcus and serum folate concentrations. Liver transcriptomic analysis on biopsy samples from a second cohort revealed downregulation of the fatty acid synthesis pathway and upregulation of folate-mediated one-carbon metabolism and fatty acid oxidation pathways. Our results highlight the potential of exploring diet-microbiota interactions for treating NAFLD.
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Affiliation(s)
- Adil Mardinoglu
- Science for Life Laboratory, KTH Royal Institute of Technology, Stockholm, Sweden; Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Hao Wu
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elias Bjornson
- Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cheng Zhang
- Science for Life Laboratory, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Antti Hakkarainen
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sari M Räsänen
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Sunjae Lee
- Science for Life Laboratory, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Rosellina M Mancina
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Bergentall
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kirsi H Pietiläinen
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland; Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Sanni Söderlund
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Niina Matikainen
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland; Endocrinology, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
| | - Marcus Ståhlman
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per-Olof Bergh
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Adiels
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Brian D Piening
- Department of Genetics, Stanford University, Stanford, CA 94305, USA
| | - Marit Granér
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Nina Lundbom
- HUS Medical Imaging Center, Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Kevin J Williams
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefano Romeo
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jens Nielsen
- Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Michael Snyder
- Department of Genetics, Stanford University, Stanford, CA 94305, USA
| | - Mathias Uhlén
- Science for Life Laboratory, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Rosie Perkins
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Bäckhed
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Marja-Riitta Taskinen
- Research Programs Unit, Diabetes and Obesity, University of Helsinki and Department of Internal Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Jan Borén
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden.
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Mardinoglu A, Bjornson E, Zhang C, Klevstig M, Söderlund S, Ståhlman M, Adiels M, Hakkarainen A, Lundbom N, Kilicarslan M, Hallström BM, Lundbom J, Vergès B, Barrett PHR, Watts GF, Serlie MJ, Nielsen J, Uhlén M, Smith U, Marschall HU, Taskinen MR, Boren J. Personal model-assisted identification of NAD + and glutathione metabolism as intervention target in NAFLD. Mol Syst Biol 2017; 13:916. [PMID: 28254760 PMCID: PMC5371732 DOI: 10.15252/msb.20167422] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
To elucidate the molecular mechanisms underlying non‐alcoholic fatty liver disease (NAFLD), we recruited 86 subjects with varying degrees of hepatic steatosis (HS). We obtained experimental data on lipoprotein fluxes and used these individual measurements as personalized constraints of a hepatocyte genome‐scale metabolic model to investigate metabolic differences in liver, taking into account its interactions with other tissues. Our systems level analysis predicted an altered demand for NAD+ and glutathione (GSH) in subjects with high HS. Our analysis and metabolomic measurements showed that plasma levels of glycine, serine, and associated metabolites are negatively correlated with HS, suggesting that these GSH metabolism precursors might be limiting. Quantification of the hepatic expression levels of the associated enzymes further pointed to altered de novo GSH synthesis. To assess the effect of GSH and NAD+ repletion on the development of NAFLD, we added precursors for GSH and NAD+ biosynthesis to the Western diet and demonstrated that supplementation prevents HS in mice. In a proof‐of‐concept human study, we found improved liver function and decreased HS after supplementation with serine (a precursor to glycine) and hereby propose a strategy for NAFLD treatment.
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Affiliation(s)
- Adil Mardinoglu
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden .,Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Elias Bjornson
- Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cheng Zhang
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Martina Klevstig
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sanni Söderlund
- Research programs Unit, Diabetes and Obesity, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Marcus Ståhlman
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Adiels
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Antti Hakkarainen
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Nina Lundbom
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Murat Kilicarslan
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Björn M Hallström
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Jesper Lundbom
- Department of Radiology, HUS Medical Imaging Center, Helsinki University Central Hospital, University of Helsinki, Helsinki, Finland
| | - Bruno Vergès
- Department of Endocrinology-Diabetology, University Hospital and INSERM CRI 866, Dijon, France
| | - Peter Hugh R Barrett
- Faculty of Engineering, Computing and Mathematics, University of Western Australia, Perth, WA, Australia
| | - Gerald F Watts
- Metabolic Research Centre, Cardiovascular Medicine, Royal Perth Hospital, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jens Nielsen
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden.,Department of Biology and Biological Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Mathias Uhlén
- Science for Life Laboratory, KTH - Royal Institute of Technology, Stockholm, Sweden
| | - Ulf Smith
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marja-Riitta Taskinen
- Research programs Unit, Diabetes and Obesity, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jan Boren
- Department of Molecular and Clinical Medicine, University of Gothenburg, and Sahlgrenska University Hospital, Gothenburg, Sweden
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Zussman L, Zussman S, Sunley R, Bjornson E. Sexual response after hysterectomy-oophorectomy: recent studies and reconsideration of psychogenesis. Am J Obstet Gynecol 1981; 140:725-9. [PMID: 7196155 DOI: 10.1016/0002-9378(81)90730-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Recent studies conducted in the United Kingdom show that 33% to 46% of women report decreased sexual response after hysterectomy-oophorectomy. The prevailing theory in the United States for over 30 years in counseling women is that such decreases are infrequent and, if they do occur, are psychogenic. The postulates of the psychogenesis theory were examined and found no longer tenable in the light of current physiologic knowledge of female sexuality, which suggests that when sexual response is diminished after this surgery, hormonal changes (including ovarian androgens) and anatomic changes (removal of the cervix-uterus as a trigger for orgasm in some women) may be etiologic factors. The newer knowledge may now be utilized in counseling the one of four women who reaches menopause through surgery. In cases of decreased response, women may be helped by hormone replacement therapy and/or conjoint sex therapy.
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