205

Ann Ist Super Sanità 2016 | Vol. 52, No. 2: 205-212

DOI: 10.4415/ANN_16_02_12

Sex-based differences
in autoimmune diseases

section
Elena Ortona1, Marina Pierdominici1, Angela Maselli2, Caterina Veroni1, Francesca Aloisi1
and Yehuda Shoenfeld3

M onographic
1Dipartimento di Biologia Cellulare e Neuroscienze, Istituto Superiore di Sanità, Rome, Italy
2Dipartimento del Farmaco, Istituto Superiore di Sanità, Rome, Italy
3Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center (affiliated to Tel-Aviv University),

Tel-Hashomer, Israel

Abstract Key words

Autoimmune diseases are characterized by an exaggerated immune response leading to • sex
damage and dysfunction of specific or multiple organs and tissues. Most autoimmune • autoimmunity
diseases are more prevalent in women than in men. Symptom severity, disease course, • systemic lupus
response to therapy and overall survival may also differ between males and females with erythematosus
autoimmune diseases. Sex hormones have a crucial role in this sex bias, with estrogens • rheumatoid arthritis
being potent stimulators of autoimmunity and androgens playing a protective role. Accu- • multiple sclerosis
mulating evidence indicates that genetic, epigenetic and environmental factors may also
contribute to sex-related differences in risk and clinical course of autoimmune diseases.
In this review, we discuss possible mechanisms for sex specific differences in autoimmu-
nity with a special focus on three paradigmatic diseases: systemic lupus erythematosus,
rheumatoid arthritis, and multiple sclerosis.

INTRODUCTION somes versus one X and one Y chromosome, and the

Autoimmune diseases include more than 80 chronic different response to environmental factors, such as
disorders that affect nearly 5% of the population in microbial exposure and diet [5]. Sociological differenc-
Western countries. They are characterized by an exag- es between genders may also affect the development of
gerated immune response leading to damage and dys- autoimmunity. However, the discussion of this topic is
function of specific or multiple organs and tissues. The beyond the scope of this article and readers can refer
aetiology of autoimmune diseases is still unknown, but to recent reviews [6]. Here, we briefly review the role
the available evidence points to an interaction between of sex-related factors in autoimmunity and then high-
genetic, environmental and life style factors in disease light key discoveries and controversies on the role of
development. Autoimmune diseases are typically more sexual dimorphism in three paradigmatic autoimmune
prevalent in women than in men and are considered diseases: SLE, RA and MS.
the fourth leading cause of disability for women [1].
The strongest sex bias is observed in Sjogren’s syn- SEX HORMONES IN AUTOIMMUNITY
drome, systemic lupus erythematosus (SLE), autoim- Due to the presence of hormone receptors on im-
mune thyroid disease and scleroderma where the ratio mune cells [7], sex hormones, such as estrogens, pro-
of women to men is 7:1-10:1. In rheumatoid arthritis gesterone, androgens and prolactin, can influence
(RA), multiple sclerosis (MS) and myasthenia gravis, different aspects of immune system function and po-
the female to male ratio is 2:1-3:1, while there is little tentially affect the risk, activity and progression of au-
or no sex bias in inflammatory bowel diseases and type toimmune diseases. Generally, estrogens, in particular
1 diabetes [2-4]. Symptom severity, disease course, re- 17-β estradiol (E2) and prolactin, act as enhancers at
sponse to therapy and overall survival may also differ least of humoral immunity, and testosterone and pro-
between males and females with autoimmune diseases. gesterone as natural immunosuppressants [3]. Sex hor-
In general, women mount stronger humoral and cellu- mones have different effects depending not only on the
lar immune responses than men and this is believed to concentration but also on the type of target cell and
have an effect on the different susceptibility to develop the receptor subtype expressed on a given cell type. At
autoimmune diseases. The main factors affecting the periovulatory to pregnancy levels [8], E2 has mainly
differences between female and male immune systems anti-inflammatory effects, by inhibiting production and
are the sex hormones, the presence of two X chromo- signaling of pro-inflammatory cytokines, such as tumor

Address for correspondence: Marina Pierdominici, Dipartimento di Biologia Cellulare e Neuroscienze, Istituto Superiore di Sanità, Viale Regina Elena
299, 00161 Rome, Italy. E-mail: [email protected].
206
Elena Ortona, Marina Pierdominici, Angela Maselli et al.

necrosis factor (TNF), interleukin (IL)-1β and IL-6, (Klinefelter syndrome) are associated with an altered
and natural killer (NK) cell activation, and by inducing susceptibility for some autoimmune diseases as com-
expression of anti-inflammatory cytokines favoring a T pared with sex-matched general population (e.g., SLE
helper 2 (Th2) phenotype [9], such as IL-4, IL-10 and prevalence is decreased in Turner syndrome and in-
transforming growth factor (TGF)-β, and by activating creased in Klinefelter syndrome) [17, 18]. Experimen-
section

regulatory T cells (Treg) [10]. At lower concentrations, tal studies suggest that the Y chromosome may play a
E2 stimulates TNF, interferon (IFN)-γ, IL-1β and NK protective role in the development of autoimmunity
cells, while it enhances antibody production by B cells [19].
both at high and low concentrations [9]. Prolactin in-
M onographic

