Female Reproductive Disorders, Diseases, and Costs of Exposure to Endocrine Disrupting Chemicals in the European Union

Patricia A Hunt; Sheela Sathyanarayana; Paul A Fowler; Leonardo Trasande

doi:10.1210/jc.2015-2873

Lifestyle and Environment · Environmental Exposures

Female Reproductive Disorders, Diseases, and Costs of Exposure to Endocrine Disrupting Chemicals in the European Union

Hunt PA, Sathyanarayana S, Fowler PA, Trasande L

Published April 2016 The Journal of clinical endocrinology and metabolism

DOI 10.1210/jc.2015-2873 PMID 27003299 PMC PMC4880176

RRM Academy Synopsis

Phthalates may account for 145 000 EU endometriosis cases in 2010

An expert-panel cost model estimates that phthalate exposure may account for 145 000 endometriosis cases in the EU, among women aged 20 to 44 in 2010, costing €1.25 billion. It estimates adult DDE exposure may account for 56 700 surgical fibroid interventions. For both pairings, the panel rated epidemiological evidence low and put the probability of causation at 20%–39%.

Key Findings

The panel's strongest data covered diphenyldichloroethene (DDE) with fibroids and phthalates with endometriosis. For both, epidemiological evidence (studies in people) was rated low and toxicological evidence (laboratory and animal work) moderate.
The panel set the probability of causation at 20%–39% for DDE with fibroids and for phthalates with endometriosis.
In 2010, an estimated 56 700 women had fibroid interventions requiring surgical attention that the model linked to adult DDE exposure. The cases cost €163 million.
The analysis suggests that 145 000 endometriosis cases among women aged 20 to 44 were attributable to phthalates, costing €1.25 billion in 2010.
The endometriosis estimate used an odds ratio of 1.35 for each log-unit rise in total phthalates, taken from a study of 495 women, and applied it to European urine measurements.

Interpretation

The study is an expert-panel cost-of-illness model for 2010. For each pairing, the panel drew its exposure-response estimate from one published observational study. The panel applied that estimate to European exposure data. The panel assumed that EU women matched the levels measured in pregnant women and mothers. The authors state that the figures likely understate the burden. The analysis left out prenatal exposures, other chemicals, and conditions such as infertility and pregnancy complications.

RRM Context

Restorative reproductive medicine looks for the cause of endometriosis and fibroids. The panel examined environmental exposure as one candidate cause. The authors cite higher risks of autoimmune disorders and cancer among women with endometriosis. That finding supports an evaluation that looks beyond the pelvis. The authors hope ongoing birth cohort studies will allow updated estimates.

Our editorial summary of this paper, not the article's abstract.

Abstract

Context

A growing body of evidence suggests that endocrine-disrupting chemicals (EDCs) contribute to female reproductive disorders.

Objective

To calculate the associated combined health care and economic costs attributable to specific EDC exposures within the European Union (EU).

Design

An expert panel evaluated evidence for probability of causation using the Intergovernmental Panel on Climate Change weight-of-evidence characterization. Exposure-response relationships and reference levels were evaluated, and biomarker data were organized from carefully identified studies from the peer-reviewed literature to represent European exposure and approximate burden of disease as it occurred in 2010. Cost-of-illness estimation used multiple peer-reviewed sources.

SETTING, PATIENTS AND PARTICIPANTS AND

Intervention

Cost estimation was carried out from a societal perspective, ie, including direct costs (eg, treatment costs) and indirect costs such as productivity loss.

Results

The most robust EDC-related data for female reproductive disorders exist for 1) diphenyldichloroethene-attributable fibroids and 2) phthalate-attributable endometriosis in Europe. In both cases, the strength of epidemiological evidence was rated as low and the toxicological evidence as moderate, with an assigned probability of causation of 20%–39%. Across the EU, attributable cases were estimated to be 56 700 and 145 000 women, respectively, with total combined economic and health care costs potentially reaching €163 million and €1.25 billion.

Conclusions

EDCs (diphenyldichloroethene and phthalates) may contribute substantially to the most common reproductive disorders in women, endometriosis and fibroids, costing nearly €1.5 billion annually. These estimates represent only EDCs for which there were sufficient epidemiologic studies and those with the highest probability of causation. These public health costs should be considered as the EU contemplates regulatory action on EDCs.

Topics

Lifestyle and Environment › Environmental Exposures › Endocrine Disrupting Chemicals · Cost and Access › Cost of Care › Treatment Costs · Research Methods › Evidence Synthesis › Systematic Reviews

Patricia A Hunt, Sheela Sathyanarayana, Paul A Fowler, Leonardo Trasande

Pat Hunt, Trish Hunt, P Hunt, S Sathyanarayana, P Fowler, L Trasande

PMID 27003299 27003299 DOI 10.1210/jc.2015-2873 10.1210/jc.2015-2873 Hunt et al. 2016, Hunt 2016

Female Reproductive Disorders, Diseases, and Costs of Exposure to Endocrine Disrupting Chemicals in the European Union

Phthalates may account for 145 000 EU endometriosis cases in 2010

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

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