creases antibody production, regulates the develop- SEX DIFFERENCES IN microRNA

ment of CD4+ T cells and triggers pro-inflammatory EXPRESSION IN AUTOIMMUNITY
cytokine production [11]. Progesterone stimulates a MicroRNAs (miRNAs) are short non-coding RNAs
switch from a predominantly pro-inflammatory to an (19-24 nucleotides in length) that regulate gene expres-
anti-inflammatory immune response, favors Treg dif- sion mainly at the post-transcriptional level by binding
ferentiation [12], and exerts an inhibitory effect on to the 3’ UTR of target genes and inducing translational
NK cells. Several studies indicate that testosterone has inhibition or degradation of the target mRNA. Their
suppressive effects on the immune system by inhibiting expression and function are essential for the develop-
pro-inflammatory cytokine production, Th1 differentia- ment of different physiological systems and the main-
tion, immunoglobulin production and NK cell cytotoxic tenance of cell homeostasis. Because miRNAs are criti-
activity, and by potentiating the expression of anti-in- cal for the development, differentiation and function of
flammatory cytokines [13]. both innate and adaptive immune cells, dysregulation
Consistent with the effects of sex hormones on im- of their expression may contribute to the development
munity, changes in the severity of autoimmune diseases of autoimmune diseases [20]. It has been reported that
are observed during pregnancy, when estrogens and miRNAs are differentially expressed in males and fe-
progesterone reach the highest levels [14]. Maternofe- males in both gonadal and non-gonadal tissues, but it
tal immune tolerance is essential to maintain pregnancy is not clear yet what drives this sex-related differential
and one of the important adaptations leading to this expression. The X chromosome is highly enriched in
immune tolerance is the shift, at implantation, from a miRNAs whereas only two miRNAs, at least in humans,
pro-inflammatory Th1/Th17 response, which promotes have been assigned to the Y chromosome thus far [21].
rejection, toward a Th2/Treg cell response that pro- Although most of the X-linked miRNAs have no known
motes tolerance and inhibits NK cell cytotoxicity. Due function, some of them are reported to play a role in
to these adaptive changes in immune system function, immunity or autoimmunity [22, 23]. The presence of
pregnancy has opposite effects on some autoimmune a second X chromosome in females can affect miRNA
diseases. For instance, pregnancy is associated with an expression levels and this may be crucial for the devel-
increase in disease flares in SLE, this effect being re- opment of female biased-autoimmunity. Interestingly,
lated to the increased Th2 response and enhanced pro- E2 can regulate miRNA expression in different cell
duction of pathogenic autoantibodies [15]. Conversely, types and tissues, by both genomic and non-genomic
pregnancy has a protective effect in Th1-dominant im- mechanisms of action [24], while miRNAs regulate E2-
mune diseases, like RA and MS. dependent signaling by targeting proteins and signaling
molecules that are involved in estrogen signaling [22].
SEX CHROMOSOMES IN AUTOIMMUNITY Exploring miRNAs in the context of sex-biased auto-
The female karyotype includes two X chromosomes, immune disorders may provide novel insights into dis-
one derived from each parent, while men carry one ease pathogenesis and lead to the identification of new
maternal X and one paternal Y chromosome. To avoid therapeutic targets.
double dosage of X chromosome-derived proteins, one
of the X chromosomes is randomly silenced in females SEX DIFFERENCES IN THE GUT
in the early stages of embryogenesis. However, X chro- MICROBIOTA
mosome inactivation is not complete and about 15% It is well established that gut microbiota (i.e., the col-
of the genes escape inactivation, leading to overexpres- lection of bacteria, viruses, fungi and protozoa lining
sion of some X-linked genes in females [16]. The X the gastrointestinal mucosa) affects innate and adaptive
chromosome encodes several immune-related genes, immune responses. On the other hand, the immune sys-
such as CD40 ligand, chemokine receptor CXCR3, O- tem influences the composition of the gut microbiota
linked N-acetylglucosamine transferase, forkhead box and this interaction can have important consequences
P3(FOXP3), toll-like receptor (TLR)7, TLR8, IL-2 re- for the development of inflammatory diseases [25]. A
ceptor gamma, tyrosine-protein kinase BTK, and IL-9 role for gut microbiota in the sex bias in autoimmunity
receptor, whose overexpression may influence the im- has been revealed by different studies in animal models.
mune response in a sex-dependent manner [5]. An For instance, in the spontaneous NOD model of type 1
important role for genes on the partially inactivated X diabetes characterized by a strong female bias, disease
chromosome in immune system function is highlighted rate was similar in germ-free (GF) female and male
by the finding that both the absence of a normal sec- NOD mice, suggesting that male-specific microbiota
ond X-chromosome in females (Turner syndrome) and play a protective role [26]. This effect could be medi-
the presence of two or more X chromosomes in males ated, at least partially, via microbiota metabolism of sex
 207
Sex and autoimmunity

hormones. In fact, gavage of female NOD weanlings the formation of immune complexes that, once depos-
with male NOD-derived intestinal microbiota resulted ited, cause tissue injury [33].
in elevated testosterone levels and type 1 diabetes pro- SLE is often called a “woman’s disease” because of
tection as compared with unmanipulated females [26]. the striking differences in prevalence related to sex.
Conversely, sex hormones may affect gut microbiota Pre-menopausal women have SLE incidence rates of

section
because sex-specific differences in the composition of 8:1-15:1 when compared to age-matched males; these
the microbiota are found only after puberty [26, 27]. rates decline to 3:1 in the pre-adolescent population
Similarly to what observed in NOD mice, the composi- and to 5:1 after menopause, when estrogen levels are
tion of gut microbiota in mouse models of lupus and more similar between genders. Clinical observations

M onographic
RA has been found to be significantly different in male and experimental data clearly indicate that E2 influ-
and female adult mice [28, 29]. Summarizing, specific ences the development of SLE [3, 34]. Studies in lupus
gut microbiota patterns appear to be associated with experimental models have demonstrated that E2 pro-
autoimmunity. However, the role of gut microbes and motes disease via estrogen receptor (ER) α activation
their interactions with hormones in the sex bias in au- [35] whereas ERβ activation has mild immunosuppres-
toimmunity is still poorly characterized and no data sive effects [36]. ERα-deficient mice show significantly
are available in humans. Further studies are needed less aggressive renal disease and proteinuria and survive
to elucidate the specific mechanisms and/or molecules better than wild-type mice [37]. Importantly, an accel-
produced by gut commensals that are affected by and erated metabolic conversion of androgen precursors to
affect sex hormones, and may be involved in the protec- E2, due to aromatase activation, has been observed in
tion from autoimmune diseases. SLE, partially explaining the increased availability of
E2 in this disease [38]. Moreover, the identification
OTHER FACTORS POTENTIALLY INVOLVED of autoantibodies reacting with ERα in SLE patients
IN THE SEX BIAS IN AUTOIMMUNITY and their correlation with disease activity [39] have dis-
Microchimerism. Maternal and fetal cells are ex- closed a new research area in estrogen-related effects
changed during pregnancy, leading to fetal cell persis- in autoimmunity. Results from different studies indi-
tence in the mother (microchimerism). Chimeric fetal cate that the use of oral contraceptives and hormone
cells are often hematopoietic and can differentiate into replacement therapy increases the risk of developing
somatic cells in different organs, becoming a potential SLE; however, some retrospective studies suggest no
target for autoimmunity [30]. The available data on the increase in clinical flares with hormonal therapy [40].
role of fetal microchimerism in autoimmunity are weak Importantly, a reduction in disease activity has been
or inconclusive. observed in SLE patients treated with the pure ER an-
Environmental estrogens. In addition to endogenous es- tagonist Fulvestrant (Faslodex) [41].
trogens, the immune system can be targeted by natural X-linked genes, such as FOXP3, TNF and TLR7, have
(phytoestrogens and mycoestrogens) or synthetic (xe- been associated with gender bias in SLE [5]. Addition-
noestrogens) compounds with estrogenic activity, i.e., ally, several X-linked miRNAs have been found to be
estrogenic endocrine disruptors [31]. Xenoestrogens upregulated in CD4+ T cells from female SLE patients
can be present in cosmetics and personal care products compared to male patients [22], potentially contribut-
(makeup, hair dyes, soaps, perfumes) more commonly ing to the sex bias in SLE. E2 may contribute to the
used by women. The actual impact of both endogenous gender bias in SLE by modulating expression of selected
and environmental estrogens on the immune system is miRNAs [42]. miR146a, which is a negative regulator
still under investigation. Environmental estrogens may of the IFN-α pathway, and miR125a, which negatively
display a synergic/additive effect with endogenous es- regulates the inflammatory chemokine RANTES, are
trogens potentially affecting the immune response. The profoundly decreased in peripheral blood mononuclear
influence of oral contraceptives and hormone replace- cells from patients with SLE as compared to healthy do-
ment therapy on the risk and progression of autoim- nors [43, 44]. Conversely, miR148a, which contributes
mune disease in women also deserves consideration. to DNA hypomethylation in lupus CD4+ T cells, has
been found up-regulated [45]. In splenocytes from es-
SYSTEMIC LUPUS ERYTHEMATOSUS trogen-treated mice, miR148a was up-regulated where-
SLE is a multifactorial and highly polymorphic sys- as miR146a and miR125a were down-regulated [46].
temic autoimmune disease that affects multiple organs In males, SLE has a late onset and different clinical
including kidneys and heart [32]. The incidence of the features and outcomes, suggesting that male-specific
disease is estimated at 20–50 cases/100 000 individu- predisposing and/or pathogenetic factors exist. To date,
als. To date, the etiology of SLE remains unknown; there is limited evidence to suggest an altered hormonal
however, it is likely that a complex interaction between milieu in men with lupus [47, 48]. Potential risk factors
genetic, environmental (e.g., infectious agents, includ- include X-chromosome abnormalities (as supported by
ing Epstein-Barr virus and parvovirus, UV light, drugs, the increased incidence of SLE in patients with Kline-
cigarette smoking and silica dust), and hormonal fac- felter syndrome) and various somatic genetic polymor-
tors promotes the immune dysfunction leading to the phisms. Further studies are required to understand the
disease. SLE is characterized by autoantibody produc- sex-related aspects of SLE disease susceptibility, clinical
tion by dysregulated B cells, target organ infiltration by features and outcome, potentially providing new tools
inflammatory T cells and aberrant immune cell activa- for clinical intervention. Sex-specific factors affecting
tion. The autoantigen-autoantibody interaction triggers SLE are summarized in Table 1.
208
Elena Ortona, Marina Pierdominici, Angela Maselli et al.

Table 1
Sex specific factors affecting systemic lupus erythematosus

Accelerated metabolic conversion of androgen precursors to E2 (aromatase activation) [38]

Hormones
E2 effects on immune function [3, 34]
section

Genetic factors X-linked genes (FOXP3, TNF, TLR7) [5]

X-linked miRNAs [22]

Epigenetic factors Estrogen up-regulated miRNA (miR148a) [22]
Estrogen down-regulated miRNA (miR146a, miR125a) [46]
M onographic

Incidence of Raynaud’s phenomenon, alopecia, malar rash and arthralgia/arthritis higher in females than in
Clinical phenotype
males [47]

RHEUMATOID ARTHRITIS Regarding male sex hormones, the available data sug-
RA affects approximately 1% of the general popula- gest that the onset and severity of RA are inversely as-
tion and is characterized by chronic joint inflamma- sociated with androgen levels, providing a possible ex-
tion, functional impairment, disability, and premature planation for the increased rate of RA incidence in men
mortality. It is widely accepted that RA is caused by after 55 years and for the less severe disease course in
various environmental factors in genetically predisposed men as compared to females [56, 57]. Men also have
individuals. RA is about three times more common in a better response to RA therapy than women [58]. In-
women than in men, with a peak age of onset in the terestingly, there is evidence that some RA patients of
fifth decade of life. The female to male prevalence ratio both sexes have reduced amounts of serum androgens
is around 2:1 in 55 to 64-year-olds, shifting to a male already several years before disease onset. In particu-
excess in people over 75-years old. Data concerning fe- lar, female RA patients have lower than normal levels
male sex hormone exposure and RA risk are conflict- of dehydroepiandrosterone and/or dehydroepiandros-
ing [49]. The higher prevalence of RA in females than terone sulfate. Androgen replacement therapy has posi-
males, at least before 75 years of age, could suggest tive effects in male RA patients, particularly as adjuvant
that E2 and progesterone increase the risk of disease. treatment [59], and a slight disease-modifying effect,
However, as stated above, RA presents more often after not statistically significant, in postmenopausal women
menopause, and past large cohort studies did not estab- with RA [60]. There is incomplete information on ge-
lish any relationship between oral contraceptives or hor- netic influences on sex disparities in RA. Recently, poly-
mone replacement therapy and the risk of developing morphisms in the CYB5A gene, which is relevant for
RA [40]. Nulliparity is associated with an increased risk androgen synthesis, have been found to be associated
of disease development whereas pregnancy seems to de- with risk of RA in women, but not men, thus contrib-
crease it [50]. These data show, pregnancy effects apart, uting to the sex bias observed in RA [61]. In contrast
that the female to male ratio observed in RA probably to SLE, RA has been described very rarely in patients
involves factors other than E2 and progesterone. Re- with Klinefelter syndrome, suggesting that the extra
garding disease activity, whereas in animal models of RA X chromosome does not confer an added risk for RA.
female sex hormones have beneficial effects, their role in One study found an association between RA and single
humans is less clear as both pro- and anti-inflammatory nucleotide polymorphisms (SNP) of the X-encoded
effects have been described. On the one hand, higher genes TIMP1 (which inhibits matrix metalloproteinases
disease activity scores have been reported in women as and prevents cartilage degradation) and IL-9 receptor
compared to men [51]. Additionally, estrogens are sig- (which is involved in IL-9 signaling and in early T cell
nificantly elevated, relatively to androgens, in synovial development) [62]. To date, no data are available on
fluid from both male and female RA patients; this is epigenetic modification of the inactivated X chromo-
due to high aromatase activity that is induced by locally some in relation to RA susceptibility. Sex-specific fac-
produced inflammatory cytokines, favoring macrophage tors affecting RA are summarized in Table 2.
and fibroblast proliferation and therefore the inflamma-
tory process [52]. On the other hand, the clinical fea- MULTIPLE SCLEROSIS
tures of RA are ameliorated in approximately 75% of MS affects 1 in 1000 people in Western countries and
pregnant patients who have high serum levels of E2 and is the most common chronic inflammatory disease of
progesterone [53]. Notably, relapses are frequent in the the central nervous system causing neurological disabil-
postpartum period when the levels of these hormones ity. MS is usually diagnosed in young adults and charac-
fall [54]. Clinical trials examining the effects of oral con- terized by bouts and remissions followed by a secondary
traceptives or hormone replacement therapy on the se- progressive course. Less frequently, MS has a progres-
verity or progression of existing RA in postmenopausal sive course right from the onset. MS affects women
women have yielded contrasting results, some studies two to three times as often as men. While females are
showing evidence of a beneficial effect of estrogens and at higher risk for MS, males are more likely to display
other studies finding no effect [40]. Finally, active RA is primary progressive disease and accumulate disability
characterized by an activity peak early in the morning faster than female patients in relapse-onset MS [63].
which correlates with prolactin plasma levels [55]. The sex ratio in MS appears to be rising; this trend is
 209
Sex and autoimmunity

Table 2
Sex specific factors affecting rheumatoid arthritis

Estrogen effects on immune function (both pro-inflammatory and anti-inflammatory effects, induction of Tregs)
[50]
Hormones Progesterone effects on immune function (anti-inflammatory effects, induction of Tregs) [50]

section
Androgen effects on immune function (anti-inflammatory effects) [57]
High aromatase activity in synovial fluid (® prevalence of synovial estrogens relative to androgens) [52]

Single nucleotide polymorphisms of the CYB5A gene in RA females [61]

Genetic factors
Single nucleotide polymorphisms of the X-encoded genes TIMP1 and IL-9R [62]

M onographic
Less severe course of illness and better response to therapy in males as compared to females [56, 58]
Clinical phenotype
Amelioration of RA in pregnant females [53]

noted primarily in relapsing-remitting MS and is associ- effects in preclinical models of MS, suggesting the po-
ated with a latitudinal gradient [64]. tential use of these hormones for the treatment of MS
As for other autoimmune diseases, the cause of MS is [70]. Lower testosterone levels have been associated
not well understood but a complex interaction between with higher disability in men with MS [71]. The results
genetic and environmental factors is clearly involved. of two phase 2 trials of transdermal testosterone in male
The HLA-DR2 allele within the MHC region is the MS patients [72] and oral estriol in female MS patients
major genetic risk factor for MS [65]. In recent MS ge- [73] are encouraging but warrant further investigation
nome wide association studies, 110 variants have been in phase 3 trials.
identified outside the HLA region, which are typically Findings of an increasing sex ratio in MS implicate
common, mostly related to immune system function heightened female responsiveness to changing cultural
and have very modest effects on disease risk [66]. To and environmental cues. Vitamin D deficiency, Epstein-
date, none of the studies of HLA and non HLA genes Barr virus infection and smoking history are known to
have convincingly shown that genetic differences be- influence MS risk [74]. Recent studies indicate that cig-
tween women and men affect MS susceptibility. Also, arette smoking is also a risk factor for disease progres-
no MS susceptibility loci are confirmed to be located on sion [75]. However, it is still poorly understood how en-
the X chromosome. vironmental factors interact with hormones, metabolic
The role of hormonal changes in the modulation of factors, including diet and/or altered gut microbiota,
MS risk and course in female patients has been exten- and a susceptible genetic background to shape MS.
sively investigated. Puberty and pregnancy have re- Sex-related differences in neuroimaging features [76],
ceived much attention in MS research, while the impact cerebrospinal and peripheral blood biomarkers [77,
of breastfeeding, oral contraceptives use, menopause 78] and effectiveness of first- and second-line therapies
and HRT on MS risk and course is less understood. Af- for MS need to be thoroughly explored to yield new
ter puberty there is a dramatic, female-specific increase insights into MS pathological mechanisms and help in
in MS risk; earlier puberty and obesity during child- treatment decisions in the growing armamentarium of
hood are significant risk factors for MS [67]. Female drugs that can ameliorate MS. Sex-specific factors af-
MS patients experience clinical improvements during fecting MS are summarized in Table 3.
pregnancy, particularly in the last trimester, with a re-
bound in relapses occurring in the first trimester post- CONCLUSIONS
partum [68]. Specific changes in the expression of a Differences in prevalence and severity of autoim-
limited number of immune-related genes during preg- mune diseases between males and females result from
nancy were found associated with a decrease in MS dis- complex and still poorly understood interactions be-
ease activity assessed by occurrence of relapses during tween genetic, hormonal and environmental factors.
pregnancy [69]. Testosterone, progesterone and estriol, The increasing use of multi-omics and bioinformatic
the major estrogen during pregnancy, have been found approaches in large and clinically well characterized
to induce anti-inflammatory as well as neuroprotective patient cohorts will help identify critical pathways and

Table 3
Sex specific factors affecting multiple sclerosis

Female specific increase in MS risk after puberty [67]

Neuroprotective and anti-inflammatory effects of testosterone, progesterone and estriol in MS-like disease
Hormones models [70]
Dramatic decrease in MS relapse frequency during the second half of pregnancy, followed by a rebound in
relapses in the first trimester postpartum [68]

Genetic factors Still unknown

Clinical phenotype Faster accumulation of disability in male than female patients in relapse-onset MS [63]
210
Elena Ortona, Marina Pierdominici, Angela Maselli et al.

networks that can be useful for the discovery of new nancial or personal relationships with other people or
biomarkers and targeted for sex-specific therapeutic in- organizations that could inappropriately bias conduct
tervention and/or prevention of autoimmune diseases. and findings of this study.

Conflict of interest statement Submitted on invitation.

section

There are no potential conflicts of interest or any fi- Accepted on 16 March 2016.

REFERENCES
M onographic

1 Quintero OL, Amador-Patarroyo MJ, Montoya-Ortiz G, 10.1002/1529-0131(199902)42:2<328::AID-ANR16>

Rojas-Villarraga A, Anaya JM. Autoimmune disease and 3.0.CO;2-#
gender: Plausible mechanisms for the female predomi- 16. Selmi C, Brunetta E, Raimondo MG, Meroni PL. The
nance of autoimmunity. J Autoimmun 2012;38(2-3):J109- X chromosome and the sex ratio of autoimmunity. Au-
19. DOI: 10.1016/j.jaut.2011.10.003. toimmun Rev 2012;11(6-7):A531-537. DOI: 10.1016/j.
2. Shapira Y, Agmon-Levin N, Shoenfeld Y. Defining and autrev.2011.11.024
analyzing geoepidemiology and human autoimmunity. 17. Jørgensen KT, Rostgaard K, Bache I, Biggar RJ, Nielsen
J Autoimmun 2010;34(3):J168-177. DOI: 10.1016/j. NM, Tommerup N, Frisch M. Autoimmune diseas-
jaut.2009.11.018 es in women with Turner’s syndrome. Arthritis Rheum
3. Zandman-Goddard G, Peeva E, Shoenfeld Y. Gender 2010;62(3):658-66. DOI: 10.1002/art.27270
and autoimmunity. Autoimmun Rev 2007;6(6):366-72. 18. Seminog OO, Seminog AB, Yeates D, Goldacre MJ.
DOI: 10.1016/j.autrev.2006.10.001 Associations between Klinefelter’s syndrome and au-
4. Bauer M, Glenn T, Pilhatsch M, Pfennig A, Whybrow toimmune diseases: English national record link-
PC. Gender differences in thyroid system function: rel- age studies. Autoimmunity 2015;48(2):125-8. DOI:
evance to bipolar disorder and its treatment. Bipolar Dis- 10.3109/08916934.2014.968918
ord 2014;16(1):58-71. DOI: 10.1111/bdi.12150 19. Murphy ED, Roths JB. A Y chromosome associated factor
5. Rubtsova K, Marrack P, Rubtsov AV. Sexual dimorphism in strain BXSB producing accelerated autoimmunity and
in autoimmunity. J Clin Invest 2015;125(6):2187-93. lymphoproliferation. Arthritis Rheum 1979;22(11):1188-
DOI: 10.1172/JCI78082 94. DOI: 10.1002/art.1780221105
6. Borchers AT, Gershwin ME. Sociological differences be- 20. Singh RP, Massachi I, Manickavel S, Singh S, Rao NP,
tween women and men: implications for autoimmunity. Hasan S, Mc Curdy DK, Sharma S, Wong D, Hahn BH,
Autoimmun Rev 2012;11(6-7):A413-421. DOI: 10.1016/j. Rehimi H. The role of miRNA in inflammation and au-
autrev.2011.11.016 toimmunity. Autoimmun Rev 2013;12(12):1160-5. DOI:
7. Pierdominici M, Maselli A, Colasanti T, Giammarioli 10.1016/j.autrev.2013.07.003
AM, Delunardo F, Vacirca D, Sanchez M, Giovannetti 21. Ghorai A, Ghosh U. miRNA gene counts in chromo-
A, Malorni W, Ortona E. Estrogen receptor profiles in somes vary widely in a species and biogenesis of miRNA
human peripheral blood lymphocytes. Immunol Lett largely depends on transcription or post-transcriptional
2010;132(1-2):79-85. DOI: 10.1016/j.imlet.2010.06.003 processing of coding genes. Front Genet 2014;5(100):1-
8. Neill JD. Knobil and Neill’s physiology of reproduction. 11. DOI: 10.3389/fgene.2014.00100
Third Edition. New York: Academic Press; 2005. 22. Khan D, Dai R, Ansar Ahmed S. Sex differences and es-
9. Straub RH. The complex role of estrogens in inflam- trogen regulation of miRNAs in lupus, a prototypical au-
mation. Endocr Rev 2007;28(5):521-74. DOI: 10.1210/ toimmune disease. Cell Immunol 2015;294(2):70-9. DOI:
er.2007-0001 10.1016/j.cellimm.2015.01.004
10. Prieto GA, Rosenstein Y. Oestradiol potentiates the 23. Pinheiro I, Dejager L, Libert C. X-chromosome-located
suppressive function of human CD4 CD25 regula- microRNAs in immunity: might they explain male/female
tory T cells by promoting their proliferation. Immu- differences? The X chromosome-genomic context may af-
nology 2006;118(1):58-65. DOI: 10.1111/j.1365- fect X-located miRNAs and downstream signaling, there-
2567.2006.02339.x by contributing to the enhanced immune response of
11. Shelly S, Boaz M, Orbach H. Prolactin and autoim- females. Bioessays 2011;33(11):791-802. DOI: 10.1002/
munity. Autoimmun Rev 2012;11(6-7):A465-470. DOI: bies.201100047
10.1016/j.autrev.2011.11.009 24. Klinge CM. Estrogen regulation of MicroRNA ex-
12. Tan IJ, Peeva E, Zandman-Goddard G. Hormonal modu- pression. Curr Genomics 2009;10(3):169-83. DOI:
lation of the immune system - A spotlight on the role of 10.2174/138920209788185289
progestogens. Autoimmun Rev 2015;14(6):536-42. DOI: 25. Gomez A, Luckey D, Taneja V. The gut microbiome in au-
10.1016/j.autrev.2015.02.004 toimmunity: Sex matters. Clin Immunol 2015;159(2):154-
13. Trigunaite A, Dimo J, Jorgensen TN. Suppressive ef- 62. DOI: 10.1016/j.clim.2015.04.016
fects of androgens on the immune system. Cell Immunol 26. Markle JG, Frank DN, Mortin-Toth S, Robertson CE,
2015;294(2):87-94. DOI: 10.1016/j.cellimm.2015.02.004 Feazel LM, Rolle-Kampczyk U, von Bergen M, McCoy
14. Borchers AT, Naguwa SM, Keen CL, Gershwin ME. The KD, Macpherson AJ, Danska JS. Sex differences in the
implications of autoimmunity and pregnancy. J Autoimmun gut microbiome drive hormone-dependent regulation
2010;34(3):J287-299. DOI: 10.1016/j.jaut.2009.11.015 of autoimmunity. Science 2013;339(6123):1084-8. DOI:
15. Kanda N, Tsuchida T, Tamaki K. Estrogen enhance- 10.1126/science.1233521
ment of anti-double-stranded DNA antibody and 27. Yurkovetskiy L, Burrows M, Khan AA, Graham L, Volch-
immunoglobulin G production in peripheral blood kov P, Becker L, Antonopoulos D, Umesaki Y, Chervon-
mononuclear cells from patients with systemic lupus sky AV. Gender bias in autoimmunity is influenced by mi-
erythematosus. Arthritis Rheum 1999;42(2):328-37. DOI: crobiota. Immunity 2013;39(2):400-12. DOI: 10.1016/j.
 211
Sex and autoimmunity

immuni.2013.08.013 NA-146A contributes to abnormal activation of the type

28. Kosiewicz MM, Dryden GW, Chhabra A, Alard P. Re- I interferon pathway in human lupus by targeting the key
lationship between gut microbiota and development of signaling proteins. Arthritis Rheum 2009;60(4):1065-75.
T cell associated disease. FEBS Lett 2014;588(22):4195- DOI: 10.1002/art.24436
206. DOI: 10.1016/j.febslet.2014.03.019 44. Zhao X, Tang Y, Qu B, Cui H, Wang S, Wang L, Luo X,
29. Gomez A, Luckey D, Yeoman CJ, Marietta EV, Berg Huang X, Li J, Chen S, Shen N. MicroRNA-125a con-

section
Miller ME, Murray JA, White BA, Taneja V. Loss of sex tributes to elevated inflammatory chemokine RANTES
and age driven differences in the gut microbiome char- levels via targeting KLF13 in systemic lupus erythemato-
acterize arthritis-susceptible 0401 mice but not arthritis- sus. Arthritis Rheum 2010;62(11):3425-35. DOI: 10.1002/
resistant 0402 mice. PLoS One 2012;7(4):e36095. DOI: art.27632

M onographic
10.1371/journal.pone.0036095 45. Pan W, Zhu S, Yuan M, Cui H, Wang L, Luo X, Li J,
30. Ngo ST, Steyn FJ, McCombe PA. Gender differ- Zhou H, Tang Y, Shen N. MicroRNA-21 and microR-
ences in autoimmune disease. Front Neuroendocrinol NA-148a contribute to DNA hypomethylation in lupus
2014;35(3):347-69. DOI: 10.1016/j.yfrne.2014.04.004 CD4+ T cells by directly and indirectly targeting DNA
31. Chighizola C, Meroni PL. The role of environmental methyltransferase 1. J Immunol 2010;184(12):6773-81.
estrogens and autoimmunity. Autoimmun Rev 2012;11(6- DOI: 10.4049/jimmunol.0904060
7):A493-501. DOI: 10.1016/j.autrev.2011.11.027 46. Dai R, Phillips RA, Zhang Y, Khan D, Crasta O, Ahmed
32. Borchers AT, Naguwa SM, Shoenfeld Y, Gershwin ME. SA. Suppression of LPS-induced Interferon-gamma and
The geoepidemiology of systemic lupus erythematosus. nitric oxide in splenic lymphocytes by select estrogen-
Autoimmun Rev 2010;9(5):A277-287. DOI: 10.1016/j.au- regulated microRNAs: a novel mechanism of immune
trev.2009.12.008 modulation. Blood 2008;112(12):4591-7. DOI: 10.1182/
33. Gualtierotti R, Biggioggero M, Penatti AE, Meroni PL. blood-2008-04-152488
Updating on the pathogenesis of systemic lupus erythe- 47. Lu LJ, Wallace DJ, Ishimori ML, Scofield RH, Weis-
matosus. Autoimmun Rev 2010;10(1):3-7. DOI: 10.1016/j. man MH. Review: Male systemic lupus erythemato-
autrev.2010.09.007 sus: a review of sex disparities in this disease. Lupus
34. Pierdominici M, Ortona E. Estrogen Impact on Autoim- 2010;19(2):119-29. DOI: 10.1177/0961203309350755
munity Onset and Progression: the Paradigm of Systemic 48. Murphy G, Isenberg D. Effect of gender on clinical pre-
Lupus Erythematosus. International Trends in Immunity sentation in systemic lupus erythematosus. Rheumatology
2013;1(2):24-34. (Oxford) 2013;52(12):2108-15. DOI: 10.1093/rheuma-
35. Roubinian J, Talal N, Siiteri PK, Sadakian JA. Sex hor- tology/ket160
mone modulation of autoimmunity in NZB/NZW mice. 49. Tobon GJ, Youinou P, Saraux A. The environment, geo-
Arthritis Rheum 1979;22(11):1162-9. DOI: 10.1002/ epidemiology, and autoimmune disease: Rheumatoid
art.1780221102 arthritis. J Autoimmun 2010;35(1):10-4. DOI: 10.1016/j.
36. Li J, McMurray RW. Effects of estrogen receptor sub- jaut.2009.12.009
type-selective agonists on autoimmune disease in lu- 50. Hughes GC, Choubey D. Modulation of autoimmune
pus-prone NZB/NZW F1 mouse model. Clin Immunol rheumatic diseases by oestrogen and progesterone.
2007;123(2):219-26. DOI: 10.1016/j.clim.2007.01.008 Nat Rev Rheumatol 2014;10(12):740-51. DOI: 10.1038/
37. Svenson JL, EuDaly J, Ruiz P, Korach KS, Gilkeson GS. nrrheum.2014.144
Impact of estrogen receptor deficiency on disease expres- 51. Sokka T, Toloza S, Cutolo M, Kautiainen H, Makinen H,
sion in the NZM2410 lupus prone mouse. Clin Immunol Gogus F, Skakic V, Badsha H, Peets T, Baranauskaite A,
2008;128(2):259-68. DOI: 10.1016/j.clim.2008.03.508 Geher P, Ujfalussy I, Skopouli FN, Mavrommati M, Alten
38. Cutolo M, Capellino S, Sulli A, Serioli B, Secchi ME, Vil- R, Pohl C, Sibilia J, Stancati A, Salaffi F, Romanowski W,
laggio B, Straub RH. Estrogens and autoimmune diseas- Zarowny-Wierzbinska D, Henrohn D, Bresnihan B, Min-
es. Ann N Y Acad Sci 2006;1089:538-47. DOI: 10.1196/ nock P, Knudsen LS, Jacobs JW, Calvo-Alen J, Lazovskis
annals.1386.043 J, Pinheiro Gda R, Karateev D, Andersone D, Rexhepi
39. Colasanti T, Maselli A, Conti F, Sanchez M, Alessandri S, Yazici Y, Pincus T. Women, men, and rheumatoid ar-
C, Barbati C, Vacirca D, Tinari A, Chiarotti F, Giovan- thritis: analyses of disease activity, disease characteristics,
netti A, Franconi F, Valesini G, Malorni W, Pierdominici and treatments in the QUEST-RA study. Arthritis Res Ther
M, Ortona E. Autoantibodies to estrogen receptor alpha 2009;11(1):R7. DOI: 10.1186/ar2591
interfere with T lymphocyte homeostasis and are associ- 52. Castagnetta LA, Carruba G, Granata OM, Stefano R,
ated with disease activity in systemic lupus erythemato- Miele M, Schmidt M, Cutolo M, Straub RH. Increased
sus. Arthritis Rheum 2012;64(3):778-87. DOI: 10.1002/ estrogen formation and estrogen to androgen ratio in
art.33400 the synovial fluid of patients with rheumatoid arthritis. J
40. Lateef A, Petri M. Hormone replacement and contra- Rheumatol 2003;30(12):2597-605.
ceptive therapy in autoimmune diseases. J Autoimmun 53. Ostensen M, Villiger PM. The remission of rheuma-
2012;38(2-3):J170-J176. DOI: 10.1016/j.jaut.2011.11.002 toid arthritis during pregnancy. Semin Immunopathol
41. Abdou NI, Rider V, Greenwell C, Li X, Kimler BF. Ful- 2007;29(2):185-91. DOI: 10.1007/s00281-007-0072-5
vestrant (Faslodex), an estrogen selective receptor down- 54. Inoue K, Inoue E, Imai Y. Female sex hormones amelio-
regulator, in therapy of women with systemic lupus ery- rate arthritis in SKG mice. Biochem Biophys Res Commun
thematosus. clinical, serologic, bone density, and T cell 2013;434(4):740-5. DOI: 10.1016/j.bbrc.2013.03.111
activation marker studies: a double-blind placebo-con- 55. Zoli A, Ferlisi EM, Lizzio M, Altomonte L, Mirone L,
trolled trial. J Rheumatol 2008;35(5):797. Barini A, Scuderi F, Bartolozzi F, Magaro M. Prolac-
42. Dai R, Ahmed SA. MicroRNA, a new paradigm for un- tin/cortisol ratio in rheumatoid arthritis. Ann N Y Acad
derstanding immunoregulation, inflammation, and auto- Sci 2002;966:508-12. DOI: 10.1111/j.1749-6632.2002.
immune diseases. Transl Res 2011;157(4):163-79. DOI: tb04255.x
10.1016/j.trsl.2011.01.007 56. Wilder RL. Adrenal and gonadal steroid hormone defi-
43. Tang Y, Luo X, Cui H, Ni X, Yuan M, Guo Y, Huang X, ciency in the pathogenesis of rheumatoid arthritis. J Rheu-
Zhou H, de Vries N, Tak PP, Chen S, Shen N. MicroR- matol Suppl 1996;44:10-2.
212
Elena Ortona, Marina Pierdominici, Angela Maselli et al.

57. Cutolo M. Androgens in rheumatoid arthritis: when are mones in determining the onset and outcome of mul-
they effectors? Arthritis Res Ther 2009;11(5):126. DOI: tiple sclerosis. Mult Scler 2014;20(5):520-6. DOI:
10.1186/ar2804 10.1177/1352458513519181
58. Jawaheer D, Olsen J, Hetland ML. Sex differences in 68. Pozzilli C, Pugliatti M. An overview of pregnancy-related
response to anti-tumor necrosis factor therapy in early issues in patients with multiple sclerosis. Eur J Neurol
and established rheumatoid arthritis - results from the 2015;22(Suppl. 2):34-9. DOI: 10.1111/ene.12797
section

DANBIO registry. J Rheumatol 2012;39(1):46-53. DOI: 69. Gilli F, Lindberg RL, Valentino P, Marnetto F, Maluc-
10.3899/jrheum.110548 chi S, Sala A, Capobianco M, di Sapio A, Sperli F, Kap-
59. Cutolo M. Sex hormone adjuvant therapy in rheumatoid pos L, Calogero RA, Bertolotto A. Learning from nature:
arthritis. Rheum Dis Clin North Am 2000;26(4):881-95. pregnancy changes the expression of inflammation-re-
M onographic

DOI: 10.1016/S0889-857X(05)70174-5 lated genes in patients with multiple sclerosis. PLoS One
60. van den Brink HR, van Everdingen AA, van Wijk MJ, Ja- 2010;5(1):e8962. DOI: 10.1371/journal.pone.0008962
cobs JW, Bijlsma JW. Adjuvant oestrogen therapy does not 70. Voskuhl RR, Gold SM. Sex-related factors in multiple
improve disease activity in postmenopausal patients with sclerosis susceptibility and progression. Nat Rev Neurol
rheumatoid arthritis. Ann Rheum Dis 1993;52(12):862-5. 2012;8(5):255-63. DOI: 10.1038/nrneurol.2012.43
DOI: doi:10.1136/ard.52.12.862 71. Bove R, Musallam A, Healy BC, Raghavan K, Glanz BI,
61. Stark K, Straub RH, Rovensky J, Blazickova S, Eiselt G, Bakshi R, Weiner H, De Jager PL, Miller KK, Chitnis T.
Schmidt M. CYB5A polymorphism increases androgens Low testosterone is associated with disability in men with
and reduces risk of rheumatoid arthritis in women. Arthri- multiple sclerosis. Mult Scler 2014;20(12):1584-92. DOI:
tis Res Ther 2015;17:56. DOI: 10.1186/s13075-015-0574- 10.1177/1352458514527864
9 72. Kurth F, Luders E, Sicotte NL, Gaser C, Giesser BS,
62. Burkhardt J, Petit-Teixeira E, Teixeira VH, Kirsten H, Swerdloff RS, Montag MJ, Voskuhl RR, Mackenzie-
Garnier S, Ruehle S, Oeser C, Wolfram G, Scholz M, Graham A. Neuroprotective effects of testosterone treat-
Migliorini P, Balsa A, Westhovens R, Barrera P, Alves ment in men with multiple sclerosis. Neuroimage Clin
H, Pascual-Salcedo D, Bombardieri S, Dequeker J, Rad- 2014;4:454-60. DOI: 10.1016/j.nicl.2014.03.001
stake TR, Van Riel P, van de Putte L, Bardin T, Prum B, 73. Voskuhl RR, Wang H, Wu TC, Sicotte NL, Nakamura K,
Buchegger-Podbielski U, Emmrich F, Melchers I, Corne- Kurth F, Itoh N, Bardens J, Bernard JT, Corboy JR, Cross
lis F, Ahnert P. Association of the X-chromosomal genes AH, Dhib-Jalbut S, Ford CC, Frohman EM, Giesser B,
TIMP1 and IL9R with rheumatoid arthritis. J Rheumatol Jacobs D, Kasper LH, Lynch S, Parry G, Racke MK, Re-
2009;36(10):2149-57. DOI: 10.3899/jrheum.090059 der AT, Rose J, Wingerchuk DM, MacKenzie-Graham
63. Ribbons KA, McElduff P, Boz C, Trojano M, Izquierdo AJ, Arnold DL, Tseng CH, Elashoff R. Estriol combined
G, Duquette P, Girard M, Grand’Maison F, upperts with glatiramer acetate for women with relapsing-remit-
R, Grammond P, Oreja-Guevara C, Petersen T, Berga- ting multiple sclerosis: a randomised, placebo-controlled,
maschi R, Giuliani G, Barnett M, van Pesch V, Amato phase 2 trial. Lancet Neurol 2016;15(1):35-46. DOI:
MP, Iuliano G, Fiol M, Slee M, Verheul F, Cristiano E, 10.1016/S1474-4422(15)00322-1
Fernandez-Bolanos R, Saladino ML, Rio ME, Cabrera- 74. Ascherio A, Munger KL, Lunemann JD. The initiation
Gomez J, Butzkueven H, van Munster E, Den Braber- and prevention of multiple sclerosis. Nat Rev Neurol
Moerland L, La Spitaleri D, Lugaresi A, Shaygannejad V, 2012;8(11):602-12. DOI: 10.1038/nrneurol.2012.198
Gray O, Deri N, Alroughani R, Lechner-Scott J. Male sex 75. Ramanujam R, Hedstrom AK, Manouchehrinia A, Al-
is independently associated with faster disability accumu- fredsson L, Olsson T, Bottai M, Hillert J. Effect of smok-
lation in relapse-onset MS but not in primary progres- ing cessation on multiple sclerosis prognosis. JAMA
sive MS. PLoS One 2015;10(6):e0122686. DOI: 10.1371/ Neurol 2015;72(10):1117-23. DOI: 10.1001/jamaneu-
journal.pone.0122686 rol.2015.1788
64. Trojano M, Lucchese G, Graziano G, Taylor BV, Simpson 76. Schoonheim MM, Vigeveno RM, Rueda Lopes FC, Pou-
S, Jr., Lepore V, Grand’maison F, Duquette P, Izquierdo wels PJ, Polman CH, Barkhof F, Geurts JJ. Sex-specific
G, Grammond P, Amato MP, Bergamaschi R, Giuliani extent and severity of white matter damage in multiple
G, Boz C, Hupperts R, Van Pesch V, Lechner-Scott J, sclerosis: implications for cognitive decline. Hum Brain
Cristiano E, Fiol M, Oreja-Guevara C, Saladino ML, Mapp 2014;35(5):2348-58. DOI: 10.1002/hbm.22332
Verheul F, Slee M, Paolicelli D, Tortorella C, D’Onghia 77. Irizar H, Munoz-Culla M, Sepulveda L, Saenz-Cuesta
M, Iaffaldano P, Direnzo V, Butzkueven H. Geographical M, Prada A, Castillo-Trivino T, Zamora-Lopez G, Lo-
variations in sex ratio trends over time in multiple sclero- pez de Munain A, Olascoaga J, Otaegui D. Transcrip-
sis. PLoS One 2012;7(10):e48078. DOI: 10.1371/journal. tomic profile reveals gender-specific molecular mecha-
pone.0048078 nisms driving multiple sclerosis progression. PLoS One
65. Gourraud PA, Harbo HF, Hauser SL, Baranzini SE. The 2014;9(2):e90482. DOI: 10.1371/journal.pone.0090482
genetics of multiple sclerosis: an up-to-date review. Im- 78. Veroni C, Marnetto F, Granieri L, Bertolotto A, Ballerini
munol Rev 2012;248(1):87-103. DOI: 10.1111/j.1600- C, Repice AM, Schirru L, Coghe G, Cocco E, Anastasi-
065X.2012.01134.x adou E, Puopolo M, Aloisi F. Immune and Epstein-Barr
66. Sawcer S, Franklin RJ, Ban M. Multiple sclerosis ge- virus gene expression in cerebrospinal fluid and periph-
netics. Lancet Neurol 2014;13(7):700-9. DOI: 10.1016/ eral blood mononuclear cells from patients with relaps-
S1474-4422(14)70041-9 ing-remitting multiple sclerosis. J Neuroinflammation
67. Bove R, Chitnis T. The role of gender and sex hor- 2015;12:132. DOI: 10.1186/s12974-015-0353-1